Introduction to Health Coaching A Toolkit for Physiotherapists Permission to reproduce in part or whole is granted; please include a printed acknowledgment of Physiotherapy Alberta - College + Association. For all other inquiries, please contact [email protected]
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Physiotherapy Alberta - College + Association 300, 10357 - 109 Street, Edmonton, Alberta T5J 1N3 T 780.438.0338 | TF 1.800.291.2782 | F 780.436.1908 [email protected] www.physiotherapyalberta.ca
November 2019
2 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Table of Contents
Introduction 4 Background 4 Health Behaviours 5 Health Coaching 6 Behaviour Change 7 Facilitating the Change Process 9 The Therapeutic Alliance 9
Communication 9 Motivational Interviewing 10 Behaviour Change Techniques 10 identifying Achievable Goals 11 Bridging Patient Goals and Outcome Measures 12 Cultural Competence 12 Active Learning 13 Personal Accountability 14 Considerations Specific to Physiotherapy 15 Brief Interventions 15 Longer-term Interventions 16 Resources 17 Appendix 1: The PT-BCT Checklist 18 Appendix 2: Personal Decision Guide 23 Appendix 3: OA Go Away 25 Appendix 4: HealthChange Methodology 35 Sources 37 Acknowledgements 39
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 3 Introduction
Physiotherapy Alberta College + Association has developed the Introduction to Health Coaching for Physiotherapists Toolkit to provide physiotherapists with a clinical resource to promote self-management strategies in patients with chronic conditions.
Self-management supports an active role for patients with This Toolkit is not intended to be a comprehensive guide chronic conditions by enabling patients to learn to manage their to health coaching but will provide an introduction to symptoms, maintain independence, and achieve a better quality the essential components, along with resources to guide of life.1 Health coaching is emerging as an effective means to physiotherapists wishing to explore this approach. promote and support self-management.2 Health coaching helps patients “gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach Background their self-identified health goals.”3 More Canadians are living with chronic conditions than 9 A recent systematic review of the health coaching literature ever before. Over one in five Canadian adults live with concluded that it can be effective in improving a patient’s one of the following chronic diseases: cardiovascular lifestyle behaviour and self-efficacy and has resulted in patients disease (CVD), cancer, chronic respiratory disease (CRD), 9 achieving better overall physical and mental health.4 Health or diabetes. In addition, musculoskeletal disorders (MSD) coaching has also been shown to facilitate improved weight are the most common reason for repeated visits to a 10 management and increased physical activity, and has been physician, with chronic low back pain among the most associated with improvement in factors affecting cardiovascular common reasons for physician consultations among people 11 health, pain management in cancer patients, and adherence under 60 years of age in Canada. to self-management and lifestyle changes in patients with Chronic conditions are detrimental to a patient’s quality of diabetes.5,6 life and are an increasing economic burden on society.9 Each The physiotherapy profession is well suited to incorporate is associated with four risk factors or health behaviours health coaching. Physiotherapists are health-care professionals – smoking, unhealthy eating, physical inactivity and 9 who “promote, restore and prolong physical independence harmful use of alcohol. Obesity and hypertension may also by enhancing a client’s functional capacity. Physiotherapists contribute to the onset of a chronic condition. Similarly, encourage clients to assume responsibility for their health and these risk factors may impact quality of life and health in 12 13 participate in team approaches to health service delivery.”7 older adults and contribute to the onset of frailty. Physiotherapists treat a wide range of patients with acute and The health cost and economic burden of smoking, obesity chronic conditions; physiotherapists see them on a regular and alcohol abuse are well reported in the literature. basis and provide personalized care. They provide education Physical inactivity is increasingly being recognized as a on risk factors for prevention and management of a condition, major factor in the onset and progression of illness and prescribe exercise and physical activity to achieve and maintain chronic disease. A recent Canadian study concluded that, as independence or function as well as physical techniques to well as a higher number of physician and specialist visits, manage stress and cardio-respiratory symptoms. Given the patients who are physically inactive spend 38% more days current and growing prevalence of chronic conditions, patient in hospital than active people.14 demographics will include patients with one or more risk factor, or who are in the early or advanced stages of a chronic Addressing these risk factors can alter the effects of 8 chronic conditions on the patient, and on their use of condition either in addition to, or as the primary reason, they 14 are consulting a physiotherapist. health-care resources. To do so, the focus of care shifts from the condition to the patient and the complexity of changing health behaviours.
4 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Health Behaviours
Patients living with chronic conditions make decisions about their health and manage their symptoms daily based on their understanding of their condition, their activity level or capacity, their self-care requirements and family/social responsibilities. They rely on health professionals for support,1 for collaboration to achieve health goals, and for education on self-management.7
Health behaviours are complex and ultimately manifest as the culmination of multiple factors, including: • Personal (e.g., motivation) • Social (e.g., family influence, social media) • Environmental (e.g., living situation, built environment) • Institutional (e.g., access to resources) influences15,16 Additionally, improving or changing health behaviours may not always be seen as a priority. People generally do not experience the consequences of poor health behaviours immediately, or they may be focussed on other more immediate concerns. Despite these barriers, health behaviours are modifiable and within the patient’s control. As a result, behaviour change is dynamic, variable, and neither linear or chronological in nature. Many people are ambivalent about making any changes - the desire to change is countered by the desire to stay the same. Health coaching recognizes this tension and targets the coaching strategy to the patient.17
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 5 Health Coaching
Health coaching is patient centred. The patients’ perspective and values drive the process of behaviour change, allowing them to develop skills in self-management and the confidence to apply these skills independently.
It is a collaborative process. The health coach explores patients’ knowledge and understanding of their conditions or their associated health status, their current and past experiences, and their readiness to make changes to health behaviours or lifestyle. Have they tried other strategies or approaches? Do they know how, or are they ready, to set goals or are there other priorities to address? With those who are ready and able, the coach works with the patient as they prioritize their goals - the behaviours they want to change or improve – helping them find ways to meet them, or, in some cases, to set more achievable goals. With those who, for various reasons, are ambivalent about or not ready for behaviour change, the health coach explores and resolves the perceived barriers to change helps them to take the next step towards change. Health coaches: • Support the patient in problem solving how to overcome and learn from any obstacles he/she encounters in achieving goals and facilitates the selection and use of “markers,” or indicators, that will help measure patient progress. • Acknowledge and respect patients’ autonomy18 so patients learn to be personally accountable for aspects of their own care19 and build intrinsic, or internal, motivation, and a sense of self-efficacy, or belief in their own ability to be successful in achieving a goal.20 • Do not identify problems and/or tell the patient what to do; health coaches are supportive, “well-informed guides,” and are neither directive nor prescriptive.21 • Facilitate and guide the patient’s change process.19 • Help the patient identify his/her own achievable goals for change.19 • Facilitate an active learning process for working towards goals.19 • Help patients be accountable for and monitor, their own progress.19
6 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Behaviour Change
Health coaching for behaviour change begins with assessing the patients’ readiness to change and their level of engagement to follow through on the goal.
The coach will focus on the dynamics of change - what patients Self-efficacy is critical for achieving positive outcomes in health know and understand about their conditions, and what they behaviour change in patients with a range of chronic conditions, wish to change, but also what they see as the pros and cons for such as osteoarthritis,25 chronic pain,26,27 and COPD.24 It is also making (or not making) changes and how that change will affect essential for those living with a chronic MSD, such as non- their day-to-day life. For example, while the patient recognizes specific low back pain.28 that a change will be beneficial, there may be negative Self-efficacy can be fostered in a number of ways, such as: associations that reinforce their ambivalence – what else are they changing, what will they lose when they make the change? • Mastering a task: Achieving goals will build and reinforce Previous experience is also a factor – is this the patient’s first patients’ belief in their self-efficacy. While a failure may attempt at making a change, or have they tried multiple times undermine that sense, setbacks can also reinforce the value unsuccessfully? How confident are they in their ability to make of sustained effort. For example, reframing a setback as and sustain a change? achieving a percentage (e.g., 25%) of a defined goal can be a reinforcement to continue. “Normalizing” the occurrence of Success in making and sustaining a change in a health behaviour setbacks will also help the patient build self-efficacy. is determined by resolving ambivalence and facilitating a belief in one’s ability. These two concepts have been termed • A vicarious experience: Seeing others similar to oneself “decisional balance” and “self-efficacy” and are described below. achieving a goal. This can reinforce a belief that patients do have the capacity to master a task. However, patients must Decisional balance is a health coaching tool that can be used to not perceive or feel they are being compared unfavourably help patients quantify their ambivalence and visualize how they to others. see the implications of making an identified change.22 During goal identification, it clarifies any discrepancy between the • Verbal persuasion: Support for, or confidence in the patient’s stated goal and their actual situation. It will also assist patient’s capacity expressed by an influential person, such in determining their readiness to change a health behaviour. as a health coach or a health care professional, can enhance Decisional balance is discussed further in the section on self-efficacy.23 identifying achievable goals. The Transtheoretical Model (TTM) of change is an integrative, Self-efficacy is a patient’s confidence in his or her ability biopsychosocial model that describes the process of intentional to successfully make and sustain a behaviour change.23 It is behavior change.22 It describes a series of stages patients move affected by a number of factors, including whether it is the through when modifying or changing a behaviour. The principles initial attempt to make a change, whether he or she has had of decisional balance and self-efficacy are used in health repeated (and possibly unsuccessful) attempts in the past, and coaching to help determine the patient’s current stage and the by emotional and psychological state.24 appropriate coaching strategy to facilitate the process.
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 7 TTM views change as a five-stage process, not a single action or decision and integrates the patient’s current status with the patient’s intention to change. Change is frequently non-linear, and regression to previous stages, or re-cycling through the current stage, is part of the overall process, as shown in Figure 1. The Five Stages of Change in TTM • Precontemplation: Patients who are not intending to make changes within the next six months. For example, they may not understand the issue/consequences or may have other personal priorities that take precedence. In some cases, previous attempts to change a behaviour have been unsuccessful and the patient lacks confidence to try again.22 • Contemplation: Patients who intend to take action within the next six months. For example, they may have just been diagnosed with a chronic condition, or they have just identified a health behaviour they would like to change, or their life circumstances are such that it is possible to make a change now, or within the next six months.22 • Preparation: Patients are now ready to take action within 30 days, and have begun taking small steps towards their goal, a healthier lifestyle.22 • Action: Patients who intend to take action within the next 30 days and have already begun, but it is not yet part of their routine. For example, they may have begun to exercise, but not on a regular basis.22 • Maintenance: Patients who have made changes in behaviour in the last six months. They may be following a regular home Figure 1. Transtheoretical Stages of Change Model.29 Used routine or are participating in a group activity.22 with permission.
8 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Facilitating the Change Process
The relationship between the health coach and the patient is critical for a successful collaboration in planning and achieving a behaviour change.40 Behavioural change interventions require trust, thoughtful and non-judgmental communication that respects the patient’s autonomy, and a process that is appropriate to their knowledge, motivation and capacity.
The Therapeutic Alliance Communication in health coaching strategies includes: The skills employed in health coaching are congruent with those • Asking, not telling: Open ended questions communicate of physiotherapists as described in the therapeutic alliance that the coach values the autonomy of patients as a partner in physiotherapy.30 Both stress the importance of setting and encourages a discussion of their concerns about their collaborative goals, setting tasks aligned with those goals, and the condition, what they would like to change, and when and how importance of an interpersonal, trusting bond between the patient this might happen. Examples include, “What do you see as and the health-care professional.31 Research has identified that your biggest challenge?”, “What have you tried in the past?,” being present, receptive, committed, and genuine were necessary “Would you like to know more about....” or “How do you think conditions for a positive physiotherapy therapeutic relationship.30 you could....” These conditions reinforce actions that establish connections This also helps the coach learn about his/her patients’ level of with the patient, through acknowledging the patient as a patient health literacy – what they understand about their condition. by meeting them as a partner, validating their experiences, and The coach can then target any evidence-based information to 32 individualizing treatment to the needs of the patient. provide regarding their level of understanding and needs. Health coaches consistently demonstrate empathy and a respectful • Active listening: The health coach is aware of his/her own manner that builds a non-judgmental, collaborative relationship. body language and non-verbal cues that let patients know They show respect for the patient and their unique perspective, they have the coach’s attention. (e.g., making eye contact, feelings and values and maintain an attitude of acceptance, but mirroring postures, nodding to acknowledge comments). not necessarily approval or agreement. Using verbal and non- verbal messaging to communicate that they understand the Being open-minded and non-judgmental. The health coach patient’s situation will reinforce collaboration and concordance in avoids making negative comments, criticism and/or correcting setting goals. the patient, seeking only to clarify the patient’s perspective (e.g., “It sounds like you have...” , “Am I correct in thinking that...” rather than “You shouldn’t...” or “you need to...) Communication • Reflective listening/responses:Repeating, restating Thoughtful communication is an essential element in health or clarifying the key points in what patients have said coaching. It can facilitate and support the patient’s consideration communicates to patients that the health coach has heard of, and decision to make a change in health behaviour. The health them, values their concerns and wants to understand their coach seeks to learn the patients’ knowledge or understanding point of view. It may also help the patient gain an additional of their condition, the goals they would like to achieve, and perspective to reflect on as they consider making a change in the factors that will affect achieving them (both positive and behaviour. negative). The health coach then provides information that is • Maintaining a respectful manner: Communicating a positive targeted to the patient’s understanding, needs and personal regard for the autonomy of patients will allow a discussion of situation. their situation without overwhelming them with information. For example, when patients identify a specific concern, the health coach first explores what the patients know already, and then inquires if they are interested in knowing more.
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 9 By responding to the specific question or issue, rather • Exchanging information– elicit what the patient than providing a global explanation of the whole topic, understands, provide information on potential results patients are enabled to review their situation and make of not changing (both positive and negative), elicit their decisions based on their understanding and new learning. understanding of any personal implications of making a change, as well as not making the change. As in all aspects of care, thoughtful communication improves compliance and is an important factor in improved • Responding to patients’ language – as in active listening. 33 outcomes. • Use open-ended questions. When patients engage in “change talk,” which suggests they are thinking of Motivational Interviewing change (e.g., “I should...” “I want to...“ or “I know it would be better if I ...”) the coach’s response might be to Motivational Interviewing (MI) is one methodology used say “You feel that…” or “How do you think you might...” effectively in health coaching. MI is a “collaborative, person- that encourages more discussion about change. When centred form of guiding to elicit and strengthen motivation for they use “sustain talk,” indicating preference for the change,”34 and like all other professional skills, requires training status quo ( e.g., “I enjoy...” or “I have never succeeded and practice. Within health coaching, MI is used to assess the in...”) the coach attempts to move the conversation readiness of patients for change, build on their ability or capacity towards change, using questions such as “What do you to make a change, and to set realistic goals. see as drawbacks to...”, “What would happen if...” or “How might things be different if...” MI focuses on “evoking and strengthening” the client’s own verbalized motivations for change.35 Its guiding principle is MI requires training to learn the skill and achieve competency to that the patient articulates the arguments for change, not the practice. The Resources Section provides links to opportunities professional.35 Arguments, or reasons, for change are classified for training and online resources in MI, including a webinar on as “change talk.” Conversely, reasons for maintaining the status MI by D. Gross, PT, PhD and Joanne Park, OT, PhD hosted by quo are classified as “sustain talk.” The focus of MI is to explore Physiotherapy Alberta College + Association. those reasons, resolve the ambivalence to change and guide the patient as they shift to “change talk.”35 Behaviour Change Techniques MI integrates common communication strategies under the following set of principles: Behaviour change interventions include all the components of a health coaching strategy. Behaviour Change Techniques • It requires the physiotherapist to adopt an empathic style (BCTs) are the active and measurable components.36 These that is accepting and a belief that ambivalence about change techniques offer a broad range of tools a health coach can 34 is normal. employ to facilitate health behaviour change at any stage in the • Using MI techniques helps the patient recognize process of behaviour change. Similar to MI, BCTs can prompt discrepancies between their stated goals and their current reflection, identify barriers or obstacles to change, build self- situation, avoids arguments (“rolls with resistance”) efficacy and help implement or maintain a behaviour change. For and supports self-efficacy. “Rolling with resistance” example, an active learning strategy may use problem solving acknowledges any negative comments and reframes them (a BCT) in conjunction with other BCTs such as goal setting, by, for example, restating them as a neutral reflection, self-monitoring, behavioral prompts, cognitive coaching, and or by providing information that may shift the patient’s reinforcement to achieve a goal. 34 perspective. BCTs may be behavioural, cognitive or motivational and can • It requires the physiotherapist to remain focused on the be implemented throughout the behavioural change process. goals and values of patients – it is not a series of questions Recent research suggests that combining BCTs that facilitate intended to convince them to change behaviour, or to self-regulation, defined as the physical skills and function, or the pressure them into making a change that the coach has “how to,” with communication that addresses the underlying identified as important.34 motivation, the “why,” supports maintaining a new behaviour over time.37 For example, an older adult may cite maintaining Although training in MI is recommended, Rollnick et al provided independence as their primary goal because they enjoy travel, 21 family physicians an introduction to the core strategies, and while a younger person may focus more on resuming a particular recommended the use of: sport or activity, because he or she is looking forward to a • The guiding style tournament. For the former, BCTs may be targeted to prompting graded exercise and identifying barriers, while for the latter, • Open ended questions that ask the patient to consider pacing and visualization may be most effective. how and why he or she might change “Active” or behavioural BCTs, such as pacing and self-regulation, • Using reflection or other means to show empathy and which encourage symptom self-management, have been shown encourage discussion to be more effective than “passive” or cognitive techniques, • Asking permission to provide evidence-based such as education and advice, for maintaining physical activity information; ask what more information might mean in people with OA.36 Similarly, BCTs such as graded activity, to them (e.g., “would you like to know more about?”, self-monitoring, recording activity outcomes, or planning and i.e., effects of physical inactivity, weight gain or chronic implementing environmental changes are effective for increasing condition diagnosis, ..or “what do you think that physical activity and for healthy eating.37 (information) means for you?”) Appendix 1 is the PT-BCT Checklist, developed in 2014 by Harman, • Building on patients’ strengths, such as: MacRae, Vallis and Barrett,38 and is used with permission. The checklist includes BCTs specific to physiotherapy practice and • Setting the agenda by asking them to select the issue or were selected from Abraham and Michie’s taxonomy of BCTs.39 problem that is their priority. The BCTs and their descriptions in the checklist relate to chronic • Assessing their ambivalence to change – what are the MSD disorders, but are applicable to other areas of physiotherapy pros and cons? Is change a possibility? practice. • Determining what the importance of making a change is. If its importance is not high, supply information for further review, recognizing their autonomy in decision making.
10 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Identifying Achievable Goals
The strongest predictor of success in health coaching is how the goals are set.40 To bridge the gap between intention and behaviour, any goal must be specific to the patient’s personal preferences and ability, recognize potential obstacles and plan strategies in advance to overcome them.41
The health coach recognizes that throughout the change process, • An Adapted OPDG, for use with indigenous populations, is also the patient’s readiness to change and their resulting decisions included in the Appendix 2.43 and actions will be influenced by both their decisional balance and Lower scores in the tools assessing decisional balance suggest the self-efficacy. patient is likely either in the Pre-contemplation or Contemplation There are several tools available to ascertain readiness to change. stage within the TTM model. Pre-contemplators may rate For example, the Likert scale (1-10) can quantify both how importance of change at three or lower. These patients are more important making the change is to the patient and how confident likely to speak more about reasons not to change - the cons - than he or she is that the changes can me made. Patients’ responses the benefits for making a change - the pros. By contrast, the will give a strong indication of the value they attach to the change reverse occurs for patients in the Action or Maintenance stages: and their readiness to make that change.21 they tend to speak more about the pros for maintaining the change than the cons.44 Additional tools to evaluate or monitor decisional balance include: Similarly, there is evidence that there is a strong correlation • The “Readiness Ruler” (Figure 2), is also a 10-point scale that between self-efficacy scores on the tools and the patient’s stage can be used throughout the coaching process and beyond to within the TTM. Scores on the Likert scale or the Readiness Ruler weigh decisions about the importance of making a change and are lower in the pre-contemplation stage than in the maintenance confidence in their ability to make that change. stage.44 • The Ottawa Personal Decision Guide (OPDG) is a take home Along with the observations about the patient’s understanding guide that is valid across populations and is included in of their condition, their health beliefs and their social and family Resources Section of this document. The coach may provide it support, the scores for both decisional balance and self-efficacy as part of the consultation with the patient. The OPDG walks assist the health coach to determine the patient’s stage in the the patient through the process of identifying problems, TTM and to plan the appropriate health coaching approach. weighing the pros and cons for each risk and benefit, identifies available support and clarifies the approach the patient prefers.42
Figure 2. Readines Ruler
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 11 Stage Goal: increase physical activity Coaching approach Examples of potential BCTs to select from PT-BCT Checklist Pre-contemplation May be unaware of the benefits they Discussions on benefits of physical Providing information on behaviour might gain by increasing physical activity, explore cons, barriers of making – health link, prompting intention activity, have other priorities that take a change, as well as pros and cons of formation, prompting self-monitoring precedence, or have barriers such as not making a change. Problem solving, if of behaviour. location or a lack of equipment to engage appropriate, including whether this is the in a physical activity. They may not right time in the patient’s life to make a recognize the gap between their goal and change in this area. their current status. Contemplation/ May feel the cons of (barriers to) physical Discuss potential benefits of physical Role modelling, providing information Preparation activity outweigh the pros. May have activity, explore cons and engage in on the approval of others, prompting pre-conceptions for what is required or problem solving to resolve cons/barriers, visualization, facilitating internal may have not been successful in past as well as the pros and cons of not reinforcement. attempts. making the change. Encourage reflection on intrinsic reasons for goal by exploring what will change in the patient’s life by making a change, and/or past successes, as well as the contributing factors. Action Has begun to increase activity but it is Confirm benefits of regular physical Pacing, agreement to behavioural irregular. activity, problem solving for barriers, contract, positive feedback. support self-efficacy in keeping schedule, routine, and contingency planning for occasions when activity is not possible. Maintenance Regular participant Support self-efficacy, discuss value of Setting graded activity, stress variety of activities, social support management, review of behavioural goals, internal reinforcement Table 1.
Table 1 demonstrates how a health coach may approach Cultural competence collaborative goal setting with patients at various stages and/or readiness to change when “increased physical activity” was the Cultural competence is the ability to communicate effectively and first goal the patient selected. NOTE: BCTs are suggestions only respectfully with people from different backgrounds. In health and will be selected as appropriate to the patient. care, it has been defined as “acknowledging and incorporating the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural Bridging patient goals and outcome measures differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs.”46 The term also refers Patients’ goals are specific to their personal situation or needs. to ethno-cultural, gender and/or gender identity and expression, However, in the clinic, the physiotherapist’s assessment goals sexual orientation, age, disability, income, and educational level or intervention measures may not address the patient’s goals differences. directly.45 A study comparing patient goals and clinical outcome measures used in chronic low back pain found that patient goals Health-care professionals have the same implicit biases as the were not directly tied to the clinical outcome measures used general population.47 Implicit biases are those a person may for pain or for recording the patient’s clinical improvements.45 not be conscious of; the “stereotype –confirming thoughts that For example, while treatment was progressed or adjusted based pass spontaneously through one’s mind, and that can lead to on changes in range, strength, or other outcome measures, discrimination.”48 Implicit biases may even exist regardless of patients’ goals (and their own measure of success) were their the person’s expressed values.48 Research shows that biases ability to resume a specific activity. Health coaching is an in health care can result in poorer health outcomes, as well excellent tool that can be used to bridge the patient’s goals to as reduced adherence to health care in targeted populations.48 the outcome measures used by physiotherapists to measure Biases do not have to be overt – they can be expressed through progress, providing the goals are aligned and the physiotherapist “micro-aggressions - brief, verbal or non-verbal expressions that is able to articulate how the goals support one another. may or may not be intentional, but convey a derogatory or hostile attitude.”49 Throughout the health coaching relationship, the focus is on patients setting and achieving their goals, with the health coach The following are examples of strategies for incorporating facilitating the patients’ ability to identify and solve problems, cultural competence within health coaching: and respecting their autonomy.18 • Be aware of how your personal status (e.g., gender, race, HealthChange(R) Australia is a methodology that promotes physical abilities or health, income, sexual orientation, behaviour change to support self-management. The education etc.) may predispose you to implicit biases, such as physiotherapist in the video in the link below describes how she your expectations for health behaviours in others incorporates health coaching principles within physiotherapy • Reflect on your own implicit and explicit biases management of a woman with an acute ankle injury, and is used with permission: • Develop and use an inclusive assessment form https://vimeo.com/healthchange/review/83546314/3d15a2bdf8 • Provide culturally specific examples to communicate concepts • Link goals to culturally informed roles and expectations • Provide links to appropriate community supports for follow up
12 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Active Learning
Successful health coaching strategies use a patient-initiated agreement on goals and tasks.50 Within the trust built by the therapeutic alliance, the overall goal is broken down into manageable steps.
As the steps are accomplished, patients (especially those in the The health coach also recognizes that the means or activities to initial stages of behaviour change) gain self-efficacy and learn they meet the desired goal for “increased physical activity” will be more have the ability and capacity to succeed in other situations. successful if it is the patient’s preference or choice – this may include whether this is done independently or with a peer group, Whether a goal is focused on physical activity, a functional goal or as an example. Similarly, some patients prefer non-competitive a social activity, it must be stated in the patient’s own words and activities, while others gain from being part of a competition.51 In be meaningful to them. For example, the patient who has stated some situations, it may be that formal physiotherapy treatment is broadly that his or her goal is to “increase their level of physical the patient’s choice and the optimal means to achieving the goal: activity”, may further elaborate that he or she misses going to the health coach is attuned to this as well. her/his weekly walking club and would like to re-join. This goal has meaning and value to them. Their statement “I would like to rejoin Table 2 illustrates a patient-led plan for increasing physical my walking group” may be further broken down into “I would activity. In this case, the health coach used the SMART model of like to walk for 30 minutes at a moderate pace so I can rejoin my goal setting to facilitate the process. walking group with confidence”. Goal setting includes talking about managing any setbacks In the ensuing discussion, the patient expresses concern that may happen such as the possibility that patients may about their endurance, as he or she has been diagnosed with encounter obstacles (e.g., time constraint, symptom flare) or osteoarthritis and feels his or her legs are getting weaker and that their situation may change (family or work requirements) knees are stiff lately. Together the physiotherapist and the patient and ensuring that this is a part of the change process. The coach consider the actions required to resume distance walking and will reinforce to the patient that behaviour change is not always work out a strategy that prioritizes the steps and is achievable. straightforward. If a patient finds he/she has fallen short of a Steps the patient proposes might include getting stronger, goal, the patient and the health coach will look at contributing improving stamina, and/or buying better footwear. The coach uses factors together, and will either revise the plan or problem open ended questions to help them prioritize the steps and decide solve to overcome the obstacle. The underlying message is that on an action plan (e.g., “what gives you the most difficulty?”, both sustained effort and problem solving are valuable tools in “which of these would you like to work on first?”) achieving self-efficacy,23 and will be applicable to future situations.
Goal Specific Measurable Action oriented Realistic Time dependent What would you like What specific steps How will you measure What actions will you Is this doable? What is your to accomplish and can you take? your progress? How need to take? timeframe? When will why? often will you follow you start? your plan? I want to exercise I will begin with daily I can go every day I will add it to my I can walk outside in I will walk four days more so I have more walks either before 10:00 or calendar four days of good weather or to a week for a month energy after 3:00 and walk for every week and log my go to the mall other starting next Monday. 15 minutes. walk times. days. Each week I will increase the time by five minutes. Table 2.
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 13 Personal Accountability
With support from the health coach, patients finalize their plan, and the coach provides a means for recording the actions supporting the progress towards and achievement of the goal.
In the case of the patient whose goal is to return to their walking group, the plan may include recording pacing progress and problem solving about potential flare-ups (BCTs). Self- monitoring encourages perseverance, and a visible record provides information on self-efficacy. It may also reveal where a barrier occurs or if the goal itself requires modification. Depending on the patient’s preference, the coach may recommend tools such as a written log or a diary, wearable technology, or an online program. Examples of each tool can be found in the Resources section of this document. Patients carry out the actions in the plan, with the coach following their progress and providing feedback in person, by phone or by email, depending on the patient’s needs and preferences. Health coaches may also schedule “booster” sessions to review progress and modify actions with the client and provide feedback and encouragement in person.
14 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Considerations Specific to Physiotherapy
With support from the health coach, patients finalize their plan, and the coach provides a means for recording the actions supporting the progress towards and achievement of the goal.
Of the four identified risk factors in chronic conditions, physical • A question about smoking (amount, frequency) may generate inactivity is the health behaviour most associated with current a discussion on awareness of the health benefits of changing physiotherapy practice. However, physiotherapists may also that behaviour, perceived obstacles for quitting and how have a role in smoking cessation and are often asked questions patients might overcome them, as well as building the regarding nutrition. Similarly, while weight loss is not a primary physiotherapist’s understanding of why a person values goal in physiotherapy practice, physiotherapists may be part smoking or why they smoke. Throughout, the physiotherapist of an obesity management team and participate in coaching maintains a non-judgmental attitude. If patients indicate and facilitating increasing physical activity as well as assessing they are interested in receiving more information, the mobility, balance, and physical function in this population. In physiotherapist can provide a link to Alberta Quits, a free recent years, physiotherapists have also participated in the self-management program offered by Alberta Health Services. management of sleep hygiene and stress management. The The physiotherapist may also offer to provide information on following section demonstrates the application of the principles of other formal programs in the area if the patient is interested. health coaching to clinical physiotherapy practice, with examples • When a patient presents to physiotherapy, and obesity from the literature. may be a contributing factor to their diagnosis, the Physiotherapists may incorporate health coaching principles as physiotherapist may request permission to discuss their brief interventions within traditional physiotherapy treatments, weight. Then, using a coaching approach, the physiotherapist or in some cases, may use health coaching as a stand-alone explores their understanding of their weight and weight intervention to assist with chronic disease management management specific to their current situation. If the patient (depending on the physiotherapist, the patient served and the expresses interest, the physiotherapist may provide access to practice setting). online resource such as My Health Alberta’s online learning module for weight management, or initiate a referral to a community dietician or a formal program in the community. Brief interventions • Restful sleep is a challenge for many patients with chronic Physiotherapists may gather information about health behaviours conditions and not getting enough can be detrimental to their in the initial assessment as follows: overall health. The assessment may include a question about • Including a question about physical activity can generate sleep patterns and if appropriate, the physiotherapist may a discussion about the patient’s knowledge of the health inquire if the patient would like more information. My Health benefits of physical activity, as it applies to their reason Alberta provides an online module on strategies for improving for consulting a physiotherapist. Part of a brief coaching sleep patterns. The physiotherapist may determine that a intervention may include sharing information about the coaching approach to a program of sleep hygiene within their 53 health benefits of, for example, short bursts of “incidental treatment plan is appropriate, or refer the patient to their physical activity,” or prompt a discussion about Canada’s physician or a community program. Physical Activity Guidelines.52 Physiotherapists may also • Similarly, if the patient identifies stress or anxiety during consider linking the patient to HealtheStepsTM, a free online the assessment, such as concern about work performance and app-based coaching program to help patients increase or relationships, the physiotherapist may inquire about their activity level. steps the patient has already taken and/or interest in information about stress management. With an affirmative response, the physiotherapist may provide the My Health Alberta link. Similar to the approach to sleep hygiene, if the physiotherapist has training in stress management, he or she may consider using a health coaching approach to address that within the treatment plan or refer the patient to a formal program.
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 15 Alternately, when the patient’s comments related to changing Depending on the clinical setting, health coaching can be a team a health behaviour are couched with negatives, or “wishes” strategy or practiced by the physiotherapist independently. In (“I would but I have no time,” “It’s too hard” etc.), the some situations, a certified health coach is part of the team. physiotherapist may use reflective listening to explore their Regardless of the setting, the physiotherapist practices health rationale and offer to work with them to develop a plan when the coaching in collaboration with other team members (including the patient chooses to do so. For example, the physiotherapist may patient) to support the achievement of the goals the patient has suggest patients reflect on their use of personal strengths in past established. situations and how this might apply to the current situation.19 Several studies illustrate how physiotherapists have implemented various health coaching strategies for health behaviour change in Longer-term interventions different practice areas. A longer-term health coaching intervention may result from the Patients with MS, at any level of disability, improved their level of earlier conversation during the assessment or be introduced as an physical activity through an innovative program that helped them option in the physiotherapy treatment plan. select an activity that had value to them. The physiotherapist interspersed bi-weekly home visits to patients with MS with Here, the physiotherapist asks patients what concerns them texts, emails and online patient support groups. The patients in most about their current condition and what they think are the the program perceived it as supportive and enabled them to adopt main issues. This message communicates a respectful approach new health behaviours.55 and recognizes the patient’s autonomy in self-management but may also help the physiotherapist determine how to focus the Patients with non-chronic LBP who received telephone coaching physiotherapy assessment. in addition to their usual physiotherapy showed significant improvement in the Patient Specific Functional Scale and in The physiotherapist introduces the concept of a collaborative recovery expectation.56 relationship in setting goals and action plans for self- management, with the physiotherapist providing evidence- Patients with chronic LBP who identified personal challenges based information, collaborating on setting achievable goals, in managing their LBP, and were supported in goal setting and developing the action plan, as well as giving feedback and evidence based strategies to achieve them, showed significant guidance on the chosen goals and strategies. The patient carries improvement in a number of measures, including pain, disability, 57 out their action plan, tracks their own progress and meets with fear avoidance, quality of life self-efficacy. the physiotherapist to review successes or lapses as part of an active learning process (what works/what doesn’t?) for self- management. When the assessment is complete, the physiotherapist offers the patient the options for care, whether self-management strategies or traditional physiotherapy interventions. For those patients who choose traditional management, the physiotherapist may incorporate a health coaching approach for the education component of the treatment plan, using discussion of health behaviour change and an active learning process. In either situation, the physiotherapist documents the assessment findings, selected interventions, progress and outcomes. Appendix 4 is a description by a physiotherapist of their strategy to introduce a patient to behaviour change and self-management. It is used with permission of HealthChange Australia,54 a methodology that uses behaviour change to support and promote self-management in health care.
16 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Resources
Behaviour Change Information Apps to support health coaching Health Change Australia offers an extensive selection of Myhealth - Pain Care resources, tools and publications. A 2019 study, by Yang et al, found that an “app APPS-based Physiopedia has published an extensive review of health coaching self-management program appears to bring additional benefits including a review of apps that physiotherapists can incorporate to physiotherapy for patients with CLBP. Self-management is a within a coaching strategy. potential approach for people with CLBP”.59 Alberta Health Services has adopted the work of Health Change Accupedo Pro pedometer Australia and is in the process of training their staff in the A 2014 study by Glynn et al found that a simple smartphone app methodology. They provide additional information about the improved physical activity in a primary care population.60 methodology and theoretical foundations. Motivational Interviewing Webinar for Injured Workers, presented by Joanne Park, OT, PhD, Douglas Gross, PT, PhD, Additional Training outlines the technique of motivational interviewing and research This toolkit is intended to introduce readers to the concepts that regarding the effectiveness of the technique, when working with underly health coaching and equip them with beginner-level skills. injured workers. Physiotherapists wishing to advance their skills in this area are HealtheSteps is a free online coaching program available to encouraged to seek additional training. The list below includes anyone interested in improving health behaviours. It was organizations that offer additional training in coaching and developed at the Lawson Health Research Institute at Western motivational interviewing. Physiotherapy Alberta does not endorse University. any training programs. Physiotherapists are encouraged to fully investigate all training options for themselves to determine the program that best addresses their learning needs. Tools • Excel Academy Readiness Ruler is available from the centre for evidence-based • Change Talk Associates practice. It can be used in the assessment of decisional balance and self-efficacy. • Alberta Home Visitor Network Ottawa Personal Decision Guide was developed at the Ottawa • AIM Alberta Health Research Institute. It is protected by copyright but is • The Monarch System “freely available to use, provided you: a) cite the reference in any documents or publications; b) do not charge for or profit from * Please note this is not an endorsement of these courses by them; and c) do not alter them except for prefilling them for a Physiotherapy Alberta. specific condition/decision as necessary”. The Culturally Adapted OPDG (Appendix 2) was developed to support decision making by Indigenous women and is thought to have broad application. PDF OA GO AWAY (Appendix 3) was a self-management tool for increasing physical activity and exercise in patients with OA of the hip or knee. Self-Efficacy for Managing Chronic Disease – Six Item Scale My Health Record is a tool from Alberta Health that enables Albertans to keep records of their sleep, mood, weight, and fitness goals and track of their medications and lab results.
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 17 Appendix 1: The PT-BCT Checklist
18 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 19 20 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 21 22 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Appendix 2: Personal Decision Guide
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 23 24 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Appendix 3: OA Go Away
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 25 26 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 27 28 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 29 30 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 31 32 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 33 34 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Appendix 4: HealthChange Methodology
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 35 36 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Sources
1. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient Self- AM, Daei A. Transtheoretical Model of Health Behavioral management of Chronic Disease in Primary Care. JAMA. 2002; Change: A Systematic Review. Iran J Nurs Midwifery Res. 2019; 288(19):2469–2475. doi:https://doi.org/10.1001/jama.288.19.2469 24(2):83–90. doi:10.4103/ijnmr.IJNMR_94_17 2. Boehmer KR, Barakat S, Ahn S, Prokop LJ, Erwin PJ, Murad 18. Diener I, Kargela M, Louw A. Listening is Therapy: Patient MH. Health Coaching Interventions for Persons with Chronic Interviewing from a Pain Science Perspective. Physiother Conditions: A Systematic Review and Meta-analysis Protocol. Theory Pract. 2016; 3(5):356-367. http://dx.doi.org/10.1080/095 Syst Rev 5; 146(2016) doi:10.1186/s13643-016-0316-3 93985.2016.1194648 3. Bennett HD, Coleman EA, Parry C, Bodenheimer T, Chen EH. 19. Wolever RQ, Simmons LA. A Systematic Review of the Health Coaching for Patients with Chronic Illness. Fam Pract Literature on Health and Wellness Coaching: Defining a Key Manag. 2010; 17(5):24-29. Behavioral Intervention in Healthcare. Glob Adv Health Med. 4. Kivela K, Elo S, Kyngas H, Kaariainen M. The Effects of 2013; 2(4):38-57. Health Coaching on Adult Patients with Chronic Diseases: A 20. Frates EP, Bonnet J. Collaboration and Negotiation: The Key Systematic Review. Patient Educ Couns. 2014; 97(2):147-57. doi: to Therapeutic Lifestyle Change. Am J Lifestyle Med 2016; (5): 10.1016/j.pec.2014.07.026. Epub 2014 Aug 1. 302–312. doi:10.1177/1559827616638013 5. Finn HE, Watson RA. The Use of Health Coaching to Improve 21. Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Outcomes: Implications for Applied Behavioural Analysis. The Motivational Interviewing. BMJ. 2010; 340. https://doi. Psychological Record. 2017; 67(2): 181-187. org/10.1136/bmj.c1900 (Published 27 April 2010) 6. Wong-Rieger D, Rieger F. Health Coaching in Diabetes: 22. Prochaska JO, Velicer WF. The Transtheoretical Model of Empowering Patients to Self-Manage. Canadian Journal of Health Behaviour Change. Am J Health Promot. 1997; 12(1):38- Diabetes. 2013; 37(1):41–44. 48. 7. Canadian Physiotherapy Association. Description of 23. Bandura A. Self-efficacy. In V.S. Ramachandran (Ed) Physiotherapy in Canada. 2012. Canadian Physiotherapy Encyclopedia of Human Behaviour. Academic Press. 1994; (4): Association. Available at https://physiotherapy.ca/sites/default/ 71-81. files/site_documents/dopen-en.pdf. Accessed November 14, 24. Sommaruga M, Gremigni P, Zaga V, Goti C, Bassi L, Santus P. 2019. Self-efficacy and Quality of Life in COPD Patients. European 8. Frerichs W, Kaltenbacher E, van de Leur JP, Dean E. Can Respiratory Journal 2012; 40: 1462. Physical Therapists Counsel Patients with Lifestyle-related 25. Brisson NM, Gatti AA, Stratford PW, Maly MR. Self-efficacy, Health Conditions Effectively? A Systematic Review and Pain, and Quadriceps Capacity at Baseline Predict Changes Implications, Physiother Theory Pract. 2012; 28(8):571-587, doi: in Mobility Performance Over 2 years in Women with Knee 10.3109/09593985.2011.654179 Osteoarthritis. Clin Rheumatol. 2018; 37(2):495-504. doi: 9. Public Health Agency of Canada. How Healthy are Canadians: 10.1007/s10067-017-3903-3. Epub 2017 Nov 10. A Trend Analysis of the Health of Canadians from a Healthy 26. Arnstein P, Caudill M, Mandle CL, Norris A, Beasley R. Self- Living and Chronic Disease Perspective. Public Health efficacy as a Mediator of the Relationship Between Pain Agency of Canada; 2016. Available at https://www.canada.ca/ Intensity, Disability and Depression in Chronic Pain Patients. content/dam/phac-aspc/documents/services/publications/ Pain. 1999; 80(3):483-91. healthy-living/how-healthy-canadians/pub1-eng.pdf. Accessed 27. Andenaes R, Bentsen SB, Hvinden K, Fagermoen MS, Lerdal A. November 14, 2019. The Relationships of Self-efficacy, Physical Activity, and Paid 10. Petrella RJ, Davis P. Improving Management of Work to Health-related Quality of Life Among Patients with Musculoskeletal Disorders in Primary Care: The Joint Chronic Obstructive Pulmonary Disease (COPD). J Multidiscip Adventures Program. Clin Rheumatol. 2007; 26:1061-1066. doi: Healthc. 2014; 7:239-47. doi: 10.2147/JMDH.S62476. eCollection 10.1007/s10067-006-0446-4. 2014. 11. Rapoport J, Jacobs P, Bell NR, Klarenbach S. Refining the 28. LaTouche R, Grande-Alonso M, Arnes-Prieto P, Paris-Alemany Measurement of the Economic Burden of Chronic Diseases in A. How Does Self-efficacy Influence Pain Perception, Postural Canada. Chronic Dis Can. 2004; 25:13–21. Stability and Range of Motion in Individuals with Chronic Low 12. Bae W, Ik Suh Y, Ryu J, Heo J. Physical Activity Levels and Back Pain? Pain Physician. 2019; 22(1):E1-E13. Well-being in Older Adults. Psychol Rep. 2017; 120(2):192–205. 29. Hammond A, Niedermann. Patient Education and Self 13. Tribess S, Virtuoso Junior JS, Oliveira RJ. Physical Activity as Management. In Dziedzic K, Hammond A, editors. a Predictor of absence of Frailty in the Elderly. Rev Assoc Med Rheumatology: Evidence Based Practice for Physiotherapists Bras (1992). 2012; 58(3):341-7. and Occupational Therapists. New York: Elsevier; 2010. p.83. 14. Sari N. Physical Inactivity and its Impact on Healthcare 30. Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. The Utilization. Health Econ. 2009; 18(8):885-901. doi: 10.1002/ Necessary Conditions of Engagement for the Therapeutic hec.1408 Relationship in Physiotherapy: An Interpretive Description 15. Lawn S, Shoo A. Supporting Self-management of Chronic Study. Arch Physiother. 2018; 8:3. doi:10.1186/s40945-018- Health Conditions: Common Approaches. Patient Educ Couns. 0044-1 2010; 80(2):205-11. doi: 10.1016/j.pec.2009.10.006. 31. Hutting N, Johnston V, Staal JB, Heerkens YF. Promoting the 16. Ingledew DK, Markland D. The Role of Motives in Exercise Use of Self Management Strategies for People with Persistent Participation. Psychol Health. 2008; 23(7):807-28. doi: 10.1080/08870440701405704. 17. Hashemzadeh M, Rahimi A, Zare-Farashbandi F, Alavi-Naeini
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 37 Musculoskeletal Disorders: The Role of the Physical Therapist. Worse Health. Centre for health Journalism. November 10, J Orthop Sports Phys Ther. 2019; 49(4):212-215. doi: 10.2519/ 2017. Available at https://www.centerforhealthjournalism. jospt.2019.0605. org/2017/11/08/how-racism-and-microaggressions-lead-worse- 32. Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. A health. Accessed November 14, 2019. Framework for Establishing Connections in Physiotherapy 50. Gessnitzer S, Kauffeld S. The Working Alliance in Coaching: Practice. Physiother Theory Pract. 2019; 35(1):40-56. doi: Why Behavior Is the Key to Success. J Appl Behav Sci. 2015; 10.1080/09593985.2018.1434707. 51(2):177–197. https://doi.org/10.1177/0021886315576407 33. Zolnierek KB, Dimatteo MR. Physician Communication and 51. Burton NW, Khan A, Brown WJ. How, Where and With Whom? Patient Adherence to Treatment: A Meta-analysis. Med Care. Physical Activity Context Preferences of Three Adult Groups 2009; 47(8):826–834. doi:10.1097/MLR.0b013e31819a5acc at Risk of Inactivity. Br J Sports Med. 2012; 46(16):1125-31. doi: 34. Miller WR, Rollnick S. Ten Things That Motivational 10.1136/bjsports-2011-090554. Epub 2012 Jan 20. Interviewing is Not. Behav Cogn Psychother. 2009; 37(2):129- 52. Canadian Society of Exercise Physiology, Canadian Physical 40. doi: 10.1017/S1352465809005128 Activity Guidelines, 0 – 65+. Available at http://csep.ca/CMFiles/ 35. Miller WR, Rose GS. Toward a Theory of Motivational Guidelines/CSEP_PAGuidelines_0-65plus_en.pdf. Accessed Interviewing. Am Psychol. 2009; 64(6):527–537. doi:10.1037/ November 14, 2019. a0016830 53. Siengsukon CF, Al-dughmi M, Stevens S. Sleep Health 36. Willet M, Duda J, Gautrey C, Fenton S, Greig C, Rushton Promotion: Practical Information for Physical Therapists. Phys A. Effectiveness of Behavioural Change Techniques in Ther, 2017; 97 (8) 826–836. https://doi.org/10.1093/ptj/pzx057 Physiotherapy Interventions to Promote Physical Activity 54. Health Change Australia. Health Change Australia. 2019. Adherence in Patients with Hip and Knee Osteoarthritis: A Available at http://www.healthchange.com/. Accessed Systematic Review Protocol. BMJ Open. 2017; 7(6):e015833. doi: November 14, 2019. 10.1136/bmjopen-2017-015833 55. Smith CM, Hale LA, Mulligan HF, Treharne GJ. Participant 37. Samdal GB, Eide GE, Barth T, Williams G, Meland E. Effective Perceptions of a Novel Physiotherapy Approach (“Blue Behaviour Change Techniques for Physical Activity and Healthy Prescription”) for Increasing Levels of Physical Activity in Eating in Overweight and Obese Adults: A Systematic Review People with Multiple Sclerosis: A Qualitative Study Following and Meta-regression Analyses. Int J Behav Nutr Phys Act. 2017; Intervention. Disabil Rehabil. 2013; 35:14, 1174-1181, doi: 14(1):42. doi:10.1186/s12966-017-0494-y 10.3109/09638288.2012.723792 38. Harman K, Macrae M, Vallis M, Bassett R. Working with People 56. Iles R, Taylor NF, Davidson M, O’Halloran P. An Effective to Make Changes: A Behavioural Change Approach Used in Coaching Intervention for People with Low Recovery Chronic Low Back Pain Rehabilitation. Physiother Can. 2014; Expectations and Low Back Pain: A Content Analysis. J 66(1):82-90. doi: 10.3138/ptc.2012-56BC. Back Musculoskelet Rehabil. 2014; 27(1):93-101. doi:10.3233/ 39. Abraham C, Michie S. A Taxonomy of Behavior Change BMR130424. Techniques Used in Interventions. Health Psychol. 2008; 57. Gardner T, Refshauge K, McAuley J, Goodall S, Hubscher M, 27(3):379-87. doi: 10.1037/0278-6133.27.3.379. Smith L. Patient-led Goal Setting: A Pilot Study Investigating a 40. Bailey RB. Goal Setting and Action Planning for Health Promising Approach for the Management of Chronic Low Back Behavior Change. Am J Lifestyle Med. 2017; 13(6):615-618. Pain. Spine (Phila Pa 1976). 2016; 41(18):1405-13. doi: 10.1097/ https://doi.org/10.1177/1559827617729634 BRS.0000000000001545. 41. Bassett SF. Bridging the Intention-Behaviour Gap with 58. Paterson G. April KT, Backman C, Tugwell P. OA Go Away: Behaviour Change Strategies for Physiotherapy Rehabilitation Development and Preliminary Validation of a Self-management Non-adherence. New Zealand Journal of Physiotherapy 2015; Tool to Promote Adherence to Exercise and Physical Activity 43(3): 105-111. doi 10.15619/NZJP/43.3.05 for People with Osteoarthritis of the Hip or Knee. Physiother Can. 2016; 68(2):124–132. doi:10.3138/ptc.2014-68 42. O’Connor, Stacey, Jacobsen. Ottawa Personal Decision Guide [Internet]. Ottawa: Ottawa Hospital Research Institute & 59. Yang J, Wei Q, Ge Y, Meng L, Zhao M. Smartphone-based University of Ottawa, Canada; 2015. November 19, 2019. Remote Self-management of Chronic Low Back Pain: A Available from: https://decisionaid.ohri.ca/docs/das/OPDG.pdf Preliminary Study. J Healthc Eng. 2019; 2019: 4632946. Doi: 43. Jull J, Giles A, Minwaashin Lodge, The Aboriginal Women’s 10.1155/2019/4632946. Support Centre, Boyer Y, Stacey D. Cultural Adaptation of 60. Glynn LG, Hayes PS, Casey M, Glynn F, Alvarez-Iglesias A, a Shared Decision Making Tool with Aboriginal Women: A Newell J, et al. Effectiveness of a Smartphone Application Qualitative Study. BMC Med Inform Decis Mak. 2015; 15(1). to Promote Physical Activity in Primary Care: The SMART https://doi.org/10.1186/s12911-015-0129-7 MOVE Randomised Controlled Trial. Br J Gen Pract. 2014; 44. Herrick AB, Stone WJ, Mettler MM. Stages of Change, 64(624):e384–e391. doi:10.3399/bjgp14X680461. Decisional Balance, and Self-efficacy Across Four Health Behaviors in a Worksite Environment. Am J Health Promot. 1997; 12:49-56. 45. Gardner T, Refshauge K, McAuley J, Goodall S, Hurscher M, Smith L. Patient Led Goal Setting in Chronic Low Back Pain- What Goals Are Important to the Patient and Are They Aligned to What We Measure? Patient Educ Couns. 2015; 98(8):1035-8. doi: 10.1016/j.pec.2015.04.012. Epub 2015 Apr 27. 46. Betancourt J, Green AR, Carrillo JE, Ananeh-Firempong O. Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care. Public Health Rep, 2003; 118:293-302. 47. Fitzgerald C, Hurst S. Implicit Bias in Healthcare Professionals: A Systematic Review. BMC Med Ethics. 2017; 18(1):19. doi: 10.1186/s12910-017-0179-8. 48. Payne K, Niemi L, Doris JM. How to think about implicit bias. Scientific American, March 27, 2018. Available at https://www. scientificamerican.com/article/how-to-think-about-implicit- bias/. Accessed November 14, 2019. 49. Torino G. How Racism and Micro-aggressions Lead to
38 Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists Acknowledgements
The Introduction to Health Coaching was developed by Clare Smith graduated from University of London, Kings College, Physiotherapy Alberta College+ Association with the following with BScPT in 1993. She has spent the last 25 years working in advisory committee members, and thanks them for their many aspects of Acute Care, but specializing in Cardiorespiratory contribution and commitment to the project outcome. Project physiotherapy in Paediatric and Adult populations. The last 18 lead was Carol Miller, Consultant in Knowledge Mobilization for have been spent working with truly dedicated teams involved Physiotherapy Alberta. with the care of people with Cystic Fibrosis, from bedside care, to support in daily life and finally into clinical research. Cari Cooke has been a Physiotherapist for 24 years working with neurological and geriatric populations. Previous experiences as a clinician, program coordinator, research assistant, and Review panel clinic owner have all lead to her current passion of working with persons with Parkinson’s disease as a consultant for the The draft document was circulated to a review panel composed Parkinson Association of Alberta. She has certifications in PWR! of researchers, educators and clinicians. Their comments and Moves, Neurodevelopmental Therapy (NDT) for hemiplegia and recommendations were invaluable to the project outcome. gait, LSVT/BIG and Urban Poling. Dr. Sinead Dufour Neera Garga is a University of Toronto graduate and has been Assistant Clinical Professor practicing for 19 years with a focus on neurological populations. School of Rehabilitation Science Currently she is working at the Glenrose Rehabilitation Hospital Adjunct Faculty treating stroke, MS and general neurological clients in the Michael G. DeGroote School of Medicine outpatient clinic. In addition, she is a team member of the McMaster University Glenrose spasticity and adult stroke clinics. Prior to moving to Edmonton 8 years ago, she worked in Calgary at the MS Jim Millard BSc PT, MClS(Manipulative PT) 2010, FCAMT clinic (OPTIMUS – Foothills Hospital) and was the physiotherapy Clinical Instructor/lecturer Western University consultant for the Parkinson Society of Southern Alberta. Physiotherapist, Lifemark Health Group Cindy Grand is a change maker fueled by good coffee and Co-founder and Facilitator COMPASS Interactive Workshops a passion for patient centred care. She worked in sports/ orthopedics for 14 years and then on the Provincial Bariatric Todd Wolansky PT (Clinical Specialist – Seniors’ Health) Resource team, a multidisciplinary team supporting providers Physiotherapist + Program Facilitator of care for patients with obesity for 5 years. She completed Rural Allied Health, Calgary Zone her Master of Public Health and is Prosci Change Management Alberta Health Services Certified, has her HealthChange Associates Peer Training levels Clinical Assistant Professor, University of Alberta 1&2 and has completed Foundational Training in Cognitive Coaching. Cindy has had the honor of being a lecturer at the Resources University of Alberta for physiotherapy and interdisciplinary students. You can currently find her in a temporary role of The PT-BTC checklist is used with thanks and with the Implementation Lead on the Walter McKenzie Campus Connect permission of the developers, Katherine Harman, PT PhD, Care Implementation Team before she returns to the Integration Dalhousie University and Major Marsha MacRae, BscPT MscPT, & Innovation Team within the Provincial Primary Health Care CFB Stadaconda. Program, AHS. Physiotherapy Alberta thanks Janet Jull OT Reg, PhD, Queens Dr. Maxi Miciak is the Cy Frank Fellow in Impact Assessment University, who provided the Adapted Ottawa Personal Decision at Alberta Innovates and an adjunct associate professor in Guide, which has recently been released for clinical use the Faculty of Rehabilitation Medicine, University of Alberta. Her research interests involve developing, implementing, and evaluating practices that impact the quality of the patient- practitioner therapeutic relationship, including how health services and policies support this relationship. Most notably, she developed a pragmatic framework of the therapeutic relationship in physiotherapy to support physiotherapists in taking meaningful action when developing positive relationships with patients. Her appreciation for the therapeutic relationship developed over 13 years working in private practice and on interdisciplinary rehabilitation teams supporting people with a diverse range of musculoskeletal conditions, chronic pain conditions, mild traumatic brain injury, and psychological dysregulation (e.g. depression, post-traumatic stress).
Physiotherapy Alberta - College + Association | Introduction to Health Coaching for Physiotherapists 39 www.physiotherapyalberta.ca 300, 10357 - 109 Street, Edmonton, Alberta T5J 1N3 T 780.438.0338 | TF 1.800.291.2782 | 780.436.1908 www.physiotherapyalberta.ca