Mulligan, Hilda PhD; Treharne, Gareth J. PhD; Hale, Leigh A. PhD; Smith, Cath PhD
Increasing participation in physical activity is a global health goal. Physical activity is particularly important for individuals with chronic or disabling conditions to prevent secondary conditions such as depression, pain, and deconditioning, all of which have a negative impact on quality of life.1–5 It is not easy, however, for individuals living with disability to participate in regular physical activity, not only because of impaired physical capacity, but also because of the many physical and social barriers to participation.6–10
Health care professionals, including physical therapists, can be influential in facilitating health-promoting physical activity for people with disability.11,12 Health care professionals have also recognized the need to help persons with chronic conditions/disability learn to build the skills for self-management13–18 and self-efficacy in the long term.19,20 There is, therefore, a need to develop approaches that integrate self-help with professional help for autonomous yet supported health promotion.21 This article outlines an innovative approach by physical therapists to promote community-based physical activity for people living with multiple sclerosis (MS) in Aotearoa/New Zealand, by combining self-help with professional help.
Examples from previous studies aimed at promoting physical activity in individuals with MS have shown a focus on the prescription of physical activity according to the recommended amount required for health, or on considerations and reasons for maintaining adherence to physical activity.22–25 Our goal was not so much to find the perfect intervention for determining the required amount of physical activity, nor to enforce adherence, but to develop an innovative way to motivate participation in health-giving physical activity that is feasible and acceptable and one that can be sustained.
Our previous research has identified that longer-term adherence to physical activity by individuals with disability could be enhanced by health care professionals acknowledging the desires and capabilities of the person for whom the intervention is targeted, so that the individual has choice, control, and confidence over their engagement in physical activity.26–29 For example, our research has investigated the levels of choice that are involved with decision making around fatigue and exercise as a physical activity for individuals with MS.29 It shows how control is influenced by the belief that control is possible, feeling safe and supported in one's choice, being able to manage one's limitations, and being satisfied with trade-offs of the costs and benefits of decisions made around physical activity participation.29 Control, choice, and confidence are related to the concept of self-efficacy, described by Bandura30 as having belief in one's capabilities to achieve a particular goal. Self-efficacy is facilitated by mastery experiences, seeing others being successful, perceiving the benefits of one's actions, and being persuaded and supported by others toward a realistic goal.30,31
In New Zealand, “Green Prescription” is an initiative supported by our national health service. It allows general practitioners (family physicians) to “prescribe” physical activity, often outdoors (hence the term “Green”). Patients are then encouraged by a paid “Patient Support Person” to be more active, using strategies such as monthly telephone calls or advising on access to community groups who provide physical activity opportunities.32 Our research group, made up of 3 physical therapists and a psychologist, has expanded the idea of the Green Prescription approach by utilizing the active support of physical therapists, with the idea that including support from physical therapists could enhance promotion of physical activity for people who are likely to require adaptation of physical activity to enable their participation. Given that physical therapists traditionally wear blue uniforms in New Zealand, we named our approach “Blue Prescription” to reflect the role of the physical therapist. The philosophy of the Blue Prescription approach is for individuals living with disability to be enabled to choose both a physical activity program and a method of ongoing contact (support) that suits their needs, thereby enhancing autonomy and development of a plan to maintain physical activity into the future. We chose to trial the Blue Prescription approach with individuals with MS as a starting point. We used a noncontrolled clinical trial to examine the feasibility and acceptability of the Blue Prescription approach. This article describes the content and resources required for delivery of Blue Prescription by physical therapists in New Zealand; outcomes and participant perceptions of our trial are reported elsewhere.33,34
Motivational interviewing is an important aspect of the Blue Prescription, which was originally developed as a counseling strategy in the addictions field but is becoming increasingly used in other health care settings.35–37 It is a method of communicating with patients that is designed to build motivation for behavior change desired by the individual by allowing and encouraging the person to act on his or her own arguments and reasons for choosing a course of action.36–38 It was previously thought that exercise participation was detrimental for people with MS because of the overwhelming sense of fatigue that is often part of living with MS.9,39–41 Current evidence, however, suggests the contrary.13,42–45 Because people with MS experience fatigue as a major barrier to exercising,46 we incorporated the concept of motivational interviewing into our approach as a way to assist confidence to exercise despite fatigue.
This article uses the data from the feasibility trial to describe what the Blue Prescription approach entails, and to inform its further development. In this article, we specifically address 3 objectives: (1) to outline the content and pragmatics of the Blue Prescription approach, (2) to uncover what interactions are required to best deliver it, and (3) to identify enhancements to the approach. By doing this, we hoped to identify and develop the core components of Blue Prescription for its future use in physical therapist practice.
The trial of the Blue Prescription approach involved 27 participants with MS, recruited in sequence using quota sampling from volunteers from MS Societies in 2 urban centers and their proximal rural areas in the South Island of Aotearoa/New Zealand. Inclusion criteria were broad (to reflect the reality of clinical practice), so that volunteers were included as study participants if they were older than 18 years and had MS of any type, severity, or duration that had been diagnosed by a neurologist (see Table 1). We also recruited 2 physical therapists (1 in each center) to work alongside the participants. The physical therapists were recruited purposefully for their (1) clinical experience in community services for people living with disabling conditions, (2) experience with patients with MS, and (3) interest in being involved in the development of an innovative approach to their clinical practice.
A physical therapist initially visited each participant at his or her selected venue (eg, his or her home) for about 1 hour on 1 to 3 occasions (1-2 weeks apart). The intent of each visit for the physical therapist was to use motivational interviewing with the participant to discuss goals around physical activity levels and to problem-solve together how a desired physical activity program was to be achieved.38 Choice of physical activity was, in every case, something the participants felt they could attempt on their own or with the support of friends or family. Over a period of 3 months for each participant, he or she chose, trialed, and modified engagement in physical activity on his or her own terms. Activities chosen by participants ranged from a home-based, tailored exercise program (some assisted with information on DVD) to walking, playing a recreational sport, or attending exercise classes or a local gymnasium or a local swimming pool (see Table 1).
The physical therapist provided assistance in the beginning of the activity, for example, accompaniment to a gymnasium to provide advice on how exercise equipment could be appropriately modified, or to a swimming pool facility to provide advice on how the participant could get into and out of the pool safely. Participants were also encouraged to keep in regular contact, for example, weekly, fortnightly, or monthly, with the physical therapist via text messaging, e-mail, or telephone contact (depending on personal preference). At the end of 3 months, each participant had an “exit” visit with his or her physical therapist to identify strategies the individual had used or could use to maintain physical activity into the future, using a volitional “help sheet.”47 The participants recorded these strategies in a written format to remind themselves of the decisions they had made.
An Advisory Group was made up of the research team members, people with MS, physical therapists with a special interest in disability issues, and MS Society field officers.48 This group supported the physical therapists in their implementation of the approach. The purpose of the Advisory Group was to provide local knowledge, advice, ideas, and strategies to the physical therapists. The Advisory Group and therapists met at 2-week intervals via teleconference. In addition, the physical therapists accessed the Advisory Group members via e-mail in between the regular meetings for advice if required.
DATA AND ANALYSIS
For the purposes of this article, we have used 4 sources of data: (1) transcriptions of individual semistructured interviews with each participant conducted after the feasibility trial that explored their perceptions of the Blue Prescription approach, (2) transcriptions of individual interviews with the 2 physical therapists (conducted before and after the feasibility trial) that explored their understanding of what the approach entailed and to ask about strategies they had found useful for implementing it, (3) the physical therapists' clinical notes recorded during the trial, and (4) meeting records of the Advisory Group.
We analyzed the data from the 4 sources, using the General Inductive Approach, a method of analyzing qualitative evaluative data.49 To do this, each member of the research team individually read and re-read the data to become familiar with it. We each made notes about the data and then came together to discuss the data and to name and define categories within the data. We thus built up a coding template, which we subsequently added to as we progressed through the analysis, coming together on 6 further occasions to discuss the emerging findings and to organize our findings into 3 sections pertaining to each of this article's objectives.
Our results are described in 3 sections, 1 for each of the 3 objectives. Each section is illustrated with quotes taken from the data.
Content and Pragmatics of Blue Prescription
The factor that drew most of the participants to volunteer for the trial of Blue Prescription was receiving an invitation, via the MS society to which he or she subscribed, clearly stating that the trial was about becoming more physically active and was open to anyone with MS, no matter the type or severity. Some participants' perceptions were that people whose level of disability required the use of a wheelchair traditionally received preferential access to health services, advice, and support. Therefore, an invitation that was inclusive had been welcomed.
Participants expressed satisfaction that physical therapists' visits took place wherever the participant chose, at a time that suited them (eg, in the evenings for participants who worked during the daytime). They also acknowledged how enjoyable it had been to have therapist accompaniment to trial physical activity. Most participants required only 2 visits, after which they took responsibility to continue their own program of physical activity.
Since the physical therapists allowed participants to choose their own activity and be supported in this choice, our approach enabled them to learn self-directed decision making. For example, “[Blue Prescription] made me feel like I was taking part in my own management” (location B, participant 12).
While participants acknowledged the usefulness of advice and support that the Blue Prescription approach had afforded them, they also acknowledged that the approach had provided them the freedom and flexibility to choose their own preferred mode and approach to physical activity. Therefore, instead of previously “feeling crap at [a previously loved sport]” (location A, participant 13) or “always tagging along behind with the MS asterisk” (location A, participant 5), it had allowed them to be physically active without fear and the stigma of failure, because they were free to change their minds about previous decisions, for example:
... well I'd been thinking about doing some aqua jogging but I was too scared I wasn't going to be able to get out of the pool so I went with [physical therapist], and yes I could get out of the pool, so I did that for a while but found that it was getting harder and harder to walk around the side of the pool without using my stick and my left leg was dragging by the time I got out of the pool...difficult to get back to the changing rooms. So I had to put on my thinking cap and do something else. Now I've joined a gym called [name of gym] which is a machine-driven Pilates-type exercise, which I go to four or five times a week. (location A, participant 7)
Much of the advice provided by the Advisory Group was about strategies to manage challenges that, unless attended to, would have derailed progress toward participants' physical activity goals. Examples of these strategies were the use of cooling devices such as gel pads and air conditioning for participants who struggled with the feeling of overheating, advice about equipment such as walking poles, information about where to access inexpensive, home exercise-based DVDs, and advice on ways to modify physical activity to suit individual levels of ability. An example of the latter was to lower the height of the bicycle seat so that a participant who wished to accompany her young daughter while cycling in the park could easily reach both feet to the ground, thereby eliminating her fear of falling.
Interactions Required for Delivery of Blue Prescription
The 2 physical therapists we employed for the feasibility trial understood that, for the Blue Prescription approach, their role was to support participants to choose something that they would enjoy and at which they could be successful. The physical therapists endeavored to understand a participant's own perceptions of living with MS, explored how this impacted on her or his intentions and actions, acknowledged the individual's real or perceived challenges and issues, and was prepared to delve into and explore various possibilities for physical activity with the individual. The therapist's words later show how they understood that they were not the fount of all knowledge, and that “success” and satisfaction had come via participants building confidence by choosing their own pathway toward physical activity.
[The participant]...decided that swimming was the right one for her, so I came back a week later and she'd said “actually it's not”; she had realized that she didn't want to have to get wet and get changed... But in the meantime she had set it up, really simple, how she was going to get back to walking her dog. She had negotiated with [her parents] that if she walked her dog and got tired she'd phone her parents and they'd come and pick them up. You know it was something simple, but if I hadn't gone back that second time...it's like she'd already done it, but having me go back there gave her that permission to throw the swimming idea out the window and for me to say “yes well what you're doing with the dog is fantastic, you know, keep that up.” (Physical therapist A)
I enjoyed the fact that they...I guess that they had the power to choose what they wanted to do long-term and they had the freedom to do that. I got quite a lot of good feedback from them about how helpful they found that, so it was really rewarding to feel like you were on the same team from the outset. (Physical therapist B)
Many of our participants described previous unhelpful encounters with health care or recreational professionals around physical activity. They described such encounters as being about exercises that hurt, or about encounters that felt disrespectful because they had been told what to do without being acknowledged for their personal choice or context. In contrast, the support received from physical therapists in Blue Prescription was perceived to be different. Participants identified that the physical therapist had respected them as a person, with individual personal circumstances, wishes, preferences, targets, and challenges. For example, participant 3 in location A described her Blue Prescription physical therapist as one who “listens and understands.”
From the therapists' clinical notes, we saw that by far the most preferred method of ongoing communication and support for participants was e-mail. However, interview data also identified that knowing that the therapist was to return for a final visit in 3 months' time to see how things were going had provided a measure of extrinsic motivation for participants to keep up their physical activity.
Improvements and Refinements to the Blue Prescription Approach
We found 4 suggestions or issues that need to be considered for developing Blue Prescription into the future. One suggestion was that new participants be provided with the opportunity to “meet” other participants (using Facebook or other social networking) to receive encouragement and hear others' experiences. There was also the suggestion that, because an individual's circumstances may change through ill health or injury, people should know where to access advice and support from a physical therapist if/when this occurs. Both physical therapists identified that Blue Prescription might be successful for some individuals only if other services beyond the scope of the approach (such as social services) are also available, especially for individuals who are in crisis, for example, over monetary or family issues. Furthermore, both physical therapists perceived the possibility of resistance by health services to incorporate the philosophy of the Blue Prescription approach because, in their opinion, current services tend to be aimed at remediation of an incident (eg, provision of rehabilitation after a fall), with the intent being discharge of a patient once the incident has been resolved.
Refinements for trialing Blue Prescription further were also identified. We had used an Activity Diary in the feasibility trial. Many participants thought that the activity diary was a motivational tool to encourage engagement in physical activity, rather than a measure of levels of physical activity for the purposes of the trial. As a measure, participants felt that the diary did not afford them opportunity to explain their levels of physical activity by capturing other things that were happening in their lives, such as caring for family members, the presence of extra and unforeseen fatigue, or changes to their work or personal situations. For example, the physical therapist in location A had written in the clinical notes for participant 5 that this participant “says the activity diary makes her feel incompetent and as though we would be cross about how little she does.”
Furthermore, some participants reported that the diaries had been challenging to complete because of issues with fatigue, particularly at the end of the day, which is when they had been asked to complete it. Also, we had measured the outcomes of the feasibility trial with the MS Impact Scale,50 the MS Self Efficacy Scale,51 and the European Quality of Life Scale.52 Many participants voiced frustration with our use of these questionnaires, because they felt that the questions were not clearly phrased or did not reflect their lived experiences. As an example, they found it a challenge to answer a question about health when they were not told explicitly whether this referred to the context of general health or the context of having MS.
A summary of the contents and pragmatics of Blue Prescription, the interactions required for its delivery, and additions and refinements for future delivery of the approach are shown in Table 2.
In this article, our intent was to describe and detail the content and interactions required for the Blue Prescription approach to encouraging long-term participation in physical activity for people with MS, and to identify further developments for this approach. In the Blue Prescription approach, individuals with MS were allowed and encouraged to be flexible, for example, around their levels of fatigue. This resulted in participants feeling that they had “permission” to change the amount and extent of physical activity they undertook, thereby releasing them from what would previously have been a feeling of guilt that what they achieved was insufficient. The use of techniques from motivational interviewing37,38 enabled our participants to choose the type and nature of physical activity undertaken and allowed individuals to reset their own goals and choices if required, thereby building confidence in decision making so that physical activity was sustained in some form or another over time. Indeed, motivational interviewing has shown success in a recent randomized controlled trial of community-residing persons with MS, where telephone counseling was specifically trialed as a health-promoting strategy.35 The counseling was intended to include discussion of exercise, and this had proved a relatively popular focus, with 59% of the intervention group selecting support with exercise, leading to an improvement in walking speed.35
We identified a number of issues in our first foray with the Blue Prescription approach, as well as strategies we could use for taking the approach into the future. An activity diary could be used as a motivating tool but would need to be explicitly introduced as such so that the participant would not feel that they were being watched by “Big Brother.” For some individuals, an electronic means of collecting reports of physical activity could be more appropriate than a written diary because of inability or unwillingness to spend energy on writing.53 This could be via a small digital recorder carried on the person. In the interests of objectively measuring levels of physical activity, it would be advantageous to use accelerometers. However, we have personally experienced challenges to the accurate measurement of physical activity by individuals with disability using accelerometers in free-living environments,54 and others have identified the challenges to measuring physical activity via accelerometers in persons with MS.55
The questionnaires we used in the feasibility study posed problems to many participants who did not see the relevance of the questions to their lived experience. We suggest that this be addressed in future application of the Blue Prescription approach. The use of the “Think Aloud” method could be a useful way to select or develop suitable and user-friendly questionnaires. In the “Think Aloud” approach, respondents are asked to talk through their thought processes as they complete a questionnaire so that the instructions and questions can be investigated from the respondents' perspective rather than from the researchers' perspective.56,57 We are currently researching development of the questionnaires we used in our Blue Prescription feasibility trial with the “Think Aloud” approach.
To develop the Blue Prescription approach further, we suggest that the physical therapist's training required to implement it be undertaken in 3 phases: (1) explicitly train the physical therapist in the technique of motivational interviewing,37,38 (2) introduce the physical therapist to the intent of an Advisory Group, and (3) train the physical therapist to be able to implement a volitional help sheet with individuals that will allow reflection and decision making.47 We suggest that the philosophy and approach to Blue Prescription could be taught via the use of a training video with clips of interactions between an individual and a physical therapist.
In this article, we have outlined the content and interactions required to put Blue Prescription into practice with individuals with MS in order to promote health via physical activity. It would appear that our approach could potentially be used for any person with a chronic condition or disability, because its philosophy and approach are flexible enough to allow individuals to choose both a physical activity program and a method of support to suit individual needs and context. However, we also identified an important issue to be addressed in furthering our approach; the issue of health services providing long-term management versus shorter-term remediation for individuals with disability needs to be resolved before an innovative approach such as ours can become part of “usual” practice. This would be assisted if short-term remediation services and longer-term management could undergo economic evaluation to identify their relative economic effectiveness. In addition, development of advisory groups within the health sector could be a powerful means to help shape policy and practice into the future, because they include the people for whom interventions are developed.48
CONCLUSIONS AND FUTURE DIRECTIONS
The Blue Prescription approach described in this article allows physical therapists to support people living with disability to identify and choose a physical activity that is feasible, acceptable, and therefore maintained. A core concept of the approach is the recognition that people are different (with diverse needs, likes, and dislikes), and that sustained participation in physical activity programs by people with physical disabilities requires autonomy coupled with meaningful support from a health care professional such as a physical therapist. We intend to plan a research program to systematically evaluate the long-term effectiveness of the Blue Prescription approach for people living with a range of chronic disabling conditions in various geographical areas. The use of cluster randomization would provide opportunity to have broad inclusion criteria into the study, thereby more closely mirroring the characteristics of patients seen in usual clinical practice.
We thank Dr Sarah Dean, Senior Lecturer in Health Services Research, Peninsula College of Medicine and Dentistry, University of Exeter, for contributions to the development of the Blue Prescription approach. We also thank the Advisory Group, our participants, and our physical therapists.
The University of Otago Human Ethics Committee provided Ethical Approval for the research on which this article is based.
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disability; enablement; health; participation; physical activity; physical therapist