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Discussion/Opinion paper
Motivational strategies for physiotherapists
Niall McGrane
1
, Tara Cusack
2
, Grainne O’Donoghue
3
, Emma Stokes
1
1
Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Trinity Centre for Health Sciences,
James’ St., Dublin 8, Republic of Ireland,
2
School of Public Health, Physiotherapy and Population Science,
College of Life Sciences, University College Dublin, Belfield, Dublin 4, Republic of Ireland,
3
Centre for Preventive
Medicine, School of Health and Human Performance, Dublin City University, Dublin 9, Republic of Ireland
Physical inactivity and non-adherence to physiotherapy are common problems. Physiotherapists as
promoters, preventers and rehabilitators are ideally placed to influence physical activity behaviours.
Possessing the knowledge and skills to facilitate this behaviour change and to promote adherence to
physiotherapy must be viewed as clinical competency. This paper reviews four psychological strategies;
self-determination theory, social cognitive theory, cognitive behavioural therapy and motivational
interviewing that have been shown to have a positive influence on exercise behaviour. The origins and
theoretical model of all four are discussed and an example of an intervention based on each model from the
literature is provided. A review of how physiotherapists can use each to inform their practice follows. To
conclude the similarities between all four that can be implemented into practice are discussed.
Keywords: Exercise, motivation, patient adherence, physical activity, physiotherapy
Introduction
Physical inactivity and all the resulting consequences are
well known to healthcare professionals (HCP).
Recommended levels of physical activity (PA) have
been devised by the American College of Sports
Medicine (ACSM) to guide HCP and the public. Non-
adherence to PA guidelines is common with evidence
suggesting that 31% of the world’s population are not
meeting them.
1
While there is an abundance of research
revealing the benefits of PA
2
there is also evidence
of non-compliance with PA guidelines
1
and physiother-
apy prescriptions and non-attendance to physiotherapy
sessions.
3
The World Confederation for Physical Therapy
state that physiotherapists are ‘experts in movement
and exercise and with a thorough knowledge of risk
factors and pathology and their effects on all systems,
physical therapists are the ideal professionals to
promote, guide, prescribe and manage exercise
activities and efforts’.
4
Incontestable epidemiological
trends highlight the fact that for the foreseeable
future, illness care will be dominated by an escalation
in chronic lifestyle-related diseases.
5
Furthermore,
with the shift in focus from episodic individual care to
promotion of health in the community and recogni-
tion of the importance of lifestyle, physiotherapists’
role as promoters, preventers, and rehabilitators has
them ideally placed to influence PA behaviours.
6
Many people treated by physiotherapists may not
grasp the importance of completing exercise pro-
grammes for a successful outcome or have little or no
prior history of sustained exercise. A report published
by the United Kingdom’s National Health Service in
2011 states that the majority of adults are aware that
PA recommendations exist, but few know what they
are.
7
Of a random sample of US adults only 33%
correctly identified the ACSM guidelines for PA.
8
Increasing PA, exercise prescriptions, and mainte-
nance of rehabilitation regimes are essential interventions
for physiotherapists. Adherence to these interventions
is an important part of the rehabilitation process and
adherence to prescriptions is necessary for a positive
outcome. The success of many physiotherapy plans
require not only attendance at treatment sessions but
adherence to exercise prescriptions that are completed
in the individual’s own time, unsupervised.
Despite physiotherapists’ unique position of influ-
ence, physiotherapy education fails to provide instruc-
tion on strategies to positively influence PA behaviour
and tackle the problem of non-adherence.
9
In a recent
study, physiotherapy clinical educators identified
psychological strategies for changing PA behaviour
as one of the mainareas absent from clinical education
9
while experienced physiotherapists reported being
unaware of strategies to change PA behaviour and
improve adherence.
10
Possessing the knowledge and skills to facilitate
behaviour change must be viewed as a clinical compe-
tency for contemporary physiotherapy. Physiotherapists
Correspondence to: Emma Stokes, Discipline of Physiotherapy, School of
Medicine, Trinity College Dublin, Trinity Centre for Health Sciences,
James’ St., Dublin 8. Republic of Ireland. Email: estokes@tcd.ie
136
ßW. S. Maney & Son Ltd 2014
DOI 10.1179/1743288X13Y.0000000117 Physical Therapy Reviews 2014 VOL.19 NO.2
must promote PA and adherence in a proven evidence-
based manner. Therefore the purpose of this article is to
present four psychological strategies, self-determination
theory (SDT), social cognitive theory (SCT), cognitive
behavioural therapy (CBT), and motivational interview-
ing (MI), that can be utilized to influence PA behaviour.
These four strategies have been shown to have a
positive influence on exercise behaviour.
11
Based on
the literature, this article will provide a brief
description of the origins of each theory, an under-
standing of how each model works, an example of an
intervention based on the model, and a review of how
physiotherapists can use them to fulfil their role as
PA promoters, preventers, and rehabilitators.
Self-determination Theory
Origins
Self-determination is defined by Webster’s Dictionary
as the act or power of making up one’s own mind
about what to think or do, without outside influence
or compulsion. According to Ryan and Deci
12
self-determination theory is the concept of autono-
mous self regulation comprising both intrinsic and
well-internalized extrinsic motivation. Intrinsic motiva-
tion exists when an individual participates in an activity
for enjoyment and fulfilment; there is no external
reward (extrinsic motivation). In terms of maintenance
of health, SDT is focussed on the process by which an
individual initiates a new, health-related behaviour and
maintains it over time.
13
It is widely accepted that
human beings are intrinsically motivated, however it
appears that intrinsic motivation is prevalent only
under certain conditions and in particular circum-
stances. Self-determination theory focuses on the
environmental and social supports that when present
facilitate and enhance intrinsic motivation.
Theoretical model
Self-determination theory focuses primarily on an
individual’s psychological needs, namely autonomy,
competence, and relatedness. Autonomous behaviour
refers to acting with a sense of volition and willingness.
When individuals are autonomously motivated they are
interested and invested in what they are doing. Deci and
Ryan
14
maintain that autonomy in relation to health
care means encouraging individuals to make choices
about how to behave, providing them with the
information they need, and respecting the choices they
make. Competence is the degree to which people feel
able, and have the confidence to achieve their desired
outcomes.
14
Creating a sense of autonomy and
competence are essential for the internalization and
integration of behavioural change. Individuals are more
likely to adopt changes if they have a sense of being
respected, understood, and cared for. Self-determination
theory terms this relatedness. This will enable the
development of trust and connection which will allow
internalization to occur.
13
Self-determination theory suggests that mainte-
nance of self-determined motivation depends, in part,
on social and contextual factors which can facilitate
or undermine intrinsic motivation. Specifically a
subcomponent of SDT, cognitive evaluation theory,
suggests that the level of intrinsic motivation
experienced is dependent on whether the social
environment supports the individual’s needs for
autonomy and competence.
15
For example, in the
presence of a physiotherapist adherence may be
high. However, in the absence of a physiotherapist
the non-self-determined individual’s adherence will
decrease. Specific factors within social environments
that are referred to as autonomy supportive have
been found to promote autonomous self-regulation
both by helping people maintain intrinsic motiva-
tions and facilitating internalization of extrinsic
motivation.
14
Example from the literature
In the literature it would appear that SDT is not
widely used in current physiotherapy practice.
However it has been successfully employed in other
areas including medication adherence,
16
weight
management,
17
and substance abuse.
18
Lonsdale
et al.
15
examined the relationship between self-
determined motivation and students’ objectively
measured PA levels. This study demonstrated that
students with self-determined motivation in physical
education classes achieved more PA than non self-
determined individuals. Thøgersen-Ntoumani and
Ntoumanis
19
conducted a study examining the role
of self-determined motivation in the understanding of
exercise-related behaviours. The results illustrated the
importance of promoting self-determined motivation
in exercisers to improve the quality of their experi-
ences, as well as to foster exercise behaviour.
Use by physiotherapists
Self-determination theory suggests that autonomy
support from others is important in motivating change
of various health behaviours.
20
This is an important
consideration for physiotherapists who are frequently
concerned with modifying individuals’ lifestyle choices.
In SDT there is an emphasis on not attempting to
control individuals, but respecting their frame of
reference and facilitating them to engage in their own
care.
14
Self-determination theory means providing
individuals with relevant information to make their
own informed choices. Facilitating individuals to be
more knowledgeable allows physiotherapists to en-
hance understanding and hence increase the possibility
that the individual will persevere with lifestyle changes
which they themselves have determined.
McGrane et al. Motivational strategies
Physical Therapy Reviews 2014 VOL.19 NO.2 137
Increasing PA may not be an intrinsically enjoy-
able activity. However, if an individual understands
and values the benefits of PA after discussing it with
their physiotherapist, their intrinsic motivation to
participate will increase. In time an individual will,
with the extrinsic support of a physiotherapist, develop
the confidence to change and embrace change on a
voluntary basis. Autonomy support from HCP has
been shown to facilitate the internalization of auton-
omy and competence.
20
The expertise, together with
the respectful caring approach that physiotherapists
bring to the practitioner–patient relationship, increases
experiences of connection and trust thereby facilitating
the internalization of change. Embracing SDT would
offer physiotherapists the possibility of improving an
individual’s adherence to an exercise programme and/
or health behaviour changes. Self-determination the-
ory, for example, is ideal for individuals progressing
through the stages of cardiac rehabilitation. Enhancing
understanding, creating an autonomy supportive
programme, increasing competence and relatedness
could be implemented successfully to progress indivi-
duals to become long-term exercisers.
Cognitive Behavioural Therapy
Origins
Cognitive behavioural therapy emerged from two
theories of learning, classical and operant condition-
ing. Classical conditioning originated from the work
of Pavlov and his dogs while operant conditioning
was described by Thorndike’s Law of Effect and was
further developed by Skinner in the 1950s. Pavlov
conducted experiments on dogs, ringing a bell when
he served them food. When the food was served the
dogs would automatically salivate. This was termed
the unconditioned response to an unconditioned
stimuli. Over time, with continued repetition of the
sequence of events the dogs would salivate to the
sound of the bell. This is a conditioned response to a
conditioned stimuli. The Law of Effect states that
behaviour that is followed by satisfying consequences
will tend to be repeated while behaviour that is
followed by unpleasant consequences will occur less
frequently, defined by Skinner as positive and
negative reinforcements.
During the 1970s there was a growing realization
that cognitive factors had a role in learning. It was
not only stimulus and the resulting behaviours but
also thoughts and perceptions that influenced learn-
ing. Bandura’s
21
observation/social learning theory
(SLT) described observational learning: if one
observes another being successful, they will learn
that it is wise to do the same. Another important
feature of Bandura’s work was self-efficacy, if one
perceives themselves capable of carrying out a
behaviour, the behaviour will occur.
By the end of the 1970s new behavioural techni-
ques had been developed and experimentally vali-
dated. These theories and techniques were added to
the cognitive theories of Aaron Beck. Beck, working
on depression, had a major influence on behavioural
therapy.
22
He introduced the idea that people can
have two concurrent levels of thinking, a conscious
level of thinking and an automatic level of thinking
(where evaluative thoughts spontaneously arise in
people’s minds).
23
Using behavioural and cognitive
techniques individuals can be helped to identify and
modify their negative thoughts. This led to cognitive
and behavioural techniques merging during the 1980s
and 1990s to form CBT.
Theoretical model
The major goal of CBT is to replace maladaptive
coping skills, thoughts, emotions, and behaviours
with more adaptive ones.
24
Cognitive behavioural
therapy is used to help individuals recognize patterns
of distorted thinking and dysfunctional behaviour. A
systematic discussion and carefully structured beha-
viour assignments are used to help individuals
identify and modify their thoughts and behaviours.
25
Much of the treatment is based on the present and the
main goal is to assist individuals in bringing about
desired changes in their lives. This is achieved by
collaboration between the therapist and the indivi-
dual in developing skills to overcome current and
future problems through planning strategies and
setting agreed upon goals. A major part of the
success of CBT is that therapy occurs in everyday life
and what has been discussed and agreed is put into
practice.
Example from the literature
Physiotherapists delivered a CBT-led programme to
people with chronic musculoskeletal pain in a study
by Asenlo¨f et al.
26
The programme, delivered over 8–
10 sessions, had seven general phases: behavioural
goal identification; self-monitoring (using diaries);
individual functional behavioural analysis; basic
physical, cognitive, and behavioural skill acquisition
to aid in goal attainment and to increase self-efficacy;
putting into practice the basic skills and merging
motor behaviours with cognitive and problem solving
skills; generalization; and maintenance and relapse
prevention. The experimental group did not receive
any routine physiotherapy. The control group
received 8–10 best practice physiotherapy sessions.
This study measured pain disability, pain, and self-
efficacy and reported significant differences over time
in all measures within both groups. There was a
significant difference between groups in favour of the
experimental group with regards to pain disability
and pain. Fear of movement, physical performance,
and global improvements were also measured. There
McGrane et al. Motivational strategies
138 Physical Therapy Reviews 2014 VOL.19 NO.2
was a significant difference in favour of the experi-
mental group for fear of movement, while both
groups’ physical performance improved significantly.
Global improvement occurred in the experimental
group but no differences were reported at 3-month
follow up.
Use by physiotherapists
A major part of CBT treatment is based on the present
and therefore may be more useful to physiotherapists
when a person wants to or is actively trying to change,
such as an overweight individual having changed their
diet and seeking to safely increase their PA.
Physiotherapists can help the individual to recognize
individual barriers, be they physical, psychological,
behavioural, or environmental, to exercise. Lack of
time or feeling embarrassed exercising in public are
examples of such barriers and physiotherapists can
assist in developing individual plans to overcome them.
In conjunction with the therapist, behavioural goals are
identified and plans are put in place to attain them,
recognizing dysfunctional thoughts, behaviours, and
personal barriers and devising plans to overcome them.
Self-efficacy plays a major role, both to complete the
behaviour change and to complete new exercises.
Social Cognitive Theory
Origins
SCT stemmed from work in the area of SLT
conducted by Miller and Dollard in the 1940s.
Identifying four key factors in learning new beha-
viour (drives, cues, responses, and rewards), they
proposed that if one was motivated to learn a
particular behaviour, then that particular behaviour
would be learned through clear observations. By
imitating observed actions, the observer would
solidify that learned action and would be positively
reinforced.
27
The proposition of SLT was expanded
upon by Albert Bandura from 1962 until the present,
resulting in SCT.
21,28,29
According to the SCT, people learn by observing
others, with cognition, the environment, and beha-
viour all recognized as chief factors influencing
development. These three factors are not static or
independent. They mutually influence each other and
any can be stronger at any given time. Strategies for
increasing well-being can therefore be aimed at
improving emotional, cognitive, or motivational
processes, increasing behavioural competencies, or
altering social conditions.
Bandura’s SCT stands in clear contrast to theories
of human functioning that overemphasize the role of
environmental factors and the influence of biological
factors in the development of human behaviour,
learning, and adaption. Although it acknowledges the
influence of both environmental and biological
factors, SCT is rooted in a view that by looking into
their own conscious mind, people make sense of their
own psychological processes. To predict how human
behaviour is influenced by environmental and biolo-
gical outcomes, it is critical to understand how the
individual cognitively processes and interprets these.
Theoretical model
Social cognitive theory promotes effective self-
management of health habits that keep people
healthy through their lifespan.
30
More specifically,
the SCT framework specifies five core determinants,
the mechanism through which they work, and the
optimal ways of translating this knowledge into
effective health practices.
These five core determinants include knowledge of
health risks and benefits, perceived self-efficacy that
one can exercise control over one’s health habits,
outcome expectations about the expected costs and
benefits, health goals people set for themselves and
the plans and strategies for realizing them, and perceived
facilitators and social and structural impediments to the
changes they seek.
30
Knowledge of health risks and benefits creates the
precondition for change. If people lack knowledge
about how their lifestyle affects their health, they
have little reason to change. Self-efficacy plays a
central role in personal change. One must believe they
can produce desired effects by their actions; otherwise
they will have little incentive to change or persevere in
the face of difficulties. Outcome expectations also
affect health behaviour and can take several forms.
What people expect their action to produce is
important in determining behaviour change. For
example physiotherapists can explain what to expect,
how it will feel or how long it will take. Personal goals,
both long and short-term, rooted in the individual’s
value system, will provide further self-incentives.
30
Individual barriers and facilitators are another
determinant of health habits. These are personal and
form an integral part of self-efficacy and of all the
thoughts that affect human functioning. At the core
of SCT are self-efficacy beliefs. Self-efficacy beliefs
must be measured against gradations of challenges to
successful performance.
Example from the literature
An example of how SCT has been utilized in practice
is provided by Annesi et al.
31
The effects of ‘The
Coach Approach’, based on SCT, was investigated on
exercise adherence in a population of obese females
(n5137). Those in the experimental group met with a
trained wellness specialist once a month for six
months. These meetings instructed the participants
on self-management and self-regulatory skills aimed
at increasing mastery and competence of exercising
and overcoming barriers. Instruction was given at
each meeting on a different skill: cognitive restructur-
McGrane et al. Motivational strategies
Physical Therapy Reviews 2014 VOL.19 NO.2 139
ing, stimulus control, disassociation for discomfort,
self-reward, and preparing to overcome barriers to
exercise. Exercise plans were adjusted to induce
favourable post-exercise feelings while goal setting
and behavioural contracts were also discussed and
signed. Both groups were assigned three exercise
sessions per week. The findings reported show that
the experimental group had significantly better
attendance and were significantly different from
controls for all outcomes.
Use by physiotherapists
Social cognitive theory is extremely relevant to health
communication. Healthcare professionals have tradi-
tionally relied on persuading individuals to change
through ‘informational power’ (sharing facts about
health and illness) and ‘expert power’ (using profes-
sional credentials at least implicitly to impress
individuals with the potential effectiveness of the
prescribed behaviour change).
32
The concepts of SCT
provide alternative ways for health education and
communication. It is relevant for designing health
behaviour and health education programmes. The
theory can also be used for providing the basis for
intervention strategies.
32,33
Physiotherapists can employ all five core determi-
nants of SCT. Educating individuals on the risks and
benefits will increase their knowledge. Thorough
explanations and clear demonstrations of exercises
and what one should feel or expect will tackle self-
efficacy and outcome expectations. For example an
individual who is learning a new rehabilitation
exercise may lack experience of how this new exercise
will feel; muscle soreness, tiredness, or cramps.
Informing them of what to expect will provide
realistic outcome expectations. In assessing personal
efficacy to stick to an exercise routine, people judge
their efficacy at regularly exercising in the face of
different barriers: when they are under pressure from
work, are tired, or face foul weather. If there are no
impediments to surmount, the behaviour will be easy
and everyone will be successful. Prescribing exercises
and PA that will provide a challenge but are
achievable will also boost self-efficacy. Identifying
both the individual’s personal and social barriers and
devising plans to overcome them to achieve agreed
upon health goals will assist in maintaining the
change.
Motivational Interviewing
Origins
Motivational interviewing developed as a result of
‘surprising’ findings on the extent to which counsellor
empathy explained the variance in successful beha-
vioural change ina research study on problem drinking.
Thereafter, with further reflection and discussion,
William Miller described a conceptual model and
clinical guidelines for MI.
34
The definition of MI has
evolved and Miller and Rollnick currently offer three
levels of definition with the layperson’s definition being
that ‘MI is a collaborative conversation style for
strengthening a person’s own motivation and commit-
ment to change’ while the most technical is ‘MI is a
collaborative, goal-orientated style of communication
with particular attention to the language of change. It is
designed to strengthen personal motivation for com-
mitment to a specific goal by eliciting and exploring the
person’s own reasons for change within an atmosphere
of acceptance and compassion’.
35
Theoretical model
Four key aspects are embodied in the spirit of MI;
partnership, acceptance, compassion, and evocation.
35
Partnership refers to the collaboration that exists in
MI as it is not done ‘to’ or ‘on’ someone but ‘for’ or
‘with’ someone. The individual is the expert on himself
or herself. Acceptance refers to the worth of the
individual, supporting their autonomy and seeking to
understand the individual’s perspective, accurate
empathy, and affirmation of their strengths and efforts
to change. Compassion refers to actively promoting
the individual’s welfare and best interests. Evocation
refers to the drawing out of the individual’s reasons for
change and their own resources to achieve it.
35
There are four processes in MI: engaging, focuss-
ing, evoking, and planning. Engaging begins the
process of forming a collaborative partnership.
Focussing is the development of a specific direction
in the conversation about change and the surfacing of
goals. Evoking involves eliciting motivations for
change, not installing reasons and finally, planning
is put in place when the individual reaches the
threshold of readiness to change.
35
Example from the literature
Since the 1980s, there has been a significant amount
of research carried out on the efficacy of MI in
various groups of people
36
and the number of
publications on MI has been doubling every three
years.
37
It has been investigated in many conditions,
including alcohol, drug, and gambling addictions,
reducing risky behaviour and increasing healthy
ones.
36
In a study on the effect of motivational
enhancement therapy (MET), an adaption of MI
techniques, physiotherapists delivered the interven-
tions to individuals with chronic low back pain.
38
All
subjects received 10 sessions of 30-minute physiother-
apy in eight weeks. Those in the experimental group
received MET training during these sessions while the
control group received general communication. The
intervention assessed proxy efficacy, which refers to
the patient’s confidence in their therapist, treatment
expectancy, and working alliance between the indivi-
dual and the therapist. There was a significant
McGrane et al. Motivational strategies
140 Physical Therapy Reviews 2014 VOL.19 NO.2
difference between groups in favour of the interven-
tion for proxy efficacy, working alliance, and treat-
ment expectancy while there were within group
significant differences for pain, lifting capacity,
disability, and physical function. The groups differed
significantly in favour of the intervention in general
health and home exercise.
Use by physiotherapists
The three core communication skills, asking, listening,
and informing are covered in the five key communica-
tion skills used throughout MI:
39
open-ended ques-
tions, affirming, reflecting, summarising, and providing
advice and information with permission.
35
Using MI, with an individual who should become
more active, requires a physiotherapist to establish a
partnership and accept the individual as they are.
Empathy and compassion about the challenges and
barriers to exercise participation the individual
describes will evoke more discussion. Engaging with
the individual with empathy, and acknowledging that
the choice to change is theirs, will increase the like-
lihood of honesty from the individual. Open-ended
questions will engage the client and will evoke
positives, ‘change talk’, and negatives, ‘sustain talk’,
and allow for the exploration of ambivalence towards
exercise. Reflective listening, summarizing what the
client has said, and affirming their reasons for change
will decrease ambivalence and reduce discrepancies.
Focussing on and evoking the individual’s change talk
and rolling with resistance will help develop self-
efficacy. Once the individual is committed to change
the therapist can assist them, by evoking the indivi-
dual’s own plans and goals and providing advice and
information with permission.
Conclusion
These four theories, SDT, SCT, CBT, and MI can be
used to stimulate a change in exercise behaviour and
most importantly sustain it. Incorporating a strategy
to positively influence PA into all aspects of
physiotherapy practice, empowering individuals to
adhere, self-managing and completing courses of
treatment is vital and plays a central part in
physiotherapists’ role as promoters, preventers, and
rehabilitators. To become skilled in the use of any of
these four strategies training is necessary, but these
four theories have a number of similarities and can be
implemented into practice.
Firstly the motivation to change must come from
the individual; it must be his or her autonomous
decision. Autonomy is present in all four theories.
One cannot force another to change; only informa-
tion on why change is necessary can be provided.
Physiotherapists are experts and can educate on the
health risks of behaviours. They can evoke reasons
for change and challenge individual’s ambivalence
but it is the individual who is the expert on himself or
herself. He or she must weigh up his or her own pros
and cons, recognize own individual barriers, and
reach own decisions for any change to be sustainable.
Any decision made must be supported to maintain
autonomy.
Empathy, known as relatedness in SDT, also
features. An accepting and trusting relationship
where the client feels cared for should be created.
This will allow for frank and open discussion where
personal barriers to change and dysfunctional
thoughts and behaviours may be identified. An
attempt must be made to empathize with each
individual and the challenges they face. This will also
foster autonomy and increase the individual’s self-
efficacy for change. Open-ended questions, reflective
listening, and summarizing are useful tools that can
be used to create empathy, trust, and open discussion.
Bandura’s self-efficacy is evident in all four
theories, known as competence in SDT. One must
have the belief that one has the power to produce the
desired effect before one will attempt it. If the
individual does not believe that they can change their
behaviour, or even something as simple as executing
an exercise, then little or no attempt will be made.
Self-efficacy must be nurtured by building on success,
therefore exercises that are challenging but most
importantly achievable must be prescribed. Providing
individuals with outcome expectations will inform
them as to what to expect, increasing self-efficacy as
the individuals know what is normal as a result of
their change. An example of this would be informing
an individual that delayed onset muscle soreness is
perfectly normal and may be expected after PA.
Finally planning is an integral part of these
theories. Once the decision is made to change,
planning is vital to initiate and sustain change.
Autonomy, empathy, and self-efficacy are all aspects
to consider when planning. Plans can be devised
together but it must be the individual’s own, it must
include his or her personal barriers and facilitators,
personal strategies to overcome them, and personal
goals. This will continue to support their autonomy.
The therapist must be empathetic when assisting the
client to devise plans and goals whilst also ensuring
that the plan is challenging and achievable, support-
ing, and enhancing self-efficacy.
Time must be taken to learn, understand, and
practice these strategies and training is essential to
become skilled in their use. However changing the
mindset of physiotherapy practice to incorporate an
autonomous supportive service, empathetic commu-
nication/environment, nurturing self-efficacy, and
informative assisting of individual’s own planning is
necessary to maintain their continued and successful
use.
McGrane et al. Motivational strategies
Physical Therapy Reviews 2014 VOL.19 NO.2 141
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