1. SHRUTI MUTALIK, MD Resistance to Exercise and Psychological Factors that Affect Functional Recovery in Chronic Disorders

2. I have no financial relationships with any commercial interests related to the content of this activity Disclosure

3. Pain Pain : Solitary, consuming Pain : Multimodal, not merely sensory Nociceptive, and emotional/sensory processing Pain and psychopathology :Bidirectional correlation

4. Pain : Psychopathology Depression: link with functional outcomes, disability Anxiety Personality Disorders Comorbid anxiety and depression : link with severity of pain PTSD Somatic Symptom Disorders Substance abuse/dependence Phantom limb pain Complex regional pain syndromes

5. Screening for psychiatric disorders Depression, anxiety screening, questionnaires Recognition of need for focused psychiatric treatment Antidepressants in chronic pain Multidisciplinary approach

6. Functional outcomes Impact on functional recovery Impact on functional recovery Impact on participation in exercise Impact on participation in exercise Link between psychopathology and functional outcomes Link between psychopathology and functional outcomes

7. Exercise Evidence for mood and cognitive benefits Meta-analysis of cohort studies : improved physical and physiological function in patients with chronic lower back pain Exercise and functional outcomes

8. Coping with pain Health locus of control Pain related self efficacy Pain acceptance Predictors of treatment benefit?

9. Understanding Resistance Barriers to physical activity Patient perceptions, participatory social support (Heart failure patients) Motivation to exercise and mood/anxiety/cognition

10. Motivating patients to exercise Cognitive behavioral framework for conceptualizing resistance- CBT group therapy in chronic back pain to improve pain tolerance, lower disability Interpersonal Therapy framework Psychodynamic framework: Unconscious conflicts Motivational interviewing, ambivalence

11. Motivational Interviewing: Evidence Base Motivational Interviewing to increase physical activity in people with chronic health conditions: meta-analysis of ten trials, small effect in increasing physical activity levels in chronic health conditions Improvement of exercise experience in MS Motivational Interviewing and Exercise Programme for Community Dwelling older persons with Chronic Pain : improvements in mobility, pain intensity, anxiety

12. Motivational Interviewing A collaborative, person-centered form of guiding to elicit and strengthen motivation for change

13. Motivational Interviewing Collaboration Evocation Autonomy 1980s: William Miller, Stephen Rolnick Non- judgemental Client Centered Ambivalence

14. Prochaska & Diclemente Stages of Change

15. Motivational Interviewing

16. Avoid Arguing Roll with Resistance Express Empathy Develop Discrepancy Support Self-Efficacy

17. Summary Heterogeneous psychopathology Identification of psychiatric syndromes Barriers to exercise Collaborative approach to overcoming barriers CBT, Motivational Interviewing

18. Thank you all!!

19. References A Patient-Centered Approach to Addressing Physical Inactivity in Older Adults : Motivational Interviewing K, Goodman JH.J Gerontol Nurs. 2014 Randomised controlled trial on the effectiveness of cognitive behavior group therapy in chronic back pain patients M, Scherbe S, Cicholas B.J Back Musculoskelet Rehabil. 2014 Aug 5 Psychiatric aspects of pain.Curr Opinion Psychiatry 2007 Jan;20(1):42-6. Pain and depression: an integrative review of neurobiological and psychological factors.Goesling J, Clauw DJ, Hassett AL Psychiatry Rep. 2013 Dec;15(12):421. doi: 10.1007/s11920-013-0421-0.. www.motivationalinterview.org Motivational Interviewing to Increase Physical Activity in people with chronic health conditions : a systematic review and meta-analysis PD, Blackstock F, Shields N, Holland A, Iles R, Kingsley M, Bernhardt J, Lannin N, Morris ME, Taylor NF.Clin Rehabil. 2014 Jun 18. Motivational interviewing and exercise programme for community-dwelling older persons with chronic pain : a randomized controlled study MM, Vong SK, Tang SK.J Clin Nurs. 2013 Effect of Aerobic Exercise for Treatment of Chronic Lower Back Pain : A Metaanalysis Meng XG, Yue SW.Am J Phys Med Rehabil. 2014 Oct 8.