Total knee arthroplasty (TKA) places a large burden on the Canadian Health care system with over 700 million dollars spent on this procedure annually. Exercise has been shown to be effective in improving pain, physical function, mobility and quality of life post-operatively. There is very limited research on adherence to rehabilitation and exercise after TKA. The aim of this thesis was to increase understanding of exercise adherence in this population. The first manuscript in this thesis was a scoping review that evaluated exercise adherence and the quality of reporting of exercise interventions within post-operative TKA rehabilitation trials. A systematic search of scientific databases was conducted for randomized controlled trials (RCT) with an exercise intervention for post-operative TKA. In total, 112 articles were included in this review. This study found that the vast majority of articles (85%) were of poor quality having either high/unclear risk of bias. The majority of RCTs (63%, N=71) on post-operative TKA rehabilitation did not adequately report exercise adherence (e.g., definition, outcome measure used and results), while only 23% (N=15) provided a definition of adherence in the context of their study. Overall reporting of the exercise intervention was poor, with 15 items (of 19) of the Consensus on Exercise Reporting Template (CERT) reported less than 60% of the time. Inadequate reporting of exercise interventions and adherence to exercises leads to decreased reproducibility and translation into clinical practice. Proper reporting of rehabilitation exercises after TKA will ensure standardization for future studies and clinical replication. The second manuscript in this thesis was a qualitative study that aimed to understand the patient- related barriers and facilitators to exercise adherence in patients immediately after undergoing TKA. Using an interpretive description approach, semi-structured qualitative interviews were conducted. Seven participants were interviewed at 8-weeks post-operatively in order to better capture physical, psychological, social and contextual factors linked to exercise adherence. Interview questions explored participants’ experience with physical activity and exercise, motivation to perform physical activity, beliefs that exercise will reduce pain, the factors that limit their ability to engage in exercise, and the importance of using self-regulation to improve exercise adherence. Emergent themes were mapped onto the domains of the WHO adherence framework. This study identified 4 themes that fit within the WHO adherence framework: patient-related factors, condition-related factors, health care system, and social support. In particular, self-regulation, previous knowledge of exercise, post-operative complications, comorbidities, social support, and lack of guidance from health care providers were identified as personal and environmental characteristics that affect exercise adherence. The overall findings of this study suggest exercise adherence is a multifaceted construct with interconnected concepts. / Thesis / Master of Health Sciences (MSc) / Total knee replacement (TKR) surgery costs the Canadian Health care system millions of dollars per year. Exercise is an effective method for improving function and decreasing pain after surgery. However, it is unclear how much patients perform exercise as recommended by health care providers. The purpose of this study was to understand exercise behaviour after knee surgery. The first study was a scoping review that looked at exercise adherence and the characteristics of exercise treatments delivered after knee surgery in previously published clinical trials. The study found that most studies did not report enough information for replication of exercise treatment protocols (e.g. description of provided exercises/progression, who implemented the intervention, etc.). Similarly, exercise adherence was also poorly reported (e.g., definition, how adherence was measured). Poor reporting of exercise treatment methods, and how well participants complete exercises decreases the ability of researchers and therapists to apply the results of these trials. In the second study, patients were interviewed after knee surgery to understand why patients do or do not exercise after surgery. There were several factors, both positive and negative, that patients identified that affected their ability to exercise (e.g. self-regulation (referring to the ability to control thoughts, emotions and behaviour to pursue long-term goals), prior knowledge of exercise, having social support from family and friends, as well as lack of support from health care providers). The overall findings suggest that how well participants exercise after surgery is a complex issue. In order to improve exercise adherence, we need to have a better understanding of the individual factors that may influence adherence.

Regular exercise is challenging and lapses in activity may lead to non-adherence. Adherence may be particularly challenging for symptomatic individuals with disease-related symptoms that may impede exercise. The combined use of cognitive-behavioural strategies including problem-solving has been strongly encouraged for promoting exercise adherence. However, evidence supporting the link between the use of the independent strategy of problem-solving and exercise adherence is limited. The overall purpose of this dissertation was to examine problem-solving relative to exercise-lapse related problems. Using two theoretical frameworks that offer insight into problem-solving (Model of Social Problem-Solving and Social Cognitive Theory), three studies were conducted to examine proposed relationships in various asymptomatic and symptomatic exercising samples. In Study 1A, relationships between self-regulatory efficacy (SRE) for exercise and problem-solving approach (task-diagnostic and self-diagnostic) were explored in a sample of exercising university students (n = 79). Results indicated that SRE beliefs were significantly and (1) positively related to task-diagnostic problem-solving approach and (2) negatively related to self-diagnostic problem-solving approach. In Study 1B, relationships between problem-solving effectiveness and exercise-related social cognitions were examined in the same sample. Findings demonstrated that problem-solving effectiveness was positively associated with social cognitive correlates of exercise adherence linked to adaptation. Relationships demonstrated in Study 1 provide preliminary support for previously unexamined problem-solving research questions relative to exercise. In Study 2, relationships between problem-solving effectiveness and exercise-related social cognitions (self-efficacy and persistence) were examined in a sample of exercising cardiac rehabilitation initiates (n = 52). These relationships were considered relative to two distinct components of the problem-solving process (seeking solutions to problems and carrying out solutions), which have not previously been examined relative to exercise lapses. Findings indicated significant relationships between problem-solving effectiveness and (a) self-efficacy for problem-solving (seeking solutions to problems), (b) persistence with problem-solving, (c) self-efficacy for solution implementation (carrying out solutions) and (d) persistence with solution implementation. In Study 3, problem-solving was examined among exercising cancer survivors (n = 35) with cancer-related fatigue, a problematic exercise barrier. Partial support was demonstrated for differences between more and less effective problem-solvers on fatigue-related variables. An under-examined area in problem-solving research was also examined in this study; the relationship between problem-solving and positive psychological functioning. Findings indicated significant differences for positive psychological functioning between individuals with higher and lower positive problem orientation. Taken together, the three studies represent an initial attempt to advance exercise and problem-solving literature by illustrating important theoretical relationships in three samples of exercisers, and addressing important gaps in the exercise and problem-solving literature. In regard to the latter point, the research was the first to examine (a) variables that may link problem-solving to exercise adherence, (b) two distinct components of the problem-solving process relative to an exercise lapse situation, and (c) potential links between problem-solving and selected positive psychological outcomes. Future research directions relative to problem-solving and exercise are suggested as possible next steps to advance this preliminary research.

abstract: The U.S. Surgeon General has recommended that all Americans engage in regular physical activity throughout the lifespan as a way to maintain and improve health and reduce the risk of developing cardiovascular disease, diabetes, obesity, or other chronic conditions. The recommendation for children is a minimum of 60 minutes of moderate and intense physical activity everyday. As children enter adolescence their level of physical activity often decreases; and active adults were typically active adolescents. More than 50% of adults that begin a physical activity program discontinue the behavior within 9 months. Interventions to increase physical activity have looked at self-esteem and self-efficacy. Locus of control (LOC) is a concept that people either view their own behavior as influencing the events around them (internal) or other events controlling their fate or destiny (external). This study looked at locus of control as a predictor of exercise adherence and future exercise patterns in children ages 6-12 in Mesa, AZ. Locus of control as measured by the Child Nowicki-Strickland Internal External (CNSIE) scale differed by gender and by physical activity group at school at post-intervention. Self-reported physical activity as measured by the Physical Activity Questionnaire for Older Children (PAQ-C) showed differences in physical activity (PA) levels by gender for baseline school PA, by age group for baseline non-school PA, by gender and age group for post-intervention school PA, and by gender only for post-intervention non-school PA. A secondary objective was to assess if the Think Healthy About Nutrition and eXercise (THANX) after school program influenced participants' LOC or PA patterns. This study found that the THANX program had no effect on LOC or PA level at any time point. / Dissertation/Thesis / M.S. Exercise and Wellness 2012

It has been well-documented in the literature that there are many physical and psychological benefits to be derived from regular aerobic exercise. It has also been noted that adherence/compliance to aerobic exercise regimens tends to be quite low. Investigators have found that a number of factors tend to correlate with adherence, but it has been difficult thus far to determine a mechanism which underlies a tendency to adhere versus a tendency to drop-out. This study examined the problem of non-adherence from the perspective of Self-Efficacy Theory (Bandura, 1977). Subjects for this investigation included all patients seen during a four week period in the Cooper Clinic at the Aerobics Center in Dallas, Texas. Patients at the clinic receive a complete physical examination and health prescriptions based upon the results of their examination. During this four week period, half were administered a Self-Efficacy Questionnaire. Approximately three months later all patients seen during this four week period received a followup (adherence questionnaire in the mail). It was hypothesized that there would be a positive relationship between responses on the Self-Efficacy Questionnaire and responses on the Adherence Questionnaire. A second hypothesis stated that there would be a positive relationship between items which specifically pertained to exercise on each of the questionnaires. In addition, it was expected that there would be no difference in adherence rates between those who made self-efficacy judgments and those who did not. Results of a t-test conducted between the group which made self-efficacy judgments and the group that was not asked to make such an evaluation demonstrated no significant difference in adherence rates. A correlational analysis revealed that there was not a statistically significant relationship between total self-efficacy scores and total adherence scores. There was, however, a statistically significant relationship between levels of exercise self-efficacy and levels of exercise adherence. In addition to these main variables of interest, correlations between other variables (sex, age, percent bodyfat, etc.) were examined and discussed.

In this study, exercise adherence levels were examined from archival data collected from 2004 to 2006 to determine if an association existed with the levels of depression among individuals over 49 in 3 rural community centers. Abundant research has shown that exercise is effective in alleviating depression but has not shown how levels of exercise adherence may impact the efficacy of exercise in the treatment of depression. The focus of the study was to determine if an increase in exercise adherence may be associated with a decrease in the symptoms of depression. An ANCOVA was used to determine if differences in levels of depression were significantly associated between low and high exercise adherence. The results did not provide evidence that a high level of exercise adherence is associated with lower symptoms of depression. An independent samples t test was used to determine if gender makes any difference in exercise adherence. The results did not provide evidence that gender made any difference in exercise adherence. An ANOVA was used to determine if the type of exercise was associated with exercise adherence. The results provided significant evidence that select exercises were adhered to more than others. A new study comparing varying levels of exercise adherence, not merely low exercise adherence and high exercise adherence, would allow for a more precise measurement of the association between exercise adherence and depression. It is hoped that providing further insight into an adjunct treatment of depression will result in an increased efficacy of treatment and a positive social change for society.

yes / Exercise classes provide a range of benefits for older adults, but adherence levels are poor. We know little of instructors’ experiences of delivering exercise classes to older adults. Semi-structured interviews, informed by the Theory of Planned Behaviour (TPB), were conducted with instructors (n=19) delivering multi-component exercise classes to establish their perspectives on older adults’ uptake and adherence to exercise classes. Analysis revealed ‘barriers’ related to identity, choice/control, cost, venue and ‘solutions’ including providing choice, relating exercise to identity, a personal touch and social support. ‘Barriers’ to adherence included unrealistic expectations and social influences and ‘solutions’ identified were encouraging commitment, creating social cohesion and an emphasis on achieving outcomes. Older adults’ attitudes were an underlying theme, which related to all barriers and solutions. The instructor plays an important, but not isolated, role in older adults’ uptake and adherence to classes. Instructors’ perspectives help us to further understand how we can design successful exercise classes.

The purpose of this study was two-fold: to quantitatively explore competitive rowers' perspectives of the benefits and barriers to exercise, and to use follow-up qualitative interviews to elicit insight into rowers' views of their sport culture, personal experience, and what it takes to be a dedicated, adherent athlete. A mixed-methods approach was used with online surveys and semi-structured interviews. Participants were club and university rowers in the Northeast Atlantic region, all of whom were at least 18 years of age and actively rowing at the time of study One hundred thirty-one athletes, 77 female and 54 male, participated in the quantitative phase of the study. The online survey included the Exercise Benefits/Barriers Scale (EBBS), a 43-item, 4-point Likert scale measure, and a Basic Demographics Questionnaire (BDQ). The EBBS measured perceived benefits of and barriers to physical exercise. Statistical analysis revealed no strong correlations between the EBBS factors and demographic data. An eight-factor solution resulted, with five benefits (psycho-physical competence, daily functional efficiency, psycho-emotional stability, preventative health, and social interaction) and three barriers (personal inconvenience, physical exertion, and family encouragement). The eight-factor solution correlated strongly with the original nine-factor solution from Sechrist, Walker, and Pender (1987). Nine participants, five men and four women, participated in follow-up interviews. Interviews were performed at a time and place convenient for the rower. The purpose of the interview was to elicit specific, genuine, rich content related to their rowing experience and how the benefits and barriers to physical activity and their place in rowing culture affect exercise adherence. Using an inductive-deductive approach prescribed by grounded theory, two core categories and additional sub-categories were developed in the coding process. From the data analysis, hindering factors and facilitating factors emerged as the core categories. Physical conditioning and health, optimization of personal characteristics, psycho-emotional stability, strong social community, environment, and interpretation of perceived barriers were subsumed under facilitating factors. The following sub-themes were contained in hindering factors: exercise demands, environment, and social issues. Rowers perceived strongly the benefits of their rowing experience, and stated that barriers are inherent to exercise and they are responsible for adapting to them. / Kinesiology

Using Social Cognitive Theory, Social Identity Theory, and Source Credibility, this study examined the role of instructor source credibility as related to exercise adherence. A one-time survey was given to participants of an eight-week exercise program. Hierarchical multiple linear regression was used to test hypotheses. Results indicate that perceived expertise was a significant predictor of intentions to adhere to class. Additionally, this study shows how Social Identity Theory can predict lower levels of identification in an exercise context. The scales used to text source credibility were shown to be accurate measures of perceived instructor expertise, likeability, and enthusiasm. Thus, these scales can be used to examine this subject in later studies.

xv, 162 p. ; ill. (some col.) A print copy of this thesis is available through the UO Libraries. Search the library catalog for the location and call number. / Each year, over 65,000 brain injury survivors are discharged home from hospitals with ongoing rehabilitation needs due to acquired impairments, such as dysphagia. Emerging empirical evidence supports the benefits of intensive swallowing exercise programs when dysphagia results from muscle weakness. However, many of these survivors cannot complete intensive home exercise programs due to co-occurring cognitive impairments in memory or initiation. This project investigated the potential benefits of a new experimental assistive technology device, the Television Assisted Prompting (TAP) system to increase completion of home swallowing exercises. The TAP system was designed as a treatment package to provide both automated prompts and multimedia motivational instructional exercise videos via a person's home television. Three participants were recruited, all of whom had survived a hemispheric stroke and presented with neurogenic dysphagia and co-occurring cognitive impairments. Two home program delivery conditions were alternately presented on randomized days in a single-case experimental alternating treatment design: TAP delivery (e.g., TV prompting with motivational videos) or typical practice (TYP) delivery (e.g., care provider prompting as needed to follow assigned written home programs). The same exercises were presented in each condition. Measures included feasibility (e.g., reliability of the TAP system), efficacy (e.g., number of exercises completed per session), and satisfaction. Results revealed that two of three participants showed dramatic benefits from the TAP system. Participant 1 was 17 times more likely to complete exercises when prompted by the TAP system; participant 2 was six times more likely. Participant 3 completed exercises with equal likelihood on TAP or TYP days. All three participants reported preference for TAP system delivery and requested to increase the frequency of TAP delivery to every day. Care providers unanimously reported preference for the TAP system to prompt patients and reduce their burden of care. The TAP system malfunctioned during 21.70% (23/106) of scheduled sessions; two participants needed clarifications, instruction to use the system, or customized modifications in order to interact independently with the device. Recommendations for system improvements and applications to the field of assistive technology are provided. / Adviser: McKay Moore Sohlberg

Indiana University-Purdue University Indianapolis (IUPUI)