Patient Profile

• David, a 35-year-old office worker, attends physiotherapy with complaints of chronic neck and shoulder pain, fatigue, and low motivation to exercise.
• He has been on and off physiotherapy for years and reports feeling “too drained” after work to do any form of physical activity.
• The physiotherapist notices his flat affect and minimal engagement during the initial session and wonders whether depression might be a contributing factor.

Assessment

• Depression screening:
  • The physiotherapist administers the PHQ-2 (Patient Health Questionnaire-2) conversationally to quickly assess for depressive symptoms:
    • “Little interest or pleasure in doing things?” → Not at all (0)
    • “Feeling down, depressed, or hopeless?” → Not at all (0)
    • Total = 0 (negative screen for depression).
• Interpretation: Despite David’s tired appearance and low energy, his PHQ-2 score suggests depression is unlikely. This prompts the physiotherapist to explore other psychological factors that may influence his engagement.

Exploring further (why)

• Symptoms like fatigue, lack of motivation, and withdrawal can mimic depression, but they may also reflect low self-efficacy.
• Because exercise adherence is closely tied to self-efficacy, clarifying this dimension is clinically relevant for tailoring treatment.

1. Stage of change

• David is likely in the precontemplation/contemplation stage:
  • He recognizes he is not active, but his fatigue and past unsuccessful attempts limit readiness to engage in regular activity.
  • He may need motivational strategies and gradual exposure rather than being pushed into structured exercise immediately.

2. Explore goals, barriers and facilitators

• Ask about goals:
  • “David, what would you most like to achieve with physiotherapy or physical activity? Even small changes matter.”
    • Examples: reduce stiffness, have more energy after work, improve posture, prevent flare-ups.
• Ask about barriers:
  • “What makes it difficult to be active after work?”
  • Likely barriers: fatigue, low motivation, sedentary work, past failed attempts, pain flare-ups.
• Ask about facilitators:
  • “What could make it easier for you fit in activity?”
    • Examples: short breaks at work, support from family, morning exercise, ergonomic setup.
  • Purpose of this step:
    • Clarifies patient priorities and helps tailor the intervention.
    • Identifies barriers to address in the next step (problem-solving).
    • Provides context for a realistic self-efficacy assessment later.

3. Reflect and problem-solve

• Collaboratively brainstorm practical strategies:
  • Micro-breaks: 1–2 minutes of neck/shoulder stretches during work.
  • Short home sessions: 5–10 minutes morning or evening.
  • Ergonomics: adjust chair, monitor, desk height.
  • Pacing/energy management: avoid pushing through fatigue, schedule high-energy times.
• Purpose: Bridges awareness of barriers to achievable action.

4. Assess self-efficacy

• Use a graded, realistic scale informed by problem-solving:
  • “On a scale from 0–10, how confident are you that you could:
    • Do 2–5 minutes of neck/shoulder stretches today?
    • Take a 5-minute walk after work this week, even if tired or stiff?”
• Discuss what could increase confidence (e.g., shorter bouts, reminders, support).
• Purpose: Identifies achievable goals and guides goal-setting.

Goal setting

5. Co-create small goals

• Examples of short-term goals:
  • 5 minutes of neck/shoulder stretches today.
  • 5-minute walk tomorrow (morning or after work).
  • 1–2 micro-breaks for mobility during workday.
• Tips:
  • Keep goals flexible, measurable, and patient-driven.
  • Celebrate small successes to build mastery experience.

6. Communication and education

• Use open-ended questions: explore feelings, barriers, and facilitators.
• Normalize fatigue and pain while encouraging safe, gradual activity.
• Emphasize reflection and autonomy: “You decide pace, timing, and duration; we adjust as needed.

7. Behaviour change integration

• Combine motivation, confidence, problem-solving, and self-monitoring.
• Encourage reflection: what worked, what didn’t.
• Reinforce small successes to gradually increase activity and self-efficacy

Take home messages

• This case highlights that low self-efficacy can masquerade as depression in physiotherapy.
• Using the PHQ-2 helps rule out depression efficiently, while self-efficacy assessment (via a numeric rating scale) reveals the real barrier to behaviour change.
• Addressing self-efficacy directly prevents mislabelling the patient as “depressed” and enables tailored, achievable physiotherapy planning.
• For patients like David, success depends less on prescribing exercise volume and more on meeting them where they are, breaking the inactivity cycle with manageable, confidence-building activities, and gradually expanding as self-efficacy grows.

Prioritize recovery as well through sleep and stress management

• Poor sleep and high stress both amplify pain perception, drain energy, and lower motivation.
• Encourage David to:
  • Keep a consistent sleep routine (regular bedtime/wake time, screen curfew).
  • Try brief relaxation techniques (breathing, stretching, mindfulness) at the end of the workday to transition from “work mode” to “recovery mode.”
  • Use evenings for restorative, low-effort activity (gentle mobility, short walk) instead of avoiding movement completely