Enhancing exercise adherence in a population with persistent musculoskeletal pain:the development and preliminary testing of a complex behaviour change intervention

Background. Persistent musculoskeletal (PMSK) pain affects over one quarter of the United Kingdom population. Exercise and physical activity have been found to be effective in managing these conditions, however upwards of half of these patients do not adhere to their prescribed programmes. There is a paucity of research exploring the factors impacting on exercise adherence in this population to inform the development of a complex behaviour change intervention. Methods. The Intervention Mapping approach led the development of a theoretically informed, empirically driven intervention guided by four studies: i) a systematic review identified the content and context of behaviour change interventions that have aimed to enhance exercise adherence in a population with PMSK pain (study one); ii) a qualitative study explored the perceived barriers and facilitators to exercise adherence from the perspectives of patients with PMSK pain and physiotherapists with experience working with these populations (study two); iii) the appropriateness of a measure of exercise adherence was assessed in a PMSK pain population for its suitability as an outcome measure (study three); iv) a feasibility and acceptability study of the proposed intervention was conducted to inform amendments to the final study design (study four). Results. The systematic review identified five behaviour change techniques (BCTs), social support (unspecified), goal setting (behaviour), instruction of behaviour, demonstration of behaviour and behaviour practice/rehearsal effectively enhance exercise adherence in a PMSK pain population. It is suggested that studies employing ≤ seven BCTs are more effective. The qualitative study concluded that the physical and social environment, the influence of pain, and negative affect act as barriers to exercise adherence, while fostering a collaborative therapeutic relationship and facilitating self-management enhances exercise adherence. The Exercise Adherence Rating Scale was found to be understandable with good face validity in a population with PMSK pain, and appropriate to be used in the final intervention with minor amendments to the instructions. Informed by this preliminary research, the Health Action Process Approach underpinned the development of the Managing Exercise ADhErence (MEADE) intervention. The intervention encompasses an app-based tailored exercise programme and online one to one motivational interviewing. The feasibility and acceptability study demonstrated that recruitment, completion of study measures and intervention fidelity of the MEADE intervention were feasible, and patient and provider acceptability of the intervention was demonstrated. Refinements to the intervention and study processes were identified to inform progression to a full trial. Conclusions. This thesis successfully addressed and provided evidence for the possibility to develop an intervention to systematically enhance exercise adherence in a population with PMSK pain. The Intervention Mapping approach facilitated the development of a theoretically informed, empirically driven intervention. This PhD identified the content and contextual factors for consideration to target exercise adherence in a population with PMSK pain and presents an intervention which has demonstrated feasibility and acceptability. The intervention aligns with the current clinical guidelines for the treatment and management of PMSK pain and warrants progression to further testing and evaluation