A Walking Education Program for Patients with Osteoarthritis of the Knee: Theory and Intervention...

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Health Education & Behavior

DOI: 10.1177/109019819302000107 1993; 20; 63 Health Educ Behav

and Bernard Gutin John P. Allegrante, Pamela A. Kovar, C.Ronald MacKenzie, Margaret G. E. Peterson

Theory and Intervention StrategiesA Walking Education Program for Patients with Osteoarthritis of the Knee:

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63

A Walking Education Program for Patients withOsteoarthritis of the Knee: Theory and

Intervention StrategiesJohn P. Allegrante, PhD

Pamela A. Kovar, PT, EdDC. Ronald MacKenzie, MD

Margaret G. E. Peterson, PhDBernard Gutin, PhD

Walking is an ideal physical activity for patients with osteoarthritis because it can helpto improve functional status without exacerbating pain or necessitating an increase in theuse of medication. Although patient education programs designed to encourage walkinghave become increasingly important in the management of this condition, there is no

This work was supported by NIH Multipurpose Arthritis Center Program grant no. 1 P60AR38520-01A1, and in part by a predoctoral research fellowship grant to Dr. Kovar from theArthritis Foundation. We thank Dr. Kate Long of the Stanford Arthritis Center, for providingnumerous helpful suggestions m the early stages of developing this program; our colleagues at theCornell Arthritis and Musculoskeletal Diseases Center, Dr. Mary Charlson and Dr. Mark Kasper,for reading and commenting on several drafts of the manuscript; and Dr. Lawren Daltroy, of theMultipurpose Arthritis Center at the Bngham and Women’s Hospital, and the anonymous reviewers,whose helpful comments and editorial guidance enabled us to improve the manuscript. Portions ofthis paper were presented at the Northeast Arthritis Health Professions Association, May 19, 1990,New York, NY, and the 41st Annual Meeting of the Society for Public Health Education, October5, 1990, New York, NY.

Dr. Allegrante is Associate Professor of Health Education and Director, Center forHealth Promotion at Teachers College, and Associate Professor of Clinical Public Healthin Sociomedical Sciences, School of Public Health, Columbia University; and Directorof Educational Research and Development, Cornell Arthritis and Musculoskeletal Dis-eases Center, The Hospital for Special Surgery, New York, New York.

Dr. Kovar is Research Associate in Educational Research and Development, CornellArthritis and Musculoskeletal Diseases Center, The Hospital for Special Surgery, NewYork, New York.

Dr. MacKenzie is Associate Professor of Clinical Medicine, Cornell University MedicalCollege, and Associate Attending Physician, The Hospital for Special Surgery, New York,New York.

Dr. Peterson is Biostatistician in Biomechanics, Research Division, The Hospital forSpecial Surgery, New York, New York.

Dr. Gutin is Professor of Exercise Science, Department of Pediatrics and GeorgiaPrevention Institute, Medical College of Georgia, Augusta Georgia.

Address reprint requests to Dr. John P. Allegrante, Cornell Arthritis and Musculo-skeletal Diseases Center, The Hospital for Special Surgery, 535 East 70th Street, NewYork, NY 10021.

Health Education Quarterly, Vol. : 1@ 1993 by SOPHE. Published by John Wiley & Sons, Inc.



64

single synthesis or other published source of theory and intervention strategies to guidethe practitioner in the development of such programs. This paper describes a hospital-based patient education program designed to enhance the functional capacity of patientswho have osteoarthritis of the knee by encouraging the adoption and maintenance ofwalking. The paper describes the goals, objectives, process, and impact of the program;the principal theoretical model utilized in the design of the program; and how conceptsand intervention strategies from the literatures on patient compliance and patient edu-cation, exercise compliance, behavioral psychology, and relapse prevention have beenoperationalized and integrated in a walking program that we have evaluated for safetyand efficacy.

INTRODUCTION

Over 16 million people in the United States have osteoarthritis, a chronicdegenerative disease of the joints.1.2 Walking is an ideal physical activity forpatients with osteoarthritis because it is a low-impact activity that is toleratedwell by those whose overall health status may be compromised .3-1 Althoughwalking has become increasingly important in the management of this condition,there is no single synthesis or other published report describing the use of theoryand intervention strategies to guide the practitioner in the development of safeand effective walking programs designed to improve the functional status ofpatients with osteoarthritis.

This paper provides a detailed description of a hospital-based patient edu-cation program designed to enhance the functional capacity of patients who haveosteoarthritis of the knee by encouraging the adoption and maintenance ofwalking. We have organized the paper into several major sections. First, wesummarize the goals, objectives, process, and impact on functional status andarthritis-related self-efficacy beliefs of the walking program we have developed.We then review the relevance of self-efficacy as the principal theoretical basisfor the program’s design, and describe how the major sources of self-efficacyinformation have been operationalized in the program. Finally, we describe indetail how concepts and intervention strategies synthesized from the literatureon patient compliance and patient education, exercise compliance, behavioralpsychology, and relapse prevention have been integrated throughout the fourphases of the program.

GOALS, OBJECTIVES, PROCESS, AND IMPACT OF THESIDEWALKERS WALKING PROGRAM

Goals and Objectives

The Sidewalkers Walking Program is a four-phase, hospital-based educa-tional, support, and walking program, the aim of which is to increase the func-tional capacity of patients who have chronic osteoarthritis of the lower extrem-ities. The program is designed to teach participants how to effectively managearthritis-related pain and other symptoms through fitness walking. Thus, the



65

Table 1. Goals of the Sidewalkers Walking Program

goals of the program are to empower participants with the knowledge, attitudes,and specific skills necessary to engage in walking safely and confidently (seeTable 1).

The objectives of the program are organized into cognitive, affective, andbehavioral domains. Cognitive objectives are designed to help participants gainpractical knowledge of the principles and guidelines fundamental to a safe walk-ing program; affective objectives are designed to help participants gain an ap-preciation for the intrinsic rewards and benefits of regular walking; and thebehavioral objectives of the program are designed to help participants becomeindependent in adopting and maintaining a regular program of walking. (Note:A more detailed list of the goals and objectives of the program can be obtainedby writing to the corresponding author.)

Process

Patients participating in the 8-week program meet as a group three times eachweek for approximately 90 minutes. Group size is limited to between 10 and 15patients. Patients in our program have ranged in age from 40 to 89, with anaverage of 70 years, and have moderate to severe osteoarthritis of one or bothknees. Each session includes direct educational instruction led by a trainedinterventionist or a guest speaker on a topic of special interest, social support,light physical activity, and walking. Each participant receives a program manualcontaining information and photographs of various stretching and strengtheningexercises to be learned, a videotape and an audio cassette about walking, anda diary to record their physical activity during the course of the program.

The program was developed using planning concepts from Green’s PRE-CEDE framework,8 an outcome-based health education planning model. Spe-cific educational activities were designed using principles from Bandura’s theory



66

of self-efficacy.9,10 Portions of the program content and some of the activitieswere also modeled after programs such as the Arthritis Self-Help Course&dquo; andthe Rockport Walking Program.’2 In addition, concepts and intervention strat-egies gleaned from the relevant literatures on patient compliance and patienteducation,13-17 exercise compliance, 18-20 behavioral psychology,21-28 and relapseprevention 29-32 were utilized in the program design.

Program Impact

We have conducted a randomized, controlled trial of walking in patients withosteoarthritis of the knee to assess the impact of the program on functionalstatus, pain, and medication use, the results of which have been reported else-where. 33 We studied 92 patients, 47 of whom completed an average of 21 ± 6program sessions (range, 3 to 28 sessions) in the walking group, and 45 of whomwere followed as controls. Figure 1 summarizes the impact of the program interms of the percent change in outcomes for all patients.

These data show that our walking program resulted in clinically meaningfulimprovements in the functional status of patients as measured by a 6-minutetest of walking distance 34 and by changes in scores on the physical activitysubscale of the Arthritis Impact Measurement Scales,35 a widely employed mea-sure of functional status in patients with arthritis. Although improvements inarthritis impact and medication use were not statistically significant, our studyalso demonstrated that participation in the walking program did not significantlyworsen pain, increase medication use, or exacerbate other arthritis-related symp-toms.

Figure 1. Percent change in outcomes.



67

We have also analyzed the program’s impact on patients’ scores on the arthritispain and arthritis-related symptoms subscales taken from Lorig’s scale of arthritisself-efficacy.36 Although patients in the walking program improved their scoreson the pain subscale compared with control subjects, differences were not sig-nificant. Scores on the subscale measuring ability to manage other arthritis-related symptoms, however, improved for intervention subjects but not in con-trols (p < .01). Pre-to-posttest difference scores differed by gender, with womenexperiencing a substantial change in efficacy beliefs regarding their ability tomanage other arthritis-related symptoms. These findings suggest that our pro-gram had an impact on enhancing patients’ efficacy beliefs regarding their abilityto manage symptoms related to their arthritis, with the most pronounced impactoccurring in women. 37

SELF-EFFICACY AS A THEORETICAL BASIS FORPROGRAM DESIGN

The relationship between health-related behavioral change and self-efficacyhas received considerable attention in the patient education literature. Over thelast decade, numerous studies of outcomes in clinical research on chronic diseasehave demonstrated that self-efficacy is an important determinant of the abilityto learn, adopt, and maintain new skills and specific behaviors in coping withchronic illness. Research has provided converging evidence that educationalinterventions designed to improve people’s perceptions of their self-efficacysignificantly affect their level of motivation, confidence, and ability to initiateand maintain behaviors that enhance psychosocial functioning and improvehealth outcomes.38-40 The concept of self-efficacy has been applied in the de-velopment of educational and behavioral interventions designed to improvefunctioning and outcomes in a range of health problems and diseases, includinganxiety disorders,4’ depression ’42 cardiac rehabilitation ’43 arthritis ’44 post-hip-fracture rehabilitation,45 the management of pain in childbirth,46 and tensionheadaches. 17 Thus, educational and behavioral interventions designed to enhanceself-efficacy have demonstrated considerable clinical utility in the managementof conditions where patients must adopt and maintain new coping behaviors inresponse to a wide range of tasks.

Improving personal efficacy is dependent on exposing the individual to severalsources of self-efficacy information: (a) performance accomplishments, (b) vi-carious experience, (c) social persuasion, and (d) physiological states. Through-out the Sidewalkers Walking Program, the interventionist utilizes these foursources of self-efficacy information to enhance participants’ self-efficacy regard-ing walking as well as the management of pain and other symptoms. Below wedescribe how we have applied each of these components of the theory in thedesign of our program.

Performance Accomplishments

Past and present performance accomplishments have been shown to be themost reliable and effective source of self-efficacy information because they pro-



68

vide a direct demonstration of the individual’s current level of skill. To increasethe likelihood of achieving early success with walking, participants begin theirwalking program at an easily mastered intensity and frequency. Participants startby doing a 6-minute test of walking distance 34 to establish a baseline againstwhich later performance may be measured. During the first 4 weeks, participantsare encouraged to walk three times per week and at an intensity that does notexacerbate their knee pain or cause them to become overly fatigued. We alsoencourage participants to limit the initial duration of the aerobic phase of theirwalking program to approximately 5 minutes. Walking time is progressivelyincreased each week (as tolerated) until the goal of walking four times a weekfor 25 minutes can be comfortably and safely achieved. Most participants arethus assured of experiencing repeated, incremental performance accomplish-ments by the end of each week.

Vicarious Experiences

Observing the successful behavior of others conveys information about taskdemands and thus constitutes a powerful source of efficacy-enhancing infor-mation. We use this source of self-efficacy information in several ways. First,we have participants identify individuals whom they know to be successful atphysical activity and whom they might wish to emulate. Second, in addition tolearning from the interventionist, we also encourage program participants toteach and learn from each other. For example, as the program progresses, thewarm-up and cool-down exercises are performed in a group, with participantsrotating as the group leader. The modeling strategy is used throughout the earlyphases of the program until walking techniques and related physical activitiesare mastered. By the fifth week, all participants are expected to have masteredthe regimen and modeling is no longer needed.

Social Persuasion

Bandura’s work has consistently shown that social persuasion and other kindsof social influence have an important impact on personal efficacy. People whoreceive verbal persuasion and support from others indicating that they possessthe capabilities to master a given task and achieve goals, are more likely toinitiate and sustain behavioral effort than if they harbor self-doubts or dwell onpersonal deficiencies when temporary barriers or other difficulties arise. Weutilize this concept throughout the program in the form of individualized andgroup verbal feedback. The interventionist provides specific corrective and rein-forcing feedback during early walking sessions to help participants gauge andmonitor their performance. We also teach participants skills in giving and re-ceiving feedback and social reinforcement. Social influence is thus used through-out the program as a means of helping participants monitor performance andacquire the belief that they possess capabilities that will enable them to achieveindividual walking goals.



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Physiological States

Physical sensations that provide feedback to individuals regarding their actualperformance of tasks and their capability to perform them successfully can bean important source of self-efficacy information. Participants in our programare taught how to correctly interpret their internal physiological reactions towalking and physical activity. Strategies that help the individual focus on inter-oceptive (i.e., bodily) sensations and intense goal-directed concentration havebeen shown to facilitate exercise performance in trained athletes.48-51 In contrast,similar kinds of cognitive processes, such as dwelling excessively on minor dis-comfort and fatigue associated with exercise and rigid performance goals, aredetrimental to adherence for untrained, noncompetitive individuals. The neg-ative influence of physiological feedback on one’s perceived sense of self-efficacyhas also been reported.52 This work has shown that in activities involving strengthand stamina, people interpret their fatigue, aches, and pains as indicators oftheir physical inefficacy. We teach participants how to interpret the normaleffects of exercise (e.g., occasional muscle soreness or fatigue) and how to avoidmisinterpreting other responses such as pain due to physical injury. Participantsare also taught strategies to help themselves recover from overexertion duringphysical activity.

PHASES OF THE INTERVENTION PROGRAM AND USE OFBEHAVIORAL STRATEGIES

With self-efficacy theory as a context for the intervention design, the programis organized into four phases: (a) promoting adoption of behavior change, (b)facilitating behavioral compliance, (c) maintaining behavioral change, and (d)preventing relapse of behavior. Selected methods of behavior change derivedfrom behavioral psychology are incorporated throughout the phases of the pro-gram. Below, we describe how these strategies are utilized in each phase.

Phase I: Promoting Adoption of Behavior Change

During the first 4 weeks of the intervention, a combination of behavioralstrategies are used to promote and facilitate the acquisition of skills necessaryto safely engage in fitness walking.

Shaping and Guided Practice

Shaping and guided practice is the process by which a complex behavior isbroken down into a series of successive steps or component parts to be masteredbefore the desired behavior can be achieved. A principle of shaping is to startwith simple, easily performed components of the behavior and provide oppor-tunity for guided practice before moving on to the next component. Anotherprinciple is to start at too low or too easy a level and accelerate the program,



70

rather than to begin the individual at a level beyond one’s capabilities. Forexample, in our program, we help participants identify and practice the com-ponent parts of safe and effective fitness walking. This includes warm-up andstretching muscles, proper walking posture, stride length, walking speed, andcool-down. Thus, each component part of the walking regimen is discussed andpracticed before going on to learn the next.

Reinforcement Control

A reinforcer is any stimulus that is presented during or following the behaviorthat increases the probability of the behavior occurring again.2’ In general,reinforcement should be provided as frequently as possible in the early stagesof habit formation (e.g., the first 4 to 6 weeks). To be maximally effective,reinforcement should be delivered during or shortly after the performance ofthe behavior. Various kinds of reinforcements have been used to enhance com-

pliance with exercise regimens. For example, token reinforcements (i.e., award-ing money-like tokens, contingent on a behavior, that can be cashed in) havebeen used to increase exercise compliance in various ways: token reinforcementsystems for institutionalized geriatric patients51; lottery systems in which an end-of-program cash prize is awarded for class attendance 14 ; and reinforcement byway of returning valuable personal items or money left on deposit upon com-pletion of the program, or achievement of a certain level of fitness change.&dquo;Achievement awards such as gold stars, gift certificates, T-shirts, and exerciseequipment have also been used as reinforcements .21 In our program, achieve-ment awards such as a walking suit, exercise socks, a necklace/key chain, andcertificate of achievement are awarded to the participants at different stages ofthe program. Token reinforcements (usually in the form of a $5 gift certificatethat can be used at a local sports store) are also awarded to participants forgood class attendance.

Stimulus Control

Stimulus-control strategies utilize environmental cues to prompt and motivatepeople to engage in behavior. Various environmental factors have been shownto stimulate people to exercise by controlling and overriding the negative an-tecedents or stimuli that deter them from exercising .2 Examples of exercise-inducing prompts include public posting of running mileage or time; signs, pos-ters, or billboard advertisements depicting people exercising; and public serviceannouncements appearing in the news media to promote a scheduled exerciseprogram or event.2’ For example, Brownell et al. 56 have increased the rate of

stair-climbing by posting a cartoon sign by an escalator-stairway that depicteda healthy heart bouncing up the stairs and coaxing others to do the same.Similarly, otherS51.51 have used telephone calls to prompt member-dropouts en-rolled in a health club, finding that exercise adherence was improved amongthose members who were reminded of their perceived benefits for returning tothe health club.



71

Stimulus-control strategies used in our program include telephoning partici-pants who miss a session to determine why they missed and to remind them ofthe positive reasons that they previously expressed for returning. We also remindparticipants of how valuable their presence and comments are to the group andthe importance of having successful exercisers encourage classmates to sharetheir exercise likes, dislikes, and motivational strategies. We utilize a collage ofphotographs of class participants walking and posters promoting walking andphysical activity that are displayed in the classroom. We also distribute reprintsof newspaper and magazine articles about walking each week. Finally, we teachparticipants to lay out their exercise clothes the night before planned exercisesessions, to wear exercise clothes around the house and when shopping, and toalways pack exercise equipment when going on day trips or vacations so thatthey learn how to incorporate exercise into their lives. Participants are alsoencouraged to spend time with others who exercise regularly, to avoid the tel-evision and telephone calls during regular exercise time, to avoid or ignoresaboteurs (i.e., those who may try to dissuade the participant from exercisingroutinely), and to travel to the exercise class even though they may not be inthe mood for exercising that day.

Phase II: Facilitating Behavioral Compliance

Behavioral strategies that strengthen compliance with the walking require-ment of the program are utilized in the second phase. These include behavioralcontracting, commitment strategies, and various cognitive strategies.

Behavioral Contracting

Dunbar et al.11 have suggested that behavioral contracting is useful in exerciseprograms for several reasons. First, developing a contract makes the patient anactive participant in planning treatment. Second, a contract provides a writtenoutline of what behaviors are expected, and thus, can be used as a reference ata later time when details might be forgotten. Third, a contract elicits a formaland public commitment from the patient and the other parties involved. Finally,the terms of a behavioral contract provide meaningful incentives to change thespecified behavior in order to gain a reward and avoid the punishment fornoncompliance.A behavioral contract can be made between the patient and a health profes-

sional, between the patient and a family member or significant other, or betweenthe patient and another participant in the program. The components of a be-havioral contract typically include: (a) a written agreement; (b) a clear descrip-tion of the behavior to be changed so that it is evident when the change occurs;(c) clearly specified consequences of the behavior change (and the absence ofthe behavior) so that the individual is aware of what will be gained or forfeitedby compliance or noncompliance; and (d) an established criterion for time orfrequency limitations.60.61 Various kinds of behavioral contracts have been usedto enhance exercise adherence. Examples include use of weekly attendance



72

contracts where the interventionist returns $1 per week from each participant’sinitial deposit for the duration of the exercise program; an attendance lotterywhere, in exchange for each exercise session attended, a &dquo;chance ticket&dquo; for a

prize is given to participants; and contracting where, in exchange for each ex-ercise session attended, aerobic points are awarded to participants so that theycan earn back personal items that have been placed on deposit.&dquo; .49,62 In eachof these examples, the behavioral contract is used as a means of maintainingattendance and preventing attrition.

Although contracting is an effective strategy for improving exercise adher-ence, precautions should be taken when designing a behavioral contract. First,participants must have the skills necessary to make the specified behaviorchanges; second, the method of determining whether behavior change has oc-curred must be objective rather than subjective; third, safety precautions mustbe taken to ensure that participants do not engage in unhealthy practices tomeet contract requirements (e.g., exercising despite onset of increasing arthriticsymptoms in order to meet a short-term goal); and, finally, the conditions ofthe contract must be acceptable to all parties.2’

In our program, each contract with a participant is renewed every 2 weeksand specifies the participant’s responsibility for setting new short-term goals,attending three times per week, complying with the fourth-day home walkingsession, and completing the diary entry. The consequences of adherence orfailure to adhere to the program are clearly stated, as well as those circumstancesunder which exceptions will be permitted. Participants enlist a classmate as theirsignificant other if they do not have a reinforcing co-contractor at home. Thecontract is signed by the participant, the significant other, and the programinterventionist. Participants receive a copy of their contract as a reminder oftheir agreement.

Commitment Strategies

To further enhance each participant’s commitment to the 8-week program,several commitment strategies proposed by Meichenbaum and Turk 28 are used.First, the commitment to attend class and adhere to the specifications of thebehavioral contract is made public (in verbal and written form) to the programinterventionist, classmates, and significant others. The obligations of the par-ticipant’s commitment are written clearly and in large print on the participant’sbehavioral contract. Participants are given the opportunity to make choices whendecisions have to be made, from either a range of alternatives (e.g., the kindsof physical activities they want to increase in their lives) or from their owninterests. Finally, barriers to adherence (e.g., excuses, problems, and anticipatedobstacles) are identified by the interventionist and discussed with the group eachweek.

Cognitive Strategies

Cognitive strategies are techniques that influence one’s thoughts and beliefs.Bandura’° has demonstrated that what individuals believe before, during, and



73

after a behavior has a significant impact on their self-efficacy and adherence.Compliance in beginning exercisers is enhanced by incorporating various cog-nitive strategies into an exercise program.2’ We incorporate the use of goal-setting and coping thoughts as cognitive strategies in our program.

Goal-setting. Studies22.63 have shown that setting appropriate goals has animportant impact on one’s adherence to an exercise program. For beginningexercisers, short-term, time-based goals (i.e., time walked per session) are gen-erally preferable to long-term, distance-based goals (i.e., distance walked). Re-search has also shown that individuals who believe that their personal choicesand preferences help determine their exercise goals demonstrate better adher-ence to exercise than those whose preferences are not included in the goal-setting process. 58 Our program utilizes a personal goal-setting approach to helpparticipants achieve time-based, short-term goals for walking. The interven-tionist teaches participants to set challenging, yet attainable, goals that are tai-lored each week to accommodate each patient’s physical capabilities. Long-termgoals are set on a monthly basis at the beginning and midpoint of the program.Finally, participants are taught how to monitor their progress against goals inthe diary. The diary helps to sustain the participant’s motivation, commitment,and involvement in the program while documenting progress, and facilitatesadjusting goals or setting new ones.

Coping thoughts. The exercise compliance literature suggests that beginningexercisers should be taught cognitive strategies that combine distraction strat-egies with flexible, realistic goal-setting, and with training to recognize andmodify self-defeating thoughts.1o.32 In our program, the content for the copingthoughts is created by the participants during class discussions and role-playingsessions, as well as derived from personal feelings that they record in their diaries.Program participants are instructed to talk to themselves and their walkingpartners while they exercise. When they became aware of negative thoughts orimages, such as &dquo;I’m not doing as well as I should ... I have a long way to gountil I am finished ... This is boring ... ,&dquo; they are encouraged to makepositive self-statements32 such as, &dquo;I’m doing well to exercise at all today, sinceI was not looking forward to it ... I’m nearly halfway finished ... I’m terrificand I am going to look my best.&dquo; Participants are also encouraged by theinterventionist to be generous in evaluating their performance and in reinforcingthemselves with positive coping imagery.

Phase III: Maintaining Behavioral Change

During the last 4 weeks of the program several behavioral strategies areintroduced to prepare participants for the maintenance phase of their walkingprogram. In this phase of the program, we focus on generalization training,reinforcement fading, and teaching several self-control strategies.

Generalization Training

Martin et a1.2I.22 have recommended that formal exercise sessions be graduallyfaded before terminating the structured portion of a program. Generalization



74

training prepares the participant for making the transition from exercising in astructured, hospital-based program to exercising independently in the homeenvironment. This is an important component of our program because uponcompletion of the program most individuals must rely exclusively on their in-dividual resources to maintain their exercise regimen. Generalization traininginvolves practicing a similar target behavior (exercise) in a new setting (stimulusgeneralization) or a new behavior (a second exercise) in the same environment(response generalization), or both .2 This training involves reinforcement con-tingencies and methods quite different from those used in the structured be-havior-acquisition phase.

In our program, an additional walking day is required after the second week.Participants are encouraged to involve family, coworkers, or friends in theirhome walking program and to do it in a community location convenient to homeor work. If and when participants report having difficulty, other class membersare encouraged to meet them in their own environment for several exercisesessions. A walking directory (containing all consenting participants’ telephonenumbers and home addresses) is compiled and circulated to the group as anothermeans to stimulate peer support, vicarious modeling, and generalization training.Following each walking session, participants also record when, where, and howintensely they have walked; what their postexercise heart rate and perceivedexertion level were; with whom they walked (if anyone); and the level of en-joyment they perceived experiencing during the walking session. Thus, gener-alization of the exercise response is promoted from the outset. Moreover, prob-lems can be identified early and subsequent instruction tailored to addressdifficulties. For example, walking and other physical activities are introduced inthe class environment first and then generalized to the home environment. Thisfacilitates the transition from programmed acquisition of walking behavior tounstructured maintenance.

Reinforcement Fading

Although systematic reinforcement of some form (e.g., social or financial)should always be used in the early stages of the acquisition period, it is desirableto fade the frequency and intensity of the reinforcement once the behavior hasbeen well established. Fading the reinforcement, as in shaping, should be gradualso as not to abruptly extinguish the behavior. For example, transferring theartificial reinforcement to the daily environment of the home should begin earlyand be expanded as program reinforcers are faded. 21 We encourage the spouse,family, or a friend of participants to become involved from the outset so thatthey are associated with and can provide stimulus and reinforcement for walking.Eventually, natural reinforcers such as positive comments from others, increasedfeelings of self-control and self-esteem, increased energy levels, and the cessationof negative feelings associated with inactivity, take over and serve to reinforceparticipants in the walking program.

Self-Control Strategies

When nearing the maintenance phase of treatment, participants should beencouraged to take more control over their treatment plan. Self-monitoring,



75

contingency management, and self-contracting strategies enable patients to be-come more responsible for their behavior and are integrated throughout thisphase of our program.

Self-monitoring. This is the most commonly used self-control strategy tocollect information about an individual’s behavior outside the treatment session.This strategy is useful for monitoring and providing feedback for adherence bothin the early acquisition and maintenance phases of learning an exercise habit.2’Participants are asked to record the relevant behavior(s) in a notebook, on anindex card, calender, or special form provided by the interventionist. In someprograms, participants are asked to graph daily or weekly progress (e.g., mileswalked and sessions attended); in other programs, self-monitoring typically in-cludes recording the kind of activity performed and a measure of the durationand intensity (i.e., heart rate, time, distance, or aerobic points). The informationto be monitored is specified by the program interventionist and is based ontreatment goals and the individual’s ability to keep detailed records.

Self-monitoring requirements should be kept to a minimum so as not tobecome burdensome. However, more detailed self-monitoring records have beenshown to be useful for evaluating patients’ progress and indicating the environ-mental circumstances that seem to support or interfere with adherence to ex-ercise.2’ For example, if new patients are asked to record the time of day, place,and with whom they have exercised, over time their records might reveal specifictrends that describe their adherence behavior. Such a record might show thatphysical activity is most consistently practiced when performed in the morningbefore work and in the company of others, rather than at other times of dayand when the participant is alone.

Although self-monitoring is usually used to collect information, this kind ofrecord-keeping has been shown to be an effective intervention strategy to inducechange in the behavior that is being monitored. Patients who self-monitor thedistance they walk each day tend to increase their walking distance without anyexplicit rewards from the interventionist. 64 In our program, we teach participantsto monitor their postwalking heart rate, walking time, and the time of day, place,and with whom they exercise. We have found that this level of self-monitoringis manageable and enables participants to both evaluate their progress and setsubsequent short-term goals utilizing the information in their physical activitydiaries.

The reactive effect of self-monitoring (i.e., people evaluating their behaviorand rewarding themselves if they believe that they have made progress or mettheir goals) tends to be transient if self-monitoring is not supported by otheradherence strategies.2’ Therefore, we have also combined self-monitoring withcontingency management and self-contracting strategies in this phase of theprogram.

Contingency management. The use of contingency management in a self-control program requires that exercisers arrange reinforcing events subsequentto each exercise session. The reinforcement is granted to the participant uponcompletion of the planned exercise session. To illustrate, Keefe and Blumenthal65conducted a self-control exercise adherence program with overweight men. Ata 2-year follow-up the men were still exercising and scored in the excellent fitnesscategory. Rather than relying on the external self-control procedures as a stim-ulus to exercise, motivation to exercise was enhanced by an internal factor by



76

the end of participation in the program. Subjects in the study reported that theyfound the mental and physical benefits derived from exercise to be rewardingin themselves.

Self-contracting. Written self-contracts that specify behaviors to be changedand the contingencies for reinforcement are useful for several reasons: contractsclearly define the desired behaviors; written agreements serve as a permanentrecord and a formal commitment; and the incentives for compliance are explicitlystated .2 The major difference in using a self-contract versus a behavioral contractis that self-contracts specify that the individual, rather than the interventionistor a significant other, is given control over enforcement of the contract anddelivery of the reinforcement. Again, participants are taught to set easily at-tainable goals and to reinforce themselves for meeting these goals.

Phase IV: Preventing Relapse of Behavior

Marlatt and Gordon29 have observed that a new behavior can be extinguishedwhen individuals change a usual routine and encounter a situation that placesthem at high risk for returning to the old behavior. Additional research hasshown that nearly every person involved in a health-enhancing program expe-riences lapses in adherence. Sternberg~~ has suggested that the way in which onedefines these &dquo;slips&dquo; or relapses determines whether these events are temporaryor permanent. However these are defined, programs that incorporate the teach-ing of relapse-prevention strategies demonstrate better outcomes than programsthat do not.

Based on the work of Martin and Dubberel and Marlatt and Gordon,&dquo;, wehave adapted the following relapse-prevention strategies for use in our walkingprogram: (a) realignment of normative beliefs to recognize that relapses arenormal events for people learning new behaviors; (b) the abstinence-violationeffect; (c) techniques to recognize and ways to avoid high-risk situations; and(d) a guided, class-planned relapse experience.

Realignment of Normative Beliefs

The realistic probability of adherence slips is discussed with participants be-ginning in week 2 of our program. The rationale for this is that it is highlyunlikely that anyone would be able to adhere to a planned exercise regimen,even with the highest motivation, without some deviance from complete ad-herence. To minimize the detrimental impact of failing to meet one’s standard,participants are taught (through group lecture and open discussions) that slipsin maintaining a program of regular walking should be anticipated and viewedas temporary and inevitable lapses, rather than an indication of impending break-down in one’s ability to adhere to the program.

The Abstinence-Violation Effect

The abstinence-violation effect is based on the belief that once the abstinencerule is broken, total relapse is inevitable. This phenomenon has been shown to



77

be a powerful contributor to relapse in many individuals treated for addictions.For example, just one cigarette, one beer, or one dish of ice cream will undoweeks or months of successful abstinence. Similarly, in the context of exerciseadherence, individuals tend to believe that if they miss one session, they willnot be able to begin again.&dquo; To counteract these misconceptions, new exercisersshould develop a more realistic perspective. Participants in our program learnto be flexible in planning their walking sessions and understand that missing asession does not necessarily place them at risk for failure. Failure is not viewedas an inevitable consequence if they are prepared to resume behavior changeeffort after a slip occurs. Highly self-efficacious persons are inclined to regarda slip as a temporary setback and reinstate control, while less self-efficaciousindividuals display a marked decrease in perceived self-efficacy and often relapsecompletely.67

In our program, participants are encouraged to view adherence to their walk-ing program as a continuum rather than as a dichotomous (totally adherent vs.totally nonadherent) situation. In this context, a lapse of one session after 8weeks (or 24 sessions) of adherence is viewed as a slip from 100% to 95%,rather than a sudden fall to 0%. When a class member experiences a slip (i.e.,misses a planned walking session) the program interventionist encourages class-mates to help the person understand that even though they had to miss a classor did not feel like walking, that person should not feel discouraged. In addition,participants are taught coping self-talk, 111.12 such as: &dquo;I’ll continue to go back toclass (or take my out-of-class walks again), as I did before ... I know that onceI get started I really enjoy exercising... If I was able to get into the exerciseroutine once, I’ll be able to get used to it again.&dquo; This self-talk is practicedweekly, from the second week of the program.

Recognizing High-Risk Situations

Participants are also taught to recognize and avoid high-risk situations thatwill challenge their exercise-compliance coping skills. For example, programparticipants are encouraged to seek out or create situations that make walkingmore convenient and enjoyable, and to avoid people, places, or situations thatmay compromise their efforts to adhere to their walking program. Participantsare taught to avoid starting to watch a television program at or near the timethey are scheduled to walk, planning a vacation during which eating and drinkingwill be encouraged and physical activity is likely to be limited, and making atelephone call near their scheduled walking session.

The Planned Relapse

Participants also experience a planned relapse during which they voluntarilyfail to walk for one in-class session and one scheduled out-of-class session.

Participants then resume their walking program the following week. The ra-tionale for the planned relapse is to give participants an opportunity to experiencethe abstinence-violation effect under a controlled and supported condition. Bydoing so, participants have an opportunity to discuss their reactions to the relapse



78

and use their problem-solving skills to address issues and dilemmas identifiedduring the experience.

SUMMARY

Because of growing recognition and documented evidence of the benefits ofregular physical activity in the management of patients with chronic osteoar-thritis, educational programs designed to encourage patients to adopt and main-tain walking are becoming increasingly important. The theoretical and empiricalresearch literature from patient compliance and patient education, exercise com-pliance, behavioral psychology, and relapse prevention have documented a num-ber of successful intervention strategies to promote the adoption and long-termmaintenance of physical activity. Our experience with the walking programdescribed suggests that such theory and intervention strategies can and shouldbe integrated into hospital-based educational programs whose goals and objec-tives are to enhance the functional capacity of patients with osteoarthritis. Theeducational program we have described should be readily adaptable for imple-mentation in a wide range of patient-care and other community settings.

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A Walking Education Program for Patients with Osteoarthritis of the Knee: Theory and Intervention...

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