How do care-provider and home exercise program characteristics affect patient adherence in chronic neck and back pain: a qualitative study

Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study

Background

For medical teams, one of the main objectives of rehabilitation for people with chronic low back pain is adherence to physical activity (PA).

Objective

The objective of this study was to identify PA barriers and facilitators in this population.

Methods

This qualitative study included 4 discussion groups and 16 semi-structured interviews conducted among people with non-specific chronic low back pain who were involved in a specific rehabilitation program or seen in primary care settings.

Results

Three main themes were identified: physical factors, psychological factors and socio-environmental factors. The main barrier to PA practice is pain. Psychological barriers were associated with the difficulty in integrating PA in the person’s daily life. Environmental barriers were dominated by lack of time. Facilitators identified associated the supervised nature of the physical activity (supervision by professionals) and group practice, which improved people’s adherence.

Conclusion

The results of this study will allow teams to target relevant educational objectives for these people and develop dedicated self-management programs.

Perceived task complexity of trunk stability exercises

BACKGROUND

Perceived task complexity can impact participation in an exercise programme and the level of skill acquisition resulting from participation. Although trunk stability exercises are commonly included in the management of people with low back pain, potential differences in perceived task complexity between those exercises have not been investigated previously.

OBJECTIVE

To investigate the perceived task complexity following first time instruction of two common stability exercises: the abdominal brace and abdominal hollow.

DESIGN

Cross-sectional.

METHODS

Twenty-four naïve healthy participants received instruction in the performance of an abdominal brace and an abdominal hollow with feedback. Participants rated their perceived task complexity (mental, physical, and temporal demand, performance, effort, frustration) for each exercise on the NASA-Task Load Index.

RESULTS

The abdominal hollow was associated with higher perceived mental demand than the abdominal brace (p = 0.01), and required more time to learn (p < 0.01). The abdominal brace was associated with greater mental demand and frustration when performed after the abdominal hollow than before.

CONCLUSIONS

This study has provided the first evidence for differences in perceived task complexity between two commonly used trunk stability exercises. Those differences in perceived task complexity may influence the selection of exercises intended to enhance the robustness of spinal stability.

Toward Patient-Centered Telerehabilitation Design: Understanding Chronic Pain Patients' Preferences for Web-Based Exercise Telerehabilitation Using a Discrete Choice Experiment

Background

Patient-centered design that addresses patients’ preferences and needs is considered an important aim for improving health care systems. At present, within the field of pain rehabilitation, patients’ preferences regarding telerehabilitation remain scarcely explored and little is known about the optimal combination between human and electronic contact from the patients’ perspective. In addition, limited evidence is available about the best way to explore patients’ preferences. Therefore, the assessment of patients’ preferences regarding telemedicine is an important step toward the design of effective patient-centered care.

Objective

To identify which telerehabilitation treatment options patients with chronic pain are most likely to accept as alternatives to conventional rehabilitation and assess which treatment attributes are most important to them.

Methods

A discrete choice experiment with 15 choice tasks, combining 6 telerehabilitation treatment characteristics, was designed. Each choice task consisted of 2 hypothetical treatment scenarios and 1 opt-out scenario. Relative attribute importance was estimated using a bivariate probit regression analysis. One hundred and thirty surveys were received, of which 104 were usable questionnaires; thus, resulting in a total of 1547 observations.

Results

Physician communication mode, the use of feedback and monitoring technology (FMT), and exercise location were key drivers of patients’ treatment preferences (P<.001). Patients were willing to accept less frequent physician consultation offered mainly through video communication, provided that they were offered FMT and some face-to-face consultation and could exercise outside their home environment at flexible exercise hours. Home-based telerehabilitation scenarios with minimal physician supervision were the least preferred. A reduction in health care premiums would make these telerehabilitation scenarios as attractive as conventional clinic-based rehabilitation.

Conclusions

“Intermediate” telerehabilitation treatments offering FMT, some face-to-face consulting, and a gym-based exercise location should be pursued as promising alternatives to conventional chronic pain rehabilitation. Further research is necessary to explore whether strategies other than health care premium reductions could also increase the value of home telerehabilitation treatment.

Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To evaluate whether interventions aimed at increasing adherence to therapeutic exercise increase adherence greater than a contextually equivalent control among older adults with chronic low back pain and/or hip/knee osteoarthritis.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Five databases (MEDLINE (PubMed), CINAHL, SportDISCUS (EBSCO), Embase (Ovid) and Cochrane Library) were searched until 1 August 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials that isolated the effects of interventions aiming to improve adherence to therapeutic exercise among adults ≥45 years of age with chronic low back pain and/or hip/knee osteoarthritis were included.

RESULTS

Of 3899 studies identified, nine studies (1045 participants) were eligible. Four studies, evaluating strategies that aimed to increase motivation or using behavioural graded exercise, reported significantly better exercise adherence (d=0.26-1.23). In contrast, behavioural counselling, action coping plans and/or audio/video exercise cues did not improve adherence significantly. Meta-analysis using a random effects model with the two studies evaluating booster sessions with a physiotherapist for people with osteoarthritis revealed a small to medium significant pooled effect in favour of booster sessions (standardised mean difference (SMD) 0.39, 95% CI 0.05 to 0.72, z=2.26, p=0.02, I²=35%).

CONCLUSIONS

Meta-analysis provides moderate-quality evidence that booster sessions with a physiotherapist assisted people with hip/knee osteoarthritis to better adhere to therapeutic exercise. Individual high-quality trials supported the use of motivational strategies in people with chronic low back pain and behavioural graded exercise in people with osteoarthritis to improve adherence to exercise.

The effectiveness of home-based exercise programs for low back pain patients

[Purpose] The purpose of this study was to investigate the effectiveness of home-based exercise programs for low back pain (LBP) patients. [Subjects and Methods] The study subjects were 49 volunteer chronic LBP patients. Home-based exercises that had been specifically modified for the individual patients were prescribed for a period of four weeks, and the volunteers were asked to return for a control evaluation at the end of this period. Exercise adherence and correct performance, pain intensity, disability, endurance, and flexibility were compared between pre- and post intervention, and correlations between exercise adherence and correct performance with, pain intensity score, endurance, disability, and flexibility were investigated. [Results] Twenty-eight patients (57.14%) did not return for the control evaluation. The mean age of the patients who participated in this control test was 43.24 ± 10.89 years. The adherence rate of the home exercise program was 54.10 ± 26.01%, and the correctly performed execises score was 2.7 ± 1.9. All of the parameters had improved at the final evaluation; however, there was no correlation among the parameters. [Conclusion] Clinicians should be aware of the patient’s adherence level when recommending home-based exercises, and should also realize that exercises might be performed inaccurately in an unsupervised environment.

What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis

BACKGROUND

Musculoskeletal physical therapy involves both specific and nonspecific effects. Nonspecific variables associated with the patient, therapist, and setting may influence clinical outcomes. Recent quantitative research has shown that nonspecific factors, including patient-therapist interactions, can influence treatment outcomes. It remains unclear, however, what factors influence patient-therapist interaction.

PURPOSE

This qualitative systematic review and meta-synthesis investigated patients' and physical therapists' perceptions of factors that influence patient-therapist interactions.

DATA SOURCES

Eleven databases were searched independently.

STUDY SELECTION

Qualitative studies examining physical therapists' and patients' perceptions of factors that influence patient-therapist interactions in musculoskeletal settings were included.

DATA EXTRACTION

Two reviewers independently selected articles, assessed methodological quality using the Critical Appraisal Skills Programme (CASP), and performed the 3 stages of analysis: extraction of findings, grouping of findings (codes), and abstraction of findings.

DATA SYNTHESIS

Thirteen studies were included. Four themes were perceived to influence patient-therapist interactions: (1) physical therapist interpersonal and communication skills (ie, presence of skills such as listening, encouragement, confidence, being empathetic and friendly, and nonverbal communication), (2) physical therapist practical skills (ie, physical therapist expertise and level of training, although the ability to provide good education was considered as important only by patients), (3) individualized patient-centered care (ie, individualizing the treatment to the patient and taking patient's opinions into account), and (4) organizational and environmental factors (ie, time and flexibility with care and appointments).

LIMITATIONS

Only studies published in English were included.

CONCLUSIONS

A mix of interpersonal, clinical, and organizational factors are perceived to influence patient-therapist interactions, although research is needed to identify which of these factors actually influence patient-therapist interactions. Physical therapists' awareness of these factors could enhance patient interactions and treatment outcomes. Mechanisms to best enhance these factors in clinical practice warrant further study.

Barriers to home-based exercise program adherence with chronic low back pain: Patient expectations regarding new technologies

OBJECTIVE

To assess views of patients with chronic low back pain (cLBP) concerning barriers to home-based exercise program adherence and to record expectations regarding new technologies.

DESIGN

Qualitative study based on semi-structured interviews.

PARTICIPANTS

A heterogeneous sample of 29 patients who performed a home-based exercise program for cLBP learned during supervised physiotherapy sessions in a tertiary care hospital.

INTERVENTIONS

Patients were interviewed at home by the same trained interviewer. Interviews combined a funnel-shaped structure and an itinerary method.

RESULTS

Barriers to adherence related to the exercise program (number, effectiveness, complexity and burden of exercises), the healthcare journey (breakdown between supervised sessions and home exercise, lack of follow-up and difficulties in contacting care providers), patient representations (illness and exercise perception, despondency, depression and lack of motivation), and the environment (attitudes of others, difficulties in planning exercise practice). Adherence could be enhanced by increasing the attractiveness of exercise programs, improving patient performance (following a model or providing feedback), and the feeling of being supported by care providers and other patients. Regarding new technologies, relatively younger patients favored visual and dynamic support that provided an enjoyable and challenging environment and feedback on their performance. Relatively older patients favored the possibility of being guided when doing exercises. Whatever the tool proposed, patients expected its use to be learned during a supervised session and performance regularly checked by care providers; they expected adherence to be discussed with care providers.

CONCLUSIONS

For patients with cLBP, adherence to home-based exercise programs could be facilitated by increasing the attractiveness of the programs, improving patient performance and favoring a feeling of being supported. New technologies meet these challenges and seem attractive to patients but are not a substitute for the human relationship between patients and care providers.

The impact of hospital-based and community based models of cerebral palsy rehabilitation: a quasi-experimental study

BACKGROUND

Cerebral palsy requires appropriate on-going rehabilitation intervention which should effectively meet the needs of both children and parents/care-givers. The provision of effective support is a challenge, particularly in resource constrained settings. A quasi-experimental pragmatic research design was used to compare the impact of two models of rehabilitation service delivery currently offered in Harare, Zimbabwe, an outreach-based programme and the other institution-based.

METHOD

Questionnaires were distributed to 46 caregivers of children with cerebral palsy at baseline and after three months. Twenty children received rehabilitation services in a community setting and 26 received services as outpatients at a central hospital. The Gross Motor Function Measurement was used to assess functional change. The burden of care was measured using the Caregiver Strain Index, satisfaction with physiotherapy was assessed using the modified Medrisk satisfaction with physiotherapy services questionnaire and compliance was measured as the proportion met of the scheduled appointments.

RESULTS

Children receiving outreach-based treatment were significantly older than children in the institution-based group. Regression analysis revealed that, once age and level of severity were controlled for, children in the outreach-based treatment group improved their motor function 6% more than children receiving institution-based services. There were no differences detected between the groups with regard to caregiver well-being and 51% of the caregivers reported signs consistent with clinical distress/depression. Most caregivers (83%) expressed that they were overwhelmed by the caregiving role and this increased with the chronicity of care. The financial burden of caregiver was predictive of caregiver strain. Caregivers in the outreach-based group reported greater satisfaction with services and were more compliant (p < .001) as compared to recipients of institution-based services.

CONCLUSION

Long term caregiving leads to strain in caregivers and there is a need to design interventions to alleviate the burden. The study was a pragmatic, quasi-experimental study thus causality cannot be inferred. However findings from this study suggest that the provision of care within a community setting as part of a well-structured outreach programme may be preferable method of service delivery within a resource-constrained context. It was associated with a greater improvement in functioning, greater satisfaction with services and better compliance.

Adherence to home exercises in non-specific low back pain. A randomised controlled pilot trial

Specific exercises for the improvement of movement control of the lumbopelvic region are well-established for patients with non-specific low back pain (NSLBP) and movement control impairment (MCI). However, a lack of adherence to home exercise regimens is often observed. The aim of the study was to explore the differences in home exercise (HE) adherence between patients who perform conventional exercises and those who exercise with Augmented Feedback (AF). Twenty patients with NSLBP and MCI were randomly allocated into two groups. The physiotherapy group (PT group) completed conventional exercises, and the AF group exercised with an AF system that was designed for use in therapy settings. The main outcome measure was self-reported adherence to the home exercise regimen. There was no significant difference in HE duration between the groups (W = 64, p = 0.315). The AF group exercised for a median of 9 min and 4 s (IQR = 3'59"), and the PT group exercised for 4 min and 19 s (IQR = 8'30"). Exercising with AF led to HE times that were similar to those of conventional exercise, and AF might be used as an alternative therapy method for home exercise.

Quality and Quantity of Rehabilitation Exercises Delivered By A 3-D Motion Controlled Camera: A Pilot Study

INTRODUCTION

Tele-rehabiliation technologies that track human motion could enable physical therapy in the home. To be effective, these systems need to collect critical metrics without PT supervision both in real time and in a store and forward capacity. The first step of this process is to determine if PTs (PTs) are able to accurately assess the quality and quantity of an exercise repetition captured by a tele-rehabilitation platform. The purpose of this pilot project was to determine the level of agreement of quality and quantity of an exercise delivered and assessed by the Virtual Exercise Rehabilitation Assistant (VERA), and seven PTs.

METHODS

Ten healthy subjects were instructed by a PT in how to perform four lower extremity exercises. Subjects then performed each exercises delivered by VERA which counted repetitions and quality. Seven PTs independently reviewed video of each subject's session and assessed repetitions quality. The percent difference in total repetitions and analysis of the distribution of rating repetition quality was assessed between the VERA and PTs.

RESULTS

The VERA counted 426 repetitions across 10 subjects performing the four different exercises while the mean repetition count from the PT panel was 426.7 (SD = 0.8). The VERA underestimated the total repetitions performed by 0.16% (SD = 0.03%, 95% CI 0.12 - 0. 22). Chi square analysis across raters was χ² = 63.17 (df = 6, p<.001), suggesting significant variance in at least one rater.

CONCLUSION

The VERA count of repetitions was accurate in comparison to a seven member panel of PTs. For exercise quality the VERA was able to rate 426 exercise repetitions across 10 patients and four different exercises in a manner consistent with five out of seven experienced PTs.

A prospective, cluster-randomized controlled trial of exercise program to prevent low back pain in office workers

PURPOSE

The objective of this study was to evaluate the effects of an exercise program focusing on muscle stretching and endurance training on the 12-month incidence of low back pain (LBP) in office workers.

METHODS

A 12-month prospective cluster-randomized controlled trial was conducted in healthy office workers with lower-than-normal trunk extension flexibility or trunk muscle endurance. Healthy office workers (n = 563) were randomly assigned at the cluster level into either intervention (n = 282) or control (n = 281) groups. Participants in the intervention group received an exercise program that included daily stretching exercise and twice-a-week muscle endurance training. Those in the control group received no intervention. The 12-month incidence of LBP was the primary outcome. Secondary outcome were pain intensity, disability level, and quality of life and health status. Analyses were performed using the Cox proportional hazard models.

RESULTS

Over the 12-month follow-up, 8.8% of participants in the intervention group and 19.7% in the control group developed incidence of LBP. Hazard rate ratios showed a protective effect of the exercise program for LBP (HR = 0.37, 95% CI 0.22-0.64) after adjusting for biopsychosocial factors. There was no significant difference in pain intensity, disability, and quality of life and health status between those who reported incidence of LBP in the intervention and control groups.

CONCLUSION

An exercise program consisting of muscle stretching and endurance training is an effective intervention to reduce incident LBP for office workers with lower-than-normal trunk extension flexibility or trunk muscle endurance.

Evaluation of pain and function after two home exercise programs in a clinical trial on women with chronic neck pain - with special emphasises on completers and responders

Background

Different types of exercises can help manage chronic neck pain. Supervised exercise interventions are widely used, but these protocols require substantial resources. The aim of this trial, which focused on adherence, was to evaluate two home exercise interventions.

Methods

This parallel group randomized controlled trial included 57 women randomly allocated into two groups – a strength training group (STRENGTH, 34 subjects) and a stretching group (STRETCH, 23 subjects). The interventions focused on the neck and shoulder muscles and lasted for 12 months. The STRENGTH group performed weight training and ended each session with stretching exercises. These stretching exercises constituted the entirety of the STRETCH group’s training session. Both groups were instructed to exercise three times per week. All the participants kept an exercise diary. In addition, all participants were offered support via phone and e-mail. The primary outcomes were pain intensity and function. The trial included a four- to six-month and a twelve-month follow-up. A completer in this study exercised at least 1,5 times per week during eight unbroken weeks. A responder in this study reported clinically significant improvements on pain and function. The statistical analyses used the Mann Whitney U-test, Wilcoxon signed-rank test, and X² test.

Results

At four- to six-months, the numbers of completers were 19 in the STRENGTH group and 17 in the STRETCH group. At twelve months, the corresponding numbers were 11 (STRENGTH) and 10 (STRETCH). At four- to six-months, the proportions of subjects reporting clinically important changes (STRENGTH and STRETCH) were for neck pain: 47% and 41%, shoulder pain: 47% and 47%, function: 37% and 29%. At twelve months, the corresponding numbers were for neck pain: 45% and 40%, shoulder pain: 55% and 50%, function: 55% and 20%.

Conclusions

No differences in the two primary outcomes between the two interventions were found, a finding that may be due to the insufficient statistical power of the study. Both interventions based on home exercises improved the two primary outcomes, but the adherences were relatively low. Future studies should investigate ways to improve adherence to home exercise treatments.

Trial registration

ClinicalTrials.gov Id: NCT01876680

Use of outcome measures in managing neck pain: an international multidisciplinary survey

Purpose:

To determine the outcome measures practice patterns in the neck pain management of various health disciplines.

Methods:

A survey of 381 clinicians treating patients with neck pain was conducted.

Results:

Respondents were more commonly male (54%) and either chiropractors (44%) or physiotherapists (32%). The survey was international (24 countries with Canada having the largest response (44%)). The most common assessment was a single-item pain assessment (numeric or visual analog) used by 75% of respondents. Respondents sometimes or routinely used the Neck Disability Index (49%), the Patient Specific Functional Scale (28%), and the Disabilities of the Arm, Shoulder and Hand (32%). Work status was recorded in terms of time lost by more than 50% of respondents, but standardized measures of work limitations or functional capacity testing were rarely used. The majority of respondents never used fear of movement, psychological distress, quality of life, participation measures, or global ratings of change (< 10% routinely use). Use of impairment measurers was prevalent, but the type selected was variable. Quantitative sensory testing was used sometimes or routinely by 53% of respondents, whereas 26% never used it. Ratings of segmental joint mobility were commonly used to assess motion (44% routinely use), whereas 66% of respondents never used inclinometry. Neck muscle strength, postural alignment and upper extremity coordination were assessed sometimes or routinely by a majority of respondents (>56%). With the exception of numeric pain ratings and verbal reporting of work status, all outcomes measures were less frequently used by physicians. Years of practice did not affect practice patterns, but reimbursement did affect selection of some outcome measures.

Conclusions:

Few outcome measures are routinely used to assess patients with neck pain other than a numeric pain rating scale. A comparison of practice patterns to current evidence suggessts overutilization of some measures that have questionable reliability and underutilization of some with better supporting evidence. This practice analysis suggests that there is substantial need to implement more consistent outcome measurement in practice. International consensus and better clinical measurement evidence are needed to support this.

What is the Experience of Receiving Health Care for Neck Pain?

This study used a descriptive phenomenological approach to describe the experience of finding and receiving health services for neck pain. Nineteen participants (18 females, 1 male) with neck pain (>3 months) were interviewed using a semi-structured questionnaire guide. Interviews were recorded, transcribed and coded. Two overarching themes described the experience: complexity in finding effective health care; and the need for informative, personalized, respectful communication. Complexity in finding effective health care was attributed to the variable approach and effectiveness of different health professionals, the need to experiment with care to find what works, the need to differentiate temporary versus permanent treatment effects, concerns about treatment side effects and the sense that financial factors influence personal treatment choices and provider behaviours. The need for informative, personalized, respectful communications was broken down into the following subthemes: the importance of being listened to, seen and believed; the need for useful information; and a desire to have outcomes formally tracked as a means of individualizing treatment. Overall, patients struggled to navigate the variable health services and providers that were available and that provided variable outcomes. They often did so through a trial and error approach. As such, patients remain open to unproven, even controversial treatment options. Research evidence was not a key ingredient in patient decision-making about accessing health services. The environmental, personal, health behavior factors interacted to contribute to health service utilization and would increase the burden of these for both the individual and society at large. The effectiveness of neck pain interventions is dependent on complex interactions between the context, individual, and health care provider, therefore, physiological responses cannot be considered as being distinct from these determinants.

Relevant patient perceptions and experiences for evaluating quality of interaction with physiotherapists during outpatient rehabilitation: a qualitative study

OBJECTIVE

To identify elements of the physiotherapist-patient interaction considered by patients when they evaluate the quality of care in outpatient rehabilitation settings.

DESIGN

A qualitative study with nine focus groups, Two researchers conducted the focus groups, and a topic guide with predetermined questions was used. Each group discussion was audiotaped,, transcribed verbatim and analyzed thematically according to a modified grounded theory approach.

SETTING

Three postacute ambulatory centers in Barcelona, Madrid and Seville (Spain).

PARTICIPANTS

Fifty-seven adults undergoing outpatient rehabilitation for musculoskeletal conditions/injuries.

RESULTS

Patients based their evaluations of quality of care on their assessment of physiotherapists' willingness to provide information and education, technical expertise and interpersonal manners (eg. respect, emotional support and sensitivity changes in the patient's status). Both positive and negative aspects of the physiotherapist-patient interaction emerged under all these themes, except for friendly and respectful communication.

CONCLUSION

This study identified which elements of the physiotherapist-patient interaction are considered by patients when evaluating the quality of care in rehabilitation outpatient settings. Further research should work to develop self-report questionnaires about patients' experiences of the physiotherapist-patient interaction in rehabilitation services to provide empirical and quantitative evidence.

Consumers' experiences of back pain in rural Western Australia: access to information and services, and self-management behaviours

Background

Coordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP.

Methods

Fourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals’ access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes.

Results

Five key themes were identified that affected individuals’ experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP.

Conclusions

Consumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care.

A qualitative investigation of physical therapists' experiences and feelings of managing patients with nonspecific low back pain

BACKGROUND

Physical therapists' management of patients with nonspecific low back pain (NSLBP) has been found to be associated with their beliefs and attitudes toward NSLBP, as well as with guideline recommendations. Greater knowledge of physical therapists' experiences and feelings of treating patients with NSLBP may help to explain these associations and increase our understanding of some of the challenges physical therapists face when treating patients with NSLBP in clinical practice.

OBJECTIVES

The objective of this study was to understand more about how the personal experiences and feelings of physical therapists might influence their decision making when treating patients with NSLBP.

DESIGN

This was a qualitative study using a phenomenological hermeneutical approach and practitioner-as-researcher model.

METHODS

Eleven semistructured interviews with physical therapists were conducted and analyzed using the hermeneutical circle to identify key themes relating to their experiences and feelings in treating patients with NSLBP.

RESULTS

Three linked themes emerged: (1) physical therapists believe that NSLBP has an underlying mechanical and recurring nature, (2) physical therapists' attitude toward managing NSLBP is to empower patients to exercise and self-manage their pain and functional problems, and (3) physical therapists experience feelings of tension between the advice and treatment they feel is best for their patient and the patient's own beliefs and attitudes.

CONCLUSIONS

The experiences and feelings of physical therapists treating patients with NSLBP include conflict among their pain beliefs, attitudes, and working partnerships with patients. Treatment decisions may be influenced when physical therapists modify their beliefs and attitudes to reduce this sense of conflict. Improving physical therapist communication skills may help decrease feelings of conflict, enhance working relationships, and encourage a more consistent approach toward patients with NSLBP.

Individuals with chronic low back pain have greater difficulty in engaging in positive lifestyle behaviours than those without back pain: an assessment of health literacy

BACKGROUND

Despite the large volume of research dedicated to understanding chronic low back pain (CLBP), patient outcomes remain modest while healthcare costs continue to rise, creating a major public health burden. Health literacy - the ability to seek, understand and utilise health information - has been identified as an important factor in the course of other chronic conditions and may be important in the aetiology of CLBP. Many of the currently available health literacy measurement tools are limited since they measure narrow aspects of health literacy. The Health Literacy Measurement Scale (HeLMS) was developed recently to measure broader elements of health literacy. The aim of this study was to measure broad elements of health literacy among individuals with CLBP and without LBP using the HeLMS.

METHODS

Thirty-six community-dwelling adults with CLBP and 44 with no history of LBP responded to the HeLMS. Individuals were recruited as part of a larger community-based spinal health study in Western Australia. Scores for the eight domains of the HeLMS as well as individual item responses were compared between the groups.

RESULTS

HeLMS scores were similar between individuals with and without CLBP for seven of the eight health literacy domains (p > 0.05). However, compared to individuals with no history of LBP, those with CLBP had a significantly lower score in the domain 'Patient attitudes towards their health' (mean difference [95% CI]: 0.46 [0.11-0.82]) and significantly lower scores for each of the individual items within this domain (p < 0.05). Moderate effect sizes ranged from d = 0.47-0.65.

CONCLUSIONS

Although no differences were identified in HeLMS scores between the groups for seven of the health literacy domains, adults with CLBP reported greater difficulty in engaging in general positive health behaviours. This aspect of health literacy suggests that self-management support initiatives may benefit individuals with CLBP.

An exploration of chronic pain patients' perceptions of home telerehabilitation services

OBJECTIVES

To explore patients' perceptions regarding prospective telerehabilitation services and the factors that facilitate or impede patients' intentions to use these services.

DESIGN

Using semi-structured interviews, patients reflected on the pros and cons of various scenarios of prospective telerehabilitation services. Patients' arguments were first arranged according to the Unified Theory of Acceptance and Use of Technology (UTAUT). Next, using inductive analysis, the data for each UTAUT component were analysed and arranged into subthemes.

SETTING AND PARTICIPANTS

Twenty-five chronic pain patients were selected from a rehabilitation centre in the Netherlands.

RESULTS

Overall, participants considered telerehabilitation helpful as a complementary or follow-up treatment, rather than an autonomous treatment. Arguments mainly related to the UTAUT constructs of 'performance expectancy' and 'facilitating conditions'. Patients valued the benefits such as reduced transportation barriers, flexible exercise hours and the possibility to better integrate skills into daily life. However, many patients feared a loss of treatment motivation and expressed concerns about both reduced fellow sufferer contact and reduced face-to-face therapist contact. Few arguments related to 'social norms' and 'effort expectancy'.

CONCLUSIONS

The effect of telerehabilitation on healthcare strongly depends on patients' willingness to use. Our study showed that chronic pain patients valued the benefits of telerehabilitation but hesitate to use it as an autonomous treatment. Therefore, future initiatives should maintain traditional care to some degree and focus on patients' attitudes as well. Either by giving information to increase patients' confidence in telerehabilitation or by addressing reported drawbacks into the future design of these services. Further quantitative studies are needed to explore patients' intentions to use telerehabilitation.

Effectiveness of a 'Global Postural Reeducation' program for persistent low back pain: a non-randomized controlled trial

BACKGROUND

The aim of this non-randomized controlled trial was to evaluate the effectiveness of a Global Postural Reeducation (GPR) program as compared to a Stabilization Exercise (SE) program in subjects with persistent low back pain (LBP) at short- and mid-term follow-up (ie. 3 and 6 months).

METHODS

According to inclusion and exclusion criteria, 100 patients with a primary complaint of persistent LBP were enrolled in the study: 50 were allocated to the GPR group and 50 to the SE group. Primary outcome measures were Roland and Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI). Secondary outcome measures were lumbar Visual Analogue Scale (VAS) and Fingertip-to-floor test (FFT). Data were collected at baseline and at 3/6 months by health care professionals unaware of the study. An intention to treat approach was used to analyze participants according to the group to which they were originally assigned.

RESULTS

Of the 100 patients initially included in the study, 78 patients completed the study: 42 in the GPR group and 36 in the SE group. At baseline, the two groups did not differ significantly with respect to gender, age, BMI and outcome measures. Comparing the differences between groups at short- and mid-term follow-up, the GPR group revealed a significant reduction (from baseline) in all outcome measures with respect to the SE group.The ordered logistic regression model showed an increased likelihood of definitive improvement (reduction from baseline of at least 30% in RMDQ and VAS scores) for the GPR group compared to the SE group (OR 3.9, 95% CI 2.7 to 5.7).

CONCLUSIONS

Our findings suggest that a GPR intervention in subjects with persistent LBP induces a greater improvement on pain and disability as compared to a SE program. These results must be confirmed by further studies with higher methodological standards, including randomization, larger sample size, longer follow-up and subgrouping of the LBP subjects.

TRIAL REGISTRATION

NCT00789204.

[Mitosis in regenerating comb row and the double-nucleated cells of Ctenophora]

Background

Conservative scoliosis therapy in the form of assisted physiotherapeutic scoliosis exercises is supplemented by self-contained training at home, depending on the approach (eg, Schroth, the Scientific Exercises Approach to Scoliosis). Complex exercises, lack of awareness of the importance of training, and missing supervision by therapists often lead to uncertainty and reduced motivation, which in turn reduces the success of home-based therapy. Increasing digitalization in the health care sector offers opportunities to close this gap. However, research is needed to analyze the requirements and translate the potential of digital tools into concrete solution concepts.

Objective

The aim of this study is to evaluate the potential for optimizing home-based scoliosis therapy in terms of motivation, assistive devices, and digital tools.

Methods

In collaboration with the Institute of Physiotherapy at the Jena University Hospital, a survey was initiated to address patients with scoliosis and physical therapists. A digital questionnaire was created for each target group and distributed via physiotherapies, scoliosis forums, the Bundesverband für Skoliose Selbsthilfe e. V. newsletter via a link, and a quick response code. The survey collected data on demographics, therapy, exercise habits, motivation, assistive devices, and digital tools. Descriptive statistics were used for evaluation.

Results

Of 141 survey participants, 72 (51.1%; n=62, 86.1%, female; n=10, 13.9%, male) patients with scoliosis with an average age of 40 (SD 17.08) years and 30 scoliosis therapists completed the respective questionnaires. The analysis of home-based therapy showed that patients with scoliosis exercise less per week (2 times or less; 45/72, 62.5%) than they are recommended to do by therapists (at least 3 times; 53/72, 73.6%). Patients indicated that their motivation could be increased by practicing together with friends and acquaintances (54/72, 75%), a supporting therapy device (48/72, 66.7%), or a digital profile (46/72, 63.9%). The most important assistive devices, which are comparatively rarely used in home-based therapy, included balance boards (20/72, 27.8%), wall bars (23/72, 31.9%), mirrors (36/72, 50%), and long bars (40/72, 55.6%). Therapists saw the greatest benefit of digital tools for scoliosis therapy in increasing motivation (26/30, 87%), improving home therapy (25/30, 83%), monitoring therapy progress (25/30, 83%), and demonstrating exercise instructions (24/30, 80%).

Conclusions

In this study, we investigated whether there is any potential for improvement in home-based scoliosis therapy. For this purpose, using online questionnaires, we asked patients with scoliosis and therapists questions about the following topics: exercise habits, outpatient and home-based therapy, motivation, supportive devices, and digital tools. The results showed that a lack of motivation, suitable training equipment, and tools for self-control leads to a low training workload. From the perspective of the patients surveyed, this problem can be addressed through community training with friends or acquaintances, a supportive therapy device, and digital elements, such as apps, with training instructions and user profiles.