Low back pain patients' perspectives on long-term adherence to home-based exercise programmes in physiotherapy

Finding Predictive Factors of Stabilization Exercise Adherence in Randomized Controlled Trials on Low Back Pain: An Individual Data Reanalysis Using Machine Learning Techniques

OBJECTIVE

To identify predictors of adherence in supervised and self-administered exercise interventions for individuals with low back pain.

DESIGN

Cohort study.

SETTING

Rehabilitation.

PARTICIPANTS

This preplanned reanalysis within the Medicine in Spine Exercise Network included 1511 participants with low back pain (57% female, mean age 40.9 years, SD ±14 years).

INTERVENTIONS

Participants underwent an initial 3-week supervised phase of sensorimotor exercises, followed by a 9-week self-administered phase.

MAIN OUTCOME MEASURES

Biological, psychological, and social factors potentially impacting training adherence were evaluated. During the supervised phase, adherence was tracked through a standardized training log. During the self-administered phase, adherence was monitored via a diary, with adherence calculated as the percentage of scheduled versus completed sessions. Adherence was analyzed both as an absolute percentage and as a dichotomized variable (adherent vs nonadherent, with a 70% adherence cut-off). Predictors for adherence were identified using Gradient Boosting Machines and Random Forests (R package caret). Seventy percent of the observations were used for training, whereas 30% were retained as a hold-out test-set.

RESULTS

The average overall adherence was 64% (±31%), with 81% (±28%) adherence during the supervised phase and 58% (±39%) in the self-administered phase. The root mean square error for the test-set ranged from 36.2 (R2=0.18, self-administered phase) to 19.3 (R2=0.47, supervised phase); prediction accuracy for dichotomized models was between 64% and 83%. Predictors of low to intermediate adherence included poorer baseline postural control, decline in exercise levels, and fluctuations in pain intensity (both increases and decreases).

CONCLUSION

Identified predictors could aid in recognizing individuals at higher risk for nonadherence in low back pain exercise therapy settings.

Learning Transversus Abdominis Activation in Older Adults with Chronic Low Back Pain Using an Ultrasound-Based Wearable: A Randomized Controlled Pilot Study

Background/Objectives: Chronic low back pain (CLBP) is prevalent among older adults and leads to significant functional limitations and reduced quality of life. Segmental stabilization exercises (SSEs) are commonly used to treat CLBP, but the selective activation of deep abdominal muscles during these exercises can be challenging for patients. To support muscle activation, physiotherapists use biofeedback methods such as palpation and ultrasound imaging. This randomized controlled pilot study aimed to compare the effectiveness of these two biofeedback techniques in older adults with CLBP. Methods: A total of 24 participants aged 65 years or older with CLBP were randomly assigned to one of two groups: one group performed self-palpation biofeedback, while the other group used real-time ultrasound imaging to visualize abdominal muscle activation. Muscle activation and thickness were continuously tracked using a semi-automated algorithm. The preferential activation ratio (PAR) was calculated to measure muscle activation, and statistical comparisons between groups were made using ANOVA. Results: Both groups achieved positive PAR values during all repetitions of the abdominal-draw-in maneuver (ADIM) and abdominal bracing (AB). Statistical analysis revealed no significant differences between the groups in terms of PAR during ADIM (F(2, 42) = 0.548, p = 0.58, partial η2 = 0.025) or AB (F(2, 36) = 0.812, p = 0.45, partial η2 = 0.043). Both groups reported high levels of exercise enjoyment and low task load. Conclusions: In conclusion, both palpation and ultrasound biofeedback appear to be effective for guiding older adults with CLBP during SSE. Larger studies are needed to confirm these results and examine the long-term effectiveness of these biofeedback methods.

Barriers and enablers to exercise adherence in people with nonspecific chronic low back pain: a systematic review of qualitative evidence

ABSTRACT

Exercise is a first-line treatment for chronic low back pain (CLBP), reducing pain and disability in the short term. However, exercise benefits decrease over time, with a lack of long-term exercise adherence a potential reason for this. This study aimed to synthesize the perceptions and beliefs of individuals with CLBP and identify their barriers and enablers to exercise adherence. We searched CENTRAL, Embase, CINAHL, SPORTDiscus, PubMed, PsycINFO, and Scopus databases from inception to February 28, 2023, for qualitative studies that explored the factors influencing exercise adherence for people with CLBP. A hybrid approach combining thematic synthesis with the Theoretical Domains Framework was used to analyze data. We assessed methodological quality using the Critical Appraisal Skills Programme checklist and the level of confidence of the themes generated using the Confidence in the Evidence from Reviews of Qualitative Studies. Twenty-three papers (n = 21 studies) were included (n = 677 participants). Four main themes affected exercise adherence: (1) exercise, pain, and the body, (2) psychological factors, (3) social factors, and (4) external factors. These themes contained 16 subthemes that were predominantly both barriers and enablers to exercise adherence. The individual's experiences of barriers and enablers were most appropriately represented across a spectrum, where influencing factors could be a barrier or enabler to exercise adherence, and these could be specific to pre-exercise, during-exercise, and post-exercise situations. These findings may be used to improve exercise adherence and ultimately treatment outcomes in people with CLBP.

The Effect of Combining Spinal Manipulation and Dry Needling in Individuals With Nonspecific Low Back Pain

Low back pain (LBP) is one of the most common and costly musculoskeletal conditions impacting health care in the United States. The development of multimodal strategies of treatment is imperative in order to curb the growing incidence and prevalence of LBP. Spinal manipulative therapy (SMT), dry needling (DN), and exercise are common nonpharmacological treatments for LBP. This study is a 3-armed parallel-group design randomized clinical trial. We enrolled and randomized 96 participants with LBP into a multimodal strategy of treatment consisting of a combination of DN and SMT, DN only, and SMT only, followed by an at-home exercise program. All participants received 4 treatment sessions in the first 2 weeks followed by a 2-week home exercise program. Outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (lumbar multifidus, erector spinae, and gluteus medius muscle activation) measures at baseline, 2, and 4 weeks. Participants in the DN and SMT groups showed larger effects and statistically significant improvement in pain and disability scores, and muscle percent thickness change at 2 weeks and 4 weeks of treatment when compared to the other groups. This study was registered prior to participant enrollment. PERSPECTIVE: This article presents the process of developing an optimized multimodal treatment plan utilizing SMT, DN, and exercise to address the burden of LBP for impacted individuals and the health care system. This method could potentially help clinicians who treat LBP to lower initial pain and increase exercise compliance. (clinicaltrials.gov NCT05802901).

Adherence of individuals with shoulder pain to home exercise booklets: Barriers, facilitators, and the impact of disability, self-efficacy, and treatment expectations

BACKGROUND

home exercise booklets offer several benefits to individuals with shoulder pain. However, it is necessary to investigate the factors that determine adherence to home exercises.

OBJECTIVES

1) To investigate the level of adherence of individuals with chronic shoulder pain to a home exercise booklet conducted without the mediation of a healthcare professional, 2) To describe the barriers and facilitators to adherence, and 3) to determine if shoulder disability, self-efficacy, and treatment expectations are predictors of the level of adherence.

DESIGN

prospective longitudinal study.

METHODS

A total of 47 individuals with chronic shoulder pain were recruited. The Numeric Pain Rating Scale (NPRS) was used to assess pain intensity, the Shoulder Pain and Disability Index (SPADI) to measure shoulder disability, the Pain Self-Efficacy Questionnaire (PSEQ-10) for self-efficacy, and a likert scale to measure treatment expectations. Adherence was measured by Exercise Adherence Assessment Scale (EAAE-Br).

RESULTS

A total of 23 individuals (48.93%) adhered to the home exercise program. The most commonly cited barriers were pain and health-related issues, while the most cited facilitators were pain improvement and symptom relief. Barriers associated with adherence were time constraints and other commitments, while the facilitator associated with adherence was enjoying the exercises. Binary logistic regression analysis revealed that shoulder disability, self-efficacy, and treatment expectations were unable to predict adherence to home exercises in individuals with shoulder pain [F (1,47) = 2.384; p = 0.130; R2 = 0.056].

CONCLUSION

The study revealed barriers and facilitators to home exercise in individuals with shoulder pain. Disability, self-efficacy, and treatment expectations were not able to predict adherence.

Exploring the association between adherence to home-based exercise recommendations and recovery of nonspecific low back pain: a prospective cohort study

BACKGROUND

Adherence to home-based exercise (HBE) recommendations is critical in physiotherapy for patients with low back pain (LBP). However, limited research has explored its connection with clinical outcomes. This study examined how adherence to HBE relates to changes in physical function, pain intensity, and recovery from LBP in patients undergoing physiotherapy treatment.

METHODS

Data from a multicenter cluster randomized controlled trial in the Netherlands involving patients with LBP from 58 primary care physiotherapy practices were used. Adherence to HBE was assessed with the Exercise Adherence Scale (EXAS) at each treatment session. Previously identified adherence trajectories served as a longitudinal measure of adherence and included the classes "declining adherence" (12% of participants), "stable adherence" (45%), and "increasing adherence" (43%). The main outcomes included disability (Oswestry Disability Index), pain (Numeric Pain Rating Scale), and recovery (pain-free for > 4 weeks), which were measured at baseline and after three months. Linear and binomial logistic regression analyses adjusted for confounders were used to examine adherence-outcome relationships.

RESULTS

In the parent trial, 208 participants were included. EXAS scores were available for 173 participants, collected over a median of 4.0 treatment sessions (IQR 3.0 to 6.0). Forty-five (28.5%) patients considered themselves to have recovered after three months. The median changes in the Oswestry Disability Index and Numeric Pain Rating Scale were - 8 (IQR - 1 to -20) and - 2 (IQR - 0.5 to -4), respectively. The mean EXAS scores varied among patient classes: "declining adherence" (46.0, SD 19.4), "stable adherence" (81.0, SD 12.4), and "increasing adherence" (39.9, SD 25.3), with an overall mean of 59.2 (SD 25.3). No associations between adherence and changes in physical functioning or pain were found in the regression analyses.

CONCLUSIONS

No association between adherence to HBE recommendations and changes in clinical outcomes in patients with LBP was found. These findings suggest that the relationship between adherence to HBE recommendations and treatment outcomes may be more complex than initially assumed. Further research using detailed longitudinal data combined with qualitative methods to investigate patient motivation and beliefs may lead to a deeper understanding of the relationship between adherence and clinical outcomes in patients with LBP.

Effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): a randomised controlled trial

BACKGROUND

Recurrence of low back pain is common and a substantial contributor to the disease and economic burden of low back pain. Exercise is recommended to prevent recurrence, but the effectiveness and cost-effectiveness of an accessible and low-cost intervention, such as walking, is yet to be established. We aimed to investigate the clinical effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention to prevent the recurrence of low back pain.

METHODS

WalkBack was a two-armed, randomised controlled trial, which recruited adults (aged 18 years or older) from across Australia who had recently recovered from an episode of non-specific low back pain that was not attributed to a specific diagnosis, and which lasted for at least 24 h. Participants were randomly assigned to an individualised, progressive walking and education intervention facilitated by six sessions with a physiotherapist across 6 months or to a no treatment control group (1:1). The randomisation schedule comprised randomly permuted blocks of 4, 6, and 8 and was stratified by history of more than two previous episodes of low back pain and referral method. Physiotherapists and participants were not masked to allocation. Participants were followed for a minimum of 12 months and a maximum of 36 months, depending on the date of enrolment. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected in the intention-to-treat population via monthly self-report. Cost-effectiveness was evaluated from the societal perspective and expressed as incremental cost per quality-adjusted life-year (QALY) gained. The trial was prospectively registered (ACTRN12619001134112).

FINDINGS

Between Sept 23, 2019, and June 10, 2022, 3206 potential participants were screened for eligibility, 2505 (78%) were excluded, and 701 were randomly assigned (351 to the intervention group and 350 to the no treatment control group). Most participants were female (565 [81%] of 701) and the mean age of participants was 54 years (SD 12). The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio 0·72 [95% CI 0·60-0·85], p=0·0002). The median days to a recurrence was 208 days (95% CI 149-295) in the intervention group and 112 days (89-140) in the control group. The incremental cost per QALY gained was AU$7802, giving a 94% probability that the intervention was cost-effective at a willingness-to-pay threshold of $28 000. Although the total number of participants experiencing at least one adverse event over 12 months was similar between the intervention and control groups (183 [52%] of 351 and 190 [54%] of 350, respectively, p=0·60), there was a greater number of adverse events related to the lower extremities in the intervention group than in the control group (100 in the intervention group and 54 in the control group).

INTERPRETATION

An individualised, progressive walking and education intervention significantly reduced low back pain recurrence. This accessible, scalable, and safe intervention could affect how low back pain is managed.

FUNDING

National Health and Medical Research Council, Australia.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review

OBJECTIVE

To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy.

METHODS

We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized.

RESULTS

Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient's understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls.

CONCLUSION

Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain.

STUDY REGISTRATION

Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

The Added Value of Face-to-Face Supervision to a Therapeutic Exercise-Based App in the Management of Patients with Chronic Low Back Pain: A Randomized Clinical Trial

Low back pain (LBP) is a significant global health challenge due to its high prevalence, and chronicity and recurrence rates, with projections suggesting an increase in the next years due to population growth and aging. The chronic and recurrent nature of LBP, responsible for a significant percentage of years lived with disability, underscores the need for effective management strategies, including self-management strategies advocated by current guidelines, to empower patients and potentially improve healthcare efficiency and clinical outcomes. Therefore, the aim of this study was to analyze the added value of face-to-face visits in patients with chronic LBP undergoing a self-management program based on therapeutic exercises on pain intensity, disability, quality of life and treatment adherence and satisfaction. A randomized clinical trial was conducted, allocating 49 patients into a experimental group with a mobile health (mHealth) app usage and face-to-face sessions and 49 patients into an active control group without face-to-face sessions. Pain intensity, disability and quality of life were assessed at baseline, 4 weeks postintervention and 12 weeks postintervention. Patients' satisfaction and adherence were assessed at the end of the study. The multivariate general model revealed no statistically significant time × group interaction for any outcome (p > 0.0068) but mental quality of life (p = 0.006). Within-group differences revealed significant improvements for all the clinical indicators (all, p < 0.001). Patients allocated to the experimental group reported greater satisfaction and adherence (both, p < 0.001) compared to the control group. The use of mHealth apps such as Healthy Back® as part of digital health initiatives may serve as a beneficial approach to enhance the management of LBP.

Mind-Body Exercise Performed by Physical Therapists for Reducing Pain and Disability in Low Back Pain: A Systematic Review With Meta-analysis

OBJECTIVE

To assess the effectiveness of mind-body (MB) exercise interventions provided by physical therapists for reducing pain and disability in people with low back pain (LBP).

DATA SOURCES

MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for articles published in English between December 2010 and June 2020.

STUDY SELECTION

Randomized controlled trials evaluating the effects of Pilates, yoga, and tai chi interventions performed by physical therapists on pain or disability outcomes in adults with musculoskeletal LBP were included.

DATA EXTRACTION

Data were extracted by 2 independent reviewers. Quality of evidence and risk of bias were assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework and Cochrane risk of bias tools, respectively.

DATA SYNTHESIS

21,230 exercise trials were identified; 161 progressed to full-text review. Eight trials, 7 reporting on Pilates and 1 reporting on yoga, were included. Short-term outcomes for pain (SMD: -0.93; 95% confidence interval [CI]: -1.65 to -0.021) and disability (SMD: -0.74 95% CI: -1.36 to -0.012) indicated MB exercise was more effective than control intervention. Tests for subgroup differences between studies with exercise vs non-exercise control groups revealed a moderating effect on short-term outcomes where larger effects were observed in studies with non-exercise comparators. Long-term outcomes for pain (SMD: -0.60; 95% CI:-1.43 to 0.23) and disability (SMD: -1.05; 95% CI:-3.51 to 1.41) suggested that MB exercise is not more effective than control interventions for pain or disability. Quality of the evidence ranged from very low to low.

CONCLUSIONS

Physical therapist-delivered MB exercise interventions, which overwhelmingly consisted of Pilates, were more effective than control in the short and long-term for pain and in the short-term for disability, with differences in the short-term effects lessened when compared with an active intervention. Pilates interventions delivered by physical therapists represent a viable tool for the clinical management of chronic LBP.

Evaluation of the impact of a smartphone application on adherence to home exercise program for people with chronic low back pain: research protocol for a pilot randomised controlled trial

INTRODUCTION

Multidisciplinary rehabilitation programmes are highly recommended for individuals with the most disabling low back pain (LBP). However, the long-term adherence to regular home exercise is often poor. We aim to perform a prospective, controlled, pilot, randomised study that will evaluate the impact of a smartphone application on adherence to exercise programme for people with chronic LBP (CLBP).

METHODS AND ANALYSIS

120 participants with non-specific CLBP aged 18-65 years will be recruited and randomised in two groups: an experimental group benefitting from education in the application's use in addition to a conventional multidisciplinary rehabilitation programme (exercises and self-management education) and a control group who will only participate in the multidisciplinary rehabilitation programme. Both groups will undergo the programme 5 days a week for 3 weeks. The primary outcome will be a change in patient's adherence to physical exercise (Exercise Adherence Rating Scale) at 6 months. Secondary outcomes will be function (Oswestry Disability Index), beliefs concerning physical activity (Evaluation of Physical Activity Perception), pain (Numeric Rating Scale), and physical capacity and qualitative adherence (video).Statistical analyses will be performed according to intention to treat. A linear mixed model will be used to compare the primary endpoint between groups at 6 months post-randomisation.The study could demonstrate the impact of using a smartphone application on adherence to exercise programme in people with CLBP. We hypothesise that the application's use will improve outcomes through improved exercise adherence.

ETHICS AND DISSEMINATION

The study was approved by the medical ethics committee of Ile de France 3. The results of this study will be disseminated in peer-reviewed publications and presentations at international scientific meetings and will also be disseminated to the participants.

TRIAL REGISTRATION NUMBER

NCT04264949.

Efficacy of e-Health Interventions in Patients with Chronic Low-Back Pain: A Systematic Review with Meta-Analysis

Introduction: Low-back pain (LBP) is the leading cause of disability worldwide. Around 75-84% of the world's population will experience LBP at some point, establishing it as a major global health problem. e-Health is the remote delivery of therapeutic services, clinical information, and medical care, and may prove a very useful approach to tackle this pathology. Objectives: To evaluate the efficacy of e-health-based interventions in improving the symptoms of chronic LBP. Methods: A systematic review with meta-analysis was performed in PubMed, Web of Science, and PEDro until January 2022 through the assessment of methodological quality of systematic reviews (AMSTAR). Studies were included in which e-health interventions were used as experimental treatment compared to physical therapy to determine changes in back-specific functional status and pain in patients with chronic LBP. Two reviewers examined the sources individually, calculated the risk of bias, and extracted the data (PROSPERO number CRD42022306130). The effect size was calculated using the standardized mean difference (SMD) and its confidence interval (95% CI). Results: A total of 9 randomized controlled trials with 3,180 participants were included. The results of the findings showed an effect of e-health compared to other physical therapy on short-term (SMD = -0.59, 95% CI: -1.77 to 0.59) and intermediate short-term (SMD = -0.40, 95% CI: -0.91 to 0.11) pain intensity and back-specific functional status in the short term (SMD = -0.20, 95% CI: -0.81 to 0.41) and intermediate short term (SMD = -0.30, 95% CI: -0.74 to 0.14). The effect of e-health compared to minimal intervention on short-term intermediate pain intensity (SMD = -0.64, 95% CI: -1.72 to 0.45) and short-term intermediate back-specific functional status (SMD = -0.39, 95% CI: -0.87 to 0.09). Conclusions: e-Health interventions based on self-maintenance and education are as effective on pain and back-specific functional status as other face-to-face or home-based interventions in patients with chronic LBP, with moderate scientific evidence.

"Back Rx, a personalized mobile phone application for discogenic chronic low back pain: a prospective pilot study"

Background

Intervertebral disc pathology is the most common identifiable cause of chronic lower back pain (CLBP). There are limited conservative alternatives to treat discogenic axial CLBP. Back Rx is a mobile application (app) developed to treat patients with this condition, following the Back Rx exercise program, assisted by a virtual coach.

Methods

Patients 18 to 65 years of age, with axial CLBP (more than 3 months), and evidence of lumbar disc pathology by magnetic resonance imaging (MRI) were enrolled to the study. Patients’ symptomatology was prospectively evaluated at baseline and after 3 months of using the Back Rx app. The main outcome of the study was back pain evaluated using the visual analog scale (VAS) for pain. Secondary outcomes were the patient's functionality, the weekly pain medication intake, the patients’ adherence to the app, and the patients´ satisfaction rate.

Results

Seventy-five patients with CLBP were enrolled in the study. All patients had a statistically significant improvement from baseline to final follow-up in the average VAS scores, and the functionality evaluations. Average VAS scores decreased from 5.17 ± 2.1 at baseline to 3.8 ± 2.6 at final follow-up (P = 0.016). Patients showed a significant decrease in the number of pain medications taken during a week (P = 0.001). Overall compliance with the app was 52%, and 65% of the patients rated the overall experience as good or excellent.

Conclusion

The Back Rx app decreased pain and increased function in patients with discogenic axial CLBP compared to their baseline status. Further measures are needed to increase patients' compliance with the app and the Back Rx program.

Trial registration

Retrospectively registered in 2/2/2017 NCT03040310 (ClinicalTrials.gov).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05883-9.

Telerehabilitation for upper limb disabilities: a scoping review on functions, outcomes, and evaluation methods

BACKGROUND

Upper limb (UL) disabilities have attracted worldwide attention due to the high economic costs of health care and the negative effects on the quality of life of patients with these disabilities. Telerehabilitation technologies are one of the most important ways to reduce rehabilitation costs and increase the quality of life of patients. Therefore, the aim of this study was to investigate the role of telerehabilitation in improving the health status of patients with upper limb disabilities.

METHODS

This scoping review was conducted by searching the Web of Science, PubMed, and Scopus until July 30, 2021. We used a data extraction form with 18 fields to extract data from primary studies. The selection of articles and data extraction was made by four researchers using a data collection form based on inclusion and exclusion criteria. Disagreements were resolved through consultation with the fifth and sixth researchers.Inclusion criteria were studies published in English, studies on upper limb disability, and telerehabilitation based on any technology (synchronous telerehabilitation, asynchronous, or both). Exclusion criteria were articles that did not focus on telerehabilitation and upper limb disabilities. Also, books, book chapters, letters to the editor, and conference abstracts were also removed.

RESULTS

A total of 458 articles were retrieved, and after removing irrelevant and duplicate articles, 29 articles were finally included in this review. Most telerehabilitation was performed for patients with stroke (65%). Among the 15 different services provided with telerehabilitation technologies, "Evaluation of exercises and also a musculoskeletal function of patients by the therapist","Recording of patients' rehabilitation exercises and sending them to the therapist" and "Prescribing new rehabilitation exercises by the therapist" were the most widely used services, respectively. Virtual reality technologies, smart wearables, and robots were used to provide telerehabilitation services. Among the 13 types of evaluation used for telerehabilitation systems, "Evaluation and measurement of upper limb function" was the most used evaluation in the studies. "Improvement in musculoskeletal functions", "Increasing patients' interest and motivation to perform rehabilitation exercises", and "Increasing adherence to rehabilitation exercises and greater participation in treatment processes" were the most important outcomes, respectively.

CONCLUSION

Our findings indicate that telerehabilitation provides individuals with equitable access to rehabilitation services, improves musculoskeletal function, and empowers individuals by providing a variety of rehabilitation capabilities.

Why Are Patients Not Doing Their Prescribed Home-Based Exercises? An Updated Review of the Factors Affecting Adherence to Prescribed Home-Based Exercise in Patients With Chronic Low Back Pain

Prescribed home-based exercise programs have been found to be an effective non-pharmacological treatment for the management of chronic low back pain. However, such programs rely on continued patient adherence to performing the exercises. The purpose of this integrative review is to present the key factors that influence adherence to prescribed home-based exercise for individuals with chronic low back pain. Searches of AMED, SPORTDiscus, CINAHL, MEDLINE, ScienceDirect, and Cochrane Library databases were performed for the period 2015 to 2021, using the following key search terms: exercise adherence, exercise compliance, exercise therapy, home-based exercise, chronic low back pain, and enabler, barrier or factor. Eight studies met the inclusion criteria and included Qualitative, Prospective Observation, Feasibility, Case Series and Randomised Controlled Trial studies. All participants were adults ranging from 18 to 85 years old with chronic low back pain and there was an overall female representation of 53.4%. Studies were assessed for methodological quality using the Critical Appraisal Skills Programme (CASP) checklist. The findings highlighted 2 key factors influencing adherence to home-based exercise programs for individuals with chronic low back pain: (1) the need for practitioners to develop effective communication skills that focus on the individual’s needs, including personalisation of exercise programs aimed at an individual’s symptoms, lifestyle and treatment goals; and (2) follow-up feedback and support strategies via electronic (virtual) or face to face in-clinic and home visits. Adherence to home-based exercise programs requires effective practitioner communication and targeted follow-up support and feedback.

Unique considerations for exercise programs to prevent future low back pain: the patient perspective

ABSTRACT

There is moderate quality evidence that exercise can help to prevent future low back pain (LBP). This study aimed to explore patient needs and preferences for exercise programs to prevent LBP and the outcomes of these programs that would be most important to a patient. Researchers conducted 26 semistructured interviews with people with LBP. Interviews were audio-recorded, transcribed, and analysed using framework thematic analysis. Three themes were developed. Theme 1 emphasised that everyone's LBP was different, translating to preferences for tailored prevention programs with a high level of initial supervision and individualised biomedical explanations for the program. Theme 2 highlighted important outcomes. Pain was considered not only for intensity but also for the duration, frequency, and severity of flare-ups or episodes. Other important outcomes were general fitness and capacity to engage in everyday activities, social interactions, and work. Theme 3 outlined aspects of exercise programs that were considered important for people with fluctuating pain, including how to foster a sense of "progress," set realistic expectations, and support patients to establish exercise routines that can adapt to fluctuating pain. Theme 4 discussed participants' desire for social connection. Patients want exercise programs for LBP prevention, which are highly individualised, provide meaningful explanations of exercises, and help them maintain exercise in the long-term. Clinicians should discuss with patients the transition from a focus on treatment to the prevention of LBP. This provides greater opportunity to adjust goals and expectations and provide relevant education. Balancing the need for individualised care against affordability presents an ongoing challenge.

An Investigation Into the Use of mHealth in Musculoskeletal Physiotherapy: Scoping Review

BACKGROUND

Musculoskeletal physiotherapy provides conservative management for a range of conditions. Currently, there is a lack of engagement with exercise programs because of the lack of supervision and low self-efficacy. The use of mobile health (mHealth) interventions could be a possible solution to this problem, helping promote self-management at home. However, there is little evidence for musculoskeletal physiotherapy on the most effective forms of mHealth.

OBJECTIVE

The aim of this review is to investigate the literature focusing on the use of mHealth in musculoskeletal physiotherapy and summarize the evidence.

METHODS

A scoping review of 6 peer-reviewed databases was conducted in March 2021. No date limits were applied, and only articles written in the English language were selected. A reviewer screened all the articles, followed by 2 additional researchers screening a random sample before data extraction.

RESULTS

Of the 1393 studies, 28 (2.01%) were identified. Intervention characteristics comprised stretching and strengthening exercises, primarily for degenerative joint pain and spinal conditions (5/28, 18%). The most reported use of mHealth included telephone and videoconferencing calls to provide a home exercise program or being used as an adjunct to physiotherapy musculoskeletal assessment (14/28, 50%). Although patient satisfaction with mHealth was reported to be high, reasons for disengagement included a lack of high-quality information and poor internet speeds. Barriers to clinical uptake included insufficient training with the intervention and a lack of time to become familiar.

CONCLUSIONS

mHealth has some benefits regarding treatment adherence and can potentially be as effective as normal physiotherapy care while being more cost-effective. The current use of mHealth is most effective when ongoing feedback from a health care professional is available.

Prehabilitation for Recreational Runners: Motivators, Influencers, and Barriers to Injury Prevention Strategies for Running-Related Injury

CONTEXT

Injury prevention programs are effective when implemented in team sports, but many recreational runners have less access to such focused interventions or peer support and often seek other sources to learn about injury reduction strategies.

OBJECTIVE

This study aimed to explore runners' motivations in attending a prehabilitation (prehab) for runners workshop, establish their comprehension of prehab, and identify barriers to ongoing engagement with injury prevention.

DESIGN

Qualitative study using focus groups.

PARTICIPANTS AND SETTING

Twenty-two runners participating in prehab for runners workshops took part in one of 4 focus groups, each recorded, transcribed, and analyzed using Grounded Theory to create codes, subthemes, and themes.

RESULTS

Four themes emerged: (1) Participation was influenced by experience of previous injury and worry of cessation of running. As the workshop ran weekly for 4 weeks, opportunity to see someone more than once who was also a physiotherapist influenced participation. (2) Runners welcomed clarification for online exercises and advice suggested for runners. They were surprised by the difficulty of single-leg neuromuscular facilitation exercises and reported benefit from most or all information especially non-exercise-based approaches such as load management, pain monitoring, and running cues. (3) Participants were empowered by a structured, holistic, and evidence-based approach that embraced autonomy for exercise self-selection and progression. Confidence to engage in open discussion was due to small group size. (4) Barriers to prehab were personal responsibility, equipment, time, lack of supervision, and peer influence.

CONCLUSION

A composite approach to strategies for injury risk reduction during prehab, combining progressive exercises with educational resources, can address runners' individual needs. Early discussion of motivational tools on commencement of prehab with guidance from runners on how to incorporate prehab independently into running training is recommended. Providing these tools allows runners to self-identify the approach best suited to their personal running profile at that given time.

Comparison of the effectiveness of an e-health program versus a home rehabilitation program in patients with chronic low back pain: A double blind randomized controlled trial

OBJETIVE

We conducted a randomized double blind clinical trial, to compare the effectiveness of McKenzie exercises and electroanalgesia via an e-Health program versus a home rehabilitation program on functionality, pain, fear of movement and quality of life in patients with non-specific chronic low back pain.

METHODS

Seventy-four participants with non-specific chronic low back pain were randomized to either the e- Health program group (n = 39) or the home rehabilitation program group (n = 35). The interventions consisted of the e-Health program group performing McKenzie exercises and received transcutaneous electrical nerve stimulation, while the home rehabilitation group attended an information session to explain the exercises, which they then performed at home with printed instructions. Both groups performed 3 weekly sessions for 8 weeks. The following were analyzed main measures: pain, disability, fear of movement, quality of life, trunk muscle endurance and trunk anteflexion motion were assessed at baseline and at 2 months.

RESULTS

Independent samples Student's t-tests showed that although the patients who followed the e-Health program showed significantly greater improvement than those who followed the home disability rehabilitation program in terms of intensity of pain, lumbar flexion mobility (P < 0.001), and the following dimensions of quality of life (P < 0.005), both groups improved significantly in the immediate post-treatment follow up compared with baseline scores.

CONCLUSIONS

Patients with chronic low back pain who followed an unsupervised home intervention supported by an individualized video exercise program showed greater post-treatment improvement than those who followed the same program with printed instructions.

Effects of an Individualized Educational Program for Korean Patients With Chronic Low Back Pain: A Randomized Controlled Trial

BACKGROUND

Most patients with low back pain prefer to ignore symptoms and avoid medical management because of incorrect perceptions about this condition. However, over 90% of patients with chronic low back pain are hardly unable to perform daily activities, with 50% reporting that their daily activities have been severely impeded.

PURPOSE

In this study, an individualized educational program was developed and implemented in a sample of Korean patients with chronic low back pain, and the effectiveness of this program was evaluated.

METHODS

This study was conducted as a randomized controlled trial with outpatients (n = 43) in an orthopedic clinic. The Analysis, Design, Development, Implementation, and Evaluation model was applied to develop the educational program. The experimental group was provided with an educational booklet and contacted via biweekly personalized telephone and face-to-face counseling sessions. The control group was provided the educational booklet only. SAS Version 9.4 was used to analyze collected data using the χ2 test, t test, Fisher's exact test, Wilcoxon test, linear regression analysis, and Spearman partial correlation analysis.

RESULTS

After 8 weeks, the experimental group demonstrated a significantly greater reduction in maximum, average, and current low back pain experienced within the immediately preceding 24 hours than the control group (p = .001, p = .002, and p = .014, respectively). In addition, daily living disability showed a greater reduction, and average back muscle strength showed a more significant improvement in the experimental group than in the control group (p = .001 and p = .035). The difference in medication adherence between the groups was not statistically significant (p = .089). The experimental group rated an average of 4.3 out of 5.0 points on the program satisfaction scale, indicating an 86% rate of satisfaction.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

In this study, the individualized educational program was shown to be effective in helping alleviate symptoms in patients with chronic low back pain, decrease daily living disability, and improve average back muscle strength. It was further demonstrated that following up with expert medical staffs can motivate patients to incorporate the recommendations of the program into their daily routine, leading to higher patient satisfaction.

Making exercise count: Considerations for the role of exercise in back pain treatment

INTRODUCTION

Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP.

AIM

This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals.

METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP.

RESULTS/DISCUSSION

Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain.

CONCLUSION

To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

Patient Satisfaction Using a Home-Based Rehabilitation Protocol for the Non-Surgical Treatment of Proximal Humeral Fractures: A Prospective Longitudinal Cohort Study

Supervised, center-based, daily physiotherapy presents limitations: transport, need for an accompanying person, or risk of infection. Home-based rehabilitation protocols (HBRP) can be effective alternatives. We use a HBRP for the non-surgically treated proximal humeral fractures (PHF) in older patients.

Effect of Home Exercise Training in Patients with Nonspecific Low-Back Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Exercise therapy is recommended to treat non-specific low back pain (LBP). Home-based exercises are promising way to mitigate the lack of availability of exercise centers. In this paper, we conducted a systemic review and meta-analysis on the effects of home-based exercise on pain and functional limitation in LBP.

METHOD

PubMed, Cochrane, Embase and ScienceDirect were searched until April 20th, 2021. In order to be selected, studies needed to report the pain and functional limitation of patients before and after home-based exercise or after exercise both in a center and at-home. Random-effect meta-analyses and meta-regressions were conducted.

RESULTS

We included 33 studies and 9588 patients. We found that pain intensity decreased in the exclusive home exercise group (Effect size = -0.89. 95% CI -0.99 to -0.80) and in the group which conducted exercise both at-home and at another setting (-0.73. -0.86 to -0.59). Similarly, functional limitation also decreased in both groups (-0.75. -0.91 to -0.60, and -0.70, -0.92 to -0.48, respectively). Relaxation and postural exercise seemed to be ineffective in decreasing pain intensity, whereas trunk, pelvic or leg stretching decreased pain intensity. Yoga improved functional limitation. Supervised training was the most effective method to improve pain intensity. Insufficient data precluded robust conclusions around the duration and frequency of the sessions and program.

CONCLUSION

Home-based exercise training improved pain intensity and functional limitation parameters in LBP.

Physical Therapists' Opinion of E-Health Treatment of Chronic Low Back Pain

(1) Background: Using new technologies to manage home exercise programmes is an approach that allows more patients to benefit from therapy. The objective of this study is to explore physical therapists’ opinions of the efficacy and disadvantages of implementing a web-based telerehabilitation programme for treating chronic low back pain (CLBP). (2) Methods: Nineteen physical therapists from academic and healthcare fields in both the public and private sector participated in the qualitative study. Texts extracted from a transcript of semi-structured, individual, in-depth interviews with each consenting participant were analysed to obtain the participants’ prevailing opinions. The interviews lasted approximately 40 min each. The participants’ responses were recorded. (3) Results: The results suggest that telerehabilitation can only be successful if patients become actively involved in their own treatment. However, exercise programmes for LBP are not always adapted to patient preferences. New technologies allow physical therapists to provide their patients with the follow-up and remote contact they demand, but long-term adherence to treatment stems from knowledge of the exercises and the correct techniques employed by the patients themselves. (4) Conclusions: Physical therapists treating patients with chronic non-specific low back pain believe that new technologies can provide highly effective means of reaching a greater number of patients and achieving significant savings in healthcare costs, despite the limitations of a telerehabilitation approach in developing an appropriate and effective patient-based physiotherapy programme.

The Relevance of a Physical Active Lifestyle and Physical Fitness on Immune Defense: Mitigating Disease Burden, With Focus on COVID-19 Consequences

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a fast spreading virus leading to the development of Coronavirus Disease-2019 (COVID-19). Severe and critical cases are characterized by damage to the respiratory system, endothelial inflammation, and multiple organ failure triggered by an excessive production of proinflammatory cytokines, culminating in the high number of deaths all over the world. Sedentarism induces worse, continuous, and progressive consequences to health. On the other hand, physical activity provides benefits to health and improves low-grade systemic inflammation. The aim of this review is to elucidate the effects of physical activity in physical fitness, immune defense, and its contribution to mitigate the severe inflammatory response mediated by SARS-CoV-2. Physical exercise is an effective therapeutic strategy to mitigate the consequences of SARS-CoV-2 infection. In this sense, studies have shown that acute physical exercise induces the production of myokines that are secreted in tissues and into the bloodstream, supporting its systemic modulatory effect. Therefore, maintaining physical activity influence balance the immune system and increases immune vigilance, and also might promote potent effects against the consequences of infectious diseases and chronic diseases associated with the development of severe forms of COVID-19. Protocols to maintain exercise practice are suggested and have been strongly established, such as home-based exercise (HBE) and outdoor-based exercise (OBE). In this regard, HBE might help to reduce levels of physical inactivity, bed rest, and sitting time, impacting on adherence to physical activity, promoting all the benefits related to exercise, and attracting patients in different stages of treatment for COVID-19. In parallel, OBE must improve health, but also prevent and mitigate COVID-19 severe outcomes in all populations. In conclusion, HBE or OBE models can be a potent strategy to mitigate the progress of infection, and a coadjutant therapy for COVID-19 at all ages and different chronic conditions.

Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain-A Scoping Review and Theoretical Models

(1) Background: Adherence to and the maintenance of treatment regimens are fundamental for pain self-management and sustainable behavioural changes. The first aim was to study older adults' (>65 years) levels of adherence to and maintenance of musculoskeletal pain self-management programmes in randomized controlled trials. The second aim was to suggest theoretical models of adherence to and maintenance of a behaviour. (2) Methods: The study was conducted in accordance with the recommendations for a scoping review and the PRISMA-ScR checklist. Capability, motivation and opportunity were used to categorize the behavioural change components in the theoretical models. (3) Results: Among the four studies included, components targeting adherence were reported in one study, and maintenance was reported in two studies. Adherence was assessed by the treatment attendance rates, and maintenance was assessed by the follow-up data of outcome measures. For adherence, the capability components were mostly about education and the supervision, grading and mastery of exercise to increase self-efficacy. The motivation components included the readiness to change, self-monitoring and goal setting; and the opportunity components included booster sessions, feedback and social support. For maintenance, the capability components consisted of identifying high-risk situations for relapse and problem-solving skills. The motivation components included self-regulation and self-efficacy for problem solving, and the opportunity components included environmental triggers and problem solving by using social support. (4) Conclusion: There are several behavioural change components that should be used to increase older adults' levels of adherence to and maintenance of a pain self-management behaviour.

Study protocol randomised controlled trial comparison of cost-utility and cost-effectiveness of a face-to-face rehabilitation programme versus a telemedicine programme in the treatment of patients with chronic low back pain

INTRODUCTION

Chronic lower back pain is a highly prevalent medical condition in Western countries, which that incurs a considerable social and economic burden. Although prescription exercise at home for chronic pain has become a widely used alternative to reduce healthcare costs, the evidence regarding patient adherence and decreased in costs in European countries is scarce and inconclusive. The objective of this study is to examine the cost-utility and cost-effectiveness in patients with chronic lower back pain treated with the McKenzie Method and electroanalgesia via a telemedicine programme versus a face-to-face programme.

METHODS AND ANALYSIS

This study reports the protocol for a randomised, two-arm, multicentre, parallel controlled trial. A total of 540 patients with chronic lower back pain (onset time ≥3 months, Roland Morris Disability Questionnaire ≥4) will be recruited in three hospitals in Andalusia. Participants will be assigned to one of two groups (n=270, respectively) to receive electroanalgesia and Mckenzie method exercises through a telemedicine or a face-to-face programme. A total of 24 sessions will be administered three times a week for 8 weeks. Since the study design does not allow participant blinding, the outcome assessor and the statistician will be blinded. Use of helth care resources and costs due to work absenteeism will be captured and analysed. In addition, pain, intensity, fear of movement, quality of life and strength of the core muscle and anteflexion lumbar will be recorded at 2 and 6 months after the start of treatment.

ETHICS AND DISSEMINATION

Human Research and Local Ethics Committee of the 'Hospital Complex Torrecárdenas of Almeria, University Hospital of Granada and Virgen Macarena de Sevilla Hospital-Andalusian Health Service'. Study findings will be released to the research, clinical and health service through publication in international journals and conferences.

TRIAL REGISTRATION NUMBER

NCT04266366.

Effect of the Abdominal Draw-In Maneuver and Bracing on Abdominal Muscle Thickness and the Associated Subjective Difficulty in Healthy Individuals

We evaluated the trunk abdominal muscle thickness while performing different exercises to identify the most effective training and to investigate the subjective difficulty associated with exercising. Twenty-eight men (mean age: 21.6 ± 0.9 years) without orthopedic diseases were enrolled. Ultrasonic imaging was used to measure the thickness of the transversus abdominis (TA), internal oblique, and external oblique muscles while at rest and while performing the abdominal draw-in maneuver and abdominal bracing. Measurements were made in the supine and sitting positions, and the subjective difficulty in performing each exercise was examined using a 5-level evaluation scale. The TA and internal oblique muscle thicknesses were significantly greater during the abdominal draw-in maneuver (ADIM) than during bracing or resting, in the supine and sitting positions. The subjective difficulty of abdominal bracing (AB) was graded significantly higher than that of ADIM. Additionally, a correlation between subjective difficulty and muscle thickness was found for the TA and IO. Our results may contribute to the choice of more effective exercises for spinal stability.

A logic model for a self-management program designed to help workers with persistent and disabling low back pain stay at work

BACKGROUND

Workers with persistent disabling low back pain (LBP) often encounter difficulty staying at work. Self-management (SM) programs can offer interesting avenues to help workers stay at work.

OBJECTIVE

To establish the plausibility of a logic model operationalizing a SM program designed to help workers with persistent disabling LBP stay at work.

METHODS

We used a qualitative design. A preliminary version of the logic model was developed based on the literature and McLaughlin et al.'s framework for logic models. Clinicians in work rehabilitation completed an online survey on the plausibility of the logic model and proposed modifications, which were discussed in a focus group. Thematic analyses were performed.

RESULTS

Participants (n = 11) found the model plausible, contingent upon a few modifications. They raised the importance of making more explicit the margin of maneuver or "job leeway" for a worker who is trying to stay at work and suggested emphasizing a capability approach. Enhancing the workers' perceived self-efficacy and communication skills were deemed essential tasks of the model.

CONCLUSION

A plausible logic model for a SM program designed for workers with disabling LBP stay at work was developed. The next step will be to assess its acceptability with potential users.

Factors in the Effectiveness of e-Health Interventions for Chronic Back Pain: How Self-Efficacy Mediates e-Health Literacy and Healthy Habits

Background: Self-management and healthy habits (long-term health-related behaviors) are life-long requirements for the prevention of chronic back pain. Adherence to health interventions is often low because of the target groups' lack of interest. Electronic health (e-Health) information offers an opportunity to solve this issue, but many e-Health interventions are of poor quality. This study explores factors in the effectiveness of e-Health interventions and health-related behavioral changes and, thus, is among the first to develop a theoretical basis for e-Health programs. Materials and Methods: An online survey was conducted among the target groups of primary and secondary health programs promoting the management of possibly chronic back pain in Germany and Austria (N = 224). Measurements of e-Health literacy (eHL), self-efficacy, organized physical exercise, and the patients' social and mental balance were applied in all cases. Participants were categorized into dichotomous subgroups regarding the severity of their back pain. In addition to several significance tests, a correlation analysis and mediation analysis were both performed using PROCESS version 2.0 for SPSS. Results: It was observed in the nonrisk group that self-efficacy has a mediation effect on the connection between eHL and healthy habits. Significant correlations between eHL and self-efficacy in both groups revealed associations between the major driving forces of healthy habits. Conclusion: In keeping with previous research, the findings suggest that a high level of self-efficacy plays a significant role in correctly performing e-Health interventions. Nevertheless, further research should identify the effects of online social surroundings on eHL and self-efficacy in detail.

"It's important to buy in to the new lifestyle": barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain

INTRODUCTION

Exercise and physical activity may improve pain and function in people with persistent musculoskeletal pain, but adherence is often low. Understanding the barriers and facilitators of exercise adherence could aid in the development of an intervention to promote exercise adherence. This study explored the factors influencing adherence to prescribed exercise in people with persistent musculoskeletal pain.

METHODS

Qualitative semi-structured interviews were conducted with patients with persistent musculoskeletal pain. Registered physiotherapists specializing in the treatment of persistent musculoskeletal pain were recruited to two focus groups. Data was analyzed using framework analysis informed by the Theoretical Domains Framework.

FINDINGS

Twenty patient participants (mean age = 44 years, standard deviation = 14) and ten physiotherapists (mean duration registered = 11 years, standard deviation = 5) were included. Four themes were identified: the role of environment, the therapeutic relationship, facilitating engagement with self-management and the influence of pain and negative affect. The Health Action Process Approach was identified as an appropriate model to inform intervention development.

CONCLUSIONS

Personal, social, and environmental factors as well as the relationship with the physiotherapist influences exercise adherence. These findings may inform practice and the development of theoretically-informed interventions to enhance exercise adherence in people with persistent musculoskeletal pain.Implications for rehabilitationExercise and physical activity can decrease pain while improving mobility in a population with persistent musculoskeletal pain, but adherence to prescribed programs is low.The physical and social environment, the influence of pain, and negative affect may act as barriers to exercise adherence, while fostering a collaborative therapeutic relationship and facilitating self-management may enhance exercise adherence.The findings from the current study align with the constructs theorized by the Health Action Process Approach to support initiation and maintenance of behavior. This may provide a suitable theoretical framework to support the development of a targeted intervention.Healthcare providers, specifically physiotherapists, may find that facilitating self-management strategies that emphasize coping skills to overcome personal, social and environmental barriers may enhance exercise adherence in their patients.