Osteoarthritis Patients Identify Key Factors in Long-Term Adherence to Exercise
Key findings
- Among 25 patients with knee osteoarthritis who were followed in a two-year trial of strength training, those who reported low adherence expressed ambivalence about the benefits of exercise and a desire for more social support
- Patients who reported high adherence exhibited self-determination and self-efficacy
- Patients valued the monitoring provided by peers and instructors during group exercise
According to the National Center for Health Statistics, less than 21% of adults between the ages of 45 and 65 engage in strength training twice a week, and those with knee osteoarthritis exercise even less. Yet few studies of exercise in adults with chronic musculoskeletal conditions have examined what motivates them to continue.
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Julie J. Keysor, PT, PhD, chair in the Department of Physical Therapy, and colleagues recently interviewed patients with knee osteoarthritis after they participated in a randomized, controlled trial in which long-term adherence to exercise was the primary outcome. Their findings, reported in Physiotherapy Theory and Practice, show that identifying patients' beliefs about their autonomy and competence, and their need for social support, should help clinicians encourage persistence with exercise.
BOOST Trial Design
The interviewees were recruited from Boston Overcoming Osteoarthritis through Strength Training (BOOST), a two-year clinical trial. The control group received monthly telephone reminders to exercise; the intervention group also received personalized coaching and motivational messages from an interactive telephone system.
The trial enrolled adults ages 50 and older who had knee pain and reported a physician diagnosis of knee osteoarthritis. The patients joined a six-week class on strength training, led by professional instructors who gave individualized feedback. After completing the class, patients received ankle weights to be used at home three times a week for two years. They rated their adherence to exercise immediately after the class and six, 12, 18 and 24 months later.
Ancillary Study Design
Dr. Keysor's team selected and reviewed 25 BOOST participants who would provide diversity in gender, race, age and level of adherence to exercise. They were willing and able to participate in private interviews about their experience in BOOST, all conducted by the same physical therapist.
The average age of the participants was 67 (range, 57–79) and 21 were female. Self-reported adherence levels were evenly distributed among participants. Fourteen had been in the BOOST intervention group, but the efficacy of the telephone system was not a focus of the ancillary study.
Overarching Findings
The interviews were recorded and analyzed by the interviewer and another physical therapist. The researchers amalgamated the participants' comments about BOOST into three conceptual categories: monitoring, knowledge of how to manage exercise and benefits of exercise.
Monitoring
- Participants valued being monitored during the class by instructors
- A large majority of participants expressed enthusiasm about exercising in a group, appreciating the opportunities to watch classmates do various exercises, see others improve and compare themselves to others
- Many participants came to see themselves as accountable to their instructors and classmates
Knowledge of Exercise Management
- In the BOOST trial, the clinic room had different stations for exercising and participants progressed at a self-selected pace. Interview comments confirmed that this setup helped participants learn how to perform the exercises, improved their confidence about performing exercises and gave them autonomy in choosing their pace
- Participants expressed appreciation for individualized feedback from instructors, as it increased their confidence about exercising safely at home
Perception of exercise benefits
- For most participants, the perceived benefits of strength training were pain relief and improved physical function
- As a result of those improvements, participants described being more independent in their daily activities
Factors Influencing Adherence
The researchers categorized the participants into three groups, based on their self-reports of adherence to exercise after the BOOST trial. Those in the lowest group said they did not master the program well enough to feel confident about continuing without expert supervision. Compared with the participants who adhered best, they also described more ambivalence about the ultimate value of exercise and greater desire to have social support, such as an exercise partner.
One of the factors related to high adherence was the feeling of having mastered the exercise program. Another was signs of self-determination such as having an exercise routine and having a space at home dedicated to exercising.
The researchers recommend that in counseling patients about exercise, clinicians should consider their needs for autonomy, competence and connection to others. How these needs are met, the authors say, may influence patients' motivation toward long-term adherence.
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