Lifestyle- and behaviour-change interventions in musculoskeletal conditions




Abstract


This review discusses several health behaviours associated with the progression and impact of osteoarthritis (OA) and rheumatoid arthritis (RA), including weight management, physical activity, medication adherence and smoking. An overview of current theories of behaviour-change is provided in terms of principles that can guide medical practice. Finally, evaluation studies of interventions targeting weight loss, physical activity and medication adherence in patients with OA or RA are presented and discussed. Of existing behaviour-change interventions in this population, few have taken a comprehensive theory-based approach to behaviour-change. Practitioners who provide lifestyle or behavioural advice to patients would do well to adopt a less prescriptive and more patient-centred approach in which they, or other health professionals to whom they refer the patient, assist the patient in formulating personal change goals, in translating good intentions into specific action plans and in closely monitoring their progress towards self-chosen goals.


Many chronic diseases are closely linked to health behaviours such as an unhealthy diet, lack of physical activity (PA), smoking, alcohol and drug abuse and non-adherence to prescribed medication regimens . This chapter reviews the associations between health behaviours and lifestyle factors and outcomes within osteoarthritis (OA) and rheumatoid arthritis (RA). We will first discuss several health behaviours and lifestyle factors related to the onset or outcome of these illnesses. We then provide an overview of the theory behind effective behaviour-change, highlighting the steps necessary for practitioners wishing to help patients change their behaviour. Finally, we assess recent interventions that target changes in health behaviours and lifestyle factors in patients with OA or RA, examine the success of these interventions and the extent to which researchers applied behaviour-change theories.


Health behaviours and lifestyle factors important in OA and RA


Osteoarthritis


OA is the most common musculoskeletal disease, and is the most prevalent chronic illness among individuals over the age of 65 years. OA is a chronic and progressive joint disease resulting in loss of articular cartilage, a process which can be exacerbated by activities or situations that place joints under extra stress and use of joints while poorly aligned . Elimination of such activities or situations may therefore be useful in preventing, alleviating and slowing OA progression. We have therefore identified two key lifestyle factors related to outcomes in OA: weight management and PA.


Weight management


Individuals who are overweight or obese place their joints under greater strain than their normal-weight counterparts, and are roughly 2–4 times more likely to develop OA . Weight reduction is advisable as a secondary prevention strategy for persons who are overweight, and as a tertiary intervention among overweight individuals with OA. Several studies have investigated the effects of weight loss on joint loadings among individuals with OA. For example, Aaboe and colleagues demonstrated that a 1-kg reduction in body weight can result in a 2.2-kg reduction in knee joint loading, indicating that losing 1 kg may have a protective effect 120% greater than expected .


Weight reduction also reduces pain and improves function among obese and overweight individuals with OA. Christensen and colleagues demonstrated that a 10% reduction in weight could produce a 28% improvement in functional ability , and at least three studies have demonstrated an association between weight loss and pain reduction within this population .


PA and pacing


PA is related to numerous outcomes in OA, and certain forms of PA are related to an increased incidence of OA. For example, individuals whose occupation required excessive kneeling, squatting or lifting were 2.6 times more likely to develop OA, as were those who had suffered previous knee trauma . Although these strenuous activities appear related to an increased rate of developing OA, light-to-moderate forms of PA carry no extra risk of developing OA , and aerobic and water-based activities are related to improved outcomes in OA . Furthermore, individuals with OA who are more physically active appear to maintain their functional ability over time better than their less-active counterparts . For these reasons, PA is likely worth targeting among individuals with OA. When doing so however, it is important that individuals be taught to pace themselves when starting new PA regimens. As prolonged periods of activity can exacerbate symptoms of pain and fatigue among individuals with OA, planning alternating periods of rest and PA, and breaking large tasks down into smaller, more manageable tasks might help to reduce or prevent these symptoms .


Rheumatoid arthritis


RA is a chronic, progressive inflammatory condition typified by painful, tender and swollen joints, stiffness and fatigue. Over time, RA can progress, and tends to cause deficits in functional ability (disability). To slow disease progression, treatment with disease-modifying anti-rheumatic drugs (DMARDs) typically begins shortly after RA diagnosis, and patients often use non-steroidal anti-inflammatory drugs to alleviate pain and swelling. Furthermore, patients with RA are 50% more likely to die from cardiovascular disease (CVD) than individuals from the general population , indicating that clinicians should place an increased emphasis on changing behaviours and lifestyle factors associated with CVD risk, such as PA and smoking cessation . As fatigue is also burdensome for individuals with RA, sleep maintenance may also be an important target for clinicians.


Medication adherence


As stated, medication regimens typically begin shortly after one receives a diagnosis with RA. DMARD therapy is continually improving, but to provide their maximum benefit, administration should be regular and consistent. Recent research indicates that non-adherence to DMARD regimens has the potential to increase disease progression and that adherence may be the primary determinant of treatment effectiveness . With adherence to DMARD regimens reportedly no higher than 73% , improvements in adherence appear a likely target for clinicians looking to ensure optimal effectiveness of pharmacological treatments for RA.


PA and pacing


Since the appearance of research demonstrating the apparent safety of PA for individuals with RA, regular, moderate-intensity PA has been a recommended part of treatment for RA . PA not only increases muscle strength and aerobic capacity, but may also act to reduce the risk of CVD incidence . Despite the benefits of PA for individuals with RA, a large percentage of RA patients do not meet recommended PA guidelines. In fact, fewer than 50% of individuals meet the recommended PA level of 30 min, 5 days a week . Increasing PA among inactive individuals with RA may help to maintain patient independence and limit functional declines. As previously described among individuals with OA, pacing of activities may also play a role in the prevention of fatigue among these individuals .


Smoking


Cigarette smoking appears to be related to the onset of RA, with smokers roughly 1.8 times more likely to develop RA than non-smokers . In addition, there is some evidence that smoking interacts with genetic markers in predicting a worse prognosis in RA . Because of the increased incidence of and mortality from cardiac events among individuals with RA, and the link between smoking and CVD risk, smoking cessation has been recommended by the European League Against Rheumatism as a target of standard CVD risk reduction in this population .


Sleep


Fatigue, a chief complaint among individuals with RA, is associated with disturbances in sleep patterns. Although evidence exists that demonstrates improvements in sleep following cognitive behaviour therapy, sleep is a complex entity that involves multiple behaviours, and is therefore beyond the scope of this review. For a detailed review on sleep within patients with rheumatic disease, please see Abad et al. (2008) .




The theoretical basis of interventions to change health behaviours and lifestyle factors


While there is a growing body of evidence suggesting that simply providing patients with information and advice or using fear-arousing communications does not relate to beneficial health behaviour-change in patients, many health professionals are not aware of more effective ways to influence relevant health behaviours in patients. As it would go far beyond the scope of this chapter to describe all existing health behaviour (change) theories, we will rather organise the existing theoretical knowledge around a few basic principles.


First of all, while many patients may be relatively passive in a consulting room, to succeed in health behaviour-change, they need to be active, vigilant, decision makers . In other words, self-management of important illness-related issues such as taking medication, lifestyle changes, health-care visits or undertaking preventive actions is the key to success. Self-management can be described as “an individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition” . While self-management involves more than health behaviour-change alone, this definition clearly illustrates that a “we will do it for you” approach is not congruent with current insights regarding the management of chronic illness. The shift from a passive role of the individual within the health-care system towards a more independent, self-determining position is reflected in the development of terminology over the last decades. Descriptions of what the patient must do have evolved from “compliance with medical regimens,” reflecting obedience to medical advice, to “adherence,” which suggests adoption of medical advice, to “self-management,” which stresses the responsibility and relative autonomy of the patient in the disease-management process.


Self-management is however complex and implies a gradual learning process that should be guided by supportive interventions. In the following, we describe and explain three basic principles for such interventions: (1) health behaviour-change occurs in stages and interventions should be tailored to these stages; (2) health behaviour (change) is controlled by several underlying mechanisms and interventions that target these mechanisms are likely to be the most effective; and (3) self-management is an active process, determined by several self-regulation cognitions and skills that should be enhanced by interventions.


Health behaviour-change occurs in stages


The acquisition of most health behaviours such as becoming physically active, healthy eating, losing weight or taking prescribed medication does not occur from one moment to another. According to the Transtheoretical Model , behaviour-change is seen as a process involving progress through a series of six stages. While the existence of these stages is confirmed by many empirical studies, it is current practice to discern at least three stages of change within interventions: (a) a motivational phase (people need to be motivated to take action); (b) an action stage (people need guidance and support when they are involved in an active behavioural-change process); and (c) a maintenance or disengagement stage (people need support to prevent relapse and modify their self-management trajectories). Interventions should thus be tailored to the stage that characterises the patient: the unmotivated should be motivated, the motivated should be offered specific change programmes and the ones who followed such programmes should receive support to be persistent in their efforts to prevent relapse and adjust course and reformulate goals when necessary.


Behaviour-change is controlled by underlying mechanisms


While many health behaviour (change) models such as the Health Belief Model , the Theory of Planned Behaviour and Protection Motivation Theory have been used to explain and instigate health behaviour-change, they focus especially on cognitive factors and processes as determinants of change. The conceptual viewpoint stressed by these models suggests that humans are rational, and that decisions are mainly taken on the basis of perceived advantages or disadvantages of certain actions. However, additional research has shown that other factors and mechanisms play an equally important role in health behaviour-change .


The following additional mechanisms of behaviour-change have been identified: (1) social control, implying that behaviour (change) results from coping with social demands (if a behaviour is valued by their health-care providers, family and friends, patients will more easily engage in that behaviour); (2) emotional or stress control, meaning that (opposition to) behavioural-change can be a consequence of stress regulation (if a behaviour interferes with valued personal activities such as relaxing, spending time with important others or watching TV, and thus negatively affects an individual’s well-being, he or she will be less likely to persist with the behaviour); (3) symptom-related control, implying that symptoms or sensations are signs of illness threats, which have strong influences on behaviour (if symptoms disappear, patients might stop taking medications, and when they reappear, they might discontinue PA if it is perceived to increase pain or fatigue); and (4) conceptual control, implying that commitments to specific beliefs control health and risk behaviours (if patients believe that a behaviour will reduce pain over time and prevent disability, they are more likely to begin and maintain this behaviour).


Effective behaviour-change programmes should take into account all four underlying mechanisms, which is more difficult than one might think. For example, not all rheumatologists believe that promoting PA among patients with rheumatic disease is defendable , while others believe that giving advice on weight reduction or smoking cessation is not their responsibility, but rather that these tasks are better left to physical therapists, dieticians or psychologists. In addition, patients’ partners are frequently not included in decision-making processes to start and maintain behaviour-change, thus excluding an important source of patient support . Furthermore, patients may have needs or other valued activities that interfere or conflict with PA, diet or medication adherence. Even though such conflicts are an important source of relapse and despite the fact that there are ways to explore these issues , competing or conflicting goals are seldom recognised during lifestyle programmes. Finally, existing behaviour programmes are often offered to all patients without assessing whether they really believe in the efficacy and beneficial outcomes of the programmes.


Effective intervention techniques to support self-management


Taking into account the fact that health behaviour-change occurs in stages, and that behaviour-change is controlled by at least four underlying mechanisms, we now address how health professionals can support self-management or self-regulation in their patients. Self-management interventions (SMIs) are problem-focussed, action-oriented and emphasise patient-generated care plans . Ideal SMIs include a motivational, an action and a maintenance phase, address social, emotional, symptom-related and cognitive determinants of change, and facilitate the acquisition of specific self-regulation skills by the patients.


Motivation and intention formation


During the motivational stage of an SMI, patients’ intrinsic or autonomous motivation for change should be increased. Deci and Ryan make a clear distinction between autonomous and controlled behaviour regulation in their Self-Determination Theory . Autonomous regulation occurs when a (change) goal is of personal importance. Controlled regulation occurs when people feel coerced or pressured to attain a goal by external or internal forces. Empirical evidence supports that autonomous motivation is an important predictor of health behaviour-change and maintenance . The development of autonomous regulation may however require support from health-care providers. A specific method to increase and support autonomous regulation in patients is motivational interviewing. The health professional’s role in motivational interviewing is to elicit the patient’s ideas about how, why and if change should occur, assuming that the patient already has the knowledge and resources needed to bring about change, and to affirm the patient’s choice in the matter . Information and advice should only be offered when the patient wants it (avoiding the expert role), but empathy and understanding should be expressed throughout. This set of techniques is difficult to master, but it can be implemented in health-care settings, even when time is limited. For a practical guide of how this can be done, please see Rollnick et al. (2008) .


Goal setting is another important issue during a motivational stage. Numerous studies on goal setting have demonstrated that, to improve performance, goals should follow the SMART principles (i.e., specific, measurable, achievable, relevant, time-limited) .


Active goal pursuit


Stimulating autonomous motivation and setting a well-defined goal are a good start, but are not sufficient to bridge the gap between cognition and action. Research indicates that the formation of specific action plans, also called implementation intentions, explain this transition. Such an intention is characterised by the thought “I intend to do x, when situation y is encountered” . Individuals should thus reflect on when, where, how and with whom to act, thus creating specific plans for action. This process extends across all health behaviours and lifestyle factors mentioned earlier. Without such a plan, good intentions are rarely put into action .


Once a patient has begun pursuing his or her goals, feedback and feedforward processes are important predictors of success. The provision of feedback on goal progress is crucial for goal attainment. This feedback can initially be provided by a health professional, but is optimally a task for the patient. Checking and controlling one’s own progress towards a specific observable goal is called self-monitoring, and this can be done with a diary of medication taking or by using devices such as pedometers and accelerometers to monitor PA levels. Self-monitoring also serves to focus an individual’s attention on the behaviour in question.


Bandura has repeatedly stressed that feedforward or anticipatory mechanisms are equally important . He distinguished between two types of feedforward mechanisms: efficacy beliefs and outcome expectancies. Outcome expectancies reflect an individual’s belief that a specific behaviour will lead to particular outcomes. Behaviours associated with highly valued outcomes will more likely be undertaken. Efficacy beliefs refer to the belief that one is capable of executing the behaviours necessary to produce these outcomes. Efficacy beliefs determine whether people will invest effort, and how long they will persist in this effort in the face of obstacles and aversive experiences. Efficacy beliefs (commonly referred to as self-efficacy) can be increased by successful performance of the behaviour, by observation of successful others, by verbal persuasion or by successfully overcoming stressful or taxing situations . Patients’ interactions with health professionals can have great influence on their sense of efficacy, in either a beneficial or a detrimental way.


Control processes also play an important role in successful goal pursuit. These include attention control (focussing on goal-related rather than on distracting information), emotion control (disengaging from negative mood if it interferes with goal pursuit), motivation control (enhancing the attractiveness of the goal) and coping with failure (using failure as an opportunity for learning rather than as a source of discouragement). Helping patients to exercise these forms of control on goal pursuit can improve the efficacy of SMIs in changing behaviour.


Maintenance and disengagement


In the final maintenance and disengagement stage, self-efficacy (confidence to overcome obstacles and maintain behaviour), social support (from health professionals, friends and partners), satisfaction with the behaviour-change and ownership (attributing the change to your own doing) are important. If a current behavioural goal cannot be attained, patients should be supported to modify the goal into a more manageable goal that enhances the likelihood of goal achievement .


Among the existing SMIs, the Arthritis Self-Management Program (ASMP) that includes weekly exercise practice (stretching, strength and walking) includes most of these aforementioned insights. A recent review showed that the ASMP and similar programmes are indeed the most effective at reducing pain and improving physical and social functioning . Various iterations of the ASMP have some commonalities: duration of at least 6 weeks, explicit use of most of the self-regulation cognitions and skills described above, individualised weekly action plans with progress review and distribution of participant handbooks. Most trials of the ASMP have been conducted with volunteers, or in other words, with patients who are motivated to change. Further research is needed to appropriately target interventions to the needs of less-motivated patient groups, and to identify which patient attributes are related to better outcomes.


Having discussed the necessary components of interventions to change health behaviours and lifestyle factors in general, we now shift our focus toward specific interventions that have targeted health behaviours and lifestyle factors important to outcomes in OA and RA.




The theoretical basis of interventions to change health behaviours and lifestyle factors


While there is a growing body of evidence suggesting that simply providing patients with information and advice or using fear-arousing communications does not relate to beneficial health behaviour-change in patients, many health professionals are not aware of more effective ways to influence relevant health behaviours in patients. As it would go far beyond the scope of this chapter to describe all existing health behaviour (change) theories, we will rather organise the existing theoretical knowledge around a few basic principles.


First of all, while many patients may be relatively passive in a consulting room, to succeed in health behaviour-change, they need to be active, vigilant, decision makers . In other words, self-management of important illness-related issues such as taking medication, lifestyle changes, health-care visits or undertaking preventive actions is the key to success. Self-management can be described as “an individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition” . While self-management involves more than health behaviour-change alone, this definition clearly illustrates that a “we will do it for you” approach is not congruent with current insights regarding the management of chronic illness. The shift from a passive role of the individual within the health-care system towards a more independent, self-determining position is reflected in the development of terminology over the last decades. Descriptions of what the patient must do have evolved from “compliance with medical regimens,” reflecting obedience to medical advice, to “adherence,” which suggests adoption of medical advice, to “self-management,” which stresses the responsibility and relative autonomy of the patient in the disease-management process.


Self-management is however complex and implies a gradual learning process that should be guided by supportive interventions. In the following, we describe and explain three basic principles for such interventions: (1) health behaviour-change occurs in stages and interventions should be tailored to these stages; (2) health behaviour (change) is controlled by several underlying mechanisms and interventions that target these mechanisms are likely to be the most effective; and (3) self-management is an active process, determined by several self-regulation cognitions and skills that should be enhanced by interventions.


Health behaviour-change occurs in stages


The acquisition of most health behaviours such as becoming physically active, healthy eating, losing weight or taking prescribed medication does not occur from one moment to another. According to the Transtheoretical Model , behaviour-change is seen as a process involving progress through a series of six stages. While the existence of these stages is confirmed by many empirical studies, it is current practice to discern at least three stages of change within interventions: (a) a motivational phase (people need to be motivated to take action); (b) an action stage (people need guidance and support when they are involved in an active behavioural-change process); and (c) a maintenance or disengagement stage (people need support to prevent relapse and modify their self-management trajectories). Interventions should thus be tailored to the stage that characterises the patient: the unmotivated should be motivated, the motivated should be offered specific change programmes and the ones who followed such programmes should receive support to be persistent in their efforts to prevent relapse and adjust course and reformulate goals when necessary.


Behaviour-change is controlled by underlying mechanisms


While many health behaviour (change) models such as the Health Belief Model , the Theory of Planned Behaviour and Protection Motivation Theory have been used to explain and instigate health behaviour-change, they focus especially on cognitive factors and processes as determinants of change. The conceptual viewpoint stressed by these models suggests that humans are rational, and that decisions are mainly taken on the basis of perceived advantages or disadvantages of certain actions. However, additional research has shown that other factors and mechanisms play an equally important role in health behaviour-change .


The following additional mechanisms of behaviour-change have been identified: (1) social control, implying that behaviour (change) results from coping with social demands (if a behaviour is valued by their health-care providers, family and friends, patients will more easily engage in that behaviour); (2) emotional or stress control, meaning that (opposition to) behavioural-change can be a consequence of stress regulation (if a behaviour interferes with valued personal activities such as relaxing, spending time with important others or watching TV, and thus negatively affects an individual’s well-being, he or she will be less likely to persist with the behaviour); (3) symptom-related control, implying that symptoms or sensations are signs of illness threats, which have strong influences on behaviour (if symptoms disappear, patients might stop taking medications, and when they reappear, they might discontinue PA if it is perceived to increase pain or fatigue); and (4) conceptual control, implying that commitments to specific beliefs control health and risk behaviours (if patients believe that a behaviour will reduce pain over time and prevent disability, they are more likely to begin and maintain this behaviour).


Effective behaviour-change programmes should take into account all four underlying mechanisms, which is more difficult than one might think. For example, not all rheumatologists believe that promoting PA among patients with rheumatic disease is defendable , while others believe that giving advice on weight reduction or smoking cessation is not their responsibility, but rather that these tasks are better left to physical therapists, dieticians or psychologists. In addition, patients’ partners are frequently not included in decision-making processes to start and maintain behaviour-change, thus excluding an important source of patient support . Furthermore, patients may have needs or other valued activities that interfere or conflict with PA, diet or medication adherence. Even though such conflicts are an important source of relapse and despite the fact that there are ways to explore these issues , competing or conflicting goals are seldom recognised during lifestyle programmes. Finally, existing behaviour programmes are often offered to all patients without assessing whether they really believe in the efficacy and beneficial outcomes of the programmes.


Effective intervention techniques to support self-management


Taking into account the fact that health behaviour-change occurs in stages, and that behaviour-change is controlled by at least four underlying mechanisms, we now address how health professionals can support self-management or self-regulation in their patients. Self-management interventions (SMIs) are problem-focussed, action-oriented and emphasise patient-generated care plans . Ideal SMIs include a motivational, an action and a maintenance phase, address social, emotional, symptom-related and cognitive determinants of change, and facilitate the acquisition of specific self-regulation skills by the patients.


Motivation and intention formation


During the motivational stage of an SMI, patients’ intrinsic or autonomous motivation for change should be increased. Deci and Ryan make a clear distinction between autonomous and controlled behaviour regulation in their Self-Determination Theory . Autonomous regulation occurs when a (change) goal is of personal importance. Controlled regulation occurs when people feel coerced or pressured to attain a goal by external or internal forces. Empirical evidence supports that autonomous motivation is an important predictor of health behaviour-change and maintenance . The development of autonomous regulation may however require support from health-care providers. A specific method to increase and support autonomous regulation in patients is motivational interviewing. The health professional’s role in motivational interviewing is to elicit the patient’s ideas about how, why and if change should occur, assuming that the patient already has the knowledge and resources needed to bring about change, and to affirm the patient’s choice in the matter . Information and advice should only be offered when the patient wants it (avoiding the expert role), but empathy and understanding should be expressed throughout. This set of techniques is difficult to master, but it can be implemented in health-care settings, even when time is limited. For a practical guide of how this can be done, please see Rollnick et al. (2008) .


Goal setting is another important issue during a motivational stage. Numerous studies on goal setting have demonstrated that, to improve performance, goals should follow the SMART principles (i.e., specific, measurable, achievable, relevant, time-limited) .


Active goal pursuit


Stimulating autonomous motivation and setting a well-defined goal are a good start, but are not sufficient to bridge the gap between cognition and action. Research indicates that the formation of specific action plans, also called implementation intentions, explain this transition. Such an intention is characterised by the thought “I intend to do x, when situation y is encountered” . Individuals should thus reflect on when, where, how and with whom to act, thus creating specific plans for action. This process extends across all health behaviours and lifestyle factors mentioned earlier. Without such a plan, good intentions are rarely put into action .


Once a patient has begun pursuing his or her goals, feedback and feedforward processes are important predictors of success. The provision of feedback on goal progress is crucial for goal attainment. This feedback can initially be provided by a health professional, but is optimally a task for the patient. Checking and controlling one’s own progress towards a specific observable goal is called self-monitoring, and this can be done with a diary of medication taking or by using devices such as pedometers and accelerometers to monitor PA levels. Self-monitoring also serves to focus an individual’s attention on the behaviour in question.


Bandura has repeatedly stressed that feedforward or anticipatory mechanisms are equally important . He distinguished between two types of feedforward mechanisms: efficacy beliefs and outcome expectancies. Outcome expectancies reflect an individual’s belief that a specific behaviour will lead to particular outcomes. Behaviours associated with highly valued outcomes will more likely be undertaken. Efficacy beliefs refer to the belief that one is capable of executing the behaviours necessary to produce these outcomes. Efficacy beliefs determine whether people will invest effort, and how long they will persist in this effort in the face of obstacles and aversive experiences. Efficacy beliefs (commonly referred to as self-efficacy) can be increased by successful performance of the behaviour, by observation of successful others, by verbal persuasion or by successfully overcoming stressful or taxing situations . Patients’ interactions with health professionals can have great influence on their sense of efficacy, in either a beneficial or a detrimental way.


Control processes also play an important role in successful goal pursuit. These include attention control (focussing on goal-related rather than on distracting information), emotion control (disengaging from negative mood if it interferes with goal pursuit), motivation control (enhancing the attractiveness of the goal) and coping with failure (using failure as an opportunity for learning rather than as a source of discouragement). Helping patients to exercise these forms of control on goal pursuit can improve the efficacy of SMIs in changing behaviour.


Maintenance and disengagement


In the final maintenance and disengagement stage, self-efficacy (confidence to overcome obstacles and maintain behaviour), social support (from health professionals, friends and partners), satisfaction with the behaviour-change and ownership (attributing the change to your own doing) are important. If a current behavioural goal cannot be attained, patients should be supported to modify the goal into a more manageable goal that enhances the likelihood of goal achievement .


Among the existing SMIs, the Arthritis Self-Management Program (ASMP) that includes weekly exercise practice (stretching, strength and walking) includes most of these aforementioned insights. A recent review showed that the ASMP and similar programmes are indeed the most effective at reducing pain and improving physical and social functioning . Various iterations of the ASMP have some commonalities: duration of at least 6 weeks, explicit use of most of the self-regulation cognitions and skills described above, individualised weekly action plans with progress review and distribution of participant handbooks. Most trials of the ASMP have been conducted with volunteers, or in other words, with patients who are motivated to change. Further research is needed to appropriately target interventions to the needs of less-motivated patient groups, and to identify which patient attributes are related to better outcomes.


Having discussed the necessary components of interventions to change health behaviours and lifestyle factors in general, we now shift our focus toward specific interventions that have targeted health behaviours and lifestyle factors important to outcomes in OA and RA.

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Nov 11, 2017 | Posted by in RHEUMATOLOGY | Comments Off on Lifestyle- and behaviour-change interventions in musculoskeletal conditions

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