Published Online: May 30, 2014
Abstract
Background
Incontestable epidemiological trends indicate that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases. International guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. Motivational interventions to increase adherence and physical activity are not part of traditional physiotherapy for any condition.
Objective
To evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions.
Data sources
A literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database using keywords and subject headings.
Study selection
Only randomised controlled trials comparing two or more arms, with one arm focused on motivational interventions influencing exercise and one control arm, were included. The search identified 493 titles, of which 14 studies (comprising 1504 participants) were included.
Data extraction
The principal investigator extracted data that were reviewed independently by another author. Methodological quality was assessed independently by two authors using the Cochrane Risk of Bias tool and the PEDro scale. Outcomes were measured at the level of impairment, activity limitation and participation restriction. The standardised mean difference between the control and intervention groups at follow-up time points was used as the mode of analysis. I2 ≤ 50% was used as the cut-off point for acceptable heterogeneity, above which a random effects model was applied.
Results
Exercise attendance was measured in six studies (n = 378), and the results indicate that there was no significant difference in exercise attendance between the groups (Random effects model, standardised mean difference 0.33, 95% confidence interval −0.03 to 0.68, I2 62%). Perceived self-efficacy results were pooled from six studies (n = 722), and a significant difference was found between the groups in favour of the interventions (Fixed effects model, standardised mean difference 0.71, 95% confidence interval 0.55 to 0.87, I2 41%). The results for levels of activity limitation were pooled (n = 550), and a significant difference was found between the groups in favour of the interventions (REM, standardised mean difference −0.37, 95% confidence interval −0.65 to −0.08, I2 61%).
Limitations
The majority of the included studies were of medium quality, and four studies were of low quality. Data were pooled from a wide variety of different populations and settings, increasing the assortment of study characteristics.
Conclusions
Motivational interventions can help adherence to exercise, have a positive effect on long-term exercise behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory choice and the most beneficial length and type of intervention have not been defined, although all interventions showed benefits. There is a need to determine how practising physiotherapists currently optimise adherence, and their current levels of knowledge about motivational interventions.
Implications of key findings
The results indicate that motivational interventions are successful for increasing healthy physical activity behaviour. Physiotherapists are ideally placed to take on this role, and motivational interventions must become part of physiotherapy practice.
Introduction
Incontestable epidemiological trends show that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases [1]. The Wanless Report (2004) outlined the need to optimise primary and preventive services [2]. This shift in focus from episodic individual care to health promotion places emphasis on health behaviours in healthcare delivery. This – coupled with the education of physiotherapists and their roles as promoters, preventers and rehabilitators – means that physiotherapists are ideally placed to influence physical activity behaviour.
The benefits of physical activity, defined as any bodily movement produced by skeletal muscles that results in energy expenditure [3], are well recognised [4]. However, high levels of inactivity exist. Research suggests that 31% of the world's population do not meet recommended levels of physical activity [5]. Non-compliance with recommendations is not the only health behaviour that physiotherapists need to influence. The success of many conventional physiotherapy treatment plans requires both attendance at treatment sessions and adherence to exercises that are to be completed, unsupervised, in the individual's own time. Evidence suggests that approximately 65% of individuals are likely to be non-adherent to home exercises, and 10% fail to complete their prescribed course of physiotherapy [6].
Existing UK [7], European [8] and US [9] guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. The use of different interventions and strategies to enhance adherence to physical activity and exercise regimes is beginning to emerge in the international research literature, yet all of the guidelines recognise inconsistencies and gaps in the evidence. Motivational interventions are not part of traditional physiotherapy and are not provided by physiotherapists. Therefore, the aim of this review is to evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions.
Methods
Identification of literature
The PRISMA standardised reporting guidelines were followed to standardise the conduct and reporting of this review. A systematic literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database was conducted. The search was undertaken in accordance with the specific requirements of each database, using the keywords in Box A (see online supplementary material).
Inclusion and exclusion criteria
The inclusion criteria were based on the PICO (Population, Intervention, Comparison and Outcome) design as follows:
- •All adult study populations were included.
- •Randomised controlled trials comparing two or more arms, with one arm focused on the effect of a motivational intervention in addition to exercise and one control arm, were included.
- •Motivational interventions as part of a package, psychological strategies, theory-based instructional manuals, internet-based behavioural programmes and relapse prevention and re-inforcement strategies were included.
- •All types of exercise and delivery methods were included.
- •All measures of adherence were included. Secondary measures of adherence included all outcomes at the level of impairment, activity limitation and participation restriction, in keeping with the International Classification of Functioning, Disability and Health.
Articles with educational only, subsidisation or money as motivation, differential re-inforcement techniques or use of pets as motivation were excluded.
Study selection
Two authors (NMcG and TC) identified and screened the titles retrieved through the electronic searches. Two reviewers (NMcG and ES) assessed the abstracts and full-text articles independently to identify eligible studies. Any disagreements were resolved through discussion. In cases where disagreement persisted, a third reviewer (TC) assessed suitability.
Data extraction
Data extraction was completed independently by the principal investigator (NMcG). Data extracted for the meta-analysis included mean, median and standard deviation for all outcome measures for each group at all time points. This was reviewed by a second author (RG). Data extracted for the narrative review were reviewed by another author (ES), and included authors, study setting, sample population and size, type and duration of intervention, mode and frequency of delivery, and outcome measures. The narrative synthesis was guided by the process outlined in the Cochrane Handbook of Systematic Reviews [10].
Methodological quality assessment
Methodological quality of the studies was evaluated using the Cochrane Risk of Bias tool. Two authors (NMcG and ES) independently assessed the methodological quality of each study. A study was considered to have a low risk of bias if all of the criteria were met. If one criterion or more was not met or was only partially met, the study was considered to have an unclear or high risk of bias [11].
The internal and external validity of studies was assessed using the Physiotherapy Evidence Database (PEDro) scale, which is a valid, reliable tool [[12], [13]]. The PEDro scale includes 11 items, scored 0 or 1, resulting in a maximum of 11 points. Studies scoring seven points or more are considered to have moderate to high methodological quality.
Statistical analysis
Statistical analysis was conducted using Review Manager (RevMan) Version 5.1.7 software from the Cochrane collaboration. In studies with multiple comparison groups, the most relevant comparison group was chosen for analysis; for example, where comparisons consisted of exercise and motivational intervention compared with other active treatments or routine care, the routine care group was chosen to represent the comparison group. Authors were contacted if further information was needed. The difference in outcomes between the control and the intervention group at the end of the intervention and at follow-up time points was used as the mode of analysis. A number of different scales or instruments were employed to assess the same outcome (i.e. impairment, activity limitation or participation restriction); therefore, the standardised mean difference with 95% confidence interval (CI) was used as the primary measure to assess treatment effect. The impact of sample size was addressed by estimating a weighting factor for each study, and assigning larger effect weights in studies with larger samples. In studies where the mean was unknown, the median was used as a proxy and the standard deviation was calculated based on 0.75 × interquartile range or 0.25 × range [14]. Statistical heterogeneity was measured using the I2 statistic. I2 ≤ 50% was used as the cut-off point for acceptable heterogeneity, and the fixed-effects model was applied below this point. When I2 > 50%, the more conservative random effects model was used.
Results
Study identification and selection
Supplementary Figure S1 shows the flow of studies through the review. The search identified 493 titles. Studies were eliminated if the title clearly identified that the study did not include a motivational intervention. Abstracts for the remaining studies (n = 102) were reviewed and 80 were excluded. Of those remaining, four studies reported results from two study populations and six studies did not meet the inclusion criteria. Therefore, 14 studies were included in this review.
Study characteristics
Table 1 shows the characteristics of the studies included in this review. Five studies investigated patients with chronic musculoskeletal pain [[15], [16], [17], [18], [19], [20]], four of which studied patients with chronic low back pain [[15], [16],[17], [18], [19]]. Four studies investigated obesity [[21], [22], [23], [24]], three studies investigated patients enrolled in cardiac rehabilitation [[25], [26], [27], [28]], one study investigated fatigue in patients with cancer [29] and one study investigated sedentary females [30]. Six different theories informed the interventions. Four studies were based on cognitive behavioural therapy (CBT) [[16], [20], [22], [29]]. Motivational interviewing [[15], [23], [27], [28]] and social cognitive theory [[24], [25], [26]] were used three times. Self-determination theory [21], transtheoretical model [19] and social learning theory [30] were each used once. One study did not base their intervention on a defined theory [[17], [18]]. The wide range of conditions and theories resulted in many outcome measures being employed. Primary and secondary outcome measures, timing of assessments and results are detailed in Supplementary Table S1.
Data extraction
| |||||||
|---|---|---|---|---|---|---|---|
Authors and year
|
Intervention
| ||||||
Target group (n)
|
Description: form
|
Description: duration, frequency, timing
|
Based on which construct
|
Delivered by whom and setting
|
Exercise component
|
Control
| |
Annesi et al. (2011)
|
Females with obesity (137)
|
One-on-one sessions supported by computer programme.
Self-management and self-regulatory techniques.
Increasing mastery and competence
|
Six 1-hour meetings with wellness specialist over 6 months
|
Coach approach/social cognitive theory
|
One-on-one sessions with a wellness specialist trained in the coach approach at wellness centre
|
Three exercise sessions per week at 60 to 75% maximal oxygen uptake
|
Standard wellness centre practice.
Time with exercise specialists matched
|
Vong et al. (2011)
|
Patients with chronic low back pain (76)
|
Motivational enhancement therapy delivered during physiotherapy sessions.
Motivational interviewing strategies
|
10 × 30-minute sessions delivered during physiotherapy sessions over 8 weeks
|
Motivational enhancement therapy/motivational interviewing
|
Physiotherapists trained in motivational enhancement therapy delivered during physiotherapy session
|
10 × 30-minute sessions + 15-minute interferential + tailored back exercise programme
|
Same exercise component with usual communication
|
Silva et al. (2010)
|
Females with obesity (239)
|
Educational content; interactive discussion; and small group activities on physical activity and exercise, nutrition and eating behaviour, cognitive and behavioural aspects (motivation and overcoming barriers), promoting self-determination and improving body image.
Five modules in total
|
30 × 120-minute group (25 to 30) meetings weekly/bi-weekly
|
Self-determination theory
|
Intervention team: six PhD/MSc exercise physiologists, nutritionists/dieticians and psychologists
|
No supervised exercise/physical activity
|
29 general health education sessions
|
Van Weert et al. (2010)
|
Cancer survivors (147)
|
Psychotherapeutic, systematic goal-orientated approach.
Self-management skills based on cognitive behavioural problem-solving approach
|
1 × 2 hours per week for 12 weeks.
Group setting
|
Cognitive behavioural theory
|
Two psychologists
|
2 × 1-hour individual sessions with physiotherapist + 2 × 1-hour group sports and games for 12 weeks (48 hours total) delivered by physiotherapists.
Aerobic (based on individual maximal heart rate), strength training and information on the benefits of exercise
|
First group: same exercise component.
Second group: patients on waiting lists
|
Millen et al. (2009)
|
Patients undergoing cardiac rehabilitation (40)
|
Manual
|
Self-directed, six upper limb strengthening exercises with Thera-Band.
Social-cognitive-theory-based instruction manual
|
Social cognitive theory
|
Self-directed at home
|
Resistance training manual and Thera-Band resistive bands and exercises prescribed by cardiac rehabilitation team
|
Exercise as prescribed by cardiac rehabilitation team
|
Schellinget al.(2009)
|
Adults with obesity (38)
|
Group session offering individualised treatment approach using well-known cognitive behavioural theory strategies
|
One 90-minute session
|
Cognitive behavioural theory
|
Led by clinical psychologist and student co-therapist following standardised manuals
|
8 weekly, 50-minute progressive aerobic individually prescribed sessions (both groups)
|
One 90-minute relaxation session
|
Befort et al. (2008)
|
African American females with obesity (34)
|
Semi-structured format focusing on target behaviours identified by participants
|
Four 30-minute sessions at Weeks 0, 3, 8, 7, and 13
|
Motivational interviewing
|
Two in person, two via phone and in person by trained councillors supervised by doctoral level clinical psychologist
|
16 × 90-minute sessions culturally targeting behavioural weight loss. Groups of 12 to 14 women. Weekly weigh in and self-monitoring logs (diet and physical activity). Weekly topic and cultural adoptions
|
Four sessions on health education, with same duration, frequency, timing and councillors
|
Brodie et al. (2005, 2008)
|
Adults aged 65+ years with chronic heart failure (60)
|
Problem-solving techniques and behaviour change strategies
|
8 weeks, 1-hour sessions
|
Motivational interviewing
|
Researcher experienced in motivational interviewing techniques with no clinical qualifications
|
Encouraged to increase physical activity
|
Usual care: information and recommendations to increase physical activity
|
Göhner and Schlicht (2006)
|
Patients with chronic back pain (47)
|
Positive feedback and interpretation of physiological status to enhance self-efficacy. Discussion on barrier perceptions and how to overcome them. Information on the spine and chronic back pain to maximise severity perceptions
|
Three 50-minute training sessions between first and last physiotherapy sessions
|
Cognitive behavioural theory
|
Psychologist
|
6 to 8 weeks of partially standardised physiotherapy comprised of 10 compulsory and 12 optional exercises
|
Physiotherapy sessions only
|
Basler et al. (2005)
|
Older adults with chronic low back pain (152)
|
Standardised counselling service aimed at increasing self-efficacy, positively influencing decisional balance, enhance commitment, self-re-inforcement, and use of social support to deal with relapse
|
5 weeks, 10 × 20-minute sessions of standard treatment, manual and homework.
10 minutes before session
|
Transtheoretical model
|
Same physiotherapists who delivered treatment 10 minutes before treatment session.
Physiotherapist received 8 hours of transtheoretical model with trial counselling sessions
|
5 weeks, 10 × 20-minute sessions of standard treatment, manual and homework
|
5 weeks, 10 × 20-minute sessions of standard treatment, manual and homework.
10 minutes of inactive ultrasound before session
|
Sniehottaet al.(2005)
|
Patients with coronary heart disease after cardiac rehabilitation (199)
|
Planning: planning booklet with sheets for action plans and coping plans.
Planning and diary: as above and 6-weekly diaries, how often during the last 7 days did plan occur and how optimistic were they that plan would occur for next 7 days
|
Booklet provided on discharge for inpatient cardiac rehabilitation
|
Social cognitive theory/planning and action control
|
Booklet.
At home.
Trained interviewers on hand in case of questions
|
Standard care: recommended to increase physical activity in general, engage in regular strenuous exercise and participate in cardiac sports groups
|
Standard care
|
Asenlofet al.(2005)
|
Patients with musculoskeletal pain for >4 weeks (122)
|
Seven general phases: behavioural goal identification, self-monitoring, individual functional behavioural analysis, basic skill acquisition, applied skill acquisition, generalisation and maintenance, and relapse prevention.
No physical activity/exercise intervention
|
Eight to 10 sessions over 2 to 3 months and homework.
One to two booster sessions after 1 and 3 months
|
Cognitive behavioural theory
|
Physiotherapists trained in 7 × 3-hour sessions (21 hours)
|
Own physical activity of choice at home
|
Eight to 10 best practice physiotherapy sessions
|
Friedfichet al.(1998, 2005)
|
Patients with chronic low back pain (93)
|
Five interventions: counselling and information strategies, re-inforcement techniques, posted treatment contract and exercise diary
|
10 sessions, two to three per week.
No other information
|
Own
|
Physiotherapists.
No information
|
10 × 25-minute individual progressive exercise sessions with physiotherapists and advised to exercise daily
|
Physiotherapy sessions only
|
Marcus and Stanton (1993)
|
Sedentary females (120)
|
Relapse prevention: identification of non-adherence triggers, development of effective coping strategies and employment of planned relapse.
Re-inforcement: rewards for exercise attendance
|
18 × 20-minute weekly sessions
|
Relapse prevention and re-inforcement developed from social learning theory
|
Advanced postgraduate students supervised by faculty psychologist
|
18-week strength, flexibility and aerobic dance programme (35 minutes for weeks 1 to 3, 50 minutes for weeks 4 to 18)
|
Exercise sessions only
|
Methodological quality
Table 2 shows the details of the methodological quality assessment. Four studies had poor internal and external validity, scoring less than four points on the PEDro scale [[22], [25], [27], [28], [30]]. The remaining studies had scores ranging from five to eight points. Allocation concealment was only specified in three studies [[19], [23], [29]]. Blinding emerged as an issue from the methodological quality assessment. No study was classified as having a low risk of performance bias, while all but four studies [[15], [19], [23], [24]] had a low risk of detection bias.
Authors
|
Cochrane biases
|
PEDro scale
| ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Selection
|
Performance
|
Detection
|
Attrition
|
Reporting
|
Other
|
P1
|
P2
|
P3
|
P4
|
P5
|
P6
|
P7
|
P8
|
P9
|
P10
|
P11
|
Score
| |
Annesi et al. (2011)
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
Y
|
Y
|
N
|
Y
|
N
|
Y
|
Y
|
Y
|
8
|
Vong et al. (2011)
|
Low risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
Y
|
N
|
N
|
Y
|
N
|
Y
|
Y
|
Y
|
7
|
Silva et al. (2010)
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
Y
|
N
|
N
|
N
|
Y
|
Y
|
Y
|
Y
|
7
|
van Weert et al. (2010)
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
Y
|
Y
|
N
|
N
|
N
|
Y
|
Y
|
Y
|
Y
|
8
|
Millen and Bray (2009)
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
Y
|
N
|
N
|
N
|
Y
|
N
|
Y
|
Y
|
6
|
Schellinget al.(2009)
|
High risk
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
N
|
N
|
N
|
N
|
N
|
N
|
Y
|
Y
|
4
|
Brodie et al. (2008, 2005)
|
High risk
|
High risk
|
High risk
|
High risk
|
High risk
|
Unclear risk
|
Y
|
Y
|
N
|
N
|
N
|
N
|
N
|
N
|
N
|
Y
|
Y
|
4
|
Befort et al. (2008)
|
Low risk
|
High risk
|
Low risk
|
High risk
|
High risk
|
Low risk
|
Y
|
Y
|
Y
|
Y
|
N
|
N
|
Y
|
N
|
N
|
Y
|
Y
|
7
|
Basler et al. (2007)
|
Low risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
Y
|
Y
|
N
|
N
|
Y
|
Y
|
Y
|
Y
|
Y
|
9
|
Göhner and Schlicht (2006)
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
Y
|
N
|
N
|
N
|
Y
|
N
|
Y
|
Y
|
6
|
Asenlofet al.(2005)
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
Y
|
N
|
N
|
N
|
N
|
Y
|
Y
|
Y
|
6
|
Friedfichet al.(2005, 1998)
|
High risk
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
N
|
N
|
N
|
N
|
Y
|
Y
|
Y
|
Y
|
6
|
Sniehottaet al.(2005)
|
Low risk
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
N
|
Y
|
N
|
N
|
N
|
N
|
N
|
N
|
N
|
Y
|
Y
|
3
|
Marcus and Stanton (1993)
|
Unclear risk
|
High risk
|
High risk
|
High risk
|
Low risk
|
Low risk
|
Y
|
Y
|
N
|
N
|
N
|
N
|
N
|
N
|
N
|
Y
|
Y
|
4
|
PEDro, Physiotherapy Evidence Database.
Meta-analysis
Attendance and adherence
Attendance and adherence was measured using various outcomes. Most studies used self-reported outcome measures such as log books/exercise diaries and questionnaires [[15], [17], [18], [19], [21], [23], [25], [26]]. Only one study [21]measured physical activity objectively with accelerometers and pedometers. One study [20] did not directly measure attendance or adherence. Six studies reported attendance at physiotherapy sessions or exercise classes [[17], [18], [22],[23], [24], [29], [30]]. The subject populations included adults with obesity [[21], [23], [24]], sedentary women [30], patients with chronic low back pain [[17], [18]] and cancer survivors [29]. The interventions included CBT [[22], [29]], motivational interviewing [23], social cognitive theory [24] and social learning theory [30], while one study selected aspects from each of CBT, motivational interviewing, social cognitive theory and self-determination theory [[17], [18]]. These six studies were pooled (n = 378), and the results indicate that there was no significant difference in exercise attendance between the groups [REM, standardised mean difference 0.33, 95% CI −0.03 to 0.68, I2 62%) (Fig. 1). A subgroup analysis was conducted to exclude the latter three patient groups and the non-significant effect remained [REM, standardised mean difference 0.25, 95% CI −043 to 0.92, I2 80%).
Fig. 1
Attendance at physiotherapy sessions/exercise classes.
Self-efficacy
Seven studies measured perceived self-efficacy using different outcome measures, including the Exercise Barriers Self-Efficacy Scale, Fuch's Exercise Self-Efficacy Scale and measures derived based on Bandura's work [[16], [21], [23], [24],[25], [26], [27], [28]]. Six of these studies [[16], [21], [24], [25], [26], [27], [28]] were pooled (n = 722). Subject populations included females with obesity [[21], [24]], cardiac patients [[25], [26], [27], [28]] and patients with chronic low back pain [16]. The interventions investigated included CBT [16], motivational interviewing [[27], [28]], social cognitive theory [[24], [25],[26]] and self-determination theory [21]. The results indicate that, post intervention, there was a significant improvement in perceived self-efficacy in the intervention groups (FEM, standardised mean difference 0.71, 95% CI 0.55 to 0.87, I2 41%) (Fig. 2). These results also remained significant when the cardiac populations were examined individually.
Fig. 2
Perceived self-efficacy following the intervention.
Levels of activity limitation
Six studies examined levels of activity limitation using the Roland Morris Disability Questionnaire, the Hanover Functional Disability Scale, the Pain Disability Index and the 13-item Disability Questionnaire [[15], [16], [17], [19], [24], [27]]. The populations investigated included patients with chronic low back pain [[15], [16], [17], [18], [19]], patients with chronic musculoskeletal pain [20] and cardiac patients [[27], [28]]. The interventions investigated were based on CBT [[16], [20]], motivational interviewing [[15], [27], [28]], the transtheoretical model [19] and the authors’ own intervention [[17], [18]]. The findings were pooled (n = 550), and there was a significant difference between the groups with respect to levels of activity limitation in favour of the intervention groups (REM, standardised mean difference −0.37, 95% CI −0.65 to −0.08), I2 61%) (Fig. 3). This difference also persisted when patients with chronic low back pain were examined in a subgroup analysis.
Fig. 3
Levels of activity limitation following the intervention.
It was not possible to pool other measures of impairment, activity limitation or participation restriction due to the inconsistency of outcome reporting between studies.
Narrative review
CBT was the most popular approach. Van Weert et al. [29] studied fatigue in cancer survivors (n = 147). Results showed no difference in attendance but significant differences between groups in levels of reported physical fatigue. Schelling et al. [22] studied adults with obesity (n = 38). Results showed no difference in motivational stage and attendance, but did show a significant difference in dropouts, with a higher number reported in the control group. There was a significant difference in physical activity and weekly minutes of physical activity between groups at 6 months. Göhner and Schlicht [16] studied patients with chronic low back pain (n = 47). This study reported an improvement in self-efficacy, and barriers reduced over time within the intervention group with a significant difference between groups at all time points. Severity, intention and behaviour also showed significant differences over time and between groups but not at all assessment points. Asenlof et al. [20] investigated individuals with chronic musculoskeletal pain (n = 122). Significant differences in pain disability, fear of movement and pain were reported between the groups. Global improvement improved for the intervention group, but no differences were reported between the groups at 3 months.
These studies indicate that CBT improves self-efficacy and activity limitation. Proxy measures for adherence such as attrition, physical activity and pain also indicated a positive effect, although this did not affect attendance.
Social cognitive theory was the basis for three studies. Annesi et al. [24] investigated the effects of the coach approach in a population of females with obesity (n = 137). The findings demonstrated that the experimental group had significantly better attendance and differed significantly from the control group for all other outcomes. Millen and Bray [26] investigated individuals enrolled in cardiac rehabilitation (n = 40). Post intervention, significant differences in self-efficacy of technique and attendance were found between the groups. The experimental group had completed significantly more exercises and sets at 4 weeks, and had spent significantly more days exercising at 3 months. The third study [25] examined individuals with coronary heart disease (n = 199). A significant difference in both action and coping planning was found at 2 months in the experimental groups, but this only remained significant for coping planning at 4 months. Behavioural intentions in both experimental groups differed significantly from the control group at all assessment points, while both experimental groups had significantly different self-efficacy at 4 months. The planning group had significantly higher general physical activity at 2 months, but there was no difference at 4 months. Strenuous exercise showed promising results with a significant difference in the planning plus diary group at 2 months, and both experimental groups completed significantly more exercise than the control group at 4 months.
These three studies indicate that social cognitive theory has a positive effect on attendance, self-efficacy, and both long- and short-term exercise and physical activity, although there are conflicting results regarding these last two outcomes.
Motivational interviewing was employed in three studies. Vong et al. [15] investigated motivational enhancement therapy, which integrates motivational interviewing with several psychological components, in patients with chronic low back pain (n = 76). Significant differences in proxy efficacy, working alliance and treatment expectancy were found between the groups. The groups differed significantly in general health and home exercise. The second study [23] was a pilot randomised controlled trial that investigated the effect of motivational interviewing on African American women with obesity (n = 34). No difference in attendance or adherence was reported. No differences in physical activity, dietary intake and self-efficacy for diet and exercise were found between the groups. The final study [[27], [28]] investigated adults aged ≥65 years with chronic heart failure (n = 60). Both intervention groups had a significant increase in physical activity (energy expenditure), and all groups had a significant increase in exercise capacity.
The three studies reveal that motivational interviewing interventions increase physical activity, general health and home exercise. One study, a pilot, showed no effect for the intervention.
Self-determination theory, transtheoretical model and social learning theory were each investigated in one study. Silva et al. [21] investigated the effect of a weight management programme based on self-determination theory on women with obesity (n = 239). Physical activity differed significantly between the groups, with the intervention group taking more steps per day and spending more time undertaking moderate to vigorous activity. There was also a significant difference in body composition. The study reported higher levels of self-determination, autonomous self-regulation, internal locus of causality, and exercise and fitness motives for the intervention group.
Basler et al. [19] investigated an intervention based on the transtheoretical model in older adults with chronic low back pain (n = 152). Both groups reported significant increases in physical activity and functional capacity, but there were no significant differences between the groups.
Friedrich et al. [[17], [18]] published two articles in 1998 and 2005 investigating the effects of their own motivational intervention on patients with chronic low back pain (n = 93). The results showed that the experimental group differed significantly from the control group in terms of pain, disability and working ability 5 years after the intervention. A significant difference in compliance was also reported between the groups. There were significant differences in physical impairment and motivation within and between groups at various time points.
Marcus and Stanton [30] studied an intervention based on the social learning theory in sedentary females (n = 120). This study concentrated on relapse prevention and re-inforcement. The relapse prevention group had significantly greater attendance at 9 weeks. There was no difference between the groups at 18 weeks. There was no difference in self-reported exercise behaviour between the groups.
The results indicate that self-determination theory was the most successful theory from these four studies. Freidrich et al.[[17], [18]] conceived a unique intervention based on established theories, and reported between-group differences 5 years after the intervention. Basler et al. [19] reported that the transtheoretical model had no significant effect, while Marcus and Stanton [30] reported a difference in short-term attendance in favour of the intervention group although this was not maintained in the long term.
Discussion
Statement of principal findings
The results of this systematic review with meta-analysis indicate that motivational interventions are successful for increasing adherence and physical activity among individuals with a variety of conditions. The meta-analysis demonstrates a significant difference in perceived self-efficacy and levels of activity limitation in favour of the intervention groups. However, due to heterogeneity in the different approaches applied, it was not possible to complete a subgroup analysis to determine the most effective method. Differences in adherence and attendance approached significance. Of the six studies included in the meta-analysis, only two had significant differences in attendance. The other four studies had significant results in other outcome measures. The narrative review indicates that CBT, social cognitive theory, motivational interviewing and self-determination theory have a positive effect on physical activity, self-efficacy, activity limitation, attendance and other proxy measures for adherence.
Clinical and policy implications
Current guidelines [[7], [8], [9]] recommend the implementation of evidence-based approaches to foster health behaviour changes. This review indicates that motivational interventions are successful in increasing healthy physical activity behaviour. Physiotherapists are ideally placed to take on this role, and motivational interventions must become part of physiotherapy practice. In light of these findings, there is a need to investigate the current levels of knowledge and current practice of physiotherapists with regard to motivational interventions, and to determine where the profession stands with regards to the Health Behaviour Change Competency Framework [31]. From there, educational strategies fostering knowledge and skills for pre- and post-registration physiotherapists can be developed to ensure that physiotherapists are operating at Level 3.
Strengths and weaknesses of the review
This is the first systematic review with meta-analysis on this topic. The methodological quality of the included studies was assessed using valid methods, and while most were of medium methodological quality, four studies were deemed to be of low methodological quality. These studies were included to provide the reader with a sense of the totality of evidence. Issues with blinding resulted in poor scores for methodological quality. Data were pooled from a wide variety of different populations and settings. This enhances the generalisability of the findings, but is also a weakness as it increases the assortment of study characteristics. This contributed to only six studies being pooled for each of the meta-analyses, although all 14 studies were included in at least one analysis. Four studies appeared in more than one analysis [[16], [17],[24], [27]].
Results in the context of the current literature
The results of the meta-analysis indicate that motivational interventions have positive effects on self-efficacy and activity limitation, but not attendance. The method of assessing adherence is complex and this is evident from the array of outcome measures. Due to this complexity, all measures of adherence were included. The most obvious proxy measure, attendance, is dissimilar to adherence. Assessing attendance of exercise classes and physiotherapy sessions is important for positive outcomes and to decrease cancelled and missed appointments; however, the authors of these studies can only hypothesise that their intervention influences long-term adherence and long-term physical activity behaviour. The six studies [[17], [18], [22], [23], [25], [29], [30]] that chose to assess in this manner also assessed long-term physical activity behaviour with self-report and other outcomes that could be used as proxy measures of long-term physical activity. Of the six studies that measured session attendance, only Befort et al. [23] reported no difference between groups in other outcomes. This pilot study with African American women involved a select population and assessed cultural adaptations to motivational interviewing.
An alternative method for assessing exercise adherence and physical activity was the use of log books, activity diaries, physical activity recall interviews and questionnaires. These methods of data collection are popular but are vulnerable to different types of bias including recall, reporting, regression dilution, extreme response and attention bias (also known as the ‘Hawthorne effect’) [32]. Two types of clinician-centric biases are also prevalent: observer expectation and interviewer bias. Silva et al. [21] was the only study to use both self-reported and objective measures, reporting positive results for both.
Another aspect of the studies that may result in bias is blinding. This became evident from the methodological quality assessments (Table 2). Blinding is a challenge in behavioural interventions as subjects and interventionists inherently know if they are receiving/delivering the intervention. Blinding of assessors may serve to eliminate detection, observer expectation and interviewer bias. Only four [[15], [19], [23], [24]] of the included studies blinded their assessors.
The aim of this review was to examine short- and long-term changes. The time points for assessments are therefore of interest. Friedrich et al. [18] reported positive results after 5 years. The remaining studies did not exceed 1 year in their follow-up, but still reported positive results. Some studies [[21], [23], [29]] only assessed subjects at the end of the intervention, leading to difficulty in gauging whether the results were sustainable.
There was great variation in the length of the interventions. The longest lasted for 52 weeks [21] and the shortest lasted for 3.5 weeks [[17], [18]]. The remainder varied from 4 to 24 weeks. Two studies [[19], [23]] with no significant difference between groups lasted for 7 and 16 weeks, respectively. It is therefore difficult to draw a conclusion on the ideal length, as both the longest and the shortest interventions had positive results.
Delivery of the intervention, by whom and when, is of interest and varied. Physiotherapists were the interventionists in four studies [[15], [17], [18], [19], [20]], with the remaining studies being self-administered (booklet or manual) or administered by psychologists, other healthcare professionals or trained wellness specialists. Physiotherapists received training and delivered the intervention in conjunction with routine sessions. Training physiotherapists to incorporate an intervention into their routine physiotherapy session would be the most practical method of delivery. This eliminates the need for additional appointments with another professional, and increases the effectiveness of physiotherapy. The provision of a booklet or manual is also a viable option [[25], [26]].
Areas for future research
While 14 studies in this area were identified, their heterogeneous nature makes it difficult to draw robust conclusions. There is a need for a large exploratory mixed methods study to determine current levels of knowledge about motivational interventions among working physiotherapists, and how physiotherapists currently optimise adherence to prescribed exercises and physical activity guidelines. This information will show how far the profession is from fully integrating motivational strategies into practice.
Conclusion
This review has shown that motivational interventions can increase adherence to exercise, have a positive effect on long-term physical activity behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory to follow and the most beneficial length and type of intervention are yet to be determined. The roles of physiotherapists as promoters, preventers and rehabilitators puts them in an ideal position to influence exercise behaviours in every individual they treat, re-inforcing the ‘Make Every Contact Count’ policy. Enabling adherence to exercises and increasing physical activity must become an integral part of physiotherapy treatment. Promoting and positively influencing adherence and physical activity behaviour is an important area, and it is clear that physiotherapists are well positioned and capable of providing such interventions with the appropriate education and skills acquisition.
Ethical approval: None required.
Conflict of interest: None declared.
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