Habit-Centered Rehabilitation: A New Approach to Goal Setting

Setting patient goals is a fundamental part of our clinical work. We use goals to track our patients progress, celebrate milestones in their rehab, and focus our treatment on their functional needs.

But what if were approaching goals the wrong way? Maybe our patients could benefit from a new approach to goal settingan approach that focuses on establishing new habits and identifying cues that trigger behaviors.

In his book The Power of Habit, Charles Duhigg reveals the habit loop as a way to understand how habits work. Simply stated, a habit loop is created when a cue leads to a routine and results in a reward. According to Duhigg, this cue-routine-reward cycle is the basis of all habits. Understanding how this works can help us in motivating our patients to achieve the goals we set together in rehabilitation.

Heres Your HEPGood Luck!

We establish short-term and long-term goals with our patients and work toward them every week. But if our patients dont know how to create the positive habit of performing the activities we provide through home exercise programs, good luck on meeting those goals.

Duhigg shares a story of a psychologist who visited an orthopedic hospital and was surprised to see the difference in success levels of people who underwent knee- or hip-replacement surgery. The psychologist wondered if they could harness the power of patient willpower to complete the necessary rehab required to succeed with the joint replacement.

The psychologists strategy was simple: Provide each patient with a blank notebook and have them write down their goals for the week and exactly which activities they were going to do to meet those goals. As an example, a patient might write, My goal this week is to walk to the cafeteria at lunchtime every day. Ill use my walker and sit down at the bench halfway if needed. Writing down the specific time and location was encouraged as patients used their daily sheets to write out detailed plans for their weekly activities.

The psychologist found that this writing routine enabled patients to achieve their functional goals much quicker than those who didnt write anything down at all.

How Can I Apply This Lesson to My Work?

Im not suggesting that we get rid of short-term or long-term goals. But I do want to challenge you to think about the ways youll help your patients meet those goals. Yes, providing them with educational resources and a stunning home exercise program is part of the solution.

I also think we can help people identify their own habit loops and create new habits based on the suggestions we give in rehab sessions.

3 Ways to Establish Better Habits with Our Patients

1. Ask them to write down one to three big goals for the week.

Research points to an association between setting written goals and improved performance.^{1, 2}

Its a simple request to ask of your patients, but it may lead to significant results. The format doesnt need to be fancyit just needs to be. You might even create a goal sheet that provides a basic structure of functional goals you want to work toward.

2. Develop a habit loop around HEP and goals.

A habit loop occurs when a cue is followed by a routine that leads to a reward. To build new habits with your patients, youll need to think through a few cues that can act as a trigger for a new routine. A cue can be a location, a time of day, or an emotional feeling. It could also involve being around certain people. It may also simply be a pattern of behaviors that trigger a specific routine.

Lets consider someone who is recovering from a knee replacement. If your goal is for them to practice squatting with even pressure through both legs, ask the patient to write down this goal and identify a cue:

• I will sit and stand ten times at every meal.

• Every time I finish using the restroom, I will perform ten squats at the sink.

Youre helping them identify cues (in this case, meal time and bathroom time) and establishing a routine of performing their exercises on the spot. As for the reward, it may sound simple, but placing a sticky note at the cue location (the kitchen table or bathroom mirror) and instructing them to check off the task can produce a sense of accomplishment, which functions as the reward.

3. Reinforce with positive feedback and accountability.

Another reward is the positive feedback you provide at the next session. In the Dominican University study cited above, accountability was a key component, leading to a higher success rate for goal achievement when participants physically wrote out their goals and provided weekly updates to a colleague. When your patient knows that youll ask them about a specific task or goal for the week, this may be the accountability they need to stick with the habit loop youre trying to establish.

One of the ways you can improve accountability with your patients regarding their home exercise program is by using the Medbridge GO app. The app integrates gamification, reminders, and push notifications to engage patients and encourage positive habits. Within the app is a streak tracker, which acts on our natural desire for rewards. Keeping a streak is a powerful strategy to build habits, so encourage your patients to aim for weekly streaks.

Achieve Your Goals By Creating Better Habits

Goals and habits go together like chips and salsa. Sure, you can enjoy them independent of each other, but its just not the same. When we understand the basic components of a habit (cue, routine, and reward) and think of creative ways to build these components into our patient goals, we set our patients up for a higher chance of success.

If you can identify these elements of the habit loop, you have the power to change or create a habit. And when you can create good habits, you can achieve extraordinary goals.