Patient Adherence With At-Home Hand and Wrist Exercises: A Randomized Controlled Trial of Video Versus Handout Format

Abstract

Background:

Patient adherence is important for maximizing patient outcomes. The purpose of this randomized controlled trial was to determine patient adherence and confidence in home therapy exercises of the hand and wrist at multiple time points when distributed by either paper handout or video.

Methods:

Patients were prospectively enrolled and randomized in orthopedic clinics to either the handout or video exercise group. Exclusion criteria included patients less than 18 years old. Questionnaires were electronically distributed each week for 4 weeks following enrollment. Questionnaires assessed the frequency of exercise performance, percentage of exercises utilized, and confidence in performing the exercises correctly. The handout and video groups were compared via 2-sample t tests for continuous data and χ² tests for categorical data.

Results:

Of the 89 patients enrolled, 71 patients responded to the initial follow-up survey (80% of randomized patients), and 54 of these patients (76%) completed all surveys at each time point. The handout group (37 patients) and the video group (34 patients) had no differences in response rate or demographics. There were no differences in frequency, exercise utilization rate, or confidence in performing exercises between groups at week 1. However, the video group reported higher exercise utilization and confidence than the handout group at subsequent time points.

Conclusions:

Video-format distribution of home therapy exercises is superior to that of paper handout distribution for the distal upper extremity rehabilitation. Patients in the video group utilized more exercises and had higher confidence in completing them correctly following initiation of the exercise program.

Introduction

Patient adherence to physician recommendations has remained a topic of investigation and area of improvement for all medical specialties. The World Health Organization noted that adherence rates in developed countries average only around 50% among patients with chronic illnesses. ¹ In the same report, the World Health Organization also stated that adherence to therapy is a primary determinant of treatment success. Treatment success is particularly pertinent to musculoskeletal injuries where physical therapy exercises play a significant role in improving pain, physical function, and quality of life. ²

Previous studies in patient adherence have evaluated various interconnected factors and have thus provided valuable insight in determining the best approaches to improve adherence and the resultant outcomes in treating musculoskeletal injuries. Pisters et al ³ found that those who had higher adherence to their home exercises reported decreased pain and improved physical function among hip and knee osteoarthritis patients. The type of instruction is another essential factor that has been evaluated, and previous studies have shown that technology-based exercise programs are associated with a higher adherence rate, even in elderly populations.^4,5 Lysack et al ⁶ reported that therapy adherence was not significantly different among orthopedic rehabilitation patients when standard care was supplemented with videotaped lessons.

Despite previous literature investigating patient adherence in orthopedics, limited research has examined the use of technology-based distribution of home therapy exercise regimens for the distal forearm and hand. Home therapy programs are of particular interest due to their convenience for patients and their escalated implementation during the COVID-19 pandemic. The purpose of this study was to evaluate patient adherence rates with handout versus video formats of instruction for home-based exercises for the distal forearm and hand. Adherence, in terms of frequency and exercise utilization, along with patient confidence in performing these exercises, was assessed at multiple time points.

Materials and Methods

Data Collection and Study Design

We received approval from our institutional review board before enrollment for this study. Patients who were recommended home therapy exercises for their wrist or hand at the discretion of a board-certified orthopedic surgeon were prospectively enrolled in an outpatient orthopedic clinic between September 2020 and June 2021, and informed consent was obtained from all individual participants included in this study. All types of pathology, as well as any patient undergoing either operative and nonoperative treatment, were included in the study, so long as they were recommended at home physical therapy. Exclusion criteria included patients less than 18 years of age, patients not fluent or literate in English, or patients without access to technology to view the video. Patients were randomized to either the handout or video group and were instructed to perform the exercise set 3 times per day for 28 consecutive days. The handout group received a printed handout that detailed their exercises, while the video group received an e-mail with a link to a 6-minute video hosted on YouTube (San Bruno, California) that detailed the same exercises. Neither group received in-person instruction for the exercises from therapists, nurses, surgeons, or other medical staff. Patients in both groups received an online questionnaire through REDCap (Nashville, Tennessee) at 1-week, 2-week, 3-week, and 4-week time points following their enrollment. This questionnaire assessed the number of times they performed exercises each week (0, 1, 2, or 3 or more), their exercise utilization rate (percentage of the exercises described that they utilized), and their confidence in performing the exercises correctly (not confident, mildly confident, moderately confident, very confident, or extremely confident) at each time point.

Statistical Analysis

A preliminary power analysis suggested a sample size of approximately 60 patients. Enrollment was concluded once statistical power reached 80%, which was met after 54 patients completed each survey. Patients were separated based on the group to which they were randomized, which included the handout group and the video group. Descriptive statistics, reported as mean and standard deviation, were compared between groups. Two-sample t tests were used for normal continuous data, and Mann-Whitney U tests were used for non-normal continuous data while chi-square tests were used for categorical data. Patients who did not respond to the survey at a particular time point were not included in the statistical comparison at that time point. All analyses were performed in R Studio Version 4.0.2 (Boston, Massachusetts). A P value of less than .05 indicated statistical significance.

Results

Of the 89 patients enrolled in the study, 71 patients responded to the initial follow-up survey (80% of randomized patients). Of the 71 patients, 54 patients (76%) completed each survey over the 4 weeks. The handout group consisted of 37 patients (response rate of 84%), whereas the video group consisted of 34 patients (response rate of 77%). There was no significant difference in response rate (P = .561), age (handout: 56.8 years, video: 55.1 years; P = .623), or sex (handout: 62.2% female, video: 58.8% female; P = .774) between groups.

For week 1, there was no difference in times per week, exercise utilization rate, or confidence with home therapy exercises between groups. There were no differences in times per week for the remaining 3 weeks that patients performed home therapy exercises. By week 2, the video group had a statistically higher proportion of patients reporting to be either “extremely confident” (35.3% vs 13.5%) or “very confident” (50.0% vs 40.5%) in their home therapy exercises as compared with the handout group (P = .031). The video group also reported higher confidence levels than the handout group for week 3 (“extremely” or “very” confident: 85.3% vs 48.6%, P = .020) and week 4 (“extremely” or “very” confident: 76.5% vs 40.5%, P = .021). No patients in either the handout or video groups reported being “not confident” in their home therapy exercises at any of the study time points. For week 2, there was no difference in exercise utilization rate (handout: 74%, video: 83%; P = .121). However, for both week 3 and week 4, the video group reported a higher percentage of exercise utilization (week 3: 80% vs 62%, P = .014; week 4: 73% vs 58%, P = .049) (Table 1). The relationship between home therapy exercise utilization rates between groups over time is graphically represented in Figure 1.

Table 1.

Home Therapy Exercise Adherence Outcomes at Each Time Point.

	Week 1			Week 2			Week 3			Week 4
Variables	Handout (n = 37)	Video (n = 34)	P	Handout (n = 31)	Video (n = 31)	P	Handout (n = 28)	Video (n = 31)	P	Handout (n = 26)	Video (n = 28)	P
Times per week			.852			.307			.388			.281
0	1 (2.70%)	0 (0.00%)		1 (3.23%)	0 (0.00%)		1 (3.57%)	0 (0.00%)		3 (11.5%)	2 (7.14%)
1	4 (10.8%)	2 (5.88%)		4 (12.9%)	2 (6.45%)		6 (21.4%)	7 (22.6%)		8 (30.8%)	4 (14.3%)
2	6 (16.2%)	7 (20.6%)		12 (38.7%)	8 (25.8%)		8 (28.6%)	9 (29.0%)		5 (19.2%)	11 (39.3%)
3 or more	26 (70.3%)	25 (73.5%)		14 (45.2%)	21 (67.7%)		13 (46.4%)	15 (48.4%)		10 (38.5%)	11 (39.3%)
Exercise utilization (%)	80 (23)	88 (17)	.454	74 (25)	83 (23)	.121	62 (28)	80 (20)	.014*	58 (32)	73 (30)	.049*
Exercise confidence			.080			.031*			.020*			.021*
Not confident	0 (0.00%)	0 (0.00%)		0 (0.00%)	0 (0.00%)		0 (0.00%)	0 (0.00%)		0 (0.00%)	0 (0.00%)
Mildly confident	5 (13.5%)	0 (0.00%)		3 (9.68%)	0 (0.00%)		3 (10.7%)	0 (0.00%)		1 (3.85%)	0 (0.00%)
Moderately confident	7 (18.9%)	4 (11.8%)		8 (25.8%)	4 (12.9%)		7 (25.0%)	2 (6.45%)		10 (38.5%)	2 (7.14%)
Very confident	17 (45.9%)	17 (50.0%)		15 (48.4%)	17 (54.8%)		11 (39.3%)	15 (48.4%)		7 (26.9%)	11 (39.3%)
Extremely confident	8 (21.6%)	13 (38.2%)		5 (16.1%)	13 (41.9%)		7 (25.0%)	14 (45.2%)		8 (30.8%)	15 (53.6%)

^*Statistical significance (P < .05) are bolded.

Figure 1.

Exercise utilization rate per week based on distribution method.

Discussion

Patients were randomized to either the handout or video group in our study. Our findings suggest that, while there were no differences in the number of times per week exercises were performed, the video group had a higher exercise utilization rate and had higher confidence that they were performing the exercises correctly. This topic is particularly interesting due to the positive impact of physical therapy exercises on patient outcomes in the hand and wrist orthopedic patient population.^7,8 As patient outcomes may be optimized with maximal adherence, it is essential to understand the role of exercise instruction in adherence to therapy.

Studies on physical therapy for the upper extremity have previously focused on functional outcomes in supervised versus home treatments, cost of therapy, and early or late therapy outcomes.^9-13 Barriers to therapy adherence have been identified before by Hickey et al, ¹⁴ which are mainly transportation and cost. Home-based therapy may be a more reasonable option for patients who lack the means to attend and pay for therapy. The format of instruction in home-based exercise therapy was previously assessed in a study of 40 randomized patients by Reo and Mercer, which found that patients who received videotaped exercise instruction for the shoulder displayed greater performance accuracy with fewer errors than those who received a written handout. ¹⁵ In our study, patient performance was not assessed by an independent observer, and instead, participants were asked the proportion of utilized exercises and their confidence level in performing the exercises correctly. We found that patients in the video group ultimately performed a higher proportion of exercises and reported greater confidence in performing them correctly. In a cross-sectional survey of 30 patients by Ouegnin and Valdes, a higher proportion of patients preferred video delivery of their home exercise program rather than paper handouts. ¹⁶ Our findings complement these studies by further supporting video format for home exercise instruction to improve patient accuracy and adherence while also accommodating patient preference.

A systematic review by Essery et al ¹⁷ analyzed different predictive factors that affect patient adherence to home-based therapies. Motivation, self-efficacy, social support, and prior history of adherence were concluded to be substantial factors that predicted adherence. Picha et al ¹⁸ developed a model to increase patient adherence solely based on the theory of self-efficacy. They recommended that physicians assess patients’ self-efficacy before designing a home exercise treatment plan, as it is a common and significant barrier to adherence. While our study design did not specifically focus on a self-efficacy model, we did assess the patients’ subjective level of self-confidence with their exercises. In light of the role that self-efficacy plays in improving adherence, we hypothesize that the video-based mode of instruction provided better clarity in learning the exercise skills and thus contributed to the increased level of confidence in performing the exercises accurately. Video-based education has been shown to be effective among patients and medical students learning clinical procedures. ¹⁹

Smartphone applications are an additional form of communication and feedback system that may be used to increase adherence. Lambert et al ²⁰ found that patients had better adherence to home exercises for upper and lower musculoskeletal injuries when provided with application-based exercises instead of paper handouts. MedBridge, a health education software company, designed an application that provided a video playlist of exercises to be completed at home, and 98% of their users reported that use of the application improved their rehabilitation. ²¹ The incorporation of application-based treatment plans provides many opportunities for increased outreach to patients, and it is a worthy future direction based on the findings in this study.

The limitations of this study are rooted in the subjective nature of the data collected. Patients may be subject to recall bias when filling out the survey and unknowingly report an inaccurate measure of their adherence. Furthermore, the orthopedic clinics performing the investigation prepared the handouts and videos, and they are not standardized by a particular orthopedic association. Patient adherence may decrease over time, but our study included the distribution of surveys at multiple time points to counteract this. However, not all patients responded at each of the selected time points. Furthermore, patients performing the exercises 3 or more times per week were grouped together and considered compliant, despite patients being instructed to perform the exercises each day. The purpose of this was to focus on differences in patients infrequently performing the exercises, as 3 or more times per week was considered satisfactory. Finally, patients recommended home therapy were randomized regardless of their diagnosis, and there was no consideration of this in the randomization process. However, there were no significant differences in demographics between patients, suggesting adequate randomization, and severe conditions were recommended formal physical therapy and thus not included in the study. Additional strengths of our study include its prospectively randomized design, high response rate, and adequately powered comparisons.

Future research may evaluate and correlate adherence with functional outcomes. Such information would provide further evidence for the clinical significance of the benefits of increased adherence to physical therapy for the distal upper extremity. Finally, patient adherence and confidence decreased over time in our study cohort. Interventions that may increase adherence, such as e-mail or smartphone reminders, may be worthy of investigation to maximize patient adherence over time. Long-term studies may also further elucidate the impact of exercise instruction on adherence and patient outcomes.

Conclusions

Overall, we found that video distribution of home therapy exercises was superior to handout distribution based on exercise utilization and confidence. This topic is of particular importance due to the impact of patient adherence on patient outcomes. Furthermore, due to the COVID-19 pandemic, telemedicine and patient convenience have become important considerations in the distribution and access of health care. Video-based distribution of home therapy exercises has been shown to result in superior patient adherence and confidence, and remains an effective distribution method moving forward.