Dr Laura Meade
Chronic musculoskeletal (MSK) pain such as low back pain has substantial personal, social and economic impacts.1, 2 This month for Pain Awareness Month we look at the relationship between chronic MSK pain and treatment adherence.
The complexity of pain
Due to its complex etiology and symptomology, treatment of chronic MSK pain often consists of a combined management strategy including pharmacological, psychological and active treatment, requiring adherence to many health behaviours. 5-7 Active treatment, such as physiotherapist-prescribed exercise has been shown to alleviate pain and improve function and quality of life. 8 However, fewer than half the people with chronic MSK pain adhere to their exercise treatment. 9
Using behaviour change techniques to influence treatment adherence
A systematic review evaluated the effectiveness of eight randomised controlled trials to improve exercise adherence in populations with chronic MSK pain. Five behaviour change techniques (BCTs) were identified as having the most influence on individuals’ adherence to exercise: 10
|Behaviour change technique (BCT)||Description|
|Receiving social support||Support and guidance from family members and/or a physiotherapist|
|Goal setting||Setting a specific behavioural goal, for example completing prescribed exercises twice per week after dinner|
|Practising the behaviour||Practising prescribed exercises in a supervised setting prior to establishing a home exercise plan|
|Viewing a demonstration of the behaviour||Having a therapist demonstrate how to accurately perform the prescribed exercise, or watching a video online or on an app|
|Receiving written or verbal instruction on carrying out the behaviour||Receiving clear instructions from a therapist, either in person or digitally, on how to accurately perform the prescribed exercise.|
An interesting finding from the review was that too many BCTs can overburden individuals and have negative effects. Interventions that administered seven or more BCTs were less effective than those administering less than seven. 10 Therefore developing an evidence-informed treatment plan to address the patient’s specific needs may be most effective. To meet this challenge, programmes are needed that identify the barriers to exercise adherence and use targeted behavioural interventions, yet the evidence to inform this approach is still in its infancy. 10
How can healthcare professionals support adherence in a pain population
People experiencing pain need personalised support to help them adhere to their exercise programme.11 Providing holistic, accessible psychological support can help encourage adherence to treatment recommendations. 12 Early in the treatment plan, it is important for healthcare professionals (HCPs) to explain the importance of identifying individual internal and external barriers so that the patient can establish realistic coping strategies. 13Attention to the following factors may support this process and consequently a patient’s adherence to their active treatment: 11
Consider the physical and social environment
An individual’s physical space and their support system may play a big role in adherence to home-based prescribed exercise. Encourage individuals to establish a plan of where the exercise will take place and discuss these plans with their support system.
Don’t underestimate the impact of a collaborative therapeutic relationship
Creating and cultivating a strong therapeutic relationship requires effort from both the HCP and the patient. This relationship can greatly influence patient adherence 14 and understanding the patient needs will support the development of a tailored exercise prescription that meets their current level of readiness.
Establish realistic treatment expectations that facilitate self-management
Expectations of treatment can modify a patient’s ability or willingness to engage in their treatment. Often, a lack of progress or improvement leads to frustration and non-adherence. Underlining these expectations and realistic outcomes early on may impact a patient’s willingness to engage.
Recognize the influence and impact of pain on affect
For many, pain represents a situation wherein something is “wrong” that needs fixing. This experience can trigger anxiety, leading to activity avoidance and a heightened sensitivity to pain, resulting in an ongoing negative feedback loop. Some patients may require additional support and education around understanding their pain and how to manage its affectual impact.
Living well with pain
Pain management is a collaborative effort, where greater education and patient support is needed. To read a recent publication by Dr Laura Meade on the development of a behaviour change intervention to enhance exercise adherence click here. To learn more about Pain Awareness Month click here.
Please reach out to us at email@example.com if you would like to discuss any pain-related research needs. Sprout has expertise in pain measurement for clinical trials, real world research and clinical practice and in developing and evaluating pain interventions.
- Lynch ME. The need for a Canadian pain strategy. Pain research & management. 2011;16(2):77.
- Institute for Health Metrics and Evaluation. Findings from the Global Burden of Disease Study 2017 2018.
- Public Health England. Musculoskeletal health: applying all our health Available: https://www.gov.uk/government/publications/musculoskeletal-health-applying-all-our-health/musculoskeletal-health-applying-all-our-health. Accessed 20 March, 2019.
- Arthritis UK. State of musculoskeletal health 2018.
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624-1645.
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s:assessment and management. NICE guideline. 2016.
- National Institute for Health Research. Moving forward: physiotherapy for musculoskeletal health and wellbeing 2018.
- Geneen LJ, Moore RA, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews (Review). Cochrane Database of Systematic Reviews. 2017(1).
- Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. New Zealand Journal of Physiotherapy. 2003;31(2):60-66.
- Meade LB, Bearne LM, Sweeney LH, et al. Behaviour change techniques associated with adherence to prescribed exercise in patients with persistent musculoskeletal pain: Systematic review. British journal of health psychology. 2018.
- Meade LB, Bearne LM, Godfrey EL. “It’s important to buy in to the new lifestyle”: barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain. Disability and Rehabilitation. 2019:1-11.
- Meade LB, Bearne LM, Godfrey EL. Using Intervention Mapping in the Systematic Development of a Behaviour Change Intervention to Enhance Exercise Adherence among People with Persistent Musculoskeletal Pain. Physiotherapy Canada.2021.
- Kelly MP, Barker M. Why is changing health-related behaviour so difficult? Public health. 2016;136:109-116.
- Meichenbaum D, Turk DC. Facilitating treatment adherence : a practitioner’s guidebook. New York ; London: New York ; London : Plenum Press 1987.