The effectiveness of Motivational Enhancement Therapy on physiotherapy for patients with chronic low back pain : a randomized controlled trial

Abstract

Background: Chronic low back pain (LBP) is a highly prevalent condition. It is a multi-facet disorder affecting many factors including the psychosocial status of the patient. Physiotherapy usually leads to satisfactory outcomes in reducing pain and improving physical functions. However, some patients do not respond well to treatments or relapse over time. Several studies have indicated that low motivation in self-management and change for maladaptive pain behavioral patterns can be obstacles to achieve desirable rehabilitation outcomes. Therefore, Motivational Enhancement Therapy can be potentially an effective treatment approach to enhance pain modulation and promote exercise compliance for this patient group. Objectives: This thesis aimed to develop and validate a treatment package of Motivational Enhancement Therapy (MET) that can be used to augment traditional physiotherapy for pain treatment. Specifically, a randomized clinical trial was conducted to investigate the effectiveness of an integrating MET and conventional physiotherapy (PT) for enhancing treatment outcomes in patients with chronic LBP, as compared to a control group who received PT alone. The psychometric properties of the Chinese version of Pain Self-Efficacy Questionnaire (C-PSEQ) were also evaluated. Methodology: First, the psychometric properties of the Chinese version of PSEQ were examined. Second, a MET treatment program focused on the principles and counseling strategies of Motivational Interviewing (MI) and motivational enhancing factors was developed. The MET is composed of the techniques of eliciting patients' self- recognitions of pain, helping patients to recognize discrepancies between behaviors and treatment goals, providing positive feedback to patients, enhancing patients' self-efficacy and proxy efficacy beliefs in coping with pain, promoting patients' therapeutic alliance with therapists, improving their expectancy to treatment, and motivating them to self-manage their pain problems. Third, physiotherapists were recruited and put through the training of the standardized treatment protocol. Fourth, a randomized controlled trial study was conducted in a local clinical setting to examine whether the integration of MET to conventional physiotherapy would produce better treatment outcomes in terms of patients' motivation, exercise compliance, pain intensity, physical and psychosocial function than PT alone in people with chronic LBP. Also, the extent to which motivational measures would contribute to enhance the pain and physical outcomes were explored. Results: The validation study revealed that the C-PSEQ was best to be presented by a one-factor structure. The Cronbach's a was 0.94. Item-total correlations ranged from 0.71 to 0.85. The scores on C-PSEQ was significantly correlated with the modified Roland-Morris Disability Questionnaire and SF-36 subscales (r>0.4, p<0.01). However, there was no significant correlation between the C-PSEQ and perceived pain intensity as measured by Visual Analog Scale. These findings are comparable with those of the original PSEQ. For the randomized controlled study, the subjects in the experimental group (MET+PT) showed significantly better results in three motivational enhancing factors (proxy efficacy, working alliance, and expectancy to treatment), physical functions, and exercise compliance than did the control group as shown by repeated measures ANOVA (all between-group differences: /K0.05). Regression models found that the motivational enhancing factors significantly predicted the perceived pain intensity, lifting capacity, and physical function. Conclusions: Evidence of structural and substantive validity of the C-PSEQ is found comparable to that of the original instrument. Our proposed approach of integrating Motivational Enhancement Therapy into conventional physiotherapy significantly enhanced the motivation, physical functioning, and exercise compliance in patients with chronic LBP, as compared with those only received physiotherapy. Our findings also suggest that the increase in motivational enhancing factors might play a role in further reducing the perceived pain intensity and enhancing other physical outcomes among those who received the integrating interventions.