Factors Associated With Compliance With Self-Management Home Therapies for Spine Pain: A Survey of Participants Attending a Chiropractic Teaching Clinic in South Africa

Abstract

Objective

The purpose of this study was to determine factors that affect compliance with various prescribed home therapies based on reported feedback from participants with spine pain.

Methods

This was a descriptive, quantitative, cross-sectional survey. A purposive sampling method was used to recruit 121 participants with neck and back pain attending the Durban University of Technology Chiropractic Day Clinic located in KwaZulu-Natal, South Africa. Data were collected using a self-administered questionnaire. Descriptive statistics, including frequencies and percentages, were used to summarize the data, and odds ratios (ORs) were calculated.

Results

Most participants presented with chronic pain, reporting an average severity of 6 out of 10 and little disability from the pain. Home therapy included stretches (92.2%), heat therapy (49.1%), and ice therapy (38.8%). Almost two-thirds (62.1%) of participants reported being fully compliant with the prescribed home therapy, while 32.8% reported partial compliance. The main factors that potentially affected compliance were laziness and forgetfulness. Participants who reported having depression were less compliant (OR, 0.181), while those with chronic pain were more compliant (OR, 3.74). Those who believed that home therapy would alleviate their pain were also more compliant (OR, 3.83).

Conclusion

The study found that a majority of participants with spine pain were compliant with prescribed chiropractic home treatment. Key factors that potentially influenced compliance were identified.

Introduction

Exercise therapy is a recommended treatment approach in most back pain guidelines.^1,2 Chiropractors frequently prescribe home-based therapies, including exercise for patients with spinal pain, to help reduce pain and rehabilitate the patient.^{3, 4, 5, 6, 7, 8} These home therapies include exercises to strengthen weak muscles, stretches for tight muscles, heat and ice therapy for affected muscles, and ergonomic advice. These instructions are usually given verbally and demonstrated during a consultation, with sometimes written, printed, or electronic instructions with the expectation that patients will follow through with the prescribed regimen at home.

Poor compliance with prescribed treatment regimens has been noted as a serious problem for patients in various settings.⁹ Studies have generally reported on compliance with prescribed home exercise regimens.^{10, 11, 12} In 1 study, there was a 40% to 50% dropout rate within 6 months to a year, with an estimated 64% of patients complying with short-term exercise regimens and only 23% persevering with long-term exercise.¹⁰ Noncompliant patients generally had lower levels of prior physical activity compared to those who complied with the treatment regimen.^10,11 Worsening pain during the exercise regimen was also cited as a barrier for compliance. These studies have largely been conducted among patients seeking physiotherapy.^11,12

Other factors that negatively affect compliance include low self-efficacy, depression, anxiety, helplessness, poor social support, and a lack of time.^11,12 Although social support has a positive impact on the physiotherapy treatment, it did not improve compliance with the prescribed home treatment.¹² Many of these factors reflect a lack of confidence to overcome the pain.¹¹ Communication and economic barriers, the health status of the patient at the time of prescribing exercise, and lack of community physical resources have also been cited as barriers to complying with home exercise programs.¹⁰ It has also been reported that patients lack the basic background knowledge regarding importance of home therapy, particularly after the pain has subsided.¹²

Although exercise has been reported as an effective intervention for the treatment of back pain,¹² other options, such as heat and ice therapy, could be considered as home treatment options, as these can also alleviate pain.¹¹ Exercise regimens commencing at low intensity levels with gradual incremental increase in intensity could be useful in encouraging patients to commence and adhere to this form of treatment.¹¹ Providing the patient with various options from which to choose may also benefit compliance.¹⁰

Within the chiropractic profession, little research has been done in determining the proportion of patients who are compliant with chiropractic home exercise recommendations in both short- and long-term management of spinal pain and investigating factors that influence noncompliance. We could find only 1 study on chiropractic that reported on home exercise regimens,¹⁰ despite chiropractors prescribing other forms of home treatment such as ice and heat therapy.

The purpose of the present study was to determine the factors that potentially influenced chiropractic patient compliance with prescribed home therapy. The secondary aim was to identify the types of home therapy prescribed and to measure compliance based on reported feedback from patients.

Methods

This study was a descriptive, quantitative, cross-sectional survey that was conducted by means of a survey.

Ethics

Ethical approval was received from the Durban University of Technology Institutional Research Ethics Committee (IREC 113/18). Patients consented to participate by completing an informed consent form after information was provided to them by the researcher through a letter of information.

Survey

The literature prompted the development of the relevant questions in the survey,^{11, 12, 13, 14} which comprised the following 4 sections: demographics, clinical data, chiropractic advice (which detailed the types of home therapy prescribed), and compliance to home therapy (see questionnaire). A focus group discussion comprising 6 members (researchers and peers) was held. The focus group interrogated the questionnaire for validity, and recommendations were made to strengthen the questionnaire. A pilot study was conducted among 4 participants who met the inclusion criteria and were subsequently excluded from the main study. No changes were made to the questionnaire after the pilot study, as the pilot study participants understood all the questions. No grammatical or other errors were found.

A purposive sampling method was used by the researcher to recruit participants seeking treatment at the Durban University of Technology (DUT) Chiropractic Day Clinic (CDC) in KwaZulu-Natal, South Africa. The DUT CDC is the only chiropractic teaching clinic in KwaZulu-Natal, with an average of 420 spinal pain patients per month seeking treatment. Treatment is provided to patients by senior chiropractic students under the supervision of and training by a chiropractor. A sample size of 111 was calculated using the Raosoft sample size calculation software, with a 95% confidence level and an 8% margin of error. Data were collected from 121 participants, and all were included in the analyses.

Inclusion criteria comprised those with spinal pain who were above the age of 18 years and visiting the clinic for the second or subsequent visit. The participants were approached directly by the researcher, who explained the topic with the use of the letter of information. Those who agreed signed informed consent and were presented with the questionnaire to complete. This was a self-administered questionnaire, and participants were not aided in any way in answering the questions.

The data from the questionnaire regarding the type of self-management prescribed were recorded on the researcher's data sheet and compared with the participants’ subjective, objective, assessment, plan, and education (SOAPE) note. It was then confirmed if the patient's response was in accordance with the instructions given by the consulting senior chiropractic student.

Data Analysis

Data were collected from April 2019 to November 2019 and were analyzed by a biostatistician using IBM Statistical Package for the Social Sciences (IBM Corp), version 26. Descriptive statistics such as frequencies, percentages, medians, and interquartile ranges were used to summarize the data. The data were analyzed using the McNemar-Bowker χ² tests. Odds ratios (ORs) were calculated where appropriate.

Factors associated with compliance were screened from the responses on the questionnaire. Participants were asked their reasons for noncompliance that they could respond freely as well as select potential reasons on the questionnaire (eg, cost of buying specific products, not understanding how to perform the home therapy, laziness, too time-consuming, a lack of space, difficulty in keeping to the schedule, lack of confidence in the therapy, an experience of pain while performing the therapy, forgetfulness, among others). Those that showed an association at the univariate level at P < .05 were selected for logistic regression modeling. All factors were entered singly into a model, and crude ORs and 95% confidence intervals (CIs) were reported. Secondly, all factors were entered into the model together, and adjusted ORs and 95% CIs were reported. Thirdly, a backward selection method based on likelihood ratios was used to eliminate nonsignificant variables from the model until only significant variables remained.

Results

Demographics

Ages 21 to 25, 41 to 50, and older than 60 years were the most highly represented age groups. The age distribution was as follows: 18 to 20 years (4.1%, n = 5), 21 to 25 years (17.4%, n = 21), 26 to 30 years (15.7%, n = 19), 31 to 35 years (6.6%, n = 8), 36 to 40 years (9.1%, n = 11), 41 to 50 years (18.2%, n = 22), and over the age of 60 years (17.4%, n = 21). There was an equitable representation of men (50.4%, n = 61) and women (49.6%, n = 60). There was a greater proportion of Indian (people of South Asian descent) participants represented in the study (41.3%, n = 50), followed by Black participants (people of African descent) (28.9%, n = 35), White participants (people of European descent) (22.3%, n = 27), participants of mixed race (6.6%, n = 8), and Asian participants (0.8%, n = 1).

Clinical Data Extracted From Survey

Among the participants, 58.7% (n = 71) had neck pain, 47.9% (n = 58) had pain in the thoracic region, and 61.2% (n = 74) had low back pain, with many participants reporting pain in more than 1 region. The majority of participants (87.6%, n = 106) previously experienced the same type of pain. Most reported chronic pain (61.2%, n = 74), with subacute and acute pain being experienced by 22.3% (n = 27) and 16.5% (n = 27) of participants, respectively. A third (33.1%, n = 40) of participants had more than 4 clinic visits for the same complaint, while 38% (n = 46) visited the clinic twice, 24% (n = 29) 3 times, and 5% (n = 6) were at their fourth visit to the clinic, for the same problem.

With regard to the debilitating nature of their pain, most of the participants reported no disability (70.2%, n = 85), while only 28.9% (n = 35) reported some disability due to the pain. On a scale of 1 to 10, the average pain score was 6, and the average disability score was 2.

Home Therapies

Overall, 95.9% (n = 116) of participants reported that they were prescribed home therapy by a chiropractor. Only these 116 participants who were prescribed home therapy were included in the rest of the analysis.

Table 1 shows the home therapies that were reported by patients who responded to the survey. The most frequent was stretches (92.2%, n = 107), followed by heat therapy (49.1%, n = 57). The amount of home therapy reported was prescribed twice daily (44.8%, n = 52), followed by 31% (n = 36) once a day, and 20.7% (n = 24) were prescribed 3 times a day. Only 3.4% (n = 4) were prescribed home therapy 2 to 3 times a week. Most participants were advised to continue home therapy for 3 weeks or more. All participants (100%) said that they understood the home therapy that was prescribed to them, and 97.41% rated their chiropractor 10 out of 10 for their ability to explain the home therapy.

Table 1.

Type of Prescribed Home Therapies as Reported by Patients (n = 116)

Type of Home Therapy Prescribed	n	%
Stretches for the affected muscles	107	92.2
Heat therapy	57	49.1
Ice therapy	45	38.8
Posture correction	41	35.3
Abdominal (core) strengthening exercises	40	34.5
Strengthening of affected muscles	39	33.6
Workplace advice	16	13.8
Uncertain	1	0.9

Participants were asked about their compliance with home therapy in several questions relating to its performance as prescribed, its duration, and frequency. Full compliance was self-reported by 62.1% (n = 72) of the participants. About one-third of participants (32.8%, n = 38) were partially compliant, and 5.2% (n = 6) were not compliant with the prescribed home therapy.

A significant difference (P < .001) was noted with the home therapy advice given when comparing the participant's file to the SOAPE note. It was revealed that 78.5% of participants reported receiving strengthening home therapy, while the SOAPE note only indicated 2.5%. Data revealed that 29.8% reported receiving ice therapy, while only 5.8% was recorded on the SOAPE note; 31.4% reported receiving heat therapy, while the SOAPE note only recorded 14%; core strengthening was recorded as 20.6%, while the SOAPE note only recorded 10.7%.

Factors Affecting Compliance

Table 2 lists the reasons that participants cited for noncompliance to the prescribed home therapy. Table 3 indicates the factors associated with compliance with home therapy. Bivariate analysis indicated that participants with chronic pain were more likely to be compliant with the home treatment than those with acute pain. Multivariable analysis, which was adjusted for each of the factors in the bivariate model, showed no association of any of the factors to compliance with home therapy.

Table 2.

Patient Self-Reported Factors Attributed to Noncompliance of Home Therapy

Patient Self-Reported Factors	n	%
Laziness	38	32.75
Forgetfulness	33	28.44
Difficulty keeping to the schedule	16	13.79
Time consuming	9	7.75
Regular activities are an adequate substitute to home therapy	8	6.89
Lack of space to perform the home therapy	4	3.44
Cost of buying specific products	1	0.86
Pain while performing the home therapy	1	0.86
Feeling better after being treated	1	0.86
Lethargy	1	0.86
Did not have pain all the time	1	0.86

Table 3.

Patient Self-Reported Factors Associated With Compliance to Home Therapy

Patient Self-Reported Factors	OR (95% CI)	P Value
Duration of pain
Acute	1.00
Subacute	1.964 (0.583-6.615)	.276
Chronic	3.741 (1.276-10.973)	.016*
Depression	0.181 (0.035-0.941)	.042*
Type of home activity prescribed	3.632 (0.859-15.349)	.079
Belief in home therapy	3.832 (1.185-12.392)	.025*
Chiropractor assessing home therapy	2.283 (0.924-5.639)	.074
Disability from pain	0.911 (0.801-1.036)	.157
Chiropractors’ ability to explain home therapy	1.264 (0.936-1.706)	.126
Satisfaction with home therapy	1.169 (0.911-1.502)	.733

CI, confidence interval; OR, odds ratio.

^⁎Statistically significant.

Discussion

This study showed that almost two-thirds of chiropractic participants were fully compliant with prescribed home therapies. Those who were not compliant reported reasons that they were either lazy or had forgotten to perform the home therapy.

Of all participants, approximately one-third visiting the clinic on more than 1 visit were over the age of 50 years. This is consistent with previous studies that reported the likelihood of low back pain severity increasing with age^{15, 16, 17, 18, 19, 20}; hence, these patients were more likely to seek treatment compared to younger patients. It is noted that well over half the participants had chronic pain, thus substantiating their recurrent visits to the clinic.

A mean of 6 was reported regarding severity of pain and 2 for disability caused by the pain. Pain intensity and disability from pain gradually decreased after completion of interventions using both home therapy and education, demonstrating the importance of a combination of home therapy with brief education.²¹

Our results show that participants received various forms of home therapy, including stretching and strengthening of the affected muscles, posture correction, workplace advice, abdominal (core) strengthening exercises, ice therapy, and heat therapy. The most frequent (>90%) of these was stretching. This corroborates the findings of Carlesso et al, who found that 98% of chiropractors and physical therapists prescribed stretches for affected muscles.⁶ However, chiropractors in Denmark and Australia preferred prescribing therapy using strengthening techniques,^5,7 which were only prescribed to over one-third of the participants in the present study.

Therapy to improve posture was only prescribed to just over one-third of the study population, in contrast to chiropractors in the United Kingdom prescribing this to almost all their patients.⁸ Incorrect posture results in muscle imbalances, causing some muscles to be in a constant state of contraction while other opposing muscles remain weak and overstretched, which could lead to pain.²² This should be emphasized by all chiropractors. Muscle resistance, as well as contraction, can be improved using heat therapy, which was prescribed to almost half of the participants.²³ However, this did not seem to be favored in other areas of the world.^4,7 Nevertheless, the home therapies recommended to participants in this study were in line with those highlighted in a prior study.²⁴

Compliance with home therapy among the study participants was generally good, with almost two-thirds reporting full compliance and roughly a third partially compliant. Another study reported an estimated 40% to 50% dropout rate within 6 to 12 months.¹⁰ The latter study also noted that 64% of the patients comply with short-term home therapy regimens, but only 23% persevere with long-term therapy.

Laziness, forgetfulness, and difficulty in adhering to a schedule were self-reported as potential reasons for defaulting on the home therapy. This could be overcome by sending patients reminders in the form of text messages. This type of intervention improved adherence to home therapy by 6-fold in another setting.²⁵ Supervision by caregivers was also reported to improve compliance.^26,27 This will be of particular importance for older patients but will require caregiver education regarding home therapy.

A study conducted in Argentina found that pharmacological adherence for treatment of diseases like rheumatoid arthritis and ankylosing spondylitis was much higher than adherence to home therapy.⁵ An Australian study reported that nonadherence to home rehabilitation was either comparable to or higher than nonadherence to medication.²⁸

The present study found that patients with chronic pain reported having better compliance with home therapy. In contrast, a prior study found that 70% of patients with chronic low back pain did not engage in home exercises prescribed by physiotherapists.²⁷ These practitioners prescribe similar home therapy to chiropractors, which includes exercises, stretches, muscle strengthening activities, as well as heat therapy.^29,30 The possible reasons for better compliance among participants with chronic pain at the DUT CDC could be similar to those identified by Robinson et al and include reduced pain levels, improved mood, satisfaction with the care, perceived control of the pain, and perceived benefits of the home therapy.³¹

Our finding that those who had a positive outlook (ie, those who believed that home therapy would be useful) were more likely to be compliant corroborates with the findings of Medina-Mirapeix, who reported that patients who did not believe in the effectiveness of the active-care component of patient management were less likely to adhere to the program.¹² Another study also reported that adherence to exercise increased when participants perceived the benefits of home therapy.²⁶

Depression was 1 of the potential factors that significantly reduced patient compliance with home therapy. Depression was also negatively associated with compliance with home therapy prescribed by physiotherapists.¹¹ Among patients experiencing depression, the ability to self-manage pain may be more challenging, leading to reduced self-efficacy and lowered self-management efforts.³² Other studies also identified depression in discontinuing physical activity programs.^33,34

Additionally, we report that laziness and forgetfulness were the main potential reasons provided for noncompliance. Similarly, these factors were documented by Medina-Mirapeix et al, who also identified barriers which included the lack of time to exercise and adverse effects of the activities, such as pain.¹² The latter authors further stated that effective resources to overcome barriers, such as a lack of space to exercise, included attending recreational centers, helped adherence.

It is noted in the literature that the amount of prescribed home therapy affects adherence and that the greater amount of home therapy that is prescribed, the lower the adherence as patients felt overwhelmed. Along with the complexity of the program, the more complicated the exercise, the more unsure the patient was, leading to reduced adherence.³⁴

The results of this study also demonstrate incongruence between the patients’ report on home therapy advice received versus what was documented in the SOAPE note. This could be due to under-reporting on the SOAPE note, possibly due to inadequate space on the form. A similar problem was noted in a qualitative study that looked at the perceptions of undergraduate dental students in Uganda regarding patient record keeping. In the reported study, 3 major themes emerged, including poorly designed clerking forms (with inadequate space for recording all clinical notes for the patient), inadequate storage space, and poor maintenance of records.³⁵ A problem of incomplete or incorrect documentation was also reported in other studies. In a study identifying patterns and frequency of documentation errors on SOAPE notes among candidates who failed the Comprehensive Osteopathic Medical Licensing Examination in the United States, it was found that a total of 662 errors were recorded among these candidates due to misrepresentation in history taking and physical examination on the SOAPE note.³⁶ These errors could adversely affect patient care. As recommended by Kutesa and Frantz, the authors encourage an electronic system at the DUT CDC as an ideal solution to the problems arising from paper-based record systems.³⁵

Limitations

This cross-sectional study assessed compliance via reported feedback from participants and, hence, was not an objective measurement. A longitudinal study assessing compliance over a period of time may yield more accurate results. Data on the education level of the participants were not collected, and this could have yielded better insight as to the patient's understanding of the instructions regarding home therapy. Additionally, the measure of disability from pain reported by participants was subjective and not based on a validated scale, which limits the precise understanding of pain.

The small sample size and the study being confined to a single practice imply that the results cannot be generalized to all regions in South Africa. Further studies that include more practices in other areas of the country are required.

Furthermore, the findings in this study relate to compliance within the ambit of a training facility and may not necessarily be the same for patients attending a chiropractic practice outside of a training environment.

Conclusion

Two-thirds of participants with spine pain attending the DUT CDC self-reported that they were compliant with the home therapy prescribed. Participants mainly cited laziness and forgetfulness as potential reasons for noncompliance. Those who were depressed were also less likely to be noncompliant. Chronic pain and the belief that home therapy would help alleviate the pain improved compliance.

Funding Sources and Conflicts of Interest

Funding was provided by Durban University of Technology. No conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): D.M.

Design (planned the methods to generate the results): Y.T., D.M., F.H.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): Y.T., F.H.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): D.M.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): D.M., Y.T., F.H.

Literature search (performed the literature search): D.M.

Writing (responsible for writing a substantive part of the manuscript): Y.T.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): F.H.

Practical Applications.

• •We evaluated factors that might influence patient compliance with home therapies from participants with spine pain.
• •A majority of participants reported being fully compliant with the prescribed home therapy. The main factors that potentially affected compliance were laziness and forgetfulness. Those who believed that home therapy would alleviate their pain were more compliant.
• •Most patients with spine pain were compliant with prescribed chiropractic home treatment.

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