Comparison between patients who completed the CBCLBP programme and those who dropped out of the programme

This study provided some significant baseline difference between patients who completed the programme and those who dropped out. This information may be useful for physiotherapists and managers when screening appropriate NSCLBP patients prior to the CBCLBP programme in their physiotherapy service.

Baseline differences between patients who completed the programme and those who dropped out

A total of n= 70 eligible patients with NSCLBP were initially recruited, with n=

55 (79%) completing the study and all outcome assessments. Patients who dropped out of the programme (i.e. patients who were consented for the programme, but they never attended, or only attended the first session of the programme) (n= 15, 21%) were significantly: (a) of poorer employment status;

(b) of poorer financial status; and (c) possessing a higher level of ELOC. This latter factor suggests that those who dropped out of the programme were significantly more externally orientated, i.e. held the belief that the responsibility for their health was assigned to other people such as medical professionals and families. This is supported by the literature, which suggests that individuals with higher ELOC are less likely to assume responsibility for their health, and are less likely to engage in behavioural involvement such as self-care and active participation in medical care (Wallston & Wallston, 1982;

Koleck et al., 2006).

Comparison to other studies

Dropout from treatment is common problem in CBT management for CLBP (Glombiewski et al., 2010). In the current study, n=15 (21%) consented patients did not attend or only attended the first session of the programme. All remaining patients attended all sessions resulting our study having complete data at each outcome assessment (-4 week, week 1, week 6, 3-months and 6-months) for all the 55 patients. It is suggested that a loss of ≤ 20% follow-up rate is acceptable in RCTs or cohort studies (Fewtrell et al., 2008). With the

CHAPTER 5 Discussion Page 180 present study has no patient dropped out during follow-up, this is considered acceptable and posing no serious threats to validity (Fewtrell et al., 2013).

Compared to other high to moderate quality studies investigating NSCLBP patients in physiotherapy rehabilitation, the dropout rate during follow-up is ranging from 16% to 35% (Woby et al., 2004a; Johnson et al., 2007; Critchley et al., 2007; Woby et al., 2008).

According to qualitative and quantitative evidence, there are many reasons for NSLBP patients to dropout in their rehabilitation. Examples include: patients’

expectation to be provided a specific diagnosis of NSCLBP (Rhodes et al., 1999; Sloots., 2010), wanted medical treatment to cure their pain (Sloots et al., 2009; Sloots et al., 2010), the idea that exercise does not help or aggravates pain (Mailloux et al., 2006), different views on responsibilities with regard to the rehabilitation (e.g. patients expected more responsibilities to be taken by the clinicians) (Sloots et al., 2009), and a lack of trust in the rehabilitation clinician (Sloots et al., 2010).

A lower attrition found in the present study could at least be partially attributed by the successful change of patients’ expectation and beliefs regarding the nature and treatment principle of NSCLBP through the highly-structured programme. The PI and the physiotherapists were acutely aware of the importance of patient skills when delivering the CBCLBP programme (as described in Figure 3.4). Being an active listener, caring, confident, competent and acknowledging patients’ complaints may establish trust and rapport between physiotherapists and patients, which may then result in a higher uptake and adherence to the CBCLBP programme.

Patients who dropped out of the programme were probably those who failed to change, or not ready to change their expectation and beliefs about the NSCLBP.

It must be noted that the group-structured intervention is not universal for all NSCLBP patients, particularly the CBA intervention assumes that individuals are proactive, and places more responsibility on patients and challenges their

CHAPTER 5 Discussion Page 181 expectations about pain management and prognosis (Nordin et al., 2006;

Waddell & Burton, 2005). For instance, it may not make much sense, from the patients’ perspective, to self-care, or be interested in the CBA component if they hold a higher level of ELOC. Therefore, an alternative such as CBT delivered by trained cognitive-behavioural therapists or one-to-one session given by experienced physiotherapist in CBA can be considered for this subgroup of patients with profile characteristics of poor employment and financial status and high ELOC.

Implication for physiotherapists

On the basis of current findings, physiotherapists could consider using assessment of patients’ HLOC as one alternative to reduce dropout rate in their CBCLBP service. More specifically, those with a combination of poorer employment status, poorer financial status and higher ELOC may not be appropriate for a group-structured CBA approach intervention. Physiotherapists could also consider asking questions along the HLOC continuum. Yellow flags assessment questions such as “What do you currently do to help your own back pain?” and “What do you expect and hope to gain from physiotherapists?” are useful starting points to understand patients’ perception of control about their NSCLBP prior to referral onto the group intervention.

Generalizability of included patients

Aside from the baseline differences in employment status, financial status and ELOC, there were no other significant baseline differences between those who completed the programme and those who dropped out of the programme.

The current study targeted NSCLBP patients with high FAB because this sub-group of NSCLBP patients is more likely to benefit from psychological approaches such as CBA intervention (Airaksinen et al., 2006; Savigny et al., 2009). This followed the current physiotherapy practice and NICE guidelines in the UK, which state those patients with significant psychological distress (such as high FAB), disability and failure to respond to other conservative treatments

CHAPTER 5 Discussion Page 182 are recommended to be managed by combined active exercises and CBA treatment (Savigny et al., 2009).