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ORIGINAL ARTICLE

Motivational Enhancement Therapy in Addition to Physical Therapy Improves Motivational Factors and Treatment Outcomes in People With Low Back Pain: A Randomized Controlled Trial
Sina K. Vong, MPhil, Gladys L. Cheing, PhD, Fong Chan, PhD, Eric M. So, MSc, Chetwyn C. Chan, PhD
ABSTRACT. Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Phys Med Rehabil 2011;92:176-83. Objectives: To examine whether the addition of motivational enhancement treatment (MET) to conventional physical therapy (PT) produces better outcomes than PT alone in people with chronic low back pain (LBP). Design: A double-blinded, prospective, randomized, controlled trial. Setting: PT outpatient department. Participants: Participants (N76) with chronic LBP were randomly assigned to receive 10 sessions of either MET plus PT or PT alone. Intervention: MET included motivational interviewing strategies and motivation-enhancing factors. The PT program consisted of interferential therapy and back exercises. Main Outcome Measures: Motivational-enhancing factors, pain intensity, physical functions, and exercise compliance. Results: The MET-plus-PT group produced signicantly greater improvements than the PT group in 3 motivationenhancing factors; proxy efcacy (P.001), working alliance (P.001), and treatment expectancy (P.011). Furthermore, they performed signicantly better in lifting capacity (P.015), 36-Item Short Form Health Survey General Health subscale (P.015), and exercise compliance (P.002) than the PT group. A trend of a greater decrease in visual analog scale and Roland-Morris Disability Questionnaire scores also was found in the MET-plus-PT group than the PT group. Conclusion: The addition of MET to PT treatment can effectively enhance motivation and exercise compliance and show better improvement in physical function in patients with chronic LBP compared with PT alone. Key Words: Low back pain; Motivation; Physical therapy; Rehabilitation. 2011 by the American Congress of Rehabilitation Medicine OW BACK PAIN is the most common reason for visiting L a physician. The lifetime prevalence of LBP in industrialized countries was approximately 60% to 85%, annual
1,2

prevalence ranged from 15% to 45%, and point prevalence averaged 30%.3-5 Recent evidence showed that up to half the patients visiting a practitioner with a rst episode of LBP will continue to experience pain and disability 3 months later.6 Exercise and multidisciplinary therapy are being implemented to reduce both the medical and social burden.6 The biopsychosocial approach has been successful in relieving pain, improving function, and enhancing the use of selfmanagement skills for people with LBP.7,8 However, many patients still prefer to receive passive treatment than actively participate in a biopsychosocial treatment program.9,10 Motivation inuences people in their initiation, intensity, and performance of a behavior (eg, exercise self-management) and affects treatment outcomes in terms of pain relief or functional improvement.10-15 MI is a client-centered counseling technique that aims to improve the motivation and commitment of clients to achieving behavioral changes.16 There are 4 main principles in MI: (1) expressing accurate empathy, (2) developing discrepancy, (3) avoiding argumentation and rolling with resistance, and (4) supporting self-efcacy.10,17,18 Particular MI strategies for pain management are divided into 3 phases, enhancing, strengthening, and maintaining behavioral changes according to the transtheoretical (stages of change) model.10,19 Very few studies have examined MI in association with a PT program for patients with LBP, and no study has found a signicant increase in motivation measures after treatment. Although motivation-based treatment often is provided by clinical and rehabilitation psychologists, studies of its effects in other areas of the medical profession, such as PT, have been very limited.20-24 Friedrich et al20,25 compared the effects of a combined exercise and motivation program delivered by physical therapists to people with chronic LBP with those of an exercise program alone. Their results showed that the com-

List of Abbreviations
From the Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong Special Administrative Region, China (Vong, Cheing, C.C. Chan); Department of Rehabilitation Psychology and Special Education, University of Wisconsin, Madison, WI (F. Chan); and Physiotherapy Department, Princess Margaret Hospital, Hong Kong Special Administrative Region, China (So). No commercial party having a direct nancial interest in the results of the research supporting this article has or will confer a benet on the authors or on any organization with which the authors are associated. Reprint requests to Gladys L. Cheing, PhD, Dept of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, HKSAR, China, e-mail: rsgladys@inet.polyu.edu.hk. 0003-9993/11/9202-00275$36.00/0 doi:10.1016/j.apmr.2010.10.016

ANCOVA GH LBP MET MI PRES PSEQ PT RMDQ SF-36 VAS

analysis of covariance General Health low back pain motivational enhancement therapy motivational interviewing Pain Rehabilitation Expectations Scale Pain Self-Efcacy Questionnaire physical therapy Roland-Morris Disability Questionnaire 36-Item Short-Form Health Survey visual analog scale

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bined program led to a signicantly greater decrease in pain intensity and disability than the exercise program, but no signicant differences were found in measures of motivation (ie, distress, internal locus of control, attitude toward exercise). The treatment protocol for their study involved only exercise, with no pain-relieving modality. The lack of signicant ndings in motivation measures could be explained in part because patients experiencing severe pain were poorly motivated to engage in exercise. Basler et al23 examined the effects of incorporating counseling based on the transtheoretical model with exercise for people with LBP. Both groups received exercise therapy prescribed by physical therapists. The experimental group also received counseling, whereas the control group received a placebo ultrasound treatment. The study showed that both groups experienced some improvement in physical capacity, but the difference between groups did not reach signicance. Escolar-Reina et al24 showed an observational study that pain self-management training combined with PT was associated with better adherence to pain self-management in people with LBP and neck pain. Based on the very limited studies in this area and limitations in study design (eg, no control group or lack of a sensitive instrument to assess motivational outcomes), no signicant ndings associated with MI and PT treatment have been reported. With the recent development and psychometric validation of the PSEQ26 and PRES,27 it is possible to conduct better motivational studies in PT research. In addition, exercise compliance, pain level, and functional capacity were common outcome measures in motivational studies.20,23,28 Physical therapists have an important role in decreasing pain, enhancing physical function, and teaching self-coping skills to patients. These treatments aim to foster the development of pain coping behavior, decrease the recurrence of pain symptoms, and decrease the frequency of medical treatment. MI aims to strengthen the intention of people with LBP to engage in treatment and take action to cope with pain. Integrating MET, an adaptation of MI techniques, into PT potentially may enhance the effectiveness of conventional treatments. Therefore, the aim of the present study was to examine whether the addition of MET to conventional PT would produce better outcomes for motivational status, pain intensity, physical function, and exercise compliance than PT alone for people with chronic LBP. METHODS Participants People with chronic LBP were recruited consecutively from a local outpatient PT department. Inclusion criteria were people aged 18 to 65 years for whom LBP had been diagnosed for at least 3 months. Exclusion criteria were people who were pregnant or had a cardiac pacemaker, pain from neurologic disorders or rheumatologic disease, consistent symptoms of sciatica, spondylolisthesis more than lcm, received PT for LBP in the past 3 months, psychiatric problems, or received compensation for work-related disabilities. Design Subjects and the assessor were blinded for group allocation. All subjects were randomly assigned to either (1) the integrated MET-plus-PT group or (2) the PT-alone group by using a computerized randomization table generated by a third party. Subjects were told that they would receive either 1 of the 2 types of conventional PT treatment. They did not know anything about MET. Ethical approval was obtained from the

research committee of a local university and a local hospital. Written consent was obtained from each subject. A pilot study was performed before the study to verify the validity of MET for patients with pain. MET content rst was developed based on MI strategies and a review of the research literature for motivation-enhancing factors.10,29-33 People with pain (n30) and pain experts (n8) rated the MET program content, and it was modied based on their comments. The nalized MET contents were used in MET training for therapists. Eight-hour training then was provided to the involved physical therapists before the study. Six physical therapists (average, 14.1y of clinical experience) participated in the present study. They were randomly divided into either the METplus-PT or PT group by drawing a lot from a sealed envelope. In particular, specic MET skill training was provided to therapists involved in the MET-plus-PT group, whereas the PT group received general communication skill training. Therapists were asked not to discuss concepts related to their training with other therapists. A clinical psychologist provided MET or general communication skills training. After training, all physical therapists practiced the required skills on their patients with pain for 2 weeks. An investigator who had received MI and counseling training observed and evaluated the quality of the therapists communication with their patients by using a checklist. A 5-point MET strategy scale was used to count the frequency of using the strategy in 1 practical session as follows: 0 indicates did not use any MET strategy (0%); 1, rarely used (25%); 2, occasionally used (50%); 3, frequently used (75%); and 4, used MET strategies most of the time in a session (90%). Results showed that therapists in the MET-plus-PT group had a mean score of 2 or 3, indicating that MET strategies were adopted greater than 50% of the time in their practical sessions. Those in the PT group had a mean score of 0 or 1, indicating that they did not use or rarely adopted MET strategies in their treatment sessions. Performance of the therapists conformed to the requirements of their respective groups. Conventional PT All subjects received ten 30-minute PT sessions in 8 weeks, which included 15 minutes of interferential therapy and a tailor-made back exercise program. Interferential therapy is one of the most frequently used electrophysical modalities in clinical settings.34,35 Four interferentiala suction electrodes were placed over the L2 to S1 paraspinal muscles on both sides of the back. The frequency of the current was swept from 80 to 100Hz, and intensity was set at a moderate tingling sensation. Therapists conducted a thorough physical assessment for each patient. Based on assessment results, they prescribed a specic set of exercises adopted from an exercise booklet with detailed descriptions of stretching and strengthening exercises for the trunk and lower limbs (eg, pelvic tilt, trunk rotation in a crook-lying position, stretching hamstrings and back muscle, strengthening abdominal and back muscles). The patients exercise performance was monitored during treatment sessions to ensure that these exercises were performed correctly. Exercises also were prescribed as home exercises, and patients were requested to exercise daily. Motivational Enhancement Therapy During PT sessions, subjects in the experimental group received MET from their respective physical therapists, who integrated MI skills and several psychosocial components designed to enhance the motivation of subjects to engage in treatment and make appropriate behavioral changes. MI stratArch Phys Med Rehabil Vol 92, February 2011

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egies for pain management were recommended by Jensen.10 One psychosocial factor relevant to the motivational approach is proxy efcacy. It refers to patients condence in their therapists ability to function effectively on their behalf.29 It correlated with self-efcacy in rehabilitation programs.30,31 Treatment expectancy refers to belief in the consequences of performing a behavior, which helps boost patients motivation in exerting self-control to pursue a goal, take action, and persist in adhering to specic behavior.31,32,36 Working alliance refers to a therapeutic relationship built between the patient and therapist.33 Dummy MET included general communication skills, but deliberately removed the MET element and avoided adopting counseling-related skills. Therapists in the PT group adopted the usual communication manner with patients in clinical practice. Treatment time for both groups was kept within 30 minutes. Outcome Measures All outcome measures except for the PRES and exercise compliance were assessed before treatment session 1, after treatment sessions 5 and 10, and 1 month after cessation of treatment. The PRES was assessed right after sessions 1, 5, and 10, and exercise compliance was recorded in sessions 5 and 10 and at the 1-month follow-up. Primary outcome: motivational status. Motivational status was assessed using the PRES and PSEQ. The PRES consists of 35 treatment- and/or therapist-oriented items measured using a 4-point Likert scale (1 strongly disagree to 4 strongly agree). These items are grouped under the 3 subscales of proxy efcacy, working alliance, and treatment expectancy, and the mean value for each subscale score was calculated. The instrument has been reliable in measuring motivation and expectations of patients regarding pain rehabilitation.28 The PSEQ consists of 10 self-reported questions that measure subjects self-efcacy beliefs about performing activities despite experiencing pain by using a 7-point Likert scale (0 not at all condent to 6 completely condent).29 Scores for the items were added to yield a total PSEQ score. Good reliability and construct-related validity have been shown in patients with chronic pain in the Chinese population.37,38 Secondary outcomes: pain intensity. A 10-cm VAS labeled no pain at the left end and pain as bad as it can be at the right end was used. Subjects made a mark along the line to represent the present level of pain intensity. This is the most common and valid tool for measuring self-perceived pain intensity.39,40 Secondary outcomes: physical function. The range of trunk motion (lumbar exion, extension, side exion, rotation) was tested according to procedures recommended by Clarkson.41,42 Each direction of movement was tested under 2 trials. Functional strength of the trunk muscles was evaluated using a lifting capacity test.41,42 Subjects stood on a wooden board with the trunk upright and feet apart at a distance of shoulder width with knees slightly exed. Subjects then applied the maximal pain-free lifting force on the handle that connected to a chain adhered perpendicularly to the board. A strain gauge was connected at the end of the chain to measure lifting capacity in kilograms. The mean value of the 2 trials was recorded. The RMDQ was used to assess subjects self-reported LBP disability level.43 Twenty-four items with a score of either 1 (agree with the statement) or 0 (disagree with the statement) were summed to a total score that ranged from 0 (no pain and normal function) to 24 (maximum pain and dysfunction). The reliability and validity of this questionnaire has been established.43,44 Physical subscales (Physical Function, RolePhysiArch Phys Med Rehabil Vol 92, February 2011

cal, Bodily Pain, GH) of the SF-36 were used to measure self-perceived physical status, which is commonly used to assess people with LBP.45 Secondary outcomes: exercise compliance. The frequency of practicing the prescribed home exercises was recorded in an exercise log book in both groups. Exercise compliance was computed by how many sessions of home exercise subjects had performed in a day multiplied by how many days they had practiced in a week.20,23,28 We measured exercise compliance in sessions instead of minutes. Data Analysis All data analyses were performed using the Statistical Package for the Social Sciencesb. A series of 2-way repeatedmeasures ANCOVA was computed to compare mean differences between the MET-plus-PT and PT groups, within groups, and the interaction effect over assessment periods for 4 outcome variables (motivational factors, pain intensity, physical function, exercise compliance). Sex, baseline lifting capacity, and SF-36 GH score were entered as covariates. All analyses were calculated by using an intention-to-treat approach. Any missing data at posttreatment sessions were replaced according to the last-observation-carried-forward procedure. Level of statistical signicance was set at P equals .05. Comparing group differences for outcome variables by using several subscales (eg, 3 subscales of the PRES), level was divided by the number of comparisons to control for type I error. RESULTS Baseline Characteristics Eligible patients (N88) initially were recruited for the present study and were randomly assigned to either the MET-

Fig 1. The Consolidated Standards of Reporting Trials ow diagram of the study.

MOTIVATIONAL-ENHANCED THERAPY FOR PAIN, Vong Table 1: Demographic Characteristics of Subjects

Characteristic METPT Group (n38) PT Group (n38) P

179

Age (y) Sex Women Men Body mass index (kg/m2) LBP duration (mo) Subjects with recurrent LBP Subjects had previous PT Subjects had regular analgesia Baseline outcome measures VAS score Lifting capacity (kg) RMDQ score Range of motion Flexion (cm) Extension (cm) Side exion (cm) Right Left Rotation () Right Left SF-36 physical subscales Physical Function RolePhysical Bodily Pain GH PSEQ score

44.611.2 22 16 24.34.67 41.656.8 8 6 12 5.32.2 42.4622.40 10.04.31 18.921.25 13.370.75 48.965.47 49.275.99 62.5421.97 59.3819.08 67.3716.84 22.3726.50 33.2915.37 40.6117.42 39.459.71

45.110.7 26 12 23.83.2 51.071.5 13 11 11 5.32.0 32.1417.54 10.055.54 18.641.13 13.180.76 47.005.53 47.945.86 61.7219.36 62.4219.84 63.2918.39 29.6136.23 33.1616.12 49.3720.27 40.4710.24

0.85 0.48*

0.58 0.53 0.31* 0.27* 1.00* 0.99 0.029 0.96 0.30 0.28 0.12 0.33 0.86 0.50 0.32 0.32 0.97 0.047 0.66

NOTE. Values expressed as mean SD or n. Range of motion in exion and extension: distance between a point 15cm above the midpoint of the line connecting the posterior superior iliac spines. The subject exed the trunk forward to the pain-free limit of motion for lumbar exion and extended the trunk backward to the pain-free limit of motion for lumbar extension. Range of motion in side exion: distance measured between the tip of the third digit and the oor. The subject exed the trunk laterally to the pain-free limit of motion. Range of motion in rotation: the subject sat and crossed the arms in front of the chest, a Myrin goniometerc was then put on the wrist. The subject rotated the trunk to the pain-free limit of motion. *Group difference was analyzed by using chi-square test.

plus-PT (n45) or PT group (n43). However, before the study began, 12 patients refused to participate for medical reasons or time conicts. No signicant differences for demographic data were found between dropout subjects and participants. Therefore, 76 subjects participated in the present study (g 1). Their baseline characteristics are listed in table 1. No signicant differences were found between the 2 groups for demographic data and most baseline measurements, with the exception of lifting capacity and SF-36 GH subscale. Baseline values for lifting capacity and SF-36 GH were treated as covariates of that of posttreatment outcomes when performing repeated-measures ANCOVA. Lifting capacity also had a signicant sex difference. Lifting capacity in men was 52.8kg, and in women, 30.2kg (P.001). Thus, sex also was entered as a covariate for lifting capacity analysis. Motivational Factors Table 2 lists mean scores for the 3 PRES subscale and PSEQ scores of 2 groups. The level was divided by 3 for each pairwise comparison to control for type I error (.05/3, P.017). The 3 PRES scores in the MET-plus-PT group were signicantly higher than for the PT group (proxy efcacy, P.001; working alliance, P.001; treatment expectancy, P.011). There was no signicant interaction effect in these 3 subscales. The PSEQ showed no signicant group or interac-

tion effect, although scores in both groups showed signicant increases compared with baseline (within-group effect, P.001). Pain Intensity Table 3 lists VAS scores measured at baseline, session 5, session 10, and 1-month follow-up. VAS scores for both groups showed a signicant decrease over time (within-group effect, P.001), but the group (F0.47, P.50) and interaction effects did not reach signicance. Nevertheless, the METplus-PT group showed a greater VAS score decrease trend than the PT-alone group. In particular, the MET-plus-PT group showed a continuous pain decrease trend from baseline to 1-month follow-up, in which VAS scores decreased from 5.3 to 3.1. The PT group showed an increase in VAS scores at 1-month follow-up. Physical Function No signicant group effect was found in any measurement of range of trunk motion (exion, P.26; extension, P.68; side exion to left and right, P.78 and P.82; rotation to left and right, P.96 and P.24). A signicant interaction effect was found in only the side exion range of motion to the right, in which the MET-plus-PT group had a decrease in distance between third nger tip and the oor; in contrast, the PT group
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MOTIVATIONAL-ENHANCED THERAPY FOR PAIN, Vong Table 2: Comparison of Motivation-Enhancing Factors Between Groups Over Time: Proxy Efcacy, Working Alliance, Treatment Expectancy, and Pain Self-Efcacy
Variable and Assessment Time METPT (n38) PT Alone (n38) 95% CI for Difference Group Effect Interaction Effect

Proxy efcacy Session 1 Session 5 Session 10 Working alliance Session 1 Session 5 Session 10 Treatment expectancy Session 1 Session 5 Session 10 Pain self-efcacy Baseline Session 5 Session 10 1-mo follow-up

3.250.36 3.350.38 3.370.38 3.490.38 3.500.39 3.530.40

2.910.44 3.010.41 3.080.47 3.170.37 3.140.40 3.290.47

0.15 to 0.50

.001*

.61

0.15 to 0.47

.001*

.26

3.360.32 3.380.32 3.380.34 39.459.71 41.588.70 44.429.86 45.378.77

3.200.32 3.240.26 3.190.28 40.4710.24 43.928.68 45.508.70 45.6110.18

0.04 to 0.29

.011*

.60

4.53 to 2.19

.490

.75

NOTE. Values expressed as mean SD unless noted otherwise. Abbreviation: CI, condence interval. *P.0167 (signicant level was divided by number of comparisons). The values of 95% CI for difference, Group effect and Interaction effect represent the results obtained from 2-way repeated-measures ANOVA over different time intervals.

showed an increase in the distance measurement over time (P.007). Both groups improved lifting capacity after the intervention (within-group effect, P.001). After putting baseline lifting capacity and sex as covariates, adjusted lifting capacity showed a signicant group effect: subjects in the MET-plus-PT group showed signicantly greater lifting strength than the PT group (F6.19, P.015) (table 4). It also showed a signicant interaction effect (P.006). Both groups showed a decrease in RMDQ scores over time (within-group effect, P.001), but no signicant group (F.42, P.424) or interaction effect (P.221) was found. However, a greater decrease trend was observed in the METplus-PT group (see table 4). Improvements in all 4 SF-36 physical subscale scores were seen in both groups (all within-group effect, P.05), but only in the SF-36 GH subscale score was there a signicant group difference over time. By entering the baseline GH subscale score as covariate, the adjusted SF-36 GH subscale score for the MET-plus-PT group was higher than for the PT-alone group (F6.21, P.015). No signicant interaction effects were found in the 4 subscales.

Exercise Compliance Subjects in the MET-plus-PT group performed signicantly more frequent home exercise over time (F12.11, P.002). The MET-plus-PT group performed home exercises 2 times more frequently than the PT group in session 10 (MET-plusPT, 13.98.2 vs PT, 6.23.6sessions/wk) and 1-month follow-up (MET-plus-PT, 12.97.2 vs PT, 5.84.1sessions/wk). No signicant interaction (F.614, P.501) or within-group effect (P.436) was found (table 5). DISCUSSION MET is a relatively new intervention used in pain management. Our ndings showed that the addition of MET to conventional PT produced signicantly better motivation outcomes, physical capacities, self-perceived general health, and compliance in performing home exercise than in the PT group. No adverse effect or harm was reported in either group. Of the very few MET-related studies of chronic LBP,20,23,36,46 this is the only one that found signicant motivational outcomes for the comparison of motivational approach and PT or other pain management (eg, general practitioner, nurse, education, active

Table 3: Comparison of VAS Scores Between Groups Over Time

Assessment Time METPT (n38) PT Alone (n38) 95% CI for Difference Group Effect Interaction Effect

Baseline Session 5 Session 10 1-mo follow-up

5.32.2 4.32.0 3.32.1 3.12.1

5.32.0 4.21.8 3.62.4 3.92.5

1.09 to .54*

.50*

.242*

NOTE. Values expressed as mean SD unless noted otherwise. Abbreviation: CI, condence interval. *The values of 95% CI for difference, Group effect and Interaction effect represent the results obtained from 2-way repeated-measures ANOVA over different time intervals.

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MOTIVATIONAL-ENHANCED THERAPY FOR PAIN, Vong Table 4: Comparison of Lifting Capacity and RMDQ Scores Between Groups Over Time
Variable and Assessment Time METPT (n38) PT Alone (n38) 95% CI for Difference Group Effect Interaction Effect

181

Lifting Capacity Baseline Session 5 Session 10 1-mo follow-up RMDQ score Baseline Session 5 Session 10 1-mo follow-up

42.522.4 50.326.6 58.629.6 58.529.0 10.04.3 7.94.2 6.34.8 5.64.5

32.117.5 36.421.2 39.320.9 38.921.3 10.15.5 8.45.4 7.25.6 7.66.4

1.10 to 10.03

.015*

.006

2.83 to 1.44

.517

.221

NOTE. Values expressed as mean SD unless noted otherwise. Baseline lifting capacity and sex were the covariates in the repeated-measures ANOVA for lifting capacity. Abbreviation: CI, condence interval. *P.05. The values of 95% CI for difference, Group effect and Interaction effect represent the results obtained from 2-way repeated-measures ANOVA over different time intervals.

exercise). Of the very few previous studies that examined the effectiveness of integrating the motivational approach with exercise programs,20,23,46 this is the only study that incorporated the motivational approach with a conventional pain PT program that consisted of a electrophysical modality. We showed signicant between-group differences in 3 of 4 motivation-enhancing factors, proxy efcacy, working alliance, and treatment expectancy. At the end of session 1, the MET-plus-PT group already had signicantly higher scores in all PRES subscales (3.253.36) than the PT group (2.913.20), which implies that MET had an effect at the rst treatment session. Satisfactory powers (proxy efcacy, .96; working alliance, .96; treatment expectancy, .73) were shown in these 3 primary outcomes. The small to moderate effect sizes (proxy efcacy, .55; working alliance, .49; treatment expectancy, .26) were similar to those in a previous study.47 In particular, the experimental group showed a higher level of condence in the capability of their therapists, a stronger belief in the outcome of the treatment, and more trust in the therapist, all important motivational factors in enhancing the effects of treatment. However, no signicant group difference was found in selfefcacy measured by using the PSEQ. The observed power was low (0.4) in this outcome. It may be interpreted that subjects in the control group also showed an increase in ability to cope with daily activities through receiving conventional PT. Bandura48 indicated that the most powerful way of enhancing a persons self-efcacy in performing a particular task is to allow that person to have some self-experience of that task. Because both groups made progress during the treatment period, it was not surprising to nd no signicant between-group difference in PSEQ scores.

We showed signicant between-group differences in some secondary outcomes, such as lifting capacity and self-perception of GH measured by using the SF-36. The aim of MET is to motivate patients to make changes to their maladaptive behavior and perform self-management skills to maintain daily functions.9 If patients adhere to these changes, greater improvements can be found in active physical performance and perception of bodily health. Compliance with home exercise reects the extent to which a participant commits to self-management against pain, and this can bring a longer effect. We showed signicantly higher exercise compliance in the MET-plus-PT group. This supports the suggestion by Rollnick et al12 that clinicians should integrate motivational skills in their clinical practice, the aim of which is to guide patients toward favorable behavioral modication for adherence to home exercise, even after the treatment has stopped. This may decrease practitioner visits and the chance of recurrence, which subsequently may decrease health burden and societal costs. We found no signicant group difference in pain intensity, which is consistent with results of a previous study.49 Previous studies showed that biopsychosocial management of musculoskeletal pain tended to be effective in improving physical and psychosocial function, but seemed unable to produce a significant change in the nature or intensity of pain.7,50 Nevertheless, we found that the MET-plus-PT group showed a better trend of pain decrease than the PT-alone group. Because the observed power is low (0.4), it is still premature to conclude that MET has no effect on pain intensity. A larger sample size can be recruited in a future study to investigate the effects of motivational adjunct treatment on pain intensity. Also, no signicant

Table 5: Comparison of Exercise Compliance Between Groups Over Time

Assessment Time METPT PT Alone 95% CI for Difference Group Effect Interaction Effect

Session 5 Session 10 1-mo follow-up

12.88.1 13.98.1 12.97.2

6.83.7 6.23.6 5.84.1

2.9111.23

.002*

.501

NOTE. Values expressed as mean SD unless noted otherwise. Abbreviation: CI, condence interval. *P.01. The values of 95% CI for difference, Group effect and Interaction effect represent the results obtained from 2-way repeated-measures ANOVA over different time intervals.

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between-group difference was found in RMDQ scores. Similar results were found in previous studies that compared RMDQ scores between different exercise treatment groups.51,52 Study Limitations There are several limitations to the present study. We reported follow-up assessments only up to 1 month after treatment cessation. We attempted to record the VASs by using a telephone interview 1 year after treatment cessation. However, the response rate was relatively low (MET-plus-PT group, 57%; PT-alone group, 26%). Therefore, we did not include these data in results. To investigate the long-term effects of MET, longer follow-up for all outcome measures can be used in a future study. Ten subjects in the MET-plus-PT group and 11 subjects in the PT group dropped out of the study during the treatment period. The intention-to-treat method was used to manage their data. Our results may not fully show treatment effects for these people. In addition, we acknowledge that 8 hours of training in MET for physical therapists is shorter than the time recommended by the MI Network of Trainers.53 However, the design of the training and ndings of the present study are similar to those in earlier studies.23,46 In our study, we conducted a 2-week trial to standardize the performance of physical therapists on real patients. This was to ensure that therapists had achieved the requirements needed to attend to each group. We also acknowledge that depression and anxiety are important factors that contribute to chronic pain. Subjects were screened in a formal interview and by checking medical records. People with obvious depression and anxiety problems at the interview or a history of psychiatric problems had been excluded. We assessed subjects baseline physical, psychosocial, and motivational status by using the RMDQ, SF-36, and PSEQ. Baseline score ranges were not extremity high or low. Our ndings may not be able to be generalized to patients who have depression and anxiety problems, and this is a limitation of our study. CONCLUSIONS We found that the integrated MET-plus-PT treatment produced signicantly higher motivational status during the study period than PT-alone for patients with chronic LBP. This integrated intervention also produced signicantly greater improvements in lifting capacity, self-perceived GH, and compliance with exercise up to 1-month follow-up.
Acknowledgments: We thank C.C. Lam and the physical therapists of the outpatient PT department in the Princess Margaret Hospital for support throughout this study. References 1. Jones GT, Macfarlane GJ. Epidemiology of low back pain in children and adolescents. Arch Dis Child 2005;90:312-6. 2. Lind BK, Lafferty WE, Tyree PT, Sherman KJ, Deyo RA, Cherkin DC. The role of alternative medical providers for the outpatient treatment of insured patients with back pain. Spine 2005;30: 1454-9. 3. Deyo RA, Weinstein JN. Primary care: low back pain. N Engl J Med 2001;344:363-70. 4. Andersson GBJ. Epidemiological features of chronic low-back pain. Lancet 1999;354:581-5. 5. Cassidy JD, Cote P, Carroll LJ, Kristman V. Incidence and course of low back pain episodes in the general population. Spine 2005; 30:2817-23. 6. Johnson RE, Jones GT, Wiles NJ, et al. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Spine 2007;32:1578-85.
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