The One About Motivation

Image by Gerd Altmann from Pixabay

Somewhere in the middle of the last blog about EBP, this blog was born. While we all work to keep our 3-legged stool balanced, we are also tasked with keeping our patients motivated. 

Some patients make this very easy-  they embrace movement and exercise and look forward to the challenge of a hard session. Others (more of them than you think) won’t understand or appreciate the value of movement and will keep you up at night racking your brain for ways to get them excited about exercise. The beauty- and the challenge- in what we do as rehab professionals, is figuring out how to bring out the best in both types of patients.   

Psychologists have long studied motivation (as have athletic trainers and physical therapists thanks to endless psychology classes and lots of good reading on teamwork, leadership and motivation). The patients who come to you already loving exercise are intrinsically motivated. They already believe in the value of healthy behaviors, moving their bodies, and building strength.  The “crazy” ½ marathoner who tells you she runs because she “likes the way her body feels” instead of because finishers get a super cool medal and a long-sleeve shirt is intrinsically motivated.  

Conversely, the guy who is only willing to run a 5K because he gets a cool shirt and a free beer at the end, is extrinsically motivated– his behavior is driven by rewards or incentives rather than the inherent joy of running.

Photo by Engin Akyurt on Pexels.com

What do you do in the rehab world when a patient isn’t intrinsically motivated? Is it enough to play up their extrinsic motivation? In short, no. It’s not enough, but it is helpful.

Some examples of extrinsic motivation options that could apply in a non-traditional Athletic Training (this is obviously not permissible in traditional AT setting) or Physical Therapy setting might be:

  • Money: A discount on wellness services if they finish their rehab program…a coupon for a nearby smoothie place…or a loyalty program for local businesses that they can use while they are a patient…
  • Fame: A wall of success stories…a feature in your newsletter…a video testimonial that runs on the local TV station…any variation of social media post you can think of…
  • Shirts: This can be a 2-for-1 for motivation and marketing! People love a free t-shirt.  Put your logo on it and all of the sudden you have tons of cost-effective advertising that also lends to on-the-spot testimonials.  Think of how much more effective it is when someone can say “I see you went to XYZ Rehab Clinic, how did you like it?”  vs. the same person seeing a Facebook Ad and thinking “I wish I knew someone who had been there that could tell me about their experience.”  This can definitely be a win-win.
  • Outcome scores: Wait, what? Something we already do (or should be doing) for everyone! Yep.  This can be your most powerful extrinsic motivator if you use them correctly.  Sure, they’re great to show medical necessity and progress to payers but they’re also the cheapest, easiest to implement tool for increasing motivation.  No matter what outcome measure you choose, you should be educating the patient on how they scored (and what the score means), when you will test again (either a date or a visit number), and what you expect their score to be next time. By now you have heard “Test-Treat-Re-test?” ad nauseum but this applies to outcome measures too. Give them starting and ending points and use your programming to help them get there.  Which would you prefer to hear? Which would keep you motivated and engaged in your program?

vs.

Moral of the story: Extrinsic motivation is easy to create in the rehab setting. 

Secondary moral of the story: Intrinsic motivation is not as easy to generate.  You can do it, but it takes work. 

When I was in grad school at SDSU I fell in love with Self-Determination Theory (SDT).  It is super straightforward and you’d be hard-pressed to find a situation where it doesn’t fit. To this day, it has been the single most effective element of my rehab plans (tool in my toolbox, if you will) as both an Athletic Trainer and Physical Therapist. 

SDT simply says we all become our best selves, and are motivated to grow and change, when these 3 conditions are met:

We need to feel competent. Competence is achieved when we master tasks and learn new skills. In short, we like to feel like we know what we are doing.  Don’t take for granted that most people will not know as much about exercise or their bodies as you do.  They won’t know what they are supposed to feel during an exercise or which body part should be working at any given time.  Educate them not only on how to do the exercise but also on what, where, and when you want them to feel it to build competence.  Like the old saying goes: “give a man a fish and he eats for a day, teach a man to fish and he eats for a lifetime.” If you want your patient to be competent enough to feel comfortable doing their program without you, don’t just give them your fish. Teach them to fish.  

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We need to have autonomy.  Autonomy is what brought my brain here from EBP.  In the last blog, we discussed addressing patient expectations and beliefs when they are different from your own and/or the evidence. Autonomy doesn’t mean getting your way, it means being able to act on your own values or interests. You can allow a patient autonomy without letting them dictate their treatment; a patient (or anyone for that matter) is more likely to do something they don’t want to do if they’ve had the opportunity to provide input, ask questions, and understand the rationale behind it. They can commit to the activity without agreeing to all of it if they feel heard. If you want to read more about achieving commitment in the face of disagreement, check out The Advantage by Patrick Lencioni. At the end of the day, we all want to be in control of our own goals and actions. 

We all want to be involved in the decisions that shape our lives. One of the best examples of this borrows from parenting. Children start to develop autonomy when parents present specific choices. Do you remember being upset when you were told to brush your teeth and put your pajamas on to get ready for bed? Not only were you being told what to do, you were going to miss out on the fun that inevitably happened after bed time. 

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You had no say in the situation, you were going to bed whether you liked it or not.  You didn’t have any control. Conversely, if you had been asked which you wanted to do first- brush your teeth or put your pajamas on-  making this decision would have granted you autonomy. Either gleefully or begrudgingly you would have chosen one of the tasks and scurried off to do it feeling like you had some, albeit minimal, control over the situation. 

This works in rehab settings with patients who lack intrinsic motivation too.  If they hate exercise but you want them to do Spanish Squats and Split Squats, simply asking them which exercise they want to do can enable them to feel in control of their body, their session, and ensure they feel heard. I often take a very straightforward approach to this in saying things like “I know you don’t love exercise but we need to do Spanish Squats and Split Squats, which do you want to do first?”  I think the answers are near evenly split between “I hate this one more, let’s get it over with” and “Let’s save the worst for last.”  Either way, they always do both.

Once you have instilled competence, your patient can rest assured that performing that activity will create the intended results and feel empowered when they are given the autonomy to choose to continue activities that will improve their overall health and help them reach their goals. And I can’t necessarily explain how or why, but I just always get the feeling that the effort put forth is better than it would have been if I hadn’t given them the choice.

We need to feel connected. Connection, sometimes called relatedness, is the idea that people need to have a sense of belonging or attachment to other people. In team sports, this is why athletes keep going to practice and spending time with teammates despite being injured. 

Photo by Luis Quintero on Pexels.com

Similarly, the family atmosphere that is created in a CrossFit box? Connection.  The buzzword “therapeutic alliance” in rehab professions? Connection.

We all do it because we all know it works.  People like going places where they feel welcome and wanted. People enjoy being around people they like.

It’s a toss-up for who described this feeling best, Maya Angelou or Teddy Roosevelt so I will leave you with both:

“People will forget what you said. People will forget what you did.  But they will never forget the way you made them feel.”  -Maya Angelou

“People don’t care how much you know until they know how much you care.” -Teddy Roosevelt

There is a large part of rehabilitation that has nothing to do with the patient’s condition or the intervention you choose- it’s about the human. Bottom line: the more you foster competence, autonomy, and connection by making patients feel like they know what they are doing, have a voice/role in their rehab process, are part of your team or your rehab family, the easier it will be for everyone to find success. 

p.s. Interests piqued about motivation? This is a good place to start.

Published by Penny Goldberg, PT DPT ATC

Penny Goldberg, PT, DPT, ATC is the assistant director and sports physical therapist at ReQuest Physical Therapy in Gainesville, Florida. Penny earned her doctorate in Physical Therapy from the University of Saint Augustine in 2012 and completed an American Physical Therapy Association (APTA) credentialed sports residency at the University of Florida in 2014. At UF she provided physical therapy services for varsity athletes from all sports. She became a Board Certified Clinical Specialist in Sports Physical Therapy in 2017. She completed a Bachelor of Science degree in Kinesiology with an emphasis in Athletic Training and a Master of Arts degree in Physical Education with an emphasis in Biomechanics from San Diego State University in 2001 and 2004, respectively. Her Master’s Thesis was on preventing concussion and dental injuries in Division I Women’s Soccer players and prevention of athletic injuries has continued to be a major focus of her career. Prior to physical therapy school, Penny worked as a Certified Athletic Trainer at the University of San Diego, California State University at Northridge, and Butler University where she worked extensively with athletes from the volleyball, baseball, soccer and softball teams. She also has substantial experience working with swimmers as she was a competitive swimmer and later spent several years coaching in the club she grew up in. Penny is an active member of the APTA, a credentialed clinical instructor, and a Clinical Athlete Provider. She has presented at national meetings on Kinesiophobia in Outpatient Physical Therapy, Differential Diagnosis of Ankylosing Spondylitis, Transient Osteonecrosis of the Femur in an Active Female, and Tibial Plafond Fracture in a High-level Distance Runner. She has also published on topics including returning to sports after anterior cruciate ligament reconstruction and fear of movement/re-injury across the spectrum of outpatient physical therapy diagnoses. She is currently serving on the committee that is developing the assessment tool to be used in physical therapy residency training as well. Penny has focused her continuing education on running gait analysis, biomechanics of the shoulder in overhead athletes, strength training for runners and youth athletes, post-surgical rehabilitation and return to sport testing protocols, and training the female athlete. She has recently become more active in building relationships between physical therapists and athletic trainers to improve the overall experience for athletes with injuries after noticing the divide between the professions was growing rather than coming together. She has started a Facebook group called “PT/AT Connection- Physical Therapist and Athletic Trainer Mentoring” that is open to students and professionals that are PTs, ATs, and dual credentialed PT/ATs where she hopes to foster inter-professional collaboration and provide mentoring for physical therapy and athletic training students and young professionals. Additionally, she recently launched her website- oPTimal-educATion.com (but it’s still very much under construction!) where she will house educational materials and resources. The blog is up and running at www.oPTimal-educATion.com/blog with posts directed at addressing some of the most common struggles that students encounter during their clinical experiences. Additional topics to be covered in the blog include building inter-professional relationships, leadership skill development, and mentoring of students and young professionals from both disciplines.

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