THEORETICAL UNDERPINNINGS INFORMING A NEW REHABILITATION PROGRAMME FOLLOWING LUMBAR FUSION SURGERY

Greenwood J.¹, Jones F.², McGregor A.³, Hurley M.²

¹National Hospital for Neurology and Neurosurgery, London, United Kingdom, ²St George's University of London, London, United Kingdom, ³Imperial College London, London, United Kingdom

Background: Theoretically informed interventions are recommended and can produce superior effects than those conceived pragmatically. They facilitate development of causal pathways for refinement and evaluation of interventions, and inform the development of complex interventions [1].
We have designed a theoretically informed, complex rehabilitation programme to improve outcome following lumbar fusion surgery (REFS study). A recent systematic review identified 3 studies evaluating rehabilitation following lumbar fusion surgery (LFS), none of which explicitly described a theoretical framework [2].
A broad range of behavioural change models and theoretical frameworks were considered to inform the development of the intervention to improve engagement with rehabilitation and outcome following LFS.

Purpose: Describe the behavioural change model and overarching theory informing the development and evaluation of the REFS programme.

Methods: A critical review of potential behavioural change models was conducted and the behavioural change wheel (BCW) methodology [3] selected as it meets National Institute for Health and Care Excellence guidance criteria. Individual behavioral change techniques were selected, from a recent taxonomy for behaviour change reporting [4], based on their likely impact on engagement with rehabilitation and clinical outcome. The BCW also encourages mapping the outcome of the BCW methodology to an existing theory. We identified the social cognitive theory (SCT) [5] as a suitable overarching theory, informing the REFS programme. Within the SCT the preeminent construct is self-efficacy, the sources of which are mastery, verbal persuasion, vicarious observation, and emotional state.

Results: A description of the model is provided including the individual behavioural change techniques and how these map to aspects of the SCT. The detailed theoretical framework underpinning the programme, utilising BCW methodology and how this maps to the SCT is presented. Key considerations for REFs based on BCW and SCT are; 1. The outcome of the BCW methodology including, C-capability, O-opportunity, M-motive analysis to identify individual behavioural change techniques. 2. The identified, individual behavioural change techniques, or ‘active ingredients’ of the programme with taxonomy reference, and the associated intervention aspect that they had informed. Eg; Taxonomy-8.7 ‘Graded tasks’ influenced the paced and progressive nature of the programme including the three-week familiarisation phase and the inclusion of an educational component on the principle of pacing. 3. A novel, graphical representation of the entire theoretical framework, conceptualising how these behavioural change techniques map to components of the SCT forming the hypothetical causal pathway.

Conclusion(s): The proposed framework will help identify ‘active components’ of the programme for reinforcement in future studies. It is expected that many of the ‘active ingredients’ (BCT’s) could have value and could be enhanced or reinforced in future studies. Others may be shown to be ineffectual or counterproductive and omitted. It is also possible that unexpected themes will emerge for future consideration.

Implications: This framework will help inform the future development and evaluation of the REFS programme to undertake a multi-centre RCT evaluating clinical efficacy.

Funding acknowledgements: National Institute for Health Research Clinical Doctoral Research Fellowship (NIHR, CDRF)

Topic: Musculoskeletal: spine

Ethics approval: National Research Ethics Service, 14/LO/0748.

All authors, affiliations and abstracts have been published as submitted.