Low back pain is a significant global problem, with up to 85% of the population in developed countries experiencing an acute episode at some point in their lifetime [1
]. A significant number of these patients develop chronic low back pain (CLBP), defined by persistent disabling pain in the lumbar spine, with or without radiation to the buttock and lower limbs [2
], for more than 12
]. In addition to pain complaints, CLBP is associated with reduced physical function, reduced social participation, increased symptoms of psychological distress, and poorer quality of life [4
]. It is also an increasingly costly condition, due to the expense of treatment and lost productivity. Accounting for 0.8 to 2.1% of gross domestic product in many western countries [5
], CLBP is estimated to be the second largest single cause of work absence in the United Kingdom [6
]. As a result, the efficacy of treatments designed to alleviate CLBP has been the subject of much scientific attention [7
Physical activity (PA) and exercise therapy (i.e., specific repetitive movements intended to reduce LBP) [7
] are among the accepted clinical rehabilitation guidelines and are recommended self-management strategies [8
] for this condition. However, many LBP sufferers do not adhere to their physiotherapist’s recommendations regarding PA and exercises [9
]. Poor patient adherence may decrease the effectiveness of PA advice and home-based rehabilitation exercises [11
]. Therefore, interventions that can increase patients’ adherence may also enhance treatment outcomes [12
Theory-based interventions are needed in the health domain [13
], as they provide greater understanding of the process of change and may ultimately lead to more effective interventions [14
]. A recent Cochrane systematic review indicated that there was support for therapeutic interventions designed to increase adherence to treatments for musculoskeletal pain conditions [16
]. Indeed, the review found moderate sized effects on patients’ adherence. Unfortunately, only two of these interventions [17
] were based on a relevant behavior change theory that might explain the process of change resulting from the intervention. Therefore, the most effective methods to increase adherence and the active components of the majority of these interventions remain unclear. Recommendations from recent research [19
] and the Medical Research Council [15
] have reiterated the importance of (i) using theory and, where possible, empirical evidence to guide the development of interventions and (ii) investigating treatment fidelity and the process of change to allow researchers to provide effective advice for successful implementation into practice.
A theory-based intervention to improve adherence should aim to address factors that influence chronic low back pain patients’ rehabilitation behavior. Research indicates that these factors may include (i) the physiotherapist-patient relationship [21
], (ii) the delivery of advice [23
], self-efficacy [19
], and motivation for treatment [25
]. Self-determination theory (SDT) [27
] may provide a useful framework for addressing these factors, thereby increasing treatment adherence, and improving patient outcomes.
According to SDT [27
], humans have basic psychological needs for autonomy (feeling fully volitional or free to engage in a behavior), perceived competence (feeling effective in one’s actions), and relatedness (feeling safe and cared for in one’s interpersonal relationships). When these needs are supported, patients’ participation in treatment will be more autonomous and less controlled. Autonomous motivation is characterized by perceptions of valued benefits and a willingness to participate. In contrast, controlled motivation in the healthcare domain typically involves patient engagement in treatment due to external pressure, coercion, or feelings of guilt. This distinction between autonomous and controlled motivation represents a continuum rather than a dichotomy (see Figure for details), with more autonomously motivated behaviors leading to greater psychological well-being and long-term behavioral persistence [28
The Self-Determination Continuum of Motivation (with examples quotes to illustrate motives for following a physiotherapist’s recommendations).
When the social context (i.e., interactions with other people) satisfies the three basic psychological needs, individuals are more likely to autonomously regulate their behaviors, and thus lasting behavior change is more likely [28
]. In health-related domains, this suggests that healthcare practitioners’ communication behaviors can be enhanced to more fully support patients’ psychological needs and, thereby, autonomously motivate their health–related behaviors. In this context, the concept of autonomy support represents an interpersonal climate in which the provider (e.g., physiotherapist) considers the perspective of the patient, provides relevant information and opportunities for choice, and encourages the individual to accept personal responsibility for health behaviors without judging or coercing the patient (see further examples in method section) [27
]. In contrast, a controlling health care climate involves disregarding patients’ views, pressuring patients, and making the decisions on the patients’ behalf without consultation. Unfortunately, research has indicated that when interacting with patients, physiotherapists [21
] and other healthcare practitioners [29
] often adopt a controlling approach.
In line with the SDT-based model of health behavior change [30
], the relationship between the healthcare provider’s autonomy support and the patient’s behavior change via autonomous motivation and perceived competence has been supported in numerous health settings including smoking cessation [30
], physical activity [32
], medication adherence [33
], and dental hygiene [34
]. Evidence from cohort studies in physiotherapy settings has supported the positive relationship between autonomy support and adherence outcomes, such as attendance at clinic-based rehabilitation settings [35
] and adherence to home-based exercise programs [26
], However, no study has been conducted to test the effect of an intervention designed to enable physiotherapists to act in a more autonomy supportive manner during the therapeutic scenario. This type of intervention could increase CLBP patients’ autonomous motivation and competence leading to improved adherence to prescribed home-based treatment and improved LBP outcomes. A diagram presenting the proposed theoretical model of behavior change is presented in Figure .
Self-Determination Theory Model of Behavior Change.
We conducted a pilot study [36
] to establish if an SDT-based intervention designed to enhance physiotherapists’ communication skills had the capacity to influence the targeted variable (autonomy support) and produce change in the proposed mediators (perceived competence and autonomous motivation), as well as treatment adherence for CLBP patients attending physiotherapy. The findings suggested that the SDT-based training enhanced physiotherapists’ autonomy supportive communication skills and provided initial evidence that the intervention improved patients’ perceived competence, autonomous motivation, and treatment adherence. However, the study was limited by the small sample and a number of study design factors, such as unexpected between group differences in the duration of patients’ LBP and the lack of true baseline measures. Nonetheless, these preliminary results were positive and provided estimates of moderate sized effects. The proposed study is an extension of the pilot study and addresses the above limitations.
The aim of this cluster randomized controlled trial (RCT) is to assess the effect of an intervention designed to increase physiotherapists’ autonomy-supportive communication on CLBP patient’s adherence to physical activity and LBP exercise recommendations.
1. Patients in the experimental arm will report significantly greater weekly physical activity (PA) participation compared with their pre-treatment PA levels and compared with patients in the control arm. They will also report greater self-rated adherence to physiotherapists’ recommendations compared with the patients in the control arm. Compared with physiotherapists in the control arm, physiotherapists in the experimental arm will rate their patients as more adherent during physiotherapy sessions.
2. Patients in the experimental arm will report significantly decreased pain, increased function, greater low back pain (LBP)-related well-being and greater perceived global improvement after treatment compared with their pre-intervention scores, and compared to patients in the control arm.
3. Compared with their pre-treatment scores and compared with patients in the control arm, patients in the experimental arm will report significantly lower fear-avoidance beliefs and controlled motivation, as well as significantly greater competence and autonomous motivation.
4. Patients in the experimental arm will rate their physiotherapists as significantly more autonomy supportive than patients whose physiotherapists were assigned to the control arm. As a result of heightened self-awareness that comes from participation in communication skills training, physiotherapists assigned to the experimental arm will rate themselves as less autonomy supportive than physiotherapists assigned to the control arm. Independent raters of audio recordings of patient-physiotherapist interactions will rate experimental arm physiotherapists as more autonomy supportive than physiotherapists assigned to the control arm. Physiotherapists in the experimental arm will employ the specific communication strategies taught in the workshops with higher quality than physiotherapists from the control arm (who will not attend these workshops).
5. The influence of the experimental manipulation on outcomes (pain, function, and well being) will be mediated by patients’ rating of the physiotherapist’s autonomy support, perceived competence, autonomous motivation, fear-avoidance beliefs and adherence (see Figure ).