In the management of neurological conditions, rehabilitation clinicians place a substantial emphasis on the importance of a home exercise program. A well-developed and supported plan or prescription for exercise that supplements ongoing care and/or continues beyond discharge facilitates optimal functional outcomes. However, it remains a major assumption that patients will adhere to exercise prescription, and that they will make and truly maintain the recommended health behavior change. In this issue of JNPT Moren and colleagues1 investigate the effects of physical activity prescription (PaP) on the health behavior change of time spent during "moderately vigorous physical activity" and subsequent physical capacity. Their use of quantitative metrics underscores the quality of the investigation, and stands out from the literature that is dominated by patient-reported outcomes. For this reason, it offers potent information for clinicians as they consider patient adherence to prescribed home exercises, or more generally, the capability to initiate and maintain a health behavior change.

In the study by Moren et al,1 88 individuals who had a transient ischemic attack were randomized to 1 of 2 groups. Both groups received verbal and written information regarding risk factors for stroke. The experimental group also received a patient-centered prescription for physical activity that included instruction on the rationale for increasing physical activity and focused on 1 or 2 activities related to the patient's goals. Most frequently, these activities were variations of walking. Physical activity and capacity were measured using accelerometry and 6-minute walk test, respectively, at 2 weeks, 3 months, and 6 months after discharge. Time spent during moderately vigorous physical activity was quantified on the basis of established count-rate thresholds from the accelerometry data. In contrast to prior related work that relied on patient-reported outcomes, the current investigation found no significant differences between groups on physical activity at any time point, indicating that patients did not successfully change their health behaviors and increase physical activity in response to the PaP. The only significant difference between groups was for physical capacity at 6 months. However, the authors interpreted the difference to be miniscule, and therefore of questionable clinical meaningfulness.

In translating the results of the article by Moren et al1 to practice, clinicians must acknowledge that, even with patient education on the importance of increasing physical activity, and a PaP customized to patient-specific goals, patients may be no more likely to change their health behaviors than those without a patient-centered PaP. As therapists, we may be assuming that our patients are adhering to their home exercise programs. However, the data from this article suggest otherwise. Considering that the home exercise program is critical to restoration of function and our efforts in promoting it are diligent, it is possible that our approach to facilitate a successful change in health behavior is incomplete. Going forward, it is imperative that we find a way to assist our patients in making and maintaining a health behavior change, whether it be a general PaP as described by Moren et al1 or a highly specified home exercise program. Literature on health behavior change in the field of rehabilitation psychology may offer solutions.

It is valuable to consider the evidence that supports our approach to delivering our prescriptions and home exercise programs to our patients. Although it may not be immediately considered as such, the use of patient education to explain, support, and facilitate adherence to a home exercise program is in fact an intervention. And, it is suggested that better interventions are needed to improve adherence.2 The Health Action Process Approach2 is a model that clinicians may consider as they develop a plan for facilitating health behavior change such as adhering to a home exercise program. The model offers a continuum of cognitive processes that an individual goes through, specifically delineating aspects of motivation/intention to make a change and volition/action to undertake and maintain a change.

It seems likely that rehabilitation clinicians excel in the motivation/intention stage of the model that includes the processes of risk perception, outcome expectancies, and task self-efficacy. We likely address these processes in our patient education as we provide information on risks of inactivity and benefits of exercise, and provide encouragement and build confidence in the home exercise program. However, we may be less effective in the volitional/action stage of the model that includes processes of planning, action control, and maintenance/recovery self-efficacy.

Moren et al1 did not discuss efforts taken to assist the patient in planning their physical activity or developing strategies to maintain changes and/or respond to anticipated or unexpected barriers. The PaP in itself may not be the critical factor in health behavior change, but it may instead be the intervention employed to deliver the PaP that is most critical. In fact, planning has been found to be the primary mediator linking intention to behavior in the context of rehabilitation home exercise programs.3 Consider the likelihood of your patient making a behavioral change if you were to spend time working with them to develop a plan for when the home exercise program would be most likely to actually occur in their complex daily schedule. Consider further the likelihood of your patient maintaining the health behavior change if you were to spend time discussing and developing written strategies they can use in response to anticipated and unforeseen barriers to adherence to their PaP or home exercise program.

Clinicians will need to enhance the approach they employ in delivering the PaP or home exercise program to facilitate adherence. The study by Moren et al1 provides powerful quantitative evidence that a professional patient-centered PaP and education are not sufficient to bring about a health behavior change that is undeniably important for optimizing recovery, preventing recurrence or secondary conditions, and improving quality of life. We have the opportunity to reflect on how we deliver our recommendations to patients and consider making our own change.

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