Open Access Highly Accessed Study protocol

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

Chris Lonsdale1*, Amanda M Hall2, Geoffrey C Williams3, Suzanne M McDonough4, Nikos Ntoumanis5, Aileen Murray2 and Deirdre A Hurley2

Author Affiliations

1 School of Science and Health, University of Western Sydney, Locked Bag 1797, Penrith, NSW, 2751, Australia

2 School of Public Health, Physiotherapy, and Population Science, Health Sciences Centre, University College Dublin, Belfield, Dublin 4, Ireland

3 Departments of Medicine, Clinical and Social Sciences in Psychology, Psychiatry, Center of Community Health, University of Rochester, 46 Prince St Suite 3001, Rochester, NY, 14607, USA

4 Health and Rehabilitation Sciences Research Centre, School of Health Sciences, University of Ulster, Ulster, BT37 0QB, UK

5 School of Sport and Exercise Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

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BMC Musculoskeletal Disorders 2012, 13:104  doi:10.1186/1471-2474-13-104

Published: 15 June 2012



Physical activity and exercise therapy are among the accepted clinical rehabilitation guidelines and are recommended self-management strategies for chronic low back pain. However, many back pain sufferers do not adhere to their physiotherapist’s recommendations. Poor patient adherence may decrease the effectiveness of advice and home-based rehabilitation exercises. According to self-determination theory, support from health care practitioners can promote patients’ autonomous motivation and greater long-term behavioral persistence (e.g., adherence to physiotherapists’ recommendations). The aim of this trial is to assess the effect of an intervention designed to increase physiotherapists’ autonomy-supportive communication on low back pain patients’ adherence to physical activity and exercise therapy recommendations.


This study will be a single-blinded cluster randomized controlled trial. Outpatient physiotherapy centers (N =12) in Dublin, Ireland (population = 1.25 million) will be randomly assigned using a computer-generated algorithm to either the experimental or control arm. Physiotherapists in the experimental arm (two hospitals and four primary care clinics) will attend eight hours of communication skills training. Training will include handouts, workbooks, video examples, role-play, and discussion designed to teach physiotherapists how to communicate in a manner that promotes autonomous patient motivation. Physiotherapists in the waitlist control arm (two hospitals and four primary care clinics) will not receive this training. Participants (N = 292) with chronic low back pain will complete assessments at baseline, as well as 1 week, 4 weeks, 12 weeks, and 24 weeks after their first physiotherapy appointment. Primary outcomes will include adherence to physiotherapy recommendations, as well as low back pain, function, and well-being. Participants will be blinded to treatment allocation, as they will not be told if their physiotherapist has received the communication skills training. Outcome assessors will also be blinded.

We will use linear mixed modeling to test between arm differences both in the mean levels and the rates of change of the outcome variables. We will employ structural equation modeling to examine the process of change, including hypothesized mediation effects.


This trial will be the first to test the effect of a self-determination theory-based communication skills training program for physiotherapists on their low back pain patients’ adherence to rehabilitation recommendations.

Trial Registration

Current Controlled Trials ISRCTN63723433

Communication; Motivation; Patient; Low back pain; Disability; Well-being; Adherence; Compliance; Physical therapy; Physiotherapy