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Table 2 Mapping communication strategies to the ‘5A’ framework and self-determination theory

From: Communication style and exercise compliance in physiotherapy (CONNECT). A cluster randomized controlled trial to test a theory-based intervention to increase chronic low back pain patients’ adherence to physiotherapists’ recommendations: study rationale, design, and methods

Strategy Description / Example Main Basic Psychological Need(s) Targeted
ASK   
Using Open-Ended Questions “Tell me”/“What”/”How” are useful terms when asking questions, as they allow the patient to elaborate on his/her story. Example: “What kind of things are you doing to alleviate the pain at the moment” Relatedness
Using Single Questions Avoid asking multiple questions at one time. Instead, ask one question and wait for a response before asking a second question. Relatedness
Staying Silent Allow the patient to complete sentences and finish speaking before following up with further questions. Relatedness
Paraphrasing After listening to the patient, summarize your perception of the main points. Examples: “So what I am hearing is that…” or “It sounds like …” Relatedness
Empathizing Show the patient that you understood the emotions that went along with the issue being discussed. Examples: “I can see this upsets you” or “That must be very frustrating”. Relatedness
Gauging Patient Readiness to accept advice Ask the patient if he or she is ready to consider advice regarding activities outside the clinic. Example: “There a number of things you can do that will help … would you like to hear a few suggestions?” Autonomy
ADVISE   
Catering for Different Learning Preferences Use a selection of methods (aural, visual, kinesthetic) to educate the patient (during session and take home materials); these methods cater for multiple learning preferences. Competence
Closing the Loop Ask patients to paraphrase/demonstrate information that had been provided. Provide corrective feedback as required, and re-test understanding. Example: “To be sure that I was clear, could you please tell me, in your own words, your understanding of the …” Competence
Providing a Rationale Explain to the patient the rationale behind your advice. Example: “As we discussed earlier, your back needs support from the muscles around. So, if you can do these exercises, you can really provide your back with extra support …” or “Research shows that PA, such as walking, is a great way to…” Autonomy
Providing Opportunities for Patient Input or Choice Ask the patient to provide input or make choices when providing advice. Example: “Getting some physical activity –like going for a walk, riding your bike or swimming – is really good for your back. Is there a type of exercise that you prefer?” Autonomy
Using Autonomy Supportive Phrases Instead of Controlling Language Support and encourage the patient to accept personal responsibility for his/her recovery. Avoid coercion or guilt inducing phrases. Examples: “Here are some things that will help you overcome…” or “If you complete these exercises then you’ll strengthen your back and it will be less likely to give you pain”, instead of “Do this for me” or “You have to…” or “You must…”. Autonomy & Competence
AGREE
Employing SMART Goal Setting Agreed on goals that are Specific, Measurable, Achievable, Recorded, and Time-based. Example: Earlier you mentioned that you are finding it hard walking for long periods. For this week we could set a target of 15 minutes walking per day, how many days do you think you couldachieve that target in the next week?” Competence
Ensuring Active Patient Participation in Goal Setting Ask the patient for his/her opinions/comments during goal setting.Take into account patient’s subjective history (e.g. family/work commitments). Example: What time of day would suit you best for these exercises? Autonomy & Competence
ASSIST
Identifying Barriers and Obstacles Discuss at least one likely barrier to following treatment advice. Example: “Is there anything you can think of that might stop you from accomplishing your exercise goal?” Competence &Autonomy
Identifying Solutions and Obstacles Brainstorm with the patient ways to overcome this barrier (e.g. ‘identifying enablers’ and ‘cognitive restructuring’). Examples: “Walking can be a fun and social activity that doesn’t seem like hard work. How would you feel about walking with a friend/neighbor?” and suggest changing thoughts from “I am too out of shape to walk to the shop” to “If I take it nice and easy and remember to breathe, relax and take a rest when I need one, I will be able to walk to the shop.” Competence & Autonomy
ARRANGE
Providing a Rehabilitation Diary Provide the patient with a rehabilitation diary to help him/her keep track of home-based rehabilitation (e.g., exercise, physical activity). Competence & Autonomy
Following-Up Suggest a specific follow-up appointment, provide guidance regarding when an appointment should be arranged (e.g., no more than 2 weeks later), or inform the patient that no follow-up appointment is needed. Relatedness & Competence
Offering Contact Invite the patient to contact you in the event of difficulties or questions. Relatedness & Competence