Is non-adherence to rehabilitation really just about the patient?

Background: Exercise and activity advice are recommended first-line treatments for many musculoskeletal conditions, including tendinopathy. Adherence to the prescription is essential yet is understood to be as low as 30% in musculoskeletal conditions, even in efficacy trials. Known barriers include time pressures and fear-avoidance.
Purpose: The aim of this scoping review was to guide rehabilitation practice by identifying behaviour change techniques and constructs reported for exercise prescription in adults undergoing treatment for tendinopathy.
Methods: This review followed the PRISMA-ScR guidelines. Manuscripts detailing adherence mechanisms in tendinopathy protocols, published from inception to 2023 were independently screened against a priori review criteria by two reviewers. Identified behaviour change techniques and mechanisms of action that may influence adherence, were extracted and mapped to the capability, opportunity, motivation model of behaviour (COM-B). Three reviewers independently extracted data concerning trial population, trial duration, nature of tendinopathy and country ranking according to the UN Human Development Index.
Results: Of the 83 studies included in this review, only 6% addressed fidelity of the intervention delivery, in attempting to ensure that the protocol was delivered as planned. Only one trial reported details of patient receipt. Therefore, whether patients understood and found the protocols in the literature acceptable is largely unknown. The COM-B construct ‘psychological capability’ occurred most frequently (436 references from 73 papers) and included education and instruction. Social and physical opportunities such as access to health professionals and resources, were also identified as mechanisms of adherence (382 references from 64 papers). However, patient beliefs categorised in reflective motivation (44 references from 19 papers), and automatic motivation such as habit formation (3 references from 3 papers) were notably less utilised.
Conclusion(s): Health practitioner exercise delivery currently targets patient psychological capability (knowledge), and social and physical opportunity. Motivation is underutilised and could be included in future research to explore patient receipt of the education provided and whether it impacts beliefs and habit formation.
Our findings are meaningful, as common barriers to adherence are fear of damage, exacerbation of pain, and a perceived lack of time. Although education is often provided and exercise and physical activity may be tailored, we do not know if this impacts patient beliefs about their physical capability or the consequences of adhering to the exercise program, and although participants often use an exercise diary for self-monitoring, we do not know if this assists habit formation. We do know that access to health professionals is a mechanism of adherence.
Implications: Identifying behaviour change constructs promoting adherence in the adult tendinopathy literature, may enable deliberate embedding of mechanisms that could improve trial efficacy and clinical efficiency and outcomes, with the potential of long-term patient self-management leading to improved wellbeing and cost effectiveness.