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Motivational Interviewing
 ONLINE COURSE

Motivational Interviewing

Presented by:
Mandy Roscher

Description

Motivational Interviewing (MI) is an evidence-based intervention that

helps to support health behaviour change. MI uses distinct techniques
to mobilize the individuals intrinsic goals and values and to
understand and resolve ambivalence about change. [1] It was originally
used to help treat substance dependency, but is now seen as an
effective way to promote behaviour modification and to manage
chronic diseases. [2] [3] Areas where MI has been used include: weight
loss, smoking cessation, alcohol consumption, and blood sugar
control.[4] It is also growing in popularity within physiotherapy
practice.[5]

William R. Miller, a distinguished Professor of Psychology and

Psychiatry in New Mexico, wrote the first article about MI in 1983. In
1991 the first related textbook was published titled “Motivational
Interviewing” by W. Miller and S. Rollnick, and introduced the
fundamental concepts of MI, and introduced some of the language
that continues to be used to describe MI. Stephen Rollnick is a
Professor for Health Care Communication, [6] at Cardiff University,
Wales, UK.

Miller and Rollnick developed a new four-process model of MI, and

their 3rd edition book "Motivational Interviewing. Helping People
Change" was completely restructured around this. [7] This four-process
model (engaging, focusing, evoking, and planning) is discussed later
on this page.

Definitions Of MI

Lay definition

'Motivational Interviewing is a collaborative conversation style for

strengthening a person's own motivation and commitment to
change.' [7]

Definition for therapists

'Motivational interviewing is a person-centred counselling style for

addressing the common problem of ambivalence about change.' [7]

Therapeutic craftsmanship

'Motivational Interviewing is a collaborative, goal-oriented style of

communication with particular attention to the language of change. It
is designed to strengthen personal motivation for and commitment to
a specific goal by eliciting and exploring the person's own reasons for
change within an atmosphere of acceptance and compassion.' [7]

Rollnick and Miller [8] describe MI as 'a directive, client-centred

counselling style for eliciting behaviour change by helping clients
explore and resolve ambivalence'. MI has been used across various
conditions such as diabetes, asthma, cardiac rehabilitation [9].
Approximately eighty percent of studies have found that MI has
superior outcomes when compared to traditional educational
approaches[10][11].
The Approach

Ambivalence

Ambivalence is a conflict between two courses of action each of which

has perceived costs and benefits associated with it. An example might
be going for a jog: the benefits would be all of the health gains,
however, a cost might be the perceived risk of social embarrassment.
Unresolved ambivalence is often why clients are unable to commit to
behavioural change. How a therapist handles a client's ambivalence
may influence outcomes. [7]

Righting Reflex

Therapists have the desire to want to help the people under their care
and this is often expressed as the 'righting reflex'. Clinicians' beliefs
and aspirations for the patient determine the use of language and
interventions used [12]. When a therapist sees a discrepancy between
how things are and how they ought to be they want to fix it.

When patient ambivalence is confronted by the righting reflex of the

therapist, outcomes tend to be poor. Patients can feel unvalidated,
want to resist the clinician, or withdraw from the consultation.
Ultimately, people want to be understood and accepted without
judgement[13].

Rolling with Resistance

Resistance can be met with any talk of change behaviour in a client

and may be found in interrupting, arguing, excusing behaviour and
blaming others. If met with resistance the therapist can use various
techniques to roll with the resistance such as avoiding judgment,
affirming their fears and concerns, reflecting other concerns and
offering assistance.
Empathy

Empathy is the ability to accurately understand your client's meaning

and accurately reflect back to your client.

'Empathy is the listener's effort to hear the other person deeply,

accurately, and non-judgmentally. Empathy involves skilful reflective
listening that clarifies and amplifies the person’s own experiencing
and meaning, without imposing the listener’s own material.' Rogers
(1951)[14]

The Spirit of MI

There are four principles that embody what MI is about or as Miller

and Rollnick [7] [15] have termed “The Spirit of MI”:

1. Partnership - the therapist and client should work together as

two experts. The therapist a clinical expert. The client an expert
of their own behaviours, motivations, and attitudes
2. Acceptance - the therapist realises that everyone has inherent
worth, provides unconditional positive appreciation
(affirmations), support of autonomy, empathy, and respect
3. Compassion - promotion of the individuals physical and
psychological well-being
4. Evocation - the client is encouraged to develop their own plan
of action from within
Miller and Rollnick (2015) emphasize repeatedly that MI is not a
method in order to influence or persuade clients. Patients should
draw their own solutions. [16] One important aspect is, that the
therapist should not talk more than 50% of the communication time.
The communication should work like a ping pong play using the
various communication skills and techniques. Therapists want to
evoke client's self-motivation skills. Clients should formulate their
own arguments of behavior change. 'They talk themselves into
change...' [17]
Core Interviewing Skills

Open-Ended Questions

An open-ended question is a question that cannot be answered with a

yes or no but requires a developed answer.

Examples:

 Can you tell me about your back pain?

 What's your story?
 Can you tell me about your problem?
 What are you struggling with at the moment?

Affirmations

An affirmation is a direct statement of support provided by the

therapist. The statement is focused on a positive aspect of a patient’s
effort and commitment or strength. It demonstrates to the client that
the therapist is trying to understand and appreciates what the patient
is dealing with. Affirmations help build a therapeutic relationship,
they also reduce defensiveness and maintain an open, accepting
relationship.

Examples:

 You have done very well for coping so far

 It shows commitment to come as far as you have
 That’s a very good way of expressing that
Reflections

Using reflections in the interview requires the therapist to be

interested in what the person has to say and respect the client's point
of view and thought processes. This is achieved by temporarily
suspending assumptions and avoiding imposing them. Reflective
listening allows the therapist to test a hypothesis and check their
understanding of what the patient has said. Reflections allow the
therapist to check their understanding of the client's point of view,
they reduce defensiveness and can reinforce change talk.

A reflective statement aims to capture the main thing and reflect the
therapist's understanding. They can be performed through repetition,
rephrasing, paraphrasing, a reflection of a feeling, or a summary.

Examples:

 Physiotherapy hasn't worked for you in the past and you feel
that it wont for you now.
 After a hard day's work all you would really like is a cigarette
and that helps you relax.
 You don’t like being unfit.

Summarising

Summarising is often used at the end of a consultation or to draw

different aspects together. Meaning is inferred to what was said and
reflected back with new words. Summarising adds to and extends
what was actually said.

The Process of MI

Miller and Rollnick [7] describes four phases in the development

process that occurs with a successful MI intervention.

Engaging

Both Partners, client and therapist, build a therapeutic alliance from

the very beginning. It belongs to the agreement on tasks and goals
Evaluation of the therapeutic alliance through the client predicts the
outcome of the therapy, vice versa not always [18].

Focusing

Client and therapist align their communication to one or more change

targets.

Evocation

Both experts (patient and therapist) give rise to the self-motivation

skills of behavioral change of the patient. The therapist uses the
various communication skills and techniques in the interview to help
evoke change talk and strengthen motivation to change in the client.
The patient formulates his arguments for the change by himself.

Planning

This phase of MI includes a voluntary commitment to and the

formulation of an action plan from the patient.

Change Talk

Change talk is self-motivating speech. Therapists can identify

markers within the language used by the client which identify
readiness for behavioural change. The individual can express a
Desire, an Ability, Reasons why or a Need to change (DARN). The
therapist must elicit, recognise, and reinforce change talk through
appropriate questioning and listening.

MI can incorporate the use of a 'confidence ruler' and/or an

'importance ruler' which can aid in the evocation and exploration of a
client's confidence in their ability to make the change, and their
perceived importance to making a change. Both rulers are on a scale
of 0 to 10, where 0 is the least confident / important and 10 is the
most important / confident. After the client gives a number then the
reasoning for the number(s) can be further explored. Miller and
Rollnick advise against using more than two of these rulers in any one
conversation as this can become tedious to the client. [7]

Planning

Planning can proceed when:

 There is sufficient engagement.

 There is a clear shared change goal.
 Sufficient patient motivation for the change has been achieved.
Miller and Rollnick describe the role of MI as concomitant during the
patient draws his action plan. [6] They created three forms of change
talk for this special stage in the MI-process. The three forms can be
summed up with the acronym CATS: Commitment, Activation and
Taking Steps

The therapist's work is to evoke CATS-statements from the client. He

can do this through questions like the following:

 How high is your willingness to do that?

 When do you believe you will be clear on that?
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Providing Information in MI

The spirit of MI is centred around evoking change from the client by

resolving ambivalence. There is, however, room for providing
information although permission to give advice should always be
gained prior to providing it, and any advice given should be given in
small doses. This can be hard for clinicians who are not practiced in
MI techniques as they are used to taking on the 'expert' role, and
advice giving is normally part of the day to day interaction with
service users. In many healthcare roles, advice is often given
frequently and the assumption is often made that the patient will take
this advice on board and make the advised changes / undertake the
advised behaviours. Miller and Rollnick [7] advocate the use of the
Elicit-Provide-Elicit technique to ensure the client is happy to be
given advice, and that they understand the advice that has been
given.

1. Elicit - explore the gaps or inconsistencies in the client's

knowledge, ask permission to provide information, query for
interest.
2. Provide- provide information using no medical jargon and in
small manageable chunks.
3. Elicit- check for understanding.
An example would be as follows

1. Elicit- “Would you like me to give you some ideas on exercises

that would be beneficial to you”.
2. Provide- “Walking or cycling on a stationary bicycle may be a
good place for you to start”.
3. Elicit- “How does that sound”.

Indication

 Initiating any behavioural change

 Exercise prescription
 Smoking cessation
 Physical inactivity
 Educating
 Giving bad news

Examples
Evidence

A systematic review [19] found that motivational interventions as an

adjunct to traditional PT programs could have a positive effect on
adherence to exercise. The level of evidence in the in selected studies
was medium and low quality.

A RCT[20] examined a patient-centered approach (coach2move) for

frailty over 70 years old adults, which included MI. The primary
outcome was moderate-intensity PA and total PA per day, measured
per LAPA-Questionnaire. The experimental group showed a
significantly longer improvement in moderate-intensity PA (p= 0.012)
with broad 95%-CIs (4.0 to 34.9 min.) and for total PA (p=0.182) with
broad 95%CIs, too (-6.6 to 34.9 min.) per day. The secondary
outcomes (frailty, cost-saving, QALY) frailty decrease significant, the
cost-saving and the improvement in QALYs were significant, too, with
narrow 95%CIs for frailty and QUALYs.

RCT[21] looked for effects of MI in enhancing PA in people with

subacute spinal cord injury. The MI group showed significant longer
PA times, with although wide 95% CIs. PA was measured by
accelerometry.

SR with Meta-Analysis found modest improvements in PA for people

with chronic health conditions, the standardized mean difference
between intervention and control groups was significant (0.19, p=
0.004), the 95%CIs (0.06 to 0.32) were wide.

A systematic review [22] on using motivational interviewing for people

with Chronic Pain found that MI may increase short term adherence
to interventions. More research is needed to confirm this finding.

MI could be a useful therapeutic tool within physiotherapy practice in

order to enhance exercise behaviour. [23]

Case Studies

 Obesity
 Physical inactivity (i) (ii)
  Shoulder and neck pain
 Homelessness
 Schizophrenia
 Palliative care
 Intravenous drug abuse

Related articles
Practical Application of Motivational Interviewing -
Physiopedia Introduction When conducting an interview, it is important to create
a good rapport with your patient. There are many ways this can be achieved and,
with practice, these techniques can be effectively applied. It is useful to consider
how something is said and the impact this can have on the individual receiving
the information. It has been shown that a person is far more willing to divulge
information if they believe you are genuinely interested in them and the
information they are sharing. Communication is an interactive process which
involves the constructing and sharing of information, ideas and meaning through
the use of a common system of symbols, signs, and behaviours. Motivational
Interviewing[edit | edit source] Motivational Interviewing (MI) is an evidence-
based intervention that helps to support health behaviour change. It was
originally used to help treat substance dependency, but is now seen as an
effective way to promote behaviour modification and to manage chronic diseases.
[1] The model views motivation as a state of readiness to change rather than a
personality trait. Click here for more theory on Motivational Interviewing The
Spirit of Motivational Interviewing “The Spirit of MI”[edit | edit source] There are
essentially four principles, known as “The Spirit of MI” by the authors Miller and
Rollnick.[2] These principles encapsulate the aim of MI and are:[3][4] Partnership
While the therapist is known as the clinical expert, the patient is the expert of
their behaviours, motivations and attitudes. The two should respect each other
and work together for the best possible outcome. Acceptance The therapist
should strive to hold a non-judgemental and accepting space for the patient to
present their problems. They should provide positive appreciation or affirmation,
support autonomy, empathy, and respect. Compassion The therapist should always
advocate for a patient's physical and psychological well-being. Evocation A
therapist should encourage the patient to develop their own plan of action
themselves. This allows collaboration and offers a programme that the patient is
motivated to comply with. The Tools for Motivational Interviewing[edit | edit
source] There are five skills the therapist can practise, leading to an effective
Motivational Interview. These are:[5] Expressing empathy When the therapist
shows empathy, it shows they are interested, accepting and understanding of the
patient's situation. This in itself improves the rapport and often allows the patient
to open up more.[5] Avoiding arguments The therapist needs to learn to manage
conflict. Starting an argument creates an unpleasant environment and the patient
is unlikely to participate in the treatment plan.[5] Supporting self-efficacy The
therapist should show support in any optional change suggested by the patient.
This helps them build confidence in their belief that they could change.[5]
Developing goals The patient should be the driving force behind the goal setting.
The therapist should not force any goal on the patient as they won’t always align
with the patient's thoughts and beliefs.[5] Rolling with resistance This is a
technique employed by the therapist whereby they offer ideas which could
influence a patient to change their perspective. These perspectives should never
be forced, argued or imposed.[5] Steps in Motivational Interviewing[edit | edit
source] The steps of Motivational Interviewing that allow the process to work and
evoke real change include:[5] Establishing rapport Rapport is the relationship you
build with the patient and it is based on trust and good communication.[5] Setting
the agenda Throughout the course of treatment, realistic targets should be set,
but not imposed on the patient. The agenda should be reconsidered often and
changes are welcome. Try and encourage realistic goal setting as reaching a
target is very motivating.[5] Assess readiness to change Assessing their
eagerness to change, will give an insight into their level of motivation.[5] Re-
adjust the focus Make sure the focus is directed towards the patient's wants and
what has motivated them to seek therapy. It needs to be clear, to the therapist,
what exactly they want to change.[5] Identify uncertainty If the patient is
uncertain, this can be a barrier to change. Be aware and try to talk through
uncertainty.[5] Encourage self-motivation Help to create a positive attitude in the
patient and encourage them to highlight success.[5] Effective Communication[edit
| edit source] Motivational interviewing can help to improve the patient-therapist
relationship. There are four core communication skills in motivational
interviewing, which are known by the acronym OARS (see table below).[6] This
stands for open-ended questions, affirmations, reflective listening and summaries.
[6] These are crucial components of effective communication as they can
increase patient adherence, collaboration and satisfaction.[7] OARS Purpose Goal
Open Ended Questions Gather crucial information that cannot be gathered from
closed ended questions Cannot be answered yes or no Allows the patient to tell
their story Affirmations Used to show acceptance and understanding Statement of
appreciation Reflective Listening Understanding the patient's thoughts and
feelings and saying it back to them Statements not questions Summaries Used for
highlighting both sides of a patient's ambivalence Provide recap to ensure
understanding Transition from one topic to another Longer than reflections Table
1. Core Communication Skills in Motivational Interviewing (OARS).[6]
Psychosocial Risk Factors[edit | edit source] When conducting an assessment, the
mnemonic, ABCDEFW, can help a therapist remember all relevant lines of
questioning that can identify potential psychosocial risk factors.[8] This stands for
Attitudes and Beliefs; Behaviours; Compensation Issues; Diagnosis and
Treatment; Emotions; Family; and Work.[9][8] In 2014, Louis Gifford suggested
possible starting questions and the potential information that could be gathered
from each subsection.[8] Follow-up questions are often needed for further
understanding. Please see the table below with some examples of how to question
for psychosocial risk factors in a patient utilising the ABCDEFW criteria. Topic

cause of your pain? ● Fear/avoidance ● Catastrophization ● Maladaptive beliefs

area Question Information gained Attitudes and Beliefs What do you think is the

● Passive attitude toward rehabilitation ● Expectations of effect of activity or

work on pain Behaviours What are you doing to relieve your pain? ● Use of
extended rest ● Reduced activity levels ● Withdrawal from ADLs and social
activities ● Poor sleep ● Boom–bust behavior ● Self-medication – alcohol or

difficulties? ● Lack of incentive to return to work ● Disputes over eligibility for

other substances Compensation Issues Is your pain placing you in financial

benefits, delay in income assistance ● History of previous claims ● History of

examined for your pain? Are you worried that anything may have been missed? ●
previous pain and time off work Diagnosis and Treatment You have been seen and

Health professional sanctioning disability ● Conflicting diagnoses ● Diagnostic

language leading to catastrophizing and fear ● Expectation of “fix” ● Advice to
withdrawal from activity and/or job ● Dramatization of back pain by health

anything that is upsetting or worrying you about the pain at this moment? ● Fear
professional producing dependency on passive treatments Emotions Is there

● Depression ● Irritability ● Anxiety ● Stress ● Social anxiety ● Feeling useless

or not needed Family How does your family react to your pain? ● Over-protective
partner/spouse ● Solicitous behavior from spouse ● Socially punitive responses
from spouse ● Support from family for return to work ● Lack of support person
to talk to Work How is your ability to work affected by your pain? ● History of
manual work ● Job dissatisfaction ● Belief work is harmful ● Unsupportive or
unhappy current work environment ● Low educational background ● Low socio-
economic status ● Heavy physical demands of work ● Poor workplace
management of pain issues ● Lack of interest from employer Table replicated
with permission from Ina Diener, author of Listening is therapy: Patient
interviewing from a pain science perspective. While traditional interviews focus
heavily on the intensity, duration, behaviour and nature of pain,[8] it is also
necessary to ask questions associated with the patient’s beliefs. More in-depth
questions should include: the patient’s current beliefs regarding their pain; their
perspective on their pain experience including treatment effects; and perspective
on their outlook in regards to recovery. When considering questions to ask a
patient, first ask yourself:[8] What information is required? Why is it important?
How can I phrase this question? What are possible outcomes? Does this
knowledge affect the examination or treatment? Immediate Response Questions
and in depth questions often convert statements of fact into comparisons. They
often explore a patient’s cognitions, beliefs, and experiences regarding their
pain. Below are some examples of helpful phrases and questions.[8] How does
that compare with….? Is there any difference between…? In what way….? What
do you think is going on with...? What do you think should be done for...? Why do
you think...? What would it take for you to get better? Where do you see yourself
in 3 years in regard to...? What have you found to be most helpful for your...? You
have obviously seen many people seeking help. What are your thoughts on this?
What gives you hope? What is your expectation? If I could flip a switch and
remove all your pain, what things that you have given up on would you do again?
How has your pain impacted your family and friends? Are you angry at anyone
about...? Tell me about it. Has anyone made you feel like you’re “just making it
up” or “it’s in your head?” Tell me about it. Therapeutic Alliance[edit | edit
source] A strong therapeutic alliance can have positive effects on treatment
outcomes for patients.[10][11] The therapist needs to be aware of how the patient
is coping, their perception of the problem they are presenting with, and the
impact of this problem on their life and activities of daily living.[8][12] If this is
not communicated effectively at the start of an interaction, the mismatch in
knowledge and beliefs could affect the therapeutic alliance.[8] The therapist has
to understand the problem from the patient's point of view - they must be aware
of patient-specific beliefs and patient-specific risk factors. This will help the
therapist explain the biology and physiology of the condition to the patient using a
therapeutic neuroscience education (TNE) approach.[8] Any communication
strategies used during an interview need to enhance a patient's participation, and
enable them to become engaged in both "problem-posing" and "problem-solving".
[8] Communication strategies should enhance the patient's confidence, as well as
their competence to make autonomous decisions.[8] It has been found that if
clinicians are able to engage with patients with good communication skills,
"patients are more satisfied with the care they receive, there is a better recall and
understanding of information, and healthcare professionals experience greater
job satisfaction and less work stress."[13] Practical Interviewing Skills[edit | edit
source] When conducting an assessment, certain skills and techniques can help
improve rapport and make the patient comfortable. These are beneficial in the
long run as the patient will be more likely to divulge the information required
instead of keeping the therapist at an arm's length. 1. Non verbal
Communication[edit | edit source] Non verbal communication is often referred to
as body language.[14] It is thought to be stronger, quicker and more direct that
verbal communication. Non-verbal communication is "reflex in type".[15] It is,
therefore, often interpreted as more reliable and trustworthy than the spoken
word. Consider if a patient's verbal and non-verbal communications are in sync or
not, but remember it is important to respond appropriately to both scenarios.[15]
People respond better to individuals they can relate to. One technique that can
help to increase a patient's comfort level is to mimic or match their actions.[15]
This should be done naturally and in a relaxed manner,[15] so the patient doesn’t
interpret it as mockery or belittling. Always remember to acknowledge a non-
verbal response as a valid answer. Practitioner: “How has it been?" Patient
wrinkles nose. Practitioner: “That doesn't look good. Has it been worse?” Patient
cringes. Practitioner: "I'm sorry you feel this way. Let's chat more to try and get to
the root of the problem" 2. Verbal Communication[edit | edit source] The starting
point in the relationship and treatment of a patient is effective communication.
Whether this comes naturally to you or not, there are some skills that can be
learnt which will make the subjective assessment more effective.[15] The
Interview[edit | edit source] The therapist should always strive to keep control of
the interview. This can be achieved by signposting. Signposting is a verbal marker
indicating the direction you are taking your subjective assessment or where you
are presently at in order to help your patient move through different concepts,
connect the dots, and stay engaged. This can be achieved by using phrases and
words to guide the patient through the consultation. There are two main types of
signposting that are frequently used: introductions/ conclusions and outlining the
main arguments/ the direction of the argument in paragraphs / opening phrases.
We can use this skill when a patient is going off topic in order to bring them back
to the original task and the agreed upon agenda.[15] Maitland[15] encourages
practitioners to: "Speak slowly Speak deliberately Keep questions short Ask one
question at a time" Words That Heal[edit | edit source] We need to think carefully
when discussing medical terms with our patients. It is good to know what their
base level of understanding of their condition is and to find out how much
information they would like on their condition. The practitioner's focus is the
health of their patients, including their metal well-being. Even if a practitioner
thinks the patient should know some information, the patient may not be ready to
hear it. Bias[15] Some people are open to suggestions and some are not. When
constructing your questions, try not to show your bias in the questioning. If this is
not possible, when you are expecting a yes, ask a question with a bias towards no.
For example, when discussing a home exercise programme, the question “did you
enjoy your exercises?’ might be biased towards a yes answer, whereas the
question “I know life is busy, did you manage to get around to the exercises this
week?” is more neutral. Brevity[15] To avoid confusion and misinterpretation,
keep questions short and direct. They can be open ended, but the main goal is to
let the patient talk as much as possible. Spontaneous Information[15] This often
gives the therapist a clue about the patient's personality and can help
contextualise their symptoms. Keywords[15] Sometimes there is a keyword in a
patient's answer that requires further questioning. It is advisable to follow up on
this keyword while it is still fresh in the patient's mind. Once you have clarified
the point, use signposting to move the interview back to the agreed upon agenda.
Errors in Verbal Communication[15] When speaking to a patient, a therapist
needs to be sure that they are interpreting the patient's words accurately. To do
this, the therapist needs to check regularly that the patient is still interpreting
what is being said correctly. If not, the therapist needs to clarify and explain areas
of confusion. There are three key areas a therapist may need to work on when
conducting an interview: Unclear statements[15] When speaking to the patient,
always remember to check that the patient is on the same page as you and ask if
they have any questions. Misinterpreting[15] Patients can use catastrophising
language or use words that downplay their condition, depending on their
personality, pain levels and beliefs around the cause of pain. If the interview is not
conducted in the patient's main language, there may be additional communication
challenges. The therapist should remain non-judgemental and sensitive to the
patient's views. Assuming[15] Never assume, always check and confirm meaning.
For example, if a patient tells you “The pain never goes away”, it might be a good
time to dive deeper into the 24 hour pattern of their pain, fluctuating symptoms,
aggravating and easing factors. This helps provide a clear picture to the therapist
if the patient is describing a true red flag or if emotions / other factors are
impacting the portrayal of their experience. Please see the two examples below
regarding interviews. The video on the left shows an example of a poor interview
while the video on the right shows an example of a good interview. Effective
Communication Techniques - Physiopedia Introduction Effective
communication techniques in a healthcare setting have been developed on the
basis that physiotherapists are in a unique position as part of a multidisciplinary
team in that they can have substantially more contact time with patients than
other members of the team. This means the physiotherapist is more appropriately
positioned to develop a deeper patient-therapist relationship and in doing so
educate and empower the patient of their physical condition and management.
Communication is an important tool in a healthcare setting that when used
effectively can educate, empower and de-threaten common health issues patients
present within practice. However, if it is used ineffectively it can have detrimental
effects creating fear, confusion and anxiety in patients as well as encouraging
resistance to lifestyle changes and healthy behaviours. Importance of Good
Communication[edit | edit source] Communication is an interactive process which
involves the constructing and sharing of information, ideas and meaning through
the use of a common system of symbols, signs. and behaviours[1]. It includes the
sharing of information, advice, and ideas with a range of people using: Verbal
Non-verbal Written E-based These can be modified to meet the patient's
preferences and needs. Figure 1 - CSP quality assurance standards (2012) Figure
2 - HCPC standards of proficiency (2013) Skilled and appropriate communication
is the foundation of effective practice and is a key professional competence
(See CSP: quality assurance standards[1] and HCPC: Standards of Proficiency[2]
figure 2, above) which is highly valued by physiotherapy recipients[3]. Effective
communication requires consideration of the context, the nature of the
information to be communicated and engagement with technology, particularly
the effective and efficient use of Information and Communication Technology.
Benefits of Good Communication[edit | edit source] Effective communication does
not only improve understanding between health professionals and patients but it
can also have a positive impact on health outcomes. To understand why
communication may lead to improved health outcomes researchers have
identified direct and indirect pathways through which communication influences
health and well being.[4]. Direct Pathways[edit | edit source] Talk may be
therapeutic, meaning, a physiotherapist who validates the patients perspective or
expresses empathy may help a patient experience improved psychological well
being. Leading to the patient experiencing fewer negative emotions (e.g. fear and
anxiety) and more positive ones (e.g., hope, optimism and self-worth). Non-verbal
behaviours such as touch or tone of voice may directly enhance well-being by
lessening anxiety or providing comfort[5][6][7] Indirect Pathways[edit | edit
source] In most cases, communication affects health through a more indirect or
mediated route through proximal outcomes of the interaction, such as;
Satisfaction with care Motivation to adhere Trust in the clinician and system Self-
efficacy in self care Clinician - patient agreement Shared understanding This
could affect health or that could contribute to the intermediate outcomes (e.g.,
adherence, self-management skills, social support that lead to better health[8]. A
physiotherapists clear explanation and expression of support could lead to greater
patient trust and understanding of treatment options[4]. This in turn may
facilitate patient adherence to recommended therapy, which in turn improves the
particular health outcome. Increased patient participation in the consultation
could help the physiotherapist better understand the patient’s needs and
preferences as well as discover possible misconceptions the patient may have
about treatment options[4]. The physiotherapist can then have the opportunity to
communicate risk information in a way that the patient understands. This could
lead to mutually agreed upon, higher quality decisions that best match the
patients circumstances[4]. Key factors of communication to improve health
outcomes: Examination and Assessment - using clear concise language and
allowing the patient time to talk will influence the quantity, quality and accuracy
of data Respect Clients individuality and background - adjusting tone and level of
language as well as using lay terms rather than medical terms can help improve
understanding and make patients feel at ease[9][10] Respect a patients space - do
not invade their space without first asking permission Be open and create a
relaxed atmosphere Be attentive - Look at the patient when they are talking
Environment - Provide the patient with an area that is private and away from
noise and interruptions Communicating Sensitive Issues[edit | edit source]
Primary care providers and particularly physiotherapists are often faced with
sensitve issues within their daily practice. One example is dealing with obesity
and encouraging patients to take a more active approach in the management of
obesity[11]. However physiotherapists have encountered many challenges related
to addressing obesity with patients[12]. Given that obesity is becoming an
epidemic in many nations throughout the world, the need to understand how,
when and with whom to have these discussions which becomes essential in order
to provide effective care for obese patients. There is a growing need for the
training of physiotherapists in areas such as weight loss counseling in order to
reduce the barriers encountered when discussing obesity [12]. Wadden &
Didie[13] reported that patients observed the terms obesity and fatness to be very
undesirable descriptors used by their physicians when discussing their body
weight. Other terms such as large size, heaviness and excess fat were also
highlighted as undesirable. The use of these terms by physicians can be
interpreted as offensive or hurtful by the patient and lead to a breakdown in
communication. The study reported that weight was the most favourably rated
term to be used by physicians as it is easily understood and non judgemental.
Another term which was viewed as favourably, as it was non judgemental was
BMI, however it is found to be not universally known. Johnson[14] reported that
some patients preferred to be described as plus sized, large or even fat. By
embracing these terms these patients are motivated to remove the negativity and
stigma related to them. Wadden and Didie[15] reported the most beneficial
approach would be to ask the patient how they feel and their thoughts towards
their weight. Using this approach the physiotherapist should seek the patients
consent and come to an agreement to address and discuss the issue. Caution
should be taken to avoid reiterating the hazards obesity has to the patients
health. Wadden et al[16], reported obese patients often experience a feeling that
care providers seldom understand how much they suffer with their weight issues.
Utilising the conversation approach also allows the physiotherapist to show
respect and empathy to the patient by focusing on the positive steps they may
have taken previously to tackle the issue. The Issue With "Calling It As It Is"[edit |
edit source] This approach fails to avoid the degrading and offensive terms, used
by the public, and causes more negative effects than beneficial effects [14]. It is a
challenge for obese individuals to understand the medical implication of these
terms as they cannot separate them from the degrading aspects of the terms used
by the public.Using a confrontational approach instead of a discussion with the
patient is far more likely to negatively affect the patient’s moral, feelings and
confidence. Johnson[14] reports that care providers who approach the issue by
attempting to 'break through the patient’s denial of their weight issues, are more
likely abolishing the patients trust and their motivation to return for future
sessions and care. This is the most common outcome when individuals are advised
to battle their obesity by losing weight, to avoid the ominous medical
consequences. More desirable and beneficial outcomes can be achieved through
the use of motivational interviewing and discussions with patients in need of
weight management compared to a confrontational approach [17][15]. Teaching
Tools[edit | edit source] Tools such as the video below can be used in teaching and
motivating patients on lifestyle and behaviour change. Motivational
Interviewing[edit | edit source] Evidence has shown that patient-centred
approaches to health care consultations are more effective than the traditional
advice giving, especially when lifestyle and behaviour change are part of the
treatment[18]. In the past, healthcare practitioners encouraged patients to
change their lifestyle habits through provision of direct advice about behaviour
change[19]. However, this has proven to be unsuccessful, as evidence show
success rates of only 5-10%[20] . Additionally, this can put a strain on the patient-
therapist relationship with the patient perceiving this style as being lectured on
their lifestyle choices[21]. Patients can also feel that the therapist is not
considering the personal implications the change may have on their life, as they
are just placing emphasis on the future benefits and not recognising the initial
struggle the patient may have to go through[18]. Such an encounter can risk the
patient becoming resistant to change or further increasing their resistance to
change[22]. This resistance to change was seen as a personality trait that could
only be dealt with by direct confrontation which potentially placed a further strain
on the patient-therapist relationship [23]. Research has shown that patient-
centred approaches have better outcomes in terms of patient involvement and
compliance[18] [24]. The key feature to these approaches is that the patient
actively engages in discussing a solution for their problem[25]. Motivational
Interviewing (MI) is based off Miller & Rollnick’s (1991)[26] experience with
treatment for problem drinkers and is becoming increasingly popular in
healthcare settings. The model views motivation as a state of readiness to change
rather than a personality trait[27]. As such, motivation can fluctuate over time
and between situations. It can also be encouraged to go in a particular direction.
By taking this view , a patient’s resistance to change is no longer seen as a trait of
the person but rather something that is open to change[19]. Therefore, the main
focus of MI is to facilitate behaviour change by helping the patient explore and
resolve their ambivalence to the change[19]. While MI is patient centred and
focuses on what the patient wants, thinks and feels, it differs slightly from other
patient-centred approaches as it is directive[18]. In using MI there is the clear
goal of exploring the patient’s resistance to change in such a way that the patient
is likely to change their behaviour in the desired direction[18]. The focus of
Motivational Interviewing is to: Assist the patient in examining their expectations
about the consequences of engaging in their behaviour. Influence their
perceptions of their personal control over the behaviour through use of specific
techniques and skills.[27]. A benefit to this approach is that time can be saved by
avoiding unproductive discussion by using rapid engagement to focus on the
changes that make a difference[19]. For more on this topic see Motivational
Interviewing Conclusion[edit | edit source] Communication is more than just what
we say, it matters how we say it too. It is important that communication is good,
clear and compassionate in a healthcare setting. The style in which we
communicate may differ between individual patients due to learning styles,
literacy levels or the level of understanding the patient has of their condition and
the anxiety they may present with.Physiotherapy communication
approaches in management of obesity and overweight -
Physiopedia Introduction Physiotherapists have an important role in
encouraging individuals to adopt positive lifestyle changes and increase their
levels of physical activity . Obesity can be seen in a musculoskeletal clinic where
knee pain could be exacerbated or in a medical ward where a patient's diabetes
may be poorly managed. Despite the various health care professions’ efforts to
tackle the issue, obesity is still on the rise and considered a global epidemic.[1] A
reason for this could be that underlying causes of obesity and overweight may not
have been fully taken into account in previous interventions.[2] Communication is
a huge part of tackling obesity and there are many approaches of communication
eg motivational interviewing assists physiotherapists to facilitate behaviour
change with patients who are struggling with this issue. It is also important to
acknowledge that obesity is not always about nutrition and eating habits but may
be related to genetics or medical conditions such as pain and diabetes. Weight
loss may not be as simple as exercising and dieting for everyone. Understanding
Obesity[edit | edit source] Obesity and overweight are defined as "abnormal or
excessive fat accumulation that may impair health.[3] Obesity increases the
chances of developing secondary diseases, causing huge problems worldwide as
health care demands increase and people's lifestyles become more sedentary and
unhealthy. Physiotherapists will come across obesity and its related secondary
effects in all areas of healthcare, which means interventions and treatments may
need to be adapted to manage these patients effectively.[3] [4] The World Health
Organization[3] defines levels of obesity and overweight through the Body Mass
Index (BMI) scale ie BMI = body weight (kg) ÷ height (m)2. While BMI remains
widely used due to its simplicity and cost-effectiveness, it has notable
limitations[5], such as the inability to distinguish between muscle and fat and
variations among different ethnic groups[6][7]. Alternative tools include: Dual-
Energy X-ray Absorptiometry (DEXA) - Provides detailed information on body
composition, including fat distribution and bone density. Advantages: High
accuracy in measuring total and regional body fat. Limitations: Expensive and not
practical for routine use.[6][7] Bioelectrical Impedance Analysis (BIA) - Measures
body composition by passing a small electrical current through the body.[8]
Advantages: Non-invasive and quick. Limitations: Accuracy can be affected by
hydration levels, recent food intake, and specific device used.[6][7] Waist
Circumference - Measures abdominal fat, which is a significant risk factor for
metabolic diseases. Advantages: Simple and effective for identifying central
obesity. Limitations: May not provide a complete picture of overall body fat.[6][7]
Waist-to-Height Ratio - Ratio of waist circumference to height. Advantages: Better
predictor of health risks than BMI and simpler to measure than WHR. Limitations:
Still requires more validation across different populations.[6][7] Skinfold
Thickness - Measures subcutaneous fat using calipers. Advantages: Provides
estimates of body fat percentage. Limitations: Requires trained personnel for
accurate measurements and may be less reliable in obese individuals.[6][7]
Implications of Obesity[edit | edit source] There are many implications of obesity
worldwide. Obesity increases the risk of many long-term health conditions such as
Type 2 diabetes, heart disease, arthritis, hypertension, cancer, stroke, liver
problems, respiratory problems, sleep issues, mental health disorders and,
overall, may cause a reduced quality of life.[9] People with obesity also have an
increased risk of falls.[10] With the rising obesity epidemic and reduced staffing,
funding and resourcing within the NHS, the demands on the health service will
increase. This could ultimately lead to reduced quantity and quality of care.
Obesity also contributes to wider financial problems such as more increasing cost
of welfare support and loss of output within the economy.[11] Obese patients who
have been affected by an injury or have undergone surgery have an increased
recovery period. This results in an increased length of hospital stay which adds
more pressure on the health service due the increased demand for hospital beds.
Obesity places further pressures upon the NHS’s resources with the increase use
of and demand for bariatric equipment.[12] Factors Contributing to Obesity[edit |
edit source] There are many different contributing factors to obesity. Amongst all
the possible contributing factors, research highlights the following three main
factors that contribute to obesity. These three factors are prevalent within
physiotherapy practice causing an increased demand for physiotherapy
intervention.[13] Due to the high prevalence of these factors amongst overweight
people, it is essential to take these factors into consideration when carrying out
physiotherapy assessments, and when problem lists and treatment plans are
being formulated. For example, this might include a higher level of awareness of
how to communicate with these patients. Socio-Economic Status[edit | edit
source] Socio-economic status is a large factor influencing obesity. In a study
conducted in 2009, of 12,000 children and teenagers aged between 2 – 19 years,
levels of high obesity were around 1.7 times greater in those from a deprived
area, than those in a non-deprived area.[14] There are many areas within this
topic that effect people in various different ways such as: [15]Socioeconomic
status refers to a person’s position compared to other people’s personalities, this
has contributed to putting people into certain categories allowing evaluation of
discrimination between these public categories.[16] The accessibilities of food
shops and the number of services that allow physical activity influence the levels
of obesity.[16] [15] [17] [18] Akil and Ahmad[13] show the highest obesity levels
are mostly found within the people who: Earn the least; Are not taught to a high
level about obesity and health aspects; Are not educated to a high level in
general; and have access to unhealthier foods, being less expensive and more
instantly available within deprived areas. Overall, a huge factor contributing to
obesity is the economic status of people and the type of environment they live in.
[13] The MRC National Survey of Health and Development showed that BMI was
directly connected with educational success in both sexes. Highest obesity levels
were found in people with the least academic achievements. 11% of men with O-
grade level achievements had a BMI above 30, whereas, only 5% of men’s BMI
were over 30 when they were at degree level of attainment. The same result
showed within females as well- correspondingly 15% and 4%.[19] The evidence
and guidelines explain this is a large contributing factor to obesity.[20] By
recognising this problem at the beginning of physiotherapy interventions,
physiotherapists will be able to adapt their approaches to become more relevant
to the individual’s circumstances. Physiotherapists can also assist in giving the
individual advice or guidance if certain socio-economic factors are contributing to
obesity. Mental Health[edit | edit source] Mental health includes our social and
psychological well-being. It affects and can determine how we react to events,
how we handle stress, and how we feel and relate to others. Early signs of mental
health problems are: Eating too much Reduced interest in social activities Having
low energy[21] There is a lack of research in establishing a definite cause-and-
effect relationship between obesity and mental health disorders (such as
depression and anxiety).[22] However, it has been observed that a link could exist
between these variables and individuals, meaning they more vulnerable to mental
health issues and obesity.[23] The Obesity Action Coalition[24] states that it is
thought that the two could be strongly linked or that they at least co-exist,
however it has not been established which one comes first- for example whether
obesity increases onset of developing depression, or having depression increases
the chances of developing obesity. Depression, in most cases, can be quite
debilitating, therefore decreasing an individual’s motivation to take part in
exercise or other physical or social activities. Depression can also result in a
person believing they should not be taking care of themselves, and so may not
follow a healthy well-balanced diet. These factors can lead to increased chances
of developing obesity.[24] A systematic review and meta-analysis on the
longitudinal relationship between depression and overweight and obese patients
was conducted by Luppino.[25] It was observed that obesity did increase the
onset of depression. Another study by Bogart[23] showed that, in America, 50% of
women with a BMI > 30kg/m2 developed depression over their lifetime, however,
these results were not replicated with men. This might be due to higher
sensitivity levels that women have and the stigma the media conveys about small
sizes and beauty.[26] Puhl and Heuer[22] describe further research that has been
carried out around the stigma of obesity and depression. Several studies suggest
that childhood experiences have a strong link in the development of obesity and
depression.[22] [24] Studies show that the onset of either obesity or depression
(or both) is strongly linked to childhood experiences- either for being mocked
about their weight which might lead to poor body image, reduced self-worth and
depression, or for having experienced unresolved life events like bereavement
that might develop into obesity in later stages of life.[27] [22] However, it is
important to consider that a person with underlying mental issues may have
increased body weight due to the type of medications they are receiving.[24] A
study supported a strong link between schizophrenia and depression and obesity,
where results showed that metabolic risk factors can almost be double in those
suffering from schizophrenia.[28] Additional mental health factors impact the way
physiotherapists carry out assessments and treatments of overweight or obese
patients- they should be mindful of how they approach and communicate with
these people. Examples of ways physiotherapists can do this are outlined below:
Taking more time in therapy sessions combined with allowing the person to have
a chance to speak gives the person to feel more relaxed in the surroundings and
allows the therapist a chance to fully understand the main presenting problems.
Personal space can be important if a patient is anxious and uncomfortable. Trust
is essential to the patient- physiotherapist relationship. An example of how a
therapist could build this up in an initial assessment is to spend one session doing
the subjective part, then explaining for the next appointment what exactly the
objective assessment will entail (e.g. exposing a certain body part). This will put
patients more at ease. (Examples adapted from Everett et al.)[29] Genetics[edit |
edit source] Obesity is a highly heritable trait- even more so than depression and
hypertension.[30]A rare genetic condition that is a contributing factor to obesity
is Prader-Willi syndrome, where children are much more likely to overeat. Pairing
this with a decreased metabolism and lack of muscle tone, they have an increased
risk of being obese. This condition occurs when there is a defect in chromosome
number 15, and the prevalence is no more than 1 in 15,000 children.[31] Apart
from this genetic defect, hereditary factors from mothers to new-borns are found
to also contribute to obesity. It is found that BMI and waist circumference trends
are highly heritable, estimated to be ranging from 40- 70% in chance.[32]
Childhood obesity can be predicted before a child is born by investigating factors
such as: Whether the mother has a higher BMI before pregnancy Whether the
mother smokes while pregnant The inter-uterine effects on appetite Metabolism
and levels of activity[33] [34] [35] [36] Genetic influences (combined with family
influences such as parental discipline and example[37]), can play a huge part in
why a person can present with obesity or excess weight. Physiotherapists will
need to be aware that these may impact the opportunities a person has to change
or modify their behaviour, and will need to manage them accordingly. For
example, when setting goals with patients, the physiotherapist can try to explore
and emphasize what adaptations can be made instead of focusing on barriers to
changing other areas.[38] Overall, by a physiotherapist recognizing and being
aware of these contributing factors, physiotherapy approaches can be adapted to
specifically benefit overweight and obese patients. Having physiotherapy
management that is sensitive to these contributing factors can improve outcomes,
as the interventions included will be specific to the individual and relevant to
their current personal situation. The role of the physiotherapist includes advice,
guidance and behavioural change (more information about this will be included
later on in this resource). What Is Needed for Healthy Weight Loss?[edit | edit
source] It is essential to know the recommendations for healthy weight loss to
provide the right advice to obese and overweight clients. From SIGN (2010)[39]
The Role of Physiotherapy[edit | edit source] Physiotherapists may come across
patients with overweight or obesity issues. Obesity can mean that a person is
more likely to develop physiotherapy- related issues, such as osteoarthritis[40]
and restricted movement at some joints leading to functional limitation and pain.
[41] Physiotherapists often treat clients that suffer from secondary conditions due
to their obesity or excess weight. An interesting analysis was made by the
Canadian Joint Replacement Registry[42], where they found that 73% of hip
replacement patients and 87% of knee replacement patients were classified as
overweight or obese at the time of their surgery.Physiotherapists are well placed
to manage and treat people who are overweight or obese. Specialist knowledge
and skills that physiotherapists can apply to this issue include: Anatomical,
physiological, and psychosocial mechanisms of health and disease Assessment
and diagnosis Behaviour change Biomechanics Exercise prescription and
therapeutic exercise Management of long-term conditions[43] Physiotherapy
treatments for obese and overweight patients may include: Provision of
personalised lifestyle advice, taking into account individual attitudes, beliefs,
circumstances, cultural and social preferences, and the patient's readiness to
change; Prescription, supervision, and progression of appropriate physical activity
to increase muscle strength, flexibility, and endurance; to sustain energy output
as well as enhancing and maintaining weight loss under safe and controlled
conditions; Management of conditions associated with overweight or obesity eg
arthritis, back pain, and other musculoskeletal and chronic conditions (such as
heart disease). Co-ordination of comprehensive and sustainable programmes of
management in collaboration with service users, community service and other
health and social care professionals.[44] Alexander et al.[45] recommended an
evidence-based approach for the physiotherapy management of obesity as follows:
(Note: Including education on strategies for adherence to an independent
exercise program is also recommended whenever possible.[45]) Overall,
physiotherapists have a huge role in managing obese and overweight patients,
through using a combination of exercise interventions, mobility training and
cardiorespiratory programmes;[44] and also through the use of effective
communication techniques involving behaviour change.[46] Patients’ perceptions
of physiotherapists can impact the effectiveness of tackling the issue. A study by
Setchell et al.[47] found that there were a number of factors that could cause a
negative reaction to physiotherapists discussing weight with overweight patients:

patients less uncomfortable when discussing this issue. These include: ⦁

Setchell et al.[47] identified ways that physiotherapists could attempt to make

body types represented in pictures/ posters etc.); ⦁ Being sensitive about when
Considering the layout of treatment room (for example, less mirrors, a range of

are undressed or have body parts exposed; ⦁ A collaborative, rather than an

weight is discussed, and be sensitive what is discussed, particularly when patients

educational, approach is most beneficial;[48] ⦁ Being deliberately empathetic to

obtain more positive responses from patients, and; ⦁ Not ignoring or
overemphasizing the topic of weight, but being non-judgemental when discussing
it. Behaviour Change in Relation to Obesity[edit | edit source] Behaviour change
has been defined as “anything a person does in response to an internal or external
influence. [49][50] Interventions that include behavioural change are complex,
[50]designed to target and change a specific behavioural pattern and are put in
place to promote a healthier lifestyle. This type of intervention is most effective
when used for a long duration and in intense sessions, as well as being used
alongside other interventions (like prescription of medication).[51] An important
characteristic of behavioural therapy intervention is that it adopts a non-critical
and non-confrontational approach, but uses a collaborative approach instead.[46]
This means that the physiotherapist and the patient work as a team, facilitating
lifestyle changes as well as equipping the individual to maintain and self-manage
their weight post-intervention.[50] Creating and developing a strong patient-
therapist relationship is key in ensuring trust from the patient as well as optimal
motivation, willingness towards change and adherence in the long term.[52] The
development of this relationship is is key- especially for the sensitive issue that
weight can be as well as the need for encouragement and support that is
required. [53] Why Behaviour Change?[edit | edit source] Many research papers
highlight that one of the main difficulties in the process of losing weight is
maintaining weight loss in the long term.[52] The research available in regards to
follow-ups past one year is limited, however there has been a recent study
undertaken by Action for Health in Diabetes[54] looking at long term effects of
incorporating behaviour change as part of the intervention with patients with
Type 2 diabetes. A large sample of participants were recruited from 16 different
centres from the United States. They were aged between 45-76 years old,
presented with a BMI of greater or equal to 25kg/m2 and were randomly assigned
(to decrease bias) to either the intensive lifestyle intervention or the diabetes
support education. The intensive lifestyle group received advice on diet
modification and physical activity; and behavioural strategies such as goal setting,
self-monitoring and problem solving were addressed. The diabetes support
education group participants were not presented with any behavioural change
support but were only given general focus on diet and physical activity. It was
observed that there was a greater weight loss in the intensive lifestyle group
compared with the other, meaning that behavioural change interventions can be
effective amongst obese and overweight individuals. This is especially true in the
long term as it equips patients with essential tools to be able to make healthier
lifestyle choices and changes. The study did not specify whether patients suffered
from any mental health issues or from a low income, however the results can still
be applicable to such population yet keeping in mind of the difficulties in
changing external factors that could contribute to obesity. The main three key
aspects of behavioural therapy are the following: 1. Goals need to be designed in
a manner that is specific to the patient and measurable.[51] Many studies and
articles highlight the importance of physical activity and the recommendations for
exercise to aid weight loss. Common fears and misunderstood perceptions
overweight people may have in regards to physical activity can sometimes
prevent them from being active. Therefore, it is important as health care
professionals to address these expectations, and by doing so aim to alter patients'
behaviours towards exercise. One way to do this is by creating patient-centered
goals. Goal setting should be discussed with the individual and should be realistic.
Findings show that overly-optimistic goals might lead to failure and
disappointment, leading to patients becoming more demotivated in regards to
exercise.[46][51]Setting goals is an extremely important part of this type of
intervention, as they can motivate and encourage patients to be fully on board,
and give them visible goals to achieve, which they can look back and reflect on.
Setting small yet achievable changes is very important.[55] 2. It address in depth
the question “but how?”. This type of intervention does not just address what to
change, but more importantly helps those individuals identify how to change.
[51] This means that the physiotherapist can act as a facilitator in the process –
once a goal is agreed, the patient should be encouraged to examine what factors
might either facilitate or hinder achieving the agreed goals.[51] New strategies,
responses and skills are discussed and taught in order to overcome any barriers
that might be faced during the patient’s weight loss journey. Foster et al.
[51] states that is not a matter of will power that will lead to success but it is
“skill power”. 3. Another important aspect to discuss are patients expectations.
Behaviour changes should be small rather than large- this is also to avoid failure
or disappointment.[51] [46] It is important to ensure that incremental steps are
made, and that the patient fully understands that the process may be slow.
Patients should also be able to understand the benefits of setting small changes
which they can build on, instead of attempting drastic changes that might only be
short-lived. This process is important to ensure that patients are equipped to
maintain a healthy lifestyle and manage their own weight in a healthy manner.
[55] It is also important to establish what the individual is capable to sustain in
the long term so to prevent any relapse or re-gained weight. Information and
advice on healthier eating and lifestyles have gradually increased and are now
widely accessible.[56] So, why do people struggle to put this in to practice despite
being aware of the benefits of increasing physical activity and improve their diet?
Interestingly enough, a study showed that being aware of these required changes
did not automatically translate or bring the individuals to take any measure of
change in their behaviour, allowing us to raise the issues as to whether people
have become so overloaded with such health information that might be in
“danger” of switching off.[57] However, many professionals still think that the
primary and most effective tool is providing the patient with advice and
education.[51] Although educating the patient can be very useful, most
overweight patients are often already aware of what they should or should not eat
and the benefits of physical activity. In those cases, being willing and taking time
instead to explore barriers to weight loss might be more effective rather than
wanting to ‘fix’ the problem.[51] This will allow the therapist to explore the
reasons behind the person’s behaviour and lifestyle choices, trying to skillfully
identify any activities or circumstances that encourage or stimulate unhealthy
habits/balance.[53] In this resource, we have looked at the three most relevant
barriers (see section 2.5). As you have previously read, mental health issues are
growing in the current population and they can be a real hinderance and struggle
for people and there is evidence supporting that mental health and obesity could
be linked.[25] In the US Diabetes Prevention Program[58], greater readiness for
change in physical activity level, higher exercise self-efficacy, and lower perceived
stress, depression, and anxiety scores were linked with higher levels of baseline
activity and maintenance of activity levels at 1 year and at the end of the study.
These findings show that the individual’s initial psychological well-being might
play a crucial part in predicting whether the individual will adhere to changes or
not, and it is unlikely that someone with poor psychological well-being will have
the ability or the energy available to take those steps toward behaviour change.
[46] Poor psychological well-being might also impact and decrease the
individual’s confidence and self- efficacy.[46] Therefore, it comes with no surprise
that such changes are difficult and require time as well as support.[56] It is
important for therapists to keep this in mind when delivering this type of
intervention and undertaking assessments of the readiness levels of the patient,
as it might help determine which patients are most likely to increase physical
activity levels in lifestyle intervention programs. Moreover, the difficulty in
undertaking those behavioural changes could also be explained by the COM-b
model[57]: This theory model explores three aspects that are key for any
behaviour change to take place, those are: capability, opportunity and motivation.
[59] [60][61] It is said that for certain behaviour to occur the individual must have
knowledge as well as the physical and mental capability to act upon it, be
motivated to do so and be clear how to achieve the change.[60] It is useful to be
aware of this model when trying to design an intervention or when initiating the
difficult conversation, so as to be able to explore and engage the level of
readiness the individual is at, and to assist physiotherapists in creating an
intervention that can target one or more of these processes, and be patient
centered. Dealing with Ambivalence[edit | edit source] Most individuals have
either been told by a GP or by their family and friends about their weight, and
some of them will have expressed a desire in regards to change (or at least
thought about it). This demonstrates one of the COM-b model process- capability.
They see the benefits of decreasing their weight, but also the barriers stopping
them. Ambivalent means both wanting and also not wanting to change at the
same time,[62] and it is a common place to be stuck. A common pattern is to start
to think of change, then start to think of a reason not to do it and then just stop
thinking about it. The way out of this is to go with one path and stick to it.[63]
This is something to be aware of when communication with patients as it is easy
to present only the benefits losing weight and try to fix the patient, also called
“the righting reflex”. What might happened is that the person start to voice the
other side of the argument and justify why they have not done the change yet and
responds with denial and oppositional-like behavior. Exactly the opposite of what
we are looking for![63] How Can Communication Be Used to Facilitate Behaviour
Change?[edit | edit source] Motivational Interviewing[edit | edit source]
Motivational interviewing is a person-centered counselling style for addressing
the common problem of ambivalence about change[63] Communication has been
recognised as a significant factor to improve, maintain and treat health problems.
[64] Motivational Interviewing (MI) originally started as a therapeutic approach
to treat people struggling with addictions, [65] but has now been successfully
been applied to a range of health problems as an evidence-based counselling
approach for health care professionals.[64] The goal of MI is to create an
environment where the patient rather than the interviewer, becomes the main
advocate for change. The approach is aiming to enhance intrinsic motivation by
exploring and resolving the person’s ambivalence. [63] Four Processes in
Motivational Interviewing[edit | edit source] 1. Engaging[edit | edit source]
Engaging is the process where a mutually trusting and functional working
relationship is established. Even before patients attend physiotherapy, they will
have wondered about how they will be treated and what the practitioner will be
like. First impressions do leave a significant mark; on the other hand, it is not
unchangeable. During the first visit the patient will decide how much they like
and trust the practitioner and if they will come back.[63] The importance of a
good dialogue between practitioner and patient cannot be stressed enough as it
has major impact on the patient's attitudes in relation to managing weight.[66] A
study from 2014 found that patients who felt judged about their weight by their
primary care providers reported lower trust in their health practitioner compared
to others.[67] With this in mind, it is suggested that first addressing the reason
the patient is coming in for is good practice, in order to build a good relationship
and enhance patient-centred practice.[66] It is important to address the patient
with an empathetic and non-judgemental approach, trying to separate the weight
problem from the person.[68] The patient might be vulnerable and frustrated
from previous attempts to lose weight and be quite sensitive to discussing this
problem,[66] however this should not be a reason for the practitioner to shy away
from the problem and bring up the implications of being overweight.[69] It can be
easy to start in the wrong direction, even with the best of intentions. There are
different “traps” that should be avoided so as not to disengage the patient. For
example, by taking control and asking a set of questions puts the patient in a
passive position and also implies “I’m in control here, just do as I tell you and you
will be fine”. Also, casual conversation should be avoided. An important part of MI
is knowing that the practitioner requires the collaboration of the patient to
succeed. Below are factors affecting patient's engagement and suggestions on
what the practitioner should do to in order to trigger this engagement. [63] 2.
Focusing[edit | edit source] To know where the physiotherapist is going with the
MI intervention there must be a focus; i.e. what did the person come to talk
about? However, the practitioner might also have an agenda that is linked to the
original problem. For example, the patient being treated might be complaining of
low back pain or a bad knee, in addition, the same person has a BMI of 35kg/m2.
The practitioner should address the patient complaint but should also consider
bringing up the possible contributing factors to this problem. By doing so the
practitioner gets a better picture of the patients’ knowledge, self-awareness and
readiness to change.[63] Miller and Rollnick[63] identify three main sources
which will influence the focus and direction of the problem or concern: The
patient: Normally the main source to the focus of the problem. If the practitioner
is confident and competent to help the patient with the concern they are
presenting the focus is set. 2. The setting: If the setting is a weight management
clinic, this will influence the focus of the conversation. What to be aware of is that
this can limit the context as the setting predetermines it and makes it harder to
raise other issues that may arise. 3. Clinical expertise: Often, the patient will
arrive at an appointment with one goal in mind, while the physiotherapist
perceives that another kind of interaction is needed. The physiotherapist will
need to investigate the patients’ willingness and readiness to discuss this other
issue. Maybe it relates to their initial goal and may help them achieve that.[63]
Example: An obese person turns up to his physiotherapy appointment because he
has lower-back pain. The physiotherapist wants to discuss weight issues with
him.The patient may or may not recognize the relationship between the two. The
hope of the physiotherapist is that the patient is going to recognise the
relationship between the two which will increase his motivation to make a
change. There are three different communication styles that the physiotherapist
can use to find the focus[63]: 3. Evoking[edit | edit source] This stage is the
"tipping point" of the process. The patient starts to realise that the pros outweigh
the cons which again is the core of MI, i.e. resolving the persons’ ambivalence
and make them commit to change. This stage emphasises the importance of the
interviewer to promote this “change talk” in the patient.[63] Example of change
talk: "I really want to get fitter" "I am not happy about my current weight and
want to change this" "I miss being able to go for a run without being out of breath
after 2 minutes" By reflecting and exploring these responses, the physiotherapist
reinforces the patient's statements and enhances the patient's motivation for
change. A commonly used acronym for response techniques used to enhance
'change talk' is O.A.R.S [63] O: use open-ended questions instead of closed
questions as they will help to explore more in depth the patient’s feelings and
views regarding their weight. A: importance of affirmations and pointing the
patient to the need for change R: reflective listening S: summarize to the patient
what they have explained so as to assist in reinforcing goals and ideas[63] 4.
Planning[edit | edit source] Knowing that the patient is ready to take the final step
and go from “I want to do it” to “how am I going to do it?” is a subjective decision
based on the following indicators: Recognition of 'change talk', for example “I
want to do this” Questions about change: “What would this exercise group
involve?” Taking steps: “I’ve been out walking the dog for 30 minutes three days
in a row” [63] The acronym D.A.R.N.C.A.T can be helpful to identify the patients’
readiness for change. [63] The D.A.R.N is preparatory, while the C.A.T is required
for moving from general intention of wanting the change to actually doing
something about it. Desirability of change Ability to change Reasons to change
Needing to change. Commitment to change Activation that includes talk about
being willing to change Taking Steps toward change[63] When designing a plan, it
is important to have the patient's fullest possible co-operation to avoid them
falling back to being ambivalent. The planning process builds on the same
principles as the previous stages; i.e. collaborative spirit, O.A.R.S strategy and a
clear direction towards change.[63] Evidence Base for Motivational Interviewing
in Managing Overweight and Obesity[edit | edit source] MI was found to reduce
BMI and weight in overweight and obese adults in a Cochrain review from 2012 .
[65] Previous evidence also indicates that that MI has a small positive effect on
weight management[70] and significant effect on BMI, total blood cholesterol and
systolic blood pressure.[71] In addition, MI might support long-term weight loss
maintenance and was found to be a feasible intervention[72] and appropriate for
older adults with long-term medical conditions.[73] However, there are still gaps
in the literature raising questions about the effectiveness of MI. It is possible that
MI is not as effective in some ethnic minority groups. In a study by Befort et al.,
[74]obese African-American woman failed to improve outcomes after MI
interventions. Armstrong et al.[65] also raises the issue that the small data size
makes it difficult to draw a conclusion, as only 11 studies were applicable for
their meta-analysis, reducing the statistical power of the findings. Thus, more
larger studies are required to draw a clear conclusion of the effectiveness of MI.
In addition, more long-term studies are required to confirm the long-term effects
of MI.[65] What Words to Use When Addressing Excess Weight With Patients?
[edit | edit source] As obesity is an increasing problem, physiotherapists needs to
be able to address this topic in a sensitive and effective way, as there is a lot of
stigma in relation to this topic.[66] To avoid misinterpretation, physiotherapists
need to be aware of terminology used to reduce the chances of damaging their
relationship with the patient.[66][69] Large size Excess fat Excess Weight Obesity
Weight Unhealthy BMI Unhealthy weight Overweight status Fatness BMI Weight
Problem Heaviness In the studies available, there is a consistency that the terms
“weight” and “BMI” are the most desirable terms when raising the question about
patient’s excess weight.[75][76][77][78][66]) While the terms “excess fat”,
“obesity”, “fatness”, “large size” and “heaviness” were found to be undesirable
terms by participants.[75][76][77][78][66] However, a study looking at patients’
reactions when their GP used the term “obesity” compared with euphemisms e.g.,
“Your weight might be damaging your health” found, interestingly, that the obese
patients reacted more positively to the euphemisms than to the term “obesity”,
while it was the opposite for non-obese patients.[79] This suggests that different
people react in different ways depending on their weight. Research suggests that
some words, "Weight" and "BMI" are better to use than others are when
communicating with patients regarding their excess weight. Having in mind there
is a huge variation of terms that people find reasonable, and asking the patient
what terms they use might be helpful in order to avoid misinterpretation.[69]
Conclusion[edit | edit source] Physiotherapists have a major role in management
of obese and overweight patients. Obesity and overweight is a current and
concerning health issue as many people are affected by it. There are many
contributing factors to obesity- socio-economic status, mental health and genetics
being three of the largest factors. Communication can be used to facilitate
behaviour change in people who are overweight and obese. Physiotherapists can
make use of techniques like motivational interviewing to effectively make a
difference.Public Health and Physical Activity - Physiopedia Search
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citation statement. Cite article Public Health and Physical Activity Jump
to:navigation, search Original Editor Daniel Thomas Top Contributors - Andeela
Hafeez , WikiSysop , 127.0.0.1 , Tarina van der Stockt , Rucha Gadgil , Alan Jit Ho
Mak , Daniel Thomas , Wendy Walker , Michelle Lee and Kim Jackson Contents 1
INTRODUCTION 2 OBESITY 3 BARRIERS TO RECOVERY 4 2. Barriers to
effective treatment for the Physiotherapist,Health Care Provider’s views: 5
Motivational Interviewing: 6 Emerging Role of Physiotherapists in Obesity 6.1
CBT Strategies to initially engage in physical activity: 7 CURRENT ROLE OF
PHYSIOTHERAPISTS IN THE MANAGEMENT OF OBESITY 8 Physiotherapy
Treatment Pathway options 9 PHYSIOTHERAPY REMIT 10 SELF-MANAGEMENT
OF OBESITY 10.1 Individual Education 10.2 Group Education 11 CONTINUED
PROFESSIONAL DEVELOPMENT 12 CONCLUSION 13 REFERENCES
INTRODUCTION[edit | edit source] The prevalence of obesity has rocketed since
the early 1980’s, leaving 312 million adults worldwide classified as clinically

intake ↑ Portion sizes ↑ Snacking and loss of regular meals ↑ Energy dense food ↑
obese. Factors creating an obesogenic environment are [1] Increasing energy

Affluence Decreasing energy expenditure ↑ Car ownership; ↓ Walking to

school/work ↑ Automation; ↓ manual labour ↓ Sports in schools ↑ Time spent
playing video games and watching TV ↑ Central heating The categorisation of
obesity as a health condition is now widely acknowledged and publisised. Not only
is it the focus of intense scientific scrutinisation and debate, the term ‘obesity’
returning over 200,000 articles in ScienceDirect, it is the basis for films, such as
Morgan Spurlock’s award winning documentary Supersize Me, and a key factor
underlying the array of government strategies designed to promote healthy living
and tackle weight gain. However, despite awareness of the condition being at an
all time high, the prevalence of obesity in Scotland is second only to levels seen in
the US, and this prevalence is rising (SOAR, 2007). Perhaps most concerning of
all, this trend set to continue (Scottish Government, 2010). The direct cost of
obesity to NHS Scotland in 2007/8 exceeded £175 million, and is predicted to
have almost doubled by 2030 (Scottish Government, 2010). The total cost to
society was estimated to be £457 million through increased sick leave, adverse
effects on employment and mental well-being.[2] OBESITY[edit | edit source]
Obesity is the presence of excess fat, in the form of adipose tissue, which is stored
subcutaneously and viscerally. Clinically this is most often measured using the
body mass index (BMI), where BMI = weight (Kg) / height (m2). Adult weight can
then be categorised as detailed in Table 1. BMI is also used to classify childhood
weight status, however childhood BMI score must be compared to age- and
gender-specific centiles (SOAR, 2007). Under-weight Healthy Over-weight Obese
Morbidly obese BMI (Kg/m2) <18.5 18.5 – 24.9 25 – 29.9 30 – 39.9 >40 Quite
simply, weight gain occurs when we are in a state of positive energy balance, i.e.
when our energy intake exceeds our energy expenditure.A myriad of factors, both
intrinsic and extrinsic, influence our propensity for weight gain, from our genetic
profiles to our socio-economic status. The idea of a “thrifty genotype” has
circulated ever since its proposal in the 1960’s, by J.V. Neel. The idea being that
evolution through natural selection has provided us with a genetic predisposition
to store energy in the form of adipose tissue; a survival mechanism in times of
food shortage. Although no single genetic cause underlies common diet-induced
obesity, allelic variants in certain genes, such as FTO, have been shown to
correlate with increased BMI and risk of obesity (Frayling et al , 2007). A
predisposing genotype together with our increasingly obesogenic environment
may therefore promote weight gain and obesity in susceptible individuals. Socio-
economic status, relating to levels of income, education and level of deprivation,
is strongly associated with obesity (Keenen et al , 2011). There is however a
disparity between the genders regarding the strength of association in many
areas, and this should be taken into account when considering the pathogenesis
of obesity on a patient-specific level. Obesity has a clear and profound impact on
the health of our society and our economy, and with increasing prevalence it is a
highly relevant and topical area. As Physiotherapists, the treatment of obesity
according to the biomedical model of health would elicit a reductionist approach,
focusing on the treatment of the physical problem of excess body fat, by
addressing energy balance. However, as our understanding of obesity grows and
develops, so must our practice. The psychosocial dimensions of this complex
disorder must be considered when designing a patient-specific therapeutic plan,
and the thus the biopsychosocial model of health may be of benefit in this
endeavor. A multifaceted approach to the treatment of obesity is essential, and
will not only require the application of our current skills as Physiotherapists, for
example in the area of exercise therapy, but also the development and extension
of skills in the cognitive behavioural sciences, where our emerging roles lie.
BARRIERS TO RECOVERY[edit | edit source] Barriers to recovery for the patients:
• Social and Emotional Factors  children bullying  negative self worth and
increased motivation to “fit in” (Murtagh et al, 2006) • Economic  low income . •
Environmental  location inconvenience, seasonal influences (French et al, 1998)
• Gender  French et al (1998) found that women reported lack of time, family
duties, and conflict with work schedule as barriers. • Family Support (Murtagh et
al, 2006) • Education or lack of rather Women with low levels of education are
less likely to use helpful approaches to weight loss, such as combined physical
activity and energy restriction than women of high (Levy et al, 1993) •
Psychosocial factors Attitudes, beliefs, self-efficacy, coping strategies (Murtagh
et al, 2006; Van Gerwen et al, 2008; • Genetic  predisposition • Previous
Negative Experiences with weight loss and management (Murtagh et al, 2006) •
Behavioural Sacrifice (Murtagh et al, 2006) • Delayed parental recognition (in
children) (Murtagh et al, 2006) • Lack of willpower and time constraints as
barriers (Johnson et al, 1990) • Lack of access  to nutritional education or weight
loss programs (French et al, 1998) Physical and psychological levers and barriers
to weight loss in children (Murtagh et al, 2006): Barriers to action for Children
(Murtagh et al, 2006):Some children found their parents answerable for their
delay in action. A failure to distinguish the problem meant that these children
were not engaged until the problem had grown to a greater issue than it need
have been.The decision to take action, although imperative, was hardly ever the
most difficult aspect of the behavioural-change process. The real difficulty
remained in taking action and continuing it. The children acknowledged the need
for continual support as being central in raising their self-efficacy and keeping
motivated, without this they felt success would be doubtful.[3] 2. Barriers to
effective treatment for the Physiotherapist,Health Care Provider’s views:[edit |
edit source] In order to target interventions appropriately, healthcare
professionals need to consider the willingness of a patient to undertake the
necessary behaviour change required for effective weight management. The use
of behavioural modification techniques (such as goal setting, use of rewards and
self monitoring) as part of a multi-component intervention have been shown to be
effective. (NICE 43, 2006)[4] Physicians held negative views regarding their
ability to manage weight in primary care as well as stereotypical views toward
obese patients in general  patients were lazy or lacked self-control (Price et al,
1987). Counseling is futile and counseling patients would take too much time
(American Medical Association, 2003) Primary care professionals expressed that
low self-efficacy in the treatment and experienced a negative feeling regarding
obesity management as barriers to treatment (Van Gerwen et al, 2008). Van
Gerwen et al (2008) reported three key themes related to knowledge deficits, in
particular low reported use of guidelines, low levels of self perceived competency
to treat childhood obesity, inconsistent use of standard measures such as BMI and
lack of clinical consensus around treatment. Walker et al (2007) also surveyed
GP’s and nurses and found that they felt unable to cope with the scale of the
problem and doubted the effectiveness of giving advice about diet and exercise.
The HCP’s also report concerns about the sensitive nature of the subject and the
negative effect that bringing attention to a child’s weight might have on their
relationship with the parent. The lack of shared understanding about how to
manage infants at risk and the communication barriers between HCPs
particularly in relation to records about infants’ diet, growth and weight is of
concern as team working is crucial to successful prevention programmes (Walker
et al, 2007). Lifestyle interventions compared to standard care or self help can
produce a significant and clinically meaningful reduction in overweight and
obesity in children and adolescents (Oude et al, 2009).[4] The only published UK
study of an individualised behavioural intervention for childhood obesity was
performed in Scotland and showed modest benefits of family centred counselling
and behavioural strategies (eight sessions over six months) on physical activity
and sedentary behaviour (Hughes et al, 2008). All contemporary RCTs of lifestyle
interventions used programmes which targeted the family and involved at least
one parent/carer and the child. Some programmes utilised parents-only group
sessions to target family lifestyle and parenting skills (Goley et al, 2007; Golan et
al , 2006). NICE 43 (2006) guidelines noted that for a programme to be
considered a behavioural intervention for children it must incorporate the
following aspects:[5] • stimulus control • self monitoring • goal setting • rewards
for reaching goals [6] • problem solving Although not strictly defined as
behavioural techniques, giving praise and encouraging parents to role model
desired behaviours are also recommended (NICE 43, 2006). Motivational
Interviewing: [edit | edit source] Motivational interviewing (MI) was first
developed in 1983 by William R. Miller and was used with problem drinkers;
however it has since become an established method of communication used with a
range of substance use disorders (Motivational Interviewing 2011). MI is defined
as “a collaborative, person-centred form of guiding to elicit and strengthen
motivation for change” (Motivational Interviewing 2011). It has also been
explained as “a patient-centred counseling method for addressing the common
problem of ambivalence about change” (Motivational Interviewing 2011).[7]
Traditionally, HPs have seen themselves at “experts” and believed the reason
people do not change behaviour is due to a lack of
knowledge/insight/skill/concern, and therefore once they enlighten them, change
will occur (Motivational Interviewing 2011). This persuasive approach is not
beneficial in promoting a change in behaviour, firstly because information is only
exchanged in one direction (from HP to the individual) and secondly, the
ambivalence, worries and motivations of the individual have not been explored.
Imagine how an obese individual would appreciate being told “…you need to lose
weight… the health problems associated with obesity are…just start exercising…
” by a fit and healthy physiotherapist? This approach is not likely to promote a
change in behaviour as the individual may feel judged, criticised and
unsupported. In contrast, MI focuses on building a collaborative therapeutic
relationship between the HP and individual, it utilises the individual’s motivations
and skills to promote the change, as commitment to change is most powerful
when it comes from within, and it empowers the individual to be responsible for
their actions (Motivational Interviewing 2011). The following has been adapted
from Motivational Interviewing (2011) and Miller and Rollnick (2002).[8] 1.
Express Empathy • Skillful reflective listening is fundamental to expressing
empathy. • HP sees world from the individual’s perspective. • Acceptance from
HP facilitates change in the individual. • Remember ambivalence from the
individual is normal. 2. Develop Discrepancy • Discrepancy between present
behaviour and the individual’s goals. • Reasons for change should be generated
by the individual. • HP intentionally directs towards the resolution of
ambivalence/towards “positive” behaviour change. 3. Roll with Resistance •
Resistance presents as overt hostility, blaming others, changing account, making
excuses, side tracking, rejecting HPs conception of the problem, “yes, but…”
statements and pessimism about change. • Resistance is influenced by the HP
misjudging the individual’s stage of change, using a confrontational style or
failing to make the individual understood. Therefore, resistance is a signal that
the HP must change their responses. • Once identified, avoid increasing
resistance and use it constructively. • Avoid arguing for change, because as the
individual defends their standpoint they become more committed to it. •
Remember, the individual is a primary resource in finding answers and solutions,
not the HP. 4. Support Self-Efficacy[9] • The individual’s belief change is possible
is a key motivator. • HP focuses the attention of the individual’s strengths, skills
and past successes. • The individual is responsible for choosing and carrying out
change. • The HP’s belief the individual is capable of changing becomes a self-
fulfilling prophecy. • HP may validate frustrations, yet remain optimistic about the
prospect of change. As previously mentioned, MI is successful for promoting
behaviour change in substance use disorders (Smedslund et al. 2011). The meta-
analysis performed by Rubak et al. (2005) observed MI to have a significant effect
on body mass index, total blood cholesterol, systolic blood pressure and blood
alcohol concentration. Studies by West et al. (2007) and Carels et al. (2007),
observed the addition of MI to weight loss programmes resulted in greater weight
loss and adherence in obese individuals. Limbers et al. (2008) state that although
results seem favourable, more research it required to establish the effectiveness
of motivational interviewing in obesity.[10] Emerging Role of Physiotherapists in
Obesity[edit | edit source] The emerging role of physiotherapists could in part
involve the use of MI as a strategy to promote physical activity in obesity, as it is
likely to be more beneficial in encouraging lasting lifestyle changes than simply
educating individuals about the health risks of obesity and instructing them to
exercise.[11] Cognitive Behavioural Therapy (CBT) in the Management of Obesity.
CBT has frequently been used over the past 20 years and has been found to be
effective in improving adherence in this population (Dalle Grave et al, 2010).
These strategies have features which distinguish them from other forms of
psychological treatment. By incorporating concepts of CBT into their fitness
practice, physical therapists can help obese patients see the connection between
their thoughts about exercise and their behavior. CBT Strategies to initially
engage in physical activity:[edit | edit source] The first step is to educate patients
about the benefit of exercising and the need to increase the level of physical
activity for long-term weight control.[12] The next step is to create a “pros and
cons to change” table. Patients should be asked to evaluate their reasons for and
against adopting an active lifestyle. It is advised to begin by asking patients to list
the cons of changing, considering whether sedentary life provides them with
something positive that they are afraid to lose. Then patients are asked to
evaluate in detail the pros of changing their lifestyle. The list of pros and cons
should be put on a table and discussed in detail. Every reason for change should
be reinforced. It is also important to analyze the cons of changing, helping
patients reach the conclusion that the positive aspects of increasing the level of
activity are attained in the long term, and are always associated with positive
gains. The final step is to help patients reach the conclusion that adopting an
active lifestyle will be a positive opportunity for a new and healthy life and long-
term weight control. CURRENT ROLE OF PHYSIOTHERAPISTS IN THE
MANAGEMENT OF OBESITY[edit | edit source] SIGN guidelines (2010) and NICE
guidelines (2006) were both published to identify evidence based
recommendations that would help in the prevention and management of obesity
in children and adults. Both the national guidelines for the management of obesity
and the Scottish Intercollegiate guidelines are aimed at all health professionals
working in primary, secondary and tertiary care within the NHS who are actively
involved in the prevention and management of obesity in either children or adults.
However a criticism of both guidelines is that they don’t specify at any point in
their recommendations which health professionals may be the most suitable to
administer preventative or management interventions at the various stage of
childhood and adult obesity. [13]Therefore from examining these guidelines it is
difficult to understand what exactly is the current role of the physiotherapist in
the prevention and management of obesity. Both guidelines overlap considerably
in that they aim to address the primary prevention of obesity, treatment of obesity
through diet and lifestyle intervention, pharmacological therapy and bariatric
surgery and the prevention of weight regain following treatment in both adults
and children. Taking into account the Curriculum Framework for Physiotherapy
(2002) definition of physiotherapy practice; a health care profession concerned
with human function and movement and maximising potential. It uses physical
approaches to promote, maintain and restore physical, psychological and social
well-being, taking account of variations in health status, it could be concluded
that physiotherapists may have a valuable role to play in the primary prevention,
treatment through diet and lifestyle modification and prevention of weight gain
following treatment in people with obesity. General clinical recommendations,
drawn from both guidelines, for health professionals involved in the prevention of
obesity in adults or children include; offering specific individual information on
how to reduce the intake of energy dense foods, alcohol and fast foods through
the use of health promotion initiatives such as the eat well plate, encourage
increased physical activity by focusing on exercise such as walking that can easily
fit into a person’s life and provide continuing support and encouragement to
people concerned with weight management through the use of telephone/
internet follow-ups. .[13] It is difficult to examine the precise contribution
physiotherapists are making to the fight against obesity in Britain today as there
is only limited research on the current practice and on-going schemes which
physiotherapists are actively involved in. However a number of NHS weight
management services have been identified across Britain where physiotherapists
play a central role in the design of specific and individualised exercise
programmes for people attending this service. However further research is
needed which examines the current role of the physiotherapist in areas such as
the behavioral management of obesity and the also the degree to which the
physiotherapist profession is contributing to achievement of targets set in the
SIGN and NICE guidelines. Although the management of obesity is a very
important and controversial topic in todays society and there is evidence which
point to fact that the physiotherapist may have a crucial role in the fight against
an increasing obese population the evidence base in this area is significantly
lacking. Therefore it is fair to conclude that although the role of the
physiotherapist in the management of obesity is currently centered around the
prescription and distribution of exercise programmes there may be scope in the
future for the involvement of physiotherapists in the psychological aspect of
obesity management, an area which needs to be focused on in more detail.[14]
Some additional information on The Aintree Weight Management and what they

Pathway options[edit | edit source] • Tone up and feel good programme[16] ◦ 12

do (adapted from Aintree Weight Loss Programme)[15] Physiotherapy Treatment

wk group exercise programme held in 3 community venues ◦ Patients attend a

weekly 1 ½ hour session which are made up of 3 components: ▪ Exercise

minute exercises, cool down. ▪ Breathing control techniques- they teach and
component- 20 min exercise session comprising of warm-up, 10 minute circuit 1

practice a variety of breathing control and relaxation ▪ Health promotion

discussion- they discuss a wide range of topics affecting weight management and
barriers to activity. Inviting guest speakers from community activity schemes to

Programmes ◦ 12 wk group programme held at 1 community venue ◦ Weekly 2

promote their services. • Joint Physiotherapy/Dietetics/Psychotherapy Group

hour session for patients ◦ Group discussion led by any one of the 3 health
professionals (physio, dietician or psychotherapist) depending on topic ◦ 20 min
exercise component each week • Hydrotherapy Group Sessions[17] ◦ 8 week
programme ◦ 2 sessions of group Hydrotherapy each week in the Aintree Uni
Hospital Physio Dept. ◦ Patients attend a 30 minute water based group exercise
session which includes: ▪ 10 min circuit of exercise stations ▪ 5 min cool down ▪
optional 10 min free swim at the end • One to one Physiotherapy Sessions ◦ Up to

the patients choice. ◦ These are used to tackle specific barriers the patient has to
4 one to one 40 min follow up sessions can be provided at the community venue of

activity. • Pedometer Loan ◦ 3 month loan of an accurate pedometer. ◦ With

regular follow session throughout this 3 month period to have step targets to have
step targets reviewed and progressed. PHYSIOTHERAPY REMIT[edit | edit
source] Due to the breadth of knowledge and expertise of physiotherapists they
are excellently placed to treat obesity. Negative body image and confidence issues
can lead to patients being intimidated by the large numbers attending exercise
classes, therefore it is often a good starting point to introduce a home exercise
program (Perri et al 1997). As the prevalence of obesity increases a
multidisciplinary approach must be implemented in order to manage patients in
this population (Dalle Grave et al. 2011).[18] A study by Epstein and Ogden
(2005) found that general practitioners do not feel that obesity is part of their
domain because of a lack of effective medical intervention such as drug therapy,
however only 3% refer obese patients to cognitive behavioral therapy which
would tackle the root cause (Cade et al. 1991). As a result many will develop
musculoskeletal problems that result in patients requiring physiotherapy.
Physiotherapists may therefore be ideally placed to identify these patients and
treat them appropriately. Some of the skills possessed by physiotherapists that
make them qualified to deal with the growing obese population are: • Anatomy
(important to know about strengthening exercises to allow the musculoskeletal
system to cope with the extra demands placed on them by overweight individuals)
• Physiology (important to know about changes to heart rate, blood pressure,
etc.) and Exercise Physiology (important to create and implement exercise
programs) • Cardiovascular/Cardiopulmonary systems (important to know about
changes to breathing patterns, apneas, cardiovascular disease.) • Biopsychosocial
Model (important to know about environmental factors, cultural factors, social
factors, etc., that lead to the development of this condition) • Physiotherapists
have got a large amount of contact time with obese people in the NSH, therefore
they can potentially make a bigger impact than other health professionals •
Physiotherapists also have good knowledge of secondary complication such as –
hypertension, diabetes, osteoarthritis and complex profound physiological
changes.[18] SELF-MANAGEMENT OF OBESITY[edit | edit source] Many
approaches have been assessed to support self-management, ranging from
passive approaches such as information sharing at one end of the spectrum to
active behavioural change interventions at the other. 2 Divisions: Self-
management support can be conceptualised by dividing interventions into those
that focus on building knowledge and skills (such as healthy eating habits) versus
those that target self-efficacy. Figure 1 (taken from the Health Foundation, 2011)
illustrates these divisions and types of self-management support along a
continuum.[19] Categorising such interventions is difficult; an intervention may
focus one behavior change only whereas another intervention may address self-
efficacy and behavior change. Although only an illustrative figure it can be useful
for Health Professionals to conceptualise interventions within such a continuum.
The Health Foundation (2011) reviewed hundreds of studies and found that
proactive self-management schemes located in the top right area of figure 1 are
associated with increased change or more consistent levels of behavioural and
clinical benefits. We will now introduce some of the self-management approaches
and the relevant evidence. As a physiotherapist, an understanding of the efficacy
of each approach will help the practitioner to advise patients how to self-manage
most effective The National Heart Lung and Blood Institute (2005) in the USA
implemented its Obesity Education Initiative using smart phones or desktop
computers as a medium for delivery. The programme generated an individualised
and evidence based assessment and treatment options for all patients included in
the initiative. The features of the programme are as follows: o Body Mass Index
calculation [20] o Assessment of cardiovascular disease risk factors o
Determination of need for treatment o Individualized weight-loss goals o
Individualized treatment recommendations (lifestyle therapy, pharmacotherapy, o
and surgery options) o Follow-up and maintenance recommendations o Evidence-
based supporting information available throughout Individual Education[edit |
edit source] Many studies have investigated the impact of one-on-one education
on chronic disease elf-management. Perhaps the earliest and most critical one-on-
one education an individual should experience is from parents. Lamerz et al
(2005) found a strong relationship between level of parental education and
childhood obesity. Children from lower socioeconomic backgrounds were exposed
to less parental education regarding healthy living, as a result they were more
than 3 times more likely to develop childhood obesity. The modern health
practitioner should have an awareness of this early family dynamic and consider
whether it is the child or the under-educated parent who is the route of the
problem. Viklund et al (2007) state that ‘empowerment programmes for diabetic
teenagers in early and middle adolescence should include parental involvement’.
[21] Studies suggest that while individual education may enhance individual’s
knowledge, it is unlikely to have significant impacts on behaviour change and
outcomes unless it is targeted, specific, and long term (Duke et al, 2009). Group
Education[edit | edit source] In the health care setting there are numerous
examples of group education programmes that cater for different demographics
and target many different diseases. Funnell et al (2005) found that culturally
sensitive group education sessions twice a week were effective in educating a
population of African Americans. Research generally suggests that group
education can improve patient’s self-efficacy, clinical outcomes and health service
use. Group sessions range from those focused on technical information such as
how to administer insulin and healthy eating, to more proactive education seeking
to change people’s attitudes towards self-management and initiate behaviour
change.[22] CONTINUED PROFESSIONAL DEVELOPMENT[edit | edit source]
CPD is becoming increasingly important in current physiotherapy practice and in
mandatory in many countries, French and Dowds (2008) state that “The ultimate
aim of CPD is to improve healthcare delivery and patient care”. Bury (2010)
describes CPD as “learning activities designed to facilitate professionals
acquiring new competencies”. In order to progress in the management of obesity
health professionals such as physiotherapists must develop their knowledge skills
and understanding of both obesity and its associated co-morbidities. The
development of additional skills may focus on secondary conditions related to
obesity (cardiovascular disease, hypertension, osteoarthritis, etc.), but also to
psychological barriers and/or cognitive strategies whose implementation will
increase the likelihood of permanent habitual change. Courses:[23] It is common
practice these days for physiotherapists to attend courses aimed at furthering
their knowledge in certain areas. Course, in-service training and clinical training
and supervision have been shown to be the most effective forms of gaining CPD
(French, 2006). There are many courses relating to obesity in areas such as: •
Obesity management • Childhood obesity • Obesity education CONCLUSION[edit
| edit source] The emerging role of physiotherapists in public health and physical
activity in relation to obesity could include the use of motivational interviewing to

edit source] ↑ Carels, R., Darby, L., Cacciapaglia, H., Konrad, K., Coit, C., Harper,
support obese individuals making lasting lifestyle changes. REFERENCES[edit |

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interviewing as a supplement to obesity treatment: a stepped-care approach.

Grumbach, K. 2002. Patient Self-management of Chronic Disease in Primary Care.

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N.A., Colledge N.R., Walker B.R. and Hunter J.A.A. 2006. Davidson’s Principles
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gain efforts? Obes. Res. 11:23–43S ↑ 4.0 4.1 lark, M. & Hampsen, S. E. 2001.
current health behavioural change models helpful in guiding prevention of weight

Implementing a psychological intervention to improve lifestyle self-management

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247-256.fckLRThe Chartered Society of Physiotherapy. 2002. Curriculum

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framework for qualifying programmes in physiotherapy. London: The Chartered

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the prevention, identification, assessment and management of overweight and

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Marchesini, G. 2011. Cognitive-behavioral strategies to increase the adherence to

London: Heinemann. ↑ Department of Health/NHS. 2004. Choosing health,

Coulson, N., Goldstein, S. & Ntuli, A. Promoting health in South Africa. 1998.

making healthy choices easier. executive Summary. Department of Health/NHS

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Senior, J. & Kendrick, T. 2004. Randomised Control Trial of the Effect of Leaflets

328, pp. 441-4. ↑ Golley, R. K., Magarey, A. M., Baur, L. A., Steinbeck, K. S. &
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Daniels, L. A. 2007. Twelve-month effectiveness of a parent-led, family-focused

trial. Pediatrics; 119(3):517-25. ↑ National Audit Office. 2001. Tackling Obesity in

weightmanagement program for prepubertal children: A randomized, controlled

England. Report by the Comptroller and Auditor General. London: The Stationery
Office. [Online] Available at:

[Accessed November 4 2011]. ↑ Samoocha, D., Bruinvels, D. J., Elbers, N. A.,

http://www.nao.org.uk/publications/0001/tackling_obesity_in_england.aspx

Anema, J. R. & Van Der Beek, A. J. 2010. Effectiveness of web-based interventions

Medical Internet Research. 12 (2), e23. ↑ 13.0 13.1 NHS Direct

on patient empowerment: a systematic review and meta-analysis. Journal of

Wales/Encyclopaedia. 2011. Physiotherapy. NHS Wales. [online] Available at:

[Accessed at 09/11/1 ↑ Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP,
http://www.nhsdirect.wales.nhs.uk/encyclopaedia/p/article/physiotherapy.

Cardon G, Carty C, Chaput JP, Chastin S, Chou R, Dempsey PC. World Health

Journal of Sports Medicine. 2020 Dec 1;54(24):1451-62. ↑ HS Direct

Organization 2020 guidelines on physical activity and sedentary behaviour. British

Wales/Encyclopaedia. 2011. Physiotherapy. NHS Wales. [online] Available at:

[Accessed at 09/11/1 ↑ Perri, M. G. Martin, A. D. Leermakers, E. A. Sears, S. F.

http://www.nhsdirect.wales.nhs.uk/encyclopaedia/p/article/physiotherapy.

Notelovitz, M. 1997. Effects of group-versus home-based exercise in the

↑ Protheroe, J., Blakeman, T., Bower, P., Chew-Graham, C. & Kennedy , A. 2010. An
treatment of obesity. Journal of Consulting and Clinical Psychology. 65 pp.278–285

intervention to promote patient participation and self-management in long term

conditions: development and feasibility testing. BMC Health Services Research.

Health;6:4–9 ↑ 18.0 18.1 Funnell, M. M., Nwanko, R., Gillard, M.L., Anderson, R.
10, pp. 206-220.fckLRRegis, D. 1998. Conformity, consistency and control. Educ

management Education Program. Diabetes Education. 31 (1), pp. 55-61. ↑

M. & Tang, T. S. 2005. Implementing an Empowerment-based Diabetes Self-

Glasgow, N. J., Ponsonby, A.L., Yates, R., Beilby, J. & Dugdale, P. 2003. Proactive

British Medical Journal. 327 (659). ↑ Foresight Report. 2007. Tackling Obesity:
Asthma Care in Childhood: General Practice Based Randomised Control Trial.

Future Choices. Full obesity system map. [Online] Available at:

http://www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/obesity_final_part
5.pdf [Accessed November 3 2011]. Frayling, T.M., Timpson, N.J., Weedon, M.N.,
Zeggini, E., Freathy, R.M., Lindgren, C.M., Perry, J.R., Elliott, K.S., Lango, H.,
Rayner, N.W., Shields, B., Harries, L.W., Barrett, J.C., Ellard, S., Groves, C.J.,
Knight, B., Patch, A.M., Ness, A.R., Ebrahim, S., Lawlor, D.A., Ring, S.M., Ben-
Shlomo, Y., Jarvelin, M.R., Sovio, U., Bennett, A.J., Melzer, D., Ferrucci, L., Loos,
R.J., Barroso, I., Wareham, N.J., Karpe, F., Owen, K.R., Cardon, L.R., Walker, M.,
Hitman, G.A., Palmer, C.N., Doney, A.S., Morris, A.D., Smith, G.D., Hattersley, A.T.
and McCarthy, M.I. 2007. A common variant in the FTO gene is associated with

(5826): 889–94. ↑ eenan, K., Grant, I. and Ramsey, J. 2011. Topic report on Obesity
body mass index and predisposes to childhood and adult obesity. Science 316

from the Scottish Health Survey series. [Online] Available at:

http://scotland.gov.uk/Publications/2011/10/25091711/0 [Accessed November 3

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2011]. Kopelman, P.G, Grace, C. 2004. New thoughts on managing obesity. Gut. 53

Brinkhues,. Brenner, H., Hebebrand, J. & Herpertz-Dahlmann, B. 2005. Social

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class, parental education, and obesity prevalence in a study of six-year-old

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[Accessed November 4 2011]. National Institute for Health and Clinical
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Available from url: http://guidance.nice.org.uk/CG43 Retrieved from
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UK, no. 1173185 Back to topCoaching in Rehabilitation -
Physiopedia Health Coaching Health coaching is an interactive and empathetic
patient-centered approach used as an intervention between the therapist and
patient, or coach and client, to help drive health behaviour change. [1] One of the
general aims of Health Coaching is to help improve one's health behaviour, in
areas such as promoting physical activity, smoking cessation, improving diet and
sleep, and minimising stress. [2] Collectively, Health Coaching can be defined as,
“a patient-centered process that is based upon behavior change theory and is
delivered by health professionals with diverse backgrounds.” [2] Another
definition of Health Coaching can be explained as, "Health coaching is the
practice of health education and health promotion within a coaching context to
enhance the well-being of individuals and to facilitate the achievement of their
health-related goals. In this way, motivation is built by guiding patients towards
their own inner throughs and desires for change." [3] Health coaching guides
towards self-determination, and self-efficacy. Self-determination can be defined as
'the process that a person takes to control their own life', while self-efficacy is
defined as 'the belief in one's self that they are able to initiate and continue a
desired action.' [3] It is important to note that Health Coaching is a useful
intervention to help prevent or reduce non-communicable diseases in the
developed world, especially since they account for a vast majority of the disease
burden in such communities. [2] It is mentioned by the World Health Organisation
that, "simply giving information to patients is unlikely to change behaviour; health
care providers must understand the psychological principles that underly self-
management training and comprehend that motivating patients requires more
than imparting brief information to the patient." [3] Health Coaching makes use
of evidence based health behaviour change treatment methods, from various
disciplines and areas, which include behavioural medicine research literature,
positive psychology, health and coaching psychology, and athletic and
performance coaching. [3] The intervention or long term behaviour change is
different than that of acute care management. Patients need to be involved in
techniques that foster self-efficacy, self-determination, and self-responsibility. [3]
The objective to empower the client into driving their own self-determined health
behaviour related goals. [2] Health coaching can be used in Health promotion,
prevention, early intervention, treatment, and management of chronic conditions.
[3] Health coaching within many conditions and disorders such as diabetes,
cancer, or cardiovascular disease, have shown positive health outcomes. [1][2]
However, health coaching may have different levels of effectiveness depending on
the chronic disease of concern. Many health coaching interventions are effective
in the short-term. [1] As is noted in the next section, Health Coaching is now an
intervention used in many different healthcare settings, including Physiotherapy.
[2] Description of a Health Coach[edit | edit source] A health coach can be
classified into 4 different categories, which include: Medical Professionals, Allied
Health Professionals, Other Health Professionals, and Professional Coaches.
These can be further broken down by profession. [4] Medical Professionals:
Physicians, Nurses, Pharmacists, Physician Assistants, and Medical Staff. [4]
Allied Health Professionals: Dieticians or Nutritionists, Psychologists (Doctorate),
Social Workers/Psychotherapists/Counsellors (Masters), Mental Health Providers,
Physiotherapists, Medical Assistants, Occupational Therapists, and Exercise
Physiologists/Specialists. [2][4] Other Health Professionals: Health
Educators/Promotors, Research Assistants, Medical or Nursing Students, and
Allied Health Students. [4] Professional Coaches: Health/Wellness, Life/Lifestyle,
Personal Vitality, and Personal Coach. [4] An individual like an educated peer can
also take the role of a health coach for a particular individual. [1] A Health Coach
that is working with a client needs to be empathetic, and provide patient centered
education. When they are searching and assessing for research to present to the
patient, or advising about research they previously read, they need to ensure that
the research is conducted with an evidence-based practice and thus is credible
information, and not commercial or anecdotal information. They need to ensure
that they are providing patient centered education, helping the patient/client with
their goals, determining the dose of coaching based on the interaction with the
client, and also being accountable for the conversation and information provided
to the client. [4] They need to ensure that the client progresses through their
goals from self-discovery and active-learning processes, and that they are
encouraging accountability for the client's behaviours. To see the modes of health
coaching in Primary Care, see the section below, on Health Coaching and Primary
Care. Modes of Coaching[edit | edit source] Coaching can be carried out through:
telephone communication, face-to-face interactions (in the clinic or office),
coaching via mail or on the internet, coaching via CD, and text and video
coaching. [1][4] Most commonly, not in person or over the phone, but online,
would be considered telehealth. [4] It is seen that coaching via telephone
communication is not effective in the long term. Face-to-face interactions are seen
to be the most effective. [1] It is identified by Olsen and Nesbitt (2010) that
techniques for an effective health coaching program include, goal setting,
Motivational Interviewing (MI), collaborating with the primary health care
provider, having a program duration of 6-12 months. [1] Interventions can be
implemented via behaviour change, empathy, emotional support from the
clinician, content education, and the patient collecting data as they’re gradually
making changes. [4] As is seen with Motivational Interviewing, clients are asked
open ended questions, experience ambivalence with their concern of change, and
increase the use of change talk change talk as they become more intentional with
their goals and changes. [4] Motivational Interviewing[edit | edit source]
Motivational Interviewing (MI) is one prominent technique used in health
coaching. See the MI Physiopedia page for the process of Motivational
interviewing, the Skills of Motivational Interviewing, the Spirit of MI, and other
relevant topics. Here's a brief video that explains motivational interviewing from
the founders of the conversation method. [5] Here is a good example of
motivational interviewing with all the various components presented. [6][edit |
edit source] When guiding the patient towards realising the intrinsic rationale
behind their desired behaviour change, it is important to make use of rating tools
or scales, asking the patient to rate their importance of change, their confidence
towards change, or their readiness towards change. Such dialogue can look like,
[3] "On a scale of 1-10, where 1 is the lowest and 10 is the highest ... How
important is it to you to be able to make the change of __________ ?", How
confident do you feel with being able to make this change of ________ ?", or How
ready do you feel in order to be able to make this change of ________ ?". Given the
patient's response, the therapist can ask why it wasn't a lower number. This will
help the patient bring out their motivating reasons and elicit change talk. [3] If
the patient gives a low number, educating, advising, or convincing the patient
toward making a change in their behaviour, by providing information, would not
be an effective idea. If the patient were to be asked why they didn't choose a
higher number, this would elicit them to outline barriers they may be facing with
the certain behaviour. In this case, the patient may have low confidence, a
knowledge gap, or competing priorities for them to commit towards change.
Based on the patient's barriers, the practitioner can help them resolve any
conflicts or explore different options. [3] The practitioner must ensure that the
goals are patient centered, and created by the patient themselves. This will give
the patient the most motivation to achieve their goals. [3] Stages of Change -
Transtheoretical Model[edit | edit source] The stages of change that the client is
in is identified, so that the Therapist or Clinician can progressively help the Client
increase self-confidence toward making a change. The self-determination theory
framework is guided by autonomy, competence, and relatedness, encouraging
clients to elicit their intrinsic motivators. Patients are guided towards their goals,
while reflecting on their values and vision. Patients are encouraged to build
confidence, as they reflect on previous accomplishments and failures, to help with
increasing facilitators and decrease barriers to the desired behaviour change. [3]
A person can only go through the stages of change once the individual realises
that a health behaviour change is needed, and shows their readiness toward
change. This would put them in the Contemplation Stage. Patient centered
questions can be asked by the therapist, to help elicit self-confidence, the
importance of change, determine related goals, and elicit change talk. The
Maintenance stage of change will be successful when the client's goals are self-
determined, and they are motivated to take action for their desired results. [3] In
the systematic review Dejonghea et al (2017), only studies that had an
intervention lasting longer than 24 weeks were included, equating to 6-months.
This was done to ensure the clients were progressed to the Maintenance stage.
Becoming a Health Coach[edit | edit source] Individuals interested in becoming a
health coach can be trained in these various methods, such as, cognitive
behavioural therapy, positivity psychology, and motivational interviewing. Short
courses, and entire programs at the postgraduate level can be taken to develop
the skills of health coaching. [3] Duration and Timeframe of Health Coaching[edit
| edit source] According to a systematic review, by Wolever et all (2013), on
Health and Wellness Coaching, the average duration of a coaching session was
35.8 minutes, and ranged from 5 minutes to 2.5 hours. There was an average of
6.2 contact hours with a coach, which can range from 15 minutes to 135 hours.
There is a median of 3 hours of contact duration with a coach. [4] There was an
average of 10.1 sessions, which ranged form 1 session to 90 sessions. There was a
median of 6 sessions. These sessions could span over 6 years. Individuals may
access the coach weekly, biweekly, or even biannually. The average timeframe of
using a coach's services was 6-12 month. [4] Coaching frequency appeared to be
related to length of the intervention, with shorter programs employing more
weekly coaching, whereas longer interventions were more likely to use monthly
coaching sessions. [4] Benefits[edit | edit source] The benefits of health coaching
in the primary care setting don't have to only be related to the patients' behaviour
change results, but also can be related to: [3] Improved job satisfaction of the
Clinician/Practitioner/Therapist Improved patient satisfaction with the services
provided, and the results obtained Increased efficiency and effectiveness of
Practitioner-Client interactions Due to the new learned self-management skills
and techniques, a decrease on the reliance of the medical system Improved
multidisciplinary collaboration of the Therapist/Practitioner with other health
professionals Health Coaching and Physiotherapy[edit | edit source] It is unclear
if Physiotherapists can play the role of providing Physiotherapy education and
treatment, and switch to a coaching framework of conversation, which is being
further studied. It is also unclear how the patient will respond to the therapist
treating in two different roles. [2] Positive Effect From a systematic review
conducted by Rethorn et al (2019) of 11 studies, it was seen that Health Coaching
produced a positive effect on physical activity, including physiological and
psychological secondary outcomes, in the Physiotherapy setting. [2]
Physiotherapists are at a suitable stance to provide health coaching. They are
providing education to patients, as well as physical activity and lifestyle changes,
for the patients to help themselves decrease or prevent further effects of their
condition. [2] With the Physiotherapists' caring and empathetic practice with their
patients, they are able to have a stronger therapist-client relationship, making it
smoother for them to practice coaching techniques, and coach their patients. [2]
In a study by de Vries et al, considering older adults, it was shown that there
were improvements in self-reported moderate intensity physical activity 6-months
after personalised physiotherapy and coaching. [2] Iles et al have shown that
adults with nonspecific low back pain have improved in physical activity after 12
weeks of a dual treatment consisting of coaching and physiotherapy care. [2] In
adults with rheumatoid arthritis, Knittle et al, have shown increases in self-
reported leisure physical activity time, with a greater number of days with 30 or
more minutes of physical activity, 32 weeks after a coaching treatment, helping to
improve physical activity. [2] In cardiac patients who did not pursue cardiac
rehabilitation, Reid et al found improvements in physical activity on a 7-day self-
recall basis 6 and 12 months after a year-long coaching program geared towards
improving physical activity. [2] The effectiveness of using measuring tools such as
an accelerometer, instead of self-reported measures, was noted by O’Halloran et
al, for a group of individuals who sustained a hip fracture, and were receiving
coaching to improve physical activity. [2] No Effect There were some studies that
reported no effect of coaching in the Physiotherapy setting on physical activity.
For patients that experienced a stroke, Physical activity was not improved with
the addition of monthly coaching sessions, even for a duration of 18 months. It
was also seen that these patients declined over the 18 month study period. [2]
When considering back pain, Basler et al found that there were no changes with
improved self-reported physical activity when coaching was added as a part of
physiotherapy care. [2] It was discovered by Brodin et al, that there were no
changes in activity levels in adults with rheumatoid arthritis with the
implementation of a 1-year coaching program. [2] There were no differences
noted, by Taylor et al, in activity levels between a supervised exercise group and a
telephone coaching group, 2 months after the implementation of a coaching
intervention. [2] Changes in physical activity, diet, and smoking were examined by
Speyer et al after a 1-year coaching program to improve lifestyle behaviors. There
were no differences in the different factors studied. [2] Health Coaching and
Primary Care[edit | edit source] The use of health coaching in primary care can
lead to success of the patient's desired behaviour change. The use of health
coaching motivates the patient to conduct and continue their own desired health
behaviour change. [3] The use of health coaching can help to enhance the
effectiveness and efficiency of consultations. This can be done in many ways,
including, [3] Making health coaching a component of the consultation Referral to
nurses or allied health professionals who are health coaches Referral to a to a
qualified health coach who can deliver the consultation within the facility, or
outside the facility in person, over the phone, or via telehealth Evidence[edit | edit
source] Systematic reviews highlighting the benefit of health coaching compared
to traditional care indicate that Health Coaching: [3] Significantly positive
impacts Clients' physiological, behavioural, and psychological, and social status
Has a significant positive impact on health behaviours such as nutrition, physical
activity, weight control, and adherence to necessary medication For individuals
with type 2 diabetes, improves glycaemic control and reduces glycated
haemoglobin Help with weight loss, with gaining motivation, autonomy, and
personal sense of accomplishment Help with managing the consumption of
calories, and reducing bodyweight and body mass index Help with improving
overall physical activity and lifestyle habits Other associated studies have shown
the effectiveness of motivational interviewing on smoking cessation, improved
nutrition alcohol minimisation, and other behavioural and lifestyle changes.
References

1. ↑ Arbuckle MR, Foster FP, Talley R, Covell NH, Essock

SM. Applying motivational interviewing strategies to enhance
organizational readiness and facilitate implementation efforts .

2. ↑ Norris M, Eva G, Fortune J, Frater T, Breckon J. Educating

Quality management in health care. 2020 Jan;29(1):1.

undergraduate occupational therapy and physiotherapy students

in motivational interviewing: the student perspective. BMC Med

3. ↑ Bahner J, Stenqvist K. Motivational interviewing as evidence-

Educ. 2019;19(1):117.

based practice? an example from sexual risk reduction

interventions targeting adolescents and young adults . Sexuality

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5. ↑ Lindson‐Hawley N, Thompson TP, Begh R. Motivational

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9. ↑ Chilton R, Pires-Yfantouda R, Wylie M. A systematic review of

Behavioural and Cognitive Psychotherapy. 1995 Oct;23(04):325.

motivational interviewing within musculoskeletal health.

10. ↑ Lauritzen T, Rubak S, Sandbæk A, Christensen B.

Psychology, Health and Medicine. 2012 Aug;17(4):392–407.

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analysis. Review Article. 2005 Apr 1 [cited 2016 Feb
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management education of primary care professionals improve
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stop talking about" non compliant" patients but rather about
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498).

14. ↑ Rogers, C.R. (1951) Client-centred Therapy. Boston:

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teachers' experiences. Educational Research. 2021 Oct

16. ↑ Kramer Schmidt L, Andersen K, Søgaard Nielsen

2;63(4):440-55.

A. Differences in the delivery of motivational interviewing across

three countries. Journal of ethnicity in substance abuse. 2022

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Aug 4;21(3):823-44.

S., Gallop, R. The Dependability of Alliance Assessments: The

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18. ↑ Critcher, C.R., Dunning, D., Armor, D.A. When Self-

doi:10.1037/a0023668.

Affirmations Reduce Defensiveness: Timing Is Key. Personality

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and Social Psychology Bulletin 2010; 36; 7; 947 –959.

Akkermans, R. Patient-centred physical therapy is (cost-)

effective in increasing physical activity and reducing frailty in
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s/PMC4864107/ (accessed on 27 Aug 2016)

M., Valent, L. A. Et al. Behavioural intervention increases

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21. ↑ O'Halloran, P. D., Blackstock, F., Shields, N., Holland, A., Iles,
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