Feasibility of Training Physical Therapists to Deliver the Theory-Based Self-Management of Osteoarthritis and Low Back Pain Through Activity and Skills (SOLAS) Intervention Within a Trial

Feasibility of Training Physical Therapists to Deliver the Theory-Based Self-Management of... Abstract Background Provider training programs are frequently underevaluated, leading to ambiguity surrounding effective intervention components. Objective The purpose of this study was to assess the effectiveness of a training program in guiding physical therapists to deliver the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) group education and exercise intervention (ISRCTN49875385), using a communication style underpinned by self–determination theory (SDT). Design This was an assessment of the intervention arm training program using quantitative methods. Methods Thirteen physical therapists were trained using mixed methods to deliver the SOLAS intervention. Training was evaluated using the Kirkpatrick model: (1) Reaction—physical therapists’ satisfaction with training, (2) Learning—therapists’ confidence in and knowledge of the SDT-based communication strategies and intervention content and their skills in applying the strategies during training, and (3) Behavior—8 therapists were audio-recorded delivering all 6 SOLAS intervention classes (n = 48), and 2 raters independently coded 50% of recordings (n = 24) using the Health Care Climate Questionnaire (HCCQ), the Controlling Coach Behavior Scale (CCBS), and an intervention-specific measure. Results Reaction: Physical therapists reacted well to training (median [IRQ]; min-max = 4.7; [0.5]; 3.7–5.0). Learning: Physical therapists’ confidence in the SDT-based communication strategies and knowledge of some intervention content components significantly improved. Behavior: Therapists delivered the intervention in a needs-supportive manner (median HCCQ = 5.3 [1.4]; 3.9–6.0; median CCBS = 6.6 ([0.5]; 6.1–6.8; median intervention specific measure = 4.0 [1.2]; 3.2–4.9). However, “goal setting” was delivered below acceptable levels by all therapists (median 2.9 [0.9]; 2.0–4.0). Limitations The intervention group only was assessed as part of the process evaluation of the feasibility trial. Conclusions Training effectively guided physical therapists to be needs-supportive during delivery of the SOLAS intervention. Refinements were outlined to improve future similar training programs, including greater emphasis on goal setting. Behavior change interventions are increasingly implemented within health care to promote positive health behaviors.1 Health care providers (HCPs), including physical therapists, should have the knowledge, skills, and confidence to deliver these interventions effectively. Therefore, to promote effectively implemented interventions, physical therapists should be trained appropriately, and the effects of this training evaluated, to ensure they are competent to deliver programs as intended and to optimize intervention effectiveness.2 Medical Research Council (MRC) guidelines recommend process evaluations to assess the fidelity to, and implementation of, intervention components to understand how variables such as study design, provider training, and provider delivery have influenced outcomes.3,4 The need to evaluate provider training is well recognized, yet frequently unreported.5,6 It therefore remains unclear whether HCP training programs effectively alter HCP behavior long-term, or whether they lead to effective patient outcomes.7 Within physical therapist interventions specifically, limitations include not reporting how therapists were trained;8,9 not directly assessing training effectiveness;10 and using physical therapist researchers to deliver interventions, thus limiting the potential for future implementation in real-world settings.11 Fidelity guidelines suggest that following training, providers should be competent to deliver the intervention.12 However, competence is poorly defined, making it difficult to judge training effectiveness, as no minimum acceptable threshold has been agreed upon.13,14 A number of frameworks exist to support researchers developing and reporting training programs, although few offer guidance on how to evaluate their effectiveness.15 The Kirkpatrick model is one of the few to suggest methods of training evaluation16 that offers a systematic, simple assessment guide across 4 levels; that is, reaction, learning, behavior, and results. The model's strength is its aim to evaluate both the acute (immediately posttraining) and long-term effects of training (HCPs’ behavior in practice), rendering it a strong framework on which to evaluate training17 and one that is increasingly being used in health care settings including physical therapist training assessments.18–20 Self-Determination Theory in Health Care Health care interventions increasingly promote the importance of patient autonomy for successful treatment outcomes.21 Autonomy is a core principle of self-determination theory (SDT),22 which posits that social agents can influence a person's autonomous motivation, and ultimately their behavior, through the HCPs communication style and interaction with the person. This represents HCPs using a communication style that supports a patient's basic needs for autonomy, competence, and relatedness, leading to increased levels of autonomous motivation for the behavior. Strategies that support this include collaborative goal setting; the provision of positive and information-rich feedback; and acknowledging a patient's feelings and perspectives.23–25 However, communication styles can also thwart a patient's basic needs, leading to decreased levels of autonomous motivation through the use of pressurizing language; and ignoring a patient's input or suggestions and providing praise based on a patient's achievement of a behavior rather than their effort toward the behavior.26 While a communication style that supports patients’ basic needs (ie, needs-supportiveness) has been previously demonstrated as effective by physical therapists in individual physical therapy,9,27,28 and in group-based education and exercise interventions,25,29,30 its use in group-based physical therapy has yet to be reviewed. Study Context: The SOLAS Intervention Consequently, this study took place within the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) cluster randomized controlled feasibility trial (ISRCTN49875385),31,32 which compared a group-based intervention designed to increase self-management behaviors in participants with osteoarthritis and chronic low back pain to usual individual physical therapy care. The intervention comprised a 6-week, once-weekly 90-minute class underpinned by SDT.23 Physical therapists delivered 45 minutes of education composed of small-group lectures and informal discussions around different self-management topics each week (ie, physical activity; specific exercises; pain-coping strategies; pacing; healthy eating for lifestyle and balanced weight; pain management approaches including medication). This was followed by 45 minutes of supervised exercises with physical therapist guidance on exercise selection. Physical therapists were trained to deliver the SOLAS intervention.31,32 Therefore, building on the need for theory-based interventions delivered by competent practitioners, the aim of the current study was to evaluate the feasibility of this training in effectively guiding physical therapists to implement the SOLAS intervention using the required communication style. Methods Thirteen consenting physical therapists from 7 primary care clinics in Dublin/Kildare, Ireland, received 2 days of training in the content and delivery of the SOLAS intervention, including 8 hours of training in 9 SDT-based communication strategies (Tab. 1). Training effectiveness was assessed using the Kirkpatrick model of evaluation across the levels of reaction, learning, and behavior (defined within Tab. 2).21 Table 1. The SOLAS Intervention Physical Therapist (PT) Training Programa   Component 1: SOLAS Intervention Content  Component 2: SDT-Based 
Communication Strategies  Component 3: Interactive Activities  Description  The aims and objectives of the SOLAS intervention and the PT training program were outlined. The content of each SOLAS intervention class was discussed individually, with key elements emphasized. SOLAS intervention exercises were demonstrated and discussed with the PTs. The PTs discussed barriers and enablers to the delivery of the SOLAS intervention within their environment, and considered methods to overcome barriers where possible.  Self-determination theory was introduced, 
including a rationale for its use within this population. The concept of needs–supportive and needs-thwarting communication style was introduced and each of the SDT-based communication strategies were outlined. Video examples of ineffective use of these strategies were provided. The PTs reflected and discussed how these strategies may be delivered in a needs–supportive manner, before being shown video examples of the effective use of 
these strategies.  Individual role-play exercises were used to support PTs’ practice of the SDT-based communication strategies learned. Physical therapists delivered part of a SOLAS class during micro-teaching activities. Fellow PT participants and expert facilitators provided feedback. Background information on the hypothetical patients was provided, and participants took turns playing the roles of patients or PTs. These sessions were audio-recorded and assessed to determine PT’s delivery of the strategies.  Time spent  4 hours  5 hours  3 hours  Mode of delivery  Pre-reading materials were provided to PTs; Lecture and group discussion; PowerPoint slides; Program handout  Lecture and group discussion; Self–reflection; Goal setting and action planning; Video examples of effective and ineffective use of the SDT-based communication strategies  Role-play and micro-teaching activities; Self-reflection; Peer and facilitator feedback  SDT-based communication strategies PTs were trained to use  Definitions of the SDT-based communication strategies as per the SOLAS training protocol  Autonomy support: Strategies to support patient autonomy for behavior  Offer a meaningful rationale for the behavior  Verbal explanations that help the patient understand why the behavior / activity would have personal relevance  Provide opportunity for input and choice to patients  Provide information about options for the behavior, encouragement of patient choice making and patient initiation of their own action.  Use support and encouragement rather than pressurizing behavior  Communication that minimizes pressure and conveys a sense of choice and flexibility in the locution of behavior.  Structure: Strategies to support participant competence to engage in the behavior  Set clear expectations and provide appropriate direction  Present clear, understandable, and appropriately detailed directions regarding structure and content of the class.  Collaborative goal setting, action planning, and problem solvingb  Patient-“led,” PT-supported behavioral goals that are specific, measurable, achievable, and time-based are agreed upon. This is followed by patient-“led,” PT-supported identification of possible barriers to the behavior and solution development.  Provide positive, information-rich feedbackc  Nonjudgmental feedback focused on reinforcing effort as much as outcome. This feedback should be information-rich so that patient knows what to do in the future.  Provide patients with opportunities to practice behaviors  Guide, demonstrate, and support patients in practicing behaviors.  Interpersonal involvement: Strategies to support relatedness  Acknowledge and take into account patient feelings and perspectives  Acknowledge feelings and display general empathy toward the patients’ situation and opinions. Tension-relieving acknowledgment that patient concerns are legitimate.  Build relationshipsd  Using patients’ names, encouraging patients to share information and support each other during the class. Using active listening techniques, staying silent and allowing patients time to speak.    Component 1: SOLAS Intervention Content  Component 2: SDT-Based 
Communication Strategies  Component 3: Interactive Activities  Description  The aims and objectives of the SOLAS intervention and the PT training program were outlined. The content of each SOLAS intervention class was discussed individually, with key elements emphasized. SOLAS intervention exercises were demonstrated and discussed with the PTs. The PTs discussed barriers and enablers to the delivery of the SOLAS intervention within their environment, and considered methods to overcome barriers where possible.  Self-determination theory was introduced, 
including a rationale for its use within this population. The concept of needs–supportive and needs-thwarting communication style was introduced and each of the SDT-based communication strategies were outlined. Video examples of ineffective use of these strategies were provided. The PTs reflected and discussed how these strategies may be delivered in a needs–supportive manner, before being shown video examples of the effective use of 
these strategies.  Individual role-play exercises were used to support PTs’ practice of the SDT-based communication strategies learned. Physical therapists delivered part of a SOLAS class during micro-teaching activities. Fellow PT participants and expert facilitators provided feedback. Background information on the hypothetical patients was provided, and participants took turns playing the roles of patients or PTs. These sessions were audio-recorded and assessed to determine PT’s delivery of the strategies.  Time spent  4 hours  5 hours  3 hours  Mode of delivery  Pre-reading materials were provided to PTs; Lecture and group discussion; PowerPoint slides; Program handout  Lecture and group discussion; Self–reflection; Goal setting and action planning; Video examples of effective and ineffective use of the SDT-based communication strategies  Role-play and micro-teaching activities; Self-reflection; Peer and facilitator feedback  SDT-based communication strategies PTs were trained to use  Definitions of the SDT-based communication strategies as per the SOLAS training protocol  Autonomy support: Strategies to support patient autonomy for behavior  Offer a meaningful rationale for the behavior  Verbal explanations that help the patient understand why the behavior / activity would have personal relevance  Provide opportunity for input and choice to patients  Provide information about options for the behavior, encouragement of patient choice making and patient initiation of their own action.  Use support and encouragement rather than pressurizing behavior  Communication that minimizes pressure and conveys a sense of choice and flexibility in the locution of behavior.  Structure: Strategies to support participant competence to engage in the behavior  Set clear expectations and provide appropriate direction  Present clear, understandable, and appropriately detailed directions regarding structure and content of the class.  Collaborative goal setting, action planning, and problem solvingb  Patient-“led,” PT-supported behavioral goals that are specific, measurable, achievable, and time-based are agreed upon. This is followed by patient-“led,” PT-supported identification of possible barriers to the behavior and solution development.  Provide positive, information-rich feedbackc  Nonjudgmental feedback focused on reinforcing effort as much as outcome. This feedback should be information-rich so that patient knows what to do in the future.  Provide patients with opportunities to practice behaviors  Guide, demonstrate, and support patients in practicing behaviors.  Interpersonal involvement: Strategies to support relatedness  Acknowledge and take into account patient feelings and perspectives  Acknowledge feelings and display general empathy toward the patients’ situation and opinions. Tension-relieving acknowledgment that patient concerns are legitimate.  Build relationshipsd  Using patients’ names, encouraging patients to share information and support each other during the class. Using active listening techniques, staying silent and allowing patients time to speak.  aSOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, SDT = self-determination theory. bThis strategy was split into 5 component behaviors: (1) review behavioral goal, (2) goal setting, (3) action planning, (4) barrier identification, and 
(5) problem solving. cThis strategy was split into 2 component behaviors: (1) provide positive encouragement toward a behavior and (2) provide positive, information-rich feedback. dThis strategy was split into 2 component behaviors: (1) active listening and (2) interest in patients. View Large Table 2. Assessment of the SOLAS Intervention Physical Therapist (PT) Training Program Using the Kirkpatrick Model of Evaluationa Kirkpatrick Model Level  Research Aim of the Level  Method of 
Measurement Within the SOLAS Intervention  Data Collection Method and 
Time Point  Outcome Measure  (1) Reaction How participants reacted to the training program  Were PTs satisfied with training?  PT self-reported satisfaction with the training program  Paper-based questionnaire, posttraining  Intervention-specific satisfaction questionnaire          Validity: Questionnaires were piloted for understanding. Questions followed the suggestions of the Kirkpatrick Model and previous research investigating provider satisfaction.16,33,63          Reliability: Not applicable          Sample question: “The videos were useful to identify different forms of facilitating”; 1 = strongly disagree; 5 = strongly agree  (2) Learning The extent to which participants change attitudes, improve knowledge, and/or increase skills as a result of participating in the training program  Did PTs’ confidence in and knowledge of the SOLAS content and SDT-based communication strategies improve with training? Did PTs have the skills to deliver the SOLAS intervention following training?  PT self-reported confidence in the SDT-based communication strategies and the intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific self-reported confidence questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your confidence in using the following:          Setting clear expectations; 1 = not at all good; 7 = very good      PT knowledge of SDT-based communication strategies  Paper-based questionnaire, pretraining and posttraining  Intervention-specific narrative questionnaire modeled on the Problems in Schools Questionnaire34          Validity: Construct validity tested previously.34 Pilot testing was completed on 4 PTs prior to commencement of the SOLAS PT training program. Following piloting a hypothetical patient scenario was developed by the researchers (X and Y) in order to standardize PT responses and provide a more accurate comparison of their knowledge of the SDT-based communication strategies.          Reliability: Tested for interrater agreement in this study using percentage agreement. Problems in School Questionnaire previously shown to have excellent interrater reliability.34,35      PT knowledge of the SOLAS intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific knowledge questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your knowledge of the following:          Physical activity prescription; 1 = not at all good; 7 = very good      PTs skills in applying the SDT-based communication strategies in a needs-supportive manner  Audio-recorded role-plays during the SOLAS training program  Intervention-specific measure of needs 
supportiveness modeled on the Reeve scale42; the SOLAS scale          Validity: Original Reeve scale shown to have content validity.42 Concurrent validity with the HCCQ tested within this study using Pearson product correlation.          Reliability: Reeve scale previously shown to have 
excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample anchor points: For the strategy of “uses support and encouragement rather than pressurizing behaviors”; 1 = uses directive, strict, controlling language; 7 = uses supportive, noncontrolling language  (3) Behavior The extent to which behavior has occurred because the participant engaged with training  Did PTs competently deliver the SOLAS intervention using a needs-supportive communication style?  PTs’ skills during the delivery of the SOLAS intervention (ie, whether the classes were delivered in a needs–supportive manner)  Audio-recorded delivery of the SOLAS intervention  The 15-item Health Care Climate Questionnaire64          Validity: Construct validity previously tested.41,64          Reliability: Previously shown to have excellent interrater reliability.9,41 Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT provided the clients with choices and options; 1 = strongly disagree; 7 = strongly agree          A 5-item version of the Controlling Coach Behavior Scale26          Validity: Content validity previously tested.26          Reliability: Previously shown to have excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT only praises clients to make them keep up with their exercise goals; 1 = strongly disagree; 7 = strongly agree          Intervention-specific measure of needs supportiveness modeled on the Reeve scale42; the SOLAS scale          As listed above  Kirkpatrick Model Level  Research Aim of the Level  Method of 
Measurement Within the SOLAS Intervention  Data Collection Method and 
Time Point  Outcome Measure  (1) Reaction How participants reacted to the training program  Were PTs satisfied with training?  PT self-reported satisfaction with the training program  Paper-based questionnaire, posttraining  Intervention-specific satisfaction questionnaire          Validity: Questionnaires were piloted for understanding. Questions followed the suggestions of the Kirkpatrick Model and previous research investigating provider satisfaction.16,33,63          Reliability: Not applicable          Sample question: “The videos were useful to identify different forms of facilitating”; 1 = strongly disagree; 5 = strongly agree  (2) Learning The extent to which participants change attitudes, improve knowledge, and/or increase skills as a result of participating in the training program  Did PTs’ confidence in and knowledge of the SOLAS content and SDT-based communication strategies improve with training? Did PTs have the skills to deliver the SOLAS intervention following training?  PT self-reported confidence in the SDT-based communication strategies and the intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific self-reported confidence questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your confidence in using the following:          Setting clear expectations; 1 = not at all good; 7 = very good      PT knowledge of SDT-based communication strategies  Paper-based questionnaire, pretraining and posttraining  Intervention-specific narrative questionnaire modeled on the Problems in Schools Questionnaire34          Validity: Construct validity tested previously.34 Pilot testing was completed on 4 PTs prior to commencement of the SOLAS PT training program. Following piloting a hypothetical patient scenario was developed by the researchers (X and Y) in order to standardize PT responses and provide a more accurate comparison of their knowledge of the SDT-based communication strategies.          Reliability: Tested for interrater agreement in this study using percentage agreement. Problems in School Questionnaire previously shown to have excellent interrater reliability.34,35      PT knowledge of the SOLAS intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific knowledge questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your knowledge of the following:          Physical activity prescription; 1 = not at all good; 7 = very good      PTs skills in applying the SDT-based communication strategies in a needs-supportive manner  Audio-recorded role-plays during the SOLAS training program  Intervention-specific measure of needs 
supportiveness modeled on the Reeve scale42; the SOLAS scale          Validity: Original Reeve scale shown to have content validity.42 Concurrent validity with the HCCQ tested within this study using Pearson product correlation.          Reliability: Reeve scale previously shown to have 
excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample anchor points: For the strategy of “uses support and encouragement rather than pressurizing behaviors”; 1 = uses directive, strict, controlling language; 7 = uses supportive, noncontrolling language  (3) Behavior The extent to which behavior has occurred because the participant engaged with training  Did PTs competently deliver the SOLAS intervention using a needs-supportive communication style?  PTs’ skills during the delivery of the SOLAS intervention (ie, whether the classes were delivered in a needs–supportive manner)  Audio-recorded delivery of the SOLAS intervention  The 15-item Health Care Climate Questionnaire64          Validity: Construct validity previously tested.41,64          Reliability: Previously shown to have excellent interrater reliability.9,41 Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT provided the clients with choices and options; 1 = strongly disagree; 7 = strongly agree          A 5-item version of the Controlling Coach Behavior Scale26          Validity: Content validity previously tested.26          Reliability: Previously shown to have excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT only praises clients to make them keep up with their exercise goals; 1 = strongly disagree; 7 = strongly agree          Intervention-specific measure of needs supportiveness modeled on the Reeve scale42; the SOLAS scale          As listed above  aHCCQ = Health Care Climate Questionnaire, SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, SDT = self–determination theory. View Large Outcome Measures Reaction Physical therapists’ satisfaction with the training methods and content was assessed posttraining using an intervention specific self-report measure (Tab. 2).16,33 Physical therapists answered 22 questions on separate 5-point Likert scales ranging from “1–strongly disagree” to “5–strongly agree.” Learning Physical therapists’ confidence, knowledge, and skills were evaluated to assess “learning.” To assess the physical therapists’ confidence in the SOLAS intervention content and SDT-based communication strategies, an intervention-specific questionnaire was used pretraining and posttraining. Physical therapists rated their confidence in the 9 SDT-based communication strategies, and the SOLAS intervention content on separate 7-point Likert scales ranging from “1–not at all good” to “7–very good.” Physical therapists’ knowledge of the SDT-based communication strategies was assessed pretraining and posttraining using a narrative case study modeled on a previously validated measure.34,35 The measure was amended to include a hypothetical patient scenario to standardize therapists’ responses. Physical therapists reported how they would interact with the patient who was described as having low back pain, a fear of movement, and limited time to exercise. Two masked raters independently assessed responses for the presence/absence of the SDT-based communication strategies, with a score of “1” for strategies that were present and “0” if absent. Physical therapists’ knowledge was listed as a percentage of those utilizing each strategy in their response. Physical therapists’ knowledge of the SOLAS intervention content (ie, information on pacing, physical activity, pain management, etc, as listed within Table 1) was also assessed pretraining and posttraining using an intervention-specific questionnaire. Physical therapists rated their knowledge of the SOLAS intervention content on separate 7-point Likert scales ranging from “1– not at all good” to “7–very good.” Physical therapists also narratively listed the stages of the cycle of change; effective pain relief strategies; and advice they would give to patients with a flare-up. Finally, physical therapists’ skills in applying the SDT-based communication strategies were measured during a simulated role-play at the end of training. Physical therapists delivered a short component of a SOLAS class while physical therapist PhD students and other participating physical therapists acted as patients. Instructions were provided on the class component to be delivered, along with short explanations regarding their patients’ main problems. They were instructed to act out the scenario applying as many of the SDT-based communication strategies as possible. These role-plays were audio-recorded and independently assessed by 2 raters using the SOLAS scale, an intervention-specific measure described in detail below. Behavior Of the 13 trained physical therapists, a subgroup of 8 delivered the intervention within the feasibility trial. Physical therapists were audio-recorded delivering all 6 SOLAS intervention classes (n = 48 audio recordings). Two raters (A.K., T.H.) independently coded 50% (n = 24) of these recordings to assess the therapists’ needs-supportive communication style, to establish whether they applied this consistently across classes, and to determine the impact of provider experience on delivery.2,36 Prior to coding, raters completed a training and familiarization process, including the use of a coding manual to support consistent and accurate coding (eAppendix, available at https://academic.oup.com/ptj). The validated Health Care Climate Questionnaire (HCCQ)37 was selected as the primary measure for the level of “behavior,” with 2 secondary measures; an adapted version of the Controlling Coach Behavior Scale (CCBS);26 and an intervention-specific measure to assess the trained SDT-based communication strategies.38 Classes 1, 4, and 6 were selected to capture physical therapists’ competence over time, as these represented the beginning, middle, and end of the intervention. In the absence of a robust definition of competence, it was defined as the midpoint of the Likert scale (>4/7) on the selected measures.39,40 The HCCQ contains 15 statements relating to providers’ provision of autonomy support.41 Each statement is scored on separate 7-point Likert scales from “1–strongly disagree” to “7–strongly agree.” Two raters independently completed a HCCQ for each of the 24 classes. Five statements were selected from the CCBS based on their relevance to the intervention, with 1 question selected from each of the CCBS subscales.26 Each statement is scored on separate 7-point Likert scales from “1–strongly disagree” to “7–strongly agree.” Two raters independently completed a CCBC for each of the 24 classes. To augment these, a measure specific to the SOLAS intervention was developed (SOLAS scale in eAppendix, available at https://academic.oup.com/ptj). The SOLAS scale was based on the tool by Reeve,42 which has been previously adapted for use in group exercise classes.43 The 9 SDT-based communication strategies were divided into 15 component behaviors in order to capture whether some were trained more effectively than others. For example, “collaborative goal setting, action planning, and problem solving” was divided into 5 components: “review behavioral goal”; “goal setting”; “action planning”; “barrier identification”; and “problem solving.” To understand if differences in the use of these strategies existed during each class, 1 measure was completed for the education component and another for the exercise component of each class. Strategies were assessed on separate 7-point Likert scales ranging from “1–not at all well” to “7–very well.” Average scores were calculated to determine whether the 15 component behaviors (based on the 9 SDT-based communication strategies) were delivered competently. Specifically, an average score per component behavior (eg, positive feedback), per class component (eg, education), and per class were calculated. Data Analysis Data from all measures were analyzed using Excel (Microsoft for Mac, version 14.2.3) and a statistical software package (IBM, SPSS Statistics, version 20). A Shapiro-Wilk test was employed to test normality of distribution for the continuous data. Reaction To assess the physical therapists’ satisfaction with the SOLAS training program, scores were averaged across physical therapists and descriptive statistics were computed (Median [interquartile range]; minimum [min]-maximum [max]). Learning Scores for each measure within this level were averaged across the physical therapists. To assess whether therapists’ confidence in these areas changed following training, a Wilcoxon Signed Rank test was used, with time (pretraining vs posttraining) the categorical independent variable, and confidence (measured on Likert scales ranging from 1 to 7) the dependent variable of interest. Results were adjusted for multiplicity using a Bonferroni correction. McNemar's test analyzed changes in the proportion of physical therapists (pretraining vs posttraining) using each of the SDT-based communication strategies during the narrative case study. Interrater agreement was established using percentage agreement based on presence or absence responses. To assess changes in the physical therapists’ knowledge of the intervention content following training, a Wilcoxon Signed Rank test was used with time (pretraining vs posttraining) the categorical independent variable, and knowledge the dependent variable of interest. Results were adjusted for multiplicity using a Bonferroni correction. To establish therapists’ skills in applying the SDT-based communication strategies during training, scores were averaged across therapists and descriptive statistics calculated (median [IQR]; min-max). Interrater reliability was established using an intraclass correlation coefficient (ICC) 2-way random model for absolute agreement with 95% confidence intervals (CI). Behavior Interrater reliability for all measures (n = 24 per rater) in the level of “behavior” was calculated using an ICC as described above (ie, HCCQ, adapted CCBS, and the SOLAS 
scale). To assess change in the physical therapists’ delivery during the course of the intervention (n = 24 for 8 therapists in 3 classes averaged across 2 raters), linear mixed-effects modeling was used. The model specifications were marginal models for the population means, using therapists as participants with repeated observations over classes and correlated residuals with unstructured variance-covariance. The HCCQ, CCBS, and SOLAS scale scores were the dependent variables, and classes were the independent variable. Criterion validity of the SOLAS scale was tested against the HCCQ using Pearson's product correlation. Data for these 3 measures were normally distributed; however, in order to list therapists’ overall competence in each measure during intervention delivery, results were averaged across the 3 classes and 2 raters. Therefore, the number of data points equaled the number of physical therapists (n = 8) and we defaulted to nonparametric descriptive statistics to report therapists’ competence (median [IQR]; min-max). The relationship between posttraining results across the 3 evaluation levels (ie, learning, reaction, and behavior) and the physical therapists’ previous experience (ie, years qualified, years delivering groups, previous communication training), motivation to participate, and expectations of treatment were calculated using Spearman's rank correlation coefficients (ordinal data) or a Mann-Whitney U test (nominal data) for each variable independently. Results were adjusted for multiplicity using a Bonferroni correction. Results Thirteen physical therapists completed training, of which pretraining and posttraining results are available for 12. The results for the Kirkpatrick model levels of “reaction” and “learning” refer to these 12 therapists, who had a median 9.0 years’ experience ([10.5]; 4–25), and 3 years’ experience working with groups ([4.8]; 1–10). Eight of these therapists (66.7%) had previously completed communication training. Results for the Kirkpatrick model level of “behavior” relate to the 8 therapists who delivered the SOLAS intervention within the feasibility trial. This subgroup had 10.5 years’ experience ([5.8]; 5–25), and 5.0 years’ experience with groups ([5.8]; 1–15). Seven therapists (87.5%) had previously undertaken some form of communication training. Reaction Physical therapists’ satisfaction with training was excellent (median = 4.7 on a 5-point Likert scale; [0.5]; 3.7–5.0). Physical therapists planned to implement the skills learned into their general practice and the SOLAS intervention (median 5.0 [0.0]; 4.0–5.0) (eTable 1 in eAppendix, available at https://academic.oup.com/ptj). Learning Physical therapists’ confidence in their use of the SDT-based communication strategies was high pretraining (median = 5.3 on a 7-point Likert scale [0.7]; 3.4–6.0), and significantly increased posttraining (z score = 2.8, P = .005; Tab. 3). Five individual strategies demonstrated improvements of P ≤ .05; however, following Bonferroni corrections, only “opportunity for patient input and choice” remained significant (Tab. 3). Physical therapists’ confidence in the SOLAS intervention content was also high pretraining (4.8 on a 7-point Likert scale [1.6]; 3.7–6.0), and did not significantly improve following Bonferroni corrections (z score = 2.8, P = .01; Tab. 4). Table 3. Change in Physical Therapist (PT) Confidence and Knowledge of the Self-Determination Theory (SDT)-Based Communication Strategiesa SDT-Based Communication 
Strategies  Median Pretraining (IQR); Min-Max  Median Posttraining (IQR); Min-Max  z Scorea  P Value  Median 
Pretrainingb (%; n = PTs)  Median Posttraining (%; n = PTs)  P Value  Confidence [1-7]c  Knowledge (Present or Absent)  Total  5.3 (0.7); 3.4-6.0  5.8 (0.4); 5.1-6.6  2.8  .005c  8 (2.0); 
5.0-9.0  7.5 (2.0); 6.0-9.0  .70  Offer a meaningful rationale (n = 5)d [1-7]  5.0 (1.5); 5.0-7.0  5.0 (1.5); 5.0-7.0  0.0  1.00  83.3% (10)  75.0% (9)  1.00  Provide opportunities for patient input and choice [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-6.0  3.0  .003c  91.7% (11)  100% (12)  1.00  Use support and encouragement rather than pressurizing behaviors [1-7]  5.0 (0.5); 4.0-5.0  6.0 (0.5); 5.0-6.0  2.3  .03  100% (12)  100% (12)  N/Ae  Set clear expectations and provide direction [1-7]  5.0 (1.5); 4.0-6.0  6.0 (1.5); 5.0-7.0  2.6  .01  Not includedf  Not includedf    Collaborative goal setting and action planning [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-60  1.7  .10  75.0% (9)  91.7% (11)  .50  Collaborative problem solvingg [1-7]  N/A  N/A  N/A  N/A  100% (12)  100% (12)  N/Ae  Provide positive information-rich feedback [1-7]  6.0 (2.0); 5.0-7.0  6.0 (1.0); 6.0-7.0  0.8  .43  66.7% (8)  66.7% (8)  1.00  Provide opportunities to practice behaviors [1-7]  6.0 (1.5); 5.0-7.0  6.0 (0.0); 5.0-6.0  1.4  .15  66.7% (8)  50.0% (6)  .63  Acknowledge patients’ feelings and perspectives [1-7]  6.0 (1.5); 5.0-7.0  7.0 (1.0); 6.0-7.0  1.9  .05  91.7% (11)  91.7% (11)  1.00  Build relationships [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.5); 6.0-7.0  2.1  .03  100% (12)  91.7% (11)  1.00  SDT-Based Communication 
Strategies  Median Pretraining (IQR); Min-Max  Median Posttraining (IQR); Min-Max  z Scorea  P Value  Median 
Pretrainingb (%; n = PTs)  Median Posttraining (%; n = PTs)  P Value  Confidence [1-7]c  Knowledge (Present or Absent)  Total  5.3 (0.7); 3.4-6.0  5.8 (0.4); 5.1-6.6  2.8  .005c  8 (2.0); 
5.0-9.0  7.5 (2.0); 6.0-9.0  .70  Offer a meaningful rationale (n = 5)d [1-7]  5.0 (1.5); 5.0-7.0  5.0 (1.5); 5.0-7.0  0.0  1.00  83.3% (10)  75.0% (9)  1.00  Provide opportunities for patient input and choice [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-6.0  3.0  .003c  91.7% (11)  100% (12)  1.00  Use support and encouragement rather than pressurizing behaviors [1-7]  5.0 (0.5); 4.0-5.0  6.0 (0.5); 5.0-6.0  2.3  .03  100% (12)  100% (12)  N/Ae  Set clear expectations and provide direction [1-7]  5.0 (1.5); 4.0-6.0  6.0 (1.5); 5.0-7.0  2.6  .01  Not includedf  Not includedf    Collaborative goal setting and action planning [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-60  1.7  .10  75.0% (9)  91.7% (11)  .50  Collaborative problem solvingg [1-7]  N/A  N/A  N/A  N/A  100% (12)  100% (12)  N/Ae  Provide positive information-rich feedback [1-7]  6.0 (2.0); 5.0-7.0  6.0 (1.0); 6.0-7.0  0.8  .43  66.7% (8)  66.7% (8)  1.00  Provide opportunities to practice behaviors [1-7]  6.0 (1.5); 5.0-7.0  6.0 (0.0); 5.0-6.0  1.4  .15  66.7% (8)  50.0% (6)  .63  Acknowledge patients’ feelings and perspectives [1-7]  6.0 (1.5); 5.0-7.0  7.0 (1.0); 6.0-7.0  1.9  .05  91.7% (11)  91.7% (11)  1.00  Build relationships [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.5); 6.0-7.0  2.1  .03  100% (12)  91.7% (11)  1.00  aIQR = interquartile range; z score = difference in pretraining and posttraining results. bReported as the percentage of PTs who used the strategies in their responses. cP ≤ .005 is significant following Bonferroni adjustments. dMissing data; only 5 PTs answered this question pretraining and posttraining. eN/A = McNemar test not calculated as no association was found, and the variables were constant. f“Set clear expectations” was not included in the narrative component of the assessment, as it was not expected to be delivered within the context of the hypothetical case study provided. gProblem solving was considered under the heading of goal setting within the confidence scale. View Large Table 4. Change in Physical Therapist (PT) Confidence and Knowledge of the SOLAS Intervention Contenta   Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Confidenceb  Knowledge  Total  4.8 (1.6); 3.7-6.0  5.7 (0.7); 
4.3-6.4  2.8  .01  4.9 (0.9); 
3.8-6.1  5.7 (1.1); 
4.4-6.6  2.3  .02  Disease mechanisms [1-7]  5.0 (1.0); 4.0-6.0  6.0 (1.0); 5.0-7.0  1.9  .06  5.0 (1.0); 3.0-7.0  6.0 (1.0); 5.0-7.0  1.7  .10  Exercise [1-7]  6.0 (1.0); 5.0-6.0  6.0 (0.8); 5.0-7.0  2.7  .01  5.5 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  1.9  .06  Physical activity promotion [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.0); 5.0-7.0  1.9  .06  6.0 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  2.1  .04  Healthy eating and 
diet [1-7]  5.0 (2.8); 3.0-6.0  6.0 (1.0); 3.0-7.0  1.9  .05  5.0 (1.0); 3.0-7.0  6.0 (1.0); 3.0-7.0  0.7  .51  Relaxation [1-7]  5.0 (2.5); 1.0-6.0  6.0 (2.5); 3.0-7.0  1.7  .08  5.0 (3.0); 2.0-7.0  6.0 (2.8); 3.0-7.0  1.7  .08  Pain relief techniques [1-7]  5.5 (1.8); 3.0-7.0  6.0 (1.0); 3.0-7.0  1.0  .32  5.5 (1.0); 3.0-7.0  6.0 (0.8); 3.0-7.0  0.6  .56  Medication [1-7]  3.5 (2.0); 2.0-6.0  5.0 (1.8); 3.0-6.0  2.6  .01  3.0 (1.8); 2.0-5.0  5.0 (1.8); 3.0-6.0  3.0  .003b  Pacing [1-7]  5.0 (1.8); 3.0-7.0  6.0 (0.0); 5.0-7.0  2.5  .01  5.0 (1.8); 3.0-7.0  6.0 (0.8); 5.0-7.0  1.7  .08  Mood regulation [1-7]  4.5 (3.8); 2.0-6.0  5.5 (2.5); 3.0-7.0  1.5  .14  5.0 (0.8); 2.0-7.0  5.0 (1.8); 3.0-6.0  0.8  .43  Narrative totalc[0–16]d  10.5 (6.8); 
5.0-16.0  13.0 (4.5); 
8.0-16.0  2.5  .011d          Cycle of change [0-5]  N/A  N/A  N/A  N/A  3.0 (2.5); 0.0-5.0  5.0 (1.8); 3.0-5.0  2.4  .02  Advice to patients [0-3]  N/A  N/A  N/A  N/A  3.0 (0.0); 2.0-3.0  3.0 (0.8); 2.0-3.0  0.6  .56  Use of pain modalities [0-8]  N/A  N/A  N/A  N/A  4.5 (4.8); 2.0-8.0  6.0 (4.5); 2.0-8.0  1.7  .09    Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Confidenceb  Knowledge  Total  4.8 (1.6); 3.7-6.0  5.7 (0.7); 
4.3-6.4  2.8  .01  4.9 (0.9); 
3.8-6.1  5.7 (1.1); 
4.4-6.6  2.3  .02  Disease mechanisms [1-7]  5.0 (1.0); 4.0-6.0  6.0 (1.0); 5.0-7.0  1.9  .06  5.0 (1.0); 3.0-7.0  6.0 (1.0); 5.0-7.0  1.7  .10  Exercise [1-7]  6.0 (1.0); 5.0-6.0  6.0 (0.8); 5.0-7.0  2.7  .01  5.5 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  1.9  .06  Physical activity promotion [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.0); 5.0-7.0  1.9  .06  6.0 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  2.1  .04  Healthy eating and 
diet [1-7]  5.0 (2.8); 3.0-6.0  6.0 (1.0); 3.0-7.0  1.9  .05  5.0 (1.0); 3.0-7.0  6.0 (1.0); 3.0-7.0  0.7  .51  Relaxation [1-7]  5.0 (2.5); 1.0-6.0  6.0 (2.5); 3.0-7.0  1.7  .08  5.0 (3.0); 2.0-7.0  6.0 (2.8); 3.0-7.0  1.7  .08  Pain relief techniques [1-7]  5.5 (1.8); 3.0-7.0  6.0 (1.0); 3.0-7.0  1.0  .32  5.5 (1.0); 3.0-7.0  6.0 (0.8); 3.0-7.0  0.6  .56  Medication [1-7]  3.5 (2.0); 2.0-6.0  5.0 (1.8); 3.0-6.0  2.6  .01  3.0 (1.8); 2.0-5.0  5.0 (1.8); 3.0-6.0  3.0  .003b  Pacing [1-7]  5.0 (1.8); 3.0-7.0  6.0 (0.0); 5.0-7.0  2.5  .01  5.0 (1.8); 3.0-7.0  6.0 (0.8); 5.0-7.0  1.7  .08  Mood regulation [1-7]  4.5 (3.8); 2.0-6.0  5.5 (2.5); 3.0-7.0  1.5  .14  5.0 (0.8); 2.0-7.0  5.0 (1.8); 3.0-6.0  0.8  .43  Narrative totalc[0–16]d  10.5 (6.8); 
5.0-16.0  13.0 (4.5); 
8.0-16.0  2.5  .011d          Cycle of change [0-5]  N/A  N/A  N/A  N/A  3.0 (2.5); 0.0-5.0  5.0 (1.8); 3.0-5.0  2.4  .02  Advice to patients [0-3]  N/A  N/A  N/A  N/A  3.0 (0.0); 2.0-3.0  3.0 (0.8); 2.0-3.0  0.6  .56  Use of pain modalities [0-8]  N/A  N/A  N/A  N/A  4.5 (4.8); 2.0-8.0  6.0 (4.5); 2.0-8.0  1.7  .09  aIQR = interquartile range; SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills. bP ≤ .005 is significant following Bonferroni adjustments. cNot tested within the confidence scale, as these were narrative questions. dP ≤ .013 is significant following Bonferroni adjustments. View Large Regarding the physical therapists’ knowledge of the SDT-based communication strategies, pretraining knowledge was high with no change posttraining (Tab. 3). Across therapists, a median 8 out of 9 strategies ([2.0]; 5.0–9.0) were used in the narrative responses pretraining, compared to 7.5 ([2.0]; 6.0–9.0) posttraining. Interrater agreement for the presence of the strategies within the case study narratives was good (mean 78.7% pretraining; mean 81.5% posttraining). Physical therapists’ knowledge of the SOLAS intervention content was high pretraining (4.9 on a 7-point Likert scale [0.9]; 3.8–6.1) and improved posttraining, although not significantly when adjusted for Bonferroni (z score = 2.3, P = .02; Tab. 4). Physical therapists’ knowledge of the 3 narrative questions was also high pretraining (10.5 [6.8]; 5.0–16.0), and significantly improved posttraining (z score = 2.5, P = .011; Tab. 4). Ten physical therapists had their simulated role-play activity successfully audio-recorded; the recordings for the other 3 therapists failed due to technical reasons. Physical therapists had a median skill level of 4.3 on a 7-point Likert scale ([1.3]; range = 3.5–4.9), indicating that they competently applied the SDT-based communication strategies within a mock clinical environment. However, 4 of the 15 behaviors failed to reach the defined threshold for competence (ie, “setting clear expectations,” “action-planning,” “provide opportunity to practice,” and “acknowledge patients’ feelings and perspectives” scored less than “4” on the 7-point Likert scale; Tab. 5). Interrater reliability for the SOLAS scale within training was moderate with an ICC = 0.8, 95% CI = 0.2–1.0. Table 5. Physical Therapist (PT) Use of the Self-Determination Theory (SDT)-Based Communication Strategies During the Micro-Teaching Component of Training and During Their Delivery of the SOLAS Intervention Classesa   Training (n = 10)b  Delivery (n = 8)  SDT-Based Communication Strategies  Median Needs 
Supportiveness (IQR); Min-Max  Class Median (IQR); Min-Max  Education Median (IQR); Min-Max  Exercise Median (IQR); Min-Max  z Scorea  P Valuec  Total [1-7]  4.3 (1.0); 3.3-4.9  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  Autonomy support  Offer a meaningful rationale [1-7]  4.3 (2.5); 3.0-6.0  4.3 (1.8); 3.8-6.3  5.2 (1.6); 4.2-6.3  3.8 (2.0); 3.0-6.2  2.5  .01  Provide opportunities for patient input and choice [1-7]  5.3 (1.3); 4.0-6.0  4.8 (1.6); 3.5-5.8  4.5 (1.5); 3.7-5.8  4.9 (2.0); 3.3-5.7  0.4  .67  Use support and encouragement rather than pressurizing behaviors [1-7]  4.3 (2.1); 3.5-6.0  4.2 (1.5); 3.1-5.3  4.0 (1.1); 2.8-5.2  4.3 (1.4); 2.7-5.7  0.4  .67  Structure  Set clear expectations and provide direction [1-7]  3.0 (3.5); 1.0-6.5  4.3 (0.5); 3.9-5.1  5.4 (0.8); 4.8-6.2  3.4 (1.2); 2.7-4.0  2.5  .01  Goal setting: Review goal setting [1-7]  5.0 (1.8); 3.5-6.0  2.7 (1.7); 1.3-4.1  3.8 (1.5) 1.0-4.5  1.6 (1.7); 1.2-4.3  2.1  .04  Goal setting: Collaborative goal setting [1-7]  5.0 (2.8); 2.5-6.5  3.7 (1.2); 2.3-4.9  3.8 (1.7); 2.7-5.0  3.3 (1.4); 1.2-5.8  0.9  .36  Goal setting: Collaborative action planning [1-7]  1.0 (3.3); 1.0-6.5  2.7 (1.2); 1.7-3.7  3.4 (2.2); 2.2-4.7  2.0 (2.3); 1.0-3.7  1.9  .06  Goal setting: Collaborative barrier identification [1-7]  5.0 (1.1); 4.5-6.5  2.9 (1.5); 2.1-4.0  3.3 (1.1); 2.7-5.0  2.6 (2.3); 1.2-3.8  1.8  .07  Goal setting: Collaborative problem solving [1-7]  4.8 (2.1); 1.0-6.5  2.9 (2.1); 1.8-4.5  3.0 (1.5); 2.2-5.7  2.8 (3.3); 1.0-4.3  1.1  .26  Provide positive encouragement [1-7]  4.5 (0.9); 3.5-6.0  4.5 (1.4); 3.5-5.3  4.3 (1.0); 3.8-5.2  4.8 (1.8); 3.2-5.7  1.4  .17  Provide positive, information-rich feedback [1-7]  4.8 (2.4); 1.5-6.0  4.5 (2.0); 2.9-5.4  4.0 (2.0); 2.5-5.0  4.8 (2.2); 3.2-6.0  2.5  .01  Provide opportunities for patient practice [1-7]  3.5 (5.0); 1.0-6.0  5.5 (1.8); 3.5-6.3  N/A  5.5 (1.8); 3.5-6.3  N/A  N/A  Interpersonal involvement  Acknowledge patients’ feelings and perspectives [1-7]  3.0 (1.2); 2.5-6.5  3.4 (2.0); 2.6-5.3  4.0 (1.3); 2.7-5.2  2.8 (2.0); 1.7-5.5  1.9  .06  Build relationships: Active listening [1-7]  5.3 (1.3); 3.5-6.5  5.0 (1.4); 3.8-5.8  5.1 (1.1); 3.8-5.8  4.8 (1.6); 3.5-5.8  1.6  .11  Build relationships: Interest in patients [1-7]  4.5 (0.6); 1.5-5.5  5.1 (1.2); 3.7-5.8  4.8 (1.0); 4.2-5.8  4.9 (1.5); 2.8-6.0  1.0  .33    Training (n = 10)b  Delivery (n = 8)  SDT-Based Communication Strategies  Median Needs 
Supportiveness (IQR); Min-Max  Class Median (IQR); Min-Max  Education Median (IQR); Min-Max  Exercise Median (IQR); Min-Max  z Scorea  P Valuec  Total [1-7]  4.3 (1.0); 3.3-4.9  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  Autonomy support  Offer a meaningful rationale [1-7]  4.3 (2.5); 3.0-6.0  4.3 (1.8); 3.8-6.3  5.2 (1.6); 4.2-6.3  3.8 (2.0); 3.0-6.2  2.5  .01  Provide opportunities for patient input and choice [1-7]  5.3 (1.3); 4.0-6.0  4.8 (1.6); 3.5-5.8  4.5 (1.5); 3.7-5.8  4.9 (2.0); 3.3-5.7  0.4  .67  Use support and encouragement rather than pressurizing behaviors [1-7]  4.3 (2.1); 3.5-6.0  4.2 (1.5); 3.1-5.3  4.0 (1.1); 2.8-5.2  4.3 (1.4); 2.7-5.7  0.4  .67  Structure  Set clear expectations and provide direction [1-7]  3.0 (3.5); 1.0-6.5  4.3 (0.5); 3.9-5.1  5.4 (0.8); 4.8-6.2  3.4 (1.2); 2.7-4.0  2.5  .01  Goal setting: Review goal setting [1-7]  5.0 (1.8); 3.5-6.0  2.7 (1.7); 1.3-4.1  3.8 (1.5) 1.0-4.5  1.6 (1.7); 1.2-4.3  2.1  .04  Goal setting: Collaborative goal setting [1-7]  5.0 (2.8); 2.5-6.5  3.7 (1.2); 2.3-4.9  3.8 (1.7); 2.7-5.0  3.3 (1.4); 1.2-5.8  0.9  .36  Goal setting: Collaborative action planning [1-7]  1.0 (3.3); 1.0-6.5  2.7 (1.2); 1.7-3.7  3.4 (2.2); 2.2-4.7  2.0 (2.3); 1.0-3.7  1.9  .06  Goal setting: Collaborative barrier identification [1-7]  5.0 (1.1); 4.5-6.5  2.9 (1.5); 2.1-4.0  3.3 (1.1); 2.7-5.0  2.6 (2.3); 1.2-3.8  1.8  .07  Goal setting: Collaborative problem solving [1-7]  4.8 (2.1); 1.0-6.5  2.9 (2.1); 1.8-4.5  3.0 (1.5); 2.2-5.7  2.8 (3.3); 1.0-4.3  1.1  .26  Provide positive encouragement [1-7]  4.5 (0.9); 3.5-6.0  4.5 (1.4); 3.5-5.3  4.3 (1.0); 3.8-5.2  4.8 (1.8); 3.2-5.7  1.4  .17  Provide positive, information-rich feedback [1-7]  4.8 (2.4); 1.5-6.0  4.5 (2.0); 2.9-5.4  4.0 (2.0); 2.5-5.0  4.8 (2.2); 3.2-6.0  2.5  .01  Provide opportunities for patient practice [1-7]  3.5 (5.0); 1.0-6.0  5.5 (1.8); 3.5-6.3  N/A  5.5 (1.8); 3.5-6.3  N/A  N/A  Interpersonal involvement  Acknowledge patients’ feelings and perspectives [1-7]  3.0 (1.2); 2.5-6.5  3.4 (2.0); 2.6-5.3  4.0 (1.3); 2.7-5.2  2.8 (2.0); 1.7-5.5  1.9  .06  Build relationships: Active listening [1-7]  5.3 (1.3); 3.5-6.5  5.0 (1.4); 3.8-5.8  5.1 (1.1); 3.8-5.8  4.8 (1.6); 3.5-5.8  1.6  .11  Build relationships: Interest in patients [1-7]  4.5 (0.6); 1.5-5.5  5.1 (1.2); 3.7-5.8  4.8 (1.0); 4.2-5.8  4.9 (1.5); 2.8-6.0  1.0  .33  aIQR = interquartile range, SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, z score = difference between the education and exercise components across all classes. bTen recordings were available for assessment. cP ≤ .003 is significant following Bonferroni adjustments. View Large Behavior Physical therapists (n = 8) delivered the SOLAS intervention to a median 3.0 participants per class ([1.7]; 1–6). The HCCQ demonstrated that therapists were needs-supportive during delivery of the intervention with a median score of 5.3 on a 7-point Likert scale ([1.4]; 3.9–6.0; Tab. 6). Linear modeling demonstrated no significant differences between classes, indicating that their communication style did not change during the intervention (F [1,2] = 0.6, P = .6). Interrater agreement was excellent (ICC = 0.87, 95% CI = 0.7–0.9). Table 6. Physical Therapists’ (PT) Needs Supportiveness During the SOLAS Intervention as Measured Using the Health Care Climate Questionnaire (HCCQ), the Controlling Coach Behavior Scale (CCBS), and the SOLAS Scalea Class ID  HCCQ Median (IQR); Min-Max  CCBS Median (IQR); Min-Max  SOLAS Scale 
Median (IQR); Min-Max  Education 
Component Median (IQR); Min-Max  Exercise 
Component Median (IQR); Min-Max  z Score  P Valueb  Total [1-7]  5.3 (1.4); 3.9-6.0  6.6 (0.5); 6.1-6.8  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  1 [1-7]  5.1 (1.5); 3.7-6.0  6.6 (0.4); 6.3-6.9  4.0 (1.1); 3.1-4.7  4.1 (0.9); 3.4-4.8  3.7 (1.3); 2.4-4.7  1.8  .07  4 [1-7]  5.3 (1.2); 4.2-5.9  6.5 (0.6); 5.4-6.8  4.0 (1.2); 3.2-5.0  4.1 (1.6); 3.5-5.7  4.1 (1.0); 2.9-4.5  1.7  .09  6 [1-7]  5.5 (1.3); 3.3-6.1  6.7 (0.7); 5.9-6.9  3.9 (1.4); 2.8-4.8  4.2 (0.4); 3.7-5.0  3.8 (1.9); 1.8-5.2  1.0  .33  Class ID  HCCQ Median (IQR); Min-Max  CCBS Median (IQR); Min-Max  SOLAS Scale 
Median (IQR); Min-Max  Education 
Component Median (IQR); Min-Max  Exercise 
Component Median (IQR); Min-Max  z Score  P Valueb  Total [1-7]  5.3 (1.4); 3.9-6.0  6.6 (0.5); 6.1-6.8  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  1 [1-7]  5.1 (1.5); 3.7-6.0  6.6 (0.4); 6.3-6.9  4.0 (1.1); 3.1-4.7  4.1 (0.9); 3.4-4.8  3.7 (1.3); 2.4-4.7  1.8  .07  4 [1-7]  5.3 (1.2); 4.2-5.9  6.5 (0.6); 5.4-6.8  4.0 (1.2); 3.2-5.0  4.1 (1.6); 3.5-5.7  4.1 (1.0); 2.9-4.5  1.7  .09  6 [1-7]  5.5 (1.3); 3.3-6.1  6.7 (0.7); 5.9-6.9  3.9 (1.4); 2.8-4.8  4.2 (0.4); 3.7-5.0  3.8 (1.9); 1.8-5.2  1.0  .33  aIQR = interquartile range, SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, z score = difference between the education and exercise components across all classes. bP < .016 is significant. View Large The CCBS results (Tab. 6) showed physical therapists were also not considered needs-thwarting during delivery, with a median score of 6.6 on a 7-point Likert scale ([0.5]; 6.1–6.8), which remained unchanged throughout the intervention (F [1,2] = 2.5, P = .2). Interrater agreement was poor for this measure (ICC = –0.3, 95% CI = –1.5–0.6); however, this may reflect the small sample size.44 Additionally, the range of ratings fell between the points of “5” and “7” on the Likert scale; therefore, the magnitude of discrepancy was small. The SOLAS scale results showed that the physical therapists delivered the SDT-based communication strategies with acceptable competence (median 4.0 on a 7-point Likert scale [1.2]; 3.2–4.9). Interrater reliability was moderate (ICC = 0.81, 95% CI = 0.6–0.9). However, none of the components of “collaborative goal setting, action planning, and problem solving” (ie, “review behavioral goal,” “goal setting,” “action planning,” “barrier identification,” and “problem solving”) were delivered with acceptable competence. More specifically, each of these components scored less than “4” on a 7-point Likert scale (Tab. 5). Concurrent validity was established, as the correlation between the HCCQ and the SOLAS scale was excellent (r = 0.86, P = .01). Physical therapists scored more highly in the education component of the intervention (median education 4.1 [0.8]; 3.7–5.2; median exercise 4.0 [1.4]; 2.7–4.6), but differences between the class components were not significant when adjusted for Bonferroni (z score = 2.4, P = .02). Linear modeling demonstrated no significant differences between classes, indicating that physical therapists consistently delivered the SDT-based communication strategies over time (F [1,2] = 0.3, P = .8; Tab. 6). Impact of Experience and Training on Physical Therapists’ Competence During Intervention Delivery When adjusted for Bonferroni corrections (P < .007), no significant relationships were found between the physical therapists’ baseline variables and their posttraining results (eTable 2 in eAppendix, available at https://academic.oup.com/ptj). Discussion Interpretation of Results Following training, the physical therapists were satisfied with the methods employed. Their confidence in the SDT-based communication strategies, and their knowledge of the advice for patients, significantly improved. Based on the simulated role-play, therapists were competent to deliver the SOLAS intervention in a needs-supportive manner following training, and implemented the intervention using this style across all classes. Therefore, training was broadly effective in preparing therapists to deliver the SOLAS intervention. However, “collaborative goal setting, action planning, and problem solving” did not reach the desired level of competence during delivery, indicating that future training should place greater emphasis on this strategy. Strengths and Limitations The findings of this study are limited to the intervention arm of the SOLAS feasibility trial. Fidelity evaluations involve the assessment of what has taken place, and as no training was provided to control group therapists, evaluation was not considered relevant. Nonetheless, a key strength of this study was the use of a formal evaluation model across multiple levels compared to previous research that simply evaluated providers during delivery, which has allowed a more comprehensive understanding of training's effectiveness.45 However, the robustness of the framework depends on the methods selected by those using it. Previous research using the Kirkpatrick model determined effectiveness solely through self-report,18 but the use of objective raters in this study provided a clearer understanding of the level of “behavior” and the skills component of “learning.” However, while the skills assessment demonstrated that the physical therapists were competent to deliver the SOLAS intervention, no pretraining assessment was completed, as it was not feasible to evaluate therapists in a group setting prior to training. Limited studies have evaluated skills either within or pretraining; 9,20,39 therefore, future research should include a pretraining skills assessment to further establish effectiveness at this level.12 Findings in Relation to the Literature Physical therapists were very satisfied with the SOLAS training program, suggesting that large-scale changes are not required to the methods employed. However, participants’ satisfaction with training programs and intention to use that training typically correlates poorly with future behavior.46 Nonetheless, participants’ reactions are important to consider to help inform future refinements and promote greater participant engagement with the program.33 Although therapists’ confidence in the SDT-based communication strategies significantly improved, their knowledge of these did not. However, their high pretraining levels suggest a ceiling effect, as therapists were highly experienced (median 9 years’ experience) and the majority had undertaken previous communication-based training (66.7%), which probably limited their potential for further improvement.47 Physical therapists’ needs-supportive behaviors during delivery were consistent with results in individual physical therapy (using the HCCQ),9,41 and are supported by the CCBS findings that demonstrated that physical therapists avoided overtly controlling behavior. This is important, as needs-thwarting behaviors negatively impact adaptive responses.26,48 Although global measures of needs-supportiveness allow researchers to compare their results to previous work, intervention-specific measures may highlight important contextual information that could influence subsequent training program refinements.38 Future research should therefore utilize both global and specific measures to comprehensively and reliably assess such training programs. Indeed, the SOLAS scale highlighted that each of the 5 components of “collaborative goal setting, action planning, and problem solving” were delivered below the minimum competence threshold (Tab. 5). This strategy should support patient autonomy, as self-determined goals are more effective than controlled goals; therefore, poor delivery of this strategy may produce diminished patient self-regulation.49,50 However, recent literature has shown that this strategy is frequently lacking within clinical environments due to the perceived difficulty in its use by both HCPs and patients.51,52 Specifically, the therapists report that more complex components such as problem solving and action planning are particularly difficult to deliver,53 a finding supported in the present study. This is important, as goals that are self-determined, specific in the required actions, and where barriers have been identified and considered are more likely to be successful than those that are not.54,55 Future training programs need to consider and define this strategy carefully.56 Implications and Future Work This study has provided valuable insights into how to best train physical therapists to deliver a communication-based group intervention. In particular, this study has highlighted the importance of the skills component of training programs. Physical therapists’ skills after training did not correlate with their delivery, while 2 components delivered below competence in training were subsequently delivered with competence. Therefore, the role-play environment of training did not sufficiently reflect the clinical environment, and could not predict physical therapists’ delivery. It is critical that future physical therapist training programs mirror their planned clinical environment as closely as possible, potentially by using actors to simulate a more realistic scenario.57,58 Fidelity guidelines suggest that providers be monitored during delivery until they are competent,2,12 with individualized feedback and coaching provided to those who need it.27,59 Individual “booster” sessions should therefore be considered within future training programs. Finally, a critical issue within training literature is the ambiguity surrounding competence, a complex, intervention-dependent issue.14,60 This study used the midpoint threshold;39,40,61 however, whether this is sufficient is debatable. Fidelity guidelines encourage a threshold of 80% for provider adherence during delivery.2 If these standards had been implemented in the current study, a minimum threshold of 5.6 on a 7-point Likert scale would have existed, equating to 0% of the physical therapists. Researchers should therefore be clear what competence looks like within their specific intervention. This study has highlighted the importance of setting a higher value on skill acquisition during training. This may allow researchers to identify strategies that require further training before delivery, but its feasibility within large-scale and pragmatic interventions warrants consideration. Excellent competence is likely to require intensive training that may be unacceptable to practitioners with limited time for training alongside clinical workload.62 E-learning may provide opportunities for HCPs to flexibly complete the theoretical and content components of training, upload audio examples of their skills for individualized feedback, and deliver this alongside further supplementary, face-to-face skills-based training.20 Utilizing such mixed methods of training should be investigated in future physical therapist education programs. In conclusion, this study contributed to the implementation and HCP training literature by using comprehensive methods guided by an evidence-based training framework to assess the feasibility of a training program in guiding physical therapists to effectively deliver the SOLAS intervention in a needs-supportive manner. Training was effective, as the therapists competently delivered the intervention. However, future similar physical therapist training programs should consider setting a higher threshold for competence, and further emphasize “collaborative goal setting, action planning, and problem solving.” Author Contributions Concept/idea/research design: A. Keogh, D.A. Hurley, J. Matthews, R. Segurado Writing: A. Keogh, J. Matthews, D.A. Hurley Data collection: A. Keogh Data analysis: A. Keogh, R. Segurado Project management: D.A. Hurley Fund procurement: D.A. Hurley Providing participants: D.A. Hurley Providing facilities/equipment: D.A. Hurley Providing institutional liaisons: D.A. Hurley Consultation (including review of manuscript before submitting): J. Matthews, R. Segurado, D.A. Hurley The authors acknowledge the work of Dr. Tim Howle in the rating of physical therapists’ behavior within this study. Ethics Approval This study was approved by the University College Dublin Human Research Ethics Committee. Funding The study was funded by the Health Research Board (no. HRA_HSR/2012/24). Disclosure and Presentations The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. References 1 Taylor C, Shaw R, Dale J, French D. Enhancing delivery of health behaviour change interventions in primary care: A meta-synthesis of views and experiences of primary care nurses. Patient Educ Couns . 2011; 85: 315– 322. Google Scholar CrossRef Search ADS PubMed  2 Borelli B. The assessment, monitoring and enhancement of treatment fidelity in public health clinical trials. J Public Health Dent . 2011; 71: S52– S63. 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Feasibility of Training Physical Therapists to Deliver the Theory-Based Self-Management of Osteoarthritis and Low Back Pain Through Activity and Skills (SOLAS) Intervention Within a Trial

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Publisher
Oxford University Press
Copyright
© 2017 American Physical Therapy Association
ISSN
0031-9023
eISSN
1538-6724
D.O.I.
10.1093/ptj/pzx105
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Provider training programs are frequently underevaluated, leading to ambiguity surrounding effective intervention components. Objective The purpose of this study was to assess the effectiveness of a training program in guiding physical therapists to deliver the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) group education and exercise intervention (ISRCTN49875385), using a communication style underpinned by self–determination theory (SDT). Design This was an assessment of the intervention arm training program using quantitative methods. Methods Thirteen physical therapists were trained using mixed methods to deliver the SOLAS intervention. Training was evaluated using the Kirkpatrick model: (1) Reaction—physical therapists’ satisfaction with training, (2) Learning—therapists’ confidence in and knowledge of the SDT-based communication strategies and intervention content and their skills in applying the strategies during training, and (3) Behavior—8 therapists were audio-recorded delivering all 6 SOLAS intervention classes (n = 48), and 2 raters independently coded 50% of recordings (n = 24) using the Health Care Climate Questionnaire (HCCQ), the Controlling Coach Behavior Scale (CCBS), and an intervention-specific measure. Results Reaction: Physical therapists reacted well to training (median [IRQ]; min-max = 4.7; [0.5]; 3.7–5.0). Learning: Physical therapists’ confidence in the SDT-based communication strategies and knowledge of some intervention content components significantly improved. Behavior: Therapists delivered the intervention in a needs-supportive manner (median HCCQ = 5.3 [1.4]; 3.9–6.0; median CCBS = 6.6 ([0.5]; 6.1–6.8; median intervention specific measure = 4.0 [1.2]; 3.2–4.9). However, “goal setting” was delivered below acceptable levels by all therapists (median 2.9 [0.9]; 2.0–4.0). Limitations The intervention group only was assessed as part of the process evaluation of the feasibility trial. Conclusions Training effectively guided physical therapists to be needs-supportive during delivery of the SOLAS intervention. Refinements were outlined to improve future similar training programs, including greater emphasis on goal setting. Behavior change interventions are increasingly implemented within health care to promote positive health behaviors.1 Health care providers (HCPs), including physical therapists, should have the knowledge, skills, and confidence to deliver these interventions effectively. Therefore, to promote effectively implemented interventions, physical therapists should be trained appropriately, and the effects of this training evaluated, to ensure they are competent to deliver programs as intended and to optimize intervention effectiveness.2 Medical Research Council (MRC) guidelines recommend process evaluations to assess the fidelity to, and implementation of, intervention components to understand how variables such as study design, provider training, and provider delivery have influenced outcomes.3,4 The need to evaluate provider training is well recognized, yet frequently unreported.5,6 It therefore remains unclear whether HCP training programs effectively alter HCP behavior long-term, or whether they lead to effective patient outcomes.7 Within physical therapist interventions specifically, limitations include not reporting how therapists were trained;8,9 not directly assessing training effectiveness;10 and using physical therapist researchers to deliver interventions, thus limiting the potential for future implementation in real-world settings.11 Fidelity guidelines suggest that following training, providers should be competent to deliver the intervention.12 However, competence is poorly defined, making it difficult to judge training effectiveness, as no minimum acceptable threshold has been agreed upon.13,14 A number of frameworks exist to support researchers developing and reporting training programs, although few offer guidance on how to evaluate their effectiveness.15 The Kirkpatrick model is one of the few to suggest methods of training evaluation16 that offers a systematic, simple assessment guide across 4 levels; that is, reaction, learning, behavior, and results. The model's strength is its aim to evaluate both the acute (immediately posttraining) and long-term effects of training (HCPs’ behavior in practice), rendering it a strong framework on which to evaluate training17 and one that is increasingly being used in health care settings including physical therapist training assessments.18–20 Self-Determination Theory in Health Care Health care interventions increasingly promote the importance of patient autonomy for successful treatment outcomes.21 Autonomy is a core principle of self-determination theory (SDT),22 which posits that social agents can influence a person's autonomous motivation, and ultimately their behavior, through the HCPs communication style and interaction with the person. This represents HCPs using a communication style that supports a patient's basic needs for autonomy, competence, and relatedness, leading to increased levels of autonomous motivation for the behavior. Strategies that support this include collaborative goal setting; the provision of positive and information-rich feedback; and acknowledging a patient's feelings and perspectives.23–25 However, communication styles can also thwart a patient's basic needs, leading to decreased levels of autonomous motivation through the use of pressurizing language; and ignoring a patient's input or suggestions and providing praise based on a patient's achievement of a behavior rather than their effort toward the behavior.26 While a communication style that supports patients’ basic needs (ie, needs-supportiveness) has been previously demonstrated as effective by physical therapists in individual physical therapy,9,27,28 and in group-based education and exercise interventions,25,29,30 its use in group-based physical therapy has yet to be reviewed. Study Context: The SOLAS Intervention Consequently, this study took place within the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) cluster randomized controlled feasibility trial (ISRCTN49875385),31,32 which compared a group-based intervention designed to increase self-management behaviors in participants with osteoarthritis and chronic low back pain to usual individual physical therapy care. The intervention comprised a 6-week, once-weekly 90-minute class underpinned by SDT.23 Physical therapists delivered 45 minutes of education composed of small-group lectures and informal discussions around different self-management topics each week (ie, physical activity; specific exercises; pain-coping strategies; pacing; healthy eating for lifestyle and balanced weight; pain management approaches including medication). This was followed by 45 minutes of supervised exercises with physical therapist guidance on exercise selection. Physical therapists were trained to deliver the SOLAS intervention.31,32 Therefore, building on the need for theory-based interventions delivered by competent practitioners, the aim of the current study was to evaluate the feasibility of this training in effectively guiding physical therapists to implement the SOLAS intervention using the required communication style. Methods Thirteen consenting physical therapists from 7 primary care clinics in Dublin/Kildare, Ireland, received 2 days of training in the content and delivery of the SOLAS intervention, including 8 hours of training in 9 SDT-based communication strategies (Tab. 1). Training effectiveness was assessed using the Kirkpatrick model of evaluation across the levels of reaction, learning, and behavior (defined within Tab. 2).21 Table 1. The SOLAS Intervention Physical Therapist (PT) Training Programa   Component 1: SOLAS Intervention Content  Component 2: SDT-Based 
Communication Strategies  Component 3: Interactive Activities  Description  The aims and objectives of the SOLAS intervention and the PT training program were outlined. The content of each SOLAS intervention class was discussed individually, with key elements emphasized. SOLAS intervention exercises were demonstrated and discussed with the PTs. The PTs discussed barriers and enablers to the delivery of the SOLAS intervention within their environment, and considered methods to overcome barriers where possible.  Self-determination theory was introduced, 
including a rationale for its use within this population. The concept of needs–supportive and needs-thwarting communication style was introduced and each of the SDT-based communication strategies were outlined. Video examples of ineffective use of these strategies were provided. The PTs reflected and discussed how these strategies may be delivered in a needs–supportive manner, before being shown video examples of the effective use of 
these strategies.  Individual role-play exercises were used to support PTs’ practice of the SDT-based communication strategies learned. Physical therapists delivered part of a SOLAS class during micro-teaching activities. Fellow PT participants and expert facilitators provided feedback. Background information on the hypothetical patients was provided, and participants took turns playing the roles of patients or PTs. These sessions were audio-recorded and assessed to determine PT’s delivery of the strategies.  Time spent  4 hours  5 hours  3 hours  Mode of delivery  Pre-reading materials were provided to PTs; Lecture and group discussion; PowerPoint slides; Program handout  Lecture and group discussion; Self–reflection; Goal setting and action planning; Video examples of effective and ineffective use of the SDT-based communication strategies  Role-play and micro-teaching activities; Self-reflection; Peer and facilitator feedback  SDT-based communication strategies PTs were trained to use  Definitions of the SDT-based communication strategies as per the SOLAS training protocol  Autonomy support: Strategies to support patient autonomy for behavior  Offer a meaningful rationale for the behavior  Verbal explanations that help the patient understand why the behavior / activity would have personal relevance  Provide opportunity for input and choice to patients  Provide information about options for the behavior, encouragement of patient choice making and patient initiation of their own action.  Use support and encouragement rather than pressurizing behavior  Communication that minimizes pressure and conveys a sense of choice and flexibility in the locution of behavior.  Structure: Strategies to support participant competence to engage in the behavior  Set clear expectations and provide appropriate direction  Present clear, understandable, and appropriately detailed directions regarding structure and content of the class.  Collaborative goal setting, action planning, and problem solvingb  Patient-“led,” PT-supported behavioral goals that are specific, measurable, achievable, and time-based are agreed upon. This is followed by patient-“led,” PT-supported identification of possible barriers to the behavior and solution development.  Provide positive, information-rich feedbackc  Nonjudgmental feedback focused on reinforcing effort as much as outcome. This feedback should be information-rich so that patient knows what to do in the future.  Provide patients with opportunities to practice behaviors  Guide, demonstrate, and support patients in practicing behaviors.  Interpersonal involvement: Strategies to support relatedness  Acknowledge and take into account patient feelings and perspectives  Acknowledge feelings and display general empathy toward the patients’ situation and opinions. Tension-relieving acknowledgment that patient concerns are legitimate.  Build relationshipsd  Using patients’ names, encouraging patients to share information and support each other during the class. Using active listening techniques, staying silent and allowing patients time to speak.    Component 1: SOLAS Intervention Content  Component 2: SDT-Based 
Communication Strategies  Component 3: Interactive Activities  Description  The aims and objectives of the SOLAS intervention and the PT training program were outlined. The content of each SOLAS intervention class was discussed individually, with key elements emphasized. SOLAS intervention exercises were demonstrated and discussed with the PTs. The PTs discussed barriers and enablers to the delivery of the SOLAS intervention within their environment, and considered methods to overcome barriers where possible.  Self-determination theory was introduced, 
including a rationale for its use within this population. The concept of needs–supportive and needs-thwarting communication style was introduced and each of the SDT-based communication strategies were outlined. Video examples of ineffective use of these strategies were provided. The PTs reflected and discussed how these strategies may be delivered in a needs–supportive manner, before being shown video examples of the effective use of 
these strategies.  Individual role-play exercises were used to support PTs’ practice of the SDT-based communication strategies learned. Physical therapists delivered part of a SOLAS class during micro-teaching activities. Fellow PT participants and expert facilitators provided feedback. Background information on the hypothetical patients was provided, and participants took turns playing the roles of patients or PTs. These sessions were audio-recorded and assessed to determine PT’s delivery of the strategies.  Time spent  4 hours  5 hours  3 hours  Mode of delivery  Pre-reading materials were provided to PTs; Lecture and group discussion; PowerPoint slides; Program handout  Lecture and group discussion; Self–reflection; Goal setting and action planning; Video examples of effective and ineffective use of the SDT-based communication strategies  Role-play and micro-teaching activities; Self-reflection; Peer and facilitator feedback  SDT-based communication strategies PTs were trained to use  Definitions of the SDT-based communication strategies as per the SOLAS training protocol  Autonomy support: Strategies to support patient autonomy for behavior  Offer a meaningful rationale for the behavior  Verbal explanations that help the patient understand why the behavior / activity would have personal relevance  Provide opportunity for input and choice to patients  Provide information about options for the behavior, encouragement of patient choice making and patient initiation of their own action.  Use support and encouragement rather than pressurizing behavior  Communication that minimizes pressure and conveys a sense of choice and flexibility in the locution of behavior.  Structure: Strategies to support participant competence to engage in the behavior  Set clear expectations and provide appropriate direction  Present clear, understandable, and appropriately detailed directions regarding structure and content of the class.  Collaborative goal setting, action planning, and problem solvingb  Patient-“led,” PT-supported behavioral goals that are specific, measurable, achievable, and time-based are agreed upon. This is followed by patient-“led,” PT-supported identification of possible barriers to the behavior and solution development.  Provide positive, information-rich feedbackc  Nonjudgmental feedback focused on reinforcing effort as much as outcome. This feedback should be information-rich so that patient knows what to do in the future.  Provide patients with opportunities to practice behaviors  Guide, demonstrate, and support patients in practicing behaviors.  Interpersonal involvement: Strategies to support relatedness  Acknowledge and take into account patient feelings and perspectives  Acknowledge feelings and display general empathy toward the patients’ situation and opinions. Tension-relieving acknowledgment that patient concerns are legitimate.  Build relationshipsd  Using patients’ names, encouraging patients to share information and support each other during the class. Using active listening techniques, staying silent and allowing patients time to speak.  aSOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, SDT = self-determination theory. bThis strategy was split into 5 component behaviors: (1) review behavioral goal, (2) goal setting, (3) action planning, (4) barrier identification, and 
(5) problem solving. cThis strategy was split into 2 component behaviors: (1) provide positive encouragement toward a behavior and (2) provide positive, information-rich feedback. dThis strategy was split into 2 component behaviors: (1) active listening and (2) interest in patients. View Large Table 2. Assessment of the SOLAS Intervention Physical Therapist (PT) Training Program Using the Kirkpatrick Model of Evaluationa Kirkpatrick Model Level  Research Aim of the Level  Method of 
Measurement Within the SOLAS Intervention  Data Collection Method and 
Time Point  Outcome Measure  (1) Reaction How participants reacted to the training program  Were PTs satisfied with training?  PT self-reported satisfaction with the training program  Paper-based questionnaire, posttraining  Intervention-specific satisfaction questionnaire          Validity: Questionnaires were piloted for understanding. Questions followed the suggestions of the Kirkpatrick Model and previous research investigating provider satisfaction.16,33,63          Reliability: Not applicable          Sample question: “The videos were useful to identify different forms of facilitating”; 1 = strongly disagree; 5 = strongly agree  (2) Learning The extent to which participants change attitudes, improve knowledge, and/or increase skills as a result of participating in the training program  Did PTs’ confidence in and knowledge of the SOLAS content and SDT-based communication strategies improve with training? Did PTs have the skills to deliver the SOLAS intervention following training?  PT self-reported confidence in the SDT-based communication strategies and the intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific self-reported confidence questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your confidence in using the following:          Setting clear expectations; 1 = not at all good; 7 = very good      PT knowledge of SDT-based communication strategies  Paper-based questionnaire, pretraining and posttraining  Intervention-specific narrative questionnaire modeled on the Problems in Schools Questionnaire34          Validity: Construct validity tested previously.34 Pilot testing was completed on 4 PTs prior to commencement of the SOLAS PT training program. Following piloting a hypothetical patient scenario was developed by the researchers (X and Y) in order to standardize PT responses and provide a more accurate comparison of their knowledge of the SDT-based communication strategies.          Reliability: Tested for interrater agreement in this study using percentage agreement. Problems in School Questionnaire previously shown to have excellent interrater reliability.34,35      PT knowledge of the SOLAS intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific knowledge questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your knowledge of the following:          Physical activity prescription; 1 = not at all good; 7 = very good      PTs skills in applying the SDT-based communication strategies in a needs-supportive manner  Audio-recorded role-plays during the SOLAS training program  Intervention-specific measure of needs 
supportiveness modeled on the Reeve scale42; the SOLAS scale          Validity: Original Reeve scale shown to have content validity.42 Concurrent validity with the HCCQ tested within this study using Pearson product correlation.          Reliability: Reeve scale previously shown to have 
excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample anchor points: For the strategy of “uses support and encouragement rather than pressurizing behaviors”; 1 = uses directive, strict, controlling language; 7 = uses supportive, noncontrolling language  (3) Behavior The extent to which behavior has occurred because the participant engaged with training  Did PTs competently deliver the SOLAS intervention using a needs-supportive communication style?  PTs’ skills during the delivery of the SOLAS intervention (ie, whether the classes were delivered in a needs–supportive manner)  Audio-recorded delivery of the SOLAS intervention  The 15-item Health Care Climate Questionnaire64          Validity: Construct validity previously tested.41,64          Reliability: Previously shown to have excellent interrater reliability.9,41 Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT provided the clients with choices and options; 1 = strongly disagree; 7 = strongly agree          A 5-item version of the Controlling Coach Behavior Scale26          Validity: Content validity previously tested.26          Reliability: Previously shown to have excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT only praises clients to make them keep up with their exercise goals; 1 = strongly disagree; 7 = strongly agree          Intervention-specific measure of needs supportiveness modeled on the Reeve scale42; the SOLAS scale          As listed above  Kirkpatrick Model Level  Research Aim of the Level  Method of 
Measurement Within the SOLAS Intervention  Data Collection Method and 
Time Point  Outcome Measure  (1) Reaction How participants reacted to the training program  Were PTs satisfied with training?  PT self-reported satisfaction with the training program  Paper-based questionnaire, posttraining  Intervention-specific satisfaction questionnaire          Validity: Questionnaires were piloted for understanding. Questions followed the suggestions of the Kirkpatrick Model and previous research investigating provider satisfaction.16,33,63          Reliability: Not applicable          Sample question: “The videos were useful to identify different forms of facilitating”; 1 = strongly disagree; 5 = strongly agree  (2) Learning The extent to which participants change attitudes, improve knowledge, and/or increase skills as a result of participating in the training program  Did PTs’ confidence in and knowledge of the SOLAS content and SDT-based communication strategies improve with training? Did PTs have the skills to deliver the SOLAS intervention following training?  PT self-reported confidence in the SDT-based communication strategies and the intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific self-reported confidence questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your confidence in using the following:          Setting clear expectations; 1 = not at all good; 7 = very good      PT knowledge of SDT-based communication strategies  Paper-based questionnaire, pretraining and posttraining  Intervention-specific narrative questionnaire modeled on the Problems in Schools Questionnaire34          Validity: Construct validity tested previously.34 Pilot testing was completed on 4 PTs prior to commencement of the SOLAS PT training program. Following piloting a hypothetical patient scenario was developed by the researchers (X and Y) in order to standardize PT responses and provide a more accurate comparison of their knowledge of the SDT-based communication strategies.          Reliability: Tested for interrater agreement in this study using percentage agreement. Problems in School Questionnaire previously shown to have excellent interrater reliability.34,35      PT knowledge of the SOLAS intervention content  Paper-based questionnaire, pretraining and posttraining  Intervention-specific knowledge questionnaire          Validity: Questionnaires were piloted for understanding, with no amendments required.          Reliability: Not applicable          Sample anchor points: How would you describe your knowledge of the following:          Physical activity prescription; 1 = not at all good; 7 = very good      PTs skills in applying the SDT-based communication strategies in a needs-supportive manner  Audio-recorded role-plays during the SOLAS training program  Intervention-specific measure of needs 
supportiveness modeled on the Reeve scale42; the SOLAS scale          Validity: Original Reeve scale shown to have content validity.42 Concurrent validity with the HCCQ tested within this study using Pearson product correlation.          Reliability: Reeve scale previously shown to have 
excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample anchor points: For the strategy of “uses support and encouragement rather than pressurizing behaviors”; 1 = uses directive, strict, controlling language; 7 = uses supportive, noncontrolling language  (3) Behavior The extent to which behavior has occurred because the participant engaged with training  Did PTs competently deliver the SOLAS intervention using a needs-supportive communication style?  PTs’ skills during the delivery of the SOLAS intervention (ie, whether the classes were delivered in a needs–supportive manner)  Audio-recorded delivery of the SOLAS intervention  The 15-item Health Care Climate Questionnaire64          Validity: Construct validity previously tested.41,64          Reliability: Previously shown to have excellent interrater reliability.9,41 Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT provided the clients with choices and options; 1 = strongly disagree; 7 = strongly agree          A 5-item version of the Controlling Coach Behavior Scale26          Validity: Content validity previously tested.26          Reliability: Previously shown to have excellent interrater reliability. Reliability within this study tested using intraclass correlation coefficients.          Sample question: The PT only praises clients to make them keep up with their exercise goals; 1 = strongly disagree; 7 = strongly agree          Intervention-specific measure of needs supportiveness modeled on the Reeve scale42; the SOLAS scale          As listed above  aHCCQ = Health Care Climate Questionnaire, SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, SDT = self–determination theory. View Large Outcome Measures Reaction Physical therapists’ satisfaction with the training methods and content was assessed posttraining using an intervention specific self-report measure (Tab. 2).16,33 Physical therapists answered 22 questions on separate 5-point Likert scales ranging from “1–strongly disagree” to “5–strongly agree.” Learning Physical therapists’ confidence, knowledge, and skills were evaluated to assess “learning.” To assess the physical therapists’ confidence in the SOLAS intervention content and SDT-based communication strategies, an intervention-specific questionnaire was used pretraining and posttraining. Physical therapists rated their confidence in the 9 SDT-based communication strategies, and the SOLAS intervention content on separate 7-point Likert scales ranging from “1–not at all good” to “7–very good.” Physical therapists’ knowledge of the SDT-based communication strategies was assessed pretraining and posttraining using a narrative case study modeled on a previously validated measure.34,35 The measure was amended to include a hypothetical patient scenario to standardize therapists’ responses. Physical therapists reported how they would interact with the patient who was described as having low back pain, a fear of movement, and limited time to exercise. Two masked raters independently assessed responses for the presence/absence of the SDT-based communication strategies, with a score of “1” for strategies that were present and “0” if absent. Physical therapists’ knowledge was listed as a percentage of those utilizing each strategy in their response. Physical therapists’ knowledge of the SOLAS intervention content (ie, information on pacing, physical activity, pain management, etc, as listed within Table 1) was also assessed pretraining and posttraining using an intervention-specific questionnaire. Physical therapists rated their knowledge of the SOLAS intervention content on separate 7-point Likert scales ranging from “1– not at all good” to “7–very good.” Physical therapists also narratively listed the stages of the cycle of change; effective pain relief strategies; and advice they would give to patients with a flare-up. Finally, physical therapists’ skills in applying the SDT-based communication strategies were measured during a simulated role-play at the end of training. Physical therapists delivered a short component of a SOLAS class while physical therapist PhD students and other participating physical therapists acted as patients. Instructions were provided on the class component to be delivered, along with short explanations regarding their patients’ main problems. They were instructed to act out the scenario applying as many of the SDT-based communication strategies as possible. These role-plays were audio-recorded and independently assessed by 2 raters using the SOLAS scale, an intervention-specific measure described in detail below. Behavior Of the 13 trained physical therapists, a subgroup of 8 delivered the intervention within the feasibility trial. Physical therapists were audio-recorded delivering all 6 SOLAS intervention classes (n = 48 audio recordings). Two raters (A.K., T.H.) independently coded 50% (n = 24) of these recordings to assess the therapists’ needs-supportive communication style, to establish whether they applied this consistently across classes, and to determine the impact of provider experience on delivery.2,36 Prior to coding, raters completed a training and familiarization process, including the use of a coding manual to support consistent and accurate coding (eAppendix, available at https://academic.oup.com/ptj). The validated Health Care Climate Questionnaire (HCCQ)37 was selected as the primary measure for the level of “behavior,” with 2 secondary measures; an adapted version of the Controlling Coach Behavior Scale (CCBS);26 and an intervention-specific measure to assess the trained SDT-based communication strategies.38 Classes 1, 4, and 6 were selected to capture physical therapists’ competence over time, as these represented the beginning, middle, and end of the intervention. In the absence of a robust definition of competence, it was defined as the midpoint of the Likert scale (>4/7) on the selected measures.39,40 The HCCQ contains 15 statements relating to providers’ provision of autonomy support.41 Each statement is scored on separate 7-point Likert scales from “1–strongly disagree” to “7–strongly agree.” Two raters independently completed a HCCQ for each of the 24 classes. Five statements were selected from the CCBS based on their relevance to the intervention, with 1 question selected from each of the CCBS subscales.26 Each statement is scored on separate 7-point Likert scales from “1–strongly disagree” to “7–strongly agree.” Two raters independently completed a CCBC for each of the 24 classes. To augment these, a measure specific to the SOLAS intervention was developed (SOLAS scale in eAppendix, available at https://academic.oup.com/ptj). The SOLAS scale was based on the tool by Reeve,42 which has been previously adapted for use in group exercise classes.43 The 9 SDT-based communication strategies were divided into 15 component behaviors in order to capture whether some were trained more effectively than others. For example, “collaborative goal setting, action planning, and problem solving” was divided into 5 components: “review behavioral goal”; “goal setting”; “action planning”; “barrier identification”; and “problem solving.” To understand if differences in the use of these strategies existed during each class, 1 measure was completed for the education component and another for the exercise component of each class. Strategies were assessed on separate 7-point Likert scales ranging from “1–not at all well” to “7–very well.” Average scores were calculated to determine whether the 15 component behaviors (based on the 9 SDT-based communication strategies) were delivered competently. Specifically, an average score per component behavior (eg, positive feedback), per class component (eg, education), and per class were calculated. Data Analysis Data from all measures were analyzed using Excel (Microsoft for Mac, version 14.2.3) and a statistical software package (IBM, SPSS Statistics, version 20). A Shapiro-Wilk test was employed to test normality of distribution for the continuous data. Reaction To assess the physical therapists’ satisfaction with the SOLAS training program, scores were averaged across physical therapists and descriptive statistics were computed (Median [interquartile range]; minimum [min]-maximum [max]). Learning Scores for each measure within this level were averaged across the physical therapists. To assess whether therapists’ confidence in these areas changed following training, a Wilcoxon Signed Rank test was used, with time (pretraining vs posttraining) the categorical independent variable, and confidence (measured on Likert scales ranging from 1 to 7) the dependent variable of interest. Results were adjusted for multiplicity using a Bonferroni correction. McNemar's test analyzed changes in the proportion of physical therapists (pretraining vs posttraining) using each of the SDT-based communication strategies during the narrative case study. Interrater agreement was established using percentage agreement based on presence or absence responses. To assess changes in the physical therapists’ knowledge of the intervention content following training, a Wilcoxon Signed Rank test was used with time (pretraining vs posttraining) the categorical independent variable, and knowledge the dependent variable of interest. Results were adjusted for multiplicity using a Bonferroni correction. To establish therapists’ skills in applying the SDT-based communication strategies during training, scores were averaged across therapists and descriptive statistics calculated (median [IQR]; min-max). Interrater reliability was established using an intraclass correlation coefficient (ICC) 2-way random model for absolute agreement with 95% confidence intervals (CI). Behavior Interrater reliability for all measures (n = 24 per rater) in the level of “behavior” was calculated using an ICC as described above (ie, HCCQ, adapted CCBS, and the SOLAS 
scale). To assess change in the physical therapists’ delivery during the course of the intervention (n = 24 for 8 therapists in 3 classes averaged across 2 raters), linear mixed-effects modeling was used. The model specifications were marginal models for the population means, using therapists as participants with repeated observations over classes and correlated residuals with unstructured variance-covariance. The HCCQ, CCBS, and SOLAS scale scores were the dependent variables, and classes were the independent variable. Criterion validity of the SOLAS scale was tested against the HCCQ using Pearson's product correlation. Data for these 3 measures were normally distributed; however, in order to list therapists’ overall competence in each measure during intervention delivery, results were averaged across the 3 classes and 2 raters. Therefore, the number of data points equaled the number of physical therapists (n = 8) and we defaulted to nonparametric descriptive statistics to report therapists’ competence (median [IQR]; min-max). The relationship between posttraining results across the 3 evaluation levels (ie, learning, reaction, and behavior) and the physical therapists’ previous experience (ie, years qualified, years delivering groups, previous communication training), motivation to participate, and expectations of treatment were calculated using Spearman's rank correlation coefficients (ordinal data) or a Mann-Whitney U test (nominal data) for each variable independently. Results were adjusted for multiplicity using a Bonferroni correction. Results Thirteen physical therapists completed training, of which pretraining and posttraining results are available for 12. The results for the Kirkpatrick model levels of “reaction” and “learning” refer to these 12 therapists, who had a median 9.0 years’ experience ([10.5]; 4–25), and 3 years’ experience working with groups ([4.8]; 1–10). Eight of these therapists (66.7%) had previously completed communication training. Results for the Kirkpatrick model level of “behavior” relate to the 8 therapists who delivered the SOLAS intervention within the feasibility trial. This subgroup had 10.5 years’ experience ([5.8]; 5–25), and 5.0 years’ experience with groups ([5.8]; 1–15). Seven therapists (87.5%) had previously undertaken some form of communication training. Reaction Physical therapists’ satisfaction with training was excellent (median = 4.7 on a 5-point Likert scale; [0.5]; 3.7–5.0). Physical therapists planned to implement the skills learned into their general practice and the SOLAS intervention (median 5.0 [0.0]; 4.0–5.0) (eTable 1 in eAppendix, available at https://academic.oup.com/ptj). Learning Physical therapists’ confidence in their use of the SDT-based communication strategies was high pretraining (median = 5.3 on a 7-point Likert scale [0.7]; 3.4–6.0), and significantly increased posttraining (z score = 2.8, P = .005; Tab. 3). Five individual strategies demonstrated improvements of P ≤ .05; however, following Bonferroni corrections, only “opportunity for patient input and choice” remained significant (Tab. 3). Physical therapists’ confidence in the SOLAS intervention content was also high pretraining (4.8 on a 7-point Likert scale [1.6]; 3.7–6.0), and did not significantly improve following Bonferroni corrections (z score = 2.8, P = .01; Tab. 4). Table 3. Change in Physical Therapist (PT) Confidence and Knowledge of the Self-Determination Theory (SDT)-Based Communication Strategiesa SDT-Based Communication 
Strategies  Median Pretraining (IQR); Min-Max  Median Posttraining (IQR); Min-Max  z Scorea  P Value  Median 
Pretrainingb (%; n = PTs)  Median Posttraining (%; n = PTs)  P Value  Confidence [1-7]c  Knowledge (Present or Absent)  Total  5.3 (0.7); 3.4-6.0  5.8 (0.4); 5.1-6.6  2.8  .005c  8 (2.0); 
5.0-9.0  7.5 (2.0); 6.0-9.0  .70  Offer a meaningful rationale (n = 5)d [1-7]  5.0 (1.5); 5.0-7.0  5.0 (1.5); 5.0-7.0  0.0  1.00  83.3% (10)  75.0% (9)  1.00  Provide opportunities for patient input and choice [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-6.0  3.0  .003c  91.7% (11)  100% (12)  1.00  Use support and encouragement rather than pressurizing behaviors [1-7]  5.0 (0.5); 4.0-5.0  6.0 (0.5); 5.0-6.0  2.3  .03  100% (12)  100% (12)  N/Ae  Set clear expectations and provide direction [1-7]  5.0 (1.5); 4.0-6.0  6.0 (1.5); 5.0-7.0  2.6  .01  Not includedf  Not includedf    Collaborative goal setting and action planning [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-60  1.7  .10  75.0% (9)  91.7% (11)  .50  Collaborative problem solvingg [1-7]  N/A  N/A  N/A  N/A  100% (12)  100% (12)  N/Ae  Provide positive information-rich feedback [1-7]  6.0 (2.0); 5.0-7.0  6.0 (1.0); 6.0-7.0  0.8  .43  66.7% (8)  66.7% (8)  1.00  Provide opportunities to practice behaviors [1-7]  6.0 (1.5); 5.0-7.0  6.0 (0.0); 5.0-6.0  1.4  .15  66.7% (8)  50.0% (6)  .63  Acknowledge patients’ feelings and perspectives [1-7]  6.0 (1.5); 5.0-7.0  7.0 (1.0); 6.0-7.0  1.9  .05  91.7% (11)  91.7% (11)  1.00  Build relationships [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.5); 6.0-7.0  2.1  .03  100% (12)  91.7% (11)  1.00  SDT-Based Communication 
Strategies  Median Pretraining (IQR); Min-Max  Median Posttraining (IQR); Min-Max  z Scorea  P Value  Median 
Pretrainingb (%; n = PTs)  Median Posttraining (%; n = PTs)  P Value  Confidence [1-7]c  Knowledge (Present or Absent)  Total  5.3 (0.7); 3.4-6.0  5.8 (0.4); 5.1-6.6  2.8  .005c  8 (2.0); 
5.0-9.0  7.5 (2.0); 6.0-9.0  .70  Offer a meaningful rationale (n = 5)d [1-7]  5.0 (1.5); 5.0-7.0  5.0 (1.5); 5.0-7.0  0.0  1.00  83.3% (10)  75.0% (9)  1.00  Provide opportunities for patient input and choice [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-6.0  3.0  .003c  91.7% (11)  100% (12)  1.00  Use support and encouragement rather than pressurizing behaviors [1-7]  5.0 (0.5); 4.0-5.0  6.0 (0.5); 5.0-6.0  2.3  .03  100% (12)  100% (12)  N/Ae  Set clear expectations and provide direction [1-7]  5.0 (1.5); 4.0-6.0  6.0 (1.5); 5.0-7.0  2.6  .01  Not includedf  Not includedf    Collaborative goal setting and action planning [1-7]  5.0 (1.0); 4.0-6.0  6.0 (0.5); 5.0-60  1.7  .10  75.0% (9)  91.7% (11)  .50  Collaborative problem solvingg [1-7]  N/A  N/A  N/A  N/A  100% (12)  100% (12)  N/Ae  Provide positive information-rich feedback [1-7]  6.0 (2.0); 5.0-7.0  6.0 (1.0); 6.0-7.0  0.8  .43  66.7% (8)  66.7% (8)  1.00  Provide opportunities to practice behaviors [1-7]  6.0 (1.5); 5.0-7.0  6.0 (0.0); 5.0-6.0  1.4  .15  66.7% (8)  50.0% (6)  .63  Acknowledge patients’ feelings and perspectives [1-7]  6.0 (1.5); 5.0-7.0  7.0 (1.0); 6.0-7.0  1.9  .05  91.7% (11)  91.7% (11)  1.00  Build relationships [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.5); 6.0-7.0  2.1  .03  100% (12)  91.7% (11)  1.00  aIQR = interquartile range; z score = difference in pretraining and posttraining results. bReported as the percentage of PTs who used the strategies in their responses. cP ≤ .005 is significant following Bonferroni adjustments. dMissing data; only 5 PTs answered this question pretraining and posttraining. eN/A = McNemar test not calculated as no association was found, and the variables were constant. f“Set clear expectations” was not included in the narrative component of the assessment, as it was not expected to be delivered within the context of the hypothetical case study provided. gProblem solving was considered under the heading of goal setting within the confidence scale. View Large Table 4. Change in Physical Therapist (PT) Confidence and Knowledge of the SOLAS Intervention Contenta   Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Confidenceb  Knowledge  Total  4.8 (1.6); 3.7-6.0  5.7 (0.7); 
4.3-6.4  2.8  .01  4.9 (0.9); 
3.8-6.1  5.7 (1.1); 
4.4-6.6  2.3  .02  Disease mechanisms [1-7]  5.0 (1.0); 4.0-6.0  6.0 (1.0); 5.0-7.0  1.9  .06  5.0 (1.0); 3.0-7.0  6.0 (1.0); 5.0-7.0  1.7  .10  Exercise [1-7]  6.0 (1.0); 5.0-6.0  6.0 (0.8); 5.0-7.0  2.7  .01  5.5 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  1.9  .06  Physical activity promotion [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.0); 5.0-7.0  1.9  .06  6.0 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  2.1  .04  Healthy eating and 
diet [1-7]  5.0 (2.8); 3.0-6.0  6.0 (1.0); 3.0-7.0  1.9  .05  5.0 (1.0); 3.0-7.0  6.0 (1.0); 3.0-7.0  0.7  .51  Relaxation [1-7]  5.0 (2.5); 1.0-6.0  6.0 (2.5); 3.0-7.0  1.7  .08  5.0 (3.0); 2.0-7.0  6.0 (2.8); 3.0-7.0  1.7  .08  Pain relief techniques [1-7]  5.5 (1.8); 3.0-7.0  6.0 (1.0); 3.0-7.0  1.0  .32  5.5 (1.0); 3.0-7.0  6.0 (0.8); 3.0-7.0  0.6  .56  Medication [1-7]  3.5 (2.0); 2.0-6.0  5.0 (1.8); 3.0-6.0  2.6  .01  3.0 (1.8); 2.0-5.0  5.0 (1.8); 3.0-6.0  3.0  .003b  Pacing [1-7]  5.0 (1.8); 3.0-7.0  6.0 (0.0); 5.0-7.0  2.5  .01  5.0 (1.8); 3.0-7.0  6.0 (0.8); 5.0-7.0  1.7  .08  Mood regulation [1-7]  4.5 (3.8); 2.0-6.0  5.5 (2.5); 3.0-7.0  1.5  .14  5.0 (0.8); 2.0-7.0  5.0 (1.8); 3.0-6.0  0.8  .43  Narrative totalc[0–16]d  10.5 (6.8); 
5.0-16.0  13.0 (4.5); 
8.0-16.0  2.5  .011d          Cycle of change [0-5]  N/A  N/A  N/A  N/A  3.0 (2.5); 0.0-5.0  5.0 (1.8); 3.0-5.0  2.4  .02  Advice to patients [0-3]  N/A  N/A  N/A  N/A  3.0 (0.0); 2.0-3.0  3.0 (0.8); 2.0-3.0  0.6  .56  Use of pain modalities [0-8]  N/A  N/A  N/A  N/A  4.5 (4.8); 2.0-8.0  6.0 (4.5); 2.0-8.0  1.7  .09    Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Median 
Pretraining (IQR); Min-Max  Median 
Posttraining (IQR); Min-Max  z Score  P Value  Confidenceb  Knowledge  Total  4.8 (1.6); 3.7-6.0  5.7 (0.7); 
4.3-6.4  2.8  .01  4.9 (0.9); 
3.8-6.1  5.7 (1.1); 
4.4-6.6  2.3  .02  Disease mechanisms [1-7]  5.0 (1.0); 4.0-6.0  6.0 (1.0); 5.0-7.0  1.9  .06  5.0 (1.0); 3.0-7.0  6.0 (1.0); 5.0-7.0  1.7  .10  Exercise [1-7]  6.0 (1.0); 5.0-6.0  6.0 (0.8); 5.0-7.0  2.7  .01  5.5 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  1.9  .06  Physical activity promotion [1-7]  6.0 (1.0); 5.0-7.0  6.0 (0.0); 5.0-7.0  1.9  .06  6.0 (1.0); 4.0-7.0  6.0 (0.8); 5.0-7.0  2.1  .04  Healthy eating and 
diet [1-7]  5.0 (2.8); 3.0-6.0  6.0 (1.0); 3.0-7.0  1.9  .05  5.0 (1.0); 3.0-7.0  6.0 (1.0); 3.0-7.0  0.7  .51  Relaxation [1-7]  5.0 (2.5); 1.0-6.0  6.0 (2.5); 3.0-7.0  1.7  .08  5.0 (3.0); 2.0-7.0  6.0 (2.8); 3.0-7.0  1.7  .08  Pain relief techniques [1-7]  5.5 (1.8); 3.0-7.0  6.0 (1.0); 3.0-7.0  1.0  .32  5.5 (1.0); 3.0-7.0  6.0 (0.8); 3.0-7.0  0.6  .56  Medication [1-7]  3.5 (2.0); 2.0-6.0  5.0 (1.8); 3.0-6.0  2.6  .01  3.0 (1.8); 2.0-5.0  5.0 (1.8); 3.0-6.0  3.0  .003b  Pacing [1-7]  5.0 (1.8); 3.0-7.0  6.0 (0.0); 5.0-7.0  2.5  .01  5.0 (1.8); 3.0-7.0  6.0 (0.8); 5.0-7.0  1.7  .08  Mood regulation [1-7]  4.5 (3.8); 2.0-6.0  5.5 (2.5); 3.0-7.0  1.5  .14  5.0 (0.8); 2.0-7.0  5.0 (1.8); 3.0-6.0  0.8  .43  Narrative totalc[0–16]d  10.5 (6.8); 
5.0-16.0  13.0 (4.5); 
8.0-16.0  2.5  .011d          Cycle of change [0-5]  N/A  N/A  N/A  N/A  3.0 (2.5); 0.0-5.0  5.0 (1.8); 3.0-5.0  2.4  .02  Advice to patients [0-3]  N/A  N/A  N/A  N/A  3.0 (0.0); 2.0-3.0  3.0 (0.8); 2.0-3.0  0.6  .56  Use of pain modalities [0-8]  N/A  N/A  N/A  N/A  4.5 (4.8); 2.0-8.0  6.0 (4.5); 2.0-8.0  1.7  .09  aIQR = interquartile range; SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills. bP ≤ .005 is significant following Bonferroni adjustments. cNot tested within the confidence scale, as these were narrative questions. dP ≤ .013 is significant following Bonferroni adjustments. View Large Regarding the physical therapists’ knowledge of the SDT-based communication strategies, pretraining knowledge was high with no change posttraining (Tab. 3). Across therapists, a median 8 out of 9 strategies ([2.0]; 5.0–9.0) were used in the narrative responses pretraining, compared to 7.5 ([2.0]; 6.0–9.0) posttraining. Interrater agreement for the presence of the strategies within the case study narratives was good (mean 78.7% pretraining; mean 81.5% posttraining). Physical therapists’ knowledge of the SOLAS intervention content was high pretraining (4.9 on a 7-point Likert scale [0.9]; 3.8–6.1) and improved posttraining, although not significantly when adjusted for Bonferroni (z score = 2.3, P = .02; Tab. 4). Physical therapists’ knowledge of the 3 narrative questions was also high pretraining (10.5 [6.8]; 5.0–16.0), and significantly improved posttraining (z score = 2.5, P = .011; Tab. 4). Ten physical therapists had their simulated role-play activity successfully audio-recorded; the recordings for the other 3 therapists failed due to technical reasons. Physical therapists had a median skill level of 4.3 on a 7-point Likert scale ([1.3]; range = 3.5–4.9), indicating that they competently applied the SDT-based communication strategies within a mock clinical environment. However, 4 of the 15 behaviors failed to reach the defined threshold for competence (ie, “setting clear expectations,” “action-planning,” “provide opportunity to practice,” and “acknowledge patients’ feelings and perspectives” scored less than “4” on the 7-point Likert scale; Tab. 5). Interrater reliability for the SOLAS scale within training was moderate with an ICC = 0.8, 95% CI = 0.2–1.0. Table 5. Physical Therapist (PT) Use of the Self-Determination Theory (SDT)-Based Communication Strategies During the Micro-Teaching Component of Training and During Their Delivery of the SOLAS Intervention Classesa   Training (n = 10)b  Delivery (n = 8)  SDT-Based Communication Strategies  Median Needs 
Supportiveness (IQR); Min-Max  Class Median (IQR); Min-Max  Education Median (IQR); Min-Max  Exercise Median (IQR); Min-Max  z Scorea  P Valuec  Total [1-7]  4.3 (1.0); 3.3-4.9  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  Autonomy support  Offer a meaningful rationale [1-7]  4.3 (2.5); 3.0-6.0  4.3 (1.8); 3.8-6.3  5.2 (1.6); 4.2-6.3  3.8 (2.0); 3.0-6.2  2.5  .01  Provide opportunities for patient input and choice [1-7]  5.3 (1.3); 4.0-6.0  4.8 (1.6); 3.5-5.8  4.5 (1.5); 3.7-5.8  4.9 (2.0); 3.3-5.7  0.4  .67  Use support and encouragement rather than pressurizing behaviors [1-7]  4.3 (2.1); 3.5-6.0  4.2 (1.5); 3.1-5.3  4.0 (1.1); 2.8-5.2  4.3 (1.4); 2.7-5.7  0.4  .67  Structure  Set clear expectations and provide direction [1-7]  3.0 (3.5); 1.0-6.5  4.3 (0.5); 3.9-5.1  5.4 (0.8); 4.8-6.2  3.4 (1.2); 2.7-4.0  2.5  .01  Goal setting: Review goal setting [1-7]  5.0 (1.8); 3.5-6.0  2.7 (1.7); 1.3-4.1  3.8 (1.5) 1.0-4.5  1.6 (1.7); 1.2-4.3  2.1  .04  Goal setting: Collaborative goal setting [1-7]  5.0 (2.8); 2.5-6.5  3.7 (1.2); 2.3-4.9  3.8 (1.7); 2.7-5.0  3.3 (1.4); 1.2-5.8  0.9  .36  Goal setting: Collaborative action planning [1-7]  1.0 (3.3); 1.0-6.5  2.7 (1.2); 1.7-3.7  3.4 (2.2); 2.2-4.7  2.0 (2.3); 1.0-3.7  1.9  .06  Goal setting: Collaborative barrier identification [1-7]  5.0 (1.1); 4.5-6.5  2.9 (1.5); 2.1-4.0  3.3 (1.1); 2.7-5.0  2.6 (2.3); 1.2-3.8  1.8  .07  Goal setting: Collaborative problem solving [1-7]  4.8 (2.1); 1.0-6.5  2.9 (2.1); 1.8-4.5  3.0 (1.5); 2.2-5.7  2.8 (3.3); 1.0-4.3  1.1  .26  Provide positive encouragement [1-7]  4.5 (0.9); 3.5-6.0  4.5 (1.4); 3.5-5.3  4.3 (1.0); 3.8-5.2  4.8 (1.8); 3.2-5.7  1.4  .17  Provide positive, information-rich feedback [1-7]  4.8 (2.4); 1.5-6.0  4.5 (2.0); 2.9-5.4  4.0 (2.0); 2.5-5.0  4.8 (2.2); 3.2-6.0  2.5  .01  Provide opportunities for patient practice [1-7]  3.5 (5.0); 1.0-6.0  5.5 (1.8); 3.5-6.3  N/A  5.5 (1.8); 3.5-6.3  N/A  N/A  Interpersonal involvement  Acknowledge patients’ feelings and perspectives [1-7]  3.0 (1.2); 2.5-6.5  3.4 (2.0); 2.6-5.3  4.0 (1.3); 2.7-5.2  2.8 (2.0); 1.7-5.5  1.9  .06  Build relationships: Active listening [1-7]  5.3 (1.3); 3.5-6.5  5.0 (1.4); 3.8-5.8  5.1 (1.1); 3.8-5.8  4.8 (1.6); 3.5-5.8  1.6  .11  Build relationships: Interest in patients [1-7]  4.5 (0.6); 1.5-5.5  5.1 (1.2); 3.7-5.8  4.8 (1.0); 4.2-5.8  4.9 (1.5); 2.8-6.0  1.0  .33    Training (n = 10)b  Delivery (n = 8)  SDT-Based Communication Strategies  Median Needs 
Supportiveness (IQR); Min-Max  Class Median (IQR); Min-Max  Education Median (IQR); Min-Max  Exercise Median (IQR); Min-Max  z Scorea  P Valuec  Total [1-7]  4.3 (1.0); 3.3-4.9  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  Autonomy support  Offer a meaningful rationale [1-7]  4.3 (2.5); 3.0-6.0  4.3 (1.8); 3.8-6.3  5.2 (1.6); 4.2-6.3  3.8 (2.0); 3.0-6.2  2.5  .01  Provide opportunities for patient input and choice [1-7]  5.3 (1.3); 4.0-6.0  4.8 (1.6); 3.5-5.8  4.5 (1.5); 3.7-5.8  4.9 (2.0); 3.3-5.7  0.4  .67  Use support and encouragement rather than pressurizing behaviors [1-7]  4.3 (2.1); 3.5-6.0  4.2 (1.5); 3.1-5.3  4.0 (1.1); 2.8-5.2  4.3 (1.4); 2.7-5.7  0.4  .67  Structure  Set clear expectations and provide direction [1-7]  3.0 (3.5); 1.0-6.5  4.3 (0.5); 3.9-5.1  5.4 (0.8); 4.8-6.2  3.4 (1.2); 2.7-4.0  2.5  .01  Goal setting: Review goal setting [1-7]  5.0 (1.8); 3.5-6.0  2.7 (1.7); 1.3-4.1  3.8 (1.5) 1.0-4.5  1.6 (1.7); 1.2-4.3  2.1  .04  Goal setting: Collaborative goal setting [1-7]  5.0 (2.8); 2.5-6.5  3.7 (1.2); 2.3-4.9  3.8 (1.7); 2.7-5.0  3.3 (1.4); 1.2-5.8  0.9  .36  Goal setting: Collaborative action planning [1-7]  1.0 (3.3); 1.0-6.5  2.7 (1.2); 1.7-3.7  3.4 (2.2); 2.2-4.7  2.0 (2.3); 1.0-3.7  1.9  .06  Goal setting: Collaborative barrier identification [1-7]  5.0 (1.1); 4.5-6.5  2.9 (1.5); 2.1-4.0  3.3 (1.1); 2.7-5.0  2.6 (2.3); 1.2-3.8  1.8  .07  Goal setting: Collaborative problem solving [1-7]  4.8 (2.1); 1.0-6.5  2.9 (2.1); 1.8-4.5  3.0 (1.5); 2.2-5.7  2.8 (3.3); 1.0-4.3  1.1  .26  Provide positive encouragement [1-7]  4.5 (0.9); 3.5-6.0  4.5 (1.4); 3.5-5.3  4.3 (1.0); 3.8-5.2  4.8 (1.8); 3.2-5.7  1.4  .17  Provide positive, information-rich feedback [1-7]  4.8 (2.4); 1.5-6.0  4.5 (2.0); 2.9-5.4  4.0 (2.0); 2.5-5.0  4.8 (2.2); 3.2-6.0  2.5  .01  Provide opportunities for patient practice [1-7]  3.5 (5.0); 1.0-6.0  5.5 (1.8); 3.5-6.3  N/A  5.5 (1.8); 3.5-6.3  N/A  N/A  Interpersonal involvement  Acknowledge patients’ feelings and perspectives [1-7]  3.0 (1.2); 2.5-6.5  3.4 (2.0); 2.6-5.3  4.0 (1.3); 2.7-5.2  2.8 (2.0); 1.7-5.5  1.9  .06  Build relationships: Active listening [1-7]  5.3 (1.3); 3.5-6.5  5.0 (1.4); 3.8-5.8  5.1 (1.1); 3.8-5.8  4.8 (1.6); 3.5-5.8  1.6  .11  Build relationships: Interest in patients [1-7]  4.5 (0.6); 1.5-5.5  5.1 (1.2); 3.7-5.8  4.8 (1.0); 4.2-5.8  4.9 (1.5); 2.8-6.0  1.0  .33  aIQR = interquartile range, SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, z score = difference between the education and exercise components across all classes. bTen recordings were available for assessment. cP ≤ .003 is significant following Bonferroni adjustments. View Large Behavior Physical therapists (n = 8) delivered the SOLAS intervention to a median 3.0 participants per class ([1.7]; 1–6). The HCCQ demonstrated that therapists were needs-supportive during delivery of the intervention with a median score of 5.3 on a 7-point Likert scale ([1.4]; 3.9–6.0; Tab. 6). Linear modeling demonstrated no significant differences between classes, indicating that their communication style did not change during the intervention (F [1,2] = 0.6, P = .6). Interrater agreement was excellent (ICC = 0.87, 95% CI = 0.7–0.9). Table 6. Physical Therapists’ (PT) Needs Supportiveness During the SOLAS Intervention as Measured Using the Health Care Climate Questionnaire (HCCQ), the Controlling Coach Behavior Scale (CCBS), and the SOLAS Scalea Class ID  HCCQ Median (IQR); Min-Max  CCBS Median (IQR); Min-Max  SOLAS Scale 
Median (IQR); Min-Max  Education 
Component Median (IQR); Min-Max  Exercise 
Component Median (IQR); Min-Max  z Score  P Valueb  Total [1-7]  5.3 (1.4); 3.9-6.0  6.6 (0.5); 6.1-6.8  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  1 [1-7]  5.1 (1.5); 3.7-6.0  6.6 (0.4); 6.3-6.9  4.0 (1.1); 3.1-4.7  4.1 (0.9); 3.4-4.8  3.7 (1.3); 2.4-4.7  1.8  .07  4 [1-7]  5.3 (1.2); 4.2-5.9  6.5 (0.6); 5.4-6.8  4.0 (1.2); 3.2-5.0  4.1 (1.6); 3.5-5.7  4.1 (1.0); 2.9-4.5  1.7  .09  6 [1-7]  5.5 (1.3); 3.3-6.1  6.7 (0.7); 5.9-6.9  3.9 (1.4); 2.8-4.8  4.2 (0.4); 3.7-5.0  3.8 (1.9); 1.8-5.2  1.0  .33  Class ID  HCCQ Median (IQR); Min-Max  CCBS Median (IQR); Min-Max  SOLAS Scale 
Median (IQR); Min-Max  Education 
Component Median (IQR); Min-Max  Exercise 
Component Median (IQR); Min-Max  z Score  P Valueb  Total [1-7]  5.3 (1.4); 3.9-6.0  6.6 (0.5); 6.1-6.8  4.0 (1.2); 3.2-4.9  4.1 (0.8); 3.7-5.2  4.0 (1.4); 2.7-4.6  2.4  .02  1 [1-7]  5.1 (1.5); 3.7-6.0  6.6 (0.4); 6.3-6.9  4.0 (1.1); 3.1-4.7  4.1 (0.9); 3.4-4.8  3.7 (1.3); 2.4-4.7  1.8  .07  4 [1-7]  5.3 (1.2); 4.2-5.9  6.5 (0.6); 5.4-6.8  4.0 (1.2); 3.2-5.0  4.1 (1.6); 3.5-5.7  4.1 (1.0); 2.9-4.5  1.7  .09  6 [1-7]  5.5 (1.3); 3.3-6.1  6.7 (0.7); 5.9-6.9  3.9 (1.4); 2.8-4.8  4.2 (0.4); 3.7-5.0  3.8 (1.9); 1.8-5.2  1.0  .33  aIQR = interquartile range, SOLAS = Self-management of Osteoarthritis and Low back pain through Activity and Skills, z score = difference between the education and exercise components across all classes. bP < .016 is significant. View Large The CCBS results (Tab. 6) showed physical therapists were also not considered needs-thwarting during delivery, with a median score of 6.6 on a 7-point Likert scale ([0.5]; 6.1–6.8), which remained unchanged throughout the intervention (F [1,2] = 2.5, P = .2). Interrater agreement was poor for this measure (ICC = –0.3, 95% CI = –1.5–0.6); however, this may reflect the small sample size.44 Additionally, the range of ratings fell between the points of “5” and “7” on the Likert scale; therefore, the magnitude of discrepancy was small. The SOLAS scale results showed that the physical therapists delivered the SDT-based communication strategies with acceptable competence (median 4.0 on a 7-point Likert scale [1.2]; 3.2–4.9). Interrater reliability was moderate (ICC = 0.81, 95% CI = 0.6–0.9). However, none of the components of “collaborative goal setting, action planning, and problem solving” (ie, “review behavioral goal,” “goal setting,” “action planning,” “barrier identification,” and “problem solving”) were delivered with acceptable competence. More specifically, each of these components scored less than “4” on a 7-point Likert scale (Tab. 5). Concurrent validity was established, as the correlation between the HCCQ and the SOLAS scale was excellent (r = 0.86, P = .01). Physical therapists scored more highly in the education component of the intervention (median education 4.1 [0.8]; 3.7–5.2; median exercise 4.0 [1.4]; 2.7–4.6), but differences between the class components were not significant when adjusted for Bonferroni (z score = 2.4, P = .02). Linear modeling demonstrated no significant differences between classes, indicating that physical therapists consistently delivered the SDT-based communication strategies over time (F [1,2] = 0.3, P = .8; Tab. 6). Impact of Experience and Training on Physical Therapists’ Competence During Intervention Delivery When adjusted for Bonferroni corrections (P < .007), no significant relationships were found between the physical therapists’ baseline variables and their posttraining results (eTable 2 in eAppendix, available at https://academic.oup.com/ptj). Discussion Interpretation of Results Following training, the physical therapists were satisfied with the methods employed. Their confidence in the SDT-based communication strategies, and their knowledge of the advice for patients, significantly improved. Based on the simulated role-play, therapists were competent to deliver the SOLAS intervention in a needs-supportive manner following training, and implemented the intervention using this style across all classes. Therefore, training was broadly effective in preparing therapists to deliver the SOLAS intervention. However, “collaborative goal setting, action planning, and problem solving” did not reach the desired level of competence during delivery, indicating that future training should place greater emphasis on this strategy. Strengths and Limitations The findings of this study are limited to the intervention arm of the SOLAS feasibility trial. Fidelity evaluations involve the assessment of what has taken place, and as no training was provided to control group therapists, evaluation was not considered relevant. Nonetheless, a key strength of this study was the use of a formal evaluation model across multiple levels compared to previous research that simply evaluated providers during delivery, which has allowed a more comprehensive understanding of training's effectiveness.45 However, the robustness of the framework depends on the methods selected by those using it. Previous research using the Kirkpatrick model determined effectiveness solely through self-report,18 but the use of objective raters in this study provided a clearer understanding of the level of “behavior” and the skills component of “learning.” However, while the skills assessment demonstrated that the physical therapists were competent to deliver the SOLAS intervention, no pretraining assessment was completed, as it was not feasible to evaluate therapists in a group setting prior to training. Limited studies have evaluated skills either within or pretraining; 9,20,39 therefore, future research should include a pretraining skills assessment to further establish effectiveness at this level.12 Findings in Relation to the Literature Physical therapists were very satisfied with the SOLAS training program, suggesting that large-scale changes are not required to the methods employed. However, participants’ satisfaction with training programs and intention to use that training typically correlates poorly with future behavior.46 Nonetheless, participants’ reactions are important to consider to help inform future refinements and promote greater participant engagement with the program.33 Although therapists’ confidence in the SDT-based communication strategies significantly improved, their knowledge of these did not. However, their high pretraining levels suggest a ceiling effect, as therapists were highly experienced (median 9 years’ experience) and the majority had undertaken previous communication-based training (66.7%), which probably limited their potential for further improvement.47 Physical therapists’ needs-supportive behaviors during delivery were consistent with results in individual physical therapy (using the HCCQ),9,41 and are supported by the CCBS findings that demonstrated that physical therapists avoided overtly controlling behavior. This is important, as needs-thwarting behaviors negatively impact adaptive responses.26,48 Although global measures of needs-supportiveness allow researchers to compare their results to previous work, intervention-specific measures may highlight important contextual information that could influence subsequent training program refinements.38 Future research should therefore utilize both global and specific measures to comprehensively and reliably assess such training programs. Indeed, the SOLAS scale highlighted that each of the 5 components of “collaborative goal setting, action planning, and problem solving” were delivered below the minimum competence threshold (Tab. 5). This strategy should support patient autonomy, as self-determined goals are more effective than controlled goals; therefore, poor delivery of this strategy may produce diminished patient self-regulation.49,50 However, recent literature has shown that this strategy is frequently lacking within clinical environments due to the perceived difficulty in its use by both HCPs and patients.51,52 Specifically, the therapists report that more complex components such as problem solving and action planning are particularly difficult to deliver,53 a finding supported in the present study. This is important, as goals that are self-determined, specific in the required actions, and where barriers have been identified and considered are more likely to be successful than those that are not.54,55 Future training programs need to consider and define this strategy carefully.56 Implications and Future Work This study has provided valuable insights into how to best train physical therapists to deliver a communication-based group intervention. In particular, this study has highlighted the importance of the skills component of training programs. Physical therapists’ skills after training did not correlate with their delivery, while 2 components delivered below competence in training were subsequently delivered with competence. Therefore, the role-play environment of training did not sufficiently reflect the clinical environment, and could not predict physical therapists’ delivery. It is critical that future physical therapist training programs mirror their planned clinical environment as closely as possible, potentially by using actors to simulate a more realistic scenario.57,58 Fidelity guidelines suggest that providers be monitored during delivery until they are competent,2,12 with individualized feedback and coaching provided to those who need it.27,59 Individual “booster” sessions should therefore be considered within future training programs. Finally, a critical issue within training literature is the ambiguity surrounding competence, a complex, intervention-dependent issue.14,60 This study used the midpoint threshold;39,40,61 however, whether this is sufficient is debatable. Fidelity guidelines encourage a threshold of 80% for provider adherence during delivery.2 If these standards had been implemented in the current study, a minimum threshold of 5.6 on a 7-point Likert scale would have existed, equating to 0% of the physical therapists. Researchers should therefore be clear what competence looks like within their specific intervention. This study has highlighted the importance of setting a higher value on skill acquisition during training. This may allow researchers to identify strategies that require further training before delivery, but its feasibility within large-scale and pragmatic interventions warrants consideration. Excellent competence is likely to require intensive training that may be unacceptable to practitioners with limited time for training alongside clinical workload.62 E-learning may provide opportunities for HCPs to flexibly complete the theoretical and content components of training, upload audio examples of their skills for individualized feedback, and deliver this alongside further supplementary, face-to-face skills-based training.20 Utilizing such mixed methods of training should be investigated in future physical therapist education programs. In conclusion, this study contributed to the implementation and HCP training literature by using comprehensive methods guided by an evidence-based training framework to assess the feasibility of a training program in guiding physical therapists to effectively deliver the SOLAS intervention in a needs-supportive manner. Training was effective, as the therapists competently delivered the intervention. However, future similar physical therapist training programs should consider setting a higher threshold for competence, and further emphasize “collaborative goal setting, action planning, and problem solving.” Author Contributions Concept/idea/research design: A. Keogh, D.A. Hurley, J. Matthews, R. Segurado Writing: A. Keogh, J. Matthews, D.A. Hurley Data collection: A. Keogh Data analysis: A. Keogh, R. Segurado Project management: D.A. Hurley Fund procurement: D.A. Hurley Providing participants: D.A. Hurley Providing facilities/equipment: D.A. Hurley Providing institutional liaisons: D.A. 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Physical TherapyOxford University Press

Published: Feb 1, 2018

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