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