Our Parting Gift

To all of our dedicated followers, we would like to sincerely thank you for following our journey to promote a sustainable and meaningful exercise rehabilitation class within physiotherapy practices today. We hope we have provided you all with the knowledge and inspiration to proactively promote a meaningful change to your practices and/or lifestyles. To conclude, we would like to provide you with a summary of our suggested solutions that were discussed over the series of blogs, presented in the form of a checklist for patients and/or physiotherapists to refer to early on; during an initial consultation of a patient eligible for exercise rehabilitation. We strongly advocate for the use of this tool in both research and clinical practice with the hope of it becoming not only a reliable, valid and responsive tool; but the gold-standard psychosocial tool used within physiotherapy rehabilitation practices around the world.

– AD, BH, JH, RJ

Untitled3.jpg

Making Time

‘A lack of time’ has long been identified as a key barrier to treatments in an early prospective study (Alexandre et al., 2002). In this study, barriers, such as busy working schedules, a lack of time, needs for child care, financial constraints are found to associate with poor  patients’ adherence. These barriers are personal and individualised. In general, male patients tend to report busy working schedules and laziness being their main barriers to rehabilitation, whereas the female patients are more likely to quit a program due to family obligations and their commitments to family, work and community activities.

https://i0.wp.com/christinambove.com/wp-content/uploads/2013/08/gluhereff6.gif
(Google images)

While a number of personal barriers can inhibit patients’ participation in rehabilitation, many of these are predictable. It is described by Giuliani (2002) that a good leader is able to identify potential problems and prepare relentlessly before barriers happen. In order to do this, clinicians need to first appreciate patients’ diverse values and cultural responsiveness. All patients’ perspective and conditions should be treated with respect. As reasons for non-adherence are individualised and multi-factorial, a patient’s individual preferences and social characteristics, such as working schedules and family situations, should be considered by clinicians during treatment planning to maximise one’s possible participation (Jones et al., 2007).

Untitled
(Google images)

Leadership is a people activity and is much more complex than planning activities. This is to say, after planning, leaders should engage followers to actively involve in the pursuit of shared plans. To do this, the Health LEADS Australia (HLA) model encourages leaders to engage others with the use of explanations and encouragements (Health Workforce Australia, 2013). One-to-one meetings and cognitive-behavioral training, such as motivational interviews, can be used to optimise the communicative process and reduce one’s perception of barriers (Gohner & Schlicht, 2006). It is also proved in a systematic review by Tierney et al. (2012) that cognitive behavioral strategies, such as education about problem-solving skills and motivational interviews can improve patients’ confidence in continuing exercise programs. Improved self-efficacy could also positively influence patients’ persistence and willingness to engage in a program. The ultimate goal of engaging patients is for each person to take responsibility to follow the plan and achieve the desired outcome.

(Google images)

Also, is it about having time or making time for rehabilitation? Setting appropriate goals can improve one’s self-management skills and long-term adherence to treatment (Pozehl et al., 2014). Rost (1993) argues that leaders and followers should keep an independent relationship and collaborate together towards shared goals. An important aspect of this is that leaders should influence followers to share a common vision with them. This idea of setting goals and implement goal-oriented plans aligns with another key focus of ‘achieves outcomes’ in the HLA. Planning how, when and where a plan can be implemented will increase the chance of performance of an intended behavior (Gollwitzer, 1999). Therefore, for patients, especially those who drop out due to their busy schedule, clinicians should set realistic and motivating goals together with them to determine how rehabilitation programs could fit into their lives.

– JH

References:

Alexandre, N. M. C., Nordin, M., Hiebert, R., & Campello, M. (2002). Predictors of compliance with short-term treatment among patients with back pain. Revista Panamericana de Salud Pública, 12(2), 86-95.

Conraads, V. M., Deaton, C., Piotrowicz, E., Santaularia, N., Tierney, S., Piepoli, M. F., & Jaarsma, T. (2012). Adherence of heart failure patients to exercise: barriers and possible solutions. European journal of heart failure, 14(5), 451-458.

Giuliani, R. W. (2002). with Ken Kurson. Leadership.

Gohner, W., & Schlicht, W. (2006). Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain. Patient education and counseling, 64(1), 87-95.

Health Workforce Australia (2013, July). Health LEADS Australia: the Australian Health Leadership Framework. Retrieved from https://www.aims.org.au/documents/item/352

Gollwitzer, P. M. (1999). Implementation intentions: Strong effects of simple plans. American psychologist, 54(7), 493.

Jones, M., Jolly, K., Raftery, J., Lip, G. Y., & Greenfield, S. (2007). ‘DNA’ may not mean ‘did not participate’: a qualitative study of reasons for non-adherence at home-and centre-based cardiac rehabilitation. Family practice, 24(4), 343-357.

Pozehl, B. J., Duncan, K., Hertzog, M., McGuire, R., Norman, J. F., Artinian, N. T., & Keteyian, S. J. (2014). Study of adherence to exercise in heart failure: the HEART camp trial protocol. BMC cardiovascular disorders, 14(1), 172.

Rost, J. C. (1993). Leadership for the twenty-first century. Greenwood Publishing Group.

Comorbidities and Premorbid Health

Following a hospital stay, a lower premorbid level of health generally means the outcomes will be worse off, simply because the patient is starting at a functional level that is lower than average. Consequently, these people as well as those with multimorbidities can struggle in programs designed specifically for just one chronic condition as they have more issues impacting physical performance (Smith et al. 2012). Compliance with exercise is understandably difficult when there are a multitude of other health issues to keep in mind, so when noting the effects of the patient’s medications and prescribing exercise, carefully consider each individual’s specific needs based on how they present and what they feel they would need to adhere to any treatments.

Exercise has been shown to be beneficial for people with multimorbidities across a plethora of conditions (Zgibor et al. 2016) and specific interventions that target functional impairment, which exercise can provide, could also be effective in managing people with multimorbidities (Smith et al. 2012). It is crucial therefore that patients continue healthy exercise behaviour within the boundaries of their health status to maintain functional capacity and quality of life.

People living with multimorbidities tend to draw on their past experiences of exercise and their perceptions and beliefs around health to guide their current exercise behaviour (Simonik et al. 2016). Using leadership principles to help shape these beliefs and experiences into something that will empower the patient and facilitate their progress towards an independent, compliant exercise routine would be beneficial to improving and/or maintaining function. Given a functional goal approach to exercise is best for patients with multimorbidities, exercise programs, like their health status, will be very individualised. It is up to the clinician then to show the client what they could be achieving and then engage them with collaborative goal setting and collaborative exercise prescription in a manner that avoids any barriers to exercise, such as how best to manage any symptoms like pain during exercise (which is normal, just not too much pain), to ensure that these patients have the best outcomes.

Looking at a wider scope of health practise, the current health system favours a biomedical approach due to the time constraints within clinical settings. It is undoubtedly effective when multiple conditions are present, but taking the extra step to a biopsychosocial approach can reap even more rewards for the patient. On top of that, spending the extra time at the beginning to consider the psychosocial factors of each multimorbidity patient, such as their barriers and facilitators to treatments and becoming more of a case manager for them (Smith et al. 2016), would end up saving time in the long run as it considers the method with the greatest chance of improving health, rather than applying a “one shoe fits all” method of exercise prescription and then scratching heads when the client discontinues their program later on. Explore avenues to shape the system of whatever setting you work in, or if you’re the patient, be active and engaged, make sure they ask you what works best for you!

PR cinderella
(Google images)

– RJ

References:

Simonik, A., Vader, K., Ellis, D., Kesbian, D., Leung, P., Jachyra, P., Carusone, S. C., & O’Brien, K. K. (2016). Are you ready? Exploring readiness to engage in exercise among people living with HIV and multimorbidity in Toronto, Canada: a qualitative study. BMJ open, 6(3), e010029.

Smith, S. M., Soubhi, H., Fortin, M., Hudon, C., & O’Dowd, T. (2012). Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Bmj, 345, e5205.

Zgibor, J. C., Ye, L., Boudreau, R. M., Conroy, M. B., Vander Bilt, J., Rodgers, E. A., Schlenk, E. A., Jacob, M. E., Brandenstein, J., Albert, S. M., & Newman, A. B. (2016). Community-Based Healthy Aging Interventions for Older Adults with Arthritis and Multimorbidity. Journal of Community Health, 1-10.

Self-Efficacy

A large number of people do not resume normal functioning during the early recovery period after an inpatient stay; in fact, they experience a decline in function. After a myocardial infarction, it has been found that most patients decline during the first month after discharge, which consequently increases the risk of one-year mortality and risk of  readmission due to either further cardiac events, or secondary sequelae such as depression (Vibulchai, Thanasilp & Preechawong, 2015). There has been extensive literature that supports the benefits of rehabilitation, however the majority of it has focused on the physical rather than the psychological well-being of patients (Lavie et al., 2015). Furthermore, the literature commonly identifies benefits in the short term, with limited benefits shown in the long term. This all leads to the hypothesis that exercise programs currently do not achieve effective behavioural change in patients and that rehabilitation should take on a multidimensional approach which will account for psychosocial factors including self-efficacy, which has been shown to be important predictors of functional status (O’Neil et al., 2013).

(Google images)

Self-efficacy refers to the beliefs in one’s capabilities to execute an action. According to Bandura’s social cognitive theory, if people lack self-efficacy, they will likely perform an action ineffectively even if they know how to do it. One way to tackle this problem is to use skills mastery (Bandura, 1997); a method in which patients master fair and achievable goals. Bandura’s theory has proven to be successful in improving a patient’s psychological and functional status across multiple settings, including exercise rehabilitation (Vibulchai, Thanasilp & Preechawong, 2015) .

Failures are problematic, particularly if they happen early. This is important in terms of functional rehabilitation and goal setting; if we choose an overly ambitious goal and the patient fails, Bandura explains that this will negatively affect self-efficacy and thus, the patient may be deterred from returning to or completing rehabilitation. If we surveyed 100 practicing physiotherapists out there, I can almost say with confidence that 90 of you approach goal setting with a sole biomedical point of view; a goal that will aim to achieve what you as a therapist wants. However, what most of you do not realise is that compliance is a huge issue as these goals may not align with the patient’s needs. Health Leads Australia highlights the importance of collaboration when it comes to achieving outcomes (Health workforce Australia, 2016). This could simply be the case of integrating exercises into patient hobbies. Furthermore, a systems based thinking approach is required, and so involvement of all stakeholders is beneficial; for example, if the patient requiring rehabilitation is a professional golfer, involve their golf coach when designing their exercise program. This may be as easy as making a phone call to the coach to find out what exactly the patient does. Finally, it is important to consider the possibility of a patient regressing, therefore ensure goal setting is well paced and each goal is carefully thought out and achievable, as this will help patients build a sense of confidence in order to move on.

For any  patients out there who are reading this blog, I encourage you to stand your ground and tell your therapist what you really think! Don’t be afraid to have your say, collaborate, rise to the top  and achieve your outcomes!

– AD

References

Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman, 1997.

Health Workforce Australia (2013, July). Health LEADS Australia: the Australian Health Leadership Framework. Retrieved from https://www.aims.org.au/documents/item/352

Lavie, C. J., Arena, R., Swift, D. L., Johannsen, N. M., Sui, X., Lee, D., …& Blair, S. N. (2015). Exercise and the Cardiovascular System: Clinical Science and Cardiovascular Outcomes. Circulation Respiratory, 117(2): 207–219    

O’Neil A, Berk M, Davis J, Stafford L. Cardiac-self efficacy predicts adverse outcomes in coronary artery disease (CAD) patients. Health Educ. Behav. 2013; 5: 6–14.

Vibulchai, N., Thanasilp, S., & Preechawong, S. (2015). Randomized controlled trial of a self‐efficacy enhancement program for the cardiac rehabilitation of Thai patients with myocardial infarction. Nursing & health sciences.

Health Literacy

Health literacy is basically how much a person is able to find and understand health information or concepts and use the health system. Turns out despite what certain celebrity chefs would have you think, health is a complex topic and not everyone gets it. Someone with a lower level of education, lower socioeconomic status, who lives in less populated areas, or has advanced age can predispose them to having inadequate health literacy (van der Heide et al. 2013; Lee et al. 2010; Howard et al. 2006) which is linked to poorer health outcomes (Bennett et al. 2009; Berkman et al. 2011; Lee et al. 2010; van der Heide et al. 2013). Only 43% of Australians have adequate health literacy (Australian Bureau of Statistics, 2006). Where do you think you sit?

It’s important to note that exercise and understanding the need to exercise is something health literacy affects. For rehabilitation following a hospital stay, if a client does not understand the relevance of the exercise they are prescribed, they will be less likely to continue with their rehabilitation (Norman, 1998). If a client chooses to discontinue their exercises then they are obviously less likely to make a full recovery, but they are also less likely to partake in independent exercise at a level high enough to be beneficial for them (Carlson et al. 2000; Daltroy, 1985). This compliance issue has existed for decades and is still considered to be a major challenge in the rehabilitation and maintenance space of physiotherapy.

It has been shown that for the elderly population, beliefs about exercise and its benefits can be major factors affecting their adherence to an exercise program (Resnick & Spellbring, 2000) and this falls under a health literacy space. To prevent low health literacy from being a factor ruining exercise compliance, the patient needs to improve their knowledge of their condition, learn how best to manage it, and then learn how to manage it themselves (Gold & McClung, 2006). Guiding the patient through that process will teach them what to do to attain their highest possible quality of life but also what to do when they have a bad day and symptoms increase. This also boosts patient self-efficacy, which determines how confident someone feels they are when managing their health. Low self-efficacy has been shown to be a major contributing factor to non-compliance (Chen et al. 1999), but health professionals are in a great position to address this.

You ready for the plug? You could use a Health LEADS approach to improve health literacy and hence exercise compliance. Collaborative goal setting is a way the clinician can negotiate around barriers and beliefs and set targets with the client, giving them a stake in their own treatment prescription, and thus engaging them. These goals must be relevant to the client and it has been shown that when the patient is involved in goal setting, they are more compliant to an exercise program (Bassett & Petrie, 1999), particularly group/team programs (Nielsen et al. 2014). Taking a goal directed approach also improves the patient’s ability to achieve their outcomes, another key element of Health LEADS. Encouraging self-management is another good option for ensuring long-term adherence to healthy behaviours (Lorig et al. 2001; Gold & McClung, 2006). Getting involved in a self-management program (if applicable) presents the client to a group of similar individuals and a peer successfully managing life with the condition which can all be used as proof of achievable outcomes through adherence to the treatment plan. You just have to know what’s out there.

rangers exercise meme

– RJ

References:

Australian Bureau of Statistics (2006). 4233.0 – Health Literacy, Australia, 2006. Retrieved from: http://abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4233.0Main%20Features22006?opendocument&tabname=Summary&prodno=4233.0&issue=2006&num=&view=

Bassett, S. F., & Petrie, K. J. (1999). The effect of treatment goals on patient compliance with physiotherapy exercise programmes. Physiotherapy, 85(3), 130-137.

Bennett, I. M., Chen, J., Soroui, J. S., & White, S. (2009). The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. The Annals of Family Medicine, 7(3), 204-211.

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: an updated systematic review. Annals of internal medicine, 155(2), 97-107.

Carlson, J. J., Johnson, J. A., Franklin, B. A., & VanderLaan, R. L. (2000). Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation. The American journal of cardiology, 86(1), 17-23.

Chen, C. Y., Neufeld, P. S., Feely, C. A., & Skinner, C. S. (1999). Factors influencing compliance with home exercise programs among patients with upper-extremity impairment. American Journal of Occupational Therapy, 53(2), 171-180.

Daltroy, L. H. (1985). Improving cardiac patient adherence to exercise regimens. Journal of Cardiac Rehabilitation, 5(1), 40.

Howard, D. H., Sentell, T., & Gazmararian, J. A. (2006). Impact of health literacy on socioeconomic and racial differences in health in an elderly population. Journal of general internal medicine, 21(8), 857-861.

Lee, S. Y. D., Tsai, T. I., Tsai, Y. W., & Kuo, K. N. (2010). Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey. BMC public health, 10(1), 614.

Lorig, K. R., Sobel, D. S., Ritter, P. L., Laurent, D., & Hobbs, M. (2000). Effect of a self-management program on patients with chronic disease. Effective clinical practice: ECP, 4(6), 256-262.

Nielsen, G., Wikman, J. M., Jensen, C. J., Schmidt, J. F., Gliemann, L., & Andersen, T. R. (2014). Health promotion: The impact of beliefs of health benefits, social relations and enjoyment on exercise continuation. Scandinavian journal of medicine & science in sports, 24(S1), 66-75.

Norman, K. V. (1998). Motivation and compliance in exercise programs for older adults. Journal of Physical Education, Recreation & Dance, 69(8), 24-27.

Resnick, B., & Spellbring, A. M. (2000). Understanding what motivates older adults to exercise. Journal of gerontological nursing, 26(3), 34-42.

van der Heide, I., Wang, J., Droomers, M., Spreeuwenberg, P., Rademakers, J., & Uiters, E. (2013). The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey. Journal of health communication, 18(sup1), 172-184.

Autonomous Motivation: Relatedness

Relatedness

Relatedness is defined as the sense of a shared experience (Walsh, 2011). Clients need to feel a warm and welcome atmosphere to stick to an exercise program. However, clients have different preferences, for example some clients like talking while doing exercise, while others prefer doing exercise in a quiet environment. Generally, practitioners need to show care to- and keep connections with- clients.

As mentioned in the Health LEADS Australia model, Leads Self is an important part of the proposed leadership model. Building effective relationships with clients is crucial to improve their motivation. Proposed strategies include arriving early or leaving work late just to have an extra conversation with clients, or simply giving phone calls to check how they are tracking with their exercise programs. These methods are aiming to show more respect and care to clients. Outside clinical time, strategies such as sending a holiday card, or sending an invitation to a clinic event have been shown to be effective in building client-practitioner relatedness (Cross, 2008).

Untitled1.jpg
(Google images)

Practitioners can also engage with patients in designing the actual exercise program. For example, practitioners can ask the client about their preference on an exercise position, or ask what their home environment is like in an attempt to negotiate with clients an exercise design that complements their home environment. In this way, practitioners show respect as well as autonomy as they design an individualised exercise program that relate to the client’s needs.

When communicating with clients, practitioners can talk about the goals perceived by the client. Then, the practitioner can integrate the client’s goal and the treatment goal. This is essential, because ‘Achieving Outcomes’ is the driving force to ensure clients continue the exercise program.

Furthermore, setting a goal together with the client is a process of engagement, and easy for the client to agree to work on.

Finally, don’t forget that it’s a two way street; practitioners need to be open to changes as well. Feedback from clients are useful for practitioners to modify their exercise programs. Innovations are vital in the leadership theory, as we strive for a rehabilitation program that will maximally benefit everyone, and this cannot be achieved without constant modification and improvement. Meanwhile, feedback from clients is helpful for practitioners to understand the exercises from the client’s perspective. Therefore making a change accordingly is a way of showing respect to clients.

To conclude, the leadership theory is useful in improving the competence and relatedness of an exercise program. These two factors are important to increase the motivation of adhering to an exercise program. With the methods mentioned in the two blogs above, motivation will hopefully be enhanced, and a better compliance to exercise will be achieved.

– BH

References:

Cross, K. 2008. Guiding client progress. IDEA Trainer Success, 5 (2), 12–14.

Self-Determination Theory: A Key to Motivation. Walsh, 2011. Retrieved from http://www.ideafit.com/fitness-library/self-determination-theory-a-key-to-motivation

Autonomous Motivation: Competence

Autonomous motivation was introduced from the Self-determination theory (Deci & Ryan, 2000); a theory focusing on the intrinsic motivation of a person. In contrast to extrinsic motivation, autonomous motivation is more significant in goal progression (Koestner et al, 2008). Literature found the need satisfaction will predict autonomous motivation, which in turn predicts exercise adherence (Weman-Josefesson et al, 2015). Therefore, in order to improve the compliance to exercise, patients need to build up autonomous motivation. Competence and relatedness were found to have positive relationships with motivation. Consequently, clinicians have to consider the competence of clients and the relatedness of the exercise when prescribing exercise program.

 

Competence

A client has to be able to complete the exercise in order to successfully follow an exercise program. The intensity, dosage, and form of exercise can all affect the competence of a client to complete the exercise. Moreover, clients with particular conditions need extra consideration when prescribing physical activity. For example, a population with chronic pain were found to experience more obstacles to complete the exercise program (Joelsson et al, 2017). Therefore, perceived efforts should be measured when completing an exercise program. The Borg RPE scale, the OMNI scale, the Talk Test and the Feeling Scale are examples of tools that can be used to assess difficulty levels and will aid in modulating  cardiorespiratory and resistance exercises (Garber et al, 2011).

Unknown

(google image-Competence)

In clinics, the measures mentioned above should be promoted to monitor the competence of  clients to complete an exercise program, with the aim to improve the motivation to adhere to the program. Practitioners can hand out these measures to clients and encourage clients to use them together with an exercise diary. Practitioners need to explain the significance of those measures to clients, and ensure that they understand these outcome measures. This is crucial as engaging others is necessary to implement a strategy successfully and it is also an inevitable part of the Health LEADS Australia model. In order to successfully engage with clients, practitioners need to communicate with clients with honesty and respect. In practice, we need to understand the difficulties for the client to implement these outcome measures such as a challenging home environment, understanding of the outcome measures or lack of family support. This highlights the importance for practitioners to discuss some strategies to address these difficulties.

Practitioners’ then need to monitor patient outcomes. As stated in the Health LEADS model, achieving outcomes is a key component for successful leadership. Practitioners can assess clients’ measures when there is a need to progress the exercise program. Moreover, questionnaires designed to assess motivation can be used. Continually monitoring the results is good to assess the success of the exercise program as well as motivate clients to adhere with the exercises.

Finally, practitioners can involve the family to monitor the outcome measures. For example, clinician can explain the BORG scale to the family and ask them to monitor the client while the client is exercising. The Health LEADS model promotes a systems based thinking approach, and so in practice, practitioners can think about the involvement of other individuals important to the client, in order to improve motivation.

Hence, outcome measures can be utilized to ensure client competence in order to improve motivation. Engaging others, Achieving Outcomes and Shaping Systems in the leadership model are useful in implementing the change.

– BH

References:

Deci, E. L., & Ryan, R. M. (2000). The” what” and” why” of goal pursuits: Human needs and the self-determination of behavior. Psychological inquiry, 11(4), 227-268.

Garber, C. E., Blissmer, B., Deschenes, M. R., Franklin, B. A., Lamonte, M. J., Lee, I. M., … & Swain, D. P. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Medicine & Science in Sports & Exercise, 43(7), 1334-1359.

Joelsson, M., Bernhardsson, S., & Larsson, M. E. (2017). Patients with chronic pain may need extra support when prescribed physical activity in primary care: a qualitative study. Scandinavian journal of primary health care, 35(1), 64-74.

Koestner, R., Otis, N., Powers, T. A., Pelletier, L., & Gagnon, H. (2008). Autonomous motivation, controlled motivation, and goal progress. Journal of personality, 76(5), 1201-1230.

Weman-Josefsson, K., Lindwall, M., & Ivarsson, A. (2015). Need satisfaction, motivational regulations and exercise: moderation and mediation effects. International Journal of Behavioral Nutrition and Physical Activity, 12(1), 67.