Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self efficacy
Article first published online: 11 OCT 2004
Copyright © 2004 by the American College of Rheumatology
Arthritis Care & Research
Volume 51, Issue 5, pages 864–867, 15 October 2004
How to Cite
Jones, K. D., Burckhardt, C. S. and Bennett, J. A. (2004), Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self efficacy. Arthritis & Rheumatism, 51: 864–867. doi: 10.1002/art.20684
- Issue published online: 11 OCT 2004
- Article first published online: 11 OCT 2004
- Manuscript Accepted: 3 JAN 2004
- Manuscript Received: 30 SEP 2003
- NIH/NINR. Grant Number: 1-R01-NR008-150-01
Fibromyalgia (FM) is a common, costly, and debilitating chronic pain syndrome diagnosed in nearly 10 million Americans, 90% of whom are women (1). By definition, people with FM have chronic widespread pain and specified tender point areas (2). Other symptoms include disrupted sleep, fatigue, decreased cognition, postexertional exercise pain, and exercise intolerance (3). Additionally, people with FM report difficulty performing personal care activities, depression and anxiety, and disruption in their family and social lives (4–6). All of these factors combine to produce a formidable impact on their quality of life and a clear obligation on the part of health care researchers and clinicians to respond.
One promising intervention for relieving a variety of FM symptoms is regular exercise. The majority of people with FM are aerobically unfit (7, 8) and have both poor muscle strength and limited flexibility (9–11). Deconditioned muscle is more prone to muscle microtrauma, which causes localized pain and triggers widespread pain through disordered central nervous system processing (i.e., central sensitization) (12, 13). A negative cycle of muscle deconditioning occurs in FM in large part due to exercise-induced pain that limits exercise tolerance. Dysfunctions in multiple hormonal channels may contribute to exercise-induced pain, due to their critical role in muscle homeostasis and repair following exercise (14–17). FM-specific exercise classes enhance patients' beliefs in their ability to exercise by providing options that are realistic and directly impact the ability to carry out activities of daily living. Disincentives, such as pain, fatigue, and limited range of motion, are minimized in these courses while specific strengthening exercises that limit eccentric muscle work are emphasized. Despite the preponderance of scientific evidence that supports FM-specific exercises as a cornerstone in the comprehensive management of fibromyalgia (18–21), most people need more than advice to exercise—they need assistance overcoming the barriers to exercise.
Commitment to a daily regimen of exercise demands considerable motivation if it is to be life long, but factors that motivate or deter individuals with FM from starting and maintaining an exercise program are largely unknown. What is missing for many people is the confidence that they can exercise in spite of their FM symptoms, and the belief that exercise will help them manage their disease and improve their quality of life (22). In our recent study of exercise in women with FM, 91% of the participants completed the exercise classes, compared with published reports of 13–80% completion of other FM exercise intervention studies (23, 24).
The purpose of this article is to suggest that building self efficacy for exercise is an important component of FM-specific exercise programs. In addition, motivational interviewing (MI) (25) will be proposed as a method for encouraging persons with FM to begin exercising and continue attending classes, even when such barriers as pain could provide an excuse to quit. The authors have conducted several studies of FM-specific exercise programs that incorporate the principles of self efficacy. We recently added MI as a communication strategy to help patients work through barriers to ongoing exercise. We propose that MI may enhance self efficacy by providing a safe, nonjudgmental means of discussing initiation and maintenance of health-promoting behaviors, such as regular exercise.
Many health care providers know that people with FM will benefit from exercise, and they do not hesitate to advise patients to engage in regular exercise. However, advice or education about exercise will not motivate an individual if he or she does not have self efficacy, or the confidence that he or she can actually do it. Self efficacy, the belief in one's capacity to organize and carry out actions that will manage future situations (26), is an essential component of undertaking a new activity and continuing to engage in that activity. According to Bandura, self efficacy beliefs provide the foundation for human motivation, wellbeing, and personal accomplishment (27). Unless people believe that they can complete a task (efficacy expectation) and that completing this task can produce the outcomes they desire (outcome expectation), they have little incentive to act or to persevere in the face of difficulties (see Figure 1). For example, people with FM need to feel confident that they can exercise and, furthermore, they must believe that exercise will make a positive difference in their lives.
Both the FM and arthritis literature contain much empirical support demonstrating that enhancing self efficacy can assist people in managing their symptoms and thereby achieving a higher quality of life (22, 28). Furthermore, self-efficacy theory has shown great promise for explaining adoption of exercise among adult populations (29–31), and is the strongest predictor of exercise maintenance in myriad chronic conditions, including FM and arthritis (29, 32). For a person with FM to join an exercise class and continue participating, he or she must have self efficacy that she can do the routines. They must also believe that expending the effort will produce worthwhile results even if exercise is difficult at first. Without these beliefs, advice or education about the benefits of exercise are of limited use.
Exercise classes may build self efficacy by maximizing the 4 major sources of efficacy in proposed descending order of power and importance. 1) Mastery: Learning through personal experience in which one achieves mastery over difficult or previously feared tasks is the most powerful means of enhancing self efficacy. For example, people with FM who begin to exercise despite their physical limitations and who realize that they can do specific physical actions gain a sense of power to change those limitations. Of course, the reverse is also true: a bad experience in an exercise class may reduce self efficacy. Therefore, an exercise prescription that is sensitive to the pathophysiology of FM is essential to building mastery (10). 2) Modeling: By creating an environment in which participants can observe others similar to themselves successfully performing an exercise task, people gain a belief in their own ability to exercise. This framework suggests that group exercise classes may be superior to home-based individual exercise for maximizing modeling. 3) Verbal encouragement: This third source of self efficacy comes from a respected authority (e.g., doctor, exercise leader, physical therapist) verbalizing confidence in an individual's ability to successfully perform a task. 4) Symptom improvement or physical feedback: Decreases in pain, fatigue, anxiety, or depression as a result of appropriate exercise positively influence self efficacy. Conversely, exercise that induces pain will result in a lowered self efficacy. Most people with FM have experienced negative physical feedback when attempting to exercise in a class that was too vigorous or geared for the general population. Also, exercise research studies in FM that prescribed higher-intensity exercises reported higher attrition rates than those with a more gentle exercise prescription (23, 24).
Although the authors' FM-specific exercise classes incorporate 4 major components of self efficacy—mastery, modeling, verbal persuasion, and physical feedback—a different strategy is needed to get people with FM to enroll in the exercise classes in the first place. Motivational interviewing may be useful to move people with FM toward the decision to take an exercise class by helping them resolve individual barriers that prevent them from beginning to exercise (see Figure 1). In addition, occasional MI sessions with a counselor may help people with FM continue to attend classes regularly.
It is natural for most people to feel ambivalent about making a behavioral change, such as starting an exercise class, so they weigh the pros and cons and find it difficult to actually get out of the cycle of ambivalence and move on to deciding to begin exercising. Engaging in exercise is a common example of ambivalence for many people; they know it is good for them, but they can think of many reasons not to do it. Thus, simple advice to begin exercising is not effective because people already know they should be exercising, but they have reasons not to begin. In contrast to delivering simple advice, a counselor trained in MI helps a patient discuss the pros and cons of exercising from the patient's viewpoint, and helps the patient himself or herself work through the barriers and solutions to adopting an exercise program. Thus, MI is patient-centered, because the patient does most of the talking and makes the decisions, and MI is also directive, because the MI counselor is consciously directing the session toward resolving the patient's ambivalence about attending exercise classes. An MI counselor will use 4 guiding principles to help persons with FM decide to begin an exercise class: 1) expressing empathy, 2) developing discrepancy, 3) rolling with resistance, and 4) supporting self efficacy.
The goal of MI is to help patients explore and verbalize their ambivalence regarding exercise, to examine how their current health behavior may conflict with their own goals and values, and to choose how to work on behavior change. In contrast to many educational interventions, MI counselors maintain a neutral tone and do not offer advice unless they ask permission from the patient to do so, or the patient asks for advice (25, 33). Although each individual MI session will vary depending on the needs of the patient, the counselor uses a foundation of patient-centered counseling skills to help the patient voice the discrepancy between his or her actual present and the desired future, and begin to talk about change. “Change talk” by the patient is encouraged, and such talk will be expressed according to each individual patient's own reasons for change. For example, a patient may talk about the disadvantages of the status quo, or may express hope about the ability to change.
Many data-based published articles have reported success with MI interventions to elicit behavior changes, but the use of MI to encourage exercise is relatively new. Jensen et al (34) and others are working toward the development of a motivational model of pain self management that utilizes MI and holds great promise for fibromyalgia. Dunn et al (35) presented a comprehensive review of 29 MI randomized controlled trials that included 3 studies with exercise outcomes. In Miller and Rollnick's book (25), a meta-analysis was reported of 30 controlled trials that used MI adaptations, including 1 with a physical activity outcome. Several recent reports of MI adaptations to increase exercise in persons with diabetes (36–39) and in healthy older adults (39) demonstrate a growing interest in the use of MI to change exercise behavior. An analysis of 30 of the best controlled clinical trials using MI (25) reached the following conclusions, which may be useful in designing exercise programs that incorporate MI. 1) MI required significantly less time and professional interaction to produce behavior change than comparable strategies, such as cognitive behavioral therapy or standard education. 2) MI was most effective when conducted by MI practitioners who had completed standardized training courses. 3) MI was most effective when used as a prelude to further clinical or health promotion services rather than as a stand-alone intervention. 4) Effect sizes were greatest in those studies that tested the utility of MI prior to a diet and exercise intervention or alcohol-related intervention. 5) Effect sizes were greatest in persons who were most likely to be resistant to change. These included people with catastrophic or fatalistic thinking regarding their ability to change behavior or to positively influence their health.
MI can be adapted
Most MI interventions consist of a 30–60-minute session in person by a therapist followed by telephone support calls. Many interventions adapt MI to fit particular settings or populations. Several alternate forms of MI can be incorporated into practice in a primary care clinic, where a physician or nurse can talk to patients about engaging in exercise (40). For example, brief motivational advice can take only 5–10 minutes, with the primary goals of the brief session being to communicate risk, provide information, and initiate a behavior change sequence, using a few MI strategies. Another variation of MI, called behavior change counseling, incorporates more MI strategies than brief advice, but stops short of a full MI session (25).
Selection of the type of MI intervention for encouraging people with FM to exercise will depend on the location of the intended intervention, whether it is planned or opportunistic, and the ultimate goal of the intervention. For example, if the intent is to raise awareness of the importance of exercise and convey information, brief motivational advice may be sufficient. Delivering advice or information in the spirit of MI may mean eliciting all that the patient currently knows about exercise (using silence and reflective listening). Then the provider may say “sounds like a lot of people have told you to exercise” followed by silence for further patient response. The provider may ask permission to share a thought. If permission is granted, the provider may state “I've worked with a lot of people with fibromyalgia who are now exercising and feeling better.” Then, if the patient asks for more information, the provider can share more details. This is a very different approach than standard education in which the provider lists the benefits of exercise and the patient passively listens.
In contrast, a formal research program to motivate people with FM to exercise may be better served with a trained MI counselor who schedules personal sessions with potential enrollees in exercise classes. For all forms of MI, formal training in the techniques is essential, though the intensity of the training will depend on the expectations and type of MI delivery. MI training can be obtained by attending workshops offered nationally and regionally by certified MI trainers who participated in formal training and are members of MINT (Motivational Interviewing Network of Trainers). MI trainers offer a variety of classes, short workshops, and lectures to teach techniques of MI in throughout the United States and many countries around the world. More information about MI and a listing of MI trainers can be found at the following website: http://www.motivationalinterview.org/.
Building self efficacy to exercise is an essential component of any exercise program offered to people with FM. If people do not believe they can do the exercise routines, or do not believe that exercise will produce positive changes in their health, they are unlikely to begin exercise classes. In an attempt to overcome the problem of motivation to exercise in a new exercise and drug study for people with FM, the authors are using trained MI counselors to talk with participants who miss 3 or more consecutive exercise classes. MI is an innovative method with potential applications in motivating people with FM to begin exercise programs and continue attending classes long term. Although MI is different from many standard education techniques, it holds great promise in answering the age-old question, “How can we get people to exercise?”
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