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

Abstract Objective 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. Design Prospective clinical trial. Setting Academic medical center. Participants 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). Intervention 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. Results 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%). Conclusions 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.