WHAT DO WE ASK PATIENTS TO DO THEMSELVES AND DO THEY DO IT? APPLYING BEHAVIOUR CHANGE THEORY TO MUSCULOSKELETAL PHYSIOTHERAPY

G. Rawlinson¹, L. Connell^2,3, R. Tarling⁴

¹University of Salford, School of Health and Society, Manchester, United Kingdom, ²University of Central Lancashire, Preston, United Kingdom, ³East Lancashire Hospitals NHS Trust, Lancashire, United Kingdom, ⁴Liverpool John Moores University, Liverpool, United Kingdom

Background: Musculoskeletal conditions cause a significant global health burden and treatment includes physiotherapy self-management programmes. Adhering to self-management programmes requires patients to undertake some form of behaviour change. Adherence is sub-optimal, and no single interventions have been shown to increase adherence. Little is known about the provision and content of self-management programmes or adherence behaviours.

Purpose: To apply behaviour change theory; the COM-B (Capability, Opportunity, and Motivation-Behaviour) model and Theoretical Domains Framework (TDF) to explore the provision of, and adherence to, self-management programmes in MSK physiotherapy in the United Kingdom (UK).

Methods: A mixed-methods longitudinal design used audio-video recordings of the first two physiotherapy appointments, questionnaires and two interviews per patient, to explore recall, adherence and patients’ capability, opportunity, and motivation to adhere (n=9 physiotherapists, n=11 physiotherapists). Inductive and deductive framework analysis was used to first identify themes from both physiotherapist’s behaviours and patients’ adherence behaviours which were then mapped to the Theoretical Domains Framework and COM-B model.

Results: Provision of self-management programmes varied greatly. Exercises were the most common strategy provided (median 4 exercises, Interquartile range 1-8). Self-reported adherence was generally higher for exercise strategies however, non-exercise strategies were rarely recalled or adhered to. Eight themes related to physiotherapists’ provision of programmes and four themes relating to patients’ experiences of undertaking programmes. All themes mapped to TDF domains.
Physiotherapists tended to provide simple, patient-led, flexible exercise programmes with no specific dosage parameters. They focussed predominantly on patients’ capability through provision of verbal and printed instructions, demonstrations, and opportunities to practice. There were no observed examples of shared decision making or goal setting. Physiotherapists’ confidence, time and environment also influenced their provision of self-management programmes.
Themes emerging from patients' experiences were patient personalisation of programmes, knowledge and memory, influence of others and patient goals and motivations. In contrast to physiotherapists, patients’ focussed more on opportunity and motivation aspects including symptom response, needing to feel challenged, identifying as an active person and belief in outcomes. Longitudinal exploration identified that factors were dynamic and inter-related over time; both within patients’ behaviours and within the therapeutic relationship.

Conclusions: Physiotherapists focussed primarily on patients’ capability compared to patients who focussed on opportunity and motivational aspects. A lack of specific dosage provision when prescribing programmes makes measuring adherence and implementation fidelity difficult. A range of dynamic and interdependent factors emerged which reinforce the need for a personalised approach. Utilising behaviour change theory (COM-B model and underpinning TDF framework) provided a comprehensive framework to evaluate patients’ adherence behaviours and the provision of self-management programmes.

Implications: Within physiotherapy education and practice, physiotherapists could better utilise behaviour change theory to facilitate adherence with self-management programmes. They should work collaboratively to understand and address patients’ capability, opportunity and motivation when providing self-management programmes. It is important that both the physiotherapist and patients consider adherence and jointly establish a threshold of adherence for programmes that is therapeutically meaningful, can be monitored and which considers quality and quantity. A pneumonic ACCOMPLISH is presented as an aide memoire to prompt physiotherapists when providing self-management programmes.

Funding acknowledgements: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Keywords:
Musculoskeletal
Self-management
Adherence

Topics:
Musculoskeletal
Professional practice: other
Health promotion & wellbeing/healthy ageing/physical activity

Did this work require ethics approval? Yes

Institution: University of Central Lancashire / Health Research Authority

Committee: UK Health Research Authority

Ethics number: 18/NW/0439