Behaviour change techniques to promote self-management and home exercise adherence

Key points

1. 0113 modifiable determinants were grouped into 8 categories: explanation and understanding, physical skills, self-efficacy, perceived treatment efficacy, number of exercises, therapeutic relationship, social support and task appreciation, and time and prioritisation
2. 02Exercise self-efficacy was the only determinant supported by at least two low-risk-of-bias cohort studies and was positively associated with adherence in five of six studies that investigated it
3. 03Providing fewer rather than more exercises was consistently identified as a facilitator; providing more exercises was a barrier
4. 04Problem solving was the most frequently mapped behaviour change technique, yet physiotherapists on average use only six behaviour change techniques in practice
5. 05Determinants mapped to psychological capability and reflective motivation most often, suggesting adherence is primarily a cognitive and motivational challenge rather than a physical one

How it was conducted

Design

Scoping review conducted and reported according to PRISMA-ScR

Databases

Medline, Embase, CINAHL, and AMED searched via Ovid from inception to December, updated January for publications to December

Study types included

Full-text quantitative and mixed-methods studies investigating determinants of adherence to physiotherapy exercises or self-management advice in musculoskeletal conditions

Exclusions

Retrospective case series, conference proceedings, in-patient populations, systemic musculoskeletal conditions managed primarily by drug therapy, falls clinics

Mapping framework

Determinants mapped to Theoretical Domains Framework (TDF) and COM-B model, then to behaviour change techniques via the Theory and Techniques Tool (TTT)

Quality assessment

QUIPS tool for cohort studies; AXIS tool for cross-sectional studies; two independent reviewers with disagreements resolved by discussion

What they found

• Studies took place in USA (n=8), Australia, Canada (n=3), Netherlands (n=2), Turkey (n=2), UK, Brazil (n=1), Hong Kong (n=1), Spain (n=1), Sweden (n=1)
• Study designs included prospective and one retrospective cohort, six cross-sectional studies, and four randomised controlled trials
• Overall adherence rates across included studies ranged from 28% (Mailloux et al.) to 89% (Welsch et al.)
• Ten studies scored high on QUIPS risk of bias, ten moderate, and eight low
• Exercise self-efficacy was positively associated with adherence in five of six studies in which it was investigated; the one study reporting no association had high risk of bias
• Determinants mapped to seven of the TDF domains and four of six COM-B components, with psychological capability and reflective motivation most frequent
• The six most frequently occurring BCT groups were: Goals and Planning, Feedback and Monitoring, Natural Consequences, Repetition and Substitution, Reward and Threat, and Antecedents
• Problem Solving was the single most common BCT mapped, matched five times across determinants
• Physiotherapists on average use six BCTs (Hall et al.), but the review identified multiple BCTs with an evidence base that could target modifiable determinants of exercise adherence
• Evidence for coping and task self-efficacy association with adherence was inconsistent: two cohort studies of moderate risk of bias and one cross-sectional study of low risk of bias showed a positive association, while five cohort studies ranging from low to high risk of bias reported no association

Limitations

• Only quantitative studies were included, which may have missed determinants best captured by qualitative methods (particularly in the automatic motivation COM-B category)
• Considerable heterogeneity existed across studies in how adherence was defined, measured, and followed up, limiting comparability
• Strength of evidence for determinants was based on frequency of association rather than magnitude of association
• Determinants initiating versus maintaining adherence were rarely distinguished in the reviewed studies and could not be separated in this review

Why it matters

For patients

Patients attending physiotherapy for musculoskeletal problems should be aware that their confidence in doing exercises at home (self-efficacy) is one of the strongest predictors of whether they will stick to their programme, and that discussing barriers with their physiotherapist before starting can help.

For clinicians

Physiotherapists should routinely assess exercise self-efficacy, prescribe a limited number of exercises, use problem-solving collaboratively, and consider social support strategies, as these are underused yet evidence-supported approaches to improving home exercise adherence.

For readers

This review provides a practical theoretical mapping from patient barriers to specific behaviour change techniques, giving clinicians a structured guide to select personalised strategies rather than defaulting to information and instruction alone.