Physiotherapists’ perceptions of patient adherence to home exercises in chronic musculoskeletal rehabilitation.

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Citation

Abstract

Background – Rehabilitation of chronic musculoskeletal conditions usually involves long-term home-based exercise programmes. Exercises have been shown to alleviate pain, improve joint mobility and stability, allow faster return to work and prevent progression of chronic conditions. Non-adherence of patients to unsupervised long-term exercise is a major problem that affects treatment outcome. This study explores UK physiotherapists’ perceptions of exercise adherence and their interventions to tackle it in clinical practice.

Method – A convenience sample of five experienced physiotherapists from Sheffield Hallam University were interviewed. Interviews were transcribed and analysed. Interpretative Phenomenological Analysis (IPA) was used to analyse data transcriptions.

Results – The identified themes revolved around issues of patient-therapist collaboration in chronic rehabilitation. The subordinate themes were: negotiating ownership and self management, education and pain, professional power and patient attitudes and communication.

Conclusion – Experienced physiotherapists recognised barriers and often critically viewed their practice. They undertook necessary interventions in their practice but persisting non-adherence made them question the patient’s role in the partnership.

Introduction

Chronic musculoskeletal pain is a detrimental health issue in today’s world and poses an added burden on the healthcare system struggling to cope with the short-term demands of acute care (Barlow et al 2002). Management of chronic conditions focuses on preventing progression of the condition, maintaining function and minimising avoidable disability (Jordan et al 2010). Long-term exercises and self-management are strongly recommended compared to passive treatments for such conditions allowing faster return to work (ARMA 2004, Airaksinen et al 2004, van Gool et al 2005, Smidt et al 2005). Pain sufferers who undertake regular exercise may be less likely to progress to recurrent, persistent or disabling pain problems (McLean et al 2007). Prescription of exercise can vary in technique and intensity, from specific exercises enhancing strength and flexibility to general aerobic fitness programs (Moffett and McLean 2006).

Adherence is “the extent to which a person’s behaviour… corresponds with agreed recommendations from a healthcare provider” (WHO 2003). Adherence is multi-factorial; components related to patients, healthcare professionals and healthcare organisations are believed to affect patient’s exercise adherence (van Gool et al 2005). Patients who adhere are identified to have better treatment outcomes than non-adherent patients; thus making non-adherence a burden on the economy (Hayden et al 2005, WHO 2003, Marwaha et al 2010). Failure to exercise regularly is recognised as the most common non-adherent behaviour among patients with chronic conditions (Middleton 2004). According to Slujis et al (1993), two-thirds of the patient population in their study were non-adherent to short-term exercises. Long-term adherence with exercise is more difficult to achieve especially when immediate benefits are unlikely to be noticed, as is often the case with exercise (Slujis et al 1993, Middleton 2004).

Many health psychologists have strived to explain health-related behaviour in patients (Armitage and Conner 2000). Low self efficacy, low levels of physical activity, psychological factors, pain on exercise and poor social support were some barriers to exercise adherence recognised in previous literature (Jack et al 2010). Studies have also shown that researched interventions are insufficiently effective in improving long-term adherence (McLean et al 2010). This qualitative study aims to investigate physiotherapists’ perceptions regarding adherence to home-based exercises among patients with chronic conditions, their experiences and interventions in clinical practice.

Method

Study design

Qualitative research aims to explore the diverse understanding of adherence behaviour and allows the participant’s views to be analysed within their personal, professional and social context (Dean et al 2005). This study employed an Interpretative Phenomenological Approach (IPA), relatively recent to qualitative research in the field of physiotherapy (Dean at al 2005, Smith and Osborn 2007b). According to Smith and Osborn (2007a, p53), IPA is a double hermeneutic approach, where the participants try to understand their world and the researcher tries to make sense of them understanding their world. It regards the participant as a cognitive, lingual and physical being and assumes a link between their perceptions, narrations and its context. IPA can help investigate multidimensional, dynamic and substantial phenomena and offers a person centred approach to understanding the experiences of healthcare professionals (Clarke 2009).

Credibility

Criteria of rigour in IPA are important to ensure a systematic, genuine and high quality methodology. DeWitt and Ploeg (2006) highlight five “expressions” or criteria of rigour that can be recognised by readers to ensure legitimacy and consistency of the study (Table 1).

Table 1: Expressions of rigour in IPA (DeWitte and Ploeg 2006)

Expressions Features
1) Balanced Integration Verbalization of general IPA philosophy, its relevance to the research topic, in-depth connection of ideas and a balance between participant’s verbatim quotes and research findings.i.e. researcher’s interpretation must be in concordance with the principles of the methodolody.
2) Openness Documentation of clear systematic explanation for choices taken by the researcher during the entire research process to study the phenomenon of inquiry (physiotherapists’ perspective of exercise adherence).
3) Concreteness Presenting the quotes such that it allows the reader to sense the context in which verbatim quotes were said by the participant at the time of the interview.
4) Resonance Ability to place the text side by side with self-understanding i.e. relate one’s own experiences with the findings.
5) Actualization Future realisation of ‘Resonance’. It represents the criterion of potential as the future contains the greatest verification for an interpretation.

The research study project was proposed and ethical approval was granted by the Dissertation Management Group of Sheffield Hallam University, UK. Due to feasibility and time constraints, participants were from a convenience sample of UK registered physiotherapists selected from the staff and students at Sheffield Hallam University, to undertake semi-structured interviews. The inclusion-exclusion criteria are listed in Table 2.

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Table 2: Inclusion and exclusion criteria for study sample

Inclusion Criteria Exclusion Criteria
  • Physiotherapists involved in managing musculoskeletal conditions.
  • Registered to practice in the UK
  • At least 2 years of clinical experience
  • Willing to participate
Physiotherapists not involved in managing musculoskeletal conditions
Cannot speak or understand English.
Not willing/Unable to participate.

Recruitment

Letters of invitation and information sheets were e-mailed to potential participants. Seven agreed to participate although two were unable to find time for the interview during the time allocated to the study and therefore had to be excluded from the study. Prior to the commencement of the interview the participants had an opportunity to ask questions and read the consent form. Five participants, who were willing, signed consent forms. The selection of a small sample was in harmony with the chosen interpretative phenomenological approach as its goal is not generally to reach saturation but to find rich and meaningful data after in-depth analysis from the sample used (Hale et al 2008, Smith and Osborn 2007a, p56). Participants were given pseudonyms to preserve anonymity; their years of experience and working environments are listed in Table 3. The average clinical experience of the participants calculated was 12 ¾ years.

Table 3: Participants’ history

Participants (pseudonyms) Clinical experience (years) Work set-up
Mathew 23 Not currently practicing
Jack 2 Non-private
Andrew 17 Private
Sam 11 Private
David 11 Private with previous non-private work experience

Data collection

Three pilot interviews on physiotherapists were conducted which helped formulate the topic guide shown in Table 4. These participants were physiotherapists studying towards a Masters Degree in Applying Physiotherapy at Sheffield Hallam University. Although they did not meet all criteria, they provided insight into the study.

Semi-structured interviews were conducted by the researcher with the participants at a mutually convenient time and venue. Participants were assured that the questions had no right or wrong answers and the objective was to gather their perspectives. The interviews were directed using the topic guide, questions were open-ended and the researcher refrained from commenting to prevent leading, though clarifying questions were asked. Semi-structured interviews provided flexibility and thorough coverage of topics and were a way to recognise participant diversity. The interviews lasted for 20-40 minutes, were recorded using a digital voice-recorder, transcribed verbatim and kept confidential by the researcher.

Table 4: Topic guide used for semi-structured interviews

  • Could you give me your opinion on home based exercises for chronic cases?
  • Do patients sometimes reveal problems they face with the home exercises?
  • Do you sometimes notice problems with prescribing home exercises?
  • What are your views on patient adherence to home exercises?
  • What other barriers to exercise have you come across in your clinical practice?
  • What methods have you tried in your clinic to overcome these barriers which have been effective or ineffective in your clinical practice?

Data analysis

Interpretative Phenomenological Analysis was used to analyse data by the researcher. Its layered format, which presents clear-cut application, is well suited for topics that are tangible and dynamic (Dean et al 2005), such as non-adherence with exercise. The stages of analysis are illustrated in Table 5.

Table 5: Stages of interpretative phenomenological analysis (Smith and Osborn 2007)

STAGES OF ANALYSIS
Look for themes in the first transcript Read the transcripts multiple times-potential of developing new insightsà Note comments on the left side margin each time to verbalise thoughtsà Once familiarised, form emerging themes from the comments onto the right side margin.
Connecting themes Identifying shared themesà build connections between themes if possible using analytical and theoretical thought process, themes must constantly be grounded by quotes in the transcript.
Produce table of themes ordered coherently Name each cluster of themes forming ‘Super-ordinate Theme’. Create a table that lists the Super-ordinate themes, the themes under them and ‘identifiers’ which are key words from transcripts justifying the theme
Continuing analysis with other transcripts The first transcript is used as a template to analyse the others. Identify repeated patterns and new ideas. Analyse shared themes.
Writing up Analysis continues. Discussion of themes into a narrative account.

Each transcript was analysed thoroughly and sequentially. Finally all the transcripts and their themes were studied together. Shared and new themes were recognised and further analysed. Table 6 gives an example of how the themes and their interpretations evolved.

Reflexivity

The researcher is a non-UK physiotherapist with a cultural background different from the participants and has no clinical experience in the UK. In the researcher’s experience, non-adherence was recognised by physiotherapists but it was assumed to be for the patients to resolve themselves. Listening to clinical experiences in UK settings was a learning experience in itself and this open-mindedness reduced any professional bias albeit certain idiosyncratic phrases and assumptions might have been inaccurately interpreted. The researcher attempted to keep these presumptions to one side while interviewing and reading transcripts. All the findings are supported by evidence where possible. An independent researcher, who was also a non-UK physiotherapist familiar with IPA methods, was able to provide verification of the analysis and help refine the data thus reducing misunderstandings and ensuring transferability.

Table 6: Example of Theme Development.

Quotes Descriptive Code Theme and its Interpretation
“Home exercise is the key to getting a chronic problem right. A lot of chronic patients come with perhaps an insidious onset and my (physiotherapist’s) belief is that it’s their (patient’s) life that’s created that problem.It doesn’t matter what I do in that physio clinic, if they are not going to take it home and change the way they live and perhaps change their lifestyle by incorporating exercise into it then you are not going to get them right, it doesn’t matter how good a physio you are hands-on.” Participant felt home exercises cannot be replaced by the best hands-on and patients needed to take responsibility and incorporate them into their lifestyle. Negotiating ownership and self-managementTherapists critically evaluate themselves and make amendments but patients need to acknowledge their share of the partnership.
“There’s always been patients who can’t, don’t do their exercises. When I first started out as a physio a long time ago, you’re full of enthusiasm and say …”and here are 35 exercises…” that doesn’t work… I changed that approach dramatically over the years because… I’m a physio and I should be practicing what I’m preaching but it’s just very difficult to fit exercises in a normal daily routine. So when I experienced that myself, I needed to have a really hard think about how to do this. You need to negotiate with your patients as to how many exercises they think they can fit in.” After critically reviewing their practice, participants felt it important to negotiate exercise plans with the patient to fit them into their busy schedule.
“Patient education is not just a nice extra. It’s a very important element of the treatment program. And it’s very important for me (physiotherapist) to make sure that the patient will be able to manage his problem later on….. (when asked about problems he faced with home exercises) They (patients) didn’t realise the importance of home exercise program…And just say, ‘I will go to the professional, he (physiotherapist) knows more than me so he should do that for me” Participant feels responsible for the patient’s long term care and felt education on self management is vital.Some, despite the education felt incapable and shed responsibility onto the therapist.

Results

The evolved themes were derived from physiotherapists’ interviews. The patient-physiotherapist collaboration in rehabilitation was the common theme that participants focussed on. The following sub-themes have been extracted from the transcripts and represented using verbatim quotes. Participants were given pseudonyms to preserve anonymity.

Negotiating ownership and self management

Chronic conditions required a long-term exercise plan which was recognised as a commitment in terms of time and lifestyle change for patients. Patients often prioritised their existing personal obligations before exercise and respecting their schedule while planning treatment was important for physiotherapists in winning them over. Physiotherapists felt negotiating realistic plans that patients felt were relevant to their treatment goals, was a reasonable intervention to improve exercise adherence.

“there’s always been patients who can’t, don’t do their exercises… you need to negotiate with your patients as to how many exercises they think they can fit in…. patients too really do have a busy life….. (physiotherapists) professionally advising them to do these 5 exercises 3 times a day, (smiles) it ain’t gonna happen.”(Mathew)

Most therapists believed that patients tend to shed their responsibility and teaching patients the need for home exercises was fundamental. The need for patients to modify their lifestyle and not depend entirely on physiotherapists for a solution was expressed by David.

“my belief is that it’s their (patient’s) life that’s created that problem (condition)…. if they are not going to take it (advice) home… perhaps change their lifestyle by incorporating exercise into it then you are not going to get them right…………. you need to educate them in terms of the importance of the home exercise program.”(David)

Education and pain

A recurrent barrier that emerged was pain on exercising. ‘Pain’ unearthed complex aspects during the interviews. Participants felt understanding each other’s interpretation of pain was important during the initial sessions where the patient shared the functional disability due to pain and the therapist shared his clinical knowledge.

“It is (physiotherapist’s duty) to explain to them (patients) why they experience the amount of pain that they have and it was getting them to explain to me, what effect it has on their life.”(Andrew)

It was thought important to educate patients that pain was a natural phenomenon, not necessarily a sign of injury. The challenge then was to ensure that patients understood pain perception; some physiotherapists felt they often lost the battle to pain despite attempts at patient education, as patients sometimes chose to discontinue exercises as a way of relieving pain.

“When they (patients) go home and… find the pain, they say ‘okay I will not continue (exercises)’…Even if I’ve already explained that (pain perception) to them in detail in the clinic” (Sam)

One of the participants believed sometimes the altered pain perception also changed the perception of their condition driving them towards non-adherence.

“… after discussing their problem with somebody like me (physiotherapist), they (patients) feel assured. The pain perception has changed so they forget to do their exercises because there is no longer a… perceived need to do them.”(Mathew)

Professional power and patient attitudes

In many instances, physiotherapists felt their place in the hierarchy of healthcare professionals acted as a barrier to adherence. One reason for them to perform hands-on treatment was to gain professional power in the patient’s view and to differentiate themselves from the other consultants.

“It’s not as powerful as a doctor telling them (patients) to do something… even though, ironically that GP probably doesn’t know more about the subject (diagnosis) than you (physiotherapists) do.”(David)

Participants believed that the patient’s adherence depended on the healthcare professional providing the exercise recommendations. The patient’s faith in physiotherapy was easily overruled by advice from other healthcare professionals.

“… let’s say I, as a therapist advised them (patients) on let’s say two particular exercises and some patients go to an osteopath or chiropractor privately as well and they get conflicting advice… they stop doing the exercises then.”(Mathew)

Communication

Communication is a two-way process between physiotherapist and patient and it was considered important to understand each other’s expectations and problems. Imparting education and negotiating treatment would be defective if the communication channel was faulty. Physiotherapists recognised that most issues could be resolved by clear communication.

“How you communicate that advice across is very important and how easy is it for that patient to communicate with you…… We started using physio tools but again that’s very fixed…….. Started to draw pictures that became a little bit easier I think… for the patient” (David)

Exercises can be quite complicated for patients to understand. David felt using the appropriate means of exercise prescription reduced the chances of them forgetting the exercises or doing them wrong. Some therapists believed the diversity in the patient population created an unintentional communication gap and thus the patients failed to understand the exercises and their impact.

“We explain them (exercises) correctly, they (patients) don’t get it correctly… accents pose a problem, accents and dialects…” (Jack)

Ensuring an open line of communication between the therapist and the patient was also commonly agreed upon as necessary. Although participants also stated that their patient loads and work restrictions were barriers to its implementation.

“Sometimes they give us a call but by the time they give us a call even we don’t keep a track of it. It’s just the way the system has been designed.”(Jack)

Discussion

The interpretation of the derived themes related to exercise adherence by patients from the physiotherapists’ perspective will be discussed in relation to the existing literature.

Negotiating ownership and self management

Chronic pain management focuses on preventing progression of the condition and avoiding or reducing disability and morbidity (Jordan et al. 2010). Chronic cases usually require long-term self-management which is complex as it requires less therapist participation and more self-direction from patients (Moffett and Richardson 1997, van Gool et al 2005). Self management of controlling symptoms and exercises are highly recommended in the literature (van Gool et al 2005, Moffett 2002). It bridges the gap between the patient’s condition and their need to seek advice from a healthcare professional (Barlow et al 2002). Strong evidence suggests that regular exercise prevents progression of chronic conditions (McLean et al. 2007, Hyun-Ja Lim et al. 2005). Physiotherapists feel patients need to take ‘ownership’ (Mathew) towards the treatment and increase their daily activity levels. It has been suggested that all patients can be categorised on a continuum of their readiness to change exercise behaviour (Table 7). Encouraging patients to transition from their existing stage to the next may assist adherence (Koenigsberg et al. 2004).

Patients understand exercise programmes based on how it changes the practical aspects of their life while physiotherapists perceive it in terms of symptom improvement (Turk and Rudy 1990). By mutual negotiation, a realistic exercise plan that can be incorporated into the patient’s lifestyle should be reached. Prescribed exercises should be evidence-based, have clear instructions and be enjoyable. Physiotherapists need to nurture self efficacy among patients to promote patient’s confidence to accept ownership of the exercises (Barlow et al. 2002). For a physiotherapist, understanding the patient’s beliefs about the condition, physical activity and pain should be important (Jensen and Lorish 1994). The extent of congruence between patient and therapist beliefs influences the patient’s faith in therapy and adherence to the exercise plan (Krupat et al. 2001). In this study, physiotherapists perceptions with regard to ‘ownership’ were in line with the theoretical evidence base.

Table 7: Stages of Exercise Behaviour (Marcus et al. 1992, Koenigsberg et al. 2004)

STAGE BEHAVIOUR THERAPIST’S GOAL
Pre-contemplation Not considering exercises in lifestyle Progress to thinking about change (education)
Contemplation Considering exercises in the next few months Progress to preparing for change (education)
Preparation Currently exercising but not regularly Progress to taking action (motivation and behaviour change)
Action Currently exercising regularly but for less than 6 months Maintain the change (exercise sheets, mental reminders, visual cues etc)
Maintenance Currently exercising regularly for over 6 months but needs reminders. Maintain the change
Identification Currently exercising regularly for over 6 months, incorporated in lifestyle. Maintain the change

Pain and education

Chronic pain consists of a dynamic interaction between biological, psychological and social factors (Woolf and Decosterd 1999). Considerable evidence suggests that chronic pain patients are likely to have some associated degree of anxiety and depression although the causal relationship between pain and anxiety/depression is uncertain (Dersh et al 2002). According to Cornwal and Doncleri (1988), anxiety was shown to decrease pain threshold in people whereas depression was linked with unsuccessful treatment outcomes. Increase in pain is a common barrier to adherence and delayed exercise outcome reduces the credibility of treatment perceived by patients, driving them towards non-adherence (Jack et al 2010, Foster 2007). Both these issues were identified in the interviews. The unsettling nature of pain also weakens exercise behaviour. Therapists believe educating patients about pain manifestation is important and reassurance could improve self-efficacy (Moffett and Richardson 1997). Despite the education, pain nonetheless continues to be a barrier to exercise. The education therapists impart must correspond to their patient’s psychological state and capacity to comprehend in order to be effective (Marcus et al. 1992). Strategies to combat initial pain should be included in self management to allow patients to accept exercise and reduce anxiety (Jack et al 2010). Modest evidence has shown that exercise reduces pain intensity in chronic pain patients with high levels of adherence (Rainville et al 2004, Salaffi et al 2004, Thomas et al 2002). By contrast, Medina-Meripeix et al (2009) found that patients used the presence of pain or disability to inspire them to undertake exercise; this was not identified in the interviews in this study. This highlights the complex attitudes, beliefs and behaviours that may exist around pain and exercise. There is a requirement for physiotherapists to try to understand patients and their perspective about pain and adjust management strategies and communication strategies that maximise patient’s confidence to exercise when pain may be present.

Professional power and patient attitudes

In this study, participants often mentioned the patients’ view of physiotherapists in the hierarchy of healthcare professionals. They felt patients disregarded their treatment because physiotherapists were considered less skilled than doctors though evidence shows them to be equally qualified (Daker-White et al 1999). The frequent mention of their “professional status” impeding adherence and the consequent frustration signifies the importance of this issue, though there is no documented evidence in previous literature to support this view.

The multidisciplinary team (MDT) is one where members work in parallel or in sequence from a specific professional base to resolve a common problem (Ferlie et al 2005). Theoretically MDTs should be effective; the multi-professional nature should ensure appropriate diagnosis and high quality evidence based treatment and delivery of care (Körner 2008). But evidence of able working of the MDT in the UK is meagre. Teams require certain factors to perform well, for example full participation of all team members, administrative support, co-ordination of clinical staff and funding (Fleissig et al 2006). Medical dominance is seen as a structural characteristic in most researched countries (Gair and Hartery 2001, Willis 1989, Friedson 1984). Doctors and consultants were often found to have an overriding role in the team (Atwal and Caldwell 2005, Gair and Hartery 2001, Phillips 1996, Adamson et al 1995) and this was found to often affect other health care professionals’ work satisfaction.

Communication

Most participants felt the mode of relaying information, for example physio tools, videos etc. needed reformation or need to be used in appropriate situations. Others sensed the language barrier between physiotherapists and patients, from different cultural backgrounds, led to information being lost during conversations about the necessity of home exercises or the exercises themselves. Effective communication is the foundation of a good therapeutic relationship (Panting 2003). It is more than just talking and listening and involves understanding and reacting appropriately. It provides an insight into and influences patient’s health beliefs, coping strategies and lifestyle behaviour (Moffett and Richardson 1997). Therapists need to clearly inform patients about the nature and rationale of treatment, available options and possible outcomes of the options and of no treatment (Panting 2003). Continual increase in the range of efficient treatment options creates the dilemma of how best to present them to patients. Since the information can be overwhelming for the patient, relaying the information appropriately is necessary (Fleissig et al 2006).

Language concordance has shown to improve patient satisfaction and adherence among diverse patient groups. Use of professional interpreters reduces errors and strengthens the patient-therapist understanding (Cooper and Powe 2004). The development of a good rapport and an open communication channel with patients is vital (Dean et al 2005). All participants had similar views but those in the non-private organisations felt hampered in this by the large patient load.

Study considerations

This study has achieved a degree of insight into the experiences of five physiotherapists prescribing home exercises for chronic pain patients. This sample size, although small, is coherent with the chosen methodology which is cautious in regards to generalisation. The diversity of the sample (Table 3) uncovered a variety of experiences in their respective practices, providing the study with rich data.

All participants spoke intensely about common issues, which show the significance they assigned to the topic, thus offering a certain degree of generalisation. But due to the nature of qualitative and IPA studies, it is possible that the views and perceptions of the participant physiotherapists’ might differ in other contexts or at different points of time. This opportunistic sample corresponds to the physiotherapists who acknowledge adherence issues and were willing and possibly wanting the opportunity to share their experiences and views. This could have influenced the emerged themes. However every idea that is brought forward gathers significant aspects of the subject under study (Smith 2004). Though data saturation could not be reached, the data gathered could be part of a body of evidence which contributes towards an understanding of adherence.

The current study helps identify some dilemmas in the therapist-patient partnership that affects exercise adherence in rehabilitation and the physiotherapist’s views on how this can be resolved. It was observed that therapists who were least experienced found it difficult to identify their role in contributing to patient non-adherence. This study may encourage physiotherapists to recognise barriers to non-adherence, whether patient-related, organisational or therapist-related, and consider strategies which may resolve them.

Some new issues recognised in the study such as ‘professional power’ are worthy of further investigation. Research is needed to explore the patient’s views on their understanding of ownership and education and its efficacy in influencing their coping strategies and exercise behaviour. Studying adherence in patient-therapist pairs could provide a holistic view and help identify or better understand issues prevalent in the literature.

Conclusion

This study has explored the experiences and perceptions of five physiotherapists regarding long term exercise adherence. The analysis revealed themes revolving around patient-physiotherapist collaboration. Earlier studies have also suggested that patient-physiotherapist “concordance” could have a positive effect on adherence (Campbell 2001). Sub-themes like negotiating ownership of a realistic treatment plan, educating the patient on pain and home exercise importance, patient’s attitudes towards physiotherapists and communication were identified as contributing to non-adherence with exercise. Specific barriers to adherence were identified as therapist’s prescribing unrealistic exercise plans, intentional non-adherence due to other commitments or pain and ambiguity of exercises. Possible steps to solve these were also identified and the overriding concept was forming an effective and agreeable partnership. The researcher’s interpretation suggests that these physiotherapists did critically view their practice and intervene appropriately. They value their practice, consider adherence to be important and believe that they have attempted to carry out their share of the bargain. The impending problem in exercise adherence at times makes most of them question the patients’ role, for example, ignoring their advice and shedding ownership. At this point it is necessary to explore further on the therapists’ perceptions and also patients’ views on self management and exercise and whether these patients grasp the education and advice the physiotherapists are attempting to impart.

Acknowledgement

The research team sincerely thanks the Department of Health and Wellbeing, Sheffield Hallam University for support needed for this research study and Miss Ruhy Valawalkar for her participation in valuable discussions that refined the analysis.

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