How do non-specific back pain patients think about their adherence to physiotherapy, and what strategies do physiotherapists use to facilitate adherence? A focus group interview study

ABSTRACT

Background

Long-term effectiveness of physiotherapy (PT) for low back pain (LBP) depends on the adherence of patients. Objectives: (1) Identify aspects associated with the adherence of patients with LBP to physiotherapy, and (2) identify factors to facilitate adherence of patients with LBP to PT.

Method

Focus group interviews were conducted with 10 patients with LBP (n = 10, 5 women) and 11 physiotherapists (5 women) from Germany and Switzerland, treating patients with LBP. Data analysis was based on structured content analysis. Deductive and inductive categories were identified and coded.

Results

Patients with LBP requested more and effective home programs, long-term rehabilitation management, and individualized therapy to achieve a higher level of adherence. Physiotherapists requested more time for patient education. Communication, quality of the therapist-patient relationship, and individualized therapy were identified as essential factors by both representatives.

Conclusion

Patients and physiotherapists identified aspects contributing to adherence. These may guide the development of multidimensional measurement tools for adherence. In addition, this information can be used to develop PT approaches to facilitate the level of adherence.

Introduction

Managing low back pain (LBP) is a multidimensional treatment process addressing cognition, function, and pain to reach long-lasting effects and reduce the risk of chronicity [1,2]. The level of program adherence is essential for the long-term management of non-specific musculoskeletal pain [2,3]. For the self-management of patients, a high level of adherence is needed [4]. The term ‘adherence’ replaces the formerly used concept of ‘compliance’ describing whether patients follow the advice of the physician or healthcare professional. Adherence is based on intrinsic motivation [5–7] and is often measured by counting the frequency and duration of home exercise performance or medication use or the number of attended treatment sessions, or by assessing behavior change [8]. Adherence to physiotherapy (PT) and PT-based home programs (HP), e.g. specific exercises, requires multifaceted behavior change. Issues such as a lack of motivation, need to be considered before they turn into barriers [9–13]. Furthermore, the professional knowledge of physiotherapists and their beliefs may influence the adherence of patients to PT. This includes the knowledge and use of national care guidelines, communication competencies, and behavior change strategies [14–17].

Current evidence supports that patient adherence can be influenced positively and negatively and that different treatment strategies may have different effects on adherence [9–17]. In a previously conducted systematic review, our workgroup found that no tools for the measurement of adherence exist, which capture its multidimensional nature. The multidimensional measurement is based on the biopsychosocial approach, such as the motivation of the patients, their trust in the PT, and the quality of the therapist-patient relationship, but also the comprehensibility of the exercises, enough appointments, etc. The most common way of measuring adherence in patients with LBP was by counting and recording exercise sessions, e.g. in diaries. The review also highlighted that no specific strategies have been developed, yet, that specifically facilitate the adherence of patients with LBP to PT [18]. A specific strategy to facilitate adherence in patients with LBP is based on the high relevance of psychosocial factors in back pain and expertise appropriate for LBP [1,2]. In other studies, the locus of control (LOC) has also been shown to influence adherence [19,20]. In PT patients, the internal locus of control (ILC) means that they are motivated to perform exercises and accept the recommendations of the physiotherapist. External locus of control (ELC) represents the expectation of patients to avoid active approaches, which may increase the risk for a PT dependency [20,21].

This current study aimed (1) to identify aspects associated with the adherence of patients with LBP to physiotherapy, and (2) to identify factors to facilitate adherence of patients with LBP to PT.

Methods

Focus group interviews based on a qualitative research approach were chosen to explore the perspectives of patients with LBP and physiotherapists. For study development, we used the COREC checklist [22]. The ethics committee of the University of Lübeck approved the study protocol (registration no.: 2022–457). The study protocol was registered on Open Science Framework: https://osf.io/48jhv/.

Qualitative research was used because there was a lack of sufficient research on this topic [23]. The focus group discussion allows for group dynamics that can lead to clarification of individual arguments, opinions, beliefs, and expectations that can be beneficial to understanding the research subject. For this purpose, a total of two focus groups were formed, consisting of either physiotherapists (PTG) (n = 11) or patients with LBP (PG) (n = 10). If the number of participants was too high, the risk of data loss would increase due to the possible dominance of some, and less speaking-up of other participants [24]. The interviews were semi-structured and followed a predesigned interview guide.

Sampling and recruitment

Patients were informed of the study by flyers placed in participating PT centers and physiotherapists were recruited via digital flyers posted in PT groups on social media. The PG included 10 patients from four PT centers in Switzerland and Germany with different characteristics (Table 1). Different recruitment centers were chosen to increase the diversity of responses. LBP was defined as lumbar pain that has been constant or recurrent for at least six months [1]. Exclusion criteria were patients with red flags, e.g. tumors, neurological diseases, spinal diseases, such as ankylosing spondylitis, the use of other therapies and medications, and patients suffering from cognitive or mental disorders.

Table 1.

Characteristics of patients with low back pain.

ID	Age (y)	Gender	Profession	Position	Professional qualification	Duration of LBP (month)	Other complaints	Smoker	Sport activity	Children (ages in years)	In a relationship
P01	53	f	Teaching	Employee	Diploma	Recurrent	Epicondylitis	No	≥1/w	17, 22, 24	Yes
P02	34	f	Office	Team Leader	B.Sc.	≥6	None	No	<3/w	None	Yes
P03	38	f	Office	Employee	M.Sc.	Recurrent	None	No	≤3	7, 7, 3	Yes
P04	33	m	Office	Manager	M.Sc.	Recurrent	Asthma	Yes	≥1/w	3	Yes
P05	24	f	Office	Public Health	B.Sc.	Recurrent	None	No	≤3	None	No
P06	34	m	Office	Employee	Diploma	Recurrent	None	No	≥1/w	1, 6, 11	Yes
P07	60	m	Office	Self-employed	M.Sc.	Recurrent	None	Yes	≥1/w	28, 31	No
P08	28	m	Education	Student/employee	B.Sc.	≤1	None	No	≤3/w	None	No
P09	41	m	Other	Self-employed	Diploma	Recurrent	Shoulder and knee pain	No	≤3/w	18, 10, 3	Yes
P10	26	f	Other	Employee	B.Sc.	Recurrent	None	No	≤3/w	None	Yes

B.Sc. = Bachelor of Science; f = female; LBP = low back pain; m = male; M.Sc. = Master of Science; w = week; y = years.

Physiotherapists were recruited, who treat patients with LBP regularly and have at least two years of clinical experience in the musculoskeletal field. This was regarded as a sufficient period of professional experience to develop patient adherence strategies. The PTG included 11 physiotherapists with different characteristics from the same centers as the patients (Table 2).

Table 2.

Characteristics of physiotherapists.

PTG1	Age (y)	Gender	Qualification	Experience as aphysiotherapist (years)	Position	Setting	Postgraduate Training
PTG01	31	f	B.Sc.	<5	Employee	Private practice	BWT (KGG)
PTG02	38	m	Diploma	>10	Employee	Private practice	COM, CBT, EP, MC, BWT
PTG03	38	f	B.Sc.	>10	Self-employed	Private practice	COM, MI
PTG03	36	f	M.Sc.	>10	Employee	Private practice	BWT, MC
PTG04	23	m	Diploma	<5	Employee	Private practice	COM, MI
PTG05	38	f	Diploma	>10	Self-employed	Private practice	COM
PTG06	28	f	B.Sc.	<5	Employee	Rehabilitation Center	None
PTG07	25	m	Diploma	<5	Employee	Private practice	COM, MI
PTG08	50	m	M.Sc.	>10	Self-employed	Private practice	COM, MI, EP, MC, BWT
PTG09	25	m	Diploma	<5	Employee	Private practice	None
PTG10	32	m	Diploma	>5	Self-employed	Private practice	COM, CBT, EP, BWT

B.Sc. = Bachelor of Science; BWT = functional movement therapy; COM = communication; EP = explain pain; f = female; KGG = machine assisted training; LBP = low back pain; m = male; MC = motor control; MI = motivational interviewing; M.Sc. = Master of Science.

We expected that different opinions would prevail in the context of adherence of patients with LBP, e.g. between older/younger, active/non-active, or male/female patients with more acute/chronic back pain. Regarding the activity level of the patients, it should be noted that active patients are also likely to have fewer problems performing their HPs (Table 1). Among physiotherapists, it was expected that professional experience and preferences toward passive or active treatment approaches might influence responses. Therefore, it was taken care to include physiotherapists with heterogeneity regarding e.g. age, gender, duration of symptoms, and experience in treating patients with LBP (Table 2).

Data collection methods

Data were collected between the first of October and the twelfth of November 2022. The focus group interviews were planned as face-to-face group discussions in PT clinics or digitally via Webex audio meetings. The participants could choose which version they preferred. All participants have chosen the digital setting. Only audio recordings were used. Consent forms and information were emailed to participants before the start of the research project for full disclosure. The interviewer used an interview guide to ask all questions related to the predefined aspects. The task of the interviewer was to encourage the participants to interact in the discussion and formulate their opinions. Interaction between the participants was encouraged.

The interview guide was semi-structured and focused on the goal of the conversation. For this purpose, introductory questions and guideline questions were prepared in advance. In addition, ad hoc and prompting questions were asked. The interviewer attempted to generate episodic knowledge with regular narrative prompts [25].

After the interviews were conducted, the interviewer immediately filled out an interview protocol in which self-perception, situational aspects of the interview, conversation content before and after the interview, the focus within the interview, initial interpretation ideas, and special features were recorded.

Data analysis

A simple transcription system was used, as the focus was on the content of the data [26]. The analysis was based on predefined deductive categories which were derived from the existing literature and previously unknown inductive categories [27] (Table 3). Different patient or physiotherapist-related aspects observed in the data (e.g. the expectation of a patient with LBP in the category ‘ILC’) helped to define the deductive categories (Table 3).

Table 3.

Predefined deductive categories.

Aspects	Categories	References
Predefined deductive aspects and categories for patients
Motivation, reminders, expectation	External locus of control (ELC)	[19–21]
	Internal locus of control (ILC)	[19–21]
Therapist – patient, patient-doctor	Cooperation	[9,12,]
Insurance, institution	Circumstances/bureaucracy	[6]
Therapy program, HP	Therapy content	[18,28,]
Assistance from people (e.g. colleagues, family)	Social situation	[11,13,29,,]
Predefined deductive aspects and categories for physiotherapists
Motivation, courage, relevance	Ambition	[12,13,]
Evidence, knowledge of guidelines, intuition, clinical relevance	Knowledge	[14–18,,,,]
MT, active therapy, CBT	Professional orientation	[16]
Therapist – patient, motivation of patients, expectation of patients	Relationship	[9,12,]
Insurance, social support, leadership	Management	[11,13,29,,]

B.Sc. = bachelor of science; CBT = cognitive behavioral therapy; ELC = external locus of control; HP = home program; ILC = internal locus of control; M.Sc. = master of science; MT = manual therapy.

Each statement was coded to fit into either one of the predefined deductive categories or used to develop a new inductive category (Table 3). When different words contained the same word sense in their respective contexts, such as ‘digital therapy programs’ and ‘apps,’ ‘motivation’ and ‘desire,’ ‘evidence’ and ‘science,’ ‘massage’ and ‘manual therapy’, they were assigned to the same category. Evaluative words that could also be understood as an accusation or provocation were not considered in the data analysis. In such cases, the statement was not used for agreement with a deductive category or to identify an inductive category. Irrelevant words that had no meaning for the research questions were ignored.

The entire research process was continuously reflected by the researchers involved.

The inductive categories that emerged, were based on responses of the interviewed participants which did not fit into the deductive categories. These included: criticism of the patients toward their physiotherapists or physiotherapists being concerned about treatment expectations raised by other healthcare professionals. For this purpose, the transcript was used as well as field notes, and recurring information on the same topic was recorded in a log (protocol). Only statements and categories related to their influence on the adherence of patients with LBP were used for category building.

Results

Patient group results

In the PG (n = 10, 5 women), eight patients had recurrent back pain, one had a duration of pain of more than six months and one had back pain for less than one month. Five patients worked in an office, two were employees. The average age was 37.5 years (Table 1).

Overall, there was almost homogeneous participation (all participants answered all questions). There were rarely contradictions among the participants but sometimes additions were offered to the answers and experiences of one or more participants. All deductive categories detailed in Table 3 were identified in the group discussion.

The patients explained that the willingness to accept effort on the part of the PT was important in promoting their ILC. They stated, ‘When I go to PT, I want explanations to understand my problem and methods I can use myself to relieve my back pain.’

In the context of ELC, the participants also clarified their expectations of PT, stating, ‘I think my physiotherapist needs to fix my back until it’s pain-free before I can do anything else.’

The participants indicated that the quality of the relationship between them and their physiotherapists was important to implement the recommendations of the physiotherapist. They stated that competence and seriousness were relevant to relationship quality, ‘I want a competent physiotherapist who listens to me and respects me and my problems.’

The patients indicated that the simplicity of the exercises and the comprehensibility of the information and recommendations provided by the physiotherapist helped them to stay adherent. They stated, ‘If I feel overwhelmed by the therapy content, I lose confidence in my therapist and reduce the practice of PT suggestions, like HP.’

Various and regularly adjusted HP helped the patients to stay adherent in the long term. They said, ‘The variation of exercises and methods within the PT or the HP keeps me more motivated to do it.’

Six inductive categories: implementation of recommendations, the critical comments of patients with LBP about their physiotherapists, patient concerns about HP, perseverance in the PT process, the job situation of patients with LBP, and digitalization were extracted from the data.

a) Implementation of recommendations

This inductive category was developed mainly from patient responses to questions about the HP. Arguments from the patients consistently referred to the ‘simplicity’ of the exercises and, in addition, to the feasibility of implementation in terms of time. They stated, ‘I find the exercise quite difficult and can’t remember how to practice it perfectly at home. I need more practice time and explanation to optimize it.’

For the long-term adherence to recommendations from the PT, ‘variations’ (versatility) were explained as relevant to keep up the motivation. One of the participants stated that recommendations from PT on behavioral changes regarding professional and/or personal life were never given. ‘Pain increase’ during PT and HP was also frequently stated as a limiting criterion.

b) Critical comments of patients with LBP about their physiotherapists

The patients stated frustration about their PT, ‘I’ve never had an HP! I often feel like I am being treated on an assembly line. There were no goals formulated. I did not receive methods that suited my personal situation. I miss an effective and well-controlled aftercare program.’ These aspects also influenced the motivation of patients for their HP, if provided. Some patients also criticized the lack of questions from the therapists, such as how they would cope with the HP or what exactly is important to them.

c) Patient concerns about HP

A statement representing this category was, ‘In the PT, I am often worried about the time pressure. If I do not know whether I am doing my exercises or my HP correctly, I worry that I will hurt myself or the pain will get worse. Hence, I prefer not to do it.’ These worries influenced patients’ adherence negatively because it stopped them from practicing their HP. Participants mentioned additionally that a lack of therapy time increased their worry about misunderstanding exercises or recommendations.

d) Perseverance in the PT process

This inductive category was illustrated by statements from patients who requested more individualized load management, and exercises that fit into their professional and home life. They said, ‘For a long-lasting participation in PT and a long-term practice of the HP, I need load-management adapted to me and my lifestyle, e.g. my preferred sports. I often lack the ability to integrate exercises or recommendations from my physiotherapist into my professional and personal life.’

e) Job situation

The inductive category job situation was discussed at length, especially by those participants working in an office. The patients explained that workplace factors such as ergonomic equipment, time off for medical appointments, and prevention programs influenced their adherence. They stated, ‘If I could just get time off for PT for acute back pain, I would find that helpful to realize PT. In my work, there are prevention programs for back pain, but they tend to have a half-hearted approach.’

f) Digitalization

None of the respondents had experience with digital therapy programs, but all agreed that they would use it if it was varied, effective against their back pain, and easy to implement. The participants could imagine digital programs to be beneficial for their adherence to HP. However, important properties of such software programs were proposed: data volume (memory space) was an issue, as well as the variation of the content, and the reminder function. They stated, ‘For me, apps are interesting and I think they would also have great potential in PT, especially for staying motivated and sustaining effectiveness.’

Physiotherapist group results

In the PTG (n = 11, 5 women), the participants had an average experience of treating patients with LBP of more than eight years. Five had an academic degree, all worked in a private PT center and the average age was 33 years (Table 2).

All participants engaged in the discussion. There was often agreement on responses and a high level of expertise was demonstrated because all answers indicated a good knowledge of patient adherence. All deductive categories that were anticipated prior to the focus group discussions emerged during the interviews (Table 3).

The physiotherapists indicated that evidence is the most relevant component of professional competence. They stated, ‘For me, expertise consists of knowledge of national healthcare guidelines and evidence.’ In addition, the benefits of using expertise from other disciplines were explained, ‘I use information from other disciplines related to adherence, such as psychology, to enhance my knowledge’.

Most of physiotherapists preferred active PT to treat patients with LBP, at least toward the end of PT. They stated, ‘Primary, I use active strategies to treat patients with LBP and if that is not completely possible, I supplement with manual techniques. If patients have too high expectations for passive therapy, I start my therapy with manual techniques.’

The psychosocial approach was mentioned in relation to the management of PT. Participants indicated that these optimize the adherence of patients to PT and, in the long term, to HP. They stated, ‘It’s important to understand how the patients think and what beliefs guide them. Once I figure that out, I can motivate the patients individually to improve their sustainability in PT.’

There were five inductive categories: elements facilitating adherence, treatment expectations raised by other health professionals, leadership quality of physiotherapists, communication in PT, and use of digital applications.

a) Elements facing adherence

The physiotherapists explained that goal setting, trust building, respecting the level of disability, and asking patients about expectations from PT are relevant strategies to facilitate adherence of patients with LBP. They stated, ‘In my opinion, the basis for adherence is building confidence, a relationship, sympathy, goal setting, and assessing the patient’s level of disability.’ The physiotherapists suggested documenting therapy success to stimulate adherence and to use questionnaires to promote reflection, asking questions for a better understanding of barriers. They argued, ‘The most important thing for adherence is to read between the lines and to listen to what the patient is saying. For me, adherence-enhancing therapy includes a lot of education, coaching, and communication’. They further perceived themselves as role models for e.g. an active lifestyle.

b) Other health professionals influencing expectations from treatment

This inductive category was based on statements from physiotherapists, that LBP patients were influenced by other PT colleagues and physicians who limited the trust of patients in their PT. They argued, ‘My ambitions drop when patients believe their doctors more than me and think they would know everything better.’ Sometimes also family members or other peers can make it difficult for patients to remain adherent to PT. This creates difficult situations for the PT. The physiotherapists stated, ‘If patients have been given wrong advice from a scientific point of view and are suffering from those wrong beliefs, I always try to talk to the responsible person about it.’

d) Leadership quality of physiotherapists

This inductive category was developed following statements about the importance of teaching patients and showing them expertise as physiotherapists to reduce negative or false expectations. Participants reported that negative expectations and ill beliefs negatively influence adherence. They stated, ‘I think, it is not only the expectation of the patients but also the expectation from us to the patients that create adherence based on effective strategies.’ The enforcement of the therapy was also mentioned by the participants. They argued, ‘We have to enforce effective therapies in a gentle and understandable way for our patients because we are the experts.’

e) Communication in physiotherapy

Most of the information about the patients, their beliefs, and behaviors is provided during the patient interview at the beginning of PT. The physiotherapists named patient encouragement and high levels of communication as methods to influence social support. They stated, ‘In my experience, communication can directly affect adherence. It gives you the chance to reduce misunderstandings and learn how to improve yourself.’

f) Digital tools used by physiotherapists

Regarding digitalization, participants reported having no experience with systems specifically designed for the therapy of LBP, such as smartphone apps. Only videos available on e.g. YouTube were used. However, physiotherapists could all imagine that such programs would promote motivation and long-term adherence to HPs. It would be necessary for the programs to create a social effect through group dynamics, ‘There are interesting programs that have a good social effect because they can point users to the adherence of other patients and thus trigger group dynamics no matter where you are. The symbolism, like, graphics show progress and a reward system that illustrates positive progress.’ In addition, the participants clarified that these programs should be free of charge, which otherwise would make it impossible for some patients to use them.

Discussion

This study identified adherence-influencing aspects from the perspectives of patients and physiotherapists. The main requirements of patients were that physiotherapists should provide HP that is individualized, goal-oriented, and controlled. A main concern was not receiving sufficient PT sessions due to health system requirements in Switzerland and Germany. In these countries, PT sessions are prescript by physicians and every prescription allows for a maximum of six to nine sessions. This was considered relevant for adherence, since insecurity about how to practice exercises correctly, raised the worry of re-injury.

Physiotherapists confirmed some of the aspects raised by the patients. They agreed that time is a limiting factor, and that time-consuming bureaucracy can be a barrier to evidence-based methods, such as pain neurophysiology education and personalized HP. Physiotherapists explained the importance of documentation and writing reports, which is often complicated due to a lack of time. Likewise, a good relationship between therapists and patients with LBP was named as important for adherence by patients and physiotherapists, because it stimulates effective education and individualized therapy approaches.

Previous publications showed factors influencing adherence from the perspective of physiotherapists. They named communication skills and knowledge on how to facilitate behavior change [14–17]. Very similar aspects were identified by the therapists in this current study. A new aspect was that other health professionals might raise false expectations about PT, making education and patient behavior changes unnecessarily complicated. In contrast to the findings from other studies [11,15,16,30,31], the physiotherapists participating in this study were aware of the importance of goal-oriented strategies, such as motivational interviewing, promoting the understanding of the patients, their motivation to exercise, and their adherence to HP.

In line with statements recorded in this study, Palazzo et al. [13] recognized that physiotherapists need to perceive HP as an attractive addition to their treatment and that they need to be supported and not hindered in the development of HP, e.g. by bureaucracy.

While increasing therapy time is partially limited by law, the use of the available time can be shifted toward attractive, patient-centered, meaningful, effective, and easy to perform HP. More time can be allocated to patient education on e.g. pain mechanisms and the subsequent importance of behavior change to promote self-efficacy. This can be enhanced by goal-setting and shared decision-making approaches.

Room et al. [32] found that patient non-adherence to recommended exercises is a challenging aspect of clinical practice. They identified a good patient-therapist relationship as the most important aspect of improving patient adherence. These findings are in line with the results of this present study. Room et al. [32] also detected high levels of frustration among physiotherapists, who often felt powerless to improve patient adherence. They recommended the use of strategies to optimize behavioral changes in patients. In the present study, methods to induce behavior change were specified and defined as communication and education.

The importance of patient motivation, self-discipline, time, reminders to exercises, difficult or ineffective exercises, patient beliefs, therapist-patient relationship, patient involvement, and patient attitudes were the topic of previous publications and confirmed by the current results [9–13,16]. Additional new aspects were that patient motivation and confidence to perform HP correctly can be influenced by the type of recommendations given by physiotherapists.

The use of digital tools was promoted in previous publications [33–35], but was not specifically highlighted by the results of this current study. Although showing a general interest in the implementation of smartphone apps or other technology, unclear working mechanisms, data protection privacy standpoint, accessibility, costs, and other factors restricted the enthusiasm.

The limitations of this study are that the focus groups were not held face-to-face, as participants chose to be interviewed digitally. This might have reduced the discussion within the groups. The data collection took place in Switzerland and participants were either German or Swiss. While this might reduce the external validity of the data due to the specific healthcare systems in countries, an attempt was made to include a wide range of physiotherapists (e.g. age, clinical approach, education) and patients (e.g. acute, chronic, gender, motivation). However, personal experiences of patients and strategies of physiotherapists will always depend on the selected sample but not all aspects may have been covered by this sample of participants.

Conclusion

LBP patients requested individual, goal-oriented, and long-term care. They expected HP and physiotherapists who take their problems seriously. Physiotherapists treating patients with LBP were interested in developing self-management and active therapy strategies. They reported conflicts with other medical actors, such as general practitioners or colleagues, restricting the implementation of behavioral change strategies for patients with LBP. Physiotherapists described communication, patient education, and attention to patient reports as essential aspects of adherence facilitating physiotherapy. Future research should specify the components for optimized adherence in patients with LBP and focus on the development of outcome measures for adherence.

Biographies

Andreas Alt, PhD student, M.Sc., University of Lübeck, Dept. of Health Science

Hannu Luomajoki, Prof. Dr., Zürcher University of applied Sciences, Dept. Physiotherapy

Katharina Röse, Prof. Dr., University of Lübeck, Dept. Health Sciences

Kerstin Lüdtke, Prof. Dr., Senior Lecturer, University of Lübeck, Dept. of Health Science

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).