Will patients stick to physical therapy? Questionnaire can help doctors predict

Patients' responses to a simple questionnaire can reliably predict whether they will adhere to physical therapy after spine surgery, Johns Hopkins researchers suggest in a new study. The findings could help physicians identify patients who might benefit from additional preoperative preparation to ensure they attend therapy sessions and follow through with prescribed exercise, a factor that can greatly affect their long-term recovery.

"It has long been known that physical therapy after spine surgery greatly improves outcomes, but to date, there has been no easy-to-administer, standardized method for assessing a patient's willingness to adhere to therapy," says Richard L. Skolasky, Sc.D., of the Department of Orthopaedic Surgery at Johns Hopkins University School of Medicine.

In the study, published online in the Oct. 1 Spine, Skolasky and his colleagues demonstrated that spine surgery patients who scored high on the Patient Activation Measure (PAM) questionnaire were 38 percent more likely to attend physical therapy and were rated as significantly more engaged in rehabilitation by their physical therapists compared to patients with low PAM scores.

The PAM, developed in 2004, is a participant-completed, 13-item questionnaire that assesses a patient's ability to play an active role in his or her health care. To date, it has been studied for use with chronic diseases such as HIV, type 2 diabetes and hypertension. This is the first time it has been applied to surgery and physical therapy.

This questionnaire asks patients to rate their agreement to a variety of statements, ranging from strongly agree to strongly disagree. Examples of statements include: When all is said and done, I am the person who is responsible for managing my health condition; Taking an active role in my own health care is the most important factor in determining my health and ability to function; and, I am confident I can follow through on medical treatments I need to do at home.

"Essentially, the test places patients on a continuum of activation ranging from those who don't see an active role on their part as necessary to those who are highly motivated to take an active role in their own health care," says Skolasky.

The researchers recruited 65 Johns Hopkins patients to participate in the study, funded by the Agency for Healthcare Research and Quality. All underwent their first surgical treatment for a degenerative spine disease between August 2005 and May 2006. Eighty-nine percent were non-Hispanic white and 58 percent were female. The mean age was 58 years old.

Before the surgery, each patient completed a PAM questionnaire. Then, for the next six weeks after surgery, patients recorded how often they attended prescribed physical therapy sessions. After the last therapy session, therapists scored the patients' engagement in physical therapy by rating their attitude, need for prompts, understanding the importance of therapy, and activity during sessions.

Results showed that attendance rose in direct correlation to PAM scores. Patients who had the lowest PAM scores attended 55.6 percent of their therapy sessions. In contrast, those with the highest PAM scores attended physical therapy 94.1 percent of the time. Similarly, engagement scale scores also went up as PAM scores increased.

"These results were very encouraging, and since the PAM is easy to administer, it may provide a practical component to a patient's preoperative treatment," says Skolasky.

Skolasky said that before they can bring the PAM into the examination room, they will need to develop a protocol for improving PAM scores. He and his colleagues are planning a randomized clinical trial in which trained interviewers will meet with patients who score low on the PAM and employ various techniques to improve involvement in their own care. Surgical outcomes for these patients would be compared to outcomes of those who receive standard pre-surgery care.

One area Skolasky plans to focus on is improving communication between patients and doctors. He says patients are sometimes resistant to bring up questions or to discuss problems or symptoms with doctors and instead are more comfortable responding to questions doctors give them. Increasing a patient's knowledge about his or her condition and the steps he or she can take to alleviate symptoms or improve recovery may greatly increase PAM scores, Skolasky notes.

Other researchers from Johns Hopkins who worked on this study include Lee H. Riley, III, M.D., of the Department of Orthopaedic Surgery; Stephen T. Wegener, Ph.D., of the Department of Physical Medicine and Rehabilitation and Ellen J. Mackenzie, Ph.D., of the Department of Health Policy and Management at the Bloomberg School of Public Health.