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Adherence to Group Exercise Physiotherapist-led experimental programmes

Patricia Crook Rachel Stott Michael Rose Sarah Peters Peter Salmon Ian Stanley

Key Words Group exercise, adherence, attendance, physiotherapy,

Summary One response to the increasing demand for physiotherapy services from primary care is to develop group exercise programmes led by physiotherapists operating in an educ- ationaVadvisory role. However, since physical symptoms in patients referred frorn primary care are often mediated by complex and unrecognised psychosocial factors, it is not clear what format of group physiotherapy will engage such patients in a programme of exercise training. This paper reports problems experienced with patient engagement in physiotherapist-led groups undertaking either an aerobic exercise or a stretching and relaxation programme. The programmes formed, respectively, the intervention and control arms of a study investigating the role of exercise in primary care patients with persistent unexplained physical symptoms. We outline ways in which these problems were addressed and review our experience in the light of previous research on patient engagement with exetcise.

Introduction The 1990 NHS reforms have exposed physiotherapy to a number of challenges, of which the most significant is to operate effectively in a ‘primary- care led’ NHS (Secretary of State, 1996a and b). One immediate effect has been a sharp increase in the long-term trend towards direct access by general practitioners to physiotherapy services (Taylor, 1992). This has led to a significant imbalance between demand for physiotherapy and, given its limited resources, feasible responses by the profession. For example, there is currently considerable doubt about the profession’s capacity to fill vacant posts with suitably qualified applicants (Palastanga, 1995). Recently it has been suggested that physiotherapists acting in an educationaVadvisory role can be more efficient, but just as effective, as their colleagues working within a more traditional framework (Worsfold et al, 1996).

However, the situation is compounded by the scale of the tasks confronting physiotherapy services for primary care. Among patients currently referred, physical symptoms are often mediated by complex psychosocial factors (Kroenke et al, 1994; Weich et al, 19951, a significant proportion of which will remain undetected by the general practitioner (GP) (Howe, 1996). In addition, evidence is accumulating which suggests that

exercise is beneficial in the management of a range of conditions: depression (Salmon, 1993), low back pain (Rose et al, 1997), obesity (NHSE, 19951, coronary artery disease (Powell et al, 1987) and osteoporosis (Swezey, 1996).

A logical response to this situation is to ask physiotherapists to act in an educational/advis- ory role to groups of patients. However, a key issue for group exercise programmes is non- attendance and non-adherence among both healthy and symptomatic populations. For example, 50% of healthy individuals who start an aerobic exercise programme will stop within the first six months (Robison and Rogers, 1994). The determinants of adherence to exercise in groups need to be clarified before physiotherapists are asked to provide group exercise therapy, particularly for a client group whose health problems often reflect a challenging combination of psychosocial and physical variables.

The majority of studies of exercise motivation and adherence have focused upon healthy populations - college students, community samples or occupational groups. Factors such as low self- efficacy (DuCharme and Brawley, 1995), neu- roticism (Potgieter and Venter, 19951, effort of attendance (Birkermer et al, 1996) and perceived barriers (Huddy et al, 1995) have all been related to low exercise take-up and adherence. Among symptomatic individuals, adherence to exercise has been positively associated with bonding between patient and therapist (Gillet et al, 1993) and physician characteristics such as ‘willingness to listen’ (DiMatteo et al, 1993). Dissatisfaction with physicians’ quality of care (Weingarten et al, 1995), low self-efficacy (Skelly et al, 1995), external health locus of control (Barlow et al, 19931, depression (Williams and Lord, 1995) and weak social support (Pham et al, 1996) have all been shown to reduce adherence to exercise programmes.

In the context of exercise provision by a physiotherapy service, non-attendance for out-patient appointments is a related issue. Here the literature suggests a complex interaction between the referring doctor, the secondary provider and the patient (Deyo and Inui, 1980). Unemployment, loss of pay, not owning a car (Gilhooly et al, 1994) lack of understanding of the requirements of the visit and patients’ dissatisfaction with prior experience of health care (Francis et al, 1969) have all been shown to influence atten-

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dance, whereas demographic factors have not (McGlade et al, 1988; Waring et al, 1998).

However, interpretation of the literature is made difficult by variations in the theoretical framework of research, subject characteristics, definitions of adherence and exercise format; no clear-cut guidelines on how to maximise patient attendance at exercise classes or how to encour- age adherence, once started, emerge. The present opportunity to explore factors influencing engagement with group exercise arose during a study designed to investigate the effects of exercise training on patients with persistent and unexplained physical symptoms, so-called somatising patients (Bass, 1996). The study aimed to apply existing research evidence indicating the benefits of exercise on mental state (Salmon, 1993) to the problem of managing somatising illness in clinical practice. In a randomised controlled design we compared group aerobic exercise training with group training in stretching and relaxation as interventions in somatising patients recruited from primary care. A report on the outcomes of the trial is in preparation.

The present paper focuses on the experience of NHS physiotherapists providing group exercise programmes within the study. It describes the basic format of exercise programmes, problems experienced with non-attendance and non- adherence by patients, and ongoing modifica- tions to the format of programmes designed to address these problems. We believe that our experience contains valuable lessons for the provision of physiotherapy in groups, particularly to patients who present a number of psychological barriers to engagement with physical exercise.

The Study Participants All 429 GPs in Liverpool and St Helens and Knowsley were asked to refer patients with a history of investigated, but unexplained, physical symptoms over the preceding 12 months. A total of 320 were referred but 15 of these were excluded from the study because of hyper- tension, ischaemic heart disease or psychosis. Of the remainder, 228 patients attended for initial interview and agreed to take part in the study. Following initial assessment, including measures of physiological tolerance of exercise, participants were randomly allocated to one of two group exercise programmes: aerobic or stretchingh-elaxation.

Details of participants’ prior contact with medical services and a qualitative thematic analysis of their perceptions of the illness have

been described elsewhere (Peters et al, in press). Scrutiny of GP records revealed that, typically, participants were polysymptomatic (those noted in GP records over the six months before referral: maximum 12 symptoms, mode 3, median 4). The major groups of symptoms are listed in the table (200 participants; 28 GP records were unavailable). Symptoms occurring in 5% or more of the 200 patients

Symptom N %

Back pain Depression Fatigue Anxiety Non-specific pain Chest pain Coughkhest infection Headache Neck pain Sore throat Superficial infection Abdominal pain Lower limb pain Non-specific bowel symptoms Upper respiratory tract symptoms Rash Dizziness Sleep disturbance Superficial infections Vomitinghausea Wheezing/breathlessness Urinary tract infection Burning sensation/paraesthesia Viral infection Earache Menstrual disorder Weaknesshalaise Shoulder pain Vaginal discharge Irritable bowel Dyspepsia Eye problems

52 26 51 25.5 46 23 43 21.5 41 20.5 39 19.5 32 16 31 15.5 30 15 30 15 28 14 27 13.5 25 12.5 24 12 22 11 19 9.5 19 9.5 17 8.5 17 8.5 17 8.5 16 8 16 8 15 7.5 15 7.5 14 7 13 6.5 13 6.5 12 6 11 5.5 11 5.5 10 5 10 5

Physiotherapists Two senior I chartered physiotherapists employed by a local NHS trust were seconded to the study on a sessional basis. One was employed by her trust as a community physiotherapist (PC) and the other (RS) worked on orthopaedic wards.

The explicit role of the therapists within the study was to develop and supervise exercise programmes which met the needs of the research design. In order to minimise potential bias, exercise programmes were jointly developed and provided in turn by the therapists.

Exercise Programmes Group exercise took place in a university physiotherapy gymnasium. Participants in both programmes were asked to attend twice weekly for


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ten weeks (20 sessions), each session lasting 60 minutes. Participants were allocated to groups of ten participants and remained in the same group throughout.

Aerobic Programme Effort was titrated to maintain participants’ heart rate at 60-65% of their estimated age- adjusted maximum (Steptoe et al , 1989). Participants were trained in the use of portable digital pulse monitors (Polar, Finland) and in palpation of their radial pulses. Each session- was preceded by ten minutes’ warm-up which involved a range of movements, requiring pro- gressively greater effort. Five specific exercises, each undertaken for about two minutes and repeated twice, formed the basis of a session which ended with the warm-up exercises carried out for five minutes in reverse order.

Relaxation and Stretching Programme Participants were taught to monitor their own heart rates and adjust effort to maintain heart rate below 50% of their estimated age-adjusted maximum. The relaxation component (about 10 minutes) was designed to foster awareness of limb position and muscle tension, with participants in their position of choice, usually supine. The stretching component (about 30 minutes) involved all major joint complexes; participants were asked to maintain muscle tension at a level which provoked ‘a feeling of stretch’.

Home Exercise In both programmes participants were recom- mended to exercise at home for 20 minutes, three times a week, guided by written and pictorial information. A home exercise diary was provided for each subject to record exercise activity.

Defining the Problems of Engagement With Exercise At the beginning of the study a significant proportion (circa 60%) of participants defaulted from exercise training; typically, they either failed to attend the first session or were lost after one or two visits. This led the research team to analyse what was being provided and to seek, informally, from participants, therapists and referring doctors feedback on problems being encountered.

Practical Difficulties The exercise programmes were held in a central site in the city of Liverpodl; many participants were referred from suburban general practices and lacked personal transport. Participants commented that they did not know what to wear

for the exercise sessions and it appeared that some might have stayed away on that account. Fears of appearing foolish when exercising or of being unable to ‘compete’ with others in a group were commonplace. With most participants unemployed or on sickness benefit, the timing of exercise sessions during the working day was not perceived by them as a problem.

Distressed Mental State and Poor Motivation The majority of participants (68%) were depressed when assessed at recruitment by the HAD scale (Zigmond and Snaith, 1983). Depression is associated with feelings of apathy, physical inertia and hopelessness. Moreover, our participants had experienced in their primary and specialist care a long period of failed medical interventions. Thus their motivation to comply with an extended programme of physical training presented a considerable challenge to the therapists.

Understanding of and Attitudes to Exercise All participants recruited to the study had experienced, for at least 12 months, disabling physical symptoms, many of which might suggest to them the need for rest rather than exercise (for example, chronic fatigue syndrome). A fun- damental challenge was to convince participants of the scientific basis of exercise as an intervention for their symptoms.

Problems in the Perceptions of Referring Doctors During the early days of the trial it became clear that participants were often being referred by doctors with little therapeutic optimism about the outcome. A characteristic of patients with somatising depression is the sense of helpless- ness (‘heart-sink’) felt by their doctors (O’Dowd, 1988). In these circumstances, while GPs may welcome a new intervention they are under- standably sceptical about its capacity to benefit such intractable problems. Moreover, in the context of a controlled trial, some of our referring GPs were worried that enthusiasm for the intervention might prejudice the results of the study.

Ambiguity in the Physiotherapists’ Role At the outset, both therapists admitted to feeling insecure about providing the exercise programmes for such a difficult group of patients. For example, they were concerned about how to respond to confidences concerning psychosocial problems in participants with depressed and/or anxious mental states.

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Addressing the Problems of Engagement The majority of problems emerged at different times during the course of the study and were addressed by the research team as they arose. We have systematised our response below.

Resolving Practical Difficulties Funds were identified to reimburse travel costs for all participants receiving income support or family credit. Attention was paid to the gymnasium in which participants were undertaking exercise with the aim of increasing privacy and group cohesion, for example through the use of window blinds and screens and by playing back- ground music. The latter proved so popular that copies of music tapes were requested by participants to use with exercise homework.

Individual Support and Counselling In response to participants’ distressed mental state, time was set aside by the therapist at the end of each session for clients to receive individual counselling and support. The physiotherapists recognised the importance, for participants, of listening to problems not directly related to the exercise programmes or to their physical symptoms. In comments from participants to the research team, this dimension of the therapeutic relationship was highly valued.

Improving Understanding of Exercise and Attitudes to It Importance of First Contact Immediately following GP referral, by letter or telephone call, the research assistant contacted participants by telephone and confirmed arrangements for initial interview by letter. This rapid response established personal contact and enabled existing worries, for example about exercise in a group, to be identified. At interview, the research assistant explored the reasons for referral and elaborated upon the rationale for the study provided by the GP. Participants’ concerns about and negative perceptions of exercise, including its relevance to their problems, were addressed.

At the end of each interview, an appointment was made for participants to meet individually the therapist responsible for the first exercise session. All participants received a letter con- firming the times and dates of their allocated course and advising them to wear ‘something loose-fitting and comfortable’.

Making Exercise Relevant: The Role of Explanatory Models A primary goal of early contact with participants was to provide an explanatory model of the ther-

apeutic benefits of exercise. This needed to be acceptable to our therapists and plausible for our participants. Initially, a simple statement was used, presenting exercise as ‘a way of keep- ing the body conditioned and so better able to cope with the strains put upon it by everyday life’. Subsequently the model was elaborated: first, to connect specific symptoms with the idea of parts of the body being weaker than others; and secondly, to introduce the idea of ‘toning up’ muscles through exercise.

Slightly differing versions of the basic model were used within the two exercise programmes and reinforced in homework diaries: for the aerobic group emphasis was on improving general fitness and building energy levels; for the stretchinghelaxation group, the emphasis was on relaxing and toning muscles to relieve tension. In addition, during individual counselling the therapists adapted explanations to fit specific symptom patterns and the subjects’ underly- ing beliefs, for example acknowledging that in chronic fatigue, energy is perceived as limited.

We were concerned that participants might, in this way, be convinced of the value of exercising but concluded that our programme offered no advantages over exercising at home. Therefore, emphasis was placed on the professional guid- ance of our physiotherapists and the technical support of pulse rate monitors, computerised feedback, and so on.

Referring Doctors: Clarifying Perceptions and Forming an Alliance Aside from communication about individual participants referred to the study, two general letters were sent out to all GPs in the area. The first thanked GPs for their support, provided progress reports on the study and encouraged further referrals. A second letter sought to reassure GPs that, given the study design, presenting it t o participants in a positive light would not skew the results.

In addition, members of the research team visit- ed a high proportion of the 60 participating practices and met GPs and other primary care team members. The explanatory model underpinning our justification of exercise to participants in the study was discussed, and its wording modified in the light of comments. Waiting room posters and leaflets describing the study were provided.

Clarifying the Therapists’ Role Induction into Exercise Programmes Interviews with the physiotherapists were intro- duced to ensure that all subjects had met their therapist (or if that was not possible had spoken to her on the telephone) before entering the exer-

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cise programme. We aimed to establish a therapeutic relationship and to minimise fears about the initial exercise session. The physiotherapists developed an interview checklist covering current health problems, previous exercise experience, expectations of the study and concerns about it. At the same time, emphasis was placed on the need for participants to allow the exercise programmes time to produce benefit. On aver- age, induction interviews lasted 20 minutes.

The Evolving Therapeutic Relationship With increased experience the physiotherapists reported growing confidence in leading group exercise. Two factors, in particular, contributed to this change: recognition that skill mastery was less important than conforming to the heart rate requirements; and increasing flexibility in the content of sessions. By encouraging participants to adapt exercises, suggest alternatives and take the lead in some sections of the programme, participants began to own the programme through changing it. Increased levels of enjoyment in exercising together became appar- ent. Social interaction among participants was fostered, although this required less direction from the therapists in the aerobic programme than in the stretchinghelaxation programme.

Feedback to Participants Informal feedback by therapists on individual performance was widely sought by participants at the end of sessions. In addition, homework diaries were reviewed by the therapist and realistic targets set for the coming week. During the fourth session all participants were provided with feedback using a lap-top computer. This provided an individualised graphic display of participants’ ability to maintain their heart rate within the target range.

Managing Exit from the Programme Three weeks before the end of the exercise programme, participants met their therapist to dis- cuss personal exercise plans; they were encouraged to identify enjoyable exercise activities and to explore practical arrangements. At the final session, each subject agreed with the therapist realistic targets for ongoing, unsupervised exercise. The aim was to establish patterns of unsupervised exercise which maintained heart rate at the appropriate level. In some instances this was a continuation of the homework programme, for others it included an activity selected by the individual, such as swimming or dancing. A diary containing the targets was provided and participants were encouraged to record activity undertaken in the coming six months.

Each participant who completed either programme was sent a letter of congratulation and a ‘Certificate of Completion’ (signed by the research team), designed to emphasise their achievement and sustain their motivation.

Discussion An important finding of this study is that many patients with persistent and disabling physical symptoms of uncertain cause can become engaged in a programme of group exercise. Overall, more than 60% of participants who began an exercise programme attended ten or more sessions and were still in touch with the therapists at the end of the ten-week period. Given the nature of the subject group, this is a satisfactory level of adherence and compares favourably with a local trial of group cognitive therapy for depression in primary care which achieved a compliance rate of 59% (Scott and Stradling, 1990). Translated into ‘everyday’ primary care, including less entrenched clinical problems and local provision of exercise programmes, a significantly higher adherence rate might be expected. Moreover, the experience of group exercise was often very positive. Relationships which formed within groups proved both therapeutic and practical: some participants shared transport to and from sessions, and some elected to exercise together outside classes. On completion of the exercise programme, a frequent comment from participants was how encouraging it had been to exercise in a group of people with similar problems and previous (negative) experience of health care.

Many of the problems of engagement with exercise identified and addressed in this study are reflected in the existing literature. Practical difficulties of travel, what to wear, etc (Pham et al , 1996; Taggart and Connor, 1995); financial inducements (Robison and Rogers, 1994); and the importance of the bond with the therapist (Gillet et al , 1993) have all been recognised. Similarly, patients’ mental state and self- esteem (Fontaine and Shaw, 1995; McCauley et al, 1995); satisfaction with previous health care (Weingarten et al , 1995); understanding of the significance of the problem (Francis et al , 1969); and the face validity of exercise for their problem (Lynch et al , 1992) are known to be relevant. I t follows that patients’ initial understanding of the benefits of exercise and, therefore, the purpose of referral for exercise therapy will, in large part, be determined by the referring doctor. Aspects of patients’ prior relationship with their doctors seem to influence adherence to advice on exercise (Di Matteo et al , 1993).


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Alongside this diverse array of specific factors, some authors have argued that the decision to exercise is an individual judgement, a balance of ‘pros’ and ‘cons’ (Bond et al, 1992; Marcus et al, 1992); if the ‘pros’ are not sufficiently convincing then the disadvantages of exercise will prevail and non-engagement or ‘drop-out’ will result. On this view, a group exercise programme, however well designed, will need to assess, optimise and maintain the motivation of individuals. Mullen, in a meta-analysis of cardiac rehabilitation programmes, draws attention to the importance in subject adherence of applying basic educational principles, including reinforcement, feedback, individualisation and making treatment relevant to patients’ abilities (Mullen et al, 1992).

Overall, our practical experience underlines the relevance of many of these factors. In the context of NHS physiotherapy practice, three, in particular, merit close attention: communication; the role of the therapist; and the format of exercise programmes. As regards communication, the referring doctor should take a positive and informed view of the intervention; induction of patients into the programme merits careful attention; and at all stages information should be clear and consistent. A key element of communication is a tangible and plausible explanatory model connecting exercise to the individual subject’s problem. This should be conveyed from the outset and reinforced at induction and throughout feedback on performance. While the model will almost certainly contain a physical/mechanical component, it should also address patients’ psychological needs, particularly for exculpation and involvement in management of the condition (Peters et al, 1997).

The physiotherapists in our study were seconded from typical NHS work, usually on a one-to- one basis, and asked to devise and lead group exercise for patients with intractable physical symptoms, many of psychological origin. This represented a valid, if extreme, test of the capacity of practising physiotherapists to undertake group work among the mixed bag of symptomatic conditions referred from primary care. A recognised difficulty in leading any form of group therapy is to strike the right balance between individual and collective needs. Our experience suggests that a clear distinction can be drawn between the importance of participants’ perception that their individual needs (for assessment, information and feedback) are being addressed and the questionable require- ment for the therapist to achieve compliance by participants with specific exercises. For the therapist, the balance to be achieved maximises

individual skill and motivation to exercise, while allowing this to be expressed in a wide variety of forms. The appropriate group dynamic, then, is not conformity and inter-subject competitive- ness but individual diversity with mutual understanding and support. This accords with the view of Jensen and Lorish (1994) that co- operation with an exercise regimen is mediated by the patient’s belief system and requires a therapeutic process of mutual inquiry, problem solving and negotiation between patient and therapist.

I t follows that group exercise programmes for primary care patients will need to be flexible in order to encompass the diverse motivation and physical capacities of group members. Traditionally, a distinction is made in physiotherapy between exercise which aims to have localised effects on joint/muscle/soft tissue dysfunction and exercise which aims to produce systemic effects on the individual. In practice this distinction may be less valid than it appears; the broad aetiological basis of much musculo-skeletal dysfunction among patients referred from primary care suggests that both the mechanical and psychological benefits of exercise are capable of being addressed by group exercise, provided that it is appropriately demanding for the individual.

Acknowledgments We are grateful to the Medical Research Council which funded the study; to Anne O’Ryan, physiotherapy manager at St Helen’s and Knowsley NHS Trust; and to Eileen Thornton, head of the Department of Physiotherapy, Liverpool University, for their support. Dr Sue Kaney, lecturer in clinical psychology, Liverpool University, provided technical assistance with physiological measurements. The study was funded by the Medical Research Council. This article was received on February 25, 1997, and accepted on May 5, 1998.

Authors Rachel Stott MCSP and Patricia Crook MCSP are senior physiotherapists at Whiston Hospital NHS Trust. They were seconded to the study and were responsible for the development and administration of the excercise classes. Sarah Peters MA is a research assistant at the University of Liverpool. She was responsible for the operational management of the study, data collection and analysis and played a major part in the study’s evolution. Peter Salmon PhD is a reader and Ian Stanley FRGCP is an emeritus professor at the University of Liverpool. Michael Rose PhD is manager of the back pain programme at Wirral Hospital NHS Trust, and honorary senior research Fellow at Keele University. All three were grant holders for the study and responsible for its design. This paper is a result of equal contributions by each of the authors.

Address for Correspondence Dr M J Rose, Back Pain Programme, Wirral Hospital NHS Trust, Clatterbridge Road, Bebbington, Wirral, Merseyside L63 4JY.


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