Motivation Enhancement Therapy

176

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
Sinfia 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
L OW BACK PAIN islifetime prevalence reason forinvisiting
1,2
a physician. The
the most common
of LBP indus-
trialized countries was approximately 60% to 85%, annual
in people with low back pain: a randomized controlled trial. prevalence ranged from 15% to 45%, and point prevalence
Arch Phys Med Rehabil 2011;92:176-83. averaged 30%.3-5 Recent evidence showed that up to half the
patients visiting a practitioner with a first episode of LBP will
Objectives: To examine whether the addition of motiva- continue to experience pain and disability 3 months later.6
tional enhancement treatment (MET) to conventional physical Exercise and multidisciplinary therapy are being implemented
therapy (PT) produces better outcomes than PT alone in people to reduce both the medical and social burden.6
with chronic low back pain (LBP). The biopsychosocial approach has been successful in reliev-
Design: A double-blinded, prospective, randomized, con- ing pain, improving function, and enhancing the use of self-
trolled trial. management skills for people with LBP.7,8 However, many
Setting: PT outpatient department. patients still prefer to receive passive treatment than actively
Participants: Participants (N 76) with chronic LBP were participate in a biopsychosocial treatment program.9,10
randomly assigned to receive 10 sessions of either MET plus Motivation influences people in their initiation, intensity,
PT or PT alone. and performance of a behavior (eg, exercise self-management)
Intervention: MET included motivational interviewing and affects treatment outcomes in terms of pain relief or
strategies and motivation-enhancing factors. The PT program functional improvement.10-15 MI is a client-centered counsel-
consisted of interferential therapy and back exercises. ing technique that aims to improve the motivation and com-
Main Outcome Measures: Motivational-enhancing factors, mitment of clients to achieving behavioral changes.16 There are
pain intensity, physical functions, and exercise compliance. 4 main principles in MI: (1) expressing accurate empathy, (2)
Results: The MET-plus-PT group produced significantly developing discrepancy, (3) avoiding argumentation and roll-
greater improvements than the PT group in 3 motivation- ing with resistance, and (4) supporting self-efficacy.10,17,18
enhancing factors; proxy efficacy (P .001), working alliance Particular MI strategies for pain management are divided into
(P .001), and treatment expectancy (P .011). Further- 3 phases, enhancing, strengthening, and maintaining behavioral
more, they performed significantly better in lifting capacity changes according to the transtheoretical (stages of change)
(P .015), 36-Item Short Form Health Survey General Health model.10,19
subscale (P .015), and exercise compliance (P .002) than the Very few studies have examined MI in association with a PT
PT group. A trend of a greater decrease in visual analog scale program for patients with LBP, and no study has found a
and Roland-Morris Disability Questionnaire scores also was significant increase in motivation measures after treatment.
found in the MET-plus-PT group than the PT group. Although motivation-based treatment often is provided by clin-
Conclusion: The addition of MET to PT treatment can ical and rehabilitation psychologists, studies of its effects in
effectively enhance motivation and exercise compliance and other areas of the medical profession, such as PT, have been
show better improvement in physical function in patients with very limited.20-24 Friedrich et al20,25 compared the effects of a
chronic LBP compared with PT alone. combined exercise and motivation program delivered by phys-
Key Words: Low back pain; Motivation; Physical therapy; ical therapists to people with chronic LBP with those of an
Rehabilitation. exercise program alone. Their results showed that the com-
© 2011 by the American Congress of Rehabilitation
Medicine

List of Abbreviations

ANCOVA analysis of covariance
From the Department of Rehabilitation Sciences, The Hong Kong Polytechnic GH General Health
University, Hong Kong Special Administrative Region, China (Vong, Cheing, C.C.
LBP low back pain
Chan); Department of Rehabilitation Psychology and Special Education, University
of Wisconsin, Madison, WI (F. Chan); and Physiotherapy Department, Princess MET motivational enhancement therapy
Margaret Hospital, Hong Kong Special Administrative Region, China (So). MI motivational interviewing
No commercial party having a direct financial interest in the results of the research PRES Pain Rehabilitation Expectations Scale
supporting this article has or will confer a benefit on the authors or on any organi-
PSEQ Pain Self-Efficacy Questionnaire
zation with which the authors are associated.
Reprint requests to Gladys L. Cheing, PhD, Dept of Rehabilitation Sciences, The PT physical therapy
Hong Kong Polytechnic University, Hung Hom, Kowloon, HKSAR, China, e-mail: RMDQ Roland-Morris Disability Questionnaire
rsgladys@inet.polyu.edu.hk. SF-36 36-Item Short-Form Health Survey
0003-9993/11/9202-00275$36.00/0 VAS visual analog scale
doi:10.1016/j.apmr.2010.10.016

Arch Phys Med Rehabil Vol 92, February 2011

MOTIVATIONAL-ENHANCED THERAPY FOR PAIN, Vong 177

bined program led to a significantly greater decrease in pain research committee of a local university and a local hospital.
intensity and disability than the exercise program, but no Written consent was obtained from each subject.
significant differences were found in measures of motivation A pilot study was performed before the study to verify the
(ie, distress, internal locus of control, attitude toward exercise). validity of MET for patients with pain. MET content first was
The treatment protocol for their study involved only exercise, developed based on MI strategies and a review of the research
with no pain-relieving modality. The lack of significant find- literature for motivation-enhancing factors.10,29-33 People with
ings in motivation measures could be explained in part because pain (n 30) and pain experts (n 8) rated the MET program
patients experiencing severe pain were poorly motivated to content, and it was modified based on their comments. The
engage in exercise. Basler et al23 examined the effects of finalized MET contents were used in MET training for thera-
incorporating counseling based on the transtheoretical model pists. Eight-hour training then was provided to the involved
with exercise for people with LBP. Both groups received physical therapists before the study. Six physical therapists
exercise therapy prescribed by physical therapists. The exper- (average, 14.1y of clinical experience) participated in the pres-
imental group also received counseling, whereas the control ent study. They were randomly divided into either the MET-
group received a placebo ultrasound treatment. The study plus-PT or PT group by drawing a lot from a sealed envelope.
showed that both groups experienced some improvement in In particular, specific MET skill training was provided to
physical capacity, but the difference between groups did not therapists involved in the MET-plus-PT group, whereas the PT
reach significance. Escolar-Reina et al24 showed an observa- group received general communication skill training. Thera-
tional study that pain self-management training combined with pists were asked not to discuss concepts related to their training
PT was associated with better adherence to pain self-manage- with other therapists. A clinical psychologist provided MET or
ment in people with LBP and neck pain. general communication skills training. After training, all phys-
Based on the very limited studies in this area and limitations ical therapists practiced the required skills on their patients
in study design (eg, no control group or lack of a sensitive with pain for 2 weeks. An investigator who had received MI
instrument to assess motivational outcomes), no significant and counseling training observed and evaluated the quality of
findings associated with MI and PT treatment have been re- the therapist’s communication with their patients by using a
ported. With the recent development and psychometric valida- checklist. A 5-point MET strategy scale was used to count the
tion of the PSEQ26 and PRES,27 it is possible to conduct better frequency of using the strategy in 1 practical session as fol-
motivational studies in PT research. lows: 0 indicates did not use any MET strategy (0%); 1, rarely
In addition, exercise compliance, pain level, and functional used (25%); 2, occasionally used (50%); 3, frequently used
capacity were common outcome measures in motivational (75%); and 4, used MET strategies most of the time in a session
studies.20,23,28 Physical therapists have an important role in ( 90%). Results showed that therapists in the MET-plus-PT
decreasing pain, enhancing physical function, and teaching group had a mean score of 2 or 3, indicating that MET strat-
self-coping skills to patients. These treatments aim to foster the egies were adopted greater than 50% of the time in their
development of pain coping behavior, decrease the recurrence practical sessions. Those in the PT group had a mean score of
of pain symptoms, and decrease the frequency of medical 0 or 1, indicating that they did not use or rarely adopted MET
treatment. MI aims to strengthen the intention of people with strategies in their treatment sessions. Performance of the ther-
LBP to engage in treatment and take action to cope with pain. apists conformed to the requirements of their respective
Integrating MET, an adaptation of MI techniques, into PT groups.
potentially may enhance the effectiveness of conventional
treatments. Therefore, the aim of the present study was to Conventional PT
examine whether the addition of MET to conventional PT
All subjects received ten 30-minute PT sessions in 8 weeks,
would produce better outcomes for motivational status, pain
which included 15 minutes of interferential therapy and a
intensity, physical function, and exercise compliance than PT
tailor-made back exercise program. Interferential therapy is
alone for people with chronic LBP.
one of the most frequently used electrophysical modalities in
clinical settings.34,35 Four interferentiala suction electrodes
METHODS 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
Participants 100Hz, and intensity was set at a moderate tingling sensation.
People with chronic LBP were recruited consecutively from Therapists conducted a thorough physical assessment for each
a local outpatient PT department. Inclusion criteria were people patient. Based on assessment results, they prescribed a specific
aged 18 to 65 years for whom LBP had been diagnosed for at set of exercises adopted from an exercise booklet with detailed
least 3 months. Exclusion criteria were people who were preg- descriptions of stretching and strengthening exercises for the
nant or had a cardiac pacemaker, pain from neurologic disor- trunk and lower limbs (eg, pelvic tilt, trunk rotation in a
ders or rheumatologic disease, consistent symptoms of sciatica, crook-lying position, stretching hamstrings and back muscle,
spondylolisthesis more than lcm, received PT for LBP in the strengthening abdominal and back muscles). The patient’s ex-
past 3 months, psychiatric problems, or received compensation ercise performance was monitored during treatment sessions to
for work-related disabilities. ensure that these exercises were performed correctly. Exercises
also were prescribed as home exercises, and patients were
Design requested to exercise daily.
Subjects and the assessor were blinded for group allocation.
All subjects were randomly assigned to either (1) the integrated Motivational Enhancement Therapy
MET-plus-PT group or (2) the PT-alone group by using a During PT sessions, subjects in the experimental group re-
computerized randomization table generated by a third party. ceived MET from their respective physical therapists, who
Subjects were told that they would receive either 1 of the 2 integrated MI skills and several psychosocial components de-
types of conventional PT treatment. They did not know any- signed to enhance the motivation of subjects to engage in
thing about MET. Ethical approval was obtained from the treatment and make appropriate behavioral changes. MI strat-


178 MOTIVATIONAL-ENHANCED THERAPY FOR PAIN, Vong

egies for pain management were recommended by Jensen.10 cal, Bodily Pain, GH) of the SF-36 were used to measure
One psychosocial factor relevant to the motivational approach self-perceived physical status, which is commonly used to
is proxy efficacy. It refers to patients’ confidence in their assess people with LBP.45
therapists’ ability to function effectively on their behalf.29 It Secondary outcomes: exercise compliance. The frequency
correlated with self-efficacy in rehabilitation programs.30,31 of practicing the prescribed home exercises was recorded in an
Treatment expectancy refers to belief in the consequences of exercise log book in both groups. Exercise compliance was
performing a behavior, which helps boost patients’ motivation computed by how many sessions of home exercise subjects had
in exerting self-control to pursue a goal, take action, and persist performed in a day multiplied by how many days they had
in adhering to specific behavior.31,32,36 Working alliance refers practiced in a week.20,23,28 We measured exercise compliance
to a therapeutic relationship built between the patient and in sessions instead of minutes.
therapist.33 Dummy MET included general communication
skills, but deliberately removed the MET element and avoided Data Analysis
adopting counseling-related skills. Therapists in the PT group All data analyses were performed using the Statistical Pack-
adopted the usual communication manner with patients in age for the Social Sciencesb. A series of 2-way repeated-
clinical practice. Treatment time for both groups was kept measures ANCOVA was computed to compare mean differ-
within 30 minutes. ences between the MET-plus-PT and PT groups, within groups,
and the interaction effect over assessment periods for 4 out-
Outcome Measures come variables (motivational factors, pain intensity, physical
All outcome measures except for the PRES and exercise function, exercise compliance). Sex, baseline lifting capacity,
compliance were assessed before treatment session 1, after and SF-36 GH score were entered as covariates. All analyses
treatment sessions 5 and 10, and 1 month after cessation of were calculated by using an intention-to-treat approach. Any
treatment. The PRES was assessed right after sessions 1, 5, and missing data at posttreatment sessions were replaced according
10, and exercise compliance was recorded in sessions 5 and 10 to the last-observation-carried-forward procedure. Level of sta-
and at the 1-month follow-up. tistical significance was set at P equals .05. Comparing group
Primary outcome: motivational status. Motivational sta- differences for outcome variables by using several subscales
tus was assessed using the PRES and PSEQ. The PRES con- (eg, 3 subscales of the PRES), level was divided by the
sists of 35 treatment- and/or therapist-oriented items measured number of comparisons to control for type I error.
using a 4-point Likert scale (1 strongly disagree to 4
strongly agree). These items are grouped under the 3 subscales RESULTS
of proxy efficacy, working alliance, and treatment expectancy,
Baseline Characteristics
and the mean value for each subscale score was calculated. The
instrument has been reliable in measuring motivation and ex- Eligible patients (N 88) initially were recruited for the
pectations of patients regarding pain rehabilitation.28 The present study and were randomly assigned to either the MET-
PSEQ consists of 10 self-reported questions that measure sub-
jects’ self-efficacy beliefs about performing activities despite
experiencing pain by using a 7-point Likert scale (0 not at all
confident to 6 completely confident).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 la-
beled “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 flexion, extension, side flexion, rotation)
was tested according to procedures recommended by Clark-
son.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 flexed. 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 estab- Fig 1. The Consolidated Standards of Reporting Trials flow diagram
lished.43,44 Physical subscales (Physical Function, Role–Physi- of the study.



Table 1: Demographic Characteristics of Subjects
MET PT PT Group
Characteristic Group (n 38) (n 38) P

Age (y) 44.6 11.2 45.1 10.7 0.85
Sex 0.48*
Women 22 26
Men 16 12
Body mass index (kg/m2) 24.3 4.67 23.8 3.2 0.58
LBP duration (mo) 41.6 56.8 51.0 71.5 0.53
Subjects with recurrent LBP 8 13 0.31*
Subjects had previous PT 6 11 0.27*
Subjects had regular analgesia 12 11 1.00*
Baseline outcome measures
VAS score 5.3 2.2 5.3 2.0 0.99
Lifting capacity (kg) 42.46 22.40 32.14 17.54 0.029
RMDQ score 10.0 4.31 10.05 5.54 0.96
Range of motion
Flexion (cm) 18.92 1.25 18.64 1.13 0.30
Extension (cm) 13.37 0.75 13.18 0.76 0.28
Side flexion (cm)
Right 48.96 5.47 47.00 5.53 0.12
Left 49.27 5.99 47.94 5.86 0.33
Rotation (°)
Right 62.54 21.97 61.72 19.36 0.86
Left 59.38 19.08 62.42 19.84 0.50
SF-36 physical subscales
Physical Function 67.37 16.84 63.29 18.39 0.32
Role–Physical 22.37 26.50 29.61 36.23 0.32
Bodily Pain 33.29 15.37 33.16 16.12 0.97
GH 40.61 17.42 49.37 20.27 0.047
PSEQ score 39.45 9.71 40.47 10.24 0.66

NOTE. Values expressed as mean SD or n. Range of motion in flexion and extension: distance between a point 15cm above the midpoint
of the line connecting the posterior superior iliac spines. The subject flexed the trunk forward to the pain-free limit of motion for lumbar flexion
and extended the trunk backward to the pain-free limit of motion for lumbar extension. Range of motion in side flexion: distance measured
between the tip of the third digit and the floor. The subject flexed 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 (n 45) or PT group (n 43). However, before the tion effect, although scores in both groups showed significant
study began, 12 patients refused to participate for medical increases compared with baseline (within-group effect,
reasons or time conflicts. No significant differences for demo- P .001).
graphic data were found between dropout subjects and partic-
ipants. Therefore, 76 subjects participated in the present study Pain Intensity
(fig 1). Their baseline characteristics are listed in table 1. No Table 3 lists VAS scores measured at baseline, session 5,
significant differences were found between the 2 groups for session 10, and 1-month follow-up. VAS scores for both
demographic data and most baseline measurements, with the groups showed a significant decrease over time (within-group
exception of lifting capacity and SF-36 GH subscale. Baseline effect, P .001), but the group (F 0.47, P .50) and interac-
values for lifting capacity and SF-36 GH were treated as tion effects did not reach significance. Nevertheless, the MET-
covariates of that of posttreatment outcomes when performing plus-PT group showed a greater VAS score decrease trend than
repeated-measures ANCOVA. Lifting capacity also had a sig- the PT-alone group. In particular, the MET-plus-PT group
nificant sex difference. Lifting capacity in men was 52.8kg, and showed a continuous pain decrease trend from baseline to
in women, 30.2kg (P .001). Thus, sex also was entered as a 1-month follow-up, in which VAS scores decreased from 5.3 to
covariate for lifting capacity analysis. 3.1. The PT group showed an increase in VAS scores at
1-month follow-up.
Motivational Factors
Table 2 lists mean scores for the 3 PRES subscale and PSEQ Physical Function
scores of 2 groups. The level was divided by 3 for each No significant group effect was found in any measurement of
pairwise comparison to control for type I error ( .05/3, range of trunk motion (flexion, P .26; extension, P .68; side
P .017). The 3 PRES scores in the MET-plus-PT group were flexion to left and right, P .78 and P .82; rotation to left and
significantly higher than for the PT group (proxy efficacy, right, P .96 and P .24). A significant interaction effect was
P .001; working alliance, P .001; treatment expectancy, found in only the side flexion range of motion to the right, in
P .011). There was no significant interaction effect in these 3 which the MET-plus-PT group had a decrease in distance
subscales. The PSEQ showed no significant group or interac- between third finger tip and the floor; in contrast, the PT group



Table 2: Comparison of Motivation-Enhancing Factors Between Groups Over Time: Proxy Efficacy, Working Alliance, Treatment
Expectancy, and Pain Self-Efficacy
Variable and MET PT PT Alone 95% CI for Group Interaction
Assessment Time (n 38) (n 38) Difference Effect Effect

Proxy efficacy
Session 1 3.25 0.36 2.91 0.44 0.15 to 0.50 .001*† .61
Session 5 3.35 0.38 3.01 0.41
Session 10 3.37 0.38 3.08 0.47
Working alliance
Session 1 3.49 0.38 3.17 0.37 0.15 to 0.47 .001*† .26
Session 5 3.50 0.39 3.14 0.40
Session 10 3.53 0.40 3.29 0.47
Treatment
expectancy
Session 1 3.36 0.32 3.20 0.32 0.04 to 0.29 .011*† .60
Session 5 3.38 0.32 3.24 0.26
Session 10 3.38 0.34 3.19 0.28
Pain self-efficacy
Baseline 39.45 9.71 40.47 10.24 4.53 to 2.19 .490† .75
Session 5 41.58 8.70 43.92 8.68
Session 10 44.42 9.86 45.50 8.70
1-mo follow-up 45.37 8.77 45.61 10.18

NOTE. Values expressed as mean SD unless noted otherwise.
Abbreviation: CI, confidence interval.
*P .0167 (significant 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 Exercise Compliance
(P .007). Subjects in the MET-plus-PT group performed significantly
Both groups improved lifting capacity after the intervention more frequent home exercise over time (F 12.11, P .002).
(within-group effect, P .001). After putting baseline lifting The MET-plus-PT group performed home exercises 2 times
capacity and sex as covariates, adjusted lifting capacity showed more frequently than the PT group in session 10 (MET-plus-
a significant group effect: subjects in the MET-plus-PT group PT, 13.9 8.2 vs PT, 6.2 3.6sessions/wk) and 1-month fol-
showed significantly greater lifting strength than the PT group low-up (MET-plus-PT, 12.9 7.2 vs PT, 5.8 4.1sessions/wk).
(F 6.19, P .015) (table 4). It also showed a significant inter- No significant interaction (F .614, P .501) or within-group
action effect (P .006). effect (P .436) was found (table 5).
Both groups showed a decrease in RMDQ scores over time
(within-group effect, P .001), but no significant group
(F .42, P .424) or interaction effect (P .221) was found. DISCUSSION
However, a greater decrease trend was observed in the MET- MET is a relatively new intervention used in pain manage-
plus-PT group (see table 4). ment. Our findings showed that the addition of MET to con-
Improvements in all 4 SF-36 physical subscale scores were ventional PT produced significantly better motivation out-
seen in both groups (all within-group effect, P .05), but only comes, physical capacities, self-perceived general health, and
in the SF-36 GH subscale score was there a significant group compliance in performing home exercise than in the PT group.
difference over time. By entering the baseline GH subscale No adverse effect or harm was reported in either group. Of the
score as covariate, the adjusted SF-36 GH subscale score for very few MET-related studies of chronic LBP,20,23,36,46 this is
the MET-plus-PT group was higher than for the PT-alone the only one that found significant motivational outcomes for
group (F 6.21, P .015). No significant interaction effects the comparison of motivational approach and PT or other pain
were found in the 4 subscales. management (eg, general practitioner, nurse, education, active

Table 3: Comparison of VAS Scores Between Groups Over Time
MET PT PT Alone 95% CI for Group Interaction

Baseline 5.3 2.2 5.3 2.0 1.09 to .54* .50* .242*
Session 5 4.3 2.0 4.2 1.8
Session 10 3.3 2.1 3.6 2.4
1-mo follow-up 3.1 2.1 3.9 2.5

*The values of 95% CI for difference, Group effect and Interaction effect represent the results obtained from 2-way repeated-measures ANOVA



Table 4: Comparison of Lifting Capacity and RMDQ Scores Between Groups Over Time
Variable and MET PT PT Alone 95% CI for Group Interaction

Lifting Capacity
Baseline 42.5 22.4 32.1 17.5 1.10 to 10.03† .015*† .006†
Session 5 50.3 26.6 36.4 21.2
Session 10 58.6 29.6 39.3 20.9
1-mo follow-up 58.5 29.0 38.9 21.3
RMDQ score
Baseline 10.0 4.3 10.1 5.5 2.83 to 1.44† .517† .221†
Session 5 7.9 4.2 8.4 5.4
Session 10 6.3 4.8 7.2 5.6
1-mo follow-up 5.6 4.5 7.6 6.4

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.
*P .05.
†

exercise). Of the very few previous studies that examined the We showed significant between-group differences in some
effectiveness of integrating the motivational approach with secondary outcomes, such as lifting capacity and self-percep-
exercise programs,20,23,46 this is the only study that incorpo- tion of GH measured by using the SF-36. The aim of MET is
rated the motivational approach with a conventional pain PT to motivate patients to make changes to their maladaptive
program that consisted of a electrophysical modality. behavior and perform self-management skills to maintain daily
We showed significant between-group differences in 3 of 4 functions.9 If patients adhere to these changes, greater im-
motivation-enhancing factors, proxy efficacy, working alli- provements can be found in active physical performance and
ance, and treatment expectancy. At the end of session 1, the perception of bodily health.
MET-plus-PT group already had significantly higher scores in Compliance with home exercise reflects the extent to which
all PRES subscales (3.25–3.36) than the PT group (2.91–3.20), a participant commits to self-management against pain, and
which implies that MET had an effect at the first treatment this can bring a longer effect. We showed significantly higher
session. Satisfactory powers (proxy efficacy, .96; working al- exercise compliance in the MET-plus-PT group. This supports
liance, .96; treatment expectancy, .73) were shown in these 3 the suggestion by Rollnick et al12 that clinicians should inte-
primary outcomes. The small to moderate effect sizes (proxy grate motivational skills in their clinical practice, the aim of
efficacy, .55; working alliance, .49; treatment expectancy, .26) which is to guide patients toward favorable behavioral modi-
were similar to those in a previous study.47 In particular, the fication for adherence to home exercise, even after the treat-
experimental group showed a higher level of confidence in the ment has stopped. This may decrease practitioner visits and the
capability of their therapists, a stronger belief in the outcome of chance of recurrence, which subsequently may decrease health
the treatment, and more trust in the therapist, all important burden and societal costs.
motivational factors in enhancing the effects of treatment. We found no significant group difference in pain intensity,
However, no significant group difference was found in self- which is consistent with results of a previous study.49 Previous
efficacy measured by using the PSEQ. The observed power studies showed that biopsychosocial management of musculo-
was low ( 0.4) in this outcome. It may be interpreted that skeletal pain tended to be effective in improving physical and
subjects in the control group also showed an increase in ability psychosocial function, but seemed unable to produce a signif-
to cope with daily activities through receiving conventional PT. icant change in the nature or intensity of pain.7,50 Nevertheless,
Bandura48 indicated that the most powerful way of enhancing we found that the MET-plus-PT group showed a better trend of
a person’s self-efficacy in performing a particular task is to pain decrease than the PT-alone group. Because the observed
allow that person to have some self-experience of that task. power is low ( 0.4), it is still premature to conclude that MET
Because both groups made progress during the treatment pe- has no effect on pain intensity. A larger sample size can be
riod, it was not surprising to find no significant between-group recruited in a future study to investigate the effects of motiva-
difference in PSEQ scores. tional adjunct treatment on pain intensity. Also, no significant

Table 5: Comparison of Exercise Compliance Between Groups Over Time
95% CI for Group Interaction
Assessment Time MET PT PT Alone Difference Effect Effect

Session 5 12.8 8.1 6.8 3.7 2.91–11.23† .002*† .501†
Session 10 13.9 8.1 6.2 3.6
1-mo follow-up 12.9 7.2 5.8 4.1

*P .01.
†



between-group difference was found in RMDQ scores. Similar 7. Gohner W, Schlicht W. Preventing chronic back pain: evaluation
results were found in previous studies that compared RMDQ of a theory-based cognitive-behavioral training programme for
scores between different exercise treatment groups.51,52 patients with subacute back pain. Patient Educ Couns 2006;64:
87-95.
Study Limitations 8. Hildebrandt J, Pfingsten M, Saur P, Jensen J. Prediction of success
There are several limitations to the present study. We re- from a multidisciplinary treatment program for chronic low back
ported follow-up assessments only up to 1 month after treat- pain. Spine 1997;22:990-1001.
ment cessation. We attempted to record the VASs by using a 9. Heapy AA, Stroud MW, Higgins DM, Sellinger JJ. Tailoring
telephone interview 1 year after treatment cessation. However, cognitive-behavioral therapy for chronic pain: a case example.
the response rate was relatively low (MET-plus-PT group, J Clin Psychol 2006;62:1345-54.
57%; PT-alone group, 26%). Therefore, we did not include 10. Jensen MP. Enhancing motivation to change in pain treatment. In:
these data in results. To investigate the long-term effects of Turk DC, Gatchel RJ, editors. Psychological approaches to pain
MET, longer follow-up for all outcome measures can be used management: a practitioner’s handbook. 2nd ed. New York: Guil-
in a future study. Ten subjects in the MET-plus-PT group and ford Pr; 2002. p 71-93.
11 subjects in the PT group dropped out of the study during the 11. Geen RG. Introduction to the study of motivation. Belmont, CA:
treatment period. The intention-to-treat method was used to Brooks/Cole Publishing Co, a division of Wadsworth Inc; 1995. p
manage their data. Our results may not fully show treatment 1-2.
effects for these people. In addition, we acknowledge that 8
12. Rollnick S, Miller WR, Butler CC. Motivational interviewing in
hours of training in MET for physical therapists is shorter than
health care: helping patients change behavior. New York: Guil-
the time recommended by the MI Network of Trainers.53
However, the design of the training and findings of the present ford Pr; 2008.
study are similar to those in earlier studies.23,46 In our study, we 13. Asghari A, Nicholas MK. Pain self-efficacy beliefs and pain
conducted a 2-week trial to standardize the performance of behavior. A prospective study. Pain 2001;94:85-100.
physical therapists on real patients. This was to ensure that 14. Meredith P, Strong J, Feeney JA. Adult attachment, anxiety, and
therapists had achieved the requirements needed to attend to pain self-efficacy as predictors of pain intensity and disability.
each group. We also acknowledge that depression and anxiety Pain 2006;123:146-54.
are important factors that contribute to chronic pain. Subjects 15. Jensen MP, Nielson WR, Kerns RD. Toward the development of
were screened in a formal interview and by checking medical a motivational model of pain self-management. J Pain 2003;4:
records. People with obvious depression and anxiety problems 477-92.
at the interview or a history of psychiatric problems had been 16. Miller WR. Motivational interviewing with problem drinkers.
excluded. We assessed subjects’ baseline physical, psychoso- Behav Psychother 1983;11:147-72.
cial, and motivational status by using the RMDQ, SF-36, and 17. Eccles JS, Wigfield A. Motivational beliefs, values, and goals.
PSEQ. Baseline score ranges were not extremity high or low. Annu Rev Psychol 2002;53:109-32.
Our findings may not be able to be generalized to patients who 18. Rollnick S, Miller WR. What is motivational interviewing? Behav
have depression and anxiety problems, and this is a limitation Cogn Psychother 1995;23:325-34.
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CONCLUSIONS Consult Clin Psychol 1983;51:390-5.
20. Friedrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I. Combined
We found that the integrated MET-plus-PT treatment pro- exercise and motivation program: effect on the compliance and level
duced significantly higher motivational status during the study of disability of patients with chronic low back pain: a randomized
period than PT-alone for patients with chronic LBP. This controlled trial. Arch Phys Med Rehabil 1998;79:475-87.
integrated intervention also produced significantly greater im- 21. Burke BL, Arkowitz A, Menchola M. The efficacy of motivational
provements in lifting capacity, self-perceived GH, and compli- interviewing: a meta-analysis of controlled clinical trials. J Con-
ance with exercise up to 1-month follow-up. sult Clin Psychol 2003;71:843-61.
22. Hettema J, Steele J, Miller WR. Motivational interviewing. Annu
Acknowledgments: We thank C.C. Lam and the physical thera-
pists of the outpatient PT department in the Princess Margaret Hospital Rev Clin Psychol 2005;1:91-111.
for support throughout this study. 23. Basler HD, Bertalanffy H, Quint S, Wilke A, Wolf U. TTM-based
counselling in physiotherapy does not contribute to an increase of
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