Physiotherapy informed by Acceptance and Commitment Therapy (PACT) for chronic low back pain: a mixed-methods treatment fidelity evaluation

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Objectives A randomised controlled trial of PACT, a new type of Physiotherapy informed by Acceptance and Commitment Therapy (ACT), found it improved functioning in people with chronic low back pain compared to usual physiotherapy care. Fidelity evaluation is necessary to understand trial processes and outcomes. This study evaluated PACT treatment fidelity including delivery, receipt, and enactment.

Methods A mixed-methods study was conducted. A total of 72 (20%) PACT treatment audio files were independently assessed by two raters according to a novel framework developed to measure PACT treatment content adherence, therapeutic alliance, ACT competence and treatment enactment. Interview transcripts from 19 recipients of PACT were analysed thematically for evidence of treatment receipt and enactment.

Results PACT physiotherapists delivered treatment as intended with high content adherence and satisfactory therapeutic alliance, but ACT competence was low. Qualitative findings indicated participant receipt of 12/16 and enactment of 3/16 components; 89% and 47% of participants reported treatment receipt and enactment of at least one component, respectively.

This mixed-methods study of PACT treatment demonstrated high fidelity reflecting treatment content delivery and receipt, and therapeutic alliance. There was some evidence of treatment enactment in participants with chronic low back pain. Low ACT competence was expected after brief training but could be addressed through additional support provider training and adaptations to therapeutic processes for delivery by physiotherapists.
Original languageEnglish
JournalBritish Journal of Health Psychology
Publication statusPublished - 3 Feb 2022


  • Fidelity assessment, chronic low back pain, physical therapy, acceptance and commitment therapy, randomised controlled trial


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