The Physiotherapy Pain-Engagement Activation Model (PEAM) for Rehab Outcomes

Thesis Abstract

This study addresses the persistent gap between pain management and functional engagement in physiotherapy rehabilitation by proposing a structured model that integrates pain processing, motivational activation, and engagement strategies to optimize rehab outcomes. The aim is to develop and validate the Physiotherapy Pain-Engagement Activation Model (PEAM) and to assess its predictive validity for functional recovery in musculoskeletal rehabilitation. Specific objectives are to (a) delineate the core constructs of PEAM and their interrelationships, (b) examine the predictive power of PEAM constructs on functional outcomes, (c) evaluate the mediating role of patient engagement in the relationship between pain and rehabilitation adherence, (d) compare PEAM-based interventions with standard care, and (e) provide actionable guidelines for clinical implementation. A convergent mixed-methods design guides the study, drawing on a sequential explanatory framework. The population comprises adults aged 18–65 undergoing outpatient physiotherapy for non-acute musculoskeletal conditions at three tertiary care centers. A sample of 320 participants is targeted for quantitative data, with qualitative insight from a purposive subsample of 40 participants to explore experiential nuances. Quantitative data are collected at baseline, six weeks, and twelve weeks using validated instruments the Brief Pain Inventory (for pain interference), the Pain Catastrophizing Scale, the Utrecht Work Engagement Scale adapted for health behavior, the Treatment Adherence Questionnaire, the Physical Functioning subscale of the SF-36, and therapist-rated functional progress. PEAM constructs are operationalized as pain processing (pain intensity, interference, catastrophizing), engagement activation (intrinsic motivation, perceived value of rehabilitation), and engagement behaviors (adherence, participation in home exercise programs). Qualitative data are gathered through semi-structured interviews conducted at week twelve, focusing on perceived barriers and facilitators to engagement, and experiences of PEAM-informed interventions. Quantitative analyses involve structural equation modeling (SEM) to test the hypothesized PEAM pathways, multiple regression to determine the incremental variance explained by PEAM over standard care, and mediation analyses to assess whether engagement mediates the pain–outcome relationship. Repeated-measures ANOVA examines changes over time in pain, engagement, and function. The qualitative data are analyzed using thematic analysis, with coding conducted independently by two researchers and integrated with quantitative findings via a mixed-methods matrix to triangulate results and refine the theoretical model. The study also includes a pilot randomized controlled trial (n=100) comparing PEAM-guided rehabilitation sessions to usual care, with primary outcomes including functional status (WOMAC or PSFS depending on condition) and pain interference at twelve weeks. Expected findings anticipate that PEAM will account for a larger share of variance in functional outcomes than conventional care, with engagement activation and adherence mediating the pain–function relationship. Specifically, higher pain processing distress and catastrophizing are predicted to undermine engagement, whereas PEAM-driven strategies—such as value-congruence messaging, goal setting, and self-regulatory support—will enhance engagement behaviors and functional gains. The qualitative component is expected to reveal themes around perceived autonomy support, therapeutic alliance, and the perceived relevance of home exercise programs as critical determinants of sustained engagement. The study contributes to knowledge by operationalizing a theoretically grounded model that unifies pain neuroscience with motivational and behavioral theories, including Self-Determination Theory and the Health Belief Model, to explain rehabilitation outcomes. PEAM offers a structured framework for clinicians to tailor interventions that simultaneously address pain processing and engagement determinants, potentially reducing non-adherence and improving long-term functional recovery. The anticipated conclusion is that PEAM-based interventions yield superior functional outcomes and adherence rates compared with usual care, particularly for patients with elevated pain interference and catastrophizing. Recommendations include integrating PEAM assessment into routine intake, training clinicians in engagement-enhancement techniques, and disseminating PEAM guidelines across musculoskeletal rehabilitation services to improve patient-centered care and rehab effectiveness. Further research should examine PEAM’s applicability across chronic pain populations and investigate cost-effectiveness in diverse clinical settings.