Compliance IS the Science
The 5 Keys to Better Clinical Outcomes in MSK
One of the issues we run into in musculoskeletal care is compliance with interventions. Whether it be physical therapy, home exercise, or even post-operative instructions, we tend to see poor compliance among the general population. Patients miss visits, are not consistent with exercise routines, and do not always follow instructions correctly or at the correct frequency. This leads to poor outcomes, and sometimes, entirely avoidable escalation to more invasive procedures.
To understand the scope of this problem, take a look at the statistics for spinal surgery. In North America, approximately 11-14% of people coming in for back pain will be escalated towards procedural care. That number should really be closer to 5%. Among other reasons, I suspect compliance with conservative interventions to be a significant contributing factor to this problem.
The compliance problem, however, is not unique to physical therapy and orthopedics. Compliance with almost anything, whether it be medications, dietary changes, or lifestyle modifications tends to vary from moderate to poor. And compliance worsens with increasing complexity. For example, you’re very likely to get a different amount of compliance when a physical therapist asks a patient to do 1-2 exercises daily, than when they ask them to do 7-10 exercises.
We Love Diagnostics
But while patients tend to be poor at compliance, they tend to be fantastic self-diagnosticians. What do I mean by that? Let’s take a patient with diabetes as an example. These patients will prick their finger and test their blood several times daily consistently for years, but how many of them have difficulty with long-term dietary compliance? Quite a few.
There appears to be this inherent phenomenon where patients are much more consistent with testing and re-testing more so than the actual intervention and behavior modification that will fix the problem. This explains the widespread demand and sale of devices that monitor various vital signs and markers, like apple watches, continuous glucose monitors, sleep tracking applications..etc.
Even the demand for diagnostic imaging can be explained by this phenomenon, despite the understanding and agreement in the medical community at-large that these images yield many false positives and false negatives.
Principle 1: Turn Patients into Self-Diagnosticians
So the first way to get patients to increase buy-in with conservative MSK interventions is to take advantage of this phenomenon and turn patients into self-diagnosticians. We do this by first utilizing intervention models that rely on a response-based assessment with excellent inter-tester reliability. For example, if there is a provocative movement such as a squat, a lunge, reaching overhead, or turning the neck in a certain direction, we want to use any one of these movements which reproduces the comparable or concordant sign as a test to see if the conservative intervention produces a change. Many clinicians do this already.
One thing that’s missed by many of these online digital therapy platforms, including those that offer remote therapeutic monitoring, is the value of the concordant sign. The concordant sign is the most valuable indicator to the patient. Much more so than a numerical pain scale or a functional outcome score. The concordant sign is also an incredibly important baseline because it will help the clinician assess progress and build a relationship with the patient.
But we want to take this assessment process a step further and train the patient to assess themselves. Doing so will allow them to monitor the status of their condition as they perform the intervention. And if patients see a continuous improvement in their symptoms as they apply the intervention strategy at home, this will increase their buy-in and they are likely to comply with clinician instructions.
Harness the power of diagnostics (which patients love), empower them to become self-diagnosticians, and you will see compliance rise. To reiterate- as soon as possible, turn the patient into a self-diagnostician (rather than just a self-treater).
Involve the Patient in the Decision-making: Ask For Permission
The next step to increasing compliance is to involve the patient in the decision-making process. Now I personally dislike phrases like “patient-centered care” which tend to be hollow and mean different things to different clinicians, but if we want to achieve that standard, we have to verbally get the patient’s permission and affirmation when presenting different interventions.
Here’s a common example that happens in our clinics. Approximately 20-30% of patients coming to physical therapy for isolated knee pain usually have a spinal source of symptoms. By that I mean that patients presenting with knee pain-only, demonstrate improvement in signs and symptoms with exercise interventions targeting only the lumbar spine. This is a common phenomenon we’ve known about for decades that is now getting more attention in the research.
For clinicians that are used to seeing this phenomenon on a daily basis, we often don’t think twice of it. But for patients, this can be an intellectual leap if they come in with complaints of isolated knee pain (and no other spinal symptoms) and a physical therapist asks them to perform lumbar extensions.
Even if they buy in to the clinician’s explanation, the minute they get in their car and tell their spouse (or the physician that referred them), that they’re doing lumbar extensions for their knee pain (without any other knee exercise), they’re very like to get a lot of push back from outside parties that may reduce the level of compliance significantly.
However, if a clinician explains to the patient why they’re doing the lumbar spine screen, and then asks the patient for permission that they spend the first visit (or 2 visits) thoroughly ruling out the lumbar spine, and the patient responds in the affirmative, they are more likely to be compliant down the line.
I can not stress this enough- It is important to ask the patient for permission. It is one of the principles of motivational interviewing…. put the locus of control in the patient’s hands. If you get a patient's permission, they are less likely to provide resistance down the road.
Explain Why They Should Care
Another way to increase compliance is to explain the “why”, explain why the patient should care…and explain it clearly. If a patient understands why a clinician is choosing a particular intervention strategy and what the patient’s role is as part of that process, their degree of compliance will likely increase.
For example, if upon assessment a clinician deems that a patient has a radiculopathy that may or may not be mechanically responsive to conservative interventions, the clinician should stress to the patient how important the subsequent 1-2 visits will be to determine whether the patient will respond to conservative management or whether there may be an opportunity for epidural steroid injections.This increases the sense of urgency and importance of the patient coming in for those follow-up sessions
Produce TANGIBLE Results
The fourth way to increase compliance is to produce texas-sized results. By that I mean that the intervention strategy should be one that produces very noticeable results for the patient. In our clinics, we typically aim for at least 20% improvement in pain scores and the minimal clinically important difference on functional outcomes scores within 2-3 visits. If the progress is too slow, we may lose them as a patient before the intervention even has a chance of working.
For patients that have structural, post-surgical, chronic pain, tissue dysfunctions, or some other non-mechanical condition where the expected time-frame and improvement is protracted, we would educate patients on this process, the expectations of improvement, and then involve them in the decision-making. “Based on the issues we discussed, we can expect on average about a 20% improvement with therapy if you come to all the visits and do everything we prescribe for you to do at home. How does 20% sound to you? Would that be worthwhile?”
Be Likable
And finally, the fifth way to increase compliance is to be likable. Unfortunately, likability in most instances will improve compliance more than subject matter expertise. If someone likes you, they will come back for more follow-up visits. Whereas if someone doesn’t like you, it doesn’t matter if you’re a genius clinician savant- they’re unlikely to return for follow-up and they certainly won’t be compliant with instructions.
At the end of the day, healthcare is based heavily on human-to-human interaction. I mentioned before the importance of asking for permission. There is an undeniable sales aspect to this process. I don’t mean sales in a sleazy, used-car salesman way, where we try to sell patients on interventions that have questionable curative value (no offense to used car salesmen). I mean that we have to make the clinical experience into a consultative process that the patient can relate to. Part of this is about being likable and earning the patient’s trust.
Turn patients into self-diagnosticians, ask for permission and involve them in the decision-making process, explain the “why”, produce BIG results, and be likable. Together, these 5 keys will help clinicians achieve meaningful impact and drive improved clinical and financial outcomes for patients seeking musculoskeletal care.