Why don't patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee

Study objectives-To understand reasons for compliance and non-compliance wi th a home based exercise regimen by patients with osteoarthritis of the kne e. Design-A qualitative study, nested within a randomised controlled trial, ex amining the effectiveness of physiotherapy in reducing pain and increasing mobility in knee osteoarthritis. In the intervention arm, participants unde rtook a series of simple exercises and repositioning of the kneecap using t ape. In depth interviews were conducted with a subset of participants in th e intervention arm using open ended questions, guided by a topic schedule, to encourage patients to describe their experiences and reflect on why they did or did not comply with the physiotherapy. Interviews were audiotaped, fully transcribed and analysed thematically according to the method of cons tant comparison. A model explaining factors influencing compliance was deve loped. Setting-Patients were interviewed at home. The study was nested within a pr agmatic randomised controlled trial. Participants-Twenty participants in the intervention arm of the randomised trial were interviewed three months after they had completed the physiother apy programme. Eight were interviewed again one year later. Main results-Initial compliance was high because of loyalty to the physioth erapist. Reasoning underpinning continued compliance was more complex, invo lving willingness and ability to accommodate exercises within everyday life , the perceived severity of symptoms, attitudes towards arthritis and comor bidity and previous experiences of osteoarthritis. A necessary precondition for continued compliance was the perception that the physiotherapy was eff ective in ameliorating unpleasant symptoms. Conclusions-Non-compliance with physiotherapy, as with drug therapies, is c ommon. From the patient's perspective, decisions about whether or not to co mply are rational but often cannot be predicted by therapists or researcher s. Ultimately, this study suggests that health professionals need to unders tand reasons for noncompliance if they are to provide supportive care and t rialists should include qualitative research within trials whenever levels of compliance may have an impact on the effectiveness of the intervention.