Pelvic Floor Muscle Training Patient Support

Engagement with Treatment

Non-compliance is a key problem for PFMT – undermining its potential benefits.

It involves:

• Non-attendance.
• Non-adherence.
• Non-concordance.

Reasons for Non-engagement

Sub-optimal outcomes due to poor engagement across many treatments:

• Pharmacotherapy discontinuation = 80-90% (D’Souza et al., 2008; Krueger et al., 2005).

• Physiotherapy discontinuation = 40-50% (Khan et al., 2013); 30% (POGP survey 2020).

Intervention to Improve Engagement

In our 2016 paper (Osborne et al., 2016), we tested a psychological support intervention with an RCT:

• The intervention focused on supporting patient engagement with PFMT, not on improving psychological state, and could be delivered by any health professional.
• Can be an individual or a group-based programme – can be short (10min) or long (30min).
• 67 PFMT patients undergoing 6 group PFMT sessions (approx. 7-8 per group).
• Participants completed HADS to assess psychological distress.
• 31 patients in mild-moderate range for depression and anxiety were randomly divided into:
• PFMT only (n = 15).
• PFMT + Motivational Interviewing and Values Support (n = 16).
• MIVS group received 3 x 20min psychological group sessions (2^nd, 3^rd, 4^th PFMT session).
• 90% of MIVS group, but only 60 of PFMT only group completed treatment.

Practical steps and procedures to support patients during physiotherapy

• Focus on patient motivation and values.
• Use principles of motivating change.
• Use principles of identifying what the patients want to achieve for themselves (values).
• Use a diary system to record goals and successes – this serves as reinforcement:
• Patients record times they practised targeted behaviours and achievements
• These can be shared and discussed in the group.

Questions that elicit self-motivated ‘Reasons to Change’

• Tell me some reasons why you might want to do this.
• Tell me some things you wouldn’t like if you didn’t change.
• Tell me some reasons why you may not want to change (fears, barriers).
• How might your life be different if you changed?
• What benefits might there be if you changed?
• How does this affect your life?
• What are some of the negative things about not changing?

Summary of important life values

• Values are intrinsically reinforcing for people.
• Behaviours congruent with values will be performed long after treatment finishes.
• Try to make results of PFMT treatment match values.
• In our 207a (Osborne et al) paper, and in our 2020 (Reed et al.) paper, we examined life values associated PFMT with engagement.
• Relationships with family and friends are a very important aspect of patients lives.
• Health values, work/achievement values, and spiritual values predict attendance.

Questions identifying individual values

When were you happiest?

• What were you doing?
• Were you with other people?
• What other factors contributed to your happiness?

When were you most proud?

• Why were you proud?
• Did other people share your pride?
• What other factors contributed to your feelings of pride?

 When were you most fulfilled and satisfied?

• What need or desire was fulfilled?
• How and why did the experience give your life meaning?
• What other factors contributed to your feelings of fulfilment?

 Try a values discussion exercise

There are several excellent tools to download to help clarify and highlight values:

Values discussion questions:

https://www.therapistaid.com/therapy-worksheet/values-discussion-questions/values/adults

Values exploration exercises:

https://www.therapistaid.com/worksheets/exploring-values.pdf

Values self-exploration:

https://www.therapistaid.com/worksheets/values-self-exploration.pdf

The Motivation Ladder

• After goals decided, the patient makes ‘motivation success’ ladder.
• Practical tool assisting goal-achievement by giving an objective representation of processes needed.
• Add to ‘representation’ (drawing, physical object) of the ladder – each rung labelled, and only added, when sub-goal achieved.

Further Goal Exploration Exercises

There are several excellent tools to download to help clarify and highlight values:

Goal Exploration:

https://www.therapistaid.com/worksheets/goal-exploration.pdf

Goal Breakdown:

https://www.therapistaid.com/worksheets/goal-breakdown.pdf

Goal Planning:

https://www.therapistaid.com/worksheets/goal-planning.pdf

Supporting Behaviours – Reinforcement

• Many patients do not notice when they achieve something.
• Depression makes patients focus on negatives, not positives.
• Achievement of goals has to be highlighted.
• Patients have to do this themselves:
• Self-efficacy.
• Social reinforcement.

‘Three good things’ exercise (promotes self-efficacy)

• Write down some things that went well (give events titles).
• Items can be small or large in importance.
• Provide explanations of why they went well – write down what happened, what was said by you and others.
• Include how events made you feel, at the time, and later.
• Explain what you think caused the events – focus on targeted behaviours to be encouraged.
• Create a physical record by writing them down – it is not enough to do this in your head.
• Do this exercise as part of a routine – daily or weekly.

‘Three good things’ tools

There are several excellent tools to download to help thinking about positives:

Three good things recording chart:

https://www.therapistaid.com/worksheets/gratitude-journal-three-good-things.pdf

Behaviour chart to record events:

https://www.therapistaid.com/worksheets/behavior-chart.pdf

Social reinforcement

• Patient records motivate patients and create a sense of self-efficacy.
• It gives a record of how things went between sessions – so goals can be adjusted.
• It gives a chance to bolster rewards socially!
• It works well in groups – so long as there is no pressure to share.