Journal of Occupational Rehabilitation, Vol. 5, No. 4, 1995

Compliance: A Barrier to Occupational Rehabilitation? Michael K. Nicholas 1,2

While patients' compliance with medical, psychological, and other treatments has received considerable attention the subject has received relatively little attention in the rehabilitation literature. This paper attempts to review the study of patients' compliance in the rehabilitation literature and to examine its role especially in relation to outcomes. The assessment of compliance, some of the factors affecting compliance in rehabilitation, as well as future research issues are also addressed. KEY WORDS: compliance; adherence; pain management; rehabilitation.

INTRODUCTION An extensive body of literature has been devoted to the subject of patients' compliance with medical, psychological, and other treatments (see Refs. 1-5 for comprehensive reviews). However, the topic appears to have received relatively little attention in the rehabilitation literature. This is somewhat surprising given that patients' compliance with rehabilitation programs, such as exercise regimes, might be expected to be a basic prerequisite for their effectiveness. This paper attempts to examine the role of patients' compliance in rehabilitation, especially in relation to outcomes. The assessment of compliance, some of the factors affecting compliance in rehabilitation, as well as future research issues will also be addressed.

PATIENTS' COMPLIANCE Patients' compliance has been defined as "the extent to which patients are obedient and follow the instructions, proscriptions, and prescriptions of (health care providers)" (p. 20) (4). In other words, "compliance" refers to patients performing 1University of Sydney Pain Management and Research Centre, Royal North Shore Hospital, St. Leonards, New South Wales 2065, Australia. 2Correspondence should be directed to Michael K. Nicholas, University of Sydney Pain Management and Research Centre, Royal North Shore Hospital, St. Leonards, New South Wales 2065, Australia. 271 1053-0487/95/1200-0271507.50/09 1995PlenumPublishingCorporation

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the behaviors required by a treatment or rehabilitation plan. The term has also been used synomonously with "adherence," although it has been argued that they hold different connotations. Meichenbaum and Turk (4), for example, contend that "compliance" suggests a passive role for the patient whereas "adherence" implies "a more active, voluntary collaborative involvement of the patient in a mutually acceptable course of behaviour to produce a desired preventative or therapeutic result" (p. 20) (4). For this reason, Meichenbaum and Turk (4) prefer to use the term "adherence" rather than "compliance," although Turk and Rudy (5) did accede to common usage and use the two terms interchangeably in their review, as do Haynes and Dantes (2). This paper will follow a similar approach. One could also argue that the concern over connotations really refers to how the treatment or rehabilitation plan was arrived at rather than whether or not it was followed which is the present focus of concern. Under the heading of adherence Meichenbaum and Turk (4) include: entering and following a treatment program; keeping referral and follow-up appointments; correct consumption of prescribed medication; following appropriate life-style changes (e.g. in diet, exercise, stress management); correct performance of home-based therapeutic regimens and avoidance of health risk behaviors (e.g. smoking, alcohol, drug abuse). (p. 20)

However, compliance or adherence may be defined in a particular case, it would seem to be an important issue in any treatment or rehabilitation program where the effectiveness of the intervention was dependent on the patients actually performing specified behaviors. In a simple example, a given drug could only be expected to be effective if the patient who was prescribed the drug actually took it according to the recommended schedule. To the extent that the drug was not taken according to schedule the treatment would be expected to be less effective, independent of the actual efficacy of the drug. Thus, as Turk and Rudy (5) argue, treatment efficacy not only depends on the appropriateness of the treatment but also the extent to which the patients adhere to the treatment. Not surprisingly perhaps, numerous studies have revealed less than optimal rates of compliance with therapeutic regimens. For example, a review by Ley (6) revealed that the percentage of patients who do not follow their medical advice (including medicine taking, diet, ante-natal exercises) ranged from 8-92%, with a median of 44%. In their review of the literature on compliance with treatment protocols Meichenbaum and Turk (4) reported similar low compliance rates even in cases where it could be potentially damaging to the patients' health. In the area of hemodialysis for renal failure, for example, a number of studies have revealed significant levels of patients' noncompliance with prescribed diets, fluid intake, and medication consumption--all of which could have life-threatening implications in this population (7). Haynes and Dantes (2) reported that only about 65% of patients who attend for medical appointments take enough of their prescribed medication to achieve therapeutic benefit and that adherence to dietary and other lifestyle changes is close to nil after a few months. Outside the clinical context (e.g., health promotion) compliance with exercise programs also varies widely, with often large drop-out rates (8, 9). In rehabilitation settings patients are often required to comply with behavioral or lifestyle changes, such as exercise programs, postural advice, medication regimens, and so on. Given the evidence that compliance with health care advice and

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lifestyle changes is often very low, especially over time (2), one might expect that compliance with rehabilitation regimens would receive particular attention. However, examination of recent publications in the rehabilitation literature reveals that relatively few studies record whether or not the patients complied with the specified programs or exercises. For example, in a review of outcomes achieved by 23 randomized controlled trials of physiotherapy exercise programs for patients with back pain (10) the investigators examined the quality of the studies reviewed and gave credit points according to specified criteria to reflect the quality of the studies. The criteria for evaluating the quality of the interventions included: interventions included in protocol and described, pragmatic study, co-interventions avoided, and placebo controlled. The criteria for measurement of effect included: patients blinded, relevant outcome measures, blinded assessments of outcome, and adequate follow-up period. However, this otherwise commendable review of an important question in the treatment of back pain made no reference to whether or not the studies examined had any measure of patients' compliance with the exercise regimes. Examination of recent studies of broader rehabilitation programs presents a similar picture. While most studies do report patient dropouts from treatment, very few mention compliance with treatment protocols either during treatment or at follow-up (11-17). To take one example, in a comparison of active vs. passive physiotherapy with patients reporting neck and shoulder symptoms Levoska and Keinanen-Kiukaanniemi (13) found little difference in outcome between those patients who received "active" physiotherapy (dynamic muscle training of neck and shoulder muscles) and "passive" physiotherapy (surface heat, massage, and stretching). Despite the active physiotherapy including a daily 10-minute home exercise program no check appeared to have been made of the compliance rates with this. Thus, it remains unclear whether a major element of the active physiotherapy actually took place. The conclusion that there was no difference in outcomes between the two treatments should therefore be treated with caution. Given that both groups showed substantial relapse rates at 3- and 12-months posttreatment and there was no attention-control condition, it could also be argued that the participation in the treatments, with the associated attention from the physiotherapists, was a substantial contributor to the effects reported, rather than the nature of the treatments received. Another recent study reported asking patients to record the frequency of exercises practised, but did not report the results so it is left unclear whether or not patients' compliance could have influenced the outcome (18). In this study, the investigators compared a group of nurses and nurse's aides who received an individually tailored exercise program and advice from physiotherapists with a control group who only received cards on which to record any back problems and work absences over the 13 months of the study. While the outcomes appeared to favor the treatment group, in the absence of evidence that this group actually performed the required exercises and with no attention control condition, it could be argued that in this study too the investigators had not adequately ruled out the possibility that the results were due to the additional attention from the physiotherapists rather than the exercise program.

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Some studies appear to infer patients' compliance with rehabilitation protocols by referring to measures of outcome, such as improved aerobic capacity or muscle strength (15, 18). While consistent with the expectation that the improvements were due to the rehabilitation protocol, in the absence of appropriate controls and measures of compliance such an approach does not exclude the possibility that other, unrecognized factors could have played a role. For example, in the Gundewall et al. (18) study referred to earlier the investigators reported that the participants in the training group increased their back muscle strength significantly more than those in the control group. The inference is that this relative improvement in the training group was due to the exercise program they received. However, as noted earlier, the absence of an attention control and the failure to check on compliance with the exercise program could allow the interpretation that the difference in muscle strength was due to psychosocial factors associated with being members of a group study and receiving the attention from the physiotherapists. As a result, the training group could have seen the muscle strength testing as more relevant and have been willing to put in more effort to the test compared to the control group who only kept records of back pain and days when they were absent from work due to back pain. In summary, in any treatment study where the patients have an active role to play, failure to assess patients' compliance with the relevant protocols makes it difficult to determine if the results were due to the treatment described. Even in well-controlled studies, failure to assess patients' compliance does not overcome this problem--at best, it only reduces the number of alternative explanations--as the different groups could have quite different compliance rates. Equally, if no measure of patients' compliance with a rehabilitation protocol is taken and no difference is found between two treatments, it remains unclear whether the finding was due to lack of compliance or to a genuine equivalence between the two treatments. On the other hand, if a given rehabilitation program is found to be ineffective relative to the natural course of the problem, failure to measure compliance with the rehabilitation protocol makes it impossible to be certain that the result was due to the program rather than the patients' noncompliance with the program. For example, if 80-90% of people with acute low back pain recover within 6-8 weeks (19) demonstrating that a given intervention was more effective than providing no treatment would not only demand an extremely effective treatment but also that the therapists ensured maximum compliance with the treatment. Haynes and Dantes (2) go so far as to maintain that without an assessment of compliance the generalizability and validity of controlled clinical trials are seriously compromised. They also suggest that without at least an 80% follow-up rate the results of any study should be treated with caution. A good example of the value of assessing patients' compliance was provided by a recent randomized, placebo-controlled trial of exercise therapy for patients with acute low back pain (20). In this study, the investigators compared three groups of randomly assigned patients: those who received exercise instruction plus advice for applications to daily life issues, those who received placebo ultrasound and an equivalent amount of time with the physiotherapist, and those who received what was termed "usual care" by their general practitioners. The investigators also as-

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sessed patients' compliance with the exercise regime on three occasions: during the program and at the 3- and 12-month follow-ups. Interestingly, 38 out of 156 (24%) of the exercise group did not meet the criteria for compliance with the treatment protocol during the treatment period. In comparison, only 17 out of 162 (10.5%) of those in the placebo group were assessed as non-compliant during the same period. At the 3-month follow-up, 82% of the exercise group reported compliance with the program in the preceding 2-months but at the 12-month follow-up this had fallen to 54%. This large study, with 473 subjects, found no difference in overall outcomes between the three groups--on measures of number of recurrences of back pain, functional health status, and medical care usage. Only in the first 3 months posttreatment were some differences evident, with the exercise group being less tired and their recurrences of back pain briefer than the usual care group, but there was no difference between the exercise and placebo groups. This study's findings, while contrary to some of the currently accepted wisdom about the value of exercise for acute low back pain (21) at least deserves to be given more weight than the numerous studies which neither control for therapists' attention nor assess patients' compliance with the exercise protocols. The decline in compliance with the exercise protocol in the Faas et al. (20) study was particularly noteworthy and consistent with many of those recorded in the studies reviewed by Ley (6). It is also interesting to note that the compliance rate with the placebo ultrasound was actually higher than that for the exercise program, although this is not that surprising when it is considered that the exercises require the patients to do something active while the ultrasound simply requires passivity. Nevertheless, this could provide an additional cautionary note for those who assume high levels of compliance with active rehabilitation protocols.

COMPLIANCE BY HEALTH CARE PROFESSIONALS As scarce as the literature on patients' compliance with rehabilitation protocols may be, studies on compliance by health care professionals with rehabilitation protocols are even harder to find. It is not difficult to imagine that unless the health care professionals follow the protocols prescribed the issue of the patients' compliance may become somewhat academic. An early indication that this may be a problem comes from Ley and Morris' (22) review of the literature on the provision of information to patients by medical and pharmacy practitioners which found evidence of serious deficiencies in the compliance with state regulations as well as with guidelines on the prescription and dispensing of medication. In another domain, numerous studies have revealed a significant level of errors by psychologists and psychology students in the scoring of psychological tests (23). In their summary of the evidence on adherence by health care professionals with clinical procedures in a range of settings Meichenbaum and Turk (4) concluded that there was widespread non-adherence. While there is no direct evidence that a similar situation exists in the rehabilitation area, it would appear unlikely that it was immune from such a problem. One way in which some studies have addressed this issue has been

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to obtain a measure of treatment fidelity--or the extent to which a given treatment is applied according to a specified protocol. In the main this has been achieved by having blind reviewers listen to audiotapes of aspects of the treatment program and rate their approximation to a written protocol. For example, Nicholas, Wilson, and Goyen (24) reported a study comparing cognitive and behavioral approaches to the management of chronic low back pain, with an attention-control condition. Two blind reviewers listened at random to audiotapes of parts of sessions covering the three conditions and were asked to identify the condition based on a written description of each. Of course, that does not ensure that the whole program was applied according to protocol, but it does at least provide a degree of confidence in that regard. Unfortunately, as noted by Turk, Rudy, and Sorkin (25), attempts to assess treatment fidelity are rare. Turk et al. (25) concluded that as a result of both a lack of clear descriptions of rehabilitation programs and failure to assess treatment fidelity "we do not actually know what treatments are being delivered in different programs" (p. 6). Consequently, there is clearly an urgent need for treatment outcome studies to address the issue of compliance by health care professionals in addition to patients' compliance.

HOW MUCH COMPLIANCE? As important as patients' compliance may be, compliance should not be seen as an end in itself. In most rehabilitation contexts return to work or resumption of normal duties are common goals. How much compliance with a rehabilitation program would be required to reach such goals will always be difficult to determine, given that such outcomes are typically subject to many influences well outside the influence of the rehabilitation provider (e.g., job availability, social security provisions, vocational support services, workers compensation issues, etc.). Furthermore, the level of compliance required may change over time. For example, while an exercise program may need to be of a certain intensity early in a rehabilitation program, once the patient returns home or back to his/her normal duties it is quite possible that the normal activities of daily life could make a contribution to the maintenance of that person's fitness (26). In this case, the level of compliance with the exercise program may change over time without adverse consequences. In fact, one could conceive of situations where full compliance with an exercise program could even be detrimental to a person's rehabilitation to his/her full role in society (e.g., if it were too time consuming and caused disruption to the person's normal duties). To some extent, the natural attrition in exercise levels over time that is evident in most studies at follow-up may take care of this concern, but that does not answer the question of the degree to which ongoing compliance is necessary to achieve the stated goals of the program. One study which did examine this question (27) found that overall compliance with individual therapy regimens was moderately associated with a range of outcome measures at over 8 months following attendance at a multidisciplinary pain-management program. In general, the studies which have reported continued rates of practice of exercises, relaxation techniques,

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and other strategies generally describe relatively modest rates of practice, such as two to five times a week (28-30). Despite this, gains made on these programs have often been maintained overall. For example, Williams, Nicholas, and Richardson et al. (31) reported that the gains made by patients with chronic pain conditions who had attended a 4-week inpatient pain management program were well-maintained at 6-months follow-up on a range of measures, including health status, physical performance, depressed mood, self-efficacy, and medication use. Despite that, patients' serf-report of adherence to treatment components after discharge were, for prescribed exercises, 5 or more times a week (66.9% of 182 patients) at 1-month follow-up. At 6-months follow-up, 56.6% of patients treated were practicing 5 or more times a week, 54.3% were practicing the prescribed stretch exercises, and 36.1% the prescribed relaxation technique. It is also possible that individual behavioral measures, such as exercise practice, may not be reliable indicators of performance in other areas. Lutz et al. (27), for example, reported that the continued practice of one pain management technique in the follow-up period was unrelated to the performance of others. In a similar vein, Turk and Rudy (5) suggested that the continued practice of pain management strategies following treatment may not guarantee the continued maintenance of initial treatment gains. In summary, at present there is insufficient information to enable an investigator to reliably estimate the degree of patients' compliance with a rehabilitation program required to achieve a given goal. However, unless compliance is assessed in the first place its role will remain to be guessed at.

ASSESSING COMPLIANCE Assessing compliance is a major problem, especially in the follow-up period. During a rehabilitation program, especially in an inpatient setting, patients' compliance can generally be observed and recorded by the staff. However, in the follow-up period understandably there is much less opportunity for such observations. Most of those studies which have assessed patients' compliance in the follow-up period have relied upon patients' self report, often in the form of estimates as to how frequently they had performed the exercise or taken the drug in question over a given period (28, 29, 31). However, without a means of verification this approach is clearly subject to the risk of the demand characteristics of the assessment occasion with patients, telling the investigators or therapists what the patients think the investigators/therapists want to hear. The achievement of a goal, such as increased muscle strength or aerobic capacity, could be one means of verification, but again that is not necessarily without demand characteristics, especially if it is predicated on effort in the assessment session. Equally, other factors unrelated to a given rehabilitation protocol, such as obtaining a new job which entailed a degree of routine physical activity, could have resulted in the performances measured. Of course, it may be argued that such a result wouldn't matter as the person concerned had clearly achieved their goal. But this wouldn't necessarily help other therapists to reproduce this outcome with other patients.

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Having patients keep detailed records of their compliance with rehabilitation protocols in the follow-up period, say on a daily basis, may provide more reliable data, but the experience with compliance in general is that the more complicated the task the less likely it is to be followed (4, 6). Regular and frequent scheduled contact with the rehabilitation staff, in person or by telephone or mail, in the follow-up period may provide an economical means of both verifying compliance reports and encouraging adherence. In the Faas et al. (20) study mentioned earlier, for example, patients were contacted by mail every 2 months for 1 year and asked if they had been complying with the exercise protocol and advice. However, many studies appear to rely on contacts at 6 or 12 months or so in the follow-up period (11, 32). In the author's experience, many patients report that the dates of the follow-up reviews act as a catalyst for resuming or increasing compliance with pain management protocols, especially if the reviews entail a return to the treatment facility. If this is generally true, the Faas et al., (20) strategy of contact every second month may be a more effective approach to both assessing compliance and to ensuring it compared to only contacting the patients every 6 or 12 months. Certainly, it would seem to offer a reasonable compromise between the demands of limited resources and time on the part of the rehabilitation facility and the imperatives of assessing and ensuring patients' compliance with the rehabilitation protocol. Involving the spouse in the rehabilitation program may also assist in this regard (33).

THEORETICAL ISSUES Given that most rehabilitation approaches, if not all, implicitly or explicitly entail patients continuing to practice behavioral or lifestyle changes following discharge from the rehabilitation program, the question arises: why do some programs address the issue of patients' compliance and not others? To a large extent one can only speculate about the answer to this question, but one possible explanation concerns the theoretical basis of the approach to behavior change and maintenance employed in a given program. Examination of the studies mentioned earlier as examples of those which have not assessed compliance reveals certain common features. These include: the use of information provision, often in didactic sessions (11, 15, 17), the use of exercise practice (11-13, 15-18), the use of work simulation (and work hardening) (11, 12, 17), and the use of individual or group sessions with a psychologist or social worker for training in coping strategies and assertiveness skills (11, 12, 15, 17). Unfortunately, these studies present insufficient information in their description of their programs to be sure of their content or their theoretical basis. However, from the information provided it appears that in the main the programs described in these studies were based on the assumption that by giving the patients the techniques and exercises described, explaining their purpose and encouraging their practice during the program the patients would not only be able to implement them following discharge from the programs, but would also maintain them. For example, no mention is made in any of these studies about attempts to ensure adherence to treatment guidelines or methods. This is somewhat surprising given the abundance

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of evidence that not only is adherence to behavior and lifestyle change advice liable to decline rapidly over time (2), but also that providing information per se typically results in minimal learning (22). Work simulation may be seen as aiding both the generalization of skills learned in a rehabilitation program and desensitization of patients to the work environment which clearly could be considered to promote maintenance of behavioral changes made in rehabilitation. Training in coping strategies and assertiveness skills could also facilitate the patients' successful return to normal duties and social roles. However, Lutz et al.'s (22) finding that continued practice of one pain management technique in the follow-up period was unrelated to the performance of others may suggest that unless all aspects of the rehabilitation program are provided with a plan for maintenance of adherence incorporated patchy adherence rates will ensue. The studies mentioned here do not appear to have considered this issue. In contrast, some programs have acknowledged the principles on which the methods for achieving the expected changes in behavior and lifestyle were based. Typically, such programs have incorporated principles of learning, especially operant methods, into all aspects of the rehabilitation program (34, 35). For example, Williams et al. (31) reported that "all programme staff (two psychologists, an anaesthetist, a physiotherapist, an occupational therapist and a nurse) applied behavioural principles to all relevant areas of patient activity and inactivity" (p. 514). The ways in which this was done were clearly described and where information was given to the patients it was supported by written material, as recommended by Ley and Morris (22). In addition, the patients were trained to apply the same learning principles to themselves to assist with adherence to the program post-discharge. As mentioned earlier, adherence rates for different aspects of the program were assessed at follow-up and they were generally at the upper end of the typical rates reported in the literature, especially the exercise components. Importantly, too, the gains made during the program were generally well-maintained at follow-up. Of course, the study design did not allow conclusions to be drawn about the specific role of employing learning principles throughout the program, but support for the additive effects of learning principles (to a rehabilitation program) can be found among the few studies to have examined this question (36, 37). The integration of cognitive therapy methods to such operant-based rehabilitation programs has been found to result in even greater gains (33). It could also be argued that when the multidisciplinary staff of a given program base their work on the same set of agreed behavior change principles adherence with the. program may be enhanced as they ought to be able to derive similar solutions to the problems presented by the patients from these principles. A treatment manual may be able to provide broad outlines or guidance for treating staff, but given the enormous variety of problems patients are likely to present it would be quite impossible to have a solution to all possible problems included in a manual. With a treatment manual based on the same principles as those employed by the treating staff, the staff ought to be able to respond both flexibly and consistently to patients' problems, regardless of which staff member is involved. A good, albeit anecdotal, example of this was provided by the author's experience on the program reported by Williams et al. (31) where numerous visits to the program by a range

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of health care professionals almost invariably resulted in their making unsolicited comments about the consistency of the approach to the patients by the different members of the staff. Whether this approach results in better outcomes compared to those studies which do not enunciate the theoretical basis of their behavior change methods is not so much the issue in this paper (see Refs. 38-40, 33 for reviews), but the provision of such details at least indicates that the investigators have addressed the issue of behavior change and its maintenance and in a way which could assist other investigators to evaluate the contributing factors to the outcomes achieved. This, in turn, could lead to further replicable improvements in treatment methods. If a study has a clear theoretical basis for the methods employed to achieve its goals it can greatly assist other investigators and clinicians in their attempts to extend or adapt them. In the context of compliance, it would appear that not only more assessment but also more systematic approaches to its study and facilitation are urgently needed ff the present shortcomings are to be overcome.

CONCLUSIONS AND RECOMMENDATIONS This paper has sought to draw attention to an important and frequent ommission from studies of rehabilitation programs; namely the assessment and ensurance of patients' compliance with rehabilitation regimens. It has been argued that failure to assess patients' adherrence to rehabilitation programs has made interpretation of the outcomes of such programs problematic. It was acknowledged that the assessment of patients' compliance is a major problem in both practical and methodological contexts. However, without it many otherwise excellent studies lose much of their potential value as it may be difficult to demonstrate that any changes achieved were due to the patients performing the tasks or exercises prescribed by the treating clinicians. Some suggestions were made in relation to feasible assessment methods and these included retrospective patients' self-reports made at periodic follow-up reviews or, better still, some form of recording made by the patients during the follow-up period. However, the latter is not without its own problems of compliance, especially if the task is complex or time consuming. Some more indirect methods may also be employed to supplement, but not replace, self-reports and examples of these included measures of muscle strength and aerobic fitness, but these too had their drawbacks, especially those requiring effort. How much compliance with rehabilitation programs is required to achieve given ends is unclear but more frequent assessment of compliance levels would make this question much easier to answer. A further consideration relates to the role of compliance by the health care professionals staffing rehabilitation programs. It seems most likely that once this is assessed more routinely serious deficiencies will emerge. Methods of assessing and ensuring adherence by health care professionals to protocols have included the use of audio recordings of therapy sessions to be evaluated by blind raters with copies of treatment outlines. But simpler and more generally feasible approaches might include having other members of the staff, or even visiting health care professionals,

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sit in on and evaluate the different sessions during a program, the use of treatment manuals (4) and regular team meetings to review and role play (with other staff) each segment of a program and the management of common patient problems. The natural corollary of the concern with compliance to the rehabilitation program by both the patient and the therapeutic staff is, of course, the extent to which the workplace arrangements also comply with the rehabilitation program. However, knowledge about this area appears sketchy and anecdotal, with comments on the issue more incidental than central (41). Clearly, ensuring good compliance in the workplace with rehabilitation plans is likely to play an important role in work retention, but at this stage systematic research is lacking. A final matter of more fundamental significance concerned the theoretical basis of the behavior change processes incorporated within different rehabilitation programs. It appears that few reports of rehabilitation programs explicitly state the theoretical or even empirical basis of their behavior or lifestyle change methods. It was argued that this represents a major impediment to both the interpretation of many previous studies and the development of new programs derived from such studies. It could also be argued that when a program is clearly based on theoretical or empirically-derived principles the promotion of compliance by both health care professionals and their patients may be enhanced. Although regretably few, studies are now emerging that do examine the role of different behavior change principles, such as operant vs. cognitive. It is to be hoped that this list will grow because it could well provide the key to improvement in the rates of patients' compliance with rehabilitation programs.

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Compliance: A barrier to occupational rehabilitation?

While patients' compliance with medical, psychological, and other treatments has received considerable attention the subject has received relatively l...
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