VanDillen Harris-Hayes Heiderscheit Session Outline CSM2014 · exercise routines Initially targeted...

Adherence: An Important but Often Forgotten Determinant of Intervention Effectiveness Linda Van Dillen, PT, PhD

Marcie Harris Hayes, PT, DPT, OCS, MSCI Program in Physical Therapy, Washington University Medical School

Bryan Heiderscheit, PT, PhD Department of Orthopedics and Rehabilitation,

University of Wisconsin School of Medicine and Public Health Session Outline

1. Introduction a. Definition of adherence b. Need for measuring adherence

i. Increased prevalence of chronic conditions and aging population ii. Known positive effects of many Physical Therapy treatments iii. Moving to a professional model of providing care across the lifespan iv. Methods to facilitate long‐term adherence needed

c. Adherence to medically‐related interventions 2. Barriers to adherence

a. Patient‐related factors b. Clinician‐related factors

3. Methods to track adherence in the outpatient setting a. Self‐report

i. Diaries ii. Visual analogue scales

b. Clinically‐based i. Performance of prescribed intervention

c. Technology‐based 4. Example of self‐report method

a. Measure of adherence to different components of intervention b. Differential effect on outcomes

5. Example of clinically‐based assessment of ability to perform prescribed intervention a. Independence in performance is a prerequisite to adherence b. Factors that influence independence

i. Cognition: ability to understand key concepts of treatment ii. Psychomotor skill: ability to physically perform the activity

c. Standardized assessment of patient’s independence i. Knowledge of key concept (cognition) ii. Performance (psychomotor skill) iii. Use of standardized scenarios to assess tester reliability

d. Use of assessment to guide treatment strategies i. Therapeutic exercise ii. Activities of Daily Living

e. Use of assessment in research studies i. Clinical trials ii. Adherence monitoring

6. Computer‐assisted individualized exercise instruction a. Web‐based exercise diary

i. Viewable history of performance and associated change in functional markers ii. Enable feedback of performance by healthcare provider

b. Physical model to increase patient confidence in ability to correctly perform exercise c. Educational material to support the need for exercise

7. Out‐of‐clinic monitoring a. Wearable sensors

i. Inertial sensors ii. GPS technology

b. Optical tracking of joint position c. Bluetooth‐enabled strain gauges for resistance training

8. Communication a. Social networks b. Texting

9. Summary

This information is the property of Bryan Heiderscheit, PT, PhD and should not be copied or otherwise used without express written permission of the author.

UW Neuromuscular Biomechanics

Lab

Use of Technology to Monitor and Promote Treatment Adherence

Bryan Heiderscheit, PT, PhDProfessor

Department of Orthopedics and RehabilitationDepartment of Biomedical Engineering

Director, UW Runners’ ClinicDirector, Badger Athletic Performance ResearchCo-director, UW Neuromuscular Biomechanics Lab


Lab

Disclosure

Due to the topic of the lecture, several commercially available products will be mentioned, without endorsement

Visual Health Information Co-PI on NIH SBIR funded project Paid consultant for unrelated work


Lab

Growth of Mobile Sensing “The whole sensor field is going to explode. It’s a little all over

the place right now, but with the arc of time it will become clearer.”

Tim Cook, CEO, Apple2013 All Things Digital Conference

Annual sensor shipments for mobile sensing health and fitness devices included 107 million units in 2012. That number is projected to climb to 515 million by 2017.

ON World, 2013 reporthttp://www.onworld.com/mobilesensing/health


Lab

Out-of-clinic monitoring

Wearable sensors Inertial sensors GPS technology Physiological signals

Orthopedic device usage

Optical tracking of joint position

Web-based exercise communities


Lab

Adherence Interaction

Oversight and involvement of health care providers improves adherence

Simek et al (2012) Prev Med

record the results of their daily exercise session Kelders et al (2012) J Med Internet Res

Sluijs et al (1993) Phys Ther

asked about their compliance at follow-up visits with a therapist or physician

Crandall et al (2013) Phys Ther

Monitoring adherence likely improves adherence Good for clinic practice, challenge for research


Lab

Activity Monitoringand Social Networks

Most involve accelerometer and/or gyroscope Worn on various locations Wireless upload to smartphones/PC Activity diary

Monitor change over time



Lab

Competition Circle

www.fitbit.comUW Neuromuscular

Biomechanics Lab

GPS Monitoring

Used to monitor running volume and detect training errors

Nielsen et al (2013) J Strength Cond Res

Adherence to training plans Post-injury return to running

Promote adherence through social networks

www.strava.com


Lab

Smart Shoes

Monitor mechanics Provide audio reminders

Google Talking Shoe RunSafer


Lab

Puma RS-Computer Shoe

Pedometer

Detachable cable to connect to Apple II+ and IIe

1987 - $200


Lab

Nike+ Training

four embedded sensors and accelerometer

“sensors will collect information about the user's movement, like how high they jump, how quick they move, and how hard they play (translated as "hustle"), and wirelessly transmit it to their phone” Released Feb 2012

Factory outlets by Oct 2012

sensors


Lab

Running Stride

Specs: Pressure sensors 3-axis accelerometer Bluetooth

Uses: measure cadence detect foot-strike

www.sensoriafitness.com



Lab

Heart Rate Monitoring

Prescribe and monitor target heart rate

Prescribe training calendar with reminders

Audio feedback and coaching

Share through email and social media

pearsports.com UW Neuromuscular Biomechanics

Lab

BioStamp

Flexible adhesive wireless sensor

Ability to monitor and communicate variety of physiological parameters Temperature Hydration Heart Rate

www.mc10inc.com


Lab

Free Weights and Tubing

RFID-enhanced system to monitor free weight exercises Detect type of exercise being performed

(94%) Detect number of repetitions within 1

Chaudhri et al (2008) Proc, 6th ACM conference

Load cell for tubing exercises Uniaxial force tracings Monitor repetitions and intensity

www.kayotechnology.com


Lab

Orthopedic Device Usage Monitoring of prescribed usage for

orthopedic devices Generic temperature sensors

RFID tags


Lab

Joint Motion Monitoring

Wear continuously over 5 day period

Activity categories

Cobian et al. (2009) Spine UW Neuromuscular Biomechanics

Lab

Cervical Motion

Axial rotation

Lateral flexion

Flexion-Extension

Cobian et al. (2009) Spine

Flexion-Extension

Distribution of motion magnitude and frequency

Majority of motion is < 25°

Less than 6% of movements exceeded 50°



Lab

Low Back Exercises Monitors trunk and motion using two wireless sensors

Instant feedback to patient to guide exercises

www.hocoma.com/products/valedo/valedomotion UW Neuromuscular Biomechanics

Lab

Motion Tracking

Kinect sensor allows low-cost tracking of body motion (30 fps)

Incorporates infra-red light camera (depth sensor) and a video camera (RGB sensor) to create a 3D map

Fully customizable using developer software


Lab

Potential applications

Activity monitoring Stone (2013) IEEE BME

Movement screening Clark et a (2012) Gait Posture Stone et al. (2013) Proc, IEEE EMBS

Patient feedback Clark et a (2013) Gait Posture

Exercise technique monitoring Chang et al (2011) Res Dev Disabil Guerrero (2013) Proc, Medicine Meets Virtual Reality

conference Neri et al (2013) Proc, Virtual Rehabilitation

conference Gonzalez-Ortega (2014) Comp Meth Prog Biomedicine


Lab

Screening Tool

Screening tool for ACL injury risk

Stone et al. (2013) Proc, IEEE EMBS


Lab

Challenges with Kinect

Additional objects and people

Occluded body parts

Joint center determination when fully extended

Obdrzalek et al. (2013) Proc, IEEE EMBSUW Neuromuscular

Biomechanics Lab

Integrated Clinical System

Combining exercises with games

Telerehabilitation platform Feedback to patients Information to clinicians

www.jintronix.com



Lab

Smart Fabrics

Sensor thread(s) integrated into fabric

Potential to monitor: Heart rate Muscle activity Breathing Temperature Sweating Joint position

Gibbs et al (2005) J Neuroeng RehabilUW Neuromuscular

Biomechanics Lab

Web-based Individualized Exercise Instruction

Physical model to increase patient confidence in ability to correctly perform exercise

Educational material to support the need for exercise

Web-based exercise diary Viewable history of performance and associated

change in functional markers Enable feedback of performance by healthcare

provider

Brooks et al. BMC Musculoskel Disord (in review)Funding: NIH SBIR Phase I 1R43HD065358-01A1


Lab

Web-Based Therapeutic Exercise Resource Center (TERC)

Web-based delivery of individualized and progressive exercise routines

Initially targeted those with mild-to-moderate knee OA



Lab

Exercise Avatars



Lab

Clinical Outcomes

mSF-WOMAC total score and all subscale scores decreased (p<0.001) with a large effect size (pr > 0.65)

Results did not vary with age, gender, BMI, duration of symptoms



Lab

User Satisfaction Patients reported a positive evaluation

Higher satisfaction was associated with better clinical outcomes

Exercise animations were especially helpful and easy to follow

90%

Helped them better understand and manage their condition

72%

Appreciated email reminders to perform exercises

88%

Would use the website in the future 80%




Lab

In-Home Falls Prevention


Lab

Web-based Video Chat

Direct remote feedback positively effects adherence Similar to supervised in-clinic

Geraedts et al (2013) Patient Educ Counsel

Remote visit with patient Assess progress Exercise technique monitoring Q&A

Group exercise possibilities Some are more likely to exercise if

accompanied by othersCampbell et al (2001) J Epi Comm Health


Lab

Electronic Queries

Automated text and email queries and reminders

Greater adherence for text-messaging feedback strategy (57.4%) than for phone-contact feedback strategy (32.1%)

Harada (2010) J Rehabil Res Dev

Commercial system for use in clinic service and research

www.mosio.com


Lab

Patient-Sensor-HealthCare Integration

Patients increasingly want mobile medical information MyChart

Continual monitoring and reporting of physiological data Will patients agree? Will insurance

companies have access?UVA Center for Wireless Health


Lab

Thank You

References 1. Campbell R, Evans M, Tucker M, Quilty B, Dieppe P, Donovan JL. Why don't patients do their

exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. Journal of epidemiology and community health. 2001;55:132-138.

2. Chang YJ, Chen SF, Huang JD. A Kinect-based system for physical rehabilitation: a pilot study for young adults with motor disabilities. Research in developmental disabilities. 2011;32:2566-2570.

3. Chaudhri R, Borriello G. An RFID based system for monitoring free weight exercises. In: 6th ACM conference on Embedded network sensor systems. Raleigh, NC, USA: 2008.

4. Clark RA, Bower KJ, Mentiplay BF, Paterson K, Pua YH. Concurrent validity of the Microsoft Kinect for assessment of spatiotemporal gait variables. Journal of biomechanics. 2013;46:2722-2725.

5. Clark RA, Pua YH, Bryant AL, Hunt MA. Validity of the Microsoft Kinect for providing lateral trunk lean feedback during gait retraining. Gait & posture. 2013;38:1064-1066.

6. Clark RA, Pua YH, Fortin K, et al. Validity of the Microsoft Kinect for assessment of postural control. Gait & posture. 2012;36:372-377.

7. Cobian DG, Daehn NS, Anderson PA, Heiderscheit BC. Active cervical and lumbar range of motion during performance of activities of daily living in healthy young adults. Spine. 2013;38:1754-1763.

8. Cobian DG, Sterling AC, Anderson PA, Heiderscheit BC. Task-specific frequencies of neck motion measured in healthy young adults over a five-day period. Spine. 2009;34:E202-207.

9. Crandall S, Howlett S, Keysor JJ. Exercise adherence interventions for adults with chronic musculoskeletal pain. Physical therapy. 2013;93:17-21.

10. Geraedts H, Zijlstra A, Bulstra SK, Stevens M, Zijlstra W. Effects of remote feedback in home-based physical activity interventions for older adults: a systematic review. Patient education and counseling. 2013;91:14-24.

11. Gonzalez-Ortega D, Diaz-Pernas FJ, Martinez-Zarzuela M, Anton-Rodriguez M. A Kinect-based system for cognitive rehabilitation exercises monitoring. Computer methods and programs in biomedicine. 2014;113:620-631.

12. Guerrero C, Uribe-Quevedo A. Kinect-based posture tracking for correcting positions during exercise. Studies in health technology and informatics. 2013;184:158-160.

13. Harada ND, Dhanani S, Elrod M, Hahn T, Kleinman L, Fang M. Feasibility study of home telerehabilitation for physically inactive veterans. Journal of rehabilitation research and development. 2010;47:465-475.

14. Kelders SM, Kok RN, Ossebaard HC, Van Gemert-Pijnen JE. Persuasive system design does matter: a systematic review of adherence to web-based interventions. Journal of medical Internet research. 2012;14:e152.

15. Neri L, Adorante G, Brighetti G, Franciosi E. Postural rehabilitation through Kinect-based biofeedback. In: 2013 International Conference on Virtual Reality. Philadelphia, PA, USA: 2013.

16. Obdrzalek S, Kurillo G, Seto E, Bajcsy R. Architecture of an automated coaching system for elderly population. Studies in health technology and informatics. 2013;184:309-311.

17. Patel S, Park H, Bonato P, Chan L, Rodgers M. A review of wearable sensors and systems with application in rehabilitation. Journal of neuroengineering and rehabilitation. 2012;9:21.

18. Rantz MJ, Skubic M, Abbott C, et al. In-home fall risk assessment and detection sensor system. Journal of gerontological nursing. 2013;39:18-22.

19. Simek EM, McPhate L, Haines TP. Adherence to and efficacy of home exercise programs to prevent falls: a systematic review and meta-analysis of the impact of exercise program characteristics. Preventive medicine. 2012;55:262-275.

20. Sluijs EM, Kok GJ, van der Zee J. Correlates of exercise compliance in physical therapy. Physical therapy. 1993;73:771-782; discussion 783-776.

21. Sterling AC, Cobian DG, Anderson PA, Heiderscheit BC. Annual frequency and magnitude of neck motion in healthy individuals. Spine. 2008;33:1882-1888.

22. Stone EE, Butler M, McRuer A, Gray A, Marks J, Skubic M. Evaluation of the Microsoft Kinect for screening ACL injury. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference. 2013;2013:4152-4155.

23. Stone EE, Skubic M. Passive in-home measurement of stride-to-stride gait variability comparing vision and Kinect sensing. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference. 2011;2011:6491-6494.

24. Stone EE, Skubic M. Unobtrusive, continuous, in-home gait measurement using the Microsoft Kinect. IEEE transactions on bio-medical engineering. 2013;60:2925-2932.

1

Adherence: An Important but Often Forgotten Determinant of Treatment

EffectivenessLinda Van Dillen, PT, PhD

Washington University

Marcie Harris-Hayes, PT, DPT, OCS, MSCI Washington University

Bryan Heiderscheit, PT, PhDUniversity of Wisconsin

Program in Physical Therapy andDepartment of Orthopaedic Surgery

Disclosures

Funding sources in laboratory

• NIH/NICHD-NCMRR R01 HD047709• Missouri Physical Therapy Association Grant• NIH/NCRR TL1 TR000449• NIH/NICHD T32 HD007434


Introduction

• Research interests - understanding mechanisms contributing to musculoskeletal conditions with goal of improving effectiveness and efficiency of treatment

• Today’s topic suggests we know enough about effects of treatment to want a patient to adhere

• Last 15-20 years many studies conducted that provide support for efficacy of physical therapy treatment of orthopedic conditions

2


Introduction

• Caveat – For any treatment to be effective in the short-term and long-term the patient must adhere

• Only way to know if a treatment is working is to track adherence

• Is the patient not responding because of the treatment itself OR the lack of adherence?


Overview

• Topic of adherence is complex and many factors contribute to non-adherence

• Goal today – exposure to some aspects of the topic so you will1. Put topic on your clinical radar2. Consider impact on your practice and outcomes3. Consider ways and aspects of adherence to track in the clinic4. Adjust behaviors to enhance adherence


Today

• Background • Facts about adherence• Measurement of adherence• Variables associated with adherence• Clinic-based measure of independence in performance• Technology-based methods for measurement and

enhancement of adherence

3


ADHERENCE

Background


Background

• Early work in area of adherence• Focused on whether people followed medication prescription

recommendations; typically referred to as “compliance”

• Adherence includes a number of health-related behaviors other than taking medications as prescribed• Multidimensional, e.g. initiating care, attending clinic visits, and

following clinic- and home-based programs

• Definition recommended by WHO (2003)• “The extent to which a person’s behavior – taking medications,

following a diet and/or executing lifestyle changes corresponds with agreed recommendations from a healthcare provider”

Bassett S, J Nov Physiother, 2012; 2(7):1000e124


Background

• Tends to be fewer studies about adherence to physical therapy treatment in people with orthopedic conditions compared to studies of adherence to treatment of other health-related conditions

• Today -• Meta-analyses of data from large numbers of studies of

adherence across health-related conditions (includes orthopedic conditions)

• Systematic review specific to adherence to physical therapy in orthopedic conditions

4


FACTS ABOUT ADHERENCEImportance/Impact

World Health Organization. Adherence to long-term therapies: Evidence for action. http://whqlibdoc.who.int/publications/2003/9241545992.pdf. Jan 2003.


Facts

• Poor adherence, particularly for chronic health conditions, is a worldwide problem of huge magnitude

• Poor adherence expected in 30-50% of all patients• Adherence for chronic conditions - estimated range of 20-

80%, average of 50%• Extent of adherence decreases with (1) complexity of

treatment, (2) extent of lifestyle changes required, (3) modification of existing habits, (4) preventative therapies

• Result of poor adherence – decreased management & control of the condition, poor health outcomes, increased health care costs

DiMatteo MR, Med Care, 2004; 42(3):200Martin LR et al., Ther Clin Risk Man, 2005;1(3): 189


Facts

• Of all of the factors that can contribute to suboptimal clinical outcomes, poor adherence is the primary reason

• Highlights the idea that when a patient has a poor response to treatment, adherence should always be considered beforechanging the treatment plan

5


Facts

• Adherence problems are observed in all situations where the self-administration of treatment is required, regardless of

• Type of condition• Severity of condition• Access to health resources


Facts

• The impact of poor adherence will grow as the burden of chronic health conditions grows

• Particularly important and timely topic for Physical Therapy for 2 reasons

1. Much of what PT will manage in the future are the non-communicable, chronic conditions of an aging population

2. Moving to a practice model of treatment of the movement system across the lifespan

APTA's Vision Statement for the Physical Therapy Profession, 2013http://www.apta.org/VisionStrategicPlan


Facts

• Adherence issues will vary with the stage of the condition (acute, post-acute)

• The suggested methods to facilitate adherence differ in the different stages

• Need to consider what is most important to measure in the different stages

6


Facts

• Typically, adherence is not an “all or nothing” situation; there are gradations of adherence

• Thresholds for how much is enough for many treatments are not known and thresholds will vary with • Patient characteristics• Specifics of health condition


Facts

• Impact on outcomes between high and low adherence is ~25% for preventative or treatment recommendations • 25% = How much outcomes can differ just by modifying

adherence

• Impact of adherence on outcomes is greatest in • Non-medication based treatments • Chronic conditions

• Treatments provided by Physical Therapists

• Conditions seen by Physical Therapists

DiMatteo MR et al, Med Care, 2002; 40(9): 794


Facts

• Improving adherence may be one of the best investments for dealing with acute and chronic conditions effectively

• Much known about adherence that has not been implemented in clinical practice

• If implemented likely would improve outcomes without even changing the treatments administered

7


MEASUREMENT OF ADHERENCE

Patient-Based, Clinic-Based


Overview

• Concept of adherence is complex, not a unitary behavior, which makes measurement challenging

• No gold standard method of measurement, e.g.,• Self-report• Direct observation• Instrumentation, e.g., accelerometry, inertial sensors

• No universal adherence measure for use with all patients

• Minimal testing of reliability and validity of adherence measures commonly used, particularly in physical therapy-related studies

Martin LR et al., Ther Clin Risk Man, 2005; 1(3):189Steiner JF, Med Care, 2012; 50(12):1011


Features to Consider in a Measure

• What aspect of behavior is measured?• Frequency of performance is most common

• How is behavior measured/quantified?• Categorical data: yes/no• Ordinal data: all/most/some/none• Continuous data: instrumented measures

• What is the time frame of measurement?• Day/week/interval since last treatment• Treatment phase vs. after formal treatment phase

Steiner JF, Med Care, 2012;50(12): 1011

8


Considerations for Clinical Application

• Primary goal in measuring adherence in the clinic is to assist you in making decisions about treatment

• What you want in a measure(s) • Simple to understand• Feasible to administer• Low patient burden• Sound measurement properties (reliability & validity)

• Particularly predictive validity, i.e., does the measure of adherence help predict outcomes?


Considerations for Clinical Application

• Overall – Choose measure(s) that captures behaviors that are key to getting a treatment effect

• Example – Changing a habitual movement strategy • Correct performance (in-clinic performance measure; Marcie)• Frequency of practice (self-report measure)

• Types of measures• Patient-based• Clinician-based


Patient-Based Measures

9


Patient-Based Measures

• Most measures• Patient completes or patient is interviewed • Typical use – report of performance of a home-based program• Considered indirect and subjective

• Commonly used measures• Diary (most popular method)• Ordinal scale question(s) of behavior(s) • Visual analogue scale rating of behavior(s)• Structured questionnaire (multiple behaviors)

• Patient completes or interview-based

Jack K et al., Man Ther, 2010;15: 220


Self-Report Methods - Advantages

• Simple & inexpensive

• Quick, easy to administer

• Carry minimal patient burden

• Identify those who are non-adherent• Those reporting non-adherence are likely to be truthful

• Can obtain information re. social, situational, behavioral factors may lead to non-adherence

Nunes V et al.. National Collaborating Centre for Primary Care and Royal College of General Practitioners; London, England, 2009


Self-Report Methods - Disadvantages

• In general, overestimates adherence

• Inaccurate reporting 2⁰ bias • Recall bias, often related to poor real-time completion of

measure• Social desirability bias

• Timeframe of recollection can affect accuracy• Specify timeframe within survey question

DiMatteo MR, Med Care, 2004; 42(3): 200

10


Self-Report Methods - Disadvantages

• Accuracy of responses affected by • Wording of questions• Skills of interviewer

• Measurement can be time-consuming, e.g., diary• Not ideal for tracking long-term adherence


Patient-Based Examples


Self Report - Daily Diary

Day/Time

Activity

Frequency

Repetitions

Intensity(light/moderate

/vigorous)

Duration

Pain(0-10)

Intensity: Light-Normal, daily activity, no increase in HR; Moderate-Slight increase in HR and breathing, still able to talk; Vigorous-Increase in HR and breathing, difficult to talk

Activity DiarySubject Name: Start Date:

11


Self Report - Daily Diary

• Typical outcome• Percentage of adherence to parameters of activity measured

e. g., intensity, repetitions, duration

• Measure• One or more components of treatment• Parameters of components (intensity, repetitions, duration)

• Format for diaries is not standardized

• Time consuming

• Primarily feasible for assessing short-term adherence


Self Report – Ordinal Scale Questionnaire

Weekly Exercise Log Subject Name: _____________ Start Date:__________

Day: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

How much ofmy prescribed home program did I complete today:

All

Most

Some

None

All

Most

Some

None

All

Most

Some

None

All

Most

Some

None

All

Most

Some

None

All

Most

Some

None

All

Most

Some

None


Self Report – Ordinal Scale QuestionnaireFor each of the treatment methods you have been told to do at home please circle

the words & number that best indicates the extent you have followed the instructions for each treatment.

Exercises

Refraining from undertaking the sporting and daily activities that the rehabilitation personnel advised not to do

Application of ice

Not at all A little Rather regularly Very regularly As advised1 2 3 4 5



12


Self Report – Ordinal Scale Questionnaire

• Typical outcome• Score or percentage of adherence

• Measure one or more components of treatment

• Simple, feasible, low patient burden

• Format for questions and scales not standardized

• May be feasible for assessment of short- and long-term adherence


Self Report - Visual Analogue Scale

Instructions: Please mark an “X” on the line to indicate what percentage of your exercises as instructed by your physical therapist you performed today.

0% 100%


Self Report – Visual Analogue Scale

• Typical outcome• Percentage of adherence


• Simple, feasible, low patient burden


13


Self-Report – Structured Questionnaire Rehabilitation Adherence Questionnaire

Scheduling StronglyAgree Agree Disagree Strongly

DisagreeI often miss my rehabilitation sessions because I find better things to do □ □ □ □

I sometimes sleep instead of getting up to make my rehabilitation appointment □ □ □ □

I sometimes forget about my rehabilitation appointment □ □ □ □

My rehabilitation is almost always a high priority for me □ □ □ □

Environmental Conditions StronglyAgree Agree Disagree Strongly

DisagreeThe training room makes me feel unpleasant □ □ □ □

I do not like the training room □ □ □ □

The training room environment is comfortable and conducive to my needs □ □ □ □

Shin JT et al., Int J Rehab Research, 2010; 33(1)64


Self Report – Structured Questionnaire

• Typical outcome• Subscale score and total adherence score


• Lends itself to asking about variables that impede aherence

• Depending on length could be simple, feasible, low patient burden



EXAMPLE – ADHERENCE DATA: CLINICAL TRIAL

Self-Report Data

Van Dillen LR et al., Proceedings of ISEK Meeting, 2012, July 18-21, Brisbane, Queensland, Australia, p. 88

14


Clinical Trial

• Clinical trial - classification-based treatment & non classification-based treatment in people with chronic LBP

• 6 week active treatment phase; 6 and 12 month follow-up

• Components of 2 treatment conditions• Exercise• Training to modify performance of functional activities

• Primary outcome - Modified Oswestry Disability Index score (mODI; 0-100%)

• Treatment effect modifier – Adherence to treatment


Adherence Measures

• Separate adherence measures• Adherence to exercise (0-100%)• Adherence to modifying functional activities (0-100%)• Time frame of measurement

• Daily (treatment phase), across last 6 months (6 & 12 mos)

• Rationale• Research interests – Role of habitual postures and

movements during daily functional activities to course of LBP• Pilot data responses


Adherence Measures

Patient Self-Report Survey Question (Daily, q 6 months)

“Across today, what percentage of your exercises as instructed by your therapist, did you perform?”

Day 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

“Across today, what percentage of your functional activities as instructed by your therapist, did you perform?”

Day 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

15


Adherence Measures

In-clinic assessment

Therapist Question (Clinic visits 2-6)

“Across the interval since your last visit, on average, what percentage of your exercises as instructed by your therapist, did

you perform?”

“Across the interval since your last visit, on average, what percentage of your functional activities as instructed by your

therapist, did you perform?”


Adherence – Consistency Exercise adherence

• Daily (survey): 76 ± 17%• “Average” estimate by participant (clinic visit): 77 ± 16%

(p>0.05) • Correlation: .95

Functional activity adherence• Daily (survey): 79 ± 15%• “Average” estimate by participant (clinic visit): 78 ± 14%

(p>0.05)• Correlation: .94


Treatment Effects - mODI Scores

16


Treatment Question

• Do the longitudinal effects on the mODI scores differ between the 2 treatment conditions (CS vs. NCs)?


mODI Scores – Treatment Group

Predicted Oswestry scores over time for the 2 treatment groups


mODI Scores

Time points:

• Baseline

• Post-treatment

• 6 mos post-treatment


17


mODI Scores

Treatment phase: 30% improvement (p<.05)

6 wks to 6 mos:35% improvement (p<.05)

6 mos to 12 mos:20% regression (p<.05)


Adherence Effects - Exercise & Functional Activity


Adherence Questions

• What was the adherence to the 2 components of treatment and did these differ?

• Did adherence to components of treatment modify treatment effects differently? • Exercise vs. modification of functional activity performance

18


Exercise & Functional Activity AdherencePredicted adherence scores over time

Time points:

• 2nd treatment visit

• 6th treatment visit



.


Exercise & Functional Activity AdherenceOverall pattern:

• Exercise: 80% - 40% (p<.01)

• Functional activity: 79% - 64% (p<.01)

• Rate of decline for exercise adherence < than for functional activity adherence (p<.01)


Exercise & Functional Activity AdherenceTreatment Phase:

Functional activity: stable (p>.05)

Exercise:declined 12% (p<.01)

19


Exercise & Functional Activity Adherence6 wks to 6 mos:

Functional activity: declined 6% (p<.05)



Exercise & Functional Activity Adherence6 mos to 12 mos:

Functional activity: declined 14% (p<.05)



Change in mODI Scores & Functional Activity Adherence

Note: Change in mODI scores parallels the change in functional activity adherence

20


Relationship Between Adherence & mODI

• When analyzed separately, both exercise adherence and functional activity adherence were related to mODI scores significantly (p<.05)• The more you adhere, the better your mODI score

• When both forms of adherence were included in the analysis, only the effect of functional activity adherence on mODI scores was significant (p<.05)

• Suggests functional activity adherence has a unique, independent effect on mODI scores above and beyond the effect of exercise adherence


Summary - Example

• Self-report adherence measure• Preliminary reliability data• Predictive validity data – adherence is predictive of functional

outcome, particularly true of adherence to training in functional activities

• Suggests it is important to consider impact of adherence to different components of treatment (exercise vs. function)

• Adherence is difficult to maintain so focusing on the component of treatment (1) with an important impact on outcomes, and (2) that patient adheres to may improve outcomes, short- & long-term


Clinician-Based Measures

21


Clinician-Based Measures

• Not a lot of measures of “clinic-based” adherence

• Most common measure – Clinic visit attendance (%)

• The degree to which patients adhere to clinic-based treatment also may be important to outcomes

• Current in-clinic assessments• Primarily based on clinician judgment• May or not be tested for reliability and validity

Brewer BW, J Appl Sport Psych, 1998; 10:70


Clinician-Based Measure - Example

Sport Injury Rehabilitation Adherence Scale (SIRAS)

• Three items; 5 point scale; clinician judgment

• Summary score 3-15; higher score = better adherence

• Various aspects of reliability and validity tested

• Primarily tested in people with sport-related injury; tested in some other more general orthopedic conditions, e.g., arthritis, LBP

Brewer BW et al., Phys Ther Sport, 2000; 1: 68Bassett SF, NZ J Physiother, 2003; 31(2): 61Kolt GS et al., Physiother, 2007; 93: 17


Example - SIRAS

1. Circle the number that best indicates the intensity with which this patient completed rehabilitation exercises during today’s appointment:

minimum effort 1 2 3 4 5 maximum effort

2. During today’s appointment, how frequently did this patient follow your instructions and advice?

never 1 2 3 4 5 always

3. How receptive was this patient to changes in the rehabilitation program during today’s appointment?

very unreceptive 1 2 3 4 5 very receptive

22


Final Notes re. Measurement

• Measurement provides opportunity to discuss factors contributing to non-adherence

• Note that measuring adherence may help promoteadherence• Measurement may increase awareness and increase

adherence• Good clinical practice

• We assume adherence influences outcomes but it could be that outcomes influence adherence


VARIABLES RELATED TO ADHERENCE

Patient, Clinician, Health-Care System


Variables

• Numerous studies of adherence and variables that affect adherence• Differ re. patients, conditions, severity, type of treatment

regimen examined

• Variables examined have included patient-, clinician-, and healthcare system-related variables

• Goal – determine the variables that affect adherence so that these can be addressed in treatment to improve adherence

23


Variables

• Provide an overview of the variables that have been found to be related most consistently to adherence• Recent systematic review• Findings from meta-analysis of data from studies across a

wide range of health-related conditions

• Highlight a few variables that you can affect by changing how you practice


Variables Associated with Non-Adherence Systematic Review

• Systematic review of studies of adherence to physical therapy treatment in people with orthopedic conditions seen in outpatient clinics

• 20 high quality studies

• Wide range of orthopedic conditions

• Overall• Strong evidence for 7 variables • Limited evidence for 7 additional variables

Jack K et al., Man Ther, 2010; 15:220


Variables Associated with Non-AdherenceSystematic Review

Strong evidence

1. Low levels of physical activity at baseline or in prior weeks

2. Low self-efficacy for exercise, tasks and coping• Self-efficacy = the belief that one is capable of performing in

a certain manner to attain certain goals

3. Presence of psychological variables (depression, anxiety, helplessness)

4. Low levels of social or family support for activity


24


Variables Associated with Non-AdherenceSystematic Review

5. Increased numbers of perceived barriers to exercise

6. Worsening of pain with treatment

7. Low adherence during active treatment period is associated with low long-term adherence



Variables Associated with Non-AdherenceMeta Analytic Studies

• Series of meta analytic studies of adherence-related literature on a variety of health-related conditions• Meta analysis – statistical method of combining results of

similar studies; provides more power to identify associations

• Beginning to identify some stable and consistent variables associated with adherence

• Highlight 2 variables associated with adherence that you can address just by adjusting some details of how you practice

DiMatteo MR, Med Care, 2004; 42(3):200DiMatteo MR, Med Care, 2003; 40(9):794 Martin LR et al., Ther Clin Risk Man, 2005; 1(3):189



• Low levels of health literacy• Definition – the degree to which people have the capacity to

obtain, process and understand basic health information and services needed to make appropriate health decisions

• Understanding what one is supposed to do is key to adhering

• Partially result of ineffective communication between patient and healthcare provider

• Use of medical jargon • Time constraints in health care setting

Martin LR et al., Ther Clin Risk Man, 2005;1(3): 18

25



• Suggested changes in practice • Perform ongoing assessment of recall and comprehension

of new concepts • Perform across the episode of care• Example today of a feasible method for conducting this kind

of regular assessment in clinical setting

Martin LR et al., Ther Clin Risk Man, 2005;1(3): 18


Variables Associated with Non-Adherence Meta Analytic Studies

• Poor memory for details of treatment prescribed• Major contributor to non-adherence is forgetting how to

perform a treatment

• Data to suggest that even when communication is effectiveand initial comprehension is high much of the information is lost within minutes of leaving (e.g., 56%)

• Contributing factors• Amount and complexity of information• Lack of detailed explanation, clarification, & review• Anxiety, unfamiliar clinical setting and clinicians

e.g., Ley P, Spelman MS, Br J Soc Clin Psychol,1965; 4:114


Variables Associated with Non-Adherence Meta Analytic Studies

• Suggested changes in practice• Explain specific steps of treatment• Review most important details• Use written instructions• Encourage questions• Provide consistency, re. clinical setting and healthcare

provider

Martin LR et al., Ther Clin Risk Man, 2005; 1(3):189

26


SUMMARY


Summary• Adherence is complex and multidimensional

• More than one behavior contributes to adherence & effect on outcomes

• No single measure of adherence

• Biggest decision in the clinic is whether to change treatment because of poor outcomes • Are poor outcomes due to non-adherence or ineffective

treatment?

• Important to have a measure(s) of adherence to assess its potential role in outcomes• Consider aspect of adherence to measure as it relates to

impact on outcomes


Summary• Consider adherence during in-clinic treatment phase and

after this phase, i.e., maintenance

• Short- and long-term adherence require different measures and different treatment approaches

27

Thank You


References

1. Bassett S, J Nov Physiother, 2012; 2(7):1000e124 2. World Health Organization. Adherence to long-term

therapies: Evidence for action. http://whqlibdoc.who.int/publications/2003/9241545992.pdf. Jan 2003

3. DiMatteo MR, Med Care, 2004; 42(3):2004. Martin LR et al., Ther Clin Risk Man, 2005;1(3): 1895. APTA's Vision Statement for the Physical Therapy

Profession, 2013 http://www.apta.org/VisionStrategicPlan6. Martin LR et al., Ther Clin Risk Man, 2005; 1(3):1897. Steiner JF, Med Care, 2012; 50(12):10118. Jack K et al., Man Ther, 2010;15: 220


References

9. Nunes V, Neilson J, O'Flynn N, et al. Clinical Guidelines and Evidence Review for Medicines Adherence: Involving Patients in Decisions About Prescribed Medicines and Supporting Adherence. London, England: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2009

10.Van Dillen LR et al., Proceedings of ISEK Meeting, 2012, July 18-21, Brisbane, Queensland, Australia, p. 88

11.Brewer BW, J Appl Sport Psych, 1998; 10:7011.Brewer BW et al., Phys Ther Sport, 2000; 1: 6812.Bassett SF, NZ J Physiother, 2003; 31(2): 6113.Kolt GS et al., Physiother, 2007; 93: 1714.Bassett SF, NZ J Physiother, 2003; 31(2): 61

28


References

14.Kolt GS et al., Physiother, 2007; 93: 1715.DiMatteo MR, Med Care, 2003; 40(9):794 17.Shin JT et al., Int J Rehab Research, 2010; 33(1)6418. Ley P, Spelman MS, Br J Soc Clin Psychol,1965; 4:114

Adherence: An Important but Often Forgotten Determinant of Treatment Effectiveness -Independence

2/4/2014

Marcie Harris-Hayes, PT, DPT, MSCI, OCS 1

Adherence: An Important but Often Forgotten Determinant of Treatment

EffectivenessMarcie Harris Hayes, PT, DPT, MSCI, OCS

Associate Professor

Program in Physical Therapy

Department of Orthopaedic Surgery

Washington University School of Medicine

K23HD67343

K12 HD055931

Financial Disclosures

Program in Physical TherapyDepartment of Orthopaedic Surgery

UL1 RR 024992

Adherence - Research• Interest in adherence

• Developing clinical trial (RCT)

• Compare 2 rehabilitation strategies for LBP

- R01 HD047709 Van Dillen LR (PI)

P i dh i f i


• Patient adherence important factor in determining treatment efficacy

• Patient performing correctly

• Standardized method - Independence

Adherence - Practice

• Examination

• Prescribe treatment

• Assess outcomes• Assume our program is appropriate


• Assume our program is appropriate

• Improved outcomes are expected

= Reduced pain= Return to previous level of activities

+


• What if outcomes are not improved?• Prescribed treatment?

• Patient adherence?

• What about performance?


What about performance?








2/4/2014




















+ = Not independent= Slow or no progress

Adherence + Independence• Adherence

• Performing the treatment at instructed

• Duration

• Frequency

• Intensity level


y

• Quantity

• Independence • Perform correctly without assistance

• Quality

• Prerequisite to adherence

Measurement

• Adherence – Quantity• Self-report questionnaires

• Number of sessions attended

• Do not provide measure of quality


• Independence - Quality• Physical therapist’s judgment

• Standardize method to

• Determine independence

• Identify factors that may be influencing independence

• Improve instruction

Independence - Factors

• Cognition – knowledge of key concept • Key concept = primary goal of exercise or activity

• Understand how the key concept relates to their limitation

• Value


Value

• Psychomotor skill - performance• Ability to physically perform the exercise or activity

without

• Instruction

• Manual assistance


2/4/2014


D ’ l i F l

Independence – Key concepts


Don’t rotate pelvis, Feel in seat muscles

Don’t flex spine

Avoid extreme hip flexion or rotation. Side lying - pillow between knees

D ’ l i F l




Don’t flex spine


D ’ l i F l




Don’t flex spine


Independence - Factors

• Cognition – knowledge of key concept • Key concept = primary goal of exercise or activity

• Understand how the key concept relates to their limitation


• Psychomotor skill - performance• Ability to physically perform the exercise or activity

without

• Instruction


Independence - Importance

Strategies to address deficits will vary• Cognition – Knowledge of key concept

• Increase understanding through

• Explanation

• Demonstration


Demonstration

• Handouts with pictures and written information

• Dos and Don’ts

• Key concept

• Psychomotor skill – Performance• Grade activity to level of patient

Independence - Importance

• Independence

• Improve adherence

• Improved outcomes


• If outcomes don’t improve as expected

• Provide insight into why


2/4/2014


Independence - Assessment

Standardized method• Developed and used during LBP clinic trial

• Currently being used in feasibility study in intra-


y g y yarticular hip disorders • Femoroacetabular impingement (FAI)

• Developmental dysplasia of the hip (DDH)

F di k l d t


Funding acknowledgementsNCMRR-NICHD

- R01 HD047709 Van Dillen LR (PI) - K12 HD055931 Harris-Hayes (Scholar)

NINDS; NCRR- 1 UL1 RR 024992-01

Independence – first visit

• Exercise prescription• Instruct in performance

• Provide Key concept

• Explain importance

• Do they understand and value?

b f


• Observe performance

• Are they able to perform without assistance?

• Assign frequency

• Repetitions, sets, days/week

• Based on goal of exercise

• Strengthening

• Neuromuscular re-education

Quadruped Rocking BackDon’t flex spine






b f







• Strengthening







b f







• Strengthening



• Instruction in ADL• Instruct in performance








2/4/2014






Independence – return visit

• Exercise assessment• Observe performance


• Physical therapist’s judgment


Independence – Assessment

Operational definitions - Independent

• Knowledge of key concept (cognition)• Able to verbalize key concept without verbal cues






Performance (psychomotor skill)


• Performance (psychomotor skill)• Able to perform without verbal cues

or physical assistance

• Performs all aspects of activity

without deviation

• Independent in performance• Assume independence in knowledge of key concept




Performance (psychomotor skill)


• Performance (psychomotor skill)• Able to perform without verbal cues or physical

assistance

• Performs all aspects of activity without deviation

• Independent in performance• Assume independence in knowledge of key concept


2/4/2014



Operational definitions – not independent

• Knowledge of key concept (cognition)• Required verbal cues or demonstration

• Performance (psychomotor skill)


• Performance (psychomotor skill)• Required verbal cues

• Required verbal cues and physical assistance






Independent in knowledge and performance


performance. Activity progressed.






2/4/2014


Independence - AssessmentQuadruped rock (don’t flex spine)






Independent in knowledge. Requires verbal cues for performance. Continue activity with instruction.





Independence Assessment????



2/4/2014






Not independent in knowledge. Requires

verbal cues for performance.

Continue activity with instruction.





Independent in knowledgeRequires verbal cues and physical assistance for performance. Continue activity with assistance.



Independent in knowledge.Unable to perform activity. Difficulty level of activity reduced.


• ADLs• Common to report performance of ADLs in

neuromuscular conditions

• Functional Independence Measure (FIM)

• Barthel Index


Barthel Index

• Modified Rankin Scale

• Not as common in musculoskeletal pain

• Mostly self-report

• Sports – functional testing


2/4/2014


Independence - AssessmentADLs

• Key Concept• Don’t let your knee

roll in

• Squeeze seat muscles


q

• Performance• Mirror


• Reduce level

• Use of railing

Hip Specific


Hip Specific Modifications



Standardized scenarios to assess rater reliability.

• Two experienced physical therapists• Provided treatment in the clinical trial (LBP)

• Training• Manual – self study


• Operational definitions

• Standardized procedures for assessment and decision making

• Testing• Test-retest

• 26 Standardized scenarios

Standardized scenarios to assess rater reliability.

Reliability Percentage of

Agreement (%)

Weighted Kappa (kw)

Kappa (k)

Intra Rater •Performance 95 k = 80


Intra-Rater Reliability (PT 1)

•Performance•Knowledge

95100

kw = .80k = 1.00

Intra-Rater Reliability (PT 2)


9080

kw = .70k = .58

Inter-Rater Reliability (PT 1&2)


9488

kw = .77k = .75

Independence - AssessmentPhysical Therapists’ Response

Based on 5 physical therapists participating in treatment trials

• Feasible to use in everyday practice • Does not result in additional treatment time


• Very useful in formally • Assessing patient’s abilities and decision to progress

• Determining specific factors preventing independence


2/4/2014


Independence - Clinical Importance

Guide treatment strategies• Not independent in Knowledge of key concepts

• Emphasis of treatment - Cognition

• Communication


• Asking patient questions

• Understand

• Do they value

Independence - Clinical Importance

Guide treatment strategies• Not independent in Performance

• Emphasis of treatment – psychomotor skills

• May require verbal cues only


• Use of props to encourage correct performance

• Reduce difficulty of the exercise or activity.

Independence - Research Importance

Trials – Treatment outcomes• Measure Adherence + Independence

• Provides additional information about patient’s ability to adhere.

P id i i ht t th b i f ti t dh


• Provide insight to the barriers of patient adherence

• Factors associated with treatment outcomes

Independence - Summary

• Adherence important to measure

• Independence – prerequisite to adherence

• Individualized treatment may be more efficient and effective if


• Patient Independent

• Knowledge of key concepts related to the treatment

• Performance of the treatment.

Marcie Harris Hayes, PT, DPT, MSCI, OCSAssociate Professor

Program in Physical Therapy Washington University School of Medicine

Campus Box 8502


Campus Box 85024444 Forest Park Avenue

St. Louis, MO 63108(314) 286-1435

[email protected]

Factors Influencing Rehabilitation Outcomes in Lower Extremity Conditions


Marcie Harris-Hayes, PT, DPT,MSCI, OCS

Bryan Heiderscheit, PT, PhD

Terese Chmielewski, PT, PhD, SCS

VanDillen Harris-Hayes Heiderscheit Session Outline CSM2014 · exercise routines Initially targeted...

Documents

Transcript of VanDillen Harris-Hayes Heiderscheit Session Outline CSM2014 · exercise routines Initially targeted...