A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation

An investigation into perceived autonomy support, motivation and competence in chronic pain patients in Ireland: A cross-sectional study

Autonomy supportive healthcare settings are associated with enhanced behaviour change and self-management strategies in individuals living with chronic disease. The level of autonomy support provided by healthcare professionals to individuals living with chronic pain in Ireland is unknown. A cross-sectional study was completed on participants living with chronic pain (>3 months) in Ireland. Participants (n = 389) completed an anonymous survey constructed of patient reported outcome measures relating to autonomy support (HCCQ), motivation (TSRQ), competence in physical activity (PCS), pain interference (BPI) and psychological factors (PHQ-9, GAD-7). Results showed the median HCCQ (H = 39.287, p < .001), Autonomous Motivation (H = 13.568, p = 0.019) and PCS (H = 30.701, p < .001) scores were significantly different when patients received care from different healthcare professionals. There was a negative correlation between PCS and pain severity (r = -0.32, <0.01), pain interference (r = -0.44, p = <0.01), PHQ-9 (r = -0.50, p = <0.01) and GAD-7 (r = -0.34, p = <0.01). This study has identified that perceived healthcare support in Ireland varies according to the healthcare professional leading pain care. Furthermore, higher levels of self-determination were associated with decreased depression and anxiety in individuals with chronic pain. Given the limited number of multidisciplinary team clinics to provide pain management programs, an alternative cost-effective community led solution is required. The results of this study indicate that allied health professionals may be well placed to fill this void. Future research exploring the barriers to providing healthcare supportive settings is required.

Developing a low back pain guideline implementation programme in collaboration with physiotherapists and chiropractors using the Behaviour Change Wheel: a theory-driven design study

BACKGROUND

Low back pain is still the leading cause of disability and societal burden, with 619 million prevalent cases worldwide in 2020. Most countries produce clinical guidelines to support healthcare professionals in evidence-based care regarding low back pain. However, several studies have identified relatively poor uptake of guidelines. Tailored strategies to facilitate the implementation of guidelines have been argued to increase uptake. This study aimed to develop a contextually tailored implementation programme to enhance evidence-based low back pain care among Danish physiotherapists and chiropractors in primary care.

METHODS

A theory-driven implementation programme development study was conducted using the Behaviour Change Wheel, with high healthcare professional involvement. Data collection included four workshops with seven physiotherapists and six chiropractors from primary care clinics. The development process consisted of [1] establishing a theoretical frame, [2] involving participants, [3] understanding the behaviour, [4] designing the implementation programme, and [5] final implementation programme.

RESULTS

The target behaviours selected (guideline recommendations) for the implementation programme were (i) screening of psychosocial risk factors and (ii) offering patient education. The barriers and facilitators for the selected behaviours were described and linked to intervention functions and behavioural techniques. Finally, the implementation programme comprised five strategies: webinars, e-learning videos, communication exercises, peer learning, and group dialogue meetings. In addition, the programme consisted of implementation support: champions, a physical material folder, a weekly email reminder, a specially designed website and a visit from an implementation consultant. An essential element of the overall programme was that it was designed as a step-by-step implementation process consisting of 16 h of education and training distributed over 16 weeks.

CONCLUSIONS

A programme for implementing low back pain guideline recommendations was developed based on behaviour change theory and four co-design workshops involving healthcare professionals to overcome the contextually identified barriers. A theory-driven approach involving healthcare professionals was useful in identifying relevant target behaviours and tailoring the programme to consider contextual barriers and facilitators for implementation. The effectiveness of the final implementation programme will be evaluated in the project's next phase.

TRIAL REGISTRATION

Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19.

Development of an interdisciplinary training program about chronic pain management with a cognitive behavioural approach for healthcare professionals: part of a hybrid effectiveness-implementation study

BACKGROUND

Many applied postgraduate pain training programs are monodisciplinary, whereas interdisciplinary training programs potentially improve interdisciplinary collaboration, which is favourable for managing patients with chronic pain. However, limited research exists on the development and impact of interdisciplinary training programs, particularly in the context of chronic pain.

METHODS

This study aimed to describe the development and implementation of an interdisciplinary training program regarding the management of patients with chronic pain, which is part of a type 1 hybrid effectiveness-implementation study. The targeted groups included medical doctors, nurses, psychologists, physiotherapists, occupational therapists, dentists and pharmacists. An interdisciplinary expert panel was organised to provide its perception of the importance of formulated competencies for integrating biopsychosocial pain management with a cognitive behavioural approach into clinical practice. They were also asked to provide their perception of the extent to which healthcare professionals already possess the competencies in their clinical practice. Additionally, the expert panel was asked to formulate the barriers and needs relating to training content and the implementation of biopsychosocial chronic pain management with a cognitive behavioural approach in clinical practice, which was complemented with a literature search. This was used to develop and adapt the training program to the barriers and needs of stakeholders.

RESULTS

The interdisciplinary expert panel considered the competencies as very important. Additionally, they perceived a relatively low level of healthcare professionals' possession of the competencies in their clinical practice. A wide variety of barriers and needs for stakeholders were formulated and organized within the Theoretical Domain Framework linked to the COM-B domains; 'capability', 'opportunity', and 'motivation'. The developed interdisciplinary training program, including two workshops of seven hours each and two e-learning modules, aimed to improve HCP's competencies for integrating biopsychosocial chronic pain management with a cognitive behavioural approach into clinical practice.

CONCLUSION

We designed an interdisciplinary training program, based on formulated barriers regarding the management of patients with chronic pain that can be used as a foundation for developing and enhancing the quality of future training programs.

Physiotherapists Using the Biopsychosocial Model for Chronic Pain: Barriers and Facilitators-A Scoping Review

The use of the biopsychosocial model in primary care physiotherapy for chronic pain is far from the recommendations given in research and current guidelines. To understand why physiotherapists have difficulty implementing a biopsychosocial approach, more insight is needed on the barriers and facilitators. This scoping review aimed to investigate and map these barriers and facilitators that physiotherapists working in primary care reportedly face when treating patients with chronic musculoskeletal pain from a biopsychosocial perspective. Four electronic databases (PubMed, Embase, CINAHL and ERIC) and the grey literature were searched. Studies were included if they investigated the experiences of physiotherapists in the treatment of chronic pain from a biopsychosocial perspective in primary care. Extracted data were discussed and sub grouped in themes following a qualitative content analysis approach. To align with current use of theories on behavior change, the resulting themes were compared to the Theoretical Domains Framework. After screening, twenty-four studies were included. Eight groups of barriers and facilitators were identified, thematically clustered in six themes: knowledge, skills, and attitudes; environmental context and resources; role clarity; confidence; therapeutic alliance; and patient expectations. The results of this review can be used to inform the development of implementation programs.

From the challenge of assessing autonomy to the instruments used in practice: A scoping review

Autonomy is one of the essential components to live a quality life. Monitoring this autonomy is, in effect, essential, to allow the nurses to conceive, implement and evaluate interventions aimed at its promotion or even maintenance. For this reason, this scoping review aims to map the evidence to identify and analyze the instruments used to assess the person’s autonomy, which emerges from scientific production.

How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review

BACKGROUND

The use of theory is recommended to support interventions to promote implementation of evidence-based practices. However, there are multiple models of behaviour change which can be complex and lack comprehensiveness and are therefore difficult to understand and operationalize. The Theoretical Domains Framework sought to address these problems by synthesizing 33 models of behaviour or behaviour change. Given that it is 15 years since the first publication of the Theoretical Domains Framework (TDF), it is timely to reflect on how the framework has been applied in practice.

OBJECTIVE

The objective of this review is to identify and narratively synthesize papers in which the TDF, (including frameworks that incorporate the TDF) have been used have been used to develop implementation interventions.

METHODS

We searched MEDLINE, PsychINFO, CINAHL and the Cochrane databases using the terms: 'theoretical domains framework*' or TDF or Capability, Opportunity, Motivation to Behaviour (COM-B) or 'behav* change wheel' or 'BCW' AND implement* or improv* or quality or guideline* or intervention* or practice* or EBP or 'evidence based practice' and conducted citation and key author searches. The included papers were those that used any version of the TDF published from 2005 onwards. The included papers were subject to narrative synthesis.

RESULTS

A total of 3540 papers were identified and 60 were included. Thirty-two papers reported intervention design only and 28 reported intervention design and testing. Despite over 3000 citations there has been limited application to the point of designing interventions to support the best practice. In particular use of the framework has not been tried or tested in non-western countries and barely used in non-primary or acute care settings. Authors have applied the framework to assess barriers and facilitators successfully but reporting of the process of selection of behaviour change techniques and intervention design thereafter was variable.

CONCLUSION

Despite over three thousand citations of the framework there has been limited application to the point of designing interventions to support best practice. The framework is barely used in non-western countries or beyond primary or acute care settings. A stated purpose of the framework was to make psychological theory accessible to researchers and practitioners alike; if this is to be fully achieved, further guidance is needed on the application of the framework beyond the point of assessment of barriers and facilitators.

Knowledge Translation Research to Promote Behavior Changes in Rehabilitation: Use of Theoretical Frameworks and Tailored Interventions: A Scoping Review

OBJECTIVE

To describe knowledge translation (KT) research as a means of changing practice behaviors in rehabilitation. We specifically aimed to explore how theories, models, and frameworks (TMFs) are used to guide KT, guide methods to tailor KT interventions, and evaluate outcomes. We hypothesized these methods would have increased over the past 10 years.

DATA SOURCES

We identified articles through searches conducted using databases Cumulative Index to Nursing and Allied Health, MEDLINE, PubMed, Academic Search Premier, and previous reviews from January 2000 to April 2020. Search terms included physical therapy, occupational therapy, speech-language pathology, knowledge translation, and knowledge-to-action (KTA).

STUDY SELECTION

Two authors interpedently screened titles, abstracts, and full-text articles. Studies were included if behavior change of rehabilitation practitioners was measured. Systematic reviews, protocols, and capacity-building interventions were excluded.

DATA EXTRACTION

Three authors extracted information on study design, theoretical frameworks, intervention strategies, and outcome evaluation.

DATA SYNTHESIS

Fifty-six studies were included in the review. Sixteen (29%) reported the use of a theoretical framework to guide the KT process. Since 2013, the KTA framework was used 35% of the time. Twenty-two studies (39%) reported barrier assessments to tailor interventions, and 82% were published after 2013. However, barrier assessment in the local context was only conducted 64% of the time. Outcomes of tailored interventions were most frequently measured using chart audits (50%) and questionnaires (41%). Further, the link between KT theory, specific barriers, and selection of intervention strategies was not consistently described.

CONCLUSIONS

Over the past 7 years, there has been an increase in the use of KT TMFs and tailored interventions. Recommendations for future research include the use of TMFs to guide local barrier assessment, KT strategy selection, intervention development, and overall KT process and mapping barriers to selected intervention strategies.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

Patient and practitioner perspectives of psychological need support in physical therapy

PURPOSE

To examine strategies utilized by physical therapists that contributed to patient perceptions of basic psychological needs support articulated within Self-Determination Theory (SDT).

METHODS

Semi-structured interviews were conducted with physical therapists (n = 9) and physical therapy patients (n = 9) undergoing rehabilitation for a variety of musculoskeletal injuries.

RESULTS

Both patients and practitioners articulated the value of specific competence (e.g. matching rehabilitation challenges with patient abilities) and autonomy support strategies (e.g. active decision-making). Interestingly, both patients and therapists emphasized the salience of relatedness need support, a finding indicative of the potential importance of this need in a rehabilitation environment. The possibility that relatedness need support may be of equal - or potentially greater - importance than the other two needs in a rehabilitation setting, is however, antithetical to SDT contentions. Whether the primacy of relatedness need support is an artifact of the sample used in the current study or a reflection of a broader rehabilitation trend, is uncertain and remains a topic for further investigation.

CONCLUSIONS

Understanding the strategies physical therapists use to support patients' psychological needs may have substantial implications for patient motivation and rehabilitation adherence, such as, improved psychological well-being, enhanced function, and increased adherence to physical therapists' recommendations.

A Framework and Resources for Shared Decision Making: Opportunities for Improved Physical Therapy Outcomes

Shared decision making (SDM) is a collaborative approach between clinicians and patients, where the best available evidence is integrated with patients' values and preferences for managing their health problems. Shared decision making may enhance patient-centered care and increase patients' satisfaction, engagement, adherence, and ability to self-manage their conditions. Despite its potential benefits, SDM is underutilized by physical therapists, and frequent mismatches between patients' and therapists' rehabilitation goals have been reported. Physical therapists can use evidence-based strategies, tools, and techniques to address these problems. This paper presents a model for SDM and explains its association with improved patient outcomes and relevance to situations commonly encountered in physical therapy. It describes freely available resources, including health literacy universal precautions, teach-back, motivational interviewing, decision aids, and patient-reported outcome measures that can help physical therapists integrate SDM into their clinical practices. This paper also explains SDM facilitators and barriers, suggests a theoretical framework to address them, and highlights the need for SDM promotion within physical therapy practice, education, administration, and research.

An assessment of physiotherapist's delivery of behaviour change techniques within the SOLAS feasibility trial

OBJECTIVES

To investigate physiotherapist's (PTs) fidelity to 31 protocol-listed behaviour change techniques (BCTs) during a group-based self-management intervention. This study also explored the PTs delivery of these BCTs beyond the present or absent dichotomy, using a third variable, partial delivery (i.e., attempted).

DESIGN

Assessment of the intervention arm of the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) cluster, randomized controlled feasibility trial, using quantitative methods.

METHODS

Eight PTs delivered six SOLAS classes each, of which 50% were audio-recorded and transcribed. Transcripts were coded by two raters using the Behaviour Change Technique Taxonomy v1 and an intervention-specific manual and assessed for the delivery (i.e., full, partial, or absent) of the 31 BCTs and their target behaviours. Fidelity was calculated as fully delivered BCTs listed as a percentage of those due to take place within each class.

RESULTS

Physiotherapists delivered a mean 20.5 BCTs per class (68.3%; range = 64.9-72.4%). Of these, 17 BCTs were fully delivered in each class representing moderate fidelity to the protocol (56.8%; range = 53.5-59.3%). A further 3.5 BCTs per class (11.5%; range = 8.7-14.8%) were partially delivered. BCTs associated with 'goals and planning' were often poorly delivered.

CONCLUSIONS

Delivering the SOLAS intervention BCTs with high fidelity was not feasible. The assessment of partial delivery of BCTs provided greater insight into the techniques that should be removed from the protocol or that may require further training. Complex interventions should consider a list of 'core' or mandatory BCTs alongside 'optional' BCTs, depending on the target behaviour, and the needs of individual participants. Statement of contribution What is already known on this subject? BCTs are the smallest active components of behavioural interventions, yet typically their effectiveness is determined through meta-analyses. Attempted delivery of BCTs is often unaccounted for yet may provide valuable insight into difficulty with delivery. There is a need to investigate BCT implementation beyond simple presence/absence to identify protocol refinements or required BCT training. What does this study add? BCT delivery was assessed in greater depth than previous research, including partial delivery. Highlights the need for appropriate training in BCTs that are difficult to deliver, particularly those associated with 'goals and planning' Highlights the need for intervention-specific criteria as to what constitutes 'high', 'moderate', and 'low' fidelity.

Assessing physiotherapists' communication skills for promoting patient autonomy for self-management: reliability and validity of the communication evaluation in rehabilitation tool

PURPOSE

To assess the inter-rater reliability and concurrent validity of the Communication Evaluation in Rehabilitation Tool, which aims to externally assess physiotherapists competency in using Self-Determination Theory-based communication strategies in practice.

MATERIALS AND METHODS

Audio recordings of initial consultations between 24 physiotherapists and 24 patients with chronic low back pain in four hospitals in Ireland were obtained as part of a larger randomised controlled trial. Three raters, all of whom had Ph.Ds in psychology and expertise in motivation and physical activity, independently listened to the 24 audio recordings and completed the 18-item Communication Evaluation in Rehabilitation Tool. Inter-rater reliability between all three raters was assessed using intraclass correlation coefficients. Concurrent validity was assessed using Pearson's r correlations with a reference standard, the Health Care Climate Questionnaire.

RESULTS

The total score for the Communication Evaluation in Rehabilitation Tool is an average of all 18 items. Total scores demonstrated good inter-rater reliability (Intraclass Correlation Coefficient (ICC) = 0.8) and concurrent validity with the Health Care Climate Questionnaire total score (range: r = 0.7-0.88). Item-level scores of the Communication Evaluation in Rehabilitation Tool identified five items that need improvement.

CONCLUSION

Results provide preliminary evidence to support future use and testing of the Communication Evaluation in Rehabilitation Tool. Implications for Rehabilitation Promoting patient autonomy is a learned skill and while interventions exist to train clinicians in these skills there are no tools to assess how well clinicians use these skills when interacting with a patient. The lack of robust assessment has severe implications regarding both the fidelity of clinician training packages and resulting outcomes for promoting patient autonomy. This study has developed a novel measurement tool Communication Evaluation in Rehabilitation Tool and a comprehensive user manual to assess how well health care providers use autonomy-supportive communication strategies in real world-clinical settings. This tool has demonstrated good inter-rater reliability and concurrent validity in its initial testing phase. The Communication Evaluation in Rehabilitation Tool can be used in future studies to assess autonomy-supportive communication and undergo further measurement property testing as per our recommendations.

Feasibility of Training Physical Therapists to Deliver the Theory-Based Self-Management of Osteoarthritis and Low Back Pain Through Activity and Skills (SOLAS) Intervention Within a Trial

BACKGROUND

Provider training programs are frequently underevaluated, leading to ambiguity surrounding effective intervention components.

OBJECTIVE

The purpose of this study was to assess the effectiveness of a training program in guiding physical therapists to deliver the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) group education and exercise intervention (ISRCTN49875385), using a communication style underpinned by self-determination theory (SDT).

DESIGN

This was an assessment of the intervention arm training program using quantitative methods.

METHODS

Thirteen physical therapists were trained using mixed methods to deliver the SOLAS intervention. Training was evaluated using the Kirkpatrick model: (1) Reaction-physical therapists' satisfaction with training, (2) Learning-therapists' confidence in and knowledge of the SDT-based communication strategies and intervention content and their skills in applying the strategies during training, and (3) Behavior-8 therapists were audio-recorded delivering all 6 SOLAS intervention classes (n = 48), and 2 raters independently coded 50% of recordings (n = 24) using the Health Care Climate Questionnaire (HCCQ), the Controlling Coach Behavior Scale (CCBS), and an intervention-specific measure.

RESULTS

Reaction: Physical therapists reacted well to training (median [IRQ]; min-max = 4.7; [0.5]; 3.7-5.0). Learning: Physical therapists' confidence in the SDT-based communication strategies and knowledge of some intervention content components significantly improved. Behavior: Therapists delivered the intervention in a needs-supportive manner (median HCCQ = 5.3 [1.4]; 3.9-6.0; median CCBS = 6.6 ([0.5]; 6.1-6.8; median intervention specific measure = 4.0 [1.2]; 3.2-4.9). However, "goal setting" was delivered below acceptable levels by all therapists (median 2.9 [0.9]; 2.0-4.0).

LIMITATIONS

The intervention group only was assessed as part of the process evaluation of the feasibility trial.

CONCLUSIONS

Training effectively guided physical therapists to be needs-supportive during delivery of the SOLAS intervention. Refinements were outlined to improve future similar training programs, including greater emphasis on goal setting.

Chinese Cardiovascular Disease Mobile Apps' Information Types, Information Quality, and Interactive Functions for Self-Management: Systematic Review

BACKGROUND

China has a large population with cardiovascular disease (CVD) that requires extensive self-management. Mobile health (mHealth) apps may be a useful tool for CVD self-management. Little is currently known about the types and quality of health information provided in Chinese CVD mobile apps and whether app functions are conducive to promoting CVD self-management.

OBJECTIVE

We undertook a systematic review to evaluate the types and quality of health information provided in Chinese CVD mobile apps and interactive app functions for promoting CVD self-management.

METHODS

Mobile apps targeting end users in China with CVD conditions were selected in February 2017 through a multi-stage process. Three frameworks were used to evaluate the selected apps: (1) types of health information offered were assessed using our Health Information Wants framework, which encompasses 7 types of information; (2) quality of information provided in the apps was assessed using the 11 guidelines recommended by the National Library of Medicine of the National Institutes of Health; and (3) types of interactive app functions for CVD self-management were assessed using a 15-item framework adapted from the literature, including our own prior work.

RESULTS

Of 578 apps identified, 82 were eligible for final review. Among these, information about self-care (67/82, 82%) and information specifically regarding CVD (63/82, 77%) were the most common types of information provided, while information about health care providers (22/82, 27%) and laboratory tests (5/82, 6%) were least common. The most common indicators of information quality were the revealing of apps' providers (82/82, 100%) and purpose (82/82, 100%), while the least common quality indicators were the revealing of how apps' information was selected (1/82, 1%) and app sponsorship (0/82, 0%). The most common interactive functions for CVD self-management were those that enabled user interaction with the app provider (57/82, 70%) and with health care providers (36/82, 44%), while the least common interactive functions were those that enabled lifestyle management (13/82, 16%) and psychological health management (6/82, 7%). None of the apps covered all 7 types of health information, all 11 indicators of information quality, or all 15 interactive functions for CVD self-management.

CONCLUSIONS

Chinese CVD apps are insufficient in providing comprehensive health information, high-quality information, and interactive functions to facilitate CVD self-management. End users should exercise caution when using existing apps. Health care professionals and app developers should collaborate to better understand end users' preferences and follow evidence-based guidelines to develop mHealth apps conducive to CVD self-management.

Enhanced Medical Rehabilitation: Effectiveness of a clinical training model

BACKGROUND

Patient engagement in medical rehabilitation can be greatly influenced by their provider during therapy sessions. We developed Enhanced Medical Rehabilitation (EMR), a set of provider skills grounded in theories of behavior change. EMR utilizes 18 motivational techniques focused on providing frequent feedback to patients on their effort and progress and linking these to patient goals.

OBJECTIVE

To examine the effectiveness of a clinical training protocol for clinicians to do EMR, as measured by clinician adherence.

METHODS

A physical therapist, physical therapist assistant, occupational therapist, and certified occupational therapist assistant were trained in EMR. Training consisted of five formal training sessions and individual and group coaching. Adherence to EMR techniques was measured during two phases: Pre-Training and Maintenance, with an a priori target of 90% adherence by clinicians to each EMR technique.

RESULTS

With training and coaching, clinician adherence per therapeutic activity significantly improved in 13 out of 18 items (p < 0.05). The target of 90% adherence was not achieved for many items.

CONCLUSIONS

Our training and coaching program successfully trained clinicians to promote patient engagement during therapeutic service delivery, although not typically to 90% or greater adherence. Ongoing coaching efforts were necessary to increase adherence.

Patient Health Goals Elicited During Home Care Admission: A Categorization

Home care agencies are initiating “patient health goal elicitation” activities as part of home care admission planning. We categorized elicited goals and identified “clinically informative” goals at a home care agency. We examined patient goals that admitting clinicians documented in the point-of-care electronic health record; conducted content analysis on patient goal data to develop a coding scheme; grouped goal themes into codes; assigned codes to each goal; and identified goals that were in the patient voice. Of the 1,763 patient records, 16% lacked a goal; only 15 goals were in a patient’s voice. Nurse and physician experts identified 12 of the 20 codes as clinically important accounting for 82% of goal occurrences. The most frequent goal documented was safety/falls (23%). Training and consistent communication of the intent and operationalization of patient goal elicitation may address the absence of patient voice and the less than universal recording of home care patients’ goals.

What do patients value about spinal manipulation and home exercise for back-related leg pain? A qualitative study within a controlled clinical trial

BACKGROUND

Patient perceptions may influence the effectiveness and utilization of healthcare interventions, particularly for complex health conditions such as sciatica or back-related leg pain (BRLP).

OBJECTIVES

To explore BRLP patients' perceptions of spinal manipulative therapy (SMT) and home exercise with advice (HEA).

DESIGN

Qualitative study in a controlled clinical trial.

METHOD

Semi-structured interviews conducted after 12 weeks of treatment asked participants about satisfaction with care and whether treatment was worthwhile. An interdisciplinary research team conducted content analysis using qualitative data analysis software to identify and summarize themes.

RESULTS

Of 192 trial participants, 174 (91%) completed interviews (66% female, age 57.0 ± 11.5 years). Participants identified interactions with providers and staff, perceived treatment effects, and information as key contributors to both their satisfaction and the worthwhile nature of treatment. HEA was liked for its convenience and ability to foster an exercise habit. SMT was liked for specific aspects of the modality (e.g. manipulation, stretching) and provider competency. Most participants reported no dislikes for SMT or HEA, but some noted the dose/time commitment for SMT and discipline of HEA as least liked aspects of the interventions.

CONCLUSIONS

The quality of patient-provider interactions, perceived treatment effects, and information sharing influenced BRLP patients' satisfaction with care. Qualitative research describing patients' preferences can facilitate translation of study findings into practice and allow clinicians to tailor treatments to facilitate compliance and satisfaction with care.

Using intervention mapping to develop a theory-driven, group-based complex intervention to support self-management of osteoarthritis and low back pain (SOLAS)

BACKGROUND

The Medical Research Council framework provides a useful general approach to designing and evaluating complex interventions, but does not provide detailed guidance on how to do this and there is little evidence of how this framework is applied in practice. This study describes the use of intervention mapping (IM) in the design of a theory-driven, group-based complex intervention to support self-management (SM) of patients with osteoarthritis (OA) and chronic low back pain (CLBP) in Ireland's primary care health system.

METHODS

The six steps of the IM protocol were systematically applied to develop the self-management of osteoarthritis and low back pain through activity and skills (SOLAS) intervention through adaptation of the Facilitating Activity and Self-management in Arthritis (FASA) intervention. A needs assessment including literature reviews, interviews with patients and physiotherapists and resource evaluation was completed to identify the programme goals, determinants of SM behaviour, consolidated definition of SM and required adaptations to FASA to meet health service and patient needs and the evidence. The resultant SOLAS intervention behavioural outcomes, performance and change objectives were specified and practical application methods selected, followed by organised programme, adoption, implementation and evaluation plans underpinned by behaviour change theory.

RESULTS

The SOLAS intervention consists of six weekly sessions of 90-min education and exercise designed to increase participants' physical activity level and use of evidence-based SM strategies (i.e. pain self-management, pain coping, healthy eating for weight management and specific exercise) through targeting of individual determinants of SM behaviour (knowledge, skills, self-efficacy, fear, catastrophizing, motivation, behavioural regulation), delivered by a trained physiotherapist to groups of up to eight individuals using a needs supportive interpersonal style based on self-determination theory. Strategies to support SOLAS intervention adoption and implementation included a consensus building workshop with physiotherapy stakeholders, development of a physiotherapist training programme and a pilot trial with physiotherapist and patient feedback.

CONCLUSIONS

The SOLAS intervention is currently being evaluated in a cluster randomised controlled feasibility trial. IM is a time-intensive collaborative process, but the range of methods and resultant high level of transparency is invaluable and allows replication by future complex intervention and trial developers.

Theory-driven group-based complex intervention to support self-management of osteoarthritis and low back pain in primary care physiotherapy: protocol for a cluster randomised controlled feasibility trial (SOLAS)

INTRODUCTION

International clinical guidelines consistently endorse the promotion of self-management (SM), including physical activity for patients with chronic low back pain (CLBP) and osteoarthritis (OA). Patients frequently receive individual treatment and advice to self-manage from physiotherapists in primary care, but the successful implementation of a clinical and cost-effective group SM programme is a key priority for health service managers in Ireland to maximise long-term outcomes and efficient use of limited and costly resources.

METHODS/ANALYSIS

This protocol describes an assessor-blinded cluster randomised controlled feasibility trial of a group-based education and exercise intervention underpinned by self-determination theory designed to support an increase in SM behaviour in patients with CLBP and OA in primary care physiotherapy. The primary care clinic will be the unit of randomisation (cluster), with each clinic randomised to 1 of 2 groups providing the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) intervention or usual individual physiotherapy. Patients are followed up at 6 weeks, 2 and 6 months. The primary outcomes are the (1) acceptability and demand of the intervention to patients and physiotherapists, (2) feasibility and optimal study design/procedures and sample size for a definitive trial. Secondary outcomes include exploratory analyses of: point estimates, 95% CIs, change scores and effect sizes in physical function, pain and disability outcomes; process of change in target SM behaviours and selected mediators; and the cost of the intervention to inform a definitive trial.

ETHICS/DISSEMINATION

This feasibility trial protocol was approved by the UCD Human Research Ethics-Sciences Committee (LS-13-54 Currie-Hurley) and research access has been granted by the Health Services Executive Primary Care Research Committee in January 2014. The study findings will be disseminated to the research, clinical and health service communities through publication in peer-reviewed journals, presentation at national and international academic and clinical conferences.

TRIAL REGISTRATION NUMBER

ISRCTN 49875385; Pre-results.