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Click here to view the Health Coaching Toolkit as a PDF. (coming soon)

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 chronic conditions by enabling patients to learn to manage their symptoms, maintain independence, and achieve a better quality of life.1 Health coaching is emerging as an effective means to 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 their self-identified health goals.”3

A recent systematic review of the health coaching literature concluded that it can be effective in improving an patient’s lifestyle behaviour and self-efficacy and has resulted in patients achieving better overall physical and mental health.4 Health coaching has also been shown to facilitate improved weight management and increased physical activity, and has been associated with improvement in factors affecting cardiovascular health, pain management in cancer patients, and adherence to self-management and lifestyle changes in patients with diabetes.6,9

The physiotherapy profession is well suited to incorporate health coaching. Physiotherapists are health-care professionals who “promote, restore and prolong physical independence by enhancing a client’s functional capacity. Physiotherapists encourage clients to assume responsibility for their health and participate in team approaches to health service delivery.”7 Physiotherapists treat a wide range of patients with acute and chronic conditions; physiotherapists see them on a regular basis and provide personalized care. They provide education on risk factors for prevention and management of a condition, prescribe exercise and physical activity to achieve and maintain independence or function as well as physical techniques to manage stress and cardio-respiratory symptoms. Given the current and growing prevalence of chronic conditions, patient demographics will include patients with one or more risk factor, or who are in the early or advanced stages of a chronic condition8 in either addition to, or as the primary reason, they are consulting a physiotherapist.

This Toolkit is not intended to be a comprehensive guide to health coaching but will provide an introduction to the essential components, along with resources to guide physiotherapists wishing to explore this approach.

More Canadians are living with chronic conditions than ever before.9 Over one in five Canadian adults live with one of the following chronic diseases: cardiovascular disease (CVD), cancer, chronic respiratory disease (CRD), or diabetes.10 In addition, musculoskeletal disorders (MSD) are the most common reason for repeated visits to a physician,11 with chronic low back pain among the most common reasons for physician consultations among people under 60 years of age in Canada.12

Chronic conditions are detrimental to a patient’s quality of life and are an increasing economic burden on society.13 Each is associated with four risk factors or health behaviours – smoking, unhealthy eating, physical inactivity and harmful use of alcohol.14 Obesity and hypertension may also contribute to the onset of a chronic condition. Similarly, these risk factors may impact quality of life and health in older adults  and contribute to the onset of frailty.16

The health cost and economic burden of smoking, obesity and alcohol abuse are well reported in the literature. Physical inactivity is increasingly being recognized as a major factor in the onset and progression of illness and chronic disease. A recent Canadian study concluded that, as well as a higher number of physician and specialist visits, patients who are physically inactive spend 38% more days in hospital than active people.17

Addressing these risk factors can alter the effects of chronic conditions on the patient, and on their use of health-care resources.18 To do so, the focus of care shifts from the condition to the patient and the complexity of changing health behaviours.

Patients living with chronic conditions make decisions about their health and manage 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,19 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) influences20,21

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

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 its 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 and 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.
  • Acknowledges and respects patients’ autonomy23 so patients learn to be personally accountable for aspects of their own care24 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.25
  • 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.26
  • Facilitate and guide the patient’s change process.
  • Help the patient identify his/her own achievable goals for change.
  • Facilitate an active learning process for working towards goals.
  • Help patients be accountable for and monitor, their own progress.27

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 know and understand about their conditions, and what they wish to change, but also what they see as the pros and cons for making (or not making) changes and how that change will affect their day-to-day life. For example, while the patient recognizes that a change will be beneficial, there may be negative associations that reinforce their ambivalence – what else are they changing, what will they lose when they make the change? Previous experience is also a factor – is this the patient’s first attempt at making a change, or have they tried multiple times unsuccessfully? How confident are they in their ability to make and sustain a change?

Success in making and sustaining a change in a health behaviour is determined by resolving ambivalence and a facilitating a belief in one’s ability. These two concepts have been termed “decisional balance” and “self-efficacy” and are described below.

Decisional balance is a health coaching tool that can be used to help patients quantify their ambivalence and visualize how they see the implications of making an identified change.28 During goal identification, it clarifies any discrepancy between the patient’s stated goal and their actual situation. It will also assist in determining their readiness to change a health behaviour. Decisional balance is discussed further in the section on identifying achievable goals.

Self-efficacy is a patient’s29 confidence in his or her ability to successfully make and sustain a behaviour change.30 It is affected by a number of factors, including whether it is the initial attempt to make a change, whether he or she has had repeated (and possibly unsuccessful) attempts in the past, and by emotional and psychological state.31

Self-efficacy is critical for achieving positive outcomes in health behaviour change in patients with a range of chronic conditions, such as osteoarthritis,32 chronic pain,33,34 and COPD.35 It is also essential for those living with a chronic MSD, such as non-specific low back pain.36

Self-efficacy can be fostered in a number of ways, such as:

  • Mastering a task: Achieving goals will build and reinforce patients’ belief in their self-efficacy. While a failure may undermine that sense, setbacks can also reinforce the value of sustained effort. For example, reframing a setback as achieving a percentage (e.g., 25%) of a defined goal can be a reinforcement to continue. “Normalizing” the occurrence of setbacks will also help the patient build self-efficacy.
  • A vicarious experience: Seeing others similar to oneself achieving a goal. This can reinforce a belief that patients do have the capacity to master a task. However, patients must not perceive or feel they are being compared unfavourably to others.
  • Verbal persuasion: Support for, or confidence in the patient’s capacity expressed by an influential person, such as a health coach or a health care professional, can enhance self-efficacy.37

The Transtheoretical Model (TTM) of change is an integrative, biopsychosocial model that describes the process of intentional behavior change.38 It describes a series of stages patients move through when modifying or changing a behaviour. The principles of decisional balance and self-efficacy are used in health coaching to help determine the patient’s current stage and the appropriate coaching strategy to facilitate the process.

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.

Figure 1. (Click to resize)

 

The Five Stages of Change in TTM

  1. 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.
  2. 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.
  3. 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.
  4. Maintenance: Patients who have made changes in behaviour in the last six months. They may be following a regular home routine or are participating in a group activity.
  5. Termination: Patients who made changes more than six months ago and are confident the change is now part of their lifestyle and they can maintain their new status.39

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

The skills employed in health coaching are congruent with those of physiotherapists as described in the therapeutic alliance in physiotherapy.41 Both stress the importance of setting collaborative goals, setting tasks aligned with those goals, and the importance of an interpersonal, trusting bond between the patient and the health-care professional.42 Research has identified that being present, receptive, committed, and genuine were necessary conditions for a positive physiotherapy therapeutic relationship.43 These conditions reinforce actions that establish connections with the patient, through acknowledging the patient as an patient by meeting them as a partner, validating their experiences, and individualizing treatment to the needs of the patient.44

Health coaches consistently demonstrate empathy and a respectful manner that builds a non-judgmental, collaborative relationship. They show respect for the patient and their unique perspective, feelings and values and maintain an attitude of acceptance, but not necessarily approval or agreement. Using verbal and non-verbal messaging to communicate that they understand the patient’s situation will reinforce collaboration and concordance in setting goals.

Communication

Thoughtful communication is an essential element in health coaching. It can facilitate and support the patient’s consideration of, and decision to make a change in health behaviour. The health coach seeks to learn the patients’ knowledge or understanding of their condition, the goals they would like to achieve, and the factors that will affect achieving them (both positive and negative). The health coach then provides information that is targeted to the patient’s understanding, needs and personal situation.

Communication in health coaching strategies includes:

  • Asking, not telling: Open ended questions communicate that the coach values the autonomy of patients as a partner and encourages a discussion of their concerns about their condition, what they would like to change, and when and how this might happen. Examples include, “What do you see as your biggest challenge?”, “What have you tried in the past?,“ “Would you like to know more about....” or “How do you think you could....”

This also helps the coach learn about his/her patients’ level of health literacy – what they understand about their condition. The coach can then target any evidence-based information to provide regarding their level of understanding and needs.

  • Active listening: The health coach is aware of his/her own body language and non-verbal cues that lets patients know they have the coach’s attention. (e.g., making eye contact, mirroring postures, nodding to acknowledge comments).

Being open-minded and non-judgmental. The health coach avoids making negative comments, criticism and/or correcting 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...)

  • Reflective listening/responses: Repeating, restating or clarifying the key points in what the patients have said communicates to the patients that the health coach has heard them, values their concerns and wants to understand their point of view. It may also help the patient gain an additional perspective to reflect on as they consider making a change in behaviour.
  • Maintaining a respectful manner: Communicating a positive regard for the autonomy of patients will allow a discussion of 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. By responding to the specific question or issue, rather than providing a global explanation of the whole topic, patients are enabled to review their situation and make decisions based on their understanding and new learning.

As in all aspects of care, thoughtful communication improves compliance and is an important factor in improved outcomes.45

Motivational Interviewing

Motivational Interviewing (MI) is one methodology used effectively in health coaching. MI is a “collaborative, person-centred form of guiding to elicit and strengthen motivation for change,”46 and like all other professional skills, requires training and practice. Within health coaching, MI is used to assess the readiness of patients for change, build on their ability or capacity to make a change, and to set realistic goals.

MI focuses on “evoking and strengthening” the client’s own verbalized motivations for change.47 Its guiding principle is that the patient articulates the arguments for change, not the professional.48 Arguments, or reasons, for change are classified as “change talk.” Conversely, reasons for maintaining the status quo are classified as “sustain talk.” The focus of MI is to explore those reasons, resolve the ambivalence to change and guide the patient as they shift to “change talk.”49

MI integrates common communication strategies under the following set of principles:

  • It requires the physiotherapist to adopt an empathic style that is accepting and a belief that ambivalence about change is normal.
  • Using MI techniques helps the patient recognize discrepancies between their stated goals and their current situation, avoids arguments (“rolls with resistance”) and supports self-efficacy. “Rolling with resistance” acknowledges any negative comments and reframes them by, for example, restating them as a neutral reflection, or by providing information that may shift the patient’s perspective.
  • It requires the physiotherapist to remain focused on the goals and values of patients – it is not a series of questions intended to convince them to change behaviour, or to pressure them into making a change that the coach has identified as important.50

Although training in MI is recommended, Rollnick et al provided family physicians an introduction to the core strategies,51 and recommended the use of:

  • The guiding style
    • Open ended questions that ask the patient to consider how and why he or she might change
    • Using reflection or other means to show empathy and encourage discussion
    • Asking permission to provide evidence-based information; ask what more information might mean to them (e.g., “would you like to know more about?”, i.e., effects of physical inactivity, weight gain or chronic condition diagnosis, ..or “what do you think that (information) means for you?”)
  • Building on patients’ strengths, such as:
    • Setting the agenda by asking them to select the issue or problem that is their priority.
    • Assessing their ambivalence to change – what are the pros and cons? Is change a possibility?
    • 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.
    • Exchanging information– elicit what the patient understands, provide information on potential result of not changing (both positive and negative), elicit their understanding of any personal implications of making a change, as well as not making the change.
  • Responding to patients’ language – as in active listening.
    • Use open-ended questions. When patients engage in “change talk,” which suggests they are thinking of change (e.g., “I should...” “I want to...“ or “I know it would be better if I ...”) the coach’s response might be to say “You feel that…” or “How do you think you might...” that encourages more discussion about change. When they use “sustain talk,” indicating preference for the status quo ( e.g., “I enjoy...” or “I have never succeeded in...”) the coach attempts to move the conversation towards change, using questions such as “What do you see as drawbacks to...”, “What would happen if...” or “How might things be different if...”

MI requires training to learn the skill and achieve competency to practice. The Resources Section provides links to opportunities for training and online resources in MI, including a webinar on MI by D. Gross, PT, PhD and Joanne Park, OT, PhD hosted by Physiotherapy Alberta College + Association.

Behaviour Change Techniques

Behaviour change interventions include all the components of a health coaching strategy. Behaviour Change Techniques (BCTs) are the active and measurable components.52 These techniques offer a broad range of tools a health coach can employ to facilitate health behaviour change at any stage in the process of behaviour change. Similar to MI, BCTs can prompt reflection, identify barriers or obstacles to change, build self-efficacy and help implement or maintain a behaviour change. For example, an active learning strategy may use problem solving (a BCT) in conjunction with other BCTs such as goal setting, self-monitoring, behavioral prompts, cognitive coaching, and reinforcement to achieve a goal.

BCTs may be behavioural, cognitive or motivational and can be implemented throughout the behavioural change process. Recent research suggests that combining BCTs that facilitate self-regulation, defined as the physical skills and function, or the “how to,” with communication that addresses the underlying motivation, the “why,” supports maintaining a new behaviour over time.53 For example, an older adult may cite maintaining independence as their primary goal because they enjoy travel, while a younger person may focus more on resuming a particular sport or activity, because he or she is looking forward to a tournament. For the former, BCTs may be targeted to prompting graded exercise and identifying barriers, while for the latter, pacing and visualization may be most effective.

 “Active” or behavioural BCTs, such as pacing and self-regulation, which encourage symptom self-management, have been shown to be more effective than “passive” or cognitive techniques, such as education and advice, for maintaining physical activity in people with OA.54 Similarly, BCTs such as graded activity, self-monitoring, recording activity outcomes, or planning and implementing environmental changes are effective for increasing physical activity and for healthy eating.55

Appendix 1 is the PT-BCT Checklist, developed in 2014 by Harman, MacRae, Vallis and Barrett,56 and is used with permission. The checklist includes BCTs specific to physiotherapy practice and were selected from Abraham and Michie’s taxonomy of BCTs.57 The BCTs and their descriptions in the checklist relate to chronic MSD disorders, but are applicable to other areas of physiotherapy practice.

The strongest predictor of success in health coaching is how the goals are set.58 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.59

The health coach recognizes that throughout the change process, the patient’s readiness to change and their resulting decisions and actions will be influenced by both their decisional balance and self-efficacy.

There are several tools available to ascertain readiness to change. For example, the Likert scale (1-10) can quantify both how important making the change is to the patient and how confident he or she is that the changes can me made. Patients’ responses will give a strong indication of the value they attach to the change and their readiness to make that change.60

Additional tools to evaluate or monitor decisional balance include:

  • The “Readiness Ruler” (Figure 2), is also a 10-point scale that can be used throughout the coaching process and beyond to weigh decisions about the importance of making a change and confidence in their ability to make that change. It is available as a free download (or hard copy purchase) from the Centre for Evidence Based Practice.
  • The Ottawa Personal Decision Guide (OPDG) is a take home guide that is valid across populations and is included in Resources Section of this document. The coach may provide it as part of the consultation with the patient. The OPDG walks the patient through the process of identifying problems, weighing the pros and cons for each risk and benefit, identifies available support and clarifies the approach the patient prefers.
  • An Adapted OPDG,61 for use with indigenous populations, is also included in the Resources Section.

Lower scores in the tools assessing decisional balance suggest the patient is likely either in the Pre-contemplation or Contemplation stage within the TTM model. Pre-contemplators may rate importance of change at three or lower. These patients are more likely to speak more about reasons not to change - the cons - than the benefits for making a change - the pros. By contrast, the reverse occurs for patients in the Action or Maintenance stages: they tend to speak more about the pros for maintaining the change than the cons.62

Similarly, there is evidence that there is a strong correlation between self-efficacy scores on the tools and the patient’s stage within the TTM. Scores on the Likert scale or the Readiness Ruler are lower in the pre-contemplation stage than in the maintenance stage.63

Along with the observations about the patient’s understanding of their condition, their health beliefs and their social and family support, the scores for both decisional balance and self-efficacy assist the health coach to determine the patient’s stage in the TTM and to plan the appropriate health coaching approach.

The following table demonstrates how a health coach may approach collaborative goal setting with patients at various stages and/or readiness to change when “increased physical activity” was the first goal the patient selected. NOTE: BCTs are suggestions only and will be selected as appropriate to the patient.

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 might gain by increasing physical activity, have other priorities that take precedence, or have barriers such as location or a lack of equipment to engage in a physical activity. They may not recognize the gap between their goal and their current status. Discussions on benefits of physical activity, explore cons, barriers of making a change, as well as pros and cons of not making a change. Problem solving, if appropriate, including whether this is the right time in the patient’s life to make a change in this area. Providing information on behaviour – health link, prompting intention formation, prompting self-monitoring of behaviour.
Contemplation May feel the cons of (barriers to) physical activity outweigh the pros. May have pre-conceptions for what is required or may have not been successful in past attempts. Discuss potential benefits of physical activity, explore cons and engage in problem solving to resolve cons/barriers, as well as the pros and cons of not 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. Role modelling, providing information on the approval of others, prompting visualization, facilitating internal reinforcement.
Action Has begun to increase activity but it is irregular. Confirm benefits of regular physical activity, problem solving for barriers, support self-efficacy in keeping schedule, routine, and contingency planning for occasions when activity is not possible. Pacing, agreement to behavioural contract, positive feedback.
Maintenance Regular participant Support self-efficacy, discuss value of variety of activities, social support Setting graded activity, stress management, review of behavioural goals, internal reinforcement
Termination Positive about value of physical activity Support to help maintain self-efficacy Positive reinforcement, review of behavioural goals, booster sessions

Bridging patient goals and outcome measures

Patients’ goals are specific to their personal situation or needs. However, in the clinic, the physiotherapist’s assessment goals or intervention measures may not address the patient’s goals directly.64 A study comparing patient goals and clinical outcome measures used in chronic low back pain found that patient goals were not directly tied to the clinical outcome measures used for pain or for recording the patient’s clinical improvements.65 For example, while treatment was progressed or adjusted based on changes in range, strength, or other outcome measures, patients’ goals (and their own measure of success) were their ability to resume a specific activity. Health coaching is an excellent tool that can be used to bridge the patient’s goals to the outcome measures used by physiotherapists to measure progress, providing the goals are aligned and the physiotherapist is able to articulate how the goals support one another.

Throughout the health coaching relationship, the focus is on patients setting and achieving their goals, with the health coach facilitating the patients’ ability to identify and solve problems, and respecting their autonomy .

HealthChange(R) Australia is a methodology that promotes behaviour change to support self-management. The physiotherapist in this video describes how she incorporates health coaching principles within physiotherapy management of a woman with an acute ankle injury, and is used with permission:
https://vimeo.com/healthchange/review/83546314/3d15a2bdf8

Cultural competence

Cultural competence is the ability to communicate effectively and respectfully with people from different backgrounds. In health 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 differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs.”67 The term also refers to ethno-cultural, gender and/or gender identity and expression, sexual orientation, age, disability, income, and educational level differences.

Health-care professionals have the same implicit biases as the general population.68 Implicit biases are those a person may not be conscious of; the “stereotype –confirming thoughts that pass spontaneously through one’s mind, and that can lead to discrimination.”69 Implicit biases may even exist regardless of the person’s expressed values.70 Research shows that biases in health care can result in poorer health outcomes, as well as reduced adherence to health care in targeted populations.71 Biases do not have to be overt – they can be expressed through “micro-aggressions - brief, verbal or non-verbal expressions that may or may not be intentional, but convey a derogatory or hostile attitude.”72

The following are examples of strategies for incorporating cultural competence within health coaching:

  • Be aware of how your personal status (e.g., gender, race, physical abilities or health, income, sexual orientation, education etc.) may predispose you to implicit biases, such as your expectations for health behaviours in others
  • Reflect on your own implicit and explicit biases
  • Develop and use an inclusive assessment form
  • Provide culturally specific examples to communicate concepts
  • Link goals to culturally informed roles and expectations
  • Provide links to appropriate community supports for follow up

Figure 2 (click to resize)

Successful health coaching strategies use a patient-initiated agreement on goals and tasks.73 Within the trust built by the therapeutic alliance, the overall goal is broken down into manageable steps. As the steps are accomplished, patients (especially one in the initial stages of behaviour change) gain self-efficacy and learn they have the ability and capacity to succeed in other situations.

Whether a goal is focused on physical activity, a functional goal or a social activity, it must be stated in the patient’s own words and be meaningful to them. For example, the patient who has stated broadly that his or her goal is to “increase their level of physical activity”, may further elaborate that he or she miss going to weekly walking club and would like to re-join. This goal has meaning and value to them. Their statement “I would like to rejoin my walking group” may be further broken down into “I would like to walk for 30 minutes at a moderate pace so I can rejoin my walking group with confidence”.

In the ensuing discussion, the patient expresses concern about their endurance, as he or she has been diagnosed with osteoarthritis and feel his or her legs are getting weaker and knees are stiff lately. Together the physiotherapist and the patient consider the actions required to resume distance walking and work out a strategy that prioritizes the steps and is achievable. Steps the patient proposes might include getting stronger, improving stamina, and/or buying better footwear. The coach uses open ended questions to help them prioritize the steps and decide on an action plan (e.g., “what gives you the most difficulty?”, “which of these would you like to work on first?”)

The health coach also recognizes that the means or activities to meet the desired goal for “increased physical activity” will be more successful if it is the patient’s preference or choice – this may include whether this is done independently or with a peer group, as an example. Similarly, some patients prefer non-competitive activities, while others gain from being part of a competition.74 In some situations, it may be that formal physiotherapy treatment is the patient’s choice and the optimal means to achieving the goal: the health coach is attuned to this as well.

Table 2 illustrates a patient-led plan for increasing physical activity. In this case, the health coach used the SMART model of goal setting to facilitate the process.

Goal Specific Measurable Action oriented Realistic Time dependent
What would you like to accomplish and why? What specific steps can you take? How will you measure your progress? How often will you follow your plan? What actions will you need to take? Is this doable? What is your timeframe? When will you start?
I want to exercise more so I have more energy I will begin with daily walks I can go every day either before 10:00 or after 3:00 and walk for 15 minutes.
Each week I will increase the time by five minutes.
I will add it to my calendar four days of every week and log my walk times. I can walk outside in good weather or to a mall other days. I will walk four days a week for a month starting next Monday.

Goal setting includes talking about managing any setbacks that may happen such as the possibility that patients may encounter obstacles (e.g., time constraint, symptom flare) or that their situation may change (family or work requirements) and ensuring that this is a part of the change process. The coach will reinforce to the patient that behaviour change is not always straightforward. If patients find they have fallen short of a goal, the patient and the health coach will look at contributing factors together, and will either revise the plan or problem solve to overcome the obstacle. The underlying message is that both sustained effort and problem solving are valuable tools in achieving self-efficacy,75 and will be applicable to future situations.

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.

Of the four identified risk factors in chronic conditions, physical inactivity is the health behaviour most associated with current physiotherapy practice. However, physiotherapists may also have a role in smoking cessation and are often asked questions regarding nutrition. Similarly, while weight loss is not a primary goal in physiotherapy practice, physiotherapists may be part of an obesity management team and participate in coaching and facilitating increasing physical activity as well as assessing mobility, balance, and physical function in this population. In recent years, physiotherapists have also participated in the management of sleep hygiene and stress management. The following section demonstrates the application of the principles of health coaching to clinical physiotherapy practice, with examples from the literature.

Physiotherapists may incorporate health coaching principles as brief interventions within traditional physiotherapy treatments, or in some cases, may use health coaching as a stand-alone intervention to assist with chronic disease management (depending on the physiotherapist, the patient served and the practice setting).

Brief interventions

Physiotherapists may gather information about health behaviours in the initial assessment as follows:

  • Including a question about physical activity can generate a discussion about the patient’s knowledge of the health benefits of physical activity, as it applies to their reason for consulting a physiotherapist. Part of a brief coaching intervention may include sharing information about the health benefits of, for example, short bursts of “incidental physical activity,” or prompt a discussion about Canada’s Physical Activity Guidelines.76 Physiotherapists may also consider linking the patient to HealtheSteps, a free online and app-based coaching program to help patients increase their activity level.
  • A question about smoking (amount, frequency) may generate a discussion on awareness of the health benefits of changing that behaviour, perceived obstacles for quitting and how patients might overcome them, as well as building the physiotherapist’s understanding of why a person values smoking or why they smoke. Throughout, the physiotherapist maintains a non-judgmental attitude. If patients indicate they are interested in receiving more information, the physiotherapist can provide a link to Alberta Quits, a free self-management program offered by Alberta Health Services. The physiotherapist may also offer to provide information on other formal programs in the area if the patient is interested.
  • When a patient presents to physiotherapy, and obesity may be a contributing factor to their diagnosis, the physiotherapist may request permission to discuss their weight. Then, using a coaching approach, the physiotherapist explores their understanding of their weight and weight management specific to their current situation. If the patient expresses interest, the physiotherapist may provide access to 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.
  • Restful sleep is a challenge for many patients with chronic conditions and not getting enough can be detrimental to their overall health. The assessment may include a question about sleep patterns and if appropriate, the physiotherapist may inquire if the patient would like more information. My Health Alberta provides an online module on strategies for improving sleep patterns. The physiotherapist may determine that a coaching approach to a program of sleep hygiene within their treatment plan77 is appropriate, or refer the patient to their physician or a community program.
  • Similarly, if the patient identifies stress or anxiety during the assessment, such as concern about work performance or relationships, the physiotherapist may inquire about 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.

Alternately, when the patient’s comments related to changing a health behaviour are couched with negatives, or “wishes” (“I would but I have no time,” “It’s too hard” etc.), the physiotherapist may use reflective listening to explore their rationale and offer to work with them to develop a plan when the patient chooses to do so. For example, the physiotherapist may suggest patients reflect on their use of personal strengths in past situations and how this might apply to the current situation.78

Longer-term interventions

A longer-term health coaching intervention may result from the earlier conversation during the assessment or be introduced as an option in the physiotherapy treatment plan.

Here, the physiotherapist asks patients what concerns them most about their current condition and what they think are the main issues. This message communicates a respectful approach and recognizes the patient’s autonomy in self-management but may also help the physiotherapist determine how to focus the physiotherapy assessment.

The physiotherapist introduces the concept of a collaborative relationship in setting goals and action plans for self-management, with the physiotherapist providing evidence-based information, collaborating on setting achievable goals, developing the action plan, as well as giving feedback and guidance on the chosen goals and strategies. The patient carries out their action plan, tracks their own progress and meets with 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.

Figure 3 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,79 a methodology that uses behaviour change to support and promote self-management in health care.

Figure 3 (click to resize)

 

Figure 3 cont. (Click to resize)

Depending on the clinical setting, health coaching can be a team strategy or practiced by the physiotherapist independently. In some situations, a certified health coach is part of the team. Regardless of the setting, the physiotherapist practices health coaching in collaboration with other team members (including the patient) to support the achievement of the goals the patient has established.

The following articles illustrate how physiotherapists have implemented various health coaching strategies for health behaviour change in different practice areas.

  • 2012 Smith et al80

Patients with MS, at any level of disability, improved their level of physical activity through an innovative program that helped them select an activity that had value to them. The physiotherapist interspersed bi-weekly home visits to patients with MS with texts, emails and online patient support groups. The patients in the program perceived it as supportive and enabled them to adopt new health behaviours.

  • 2011 Isles et al81

Patients with non-chronic LBP who received telephone coaching in addition to their usual physiotherapy showed significant improvement in the Patient Specific Functional Scale and in recovery expectation.

  • 2016 Gardner et al82

Patients with chronic LBP who identified personal challenges in managing their LBP, and were supported in goal setting and evidence based strategies to achieve them, showed significant improvement in a number of measures, including pain, disability, fear avoidance, quality of life self-efficacy.

Behaviour Change Information

Health Change Australia
Offers an extensive selection of resources, tools and publications.

Physiopedia
Physiopedia has published an extensive review of health coaching including a review of apps that physiotherapists can incorporate within a coaching strategy.

Alberta Health Services
AHS has adopted the work of Health Change Australia and is in the process of training their staff in the methodology. They provide additional information about the methodology and theoretical foundations.

Motivational Interviewing Webinar
Motivational Interviewing for Injured Workers, presented by Joanne Park, OT, PhD, Douglas Gross, PT, PhD, outlines the technique of motivational interviewing and research regarding the effectiveness of the technique, when working with injured workers.

HealtheSteps
A free online coaching program available to anyone interested in improving health behaviours. It was developed at the Lawson Health Research Institute at Western University.

Tools

Readiness Ruler
Available from the centre for evidence-based practice. It can be used in the assessment of decisional balance and self-efficacy.

Ottawa Personal Decision Guide
Developed at the Ottawa Health Research Institute. It is protected by copyright but is “freely available to use, provided you: a) cite the reference in any documents or publications; b) do not charge for or profit from them; and c) do not alter them except for prefilling them for a specific condition/decision as necessary”.

The Culturally Adapted OPDG
(Appendix 2) Developed to support decision making by Indigenous women and is thought to have broad application. PDF

OA GO AWAY 
(Appendix 3) 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
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.

Apps to support health coaching

Myhealth - Pain Care  
A 2019 study, by Yang et al, found that an “app APPS-based self-management program appears to bring additional benefits to physiotherapy for patients with CLBP. Self-management is a potential approach for people with CLBP”.86

Accupedo Pro pedometer
A 2014 study by Glynn et al found that a simple smartphone app improved physical activity in a primary care population.87

Additional Training

This toolkit is intended to introduce readers to the concepts that underly health coaching and equip them with beginner-level skills. Physiotherapists wishing to advance their skills in this area are encouraged to seek additional training. The list below includes organizations that offer additional training in coaching and motivational interviewing. Physiotherapy Alberta does not endorse any training programs. Physiotherapists are encouraged to fully investigate all training options for themselves to determine the program that best addresses their learning needs.

  • Excel Academy
  • Change Talk Associates
  • Alberta Home Visitor Network
  • AIM Alberta
  • The Monarch System

* Please note this is not an endorsement of these courses by Physiotherapy Alberta.

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  32. Sommaruga M et al. Self-efficacy and quality of life in COPD patients. European Respiratory Journal 2012 https://erj.ersjournals.com/content/40/Suppl_56/P1462
  33. Brisson NM et al. Self-efficacy, pain, and quadriceps capacity at baseline predict changes in mobility performance over 2 years in women with knee osteoarthritis. Clin Rheumatol. 2018 Feb;37(2):495-504. doi: 10.1007/s10067-017-3903-3. Epub 2017 Nov 10.
  34. Arnstein et al Self-efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain. 1999 Apr; 80(3):483-91
  35. Andenaes R et al. The relationships of self-efficacy, physical activity, and paid work to health-related quality of life among patients with chronic obstructive pulmonary disease (COPD). J Multidiscip Healthc. 2014 Jun 6;7:239-47. doi: 10.2147/JMDH.S62476. eCollection 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057325/
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  42. Miciak M et al. The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Arch Physiother. 2018;8:3. Published 2018 Feb 17. doi:10.1186/s40945-018-0044-1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5816533/
  43. Hutting N et al. Promoting the use of self management strategies for people with persistent musculoskeletal disorders: the role of the physical therapist. J Orthop Sports Phys Ther. 2019 Apr;49(4):212-215. doi: 10.2519/jospt.2019.0605. https://www.jospt.org/doi/full/10.2519/jospt.2019.0605
  44. Miciak et al 2018
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  50. ibid
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  53. Rollnick et al 2010
  54. Willet M et al. Effectiveness of behavioural change techniques in physiotherapy interventions topromote physical activity adherence in patients with hip and knee osteoarthritis: a systematic review protocol BMJ Open 2017;7:e015833. doi: 10.1136/bmjopen-2017-015833 https://bmjopen.bmj.com/content/7/6/e015833
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  68. Diener et al 2016
  69. Betancourt J et al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep, 2003;118:293-302. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497553/pdf/12815076.pdf
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The Introduction to Health Coaching was developed by Physiotherapy Alberta College+ Association with the following advisory committee members, and thanks them for their contribution and commitment to the project outcome. Project lead was Carol Miller, Consultant in Knowledge Mobilization for Physiotherapy Alberta.

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 clinic owner have all lead to her current passion of working with persons with Parkinson's disease as a consultant for the Parkinson Association of Alberta. She has certifications in PWR! Moves, Neurodevelopmental Therapy (NDT) for hemiplegia and gait, LSVT/BIG and Urban Poling.

Neera Garga is a University of Toronto graduate and has been practicing for 19 years with a focus on neurological populations. Currently she is working at the Glenrose Rehabilitation Hospital treating stroke, MS and general neurological clients in the outpatient clinic. In addition, she is a team member of the Glenrose spasticity and adult stroke clinics. Prior to moving to Edmonton 8 years ago, she worked in Calgary at the MS clinic (OPTIMUS – Foothills Hospital) and was the physiotherapy consultant for the Parkinson Society of Southern Alberta.

Cindy Grand is a change maker fueled by good coffee and a passion for patient centred care. She worked in sports/orthopedics for 14 years and then on the Provincial Bariatric Resource team, a multidisciplinary team supporting providers of care for patients with obesity for 5 years. She completed her Master of Public Health and is Prosci Change Management Certified, has her HealthChange Associates Peer Training levels 1&2 and has completed Foundational Training in Cognitive Coaching. Cindy has had the honor of being a lecturer at the University of Alberta for physiotherapy and interdisciplinary students. You can currently find her in a temporary role of Implementation Lead on the Walter McKenzie Campus Connect Care Implementation Team before she returns to the Integration & Innovation Team within the Provincial Primary Health Care Program, AHS.

Dr. Maxi Miciak is the Cy Frank Fellow in Impact Assessment at Alberta Innovates and an adjunct associate professor in 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).

Clare Smith graduated from University of London, Kings College, with BScPT in 1993. She has spent the last 25 years working in many aspects of Acute Care, but specializing in Cardiorespiratory physiotherapy in Paediatric and Adult populations. The last 18 have been spent working with truly dedicated teams involved with the care of people with Cystic Fibrosis, from bedside care, to support in daily life and finally into clinical research.

Review panel

The draft document was circulated to a review panel composed of researchers, educators and clinicians. Their comments and recommendations were invaluable to the project outcome.  

Dr. Sinead Dufour
Assistant Clinical Professor
School of Rehabilitation Science
Adjunct Faculty
Michael G. DeGroote School of Medicine
McMaster University

Jim Millard BSc PT, MClS(Manipulative PT) 2010, FCAMT
Clinical Instructor/lecturer Western University
Physiotherapist, Lifemark Health Group
Co-founder and Facilitator COMPASS Interactive Workshops

Todd Wolansky PT (Clinical Specialist – Seniors’ Health)
Physiotherapist + Program Facilitator
Rural Allied Health, Calgary Zone
Alberta Health Services
Clinical Assistant Professor, University of Alberta

Resources

The PT-BTC checklist is used with thanks and with the permission of the developers, Katherine Harman, PT PhD, Dalhousie University and Major Marsha MacRae, BscPT MscPT, CFB Stadaconda.

Physiotherapy Alberta thanks Janet Jull OT Reg, PhD, Queens University, who provided the Adapted Ottawa Personal Decision Guide, which has recently been released for clinical use