Background
Self-determination theory
Aims
Hypotheses
Methods/Design
Design overview
Participant recruitment, consent, allocation and blinding
Centers
Physiotherapists
Patients
Inclusion criteria
| |
Age | 18 to 70 years |
Diagnosis | LBP of mechanical origin with/ without radiation to the lower limb |
Pain duration | chronic (≥3 months) or recurrent (≥3 episodes in previous year) |
Language | English speaking and English literate. |
Contact status | Access to a telephone |
Exclusion criteria
| |
Pathology | Suspected or confirmed serious spinal pathology (fracture, metastatic, inflammatory or infective diseases of the spine, cauda equina syndrome/widespread neurological disorder). |
Nerve root compromise (2 of strength, reflex or sensation affected for same nerve root) | |
Past medical history | Spinal surgery or History of systemic / inflammatory disease |
Current medical status | Scheduled for major surgery during treatment |
Treatment status | Currently or having received treatment for CLBP within previous 3 months |
Pregnancy | Suspected or confirmed pregnancy |
Contraindications | Unstable angina / uncontrolled cardiac dysrhythmias / severe aortic stenosis / acute systemic infection accompanied by fever. No confounding conditions, such as a neurological disorder, intellectual disorder. |
Note: Individuals suspected of having a serious spinal pathology or any contraindication to exercise will be referred to their medical practitioner for review. Once cleared by their medical practitioner they will be reconsidered for inclusion in the trial. |
Interventions
Evidence-based care for CLBP management refresher workshop
Experimental Treatment – Theory-based Communication Skills Training Workshops (CONNECT)
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 |
Assessment
Physiotherapists
Baseline assessment
Treatment phase assessment
Patients
Baseline assessment
Variable | Pre-randomization | Baseline Pre-treatment | Baseline Post-treatment | Week1 | Week4 | Week12 | Week24 |
---|---|---|---|---|---|---|---|
Demographics
| ✓ | ||||||
Primary outcome measures
| |||||||
Adherence
| |||||||
Clinic-based adherence to physiotherapist’s recommendations | # | # | # | # | |||
General adherence to physiotherapist‘s recommendations | ✓ | ✓ | ✓ | ✓ | |||
Specific adherence to back exercises and physical activity advice | ✓ | ✓ | ✓ | ✓ | |||
Physical Activity
| |||||||
Self-reported physical activity | ✓ | ✓ | ✓ | ✓ | ✓ | ||
Low Back Pain Symptoms
| |||||||
Pain Intensity | ✓ | ✓ | ✓ | ✓ | |||
Bothersomeness | ✓ | ✓ | ✓ | ✓ | |||
Pain-related Function
| |||||||
Disability | ✓ | ✓ | ✓ | ✓ | |||
Patient specific function | ✓ | ✓ | ✓ | ✓ | |||
Pain-related Well Being
| |||||||
Quality of life | ✓ | ✓ | ✓ | ✓ | |||
Secondary Outcomes
| |||||||
Autonomy support from physiotherapist | *✓ | ✓ | |||||
Fear avoidance beliefs regarding physical activity | ✓ | ✓ | ✓ | ✓ | |||
Perceived competence regarding ability to follow physiotherapist’s recommendations | ✓ | ✓ | ✓ | ✓ | ✓ | ||
Autonomous and controlled motivation to following physiotherapist’s recommendations | ✓ | ✓ | ✓ | ✓ | ✓ | ||
Objectively measured physical activity | ✓ | ✓ | ✓ | ✓ | |||
Perception of recovery | ✓ | ✓ | ✓ | ✓ | |||
Moderating Variables
| |||||||
Expectation of treatment | * | ✓ | |||||
Patient depression | ✓ | ||||||
Physiotherapist’s general causality orientations | * | ||||||
Physiotherapist’s autonomous and controlled motivation for participation in training. | * |
Follow-up assessments (Week 1)
Follow-up assessments (Weeks 4, 12, and 24)
Outcomes
Primary outcome measures
Secondary outcome measures
Moderating variables
Treatment fidelity
Data integrity
Sample size
Statistical methods
Adverse events
Discussion points
Potential inconveniences to the participant
Limitations
Appendix A
General information
-
Demographic Information: Each participant will have a consultation with the Research Physiotherapist to collect demographic information and medical history. (i.e. age, gender, education level, occupation and work status, past medical history, and low back pain history).
Primary outcomes
Adherence
-
Sports Injury Rehabilitation Adherence Scale: This questionnaire is designed to measure physiotherapists’ perceptions of their patient’s rehabilitation adherence. It has been shown to be a reliable scale for use in clinical physiotherapy [42].
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Adherence to Physiotherapist’s Recommendations Scale: To measure overall levels of adherence, we will employ the two-item adherence scale previously employed by Chan et al. [26]. The scale demonstrated acceptable internal consistency in their study involving physiotherapists.
-
Home Exercise Compliance Assessment: To measure specific adherence to back exercise and physical activity advice we will calculate the percentage of prescribed sessions completed per week (Note: # prescribed session per week will be self-reported and confirmed from physiotherapists’ records). This measure has been previously employed in LBP studies [10].
Physical activity (PA)
-
International Short Form Physical Activity Questionnaire (IPAQ): This questionnaire has produced reliable and valid scores across diverse populations [43].
Back pain symptoms
-
Pain Intensity Numerical Rating Scale (Pain NRS): The pain intensity NRS measures the participant’s average pain over the previous seven days on a 0–10 scale where 0 is “no pain” and 10 is “worst ever pain”. This scale is easy to administer and is widely used in both research and clinical practice settings where it has been shown to demonstrate good construct validity and is sensitive to change [44].
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· Pain Bothersomeness: Following recommendations from a recent Cochrane review we will employ the “Bothersomeness Scale”, “Interference with Work Scale” and “Satisfaction with Current Symptoms Scale” from the “Core Set of Outcomes” [44].
Pain-related physical function
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Roland Morris Disability Questionnaire (RMDQ): This questionnaire consists of 24 yes/no items regarding the impact of back pain on activities of daily living. The RMDQ is used widely in low back pain studies as a standardized measure of activity limitation and has demonstrated good validity, reliability and responsiveness [45, 46].
-
Patient Specific Functional Scale (PSFS): This questionnaire is designed to assess the level of limitation on three patient-nominated activities they have difficulty performing because of their back pain. This questionnaire is anticipated to capture difficult activities that may not be represented on standardized tools. The PSFS has been shown to be a responsive measure for patients with back pain undergoing exercise-based physiotherapy treatments [47].
Well being
-
European Quality of Life Questionnaire (EuroQol): The EuroQol is a standardized instrument that provides a simple descriptive profile and a single weighted health index value for health status. It is applicable to a wide range of health conditions for which it has been shown to demonstrate good validity and reliability [48].
Secondary outcomes
-
Health Care Climate Questionnaire: is a six-item scale used to assess autonomy support that has demonstrated good reliability and validity [49].
-
Treatment Self-Regulation Questionnaire: This instrument is used to assess autonomous and controlled motivation. It has demonstrated good reliability and validity across diverse health-related behaviors [50].
-
Perceived Competence Scale: This four-item scale has consistently produced scores with good reliability and validity in relation to a variety of health-related behaviors, including PA [32].
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Fear Avoidance Beliefs Questionnaire physical activity subscale: This is a five-item self-report questionnaire that specifically focuses on participants’ beliefs about how physical activity affects their low back pain [51].
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Objectively-measure physical activity: We will measure all patients’ PA using a pedometer, which are relatively inexpensive (approximately €20) and provide basic data on daily step counts. A systematic review showed that pedometer scores correlated strongly (median r = .86) with accelerometer scores for step counts [52].
Moderating variables
-
General Causality of Orientations Scale (GCOS): This is a 17-item scale that assesses the strength of different global motivational orientations within an individual [54]. Subscales for autonomous, controlled and impersonal personality types are included.
-
Motivation to Participate Questionnaire: to be completed by Physiotherapists in experimental arm [55], this questionnaire measures participants’ autonomous and controlled motivation for learning.
-
Expectation of Treatment Scale: A numerical rating scale designed to assess the therapist and patient’s expectation of the intervention/treatment. It has been used widely in studies of physical interventions and shown to be a potential influencing factor in treatment outcome [56].
-
Depression Anxiety Stress Scale (DASS) Depression subscale: The DASS includes a set of three self-report scales designed to measure symptoms of psychological distress including depression, anxiety and stress, this study will employ the seven-item depression subscale [57].