Coaching in Rehabilitation

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Health Coaching

Health coaching is an interactive and empathetic patient-centered approach used as an intervention between the therapist and patient, or coach and client, to help drive health behaviour change. One of the general aims of Health Coaching is to help improve one's health behaviour, in areas such as promoting physical activity, smoking cessation, improving diet and sleep, and minimising stress.

Collectively, Health Coaching can be defined as, “a patient-centered process that is based upon behavior change theory and is delivered by health professionals with diverse backgrounds.”

Another definition of Health Coaching can be explained as, "Health coaching is the practice of health education and health promotion within a coaching context to enhance the well-being of individuals and to facilitate the achievement of their health-related goals. In this way, motivation is built by guiding patients towards their own inner throughs and desires for change."

Health coaching guides towards self-determination, and self-efficacy. Self-determination can be defined as 'the process that a person takes to control their own life', while self-efficacy is defined as 'the belief in one's self that they are able to initiate and continue a desired action.'

It is important to note that Health Coaching is a useful intervention to help prevent or reduce non-communicable diseases in the developed world, especially since they account for a vast majority of the disease burden in such communities.

It is mentioned by the World Health Organisation that, "simply giving information to patients is unlikely to change behaviour; health care providers must understand the psychological principles that underly self-management training and comprehend that motivating patients requires more than imparting brief information to the patient."

Health Coaching makes use of evidence based health behaviour change treatment methods, from various disciplines and areas, which include behavioural medicine research literature, positive psychology, health and coaching psychology, and athletic and performance coaching.

The intervention or long term behaviour change is different than that of acute care management. Patients need to be involved in techniques that foster self-efficacy, self-determination, and self-responsibility. The objective to empower the client into driving their own self-determined health behaviour related goals.

Health coaching can be used in Health promotion, prevention, early intervention, treatment, and management of chronic conditions.

Health coaching within many conditions and disorders such as diabetes, cancer, or cardiovascular disease, have shown positive health outcomes. However, health coaching may have different levels of effectiveness depending on the chronic disease of concern. Many health coaching interventions are effective in the short-term.

As is noted in the next section, Health Coaching is now an intervention used in many different healthcare settings, including Physiotherapy.

Description of a Health Coach

A health coach can be classified into 4 different categories, which include: Medical Professionals, Allied Health Professionals, Other Health Professionals, and Professional Coaches. These can be further broken down by profession.

Medical Professionals: Physicians, Nurses, Pharmacists, Physician Assistants, and Medical Staff.

Allied Health Professionals: Dieticians or Nutritionists, Psychologists (Doctorate), Social Workers/Psychotherapists/Counsellors (Masters), Mental Health Providers, Physiotherapists, Medical Assistants, Occupational Therapists, and Exercise Physiologists/Specialists.

Other Health Professionals: Health Educators/Promotors, Research Assistants, Medical or Nursing Students, and Allied Health Students.

Professional Coaches: Health/Wellness, Life/Lifestyle, Personal Vitality, and Personal Coach.

An individual like an educated peer can also take the role of a health coach for a particular individual.

A Health Coach that is working with a client needs to be empathetic, and provide patient centered education. When they are searching and assessing for research to present to the patient, or advising about research they previously read, they need to ensure that the research is conducted with an evidence-based practice and thus is credible information, and not commercial or anecdotal information. They need to ensure that they are providing patient centered education, helping the patient/client with their goals, determining the dose of coaching based on the interaction with the client, and also being accountable for the conversation and information provided to the client.

They need to ensure that the client progresses through their goals from self-discovery and active-learning processes, and that they are encouraging accountability for the client's behaviours.

To see the modes of health coaching in Primary Care, see the section below, on Health Coaching and Primary Care.

Modes of Coaching

Coaching can be carried out through: telephone communication, face-to-face interactions (in the clinic or office), coaching via mail or on the internet, coaching via CD, and text and video coaching. Most commonly, not in person or over the phone, but online, would be considered telehealth.

It is seen that coaching via telephone communication is not effective in the long term. Face-to-face interactions are seen to be the most effective.

It is identified by Olsen and Nesbitt (2010) that techniques for an effective health coaching program include, goal setting, Motivational Interviewing (MI), collaborating with the primary health care provider, having a program duration of 6-12 months.

Interventions can be implemented via behaviour change, empathy, emotional support from the clinician, content education, and the patient collecting data as they’re gradually making changes.

As is seen with Motivational Interviewing, clients are asked open ended questions, experience ambivalence with their concern of change, and increase the use of change talk change talk as they become more intentional with their goals and changes.

Take a look below to see how health coaching is delivered in the Primary Care Setting.

Motivational Interviewing

Motivational Interviewing (MI) is one prominent technique used in health coaching. See the MI Physiopedia page for the process of Motivational interviewing, the Sages of Motivational Interviewing, the Spirit of MI, and other relevant topics.

Here's a brief video that explains motivational interviewing from the founders of the conversation method.

Here is a good example of motivational interviewing with all the various components presented.

When guiding the patient towards realising the intrinsic rationale behind their desired behaviour change it is important to make use of rating tools, asking the patient to rate their importance of change, their confidence towards change, or their readiness towards change. such dialogue can look like,

"On a scale of 1-10, where 1 is the lowest and 10 is the highest ...

how important is it to you to be able to make the change of __________ ?",

how confident do you feel to being able to make this change of ________ ?", or

how ready do you fee in order to be able to make this change of ________ ?".

Given the patient's response, the therapist can ask why it wasn't a lower number. This will help the patient bring out their motivating reasons and elicit change talk.

If they patient gives a low number, educating, advising, or convincing the patient toward making a change in their behaviour, by providing information, would not be an effective idea. If the patient were to be asked why they didn't choose a higher number, this would elicit them to outline barriers they may be facing with the certain behaviour. In this case, the patient may have low confidence, a knowledge gap, or competing priorities to them to commit towards change. Based on the patient's barriers, the practitioner can help them resolve any conflicts or explore through different options.

The practitioner must ensure that the goals are patient centered, and created by the patient themselves. This will give the patient the most motivation to achieve the goals.

Stages of Change - Transtheoretical Model

The stage of change that the client is in is identified, so that the therapist or Clinician can help progressively help the Client increase self-confidence toward making a change. The self-determination theory framework is guided by autonomy, competence, and relatedness, encouraging clients to elicit their intrinsic motivators. Patients are guided towards their goals, while reflecting on their values and vision. Patients are encouraged to build confidence, as they reflect on previous accomplishments and failures, to help with increasing facilitators and decrease barriers to the desired behaviour change.

A person is can only go through the stages of change once they realize a health behaviour change is needed, and show their readiness to change. This would put them in the Contemplation Stage. Patient centered questions can be asked by the therapist, to help elicit self-confidence, the importance of change, determine related goals, and elicit change talk. The Maintenance stage of change will be successful when the client's goals are self-determined, and they are motivated to take action for their desired results.

In the first systematic review, only studies that had an intervention lasting longer than 24 weeks were included. This was done to ensure the clients were progressed to the Maintenance stage.

Other Psychological Techniques of Health Coaching

Neuro-linguistic programming, social cognitive theory, problem solving theory, or cognitive behavioural therapy.

Two of these techniques, including Motivational Interviewing, have a basis around the collaborative care model (CCM).

Individuals interested in becoming a health coach can be trained in these various methods, such as, cognitive behavioural therapy, positivity psychology, and motivational interviewing. Short courses, and entire programs at the postgraduate level can be taken to develop the skills of health coaching.

Duration and Timeframe

According to a systematic review, by Wolever et all (2013), on Health and Wellness Coaching, the average duration of a coaching session was 35.8 minutes, and ranged from 5 minutes to 2.5 hours. There was an average of 6.2 contact hours with a coach, which can range from 15 minutes to 135 hours. There is a median of 3 hours of contact duration with a coach.

There was an average of 10.1 sessions, which ranged form 1 session to 90 sessions. There was a median of 6 sessions. these sessions could span over 6 years. Individuals may access the coach weekly, biweekly, or even biannually. The average timeframe of using a coach's services was 6-12 month.

Coaching frequency appeared to be related to length of the intervention, with shorter programs employing more weekly coaching whereas longer interventions were more likely to use monthly coaching.

Settings

Rehabilitative Setting

When health coaching was conducted in the rehabilitative setting, there were physiological, behavioural, psychological effects.

It is seen that studies in a rehabilitative setting, there is a minimum of 24 weeks of follow-up, which has a lower percentage.

The researchers found that an effective intervention duration was 3 months in the rehabilitative setting.

Preventive Setting

Various preventive settings or situations could be present. In a systematic review analyzing coaching methods in a preventive setting, different studies focused on depressive symptoms, overweight adults, primary care setting, (see table 3) ...

Health coaching intervention is becoming more common in the preventative setting as well.

int he preventive setting, it was seen by the researchers that only a half-da intervention was effective.

Benefits

The benefits of health coaching in the primary care setting don't have to only be related to the patients' behaviour change results, but can be related to:

• Improved job satisfaction of the Clinician/Practitioner/Therapist
• Improved patient satisfaction with the services provided, and the results obtained
• Increased efficiency and effectiveness of practitioner - Client interactions
• Due to the new learned self-management skills and techniques, a decrease on the reliance of the medical system
• Improved multidisciplinary collaboration of the therapist/Practitioner with other health professionals

Health Coaching and Physiotherapy

It is unclear if Physiotherapists can play the role of providing education and treatment, and switch to a coaching framework of conversation, which is being further studied. It is also unclear how the patient will respond to the therapist treating in two different roles.

Positive Effect

From a systematic review conducted by Rethorn et al (2019) of 11 studies, it was seen that Health Coaching produced a positive effect on physical activity, including physiological and psychological secondary outcomes, in the Physiotherapy setting.

Physiotherapists are at a suitable stance to provide health coaching. They are providing educaiton ot patients, as well as physical activity, and lifestyle changes, for the patients to help themselves decrease or prevent further effects of their condition.

With the Physiotherapists' caring and empathetic practice with their patients, they are able to but a stronger therapist-client relationship, making it smoother form them to practice coaching techniques, and coach their patients.

In a study by de Vries et al, considering older adults, showed that there were improvements in self-reported in moderate intensity physical activity 6-months after personalized physiotherapy and coaching.

Iles et al have shown that adults with nonspecific low back pain have improved in physical activity after 12 weeks of a dual treatment consisting of coaching and physiotherapist care.

In adults with rheumatoid arthritis, Knittle et al, have shown increases in self-reported leisure physical activity time, with a greater number of days with 30 or more minutes of physical activity, 32 weeks after a coaching treatment, helping to improve physical activity.

In cardiac patients who did not pursue cardiac rehabilitation, Reid et al found improvements in physical activity on a 7-day self-recall basis 6 and 12 months after a year-long coaching program geared towards improving physical activity.

The effectiveness of using measuring tools such as an accelerometer, instead of self-reported measures, was noted by O’Halloran et al, for a group of individuals who sustained a hip fracture, and were receiving coaching to improve physical activity.

No Effect

There were some studies that reported no effect of coaching in the Physiotherapy setting on physical activity.

Patients that experienced a stroke, Physical activity was not improved with the addition of monthly coaching sessions, even for a duration of 18 months. It was also seen that these patients declined over the 18 month study period.

When considering back pain, Basler et al found that there were no changes with improved self-reported physical activity when coaching was added as a part of physiotherapy care.

It was discovered by Brodin et al, that there were no changes in activity level in adults with rheumatoid arthritis with the implementation of a 1-year coaching program.

There were no differences noted, by Taylor et al, in activity levels between a supervised exercise group and a telephone coaching group, 2 months after the implementation of a coaching intervention.

Changes in physical activity, diet, and smoking were examined by Speyer et al after a 1-year coachingprogram to improve lifestyle behaviors. There were no differences in the different factors studied

Health Coaching and Primary Care

The use of health coaching in primary care can lead to success of the patient's desired behaviour change. The sue of health coaching motivates the patient to conduct and continue their own desired health behaviour change.

The use of health coaching can help to enhance the effectiveness and efficiency of consultations. This can be done in many ways, including,

• Making health coaching a component of the consultation
• Referral to nurses or allied health professionals who are health coaches
• Referral to a to a qualified health coach who can deliver the consultation within the facility, or outside the facility in person, over the phone, or via telehealth

Evidence

Systematic reviews highlighting the benefit of health coaching compared to traditional care indicate that Health Coaching:

• Significantly positive impacts Clients' physiological, behavioural, and psychological, and social status
• Has a significant positive impact on health behaviours such as nutrition, physical activity, weight control, and adherence to necessary medication
• For individuals with type 2 diabetes, improve glycaemic control and reduce glycated haemoglobin
• Help with weight loss, with gaining motivation, autonomy, and personal sense of accomplishment.
• Help with managing the consumption of calories, and reducing bodyweight and body mass index
• Help with improving overall physical activity and lifestyle habits

Other associated studies have shown the effectiveness of motivational interviewing on smoking cessation, improved nutrition alcohol minimisation, and other behavioural and lifestyle changes.

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