Effective Communication Techniques

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Introduction

Resource Aims

Effective Communication Techniques in a healthcare setting has been developed on the bases that physiotherapists are in a unique position as part of a multidisciplinary team in that they can have substantially more contact time with patients than other members of the team. This means the physiotherapist is more appropriately positioned to develop a deeper patient-therapist relationship and in doing so educate and empower the patient of their physical condition and management.

Communication is an important tool in a healthcare setting that when used effectively can educate, empower and de-threaten common health issues patients present with in practice. However, if it is used ineffectively it can have detrimental effects creating fear, confusion and anxiety in patients as well as encouraging resistance to lifestyle changes and healthy behaviours.

It can be overwhelming for newly qualified or student physiotherapists as they must deal with such a broad range of conditions as well as differences in patient personalities, beliefs and motivation. This resource pack uses specific physical conditions as examples, however the communication strategies can be adapted and applied effectively across the broad range of physical conditions dealt with by physiotherapists.

This resource tool is in no way comprehensive and does not aim to cover every physical and mental condition dealt with by physiotherapists. For this reason, this tool is limited to communication around physical conditions and does not include information on communicating with mental issues or learning problems. It is a guide with suggested examples which can be adapted and applied to different situations with regards explaining and treating physical conditions. Included are further readings, reflection sections and relevant continuous professional development recommended to encourage the reader to actively engage with and consolidate their learning.

Audience

The Resource is aimed at student/ recently qualified physiotherapists. However, this should not be exclusive as other healthcare professionals, academics or individuals with an interest in the topic may extract relevant and useful information.

Learning Outcomes

Understand the importance of effective communication and identify pathways which communication may be influenced.
Identify the patients positive and negative emotional triggers and evaluate the impact on physical presentation
Analyse the prevailing language/metaphors that exist within healthcare and assess their impact on the bio-psyco-social model of pain.
Understand how assessment and explanation of disorders/pain needs to vary for different patients and select an appropriate communication technique with which to carry this out.
Identify effective communication methods that may be helpful when explaining a diagnosis/treatment to a patient.
Reflect upon one's own practice of communication techniques and identify areas requiring improvement

Importance of Good Communication

Introduction

Communication is an interactive process which involves the constructing and sharing of information, ideas and meaning through the use of a common system of symbols, signs and behavioursQuality Assurance Standards for Physiotherapy Service Delivery. (2012). Chartered Society of Physiotherapy (CSP).. It includes the sharing of information, advice and ideas with a range of people, using;

•verbal

•non-verbal

•written

•e-based

These can be modified to meet the patients preferences and needs.

Figure 2: HCPC standards of proficiency (2013).

Figure 1: CSP quality assurance standards (2012).

Skilled and appropriate communication is the foundation of effective practice and is a key professional competence (See CSP: quality assurance standardsQuality Assurance Standards for Physiotherapy Service Delivery. (2012). Chartered Society of Physiotherapy (CSP). and HCPC: Standards of ProficiencyStandards of Proficiency - Physiotherapists. (2013). Health and Care Professions Council (HCPC). figure 2, above) which is highly valued by physiotherapy recipientsPARRY, R.H. and BROWN, K.,2009. Teaching and learning communication skills in physiotherapy: What is done and how should it be done? Physiotherapy. vol.95, pp. 294-301.. Effective communication requires consideration of the context, the nature of the information to be communicated and engagement with technology, particularly the effective and efficient use of Information and Communication Technology.

Numerous studies have confirmed the importance of communication between physiotherapist and patient and interventions to enhance practice - some of which will be discussed throughout this learning resource.

Communication Pathways to improve health outcomes

To understand why communication may lead to better improved health outcomes researchers have identified pathways through which communication influences health and well being and can be simplified in figure 3 as proposed by StreetSREET, R.L., MAKOUL, G., ARORA, N.K. and EPSTEIN, R.M., 2009. How does communication heal? Pathways linking clinicial-patient communication to health outcomes. Patient and Education Counselling. vol. 74, pp. 295-301..

Direct Pathways

Talk may be therapeutic, meaning, a physiotherapist who validates the patients perspective or expresses empathy may help a patient experience improved psychological well being. Leading to the patient experiencing fewer negative emotions (e.g. fear and anxiety) and more positive ones (e.g., hope, optimism and self-worth).

Non-verbal behaviours such as touch or tone of voice may directly enhance well-being by lessening anxiety or providing comfortHENRICSON, M., ERSSION, A, MAATTA, S., SERGESTEN, K. and BERGLUND, A.L., 2008. The outcome of tactile touch on stress perameters in intensive care: a randomized controlled trial. Complement Ther Clin Pract. vol. 14, pp. 244-254.KNOWLTON, G.E. and LARKIN, K.T., 2006. The influence of voice volume, pitch and speech rate on progressive relaxation training: application of methods from speech pathology and audiology. Applied Psychophysiology Biofeedback. vol. 31, pp.173-185.WEZE, C., LETHARD, H.L., GRANGE, J., TIPLADY, P. and STEVENS, G., 2004. Evaluation of healing by gentle touch in 35 clients with cancer. Europe Journal of Oncology Nursing. vol. 8, pp. 40-49.

Indirect Pathways

In most cases, communication affects health through a more indirect or mediated route through proximal outcomes of the interaction, such as;

satisfaction with care
motivation to adhere
trust in the clinician and system Figure 3: Direct and Indirect pathways from communication to health outcomes.
self efficacy in self care
clinician – patient agreement
shared understanding

This could affect health or that could contribute to the intermediate outcomes (e.g., adherence, self-management skills, social support that lead to better healthSTEWART, M.A., 1995. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J. vol. 152, pp. 1423-1233..

A physiotherapists clear explanation and expression of support could lead to greater patient trust and understanding of treatment optionsSREET, R.L., MAKOUL, G., ARORA, N.K. and EPSTEIN, R.M., 2009. How does communication heal? Pathways linking clinicial-patient communication to health outcomes. Patient and Education Counselling. vol. 74, pp. 295-301.. This in turn may facilitate patient adherence to recommended therapy, which in turn improves the particular health outcome. Increased patient participation in the consultation could help the physiotherapist better understand the patient’s needs and preferences as well as discover possible misconceptions the patient may have about treatment optionsSREET, R.L., MAKOUL, G., ARORA, N.K. and EPSTEIN, R.M., 2009. How does communication heal? Pathways linking clinicial-patient communication to health outcomes. Patient and Education Counselling. vol. 74, pp. 295-301.. The physiotherapist can then have the opportunity to communicate risk information in a way that the patient understands. This could lead to mutually agreed upon, higher quality decisions that best match the patients circumstancesSREET, R.L., MAKOUL, G., ARORA, N.K. and EPSTEIN, R.M., 2009. How does communication heal? Pathways linking clinicial-patient communication to health outcomes. Patient and Education Counselling. vol. 74, pp. 295-301..

An article by Street et al.SREET, R.L., MAKOUL, G., ARORA, N.K. and EPSTEIN, R.M., 2009. How does communication heal? Pathways linking clinicial-patient communication to health outcomes. Patient and Education Counselling. vol. 74, pp. 295-301. explores these pathways to further broaden your knowledge. A link to this article can be found in ‘Further Reading’ section below.

Communication during Examination and Assessment

How Communication can impact the patient

The Macey Model of Doctor-patient Communication is a communication skills model that illustrates fundamental processes applicable to every meeting between physician and patient, and represents a complete set of core skills (see fig. 3.4)KALET, A., PUGNAIRE, M.P., COLE-KELLY, K., JANICIK, R., FERRARA, E., SCHWARTZ, M.D., LIPKIN, M. and LAZARE, A., 2004. Teaching communication in clinical clerkships: Models from the macey initiative in health communications. Academic Medicine. vol. 79, no. 6, pp. 511-520..

Although this tool was developed for doctors, the model provides an overall framework for systematically teaching vital communication elementsKALET, A., PUGNAIRE, M.P., COLE-KELLY, K., JANICIK, R., FERRARA, E., SCHWARTZ, M.D., LIPKIN, M. and LAZARE, A., 2004. Teaching communication in clinical clerkships: Models from the macey initiative in health communications. Academic Medicine. vol. 79, no. 6, pp. 511-520..

The medical interview, particularly the subjective assessment, will determine the quantity, quality and accuracy of data that the physiotherapist will elicit. In turn, this will affect both the approach to the problem and the consequent care of the patientKALET, A., PUGNAIRE, M.P., COLE-KELLY, K., JANICIK, R., FERRARA, E., SCHWARTZ, M.D., LIPKIN, M. and LAZARE, A., 2004. Teaching communication in clinical clerkships: Models from the macey initiative in health communications. Academic Medicine. vol. 79, no. 6, pp. 511-520.. Ensuring that we communicate effectively will directly influence the patients behaviour and well being for:

Satisfaction with careONG, L.M., VISSER, M.R., LAMMES, F.B. and de HAES, J.C., 2000. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Education Counselling. vol. 41, pp. 145-156.
Adherence to treatment plansONG, L.M., VISSER, M.R., LAMMES, F.B. and de HAES, J.C., 2000. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Education Counselling. vol. 41, pp. 145-156.
Recall and understanding of the information givenONG, L.M., VISSER, M.R., LAMMES, F.B. and de HAES, J.C., 2000. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Education Counselling. vol. 41, pp. 145-156.
Coping with the diagnosisONG, L.M., VISSER, M.R., LAMMES, F.B. and de HAES, J.C., 2000. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Education Counselling. vol. 41, pp. 145-156.
Quality of life and even state of healthONG, L.M., VISSER, M.R., LAMMES, F.B. and de HAES, J.C., 2000. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Education Counselling. vol. 41, pp. 145-156.

Figure 3: The Macey Model of Doctor-patient Communication

Table 1 below briefly describes how communication may influence the physical and psychological health of the patient.

Patient Learning Styles

Miscommunication between patients and physiotherapists is often documented when it comes to diagnosis explanation and treatment advice GILL, V. T., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; MAYNARD, D. W. (2006). Explaining illness: patients' proposals and physicians' responses. STUDIES IN INTERACTIONAL SOCIOLINGUISTICS, vol. 20, pp 115 DONOVAN, J. (1991). Patient education and the consultation: the importance of lay beliefs. Annals of the rheumatic diseases, vol. 50, Suppl 3, pp. 418. . Patients will describe symptoms in “lay” terms while physiotherapists often return feedback based on biomedical symptoms and processes of the condition using medical terms without taking into account the gap in the level of knowledge on the subject between the patient and themselvesGILL, V. T., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; MAYNARD, D. W. (2006). Explaining illness: patients' proposals and physicians' responses. STUDIES IN INTERACTIONAL SOCIOLINGUISTICS, vol. 20, pp 115 DONOVAN, J. (1991). Patient education and the consultation: the importance of lay beliefs. Annals of the rheumatic diseases, vol. 50, Suppl 3, pp. 418.. Research believes that this may be because physiotherapist’s often forget to take into account the difference in literacy levels between themselves and their patient, or they don’t know how to describe a condition outside of the medical model they have been taught during training.SULLIVAN, R. J., MENAPACE, L. W., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; WHITE, R. M. (2001). Truth-telling and patient diagnoses. Journal of medical ethics, vol. 27, issue 3, pp.192-197 .

Studies show that literacy levels in some countries can be as low as age 10, WEISS BD, REED RL, KLIGMAN EW (1995) Literacy skills and communication methods of low-income older persons. Patient Educ Counsel. Vol .25, pp.109–119. According to the Organisation for Economic Co-operation and Development,ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT, (2012), Education at a glance, available at http://www.keepeek.com/Digital-Asset-Management/oecd/education/education-at-a-glance-2014_eag-2014-en#page1, accessed on 24/11/14 the UK is now ranked 22nd in a study of 24 EU countries in terms of literacy with a national literacy age of 10 years old.
In addition to this English is not everyone’s first language. According to the 2011 UK census 92% of residents acknowledged English as their first language and of the 8% remaining (3.3 million people), only 79% claimed they could speak English well or very well OFFICE OF CENTRAL STATISTICS (2011), 2011 Census: Quick Statistics for England and Wales, March 2011, available at http://www.ons.gov.uk/ons/rel/census/2011-census/key-statistics-and-quick-statistics-for-wards-and-output-areas-in-england-and-wales/STB-2011-census--quick-statistics-for-england-and-wales--march-2011.html , accessed 24/11/14. Both of these factors may cause difficulty and confusion when trying to speak to a patient about their diagnosis and to make an informed decision around treatment options

What is Learning

By getting a better understanding of patient’s learning styles and acknowledging the difference between lay and medical terminology, we can provide effective education which, in return, may increase the compliance and cooperation of patientsDONOVAN, J. (1991). Patient education and the consultation: the importance of lay beliefs. Annals of the rheumatic diseases, vol. 50, Suppl 3, pp. 418..
Before educating the patient it is crucial that the following aspects are assessed:

Patients needs
Patients concerns
Patients motivation and readiness to learn
Patients preferences
Patients support network
Patients barriers and limitations to learning (mental health status, learning difficulties)STRÖMBERG, A. (2005). The crucial role of patient education in heart failure.European Journal of Heart Failure, vol. 7 issue 3, pp. 363-369.

Patient behaviour is determined by several factors such as family and work commitmentsSTRÖMBERG, A. (2005). The crucial role of patient education in heart failure.European Journal of Heart Failure, vol. 7 issue 3, pp. 363-369. . Patients will often weigh up these factors and consider various options before settling on the choice most suitable to their personality and lifestyle STRÖMBERG, A. (2005). The crucial role of patient education in heart failure.European Journal of Heart Failure, vol. 7 issue 3, pp. 363-369..

Learning is defined as a process in which knowledge is created through the transformation of experience CASSIDY, S. (2004). Learning styles: An overview of theories, models, and measures. Educational Psychology, vol. 24, issue 4, pp. 419-444. HAUER, P., STRAUB, C., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; WOLF, S. (2005). Learning styles of allied health students using Kolb's LSI-IIa. Journal of Allied Health, vol. 34 issue 3, pp. 77-182. Individuals use learning to manage and adapt to everyday situations, giving rise to different types of learning stylesCASSIDY, S. (2004). Learning styles: An overview of theories, models, and measures. Educational Psychology, vol. 24, issue 4, pp. 419-444. HAUER, P., STRAUB, C., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; WOLF, S. (2005). Learning styles of allied health students using Kolb's LSI-IIa. Journal of Allied Health, vol. 34 issue 3, pp. 77-182 .Through various research and studies, learning styles have been organised and categorized into levels, suggesting an individual’s capacity for flexible and adaptive model learning CASSIDY, S. (2004). Learning styles: An overview of theories, models, and measures. Educational Psychology, vol. 24, issue 4, pp. 419-444. HAUER, P., STRAUB, C., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; WOLF, S. (2005). Learning styles of allied health students using Kolb's LSI-IIa. Journal of Allied Health, vol. 34 issue 3, pp. 77-182. These levels are ranked in descending order of stability and are listed as:

Personality traits
Information processing
Social interaction
Instructional preferenceCASSIDY, S. (2004). Learning styles: An overview of theories, models, and measures. Educational Psychology, vol. 24, issue 4, pp. 419-444. HAUER, P., STRAUB, C., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; WOLF, S. (2005). Learning styles of allied health students using Kolb's LSI-IIa. Journal of Allied Health, vol. 34 issue 3, pp. 77-182

For instructional preference. Patterson (2003) PATTERSON, D. J. (2003). Learning Styles. Journal of Adventist Education Summer, vol. 39.proposed three types of learning styles: Visual, Auditory & Kinesthetic as detailed in table 2 below.

The most common learning theory model in application is Kolb’s four stages of experiential model (1984)KOLB, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall., which, as the names suggest is based around four stages. The ideology is that individual’s transition from phase to phase in their learning processCASSIDY, S. (2004). Learning styles: An overview of theories, models, and measures. Educational Psychology, vol. 24, issue 4, pp. 419-444. HAUER, P., STRAUB, C., &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; WOLF, S. (2005). Learning styles of allied health students using Kolb's LSI-IIa. Journal of Allied Health, vol. 34 issue 3, pp. 77-182. Very little research is available on the application of these teaching models to a healthcare setting perspective.

Kolb’s four stages of experiential model (figure 4):

Concrete experience: The patient learns of their diagnosis for the first time from the physio or they could have some previous knowledge or experience of the condition, possibly from news articles or friends or family members with experience or knowledge of the condition. This stage helps the patient to grasp what their diagnosis and prognosis is
Reflection on experience: The patient will go away and review and reflect on the experience and their understanding of their diagnosis.
Abstract conceptualisation: The patient learns from the experience of their treatment and diagnosis.
Experimental experience: The patient will plan and adapt to the arising situation and try out what has been learned in terms of education and treatment.

Figure 4:Kolb’s four stages of experiential model.

Facilitators of Communication

Table 3: Facilitators of communicationSIM, J. 2002. Extract- Categories of Intervention. In: J. PRYOR &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; S.A. PRASAD. Eds. Physiotherapy for Respiratory and Cardiac problems: Adults and Pediatrics. 3rd edition. Edinburgh: Churchill Livingstone

Strategies to Aid Information Recall

Table 4:Strategies to facilitate memory

An important feature of effective communication is the ability of the patients to retain the information that is impartedSIM, J. 2002. Extract- Categories of Intervention. In: J. PRYOR &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; S.A. PRASAD. Eds. Physiotherapy for Respiratory and Cardiac problems: Adults and Pediatrics. 3rd edition. Edinburgh: Churchill Livingstone. Extensive research has been conducted within health care on factors which may hinder or facilitate memory and therefore, the degree of adherence. The following table summarizes some techniques which can help maximise the information patients retain and recall. However, it is important to stress that these techniques should not be seen as a substitute for interpersonal skills and attitude that helps to create a good relationship with the patient, as this is a prerequisite for good communicationSIM, J. 2002. Extract- Categories of Intervention. In: J. PRYOR &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; S.A. PRASAD. Eds. Physiotherapy for Respiratory and Cardiac problems: Adults and Pediatrics. 3rd edition. Edinburgh: Churchill Livingstone.

Explaining Diagnosis

Breaking "Bad" News

The ethos of a physiotherapist defines what good occupational practices should be Standards of Proficiency - Physiotherapists. (2013). Health and Care Professions Council (HCPC).. General principles cover an evaluation of an adequate attitude i.e. respectable coexistence and behaviour with respect to others, as well as normal social relationships and a positive attitude towards oneself and the surrounding worldStandards of Proficiency - Physiotherapists. (2013). Health and Care Professions Council (HCPC).. A physiotherapist should possess skills of empathetic understanding of patient circumstances and how to respect patients feelings and sensations. Kindness, engagement in the recognition of a patient's individual life situation, as well as his/her personality traits, allow the physiotherapist the ‘maximisation’ of their techniques of providing assistance to a patientStandards of Proficiency - Physiotherapists. (2013). Health and Care Professions Council (HCPC)..

Bad news in the healthcare context can refer to any information that creates a negative view of a person’s healthWALSH, R.A., GIRGIS, A., and SWANSON-FISHER, R.W., 2010. Breaking bad news 2: what is available to guide clinicians?. The Journal of Behavioural Medicine. Vol 24, no. 2, pp. 61-72.. Communicating bad news can be mishandled with potentially distressing results for clinicians and especially patients. Yet few health care professionals have received formal training in this area and it is evident that many feel ill prepared to perform the task of communicating bad news effectivelyWALSH, R.A., GIRGIS, A., and SWANSON-FISHER, R.W., 2010. Breaking bad news 2: what is available to guide clinicians?. The Journal of Behavioural Medicine. Vol 24, no. 2, pp. 61-72..

Dealing with difficult situations is challenging and requires important communication skills on behalf of the physiotherapist. Besides the moral, ethical and social obligations of conveying this type of information in a sensitive and accurate manner, it can also be medico-legal responsibilityCOLLETTI, .M.,D., GRUPPEN, L., BARCLAY, AND STERN, D., 2001. Teaching students to break bad news. The Amercian Journal of Surgery. Vol. 182, pp. 20-23.. Poorly communicated diagnosis can generate feelings of mistrust, anger, fear and blameCOLLETTI, .M.,D., GRUPPEN, L., BARCLAY, AND STERN, D., 2001. Teaching students to break bad news. The Amercian Journal of Surgery. Vol. 182, pp. 20-23.. A physiotherapist’s ability to effectively communicate is typically learned through trial and error or observation of more senior staffCOLLETTI, .M.,D., GRUPPEN, L., BARCLAY, AND STERN, D., 2001. Teaching students to break bad news. The Amercian Journal of Surgery. Vol. 182, pp. 20-23..

Use of Metaphors in explaining diagnosis

“The medical profession has for a long time largely neglected the influence that language itself has in shaping and conceptualising medical practice”.Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230.
Why is this? Over the past 3 decades there has been a growing body of evidence that has looked at the role of metaphors in healthcareLoftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230.. Historically metaphors were thought of being misleading and potentially counter productive for cognitive reconceptualisingSontag, S. (1978). Illness as metaphor. Oxford. Oxford University Press.. Contemporary literature is much more welcoming of metaphors, especially within pain management. Now the research debate has shifted toward how metaphors should be applied in clinical practice rather than if metaphors are true or not. Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230. Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31.
We know that each and every patient that is seen comes with a very individual set of life experiences and different ways of shaping understanding of their “impairments". Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230. Language and more specifically metaphors can aid in this process to promote advancement of a more meaningful understanding of diagnoses, avoidance of persistent pain, and self management strategies.Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230. Bedell, S., Graboys, T., Bedell, E. and Lown, B. (2004). Words That Harm, Words That Heal. Archives of Internal Medicine, 164(13), p.1365. Despite these potential benefits, physiotherapists need to be aware of the chance of misinterpretations some patients might take from these metaphors.

In the busyenvironment of clinical practice(rephrase), physiotherapists can’t loose sight of the real people at the heart of the healthcare system.Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31. Due to the often complex idiosyncratic nature of bio-psycho-social pain, physiotherapists often use metaphors to try and create an “unique” reconceptualisation of what is really going on with the patients body.Sullivan, M. (1995). Pain in language. Pain Forum, 4(1), pp.3-14.

If we examine metaphors separate from the healthcare environment we know that metaphors can facilitate new ways of visualising the world and how we act within it. As a child we are always using our imagination or past experiences to create meaning of new experiences we face on a everyday basis. Physiotherapists must aid the patient to find meaning in the dialogue of personal, cultural, and physical experiences that have made up their lives.Gifford L S (Ed) (2000) Topical Issues in Pain 2: Biopsychosocial assessment. Relationships and pain. L. S. Gifford. Falmouth, CNS Press Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31.
Now if we integrate pain for example into this situation we can argue that pain is essentially an interpretation by that individual, it can be said that the only way to adequately understand pain is through metaphor itself.Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31. Ideally a set of metaphors that address the neurobiological contexts as well as the sociocultural contexts of their lives without looking at them dualistically but instead cohesively.Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230.

Commonly used Metaphors in practice

Over the years the use of metaphors have been looked at by many different research papers and some that are continually being used in practice produce poor patient outcomes. Below we will look at a few of the common metaphors being used across healthcare and analyse how they may benefit or be harmful to the patient.

The Body is a Machine <img src="/images/thumb/9/92/Body-machine-metaphor.jpg/250px-Body-machine-metaphor.jpg" _fck_mw_filename="Body-machine-metaphor.jpg" _fck_mw_location="right" _fck_mw_width="250" _fck_mw_height="170" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_right" />

This often implies that the patients are handing over their bodies to a health professional to locate the damage and administer treatment to repair the damage. Much like a car garage.

Encourages us to think in a Dualistic way (BIOMEDICAL VS. BIO-PSYCHO-SOCIAL) , although if we recognise that social interaction, self interpretation and meaning are important; we must look for more adequate metaphors.

Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230.

Medicine is War/ Military Metaphors <img src="/images/thumb/a/a7/Militarymetaphor.png/200px-Militarymetaphor.png" _fck_mw_filename="Militarymetaphor.png" _fck_mw_location="right" _fck_mw_width="200" _fck_mw_height="200" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_right" />

Can imply that the patients are being passive and the doctors are warriors.

Allows patients and clinicians to think that the patient has failed rather than the treatment.

These metaphors can also lead some clinicians to think of themselves as a poor “soldier” and decrease confidence.

Military metaphors can direct pain reconceptualisation away from bio-psycho-social evidence and think the war can be won with biomedical means of treatment.

(Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230.;Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056.,Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31.)

Brain as a Computer <img src="/images/thumb/c/cd/BrainXcomputerMetaphor.jpg/200px-BrainXcomputerMetaphor.jpg" _fck_mw_filename="BrainXcomputerMetaphor.jpg" _fck_mw_location="left" _fck_mw_width="200" _fck_mw_height="160" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_left" />

This metaphor can sometimes help patients understand some of the complexities of neurobiology, but downplays the idiosyncratic and adaptive properties of the CNS. Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31.

Journey Metaphor <img src="/images/thumb/e/e1/Midlife-crossroads_edited-1.jpg/300px-Midlife-crossroads_edited-1.jpg" _fck_mw_filename="Midlife-crossroads edited-1.jpg" _fck_mw_location="right" _fck_mw_width="300" _fck_mw_height="200" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_right" />

Some other metaphors paint a more adequate picture for patients and have been successful in practice, especially for patients with consistent pain.
Contrary to military metaphors, journey metaphors have destinations but in journeys there isn’t just one way to get to that destination. Patients and clinicians have the ability to adjust and try out different avenues. It has been proposed by Reisfield & Wilson Reisfield, G. and Wilson, G. (2004). Use of Metaphor in the Discourse on Cancer. Journal of Clinical Oncology, 22(19), pp.4024-4027. that journey metaphors offer “different roads to travel, various avenues to explore and always there are exits to take.”
Journey metaphors rightfully shift the focus away from failure or success and focus on personalised adaptive exploration .Hartley, T. (2012). Cutting Edge Metaphors. Journal of the Association of Surgeons of Great Britain &amp;amp;amp;amp;amp;amp;amp;amp;amp; Ireland, (37), pp.26-29.

Advice and Cautions

As mentioned before there should be certain caution’s and encouraging tips to think about when delivering metaphors in clinical practice.

“When should we use and not use metaphors?”
Well that all depends on who is seeking medical help and how the metaphors are going to be used. There isn’t one metaphor that is good or bad, one metaphor might work great with one patient and be harmful or insignificant to another patient (Loftus 2011).Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230. This is when clinicians must open our toolkit and take out their clinical appraisal skills. Therapists must look at

“What patient has the condition, not what condition does the patient have?”
Physiotherapists must be aware of the potential of imposing our own bias on our patients, this is precisely why communication should be looked at in a dialogical manner.Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31.,Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230.)

“It takes two to tango”.

Through a dialogical approach to assessment we can better understand our patients and through that subjective information co-construct more meaningful metaphors .Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230. “Thacker & Mosley have argued that clinician dominant questioning can negate the critical need for the patients to have their psychological, social and philosophical stories heard.” Yelland, M. (2011). What do patients really want?. International Musculoskeletal Medicine, 33(1), pp.1-2.
Its important that we as clinicians understand and appreciate both the power and subtlety that language can possess .Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230. The debate shouldn’t be looking at what metaphor is the truest in all senses, this is irrelevant because metaphors aren’t true or false they are useful or not in various contexts..Loftus, S. (2011). Pain and its Metaphors: A Dialogical Approach. J Med Humanit, 32(3), pp.213-230.

Communication when addressing persistent pain complaints

Introduction

Acute pain conditions have a very good rate of healing, but health care systems still find that a large portion of these patients go on to experience persistent pain and maladaptive behaviours .Darlow, B., Dowell, A., Baxter, G., Mathieson, F., Perry, M. and Dean, S. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. The Annals of Family Medicine, 11(6), pp.527-534.,Croft, P., Macfarlane, G., Papageorgiou, A., Thomas, E. and Silman, A. (1998). Outcome of low back pain in general practice: a prospective study. BMJ, 316(7141), pp.1356-1359. As a result Persistent Pain conditions place a huge strain on the healthcare system and economy .Darlow, B., Dowell, A., Baxter, G., Mathieson, F., Perry, M. and Dean, S. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. The Annals of Family Medicine, 11(6), pp.527-534. Modern pain research tells us that often patient beliefs play a huge role in the transition from acute pain to chronicity. By better understanding patient beliefs and positively influencing them with reassurance and compassion we can better manage patients perception of pain .Darlow, B., Dowell, A., Baxter, G., Mathieson, F., Perry, M. and Dean, S. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. The Annals of Family Medicine, 11(6), pp.527-534.,Butler, D. and Moseley, G. (2003). Explain pain. Adelaide: Noigroup Publications.
We know from nursing literature that pain is the most common reason for an individual to seek medical advice .Nair, M. and Peate, I. (2012). Fundamentals of Applied Pathophysiology. Chicester: Wiley. At times Healthcare Professionals can negatively impact patients beliefs about pain. It is common that some patients feel that their stories haven’t been listened to and consequently their pain is not validated .Yelland, M. (2011). What do patients really want?. International Musculoskeletal Medicine, 33(1), pp.1-2.

What is Pain?

Many believe pain is a simple sensation that you get after, lets say “closing the car door on your finger”. It’s easy to understand in a structural model of reasoning, which believes that the more pain you get the more tissue damage you are causing. Although it is not as simple as this, and much of the persistent pain that physiotherapists see on a everyday basis would not be adequately addressed by this model of thinking. Recent authors have indicated that pain could be a measure of potential threat rather than an indication of tissue health.Moseley, G. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), pp.130-140.
Lorimer Moseley’s 2007 paper “Reconceptualising Pain According to Modern Pain Science” suggests that :Moseley, G. (2007). Reconceptualising pain according to modern pain science. Phys. Ther. Rev., 12(3), pp.169-178.<img src="/images/9/9c/Table_5_-_mosely.png" _fck_mw_filename="Table 5 - mosely.png" _fck_mw_location="center" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_center" />

If we look at the work of Louis Gifford and the Mature Organism Model Gifford L (Ed) (1998) Topical Issues in Pain 1: Whiplash – science and management. Fear avoidance beliefs and behaviour. CNS Press Falmouth.(1998) we see that when we get a input nociceptive stimuli the nerve impulse travels to the brain and is sampled against a number of different factors such as:

<img src="/images/8/83/Table_6._Pain_Factors.png" _fck_mw_filename="Table 6. Pain Factors.png" _fck_mw_location="center" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_center" />After the brain scrutinises all these unconscious pieces of information it asks itself, “How dangerous is this really?” Pain is a good thing and tries to protect our tissues, we as physiotherapists need to monitor if pain is adaptive or maladaptive .Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31.

<img src="/images/f/f6/MatureOModel_picture.png" _fck_mw_filename="MatureOModel picture.png" _fck_mw_location="center" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_center" />Gifford L (Ed) (1998) Topical Issues in Pain 1: Whiplash – science and management. Fear avoidance beliefs and behaviour. CNS Press Falmouth.

Every Chronic Pain was once Acute

As pain carries on the patient may become more anxious, stressed, helpless, sedentary, further reinforcing the brain’s choice to cause pain.Moseley, G. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), pp.130-140.,Gifford L S (Ed) (2000) Topical Issues in Pain 2: Biopsychosocial assessment. Relationships and pain. L. S. Gifford. Falmouth, CNS PressWe often see a fire alarm that goes off from a piece of burning toast similarly our bodies alarm system can malfunction in much the same way if the body becomes hypersensitive..
More and more research is starting to look at pain as a disorder rather than a symptom. Bourke, J. (2014). The story of pain. London Oxford University Press. Just as asthma, diabetes or epileptic patients are educated on the mechanisms of their disease and how their actions could make their condition better or worse. Persistent pain patients should be socratically introduced to their condition by facilitating dialogical critical thinking in a similar manner .Yelland, M. (2011). What do patients really want?. International Musculoskeletal Medicine, 33(1), pp.1-2.
Often it can be easier to address peoples lack of care for their pain when patients have co-morbidities because physiotherapists are able to compare how poorly their pain is being managed. If we take a moment to look at Diabetes and persistent pain through the same lense, and imagine that doctors had a patient coming in every 3 days for an insulin injection and an overnight stay because they weren't managing their diabetes correctly there would be a problem. In a physiotherapy setting if a patient was coming into your clinic every 3 days for some manual therapy to decrease their pain while they otherwise poorly manage their condition, this would not be right. Some therapists are content with that, We shouldn’t be…!

<a href="http://giffordsachesandpains.files.wordpress.com/2013/06/biopsychosocial-part2.pdf">Further reading Louis Gifford(2000) shopping basket approach</a>

Neuroscience Education

According to Adrian Louw (2011) Neuroscience education is a cognitive based intervention that aims at reducing pain and maladaptive behaviours by guiding patients to grasp understanding of the mechanisms underpinning their pain experience.Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056.
This semi complex information needs to be delivered to the patient in a way that is clear and easy to understand. Language and other communication techniques such as drawings,pictures, videos, workbooks can aid patient learning. Research shows that traditionally clinicians tend to underestimate patients ability to understand complex pain, when in fact patients are very interested in learning about their pain .Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056.
Multiple studies have shown that Neuroscience Education combined with graded exercise is in line with the best evidence available for treating persistent pain.Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056. Resulting in decreased fear, pain, cognition and physical performance, increased pain thresholds during exercises, and reduced brain activity(especially the amygdala) that is usually involved with pain.Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056.,Veinante, P., Yalcin, I. and Barrot, M. (2013). The amygdala between sensation and affect: a role in pain. J Mol Psychiatry, 1(1), p.9.

Figure from Mike Stewart MCSP SRP PG Cert(Clin Ed): Know Pain <a href="http://knowpain.co.uk/">http://knowpain.co.uk/</a>

Explaining Pain: How to do it in under 10 minutes

Clinical Example: Osteoarthritis

When explaining a condition such as osteoarthritis to a patient we must consider what their viewpoint of the condition must be. Osteoarthritis is a condition of cartilage degeneration, subchondral bone stiffening and active new bone formationHEUTS, P.H., VLAEYEN, J.W., ROELOFS, J., DE BIE, R.A., ARETZ, K., VAN WEEL, C. and VAN SCHAYCK, O.C., 2004. Pain-related fear and daily functioning in patients with osteoarthritis. Pain. , vol. 110, no. 1, pp. 228-235..
Osteoarthritis is a complex sensory and emotional experience. An individual’s psychological characteristics and immediate psychological contest in which pain is experienced both influence their perception of painHUNTER, D.J., MCDOUGALL, J.J. and KEEFE, F.J., 2009. The symptoms of osteoarthritis and the genesis of pain. Medical Clinics of North America. , vol. 93, no. 1, pp. 83-100..

Research has utilised qualitative methods and focus groups to establish the patient’s point of view. A common theme that is emerging is that patients are sometimes dissatisfied with the overall level of understanding, help and information that is given to them by healthcare professionalsHILL, S., DZIEDZIC, K.S. and NIO ONG, B., 2011. Patients' perceptions of the treatment and management of hand osteoarthritis: a focus group enquiry. Disability and Rehabilitation. , vol. 33, no. 19-20, pp. 1866-1872.. Patients also expressed concern that there was a lack of understanding by healthcare professionals as to the impact that osteoarthritis can have on an individual’s lifeHILL, S., DZIEDZIC, K.S. and NIO ONG, B., 2011. Patients' perceptions of the treatment and management of hand osteoarthritis: a focus group enquiry. Disability and Rehabilitation. , vol. 33, no. 19-20, pp. 1866-1872..

As physiotherapists, we must be aware of current and alternative treatments for OA (hydrotherapy, acupuncture etc) as contradictory information being given to the patient from different sources may lead to confusion as to what exactly they should be doingHILL, S., DZIEDZIC, K.S. and NIO ONG, B., 2011. Patients' perceptions of the treatment and management of hand osteoarthritis: a focus group enquiry. Disability and Rehabilitation. , vol. 33, no. 19-20, pp. 1866-1872..

Somers et alSOMERS, T.J., KEEFE, F.J., PELLS, J.J., DIXON, K.E., WATERS, S.J., RIORDAN, P.A., BLUMENTHAL, J.A., MCKEE, D.C., LACAILLE, L. and TUCKER, J.M., 2009. Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability. Journal of Pain and Symptom Management. , vol. 37, no. 5, pp. 863-872.highlights that patients may adopt certain attitudes towards pain; Patients who are pain catastrophizing tend to focus on and magnify their pain sensations. This group of patients tend to feel helpless in the face of pain. Patients who adopt this stance report higher levels of pain, have higher levels of psychological and physical disability.

The second stance is patients who have pain related fear. They have a fear of physical activity as a result of feeling vulnerable to pain during activity. This group are more likely to engage in avoidance behaviours such as avoiding movementSOMERS, T.J., KEEFE, F.J., PELLS, J.J., DIXON, K.E., WATERS, S.J., RIORDAN, P.A., BLUMENTHAL, J.A., MCKEE, D.C., LACAILLE, L. and TUCKER, J.M., 2009. Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability. Journal of Pain and Symptom Management. , vol. 37, no. 5, pp. 863-872..
We as physiotherapists must remember that OA patients with a fear of engaging in painful movements may be hesitant to engage in physical activity. This can contribute to a vicious cycle of a more restricted and a physically inactive lifestyle which will lead to increased pain and disabilitySOMERS, T.J., KEEFE, F.J., PELLS, J.J., DIXON, K.E., WATERS, S.J., RIORDAN, P.A., BLUMENTHAL, J.A., MCKEE, D.C., LACAILLE, L. and TUCKER, J.M., 2009. Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability. Journal of Pain and Symptom Management. , vol. 37, no. 5, pp. 863-872.

Hendry et alHENDRY, M., WILLIAMS, N.H., MARKLAND, D., WILKINSON, C. and MADDISON, P., 2006. Why should we exercise when our knees hurt? A qualitative study of primary care patients with osteoarthritis of the knee. Family Practice. Oct, vol. 23, no. 5, pp. 558-567.conducted qualitative research on primary care patients with OA. They found that personal experience, aetiology of arthritis and motivational factors all influenced compliance rates towards physical activity. Some patients believed that their joint problems were a direct result of heavy physical activityHILL, S., DZIEDZIC, K.S. and NIO ONG, B., 2011. Patients' perceptions of the treatment and management of hand osteoarthritis: a focus group enquiry. Disability and Rehabilitation. , vol. 33, no. 19-20, pp. 1866-1872.. This is where we as clinicians must be aware that patients may present questions such as;

‘why should we exercise when our knees hurt?’

In the same study patients were asking;

‘if it is wear and tear on the bone, is it helping to do all this exercise, walking and that?’

As physiotherapists we must be careful with our choice of words, phrases such as ‘wear and tear’ may be misinterpreted by some patients and lead to further maladaptive behaviour. Grime et alGRIME, J., RICHARDSON, J.C. and ONG, B.N., 2010. Perceptions of joint pain and feeling well in older people who reported being healthy: a qualitative study. British Journal of General Practice. , vol. 60, no. 577, pp. 597-603.established that an ongoing concern of musculoskeletal professionals is that the use of this ‘wear and tear’ explanation often leads to decreased physical activity to avoid further ‘wearing of the joint’.

A unique approach adopted by a number of patients in the same study by Grime et alGRIME, J., RICHARDSON, J.C. and ONG, B.N., 2010. Perceptions of joint pain and feeling well in older people who reported being healthy: a qualitative study. British Journal of General Practice. , vol. 60, no. 577, pp. 597-603.was the ‘use it or lose it’ approach. This simply put was use the joint or lose your functional ability. As physiotherapists we could utilise a similar approach to get our patients to comply with the physical exercise that we have prescribed as an intervention. Through effective communication we can increase a patient’s self efficacy and reduce their level of physical disabilityHUNTER, D.J., MCDOUGALL, J.J. and KEEFE, F.J., 2009. The symptoms of osteoarthritis and the genesis of pain. Medical Clinics of North America. , vol. 93, no. 1, pp. 83-100.. Patients with higher self efficacy for pain control had higher thresholds for pain stimuliHUNTER, D.J., MCDOUGALL, J.J. and KEEFE, F.J., 2009. The symptoms of osteoarthritis and the genesis of pain. Medical Clinics of North America. , vol. 93, no. 1, pp. 83-100.. Can we as physiotherapists use this to our advantage to increase patient’s compliance to exercise?

Exercise has been shown to have a positive effect on functional ability in patients with OAHEUTS, P.H., VLAEYEN, J.W., ROELOFS, J., DE BIE, R.A., ARETZ, K., VAN WEEL, C. and VAN SCHAYCK, O.C., 2004. Pain-related fear and daily functioning in patients with osteoarthritis. Pain. , vol. 110, no. 1, pp. 228-235.. We as physiotherapists must consider the role of pain related fear in patients with OA and investigate different treatment approaches to combat this behaviourHEUTS, P.H., VLAEYEN, J.W., ROELOFS, J., DE BIE, R.A., ARETZ, K., VAN WEEL, C. and VAN SCHAYCK, O.C., 2004. Pain-related fear and daily functioning in patients with osteoarthritis. Pain. , vol. 110, no. 1, pp. 228-235..

Scopaz et alSCOPAZ, K.A., PIVA, S.R., WISNIEWSKI, S. and FITZGERALD, G.K., 2009. Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis. Archives of Physical Medicine and Rehabilitation. , vol. 90, no. 11, pp. 1866-1873.suggests psychological factors such as anxiety, fear and depression may also be related to physical function in patients with OA of the knee.

Further to this, a model of fear avoidance suggests that patients can either be adaptive and non-adaptive in their approach to their pain and functional abilitySCOPAZ, K.A., PIVA, S.R., WISNIEWSKI, S. and FITZGERALD, G.K., 2009. Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis. Archives of Physical Medicine and Rehabilitation. , vol. 90, no. 11, pp. 1866-1873.

This model indicates that anxiety + fear avoidance beliefs are significant predictors of self report physical function in patients with knee OASCOPAZ, K.A., PIVA, S.R., WISNIEWSKI, S. and FITZGERALD, G.K., 2009. Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis. Archives of Physical Medicine and Rehabilitation. , vol. 90, no. 11, pp. 1866-1873..

Following on from this, we may also consider the avoidance model presented by Dekker et alDEKKER, J., TOLA, P., AUFDEMKAMPE, G. and WINCKERS, M., 1993. Negative affect, pain and disability in osteoarthritis patients: the mediating role of muscle weakness. Behaviour Research and Therapy. , vol. 31, no. 2, pp. 203-206.(right).

This model indicates that a decreased muscle strength as a result of activity avoidance leads to activity limitationsHOLLA, J.F., VAN DER LEEDEN, M., KNOL, D.L., PETER, W.F., ROORDA, L.D., LEMS, W.F., WESSELING, J., STEULTJENS, M.P. and DEKKER, J., 2012. Avoidance of activities in early symptomatic knee osteoarthritis: results from the CHECK cohort. Annals of Behavioral Medicine. , vol. 44, no. 1, pp. 33-42..

Recommendations

'What can us as physiotherapists do to combat these beliefs that may be instilled in patients?'

Table 7 highlights some useful techniques when managing patients with OA.

<img src="/images/thumb/4/49/Patient-misinterpret.png/503px-Patient-misinterpret.png" _fck_mw_filename="Patient-misinterpret.png" _fck_mw_location="center" _fck_mw_width="550" _fck_mw_height="375" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_center" /> Darlow, B., Dowell, A., Baxter, G., Mathieson, F., Perry, M. and Dean, S. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. The Annals of Family Medicine, 11(6), pp.527-534.Figure from Mike Stewart MCSP SRP PG Cert (Clin Ed): Know Pain <a href="http://knowpain.co.uk">http://knowpain.co.uk</a>

Sensitive Issues: Obesity

Introduction

Primary care providers and particularly physiotherapists are being encouraged to provide a more active approach in the management of obesitySTAFFORD, R.S., FARHAT, J.H., MISRA, B. and SCHOENFELD, D.A. (2000). National patterns of physician activities related to obesity management. Archives of Family Medicine, vol 9 issue 7, pp.631-638.. However physiotherapists have encountered many challenges related to addressing obesity with patientsALEXANDER, S.C, ØSTBYE, T., POLLAK, K.I, GRADISON, M., BASTIAN, L.A. and BROUWER, R.J.K. (2007) Physicians' Beliefs about Discussing Obesity: Results from Focus Groups. American Journal of Health Promotion, 2007, vol. 21 issue 6, pp. 498-500. Given that obesity is becoming an epidemic in many nations throughout the world, the need to understand how, when and with whom to have these discussions which becomes essential in order to provide effective care for obese patients. There is a growing need for the training of physiotherapists in areas such as weight loss counseling in order to reduce the barriers encountered when discussing obesity ALEXANDER, S.C, ØSTBYE, T., POLLAK, K.I, GRADISON, M., BASTIAN, L.A. and BROUWER, R.J.K. (2007) Physicians' Beliefs about Discussing Obesity: Results from Focus Groups. American Journal of Health Promotion, 2007, vol. 21 issue 6, pp. 498-500.
Wadden & Didie (2003)WADDEN, T.A. and DIDIE, E. (2003). What's in a Name? Patients' preferred terms for describing obesity. Obesity Research, vol 11 issue 9, pp.1140-1146. reported that patients observed the terms obesity and fatness to be very undesirable descriptors used by their physicians when discussing their body weight. Other terms such as large size, heaviness and excess fat were also highlighted as undesirable. The use of these terms by physicians can be interpreted as offensive or hurtful by the patient and lead to a breakdown in communication.
The study reported that weight was the most favourably rated term to be used by physicians as it is easily understood and non judgemental. Another term which was viewed as favourably, as it was non judgemental was BMI, however it is found to be not universally known.
Johnson (2002)JOHNSON, C. (2002). Obesity, Weight Management and Self-Esteem. In: Wadden, T.A. and Stunkard, A.J Handbook of Obesity Treatment. New York, NY: Guilford Press, pp.480-493. reported that some patients preferred to be described as plus sized, large or even fat. By embracing these terms these patients are motivated to remove the negativity and stigma related to them.
Wadden and Didie (2003)WADDEN, T.A. and DIDIE, E. (2003). What's in a Name? Patients' preferred terms for describing obesity. Obesity Research, vol 11 issue 9, pp.1140-1146. reported the most beneficial approach would be to ask the patient how they feel and their thoughts towards their weight. Using this approach the physiotherapist should seek the patients consent and come to an agreement to address and discuss the issue. Caution should be taken to avoid reiterating the hazards obesity has to the patients health. Wadden et al, 2000WADDEN, T.A., ANDERSEN, R.A. AND FOSTER, G.D., BENNET, A., STEINBERG, C. and SARWER, D.B. (2000). Obese Women's Perceptions of Their Physicians' Weight Management Attitudes and Practices. Archives of Family Medicine, vol 9 issue 7, pp.854-860. reported obese patients often experience a feeling that care providers seldom understand how much they suffer with their weight issues. Utilising the conversation approach also allows the physiotherapist to show respect and empathy to the patient by focusing on the positive steps they may have taken previously to tackle the issue.

The issue with "Calling it as it is"

This approach fails to avoid the degrading and offensive terms, used by the public, and causes more negative effects than beneficial effects JOHNSON, C. (2002). Obesity, Weight Management and Self-Esteem. In: Wadden, T.A. and Stunkard, A.J Handbook of Obesity Treatment. New York, NY: Guilford Press, pp.480-493.. It is a challenge for obese individuals to understand the medical implication of these terms as they cannot separate them from the degrading aspects of the terms used by the public.Using a confrontational approach instead of a discussion with the patient is far more likely to negatively affect the patient’s moral, feelings and confidence. Johnson (2002)JOHNSON, C. (2002). Obesity, Weight Management and Self-Esteem. In: Wadden, T.A. and Stunkard, A.J Handbook of Obesity Treatment. New York, NY: Guilford Press, pp.480-493. reports that care providers who approach the issue by attempting to 'break through the patient’s denial of their weight issues, are more likely abolishing the patients trust and their motivation to return for future sessions and care. This is the most common outcome when individuals are advised to battle their obesity by losing weight, to avoid the ominous medical consequences.
More desirable and beneficial outcomes can be achieved through the use of motivational interviewing and discussions with patients in need of weight management compared to a confrontational approach MILLER, W.R. and ROLNICK, S. (2002). Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Press.WADDEN, T.A. and DIDIE, E. (2003). What's in a Name? Patients' preferred terms for describing obesity. Obesity Research, vol 11 issue 9, pp.1140-1146..

Communication tools for helping patients understand the importance of exercise

Tools such as the video below can be helpful in motivating and teaching patients behaviour and lifestyle change.

Motivational Interviewing

Introduction

Evidence has shown that patient-centred approaches to health care consultations are more effective than the traditional advice giving, especially when lifestyle and behaviour change are part of the treatmentBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155.

In the past, healthcare practitioners encouraged patients to change their lifestyle habits through provision of direct advice about behaviour changeROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. However, this has proven to be unsuccessful, as evidence show success rates of only 5-10%ROLLNICK, S., KINNERSLEY, P., STOTT, N. 1993. Methods of helping patients with behaviour change. BMJ. 307, p. 188-90 . Additionally, this can put a strain on the patient-therapist relationship with the patient perceiving this style as being lectured on their lifestyle choicesSTOTT, NCH., PILL, RM. 1990. “Advice yes, dictate no”: a patients views on health promotion in consultation. Fam Pract. 7, 125-31.

Patients can also feel that the therapist is not considering the personal implications the change may have on their life, as they are just placing emphasis on the future benefits and not recognising the initial struggle the patient may have to go throughBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. Such an encounter can risk the patient becoming resistant to change or further increasing their resistance to changeMILLER, WR., ROLLNICK, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press. This resistance to change was seen as a personality trait that could only be dealt with by direct confrontation which potentially placed a further strain on the patient-therapist relationship MILLER WR. 1994. Motivational Interviewing. III. On the ethics of motivational interviewing. Behav Cogn Psychol. 22. 111-23.

Research has shown that patient-centred approaches have better outcomes in terms of patient involvement and complianceBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155 OCKENE, J., KRISTELLER, J., GOLDBERG, R., AMICK, T., PEKOW, P., HOSMER, D. 1991. Increasing the efficacy of physician-delivered smoking interventions: a randomised control trial. J Gen Intern Med. 6, 1-8. The key feature to these approaches is that the patient actively engages in discussing a solution for their problemEMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76.
Motivational Interviewing (MI) is based off Miller & Rollnick’s (1991)MILLER, WR., ROLLNICK, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press experience with treatment for problem drinkers and is becoming increasingly popular in healthcare settings. The model views motivation as a state of readiness to change rather than a personality traitROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press. . As such, motivation can fluctuate over time and between situations. It can also be encouraged to go in a particular direction. By taking this view , a patient’s resistance to change is no longer seen as a trait of the person but rather something that is open to changeROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. Therefore, the main focus of MI is to facilitate behaviour change by helping the patient explore and resolve their ambivalence to the changeROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.

While MI is patient centred and focuses on what the patient wants, thinks and feels, it differs slightly from other patient-centred approaches as it is directiveBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. In using MI there is the clear goal of exploring the patient’s resistance to change in such a way that the patient is likely to change their behaviour in the desired directionBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155.
The focus of Motivational Interviewing is to
assist the patient in examining their expectations about the consequences of engaging in their behaviour.
Influence their perceptions of their personal control over the behaviour through use of specific techniques and skills.
ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press.
A benefit to this approach is that time can be saved by avoiding unproductive discussion by using rapid engagement to focus on the changes that make a differenceROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.

Theoretical Bases

Motivational Interviewing is not based on any one specific theory as Miller drew from different aspects of social psychology using processes such as attribution, cognitive dissonance, and self efficacyBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155, as well as empathetic processes from Rodgers (1991)MILLER, WR., ROLLNICK, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press . As interest in applying the model to healthcare setting increased, it was further elaborated and developed by Millner & Rollnick (1995)ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34

MI has been linked to the transtheoretical model of change, with the model providing the framework with which to understand the change process and MI providing the means of facilitating that changeSOBELL, LC., TONEATTO, T., SOBELL, MB. 1994. Behavioural assessment and treatment planning for alcohol tobacco and other drug problems: current status with an emphasis on clinical applications. Behav. THER. 25, 533-80.

MI differs from other patient centred approaches as it includes the concept of readiness to changeROLLNICK, S., KINNERSLEY, P., STOTT, N. 1993. Methods of helping patients with behaviour change. BMJ. 307, p. 188-90. This concept can help to explain why direct advice-giving alone can be limited in effectiveness. If the patient is not ready to change then the advice is unlikely to be acted uponROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34. Due to this, behaviour change does not have to be the only goal of the healthcare professional. They can aim to increase a patient’s readiness to change through using MIEMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76. Using this concept means that interventions can be tailored appropriately to suit the degree of readiness to change of a patient, increase greater parity between the PT and patient agendaROLLNICK, S., MASON, P., BUTLER, C. 1999. Health Behaviour Change: a guide for practitioners. Churchill Livingstone. This potentially;

decreases patient resistance
increases effectiveness of the intervention and
strengthens the patient-PT relationship

EMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76.

The principles of MI are closely related to those of cognitive dissonanceBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. MI focuses on resolving ambivalence by focusing on inconsistenciesEMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76 . This is creating dissonance. Techniques used in MI, such as reflection and summarizing, function to develop cognitive dissonanceMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press. It produces as dissonant state by focusing on the ambivalence and then controls the direction chosen for the dissonance resolution through skilful and practiced use if the MI techniquesBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155.

Principles of MI

MI is based on the following principles (See Right):<img src="/images/thumb/c/ca/5GenPrinciples.jpg/323px-5GenPrinciples.jpg" _fck_mw_filename="5GenPrinciples.jpg" _fck_mw_location="right" _fck_mw_width="400" _fck_mw_height="500" alt="" class="fck_mw_right" />

An empathetic conversational style is fundamentalROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34. The PT's attitude must be one of acceptance and they must view resistance to change as normalROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. Using this empathetic style the PT can create and amplify any discrepancy between the patients present behaviour and their goals in such a way that the patient can present an argument for changeBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. Argumentation between the patient and PT should be avoided as it is counterproductive and only serves to increase resistance to change and damage the patient PT relationshipROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press. The consultation is carried out in a facilitative way where the relationship between the PT and patient is seen more as a partnership instead of an expert/clientROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. The patient is viewed as a valuable resource to finding a solution to their problem and they are responsible for choosing and carrying out personal changeROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246 BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. In order for this to be effective the patient must have a belief in themselves and their ability to changeMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press . As such, the PT must encourage, support and build self efficacyBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155 ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.

There is one key distinction between Motivational Interviewing and other patient centred approaches. MI is not viewed as a technique which is applied to patients, but rather an interpersonal style which is shaped by guiding principles of what triggers behaviour change processesROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. The spirit of adhering to the method involves allowing patients to express their own arguments to change and the PT to accept theseEMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76. MI is an individually tailored client centred method which changes to suit each individual ensuring that effectiveness is increasedMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. As such, there is no set structure to MI as a too tightly structured model will fail to honour the uniqueness of the individual, their views and their issuesROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press. However there is a range of techniques that can be used interchangeably to effectively carry out MIROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34.

MI Techniques

It is the patient’s task to articulate and resolve their resistance to changeROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246 ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34. It is the therapist’s task to expect and recognise resistance and to be directive in helping the patient recognise and resolve this resistanceROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. This can be done through the use of MI specific trainable techniquesROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34.
There are 3 elements to the technical aspects of MI

Client centred counselling skills based on Rogerson counselling
Reflective Listening statements, directive questions and strategies for eliciting internal motivation from the patient. These are in the form of self motivating statements from the patient as is encourages them to examine their resistance to change and make their own decision about why and how to proceed.
Strategies for ensuring client resistance are minimized.
MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press

Motivational Interviewing has been modified for use in healthcare settingsROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. This is mainly to overcome issues surrounding time constraints, as intervention effectiveness increases with contact timeMILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37, yet a general first PT appointment will last 40 minutes. Models have been developed to deliver 30 minute interventions based on a framework. One such framework is Brief Motivational Interviewing (BMI)ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. This is a set menu of techniques which follow the spirit and practice of MI. It has been designed for use in a 40 minute single session in a primary healthcare settingROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.

A very clear distinction is made between the practitioners job, which is providing facts, and the patients role which is the personal interpretation of how those facts apply to themMILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press. This influences the decision making process by actively engaging the client in the evaluation of their lifestyle and behaviour and can potentially promote a change in the balance of positive and negative aspects to change relating to their behaviourMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press. Traditionally the PT would be seen in the role of an expert and the advice given and the interpretation would be delivered by the PT in one messageBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. With using MI, the patient is in the role of the expert as they must decide how the facts are interpreted and whether it is relevant to their situationMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press.

The PT uses reflective listening in seeking to further understand the patient’s point of viewsMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press. Through expressing acceptance and affirming the patients freedom of choice and self determination, they can monitor and influence the patient’s readiness to changeROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. However, care must be taken not to jump ahead of the patient or take over the decision making as this can lead to increased patient resistanceEMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76. Advice must not be given without the patient’s permission and when given, it is always accompanied by encouragement to the patient to make their own choicesROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. It is also the patient’s decision as to where to take the consultationROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. The PT should encourage this through use of agenda setting to help structure the discussion so that it is meaningful and important to the patientROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.

Personal dissonance is a strategy commonly used in motivational interviewingROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press. Its aim is to create dissonance between the patient’s positive image of themselves and their negative image of themselves BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. They are encouraged to outline the positives in remaining how they are, followed by the negatives. The PT should encourage them to talk about specific individualised problems and concerns they have about their own behaviour. The strategy concludes with a summary which highlights both the problems and concerns and the positive benefits as outlined by the patient. Following this the patient can be encouraged to weigh up the pros and con's of behaviour change. The PT can assist with support and influence the patient’s readiness to change through this discussionMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press.
These strategies are not used in isolation or in a set wayROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. All techniques are used alongside each other in a way which is unique to each individual and problemROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press . MI should not be thought of as a quick fix method or clever technique used to get patients to do something they do not want toBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155. It is something that is done with and for themROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. If the patient responds positively and becomes active in the change discussion this can be viewed as positive feedbackROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246 . However, resistance is a signal to change strategyROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. The resistance should be acknowledged by the PT and they should encourage the patient to further explore this resistance with a view to shift the patient’s perceptionROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.<img src="/images/0/09/Table_8_-_What_to_avoid_in_MI.png" _fck_mw_filename="Table 8 - What to avoid in MI.png" _fck_mw_location="right" _fck_mw_width="500" _fck_mw_height="400" alt="" class="fck_mw_right" />

Summary

MI involves helping patients to say why and how they might change based on the use of a guiding style. A guiding style is used to engage patients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy of decision making.
PT's should practise a guiding rather than a direct style, develop strategies to elicit the patient’s own motivation to change and refine their listening skills and respond by encouraging the patient to participate in change talk.

How to best Implement MI

Useful Questions

Step 1: Practice using a Guiding Style

The PT should take the stance of an informed guide, collaborate with patients, emphasise the patients role in decision making and facilitate their self efficacy and motivationMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford PressROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. The PT controls the structure of the consultation and provided information when requested but the patient is responsible for leading the change discussion and providing any solutions to problemsROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.

Using 3 core skills, the guiding style can successfully draw out the patients views and ideas:

Asking- open ended questions encourage the patient to consider why and how they might change their behaviour.

Listening to the patients experience- use reflective listening statements or brief summaries. This shows empathy and encourages the patient to elaborate further as well as it being the best way to respond to and understand resistance.

Informing- ask permission from the patient before providing information and then discuss the patients views of the implications of the advice.
MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford PressBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246

Step 2: Develop Useful Strategies

Agenda Setting: Deciding What to Change

Instead of imposing your priority on patients, the PT invites them to select an issue which they feel most ready to tackleROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246

Pro's & Con's: Deciding Why the Change

Asking the patient their views on the pro's and cons of keeping their behaviour the same can be helpful in influencing their readiness to change. The next step would be to discuss with them if change was a possibility and how they could bring it aboutROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. <img src="/images/thumb/3/38/Table_11.png/377px-Table_11.png" _fck_mw_filename="Table 11.png" _fck_mw_location="right" _fck_mw_width="400" _fck_mw_height="300" alt="" class="fck_mw_right" />

Assess Importance and Confidence

For this method to be successful the PT needs to spend their time where it is most needed. Patients who are unconvinced of the benefit of change or their ability to change are less likely to change their behaviour. The following line of questioning has been shown to be successful in MI in helping patients to quit smokingROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246

Exchange Information

Miller et al (1994)MILLER WR. 1994. Motivational Interviewing. III. On the ethics of motivational interviewing. Behav Cogn Psychol. 22. 111-23 have shown that the most successful way of exchanging information with the patient is by using the elicit-provide-elicit strategy. This is where the patient clarifies the personal implications of the information which is provided to them by the PTROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.<img src="/images/thumb/4/4a/Table_13.png/300px-Table_13.png" _fck_mw_filename="Table 13.png" _fck_mw_location="center" _fck_mw_width="300" _fck_mw_height="200" alt="" class="fck_mw_center" />

Setting Goals

Patients should set their own goals, as this will increase motivation to work towards change. Questioning styles such as the following can be used to encourage the patient to come up with practical solutions as well as offering suggestions in a way which will not increase resistanceROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246<img src="/images/thumb/c/c2/Table_14.png/400px-Table_14.png" _fck_mw_filename="Table 14.png" _fck_mw_location="right" _fck_mw_width="400" _fck_mw_height="300" alt="" class="fck_mw_right" />

Step 3: Skillfully respond to and change patients language

A PT can further enhance their MI skills by paying attention to the language used by patientsMILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37. Patients either use change talk about how or why they might change (I want to, I should exercise etc.). Or the opposite (I’ve never been able to lose weight etc.). The PT can chose whether to encourage the patient to use change talk or not but studies believe that readiness to change is more likely to be enhanced and the subsequent change is more likely to take place when change talk is usedMILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37.

Challenges faced by PT's when using MI

Practise, training, supervision and feedback on performance will increase the PT's ability and confidence in using efficient questioning that suits both their own personality, that of their patient and the settingROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.
The hardest challenge most PT's will face is using the guiding style and empathetic attitude as this requires the PT to ignore the tendency to identify and solve the problems for the patientBRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press. This can make PT's feel like they do not have control of the sessionROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246, but they can still retain control of the direction of the session while giving the control of the what, why and how to change to the patientMILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford PressROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246. The PT can still offer advice and expertise but in a way that is collaborative with the patient’s views and emphasising that the patient makes the final decision on what they will doROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246.

Examples in Practice

The videos below show a healthcare professional attempting to embark on a conversation about quitting smoking with a patient. This is a scenario very applicable to physiotherapists, especially those working in a respiratory area. The first video shows the traditional advice giving approach, while the second shows the implementation of motivational interviewing techniques.

References

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Effective Communication Techniques

Introduction

Resource Aims

Audience

Learning Outcomes

Importance of Good Communication

Introduction

Communication Pathways to improve health outcomes

Direct Pathways

Indirect Pathways

Further Reading

Communication during Examination and Assessment

How Communication can impact the patient

Patient Learning Styles

What is Learning

Facilitators of Communication

Strategies to Aid Information Recall

Explaining Diagnosis

Breaking "Bad" News

Use of Metaphors in explaining diagnosis

Commonly used Metaphors in practice

The Body is a Machine <img src="/images/thumb/9/92/Body-machine-metaphor.jpg/250px-Body-machine-metaphor.jpg" _fck_mw_filename="Body-machine-metaphor.jpg" _fck_mw_location="right" _fck_mw_width="250" _fck_mw_height="170" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_right" />

Medicine is War/ Military Metaphors <img src="/images/thumb/a/a7/Militarymetaphor.png/200px-Militarymetaphor.png" _fck_mw_filename="Militarymetaphor.png" _fck_mw_location="right" _fck_mw_width="200" _fck_mw_height="200" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_right" />

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Advice and Cautions

Communication when addressing persistent pain complaints

Introduction

What is Pain?

Every Chronic Pain was once Acute

Neuroscience Education

Explaining Pain: How to do it in under 10 minutes

Clinical Example: Osteoarthritis

Recommendations

Sensitive Issues: Obesity

Introduction

The issue with "Calling it as it is"

Communication tools for helping patients understand the importance of exercise

Motivational Interviewing

Introduction

Theoretical Bases

Principles of MI

MI Techniques

Summary

How to best Implement MI

Useful Questions

Step 1: Practice using a Guiding Style

Step 2: Develop Useful Strategies

Agenda Setting: Deciding What to Change

Pro's & Con's: Deciding Why the Change

Assess Importance and Confidence

Exchange Information

Setting Goals

Step 3: Skillfully respond to and change patients language

Challenges faced by PT's when using MI

Examples in Practice

References

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