by Phil Page PT & Dana Mackison DC
Recently, the term ‘active care’ has been used to describe rehabilitation that makes the patient an active participant in the process. In contrast to ‘passive care’ that includes modalities and manual techniques, Active Care emphasizes self-management techniques such as exercise and behavioral change. While both active and passive techniques have their place in rehabilitation, the ultimate goal is to empower the patient to take responsibility for their own care, rather than relying on the clinician.
How to Empower your Patients
Patient empowerment is accomplished by avoiding passive modalities, minimizing unnecessary visits, providing patient education, and helping the patient develop self-management strategies for preventing exacerbations. A patient-centered approach promotes a “team” approach where patients are active participants and partners in the therapeutic process, responsible for making their own choices (Law et al. 1995).
The first step in empowering patients to take control of their care is to understand behavioral change, which is the key to adopting a healthy behavior or to stopping an unhealthy behavior. Home exercise programs and self-management strategies are most effective when behavioral factors are considered within the patient education. Research has shown that chronic low back pain patients who combine therapeutic exercise with a motivation program have better compliance and greater improvements in pain and disability compared to exercise alone (Friedrich et al. 1998). Some clinically-relevant behavioral strategies based on Social-Cognitive and Cognitive-Behavioral theories are listed below:
- Promote Self Efficacy: Emphasize the patient’s ability to be successful in managing their own care.
- Provide positive outcome expectations: Emphasize the possible positive results of successful rehabilitation.
- Encourage social support: Enlist the support of family and friends to continue exercises.
- Educate the patient: Provide relevant information about the patient’s injury or condition and ‘why’ Active Care is important.
- Use behavioral modification techniques: Provide rewards and identify cues that promote healthy behavior.
- Set goals: Set both short- and long-term goals that are individualized to the patient’s anticipated outcomes.
- Keep track of progress & self-monitor: Encourage patients to maintain an exercise log.
More Effective Home Programs
Research shows that home programs are effective, particularly those that involve some level of supervision. Unsupervised home programs are generally not as effective as home programs supplemented with physical therapy (Deyle et al. 2005, McCarthy et al. 2004). Orthopedic conditions are treated well with home exercise programs under provider supervision, rather than regular clinic visits such as ankle sprains (Bassett & Prapavesis), chronic back pain (Bentsen et al. 1997), and ACL reconstruction (Beard & Dodd 1998, Grant et al. 2005). In fact, home programs are as effective as surgery in some cases of chronic low back pain (Brox et al. 2003).
More Effective Goal-Setting
Goal-setting is an important component of Active Care; clinicians should provide problem-oriented goals by working together to set them with the patient based on their ability (Holliday et al. 2005, Parry 2004). In a review of the literature, Cott and Finch (1991) identified several characteristics of effective goal setting in physical therapy: provide specific and measurable goals, select appropriate degree of difficulty, gain acceptance of the patient, and provide feedback.
Improve your Patient Education
Patient educational materials are helpful in educating patients and reducing pain (Udermann et al. 2004). Technological advancements have further enhanced the options in providing educational materials, from computer-based exercise handouts to on-demand video and DVDs. Handouts alone are not as effective as live or video demonstration of exercises (Frederich et al. 1996; Reo and Mercer 2004). Clearly, providing a handout or brochure alone is not effective; a brochure must be combined with live teaching or video demonstration. In addition, there is a strong correlation between correct exercise performance and decreasing pain (Frederich et al. 1996).
Interestingly, standardized exercises have been shown as effective as customized exercises in shoulder rehabilitation (Wang and Trudelle-Jackson 2006). This suggests that the same group of exercises can be used in a patient population, without need to customize the exercises for each individual.
More Effective Patient Learning
Learning a motor skill also requires feedback and repetition. Cuing the patient for proper movement as well as mistakes, and then repeating the movement several times to “groove” the motor pattern is effective in teaching a new exercise. Modeling is very effective to learn a new motor skill (Sidaway et al. 1993); therefore, demonstrating the exercise for the patient beforehand helps.
As stated previously, self efficacy is the primary variable that predicts physical activity (Stutts et al. 2002). Patients should use the success of a home program as self-efficacy to build life-long physical activity. By promoting a physically-active lifestyle after therapy, the clinician can retain the patient-provider relationship.
By combining aspects of behavioral change with clinically-relevant research, clinicians can improve patient outcomes and reduce health-care costs through effective home-based exercise programs.