The period after someone incurs a spinal cord injury is a delicate time. The patient is coming to terms with a serious and probably life-changing condition that affects both their mental and physical wellbeing. Some may be depressed or feel overwhelmed, and it may not seem like the time to push someone. But doctors and physical and occupational therapists know that the more aggressively patients engage in therapy, the greater chance they will make a significant functional recovery. Research has shown that how actively a person with SCI engages in therapy plays a role in how much functional independence they regain and how likely they are to be discharged to home after rehabilitation. Active participation also is a predictor of whether the person will be employed or attending school a year after they were injured. That’s important since many spinal cord injuries occur between the ages of 16 and 30 when people have long lives ahead of them.
Researchers at the Center for Rehabilitation Outcomes Research (CROR) at the Shirley Ryan AbilityLab set out to see whether training physical and occupational therapists in a behavioral counseling style known as motivational interviewing (MI) could encourage patients with spinal cord injury to more actively participate in therapy. MI is an evidence-based counseling style that involves therapists asking open-ended questions, listening closely and reinforcing their client’s positive intentions. The goal is to get the person thinking through potential lifestyle changes and then helping them devise strategies to achieve them. Key to the process is having the client come up with their own plans rather than imposing one on them. “Almost nobody likes to be told what to do,” notes CROR Clinical Research Scientist Linda Ehrlich-Jones, RN, PhD. “But people will follow through on things that they verbalize and suggest.”
Ehrlich-Jones is trained in MI and has used it in previous studies to see if the counseling style succeeded in helping patients with Parkinson’s disease, rheumatoid arthritis and osteoarthritis to increase their levels of physical activity. Other researchers also have studied MI. In almost 120 randomized-controlled trials and meta-analyses, the counseling style was found to have fostered positive health behaviors. Yet when physical and occupational therapists are taught communication skills in graduate programs, they rarely receive in-depth training in MI. Standard training in MI takes roughly 16 hours.
We have so much to learn from one another, and we each bring a unique perspective to the table.Kelly McKenzie, PT, DPT, NCS
Charles Bombardier, PhD, Professor in the Department of Rehabilitation Medicine at the University of Washington, is an MI trainer and strong believer in its positive outcomes. He wondered whether MI might encourage people with recent spinal cord injuries to work harder during inpatient therapy sessions. He reached out to Ehrlich-Jones and they collaborated on a study that would take place in Chicago at the Shirley Ryan AbilityLab because of the large number of patients with spinal cord injuries who receive rehabilitation each year. Their $200,000 grant proposal was submitted in 2016 to the Craig H. Neilsen Foundation in California, which is committed to improving quality of life and care for people with spinal cord injuries.
After the grant was funded in 2017, Ehrlich-Jones recruited 14 physical and occupational therapists who were working on the hospital’s spinal cord injury units. Half of them were randomly assigned to receive the standard training in motivational interviewing with Ehrlich-Jones as their coach. The therapists in the MI group wore a digital recording device so Ehrlich-Jones could record their patient conversations to see how well they had absorbed their training. Once she determined that the therapists had reached a certain level of proficiency, the research team started reaching out to eligible patients to have their therapy sessions monitored and recorded.
Over time, 62 patients participated in the study, which was trickier than many because it happened in a hospital setting, which was difficult to control. It also required that clinicians and researchers work together. “Collaboration between researchers and clinicians is fun,” says Kelly McKenzie, a research physical therapist at the Shirley Ryan AbilityLab who acted as a clinical advisor on the study. “We have so much to learn from one another, and we each bring a unique perspective to the table.” Originally scheduled to last two years, it ended up lasting four because of those factors as well as therapist turnover.
I am hoping to do a larger, longer study to see the effects of motivational interviewing on various patient participation in therapies.Linda Ehrlich-Jones, RN, PhD
During each therapy session over a several week period, a CROR project coordinator who didn’t know which therapists had MI training stood in the background and observed. She noted how actively the patient engaged in therapy and rated them. The therapists’ recordings were transcribed and graded by people outside CROR who were trained in MI, including Bombardier. The therapists also rated their patients’ activity levels using the Pittsburgh Rehabilitation Participation Scale (PRPS), which measures the patient’s attention level and physical exertion. The patients had input, too, using a patient-reported version of the PRPS.
“We were able to show that – based on an independent observer – people who were treated by MI trained therapists participated more actively in their therapies than those who did not,” says Bombardier. “The effect was mostly early on, which means it gave people a head start. It helped the therapist engage more deeply and quickly. Those therapists and patients got going faster.”
The researchers also wanted to determine if the patients had higher scores on the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), which measures functional independence. But they didn’t see much difference. “There are too many variables involved in terms of that particular instrument,” says Ehrlich-Jones. Patient satisfaction scores also didn’t differ much but that wasn’t completely surprising because patients usually give their therapists very high scores anyway. A fourth goal was to see if the MI training had changed the way the therapists practiced, and anecdotally it appeared to have had an effect. “When I talked with therapists later, it was very exciting for me to see them be excited,” says Ehrlich-Jones. “I’m hoping they continue to use their skills over time.”
Ehrlich-Jones and Bombardier are writing two papers about the study’s findings. They already have shared posters about their work at various conferences. The positive results should be enough to encourage other researchers to follow in CROR’s footsteps and do a larger trial, Ehrlich-Jones says. She may even do one herself. “I am hoping to do a larger, longer study to see the effects of motivational interviewing on various patient participation in therapies.”