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," said Richard L.
Skolasky, of the
Department of Orthopaedic
Surgery at the Johns Hopkins 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 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 Patient Activation Measure, 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
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," Skolasky said.
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, 58 percent were female, and 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
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 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,"
Skolasky said that before they can bring the PAM into
the examination room, they will need to
develop a protocol for improving 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
One area on which Skolasky plans to focus is improving
communication between patients and
doctors. Patients, he said, are sometimes resistant to
bringing up questions or to discussing 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 to improve recovery may greatly
increase PAM scores, Skolasky noted.
Other Johns Hopkins researchers who worked on this
study are Lee H. Riley III, Department
of Orthopaedic Surgery; Stephen T. Wegener, Department of
Physical Medicine and Rehabilitation at
the School of Medicine; and Ellen J. Mackenzie, Department
of Health Policy and Management at the
Bloomberg School of Public Health.