Rehabilitation adherence: Whose responsibility is it?

To identify mechanisms optimising adult adherence to physiotherapist delivered rehabilitation for Achilles tendinopathy.

An interpretive descriptive qualitative study using semi-structured interviews conducted during episodal-care at six timepoints across 52-weeks. Participants were experiencing moderate-to-severe Achilles tendinopathy pain and dysfunction according to their VISA-A scores at baseline. Despite having all seen a health professional, no participants were fully adhering to recommended guidelines. The sampling frame categorised participant adherence as high, partial, or low. Framework analysis was used to determine adherence mechanisms across the three groups.

Twelve mechanisms that influence adult adherence to physiotherapist delivered rehabilitation for Achilles tendinopathy were identified. Four themes had three mechanisms each:  Tendinopathy-paradigm consisted of ‘meaning-making of load and pain’, ‘comprehension of new knowledge’ and ‘operationalising knowledge’. Self-management skills consisted of ‘internal self-management capability’, ‘external life-rhythm management’ and ‘managing physical capability’. Therapeutic relationship consisted of ‘pre-scheduled regular check-ins', ‘personal and professional connection’, and ‘coaching support’.  Focus on outcome consisted of ‘motivation to maintain functional ability with progressing age’, ‘framing success’ and, ‘it’s a trial’.

Thematic profiles were identified in relation to adherence categories. Participants demonstrating high-adherence behaviour had an established tendinopathy-paradigm and self-management skills. To operationalise the rehabilitation, they needed specific parameters delivered upfront. Participants demonstrating partial-adherence behaviour required personal and professional connection enabling coaching support to build a tendinopathy-paradigm and self-management skills. Participants demonstrating low-adherence behaviour tended to find establishing a new tendinopathy-paradigm challenging. Some weighed up the effort-versus-reward proposition, preferring to self-tailor adherence according to personal preferences, priorities, or comorbidities. Pre-scheduling episodal-care was reported across all participant classifications as a mechanism optimising adherence, through reinforcement of rehabilitation technique and parameters, reassurance, and accountability. 

This longitudinal study provides new knowledge to guide physiotherapists in delivery of rehabilitation for Achilles tendinopathy in a person-centered way that optimises adult adherence to guideline-based-care and guides clinical practice and future tendinopathy research.  

This new knowledge may have implications beyond Achilles tendinopathy to other chronic, complex musculoskeletal conditions. Optimising adherence to rehabilitation delivered by physiotherapists may improve pain and functional outcomes, thereby minimising more expensive and invasive alternatives and improving wellbeing.