Motivation and RehabilitationMotivation and Rehabilitation

Martin D van den BroekMartin D van den Broek

Friday 8Friday 8thth March 2013 March 2013

The Wolfson Neurorehabilitation Centre & Atkinson Morley’s The Wolfson Neurorehabilitation Centre & Atkinson Morley’s

Regional Neurosciences Centre, Regional Neurosciences Centre,

St.George’s Hospital, LondonSt.George’s Hospital, London

• Gains may be limited

• Gains may fail to generalise

• Gains may not be maintained

Cicerone et al, 2000

Neurorehabilitation

In-/Day-patient Admission

Discharge

Goal Planning Meeting 1

Goal Planning Meeting 2

Goal Planning Meeting 6

Goal Planning Meeting 3

2 weeks

10 weeksGoal Planning Meeting 4

Goal Planning Meeting 5

Understanding Poor Motivation• Decide immediately what you are going to do

• Your decision must be definite and permanent

• You must stick to it

• You must actively work to realise it

• You must have no second thoughts

• Uncertainty will be judged as evidence that you are not serious, lacking insight, backsliding, violation of an agreement

In-/Day-patient Admission

Discharge

Goal Planning Meeting 1

Goal Planning Meeting 2

Goal Planning Meeting 6

Goal Planning Meeting 3

2 weeks

10 weeksGoal Planning Meeting 4

Goal Planning Meeting 5

• If patient’s wants do not match their

needs, then progress is unlikely

(Needs-Wants mismatch)

• What patients need is what they want

• Would you like help to become more independent (with shopping, cooking, etc)…?

• Would you like to join the memory group to help you remember things better?

• How would you feel about learning to feel less angry/irritable/depressed…?

Offers of Rehabilitation

• I could ask the physiotherapist to see you for help with your walking

• Would you like some tablets to help you with your mood?

•The speech therapist may be able to help with your speech, would you

like to see him/her?

• Staff unable to manage patient in acute setting

• Multidisciplinary team believe they can help

• Unit has services appropriate to patients’ problems

• Rehabilitation team have places on their programme

• Family or carers experiencing a burden of care

• MP or local politicians support family

• Lack of appropriate Nursing/Residential facilities

• Health Authority has policy of avoiding ‘blocked’

acute beds

Why Rehabilitation?

• Progressive GP wants best for patient

• Progressive Solicitors want best for their client

• Solicitors need to demonstrate their client is minimising

his/her loss

• Insurers want to minimise final settlement

• Rehabilitation service must fulfil contract with purchasers

• Health authority does not want to fund private referral

• Patient has problems that he/she wants to overcome

Why Rehabilitation?

• If the prime beneficiary of treatment is

not the patient, then progress is unlikely

Contemplation

Det

erm

inat

ion

Action

Maintenance

Transtheoretical Model of Change

Prochaska, DiClemente & Norcross, 1992

PrecontemplationRel

apse

1. Motivation to change is elicited from the client, and not imposed from without

2. It is the client's task, not the counsellor's, to articulate and resolve his or her ambivalence

3. Direct persuasion is not an effective method for resolving ambivalence

4. The counselling style is generally a quiet and eliciting one

5. The counsellor is directive in helping the client to examine and resolve ambivalence

6. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction

7. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles

Principles of Motivational Interviewing

Stages of Change & Therapist Tasks (Miller & Rollnick, 1991)

Precontemplation: Raise doubt - increase client’s

perception of problems

Stage Therapist’s motivational tasks

Contemplation: Tip the balance - evoke reasonsfor change, risks of not changing;

strengthen self-efficacy for change in behaviour

Determination: Help client to determine best

course of action

• Stage Therapist’s motivational tasks

Action: Help client to take steps towards

change; commence rehabilitation

Maintenance: Help client identify & use strategies to prevent relapse

• Stage Therapist’s motivational tasks

Relapse: Help client to renew the

processes of contemplation,

determination and action, without

becoming stuck or demoralised

Motivational Approach to Goal SettingMotivational Approach to Goal SettingExample: Diary Training

Goal Definition“I need to use a memory aid”

Option Appraisal“I could use a diary, notebook, organiser,

go to a self-help group”

Solution Selection“I’ll use a diary”

Precontemplation

Contemplation

Determination

Action

Problem Identification“I’ve got a problem with my memory”

Educational MethodsQuestion & Answer Method

Structured Information GatheringTest Results Feedback

Video FeedbackRole Reversal Exercises

Evoke reasons for RehabilitationDiscuss pros & cons of change

Discuss Importance & Confidence in achieving goal

Offer adviceProvide Affirmation

Clarify NeedsRemove Barriers

EnvisioningEmphasize Personal choiceClarify details (of aid use)

Strengthen Confidence

Start Diary Training

Motivational Readiness

Goal Setting Stage Intervention

Does MI work in neurorehabilitation?

Evaluation of MI after acute Stroke: Evaluation of MI after acute Stroke:

A Randomised Controlled TrialA Randomised Controlled Trial Caroline L. Watkins, Lancaster

Martin D.van den Broek, London

Cathy Jack, Belfast

Hazel Dickinson, Liverpool

C. F. Deans, M. F. Auton, D. Forshaw, H. Gardner, M. J. Leathley, C. F. Deans, M. F. Auton, D. Forshaw, H. Gardner, M. J. Leathley, C. E. Lightbody, J. Marsden, J. McAdam, I. McClelland, C. J. SuttonC. E. Lightbody, J. Marsden, J. McAdam, I. McClelland, C. J. Sutton

Aim To determine whether Motivational Interviewing early after

stroke can alter:

Mood Function Expectations about recovery

At 3 months post-stroke and then at 12 months

Results

Recruitment1388

Assessed

696 Eligible

411 Consented & randomised

204 Intervention Group

Usual Care + MI

207 Control Group

Usual Care

285Refused

Can MI alter mood?

VariableVariable

MI MI

(n = 204)(n = 204)

Usual careUsual care

(n = 207) (n = 207) Freq.Freq. %% Freq.Freq. %%

Baseline mood: Baseline mood: NormalNormal

LowLow

7777

127127

37.737.7

62.362.3

8080

127127

38.638.6

61.361.3

3m mood: 3m mood: NormalNormal

LowLow

100100

104104

49.049.0

51.051.0

8181

126126

39.139.1

60.960.9Significant benefit of MI over usual care (p=0.033)

OR (normal mood at 3m)=1.60, 95% CI = 1.04-2.46

0%

20%

40%

60%

80%

100%

Baseline 3M

Time-point

Per

cent

age

of p

atie

nts

Normal mood Low mood Dead

Usual Care

80

Change in MoodChange in Mood

0%

20%

40%

60%

80%

100%

Baseline 3M Baseline 3M

Time-point

Per

cent

age

of p

atie

nts

Normal mood Low mood Dead

Usual Care MI

80 77

Change in MoodChange in Mood

0%

20%

40%

60%

80%

100%

Baseline 3M Baseline 3M Baseline 3M Baseline 3M

Time-point

Per

cent

age

of p

atie

nts

Normal mood Low mood Dead

Usual Care MI Usual Care MI

80 77 127 127

Change in MoodChange in Mood

Conclusions

Results at 3 months post-stroke indicate that Motivational Interviewing

• Can benefit patients’ mood after stroke

• No effect on expectations or function

Results at 12 months similar.