BACKGROUND AND PURPOSE
In 2012, the United States Department of Health and Human Services outlined a list of public health priorities related to cardiovascular, pulmonary, musculoskeletal, neuromuscular, integumentary, and metabolic health. This document, known as Healthy People 2020, focuses on health conditions including heart disease and stroke, respiratory disease, arthritis, osteoporosis and chronic back conditions, diabetes, and chronic kidney disease.1 As specialists in human movement and exercise, these issues are particularly pertinent to physical therapists (PTs) and physical therapist assistants (PTAs), on account of limited physical activity being a common risk factor in the development of each of these health conditions.2,3 Sedentary behaviors are inherently linked to a significant burden of chronic disease and disability, as well as diminished health-related quality of life. The lack of appropriate levels of physical activity results in at least 300,000 cases of premature mortality and more than $90 billion in direct medical costs annually within the United States alone.4 Less than 5% of Americans currently meet the minimum recommendations of 30 minutes of moderate physical activity per day, and only 8% of adolescents and 45% of children meet recommendations for 60 minutes per day.5 Lack of exercise and the pervasiveness of a sedentary lifestyle represent a large unmet need for exercise promotion as a key strategy in chronic disease prevention and management.6 Given our level of professional knowledge and expertise, PTs and PTAs have a moral obligation to address the current health care crisis by empowering individuals to assume an active role in health promotion and wellness through changes in personal behaviors. This role is reflected by the American Physical Therapy Association's revised Vision Statement for the Physical Therapy Profession,7 adopted in 2013—“transforming society by optimizing movement to improve the human experience”—and is consistent with guiding principles enabling PTs and PTAs to achieve this vision through the prevention and treatment of impairments, activity limitations, and restrictions related to movement, function, and health.
Most people are aware that exercise is good for their health; however, an inability to overcome ambivalence and perceived barriers to an active lifestyle can interfere with participation in physical activity. While advice and personalized exercise prescription can be helpful, further consideration of additional factors is warranted. These factors often involve an individual's readiness to change, his or her interest in pursuing improved health and fitness, and a belief in his or her capacity to engage in new behaviors.8 Therefore, it is essential that PTs and PTAs possess not only the expertise to prescribe and administer the correct exercises, but the knowledge and skill to encourage individual motivation in establishing lifelong health habits known to reduce the risk of morbidity, disability, and premature mortality. PTs and PTAs can achieve these goals by working collaboratively. By including an assessment of the patient's readiness to change as part of the initial patient interview and follow-up evaluations, the PT can determine the best approach for empowering patients in choosing healthy behaviors. The PTA can further these goals by working with the PT in applying appropriate evidence-based strategies that engender and support these changes.
Motivational interviewing (MI) is a patient-centered approach to promoting changes in personal health behaviors, including improved nutrition, weight loss, and physical activity.9 Professional training in the use of MI and associated patient education methods can improve PT and PTA skill level and self-confidence in helping patients recognize the importance of behavioral risks. Through the use of motivational interviewing, PTs can assess an individual's readiness to change, deliver tailored patient education, and empower patients and clients to play an active role in self-management.10 The purpose of this position paper is to provide an overview of potential barriers and facilitators towards inclusion of MI as a component of patient education in physical therapy, and to impart a basic framework for incorporating brief MI techniques into physical therapy education and practice.
Position and Rationale
A recent survey11 of faculty members at professional level PT programs in the United States and Puerto Rico found that less than 35% of PT students received training in MI techniques, and only 48% received training in application of the Transtheoretical Model of Behavior Change (TTM), also known as the Stages of Change Model.11,12 Survey response rate was 71% and included 1 key informant from each of the 204 Doctor of Physical Therapy (DPT) programs recognized by the Committee on Accreditation for Physical Therapy Education (CAPTE). Statistics are based on the following questions: “Please indicate whether students in your program receive training in the following areas, select all that apply: (item 17.12) motivational interviewing skills; (item 21.4) Prochaska and DiClemente's Stages of Change Theory.” No known data were available to predict prevalence of MI training as a component of PTA education, and the original survey was primarily focused on the use of MI to promote smoking cessation. However, based upon the limited information available, it is clear that there is a need for better instruction in patient education to facilitate changes in personal behavior. Although MI may not be formally recognized as a technique routinely applied within physical therapy education and practice, its tenets are indeed consistent with professional values and curricular content guiding the interaction between PTs, PTAs, and patients. MI cultivates mutual respect between the provider and the patient, as espoused by Purtilo,13 and uses patient-centered communication, which is a hallmark of expert PT practice, as identified by Jensen, Gwyer, Hack, and Shepard.14 By acquiring and incorporating MI skills, PTs and PTAs can be better equipped to inspire healthy lifestyle changes, such as increased physical activity. Rehabilitative care settings can often provide a “teachable moment” for empowering patients to make these types of positive choices, thereby increasing the likelihood of enhanced health-related outcomes and reducing the risk of future disability.
Patient education is considered a basic skill in physical therapy,15 and 80% to 100% of PTs surveyed provide patient education as a routine component of care.16 While PTs generally have a strong positive attitude towards their role as patient educators,16 research has found that many clinicians do not feel adequately prepared to fulfill this role, and have a desire to increase their skills by learning more about patient teaching methods.17 Training in MI techniques equips the PT to take patient education to the next level by supporting and encouraging individuals to work towards optimal recovery and long-term maintenance of healthy personal behaviors.
Training PTs and PTAs in effective patient education for behavior change must incorporate existing evidence regarding the best methods for promoting adherence through better patient self-management. Professional training must also address potential barriers towards successful behavioral counseling present within the current health care environment. Common barriers include preconceptions regarding the patient's role in his or her own care. These types of barriers often stem from a paternalistic view of the relationship between the patient and the health care provider, where the provider is viewed as the “expert” and the patient is therefore expected to comply with the provider's advice.18 Previous studies reveal the flaws in the paternalistic approach to patient education, in that approximately 50% of Americans do not adhere to plans of care as prescribed by an “expert” provider.19 Lack of adherence to suggested medical treatment is estimated at 20% to 40% in acute illness, 30% to 60% in chronic illness, and 80% in preventive care.20 Ideal methods for patient education promote a collaborative relationship between the patient and the clinician21 based upon the recognition that motivation for change comes from the patient rather than the health care provider.9,22 Methods aimed at promoting increased exercise and other healthy behaviors have a higher chance of success when they take into consideration the patient's readiness to engage in the new course of action.23,24
MI techniques address readiness to change based on principles contained within the TTM.11 The TTM recognizes that motivation for change exists on a continuum that is often cyclical rather than linear in nature, and that the intention to modify one's personal actions is a product of many interrelated factors.25 The TTM describes the process of change as a series of stages, each involving its own unique barriers and facilitators.23 Patients who have no intention of altering their behavior within the next 6 months are said to be in the “Precontemplation Stage.” When change is intended in the near future (ie, 1 to 6 months), the patient is considered to be in the “Contemplation Stage.” As patients begin to gather necessary information and resources to set new goals and make a change in behavior (within 30 days), they pass into the “Preparation Stage.” While actively engaged in the behavioral change for the first 6 months, the individual is in the “Action Stage.” Those who successfully sustain the new behavior for more than 6 months are considered to be at “Maintenance.” (See Figure 1 for a schematic outline of the Stages of Change/TTM.) During the initial evaluation, or at other points within the process of patient education, PTs can assess a patient's readiness to change through use of an objective screening measure. An example of one such questionnaire can be found in Appendix 1.
The TTM is closely related to the Theory of Reasoned Action (TRA), which may also be employed when considering a patient's behavioral intentions or motivation for change.26 According to the TRA, intention is a direct antecedent to action (Figure 2). Intentions can be shaped by an individual's knowledge and skill, as well as the anticipated results of the recommended behavior (outcome expectations), the perceived likelihood of attaining the desired outcome (expectancy), and confidence in one's ability to succeed based on available resources (self-efficacy).26
The TTM and TRA can both be used to assess and incorporate principles of patient empowerment inherent to MI. It is known that involving patients in health care decisions produces better treatment outcomes.27 In addition, such shared decision-making is consistent with a prevailing demand among consumers for greater autonomy within their relationship with their health care provider.27 It is also important to consider the perceived barriers recognized by health care practitioners in addressing issues regarding personal choice and lifestyle-related medical issues,3 such as the need for increased physical activity. Such barriers may include anticipated patient resistance to receiving advice regarding one's personal behaviors.3 MI techniques reflect an awareness that ambivalence towards change is a natural human tendency24,28 and is an alternative for traditional methods of patient education where the provider imparts information and the patient is viewed as a passive recipient. Those types of traditional methods can actually increase resistance towards health-related recommendations.24 Instead, MI encourages reciprocity between the patient and practitioner, along with a collaborative approach to goal setting, treatment planning, self-monitoring, and reassessment.24
According to the principles of MI, commitment to behavioral change is a malleable trait that can be facilitated by expressing empathy, helping the patient recognize discrepancies between his or her current behavior and personal values, and providing support for the patient's self-efficacy by reinforcing the belief that he or she is able to initiate and maintain a healthy lifestyle.24,29 PTs are at an advantage in this regard due to the nature of patient-practitioner interactions (ie, personalized assessment and frequent follow-ups) that occur within a single episode of care. These characteristics allow the PT and PTA to work together in providing tailored patient education designed to best fit each patient's unique concerns, rather than providing general recommendations for health promotion and wellness. This type of individualized focus may provide patients with a greater sense of choice, personal control, and higher levels of investment and satisfaction with the ultimate outcome.30
The central tenets of MI are often summarized by the following template, commonly known as “The 5 A's: Ask, Advise, Assess, Assist, and Arrange” (Figure 3).31 These tenets can be applied to all areas of behavior and have been successfully employed in smoking cessation, medication adherence, glycemic control, and substance abuse treatment, as well as exercise and other health-related activities.2 The first step is for the health care provider to ask each patient about his or her concerns regarding current health and future wellness. These questions may be predicated by the patient's medical history and presenting condition, as well as other indicators such as environmental factors and access to care. This initial step opens discussion and allows the patient and provider to collaboratively agree on areas requiring further exploration, which will be based on the patient's individual health care priorities.32 Examples of questions geared towards understanding the patient's perspective include: “What problems do you have as a result of your current medical condition or behavior?” and “How do these problems impact your overall quality of life?”24
Next, the provider should advise the patient by providing information regarding health risks, while highlighting the benefits of behavior change in improving wellness and overall treatment outcomes. In this regard, PTs and PTAs may benefit from application of the International Classification of Functioning, Disability and Health33 to incorporate environmental factors and their influence on an individual's behaviors. Environmental factors may include exercise habits and social norms among an individual's family members and peers; facilities and outdoor space that encourage physical activity; and sufficient time to pursue recreational exercise, as well as other forms of non-exercise associated movement.34 This broad ecological perspective ensures the provision of relevant, tailored information which best suits an individual's interests and resources.2
In order to encourage a change in behavior, the clinician should assess the patient's willingness to act, as well as his or her current level of knowledge regarding the potential consequences of maintaining the status quo.2 PTs can gain a broader appreciation of the patient's concerns and viewpoints by inquiring, “What will happen if you continue as you are now?” and “What needs to be different in order for you to successfully manage your condition?”24 This portion of the conversation allows the patient and provider to agree upon an educational agenda that can gradually be expanded once the 2 parties gain a deeper appreciation of potential barriers, facilitators, and other issues related to health promotion and wellness.
Based on readiness to change, the PT can then assist the patient in setting mutually agreed-upon goals and a specific plan of action by selecting strategies for initiating the new behavior and identifying problemsolving techniques to address potential impediments to success. The provider may ask permission to share techniques that have worked for others, and can help the patient identify and access sources of social and environmental support.
Finally, because it is well recognized that behavior change and the maintenance of healthy behaviors can be challenged by relapse, it is important for the patient and provider to arrange opportunities for feedback and follow-up care.2 Feedback and follow-up should applaud current progress to promote continued motivation for long-term change. However, because relapses are anticipated as part of the normal course of care, patients should be encouraged to disclose these episodes in order to identify additional challenges, discuss solutions, and establish new goals.35
Throughout the process, it is essential for the PT and PTA to cultivate open communication with the patient, so that the patient can be honest about his or her motives and priorities.18 Within MI, the role of the health care practitioner primarily centers on helping the patient recognize and resolve ambivalence towards the adoption of a healthy lifestyle.9,22 Using the “5 A's,” the patient and PT or PTA can consider the benefits and drawbacks of the target behavior to ensure that decisional balance ultimately favors the desired change. Positive decisional balance (ie, a favorable attitude towards the recommended change) can be facilitated by asking people to construct a personal list of pros and cons of the new behavior, including the long-term costs and advantages. Lifestyles are a product of long-standing habits, change usually involves prior attempts at adopting the desired behavior, and past failures can influence future success. Therefore, it is important for the patient and the PT or PTA to discuss prior experiences, including past methods, results, and reasons for relapse.30
There are 2 basic phases in MI: (1) eliciting “change talk,” and (2) encouraging commitment to change.2 “Change talk” involves statements of desire, ability, reasons and need for change, commitment towards pursuing a new behavior, and thoughts concerning steps required to take action.35 Encouraging the patient to talk about what they want to happen, their confidence in making it happen, reasons why it is important, and how badly they want the change to occur provides insight into the strength of their motivation and how committed they are to change. Commitment to change can be facilitated by provider feedback and patient instruction in self-monitoring his or her own performance in order to identify and address discrepancies between the patient's current and desired level of health.2,32 Feedback can also be used as an opportunity to encourage renewed motivation.32 Before discussing objective data regarding performance feedback, the PT should ask permission from the patient to approach the subject. After gauging the patient's receptiveness and providing information, the clinician should then ask open-ended questions about the impact of the feedback on the patient's thoughts and feelings.32
During all phases of patient education, it is anticipated that the patient, as an autonomous individual, may disagree with some of the provider's advice or assessments.36 In these situations, it is especially important for the PT and PTA to convey respect for the patient's opinions. Human beings tend to behave in ways that preserve our personal sense of freedom. Therefore, if the advice conveyed by the health care provider appears to threaten the patient's autonomy, it is likely that the patient will respond defensively in order to maintain a sense of independence. This is particularly true when providers mandate behavior change with little opportunity for patient input regarding the prescribed course of action. If resistance should occur within the context of patient education, the PT or PTA can use MI to redirect communication in order to gain a better understanding of the patient's concerns.24 It is essential for the PT or PTA to encourage the patient to make his or her own decisions. This helps to establish and support the patient's self-efficacy and personal strengths.24 It is also important to emphasize the benefits of change rather than focusing on the risks of continued unhealthy behaviors. This recommendation is based upon studies that have found that positively framed messages may be more effective than negatively framed messages when encouraging the patient to work towards health promotion and wellness.36
Once the patient is ready to decide on the new course of action, he or she should be encouraged to make a verbal commitment. Giving voice to one's decision to adopt a new course of behavior can enhance the chances of success.28 The PT or PTA can also help guide the patient towards visualizing the tangible benefits of the recommended change.28 For example, the clinician might ask, “If you start increasing your levels of physical activity, what might be the best results you can imagine?” It is also known that setting specific goals increases chances of success.37 The patient's own personal goals should be explicit with regards to outcome, and the recommended course of action should be attainable and realistic given the patient's present capabilities.37 PTs can help guide patients in developing a personal action plan for behavior change using one of several templates (Appendix 2).
Each patient encounter should conclude with a reflective summary, provided by the PT or PTA and shared with the patient, to ensure an accurate understanding of what has been discussed during the session. This provides an opportunity for clarification and reinforcement of the advice that was given, as well as a chance for the PT or PTA to convey empathy and respect through a genuine interest in exploring and accepting the patient's points of view.38 An example of patient-directed dialogue, centered on perceived barriers to change, can be found in Appendix 3. In this dialogue, the PT expresses empathy and confirms his or her understanding of the patient's concerns through use of reflective listening. This enables the patient to openly explore some of the perceived challenges in pursuing the recommended levels of physical activity and come up with potential solutions that would work within his or her specific set of circumstances and personal priorities.
From the perspective of the health care practitioner, barriers to the application of MI in the clinical setting include time constraints and competing demands. Traditional MI can typically require sessions of 30–60 minutes in length, as well as advanced training in behavioral counseling techniques.39 However, a modified approach, referred to as “brief MI,” can take as little as 5 to 10 minutes.39 During brief MI, the primary goal is to communicate risk, provide information, initiate contemplation of behavioral change, or provide support for continued action.38 During the brief encounter, the health care practitioner should strive to identify reasons for change, readiness to change, potential barriers and facilitators, anticipated outcomes, the personal importance of these outcomes from the patient's perspective, and the next step in taking action designed to promote the new behavior.39 Within the rehabilitative setting, frequent patient visits over a single episode of care allow clinicians to perform these steps while enhancing reinforcement, follow-up, and deeper patient rapport.
DISCUSSION AND CONCLUSION
Though the availability of evidence specific to PT practice is scarce, research supports the impact of MI on chronic disease management.40 In one study, health coaching using MI, as opposed to standard care, increased patient self-efficacy, perceived global health status, and behavioral changes in individuals in the intervention group.40 A study conducted in 2010 called IMPAACT (Improving Motivation for Physical Activity in Arthritis Clinical Trial) also showed positive results.41 MI has been successfully employed in promoting adherence to a walking program in patients receiving chemotherapy for breast cancer,42 in improving health promotion behaviors among people with coronary risk factors,42 and in promoting exercise in patients with fibromyalgia.39 In patients with traumatic brain injury, MI was used to promote increased patient engagement in the rehabilitative process, setting the stage for a better therapeutic alliance.43
Among other colleagues within the health professions, MI has been successfully used to promote vocal behavior change through improved patient education and enhanced communication during speech therapy.44 The occupational therapy profession recognizes the value of MI as a tool for behavior change when working with patients with a history of substance abuse, eating disorders, cardiovascular and pulmonary issues, and more.45 Within physical therapy, evidence of growing awareness of the value of MI can be found in recent publications endorsing implementation of MI for tobacco cessation counseling as a component of PT practice46 and professional level education,12 as well as increasing patient adherence to treatment recommendations.47 Other examples include recent presentations at physical therapy national conferences highlighting the need for effective interventions to address lifestyle issues and health risk behaviors,48 the use of MI to improve patient self-management,49,50 and a 2012 podcast by Mary Sue Ingman, PT, DSc, on MI and other resource material available through the American Physical Therapy Association website.51
To continue to support this growing awareness of the value of PT interventions to enhance health behavior change, existing practitioners, as well as students entering the profession, will require improved training in MI and other forms of evidence-based patient education methods. In particular, students and professionals can benefit from training in the application of social and behavioral theory in order to facilitate behavioral change and effective patient self-management. In one study, the majority of PTs surveyed (75%) were unaware of the TTM of human behavior and 90% were unaware of “The 5 A's” behavioral intervention protocol inherent to MI.52 Furthermore, 40% of clinicians were unaware of the leading national health priorities, such as those delineated by Healthy People 2020, although 100% of survey respondents agree that PTs play a key role in health promotion and illness prevention.52
Within other health-related professions, training in MI has proven successful in encouraging increased student engagement in health promotion and wellness.53 MI, as outlined by “The 5 A's” behavioral intervention protocol, requires the integration of communication skills that are already a common component of physical therapy. This includes expressing empathy, using openended questions, and fostering increased patient autonomy38 and a patient-centered approach to care.54 While basic competencies in MI can be gained during professional level education, mastery, as in all aspects of physical therapy, will require increased levels of exposure and effort,55 making training for experienced professionals an additional area warranting further inquiry.
Creating a curricular blueprint and instructional materials for the application of MI by professional level students is a central strategy for increasing professional involvement in health promotion and wellness through an evidence-based approach to patient education.53 A list of learning objectives to promote the use of MI in physical therapy practice can be found in Appendix 4, along with a list of recommended resources.
As the use of MI increases within PT practice, it will be important to gather data that may be used to evaluate its efficacy in enhanced patient outcomes. Factors to consider will include the type of behavior targeted for change (eg, type of physical activity), the severity and complexity of the behavior, and methods employed (ie, whether MI is provided as a stand-alone intervention or as a complement to other physical therapy services).56 Potential effects mediators include dose (ie, the duration and number of MI encounters) and the methodological quality of any subsequent research studies.56 Studies should also explore the use of MI in promoting the maintenance of new behaviors by preventing and addressing relapse.57 It is possible that different factors are required for successful short-term versus long-term changes in behavior.57 In addition, PTs and PTAs must become more diligent in documenting details of patient education so that data will be available to evaluate various methods and results.
Healthy People 2020 outlines public health priorities for the current decade and identifies sedentary behaviors as inherently linked with a significant burden of chronic disease and disability. It is our hope that this article will spark further discussion regarding the best methods to educate and encourage students, as well as practicing PTs and PTAs, to integrate MI and associated methods of patient education as a component of patient care, especially in areas involving physical activity as a pathway to wellness and restoration of functional independence.
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Chase L, Elkins JA, Readinger J, Shepard KE. Perceptions of physical therapists toward patient education
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Karges J. Patient Education: Physical Therapists’ Perceptions Regarding the Use, Effectiveness, and Barriers of Adult Education Principles
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DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care.
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Ang D, Kesavalu R, Lydon JR, Lane KA, Bigatti S. Exercise-based motivational interviewing
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Appendix 1. Screening Instrument: Readiness to Change
Appendix 2. Template for Personal Action Plan
Appendix 3. Sample Dialogue: Steps to Success: The Patient-Directed Approach to Health Promotion and Wellness
Appendix 4. Curricular Blueprint