Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription

Key points

1. 01Trust is the foundational mechanism, built through rapport, holistic assessment, and tailored explanations; it underpins all other mechanisms and outcomes
2. 02Motivation is driven by a supportive therapeutic relationship, individualised prescription tied to personal goals, and the patient perceiving benefit or enjoyment from exercise
3. 03Confidence is linked to both clinician credibility and patient self-efficacy; supervision and education increase patient confidence to perform and adhere to exercises
4. 04Timely follow-up and peer support further sustain motivation and adherence beyond the initial consultation
5. 05Individualised exercise prescription, co-designed around the patient's goals and preferences, is more likely to produce engagement and clinical improvement than generic prescriptions

How it was conducted

Design

Realist review following RAMESES guidance

Search date

15 August 2022; databases included Ovid MEDLINE, Ovid PsycInfo, and Ovid Embase

Papers screened

522 unique papers identified; 75 included for theory testing and refinement

Stakeholder input

Steering group of experts (n=5) and stakeholder group of patients and clinicians (n=10) involved throughout

Outcomes of interest

Adherence to exercise, engagement with exercise, and clinical outcomes (including patient-reported outcomes)

Confidence assessment

GRADE-CERQual applied to each context-mechanism-outcome configuration

What they found

• 75 papers were included in the final synthesis, drawn from 522 initially identified; study types included qualitative designs (n=22), RCTs (n=15), systematic reviews (n=15), longitudinal cohort studies (n=11), secondary RCT analyses (n=4), mixed methods (n=3), case reports (n=2), and commentary/narrative reviews (n=3)
• Trust emerged as a key mechanism from 27 well-conducted studies; the majority of trust-related context-mechanism-outcome configurations were rated high confidence by GRADE-CERQual, with three rated moderate confidence
• Motivation was identified as a key mechanism in 13 studies; most motivation-related configurations were rated high confidence, two at moderate confidence, and one at low confidence (pain during exercise reducing motivation)
• Confidence featured in eight studies and was relevant only to the adherence outcome; all six confidence-related configurations were rated high confidence
• One mediation analysis found that perceived mastery (competence perceptions) influenced motivation, which impacted outcomes over a 6-week period
• Exercise interventions paired with a motivational strategy were shown in one study to improve long-term adherence and outcomes at 5-year follow-up

Limitations

• The review focused exclusively on psychosocial and behavioural mechanisms; biomedical, mechanical, and physiological mechanisms of exercise for low back pain were not explored
• The review could not establish temporal relationships between adherence, engagement, and clinical outcomes due to limited quantitative evidence linking mechanisms to outcomes
• Adherence is poorly defined and inconsistently reported in exercise RCTs, limiting the ability to draw firm conclusions about the adherence-outcome relationship
• The stakeholder group had limited diversity; recruitment yielded predominantly female patient participants and an author team that was predominantly female

Why it matters

For patients

Patients with persistent low back pain are more likely to stick with and benefit from exercise when their clinician takes time to understand their individual goals, explains the rationale clearly, and provides reassurance and follow-up.

For clinicians

Clinicians should prioritise building trust through holistic assessment and rapport, co-design individualised exercise programs around patient goals, and offer timely supervision and follow-up to sustain motivation and confidence.

For readers

This review explains why some exercise programs work better than others, pointing to the relational and motivational context of delivery rather than the exercise type itself as the active ingredient.