This review summarizes different methods to enhance exercise adherence among people with knee osteoarthritis for more than 12 months. Different factors were reported for loss of follow-up with the exercise programme. This section will focus on the main findings related to the study.
Summary of main findings
Five studies were eligible according to the inclusion criteria. Strategies used to enhance exercise adherence varies among trials. Booster sessions, behavioral approaches, telephone sessions, Telephone Linked Communication, motivational calls, and telephone reinforcement have been used as strategies in these studies.
The long-term exercise adherence rate of the following methods varied between studies. 89.69% was the adherence rate for the five-booster session group, 59.4 % was the adherence rate for the behavioral approach group, 39% adherence rate for 6 to 12 telephone sessions with a health coach, 86% was the adherence rate for the Telephone linked communication group. The individual score is not available for the telephone reinforcement group. According to the results, booster sessions and telephone-linked communication had higher percentages for exercise adherence. Therefore, future study should investigate effectiveness of these two strategies in enhancing exercise adherence.
According to the systematic review results, introducing methods to enhance exercise adherence has only a short-term impact. There are no significant differences in long-term adherence with different methods. Further, most of the secondary outcomes show positive outcomes with increasing exercise adherence. However, there are no significant differences in outcomes between experimental and control groups. The reasons for the non-significant difference might be due to a lack of adherence to the exercise guidelines. It is recommended that an individual patient should be assessed and the potential reasons for lack of adherence in future, for example lack of motivation, socioeconomic situation, family and work commitments, should be assessed when formulating exercise adherence strategies for an individual. This might potentially enhance their exercise adherence.
Outcome measures were used to measure exercise adherence in the selected studies. Those are participants’ self-rated adherence questionnaire, pedometer to monitor Physical activity, a logbook to record activity level and validated questionnaires, self-report community healthy activities model for older adults, self-report questionnaire and single self-report item. Self-rated adherence rate might have a bias as it depends on the participant's response. Therefore, a standard method, such as attendance records and validated wearable activity trackers, should be used in future studies to report exercise adherence rates (10).
Commonly reported reasons for loss of follow up were co-morbidity, selected surgical intervention option, family circumstances, decline to participate, lack of motivation, increase pain, loss of contact, withdrawal from the study due to personal reasons, other illness, family illness, lack of time, change in the location and death. It is reported that the barriers to continuing with the inventions were weather conditions and health problems of participants’ partners. A study was conducted to determine the predictors of adherence to exercise interventions during and after cancer treatment. According to the results, prominent predictors of exercise adherence were the location of the rehabilitation center, motivation for exercise (10). These factors are similar to people with osteoarthritis. Therefore, it is important to consider these barriers and reasons when identifying an interventions to enhance the exercise adherence among people with long term conditions.
Strengths
One of the strengths of this systematic review is that four studies were of "high" methodological quality. This systematic review used the PRISMA guidelines for reporting systematic review and used the PEDro scale.
Limitations
Several limitations should be considered during this study's interpretation and should be addressed in future research. Only five studies assessed exercise adherence for more than 12 months, were included in this systematic review. Different exercise interventions and exercise adherence strategies were used in these five studies; it is varied in duration, intensity. The heterogeneity is noted in these studies. Therefore, a quantitative analysis by pooling outcome data (meta-analysis) or a best evidence synthesis was inappropriate. The Interrater reliability is noted as 0.72 because of a few number of studies (5 studies) included in this study.
It is noted in the existing literature, only a limited number of studies focused on exercise adherence for more than 12 months. Also, self-reported exercise adherence was used to assess the adherence rate. Exercise should be followed as one of their routine activities among people with chronic conditions, osteoarthritis. Many studies reported exercise adherence for less than 12 months period or until patients actively participate in the clinical visits. However, it should be followed for a longer duration to ensure that patients achieve the benefits of the prescribed exercise programme. These limitations should be addressed in future studies.
Future research
Only five studies were eligible according to the criteria. Therefore, in the future, more studies should be conducted to identify the best strategies to maintain exercise adherence for more than 12 months among people with osteoarthritis. Also, attendance records and validated wearable activity trackers should be used to calculate exercise adherence among participants.
Table 3
Table shows the data extraction of included five studies
| Pisters et al 2010 | Brosseau et al 2012 | Bennell et al 2017 | Baker et al 2020 | Hughes et al 2010 |
Design | Single-blind cluster-randomised trial | Single-blind, randomised control trial | Randomised control trial | Single-Blind, parallel-arm randomised controlled trial | Randomised control trial |
Sample size | 200 (Exp (n) = 97, Con (n) = 103) | 222 [W = 79, WB = 69, Con = 74] | 168 | 104 [Con = 44, TLC = 45] | 419 [Negotiated TR = 103, Negotiated No TR = 98, mainstream Tel = 105, Main No Tel = 113] |
Duration- Follow up (months) | up to 55 | 18 (12 intervention, 6 month follow up) | 18 | 24 | 18 |
Population([N], Gender, Age, Joint involved) | Exp [Age = 65(7), Gender (males) = 24(25)], Con [Age = 65(8), Gender (males) = 22 (21)] | Age [w = 63.9(10.3), WB = 63.9 (8.2), Self-directed control = 62.3(8.6)], Men/Women, (%) [w = 24(30.4)/55(69.9), 18(26.1)/51(73.9), 69(31.1)/153(68.9) | Age [PT + Coaching = 61.1 ± 6.9, PT = 63.4 ± 7.8], Male, n (%) = [PT + Coaching = 27(32), PT = 35(42)] | Age [TLC = 65.8 ± 6.6, Con = 64.5 ± 8.3], female n (%) [TLC = 42 (80.8), Con = 43(82.7)] | Majority female, Age 71.1 |
Exercise intervention (Type, frequency, duration, intensity) | Maximum if 18 sessions over a 12-week period. The complete protocol included written materials such as education messages, activity diaries, performance charts. | Walking programme (supervised walking programme or unsupervised/self-directed walking programme) | 5* Individual Physiotherapy sessions | 6-Week group exercise class and monthly Automated Phone messages to strength Train and Complete Exercise Logs | Fit and strong programme |
Adherence facilitation | Five booster sessions in week 18,25,34,42 and 55. | Behavioural approach at the community-based walking club | 6 to 12 telephone sessions with a health coach | TLC motivational calls and | Telephone reinforcement |
Outcome measure(s) | Participants self-rated adherence, SQUASH | Validated questionnaire, Physical tests | Self-report questionnaire, 11-point NRS, WOMAC, NRS pain on walking, WOMAC pain scale, Assessment of QoL, Physical activity for the elderly (PASE), AAS, Accelerometer-based device | Single self-report item, WOMAC pain, Physical function subscales, Biodex System 3 | Physical activity Maintenance, WOMAC, functional lower extremity strength (timed-stand), functional exercise capacity (6-minute distance walk), Body Mass Index, Depression |
Lost to follow up | 21 (Exp (n) = 10, Con (n) = 11), 20% loss to follow up | 18 months [W = 44.3%, WB = 40.6%, Con = 52.1%] | Loss to follow up 26 of 168 (15%), 32 of 168 (19%) and 40 of 168 (24%) | out of 52, [TLC = 7/52, Con = 8/52] | 91 unable to locate, 29 unable to schedule, and 40 refused |
Adherence rate | - | - | PT + Coaching 3.8 [95% CI-3.1, 4.6] versus PT 3.6 [95% CI 2.9, 4.4], mean difference 0.2 [95% CI -0.8, 1.2] | [Mean control group = 4.01 [95% CI 3.03,4.99, Mean for TLC 3.63 [95% CI 2.70, 4.56]; P = 0.57) | 74% the participants completed measurement at 12 months, 62% (259) at 18 months |
Long term outcome | Significant difference is present. Higher in experimental group | There is difference. But significant level is not mentioned | No significant difference between groups | No significant difference between groups | TR positively affect perceptions around engagement |
Exp: Experimental group, Con: Control group, W: Walking, WB: Walking and Behaviour, TLC: telephone-linked communication, TR: Telephone reinforcement, Tel: telephone, QoL: Quality of Life