Treatment fidelity in the Gait Rehabilitation in Early Rheumatoid Arthritis Trial (GREAT) feasibility study

Background/purpose: Many people with early rheumatoid arthritis report foot pain and walking disability. Physiotherapists and podiatrists received a two-day bespoke training in a psychologically informed gait rehabilitation intervention (2 compulsory and 4 optional sessions delivered over 3/12), incorporating motivational interviewing (MI) and behaviour change techniques (BCTs), to address this. This study assessed fidelity of delivery within a feasibility study. Methods: Four physiotherapists and two podiatrists delivered 78 sessions across three UK centres. The Motivational Interviewing Treatment Integrity (MITI) Rating Scale and a bespoke tailored treatment fidelity measures were used to assess fidelity to MI and core components plus BCTs. Two independent assessors rated audio recordings of sessions. Results: 28 (80%) participants‘ data across 64 sessions were rated for core components and BCTs and 37 (50%) sessions were analysed for MI. Relational (score=4.4) and technical (score=4.2) aspects of MI were delivered with good fidelity. 6 core components and 7/17 BCTs in Session 1 were conveyed with high (over 80%) treatment fidelity. 5 core elements and 3/12 BCTs in Session 2 were provided with high fidelity. Sessions 3 and 4 reliably delivered 3/12 BCTs, while only one session 5 and 6 was delivered. Inter-rater reliability showed agreement of over 80% (range 82- 87%) was reached for all sessions. Conclusions and Implications: Clinicians delivered core components and MI with high fidelity, but not all BCTs. Treatment fidelity might be enhanced with further training or on-going support. Alternatively, the intervention could be amended to specify mandatory BCTs alongside optional ones, depending on the needs of individual participants.