Can a training programme in motivational interviewing change musculoskeletal physiotherapists’ practice? The example of low back pain

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.