ArticlePDF Available


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.
Discussion/Opinion paper
Motivational strategies for physiotherapists
Niall McGrane
, Tara Cusack
, Grainne O’Donoghue
, Emma Stokes
Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Trinity Centre for Health Sciences,
James’ St., Dublin 8, Republic of Ireland,
School of Public Health, Physiotherapy and Population Science,
College of Life Sciences, University College Dublin, Belfield, Dublin 4, Republic of Ireland,
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
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.
While there is an abundance of research
revealing the benefits of PA
there is also evidence
of non-compliance with PA guidelines
and physiother-
apy prescriptions and non-attendance to physiotherapy
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’.
Incontestable epidemiological
trends highlight the fact that for the foreseeable
future, illness care will be dominated by an escalation
in chronic lifestyle-related diseases.
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.
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
Of a random sample of US adults only 33%
correctly identified the ACSM guidelines for PA.
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.
In a recent
study, physiotherapy clinical educators identified
psychological strategies for changing PA behaviour
as one of the mainareas absent from clinical education
while experienced physiotherapists reported being
unaware of strategies to change PA behaviour and
improve adherence.
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:
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.
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
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
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.
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
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
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.
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.
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
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,
and substance abuse.
et al.
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
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.
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
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.
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
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
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
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).
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.
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.
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
Example from the literature
Physiotherapists delivered a CBT-led programme to
people with chronic musculoskeletal pain in a study
by Asenlo¨f et al.
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
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
The proposition of SLT was expanded
upon by Albert Bandura from 1962 until the present,
resulting in SCT.
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.
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.
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.
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.
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).
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.
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
Motivational Interviewing
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.
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’.
Theoretical model
Four key aspects are embodied in the spirit of MI;
partnership, acceptance, compassion, and evocation.
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.
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.
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
and the number of
publications on MI has been doubling every three
It has been investigated in many conditions,
including alcohol, drug, and gambling addictions,
reducing risky behaviour and increasing healthy
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.
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:
open-ended ques-
tions, affirming, reflecting, summarising, and providing
advice and information with permission.
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.
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
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
McGrane et al. Motivational strategies
Physical Therapy Reviews 2014 VOL.19 NO.2 141
1 Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W,
Ekelund U, et al. Global physical activity levels: surveillance
progress, pitfalls, and prospects. Lancet. 2012;380(9838):247–
2 Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte
MJ, Lee IM, et al. American College of Sports Medicine
position stand. Quantity and quality of exercise for developing
and maintaining cardiorespiratory, musculoskeletal, and neu-
romotor fitness in apparently healthy adults: guidance for
prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–59.
3 Bassett SF. The assessment of patient adherence to physiother-
apy rehabilitation. New Zeal J Physiother. 2003;31(2):60–6.
4 WPCT. Policy Statement: Physical therapists as exercise experts
across the life span. 2011. Available at
5 Dean E. Physical therapy in the 21st century (Part I): toward
practice informed by epidemiology and the crisis of lifestyle
conditions. Physiother Theory Pract. 2009;25(5–6):330–53.
6 Verhagen E, Engbers L. The physical therapist’s role in physical
activity promotion. Br J Sports Med. 2009;43(2):99–101.
7 Roberts K, Marvin, K. Knowledge and attitudes towards
healthy eating and physical activity: what the data tell us.
Oxford: National Obesity Observatory; 2011.
8 Bennett GG, Wolin KY, Puleo EM, Masse LC, Atienza AA.
Awareness of national physical activity recommendations for
health promotion among US adults. Med Sci Sports Exerc.
9 O’Donoghue G, Cusack T, Doody C. Contemporary under-
graduate physiotherapy education in terms of physical activity
and exercise prescription: practice tutors’ knowledge, attitudes
and beliefs. Physiotherapy. 2012;98(2):167–73.
10 Mohan N, Collins E, Cusack T, O’Donoghue G. Physical
activity and exercise prescription: senior physiotherapists
knowledge, attitudes and beliefs. Physiother Pract Res.
11 McGrane N, Galvin R, Cusack T, Stokes E. The addition of
Motivational Interventions to Exercise and Traditional Physical
Therapy: A Review and Meta-analysis. Under Review at
Physiotherapy. Under Review. 2013.
12 Ryan RM, Deci EL. Intrinsic and extrinsic motivations: classic
definitions and new directions. Contemp Educ Psychol. 2000;
13 Ryan RM, Patrick H, Deci EL, Williams GC. Facilitating
health behaviour change and its maintenance: interventions
based on self-determination theory. EHP. 2008;10(1):2–5.
14 Deci EL, Ryan RM. Self-determination theory in health care
and its relations to motivational interviewing: a few comments.
Int J Behav Nutr Phys Act. 2012;9:24.
15 Lonsdale C, Sabiston CM, Raedeke TD, Ha AS, Sum RK. Self-
determined motivation and students’ physical activity during
structured physical education lessons and free choice periods.
Prev Med. 2009;48(1):69–73.
16 Williams GC, Rodin GC, Ryan RM, Grolnick WS, Deci EL.
Autonomous regulation and long-term medication adherence in
adult outpatients. Health Psychol. 1998;17(3):269–76.
17 Silva MN, Vieira PN, Coutinho SR, Minderico CS, Matos MG,
Sardinha LB, et al. Using self-determination theory to promote
physical activity and weight control: a randomized controlled
trial in women. J Behav Med. 2010;33(2):110–22.
18 Zeldman A, Ryan RM, Fiscella K. Motivation, Autonomy
Support and Entity Beliefs: Their Role in Methadone
Maintenance Treatment. J Soc Clin Psychol. 2004;23(5):675–96.
19 Thøgersen-Ntoumani C, Ntoumanis N. The role of self-
determined motivation in the understanding of exercise-related
behaviours, cognitions and physical self-evaluations. J Sports
Sci. 2006;24(4):393–404.
20 Williams GC, Lynch MF, McGregor HA, Ryan RM, Sharp D,
Deci EL. Validation of the ‘Important Other’ climate ques-
tionnaire: assessing autonomy support for health-related
change. Families, Systems & Health. 2006;24(2):179–94.
21 Bandura A. Self-efficacy: toward a unifying theory of
behavioral change. Psychol Rev. 1977;84(2):191–215.
22 Dowd ET. Cognition and the cognitive revolution in psy-
chotherapy: promises and advances. J Clin Psychol.
23 Beck JS. In Session with Judith S. Beck, PhD: Cognitive-
Behavioral Therapy. Primary Psychiatry. 2006;13(4):31–4.
24 Gatchel RJ, Mayer TG. Evidence-informed management of
chronic low back pain with functional restoration. Spine J.
25 Whitfield G, Davidson A. Cognitive behavioural therapy
explained. Vol. xii. Oxford: Radcliffe; 2007. p. 184.
26 Asenlo¨ f P, Denison E, L indberg P. Indi vidually tailor ed
treatment targeting activity, motor behavior, and cognition
reduces pain-related disability: a randomized controlled trial in
patients with musculoskeletal pain. J Pain. 2005;6(9):588–603.
27 Miller NE, Dollard J. Social learning and imitation. New
Haven, CT, USA: Yale University Press; 1941.
28 Bandura A. Social foundations of thought and action: a social
cognitive theory. Vol. xiii. Englewood Cliffs, NJ: Prentice-Hall;
1986. p. 617.
29 Bandura A. Evolution of social cognitive theory. great minds in
management: the process of theory development. Oxford:
Oxford University Press; 2007. p. 9–35.
30 Bandura A. Health promotion by social cognitive means.
Health Educ Behav. 2004;31(2):143–64.
31 Annesi JJ, Unruh JL, Marti CN, Gorjala S, Tennant G. Effects
of the coach approach intervention on adherence to exercise in
obese women: assessing mediation of social cognitive theory
factors. Res Q Exerc Sport. 2011;82(1):99–108.
32 Elder JP, Ayala GX, Harris S. Theories and intervention
approaches to health-behavior change in primary care. Am J
Prev Med. 1999;17(4):275–84.
33 Jeffery RW. How can health behavior theory be made more
useful for intervention research? Int J Behav Nutr Phys Act.
34 Miller WR, Rose GS. Toward a theory of motivational
interviewing. Am Psychol. 2009;64(6):527–37.
35 Miller WR, Rollnick S. Motivational Interviewing, Third
Edition: Helping People Change. New York, NY, USA.
Guilford Publications; 2012.
36 Lundahl BW, Kunz C, Brownell C, Tollefson D, Burke BL. A
meta-analysis of motivational interviewing: twenty-five years of
empirical studies. Res Soc Work Pract. 2010;20(2):137–60.
37 Miller WR, Rollnick S. Ten things that motivational inter-
viewing is not. Behav Cogn Psychother. 2009;37(2):129–40.
38 Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational
enhancement therapy in addition to physical therapy improves
motivational factors and treatment outcomes in people with
low back pain: a randomized controlled trial. Arch Phys Med
Rehabil. 2011;92(2):176–83.
39 Rollnick S, Miller WR, Butler CC. Motivational Interviewing
in Health Care: Helping Patients Change Behavior. New York,
NY, USA. Guilford Publications; 2007.
McGrane et al. Motivational strategies
142 Physical Therapy Reviews 2014 VOL.19 NO.2
... In addition to specialist knowledge of the musculoskeletal system, psychosocial strategies for behavior change must be considered as clinical competencies in physiotherapy. For this purpose, Deci and Ryan's psychological concept of the self-determination theory (SDT) was scientifically examined [15]. According to the SDT, experiencing autonomy, competence and social integration is an essential prerequisite for the development of intrinsic motivation. ...
... The evidence of the practical implementation of the SDT was examined in different fields [16,20,21]. So far, only a few study results have been available for physiotherapy regarding the practical implementation of the SDT and data for adolescents with obesity are missing [15,22]. ...
Full-text available
Background This study determined to what extent the underpinning of physiotherapeutic interventions with the evidence-based motivational psychological concept of the self-determination theory (SDT) by Ryan and Deci can increase motivation and enjoyment of movement in obese adolescents. Methods In this study 12 obese adolescents aged 14–18 years were offered a targeted group-specific sports program including a home exercise program of 8 weeks. The group leaders were trained in the SDT and supported to integrate motivational aspects. A SDT-based questionnaire by Kohake and Lehnert was used to evaluate motivational interventions. Results In total, seven (58%) patients finished the study. In the before-after comparison there were little changes in motivation. Results showed that contrary to expectations the motivation of the obese adolescents to move and to participate in the study was generally high. In the study, more internalized forms of motivation dominated, the highest quality form of motivation. Conclusion Digital technologies could be a successful way to further increase motivation and compliance of our target group. This MotiMove study is a basis for future research programs and empower physiotherapists and movement experts to develop and implement training programs for obese adolescents and children.
... Physiotherapists have the clinical competency to influence physical activity behaviors in their patients as they act not only as rehabilitators but also as promoters. They possess the skills and knowledge necessary to facilitate this behavioral change as well as to promote adherence to physiotherapy itself [67]. In promoting physical activity as part of their practice, physiotherapists use a number of techniques to help modify behavior. ...
Full-text available
Physical rehabilitation plays a fundamental role in the management of individuals with disabilities associated with age-related muscle loss or affected by catastrophic conditions such as trauma, surgery, cancer or other severe pathologies. These events have in common an extended period of physical inactivity. Patients who undergo prolonged bed rest often present with a number of complications; for example, muscle loss that can exacerbate existing conditions determined by sarcopenia, which in turn greatly limits physical functions. The main scope of this work is to summarize certain key strategies for the physiotherapeutic management of physically inactive patients, regardless of the reason behind their prolonged bed rest, with a particular focus on physical rehabilitation, nutrition and forest-bathing. The importance of correct nutrition in counter-acting the loss of muscle mass and consequent function is explored alongside a description of the main nutrients that are needed for muscle regeneration. From a biomolecular perspective, some specific molecular mechanisms associated with physical rehabilitation are also reported not only in the context of physical therapy, but also within nature-inspired techniques, such as forest-bathing as well as body self-healing. Combining a targeted physiotherapeutic approach with an appropriate diet as well as nature-based therapy could thus help with the recovery of bed ridden patients.
... 3,8,9,22 Regarding the latter point, one may argue that conventional physiotherapy sessions can promote the performance of functional responses and improve body posture, but may not be sufficient to consolidate those responses and posture because of (a) the limited number of sessions generally available and (b) the presumed lack of participants' motivation to practice those responses and posture on their own. 3,[23][24][25][26] Lack of motivation can be even more evident when the responses and posture, considered to be relevant for the participants to practice, are somewhat difficult/demanding for them. 27,28 Following the second approach, Lancioni et al. 8,9,20,21 were able to show that participants with intellectual and multiple disabilities could learn to independently (a) practice responses regarded as useful by their physiotherapists and also (b) combine the practice of those responses with the achievement of improved body posture. ...
Purpose This study assessed everyday technology to help eight participants with intellectual and sensory-motor disabilities access stimulation via functional arm/hand responses and improved body posture. Methods An ABABB¹BB¹ design was used for each participant, with A representing baseline phases, B intervention phases in which arm/hand responses led to a 12-s stimulation, and B¹ intervention phases in which the stimulation for arm/hand responses was conditional on an improved/correct torso and head posture. The technology involved a Samsung Galaxy A10 smartphone fitted with Google Assistant and MacroDroid, a mini voice-recording device, and a portable mini voice amplifier. Results All participants had a large increase in arm/hand responses from the baseline periods to the B and B¹ phases. They also had a large increase in correct posture from the B phases to the B¹ phases. Conclusion This technology-aided approach may be a helpful resource for people similar to the participants of this study.
... Health appropriate behaviors create a positive impact on an individual. Thus, using effective motivational strategies through self-determination, social cognitive theory, cognitive behavioral therapy, and motivational interviewing of individuals by their physiotherapists can prove beneficial (McGrane et al., 2014). Physiotherapists' involvement across various system-based approaches like promoting a healthy environment, healthy workforces, and creating connections with community assets would now enable PA promotion (Lowe et al., 2018). ...
Introduction Coronavirus disease (COVID-19) pandemic and the nationwide lockdown has increased sedentary time and physical inactivity. Physiotherapists are one of the essential health professionals who are actively involved in promoting physical activities. The study objectives included assessing knowledge of physical activity guidelines, physiotherapist attitude towards involvement in physical activities and practice of routine physical activity assessment, and its promotion among physiotherapists in India during COVID-19. Method In this cross-sectional survey study, the study tool was prepared using Google Forms. It consisted of sixteen questions on knowledge, attitude, and practice of physical activities among physiotherapists. Study participants were physiotherapists with a minimum of a bachelor's degree qualification and practicing in India. Results One hundred and eighty responses were received from sixteen states of India. The average age of respondents was 28 years, and the average work experience of five years. This study found that only 19% of physiotherapists could give the correct answer in all three domains of WHO PA guidelines. 70% of physiotherapists found with an appropriate attitude as they met the 150 minutes of moderate PA per week. 68% reported that they promote physical activities in routine practice. Conclusion This study suggested the majority of physiotherapists perform physical activity assessment and promotion in routine practice in India. Most of them have an appropriate attitude towards physical activity, but very few physiotherapists have adequate knowledge of WHO physical activity guidelines. Physiotherapists should actively promote physical activities in routine practice to reduce the impairment due to physical inactivity especially during the Corona virus disease pandemic in India. Efforts should be made to increase the physical activity awareness in terms of knowledge of WHO physical activity guidelines, different assessment, and promotion strategies.
... Active listening is one of the core communication skills used in counseling (11,28). A systematic review reported that counseling has a positive effect on mood in stroke patients (11,12). ...
Full-text available
Background: The addition of motivational strategies to a rehabilitation program is thought to enhance patient adherence and improve outcomes. However, little is known about how rehabilitation professionals motivate stroke patients during rehabilitation. The primary objective of this study was to provide a comprehensive and quantitative list of motivational strategies for stroke rehabilitation. In addition, we aimed to examine (1) whether professionals with more clinical experience used a higher number of motivational strategies, (2) the purpose for using each strategy, and (3) the information considered when choosing strategies. Methods: This descriptive, cross-sectional study was conducted using a web survey with a convenience sample of 407 rehabilitation professionals including physicians, nurses, physical therapists, occupational therapists, and speech-language-hearing therapists. Results: We received data for 362 participants. Fifteen strategies were found to be used by more than 75% of the respondents to motivate their patients. Almost all of the respondents reported that they actively listened to and praised their patients to increase patient adherence to rehabilitation programs. Respondents with more clinical experience tended to use a higher number of motivational strategies (rho = 0.208, p < 0.001). For 11 of the 15 strategies selected by more than 75% of the respondents, the highest percentage of respondents reported that they used the strategies to make rehabilitation worthwhile for their patients. The majority of respondents reported that they decided which motivational strategy to use by considering comprehensive information regarding the patient health condition, environmental factors, and personal factors. Conclusions: The comprehensive list of motivational strategies obtained may be useful for increasing patient adherence to rehabilitation, especially for professionals with less clinical experience. Furthermore, our findings regarding the purpose for using each strategy and the information considered when choose strategies might help rehabilitation professionals to optimally utilize the motivational strategy list.
... Finally, we also added motivational interviewing and cognitive behavioral therapy to the list because these strategies were regarded as the package of motivational interventions in the previous studies. 4,26 Consequently, we prepared a list of 26 motivational strategies (Table 1). ...
Full-text available
Background and Purpose: Although various strategies are used to motivate patients during rehabilitation, consensus regarding the optimal motivational strategies for stroke rehabilitation has not been established. Expert consensus may aid rehabilitation professionals in effectively utilizing motivational strategies to produce the most beneficial outcome for their patients. The primary purpose of this study was to provide a comprehensive list of effective motivational strategies based on consensus among rehabilitation experts, generated using the Delphi technique. In addition, we sought to identify the types of information that are important when selecting motivational strategies. Methods: A total of 198 rehabilitation experts participated in a three-round Delphi survey. The rehabilitation experts included physicians, physical therapists, occupational therapists, and speech-language-hearing therapists who had worked in stroke rehabilitation for at least five years. Panelists were asked to rate the effectiveness of motivational strategies and to rate the importance of different types of information using a 5-point Likert scale. Consensus was defined as having been reached for items with an interquartile range of 1 or less. Results: A total of 116 experts (58.6%) completed the third round of the Delphi survey. Consensus was reached on all of the 26 presented strategies. Seven strategies, such as control of task difficulty and goal setting, were considered to be very effective in increasing patient motivation. In addition, all 11 of the presented types of information were deemed very important or important in determining which motivational strategies to use. Conclusions: We generated a list of effective motivational strategies for stroke rehabilitation based on expert consensus. Our results suggest that experts consider a comprehensive range of patient information when choosing motivational strategies. These findings represent a group of consensus-based recommendations for increasing patient adherence to stroke rehabilitation programs, which may be beneficial to many medical professionals working in stroke rehabilitation.
Motivatie is cruciaal bij het revalideren van je patiënt. Heel vaak wordt een patiënt gemotiveerd door externe factoren. Motivatie wordt pas duurzaam wanneer een patiënt ook vrijwillig gemotiveerd wordt. Binnen dit hoofdstuk gaan we aan de slag met de ‘zelfdeterminatietheorie’, een wetenschappelijk onderbouwde motivatietheorie. Aan de basis van deze theorie liggen drie basisbehoeften die iedereen nodig heeft: autonomie, verbondenheid en competentie. Het bevredigen van de autonomie, verbondenheid en competentie van een patiënt zal leiden tot vrijwillige motivatie, wat op haar beurt leidt tot betere uitkomsten op het vlak van gedrag, gezondheid en mentaal welzijn. Dit hoofdstuk geeft praktische tips om te werken aan een motiverende behandelingsstijl, zodat dit toegepast kan worden binnen jouw eigen therapeutische context. Het toepassen van een motiverende behandelingsstijl bij het revalideren van patiënten kan een cruciale rol spelen in het blijvend motiveren van de patiënt en een gemotiveerde patiënt leidt tot een gemotiveerde kinesitherapeut.
Background: Maintaining a physically active lifestyle across the life course can add to an individual's health and well-being. Many people are insufficiently active to achieve these gains with a trend towards further decreases in activity as people age. Community-based group exercise programmes have been shown to be one means of increasing sustained activity levels for older people. Aim: To understand how and why older people sustain participation to community-based group exercise programmes from a humanising perspective. Methods: A multiple-case study approach was employed to study three exercise programmes in the South-West of England. Data were collected through participant observation, focus groups and documentation. Data were analysed with deductive thematic analysis and mapped against the humanisation framework. Results: Findings suggest that the humanising nature of these particular exercise programmes supported sustained participation. In these programmes, agency was evidenced in the way participants self-selected their level of exertion with exercises. There was freedom to be their unique selves and exercise within the limits of their insider challenges of an ageing body. Through this non-judgemental exercise environment, there was an embodied understanding of who they were as people. The exercise programme became part of their personal journey. This journey helped inform their future by enabling them to keep active and maintain independence, allowing them to continue engaging in the world. There was a sense of togetherness and belonging which led to feelings of homeliness as they found a sense of place within the group. The friendships they formed helped them make sense and add meaning to their experiences and personal health challenges. Conclusions: When planning exercise environments to support the long-term adoption of a sustained behaviour change, in the form of physical activity for older people, it is helpful to consider dimensions that make an individual feel human.
(a)background: Musculoskeletal (MSK) first contact physiotherapy (FCP) is being rolled out in the National Health Service, but limited research exists on career pathways into MSK FCP, or on pre-and-post-registration educational preparation for the knowledge and skills that are required for musculoskeletal first contact physiotherapy. (b) objectives: From the perspectives of existing MSK FCPs, the study sought to understand the pre-and-post-registration professional developmental journey into musculoskeletal first contact physiotherapy. (c) methods: Semi-structured interviews over the telephone were conducted with a self-selected and snowball sample of 15 MSK FCPs from across Britain. Framework analysis was used to analyze the interview transcripts. (d) results: Four overarching themes were identified: (1) Decision to choose a career path as a MSK FCP; (2) Relevancy of pre-registration physiotherapy (PT) education for MSK FCP; (3) Relevancy of post-registration continuing professional development for MSK FCP, and; (4) Improving pre-registration PT education for the foundational knowledge and skills required to work in musculoskeletal first contact physiotherapy. Each overarching theme generated several subthemes. (e)conclusion: The research contributes to understanding the career pathway into the MSK FCP role and showed what relevant knowledge and skills were acquired for this role at pre-and-post registration levels. Findings will inform guidance for pre-registration PT curriculum development.
Full-text available
Background: Global epidemiological trends indicate that lifestyle related conditions will dominate illness care for the foreseeable future. With physical inactivity an established risk factor for these conditions, physical activity and exercise prescription have increasing relevance to physiotherapy practice. Purpose: In terms of physical activity and exercise prescription for healthy and clinical populations, the purpose of this study was firstly, to determine senior physiotherapists' knowledge and establish whether a postgraduate qualification enhanced this knowledge and secondly, to investigate their attitudes and beliefs relating to the role of physiotherapy in contemporary practice. Methods: One hundred senior physiotherapists from 27 health care settings throughout Ireland were invited to participate. Each therapist was sent a questionnaire (specifically developed for use in this study). It included seven key sections (73 questions) relating to physical activity and exercise prescription. Three open-ended questions invited comment on priorities for the profession in terms of future practice. Quantitative data was analysed using the Statistical Package for Social Science (SPSS version 18) and a 'Framework analysis' methodology was utilised for qualitative analysis. Results: A 71% (n = 71) response rate was achieved. All respondents reported having a specific interest in physical activity and exercise prescription. However, just over half (55%) were aware of international guidelines for physical activity. The following were identified as areas in which the physiotherapists felt they required greater proficiency: exercise prescription for healthy sedentary populations; interventions to promote physical activity and strategies to improve physical activity adherence and exercise prescription for lifestyle-related conditions. Those with a postgraduate qualification reported were significantly more knowledgeable in this field than those without. The main themes that emerged from the open-ended questions were (i) barriers preventing physiotherapists from being experts in physical activity promotion and exercise prescription and (ii) perceptions of the role of the contemporary physiotherapist. Conclusion: Senior physiotherapists identified a need for further education in the areas of health promotion and strategies to improve physical activity adherence. Furthermore, they advocated that contemporary physiotherapists adopt a more prominent role in wellness and prevention, both in the clinical setting and the community. Results of this study provide useful data to inform future developments in physiotherapy undergraduate and postgraduate education. Physical activity and exercise have increasing relevance to contemporary practice in particular in securing a central role for physiotherapists in the prevention and management of lifestyle related conditions.
Presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from 4 principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Factors influencing the cognitive processing of efficacy information arise from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. (21/2 p ref)
Self-determination theory was applied to explore the motivational basis of adherence to long-term medication prescriptions. Adult outpatients with various diagnoses who had been on a medication for at least 1 month and expected to continue (a) completed questionnaires that assessed their autonomous regulation, other motivation variables, and perceptions of their physicians' support of their autonomy by hearing their concerns and offering choice; (b) provided subjective ratings of their adherence and a 2-day retrospective pill count during an interview with a clinical psychologist; and (c) provided a 14-day prospective pill count during a subsequent, brief telephone survey. LISREL analyses supported the self-determination model for adherence by confirming that patients' autonomous motivation for adherence did mediate the relation between patients' perceptions of their physicians' autonomy support and their own medication adherence.
Intrinsic and extrinsic types of motivation have been widely studied, and the distinction between them has shed important light on both developmental and educational practices. In this review we revisit the classic definitions of intrinsic and extrinsic motivation in light of contemporary research and theory. Intrinsic motivation remains an important construct, reflecting the natural human propensity to learn and assimilate. However, extrinsic motivation is argued to vary considerably in its relative autonomy and thus can either reflect external control or true self-regulation. The relations of both classes of motives to basic human needs for autonomy, competence and relatedness are discussed.