Can a training programme in motivationalinterviewing change musculoskeletalphysiotherapists’ practice?The example of low back pain

Abstract

Background Low back pain (LBP) is a leading cause of disability nationally and globally, and forms between 40% and 65% of musculoskeletal physiotherapists’ caseloads in the UK. Despite professional expectations to deliver person-centred practice, a biomedical and practitioner-centred perspective continues to dominate within physiotherapy. Many physiotherapists lack the knowledge and skills to deliver psychologically informed practice, which for persistent LBP requires consideration of the needs, preferences and values of the patient. Motivational interviewing (MI) has been recommended as a psychologically informed approach for physiotherapists working with persistent LBP patients, although little research has been carried out into its use. Aim This study aims to investigate the effects of MI training on physiotherapists’ beliefs, attitudes and practice in relation to persistent LBP. Methods A convergent parallel mixed methods study was undertaken. Volunteer musculoskeletal physiotherapists (n=16) were recruited from two musculoskeletal physiotherapy departments within a Community NHS Trust in greater London and allocated to either a MI training Group A (n=10) or a comparison Group B (n=6). The MI training group received an initial two-day MI course followed up by monthly supervision sessions delivered in the workplace. Outcomes were measured pretraining (baseline) then at three and six months later for both groups. Beliefs and attitudes and to persistent low back pain were measured using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). Self-reported proficiency, confidence and intention to use MI were measured using visual analogues scales (VAS). The Motivational Interviewing Training Integrity scale (MITI) generated global ratings and behaviour counts from audio-recordings of initial consultations with persistent LBP patients. The implementation and impact of MI in practice was explored through semi-structured interviews with Group A physiotherapists only at six months. Results A significant post-training decrease in biomedical orientation was demonstrated between the MI training group and the comparison group at three months (HCPAIRS) and six months (PABS-PT and HC-PAIRS) using independent t-tests. The MI training group had significantly increased proficiency, confidence and intention to use MI at three and six months (VAS); and increased MITI global ratings of Spirit (at three months), Collaboration (at three months) and Evocation (at six months). Qualitative content analysis of the semi-structured interviews revealed that the physiotherapists embraced MI as an approach. They were able to overcome initial challenges of putting MI training into practice such as time pressure and level of difficulty in changing ingrained practice and language, and found positive individual and collective ways to introduce and sustain their use of MI. Discussion The results of this study contribute new insights into the understanding of the role and impact of training musculoskeletal physiotherapists in MI, although the small sample size means that the results should be interpreted with caution. MI is acceptable to physiotherapists. Physiotherapists were able to embrace the spirit of MI and to embed MI within their practice. This allows them to development their skills as person-centred practitioners and to cope more effectively with patients perceived as difficult and those with complex presentations. However, ongoing supervision is required to develop MI proficiency, which can be expensive. Mi is acceptable to physiotherapists who seem keen to adopt this psychologically informed approach However, for MI practice to become adopted more widely across the profession, sustainable training approaches and appropriate professional support structures are required.