Pairing: What MSK therapists can learn from the ABA approach to enhance adherence?

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Within musculoskeletal physiotherapy, adherence to exercise programs is a challenge and generally adherence has been reported to be in the range of 50% and can be even lower for unsupervised home exercise programs. If you don't take your medicine, its likely not to have its desired effect. Similarly, if you do not adhere to the prescribed exercise program, it is likely that effect of exercise program will be sub-optimal. 

Recently I attended a workshop on introduction to Applied Behaviour Analysis (ABA). While I will write about separately in a different article in the next week or so, it suffice to say here that it is an approach to behaviour analysis which examines the causes and consequences of behaviour in children with autism and other neurodevelopmental disorders to develop interventions to address what they term as 'Problem Behaviour'. 

In the first session, the trainer talked to us about 'Pairing' with the child to develop rapport. Simply put, it is the process of combining reinforcing and fun activities for child with the ABA therapist's presence. 

So practically how is pairing done? The advice we were provided is - 

"When working with a child, one of the main things you want to do is pair yourself with fun and reinforcing items.  You want the child to find you, and the environment, exciting and pleasing.  If the child is having fun and likes being with you, then he will be more motivated to come to therapy to work and play."

This got me thinking.. In some sense, it is pretty similar to developing therapeutic relationship with patients. I have already written about the influence of therapeutic relationship and adherence. Do they trust you enough? The role of therapeutic relationship in rehabilitation adherence

But while we talk about gaining trust and building up a relationship, this concept of 'pairing' felt like it could hold the key to enhancing the patient's engagement with the physiotherapist and consequently with the exercise program. 

Pairing is an ongoing thing where we briefly pair with the child at the top of all therapy sessions, and to continually conduct brief reinforcer preference assessments to make sure they are approaching the client with what that client wants, in that moment.

As clinical therapists, this is an assessment we need to be making continuously as well, what is the patient's motivation, what are their goals, what can reinforce them to undertake exercises, is the exercise at their level of expertise or are they finding it too hard? Sometimes they can find it too easy that they perceive it to be worthless.

In the end it is all about the perceived need. 

With pairing, ABA therapists identify what are the most important motivators for those children e.g. iPad, music, jellyfish or other toy. They use themselves as the tools to be the mediators/ providers of these motivators and get the children to do the tasks required in order to effect a behaviour change. Similarly, physiotherapists need to ensure that the perceived need for physiotherapy/ exercise program is high and the patients understand the value that can be delivered through completion of the exercise program. This will then influence their motivation to exercise, attend the clinic sessions and follow the advice from the physiotherapist. 

If the perceived need is high, they will prioritise the exercise sessions over other competing demands. On the other hand, if the perceived need is low or they do not understand why they have been referred for physiotherapy or what doing those exercise can do for them, they are unlikely to adhere to the program. If the perceived need reduced, their motivation decreases as well, even if they do understand the nature of exercise program. Many of the reception team members describe that due to the long waiting times, some of the patients might get better naturally over time and therefore not feel any need for physiotherapy and cancel before their first appointment. 

In our training programs, while we learn about assessments, we learn about interventions but very little focus is placed on developing therapeutic relationship with the patients. While it is certainly important and most physiotherapists do realise it, but we need to actively make effort during the sessions to continuously engage with the patients, to assess their motivation, their understanding of the program and their perceived need of the program. 

In ABA we were taught that you have to enter the child's world to understand their motivations and then only we can influence their behaviour. Same is true for us as well. If the client needs to return to work in a heavy manual role and we give them an exercise program that they can't see how it will help them return to their job, their perceived need, their motivation and consequently their engagement with us will wane. 

So as physiotherapists we need to ensure that we are 'pairing' with our patients in a fashion which is quite similar to the ABA therapists. Its not a once and done deal, it has to be done at the start of each session and infact has to be an ongoing conscious process throughout the therapeutic encounter. 

Do you agree?  



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