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Management eBrief No. 204

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Management eBriefs
Issue 204 July 2022

The report is a product of the VA/HSR Evidence Synthesis Program.

Interventions to Improve Long-Term Adherence to Physical Rehabilitation among Those with Hip or Knee Osteoarthritis or Chronic Low Back Pain: A Systematic Review

Takeaway: Sustaining long-term functional improvements gained during short-term rehabilitation programs requires ongoing adherence to recommended home rehabilitation programs. Existing interventions to promote long-term adherence show limited effect. Suggest future research incorporate evidence-based techniques focused on the maintenance of behaviors.

In the VA healthcare system, 25% of patients with musculoskeletal conditions receive care for low back pain annually, and 21% of Veterans receiving musculoskeletal care have osteoarthritis (OA). One approach to managing symptoms for patients with low back pain or OA is physical rehabilitation. Despite the effectiveness of rehabilitation in reducing pain and disability, patient adherence to clinician-prescribed rehabilitation regimens has been measured to be as low as 13%.

VA’s Evidence Synthesis Program (ESP) Center in Durham, NC, conducted a systematic review to evaluate the effect of physical rehabilitation interventions supplemented with one or more adherence-enhancing adjunct components among adults with hip or knee OA or chronic low-back pain on: 1) adherence, 2) functional improvements, and 3) self-efficacy at ≥ 3 months after completing an index rehabilitation program. Investigators searched MEDLINE, CINAHL, and Embase from inception through July 27, 2021. After identifying over 3,300 potentially relevant articles, 81 were reviewed at full-text, and 11 met eligibility criteria. Of these 11 articles (10 unique interventions and 1,964 participants), 7 were randomized controlled trials, only one was conducted in the US, and 7 targeted patients with knee and/or hip osteoarthritis. In 6 studies, the adjunct adherence intervention was delivered concurrently to the index rehabilitation program and sequentially in 4. Approaches to long-term adherence promotion included phone-based coaching, SMS (Short Message Service)-based reminders, practitioner training, and booster rehabilitation sessions.

Summary of Findings

There is inadequate evidence evaluating rigorously designed adherence-enhancing interventions for the specific promotion of long-term adherence to home rehabilitation programs. Identified studies were generally small and only five articulated a specific intent to promote long-term adherence. Few studies included theory-based behavioral approaches to behavior maintenance or employed different techniques to promote the initial rehabilitation program versus ongoing adherence. Only three studies showed a positive effect on long-term adherence – and none demonstrated an effect on long-term physical function, self-efficacy, or harms.

Research Gaps/Future Research

Five key areas were identified in which future research could fill existing gaps and/or improve the approach:

  1. In order to impact long-term patient outcomes, adherence-enhancing adjunct interventions should consider the use of evidence- and theory-supported approaches to help maintain adherence to a home rehabilitation regimen – distinct from those employed for the initiation of a new regimen.
  2. Future research should leverage theoretically-grounded and evidence-based approaches to promoting the maintenance of home rehabilitation programs.
  3. Adherence interventions could take advantage of the flexibility of virtual and/or asynchronous technology to improve long-term engagement.
  4. Studies should include objective functional and adherence outcomes and validated measures of self-efficacy. Continued reporting of outcomes at least six months after the rehabilitation program would enable comparisons across studies and add to the understanding of longer-term adherence patterns.
  5. Research is needed on important subpopulations, including underrepresented racial and ethnic populations and younger adults with knee and hip OA and low back pain.

Seidler KJ, Rethorn ZD, Burke C, et al. Interventions to Improve Long-term Adherence to Physical Rehabilitation Among Those with Hip or Knee Osteoarthritis or Chronic Low Back Pain: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-101; 2022.

To view the full report, go to (Intranet only)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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