In addition to the clinical and technical expertise required to address biomechanical and functional problems, O&P practitioners adopt a communication pattern to achieve specific objectives.
This pattern includes specific words, phrases, questions, and responses intended to improve both the practitioners’ understanding of patients and their situations and the patients’ understanding and acceptance of the interventions. A pattern develops (with varying levels of intention and thoughtfulness) as choices are made about how to address patient expectations, respond to concerns regarding satisfaction and adherence, and many other issues. It is common to rely on past experiences with similar cases to address these concerns with the intention of replicating past success and maximizing treatment effectiveness and positive outcomes.
Personal and Interpersonal Barriers to Effective Treatment
A properly fitted and aligned device will only be effective to the extent that it is worn appropriately. Research demonstrating significant variations in adherence rates for many O&P interventions, with nonadherence greater than 50 percent for some, highlights the common challenge of addressing patients’ motivation to use devices appropriately and sufficiently to achieve the functional outcomes for which they are intended. The success of all O&P treatment is related to appropriate device use, but in some conditions (e.g., scoliosis and cranial remolding) outcomes are dependent on time wearing the device. Other interventions do not require specific wear times, but increased benefits will be realized with increased wear time. For example, regular use of a lower-limb prosthesis or orthosis will generally result in greater functional and health benefits.
Additionally, some patient behaviors present barriers to effective treatment. Expressions of strong emotions (often anger or sadness) or distrust in the competence of the practitioner, and unreasonable expectations can challenge clinical effectiveness. Patients who exhibit these traits or behaviors are often referred to as difficult, particularly when there is a pattern of such behavior in repeated encounters. Clinicians may discover that their usual pattern of communication is not as effective in these cases and often develop a subset of responses to address them.
While O&P practitioners have extensive training in the core competencies of the profession, there is little formal training in navigating these frustrating and challenging aspects of an encounter. Lacking this training, we adopt strategies that are based on personality, individual preferences, the guidance and example of clinical mentors, and observations about which ones appear to be more or less effective. Nonadherence is often understood as a lack of motivation and addressed by providing more information and warning patients about negative outcomes in attempts to convince patients to change their behavior. Discussions about difficult behavior are often avoided unless the behavior becomes extreme enough to warrant establishing a boundary.
The Limits of Information
Healthcare providers have an ethical and legal responsibility to make treatment recommendations, educate patients regarding options and potential outcomes, and provide direction throughout the course of treatment. However, providing more information is minimally effective when the issue relates to motivation to change unhealthy or difficult behaviors. For example, most individuals who use tobacco products regularly are aware of the negative health consequences. Their motivation to change this behavior is unlikely to increase in response to more information, warnings, or criticisms, and there is evidence that this approach can actually have the opposite effect. Practitioners must provide information (and document that they have done so) but should also recognize that the timing and manner of delivery can impact effectiveness.
How’s That Working for You?
Practitioners do not measure the outcome of their communication pattern in any formal way, and instead rely on qualitative and subjective evaluation. Clinical psychologist Phil McGraw, the well-known television personality, often asked guests “How’s that working for you?” to challenge their approach to life and relational problems. A commitment to improving interpersonal clinical skills can begin with the question: How effective are the strategies I regularly use to address adherence and difficult behaviors? Continuing to encounter the same problems during interactions with an individual patient can indicate that the approach is not effective in that specific case. A pattern of cases like this can indicate that the practitioner could benefit from a broader change in his or her approach. Comparisons to the experiences of other practitioners can also be helpful. An increased incidence of nonadherence or difficult behavior could indicate that the practitioner is seeing more patients with these issues or that he or she has less skill in navigating these encounters. Just as with the health behaviors of patients, practitioners will only make a change in their communication patterns if the importance of change is recognized, and they are confident that it is possible.
Research and the experience of many practitioners demonstrate that communication and other interpersonal skills can be improved. Motivational interviewing (MI) is one approach that has been implemented to increase effectiveness in challenging clinical situations.
Motivational Interviewing Explained
MI was introduced in the 1980s by psychologists Miller and Rollnick as “a person-centered, goal-oriented style of communication with particular focus on expressions of change. The goal is to increase personal motivation for and commitment to behavior change by eliciting and intensifying a person’s own reasons for change in an atmosphere of acceptance and empathy.”1 The term MI may be confusing and warrants some explanation. According to Miller and Rollnick, “Motivation is whatever actually gets someone moving [and] motivation arises from both internal and external sources and is often interpersonal, something that happens between people. Interviewing is a particular kind of interaction…. An interviewer has a particular guiding role that is different from the role of the person being interviewed…. The interviewer’s task is to ask particular questions, listen with curiosity, and learn…. MI is not about installing motivation in people but rather evoking it from them…. MI is a particular way of having conversations about change.”2 (See Figure 1.)
MI was developed, not as a strategy or type of therapy, but as a “particular way of talking with people about change and growth” and involves specific practices and skills.2 Miller and Rollnick cautioned that MI is not a therapeutic technique, but rather a way of discussing change with clients. As such, it can be incorporated into other psychotherapy methods and medical interactions. “MI alone is…insufficient for many healthcare concerns…it is usually combined with other active treatments and more generally as a way of delivering care.”2
Research on the Effectiveness of MI
MI has been studied in more than 2,000 controlled trials in a wide variety of psychotherapy and medical contexts.2 A bibliography of controlled trials is available at motivationalinterviewing.org/motivational-interviewing-resources.3 According to Miller and Rollnick, “Most but not all meta-analyses report a statistically significant average effect of MI, usually a small to medium effect size with substantial variability across studies.”2 They caution that MI, like any therapeutic approach, “does not always help people change. About a quarter of MI trials have reported no significant benefit.”2
Frost et al. published a systematic review of 144 reviews (including 39 meta-analyses) to “to appraise and synthesize the review evidence for the effectiveness of motivational interviewing on health behavior of adults in health and social care settings.”4 The researchers categorized the reviews into four domains based on the focus of the review (Figure 2). Issues related to O&P adherence are most like those in Domain 2 (promoting healthy behavior for a specific problem).
The researchers “found no high-quality evidence from the meta-analysis data within any review, mainly due to methodological flaws in the reviews and poor quality of the included studies.”4 Many of the limitations of MI research are common in other psychotherapy research, including methodological quality and training fidelity. The authors stated that “motivational interviewing appears to be most effective for stopping or preventing unhealthy behaviors (categorized as Domain 1) such as binge drinking, reducing the quantity and frequency of drinking, smoking, and substance abuse…. For promoting healthy behavior (categorized as Domain 2) where people may have little desire to change, most of the evidence is inconclusive or of low quality. For example, there is low-quality evidence for the effectiveness of motivational interviewing for weight loss outcomes in obese and overweight adults. The exception in Domain 2 is physical activity promotion where there is moderate quality evidence of beneficial effects of motivational interviewing for increasing physical activity in people with chronic health conditions.”4
These conclusions regarding research on physical activity may have relevance for O&P interventions designed to improve and increase ambulation or other forms of activity.
The results may seem underwhelming, and insufficient to inspire a commitment to changing patterns of communication with patients, but a review of research related to the effectiveness of O&P interventions published in the same year as the Frost review of MI research provides interesting perspective. The objective of Healy et al.’s review was “to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.”5 The researchers reviewed 323 English language randomized controlled trials (RCTs), of which “319 examined orthotic interventions and four examined prosthetic interventions.”5 The researchers identified 68 categories of conditions or injuries and were only able to identify one RCT for many of those categories. For this reason, they focused on the 12 with the highest number of randomized controlled trials (which comprised 60 percent of the conditions). The researchers concluded that “at present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high-quality research to allow strong conclusions on their effectiveness and cost-effectiveness.”5
It would not be advisable to discontinue providing O&P interventions based on these results. It would be equally inadvisable to discount MI interventions for failing in a similar way to be supported by the highest levels of research evidence. Most decisions clinicians make are based on clinical experience and patient preferences, two essential elements of evidence-based practice. A responsible approach to clinical decision-making requires scrutinizing experience in the light of best available research evidence, and scrutinizing research findings for relevance and applicability to the day-to-day problems patients present with.
Application to O&P
O&P practitioners are not qualified providers of mental health and psychotherapy interventions. However, the implementation of specific skills and strategies can improve effectiveness within their scope of practice. Practitioners who recognize the limitations of their current communication approach, or who want to improve in these areas, can benefit from incorporating MI tasks and skills into their practice. A careful approach to building trust (engaging), identifying specific problems to address (focusing), understanding and strengthening each patient’s motivation (evoking), and working collaboratively with the patient to develop a treatment plan (planning) can reveal crucial patient strengths and limitations. Recommendations for improving adherence are likely to be more effective if practitioners recognize and address patient-specific strengths and deficiencies in each of these areas. Management of encounters that involve difficult patient behavior may be more effective as practitioners improve their ability to ask open-ended questions, affirm, reflect, and summarize (OARS) before rushing to offer solutions. In addition to their usefulness in more routine aspects of an encounter, the OARS skills can be more effective than providing information and correction when a patient is highly emotional or argumentative.
Practitioners can access educational resources about MI on the Academy’s Online Learning Center. Many resources are also available on YouTube and can be accessed by searching for “motivational interviewing examples” or similar terms.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.
References
- Bischof, G., A. Bischof, and H.-J.Rumpf. 2021. Motivational interviewing: An evidence-based approach for use in medical practice. Deutsches Ärzteblatt International 118(7):109.
- Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Helping People Change. Guilford Press
- https://acrobat.adobe.com/id/urn:aaid:sc:us:d596ab66-5cd4-4b7c-a3b3-e70293bc3b0c
- Frost, H., P. Campbell, and M. Maxwell, et. al. 2018. Effectiveness of motivational interviewing on adult behaviour change in health and social care settings: A systematic review of reviews. PloS One 13(10):e0204890.
- Healy, A., S. Farmer, A. Pandyan, and N. Chockalingam. 2018. A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions. PloS One 13(3):e0192094.
