Another major reason for excluding studies was the failure to report adherence to exercise or physical activity for two or more groups to enable a comparison. We also had to exclude trials where more than 50% of the participants did not have chronic musculoskeletal pain, or were suffering from a different condition, such as rheumatoid arthritis. We have included trials that needed some discussion over whether to include or exclude them from the review, as well as those where we contacted the authors, in the Characteristics of excluded studies table. However, the combinations of BCTs may also differ among conditions, personal factors and therapeutic interventions ([7],cf. [63, 64], [64–66]), and over the time.
- That is in line with the health belief model, which states that the expected benefits are key to be involved in an activity [89].
- This finding supports the conclusions of earlier reviews (Abenhaim 2000; Anon 2001; van Tulder 2000).
- Therefore, social and economic factors, as well as beliefs and group norms, must be considered when an exercise program is designed.
- However, inconsistent effects from study to study and the large variation in current methods of improving adherence to exercise and measuring exercise adherence, make it impossible to draw firm conclusions about the best way to optimise adherence to exercise for chronic musculoskeletal pain.
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- Therefore, exerting effort on a regular basis constitutes an effective lever for increasing executive control.
Creating a Supportive Environment
Second (and related to the previous), interventions are insufficiently described regarding their theoretical underpinning and active ingredients/techniques and thus limit the comparison of interventions. Difficulties concerning the derivation or deduction of concrete, practical techniques or strategies from the theories were reported. Recently, the BCT Ontology was published, which claims to provide a standard terminology and a comprehensive classification system for the content of behaviour change interventions, suitable for describing interventions [84]. Third, there is a need for studies on holistic approaches, complex interventions based on integrative theories and the combination of multiple BCTs. While many theories are based on cognitive and behavioural approaches, affective and psychosocial factors are hardly investigated, overlooked and probably underestimated.
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On the other hand, competence is one of the basic psychological needs and is focused on feelings and beliefs during the action [94]. These variables can be affected by social and contextual events, such as feedback, communication, rewards, etc., but also by challenging tailored tasks. Higher perceived competence is related to higher intrinsic motivation and adherence [114], especially when it is accompanied by a sense of autonomy; thus, participants will be more likely to adopt certain activities when they feel efficacious [94]. Communication and feedback from the staff may be related to social support from the physical exercise professional and health care specialists. Regular communication out of the usual timetable, such as phone calls, home visits, app-based interactions, reminders, or booster sessions may increase social support, exercise adherence, and the amount of physical exercise in the short- and long-term [38,40,47,58,71].
As cited in the National Obesity Observatory Report, a lack of motivation is a major reason why adults do not participate regularly in exercise or activity. Fortunately, there are several strategies and tools you can use to motivate and empower individuals to exercise and these are discussed in the next three sections. In this stage, individuals intend to change their behavior and have made an initial effort to make lifestyle changes. Not all of their ambivalence has been resolved and they have developed an initial, albeit tentative, plan of action.
Adherence is greater when patients perceive a strong, collaborative relationship with providers [28]. Clinics can help by ensuring contact with the same provider regularly across visits, minimizing waiting time, and involving the patient’s social support system in their recommendations. The pain patient must understand from the very first minute that for the therapy to be effective, active involvement on their own is necessary, and that their improvement depends mainly on them. To this end, they must integrate and learn the self-management strategies that we propose, such as exercise diaries, selection of goals, self-efficacy or self-dosification. We have all experienced in recent months the enormous evolution of Digital Health and m-Health within the healthcare field. Video call platforms, apps, digital tools, wearables… all of them allow something as important as monitoring adherence to treatment, the frequency of exercise (when, how much and how), providing instructions or prescribing exercise programs.
Building Motivation and Self-Efficacy
This stage of enduring behavior change is referred to as “maintenance” and involves consistently engaging in the health behavior for at least 6 months. In this stage, HL is becoming firmly established, and the threat of relapse, i.e., reverting back to old, unhealthy patterns becomes less frequent and intense. Individuals in maintenance typically have a plan for coping with relapse to prevent a prolonged period of non-adherence to the new healthy behaviors. Relapse can occur at any stage, but typically describes individuals who move from Maintenance or Action to less persistent health behaviors better characterized as Preparation or Contemplation.
If it is the latter, then this could have added to the evidence we have summarised in this review. As a secondary outcome, particularly if no difference is shown between the intervention and control groups, exercise adherence may not appear in the abstract or as a key word in the article. Where this is the case the full text of the papers have to be searched, which can substantially increase the number of papers that have to be obtained and filtered before they can be excluded from the review. In this review we have compared interventions that aim to improve adherence to exercise or physical activity either with other interventions with the same aim, control groups that receive no intervention or other exercise interventions in the management of chronic musculoskeletal pain. Interventions such as supervised or individualised exercise therapy and self‐management techniques may enhance exercise adherence.
References to studies included in this review
Motivational interviewing (MoI) is a patient-centered conversational approach to behavior change proposed by Miller and Rollnick [29]. The approach encourages providers to take a collaborative stance, avoid provoking resistance, elicit the patient’s own motivations for change, and focus their attention on resources and planning for carrying these changes out. MoI was initially developed as a treatment technique for individuals with alcohol abuse. Miller and Rollnick describe transitioning away from viewing people who abuse alcohol as disturbed, dishonest, or illogical actors, instead recognizing their autonomy and trying to understand their behavioral choices. Furthermore, they point out that by giving advice and assuming that the patient is uninformed or already motivated to change, a provider can alienate the patient, increase resistance, and make behavior change less likely. Another gap in coverage of this overview is that interventions that were analysed in RCTs but not included in any systematic review are not considered in this overview.
The search strategy was structured according to the PICOS (Population, Intervention, Comparison, Outcome and Study Type) scheme. The search terms related to physiotherapy and motivation or behaviour change and adherence and effectiveness/efficacy (details on the searches are listed in Additional file 1). During the exercise practice, self-efficacy can be increased through familiarity with the other participants, the staff, the environment (including the facilities and the materials used), and the procedures [73]. Thus, in the initial steps of the exercise program, the staff should be close to the participant and available to explain and solve any doubt, to ensure the patients have no negative feelings until they get familiarized with all the elements of the program. The use of behavioral graded exercise may also increase self-efficacy by increasing confidence in the capability to exercise [57]. In musculoskeletal pain disorders, graded exercise would initially target to weaker muscles or painful areas and gets increasingly more challenging [53].
Self-management programs
This may reflect the fact that although all studies targeted exercise adherence in some way, it was commonly not a primary outcome or focus, thus studies may have been insufficiently powered to detect differences in adherence between groups. This, coupled with the large number of studies that were excluded from the review due to lack of targeted exercise adherence, or measurement of exercise adherence, highlights the limited attention that adherence to exercise has received to date within the field of chronic musculoskeletal pain. We also included patient‐reported outcomes, such as pain, functional disability, quality of life, and ability to carry out usual daily activities. We have not classed measures of physical impairment, such as quadriceps strength, timed walk tests, and joint range of movement tests as a measure of function within this review, therefore we have not extracted these data.
References to the cognitive behavioural theory (CBT) and to the social-cognitive theory were frequent in the individual studies. Furthermore, the self-determination theory, the transtheoretical model, the health belief model, the social learning theory and the socioemotional selectivity theory were used in some individual studies (cf. [11]). The heterogeneity in the theoretical underpinning of the interventions is reinforced by the given overlap of the theories and models (cf. [11],[28]) and various BCTs are key components of several theories [17]. Furthermore, theories were not used enough to explicitly inform and underpin interventions and they were translated into practise in different ways; thus, interventions based on the same theory may differ substantially [17]. CL and PP independently assessed the quality and risk of bias of the systematic reviews included, using the AMSTAR-2 tool [26].
Agreements and disagreements with other studies or reviews
Motivation and self-efficacy are essential psychological factors that influence exercise adherence. Building motivation involves identifying the underlying reasons for engaging in physical activity and leveraging these reasons to maintain commitment. Self-efficacy, on the other hand, can be enhanced through experiences of success and positive reinforcement. This is one of the biggest factors in exercise adherence and is especially important in the first month of your fitness regimen.
Martire 2003 published data only
Exercise and physical activity is beneficial for the most common types of CMP, such as back and knee pain. However, poor adherence to exercise and physical activity may limit long‐term effectiveness. In total, the overlap of primary trials in the reviews is considered low; except among reviews [27, 39] and among reviews [12, 16, 28, 30].
Resources to help you with the planning phase so that you can stick to your fitness program
This happens because anticipated structured fitness routines emotions motivate people to initiate or to persist in goal-seeking behaviors [e.g. In a similar vein, a recent systematic review on behavioral change domains carried out by Michaelsen and Esch [31] led them to develop a resource model of behavioral change based on the functional mechanisms of BCTs, which include facilitating, boosting and nudging mechanisms. Facilitating and nudging are two mechanisms that can increase motivation during exercise sessions. For example, nudging (using cues and prompts) is a context-dependent strategy intended to involve people in behavioral change (e.g., removing chairs in a gymnasium or displaying images of peers doing physical activity). Facilitating (using knowledge, environmental context or social influences) targets external resources to enable new behavior (e.g., providing social support by using walking groups or developing public fitness trails). Musculoskeletal diseases [6, 7, 17, 30,31,32] and pain [13, 16, 33,34,35] were the most investigated medical conditions.
Koumantakis 2005 published data only
Hughes et al also showed significant differences in exercise adherence between the intervention and the control group and found a significant difference in pain at six months, but not at any other time point, or in function outcome measures (Hughes 2004). Adherence with health interventions is a complex problem, especially for individuals with chronic conditions. Indeed, simply measuring adherence behaviour can influence the behaviour itself (Haynes 2008). There is the added complexity of whether adherence to the treatment itself, for example the required number of treatment visits or supervised exercise classes, can be used as a measure of adherence behaviour. Given that this may provide some indication of early willingness to engage in the exercises or physical activity, it would appear a relevant marker to measure and report. For analytical purposes, adherence was frequently dichotomised, establishing a cutoff point or percentage used to distinguish adherence from non-adherence.