Despite many advances in arthritis research and management over the past two decades, the patient with arthritis remains the principal provider of his or her care. While the typical interaction between a patient and health care provider is limited to periodic, time-pressured clinical care visits, arthritis management remains a 24/7 responsibility for the patient.

When it comes to people with arthritis, the literature supports four primary self-management behaviors including: weight control, using medications appropriately, attending self-management classes and being active.

However, clinicians play a crucial role in supporting the patient’s self-management activities. The Institute of Medicine defines self-management support as the systematic provision of education and other supportive interventions to increase patient skill and confidence in managing his or her health problems.¹

While patients with arthritis may try a variety of strategies to manage their condition and providers may deluge patients with instructions for self-care, there are four primary self-management behaviors that are well supported in scientific literature. Specifically, these behaviors include using medications appropriately, attending self-management education programs, controlling weight and being physically active.²

Until the 1980s, people with arthritis were discouraged from being too physically active due to fears of aggravating the disease. Recently, Westby and Minor summarized the current literature and concluded there is consistent evidence that patients with arthritis can safely participate in moderate physical activity without aggravating their disease.³ Regular joint-friendly activities such as walking, aquatic exercise, stationary bicycling, aerobic dance and circuit training can contribute to significant clinical improvements in function, flexibility, muscle strength and endurance, cardiovascular fitness, and psychological status.

However, 44 percent of people with arthritis are sedentary and more than half are insufficiently active.⁴

Using Behavioral Counseling Techniques
Behavioral counseling is a useful form of self-management support that can help mobilize sedentary or insufficiently active people with arthritis.⁵ A review by the United States Preventive Services Task Force notes the promise of multi-component interventions that combine advice from a provider with behavioral interventions such as collaborative goal-setting, written prescriptions and regular follow-up.⁶

Glasgow and others outline the five A’s model of provider counseling, which offers a practical sequence of steps that incorporate multiple components into a simple framework for providing support for patient self-management.⁵ Initially developed and tested in smoking cessation, this model has not been tested specifically in arthritis but has been applied to other self-management strategies such as physical activity and weight loss. The American College of Preventative Medicine recommends the use of the five A’s model for physical activity counseling.⁷

The five A’s are assess, advise, agree, assist and arrange follow-up. Each is described briefly below.

Assess. One should assess the patient’s current beliefs and behaviors related to potential areas of behavior change. When developing an action plan, it is also important to assess the patient’s confidence in his or her ability to achieve the plan.

Advise. Offer clear, specific, personalized advice on the need to change, the benefits of changing and the risks of not changing.

Agree. Using a collaborative process, negotiate a mutually agreed-upon goal and action plan. In contrast to provider-driven instructions, this allows the patient to prioritize goals and developing the action plan translates those goals into concrete actions.

Assist. Provide concrete support that will help the patient achieve the action plan. This may involve providing the patient with educational materials, referrals to specific community services or social support.

Arrange follow-up. One may arrange proactive follow-up such as telephone contact through the provider office if staffing is sufficient. At a minimum, you should revisit the patient’s self-management goal and action plan during the next appointment. You can also suggest having a friend or family member follow up with the patient on his or her action plan.

Securing Patient Involvement In Physical Activity
Physical activity can be a prime focus area for self-management support. Clinicians can apply the five A’s model to physical activity counseling.

Assess. Questions such as, “What is worrying you most right now?” can begin to set a focus area for counseling. Some sample questions or statements may include “How much regular physical activity are you getting?,” “Tell me about your exercise in the past week” and “How important do you think exercise is in managing your arthritis?” These questions can be helpful in assessing attitudes, beliefs and behaviors concerning exercise and arthritis, and your patient’s current level of exercise. The question, “What keeps you from doing physical activity?,” will help assess barriers to physical activity.

Advise. Establish a credible scientific basis for your advice. For example, consider telling the patient “research shows that walking 30 minutes, at least three times a week, can reduce arthritis pain.” This advice needs to be specific with statements such as, “Since you have not been doing much exercise lately, I recommend that you begin slowly, maybe with a five to 10-minute walk once a day and gradually increase your activity to three 10-minute walks per day.”

Agree. Summarize areas that may help the patient select an area of focus. One might say, “I think losing weight and increasing your activities could help relieve your arthritis pain. Which one is more important for you right now?” Help your patient shape a more immediate specific goal by asking questions such as “What amount of exercise is realistic for you initially?”

Specific “what,” “when” and “how” questions can help create the action plan. These questions may include:
• What activity seems like a reasonable form of exercise to start?
• How much do you plan to do?
• When can you fit this in during the day?
• How many times a week do you think you can do this exercise?

Assessing self efficacy or confidence can help ensure the action plan is realistic. “On a scale of zero to 10, how sure are you that you will be able to take your walks after dinner three days a week like you plan?” If the patient’s confidence rating is less than seven, the action plan may be too ambitious and you may want to renegotiate this with the patient.

Assist. Very specific referrals to community services such as the Arthritis Foundation are useful. Providing educational materials such as pamphlets on ways to overcome barriers to physical activity can be useful assists.

Arrange follow-up. Telephone follow-up can be a very useful component of self-management support. Suggest your patient call in or leave a message when convenient. Friends and family can also do a follow up. Let the patient know he or she can have a friend or family member check in on the progress of the plan.

Final Notes
While patients have the ultimate responsibility managing their arthritis, clinicians play an essential role in self-management support.
Support key self-management behaviors such as physical activity, maintaining a healthy weight and attending self-management education programs. The five A’s model of behavioral counseling can be a pragmatic framework for providing this self-management support in clinical practice.

In their study of behavioral counseling, Flock and colleagues found that clinicians often assessed and advised but the “assist” and “arrange follow-up” steps rarely occurred.¹⁰

Combining collaboration on goal setting and the development of action plans in addition to referrals for community resources and other follow-up actions is essential. By using this model to engage and support your patient’s self-management efforts, you can help the patient with arthritis evolve from a passive recipient of health care to an active manager of his or her arthritis.