Original research| Volume 96, ISSUE 7, P1208-1214, July 2015

Health Behavior Change Counseling in Surgery for Degenerative Lumbar Spinal Stenosis. Part II: Patient Activation Mediates the Effects of Health Behavior Change Counseling on Rehabilitation Engagement

Published:March 28, 2015DOI:



      To determine the effect of health behavior change counseling (HBCC) on patient activation and the influence of patient activation on rehabilitation engagement, and to identify common barriers to engagement among individuals undergoing surgery for degenerative lumbar spinal stenosis.


      Prospective clinical trial.


      Academic medical center.


      Consecutive lumbar spine surgery patients (N=122) defined in our companion article (Part I) were assigned to a control group (did not receive HBCC, n=59) or HBCC group (received HBCC, n=63).


      Brief motivational interviewing–based HBCC versus control (significance, P<.05).

      Main Outcome Measures

      We assessed patient activation before and after intervention. Rehabilitation engagement was assessed using the physical therapist–reported Hopkins Rehabilitation Engagement Rating Scale and by a ratio of self-reported physical therapy and home exercise completion. Common barriers to rehabilitation engagement were identified through thematic analysis.


      Patient activation predicted engagement (standardized regression weight, .682; P<.001). Postintervention patient activation was predicted by baseline patient activation (standardized regression weight, .808; P<.001) and receipt of HBCC (standardized regression weight, .444; P<.001). The effect of HBCC on rehabilitation engagement was mediated by patient activation (standardized regression weight, .079; P=.395). One-third of the HBCC group did not show improvement compared with the control group. Thematic analysis identified 3 common barriers to engagement: (1) low self-efficacy because of lack of knowledge and support (62%); (2) anxiety related to fear of movement (57%); and (3) concern about pain management (48%).


      The influence of HBCC on rehabilitation engagement was mediated by patient activation. Despite improvements in patient activation, one-third of patients reported low rehabilitation engagement. Addressing these barriers should lead to greater improvements in rehabilitation engagement.


      List of abbreviations:

      HBCC (health behavior change counseling), HEP (home exercise program), HRERS (Hopkins Rehabilitation Engagement Rating Scale), MI (motivational interviewing), PT (physical therapy)
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        • Murray C.J.
        • Vos T.
        • Lozano R.
        • et al.
        Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2197-2223
        • Vos T.
        • Flaxman A.D.
        • Naghavi M.
        • et al.
        Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2163-2196
        • Costandi S.
        • Chopko B.
        • Mekhail M.
        • et al.
        Lumbar spinal stenosis: therapeutic options review.
        Pain Pract. 2014; 15: 68-81
        • Deyo R.A.
        • Gray D.T.
        • Kreuter W.
        • et al.
        United States trends in lumbar fusion surgery for degenerative conditions.
        Spine (Phila Pa 1976). 2005; 30: 1441-1445
        • Weinstein J.N.
        • Lurie J.D.
        • Olson P.R.
        • et al.
        United States' trends and regional variations in lumbar spine surgery: 1992–2003.
        Spine (Phila Pa 1976). 2006; 31: 2707-2714
        • Chen E.
        • Tong K.B.
        • Laouri M.
        Surgical treatment patterns among Medicare beneficiaries newly diagnosed with lumbar spinal stenosis.
        Spine J. 2010; 10: 588-594
        • Gibson J.N.
        • Waddell G.
        Surgery for degenerative lumbar spondylosis.
        Cochrane Database Syst Rev. 2005; : CD001352
        • Kreiner D.S.
        • Shaffer W.O.
        • Baisden J.L.
        • et al.
        An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update).
        Spine J. 2013; 13: 734-743
        • Weinstein J.N.
        • Tosteson T.D.
        • Lurie J.D.
        • et al.
        Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial.
        Spine (Phila Pa 1976). 2010; 35: 1329-1338
        • Hagg O.
        • Fritzell P.
        • Ekselius L.
        • et al.
        Predictors of outcome in fusion surgery for chronic low back pain. A report from the Swedish Lumbar Spine Study.
        Eur Spine J. 2003; 12: 22-33
        • Junge A.
        • Frohlich M.
        • Ahrens S.
        • et al.
        Predictors of bad and good outcome of lumbar spine surgery: a prospective clinical study with 2 years' follow-up.
        Spine (Phila Pa 1976). 1996; 21: 1056-1064
        • Mannion A.F.
        • Denzler R.
        • Dvorak J.
        • et al.
        Five-year outcome of surgical decompression of the lumbar spine without fusion.
        Eur Spine J. 2010; 19: 1883-1891
        • Martin B.I.
        • Mirza S.K.
        • Comstock B.A.
        • et al.
        Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures.
        Spine (Phila Pa 1976). 2007; 32: 382-387
        • Hibbard J.H.
        • Tusler M.
        Assessing activation stage and employing a “next steps” approach to supporting patient self-management.
        J Ambul Care Manage. 2007; 30: 2-8
        • Thiboutot J.
        • Sciamanna C.N.
        • Falkner B.
        • et al.
        Effects of a web-based patient activation intervention to overcome clinical inertia on blood pressure control: cluster randomized controlled trial.
        J Med Internet Res. 2013; 15: e158
        • Wilkes M.S.
        • Day F.C.
        • Srinivasan M.
        • et al.
        Pairing physician education with patient activation to improve shared decisions in prostate cancer screening: a cluster randomized controlled trial.
        Ann Fam Med. 2013; 11: 324-334
        • Committee on Quality of Health Care in America, Institute of Medicine
        Crossing the quality chasm: a new health system for the 21st century.
        National Academy Pr, Washington (DC)2001
        • Stewart M.
        Towards a global definition of patient centred care.
        BMJ. 2001; 322: 444-445
        • Wagner E.H.
        • Bennett S.M.
        • Austin B.T.
        • et al.
        Finding common ground: patient-centeredness and evidence-based chronic illness care.
        J Altern Complement Med. 2005; 11: S7-15
        • Skolasky R.L.
        • Mackenzie E.J.
        • Wegener S.T.
        • et al.
        Patient activation and adherence to physical therapy in persons undergoing spine surgery.
        Spine (Phila Pa 1976). 2008; 33: E784-E791
        • Skolasky R.L.
        • Mackenzie E.J.
        • Wegener S.T.
        • et al.
        Patient activation and functional recovery in persons undergoing spine surgery.
        J Bone Joint Surg Am. 2011; 93: 1665-1671
        • Skolasky R.L.
        • Riley III, L.H.
        • Maggard A.M.
        • et al.
        Functional recovery in lumbar spine surgery: a controlled trial of health behavior change counseling to improve outcomes.
        Contemp Clin Trials. 2013; 36: 207-217
        • Bell K.R.
        • Temkin N.R.
        • Esselman P.C.
        • et al.
        The effect of a scheduled telephone intervention on outcome after moderate to severe traumatic brain injury: a randomized trial.
        Arch Phys Med Rehabil. 2005; 86: 851-856
        • Bombardier C.H.
        • Cunniffe M.
        • Wadhwani R.
        • et al.
        The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial.
        Arch Phys Med Rehabil. 2008; 89: 1849-1856
        • Hibbard J.H.
        • Mahoney E.R.
        • Stockard J.
        • et al.
        Development and testing of a short form of the Patient Activation Measure.
        Health Serv Res. 2005; 40: 1918-1930
        • Skolasky R.L.
        • Mackenzie E.J.
        • Riley III, L.H.
        • et al.
        Psychometric properties of the Patient Activation Measure among individuals presenting for elective lumbar spine surgery.
        Qual Life Res. 2009; 18: 1357-1366
        • Kortte K.B.
        • Falk L.D.
        • Castillo R.C.
        • et al.
        The Hopkins Rehabilitation Engagement Rating Scale: development and psychometric properties.
        Arch Phys Med Rehabil. 2007; 88: 877-884
        • Li S.D.
        Testing mediation using multiple regression and structural equation modeling analyses in secondary data.
        Eval Rev. 2011; 35: 240-268
        • Bentler P.M.
        • Chou C.P.
        Practical issues in structural modeling.
        Sociol Methods Res. 1987; 16: 78-117
        • Stevens J.
        Applied multivariate statistics for the social sciences.
        Lawrence Erlbaum Associates, Hillsdale1986
        • Wolf E.J.
        • Harrington K.M.
        • Clark S.L.
        • et al.
        Sample size requirements for structural equation models: an evaluation of power, bias, and solution propriety.
        Educ Psychol Meas. 2013; 73: 913-934
        • Bentler P.M.
        • Bonett D.G.
        Significance tests and goodness-of-fit in the analysis of covariance structures.
        Psychol Bull. 1980; 88: 588-606
        • Bentler P.M.
        Comparative fit indexes in structural models.
        Psychol Bull. 1990; 107: 238-246
        • Braun V.
        • Clarke V.
        Using thematic analysis in psychology.
        Qual Res Psychol. 2006; 3: 77-101
        • Green J.
        • Thorogood N.
        Analysing qualitative data.
        in: Qualitative methods for health research. Sage Publications, London2006: 173-200
        • Hibbard J.H.
        • Stockard J.
        • Mahoney E.R.
        • et al.
        Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers.
        Health Serv Res. 2004; 39: 1005-1026
        • Hibbard J.H.
        • Cunningham P.J.
        How engaged are consumers in their health and health care, and why does it matter?.
        Res Brief. 2008; 8: 1-9
        • Mosen D.M.
        • Schmittdiel J.
        • Hibbard J.
        • et al.
        Is patient activation associated with outcomes of care for adults with chronic conditions?.
        J Ambul Care Manage. 2007; 30: 21-29
        • Crombez G.
        • Vlaeyen J.W.
        • Heuts P.H.
        • et al.
        Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability.
        Pain. 1999; 80: 329-339
        • Verbunt J.A.
        • Seelen H.A.
        • Vlaeyen J.W.
        • et al.
        Fear of injury and physical deconditioning in patients with chronic low back pain.
        Arch Phys Med Rehabil. 2003; 84: 1227-1232
        • den Boer J.J.
        • Oostendorp R.A.
        • Beems T.
        • et al.
        Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors.
        Pain. 2006; 123: 45-52
        • Archer K.R.
        • Wegener S.T.
        • Seebach C.
        • et al.
        The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions.
        Spine (Phila Pa 1976). 2011; 36: 1554-1562
        • Butler A.C.
        • Chapman J.E.
        • Forman E.M.
        • et al.
        The empirical status of cognitive-behavioral therapy: a review of meta-analyses.
        Clin Psychol Rev. 2006; 26: 17-31
        • van Tulder M.W.
        • Ostelo R.
        • Vlaeyen J.W.
        • et al.
        Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group.
        Spine (Phila Pa 1976). 2000; 25: 2688-2699
        • Bodenheimer T.
        • Lorig K.
        • Holman H.
        • et al.
        Patient self-management of chronic disease in primary care.
        JAMA. 2002; 288: 2469-2475
        • Nicholas M.K.
        • Asghari A.
        • Corbett M.
        • et al.
        Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain?.
        Eur J Pain. 2012; 16: 93-104
        • Bossen D.
        • Veenhof C.
        • Dekker J.
        • et al.
        The effectiveness of self-guided web-based physical activity interventions among patients with a chronic disease: a systematic review.
        J Phys Act Health. 2014; 11: 665-677
        • Connelly J.
        • Kirk A.
        • Masthoff J.
        • et al.
        The use of technology to promote physical activity in type 2 diabetes management: a systematic review.
        Diabet Med. 2013; 30: 1420-1432
        • Irvine A.B.
        • Gelatt V.A.
        • Seeley J.R.
        • et al.
        Web-based intervention to promote physical activity by sedentary older adults: randomized controlled trial.
        J Med Internet Res. 2013; 15: e19
        • Prince S.A.
        • Adamo K.B.
        • Hamel M.E.
        • et al.
        A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review.
        Int J Behav Nutr Phys Act. 2008; 5: 56
        • Miller W.R.
        • Rollnick S.
        Motivational interviewing. Preparing people for change.
        2nd ed. Guilford Pr, New York2002
        • Miller W.R.
        • Rollnick S.
        Motivational interviewing. Helping people change.
        3rd ed. Guilford Pr, New York2013
        • Rollnick S.
        • Butler C.C.
        • Stott N.
        Helping smokers make decisions: the enhancement of brief intervention for general medical practice.
        Patient Educ Couns. 1997; 31: 191-203
        • Harland J.
        • White M.
        • Drinkwater C.
        • et al.
        The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care.
        BMJ. 1999; 319: 828-832
        • Smith D.E.
        • Heckemeyer C.M.
        • Kratt P.P.
        • et al.
        Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM. A pilot study.
        Diabetes Care. 1997; 20: 52-54
        • Alegria M.
        • Polo A.
        • Gao S.
        • et al.
        Evaluation of a patient activation and empowerment intervention in mental health care.
        Med Care. 2008; 46: 247-256
        • Morisky D.E.
        • Bowler M.H.
        • Finlay J.S.
        An educational and behavioral approach toward increasing patient activation in hypertension management.
        J Community Health. 1982; 7: 171-182
        • Wegener S.T.
        • Mackenzie E.J.
        • Ephraim P.
        • et al.
        Self-management improves outcomes in persons with limb loss.
        Arch Phys Med Rehabil. 2009; 90: 373-380
        • Williams G.C.
        • McGregor H.
        • Zeldman A.
        • et al.
        Promoting glycemic control through diabetes self-management: evaluating a patient activation intervention.
        Patient Educ Couns. 2005; 56: 28-34
        • Miller W.R.
        • Yahne C.E.
        • Moyers T.B.
        • et al.
        A randomized trial of methods to help clinicians learn motivational interviewing.
        J Consult Clin Psychol. 2004; 72: 1050-1062