Facilitating Behavior Change: Strategies for Education and Practice
Lorish, Christopher, Journal, Physical Therapy Education
ABSTRACT- This paper develops an argument for the inclusion of brief disease prevention counseling into the training curricula of physical therapists. Cited literature suggests that practicing therapists are likelv not taking full advantage of concepts from behavior theory that can guide prevention counseling. Those concepts, along with the Brief prevention Counseling Model, are described and applied to a case scenario. In addition, the knowledge, skills, and attitude components of a counseling curriculum, including their assessment, are discussed.
Key Words: Behavior theory, Brief counseling, Exercise, Physical therapy.
Mr Jones, a 55-year-old, sedentary, obese, mate smoker, comes to you with a referral from a family physician for knee pain associated with osteoarthritis. As a skilled therapist, you assess the man's knee range of motion (ROM) and strength and decide that function may he prolonged if regular strengthening exercises are done. After telling the patient that and instructing him on how to do his exercises, you watch him do them until you are satisfied that he does them correctly. He misses his 2-week return visit. After a call to his home., he returns to your clinic 4 weeks from the initial visit, His ROM and strength are not appreciably improved, and you correctly infer that he has not adhered to his exercise regimen. When asked directly, your patient mumbles something about being too busy and that the exercises are boring. You reiterate the importance of the exercises for maintaining function, watch him do them, and make a return visit appointment.
It is likely that most therapists have had patients like Mr Jones. With a bit of reflection, most therapists would admit to the disappointment and frustration of patients like him who do not follow their advice. Although the patient has to assume responsibility for choosing to improve his condition, it may also be that the therapist did not use all the tools available to influence the patient's choices. In response to patients like Mr Jones, many therapists would try to influence the patient's adherence by giving more information. However, any therapist who reflects on his or her practice is likely to conclude that giving patients more information on the condition, its causes, or the treatment often does not increase treatment adherence. And what about the missed opportunities for prevention? The patient was obese, sedentary, and a smokerthree important cardiovascular risk factors that are modifiable but about which the therapist said nothing to the patient. Because over 875,000 deaths in the United States in 1990 were considered attributable to lifestylerelated behavior,1 the US Preventive Services Task Force recommended universal risk assessment of patients' tobacco and alcohol consumption, seat belt use, diet, stress, safe sex practices, and physical activity and discussion of these health risks with patients when indicated.2 Current recommendations by numerous health-related governmental and medical organizations make increasing patients' activity level nearly a universal prescription.3-10
This paper asserts that physical therapists have advantages over many health care practitioners for providing effective treatment and prevention counseling, especially for voluntary exercise, but that they may not be taking the fullest advantage of those opportunities. There are cognitive behavior theories that offer constructs useful for guiding therapists' efforts to influence patients' behavioral choices. There is a process that therapists can use with any patient that is brief, incorporates those behavioral theory constructs, and can be tailored to the patient. Educating student therapists about these cognitive behavior theories and providing practice and feedback in treatment adherence and prevention education could be included as part of their course work and clinical experiences.
THE PATIENT EDUCATION OPPORTUNITY
The presentation of a patient with a musculoskeletal problem to a physical therapist offers an opportunity to assess and intervene with the presenting problems and to influence prevention behavior, especially in a voluntary exercise program. …