GUEST EDITORIAL

The Evidence on Ways to Improve Patient’sAdherence in Hand Therapy

Preface to the editorial: The narrativebelow from Dr. O’Brien brings someneeded structure and suggestions relatedto what we all intuitively know to beimportant and clinically challenging,that is, optimizing adherence to handtherapy. Dr. O’Brien is a leader in thisfield, especially as it relates to adheringto the use of orthotic devices, and her ex-periences should help redirect our focuson patient-centered approaches.

Editor-in-ChiefWe have all had patients arrive for

follow-up appointments either with-out their orthotic or with some unau-thorized or unsafe modifications to it.We have all had patients who misscrucial appointments, and we haveall seen disasters (such as tendonruptures) that could have been pre-vented if the patients followed thecarefully designed program we cre-ated for them. Although it is esti-mated that nonadherence rates arerelatively low in people with acutehand injuries (#25%),1 the associatedrisks in this group are higher, as theyare more likely to result in the needfor difficult secondary surgical proce-dures, increased disability, longerrecovery times, and an increased bur-den on health care resources.2,3

The terms used to describe pa-tient’s behavior are important. Theassumption underpinning the term‘‘noncompliant’’ is that any negativeconsequences are likely to be the pa-tient’s own fault. This reflects the pre-vailing medical ideology, in whichhealth care practitioners assume therole of experts and patients the roleof passive recipients of treatment,who are expected to ‘‘comply’’ withor ‘‘obey’’ the experts’ recommenda-tions. A review of medical, nursing,

Correspondence and reprint requests toLisa O’Brien, PhD, M Clin Sci, Depart-ment of Occupational Therapy, MonashUniversity, PO Box 527, Frankston,Victoria 3199, Australia; e-mail:<lisa.obrien@monash.edu>.

doi:10.1016/j.jht.2012.03.006

and therapy literature concludedthat the term ‘‘compliance’’ used inthis context was synonymous withphysician control,4 an ideology thatdoes not fit well with our profession’scommitment to client-centered prac-tice. Thus, the term ‘‘adherence’’rather than compliance is usedthroughout this editorial, as adher-ence implies an ‘‘active, voluntary,and collaborative involvement bythe patient in a mutually acceptablecourse of behavior to produce a pre-ventative or therapeutic result.’’5(p20)

The literature exploring the de-terminants of adherence is exten-sive, prompting the World HealthOrganization to undertake a majorcritical review of the evidence in2003.6 As a result of this, theMultidimensional Adherence Model(MAM) was created (see Figure 1),which groups the key predictorsof adherence into five dimensions:1) socioeconomic, 2) health caresystem-related, 3) condition-related,4) treatment-related, and 5) patient-related factors.

INTERVENTIONS FORIMPROVINGADHERENCE

The global health care evidence hasshown that unidimensional inter-ventions for enhancing treatmentadherence (e.g., self-management ed-ucation) tend to have modest impactsat best, while multilevel, multitar-geted approaches that focus onseveral factors with multiple inter-ventions are more effective.7,8 Thefollowing evidence-based sugges-tions for improving adherence arearranged according to the five di-mensions of theMAM. It is importantto remember that a combination ofstrategies across several dimensionsis more likely to improve the chancesof success of interventions used withclients.6

Social and EconomicInterventions

Although the hand therapy andsurgery literature has not found aconsistent relationship between so-cioeconomic factors and adherence,1

it is reasonable to assume that factorssuch as access to services in the localcommunity, lack of family support,and cost of treatment (and travel toclinics) could have an impact withsome individuals. In chronic handconditions, such as rheumatoid ar-thritis, peer support groups havebeen shown to be effective.9 Thesegroup programs usually aim toprovide comprehensive informat-ion, promote sharing of experiencesregarding management of the condi-tion, and engender the patient’s senseof responsibility and self-efficacy.Additional social and economic inter-ventions for maximizing patient’sadherence are as follows:

� Building the patient’s own self-management skills, and ensuringthey are confident in using these;and

� Capacity building in the patient’slocal community (e.g., coachingstaff at the local community healthcenter in monitoring the patient’sprogress and engaging them insuitable activities).

Health Care Team and HealthSystem Interventions

In one qualitative hand therapystudy,10 a key finding was that pa-tients who trusted their treatmentproviders and were provided withclear and consistent education weremore likely to follow their orthoticand exercise program. Unfortunately,this dimension of adherence has notbeen widely investigated in the acutehand therapy literature, with most ofthe publications focusing on physicalstructures.11

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FIGURE 1. The five dimensions of ad-herence. Source: World Health Organi-zation (WHO) 2003 (reproduced withpermission from WHO, Geneva).

This is a missed opportunity, asmany of the factors that can play asignificant role in promoting adher-ence are within our control. For ex-ample, one study of 40 people in theUnited States with rheumatoid ar-thritis12 randomly assigned peopleto two groups: one group had ‘‘stan-dard treatment approach’’ from thetherapist and receptionist; the othergroup had ‘‘compliance enhance-ment approach’’ from reception andtherapy staff, which included set-ting positive expectations and con-veying positive regard for thepatient, and confidence in the pa-tient’s ability to assume responsibil-ity for the treatment program. Thepatients in the ‘‘compliance enhance-ment approach’’ group were signifi-cantly more likely to wear theirorthotics, and knowledge of orthoticpurpose correlated with actual useregardless of group. A systematic re-view of the literature on the effect ofpatientepractitioner interaction onadherence in people with arthritis13

found evidence that affective toneand the patient’s belief in the benefitof a particular treatment had a sig-nificant influence on adherence.Another found that positive feedbackfrom the therapist can improve exer-cise adherence in acute conditions.14

Health care team and health sys-tem interventions for maximizing pa-tient’s adherence include:

� Ensuring continuity of careetheentire health care team should begiving the same messages, deliv-ered in the same way;

� Encouraging the patient’s ownsense of self-efficacy; and

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� Eliciting the patient’s perceptions,expectations, wants, and needs inthe early stages of the therapeuticrelationship so that these can beaddressed and incorporated intothe treatment plan.

Therapy-relatedInterventions

The therapy-related dimension in-cludes complexity, duration, imme-diacy of benefit, interference withlifestyle, side effects, and frequentchanges to treatment pathways. Italso encompasses the availability ofsupport to deal with the abovefactors. These factors, especially theperceived complexity of treatment,interference with the completion ofdaily occupations (productivity, self-care, and leisure), and availability ofsupport (especially pain relief) ex-erted the most significant influenceon adherence in a group undergoingdistraction treatment for complex fin-ger fractures.10 Another study foundthat immediate benefit from wearingthe orthosis was the only factor sig-nificantly associated with adherence,highlighting the need for good pa-tient’s education: ‘‘the better an indi-vidual is informed of the potentialpositive effect, the better it will berealized.’’15(p93)

Previous research has found thatorthosis comfort16,17 and visual ap-pearance (and visibility to others)are important factors to the wearerand can influence adherence.18e20

For example, a modified orthosisfor axilla burns in an Indian popula-tion concluded that it had greaterpatient’s acceptance because of ‘‘aes-thetic appeal over the currently avail-able aeroplane orthoses (splints), asthis could be worn comfortablywithin one’s garment.’’18(p502)

Although there are few studies thathave examined the impact of includ-ingmeaningful, occupation-based ac-tivity into hand therapy programs,positive results on measures of rangeof motion, strength, and patient’s rat-ing of functional abilities have beenfound in one small randomized con-trolled trial in a military setting inTurkey.21 Meaningful activities canalso improve treatment adherence22

with participants in one randomizedcontrolled trial recording highernumber of repetitions of an exercise

when their device was connected toa computer game compared withparticipants given the exercise deviceand told to use it at a comfortablepace.23 This is consistent with thework of David Nelson, a U.S.researcher who has studied theimpact of Occupationally EmbeddedExercise in elderly, stroke, andbrain-injured populations. For ex-ample, a multisite randomized con-trolled trial compared rote exerciseto a simple dice game for peoplewith pronator spasticity poststrokeand found improved supination inthe game group.24

Therapy-related interventions formaximizing patient’s adherence inhand therapy include:

� Ensuring orthoses are comfortableand aesthetically acceptable to thepatient;

� Incorporating meaningful activityinto therapy programs whereverpossible;

� Preparing patients for the fact thatexercise may be painful or uncom-fortable in the early stages after anacute injury, but this does not sig-nify further damage;

� Liaising with the medical staff toensure preemptive analgesia inthe early stages postinjury; and

� Giving examples of how other pa-tients have successfully adaptedactivities without compromisingthe orthotic regimen.

Condition-relatedInterventions

Condition-related factors includeseverity of symptoms, level of disa-bility, prognosis, rate of progression,comorbidities, and the availability ofeffective treatment. There are fewstudies in the acute hand therapyliterature that have explicitly studiedthis dimension, but a systematic re-view of adherence studies in rheuma-toid arthritis25 found no relationshipbetween disease severity/level of dis-ability and compliance.Few studies of acute hand injuries

have examined the impact of comor-bidities and adherence. A study ex-amining the impact of drug andalcohol abuse, psychiatric illness,and previous brain injury on adher-ence with orthoses in an acutelybrain-injured population found nosignificant relationship.26 In contrast,

the literature on adults with acuteburns has found a strong associationbetween preinjury alcohol intake,drug dependency, and psychiatric ill-ness and adherence with therapy.27,28

Furthermore, burn patients with aprior psychiatric history were likelyto have greater depression and blamethemselves for the accident, thus re-sulting in lower adherence to therapyregimens.29

Based on the limited research inthis area, potential condition-relatedinterventions for maximizing pa-tient’s adherence are as follows:

� Ensuring that therapists are ableto identify the signs and symp-toms of comorbidities that may af-fect adherence, such as depressionor anxiety disorders;

� Ensuring that support or treat-ment for comorbidities is in place;and

� Providing clear education aboutthe expected prognosis and rateof progress for the specific condi-tion and a clear rationale for treat-ment at each stage.

Patient-related Interventions

The patient-related dimension in-cludes the resources (physical, sen-sory, and psychological), knowledge,attitudes, motivation, beliefs, percep-tions, and expectations of the patient.As hand therapists, we often assumethat the patient is (or should be)motivated to follow their treatmentprotocol, and that educating themabout their injury should be sufficientfor ensuring adherence.30 Both arequestionable assumptions.

To examine the issue of motivationfirst, the evidence from the behav-ioral sciences shows that patientsvary in their level of readiness tofollow treatment plans. These levelsof readiness are explained by the‘‘stages of change’’ or ‘‘transtheoret-ical model of change’’ and can readilybe applied to hand-injured clients.31

In this model, therapists match theirapproach to the stage the person isin to influence the patient’s own abil-ity to take action. The second as-sumption, that ‘‘an informed patientis an adherent patient’’ is potentiallya dangerous one, as informationalone is not enough for creating ormaintaining good adherence habits.6

Patients may also fail to benefit fromeducation due to being distracted oroverwhelmed at the time informationis given to them (e.g., in the hourspostsurgery or in a busy outpatientclinic) thus struggling to retain theinformation given. A study of 28 cog-nitively unimpaired patients post-flexoretendon repair32 found thatonly 42.5% recalled instructions (in-cluding ‘‘do not remove your ortho-sis’’) without the need for a cue.Patient’s beliefs and attitudes

about their condition, expected treat-ment, and their own power to influ-ence the outcome have been shownto be important factors in the previ-ously mentioned qualitative study10

and have been found to have an effecton adherence in chronic hand condi-tions.14,33 The therapist has an impor-tant role in promoting optimism,providing enthusiasm and a ‘‘realitycheck,’’ and reinforcing the patient’spower to influence their own out-come by engaging in adherencebehaviors throughout the therapyprogram.6 Activation of the patient’sown resources, such as family mem-bers, friends, and coworkers can rein-force therapy goals.Patient-related interventions for

maximizing patient’s adherenceinclude:

� Ensuring that interventions go be-yond the provision of advice andprescriptions. It is well estab-lished that education alone is aweak intervention;6

� Promoting optimism, and rein-forcing the patient’s power to in-fluence their own outcome;

� Activating the patient’s own re-sources; and

� Specific skill development fortherapists in behaviorally basedinterventions that can be incorpo-rated into daily practice.

CONCLUSION

Hand therapists, as client-centeredpractitioners, must replace the termcompliance with that of adherenceand stop blaming patients when theydo not follow their programs.Although nonadherence is a behaviorobserved in an individual patient, itis important to recognize that thecauses are not just patient related.

‘‘[Nonadherence] occurs in the con-text of treatment-related demandsthat the patient must attempt tocope with. These demands are char-acterized by the requirement to learnnew behaviors, alter daily routines,tolerate discomforts and inconve-niences, and persist in doing so whiletrying to function effectively in theirvarious life roles.’’6(p145)

There are many opportunities toinfluence adherence by adapting ourown approach (and that of our team)and our interventions, including (butnot limited to) the use of specificcounseling approaches, building thepatient’s own self-management skills,ensuring continuity of care, incorpo-rating meaningful activity, and moreclient-centered design of orthoses.

Lisa O’Brien, PhD, M Clin Sci

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