Do training diaries affect and reflect adherence to home programs?

Mechanisms of education and graded sensorimotor retraining in people with chronic low back pain: a mediation analysis

ABSTRACT

An improved understanding of the biopsychosocial influences that contribute to and maintain pain has promoted the development of new efficacious treatments for chronic low back pain (CLBP). This study aimed to investigate the mechanisms of a new treatment-education and graded sensorimotor retraining-on pain and disability. We conducted a preplanned causal mediation analysis of a randomized clinical trial which allocated 276 participants with CLBP to 12 weekly clinical sessions of education and graded sensorimotor retraining (n = 138) or a sham and attention control (n = 138). Outcomes were pain intensity and disability, both assessed at 18 weeks. Hypothesized mediators included tactile acuity, motor coordination, back self-perception, beliefs about the consequences of back pain, kinesiophobia, pain self-efficacy, and pain catastrophizing, all assessed at the end of treatment (12 weeks). Four of 7 mechanisms (57%) mediated the intervention effect on pain; the largest mediated effects were for beliefs about back pain consequences (-0.96 [-1.47 to -0.64]), pain catastrophizing (-0.49 [-0.61 to -0.24]), and pain self-efficacy (-0.37 [-0.66 to -0.22]). Five of 7 mechanisms (71%) mediated the intervention effect on disability; the largest mediated effects were for beliefs about back pain consequences (-1.66 [-2.62 to -0.87]), pain catastrophizing (-1.06 [-1.79 to -0.53]), and pain self-efficacy (-0.84 [-1.89 to -0.45]). When all 7 mechanisms were considered simultaneously, the joint mediation effect explained most of the intervention effect for both pain and disability. Optimizing interventions to target beliefs about the consequences of back pain, pain catastrophizing, and pain self-efficacy is likely to lead to improved outcomes for people with CLBP.

Body activity grading strategy for cervical rehabilitation training

A body activity grading strategy is proposed for computer-assisted cervical rehabilitation training, which employs hidden Markov model to partition an exercise into independently assessable phases and a scoring reference to rate respective kinematic features. Samples of 34 cervical rehabilitation exercises are evaluated by both manual and the proposed approaches, where the average phase segmentation difference is 93 ms, the phase scoring difference is 0.045, and the grading difference for overall samples is 5.5% between the approaches. It indicates that the proposed method has similar accuracy as physical therapists and is thus capable of performing online supervision for cervical rehabilitation training.

Is there any benefit of adding a central nervous system-focused intervention to a manual therapy and home stretching program for people with frozen shoulder? A randomized controlled trial

BACKGROUND

Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion. The aim of this study was to evaluate the effect of adding a central nervous system (CNS)-focused approach to a manual therapy and home stretching program in people with FS.

METHODS

A total of 34 patients with a diagnosis of primary FS were randomly allocated to receive a 12-week manual therapy and home stretching program or manual therapy and home stretching program plus a CNS-focused approach including graded motor imagery and sensory discrimination training. The Shoulder Pain and Disability Index score, self-perceived shoulder pain (visual analog scale score), shoulder range of motion, and the Patient-Specific Functional Scale score were measured at baseline, after a 2-week washout period just before starting treatment, after treatment, and at 3 months' follow-up.

RESULTS

No significant between-group differences in any outcome were found either after treatment or at 3 months' follow-up.

CONCLUSION

A CNS-focused approach provided no additional benefit to a manual therapy and home stretching program in terms of shoulder pain and function in people with FS.

Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment

Introduction

Complex Regional Pain Syndrome (CRPS) is most common in the upper limb and associated with high disability. The purpose of this review was to critically appraise and synthesise literature exploring non-pharmacological treatment for upper limb CRPS, to guide upper-limb-specific management.

Methods

Using an integrative review methodology, 13 databases were searched to identify all published studies on non-pharmacological management of upper limb CRPS. The Crowe Critical Appraisal Tool was used to provide quality ratings for included studies, and analysis employed a qualitative descriptive approach.

Results

From 236 abstracts reviewed, 113 full texts were read, and 38 articles selected for data extraction. Designs included single case (n = 14), randomised controlled trial (n = 8), prospective cohort (n = 8), case series (n = 4), retrospective (n = 3), and mixed methods (n = 1). Interventions were categorised as sensory retraining (n = 13), kinesiotherapy (n = 7), manual therapies (n = 7), physical modalities (n = 6), and interdisciplinary treatment programmes (n = 5). All studies measured pain intensity, and most (n = 24) measured physical parameters such as strength, movement, or perceptual abilities. Few measured patient-rated function (n = 13) or psychological factors (n = 4). Quality ratings ranged from 30% to 93%, with a median of 60%.

Conclusion

Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. Movement, desensitisation, and graded functional activity remain the mainstays of intervention. However, despite the impact of CRPS on wellbeing and function, psychological factors and functional outcomes are infrequently addressed. Further robust research is required to determine which aspects of treatment have the greatest influence on which symptoms, and when and how these should be introduced and progressed.

Clinical and Neurophysiological Effects of Progressive Movement Imagery Training for Pathological Pain

Movement limitation is a common characteristic of chronic pain such that pain prevents the very movement and activity that is most likely to promote recovery. This is particularly the case for pathological pain states such as complex regional pain syndrome (CRPS). One clinical approach to CRPS that has growing evidence of efficacy involves progressive movement imagery training. Graded Motor Imagery (GMI) targets clinical and neurophysiological effects through a stepwise progression through implicit and explicit movement imagery training, mirror therapy and then functional tasks. Here we review experiences from over 20 years of clinical and research experience with GMI. We situate GMI in terms of its historical underpinnings, the benefits and outstanding challenges of its implementation, its potential application beyond CRPS. We then review the neuropathological targets of GMI and current thought on its effects on neurophysiological biomarkers. Perspective This article provides an overview of our experiences with graded motor imagery training over the last 20 years focussing on the treatment of CRPS. It does both cover the theoretical underpinnings for this treatment approach, biomarkers which indicate potential changes driven by GMI, and experiences for achieving optimal treatment results.

A pilot single-blind parallel randomised controlled trial comparing kinesiology tape to compression in the management of subacute hand oedema after trauma

Background

Hand oedema is a common consequence of hand trauma or surgery. There are numerous methods to reduce hand oedema but lack high-quality evidence to support best practice. The primary objective of this pilot trial was to assess study feasibility when comparing treatments for subacute hand oedema after trauma.

Methods

A parallel two-arm pilot randomised controlled trial was conducted in the hand therapy department at a regional hospital in Norfolk between October 2017 and July 2018. Patients were eligible if 18 years or over, referred to hand therapy with subacute hand oedema. Randomisation was on a 1:1 basis to treatment as usual (TAU) (compression, elevation and massage) or trial treatment (TT) (kinesiology tape, elevation and massage). One blinded assessor completed all assessments (prior to randomisation, 4 and 12 weeks later). Data on study feasibility, adherence and acceptability of treatments were collected. The primary outcome measure was hand volume (volumetry). Patient-rated severity (0–5 Likert scale), hand health profile of the Patient Evaluation Measure (PEM) and quality of life (EQ-5D-5L) were also recorded.

Results

Forty-five patients were screened for eligibility and 26 consented and were randomised with 13 patients in each treatment arm. Twelve participants were lost to follow-up leaving 7 participants in each group included in the analysis. Assessor blinding was maintained in 64% of participants (9/14). Total mean acceptability scores, out of 100, were higher for TAU (87.9) than TT (76.1). Health resource use results showed TT was marginally cheaper (~£2 per patient) than TAU.

Individual adherence ranged between 39 and 100%, with higher levels of overall adherence seen in the TAU group. Four participants (28%) reported adverse effects (TT group n = 3, TAU group n = 1).

Conclusion

This pilot trial has identified that modifications are required in order to make a full-scale trial feasible. They include a formal assessment of treatment fidelity, research staff assisting with screening and recruitment of participants and multiple blinded assessors at each study site. Whilst not designed as an efficacy trial, it should be acknowledged that the small sample size and high loss to follow-up meant very small numbers were included in the final analysis resulting in wide confidence intervals and therefore low precision in parameter estimates.

Trial registration

International Standard Randomised Controlled Trial Number: 94083271. Date of registration 16th August 2017.

Trial funding

National Institute for Health Research Trainees Co-ordinating Centre (TCC); Grant Codes: CDRF-2014-05-064

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01023-1.

The effect of stretching exercises on the fibre angle of the vastus lateralis and vastus medialis oblique: an ultrasound study

[Purpose] To investigate the effects of a seven-week quadriceps stretching program on the muscle fibre orientation of the vastus medialis oblique and vastus lateralis in the lower limbs by ultrasound imaging. [Participants and Methods] Twenty-seven healthy, physically fit, asymptomatic females and males (age 21.5 ± 1.3, Tegner activity level score ≥4) were recruited. Their initial vastus medialis oblique and vastus lateralis fibre angles were determined using ultrasound. They then undertook a seven-week quadriceps stretching program, 3 sets of stretches to be performed on both lower limbs, 3 times a week on 3 separate days. One volunteer was assigned as an intra-rater control and did not take part in the stretching program. The vastus lateralis and vastus medialis oblique fibre angles were measured again on completion of the exercise regime. [Results] A statistically significant decrease in muscle fibre angle was observed in both the right and left vastus medialis oblique, and the right and left vastus lateralis. [Conclusion] A 7-week stretching program can result in a significant decrease in muscle fibre angle in both the vastus medialis oblique and the vastus lateralis. This can help in understanding the effects of prescribed stretching exercises on athletic patients with PFP.

A Central Nervous System Focused Treatment Program for People with Frozen Shoulder: A Feasibility Study

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study is to evaluate the feasibility and clinical impact of a CNS-focused treatment program for people with FS. Methods: 10 subjects with primary FS received a 10-week CNS-focused intervention including sensory discrimination training and graded motor imagery techniques delivered as clinic sessions (60 min) and home therapy (30 min five times per week). Measurements were taken at baseline, after a 2-week “washout” period, after treatment, and at three months follow-up. The Shoulder Pain and Disability Index (SPADI) was the primary outcome. Secondary measures were feasibility-related outcomes, self-reported shoulder pain, active and passive range of motion, two-point discrimination threshold (TPDT), left/right judgement task (LRJT), fear-avoidance (Tampa Scale for Kinesiophobia), pain catastrophization (Pain Catastrophizing Scale), and pain sensitization (Central Sensitization Inventory). A Student’s t-test was used to assess the “washout” period. A repeated measure analysis of variance (ANOVA) was used to evaluate within-subjects’ differences for all outcome measures in the different assessment periods and a pairwise analysis was used to compare between the different assessment points. Statistical significance was set at p < 0.05. Results: 70% of participants completed the treatment. No significant changes were found after “washout” period except for TPDT (p = 0.02) and SPADI (p = 0.025). Improvements in self-reported shoulder pain (p = 0.028) and active shoulder flexion (p = 0.016) were shown after treatment (p = 0.028) and follow-up (p = 0.001) and in SPADI at follow-up (p = 0.008). No significant changes were observed in TPDT, LRJT, fear-avoidance, pain catastrophization, and pain sensitization. Conclusions: a CNS-focused treatment program might be a suitable approach to improve pain and disability in FS, but further research is needed to draw firm conclusions.

Specific versus Non-Specific Exercises for Chronic Neck or Shoulder Pain: A Systematic Review

The current systematic review aimed to compare the effect of injury-focused (specific) exercises versus more general (non-specific) exercises on pain in patients with chronic neck or shoulder pain. We searched PubMed, EMBASE, and Web of Science. Two reviewers screened and selected studies, extracted outcomes, assessed risk of bias, and rated the quality of evidence. A total of nine eligible studies, represented in 13 articles, were identified, with a considerable risk of bias. One article investigated the acute effect of single bouts of exercise on pain and reported an immediate pain reduction after non-specific exercise. Regarding short-term effects, seven out of the nine studies found no differences in pain between interventions, with inconsistent results among two other studies. Concerning the long-term effects, while pain reduction seems to be favored by specific exercises (two out of four articles), the best format is still unclear. Based on the acute effects, a single bout of non-specific exercise seems to be a better option for pain-relief for patients with chronic neck or shoulder pain. For short-term effects, there are no differences in pain between specific and non-specific exercises. Regarding long-term effects, specific exercises seem to be the best option. Nevertheless, more studies are warranted.

Graded motor imagery modifies movement pain, cortical excitability and sensorimotor function in complex regional pain syndrome

Patients with complex regional pain syndrome suffer from chronic neuropathic pain and also show a decrease in sensorimotor performance associated with characteristic central and peripheral neural system parameters. In the brain imaging domain, these comprise altered functional sensorimotor representation for the affected hand side. With regard to neurophysiology, a decrease in intracortical inhibition for the sensorimotor cortex contralateral to the affected hand has been repetitively verified, which might be related to increased primary somatosensory cortex functional activation for the affected limb. Rare longitudinal intervention studies in randomized controlled trials have demonstrated that a decrease in primary somatosensory cortex functional MRI activation coincided with pain relief and recovery in sensorimotor performance. By applying a randomized wait-list control crossover study design, we tested possible associations of clinical, imaging and neurophysiology parameters in 21 patients with complex regional pain syndrome in the chronic stage (>6 months). In more detail, we applied graded motor imagery over 6 weeks to relieve movement pain of the affected upper limb. First, baseline parameters were tested between the affected and the non-affected upper limb side and age-matched healthy controls. Second, longitudinal changes in clinical and testing parameters were associated with neurophysiological and imaging parameters. During baseline short intracortical inhibition, as assessed with transcranial magnetic stimulation, was decreased only for hand muscles of the affected hand side. During movement of the affected limb, primary somatosensory cortex functional MRI activation was increased. Hand representation area size for somatosensory stimulation in functional MRI was smaller on the affected side with longer disease duration. Graded motor imagery intervention but not waiting, resulted in a decrease of movement pain. An increase of somatosensory hand representation size over graded motor imagery intervention was related to movement pain relief. Over graded motor imagery intervention, pathological parameters like the increased primary somatosensory cortex activation during fist movement or decreased short intracortical inhibition were modified in the same way as movement pain and hand performance improved. No such changes were observed during the waiting period. Overall, we demonstrated characteristic changes in clinical, behaviour and neuropathology parameters applying graded motor imagery in patients with upper limb complex regional pain syndrome, which casts light on the effects of graded motor imagery intervention on biomarkers for chronic neuropathic pain.

The EPIPHA-KNEE trial: Explaining Pain to target unhelpful pain beliefs to Increase PHysical Activity in KNEE osteoarthritis - a protocol for a multicentre, randomised controlled trial with clinical- and cost-effectiveness analysis

Background

Despite well-established benefits of physical activity for knee osteoarthritis (OA), nine of ten people with knee OA are inactive. People with knee OA who are inactive often believe that physical activity is dangerous, fearing that it will further damage their joint(s). Such unhelpful beliefs can negatively influence physical activity levels. We aim to evaluate the clinical- and cost-effectiveness of integrating physiotherapist-delivered pain science education (PSE), an evidence-based conceptual change intervention targeting unhelpful pain beliefs by increasing pain knowledge, with an individualised walking, strengthening, and general education program.

Methods

Two-arm, parallel-design, multicentre randomised controlled trial involving 198 people aged ≥50 years with painful knee OA who do not meet physical activity guideline recommendations or walk regularly for exercise. Both groups receive an individualised physiotherapist-led walking, strengthening, and OA/activity education program via 4x weekly in-person treatment sessions, followed by 4 weeks of at-home activities (weekly check-in via telehealth), with follow-up sessions at 3 months (telehealth) and 5 and 9 months (in-person). The EPIPHA-KNEE group also receives contemporary PSE about OA/pain and activity, embedded into all aspects of the intervention. Outcomes are assessed at baseline, 12 weeks, 6 and 12 months. Primary outcomes are physical activity level (step count; wrist-based accelerometry) and self-reported knee symptoms (WOMAC Total score) at 12 months. Secondary outcomes are quality of life, pain intensity, global rating of change, self-efficacy, pain catastrophising, depression, anxiety, stress, fear of movement, knee awareness, OA/activity conceptualisation, and self-regulated learning ability. Additional measures include adherence, adverse events, blinding success, COVID-19 impact on activity, intention to exercise, treatment expectancy/perceived credibility, implicit movement/environmental bias, implicit motor imagery, two-point discrimination, and pain sensitivity to activity. Cost-utility analysis of the EPIPHA-KNEE intervention will be undertaken, in addition to evaluation of cost-effectiveness in the context of primary trial outcomes.

Discussion

We will determine whether the integration of PSE into an individualised OA education, walking, and strengthening program is more effective than receiving the individualised program alone. Findings will inform the development and implementation of future delivery of PSE as part of best practice for people with knee OA.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12620001041943 (13/10/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04561-6.

Illusion-enhanced Virtual Reality Exercise for Neck Pain: A Replicated Single Case Series

OBJECTIVES

Body illusions have shown promise in treating some chronic pain conditions. We hypothesized that neck exercises performed in virtual reality (VR) with visual feedback of rotation amplified would reduce persistent neck pain.

METHODS

In a multiple-baseline replicated single case series, 8 blinded individuals with persistent neck pain completed a 4-phase intervention (initial n=12, 4 dropouts): (1) "baseline"; (2) "VR" during which participants performed rotation exercises in VR with no manipulation of visual feedback; (3) "VR enhanced" during which identical exercises were performed but visual feedback overstated the range of motion being performed; (4) "follow-up." Primary outcomes were twice-daily measures of pain-free range of motion and pain intensity. During the baseline and follow-up phases, measures were taken but no intervention took place.

RESULTS

No differences in primary outcomes were found between VR and baseline, VR enhanced and VR, or VR enhanced and follow-up.

DISCUSSION

Our hypothesis, that neck exercises performed in VR with visual feedback of rotation amplified, would reduce persistent neck pain was not supported. Possible explanations and future directions are discussed.

Modifications in fMRI Representation of Mental Rotation Following a 6 Week Graded Motor Imagery Training in Chronic CRPS Patients

Complex regional pain syndrome (CRPS) is a neuropathic pain condition that is difficult to treat. For behavioral interventions, graded motor imagery (GMI) showed relevant effects, but underlying neural substrates in patient groups have not been investigated yet. A previous study investigating differences in the representation of a left/right hand judgment task demonstrated less recruitment of subcortical structures, such as the putamen, in CRPS patients than in healthy controls. In healthy volunteers, the putamen activity increased after a hand judgment task training. In order to test for longitudinal effects of GMI training, we investigated 20 CRPS patients in a wait-list crossover design with 3 evaluation time points. Patients underwent a 6 week GMI treatment and a 6 week waiting period in a randomized group assignment and treatment groups were evaluated by a blinded rater. When compared to healthy matched controls at baseline, CRPS patients showed less functional activation in areas processing visual input, left sensorimotor cortex, and right putamen. Only GMI treatment, but not the waiting period showed an effect on movement pain and hand judgment task performance. Regression analyses revealed positive associations of movement pain with left anterior insula activation at baseline. Right intraparietal sulcus activation change during GMI was associated with a gain in performance of the hand judgment task. The design used here is reliable for investigating the functional representation of the hand judgment task in an intervention study. PERSPECTIVE: Twenty chronic CRPS patients underwent a 6 week GMI intervention in a randomized wait-list crossover design. functional MRI was tested pre and post for the hand lateralization task which improved over GMI but not over WAITING. Performance gain was positively related to right parietal functional MRI activation.

Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCT

BACKGROUND

Falls and fractures are a major problem.

OBJECTIVES

To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions.

DESIGN

Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice.

SETTING

Primary care.

PARTICIPANTS

People aged ≥ 70 years.

INTERVENTIONS

All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling.

MAIN OUTCOME MEASURES

The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit.

RESULTS

Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported.

LIMITATIONS

The rate of fractures was lower than anticipated.

CONCLUSIONS

Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective.

FUTURE WORK

Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71002650.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.

The impact of upper limb exercise on function, daily activities and quality of life in systemic lupus erythematosus: a pilot randomised controlled trial

Objective

To assess the effect of upper limb exercise on hand function, daily activities performance and quality of life of patients with systemic lupus erythematosus (SLE).

Methods

We performed a pilot randomised, 24-week follow-up, unmasked controlled trial. Inclusion criteria were upper limb arthralgias, a Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score >10 and a stable treatment over the past 3 months. Patients were randomly allocated in the routine care (control) or exercise group that received an individually tailored 30-min daily upper-limb exercise programme by a hand therapist for 12 weeks. We evaluated at 0, 6, 12 and 24 weeks the performance of daily activities for both groups with DASH questionnaire and Health Assessment Questionnaire (HAQ), the grip and pinch strength with Jamar dynamometer and pinch gauge tool, respectively, the dexterity with Purdue pegboard test, the quality of life with Lupus Quality of Life (LupusQoL) Questionnaire and the pain level by Visual Analogue Scale (VAS) score.

Results

From 293 consecutive SLE patients, data from 32 patients allocated to the exercise group and 30 to the control group were analysed. There was a significant difference between the two groups in percentage changes of DASH, HAQ, grip strength, pinch strength, LupusQoL-physical health and fatigue, and VAS scores from baseline to 6, 12 and 24 weeks, and from baseline to 12 weeks for dexterity test (p<0.001). No interaction was observed between exercise and disease activity or medication use at baseline and during the observation period.

Conclusion

Upper-limb exercise significantly improves hand function, pain, daily activity performance and quality of life in SLE.

Trial registration number

NCT03802578.

Pain-guided activity modification during treatment for patellar tendinopathy: a feasibility and pilot randomized clinical trial

BACKGROUND

Activity modification is a key component of patellar tendinopathy treatment but there is a lack of evidence guiding activity modification prescription. Use of activity modification in treatment studies has varied widely and the impact of those recommendations has not been directly investigated or compared. The purpose of this study was to assess (1) the feasibility of using pain-guided activity modification during treatment for patellar tendinopathy and (2) if our outcome measures are responsive to changes in tendon health over the course of treatment.

METHODS

This was an unblinded, randomized two-arm pilot and feasibility study randomized clinical trial with parallel assignment, conducted in Newark, DE. Individuals between the ages of 16 and 40 years old with patellar tendinopathy were included. Participants were randomly assigned to a pain-guided activity (PGA) or pain-free activity (PFA) group using a spreadsheet-based randomization scheme. All participants received standardized treatment using a modified version of the heavy-slow resistance protocol 3×/week for 12 weeks. For the first 6 weeks, the PGA group used the Pain-Monitoring Model to guide activity outside of treatment and the PFA group was restricted from running, jumping, or activities that provoked their patellar tendon pain. Feasibility outcomes included recruitment, enrollment, randomization, compliance, and retention percentages. Clinical evaluations were conducted at baseline, 6, and 12 weeks to assess symptom severity, psychological factors, tendon morphology and mechanical properties, lower extremity function, and quadriceps muscle performance.

RESULTS

In a ~ 13-month period, 108 individuals were screened, 47/108 (43.5%) were eligible for participation, and 15/47 (32.0%) of those were enrolled (9 PGA, 6 PFA). The recruitment rate was 1.15 participants/month. The mean ± SD compliance with treatment was PGA: 86.1 ± 13.0% and PFA: 67.1 ± 30.7%. There was one missed evaluation session and two adverse events, which were not due to study interventions. Changes exceeding the smallest detectable change were observed for at least one outcome in each domain of tendon health.

CONCLUSIONS

Use of pain-guided activity modification during exercise therapy for patellar tendinopathy was found to be feasible, and the proposed outcome measures appropriate. Computer-based allocation concealment, blinding of evaluators, and greater recruitment of high-level athletes should be implemented in future trials.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03694730 . Registered 3rd of October, 2018.

Perceived Barriers and Facilitators of Sports Rehabilitation Adherence in Injured Volleyball Athletes: A Qualitative Study From Greece

Adherence to exercise rehabilitation has been shown to be an important factor that may influence successful treatment. In professional athletes, a significant reduction in exercise adherence delays recovery. The aim of this study was to explore barriers to and facilitators of exercise rehabilitation adherence in injured volleyball athletes. Eight professional volleyball athletes were recruited, and qualitative data were collected using semistructured interviews. All athletes had completed their rehabilitation program after they had suffered a musculoskeletal injury. All data were analyzed using thematic analysis after the investigators ensured that saturation had been reached. Pain was identified as a significant barrier to exercise adherence by all athletes. The provision of social support, including mental, practical, and task related, also had a significant positive impact. The athletes’ ability to develop the necessary coping strategies and confidence on performing exercises at home was also mentioned as a factor that affected exercise adherence, although less often.

Evaluation of Machine Learning Models for Classifying Upper Extremity Exercises Using Inertial Measurement Unit-Based Kinematic Data

The amount of home-based exercise prescribed by a physical therapist is difficult to monitor. However, the integration of wearable inertial measurement unit (IMU) devices can aid in monitoring home exercise by analyzing exercise biomechanics. The objective of this study is to evaluate machine learning models for classifying nine different upper extremity exercises, based upon kinematic data captured from an IMU-based device. Fifty participants performed one compound and eight isolation exercises with their right arm. Each exercise was performed ten times for a total of 4500 trials. Joint angles were calculated using IMUs that were placed on the hand, forearm, upper arm, and torso. Various machine learning models were developed with different algorithms and train-test splits. Random forest models with flattened kinematic data as a feature had the greatest accuracy (98.6%). Using triaxial joint range of motion as the feature set resulted in decreased accuracy (91.9%) with faster speeds. Accuracy did not decrease below 90% until training size was decreased to 5% from 50%. Accuracy decreased (88.7%) when splitting data by participant. Upper extremity exercises can be classified accurately using kinematic data from a wearable IMU device. A random forest classification model was developed that quickly and accurately classified exercises. Sampling frequency and lower training splits had a modest effect on performance. When the data were split by subject stratification, larger training sizes were required for acceptable algorithm performance. These findings set the basis for more objective and accurate measurements of home-based exercise using emerging healthcare technologies.

Adherence to Physiotherapy-Guided Web-Based Exercise for Persons with Moderate-to-Severe Multiple Sclerosis: A Randomized Controlled Pilot Study

Background

Options to support adherence to physical activity in moderate-to-severe multiple sclerosis (MS) are needed. The primary aim was to evaluate adherence to a Web-based, individualized exercise program in moderate-to-severe MS. Secondary aims explored changes in 29-item Multiple Sclerosis Impact Scale, Hospital Anxiety and Depression Scale (HADS), grip strength, Timed 25-Foot Walk test, and Timed Up and Go (TUG) results.

Methods

Participants were randomized (2:1) to a physiotherapist-guided Web-based home exercise program or a physiotherapist-prescribed written home exercise program. The primary outcome was adherence (number of exercise sessions over 26 weeks). Secondary outcomes were described in terms of means and effect sizes.

Results

There were 48 participants: mean ± SD age, 54.3 ± 11.9 years; disease duration, 19.5 ± 11.0 years; and Patient-Determined Disease Steps scale score, 4.4 ± 1.6. There was no significant difference in mean ± SD adherence in the Web-based group (38.9 ± 28.1) versus the comparator group (34.6 ± 40.8; U = 198.5, P = .208, Hedges' g = 0.13). Nearly 50% of participants (23 of 48) exercised at least twice per week for at least 13 of the 26 weeks. Adherence was highest in the Web-based subgroup of wheelchair users. Medium effect sizes were found for the HADS anxiety subscale and in ambulatory participants for TUG. There were no adverse events.

Conclusions

There was no difference in exercise adherence between the Web-based and active comparator groups. There was no worsening of secondary outcomes or adverse events, supporting the safety of Web-based physiotherapy. More research is needed to determine whether wheelchair users might be most likely to benefit from Web-based physiotherapy.

A central nervous system-focused treatment approach for people with frozen shoulder: protocol for a randomized clinical trial

Background

Frozen shoulder (FS) is a musculoskeletal condition of poorly understood etiology that results in shoulder pain and large mobility deficits. Despite some physical therapy interventions, such as joint mobilization and exercise, having shown therapeutic benefit, a definitive treatment does not currently exist. The aim of this study will be to compare the effectiveness of a central nervous system (CNS)-directed treatment program versus a standard medical and physical therapy care program on outcomes in participants with FS.

Methods/design

The study is a two-group, randomized clinical trial with blinding of participants and assessors. Participants will be recruited via referrals from orthopedic surgeons and physical therapists, community-based advertisements, private care practices and hospitals. Participants will be randomized to receive either a CNS-focused treatment program or standard medical and physical therapy care. The Shoulder Pain And Disability Index (SPADI) will be the primary outcome, while the Numeric Pain Rating Scale (NPRS), shoulder range of movement (ROM), The Patient Specific Functional Scale, two-point discrimination threshold and laterality judgement accuracy will be the secondary outcomes. Assessment will occur at baseline, at the end of the treatment program (week 10), and at 3 and 6 months’ follow-up.

Discussion

Preliminary data suggest that treatments that target CNS function are a promising approach to the treatment of people with shoulder pain including patients with FS. In the context of modest effects from most available physical therapy treatments for FS, this CNS-focused approach may lead to improved clinical outcomes. The trial should determine if the CNS-directed program is more effective than traditional interventions at reducing pain intensity and improving function in a FS cohort and will follow up participants for 6 months, providing important information on the persistence of any treatment effects.

Trial registration

NCT03320200. Registered on October 25, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3585-z) contains supplementary material, which is available to authorized users.

Effectiveness of a treadmill-based aerobic exercise intervention on pain, daily functioning, and quality of life in women with primary dysmenorrhea: A randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a treadmill-based aerobic exercise intervention on pain and associated symptoms of primary dysmenorrhea.

METHODS

Seventy women with primary dysmenorrhea were included in the study. The experimental group underwent supervised aerobic training for 4 weeks followed by unsupervised home exercise for the next 6 months. The control group continued usual care. The primary outcome was pain. Secondary outcomes included quality of life (QoL), daily functioning, and sleep.

RESULTS

After the 4-week training, compared to the control group exercise significantly improved primary outcomes pain quality (mean difference (MD) -1.9, 95% CI 3.8 to -0.04, p < .05), and intensity (MD -4.7, 95% CI -9.3 to -0.09, p < .05), but not present pain. Significant effects were also reported for pain interference (MD -1.7, 95% CI -3.4 to -0.02, p < .05) at 4 weeks; the other outcomes did not significantly differ between groups at this time. During the follow-up period of 7-months, the effect on pain improved to 22 mm (95% CI 18 to 25). Significant benefits of exercise were maintained up to 7-months for present pain, QoL and daily functioning.

CONCLUSION

Exercise has significant effects on primary dysmenorrhea-related pain, QoL and function.

TRIAL REGISTRATION

ACTRN12613001195741.

A Manual Therapy and Home Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series

BACKGROUND

Manual therapy has been demonstrated to reduce pain and improve function in patients with frozen shoulder contracture syndrome (FSCS), but no evidence exists to support one form of manual therapy over another. This case series describes both short- and long-term outcomes after a manual therapy program and home stretching exercises based on specific impairments in shoulder mobility and level of tissue irritability in patients with FSCS.

CASE DESCRIPTION

Eleven patients with primary FSCS were treated with an individually tailored, multimodal manual therapy approach once weekly for 12 visits, coupled with home stretching exercises once a day, 5 days per week. Pain, disability, range of motion (ROM), and muscle strength of the affected shoulder were assessed at baseline, posttreatment, at 6 months, and at 9 months.

OUTCOMES

Significant improvements in self-reported pain, disability, shoulder ROM, and strength were reported following treatment. Additionally, 4 of 11 patients showed pain improvements that exceeded the minimal clinically important difference (MCID) on the visual analog scale postintervention, and 8 of 11 showed pain improvements at 6 and 9 months. Moreover, 7 of 11 patients showed improvements in Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores exceeding the MCID postintervention and at 6 months, and 8 of 11 exceeded the MCID at 9 months.

DISCUSSION

Clinically meaningful changes in shoulder pain and disability, ROM, or muscle strength were observed in 11 patients with primary FSCS treated with an individually tailored approach of both manual therapy techniques and stretching exercises, accounting for tissue irritability.

LEVEL OF EVIDENCE

Therapy, level 5. J Orthop Sports Phys Ther 2019;49(3):192-201. Epub 18 Jan 2019. doi:10.2519/jospt.2019.8194.

Self-reported Home Exercise Adherence: A Validity and Reliability Study Using Concealed Accelerometers

BACKGROUND

Accurate measurement of adherence to prescribed exercise programs is essential. Diaries and self-report rating scales are commonly used, yet little evidence exists to demonstrate their validity and reliability.

OBJECTIVES

To examine the concurrent validity of adherence to home strengthening exercises measured by (1) exercise diaries and (2) a self-report rating scale, compared to adherence measured using an accelerometer concealed in an ankle cuff weight. Test-retest reliability of the self-report rating scale was also assessed.

METHODS

In this clinical measurement study, 54 adults aged 45 years or older with self-reported chronic knee pain were prescribed a home quadriceps-strengthening program. Over 12 weeks, participants completed paper exercise diaries and, at appointments every 2 weeks, rated their adherence on an 11-point numeric rating scale. A triaxial accelerometer was concealed in the ankle cuff weight used for exercises. Self-reported adherence rating scale data over each 2-week period were analyzed using descriptive statistics, the Wilcoxon signed-rank test, and a Bland-Altman plot to assess agreement, Spearman correlations for validity, and intraclass correlation coefficients for test-retest reliability.

RESULTS

Exercise adherence was significantly overestimated in diaries during the 12 weeks (diary median, 220 exercises; accelerometer, 176; P<.001) and was moderately correlated with accelerometer data (r = 0.52; 95% confidence interval: 0.26, 0.69). A Bland-Altman plot indicated large between-participant variability in agreement between these measures. Self-reported adherence showed poor to fair correlations with accelerometer data (mean r = 0.23-0.39), and less than acceptable reliability (intraclass correlation coefficient = 0.79; lower 1-sided 95% confidence limit, 0.68).

CONCLUSION

Exercise diaries showed questionable validity and variable levels of agreement compared with accelerometer-measured exercise completion. A self-reported adherence rating scale had limited validity and less than acceptable test-retest reliability. J Orthop Sports Phys Ther 2018;48(12):943-950. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8275.

A feasibility study of brain-targeted treatment for people with painful knee osteoarthritis in tertiary care

Purpose: To assess the feasibility and clinical impact of brain-targeted treatment (BT; aiming to target sensorimotor processing) in knee osteoarthritis patients attending tertiary care. Methods: Randomized replicated case series. The study involved three phases, each of 2 weeks duration: (1) no-treatment phase; (2) BT phase (left/right judgments and touch discrimination training); and (3) usual care (education, strengthening, and stretching training). Primary outcomes were: timely recruitment; number of participants completing the interventions; treatment compliance and barriers; follow-up rates; and treatment impact on pain and function. Fear-avoidance beliefs and clinical measures of cortical body representation (tactile acuity and left/right judgment performance) were secondary outcomes. Results: A total of 5% (19/355) of all assessed patients were eligible to participate and of these, 58% (11/19) agreed to participate. Ten patients completed the study, and 9 were successfully followed up, with treatment compliance varying between interventions. Compliance was poor for the touch discrimination component of BT. No significant effects were observed for pain relief or knee function after any treatment. A positive impact of treatment was found for fear-avoidance beliefs (usual care vs. washout, p = 0.007; BT vs. washout, p = 0.029) and left/right judgment accuracy (usual care vs. washout; p = 0.006). Conclusions: Clear barriers were identified to implementing BT in tertiary care for knee osteoarthritis. Access to all available services (especially the use of interpreters), and treatment options that do not require additional assistance to perform (e.g., touch discrimination training) represent the main lessons learned.

Development and delivery of an exercise programme for falls prevention: the Prevention of Falls Injury Trial (PreFIT)

Objective

This paper describes the development and implementation of an exercise intervention to prevent falls within The Prevention of Fall Injury Trial (PreFIT), which is a large multi-centred randomised controlled trial based in the UK National Health Service (NHS).

Design

Using the template for intervention description and replication (TIDieR) checklist, to describe the rationale and processes for treatment selection and delivery of the PreFIT exercise intervention.

Participants

Based on the results of a validated falls and balance survey, participants were eligible for the exercise intervention if they were at moderate or high risk of falling.

Interventions

Intervention development was informed using the current evidence base, published guidelines, and pre-existing surveys of clinical practice, a pilot study and consensus work with therapists and practitioners. The exercise programme targets lower limb strength and balance, which are known, modifiable risk factors for falling. Treatment was individually tailored and progressive, with seven recommended contacts over a six-month period.

Clinical Trials Registry (ISCTRN 71002650).

What Adherence Measures Should Be Used in Trials of Home-Based Rehabilitation Interventions? A Systematic Review of the Validity, Reliability, and Acceptability of Measures

OBJECTIVE

To systematically review methods for measuring adherence used in home-based rehabilitation trials and to evaluate their validity, reliability, and acceptability.

DATA SOURCES

In phase 1 we searched the CENTRAL database, NHS Economic Evaluation Database, and Health Technology Assessment Database (January 2000 to April 2013) to identify adherence measures used in randomized controlled trials of allied health professional home-based rehabilitation interventions. In phase 2 we searched the databases of MEDLINE, Embase, CINAHL, Allied and Complementary Medicine Database, PsycINFO, CENTRAL, ProQuest Nursing and Allied Health, and Web of Science (inception to April 2015) for measurement property assessments for each measure.

STUDY SELECTION

Studies assessing the validity, reliability, or acceptability of adherence measures.

DATA EXTRACTION

Two reviewers independently extracted data on participant and measure characteristics, measurement properties evaluated, evaluation methods, and outcome statistics and assessed study quality using the COnsensus-based Standards for the selection of health Measurement INstruments checklist.

DATA SYNTHESIS

In phase 1 we included 8 adherence measures (56 trials). In phase 2, from the 222 measurement property assessments identified in 109 studies, 22 high-quality measurement property assessments were narratively synthesized. Low-quality studies were used as supporting data. StepWatch Activity Monitor validly and acceptably measured short-term step count adherence. The Problematic Experiences of Therapy Scale validly and reliably assessed adherence to vestibular rehabilitation exercises. Adherence diaries had moderately high validity and acceptability across limited populations. The Borg 6 to 20 scale, Bassett and Prapavessis scale, and Yamax CW series had insufficient validity. Low-quality evidence supported use of the Joint Protection Behaviour Assessment. Polar A1 series heart monitors were considered acceptable by 1 study.

CONCLUSIONS

Current rehabilitation adherence measures are limited. Some possess promising validity and acceptability for certain parameters of adherence, situations, and populations and should be used in these situations. Rigorous evaluation of adherence measures in a broader range of populations is needed.

Exercise for chronic musculoskeletal pain: A biopsychosocial approach

Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non-threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence-based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation.

Optimising the validity and completion of adherence diaries: a multiple case study and randomised crossover trial

BACKGROUND

Diaries are the most commonly used adherence measurement method in home-based rehabilitation trials, yet their completion and validity varies widely between trials. We aimed to: (1) generate theory to explain this variation, (2) create an optimised diary and (3) evaluate the optimised diary's validity.

METHODS

Stage 1.

DEVELOPMENT

using a multiple case study approach, we collected trialist interviews (n = 7), trial publications (n = 16) and diaries (n = 7) from seven purposively sampled UK rehabilitation trials. We explored return rates, diary designs and trialists' ideas as to what affected diary completion and validity. Using explanatory case study analysis, we developed a diary optimisation model. Stage 2.

EVALUATION

we compared a diary optimised according to several model components to one nonoptimised according to the same components in a randomised AB/BA crossover trial. Healthy adults aged 60+ years without mobility impairments undertook a home-based 8-week walking programme. They recorded walking duration and frequency for 4 weeks per diary. We hypothesised that the optimised diary would possess greater validity for self-reported adherence to walking duration (criterion: the Activpal accelerometer), assessed during each diary's final week. Participants were blinded to the hypothesis. Secondary outcomes included test-retest reliability and acceptability. Ethical approval was granted from Glasgow Caledonian University.

RESULTS

Thirty-two out of 33 participants completed the study. Diaries did not significantly differ in validity, reliability or acceptability. Both diaries agreed closely with the Activpal when assessing duration adherence at a group level, however, inter and intraindividual variation in validity was high (mean difference (95 % limits of agreement (LOA): limits of agreement plot the difference between measurements collected using two different methods against their mean and thus assess the extent to which the two measures agree with each other)) optimised diary = 3.09 % (-103.3 to 109.5 %), nonoptimised diary = -0.34 % (-131.1 to 130.5 %), p = 0.732). We found similarly wide LOA for percentage of days adhered to and percentage of walks taken, whilst frequency adherence was underestimated. Participants rated both diaries as low-burden and equal numbers favoured each diary or were neutral. Preference appeared to impact minimally upon validity.

CONCLUSION

Group-level adherence diary data are likely to be valid. However, individual diary data lack validity, which raises concerns if using this data in calculations such as predicting functional outcomes. Different diary designs are likely interchangeable, though unanticipated high variation meant that this study was underpowered.

TRIAL REGISTRATION

The trial was not eligible for registration in a clinical trial database as diary measurement property outcomes, not clinical health outcomes of participants, were assessed.

Active Treatment for Idiopathic Adolescent Scoliosis (ACTIvATeS): a feasibility study

BACKGROUND

The feasibility of conducting a definitive randomised controlled trial (RCT) evaluating the clinical effectiveness and cost-effectiveness of scoliosis-specific exercises (SSEs) for adolescent idiopathic scoliosis (AIS) is uncertain.

OBJECTIVES

The aim of this study was to assess the feasibility of conducting a large, multicentre trial of SSE treatment for patients with AIS, in comparison with standard care, and to refine elements of the study design. The objectives were to (1) update a systematic review of controlled trials evaluating the efficacy of SSE in AIS; (2) survey UK orthopaedic surgeons and physiotherapists to determine current practice, patient populations and equipoise; (3) randomise 50 adolescents to a feasibility trial of either usual care or SSE interventions across a range of sites; (4) develop, document and assess acceptability and adherence of interventions; (5) assess and describe training requirements of physiotherapists; and (6) gain user input in all relevant stages of treatment and protocol design.

DESIGN

Multicomponent feasibility study including UK clinician survey, systematic literature review and a randomised feasibility trial.

SETTING

The randomised feasibility study involved four secondary care NHS trusts providing specialist care for patients with AIS.

PARTICIPANTS

The randomised feasibility study recruited people aged 10-16 years with mild AIS (Cobb angle of < 50°).

INTERVENTIONS

The randomised study allocated participants to standard practice of advice and education or a physiotherapy SSE programme supported by a home exercise plan. Our choice of intervention was informed by a systematic review of exercise interventions for AIS.

MAIN OUTCOME MEASURES

The main outcome was feasibility of recruitment to the randomised study. Other elements were to inform choice of outcomes for a definitive trial and included curve severity, quality of life, requirement for surgery/brace, adverse events, psychological symptoms, costs and health utilities.

RESULTS

A UK survey of orthopaedic consultants and physiotherapists indicated a wide variation in current provision of exercise therapy through physiotherapy services. It also found that clinicians from at least 15 centres would be willing to have their patients involved in a full study. A systematic review update found five new studies that were generally of low quality but showed some promise of effectiveness of SSE. The randomised study recruited 58 patients from four NHS trusts over 11 months and exceeded the pre-specified target recruitment rate of 1.4 participants per centre per month, with acceptable 6-month follow-up (currently 73%). Adherence to treatment was variable (56% of participants completed treatment offered). The qualitative study found the exercise programme to be highly acceptable. We learnt important lessons from patient and public involvement during the study in terms of study and intervention presentation, as well as practical elements such as scheduling of intervention sessions.

CONCLUSIONS

A definitive RCT evaluating clinical effectiveness and cost-effectiveness of SSE for idiopathic scoliosis is warranted and feasible. Such a RCT is a priority for future work in the area. There is a sufficiently large patient base, combined with willingness to be randomised within specialist UK centres. Interventions developed during the feasibility study were acceptable to patients, families and physiotherapists and can be given within the affordability envelope of current levels of physiotherapy commissioning.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN90480705.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 55. See the NIHR Journals Library website for further project information.

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.

Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH). A randomised controlled trial and economic evaluation

BACKGROUND

The effectiveness of exercise for improving hand and wrist function in people with rheumatoid arthritis (RA) is uncertain.

OBJECTIVES

The study aims were (1) to estimate the clinical effectiveness and cost-effectiveness of adding an optimised exercise programme for hands and upper limbs to standard care for patients with RA; and (2) to qualitatively describe the experience of participants in the trial with a particular emphasis on acceptability of the intervention, exercise behaviours and reasons for adherence/non-adherence.

DESIGN

A pragmatic, multicentred, individually randomised controlled trial with an embedded qualitative study. Outcome assessors were blind to group assignment and independent of treatment delivery.

SETTING

Seventeen NHS trusts in England comprising 21 rheumatology and therapy departments.

PARTICIPANTS

Adults with RA who had pain and dysfunction of the hands and/or wrists and had been on stable medication for at least 3 months. Patients were excluded if they were under 18 years old, had undergone upper limb surgery/fracture in the last 6 months, were on a waiting list for upper limb surgery or were pregnant.

INTERVENTIONS

Usual care or usual care plus an individualised exercise programme. Usual care consisted of joint protection education, general exercise advice and functional splinting if required. The exercise programme consisted of six sessions of strengthening and stretching exercises with a hand therapist, daily home exercises and strategies to maximise adherence.

MAIN OUTCOME MEASURES

The primary outcome was the Michigan Hand Outcome Questionnaire (MHQ) overall hand function subscale score at 12 months. Secondary outcome measures included the full MHQ, pain, health-related quality of life (Short Form questionnaire-12 items), impairment (grip strength, dexterity and range of motion) and self-efficacy. European Quality of Life-5 Dimensions, medication and health-care use were collected for the health economics evaluation. Follow-up was at 4 and 12 months post randomisation. Analysis was performed on an intention-to-treat basis.

RESULTS

We randomised 490 patients (244 to usual care, 246 to exercise programme). Compliance with the treatments was very good (93% of usual care participants and 75% of exercise programme participants completed treatment). Outcomes were obtained for 89% of participants at 12 months (222 for usual care, 216 for exercise programme). There was a statistically significant difference in favour of the exercise programme for the primary outcome at 4 and 12 months [mean difference 4.6 points, 95% confidence interval (CI) 2.2 to 7.0 points; and mean difference 4.4 points, 95% CI 1.6 to 7.1 points, respectively]. There were no significant differences in pain scores or adverse events. The estimated difference in mean quality-adjusted life-years (QALYs) accrued over 12 months was 0.01 greater (95% CI -0.03 to 0.05) in the exercise programme group. Imputed analysis produced incremental cost-effectiveness ratio estimates of £17,941 (0.59 probability of cost-effectiveness at willingness-to-pay threshold of £30,000 per QALY). The qualitative study found the exercise programme to be acceptable and highlighted the importance of the therapist in enabling patients to establish a routine and incorporate the exercises into their lives.

CONCLUSIONS

The results of the Strengthening And stretching for Rheumatoid Arthritis of the Hand trial suggest that the addition of an exercise programme for RA hands/wrists to usual care is clinically effective and cost-effective when compared with usual care alone. No adverse effects were associated with the exercise programme. The economic analysis suggests that the intervention is likely to be cost-effective.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 89936343.

Movement restriction does not modulate sensory and perceptual effects of exercise-induced arm pain

BACKGROUND

Movement restriction has been proposed as an important modulator of changes in sensory and perceptual function and motor imagery performance that are observed in musculoskeletal pain syndromes. There are no empirical data to support this view.

PURPOSE

The primary objective of this experiment was to determine the effects of movement restriction on local and widespread sensory, perceptual and motor imagery changes after exercise-induced muscular pain. Further objectives were to investigate whether changes in sensory perception are correlated with pain intensity and tactile acuity or motor imagery performance.

METHODS

In forty healthy volunteers, delayed onset muscle soreness (DOMS) of the non-dominant elbow flexors was induced using eccentric contractions until exhaustion. Participants were then randomised into two groups: a movement restriction group (wearing a sling) or a control group (not wearing a sling). Sensory and perceptual functions were measured using a range of sensory tests and a motor imagery performance task (left/right limb judgements).

RESULTS

Movement restriction did not modulate any of the measures. We found concurrent mechanical hypoesthesia (p < 0.01), reduced tactile acuity (p = 0.02) and pressure hyperalgesia (p < 0.01) at the painful side. We found evidence of widespread pressure hyperalgesia. Impaired tactile acuity was associated with a decrease in pain threshold to pressure (r = -0.34, p = 0.03). Motor imagery performance was unchanged (p > 0.35) by pain or movement restriction.

CONCLUSION

Short-term movement restriction did not influence local and widespread sensory changes induced by experimentally induced muscular pain.

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.

Education, self-management, and upper extremity exercise training in people with rheumatoid arthritis: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a brief supervised education, self-management, and global upper extremity exercise training program, supplementing a home exercise regimen, for people with rheumatoid arthritis (RA; the Education, Self-Management, and Upper Extremity Exercise Training in People with Rheumatoid Arthritis [EXTRA] program).

METHODS

Adults with RA of ≤5 years' duration were randomized to receive either usual care or the EXTRA program comprising 4 (1-hour) group education, self-management, and global upper extremity exercise training sessions supplementing the first 2 weeks of a 12-week individualized, functional home exercise regimen in addition to usual care. Outcome measures were assessed at baseline, 12 weeks (primary end point), and 36 weeks and included the Disabilities of the Arm, Shoulder, and Hand questionnaire (primary outcome measure), the Grip Ability Test, handgrip strength (N), the Arthritis Self-Efficacy Scale (pain, function, and symptoms subscales), and the 28-joint Disease Activity Score.

RESULTS

One hundred eight participants (26 men, mean ± SD age 55 ± 15 years, mean ± SD disease duration 20 ± 19 months) were randomized to receive either usual care (n = 56) or the EXTRA program (n = 52). At 12 weeks, there was a significant between-group difference in the mean change in disability (-6.8 [95% confidence interval (95% CI) -12.6, -1.0]; P = 0.022), function (-3.0 [95% CI -5.0, -0.5]; P = 0.011), nondominant handgrip strength (31.3N [95% CI 9.8, 52.8]; P = 0.009), self-efficacy (10.5 [95% CI 1.6, 19.5]; P = 0.021 for pain and 9.3 [95% CI 0.5, 18.2]; P = 0.039 for symptoms), and disease activity (-0.7 [95% CI -1.4, 0.0]; P = 0.047), all favoring the EXTRA program.

CONCLUSION

The EXTRA program improves upper extremity disability, function, handgrip strength, and self-efficacy in people with RA, with no adverse effects on disease activity.

Hand exercise intervention in patients with polymyositis and dermatomyositis: a pilot study

OBJECTIVE

The aim of the present study was to develop a 12-week hand exercise intervention for patients with polymyositis (PM) and dermatomyositis (DM) and evaluate adherence, patients' opinions of the programme design and overall feasibility, and the effect on hand function and activity limitation after the intervention.

METHOD

A pilot hand exercise intervention was conducted on a convenience sample of 15 patients with reduced handgrip strength and established, inactive PM and DM. Acceptable adherence was set at 75%. The programme was evaluated based on patients' opinions regarding exertion, the movements involved and overall feasibility. Hand- and pinch-grip strength, grip ability, dexterity and activity limitation were assessed.

RESULTS

Eleven of 15 patients completed the intervention, with acceptable adherence of 78-100%. Measures of handgrip strength, dexterity and activity limitation were reduced at baseline compared with normative data from the literature. Throughout the intervention, rates of perceived exertion were scored between 'moderate' and 'fairly strong'. Finger abduction and adduction were excluded from the hand exercise programme because they were not feasible to perform. Repetitions of the exercise increased gradually to a maximum of 30 per movement. Patients regarded this as too time-consuming and suggested ten repetitions daily or 10-20 repetitions 2-4 times per week. There were some individual, clinically meaningful improvements in hand function and activity limitation. A comparison between baseline and after the intervention showed that the three-jaw (tripod) pinch-grip strength (left hand) had increased (p < 0.007; z = -2.7).

CONCLUSION

A hand exercise programme was found to be feasible to perform by patients with established PM or DM. The effect was limited, with few individual improvements in hand function and activity limitation, indicating a need to increase the resistance in the movements and to limit the duration of each exercise session.

Intervention to prevent further falls in older people who call an ambulance as a result of a fall: a protocol for the iPREFER randomised controlled trial

BACKGROUND

An increasing number of falls result in an emergency call and the subsequent dispatch of paramedics. In the absence of physical injury, abnormal physiological parameters or change in usual functional status, it could be argued that routine conveyance by ambulance to the Emergency Department (ED) is not the most effective or efficient use of resources. Further, it is likely that non-conveyed older fallers have the potential to benefit from timely access to fall risk assessment and intervention. The aim of this randomised controlled trial is to evaluate the effect of a timely and tailored falls assessment and management intervention on the number of subsequent falls and fall-related injuries for non-conveyed older fallers.

METHODS

Community dwelling people aged 65 years or older who are not conveyed to the ED following a fall will be eligible to be visited at home by a research physiotherapist. Consenting participants will receive individualised intervention strategies based on risk factors identified at baseline. All pre-test measures will be assessed prior to randomisation. Post-test measures will be undertaken by a researcher blinded to group allocation 6 months post-baseline. Participants in the intervention group will receive individualised pro-active fall prevention strategies from the clinical researcher to ensure that risk factors are addressed adequately and interventions carried out. The primary outcome measure will be the number of falls recorded by a falls diary over a 12 month period. Secondary outcome measures assessed six months after baseline will include the subsequent use of medical and emergency services and uptake of recommendations. Data will be analysed using the intention-to-treat principle.

DISCUSSION

As there is currently little evidence regarding the effectiveness or feasibility of alternate models of care following ambulance non-conveyance of older fallers, there is a need to explore assessment and intervention programs to help reduce subsequent falls, related injuries and subsequent use of health care services. By linking existing services rather than setting up new services, this pragmatic trial aims to utilise the health care system in an efficient and timely manner.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921.

Using graded motor imagery for complex regional pain syndrome in clinical practice: failure to improve pain

BACKGROUND

There is good evidence from studies conducted in a single-centre research setting for the efficacy of graded motor imagery (GMI) treatment, a complex physiotherapy intervention, to reduce pain in long-standing complex regional pain syndrome (CRPS). However, whether GMI is effective in clinical practice is not established.

AIM

To establish whether GMI is effective in clinical practice.

METHODS

We undertook a prospective audit of GMI treatment at two UK centres with a special interest in the management of patients with CRPS. All patients received GMI, in conjunction with a range of other 'best practice' physical and psychological interventions.

RESULTS

The patients' average pain intensities did not improve with treatment [centre 1: n = 20, pre-post numeric rating scale (NRS) difference 0.6 [confidence interval (CI) -0.3 to 1.5]; centre 2: n = 12, pre-post NRS difference 0.2 (CI: -0.9 to 1.2)]. Patients at centre 1 reported significant functional improvement. Improved performance on left/right judgement replicated in both centres seen in the clinical trials.

CONCLUSIONS

The failure of our real-world implementation of GMI suggests that better understanding of both the GMI methodology and its interaction with other treatment methods is required to ensure that GMI research results can be translated into clinical practice. Our results highlight challenges with the translation of complex interventions for chronic pain conditions into clinical practice.

Interdependence of movement and anatomy persists when amputees learn a physiologically impossible movement of their phantom limb

The feeling we have of our own body, sometimes called "body image," is fundamental to self-awareness. However, by altering sensory input, the body image can be modified into impossible configurations. Can impossible movements of the body image be conjured solely via internally generated mechanisms, and, if so, do the structural characteristics of the body image modify to accommodate the new movements? We encouraged seven amputees with a vivid phantom arm to learn to perform a phantom wrist movement that defied normal anatomical constraints. Four reported success. Learning the impossible movement coincided in time with a profound change in the body image of the arm, including a sense of ownership and agency over a modified wrist joint. Remarkably, some previous movements and functional tasks involving the phantom arm became more difficult once the shift in body image had occurred. Crucially, these introspective reports were corroborated by robust empirical data from motor imagery tasks, about which amputees were naïve and to which assessors were blind. These results provide evidence that: a completely novel body image can be constructed solely by internally generated mechanisms; that the interdependence between movement repertoire and structural constraints of the body persists even when the structural constraints imparted by the body do not--the body image we construct still constrains imagined movements; and that motor learning does not necessarily need sensory feedback from the body or external feedback about task performance.

Efficacy of a multifaceted podiatry intervention to improve balance and prevent falls in older people: study protocol for a randomised trial

Background

Falls in older people are a major public health problem, with at least one in three people aged over 65 years falling each year. There is increasing evidence that foot problems and inappropriate footwear increase the risk of falls, however no studies have been undertaken to determine whether modifying these risk factors decreases the risk of falling. This article describes the design of a randomised trial to evaluate the efficacy of a multifaceted podiatry intervention to reduce foot pain, improve balance, and reduce falls in older people.

Methods

Three hundred community-dwelling men and women aged 65 years and over with current foot pain and an increased risk of falling will be randomly allocated to a control or intervention group. The "usual cae" control group will receive routine podiatry (i.e. nail care and callus debridement). The intervention group will receive usual care plus a multifaceted podiatry intervention consisting of: (i) prefabricated insoles customised to accommodate plantar lesions; (ii) footwear advice and assistance with the purchase of new footwear if current footwear is inappropriate; (iii) a home-based exercise program to strengthen foot and ankle muscles; and (iv) a falls prevention education booklet. Primary outcome measures will be the number of fallers, number of multiple fallers and the falls rate recorded by a falls diary over a 12 month period. Secondary outcome measures assessed six months after baseline will include the Medical Outcomes Study Short Form 12 (SF-12), the Manchester Foot Pain and Disability Index, the Falls Efficacy Scale International, and a series of balance and functional tests. Data will be analysed using the intention to treat principle.

Discussion

This study is the first randomised trial to evaluate the efficacy of podiatry in improving balance and preventing falls. The trial has been pragmatically designed to ensure that the findings can be generalised to clinical practice. If found to be effective, the multifaceted podiatry intervention will be a unique addition to common falls prevention strategies already in use.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12608000065392

A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine

Spinal decompression is the most common type of spinal surgery carried out in the older patient, and is being performed with increasing frequency. Physiotherapy (rehabilitation) is often prescribed after surgery, although its benefits compared with no formal rehabilitation have yet to be demonstrated in randomised control trials. The aim of this randomised controlled trial was to examine the effects on outcome up to 2 years after spinal decompression surgery of two types of postoperative physiotherapy compared with no postoperative therapy (self-management). Hundred and fifty-nine patients (100 men, 59 women; 65 +/- 11 years) undergoing decompression surgery for spinal stenosis/herniated disc were randomised to one of the following programmes beginning 2 months post-op: recommended to "keep active" (CONTROL; n = 54); physiotherapy, spine stabilisation exercises (PT-StabEx; n = 56); physiotherapy, mixed techniques (PT-Mixed; n = 49). Both PT programmes involved 2 x 30 min sessions/week for up to 12 weeks, with home exercises. Pain intensity (0-10 graphic rating scale, for back and leg pain separately) and self-rated disability (Roland Morris) were assessed before surgery, before and after the rehabilitation phase (approx. 2 and 5 months post-op), and at 12 and 24 months after the operation. 'Intention to treat' analyses were used. At 24 months, 151 patients returned questionnaires (effective return rate, excluding 4 deaths, 97%). Significant reductions in leg and back pain and self-rated disability were recorded after surgery (P < 0.05). Pain showed no further changes in any group up to 24 months later, whereas disability declined further during the "rehabilitation" phase (P < 0.05) then stabilised, but with no significant group differences. 12 weeks of post-operative physiotherapy did not influence the course of change in pain or disability up to 24 months after decompression surgery. Advising patients to keep active by carrying out the type of physical activities that they most enjoy appears to be just as good as administering a supervised rehabilitation program, and at no cost to the health-care provider.