Elsevier

Physiotherapy

Volume 101, Issue 1, March 2015, Pages 1-12
Physiotherapy

Systematic review
Addition of motivational interventions to exercise and traditional Physiotherapy: a review and meta-analysis

https://doi.org/10.1016/j.physio.2014.04.009Get rights and content

Abstract

Background

Incontestable epidemiological trends indicate that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases. International guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. Motivational interventions to increase adherence and physical activity are not part of traditional physiotherapy for any condition.

Objective

To evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions.

Data sources

A literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database using keywords and subject headings.

Study selection

Only randomised controlled trials comparing two or more arms, with one arm focused on motivational interventions influencing exercise and one control arm, were included. The search identified 493 titles, of which 14 studies (comprising 1504 participants) were included.

Data extraction

The principal investigator extracted data that were reviewed independently by another author. Methodological quality was assessed independently by two authors using the Cochrane Risk of Bias tool and the PEDro scale. Outcomes were measured at the level of impairment, activity limitation and participation restriction. The standardised mean difference between the control and intervention groups at follow-up time points was used as the mode of analysis. I2  50% was used as the cut-off point for acceptable heterogeneity, above which a random effects model was applied.

Results

Exercise attendance was measured in six studies (n = 378), and the results indicate that there was no significant difference in exercise attendance between the groups (Random effects model, standardised mean difference 0.33, 95% confidence interval −0.03 to 0.68, I2 62%). Perceived self-efficacy results were pooled from six studies (n = 722), and a significant difference was found between the groups in favour of the interventions (Fixed effects model, standardised mean difference 0.71, 95% confidence interval 0.55 to 0.87, I2 41%). The results for levels of activity limitation were pooled (n = 550), and a significant difference was found between the groups in favour of the interventions (REM, standardised mean difference −0.37, 95% confidence interval −0.65 to −0.08, I2 61%).

Limitations

The majority of the included studies were of medium quality, and four studies were of low quality. Data were pooled from a wide variety of different populations and settings, increasing the assortment of study characteristics.

Conclusions

Motivational interventions can help adherence to exercise, have a positive effect on long-term exercise behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory choice and the most beneficial length and type of intervention have not been defined, although all interventions showed benefits. There is a need to determine how practising physiotherapists currently optimise adherence, and their current levels of knowledge about motivational interventions.

Implications of key findings

The results indicate that motivational interventions are successful for increasing healthy physical activity behaviour. Physiotherapists are ideally placed to take on this role, and motivational interventions must become part of physiotherapy practice.

Introduction

Incontestable epidemiological trends show that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases [1]. The Wanless Report (2004) outlined the need to optimise primary and preventive services [2]. This shift in focus from episodic individual care to health promotion places emphasis on health behaviours in healthcare delivery. This – coupled with the education of physiotherapists and their roles as promoters, preventers and rehabilitators – means that physiotherapists are ideally placed to influence physical activity behaviour.

The benefits of physical activity, defined as any bodily movement produced by skeletal muscles that results in energy expenditure [3], are well recognised [4]. However, high levels of inactivity exist. Research suggests that 31% of the world's population do not meet recommended levels of physical activity [5]. Non-compliance with recommendations is not the only health behaviour that physiotherapists need to influence. The success of many conventional physiotherapy treatment plans requires both attendance at treatment sessions and adherence to exercises that are to be completed, unsupervised, in the individual's own time. Evidence suggests that approximately 65% of individuals are likely to be non-adherent to home exercises, and 10% fail to complete their prescribed course of physiotherapy [6].

Existing UK [7], European [8] and US [9] guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. The use of different interventions and strategies to enhance adherence to physical activity and exercise regimes is beginning to emerge in the international research literature, yet all of the guidelines recognise inconsistencies and gaps in the evidence. Motivational interventions are not part of traditional physiotherapy and are not provided by physiotherapists. Therefore, the aim of this review is to evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions.

Section snippets

Identification of literature

The PRISMA standardised reporting guidelines were followed to standardise the conduct and reporting of this review. A systematic literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database was conducted. The search was undertaken in accordance with the specific requirements of each database, using the keywords in Box A (see online supplementary material).

Inclusion and exclusion criteria

The inclusion criteria were based on the PICO (Population, Intervention, Comparison and Outcome)

Study identification and selection

Supplementary Figure S1 shows the flow of studies through the review. The search identified 493 titles. Studies were eliminated if the title clearly identified that the study did not include a motivational intervention. Abstracts for the remaining studies (n = 102) were reviewed and 80 were excluded. Of those remaining, four studies reported results from two study populations and six studies did not meet the inclusion criteria. Therefore, 14 studies were included in this review.

Study characteristics

Table 1 shows the

Attendance and adherence

Attendance and adherence was measured using various outcomes. Most studies used self-reported outcome measures such as log books/exercise diaries and questionnaires [15], [17], [18], [19], [21], [23], [25], [26]. Only one study [21] measured physical activity objectively with accelerometers and pedometers. One study [20] did not directly measure attendance or adherence. Six studies reported attendance at physiotherapy sessions or exercise classes [17], [18], [22], [23], [24], [29], [30]. The

Narrative review

CBT was the most popular approach. Van Weert et al. [29] studied fatigue in cancer survivors (n = 147). Results showed no difference in attendance but significant differences between groups in levels of reported physical fatigue. Schelling et al. [22] studied adults with obesity (n = 38). Results showed no difference in motivational stage and attendance, but did show a significant difference in dropouts, with a higher number reported in the control group. There was a significant difference in

Statement of principal findings

The results of this systematic review with meta-analysis indicate that motivational interventions are successful for increasing adherence and physical activity among individuals with a variety of conditions. The meta-analysis demonstrates a significant difference in perceived self-efficacy and levels of activity limitation in favour of the intervention groups. However, due to heterogeneity in the different approaches applied, it was not possible to complete a subgroup analysis to determine the

Conclusion

This review has shown that motivational interventions can increase adherence to exercise, have a positive effect on long-term physical activity behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory to follow and the most beneficial length and type of intervention are yet to be determined. The roles of physiotherapists as promoters, preventers and rehabilitators puts them in an ideal position to influence exercise behaviours in every individual they treat,

References (32)

  • C.J. Caspersen et al.

    Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research

    Publ Health Rep

    (1985)
  • C.E. Garber et al.

    American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise

    Med Sci Sports Exerc

    (2011)
  • S.F. Bassett

    The assessment of patient adherence to physiotherapy rehabilitation

    N Z J Physiother

    (2003)
  • National Institute for Health and Care Excellence

    Behaviour change: the principles for effective interventions. PH6

    (2007)
  • J. Perk et al.

    European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the fifth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts)

    Int J Behav Med

    (2012)
  • N.T. Artinian et al.

    Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association

    Circulation

    (2010)
  • Cited by (96)

    • Musculoskeletal Pain: Current and Future Directions of Physical Therapy Practice

      2023, Archives of Rehabilitation Research and Clinical Translation
    • Measurement, determinants, barriers, and interventions for exercise adherence: A scoping review

      2023, Journal of Bodywork and Movement Therapies
      Citation Excerpt :

      Psychological concepts were similar across studies with emphasis on behavioral modifications in facilitating adherence (Burgess et al., 2017; Jordan et al., 2010; Picha and Howell, 2017; Bachmann et al., 2017; Argent et al., 2018; Meade et al., 2019). Few other interventions for improving adherence are motivational interventions (McGrane et al., 2015), having a social identity (Beauchamp, 2019), intrinsic motivation (Eynon et al., 2019), task scheduling, and self-efficacy (Rodgers et al., 2002). Other implementation strategies include use of DVD or video tapes (Kingston et al., 2010), exergames with exercise leaflets (Oesch et al., 2017) and use of mobile phone messages (Jongh et al., 2012).

    View all citing articles on Scopus
    View full text