Table 4 Barriers and facilitators related to automatic and reflective motivation

Automatic

Reinforcement

Individual mentions something increasing the probability of self-managing behaviors (symptoms, treatment, etc.) via a dependent relationship, or contingency, or responding to a stimulus. [increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus]

21

19

6

Effectiveness of exercises (12)

  “Sometimes I resent having to do it twice a day (chuckles), but I still do because it makes me feel better.” (14,479)

 Effectiveness of treatment (4)

 “Well, pointing out to me again um, how to minimize or treatment the knots in my muscles, and as I said even though shortly after the chiropractic treatments that I would get more pain. It would go away and I think overall that there was a benefit there. So even though that, you know twenty-four hours would be a bit of a price to pay I guess after that I always felt like that it was, I was stronger and-and better able to do more with that, with less pain later…So I think the mobility of it again so, you know, I think it was comparable to, what I had described as an improvement overall that I had I think that…was probably from that.” (13,709)

 Organization or schedule (2)

 “I think it just made me, again I’m an organized person and it got me to be a little bit more organized because I knew what I had to do at a certain amount of, you know. Even though I got home late at night or whatever the case may be, I still had to get it done.” (10,014)

 Pain (2)

 "Always, I take medication I you know, always, when I wake up I feel pretty rotten. You know, when I'm rotten, pretty pain, you know, I feel a lot of pain" (13,246)

“Well on an on going basis I had noted during the course of the treatment that, that the afternoon and the day following chiropractic treatment my back would be more sore, but of course the question was always do you have to get a little bit more pain short term to find long term improvement. And, the same thing was true with the exercises if I did a lot but again my back pain has always been, related to physical activity. On the other hand if you don’t do any physical activity then the stiffness and pain spreads to other parts of the back. So, so you know it was, but that was usually the day or so after. Over the course of the treatment longer term I felt there was, you know, a significant improvement probably about a twenty-five percent improvement. I judge that not by the amount of pain but by the amount of activity that I can do. For the same amount of pain (chuckles).” (13,709)

  Maintaining working (1)

“I feel that I did get something out of this and, I’m gonna use what you guys gave me for the rest of my life, to feel better. And, so I can keep working. Cause that was the main thing is that, I wanted to be able to continue to work. And I think I can do that now” (14,593)

 Effectiveness of ergonomic changes (1)

 “The adjustment, the heat…so many things that [name of Dr.] explained to me about preventing it, preventative maintenance for my lower back about, you know, for example, when I do bend now, instead of just bending down, what I do is the golfer’s kick. Which makes it a lot better, to bend down. I mean I can do that all day. You know versus what I was doin prior to that was like at work we have a sanitizing bucket, that sets on the floor that we clean the tables with. And I used to take that bucket and set it up on the table to keep from bending down, but now that I do the golfer’s kick. Oh its no problem. I bend down and get it, and that really feels good on my lower back.” (14,953)

 Confidence (1)

 “It’s been wonderful. Overall for my attitude about my back problem. With giving me skills to be able to go forward. Just overall, I’ve it’s made my life one hundred percent better. I’m very grateful for the study…I feel much more confident in taking on exercise by myself. And building my core muscles and knowing that once I build those muscles it’s going to relieve the back pain. It won’t go away but at least I’ll be able to do my normal activities everyday.” (13,767)

Wanting to progress (1)

  “Knowing that I would, feel more muscle problems, going through those, each of those steps. But I knew that it was going to be a positive turn around on the other side so I just kept going. It’s been a roller coaster, you know it heightened as it goes and as you go, but of course it’s been you know knowing that I can get to the next level has pushed me through that.” (13,767)

Pain, barrier (5)

  “Well, because it irritated, you know it hurt, and that I got scared to do em” (13,246)

Psychological impact of capabilities, barrier (2)

  “Well I guess what I liked best about it is just trying to have a discipline of, of sticking to something. There was one exercise that was always difficult for me, I know they said well don’t worry so much about that one, so that was good. You know if its something you just really detest doing then you’re not gonna do it” (14,864)

Other medical conditions, barrier (1)

  “And then, if there’s some flakes in there it’ll make me dizzy and that made the exercise much harder for about three weeks, and that thing to I think is what caused me not to come here last week to do this cause member I said I didn’t feel I felt dizzy that day. And at the middle of the day in the, I still, I saved that little, that, it was a flake that came out of my ear by the end of that day, and I know that’s what had done it. And if I had, I felt if I had come in here that day to do it I just probably wouldn’t have been able to do everything. Cause my, my…balance level was not perfect…But I did have that right before Christmas and it was around my last HEP appointment I had that. So, so that definitely did interfere. And it might be too, that my, eh, my, o- overall stuff would have been, would be a little bit better if that hadn’t been in there.” (14,864)

 Change in environment, barrier (1)

 “I mean I live alone, so I have, you know, I have, when I’m home and not busy I have plenty of time to, you know to do the things but when I’m…have my grandson with special needs then, of course that, you can’t lay on the floor but then he thinks you’re playing a game and he's going to get on top of you to wrestle or something...” (13,097)

Emotion

Individual mentions a reaction pattern involving a experiential, behavioral, or physiological element stemming from or impacting self-managing (symptoms, treatment, etc.) [a complex reaction pattern, involving experiential, behavioral, and physiological elements, by which the individual attempts to deal with a personally significant matter or event]

3

1

2

Validation (1)

  “I don’t know that I know to pick one thing in particular, each doctor that I saw provided an excellent, excellent explanation as to what they were doing with me, and why they were doing it and the fact that somehow it validated the pain that was in my head.” (10,140)

Guilt, shame, barrier (2)

  “Just that, that feeling of guilt… of not finding, making the time to, to do it.” (13,631)

Fear, barrier (1)

  “Well, because it irritated, you know it hurt, and that I got scared to do em” (13,246)

Reflective

Goals

individual mentions a mental representation of outcomes or end states they want to achieve for self-managing (symptoms, treatment, etc.) [mental representations of outcomes or end states that an individual wants to achieve]

37

36

6

Reduce pain (29)

  I thought that it would, that the pain would dimin…diminished. (10,140)

General improvement (8)

  “I took into account, my interactions with staff. I took into account, the results that I felt that I achieved during the program and the progress made, and whether it I guess whether it achieved a level of improvement that I felt was significant or satisfactory.” (13,709)

Move easier (7)

  “I didn’t know what to expect. I did have some inclination that, getting more mobility and strengthening my back and abs and core and, would help me overall. Yes.” (10,307)

 Improve strength (4)

 “Well, to be honest with permanent nerve damage, with a fourth herniated disc I didn’t expect that you would be able to improve the pain a lot and wouldn’t be able to improve the tingling and loss of feeling in my leg at all. But I did expect that there would be some strengthening of the back which did occur.” (10,178)

Improve sleep (3)

  “I think my biggest thing I took into consideration was my improvement in sleep.” (14,479)

 Increase ability to exercise (3)

“Well I think I feel a lot better. I am doing more than I was doing before. I, you know the pain has been dramatically reduced. I am able to, you know, walk three miles where as…three months ago I wouldn’t have even considered doing that. So, I am very pleased with how, I’ve changed and I think a, Dr. Taylor mentioned it, he says your like a model patient here. Because I did put out, I, you know, knocked weight off I, uh, did the heavier exercising, I did all the things your going to do and as a result I got the desired results. That all. You get out what you put into it. Not everybody, not everybody does that because of time. I am retired now, so I can, I can do it. And be focused.” (14,428)

 Improve health (2)

 “One of the key factors, is, the feeling that I did get, I was getting better. You know there were, there was some positive health related things happening” (13,537)

Increase activity level (2)

  “…and I can do twenty-five percent increased activity, involving the lower back, for you know with less much less pain then I had before. So about a twenty-five percent improvement that’s again how I describe it I know I’m going to pay a price…if I do very much but how much can I do and for what cost and that’s definitely better now.” (13,709)

  Lose weight (2)

“I think it is actually a little bit more than what I had expected. I am going to continue the weight loss, hoping to lose another forty pounds. Plan to keep the back exercises up…just because it strengthens, and I now know what I can do and what I can’t do. Keep the exercising up.” (14,428)

 Improve muscular restrictions/contractures (1)

 “On my leg, even though my leg does ache from time to time, you know before when I would like feel the back of my leg. I could feel like, um…bump, lumps kind of in the muscle. And that, I have none of that anymore. So that was a big improvement. And that’s probably the biggest thing I can mention.” (14,864)

  Less stiffness (1)

“It cost me nothing, and it, they, when I first came I couldn’t hardly sit down or walk for that matter and now I’m back to work pretty much almost back to normal…Well, I wake up in the mornings I’m a little stiff but other than that, I do the same things I normally do.”

   Interviewer: “So less stiffness?”

   Patient: “Yeah.” (11,170)

Maintain current level/don’t get worse (1)

  “Well, because like I said, I think it helped strengthen my back. It gave me some new exercises to use in helping with my own physical therapy and care at home to try to keep the back from getting any worse.” (10,178)

No change, barrier (6)

  “…going in I really didn’t expect any change and that’s about where I ended up” (10,272)

Optimism

Individual mentions confidence in outcome, attaining goals, or physical or mental capabilities for self-managing (symptoms, treatment, etc.) [the confidence that things will happen for the best or that desired goals will be attained]

33

17

9

Chiropractic treatments work (13)

  “I didn’t have any expectations. I was hoping that, that it would help, and it certainly did.” (13,091)

Exercises work (7)

  “Mm…eh, I think that you know, learning the exercises and I can once I’m able to do em I think that they’ll help.” (13,246)

Can self-manage (3)

  “I feel so much better. It’s just, it’s given me the confidence that I can help myself by listening to what they tell me to do” (10,151)

Provider recommendations work (1)

  “Every, everyone of the, I’m going to call them practitioners, I don’t know what else to call them had been really great in listening to me and explaining to me what they were doing and, and the remarkable thing is that everything they tell me works.” (10,151)

Chiropractic treatments won’t help, barrier (9)

  “I, I didn’t say you know, actually I usually, I feel worse. You know. Until finally I said, this one doesn’t work. You should try a different one. So then she tried a different one, then finally I, I realized this isn’t gonna help me” (13,246)

Beliefs about consequences

Individual mentions accepting truth, reality, or validity about outcomes of a physical or cognitive behavior in pertaining to self-managing (symptoms, treatment, etc.) [acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation]

29

24

10

Exercises will reduce pain (11)

  “Um, it’s been wonderful. Um, overall for my attitude about my back problem. Um with giving me skills to be able to go forward. Um, just overall, I’ve it’s made my life one hundred percent better. I’m very grateful for the study…I feel much more confident in taking on exercise by myself. And building my core, muscles and knowing that once I build those muscles it’s going to relieve the back pain. It won’t go away but at least I’ll be able to do my normal activities everyday.” (13,767)

Exercising will result in general progress (9)

  “Well I liked best that since it was at home I could do it on my own schedule and I could do exercises for a short period of time and then take, a break, and do some more later, so I guess those were the main things I…it kept me uh…, I think it did improve my health a little bit because exercise is always good for you and I would tend to feel a little better after I had exercise.” (13,860)

Chiropractic treatment will result in general progress (4)

  “They were bene…I think they were beneficial in helping the improvement.” (10,289)

Chiropractic treatment reduces pain (2)

  “I’m not really getting any leg pain now or very little. That’s how I answered it at least, so. My low back is still stiff, but not like it was and…It’s mainly when, the chiropractor was doing the flexion and that kind of thing, so.” (10,289)

Weight loss will improve pain (1)

  “I don’t know that I had any great expectations when I came in. I guess I was rather skeptical, but I, I do think there is some improvement, as we’ve discussed, you know, some of it is undoubtedly due to the fact that I’ve lost weight over that same period of time. But I do feel that the exercises and so on have helped.” (10,245)

Because of type of condition nothing will help the pain, barrier (3)

  “Well, I figured with the type of pain I had, a sciatic nerve type of thing, yeah, I didn’t think there was much you could do with that. You know, it’s just something that, that came about and you, you cope with it. But I found out through the exercises and things that there were things I could, I could by strengthen up the core and try and stand a little straighter and it, it has helped.” (10,343)

Not having chiropractic care would result in less or no improvement, barrier (3)

  “Well, I think what it did…I felt that if I didn’t get that side of it, if your back was misaligned all the other work that you do, (laughs), wouldn’t give you the total, the total package I felt being on the chiropractic side in addition to that. I remember [name of Dr.] first comment when he got on me the first day, when he tried to do his first adjustment he bounced back off the wall I was so tight and so by now it, you know you he actually, as I continued on through it he said, ah it just automatically falls into place where were getting there, so… It was a tremendous change from that side of it now if I had still been as tight as a drum all these other exercises wouldn’t have given me as much benefit as I had.” (14,428)

Exercise needs to be difficult to be effective, barrier (1)

  “Uh…, well, I think at first I was over-exerting myself. And then I talked to the doctor and he took me off a couple of em’, and said, “Don’t over-exert” because I just thought they weren’t strenuous enough. So I had a misconception on, on the exercises and I think I did hurt myself the first couple weeks…and then he took me off that a little bit and then I, I really, what I do is quite minimal to tell you the truth I think now, but apparently it’s really helped.” (10,014)

Focused chiropractic treatment has less benefits, barrier (1)

  “One of the things that I thought about the chiropractic is that, I’m not sure…it’s helpful to…to just spot treat like that, you know sort of like I think, you know we were treating the low back but, you know my pain…radiated all the way up the back and all, [name] really worked on that…the muscle there. I, I just really felt like if they would’ve done chiropractic, you know, treatment…in my mid back. You know, sometimes I think it is all connected. And when you just do one thing like that, then I’m not sure that you get the full benefit…that, that would be my…downside on the chiropractic part.” (13,629)

Non-prescribed exercises have the same benefit, barrier (1)

  “There near the end about week nine or so I started lacking, slacking off because I felt that my swim routine and my calisthenics and, what I was doing as far as pushups and chin ups and that kind of thing was contributing to about the same kind of um exercise that was called for by the regime to get em’ in.” (10,307)

Chiropractic treatment increased my pain, barrier (1)

  “Okay, oh gosh…you know like I say, that the exercises I was shown, this and other things.. strengthening my core will make it easier, you know that, all made sense and I think it’ll be good. But because my back is worse, I mean I couldn’t do the exercises and, and so the one part of it, is the questionnaire, which I…I don’t know what the answer would be, is uh, none of the chiropractic treatments helped me. Cause basically, you know it took me a while to realize that, well I felt worse after the treatments, you know, usually by that night or the next morning, I kept hoping that the next treatment would make me better, and then when we decided its, I probably have a herniated disc, then we discontinued em, so, if that hadn’t happened, you know they might have helped, my left leg, but once my right leg started hurting so bad… made me realize I didn’t have it so bad. In the beginning. You know so, I, I don’t want it to reflect on the chiropractor or the treatments she gave me, I just don’t think, at this time it was irritating my back instead of helping it.” (13,246)

Intentions

Individual mentions a conscious decision for performing a behavior, resolving to think or act in a certain way related to self-managing (symptoms, treatment, etc.) [a conscious decision to perform a behavior or a resolve to act in a certain way]

16

16

0

Continue exercising (13)

  “Well, I just, I think what I liked best is that maybe I’ll, I hope, the fact that I’ll continue.” (laughs) “Regardless of whether it helped my back or my leg…it’s a, it’s a good thing to be doing” (13,081)

Being disciplined (3)

  “It’s having to discipline yourself to do this on a regular basis.” (13,537)

 Resume exercising (1)

 And then, I’d just start, I’d you know I have stopped doing the exercises. But, I plan to resume them, You know, as soon as I can do so without making my pain worse.” (13,246)

Seek additional treatment (1)

  “Yes, I guess so, cause’ it did ultimately eliminate…do I have sciatica? No! And I can move on and hopefully… get treatments somewhere else for what, what is the problem.” (13,631)

Continue losing weight (1)

  “I think it is actually a little bit more than what I had expected. I am going to continue the weight loss, hoping to lose another forty pounds. Plan to keep the back exercises up. Just because it strengthens, I now know what I can do and what I can’t do. Keep the exercising up.” (14,428)

Beliefs about capabilities

Individual mentions accepting truth, reality, or validity about their ability, talent, or facility for self-managing (symptoms, treatment, etc.) [acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use]

7

5

2

Able to exercise (2)

  “It’s been wonderful. Overall for my attitude about my back problem. With giving me skills to be able to go forward. Just overall, I’ve it’s made my life one hundred percent better. I’m very grateful for the study… I feel much more confident in taking on exercise by myself. And building my core muscles and knowing that once I build those muscles it’s going to relieve the back pain. It won’t go away but at least I’ll be able to do my normal activities everyday.” (13,767)

Increased activity (2)

  “Because I was able to, I’m able to do more thing and I learn how to, do more things than I did, from the exercises and the, how I was told how to bend and lift and the strength of how to, you know, the strength that come there so…” (14,105)

Helping oneself (1)

  “I feel so much better. It’s just, it’s given me the confidence that I can help myself by listening to what they tell me to do” (10,151)

Not capable of exercise, barrier (1)

  “No I can’t. Can’t even walk a long distance, you know?…I’m good at tolerating pain, but the pain I get running or walking is, you know, way different than just you know, bending.” (13,246)

Not capable of being strong, barrier (1)

  “I would say that I accept that, you know, that I am getting older and I no longer have the strength and endurance and I have other little problems such as the heart problem. I’m doing pretty good. I feel very strongly that I’m in pretty shape, physically.” (10,307)