Treatment adherence is central to treatment success in rehabilitation for musculoskeletal conditions, including low back pain (LBP). Unfortunately, non-adherence to prescribed treatment is common and undermines treatment success.
Objective
To identify predictors of treatment adherence in physical therapy for patients with LBP.
Methods
209 cases of patients receiving physical therapy for a chief complaint of centralized LBP were retrospectively analyzed for predictors of treatment adherence. Symptom duration, pain intensity, level of disability, the presence of an opioid prescription, and patient cost were assessed as predictors of treatment adherence. Patients who completed their prescribed plan of care were classified as adherent.
Results
Logistic regression analysis revealed that individuals who had an opioid prescription were 2.56 (95% CI = 1.25–5.24, p = 0.010) times less likely to be adherent with treatment compared to individuals without an opioid prescription. Individuals who had symptoms for less than 1 month were 3.21 (95% CI = 1.12–9.24, p = 0.030) times less likely to be adherent with treatment compared to individuals who had experienced symptoms for 4 months to 1 year. Finally, individuals who paid greater than $40 per visit were 3.45 (95% CI = 1.31–9.09, p = 0.011) times less likely to be adherent with treatment compared to individuals who did not have to pay each visit.
Conclusion
The results of this study may help clinicians quickly identify and address risk factors for lower treatment adherence in patients with LBP to mitigate the impact of suboptimal treatment adherence on patient outcomes.
JamesSLAbateDAbateKH, et al.Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the global burden of disease study. Lancet2017; 392: 1789–1858.
2.
HoyDBrooksPBlythF, et al.The epidemiology of low back pain. Best Pract Res Clin Rheumatol2010; 24: 769–781.
3.
HoyDBainCWilliamsG, et al.A systematic review of the global prevalence of low back pain. Arthritis Rheum2012; 64: 2028–2037.
4.
MartinBIDeyoRAMirzaSK, et al.Expenditures and health status among adults with back and neck problems. JAMA2008; 299: 656–664.
5.
GuoHRTanakaSHalperinWE, et al.Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health1999; 89: 1029–1035.
6.
KatzJN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg2006; 88: 21–24.
7.
TraegerACBuchbinderRElshaugAG, et al.Care for low back pain: can health systems deliver?Bull World Health Organ2019; 97: 423–433.
8.
QaseemAWiltTJMcLeanRM, et al.Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American college of physicians. Ann Intern Med2017; 166: 514–530.
9.
van WambekePDesomerAJonckheerP, et al.The Belgian national guideline on low back pain and radicular pain: key roles for rehabilitation, assessment of rehabilitation potential and the PRM specialist. Eur J Phys Rehabil Med2020; 56: 220–227.
10.
ChenotJ-FGreitemannBKladnyB, et al.Non-specific low back pain. Deutsches Arzteblatt Int2017; 114: 883–890.
11.
StochkendahlMJKjaerPHartvigsenJ, et al.National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J2018; 27: 60–75.
12.
BürgeEMonninDBerchtoldA, et al.Cost-Effectiveness of physical therapy only and of usual care for various health conditions: systematic review. Phys Ther2016; 96: 774–786.
13.
FritzJMChildsJDWainnerRS, et al.Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine2012; 37: 2114–2121.
14.
LiuXHanneyWJMasaracchioM, et al.Immediate physical therapy initiation in patients with acute low back pain is associated with a reduction in downstream health care utilization and costs. Phys Ther2018; 98: 336–347.
15.
OliveiraCBMaherCGPintoRZ, et al.Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J2018; 27: 2791–2803.
16.
HeneweerHAufdemkampeGTulder M van, KiersH, et al.Psychosocial variables in patients with (sub)acute low back pain: an inception cohort in primary care physical therapy in The Netherlands. Spine2007; 32: 586–592.
17.
PistersMFVeenhofCSchellevisFG, et al.Exercise adherence improving long-term patient outcome in patients with osteoarthritis of the hip and/or knee. Arthritis Care Res2010; 62: 1087–1094.
18.
FairhallNSherringtonCCameronID, et al.A multifactorial intervention for frail older people is more than twice as effective among those who are compliant: complier average causal effect analysis of a randomised trial. J Physiother2017; 63: 40–44.
19.
JackKMcLeanSMMoffettJK, et al.Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual Ther2010; 15: 220–228.
20.
OrganizationWH. Adherence to long-term therapies. Geneva, Switzerland: World Health Organization, 2003.
21.
KoltGSMcEvoyJF. Adherence to rehabilitation in patients with low back pain. Manual Ther2003; 8: 110–116.
22.
MannionAFHelblingDPulkovskiN, et al.Spinal segmental stabilisation exercises for chronic low back pain: programme adherence and its influence on clinical outcome. Eur Spine J2009; 18: 1881–1891.
23.
BurnsDBoyerPRazmjouH, et al.Adherence patterns and dose response of physiotherapy for rotator cuff pathology: longitudinal cohort study. JMIR Rehabil Assistive Technol2021; 8: e21374.
24.
SluijsEMKokGJvan der ZeeJ. Correlates of exercise compliance in physical therapy. Phys Ther1993; 73: 771–782.
25.
ShahidiBPadwalJLeeE, et al.Factors impacting adherence to an exercise-based physical therapy program for individuals with low back pain. PloS One2022; 17: e0276326.
26.
DhondtEVan OosterwijckJCagnieB, et al.Predicting treatment adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain. J Back Musculoskeletal Rehabil2019; 33: 277–293.
27.
DantasLFFleckJLCyrino OliveiraFL, et al.No-shows in appointment scheduling - a systematic literature review. Health Policy2018; 122: 412–421.
28.
AlexandreNMCNordinMHiebertR, et al.Predictors of compliance with short-term treatment among patients with back pain. Pan Am J Public Health2002; 12: 86–94.
29.
LenoirDCoppietersIWillaertW, et al.Do sociodemographic features, pain sensitivity or pain catastrophizing relate to clinic-based adherence to physiotherapy in people suffering from chronic spinal pain? Secondary analysis of a randomized clinical trial. Musculoskeletal Sci Pract2019; 44: 102066.
30.
McDonaldMTSiebertSCoulterEH, et al.Level of adherence to prescribed exercise in spondyloarthritis and factors affecting this adherence: a systematic review. Rheumatol Int2019; 39: 187–201.
31.
KirbySDonovan-HallMYardleyL. Measuring barriers to adherence: validation of the problematic experiences of therapy scale. Disabil Rehabil2014; 36: 1924–1929.
32.
GreenbergerHBBeissnerKJewellDV. Patient age is related to the types of physical therapy interventions provided for chronic low back pain: an observational study. J Orthop Sports Phys Ther2012; 42: 902–911.
33.
WalstonZMcLesterC. Importance of early improvement in the treatment of low back pain with physical therapy. Spine2020; 45: 534–540.
34.
JensenMPMcFarlandCA. Increasing the reliability and validity of pain intensity measurement in chronic pain patients. Pain1993; 55: 195–203.
35.
ChildsJDPivaSRFritzJM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine2005; 30: 1331–1334.
36.
FrostHLambSEStewart-BrownS. Responsiveness of a patient specific outcome measure compared with the oswestry disability Index v2.1 and roland and morris disability questionnaire for patients with subacute and chronic low back pain. Spine2008; 33: 2450–2457.
37.
JohnsenLGHellumCNygaardOP, et al.Comparison of the SF6D, the EQ5D, and the oswestry disability Index in patients with chronic low back pain and degenerative disc disease. BMC Musculoskeletal Disord2013; 14: 48.
38.
DawsonAPSteeleEJHodgesPW, et al.Utility of the oswestry disability Index for studies of back pain related disability in nurses: evaluation of psychometric and measurement properties. Int J Nurs Stud2010; 47: 604–607.
39.
EaddyMTCookCLO’DayK, et al.How patient cost-sharing trends affect adherence and outcomes: a literature review. Pharm Ther2012; 37: 45–55.
40.
CareyKAmeliOGarrityB, et al.Health insurance design and conservative therapy for low back pain. Am J Manage Care2019; 25: e182–e187.
41.
FritzJMBrennanGPHunterSJ, et al.Initial management decisions after a new consultation for low back pain: implications of the usage of physical therapy for subsequent health care costs and utilization. Arch Phys Med Rehabil2013; 94: 808–816.
42.
KazisLEAmeliORothendlerJ, et al.Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open2019; 9: e028633.
43.
SunEMoshfeghJRishelCA, et al.Association of early physical therapy with long-term opioid use among opioid-naive patients with musculoskeletal pain. JAMA Network Open2018; 1: e185909.
44.
HayesCPayakachatNLiC. Evaluation of opioid use among patients with back disorders and arthritis. Qual Life Res2018; 27: 3021–3035.
HancockMJMaherCGLatimerJ, et al.Can rate of recovery be predicted in patients with acute low back pain? Development of a clinical prediction rule. Eur J Pain2009; 13: 51–55.
47.
da C Menezes CostaLMaherCGHancockMJ, et al.The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ Can Med Assoc J2012; 184: E613–E624.
48.
da SilvaTMillsKBrownBT, et al.Recurrence of low back pain is common: a prospective inception cohort study. J Physiother2019; 65: 159–165.
49.
MachadoGCMaherCGFerreiraPH, et al.Can recurrence after an acute episode of low back pain be predicted?Phys Ther2017; 97: 889–895.
50.
GarciaANCostaLOPCostaLDCM, et al.Do prognostic variables predict a set of outcomes for patients with chronic low back pain: a long-term follow-up secondary analysis of a randomized control trial. J Manual Manipulative Ther2019; 27: 197–207.
51.
StevansJMDelittoAKhojaSS, et al.Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Network Open2021; 4: e2037371.
52.
WirthBEhrlerMHumphreysBK. First episode of acute low back pain - an exploratory cluster analysis approach for early detection of unfavorable recovery. Disabil Rehabil2017; 39: 2559–2565.
53.
VittinghoffEMcCullochCE. Relaxing the rule of ten events per variable in logistic and cox regression. Am J Epidemiol2007; 165: 710–718.
54.
OliveiraDSVélia Ferreira MendonçaLSofia Monteiro SampaioR, et al.The impact of anxiety and depression on the outcomes of chronic low back pain multidisciplinary pain management-a multicenter prospective cohort study in pain clinics with one-year follow-up. Pain Med2019; 20: 736–746.
55.
AntunesRSde MacedoBGAmaral T daS, et al.Pain, kinesiophobia and quality of life in chronic low back pain and depression. Acta Ortop Bras2013; 21: 27–29.
56.
AlhowimelAAlOtaibiMRadfordK, et al.Psychosocial factors associated with change in pain and disability outcomes in chronic low back pain patients treated by physiotherapist: a systematic review. SAGE Open Med2018; 6: 2050312118757387.
57.
ZubatskyMWitthausMScherrerJF, et al.The association between depression and type of treatments received for chronic low back pain. Family Practice2019; 37: 348–354.
