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Lynne Gauthier imageBehavioral intervention needs to be at the forefront of therapy planning

In this newsletter, Dr. Lynne Gauthier, PhD, Associate Professor at the University of Massachusetts Lowell, talks about behavioral techniques therapists can use to improve rehabilitation program outcomes.


Extensive prior research has shown that rehabilitation can produce meaningful improvements in a person’s capacity.  The benefits of rehabilitation extend to neurodegenerative disorders like Multiple Sclerosis1,2 and can continue many years after injury to the brain.3-5 However, a major shortcoming of rehabilitation programs is that they typically underemphasize what a person actually does at home (versus what the person is capable of doing), which limits the practical impact of the rehabilitation program. For example, there is essentially no benefit from regaining capacity to use the weaker arm if clients still don’t use it to manage day-to-day activities.

Behavioral interventions are an important tool in the therapist’s toolbox to reduce the mismatch between a client’s regained ability and what they actually do outside of therapy sessions, as well as to improve adherence to prescribed interventions. Behavioral intervention may employ some or all of the following techniques: motivational interviewing and contracting to affirm commitment to a behavior change process, goal setting to create achievable milestones, action planning, self-monitoring progress, problem-solving to overcome barriers, and modifying the environment to increase the likelihood of success (Table 1).6,7


Table 1: Behavioral techniques (left column) and examples of how they can be implemented (right column). While these techniques can be applied to any rehabilitation program, the following examples detail how they can be incorporated into motor rehabilitation programs for Multiple Sclerosis.

Goal setting: Client identifies no more than 3 meaningful SMART goals that can be accomplished within the treatment period. Each goal should be specific, measurable, achievable, relevant, and time-bound.

Example SMART goals

  • Wear jeans again by the end of treatment.
  • Independently mow the lawn within 3 months.


  • When a client provides a goal that is not likely achievable or is unsafe in the short term, come up with a smaller goal that will support the larger goal. E.g., if a client’s goal is to drive, but there are many barriers to this, a more achievable goal in the short term may be to be able to accomplish the motor tasks required of driving.
Motivational interviewing: Ask questions that will elicit motivational statements from the client. Ask how important each goal is on a 1-10 scale. Follow up with open-ended questions such as, “What led you to rate that goal an 8/10 in importance and not a 3/10?” In explaining why a goal is important, the client’s commitment to it will deepen.
Action Planning: Break a larger goal into its component parts. Establish a plan for how each will be accomplished The following motor tasks needed for driving could be written down: unlock car door, open car door, get into car, buckle seat belt, place key in ignition, turn key, turn steering wheel, shift gears, unbuckle seat belt. The client’s plan for how each will be accomplished is written beside each task. Multiple copies of the Behavioral Plan from the Treatment Contract are provided for Self-monitoring (below).
Contracting: Client signs the behavioral plan to affirm commitment to the treatment program.
  • Client agrees to use the weaker arm for all goal-related activities in which it is safe to do so.
  • Client agrees to complete a home exercise program
  • Client agrees to attend treatment sessions and to reschedule them in advance when conflicts arise.
Self-monitoring: Client documents daily progress towards a goal
  • Client checks off which goal-related tasks from Action Planning were accomplished each day and whether the weaker arm participated in each. Logs are brought back to therapy to establish accountability and assist with problem-solving.
  • Client wears a device that tracks activity over time, such as a pedometer
  • Client completes assessments, such as the Motor Activity Log, that reflect on use of the paretic arm during ADLs.
Problem-solving: Therapist prompts the participant to self-identify potential solutions to barriers interfering with treatment goals. Behavior change is a process that evolves over time, so frequent short consultations are more effective than fewer, longer consultations.
  • Therapist prompts client to diagnose the problem: “What got in the way?”
  • Therapist prompts client to come up with a solution independently and without judgement: e.g., “How might you reduce the risk of spills when holding a cup in your weaker hand?” Ideally this would take place in the home (e.g., via telehealth) or in an environment that is similar (e.g., kitchen at the rehab).
  • Client tries the solution and therapist helps client to refine the plan as needed.
Modifying the environment: Changes to the physical environment or social support structure are put in place to increase the likelihood of success.
  • Client requests a parking space that is further away
  • Client replaces riding mower with push mower
  • Exercise equipment is cleared off and moved to a main room to promote its use.
  • Less fun activities (e.g., exercise) are paired with more fun activities, (e.g., gaming, social interactions, team sports, podcasts, TV).


There is a solid research foundation in support of incorporating behavioral intervention into neurologic rehabilitation.  Over the past 20 years, at least 14 randomized controlled trials have examined how adding behavioral intervention to a neurologic rehabilitation program impacts everyday functioning.5,8-20 Behavioral interventions have boosted time spent in leisure activity by 14 minutes per day, 8 improved depression, 8 and improved stroke survivors’ ability to complete daily activities independently.9 Motor training with behavioral intervention greatly improved everyday use of the weaker side compared to motor training alone.5,11-20  Improvements were about twice as large when behavioral interventions were comprehensive (i.e., included most of the behavioral techniques)5,11-15,19,20  than when they involved fewer behavioral techniques.10,16-18  Intensive motor interventions that lacked behavioral intervention improved capacity for movement, but did not have a meaningful impact on daily activities performance.5,12-16,18,19

Despite very strong evidence of its importance, behavioral intervention is largely omitted from rehabilitation programs. The following details how to overcome the main barriers and implement behavioral interventions into routine clinical practice.


Barrier #1: “So little time, so much to do”

Therapists are tasked with providing therapeutic exercises that are sufficiently intense, which leaves little time for behavioral intervention. An effective way to overcome this challenge is to provide a very thorough self-management program for the client. Therapeutic exercises can be effectively self-managed, but behavioral interventions cannot. This means that therapy time should give priority to behavioral interventions. The recently completed VIGoROUS multi-site trial provides empirical support for this approach.21 Much larger gains in daily arm use were observed when motor practice was self-managed through in-home rehabilitation gaming and therapy sessions were entirely devoted towards behavioral intervention; gains to motor capacity were similar (unpublished observations). The behavioral intervention/self-management model thus had greater impact than the same amount of therapist time spent delivering traditional motor intervention. Results of this trial and prior research support the need for a marked shift towards prioritizing behavioral intervention during neurologic rehabilitation.

A self-management prescription should far exceed the time spent in treatment with the therapist (e.g., 30 minutes per day of strengthening exercises plus 30 minutes per day of practicing goal-related tasks). Given that adherence to self-management averages about 50%, the therapist may choose to initially overprescribe so that imperfect adherence is still sufficient. The behavioral techniques from Table 1 can be used to establish expectations and to facilitate adherence to the home program. Individuals who have difficulty adhering to a home program may benefit from the following environmental modifications: arriving early to therapy to independently perform therapeutic exercises, working with a personal trainer, attending exercise classes, engaging with a rehabilitation gaming system, or exercising with a family member/friend.


Barrier #2: Minimal training in behavioral intervention

Therapists who have received little or no formal training in behavioral techniques can start by implementing a few techniques and then add additional techniques as they achieve mastery. Action planning, self-monitoring the Action Plan, and problem-solving are relatively easy to learn/implement, yet have a very large impact when used together.  The key to success is to formulate highly specific Action Plans.  For example, instead of “use your weaker arm to do the laundry,” the therapist and client would jointly detail a plan for how every component task (e.g., removing lint filter, cleaning lint filter, opening detergent compartment, removing cap from detergent, pouring detergent) could be accomplished. The client would document independent progress for each sub-task prior to the next treatment session, and the therapist and client would work together during the next treatment session to overcome barriers that interfered with completing some aspects of the task.


Barrier #3: Achieving reimbursement

Motor practice is incorporated into the behavioral techniques (e.g., practicing a strategy to overcome perceived barriers to completing a task). The intervention can thus be billed as Self-Care/Home Management Training, Neuromuscular Re-education, or Therapeutic Activities. Behavioral techniques can also be delivered by a Psychologist and billed using Health and Behavior codes.



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