Motivation and emotion/Book/2015/Exercise rehabilitation motivation in chronic disease patients

Overview
Exercise rehabilitation is a modern approach to recuperation in patients who are suffering or recovering from chronic diseases, injury or surgery (Pedersen & Saltin, 2006).

This book chapter endeavours to cover:
 * Benefits of Exercise Rehabilitation for Chronic Disease Patients
 * Motivators to Complete Exercise Rehabilitation
 * Perceived Motivational Barriers to Exercise Rehabilitation

History
Exercise rehabilitation has primarily been used to assist those recovering from chronic diseases, injuries and surgery in addition to traditional rehabilitation mechanisms. It is adaptable to individual patient needs and poses little to no limitations on variables such as duration, intensity and frequency (Gardner, Katzel, Sorkin, Gradham, Hochberg, Flinn & Goldberg, 2001). Primarily, the goals of exercise rehabilitation are to return to pre-incident functioning, in a physical, mental and physiological capacity and improve overall quality of life (QOL) and health related quality of life (HRQoL), as well as activities of daily living (AoDL). These can be achieved through prescribed exercises from qualified practitioners, including physiotherapists, exercise physiologists and rehabilitation specialists (Auaus, Eilayyan, & Mayo, 2012).

Prevalence
The occurrence of exercise rehabilitation is slowly growing among particular populations. This may be due to the untraditional nature of methods used, but also resistance and lack of motivation in engaging. Particularly among cardiac patients, Piepoli et al. (2011) noted only 42% of patients undergoing rehabilitation incorporated exercise specifics into their program. Furthermore Blaney, Lowe-Strong, Rankin, Campbell, Allen and Gracey (2010) reported that to 70% of cancer patients remain sedentary during their treatment and rehabilitation. With cancer and cardiovascular disease patients making up a large portion of those with chronic diseases, it is fair to assume that prevalence of exercise rehabilitation being utilised is particularly low.

Evidence
The emerging evidence for exercise rehabilitation is strong and consistent, particularly in a chronic disease population. Several studies have reported the effectiveness in increasing cardiovascular capacity, AoDL capability, but also a reduction in cardiovascular mortality, and disease related hospital admissions (Lawler, Filion, & Eisenberg, 2011).

Franklin, Lavie, Squires and Milani (2013) study supported the use of exercise rehabilitation for those with coronary heart disease (CHD) and cardiovascular diseases (CVD). They found a 40% reduction in CHD and CVD risks factors for participants completing exercise rehabilitation, by exerting effects on endothelial functioning, in turn decreasing disease progression in the heart muscles. They also noted the improvements in psychological dysfunction in participants, which has been an observed co-morbidity for those with CHD and CVD.

Further to Franklin et al. (2013), Spence, Heesch and Brown reported the effects of exercise rehabilitation on cancer patients immediately post chemotherapy. Their participants completed 12-week exercise programs with exercise physiologists, which comprised of moderate-high intensity aerobic exercise tailored to the individual’s needs and preferences. Results concluded that participants experienced reduced fatigue and increased confidence, as well as improvements in confidence to complete AoDL, in particular, return to work. It was also reported that participants enjoyed the interactions with the exercise physiologists, which enhanced the overall experience.

What Benefits Does It Provide to Chronic Disease Patients?
Benefits of exercise rehabilitation can vary between patients, diseases and methods of rehabilitation, however all experience improvements in overall well-being.

Immediate Benefits
Many chronic disease patients experience immediate benefits shortly after exercise rehabilitation sessions. In particular, Hansen, Dendale, van Loon, and Meeusen (2010) discussed the reduction in adipose tissue deposition in the body, and the further benefits it provides. The reduction in symptoms of metabolic syndrome was also mentioned, specifically blood lipids (cholesterol), blood pressure and glycaemic control. In programs designed to be continuous of nature, it has also been noted that VO2 peak measures are increased in patients, and in turn produce more oxygen to vital organs of the body. Low-intensity endurance exercise also produces immediate benefits for weight loss in order to increase skeletal fat oxidation and reduce overall adipose tissue (Hansen et al., 2010). Finally, during most training modalities, insulin sensitivity was reduced, which is particularly beneficial to patients with diabetes as a primary or co-morbid disease.

Separately, Speck, Courneya, Masse, Duval and Schmitz (2010) studied the effects of exercise rehabilitation on cancer survivors. Their findings suggested immediate benefits including reduction in fatigue post treatment, which in turn improved overall functioning. It was also suggested that there may be some positive increase in psychological functioning shortly after exercise rehabilitation sessions.

Prolonged Benefits
Many immediate benefits continue to improve the patient’s symptoms over a prolonged time period, however in addition to this, several other benefits become apparent after prolonged engagement in exercise rehabilitation.

Gayda, Brun, Juneau, Levesque and Nigam (2008) reported the benefits of exercise rehabilitation after a yearlong program with patients diagnosed with coronary heart disease. Their findings showed significant decreases in metabolic syndrome components, inclusive of bodyweight, BMI, HDL-cholesterol levels and insulin resistance levels. This is important, as metabolic syndrome is comorbid to several chronic diseases, as well as one itself. With decreases in these specific components, it also allows for increases in overall health and HRQoL.

De Backer, Vreugdenhil, Nijziel, Kester, van Breda and Schep (2008) also noted Gayda et al.’s (2008) findings however offered further evidence for exercise rehabilitation in cancer patients. They found after a one year intervention of resistance training patients experienced greater muscle strength, increased cardiopulmonary functioning, QoL and reduced levels of fatigue.

Finally, Spence, Heesch and Brown (2010) systematic review of literature documented the improvements in immune functioning and haemoglobin concentrations, which are markers of potential reoccurrence for cancer, when undertaking extensive exercise rehabilitation after treatment.

Motivation Systems
Motivation in humans can be categorised into two systems: intrinsic and extrinsic motivation. Both of these are impacts on exercise rehabilitation motivation.

Intrinsic Motivation
Intrinsic motivation is the internal drive to explore challenges to exercise one’s capabilities, and is most prominent in early childhood. Intrinsic motivation is generally autonomous within the person and is sought out for ones satisfaction only, rather than to please someone else concurrently (Ryan & Deci, 2000). Whilst intrinsic motivation may remain to be internal, it has been reported that positive external performance feedback can in fact enhance intrinsic motivation. Contrary to this, negative feedback can also diminish motivation.

For intrinsic motivation to be effective it must be autonomous and self-determined and flourish in contexts that promote safety and security. It is diminishable with the introduction of threats, deadlines, pressured evaluations and goals imposed extrinsically (Ryan & Deci, 2000). A particular theory that is supportive of intrinsic motivation is Self Determination Theory.

Extrinsic Motivation
Extrinsic motivation is based solely around motivation from outcomes that are separate to the self and directly influence the motivation of activities (Ryan and Deci, 2000). This form of motivation can be negative and lead to activities being completed with feelings of disinterest, resentment and resilience due to propelment of motivation from an external source. Some people may be solely extrinsically motivated to complete activities, undermining intrinsic motivations. It is also perceived to be non-autonomous.

Whilst some may find tasks that are extrinsically motivated dull and boring and directed by punishment, others complete extrinsically motivated activities with promise of desirable materialistic rewards, should the task be completed. Deci, Kosetner and Ryan (2001) discussed the undermining of intrinsic motivation with the offer of materialistic rewards. It was found that this was particularly prominent in classroom environments with teachers offering students incentives to complete work. Whilst extrinsic motivation may be perceived as negative it is particularly effective, as demonstrated in classroom settings.

What Motivates Chronic Disease Patients to Complete Exercise Rehabilitation?
Motivation for chronic disease patients to complete exercise rehabilitation vary depending on their disease, state, age and accessibility. However many motivational theories can be applied to this population as to the reasoning for completing exercise rehabilitation.

Self Determination Theory
Self-determination theory (SDT) is centred around ones need for innate psychological needs that in turn drive an internal motivation (Ryan, 2000). There have been three primary needs identified; need for competence, relatedness and autonomy which are believed to be necessary for optimal human functioning. SDT is an intrinsic form of human motivation, which naturally describes the primary needs identified by this theory, however may also be influenced by social or environmental factors yet remain autonomous (Ryan, 2000).

According to SDT, chronic disease patients will be more likely to complete exercise rehabilitation if they believe it will challenge their competence at tasks, relatedness and autonomy. Specifically, this may be a strong motivation factors for those who do not have complete autonomy due to their disease, and in turn feel the need to increase this. Similarly, patients may also experience higher levels of competence in AoDL on completion of their exercise rehabilitation. Interestingly, Ryan (2000) specifically reported that greater internalisation of motivation is associated with greater adherence to medications and rehabilitation in chronic disease patients, as well as improved maintenance of weight loss in obese populations, and greater glucose control in diabetics. Similarly, Russell and Bray (2010) reported that those who are self-determined have greater success in adherence to long-term behaviour modification. In addition they also found a correlation between perceived autonomy and self-determined motivation to complete exercise rehabilitation in cardiac patients, supporting SDT in exercise rehabilitation as a motivator to complete.

Theory of Reasoned Action
Theory of reasoned action (TRA) is one of the most validated and frequently used theories applied to health and exercise research (Downs & Hausenblas, 2005). The theory suggests that people’s intention to complete a behaviour is the most prominent factor in determining if it will be completed. It is believed that intention is influenced by attitudes and subjective norms of those involved.

Chronic disease patients may use TRA as a motivator to complete exercise rehabilitation due to the influencers of intention. Many chronic disease patients see exercise rehabilitation as a positive activity for a variety of reasons, producing positive attitudes. According to TRA this would in turn increase intention and motivation to engage and complete the activity. Similarly, patients may be positively encouraged by family and friends to complete exercise rehabilitation, therefore increasing intention and motivation. Blaney et al. (2010) reported that many patients in their study reported lack of motivation due to perceptions of the activities being difficult, or being unable to complete them to a level that may have been achievable at pre-incident functioning. Patients also reported the thoughts of weight loss during the rehabilitation and found motivation was higher then, than previously. Therefore, it is fair to assume that chronic disease patients are more motivated to engage in exercise rehabilitation if they have a positive attitude, and those around them are supportive of them engaging in the behaviour.

Theory of Planned Behaviour


Theory of planned behaviour (TPB) is an extension from TRA created by Ajzen (Downs & Hausenblas, 2005). TPB considers intentions, in addition to perceived behavioural control, stated as the evaluation of an activities perceived difficulty. It is proposed that people will engage in positively evaluated activities, perceived as a low level of difficulty and believe significant others want them to participate in the behaviour (Downs & Hausenblas, 2005). Similarly, negatively evaluated activities may be perceived as difficult and feel unsupported if completed.

Similarly to TRA, patients who engage in TPB for intention and motivation will find positive benefits from the completion of exercise rehabilitation. One major difference however is the dimension of perceived difficultly. According to TPB, motivation will decrease if a task is perceived as particularly difficult. Whilst this may be true, this may in fact motivate some patients to challenge themselves and use difficult tasks within the rehabilitation program as motivations. Blanchard, Courneya, Rodgers, Daub and Knapik (2002) conducted a study examining motivation for cardiac patients to engage in exercise rehabilitation. Their findings suggest that TPB is useful for assessing motivation for exercise rehabilitation, and that attitude is equally important as a factor when using the TPB model.

Transtheoretical Model
The Transtheoretical model (TTM) of behaviour change emerged from treatment strategies of psychotherapy for those with addictive behaviours. This model proposes that those changing their behaviour experience a series of stages determined by their readiness and motivation to change and engage (Marshall & Biddle, 2001).

Stages include:

·     Precontemplation: no intention of changing behaviour

·     Contemplation: contemplating changing behaviour in the future

·     Preparation: preparing to change behaviour in the near future

·     Action: changing behaviour and meeting criteria, however only in the recent past

·     Maintenance: changing behaviour and meeting criteria for longer than six months

TTM has been a prominent model in health psychology, especially in physical activity engagement (Marshall & Biddle, 2001). TTM differs in regards to motivational theories for chronic disease patients undertaking exercise rehabilitation. This model focuses more on the motivational processes to initiate and continue to engage in rehabilitation. Therefore, patients who are more eager and have greater intention to engage in exercise rehabilitation will be more successful in the action and maintenance phases and avoid relapses in motivation. TTM may be what motivates patients to initiate their behaviour, however Schwarzer (2008) noted the importance of different intervention activities at different stages of TTM in order to facilitate the motivation to continue onto the maintenance stage. There is however criticism noted about the TTM, especially the limitations in transitions between stages (Schwarzer, 2008). The initial model showed no ‘in between' stages, rather a one-step to another model.

What Are Common Perceived Motivational Barriers to Exercise Rehabilitation?
Whilst many chronic disease patients find motivation to begin and complete exercise rehabilitation, many have perceived barriers, inturn reducing motivation to commence or continue rehabilitation. Stevinson and Fox (2006) noted several perceived motivational barriers for cancer patients that prevented them from engaging in exercise rehabilitation. The most common included accessibility, location, cost and facilitating alternate plans that had to be made to attend rehabilitation sessions. However once these barriers were addressed, participants reported high enjoyment and strong benefits from completing the programs.

Similarly, Piepoli et al. (2011) noted several motivational barriers that are commonly reported in chronic disease populations:

How Can We Increase Motivation For Exercise Rehabilitation In Chronic Disease Patients?
Many chronic disease patients may already be motivated for various reasons to engage in exercise rehabilitation, however others may need some further motivation. Conraads et al. (2012) noted that there has been little research done examining how to motivate people to complete exercise rehabilitation, however the most effective ways are person-based motivation. However a particularly effective technique is motivational interviewing with the patient. This allows the patient and provider to explore various aspects of the motivational barriers that may be perceived, and break them down to reduce the foreign concepts that may be perceived. By engaging in this technique it also allows the provider to layout the benefits to the patients, particularly those which may be more appealing. The most common appealing benefits to chronic disease patients include: Conraads et al. (2012) also mentioned the use of interventions. These however have not been as successful as motivation interviewing for long-term behaviour changes, yet it has been effective in initiation of programs and adherence to short-term programs.
 * Increasing confidence
 * Improving self-appearence
 * Social interactions (Conraads et al., 2012)

Conclusion
Exercise rehabilitation is a beneficial and essential dimension to the rehabilitation program of chronic disease patients. However, prevalence is surprisingly low among many patients, despite the evidence indicating its benefits in reducing several aspects of disease symptoms, pharmaceutical side effects, and increasing AoDL and HRQoL. Engaging in exercise rehabilitation provides many immediate benefits, including reductions in adipose tissue, blood pressure, insulin sensitivity and fatigue. Short term benefits continue to improve over time, however other long term benefits mentioned included decreases in bodyweight, BMI, HDL levels, and insulin sensitivity. It also identifies increases in muscle strength, cardiopulmonary functioning, QoL and immune functioning.

The motivation to engage and complete exercise rehabilitation comes from one of two systems; intrinsic and extrinsic motivation. Both of these can be strong motivating factors, however research has shown that those intrinsically motivated have greater initiation and adherence than those extrinsically motivated. The motivation of patients can also be identified using four theories, including self-determination theory, theory of reasoned action, theory of planned behaviour and the transtheoretical model. All four theories identify that many factors influence the initiation and motivation to engage in and adhere to exercise rehabilitation programs and allow identification of critical traits that may influence the level of motivation a patient has.

While some patients perceive little to no motivational barrier to exercise rehabilitation, many find reduced levels of motivation due to perceived barriers. Common barriers are most frequently perceived to be socioeconomic, condition-related and patient-related in nature. However there are many techniques that may be employed to reduce and eliminate these barriers, mainly centring on the patient themselves. By utilising motivational interviewing and interventions this can increase patients motivation to engage in and adhere to exercise rehabilitation programs. These can be achieved by specifically outlining appealing benefits of programs, including the increases in confidence, improvement in self-appearence and social interactions that are all results of exercise rehabilitation programs.

Quiz
{Who can facilitate exercise rehabilitation sessions?} - Exercise Physiologists - Physiotherapists - Rehabilitation Specialists + All of the above

{Exercise rehabilitation has a low level of prevalence.} + True - False

{Which of the following is not an immediate benefit of exercise rehabilitation?} - Reduction in blood lipids - Increase peak VO2 + Decreased BMI - Decreased blood pressure

{Immediate benefits of exercise rehabilitation continue to improve in prolonged programs.} + True - False

{Intrinsic Motivation is:} - External drive to explore challenges to exercise one’s capabilities + Internal drive to explore challenges to exercise one’s capabilities - Motivation from an outside source - None of the above

{Undermining of intrinsic motivation due to extrinsic rewards is particularly common in which setting?} - Home - Sporting - Social + Classroom

{___________________ is an extension from ________________________ created by Ajzen.} - Theory of Reasoned Action, Theory of Planned Behaviour - Theory of Reasoned Action, Self-Determination Theory - Self-Determination Theory, Theory of Planned Behaviour + Theory of Planned Behaviour, Theory of Reasoned Action

{Which of the following is not a stage of TTM?} + Post-contemplation - Pre-contemplation - Contemplation - Action

{Which of the following is not a mechanism to overcome motivation barriers for Condition-Related Factors?} - Tailor programs to disease specificity - Demonstrate success of the program with 'role models' who have similar symptoms - Adapt program to coincide with treatment schedules appropriately + None of the above

{Which of the following is a common appealing benefit of exercise rehabilitation to chronic disease patients?} + Increasing confidence - Increasing muscle mass - Decreasing BMI - Increasing immune functioning