Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Steffan Griffin (@lifestylemedic)

So your patient saw Mike Evans’ 23.5 hours video and s/he understands that physical activity is the polypill that will maximise their chances of living a healthy life (Also see this blog de-bunking physical activity myths). They even started walking for 10 minute periods three times a day. But that was twelve weeks ago and it’s since started getting dark earlier and their daughter has started another after-school class, which further limits their spare time. Is physical activity still a priority or will the habit gently dissolve?

We all know patients who have a yo-yo relationship with physical activity, but what can we do to try and facilitate a sustainable change? In these individuals, how can we maximise the chances of adherence to a physical activity pledge/programme? This blog adresses the evidence relating to certain interventions and techniques proposed to affect adherence. It also provides some top tips to use in practice.

Why is adherence important?

Long-term adherence to physical activity is essential for the maintenance of health benefits. It has a long-term survival benefit¹, and is linked to greater fitness improvements and disease-specific outcomes as well as increased physical function and quality of life². Yet as you know, around 50% will drop out of a PA programme within a few months³.

Who is most likely to drop-out?

Essentially, exactly the population we want to get and keep active! Demographic risk factors for low adherence include older age, female gender, non-white ethnicity and low socio-economic status. Couple this with pre-existing chronic disease and/or lower physical function and weight issues and you’ve found your perfect recipe⁴ for a yo-yoer.

How can we keep these patients on the straight and narrow?

As Jorgen Jevre stated in relation to lower back pain in his recent fantastic BJSM blog, there is no golden ticket in medicine, and this especially true in trying to get and keep patients being physically active. So after assessing your patient’s activity levels, what can you do in the time you have left with your patients?

Tip 1: Inform⁴^,⁵^,⁶

• How can being active benefit them?
• What counts as activity?

Physical activity doesn’t have to mean becoming a MAMIL (middle age man in lycra).

#walkingdoeswonders

#SitLessStandMore

What does/did the patient enjoy? Enjoyment is a good indicator of long-term behaviour change.

Tip 2: Be #SMART⁴^,⁵^,⁶

Goal-setting is a good way to increase adherence. Make goals Specific (Who, What, Where, When, Why?), Measurable, Attainable, Realistic and Temporal (setting subsequent shorter term goals is better than one huge longer-term one).

Tip 3: #SmashThroughBarriers⁴^,⁵^,⁶

Identify the barriers and strategise on how they can be overcome. Teach the patient how to use this approach by themselves too.

Tip 4: #TeamEffort

Suggest that the patient involves those around them in their goals. Is group activity more suitable/realistic? Social support increases the connectedness to the activity and is more likely to lead to internalised behaviours⁴^,⁵^,⁶, the ‘golden snitch’ of health psychology.

Tip 5: MI (not the MI you’re thinking about)

Motivational Interviewing is a patient-centred form of discussion used to strengthen an individual’s motivation for a specific goal by exploring the person’s own reasons for change⁷. It may sound a bit hippy, but you can’t argue with the fact that 80% of relevant studies report that MI outperforms traditional advice-giving⁸.

#TeachmehowtoMI

Essentially, instead of adopting an expert position, the goal is to guide the patient towards directing themselves as to why/how they might increase their PA. Whilst you provide information (with permission!), the key objective is to elicit some form of patient-based change-talk.

Step 1: Engage with the patient and establish an agreed focus for the conversation

Step 2: Evoke the patient’s own motivation to change, followed by planning if the person is ready for this.

Dr Brian Johnson provides a great overview and video examples of good practice in the fantastic ‘Motivate 2 Move’ module. This document also provides a fantastic example of using MI to increase PA.

How can I summarise these tips?

The ultimate goal for long term adherence is facilitate the internalization of the desired behaviours in patients. Deci and Ryan’s⁹ self-determination theory essentially deals with this, claiming that our inherent propensity for personal development and wellbeing are governed by a few basic pscychological needs:

• Autonomy: the degree of personal control/choice in the matter
• Competence: the degree of proficiency related to a certain behaviour, task or skill
• Relatedness: the degree to which we feel connected to the behaviour in question

Focusing on each factor¹⁰

Autonomy: take the perspective of the client/patient, support their choices, minimise pressure

Competence: be realistic, limit negative feedback, provide optimally challenging goals

Relatedness: create an empathetic and positive environment

If you use these as the clinical framework to increase and maintain adherence in your patients, be it regarding physical activity or otherwise (diet, smoking, alcohol etc) and utilise the MI techniques, you will hopefully find that your patients are much better at sticking to the right path.

References

1. Morey MC, Pieper CF, Crowley GM, Sullivan RJ, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults [comment]. J Am Geriatr Soc. 2002;50(12):1929–1933

2. Belza B, Topolski T, Kinne S, Patrick DL, Ramsey SD. Does adherence make a difference? Results from a community-based aquatic exercise program. Nurs Res. 2002;51(5):285–291.

3. Dishman RK. Overview. In: Dishman RK, ed. Exercise adherence: It’s impact on public health. Champaign, IL: Human Kinetics; 1988.

4. Allen, Kelli, and Miriam C. Morey. “Physical activity and adherence.” Improving Patient Treatment Adherence. Springer New York, 2010. 9-38.

5. Rejeski WJ, Brawley LR, Ambrosius WT, et al. Older adults with chronic disease: benefits of group-mediated counseling in the promotion of physically active lifestyles. Health Psychol. 2003;22(4):414–423

6. The Writing Group for the Activity Counseling Trial Research Group. Effects of physical activity counseling in primary care: the activity counseling trial: a randomized controlled trial. JAMA. 2001;286: 677–687.

7. What is motivational interviewing? Motivational Interviewing Network of Trainers (MINT) http://www.motivationalinterviewing.org/ (Accessed 04/02/2015)

8. Rubak S, Sandback A, Lauritzen T, Chitensen B. Motivational interviewing: a systemic review and meta-analysis. British Journal of General Practitioners. 2005;55(513):305-312.

9. Ryan, R. and Deci, E. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist. 2000; 55, pp. 68-78.

10. Teixeira PJ, Carraca EV, Markland D, Silva MN, Ryan RM. Exercise, physical activity, and self-determination theory: a systematic review. Int J Behav Nutr Phys Act. 2012;9:78.

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Steffan Griffin is a third year medical student at the University of Birmingham currently intercalating at Cardiff Metropolitan University in Sports Science. As an ambassador for Move.Eat.Treat and the president of the Birmingham University Sport and Exercise Medicine Society (BUSEMS), he is passionate about the role of exercise as a proactive healthcare tool. He is involved with the Undergraduate Sports & Exercise Medicine Society (USEMS) committee as the Conference Officer. He combines a passion for all things SEM related with an avid interest in sport, and tries to live as active a life as possible.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.