J Can Chiropr Assoc. 2017 (Dec); 61 (3): 219–230 ~ FULL TEXT
Peter Stilwell, BKin, DC, MSc, Katherine Harman, PT, PhD
5869 University Ave.,
PO Box 15000
Halifax, NS, B3H 4R2.
AIM: To inform future research and exercise prescription for patients with chronic low back pain (CLBP), this study explored chiropractors' and chiropractic patients' experiences and beliefs regarding the barriers and facilitators to prescribed exercise adherence.
METHODS: A focused ethnographic approach was used involving 16 semi-structured interviews, including pilot interviews (n = 4) followed by interviews with chiropractors (n = 6) and chiropractic patients with CLBP (n = 6).
RESULTS: Barriers and facilitators to prescribed exercise adherence revolved around four themes: diagnostic and treatment beliefs motivating behavior, passive-active treatment balance, the therapeutic alliance and patient-centered care, and exercise delivery.
CONCLUSION: Exercise adherence may be facilitated in patients with chronic low back pain (CLBP) with simple exercise prescription changes made by chiropractors. However, changing chiropractors' and patients' diagnostic and treatment beliefs that are barriers to exercise adherence appears challenging. Training chiropractors in pain neuroscience education and the intentional use of behavior change techniques warrants future investigation.
KEYWORDS: adherence; chiropractic; exercise; low back pain; qualitative
From the FULL TEXT Article:
Clinical practice guidelines now recognize that most patients
with acute low back pain (LBP) will improve with
time, regardless of the treatment they receive.  However,
patients often desire immediate symptomatic relief, so
passive non-pharmacological treatments (e.g., spinal
manipulation) are an option as they can provide modest
improvements in pain and function with mild side
effects. [1, 2] Yet, the positive effects of passive therapies
typically are transient, so providing patients with reassurance
combined with active self-management strategies
(e.g., exercise) is recommended. [3–5] Further, detecting and
managing psychosocial factors for chronicity (e.g., movement
fear-avoidance) is recommended in LBP guidelines
across the world.  For patients who have transitioned to
chronic low back pain (CLBP), guidelines place a greater
emphasis on a biopsychosocial approach, including education
and self-management through exercise. [5, 7]
In Canada, 96.5% of chiropractors have reported using
exercise as a part of their treatment plans.  Patient exercise
adherence is associated with favorable clinical outcomes ;
yet, available data on patients with CLBP suggests
they have poor adherence.  Despite chiropractors
regularly prescribing exercise and wanting to tackle the
inactivity epidemic , little research has provided insight
as to how chiropractors attempt to facilitate prescribed
exercise adherence.  In fact, when looking broadly at
the non-specific chronic low back pain (NS-CLBP) and
exercise adherence literature, few studies have explored
the perspectives of exercise-prescribing clinicians (e.g,
medical doctors, physiotherapists) or their patients with
A systematic review by Slade et al.  reported
lack of time,
diagnostic uncertainty, and
fear of movement and pain aggravation as some of the most consistently cited patient perceived barriers to prescribed exercise adherence.
In contrast, patient perceived facilitators
to prescribed exercise adherence included:
good clinician-patient communication,
detailed exercise instruction,
feedback, as well as follow-up and reassurance provided by the prescribing clinicians. 
Clearly there is a massive challenge; exercise is a frequently
recommended intervention in clinical practice
guidelines for CLBP and chiropractors commonly prescribe
it; yet, patient adherence is low which impacts outcomes.
Rarely do studies incorporate both the patients’
and the exercise-prescribing clinicians’ experiences and
beliefs regarding the issue of exercise adherence.  To inform
research and the development of strategies to improve
exercise engagement in the chiropractic context,
this study aimed to explore chiropractors’ and chiropractic
patients’ experiences and beliefs related to exercise
We used a focused ethnographic design [17, 18] involving
individual semi-structured interviews. Focused ethnographies
are conducted by researcher(s) who possess
background knowledge in the area of interest. They are
problem-focused and context-specific, focus on a specific
group’s shared experiences, limited to a small number of
participants, conducted in a short time frame, conducted
to help explain the complex nature of the specific shared
experiences and issues within the targeted group(s), and
are often used to help enhance healthcare services and
practices. [17, 18] Further, focused ethnographies do not require
fieldwork/participant observation; a feature that
makes a focused ethnography significantly different than
a traditional ethnography. 
The semi-structured interview guides reflected expectancy
theory, as they attempted to unravel how past experiences
helped shape current beliefs, preferences, motivation,
and ultimately, behavior.  In its basic form, expectancy
theory suggests that individuals will be motivated
to engage in a specific behaviour if they believe that their
efforts will result in a positive performance which will result
in an outcome that is tied to a desirable reward.  In an
attempt to obtain unprimed information from the participants,
there was a deceptive component to the study design.
The participants did not know that the authors were
specifically studying prescribed exercise adherence. Instead,
participants were advised (in the consent forms and
verbally) that the interviews would be broad, exploring
chiropractic treatment preferences in adults with CLBP.
The initial sample size estimate of six chiropractor participants
and six patient participants was predetermined
with the anticipation of reaching saturation. 
This study was positioned in the post-positivist paradigm
that advocates a structured scientific approach. The
approach taken by the researchers appreciated that each
study participant had their own unique perspective and
experiences; however, there were attempts at illuminating/
approximating a single reality20 and to “see the whole
picture”  p.18. The goal was not to obtain pure objectivity,
but to strive towards objectivity by using triangulation as
well as rigorous and transparent methods, and therefore
this study was conducted and reported considering the
consolidated criteria for reporting qualitative research
(COREQ).  Ethics approval was obtained from the
Dalhousie University Health Sciences Research Ethics
Recruitment and eligibility criteria
Posters were placed on local community bulletin
boards and distributed to Nova Scotian chiropractic offices
to recruit adults (18–65 years old) with CLBP (greater
than three months) currently receiving chiropractic
care. Interested participants who emailed the first author
were administered a patient participant screening questionnaire
that asked details regarding their CLBP and
what type of treatments they had received in the last six
months. Only those who had received exercise instruction
or advice were eligible to participate. In an attempt to recruit
patients with NS-CLBP, they were excluded if they
had significant pathologies or diagnoses that are known
to contribute to LBP. This included pregnancy, infection,
tumor, fracture, or significant structural changes with
Chiropractors were eligible if they were licensed and
practicing in the Halifax metro area, Nova Scotia, Canada.
Eligible chiropractors’ email addresses were obtained
through the Nova Scotia College of Chiropractors website.
If a personal email address could not be obtained,
their clinic was contacted via email or phone. Interested
participants were administered a chiropractic participant
screening questionnaire through email that asked what
types of treatments they offer patients with NS-CLBP.
Only chiropractors reporting that they very often prescribe
home exercise for their patients were included in
Questionnaires and demographics:
To contextualize the sample, participant characteristics
were gathered. This included the administration of questionnaires
to the patient participants; the Keele STarT
Back tool that measures risk of a poor outcome/chronicity 
and the Revised Oswestry Disability Index that
measures level of disability/impairment.  Patient participants’
age, sex, and duration of CLBP, and chiropractor
participants’ sex and years in practice were also collected.
Four pilot interviews were conducted with two practicing
physiotherapists and two Dalhousie University students
who had previously been prescribed exercise for
CLBP. The pilot interviews were used to help refine the
flow and comprehension of the interview questions, and
to confirm the ability to conduct interviews with deception
(not knowing that the focus was on exercise). The
pilot interviews were not included in the analysis. After
the patient and chiropractor participants were recruited
and consented to participate, the first author (male chiropractor
and graduate student with qualitative research
training) led one-to-one audio-recorded semi-structured
interviews in a private room at Dalhousie University. The
interviews were 50–90 minutes and the second author (female
physiotherapist and Associate Professor) attended
each interview to contextualize the data and to ask for
clarifications as needed. The two years leading up to the
study, the first author (interviewer) was involved in various
chiropractic-related activities in Nova Scotia. This
resulted in him being in contact with most of the chiropractors
in Nova Scotia. This provided him with exposure
to insider knowledge, specifically the beliefs and practice
patterns of Nova Scotian chiropractors. Although this exposure
was limited, it appeared to facilitate trust and a
candid conversation during the audio-recorded interviews
with the chiropractors. He did not have any contact with
any of the patient participants prior to conducting the
study. The second author did not have any contact/exposure
to any of the participants prior to the study.
During the interviews, the participants were given the
opportunity to provide a rationale regarding their past and
current behaviors and to discuss in-depth the issues that
they believed were important regarding CLBP management.
With this approach, information was obtained in an
unrehearsed, non-contrived manner. Although the focus
of the study was to understand perspectives regarding
prescribed exercise adherence, had the interview questions
been strictly on this topic, the participants may have
felt judged somehow and might have obscured their true
treatment beliefs and priorities. Therefore, the interviewer
followed the lead of the participants and molded the interview
to elicit significant exercise-related information
while also exploring other areas that were important to
the participants regarding CLBP care. Sample interview
guide questions are found in Appendix A. Each author
took field notes during the interviews. The interviews
were transcribed verbatim and the participants were provided
with a copy of their transcripts through email and
given the opportunity to provide clarifications or feedback.
The transcriptions were imported into NVivo™ software
for analysis (Version 10 © QSR International Pty Ltd.,
Victoria, Australia). A systematic approach for analyzing
ethnographic data developed by Roper and Shapira
was used.  The authors independently coded the data,
triangulating the patient and chiropractor participant
interviews to identify overarching explanations regarding
the barriers and facilitators to prescribed exercise adherence.
The authors had regular meetings throughout the
data analysis steps to discuss field notes, compare coding
for each transcript, and to mutually develop themes.
The determination of data saturation was an iterative process;
the authors regularly discussed recurrent and new
themes before conducting further interviews. To increase
the validity of the generated themes, study participants
were also e-mailed a summary of the preliminary themes
and given the option to express disagreement and provide
Three female patients (Revised Oswestry: moderate
disability) and three male patients (Revised Oswestry:
minimal disability) participated in the study. The six patient
participants had a mean age of 34.5 years (SD 14.4)
and a mean duration of low back pain of 10.0 years (SD
8.3). All were categorized as low risk for poor outcome/
chronicity based on the STarT Back tool. Further, most of
the participants stated that they had seen several different
practitioners for their LBP; some had consulted with
multiple chiropractors that had prescribed exercise. The
six chiropractor participants had a mean of 8.3 years in
practice (SD 7.3); one was female and five were males.
Figure 1 illustrates the flow of the participants into the
Of the twelve participants, no one requested transcript
alterations or expressed disagreement after receiving an
email revealing the deceptive component of the study
and a summary of the preliminary themes. The projected
sample size was not altered and saturation was deemed
to be reached as consistent codes and themes continued
to emerge from the patient and chiropractor participants’
narratives. After the twelve interviews, it was decided that
further interviews would not likely generate any new significant
themes and there were no areas requiring further
probing or exploration based on the aim of the study. Four
main themes were generated from the data:
1. diagnostic and treatment beliefs motivating behavior,
2. passive-active treatment balance,
3. the therapeutic alliance and patient-centered care, and
4. exercise delivery.
significant conceptual overlap among the themes, with
many quotes fitting into several themes. Each theme contains
dimensions along a continuum, ranging from barriers
to facilitators to prescribed exercise adherence. Further
interviews may have revealed deviating experiences and
beliefs, or sub-themes. However, it was anticipated that
these findings would have fit within the themes already
identified or expanded beyond the aim of the study. Table 1 summarizes the themes with corresponding barriers and
facilitators identified. Table 2 provides supporting quotes
for each theme.
The results of this study suggest that in this sample, exercise
adherence is not simply the patients lacking motivation
or not having enough time in the day. Instead,
the results suggest that adherence to prescribed exercise
is the product of chiropractors’ and patients’ experiences
and beliefs, the development of their clinical relationship,
and the way exercise is prescribed and monitored
in parallel with other treatment modalities. Most of the
findings are congruent with existing qualitative literature
exploring the barriers and facilitators to exercise adherence
in patients with NS-CLBP, despite the majority of
these studies being non-chiropractic focused and conducted
outside North America. [13–16] This includes the findings
that exercise adherence may be facilitated with easy
exercise delivery changes made by exercise-prescribing
clinicians, including: prescribing simple exercises, limiting
the number of exercises prescribed, demonstrating the
exercises, providing feedback, and scheduling follow-up
appointments to review the exercises and monitor progress.
While most of the barriers and facilitators to prescribed
exercise adherence reported in this study appear
to be modifiable, effectively explaining pain and the longterm
benefits of exercise appears to be quite challenging,
as will now be discussed.
Our most complex theme, diagnostic and treatment beliefs
motivating behaviors, has also been clearly described
in the literature outside the chiropractic context. Slade et
al.  explored how Australian physiotherapists prescribe
exercise for patients with NS-CLBP. The authors described
how the physiotherapists sought out diagnostic
certainty as a means to improve their credibility and to
get patients to adhere to an exercise plan. When outcomes
were not what they or the patient expected, frustration and
blaming occurred and some physiotherapists defaulted to
inaccurate nocebo-laden structural explanations of pain
or feigned a certain diagnosis.26 Further, another study by
Slade et al.  found that patients with NS-CLBP wanted
their healthcare providers to explain their pathology and
management (exercise) to reduce uncertainty. While these
findings are congruent with our results, the patient participants
in our study were less focused on finding the cause
of their LBP than was expected based on existing literature
from the patient perspective. [13, 16] There are many possible
explanations for this. One possibility is that the patient
participants’ chiropractors had explained NS-CLBP in a
way that reduced diagnostic uncertainty. There is some
evidence that chiropractors have even more of a biomedical
focus than physiotherapists.  It is possible that
chiropractors’ patho-anatomical explanations (regardless
of their accuracy) reduced diagnostic uncertainty. If so,
this creates a dilemma as providing detailed and specific
patho-anatomical explanations for most cases of LBP is
not consistent with best practice.  Interestingly, our patient
participants were all categorized as low risk on the
STarT Back tool, yet many described debilitating flare-ups
and various psychosocial risk factors for chronicity (e.g.,
fear-avoidance, belief that pain equals damage). Further,
most of the patient participants seemed to welcome and
embrace patho-anatomical explanations for their pain.
While in-depth patho-anatomic explanations may facilitate
passive care buy-in, this type of education may
create rather than reduce psychosocial factors for chronicity.
Darlow and colleagues reported that clinicians’ biomedical-
rooted explanations can have a lasting negative
impact, with patients often viewing their backs as fragile
and needing to be protected.  These beliefs might result
in hyper-vigilance and guilt surrounding poor exercise
adherence.  Further, we suspect that this may drive a
quest for a fix and passive care dependence. While some
clinical practice guidelines explicitly state education that
increases the perceived threat or fear associated with
LBP should be avoided , little guidance is provided beyond
this. The concept of unintentional negative effects
(nocebo effects) is rarely discussed in the context of exercise
prescription or chiropractic in general.  Therefore, it
was not surprising when many of the chiropractors in our
study (and chiropractors described by patient participants)
wanted to fix the patient with tissue-based approaches and
defaulted to patho-anatomical explanations of persistent
pain. In many cases, this appeared to contribute to a poor
passive-active treatment balance – negatively impacting
exercise priority and adherence. Further, it appeared that
some clinicians’ fear-avoidant beliefs might have transferred
to their patients.
Helping clinicians and patients better understand the
science of pain, such as the hurt versus harm concept,
may improve outcomes. Pain neuroscience education
(PNE) [32, 33] is being adopted by professions outside of
chiropractic as it can reduce diagnostic uncertainty, reduce
perceived threat, and open the door to exercise
prescription with greater adherence.  Further, PNE requires
the building of a strong therapeutic alliance as
various evidence-based explanations and techniques are
used to change a patient’s beliefs and behaviors.  Similar
to other clinicians using PNE, chiropractors may be
able to better help their patients by integrating PNE into
their CLBP management, including exercise prescription.
Further, behavior change theory has been evolving  and
a taxonomy of behavior change techniques (BCTs) has
recently been put forward, with each technique having
varying levels of supporting evidence in different contexts. 
The use and description of exercise-based BCTs
has also become the focus of clinical research [38, 39] Interestingly,
most of the chiropractors in our study, unknowingly,
described the use of specific exercise-based BCTs
to help patients adhere to prescribed exercise.
Referring to a recently published BCT checklist used in the context
of exercise prescription , the chiropractor participants
in this study clearly described the use of: cognitive restructuring,
graded exposure, providing information on
consequences, setting graded exercises, booster sessions,
prompting review of behavior exercise goals, and providing
feedback on exercise performance. This suggests that
chiropractors who prescribe exercise may benefit from
behavior change training for non-psychologists – where
they are taught how to intentionally and appropriately use
evidence-based BCTs. PNE inherently involves BCTs, so
they can be used in conjunction. Training in these areas
could help chiropractors better understand pain, explore
their own beliefs about pain, and ultimately deliver more
accurate pain information alongside exercise prescription
informed by behavior change theory. Still, more research
on exercise adherence is needed that applies appropriate
use of theory in the study design.  This will provide further
evidence as to what BCTs may or may not be optimal
in given contexts.
One limitation of this study was the little variability in
patient participants’ levels of disability and risk for chronicity/
poor outcome based on the administered questionnaires.
All of the patient participants were low risk based
on the STarT Back and were categorized as having minimal
to moderate disability based on the Revised Oswestry.
This limits the generalizability and transferability of
the finding to patients scoring higher on the STarT Back
and Revised Oswestry.
Another limitation is that the study only included
chiropractors that frequently prescribe exercise. This may
have produced a selection bias, unintentionally targeting
those who are more rehabilitation focused, refining their
exercise delivery. Therefore, the study may have included
chiropractors that were more likely to identify positive exercise
prescription experiences and facilitators rather than
barriers. Additionally, this study only included one female
chiropractor, potentially limiting the transferability of the
findings. However, the interviews did provide a window
to explore the practices of other chiropractors through patient
and chiropractor participants’ second-hand reports.
Still, the generalizability and transferability of the finding
must be considered with caution.
Identified barriers and facilitators to prescribed exercise
adherence in chiropractic patients with NS-CLBP
revolved around four primary themes:
1. diagnostic and treatment beliefs motivating behavior,
2. passive-active treatment balance,
3. the therapeutic alliance and patient-centered care, and
4. exercise delivery.
Most of the
barriers and facilitators to prescribed exercise adherence
appeared to be modifiable, highlighting the possibility to
strengthen facilitators and break down barriers. Exercise
adherence may be facilitated in patients with CLBP with
simple exercise delivery changes made by chiropractors.
This includes making exercise simple, limiting the number
of exercises prescribed, demonstrating the exercises,
providing feedback, and scheduling follow-up appointments
to review the exercises and monitor progress.
However, changing chiropractors’ and patients’ diagnostic and
treatment beliefs that are barriers to exercise adherence
appears challenging. Further, addressing patients’ fears
while balancing passive and active care is not an easy
task. In addition to BCT training, chiropractors may benefit
from pain education training, such as PNE. Research
is needed testing the use of PNE and BCTs in the context
of chiropractic and exercise prescription. Combined PNE
and BCT training may help chiropractors keep up to date
with the current understanding of pain, explore their own
beliefs about pain, and ultimately deliver more accurate
pain information alongside more effective exercise prescription.
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