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Diana Hopkins-Rosseel


I wonder, when you entered your physiotherapy education program were you excited because you were getting the chance to become a behaviourist? Hmmm.


Sure, we were all exposed to Pavlov’s dog, and Classical Conditioning, and B.F. Skinner’s theory of Operant Conditioning along our journey. Or was it on The Big Bang Theory on TV? Here is a great (fun) reminder: How to train a brain: Crash Course in Psychology.

The Big Idea

Do physiotherapists need to use the theories of behavioural change to be effective in their practices? What we need are practical models – the skills to optimize patients’ adoption of our prescriptions.

Take a look at this TEDxBYU broadcast: Change Behaviour – Change the World. The story of the young woman will warm your heart and the studies with the children will make you laugh and think.

I agree with Joseph Grenny that we can change the world if we can change behaviour!

My take on things…

In the early 80’s I worked at the University of Massachusetts Medical Center and had the fortune to spend time with the cardiac rehabilitation team. Even then, and before the research evidence to support it was strong, we used a variety of behavioural therapies ranging from biofeedback through meditation. When I moved back to Canada I jumped in all hands and feet, but as time passed I started to become aware of a phenomenon – the same approach did not garner the same results in every patient. Obvious? Yes. But as a young and naïve therapist, neither the cause nor the solution was jumping out at me.

So I dove in and immersed myself in the problem: what makes rehabilitation successful for the greatest number of individuals? What emerged was the fact that (i) physiotherapists either did not employ behavioural modification techniques, or (ii) we did not publish that we did, but (iii) the research evidence for behaviour techniques as a tool for effective behaviour change was rich. Hmmm.

The predominant model, then and now? James Prochaska and Carlo DiClemente pulled decades of research concepts together into a working model they coined as The Transtheoretical Model of Behavior Change (TTM). You may not recognize that name but I am sure you recognize the common term, ‘the Stages of Change Model’ – they are one in the same! Not only did they build on numerous psychological, sociological & anthropological models of health related change but they went further and built a model that relies on short, reliable, and valid measures of the key constructs.

Behavioural Physiotherapy

Back to physiotherapists … Can we agree that we almost universally recommend to our patients that they add therapeutic exercise and fitness exercises as healthy behaviours to their life? If you look at examples in practice in women’s health, or with children with cerebral palsy, you likely can agree.

And then there are patients given pre- and post-operative joint replacement exercises. Patients want their replacement to leave them pain-free and functional, so why don’t they all adhere to the recommended exercise prescriptions?

What about chronic low back pain? Isn’t this one of our strengths? In Spine (2000), van Tulder et al. concluded in their systematic review  that “Behavioural treatment seems to be an effective treatment for patients with chronic low back pain, but it is still unknown what type of patient benefit most from what type of behavioural treatment.” Interestingly, many of the studies reviewed compared physical therapy (as standard care) to behavioural therapies. This would suggest that there is a perception that PT doesn’t incorporate the principles of behavioural therapy.

So, perhaps we don’t need physiotherapists. We just need phone apps! ScienceDaily asked “Can your smartphone help you exercise?” They quote a study that investigated 100 popular physical activity apps that incorporate behavior change techniques (BCTs) to find out which ones – and which techniques – are most effective for helping users to modify their physical activity. The short answer? “…at present BCTs have been only narrowly implemented in physical activity apps.”

OK, now what? Why not trial incorporating the TTM validated tools into your practice? Measure each individual’s baseline readiness, what process might work best for them and were they likely to avoid their ‘extinguished’ unhealthy behaviour or, harder yet, maintain their new healthy behaviour?

We would need to learn how to use the tools. No problem. The TTM has tools for everything from smoking cessation to domestic violence. Let’s use the ones for exercise adoption:

  • Stages of Change short form (1 item) or continuous measure (24 items) to determine the patient’s readiness for change. [Careful, the short form may overestimate the patient’s stage]
  • Decisional Balance tool (10 items) to know how ready a patient is to exercise or not
  • Processes of Change questionnaire (28 items) to get insights into how to tailor the interventions to the individual’s preferred methods
  • Self-efficacy tool (18 items) to be aware of their perceptions of their ability to change.

A Case

To illustrate how a patient’s scores would influence treatment approach with regard to therapeutic exercise prescription, check out this short case study.

Is Mr. Katz going to be able to adhere to this prescription, including the time it will take from his family and his day? (Read the Case Interpretation)

Absolutely! Mr. Katz’ scores should help him to be successful by directing the PT and the team to move him forward initiating at the best place for him, minimizing his barriers, and using motivators to which he is able to relate.

“Ok, but how long does this take?”

You might be concerned that TTM is time consuming and might make you less efficient in the clinic. We were worried too, so we evaluated how much time it took to fill out the TTM questionnaires. Guess what? We concluded that “The time to complete these 4 questionnaires was less than 10 minutes and therefore this would not be an onerous additional assessment tool in the cardiac rehabilitation setting.” (Read the full paper)


Is this daunting for you? Do you believe you or the profession may wish to focus more on the theories and skills of behaviour modification in your entry-level educational programs?

Share your thoughts with CPA via the CPA Facebook page or on Twitter (#CPA30reps) and with me, Diana, on LinkedIn or Twitter at @DH2450!

Dig Deeper:

If your interest is piqued, you may take a look at some other valuable skills to consider for your practice:

‘The Behavioral Science Guys’ How to Change People Who Don’t Want to Change

Nathan Smith of the University of Birmingham does a good job of helping us understand the Stages of Change model of behaviour change

Conversation Mapping – a great way to work in facilitated groups:

This piece was painted during a three day diabetes convention at the SECC in Glasgow

Grenci, A. Applying New Diabetes Teaching Tools in Health-Related Extension Programming. Journal of Extension, Feb 2010; Vol. 48(1).


About Diana Hopkins-Rosseel

Diana is a Professor at Queen’s University  in the School of Rehabilitation Therapy in Kingston, Ontario. Her research has been primarily in education, behavioural modification and the cardiac rehabilitation paradigm and its outcomes. She has also practiced physiotherapy for 33 years and remains as enthusiastic about the profession now as she was then. After rotating inpatient and outpatient positions in Toronto, Massachusetts and Kingston, she focused on cardiorespiratory physiotherapy and is now certified in Canada as a Clinical Specialist. In 1989 she opened a private cardiac rehabilitation centre in Kingston which is now a provincially funded centre at Hotel Dieu Hospital.


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