Patient profile

• Maria, a 48-year-old woman with chronic nonspecific low back pain, has been referred to physiotherapy.
• She reports reduced participation in household chores and avoids physical activity because she fears worsening her pain.
• She has not engaged in structured exercise for the past two years but expresses some willingness to consider starting gentle walking.

Assessment

Which stage of change is Maria in?

• Stage of change: Maria is in the contemplation stage: she is considering gentle walking but has not yet started.

How will you proceed with the assessment?

1. Start with open conversation
   • Ask about her current thoughts and feelings regarding activity:
     • “Maria, how are you feeling about trying some gentle walking this week? What excites you about it? Or what worries you about it”
   • This aligns with her contemplation stage: you’re listening first, not pushing.
2. Explore barriers and facilitators
   • Invite her to reflect on challenges and supports:
     • “What might make it easier for you to take a short walk? What could get in the way?”
   • Examples: pain, fatigue, time, lack of company, weather, motivation.
3. Reflect and problem-solve
   • After identifying barriers/facilitators, guide her to consider possible solutions or adjustments.
     • Examples:
       • “You mentioned feeling tired in the afternoons: what could help you fit in a short walk despite that?”
       • “You said you worry about back stiffness: how could we make the walk feel safer or more comfortable?”
   • Encourage small, achievable ideas, e.g., shorter walks, walking with support, using pain-relief strategies beforehand.
   • This step bridges awareness and action, so when you move to the self-efficacy rating, Maria can realistically evaluate her confidence based on actual strategies she can use.
4. Assess self-efficacy collaboratively
   • Use a graded confidence scale as a guide, but frame it conversationally:
     • “On a scale of 0 to 10, how confident do you feel about going for a 5-minute walk once this week?”
       • Answer Maria: 5/10:
     • Follow-up: Let’s talk about what would help you move that number up.”
     • Encourage her to voice solutions, e.g., walking with a friend, breaking the walk into smaller bouts, timing it when she has more energy.

Interpretation self-efficacy assessment

• Self-efficacy is the strongest predictor of behaviour change.
• A score of 5 indicates that Maria lacks confidence in her ability to consistently follow through, suggesting she is unlikely to adopt and maintain the new behaviour without targeted support.
• Assessing self-efficacy allows the physiotherapist to tailor the intervention, rather than just prescribing exercise.
• The physiotherapist will reassess self-efficacy. A rise up to 7/10 or above indicates readiness to progress the walking program.

Take home messsages

1. Patient-centered assessment
   • Always check how the patient feels physically and emotionally before suggesting activity.
   • Understand stage of change (contemplation, preparation, action) to tailor interventions.
   • Explore barriers and facilitators collaboratively, not just assume what’s limiting activity
2. Self-efficacy and motivation
   • Confidence to perform an activity can be more important than the activity itself initially.
   • Use graded, achievable goals (start small, e.g., 2–5 minutes).
   • Encourage patients to reflect on solutions, boosting ownership and empowerment.
3. Pain management
   • Pain should be monitored, not ignored. Teach strategies to manage flare-ups safely:
     • Gentle stretching, pacing, supportive shoes, mindful movement…
   • Respect pain signals (e.g., ≥7/10 pain → modify or delay activity).
4. Goal setting
   • Goals should be flexible, realistic, and patient-driven.
   • Use short-term, measurable targets that build mastery experience.
   • Reinforce that any small progress counts toward long-term function and confidence.
5. Communication and education
   • Use open-ended questions and active listening.
   • Normalize fears around pain while encouraging gradual, safe activity.
   • Help patients plan strategies for real-life challenges, not just the clinic session.
6. Integration of behaviour change principles
   • Combine motivation, confidence, problem-solving, and self-monitoring.
   • Encourage reflection on what works and what doesn’t, building autonomy and resilience.