According to Teyhen et. al. (2014); Health care expenditure has grown from 5% of the gross domestic product in 1960 to 17% in 2008, while at the same time preventable chronic diseases have become the largest cause of death and disability. Physical inactivity, poor nutritional choices, and insufficient sleep have been identified as contributing factors to these diseases. The increased cost, disability, and mortality associated with these preventable chronic diseases require a fundamental shift…(p. 378)
In the May 2014 Issue of JOSPT LTG Patricia D. Horoho 43rd Surgeon General, US Army commander, US Army Medical Command pitched a challenge to the healthcare community to begin a meaningful conversation about Health - “where maintaining and improving Health receive equal emphasis with Restoring Health. One where every medical intervention addresses the challenges of environment and human behavior - and their effects on health and healing” (p. 319).
You see, the Surgeon General knows a thing or two about changing a health care climate. Recently, she developed and implemented the Performance Triad pilot program for the U.S. Army, aimed at improving the way soldiers make health decisions. The program is based on the growing body of evidence supporting the important role that physical activity, nutrition and sleep play in maintaining health and resilience through life. She hopes that by educating, incentivizing and improving peoples decisions in these main areas our current healthcare system will instead evolve into a “system for health” (Bermudez 2013).
To support and strengthen this model, US Army health care specialists gathered in 2013 for a two day workshop titled “Incentives to Create and Sustain Change for Health”. Their primary aim was to review the current research and determine the most successful interventions that support the adoption of healthy behaviors. The following is a summary of the groups strongest findings and my thoughts on how physical therapists can immediately implement the findings into practice, leading our society towards a system of health:
1. Public Health and Messaging
- Messages tailored to individuals’ needs are more effective than strategies to provide information for general audiences.
- General health communication campaigns for physical activity are poorly supported for obesity.
-Technology (i.e Telehealth, EMR, Skype, etc.) provides the opportunity to individualize messages and maintain consistent relationship between patient/provider. (Teyhen et. al. p. 379)
Quality physical therapy allows for adequate time with patients. This block of time should be a seamless mix of assessment and treatment, including the addressing of future health risks and prevention. Yet another reason our profession must be proactive and fight for quality of care rather than taking a reactive stance. It’s these exact reasons, and the personal relationship that we often develop with our patients that supports exploring the idea of an annual physical with a quality physical therapist.
2. Creation of Healthier Habits and Environmental Influence on Health
-Habits are defined as behaviors that are learned gradually as people frequently and consistently repeat a behavior in the presence of stable context cues.
-Habits act as a substitute for self control.
-Behavior change interventions are more effective when they explicitly address the automatic bases of behavior (i.e. if a person eats fatty snacks late while watching tv, moving to a different room and reading disrupts the context-cueing associated with the snacking).
-Interventions aimed at promoting health often fail if they focus only on changing peoples goals and intentions.
-Interventions should harness and build on existing good habits.
-Sleep is also affected by an individual's environment.
-Poorer sleep quality = greater psychological distress. (Teyhen et. al. p. 379-80)
We must listen to our patients! Individualize and provide specific instruction/suggestions for lifestyle changes (within our scope of practice) to eliminate unhealthy habits while building on already existing healthier ones. Also, educate on the importance of quality sleep by minimizing the use of electronics and caffeine before bed.
3. Goal setting and tracking
-The following factors promote healthy behavior maintenance: satisfaction with behavioral outcomes, realistic expectations, feeling responsible for positive outcomes, and positive changes in social support. Individuals should disengage from an unattainable goal to avoid repeated failure and then identify, commit to, and start a new goal.
-Goal setting has been found to be an effective strategy for changing health behaviors, including physical activity and nutrition.
-Striving towards ambitious goals resulted in greater increases in physical activity.
-Regular self-monitoring, often within the context of goal setting, is effective.
-Detailed and concrete goals with triggers were most effective in behavior change.
-Individuals enrolled in a program or assigned to a regimen may also have goals related to sustained engagement with the program.
-Feedback through self-monitoring has been effective for physical activity, diet and weight management.
-Self-reward and self-instruction support behavior change, and enlistment of social support and encouragement from others is associated with success.
-Greater engagement in the process leads to better outcomes. (Teyhen et. al. p. 380-81)
Research also shows that many who lose weight will gain it back over time, and roughly half will gain back more than they lost. Therefore, it is important for us as clinicians to not only incorporate realistic goals and provide accountability with encouragement during our time with the patient, but we must also educate the patient on how to integrate these tools individually and through social groups following discharge. Maybe it’s time we also consider discussion the integration of Telehealth and online video for short quarterly follow-ups with patients?
4. Role of Incentives in Behavior-Change Interventions.
-When considering financial incentives, researchers found that they are effective for smoking cessation and weight loss in the short-term, but little evidence is available on long-term changes. (Teyhen et. al. p. 381-82)
With respect to healthful behavior, an important question of maintenance is how to best transition to being “creatures of habit”. Clinically, we should always reinforce positive changes and make sure patients are aware of improvements in function. Pre and post testing every session demonstrates short term gains and helps motivate and encourage long term compliance.
5. Influence of peers and social networks on change.
-Short ties within a clustered network structure provide social reinforcement for changing health behavior.
-Social reinforcement from a second source significantly increases the likelihood of adoption. -Networks where connections are clustered based on like factors such as fitness level, fitness goals and age have been found to be more effective than random networks in creating and sustaining engagement. (Teyhen et. al. p. 382)
“The average individual only seeks health care for approximately 100 minutes/year. However, health “happens” in the other 525,000 minutes of a year in real life situations” (Bermudez 2013). Encourage your patients to get involved in healthy activities and classes that are appropriate for their skill level, desires and hobbies as soon as he/she is medically appropriate. Incorporate healthy activity goals within your plan of care and always hold them accountable for their home exercises and progress.
Health care providers are beginning to better understand and acknowledge what common sense should tell us. As LTG Horoho states; “for the vast majority of these [preventable] lifestyle-induced conditions, the answer isn’t simply more pills and procedures….The answer lies in modifying the thoughts, choices, and behaviors of our patients well in advance of any onset pathology.” (p. 318-19)
It’s about individualized education that encourages prevention!
The APTA Guide to Practice specifically defines a PT’s role in prevention as: activities that are directed toward achieving and restoring optimal functional capacity, minimizing impairments, functional limitations, and disabilities, maintaining health (thereby preventing further deterioration or future illness), creating appropriate environmental adaptations to enhance independent function. The Guide even goes on to specifically state that prevention services and programs that promote health, wellness, and fitness are a vital part of the practice of physical therapy! (Guide 2003)
Check out this Health Grid developed by JOSPT based on the findings of the workshop: (for a copy visit www.jospt.org)
JOSPT Perspectives for Patients: Health and Wellness-Making the Healthy Choice the Easy Choice. Journal of Orthopedic & Sports Physical Therapy, 44, 388.
Our profession has not only the opportunity, but THE OBLIGATION to be a leader if our system is to improve. It is said that research takes up to seventeen years to integrate into everyday clinical practice. I would like to challenge PTs to improve this statistic. It’s time to stop being a reactive profession and mature into a proactive one. As the Surgeon General states: “We have to rethink how we engage with patients, and we instruct and coach them toward better Health….My challenge is to all of us in health care to talk to patients about those decisions and their ramifications for Maintenance Health” (318-19). We have a unique opportunity as providers to accept this challenge and spend quality time discussing and educating our patients on Health improvements. The pitch has been thrown, it’s time for us to step up to the plate.
Bermudez, A. (2013, February 27). Surgeon General defines end state of Performance Triad roll out. . Retrieved , from http://www.army.mil/article/97318
Interactive Guide to Physical Therapist Practice. (2003). : American Physical Therapy Association.
Horoho, P. Maintaining, Restoring, and Improving the Health of Our Nation. Journal of Orthopaedic & Sports Physical Therapy, 44, 318-319.
Teyhen, D., Aldag, M., Centola, D., Edinborough, E., Ghannadian, J., Haught, A., et al. Key Enablers to Facilitate Healthy Behavior Change: Workshop Summary. Journal of Orthopedic & Sports Physical Therapy, 44, 378-388.
Brad attended Simmons College in Boston, MA - where he graduated with his Doctorate in Physical Therapy in 2011. During his time in New England he served on the American Physical Therapy Association Student Assembly Board of Directors where he represented nearly 20,000 other PT students across the country. Following graduation, Brad enrolled in the Institute of Physical Art’s APTA Credentialed Orthopedic Residency where he spent three years studying in Annapolis, Maryland and was mentored by several of the most advanced manual physical therapist clinicians in the country - eventually gaining his Certification in Functional Manual Therapy (CFMT). Brad recently returned closer to home and has ventured into the entrepreneurial world as the co-developer and partner of the innovative business model IPA Physio Nashville; where he is bringing the FMT treatment/lifestyle approach to Tennessee and beyond. Brad's inspiration for molding his passion for his patients and profession with disruptive innovation: To improve the quality of life for all individuals and to empower his PT colleagues through inspired action. Check out Brad at LinkedIn and Twitter.