Communication Skills Training for Practitioners to Increase Patient Adherence to Home-Based Rehabilitation for Chronic Low Back Pain: Results of a Cluster Randomized Controlled Trial

Published:March 28, 2017DOI:



      To assess the effect of an intervention designed to enhance physiotherapists' communication skills on patients' adherence to recommendations regarding home-based rehabilitation for chronic low back pain.


      Cluster randomized controlled trial.


      Publicly funded physiotherapy clinics.


      A sample (N=308) of physiotherapists (n=53) and patients with chronic low back pain (n=255; 54% female patients; mean age, 45.3y).


      Patients received publicly funded individual physiotherapy care. In the control arm, care was delivered by a physiotherapist who had completed a 1-hour workshop on evidence-based chronic low back pain management. Patients in the experimental arm received care from physiotherapists who had also completed 8 hours of communication skills training.

      Main Outcome Measures

      (1) Patient-reported adherence to their physiotherapists' recommendations regarding home-based rehabilitation measured at 1, 4, 12, and 24 weeks after the initial treatment session. (2) Pain and pain-related function measured at baseline and at 4, 12, and 24 weeks.


      A linear mixed model analysis revealed that the experimental arm patients' ratings of adherence were higher than those of controls (overall mean difference, .41; 95% confidence interval, .10–.72; d=.28; P=.01). Moderation analyses revealed that men, regardless of the intervention, showed improvements in pain-related function over time. Only women in the experimental arm showed functional improvements; female controls showed little change in function over time. The Communication Style and Exercise Compliance in Physiotherapy intervention did not influence patients' pain, regardless of their sex.


      Communication skills training for physiotherapists had short-term positive effects on patient adherence. This training may provide a motivational basis for behavior change and could be a useful component in complex interventions to promote adherence. Communication skills training may also improve some clinical outcomes for women, but not for men.


      List of abbreviations:

      CONNECT (Communication Style and Exercise Compliance in Physiotherapy)
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        • Newman S.
        • Steed L.
        • Mulligan K.
        Self-management interventions for chronic illness.
        Lancet. 2004; 364: 1523-1537
        • Frih Z.
        • Fendri Y.
        • Jellad A.
        • Boudoukhane S.
        • Rejeb N.
        Efficacy and treatment compliance of a home-based rehabilitation programme for chronic low back pain: a randomized, controlled study.
        Ann Phys Rehabil Med. 2009; 52: 485-496
        • Kolt G.S.
        • McEvoy J.F.
        Adherence to rehabilitation in patients with low back pain.
        Man Ther. 2003; 8: 110-116
        • Whitlock E.
        • Orleans C.
        • Pender N.
        • Allan J.
        Evaluating primary care behavioral counseling interventions—an evidence-based approach.
        Am J Prev Med. 2002; 22: 267-284
        • Schwarzer R.
        • Lippke S.
        • Luszczynska A.
        Mechanisms of health behavior change in persons with chronic illness or disability: the Health Action Process Approach (HAPA).
        Rehabil Psychol. 2011; 56: 161
        • Craig P.
        • Dieppe P.
        • Macintyre S.
        • Michie S.
        • Nazareth I.
        • Petticrew M.
        Developing and evaluating complex interventions: the new Medical Research Council guidance.
        BMJ. 2008; 337: a1655
        • Jordan J.
        • Holden M.
        • Mason E.
        • Foster N.
        Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults.
        Cochrane Database Syst Rev. 2010; : CD005956
        • Hurley D.A.
        • Hall A.M.
        • Currie-Murphy L.
        • et al.
        Theory-driven group-based complex intervention to support self-management of osteoarthritis and low back pain in primary care physiotherapy: protocol for a cluster randomised controlled feasibility trial (SOLAS).
        BMJ Open. 2016; 6: e010728
        • Hurley D.A.
        • Murphy L.C.
        • Hayes D.
        • et al.
        Using intervention mapping to develop a theory-driven, group-based complex intervention to support self-management of osteoarthritis and low back pain (SOLAS).
        Implement Sci. 2016; 11: 1-29
        • Ryan R.M.
        • Deci E.L.
        Overview of self-determination theory: an organismic dialectical perspective.
        in: Deci E.L. Ryan R.M. Handbook of self-determination research. Univ of Rochester Pr, Rochester2002: 3-33
        • Ng J.Y.Y.
        • Ntoumanis N.
        • Thogersen-Ntoumani C.
        • et al.
        Self-determination theory applied to health contexts.
        Perspect Psychol Sci. 2012; 7: 325-340
        • Braddock C.H.
        • Edwards K.A.
        • Hasenberg N.M.
        • Laidley T.L.
        • Levinson W.
        Informed decision making in outpatient practice: time to get back to basics.
        JAMA. 1999; 282: 2313-2320
        • Holden M.A.
        • Nicholls E.E.
        • Hay E.M.
        • Foster N.E.
        UK-based physical therapists' attitudes and beliefs regarding exercise and knee osteoarthritis: findings from a mixed methods study.
        Arthritis Rheum. 2009; 61: 1511-1521
        • Butow P.
        • Sharpe L.
        The impact of communication on adherence in pain management.
        Pain. 2013; 154: S101-S107
        • Kelly B.
        • Zolnierek H.
        • DiMatteo D.
        Physician communication and patient adherence to treatment—a meta-analysis.
        Med Care. 2009; 47: 826-834
        • Jeffels K.
        • Foster N.
        Can aspects of physiotherapist communication influence patients' pain experiences? A systematic review.
        Phys Ther Rev. 2003; 8: 197-210
      1. League of European Research Universities. Gendered research and innovation: Integrating sex and gender analysis into the research process. Available at: Accessed May 8, 2016.

      2. Anson P. Women in pain report significant gender bias. National Pain Report 2014. Available at: Accessed May 27, 2016.

        • Bartley E.J.
        • Fillingim R.B.
        Sex differences in pain: a brief review of clinical and experimental findings.
        Br J Anaesth. 2013; 111: 52-58
        • Lonsdale C.
        • Hall A.
        • Williams G.
        • et al.
        Communication Style and Exercise Compliance in Physiotherapy (CONNECT): a cluster randomized controlled trial to test a theory-based intervention to increase chronic low back pain patients' adherence to physiotherapists' recommendations: study rationale, design, and methods.
        BMC Musculoskelet Disord. 2012; 13: 104
        • Savigny P.
        • Watson P.
        • Underwood M.
        Early management of persistent non-specific low back pain: summary of NICE guidance.
        BMJ. 2009; 338: b1805
        • Hurley D.A.
        • Tully M.A.
        • Lonsdale C.
        • et al.
        Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial (ISRCTN17592092).
        Pain. 2015; 156: 131-147
        • Murray A.
        • Hall A.M.
        • Williams G.C.
        • et al.
        Effect of a self-determination theory-based communication skills training program on physiotherapists' psychological support for their patients with chronic low back pain: a randomized controlled trial.
        Arch Phys Med Rehabil. 2015; 96: 809-816
        • Chan D.K.
        • Lonsdale C.
        • Ho P.Y.
        • Yung P.S.
        • Chan K.M.
        Patient motivation and adherence to postsurgery rehabilitation exercise recommendations: the influence of physiotherapists' autonomy-supportive behaviors.
        Arch Phys Med Rehabil. 2009; 90: 1977-1982
        • Craig C.
        • Marshall A.L.
        • Sjostrom M.
        • et al.
        International Physical Activity Questionnaire: 12-country reliability and validity.
        Med Sci Sports Exerc. 2003; 35: 1381-1395
        • Kolt G.S.
        • Brewer B.W.
        • Pizzari T.
        • Schoo A.M.M.
        • Garrett N.
        The Sport Injury Rehabilitation Adherence Scale: a reliable scale for use in clinical physiotherapy.
        Physiotherapy. 2007; 93: 17-22
        • Deyo R.A.
        • Battie M.
        • Beurskens A.J.
        • et al.
        Outcome measures for low back pain research: a proposal for standardized use.
        Spine. 1998; 23: 2003-2013
        • Kamper S.J.
        • Ostelo R.W.J.G.
        • Knol D.L.
        • Maher C.G.
        • de Vet H.C.W.
        • Hancock M.J.
        Global Perceived Effect scales provided reliable assessments of health transition in people with musculoskeletal disorders, but ratings are strongly influenced by current status.
        J Clin Epidemiol. 2010; 63: 760-766.e1
        • Roland M.
        • Fairbank J.
        The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire.
        Spine. 2000; 25: 3115-3124
        • Pengel L.H.
        • Refshauge K.M.
        • Maher C.G.
        Responsiveness of pain, disability, and physical impairment outcomes in patients with low back pain.
        Spine. 2004; 29: 879
        • Stratford P.W.
        • Binkley J.
        • Solomon P.
        • Gill C.
        • Finch E.
        Assessing change over time in patients with low back pain.
        Phys Ther. 1994; 74: 528-533
        • Hurst N.P.
        • Kind P.
        • Ruta D.
        • Hunter M.
        • Stubbings A.
        Measuring health-related quality of life in rheumatoid arthritis: validity, responsiveness and reliability of EuroQol (EQ-5D).
        Rheumatology. 1997; 36: 551-559
        • Waddell G.
        • Newton M.
        • Henderson I.
        • Somerville D.
        • Main C.
        A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.
        Pain. 1993; 52: 157-168
        • Fortier M.S.
        • Sweet S.N.
        • O'Sullivan T.L.
        • Williams G.C.
        A self-determination process model of physical activity adoption in the context of a randomized controlled trial.
        Psychol Sport Exerc. 2007; 8: 741-757
        • Levesque C.S.
        • Williams G.C.
        • Elliot D.
        • Pickering M.A.
        • Bodenhamer B.
        • Finley P.J.
        Validating the theoretical structure of the Treatment Self-Regulation Questionnaire (TSRQ) across three different health behaviors.
        Health Educ Res. 2006; 22: 691-702
        • Lonsdale C.
        • Murray A.
        • Tenant Humphries M.
        • McDonough S.
        • Williams G.C.
        • Hurley D.A.
        Testing a theory-based intervention designed to increase chronic low back pain patients' adherence to physiotherapists' recommendations: a pilot study.
        J Sport Exerc Psychol. 2010; 32: S192-S193
        • Williams G.C.
        • McGregor H.A.
        • Zeldman A.
        • Freedman Z.R.
        • Deci E.L.
        Testing a self-determination theory process model for promoting glycemic control through diabetes self-management.
        Health Psychol. 2004; 23: 58-66
        • Williams G.C.
        • Grow V.M.
        • Freedman Z.R.
        • Ryan R.M.
        • Deci E.L.
        Motivational predictors of weight loss and weight-loss maintenance.
        J Pers Soc Psychol. 1996; 70: 115-126
        • Friedrich M.
        • Gittler G.
        • Halberstadt Y.
        • Cermak T.
        • Heiller I.
        Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial.
        Arch Phys Med Rehabil. 1998; 79: 475-487
        • Ivers N.
        • Jamtvedt G.
        • Flottorp S.
        • et al.
        Audit and feedback: effects on professional practice and healthcare outcomes.
        Cochrane Database Syst Rev. 2012; : CD000259
        • Matthews J.
        • Hall A.M.
        • Hernon M.
        • et al.
        A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation.
        BMC Health Serv Res. 2015; 15: 260
        • Peter W.
        • van der Wees P.J.
        • Verhoef J.
        • et al.
        Effectiveness of an interactive postgraduate educational intervention with patient participation on the adherence to a physiotherapy guideline for hip and knee osteoarthritis: a randomised controlled trial.
        Disabil Rehabil. 2015; 37: 274-282
        • Colquhoun H.
        • Michie S.
        • Sales A.
        • et al.
        Reporting and design elements of audit and feedback interventions: a secondary review.
        BMJ Qual Saf. 2017; 26: 54-60
        • Lonsdale C.
        • Lester A.
        • Owen K.B.
        • et al.
        An Internet-supported physical activity intervention delivered in secondary schools located in low socio-economic status communities: study protocol for the Activity and Motivation in Physical Education (AMPED) cluster randomized controlled trial.
        BMC Public Health. 2016; 16: 1
        • Lonsdale C.
        • Sanders T.
        • Cohen K.E.
        • et al.
        Scaling-up an efficacious school-based physical activity intervention: study protocol for the ‘Internet-based Professional Learning to help teachers support Activity in Youth’ (iPLAY) cluster randomized controlled trial and scale-up implementation evaluation.
        BMC Public Health. 2016; 16: 873
        • Ostelo R.W.
        • de Vet H.C.
        Clinically important outcomes in low back pain.
        Best Pract Res Clin Rheumatol. 2005; 19: 593-607
        • Abbott J.H.
        • Schmitt J.
        Minimum important differences for the Patient-Specific Functional Scale, 4 region-specific outcome measures, and the numeric pain rating scale.
        J Orthop Sports Phys Ther. 2014; 44: 560-564
        • Guillory J.
        • Chang P.
        • Henderson Jr., C.R.
        • et al.
        Piloting a text message-based social support intervention for patients with chronic pain: establishing feasibility and preliminary efficacy.
        Clin J Pain. 2015; 31: 548-556
        • Williams G.C.
        • Lynch M.F.
        • McGregor H.A.
        • Ryan R.M.
        • Sharp D.
        • Deci E.L.
        Validation of the “Important Other” Climate Questionnaire: assessing autonomy support for health-related change.
        Fam Syst Health. 2006; 24: 179-194
        • Bennell K.L.
        • Rini C.
        • Keefe F.
        • et al.
        Effects of adding an Internet-based pain coping skills training protocol to a Standardized Education and Exercise Program for People With Persistent Hip Pain (HOPE Trial): randomized controlled trial protocol.
        Phys Ther. 2015; 95: 1408-1422
        • Naylor C.
        • Imison C.
        • Goodman N.
        • Buck D.
        • Curry N.
        • Addicott R.
        Transforming our health care system: ten priorities for commissioners.
        The King's Fund, London2011
        • Hall A.M.
        • Kamper S.J.
        • Hernon M.
        • et al.
        Measurement tools for adherence to non-pharmacologic self-management treatment for chronic musculoskeletal conditions: a systematic review.
        Arch Phys Med Rehabil. 2015; 96: 552-562
        • Peek K.
        • Sanson-Fisher R.
        • Mackenzie L.
        • Carey M.
        Patient adherence to physiotherapist prescribed self-management strategies: a critical review.
        Int J Ther Rehabil. 2015; 22: 535-543
        • Schulz K.F.
        • Grimes D.A.
        Multiplicity in randomised trials I: endpoints and treatments.
        Lancet. 2005; 365: 1591-1595