Interventions for enhancing adherence with physiotherapy: a systematic review

Multimodal guided self-help exercise program to prevent speech, swallowing, and shoulder problems among head and neck cancer patients: a feasibility study

Background

During a 6-week course of (chemo)radiation many head and neck cancer patients have to endure radiotherapy-induced toxicity, negatively affecting patients’ quality of life. Pretreatment counseling combined with self-help exercises could be provided to inform patients and possibly prevent them from having speech, swallowing, and shoulder problems during and after treatment.

Objective

Our goal was to investigate the feasibility of a multimodal guided self-help exercise program entitled Head Matters during (chemo)radiation in head and neck cancer patients.

Methods

Head and neck cancer patients treated with primary (chemo)radiation or after surgery were asked to perform Head Matters at home. This prophylactic exercise program, offered in three different formats, aims to reduce the risk of developing speech, swallowing, shoulder problems, and a stiff neck. Weekly coaching was provided by a speech and swallowing therapist. Patients filled out a diary to keep track of their exercise activity. To gain insight into possible barriers and facilitators to exercise adherence, reports of weekly coaching sessions were analyzed by 2 coders independently.

Results

Of 41 eligible patients, 34 patients were willing to participate (83% uptake). Of participating patients, 21 patients completed the program (64% adherence rate). The majority of participants (58%) had a moderate to high level of exercise performance. Exercise performance level was not significantly associated with age (P=.50), gender (P=.42), tumor subsite (P=1.00) or tumor stage (P=.20), treatment modality (P=.72), or Head Matters format (Web-based or paper) (P=1.00). Based on patients’ diaries and weekly coaching sessions, patients’ perceived barriers to exercise were a decreased physical condition, treatment-related barriers, emotional problems, lack of motivation, social barriers, and technical problems. Patients’ perceived facilitators included an increased physical condition, feeling motivated, and social and technical facilitators.

Conclusions

Head Matters, a multimodal guided self-help exercise program is feasible for head and neck cancer patients undergoing (chemo)radiation. Several barriers (decreased physical condition, treatment-related barriers) and facilitators (increased physical condition, feeling motivated) were identified providing directions for future studies. The next step is conducting a study investigating the (cost-)effectiveness of Head Matters on speech, swallowing, shoulder function, and quality of life.

A Telephone-based Physiotherapy Intervention for Patients with Osteoarthritis of the Knee

This study assessed the effects of a 6-week telephone based intervention on the pain intensity and physical function of patients with knee osteoarthritis (OA), and compared the results to physiotherapy conducted in the clinic. Fifty randomly selected patients with knee OA were assigned to one of two treatment groups: a clinic group (CG) and a tele-physiotherapy group (TG). The CG received thrice-weekly physiotherapist administered osteoarthritis-specific exercises in the clinic for six weeks. The TG received structured telephone calls thrice-weekly at home, to monitor self-administered osteoarthritis-specific exercises. Participants' pain intensity and physical function were assessed at baseline, two, four, and six weeks, in the clinic environment. Within group comparison showed significant improvements across baseline, and at weeks two, four, and six for both TG and CG's pain intensity and physical function. Between-group comparison of CG and TG's pain intensity and physical function at baseline and weeks two, four, and six showed no significant differences. This study demonstrated that a six-week course of structured telephone calls thrice-weekly to patients at their home, to monitor self-administered osteoarthritis-specific exercises for patients with knee OA (i.e., tele-physiotherapy) achieved comparable results to physiotherapy conducted in the clinic.

Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review

BACKGROUND CONTEXT

Exercise has been shown to reduce pain and increase function in patients with chronic low back pain. However up to 70% of patients do not engage in prescribed home exercise. Physiotherapists need to understand more about the complex factors influencing patients' adherence to prescribed home exercise to tailor their exercise interventions more effectively and support patients to self-manage.

PURPOSE

This review identifies factors associated with adherence to health care practitioner-prescribed home exercise in adults with chronic low back pain.

STUDY DESIGN

Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used for the reporting of this review.

PATIENT SAMPLE

We explored literature in which the authors studied adherence to home exercise in adults with CLBP.

OUTCOME MEASURES

Adherence to home exercise was the primary outcome. Additional outcome measures were recorded in the data extraction table.

METHODS

The following databases were searched: Embase, PsychINFO, MEDLINE, PEDro, and the Cochrane Central Register of Controlled Trials. Data were independently extracted and assessed for methodologic quality by two reviewers.

RESULTS

Eleven randomized controlled trials, including 1,088 participants, met the inclusion criteria. Moderate evidence was found for one individual patient subfactor and three intervention-related subfactors associated with increased adherence to home exercise. These subfactors were greater health locus of control, supervision, participation in an exercise program, and participation in a general behavior change program incorporating motivational strategies.

CONCLUSIONS

This is the first systematic review investigating adherence to prescribed home exercise in a chronic low back pain population. It is difficult to draw firm conclusions because the research lacks detailed descriptions of intervention content. The use of a taxonomy of behavior change techniques has been suggested to overcome this key problem. This review has highlighted the lack of standardized measures of adherence to prescribed home exercise. The development of a validated measure of adherence should be a priority because this will provide a better understanding of the multitude of factors that may influence adherence to home exercise.

Comparing the Effects of a Novel and a Traditional Proprioceptive Balance Training Program on Activity Adherence and Balance Control in a Healthy University Population: A Preliminary Study

OBJECTIVE

This study explored balance performance and participant adherence to either the Wii Fit™ (Nintendo of America, Redmond, WA) or a proprioceptive BOSU(®) (Ashland, OH) ball balance program.

MATERIALS AND METHODS

Twenty university-aged participants were randomly allocated to either a Wii Fit or BOSU ball balance training program. Participants engaged in one of the two training regimens for 20 minutes, three times a week, for 4 weeks. Adherence was measured by recording attendance and time spent at each session. Motivational factors associated with adherence were assessed using the Physical Activity Enjoyment Scale. Balance was measured using a stabilometer.

RESULTS

No significant difference in participant adherence was found between the groups. Significantly higher levels of activity enjoyment were reported from participants assigned to the Wii Fit intervention, and a positive correlation was found between physical activity enjoyment and adherence. A significant main effect for time demonstrating improved balance scores for both groups was found. No significant interaction between program type and time was found.

DISCUSSION

Although both interventions led to balance improvements, Wii Fit participants reported significantly higher levels of activity enjoyment. Although these higher levels of enjoyment did not lead to a statistically significant difference between the groups with regard to the number of sessions attended, participants assigned to the Wii Fit group spent more time engaged in the balance training activities than those allocated to the BOSU group. Although this study is preliminary and has the limitations of being statistically underpowered and dissimilar from the unsupervised home-based programs often prescribed by health professionals, results suggest that exergaming-based balance training may be an important adjunct to traditional training programs.

Concentric and eccentric time-under-tension during strengthening exercises: validity and reliability of stretch-sensor recordings from an elastic exercise-band

Background

Total, single repetition and contraction-phase specific (concentric and eccentric) time-under-tension (TUT) are important exercise-descriptors, as they are linked to the physiological and clinical response in exercise and rehabilitation.

Objective

To investigate the validity and reliability of total, single repetition, and contraction-phase specific TUT during shoulder abduction exercises, based on data from a stretch-sensor attached to an elastic exercise band.

Methods

A concurrent validity and interrater reliability study with two raters was conducted. Twelve participants performed five sets of 10 repetitions of shoulder abduction exercises with an elastic exercise band. Exercises were video-recorded to assess concurrent validity between TUT from stretch-sensor data and from video recordings (gold standard). Agreement between methods was calculated using Limits of Agreement (LoA), and the association was assessed by Pearson correlation coefficients. Interrater reliability was calculated using intraclass correlation coefficients (ICC 2.1).

Results

Total, single repetition, and contraction-phase specific TUT – determined from video and stretch-sensor data – were highly correlated (r>0.99). Agreement between methods was high, as LoA ranged from 0.0 to 3.1 seconds for total TUT (2.6% of mean TUT), from -0.26 to 0.56 seconds for single repetition TUT (6.9%), and from -0.29 to 0.56 seconds for contraction-phase specific TUT (13.2-21.1%). Interrater reliability for total, single repetition and contraction-phase specific TUT was high (ICC>0.99). Interrater agreement was high, as LoA ranged from -2.11 to 2.56 seconds for total TUT (4.7%), from -0.46 to 0.50 seconds for single repetition TUT (9.7%) and from -0.41 to 0.44 seconds for contraction-phase specific TUT (5.2-14.5%).

Conclusion

Data from a stretch-sensor attached to an elastic exercise band is a valid measure of total and single repetition time-under-tension, and the procedure is highly reliable. This method will enable clinicians and researchers to objectively quantify if home-based exercises are performed as prescribed, with respect to time-under-tension.

Long-term effects of medical exercise therapy in patients with patellofemoral pain syndrome: results from a single-blinded randomized controlled trial with 12 months follow-up

OBJECTIVES

To evaluate the long-term effect of high-dose, high-repetition medical exercise therapy (MET) in patients with patellofemoral pain syndrome (PFPS).

DESIGN

Follow-up study one year after completion of a randomized, controlled trial.

SETTING

Follow-up testing in the primary healthcare physiotherapy clinics, where intervention was undertaken.

PARTICIPANTS

Twenty-eight patients with PFPS completed follow-up testing, fourteen in each group.

INTERVENTIONS

The groups received three treatments per week for 12 weeks: high-dose, high-repetition MET for the experimental group, and low-dose, low-repetition exercise therapy for the control group.

MAIN OUTCOME MEASURES

Pain measured using a visual analogue scale (VAS: 0-10cm), and function measured using a step-down test (numbers of completed step-downs in 30 seconds) and the modified Functional Index Questionnaire (FIQ: 0 points indicates maximal disability, 16 points no disability).

RESULTS

At baseline there were no differences between groups. After intervention, there were statistically significant (p<0.05) and clinically important differences between groups for all outcome parameters, also when adjusting for gender and duration of symptoms: -1.6 for mean pain [95% confidence interval (CI) -2.4 to -0.8], 6.5 for step-down test (95% CI 3.8 to 9.2), and 3.1 for FIQ (95% CI 1.2 to 5.0). At follow-up the differences between groups were maintained and even increased for mean pain and step-down with significant differences (p<0.05) between groups; -1.8 for mean pain (95% CI: -2.7 to -1.0) and 4.5 for step-down test (95%CI: 2.4 to 6.5). The difference between groups for FIQ at follow-up: 1.1 (95% CI: -1.1 to 3.3).

CONCLUSION

There appear to be long-term effects of high-dose, high-repetition MET in patients with PFPS with respect to pain and functional outcomes. One year after completed intervention the experimental group has continued to improve, while the control group has relapsed. Registered on http://www.clinicaltrials.gov (identifier: NCT01290705).

Interventions employing mobile technology for overweight and obesity: an early systematic review of randomized controlled trials

Obesity is a global epidemic with major healthcare implications and costs. Mobile technologies are potential interventions to promote weight loss. An early systematic review of this rapidly growing area of research was conducted. Electronic databases were searched for articles published between January 1998 and October 2011. Data sources included Medline, Embase and the Cochrane Central Register of Controlled Trials. Ongoing research was searched for using clinical trials databases and registers. Out of 174 articles retrieved, 21 met the inclusion criteria of randomized controlled trials (RCTs) on mobile technology interventions facilitating weight loss in overweight and obese adults with any other comparator. A narrative synthesis was undertaken. Seven articles were included and appraised using the Cochrane risk of bias tool: four presented a low risk of bias and three presented a high risk of bias. There is consistent strong evidence across the included multiple high-quality RCTs that weight loss occurs in the short-term because of mobile technology interventions, with moderate evidence for the medium-term. Recommendations for improving the reporting and quality of future trials are made including reporting weight loss in percent to meet clinical standards, and including features such as long-term follow-up, cost-effectiveness and patient acceptability.

Novel stretch-sensor technology allows quantification of adherence and quality of home-exercises: a validation study

OBJECTIVE

To investigate if a new stretch sensor attached to an elastic exercise band can assist health professionals in evaluating adherence to home exercises. More specifically, the study investigated whether health professionals can differentiate elastic band exercises performed as prescribed, from exercises not performed as prescribed.

METHODS

10 participants performed four different shoulder-abduction exercises in two rounds (80 exercise scenarios in total). The scenarios were (1) low contraction speed, full range of motion (0-90°), (2) high contraction speed, full range of motion (0-90°), (3) low contraction speed, diminished range of motion (0-45°) and (4) unsystematic pull of the elastic exercise band. Stretch-sensor readings from each participant were recorded and presented randomly to the raters. Two raters were asked to differentiate between unsystematic pull (scenario 4), from shoulder abduction strength exercises (scenarios 1-3). The next two raters were asked to identify the four different exercise scenarios (scenarios 1-4).

RESULTS

The first two raters were able to differentiate between unsystematic pull (scenario 4) from shoulder abduction strength exercises (scenarios 1-3). They made no errors (100% success rate). The second two raters were both able to identify each of the 80 scenarios (scenarios 1-4). They too made no errors (100% success rate).

CONCLUSIONS

The stretch-sensor readings from the elastic exercise band allow health professionals to quantify whether strength-exercises have been performed as prescribed. These findings have great implications for future clinical practice and research where home exercises are the drugs-of-choice, as they enable clinicians and researchers to measure the exact adherence and quality of the prescribed exercises.

A randomised controlled trial comparing graded exercise treatment and usual physiotherapy for patients with non-specific neck pain (the GET UP neck pain trial)

Evidence supports exercise-based interventions for the management of neck pain, however there is little evidence of its superiority over usual physiotherapy. This study investigated the effectiveness of a group neck and upper limb exercise programme (GET) compared with usual physiotherapy (UP) for patients with non-specific neck pain. A total of 151 adult patients were randomised to either GET or UP. The primary measure was the Northwick Park Neck pain Questionnaire (NPQ) score at six weeks, six months and 12 months. Mixed modelling identified no difference in neck pain and function between patients receiving GET and those receiving UP at any follow-up time point. Both interventions resulted in modest significant and clinically important improvements on the NPQ score with a change score of around 9% between baseline and 12 months. Both GET and UP are appropriate clinical interventions for patients with non-specific neck pain, however preferences for treatment and targeted strategies to address barriers to adherence may need to be considered in order to maximise the effectiveness of these approaches.

Factors associated with exercise behavior in people with Parkinson disease

BACKGROUND

The benefits of exercise for reducing disability in people with Parkinson disease (PD) are becoming more evident. Optimal benefit, however, requires regular and sustained participation. Factors associated with engaging in regular exercise have received little scientific scrutiny in people with PD.

OBJECTIVE

The purpose of this study was to explore factors associated with exercise behavior in patients with PD using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework.

DESIGN

This was a cross-sectional study.

METHODS

The participants in this study were 260 patients with PD from 4 institutions. Participants were designated as "exercisers" or "nonexercisers" based on responses to the Stages of Readiness to Exercise Questionnaire. Exercise status was validated using the Physical Activity Scale for the Elderly and an activity monitor. Factors potentially associated with exercise behavior included measures of body structure and function, activity, participation, environmental factors, and personal factors. Their relative contributions were analyzed using logistic regression and quantified with odds ratios.

RESULTS

One hundred sixty-four participants (63%) were designated as exercisers. Participants with high self-efficacy were more than twice as likely to engage in regular exercise than those with low self-efficacy (adjusted odds ratio=2.34, 95% confidence interval=1.30-4.23). College educated and older participants also were more likely to exercise. Disabling influences of impairments, activity limitations, and participation restrictions were not associated with exercise behavior.

LIMITATIONS

The cross-sectional nature of the study limited the ability to make causal inferences.

CONCLUSIONS

Self-efficacy, rather than disability, appears to be strongly associated with whether ambulatory, community-dwelling people with PD exercise regularly. The results of this study suggest that physical therapists should include strategies to increase exercise self-efficacy when designing patient intervention programs for patients with PD.

What does the evidence tell us about design of future treatment trials for whiplash-associated disorders?

STUDY DESIGN

Reflective critique and recommendation development.

OBJECTIVE

To reflect on limitations in past trials and propose recommendations on innovative trial designs and methodologies for whiplash-associated disorders (WAD).

SUMMARY OF BACKGROUND DATA

The cost of doing clinical research and risk of retaining an evidence void is an overarching threat to lessening the transition of WAD to chronicity.

METHODS

Review trial limitations on neck pain and propose recommendations to amend these.

RESULTS

Three innovative trial designs, 20 methodological recommendations, and two knowledge translation (KT) research strategies are proposed. Many of the gaps in our current understanding of neck disorders can be linked to an inadequate research design and implementation. Increased utilization of three design options for evaluating therapies could lead to a more accurate and efficient understanding of the merits of various therapies singly and multimodal. Increased utilization of mixed methods or biological subcomponents may advance our understanding of neck disorders and the resulting disability. There is a need for harmonization and standardization across participant disorder classification; identification and tracking of prognostic factors and adverse events; adequate intervention description and dosing; and outcome selection comparable across studies and across International Classification Framework domains. Reasons for discordant conclusions including subjective elements need to be explored in future trials using qualitative methods. KT research that defines the barriers to implementation of existing knowledge and strategies to reduce the evidence to practice gap is urgently needed.

CONCLUSION

Our recommendations suggest an overarching need for adherence to CONSORT guidelines, a consensus taxonomy illuminating neck pain characterization, prognostic indicators, and diagnostic criteria as well as a core set of trial outcomes. Innovative trial design could lead to a more accurate and efficient understanding of the merits of various therapies. As the evidence emerges, studies of KT can inform us how it will impact clinical actions.

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.