Introduksjon

As a clinician working with a wide variety of different people, each with their own unique characteristics and personalities, you’d certainly know that each encounter might need a unique approach. Some people might be confident to engage in exercise, while others fear any sort of active movement. With some, you’ll act more as a coach, whilst with others you would have to give a lot of extra attention and explanations. People with low back pain arising from lumbar disc herniations are frequently seen in physiotherapy practices and need an active approach. But in some people, you’ll find low adherence to your exercise prescription. Therefore, this study investigates how people with lumbar disc herniations who were prescribed non-operative care, consisting of a structured exercise program, adhere to that program. It is proposed that low adherence might be a factor negatively influencing outcomes and increasing recurrence rates. To provide a more personalized approach to physiotherapy interventions, this study examines which patient profiles predict exercise adherence in lumbar disc herniations. 

Metoder

This study used a cross-sectional design to analyze patients’ responses from a questionnaire. The Protective Motivation Questionnaire was created to study exercise adherence and its influencing factors. The questionnaire was based on the “Protection Motivation Theory”, which is a psychological framework that helps explain why people choose to engage in or avoid health-related behaviors. In this case, the studied health-related behavior was exercise adherence. 

The questionnaire assesses six core constructs of the Protection Motivation Theory:

1. Perceived severity
2. Perceived susceptibility
3. Internal/external rewards
4. Recovery value
5. Self-efficacy
6. Response costs

The Protection Motivation Theory suggests that someone’s motivation to protect their health is based on two main thought processes:

• Threat appraisal: “How bad is it?” The patient interprets the health danger based on the:
  • Perceived severity: The severity is interpreted by the patient, for example, if it will lead to permanent damage or not.
  • Perceived susceptibility: “Will I experience flare-ups or worsening pain if I don’t exercise?”
  • Internal/external rewards: “What good things do I get from NOT doing the exercises?” The maladaptive or negative reasons why a patient might choose not to adhere to their exercise program. It represents the perceived positive benefits (or ‘rewards’) that a patient gets from avoiding the prescribed protective behavior (in this case, the exercise). These rewards reduce the overall motivation to change. For example, an internal reward would be getting to rest and relax instead of exercising, or avoiding the anxiety of doing my exercises incorrectly. An external reward, for example, could be getting to spend more time with family instead of exercising, focusing on work instead of taking a break to exercise, or not having to spend money on exercise equipment, etc. 
• Coping appraisal: “What can I do about it?” The patient evaluates their ability to manage the threat, based on:
  • Recovery value: “Will the treatment (in this scenario, adhering to the exercises) actually work to relieve my pain and prevent recurrence?”
  • Self-efficacy: “Am I capable of doing it correctly and consistently, even in case of a busy schedule or having pain?”
  • Response costs/rewards: The costs represent barriers (time, money, effort, pain,..) and the rewards are the related benefits (less pain, more activity,…) of doing the exercises.

Knowing this, a patient perceiving a high threat, but who believes that they can handle it (high coping), will likely be more motivated to adhere to their exercises. 

Based on this theory, the authors collected data using online surveys. Participants with an MRI-confirmed and a clinical diagnosis of symptomatic lumbar disc herniation were recruited from tertiary care settings in China. They were only eligible to participate if conservatively treated with a prescribed exercise program. 

Besides demographic information, the surveys also collected the scores on the Protection Motivation Questionnaire and the adherence scores. Using Latent Profile Analysis (LPA), patterns in the answers were revealed and grouped to construct patient profiles who carry similar thoughts about their health and exercise. These profiles were compared for their adherence to the exercise program they were prescribed.

Resultater

Using 372 questionnaires, the data of these people with lumbar disc herniation and a mean age of 48 years were analyzed. Half of the respondents had symptoms for less than 3 years and reported a mild pain score (VAS 1-3/10). Almost two-thirds had one comorbid condition. 

Latent Profile Analysis (LPA) identified three distinct exercise protection motivation profiles among patients with lumbar disc herniation, which differed significantly in their degree of adherence. 

1. Profile 1: High Protection Motivation – Autonomous Management (26.1%)
   1. Characteristics: High scores for threat appraisal and coping appraisal and low scores for reward/cost. These individuals had a clear risk perception and a strong self-efficacy.

1. Profile 2: Medium Protection Motivation – Cognitive-Behavioral Disconnection (43.8%)
   1. Characteristics: High scores for threat appraisal but low scores for coping appraisal (low to moderate self-efficacy and recovery value). They showed heightened internal and external rewards and response costs. These individuals recognize the health threat but lack the confidence and perceived ability to act. There was a disconnection between their interpretation (cognitive) and their response (behavior) to the threat. 
2. Profile 3: Low Protection Motivation – Negative Avoidance (30.1%)
   1. Characteristics: Low scores across most protective motivation dimensions, which means that overall, in this patient profile, there is a weak perception of the threat and low efficacy. 

People from the first profile demonstrated the highest adherence scores to their prescribed exercise program. On the other hand, people from the third profile had the lowest adherence to their exercises. The patients of the second profile had lower adherence than the first profile, but higher than the third profile.

Spørsmål og tanker

These results teach us how to approach individual patients based on their unique characteristics. Patients with characteristics of profile 1 are autonomous managers: they have a high threat appraisal based on a high severity and susceptibility, and this is combined with a strong sense of responsibility, leading to high self-efficacy and confidence. These are the patients we shouldn’t see often. Mostly, it will be enough to explain to them some core concepts about their exercise program and progressions. With these patients, we can take up a role of coach or consultant, where we refine some exercises, provide some subtle progression challenges, and support their self-management efforts.

A patient with profile 2 has a disconnection between their thoughts about their lumbar disc herniation and the way they act. They are well aware of why they should exercise, but have a low level of self-efficacy, and they value the response costs (barriers) as high. These people recognize that the lumbar disc herniation poses a certain threat, but they lack the confidence in their ability to act and follow through, which results in a medium level of exercise adherence. It is understandable that these people should be followed more closely and that we as physiotherapists should act to overcome the self-efficacy gap. This can be done by using motivational interviewing, breaking down the exercise program into tiny but achievable steps, and trying to help problem-solve the barriers they experience.

Profile 3 patients are negative avoiders. They have a low threat appraisal in the sense that they have an inadequate understanding of the severity or the associated risks of their lumbar disc herniation. Together with a low coping appraisal, they are not committing to their exercise program. How can we approach these patients without “forcing” them to adhere? The authors propose psychoeducation using visual aids such as their MRI scan and disease progression charts, to create a sense of urgency and understanding why their adherence to exercise is necessary. Only then can interventions targeting behavioral change work effectively. 

The multiple linear regression confirmed that profile membership was an independent predictor of exercise adherence, even after adjusting for covariates such as age and pain intensity. Compared to the high-motivation group, those in profiles 2 and 3 who demonstrated lower adherence were more likely to be younger, have a lower pain intensity, and have a lower economic status. 

Snakk nerdete til meg

It is important to underscore that the results only represent a certain population at one point in time, and that their responses to the questionnaire were not generalizable to all lumbar disc herniation patients worldwide. The use of self-report questionnaires can introduce response biases, in a way that patients may over-report their exercise adherence. 

Furthermore, the cross-sectional design can show us the associations between exercise adherence in lumbar disc herniation patients, but we can not be sure that belonging to a certain patient profile causes low adherence. 

Also, the explained variance in the final regression model was only 37.6%, meaning that more than 60% of the variance is likely due to other unmeasured factors. This can be the type and severity of the disc herniation, for example, but likewise the quality of the exercise program they got prescribed, or the patient-therapist interaction, or work or family-related factors, and maybe even more! Please note that the observed patient profiles do not necessarily apply to every person with a lumbar disc herniation. 

Ta med hjem meldinger

This study on exercise adherence in patients with lumbar disc herniation reveals that adherence to rehabilitation exercises is strongly influenced by three distinct motivational profiles, challenging the traditional one-size-fits-all approach to treatment. Patient motivation can, therefore, be a powerful predictor of program success.

The profile 1 patient, the “Autonomous Managers,” exhibits the highest adherence. They possess a clear understanding of their condition’s risk and are highly confident in their ability to perform the prescribed exercises.

Conversely, the most common group is the “Cognitive-Behavioral Disconnect” patients. While they understand the seriousness of their lumbar disc herniation, they lack the self-confidence needed for the exercises and are concerned about the required effort or associated costs.

The third group is the hardest group to motivate and the least likely to adhere to their exercises.

Identifying these distinct motivational types is the critical first step for you to tailor treatment plans effectively. However, remain aware of the fact that the limited generalizability to other countries and patient populations (the study was conducted at one point in time in China), there may be other patient profiles than the ones brought up by this study. 

Referanse

Gao C, Wang R, Zhang J, Han L, Zhou H. Identifying patient profiles based on protection motivation theory to predict exercise adherence in patients with lumbar disc herniation: a latent profile analysis. BMC Musculoskelet Disord. 2026 Jan 30. doi: 10.1186/s12891-026-09554-x. Epub ahead of print. PMID: 41612303.