Addressing the Issue Of Poor Adherence To Home Exercise Programs In Older Adults

Addressing the Issue Of Poor Adherence To Home Exercise Programs In Older Adults

Andrew Newman SPT

University of North Carolina at Chapel Hill

 

Introduction

During my time at my outpatient orthopedic clinical rotation, I had an elderly fall risk patient come in who was determined to do his therapy his way. He struggled to comprehend how another medical professional, who wasn’t his doctor, could understand his body better than he could. I prescribed this client with several home exercises but he would not perform any of them initially. I asked him why he wasn’t doing the exercises and he said that he didn’t think they were going to improve his balance issues, they were too time consuming, and he thought he already did enough ‘exercise’ without the need to ‘add more.’ It was apparent that his home exercise program (HEP) was not effective in that he wouldn’t complete the program as asked! My initial reaction was that this gentleman was being stubborn, how could my perfectly developed HEP be deemed ‘unhelpful’ and ‘useless’? After spending some time to calm down, I realized that the problem extended beyond simple stubbornness. I was the one making critical errors.

Unfortunately, this was not my only episode concerning poor patient compliance to a HEP. Poor compliance to a HEP was a recurring theme on all of my rotations; a finding similarly shared by many of my classmates and other practicing physical therapists.

Overview

I knew that my capstone project was going to be centered on improving adherence to a HEP in the older population and this project has been roughly 1 year in the making. I have built on specific research conducted in the Evidence Based Practice II class whereby I produced a critically appraised topic that answered the PICO question:

For fall risk patients receiving physical therapy home exercises, does patient selection of exercises from a range of options increase adherence compared to strictly assigned exercises given by a PT?

Initially, I was going to perform a mini-research project that would provide older adults with the ability to select exercises from an appropriate set as determined by the PT (Carol Giuliani) and PT student (me). This pilot research project would be conducted to answer the above PICO question, utilizing the literature to shape the intervention protocol. However, upon regular meetings with Carol, we realized that this protocol would be too time consuming. Therefore, I decided to expand my review of the  literature and develop an educational capstone that focused on providing clinically relevant solutions to improving adherence to a HEP in older adults.

Due to the expanded scope of my capstone project beyond my initial PICO question, I have produced a new evidence table incorporating some of the papers utilized in my EBP2 class along with new research on this topic. I wanted to produce an educational capstone that could be used by current students and professionals in the field to improve adherence to a HEP in older adults with, or without, a fall risk. In addition to the evidence table (Newman_Evidence-table-2_Capstone), I have completed a detailed literature review paper, (which can be read below), a PowerPoint presentation (Capstone powerpoint_solve poor HEP adherence_AN_edit_3), and a summary handout (AN_Capstone_Summary handout_ed), which could be presented as a potential in-service to first year UNC PT students as they prepare to enter their first clinical rotations, or to rehabilitation staff on my final clinical rotation. In addition to the PowerPoint and handout, a separate project evaluation/feedback form (AN_Capstone_Feedback forms)has been developed to gauge audience interest, learning, and recommendations for future improvements. Based on the level of knowledge expected of first year PT students and rehabilitation professionals in current practice, the materials will incorporate appropriate use of scientific language, but, in the hopes that these materials (the handout primarily) will be used in the clinic, these materials will be simple to understand and easy to read.

Thanks To Contributors/Evaluation

I would first like to thank my committee members Carol Giuliani, PT, PhD and Charron Andrews, PT for their significant contributions in helping me to complete this capstone project. This was a complex and detailed project and the time, energy, and passion generously provided by Carol and Charron must be acknowledged. In preparation for presenting my project, I was planning to use the feedback forms as a separate form of project evaluation but, having been unable to present to an audience, feedback gathered via e-mails, phone calls and in-person meetings with Carol and Charron had become the dominant evaluation component of my project.

I would also like to thank my Capstone adviser Karen McCulloch, PT, PhD, NCS who helped to ‘keep me on track’ during moments of panic!

Self-assessment

Constructing this capstone project has been a love-hate relationship. While I am extremely interested in researching and targeting improved adherence to a HEP in older adults, I did not realize the initial scope of this project! The literature was so vast that I had to generate four sub-topics in which to place the best resources. I have learned a great many techniques to improve HEP adherence in older adults and will actively seek to incorporate these ideas in future practice.

Although these materials are lengthy, I have had to spend considerable time condensing them. I found it most difficult to identify and include only the most important points/topics in my materials. Based on her expertise in the area, Carol was instrumental in guiding me through the jungle of literature!

Having initially decided to produce a mini-research project, I had great difficulty in swiftly switching to a more traditional literature review and presentation style project. The switch meant that my already condensed timelines were shortened even more and because of this I had been unable to present this project as intended, despite a concerted effort to find a time/location. However, I am hopeful that I can use these materials in the future to benefit other PT students or licensed practitioners.

 

Literature Review Paper

Background

A large part of current physical therapy treatment centers on the provision of exercise prescription in the home as well as in the clinic. Health care providers in rehabilitation have identified home exercise program (HEP) adherence extremely important for intervention efficacy.¹ However, Simek et al. reported just 21% with HEP adherence rates in the older adult population.² Hardage et al. also reported similar findings for poor HEP adherence.³ Hardage et al. found that only 36-38% of older adults maintained long term adherence to a HEP at 1 to 2 years.³ This is becoming an increasingly important problem as the number of older adults in the U.S.A. is continuing to rise. With an increasing number of older adults making up larger a client base for physical therapists (PTs) and other rehabilitation staff, there is an increased likelihood that these professionals will be confronted with frail older adults.⁴ An HEP prescription, which promotes a healthy active lifestyle and incorporates regular physical activity, has been considered an excellent approach to reduce the effects of frailty and improve daily functioning, strength, and balance in the older population.⁴ Therefore, significant efforts must be undertaken to improve traditionally low adherence levels to a HEP in this population.

Due to the individual limitations of each unique client and the necessary HEP interventions needed to improve functional, safety, strength etc., there is a lot of conflicting evidence within the literature detailing optimum program characteristics to improve HEP adherence. However, through-out the course of my literature search, I have identified recurring general ‘themes’ and methods that have been shown to improve adherence in the older population

Themes

I found 19 research papers in the literature that measured adherence to a HEP in the older population. The age of adults ranged from 16-85+ years old, but most of the papers analyzed the adherence to a HEP of adults aged 65+ years old. There were multiple study designs across the number of papers included in this capstone summary (randomized control trials (RCTs), systematic reviews (SR) and meta-analyses (MA), cross-sectional reviews (CSR) and cohort studies (CS)).

Due to the various types of studies in this review and the complexity involved with discussing each individual paper, I have decided to separate my findings into commonly discussed themes. However, these themes are not mutually exclusive and some papers could belong under numerous theme headings. The identified themes to for improving HEP adherence in the older population and the numbers of papers belonging to each theme include:

1. Use of novel technology (2 papers)
2. Education (3 papers)
3. Tailoring a HEP (4 papers – Henry et al. utilized in this theme but counted in theme #4 below)
4. HEP parameters/components to improve adherence (14 papers – 9 papers discussed in the PowerPoint presentation)

Use of novel technology

Use of novel technology was incorporated by Silveira et al.⁵ who had 44 independent older adults participate in an autonomous 12 week strength and balance personalized HEP using a tablet based application (ActiveLifestyle). The authors found that the 33 participants, who completed the 12 week trial, believed that the tablet application improved motivation to home exercise. The tablet application allowed users to create and track goals as well as track and interact with other users of the application. Silveira et al. found that this social aspect provided more effective motivation than individual strategies alone to boost HEP adherence and enact long-term healthy behavior changes. Geraedts et al. were also in agreement with Silveria et al. that in addition to increased self-efficacy, the use of novel technology would improve adherence because the HEP would be delivered at physically attainable levels, would be individualized, and is delivered in an easy to understand format (use of tablet pc).⁴ Schoene et al. conducted a pilot RCT to assess the feasibility and safety of a HEP that incorporated a home-based step pad training to the video game ‘Dance-Dance Revolution’ (DDR) to improve stepping performance and fall risk in 37 older adults in independent living accommodation.⁶ Between the intervention group (step-pad) and the control (no step-pad) it was found that adherence to the HEP was higher in the intervention group as were the results of the outcome measures used to quantify improvements (Timed-up and go (TUG) and postural sway etc.).⁶

Although there is not a large amount of literature available on the evidence for novel technology to improve adherence to a HEP, this does not imply that use of such technology will not provide any benefit. Silveira, Schoene and Garaedts et al. agree that use of novel technology will allow for better utilization of a HEP in the privacy and comfort of the clients’ own home.^5,6,4 The authors argue that performance of the HEP in the home will increase the likelihood of adherence, compared to performance of a HEP in a different environment.^5,6,4 It is also agreed that the use of novel technology may provide decreases in perceived pain levels due to increased distractibility.⁶ This will enable clients to perform at a greater intensity and/or frequency of exercise, thereby improving HEP adherence.^6,4 Increased use of novel technology may also lead to improved adherence due to increased client self-efficacy, facilitation, cues to action, and self-regulation.⁴ Self-efficacy is the belief that an individual can succeed in a particular situation given their level of ability.^7,8 The use of novel technology such as a video game or tablet PC will provide clients with self-selective levels of difficulty and improved control over their HEP. A study by Cramer et al. found that self-efficacy might improve adherence to health-promoting behavior after lifestyle modification programs.⁹ Improving facilitation can improve outcomes via the provision of tools, resources, or environmental changes that make new behaviors easier to perform.⁸ Use of novel technology may improve adherence to a HEP by affording simple, more enjoyable exercises which will improve behavior. Cues to action are people, events or things that motivate people to improve behavior outcomes.⁷ Self-regulation is the use of self-monitoring, goal-setting, feedback, self-reward, self- instruction, and enlistment of social support to improve health outcomes.⁸ The use of in-game targets or goals and the ability to monitor or track accurate exercise performance may improve HEP adherence via the cues to action and self-regulation constructs of the health beliefs model (HBM) and social cognitive theory (SCT) respectively.^7,8 Finally, use of novel technology may improve HEP adherence due to an increased ‘fun factor’ as the clients are likely to be more engaged and enjoy their HEP (less likely to feel like HEP adherence is ‘work’ and be less affected by boredom).⁶

Education provision

A RCT by Volger et al. measured detraining effects on strength and balance at baseline (immediately after 12 week exercise intervention) and at 12 weeks post 12 week exercise program in 180 older adults who were recently discharged from hospital with a mean length of stay 12.3+/- 10 days.¹⁰ There were no significant differences in adherence to a HEP in the weight-bearing or seated resistance exercise groups but at 12 weeks following termination of the exercise program, there were significant detraining effects with nearly all patients returning to pre-intervention baseline levels of strength and balance.¹⁰ The authors argue that clients undergoing an HEP as part of a “time-limited” exercise program need to be educated on the importance of long-term adherence and of the detrimental effects that can appear with poor adherence.¹⁰ However, the use of a population in this study that had recently been discharged from the hospital setting may limit the external validity of these findings. The short-term nature of the follow-up period also meant a lack of availability to draw conclusions on other reasons for poor adherence including the costs imposed by the HEPs, the residential status of the patients and other intrinsic health factors (poor health).¹⁰

Two cross-sectional reviews were included in this review of the literature that focused on education as a key parameter to improve adherence to a HEP. Horne et al. attempted to identify the salient beliefs that influence uptake and adherence to exercise for fall prevention among community dwelling older adults of Caucasian and Asian racial backgrounds in the UK.¹¹ This ethnographic study utilized 15 focus groups and 40 individual semi-structured interviews to obtain the information.¹¹ Interestingly, both ethnic groups were confused as to what constituted exercise as opposed to physical activity. Most believed that physical activity was akin to exercise and so were less likely to adhere to a prescribed HEP believing that already performed enough ‘exercise.’¹¹ Most of the adults identified (average age 65.7 years), believed they were too young to fall or neglected to acknowledge the consequences of falling, even if they were at a fall risk. Horne et al. also identified that fatalism was a common theme shared among both racial groups.¹¹ Fatalism is the perception that declining health and subsequent falls were a part of the natural ageing process and that ‘nothing can be done to prevent it’. However, fear of falling was indicated as a large motivator for increased adherence to a HEP.¹¹ Therefore, the authors argue that rehabilitation professionals should place improved emphasis on educating clients that adherence to a HEP is crucial to prevent negative outcomes, even if the client has not suffered any adverse events. PTs should also educate their clients that falling is not part of the natural ageing process and that declines in balance and strength, in addition to other physical deficits, can be reversed or halted with increased adherence to a HEP. For clients who stubbornly refuse to acknowledge declines in physical performance indicators, perhaps having clients perform outcome measures such as the TUG or the Activities-Specific Balance Confidence scale (ABC), and informing and educating these clients about what their personal performance indicates with regard to future risk and other issues. Utilization of outcome measures would provide the client with increased intrinsic acknowledgement of their own limitations and is therefore likely to improve adherence to a HEP. As a final piece of advice concerning increased provision of education to clients in need of a HEP, Horne et al. state that focus should also be placed on the benefits of exercise and leading a healthy active lifestyle as it relates to the clients’ goals and personal life as this will likely improve exercise ‘ownership’ and adherence to a HEP.¹¹

A second cross-sectional review by Yardley et al. sought to obtain quantitative measures from 558 older adults (mean age 74.4 years) at different levels of physical capability about their attitudes, beliefs, and intentions to initiate and adhere to a strength and balance exercise program.¹¹ Client recruitment was achieved using a postal questionnaire for 451 clients, and face to face semi-structured interviews at independent but supervised living accommodation for the remaining 107 clients.¹¹ It was found that adherence to a HEP was more strongly predicted by higher levels of self-efficacy and concerns with the difficulty of performing the HEP.¹¹ In contrast to Horne et al., intrinsic acknowledgement of being at a fall risk, and, or having a fear of falling, were not indicators for improved adherence among this population.¹¹ To improve adherence to a HEP, Yardley et al. suggest that recruitment messages and provision of information on the need for continual adherence should be more positive in nature and focus on multiple benefits such as increased enjoyment, achievable health improvements, and improved mobility and independence, rather than focus on the need for improved adherence because of a fall risk.¹¹ The authors suggest that rehabilitation professionals should also emphasize the positive social identity that is associated with undertaking an exercise routine and ensure that subjects feel that those who care about the well-being of the individual client would approve of adherence to a HEP.¹¹

Individual tailoring of a HEP

Due to the ubiquity of individualized tailoring as a theme in the literature to boost adherence to a HEP, we might expect that all practitioners automatically tailor each individual HEP. However, based on first-hand accounts and direct observation in the clinic, this has not been the case with the majority of my experiences. I have found that limited time, especially in the outpatient clinic setting, significantly hinders the provision of a detailed, individualized HEP. It should be noted, however, that there is a difference between tailoring an exercise program based on a clients’ physical limitations, and tailoring an exercise program based on client preference, enjoyment, and ability to perform the program in a context that best fits with their lifestyle.

Freiburger et al. conducted a RCT that used a 16 week intervention composed of supervised (GP office setting) and unsupervised (home with instruction booklet) exercise sessions in 378 functionally limited, community dwelling older adults (mean age 78.1 years).¹³ Adherence to the supervised office setting was recorded on a register and in the unsupervised home settings by completion of an exercise log.¹³ Although adherence to all exercise sessions was generally high, the authors suggest that “addressing individual functional levels with exercise variations seemed valuable to foster adherence and motivation.”¹³ In other words, each prescribed HEP should include variation in parameters (type, duration, intensity, frequency) that are developed and conform to individual client capabilities based on direct input from the individual client.¹³

A qualitative study from a phenomenological perspective by Haas et al. also supported the use of an individualized HEP to boost adherence.¹ Haas et al. performed semi-structured interviews with 24 PTs who had an average of 6 years’ experience in providing and developing HEPs for older adults with a fall risk at the Victoria Falls Clinic Coalition in Australia.¹ The results from this study were interesting. The general consensus was that HEP adherence is likely to be improved when the prescribing practitioner selects HEP components that carefully reflect individual patient safety and likely compliance behaviors. Haas et al. found that individualizing a HEP was likely to improve adherence because the exercises would be more meaningful and relevant to the individual client.¹ For example, if a client enjoys taking walks, the prescribing professional should seek to include walking as a part of the HEP if applicable. In this sense, the client is less likely to see performance of the HEP as a chore and would be more likely to incorporate HEP activities if they are more readily and easily integrated within the normal context of the client’s life. The authors suggest that developing an individualized HEP, the prescribing health professional should include the client in the decision making and design of the HEP to maximize adherence to and efficacy of treatment.

Individualizing a HEP will likely improve adherence according to a RCT¹⁴ and a systematic review by Jack et al.¹⁵ Both studies concluded that prescribed HEPs that require fewer or less intensive changes in lifestyle for a client are likely to boost adherence.^14,15 Henry et al. believe that PTs may be currently overly-prescribing HEP instruction.¹⁴ In addition to the suggestions made in the Haas et al. paper, Jack et al. believe that use of copying plans and HEP customization around life barriers such as work schedules, child care, lack of time, financial constraints, convenience, and forgetting, should be incorporated in the design of an effective HEP to improve adherence. ¹⁵

A 2006 descriptive cross-sectional design by van der Weel et al., attempted to examine all dimensions of compliance and its related factors in 501 patients diagnosed and hospitalized with heart failure who had participated in the COACH study.¹⁶ The mean age of the participants was 72 years.¹⁶ They found that 80% of the patients believed that exercise was important, but only 39% reported performing exercise at home.¹⁶ The two main reasons provided for reduced activity were physical symptoms (27%) and a lack of energy (25%).¹⁶ They also found that patients with better mental health were more likely to be compliant with a HEP.¹⁶ Van der Weel et al. believe that tailoring a HEP is crucial to improve adherence in this population because provision of adequate rest breaks for each individual client was likely to improve adherence drastically.¹⁶ The authors also believe that tailoring of a HEP should include education on the benefits rather than focus on more negative reasons for HEP (although these may need to be discussed).

HEP components/parameters shown to be useful in increasing adherence

I found many papers that had multiple HEP components which were stated as necessary to improve adherence in the older population. Some of these papers provided contrasting opinions about the best items to include in a HEP.

The previously described ‘lifestyle integrated approach’ has been shown to improve HEP adherence in older adults. However, Clemson et al. performed a RCT to determine which types of exercise were likely to yield improve adherence to a HEP and reduce the rate of falls in older, high risk people living at home.¹⁷ This study used a control group (3 exercise sessions of non-progressed flexibility exercises and 6 follow-up phone calls), a structured exercise group (7 balance exercises, and 6 lower limb strengthening exercises using ankle cuff weights performed 3x/week) and the LIFE approach exercise group (incorporating multiple movement repetitions in everyday activities in order to improve strength and balance).¹⁷ Both the structured group and the LIFE group were taught over 7 sessions and clients were provided with 2 follow-up phone calls over a 6 month period.¹⁷ Both of these groups had a HEP that was prescribed, tailored, and progressed.¹⁷ Exercises performed at home were reported using a weekly planner and returned on a monthly basis by mail.¹⁷ At 6 months, adherence to the structured group was significantly lower than to the LIFE group, or the control group.¹⁷ At 12 months follow-up, all three groups still had high adherence rates, although adherence to the HEP in the LIFE group was superior.¹⁷ This study supported other research that incorporating use of everyday activities into a HEP is likely to improve adherence because the clients do not need to make drastic changes to their lifestyle.¹⁷ In fact, subjects in the structured exercise group had complaints concerning the cumbersome nature of the equipment used for the HEP. Subjects in the control group also stated that they did not understand the importance of performing flexibility exercises for reducing falls and felt these exercises were too easy.¹⁷ The take-home message from this study should be that clients need to be educated on the purpose of each exercise so they understand the perceived benefits. Similarly, HEPs should use progression of exercise so that clients are challenged and can better judge their improved performance.

Thomas et al. performed a systematic review and meta-analysis to synthesize and evaluate the links between adherence to the Otago exercise program (OEP) and death rate.¹⁸ Seven studies matching the inclusion criteria which composed 1,502 ambulatory community dwelling older adults (mean age 81.6 years). HEP adherence was recorded using weekly log reports.¹⁸ The OEP is primarily a home based exercise protocol involving strengthening, balance, stability and range of motion exercises.¹⁹ Clients also receive a series of visits from PT or nursing staff over a certain period of time and monthly follow-up telephone calls (when no visits are schedule) to maintain client motivation.¹⁸ The OEP requires clients to perform home exercise at least three times weekly to qualify as fully adherent.¹⁹ However, Thomas et al. found that full adherence to the OEP was low at 36.7% (+/-15.8%) but that client adherence increased significantly to 55.9% (+/-14.8%) if full adherence was classified as exercising at least two times per week.¹⁸ They also discovered that there were still significant improvements in the health of clients even when performing the OEP only twice per week instead of three times per week.¹⁸ Even though Thomas et al. found increased adherence and significant outcome improvement with provision of the OEP at a twice weekly frequency instead of thrice weekly, the actual components and of the OEP may be of more use to the practicing clinician for improved client adherence and benefits.

A cross-sectional survey by Forkan et al. investigated adherence and factors related to adherence to a prescribed HEP in 175 community dwelling, older adults.²⁰ The older adults in this study had also been recently discharged from physical therapy and had taken part in ether the SAGE study or the Strong and Steady program in the hospital setting.²⁰ A self-administered 43-item questionnaire was used to gauge barriers and motivators to HEP adherence. 90% reported receiving a HEP from physical therapy but 36% responded that they no longer performed any of the HEP 4 weeks post therapy. Only 9.2% reported performing the HEP on five or more days out of the week. 22.9% performed the HEP between two and three times per week. Strengthening and balance exercises were the two most frequent modes of exercise performed at 70.9% and 69.9%, respectively.²⁰ Flexibility exercise were performed by 52.4%, clients whereas aerobic exercise was only performed 45.6% of the time. Interestingly, adherence to HEP levels was independent of time since discharge from therapy.²⁰ The majority (56.7%) of those adults continuing to perform the HEP performed exercise for 15-30 minutes during each session. The authors argue therefore that as a general guideline during the provision of a HEP, a HEP should be given at a reasonable frequency of 2-3 times per week with a duration of 15-30minutes per session. Due to increased adherence with strength and balance exercises, the authors argue that these are vital components to include in any HEP, but other types of exercise (flexibility or aerobic) should not be avoided, rather, education must be provided to clients on the benefits these types of exercise.

In addition to obtaining data about adherence to specific HEP parameters (frequency, type, duration), Forkan et al. also reported reasons for poor adherence to a HEP. The most frequent reason for poor adherence was a change in health (30.7%) followed by: doing other exercise (11.9%), lack of motivation (11.9%), too long (7.9%), uncomfortable (7.9%), too hard (5.9%), do not have equipment (4.0%), lack energy (4.0%), do not know how to do it (2.0%).²⁰ Forkan et al. also discovered eight more barriers that were linked to poor HEP adherence: lack of interest, poor health, bad weather, depression, lack of strength, fear of falling (in agreement with Horne et al. and in contrast to Yardley et al.), shortness of breath, and low outcome expectation. The authors suggest that barriers play a greater role than motivators in HEP adherence (no motivators were significantly linked with improved HEP adherence).²⁰ Therefore, PTs must provide education and information to reduce the effects of these barriers on poor HEP adherence. For example, PTs should educate their clients that during adverse weather, it is acceptable to perform endurance exercises inside. This ensures that the client understands that some personal modification of the HEP is acceptable when certain exercise elements are not feasible.

A systematic review by Nyman et al. analyzed participation and engagement in fall prevention exercises in older adults delivered via classroom and home settings.²¹ The exercise programs included either individually targeted interventions, or multifactorial interventions (traditional exercise component as well as education and implementation of psychosocial models such as the SCT and HBM to improve exercise behavior).²¹ Adherence rates for individually targeted exercise were between 60-70% whereas adherence to programs with multifactorial elements was >/=75%.²¹ Using median rates for recruitment, attrition, and adherence, the authors calculated that at 12 months, only 50% of typical community dwelling older adults are likely to be fully adhering to falls prevention interventions.²¹ In this study, adherence was high for home based interventions at 12 months at above 80% for the first 2-4 months. However, adherence dropped by 50% in those performing individually targeted interventions at home. Nyman et al. were worried that adherence to HEP for falls prevention was only high for self-motivated individuals; therefore, they recommend that PTs should utilize follow-up appointments or telephone calls and provide a structured, yet flexible HEP protocol. These recommendations were also shared by Forkan et al.²⁰ and Simek et al.² (below).

Simek et al. performed a similar systematic review to Nyman et al., but also included a meta-analysis of the data.² Searching four databases and incorporating 23 studies with over 1,800 community dwelling older adults, Simek et al. found that different HEP parameters altered partial and full HEP adherence levels. Interestingly, Simek et al. also discovered that neither full nor partial adherence levels were found to be significantly associated with exercise program efficacy. The authors suggest that regular inclusion of a balance training component to a HEP would improve low adherence rates but that inclusion of flexibility exercises would likely lower adherence rates.² The was a significant increase in full adherence to a HEP with the inclusion of balance exercises, moderate home visit support, and provision of the HEP by a PT (as opposed to any other healthcare professional identified in this systematic review).² Significant increases in partial adherence to a HEP occurred with telephone/home visit support (in agreement with Nyman et al.) and recruitment of clients into an exercise program by a health service participant.² Simek et al. found that clients who performed their HEP with a group of friends did not lead to improved adherence. In addition to including the above elements in a HEP to improve general adherence, and in agreement with Forkan et al., the authors suggest that practitioners should not discount incorporation of elements that appear to lower HEP adherence (flexibility exercises), rather, if these types of exercise are required, they should educate the client on how these components can improve their individual health status.²

A RCT by Wu et al. attempted to compare adherence to, and effectiveness of, a Tai Chi exercise program through a live, interactive, telecommunications-based exercise group (tele-ex), with that of a similar program through a community center-based exercise group (comm-ex) and a home video-based exercise group (home-ex) in 64 community dwelling older adults.²² Three weeks of Tai Chi exercise at 3 hours/week was performed in each group. A log sheet was used to record attendance data for each group. The tele-ex and comm-ex groups showed greater attendance rates and practice time than the home-ex group.²² Interestingly, the authors found that the comm-ex group had significantly improved compliance and fewer drop-outs than the home-ex group.²² Therefore, using the results of this study, use of a group component may be useful to improve adherence to a HEP based on a reduction in the feelings of isolation and increased levels of motivational support from other participants, although this finding was not shared by Simek et al. who hypothesized that incorporating a group element may lead to increased distractions from adequate performance of a HEP.^22,2 I believe these contrasting findings reflect client preferences to utilize group exercise at home. Therefore, PTs should attempt to incorporate the use of family or friends when designing a HEP for clients that voice a desire to exercise in a group at home. This may make adherence to a HEP more appealing and will increase feelings of accountability, motivation and enjoyment (social gathering). Martin et al. also found that group-therapy can improve exercise adherence.²³ Martin et al. also support the potential incorporation of a group therapy component for increased enjoyment and accountability. However, incorporation of a group therapy component may not always be feasible due to the individualized nature of the HEP, amongst other reasons. In these circumstances, PTs must provide alternative suggestions to group therapy such as encouraging a client to attend a gym or local senior exercise center However, Wu et al. suggest that for patients who are homebound, or have limited access to transportation, the use of novel telecommunication may improve HEP adherence by providing indirect contact with a PT which will increase motivation and support.²²

Important sub-factors and psychosocial model elements suggested for improved HEP adherence

A systematic review and meta-analysis of the factors related to HEP adherence in 1,088 patients with chronic low back pain by Beinart et al. yielded moderate evidence for a correlation between improved adherence with one patient sub-factor: greater health locus of control and three intervention sub-factors: supervision, participation in an exercise program, and participation in a general behavior change program using motivational strategies.²⁴ PTs should utilize methods to accommodate these identified sub-factors but should place increased emphasis on educating clients about health behavior changes by incorporating elements of the SCT and HBM into HEPs.²⁴ This would likely yield improved adherence. Incorporation of the SCT and HBM to improve HEP adherence were similar to the findings of the Schoene and Silveira studies. However, Emery et al. who performed a prospective cohort study over the course of a year on older adults who had participated in the Duke Exercise and Aging Study, found that self-esteem was not related to greater exercise performance levels. Rather, belief in outcome improvement was the larger reason for improved adherence to a HEP.²⁵ Outcome expectancy is a component of the HBM.⁷ Emery et al. also suggested that sub-maximal intensity was best to promote improved adherence to a HEP in the older population as increased energy levels and alertness were found to be important reasons for increased adherence to a HEP.²⁵

Number of exercises

In a small RCT conducted by Henry et al., 15 older adults (average age 72.8) from an upper socioeconomic background were randomly prescribed 2, 5 or 8 general strengthening exercises to memorize and perform at home after an initial instructional session.¹⁴ The participants were required to log their exercise activities and return the completed logs at the return session 7-10 days later. Henry et al. found that participants who were assigned two exercises performed these exercise much more accurately than participants who had to perform five or eight exercises at the return session.¹⁴ It was assumed that improved performance of the exercises by the group assigned only 2 was secondary to increased practice and thus adherence with the HEP.¹⁴ Therefore, Henry et al. believe that the provision of fewer exercises is more beneficial for adherence than provision of a larger number.

And finally, a cross-sectional review conducted by Suttanton et al. was performed in order to identify different factors related to starting and maintaining adherence to a HEP in older adults with mild to moderate Alzheimer’s’ dementia (AD).²⁶ The HEP was focused primarily on balance exercises. This program included ten patients with AD and nine caregivers who monitored the home programs. This HEP was based on the OEP as discussed by Thomas et al., but modified to run for 6 months with five sessions of walking and five individual sessions of exercise at 15-20 minutes in length.²⁶ Six home visits were provided by a PT during the first 6 month period for progression of exercises, provision of advice and monitoring of adherence. Semi-structured interviews were held at an average of 47 days after completion of the 6 month program for qualitative assessment of factors related to adherence. Clients or their caregivers were instructed to record weekly exercise adherence on a log sheet during the program. Six facilitators of increased adherence to the HEP were identified as were five barriers to adherence.

The six facilitators to improved adherence were:²⁶

• Positive program characteristics – good timeframes, well-spaced PT visits, appropriate exercise session lengths of 15-20 minutes, provision of an exercise booklet with clear illustrations and instructions.
• PT role – ongoing support was appreciated, professional regarded as a valued characteristic time management, knowledgeable, firm but encouraging, understanding, kind, and supportive.
• Incorporation of exercise recording log – provided point of self-accountability and achievement.
• Level of caregiver support – supportive environment and well received encouragement during the session.
• Subjects’ sense of commitment – self-efficacy and determination.
• Perceived benefit – view that the program was providing tangible and relatable improvements and increased client functional abilities.

The five barriers to improved adherence were: ²⁶

• Health deterioration
• Health and other commitments of the caregivers
• Dislike of structured exercise
• Limited transportation (if exercise was to be completed off-site)
• Inclement weather (for outdoor activities or effects on mood and motivation)

Based on these findings, PTs should prescribe HEPs that incorporate as many of the facilitators that are possible and as prudent (not all older adults will require a caregiver for example). The restrictive nature of this study population (older adults with mild to moderate AD) limits the generalizability of these findings.²⁶ However, steps should also be taken by prescribing physicians and other health professions to limit the barriers to adherence wherever possible.²⁶ For example, clients and there physicians should be educated on the need to return to PT when there is a change in health condition, so that specific alterations and modifications to the HEP can be made. Similarly, if the client would benefit from performing the HEP at a location different to ‘in home environment’, PTs should provide information about possible transportation should this be a foreseeable issue.²⁶

Limitations of the evidence       

There were several limitations mentioned in each of the studies used in this review of the evidence, therefore only the most major limitations are discussed in this paper. For more specific limitations please refer to the evidence table.

There were a high number of drop-outs in two of the studies which could skew the results obtained and these papers did not report reasons for the drop-out data.^13,20 There was a lack of subject blinding also identified in two separate papers which could introduce bias and lower the validity of the findings.^6,13 Incorporation of a small sample size was also an issue in some of these papers.^{6,14,17,22,26} A small sample size can increase the possibility of committing a type 2 error and incorrectly fail to reject the null hypothesis. The limitation of utilizing very specific sample populations was found in a few papers.^{1,6,10,12-14,20,22,26} Use of specific populations limits the generalizability of the findings to the general population. Two of the studies also had a very short term study length.^10,14 A short term study length limits the ability to draw conclusions on other items that may affect the outcomes. Four papers noted a large heterogeneity between the studies each incorporated.^2,15,18,23 Large heterogeneity between studies included in a review lowers the generalizability of the findings to the general population and can also lead to inaccurate findings. Five studies reported that their individual study designs meant that they could not control for external study variables which may introduce external bias in the findings.^{14,16,20,25,26}

The largest limitation of a majority of the studies reviewed was the potential for recall bias with respect to client self-reporting of exercise activity on log sheets.^{2,6,13-15,17,18,22-26} Unfortunately, use of exercise logs is the most feasible way of collecting HEP adherence data at this time. It has been suggested that more reliable methods of tracking HEP adherence will come from increased use of novel technology.^4,5 Of the remaining papers that did not use self-report exercise logs, bias could also be present as leading questions in interviews of questionnaires.^{1,11-12,16,20}

Summary and Conclusions

     Increasing adherence to a HEP for older adults is more than simply selection of effective exercises to improve limitations. The prescribing practitioner must take into account the specific components of the HEP based on integrated client feedback, and understand the context in which the HEP will fit into the lifestyle of each client.

The review of literature has demonstrated four main themes that should be utilized in the development of any HEP, for any patient population, in order to improve adherence. These four themes are: use of novel technology, providing ample client education, tailoring a HEP to the specific needs of the client, and utilizing some of the common HEP parameters shown to increase HEP adherence.

Novel Technology:

Athletic video-games utilizing a step-pad, use of exercise tracking technology or tablet applications with a social function (pedometer or other technology such as exercise applications for smart phones), and potential incorporation of telecommunication for homebound clients have all been suggested as methods to improve HEP adherence.^4,5,6,22

Education Provision

Provision of adequate education to clients was also shown to improve adherence to a HEP. Specifically, PTs must educate their clients on the importance of long-term adherence, that falling is not part of the natural ageing process and that current limitations can be improved and maintained.^10,11 The use of outcome measures and explanation of the findings may be helpful to achieve intrinsic acknowledgement of personal deficits and the need for adherence to a HEP.¹¹ Prescribing PTs must also provide education on realistically achievable benefits from increased adherence to a HEP and how these benefits will help each individual client achieve their personal goals.^11,12,16 PTs must also educate hesitant clients on the positive social identity that accompanies increased adherence to a HEP.¹² Increased HEP adherence is likely when PTs educate clients on the need and benefit associated with the performance of certain exercises, as the client may not find some exercises intuitive.^20,2

Tailoring a HEP

Tailoring a HEP reduces the need for intensive lifestyle changes which may lower adherence.^14,15 Prescribing physicians should seek to develop a HEP that includes activities which are suitable in intensity, type, duration, and frequency for each client.^13,1 By tailoring a HEP, the prescribing physician is able to include exercise activities that the client views as meaningful and relevant and is therefore likely to improve adherence.¹ Tailoring a HEP has also been shown to effectively lower the likelihood of adverse events occurring during performance of the HEP which will assist in each clients’ ability to sustain performance of the HEP.¹⁶

Useful HEP components to improve adherence

HEPs should be individually tailored and varied to match specific client characteristics and goals. Therefore, it is difficult to provide specific components that every HEP should include. However, the literature does reveal some general parameters that appear to improve adherence to a HEP in the older adult population.

Incorporating the use of functional, everyday activities in the HEP has shown to increase adherence and carry-over.¹⁷ It is also important to progress exercises to maintain interest and motivation.^20,2 Progression will also incorporate the principals of specificity and overload which are necessary to achieve continued exercise benefits. Research suggests that a HEP frequency of two to three times per week with each session lasting 15-30 minutes will improve adherence.^19,21,2 For older adults, prescription of HEP intensity should be at a submaximal level to limit the amount of fatigue.²⁵ Provision of fewer exercises (2-4) is preferred over the provision of a larger number of exercise (5+).¹⁴ Strengthening and balance exercises are important for increasing levels of HEP adherence.² Prescribing physicians must also provide alternative exercises and suggestions if there are any external barriers to HEP adherence.²¹ Education and reassurance must be provided to the client. The client should be informed that modification of certain elements of the HEP is encouraged if the client is having moderate difficulty performing exercise (number of repetitions based on varying fatigue levels), and that the HEP is not a rigid, inflexible, ‘all-or-nothing’ schedule.^22,25

Multiple papers comment on the need for follow-up care to improve adherence to a HEP. It has been suggested that even once monthly telephone check-ups are very helpful.^2,18,21,26 Other components of a HEP that have been shown as useful include:²⁶

• provision of a clear and simple exercise sheet/booklet with pictures and written explanations (in large font)
• provision of an exercise calendar and/or a log sheet to track exercise behaviors
• provision of materials or resources concerning alternative exercise venues such as performance of the HEP in a gym, or going to a local swimming pool

Information regarding transportation to alternative exercise venues is also warmly received and likely to improve adherence to a HEP.²⁶ PTs should build HEPs and provide client education on the principles of the SCT and HBM, as these principles have been shown useful in improving client empowerment as well as increasing outcome expectation, motivation, self-efficacy, and perceived benefits.^7,8

There was mixed evidence regarding the importance of social interaction for improved adherence to a HEP in the older adult population. Three papers found that incorporation of a group element to the HEP improved adherence.^5,22,23 However, one study found that performance of a HEP in a group format may lead to increased levels of distraction from adequate performance of the HEP which decreased the efficacy of the HEP.² The same paper also found that clients were more likely to focus on social engagement practices rather than HEP performance thus reducing adherence levels.² By asking for client input regarding group exercise during the construction of a HEP, the prescribing physician will better incorporate the wishes of the client which has shown as a very important factor in improving adherence.

References

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