Transformative Dialogues: The Use of Motivational Interviewing in Physical Therapy
By Rose Pignataro, PT, DPT, PhD
Patient-centered care is the hallmark of physical therapist (PT) practice. Individualized patient and client assessment helps us tailor treatment to support effective self-management and optimal independence. PTs and physical therapist assistants (PTAs) often underestimate the powerful impact of our patient relationships; successful outcomes are largely dependent on the personal investment of both parties. Motivational interviewing (MI) is one strategy to strengthen the therapeutic alliance.
MI is an evidence-based, patient-centered form of communication that has been used effectively to encourage a broad range of healthy behaviors, such as vaccinations, preventive screenings, exercise, weight management, and tobacco cessation. When done effectively, MI fosters rapport, creates transformative dialogues, enhances adherence, and inspires successful lifestyle changes. Ultimately, it can result in better outcomes and long-term wellness.
How Is MI Different From Typical Patient Care?
The approach is very versatile; MI is applicable across practice settings and in diverse populations because it is specifically tailored to the unique needs of the individual. The provider begins by asking open-ended questions to learn why the individual is seeking professional consultation. Using the patient's goals as a starting point helps the provider establish credibility and lays the foundation for a trusting relationship built on a strong sense of collaboration. This is a dramatic shift from traditional models of care that employ a hierarchical, paternalistic approach toward providing advice and presuming patient adherence.
Techniques used in MI often are represented by the acronym OARS:
O: Ask open-ended questions.
A: Use affirmations, or positive statements that demonstrate an authentic interest in the patient's own perspectives.
R: Reflective listening reinforces this interest and offers opportunities to clarify information or make inferences that invite the patient to continue to share his or her thoughts and opinions.
S: The provider can pause the conversation to summarize information, pulling together pieces of the dialogue in a way that inspires action.
For example, home exercise programs are frequently a key component of the physical therapist plan of care. Ideally, the PT selects exercises based on examination findings that reveal impairments in strength, flexibility, endurance, coordination, and/or balance. Hopefully, the provider explains the supporting rationale and expected benefits, but may not totally consider other factors that may affect the likelihood of adherence. Open-ended questions can uncover patients' perceived barriers to exercise. Common issues include time constraints, pain or fear avoidance, and lack of confidence, particularly for individuals with little or no history of regular physical activity. Providers can use affirmations and reflective listening to learn more about these barriers and encourage patients to set small, incremental goals. This often makes larger tasks seem more manageable and also allows patients to build confidence and track their own progress, creating positive outcome expectations and greater willingness to continue working toward success.
Empathy, Not Just Education
It is rarely lack of knowledge that prevents someone from enacting healthy lifestyle changes. For instance, most people who are overweight or obese are aware of the problem and the toll it can have on their health. Excess weight and sedentary lifestyles are chronic issues that develop over time. Often, the person has made multiple attempts to correct the issue, only to fail repeatedly. These past failures slowly erode the belief in one's own capabilities. Advice from a PT or PTA can seem threatening or even judgmental, unless we express empathy and anticipate ambivalence.
A patient may genuinely want to lose weight and establish a regular exercise routine, but for some reason feels that he or she is simply incapable. If the provider challenges this belief, it may lead to patient resistance. It is important to remember that resistance to change is a normal human reaction. Talking it through allows the provider to learn more about the patient's perceptions regarding barriers to weight loss.
Some barriers may be cultural. In this regard, MI provides a helpful tool to enhance cultural competence, since it is impossible for us to be completely familiar with someone else's background and beliefs, even when we share the same racial and ethnic characteristics. For example, a person who is overweight may have grown up in an environment where social events and relationships were closely linked to meals. Certain food choices might provide comfort, or lead to preferences that do not seem compatible with nutritional recommendations. As the patient-provider conversation continues, the patient may learn to identify successful solutions to these challenges. Describing solutions out loud is a powerful form of self-talk. We each pay close attention to our own choice of words, and this alone increases the likelihood of success.
Working together with our patients also can make problems seem less intimidating. For a patient who is significantly overweight, losing 50 pounds may seem impossible. However, losing 10% of body weight is not only manageable but has been shown to significantly reduce metabolic and cardiovascular risk. Smaller weight losses also can improve low back and lower extremity joint pain, as well as energy levels, making the patient more likely to want to continue making changes that support these positive outcomes.
Of course, patients will at times need to lean on our professional expertise. Although MI is patient-centered, there are still opportunities for providers to provide advice and recommendations. Asking permission to share possible strategies and solutions demonstrates respect for patient autonomy. It also allows the provider to select the appropriate "teachable moment." If someone is having a bad day or is particularly emotional, the provider and patient can mutually agree to table the topic of conversation until the patient is ready for further discussion.
It is well recognized that PTs and PTAs are masters of patient education. After all, patient education represents a large portion of what we do when working toward lasting functional improvement. MI fits well with our usual methods of practice and our professional roles. One-on-one contact and regular visits throughout an episode of care provide opportunities for follow-up and establish close relationships that create a deeper level of sharing than what may occur in other health care settings. MI capitalizes on these relationships, using them to optimize treatment outcomes, enhance adherence, and reduce rates of disability. This enables PTs and PTAs to achieve our vision—transforming society—one conversation at a time.
Rose Pignataro is associate professor in the physical therapy program at Adventist University of Health Sciences.