Narrator

Hello and welcome to the Talking Physio podcast. In this episode, clinical Associate Professor Mark Elkins, the scientific editor of Journal of Physiotherapy, chats with Dr Rachel Fuller, lecturer in marketing at Latrobe University Business School, about the positive influence physios can have in fostering, facilitating and nudging their patients to be more active. Before we dive in, this episode has been brought to you by the Physiotherapy Research Foundation, supporting the promotion and translation of research, and sponsored by FlexEze, the exclusive partner of the Physiotherapy Research Foundation. Let's get started.

Mark
Thanks very much for joining me, Rachel, to talk about this study in the Journal of Physiotherapy. Your study investigates a really interesting issue. It's looking at how patients feel about receiving advice to increase physical activity levels as part of a physiotherapy appointment. What previous evidence was there on this topic?

Rachel
Yeah, so not a lot really. So when you go back to the literature and you look at kind of patient expectations for physiotherapy it's typically relating to kind of outcomes. So it's their expectations of reducing their pain, reducing their swelling, increasing their strength, getting them back to kind of their normal activities, and actually when you look at kind of expectations for physiotherapy services and specifically those relating to kind of general health behaviours or advice, there's really not a lot there. So yeah, this research is quite unique in that it looks at those services for general health. So whether that's physical activity advice, smoking cessation, kind of healthy eating, healthy weight and so forth, looking at it from a different perspective in terms of the services that we're offering rather than maybe just the pain outcomes.

Mark
So how did then your study address the topic? What question did you try to answer? What participants did you recruit and what did you do with the participants in the study?

Rachel
Yeah. So we used a cross sectional study design using a survey of Australian adults. So our sample size was 587 and we surveyed adults that had both had experience of physiotherapy, whether they were currently seeing a physiotherapist or they had previously seen one, as well as people that had never seen a physiotherapist as well.

Mark
So that's quite a big sample size. And looking, not trying to narrow it down to people who've already seen a physio or people who haven't, so just getting a broad cross section of the Australian community.

Rachel
Yeah, and that's what we really wanted. We kind of wanted to gauge general expectations for physiotherapy services. And that had to come from both those people that had seen a physio as well as those that were yet to see a physio or that would never see a physio. So yeah, what we were primarily interested in was understanding their likelihood to receive certain physiotherapy services and also the importance that they placed on those physiotherapy services. So we asked, I think it was about 52 different services in the end relating to kind of clinic management. But also your general services on relating to physical therapies. So kind of your massage, your acupuncture and so forth and then those general health behaviours. And so this particular paper focused on those manual therapies and then those general health behaviours, such as the likelihood or the importance that patients might perceive a physio to offer them physical activity advice to help them increase their fitness levels, to help them to eat healthier, to stop smoking, to manage kind of alcohol consumption. And so forth.

Mark
So the adults that you surveyed did they think it was likely and important that physiotherapists would give advice about physical activity during an appointment where someone's come in for some other condition, say, a painful shoulder or sprained ankle or whatever?

Rachel
Yes, so we did. And that was like a really interesting result for us. So we found that the majority of those adults that we surveyed did expect and find important for physiotherapists to promote physical activity to them, and also to help them to improve their fitness levels. So the figures were kind of 69% of people thought that it was likely that a physiotherapist would offer them physical activity advice and it shot up to 76% thought that it was important that they would do so. So this is very much kind of what we were seeing and this was consistent whether they had already seen a physiotherapist before or had never seen a physiotherapist. So yeah, the outcomes that this is the general perception of Australian adults that yes, a physiotherapist would offer them physical activity advice.

Mark
So that seems a bit different from the impressions we got from research that was done, say, 10 years ago where people felt that that wasn't going to be well received by patients. So I think that's made maybe some physiotherapists a bit reluctant to do that. But your findings suggests physiotherapists shouldn't be shy about raising this as a topic.

Rachel
That's exactly the message that comes out of this study is, and it's also the response of the driver of this paper. So Bree, in her PhD, had looked and interviewed physiotherapists regarding, kind of their experiences of promoting physical activity, some of the barriers that they face in terms of actually motivating patients to be physically active outside of the clinic. And it was that hesitation that she picked up on as to actually this is highly complex, kind of changing behaviour is highly complex. And physiotherapists were hesitant that, do patients even want to expect, or do they even expect that advice from a physiotherapist? And that's what we're kind of saying that yes, they do actually expect it, so you don't need to be hesitant. Another thing that Bree kind of picked up on and her [indistinguishable] was that yes, so physiotherapists are promoting physical activity. They sometimes have that hesitation but they also maybe wait and delay it until they've built a rapport with that patient before they then go into those kind of more general health behaviours. And again, that's kind of what we're seeing from the results is that actually, people that have never seen a physiotherapist before, that don't already have an established rapport with their physiotherapist, still think that it's important and likely that they'd receive the advice.

Mark
So what's going on in people's heads? Do you think it's that they, maybe they've seen the community level public health messages about find your 30 minutes of exercise and those sort of things, and they just know that it would be helpful for someone to nag them? To read them the riot act and say, well not read them the riot act, but give them advice that personally, and they would find it motivating to get a bit of impetus from outside their own willpower to pick up their physical activity levels. Do you think people want that external stimulus? 

Rachel
Yeah, I think there's an element of, yep we're now seeing the outcomes of all of those mass promotional messages coming from government as to yes, you need to be physically active to be healthy and so forth. And so, yes, a physiotherapist is someone that you go to when you've got a musculoskeletal issue or some kind of movement. And so they're naturally a person that you might associate with also offering physical activity advice. But I think what's the interesting point that came out of the research is that maybe those 10, 20 years ago would have thought that maybe, even if they expected physical activity advice from the physio that it would be less important than those traditional kind of manual hands on therapies. And we actually saw that it was more important for physical activity advice.

Mark
Right.

Rachel
Yeah.

Mark
That's amazing. So compared to things like heat and cold, or electrotherapy, or manual therapy, or exercise prescription, it was rating above all those things?

Rachel
Yeah, so if you compare it to massage, so the likelihood that a physio would offer massage and physical activity advice was fairly similar. So it was 69% thought that it was likely for a physio to offer physical activity advice versus 66% for a massage, so fairly similar. But then we compared the importance levels and we said that it was 76% thought that it was important for a physio to offer physical activity advice, but only 67% thought that it was important to offer massage. And that's slightly similar. Like we're seeing that we asked the likelihood to offer physical activity advice, but also to improve kind of fitness levels. And with the massage and manual therapies, we also asked kind of taping, manipulation, cracking, acupuncture and so forth. And that's consistent across all of them, especially when you look at kind of manipulation and cracking and acupuncture, that was much lower in both expectations and importance placed on them. So it's consistent. Yeah.

Mark
Yeah. I liked the way you used terms like that that patients would use to describe physiotherapy interventions. I think it would have had more resonance with patients because if it's a technical term for a particular intervention that physiotherapists would use, that wouldn't be familiar to patients, I'm not sure if you would have got the same accuracy of responses. So it's kind of unusual for us to include terms like cracking in the journal, but that's what you used in the study, and I think it was a smart idea. So yeah, that was a really good aspect of the study. So one thing we haven't really touched on yet in the interview, is that you come from a marketing background and sports and exercise science background, and you're not a physiotherapist. But you were one of a team. So you had a couple of marketing people and a couple of physiotherapists on the team, so it would be really interesting to get your, I guess, marketing view on these results. Do you think it's limited to what I said before about physiotherapists just shouldn't be reticent? They shouldn't be shy to bring up the topic and bring it up early, say, in the first appointment. But do you think there are other marketing implications from this study? Should physiotherapists be saying, come to us for physical activity, advice and prescription in their advertising? Or I don't know how a marketing person would view it, but I'd be interested in your, if you have comments on the marketing take from these results.

Rachel
Yeah, I think one of the key messages that's coming out of this is that patients do expect physiotherapists to offer physical activity advice. So we've long known in the profession, also in allied health in general, that physiotherapists are well placed to offer physical activity advice. Like they're well trained. They're skilled, but they've also got that one-to-one contact. And I think one of the key outcomes of this paper is that actually, Australian adults verify that. They're also are seeing physiotherapists as credible messengers, for physical activity advice. But what's perhaps interesting and what I've picked up on in the last two days of the conference as well, is that maybe it needs to go beyond just the consultation room for the physiotherapists now, and so there's a few points to mention there. So the first one is if I just quickly go back to the results. We found that those that expected, or were more likely to expect physical activity advice from their physios, were also those that expected a home exercise program. And those that were more likely to expect and place importance on massage were those that went to the physiotherapist, not necessarily expecting or wanting, a home exercise program. So I think that there's some things that physios could do outside of the consultation room to influence those expectations, so that when patients come into the room that they're already well placed and expect that home exercise program, which will then also kind of associate with receiving physical activity advice. But there's also that issue of physical activity is hugely complex, as is any kind of change in behaviour.
And as I've listened to some of the talks, it's not just a problem for physiotherapists. Like it's a social problem, a systemic problem that obviously needs a systemic solution. And it would be really good to see if physios could get more involved in the community, local and government levels as credible messengers to help promote physical activity and then that will also tie into the expectations of a home exercise program when they see the physiotherapist. So there's a few different roles that they could do here. One is obviously in terms of promoting physical activity advice. Like there's no reason why physios couldn't begin to be the face of some of these national physical activity promotions because they are such credible messengers. And you see this in a lot of the other kind of allied health - nutrition. Especially at the moment where nutritionists are stepping up in terms of social media, becoming social media influencers for these nutritional messages, and it would be great to see physiotherapists also maybe looking at those other tools outside of just the one-to-one consultation room that they could get involved in to promote the message. The other kind of role would be, I mean, physiotherapists know so much about the musculoskeletal system. They know the impact that movement has on the musculoskeletal system and all of the chronic diseases, noncommunicable diseases. They're well placed to talk to government about kind of town planning. Okay, so what we talk about the physical activity is you've got to make it easy for people. So there's that, we always kind of use Copenhagen as an example here, but their whole city is set up that they've got clear bike paths around the whole of the city. It's incredibly safe. The large majority of people do it.
So if you go to work and you've cycled to work, you're kind of the majority. The government taxes cars, they tax petrol really highly. And you're making it a really attractive place to cycle. And it's little decisions and involvements and roles that the physiotherapist could play in advising government of the importance of these environmental and contextual issues that actually just help people be physically active. And it ties into the concept that we term in marketing or social marketing, behavioural economics called nudging. So I'm not sure how familiar maybe your readers are, but it's that idea of, actually, we're not rational human beings. We don't make those perfect decisions. We don't weigh up all of the pros and cons to being physically active every single day. Instead, we're driven by mental shortcuts or heuristics, and we make very fast decisions. So the best example is we're making decisions every single moment of the day. When you drive to work, you're not actively thinking about the route that you need to take. You just get there. Okay, so that's your mind subtly making those decisions for you and very fast. So maybe it's not that people don't know that they need to be physically active. It's that we need to just keep reminding them. Make sure that it's top of mind. It's one of those things that's mentally available to them to do, and so that's away from kind of the rational messages that you can offer in the physiotherapist’s consultation room. That's really just mass marketing the message and just reminding them. Keep cueing them, that actually to do physical activity. And the other thing to mention there is that those strategies, they're not complex, like we've been doing them ourselves all the time.
It's that idea of, you put your gym bag in your car before you go to work, so that you can just go on your way home from work. When you know that you're tired, you're going to pick up every excuse not to go to the gym that it's just easy. It's the fact that some people fast forward their watches so that they are like three minutes faster or something, because they know that they might be late somewhere. They're already anticipating where they might fall short in not doing physical activity. So maybe the advice is also just - let's make it easier rather than keep telling people that it's so important to do, because I think that they know that now. So it's maybe just targeting to make sure that it's kind of top of mind for them.

Mark
It's really fantastic to get your marketing view on it, because a lot of the things you just said hadn't occurred to me. But the main thing that had occurred to me in wrapping up this paper was I really felt there was an opportunity for physiotherapists to say in their advertising something like, 'Why wait till you're injured. Come and get physical activity advice from a physiotherapist now.' And I think that ties in a lot with what you're saying, which is, people probably have heard the public health message and they have the intention. But by making, say, an appointment with the physiotherapist exclusively for that, it will be, okay, how are you going to fit this into your day? How are you going to start at a level that's not going to predispose you to overdoing it and getting injured in your first five days of cycling to work or whatever? And the other thing that I think, I wonder whether physiotherapists could promote more is yeah, a lot of professions are out their treating back pain or whatever. There are competitive professions. But I think physiotherapists don't just have training in the musculoskeletal system. They understand endocrine problems. They understand neurological problems. If people have got a previous, like a burn on their skin and they've got limited range because of the scar tissue, and all these extra issues physiotherapists just take that on board easily and go, yeah, I can incorporate that into my thinking. Where if someone's got chronic respiratory disease, they can incorporate those issues and they understand the comorbidities that people have.
And I think maybe physiotherapists could use that more in marketing of the profession rather than just saying, oh, yeah, we're the best at managing musculoskeletal stuff. Say, actually, we manage musculoskeletal stuff and we can take on board all these other comorbidities that you might have from other body systems. So I don't know how that strikes you as a marketing person, but I think it's something that physiotherapists could capitalise on because we do have that whole body training. We understand all these other systems.

Rachel
Yeah, so in stepping away from just that physical activity promotion and just getting people aware of the services in general that physiotherapists can offer. Then that's exactly what you're saying and in marketing we term turn it category entry points. It's that idea with, that any products that you've got, if you can bring it to mind in lots of different occasions, then someone is more likely to then buy something. So with the physiotherapist, if yeah, you are building those links and consumer memory that you can go to it if you've got an injury. But also to get this advice, this advice, this advice, then that's also going to make the physiotherapy profession top of mind whenever they've got those issues. So it's definitely a strategy that they could do. Yeah.

Mark
I like the idea of getting physiotherapists involved in the town planning or that that sort of environment.

Rachel
But they're perfect to do it. Yeah.

Mark
And I recently started cycling to and from work. I used to use public transport, and I was astounded at the bike lane system that gets me to work. And I've been going on public transport and occasionally would have someone's car and drive. And it hadn't occurred to me that all these bike lanes were there, and when I got to cycle the first time, I was almost disappointed at how quick and easy it was. I thought I was going to get lots more exercise into my day, but here I am. But it was motivating too, because I thought I’ll be able to do this even on days when I'm tired. Even when I think it's going to be cold and windy, I think I'll be home in 15 minutes, you know, and I think, a physiotherapist would be really good to get involved in that planning of the environment, to foster and facilitate and nudge and remind people to be active. Another case that comes to mind was there was a redevelopment of some parkland at the back, and they wanted to put in what they called a disability path, and the slope of the path was the maximum slope that they recommend for building. But the path just zig zagged backwards and forwards all the way up this path. And it's kind of the maximum slope that you would want to get into a building off a footpath in the city. It would be so difficult for many people to maintain that maximum slope over the incredible distance that they want a [indistinguishable], but they obviously didn't contact a physiotherapist. So I mean, it's not a bad path for mums with prams and stuff like that. But I always chuckle when I see it and think disability path! They obviously did not speak to a physiotherapist, so.

Rachel
Yeah, but it's also maybe physios getting involved in that, in just their local community. So the idea that actually, if we want to build those sustained physical activity behaviours, then that's going to be different, and they're going to be different for every single person. So for some people, they might click with going to the gym. For others, it will be walking, maybe with a friend or their family. For others, it might be a yoga class and so forth. And so maybe with physiotherapists they could build awareness of, it's not just go to the gym. There's lots of different offers. Try them out and see what fits you as well, because ultimately it is what we were talking about initially that it's just move a little bit more. And that's, you're not going to move a little bit more over a sustained period of time if you don't enjoy it. And there are physical activity behaviours out there that people will enjoy. So it's also just finding that and physios are well placed to understand that as well. So you really are kind of credible messengers to get the point across?

Mark
Yeah, I think that's true. I think physiotherapists have a lot of skills in problem solving and saying, okay, maybe with your current injury or your current fitness or whatever your current circumstances are, maybe some things that you enjoy aren't an option for you at the moment. But what is it about them that you enjoy? Okay. Can we modified and do this? And would this be enjoyable for the same reasons? Yeah. Okay, let's try that. Yeah, I think physiotherapists really do have that skill. So where do you, do you have future plans with this research group? Do you plan to do follow on research from this study?

Rachel
Yeah. So it would be great to do some interventions both around those promotional messages that we were talking about, but also the integration of maybe some technology as well. So Apps. Whether they're used, again not necessarily to get those rational messages of, you need to do physical activity for these reasons. But as nudges, it's to remind people to do it to maybe give them some scenarios that they could do it to get them to build those intentions to do things. So have you thought about what physical activity you're going to do tomorrow by beginning to plan it and forward thinking, then they're more likely to do it than kind of if you ask them, what did they do yesterday and so forth? So, yeah, that would be kind of where we're going to go from here and see what's working. How, actually physiotherapists can be promoting this physical activity because, yeah, as we kind of mentioned at the start as well, the perception has always been that they may be a little bit hesitant to do it. So now this research kind of gives that baseline of no, actually have the confidence to do something, and then we can play around with what actually works. What physios are confident doing, but also what works for the patient as well.

Mark
Yeah. They want it and they expect it, and they think it's important. So yeah, don't be shy. Yeah. Okay. Well, thanks very much for a fascinating marketing view on this study and for the great contribution to the journal.

Rachel
Thank you very much. Thank you for having me as well. It's been great.

Narrator
That was clinical Associate Professor Mark Elkins, the scientific editor of Journal of Physiotherapy, and Dr Rachel Fuller, lecturer in marketing at Latrobe University Business School. And you've been listening to another episode of Talking Physio brought to you by the Physiotherapy Research Foundation and FlexEze. Thanks for listening. And make sure you catch the next episode of the Talking Physio podcast.

https://doi.org/10.1016/j.jphys.2019.08.002