Physiotherapists' experiences with a blended osteoarthritis intervention: a mixed methods study

Patient and clinician perspectives of online-delivered exercise programmes for chronic musculoskeletal conditions: a mixed-methods systematic review

PURPOSE

To synthesize common or differing perceptions of patients' and clinicians' that influence uptake of online-delivered exercise programmes (ODEPs) for chronic musculoskeletal (MSK) conditions.

METHODS

Eight databases were searched from inception to April 2023 for studies including (1) patients with and/or clinicians delivering ODEPs for chronic MSK conditions, and (2) synchronous ODEPs, where information is exchanged simultaneously (mode A); asynchronous ODEPs, with at least one synchronous feature (mode B); or no ODEPs, documenting past experiences and/or likelihood of participating in an ODEP (mode C). Critical Appraisal Skills Programme checklists were used to assess study quality. Perceptions of patients' and clinicians' influencing uptake of ODEPs were extracted. Quantitative and qualitative data were synthesised and integrated.

RESULTS

Twenty-one studies were included (twelve quantitative, seven qualitative, and two mixed-methods) investigating the perceptions of 1275 patients and 534 clinicians on ODEP mode A (n = 7), mode B (n = 8), and mode C (n = 6). Sixteen of the 23 identified perceptions related to satisfaction, acceptability, usability, and effectiveness were common, with 70% of perceptions facilitating uptake and 30% hindering uptake.

CONCLUSIONS

Findings highlight the need to promote targeted education for patients and clinicians addressing interconnected perceptions, and to develop evidence-based perception-centred strategies encouraging integrated care and guideline-based management of chronic MSK conditions.

Limited use of virtual reality in primary care physiotherapy for patients with chronic pain

BACKGROUND

Chronic pain is a disabling condition which is prevalent in about 20% of the adult population. Physiotherapy is the most common non-pharmacological treatment option for chronic pain, but often demonstrates unsatisfactory outcomes. Virtual Reality (VR) may offer the opportunity to complement physiotherapy treatment. As VR has only recently been introduced in physiotherapy care, it is unknown to what extent VR is used and how it is valued by physiotherapists. The aim of this study was to analyse physiotherapists' current usage of, experiences with and physiotherapist characteristics associated with applying therapeutic VR for chronic pain rehabilitation in Dutch primary care physiotherapy.

METHODS

This online survey applied two rounds of recruitment: a random sampling round (873 physiotherapists invited, of which 245 (28%) were included) and a purposive sampling round (20 physiotherapists using VR included). Survey results were reported descriptively and physiotherapist characteristics associated with VR use were examined using multivariable logistic regression analysis.

RESULTS

In total, 265 physiotherapists participated in this survey study. Approximately 7% of physiotherapists reported using therapeutic VR for patients with chronic pain. On average, physiotherapists rated their overall experience with therapeutic VR at 7.0 and "whether they would recommend it" at 7.2, both on a 0-10 scale. Most physiotherapists (71%) who use therapeutic VR started using it less than two years ago and use it for a small proportion of their patients with chronic pain. Physiotherapists use therapeutic VR for a variety of conditions, including generalized (55%), neck (45%) and lumbar (37%) chronic pain. Physiotherapists use therapeutic VR mostly to reduce pain (68%), improve coordination (50%) and increase physical mobility (45%). Use of therapeutic VR was associated with a larger physiotherapy practice (OR = 2.38, 95% CI [1.14-4.98]). Unfamiliarity with VR seemed to be the primary reason for not using VR.

DISCUSSION

Therapeutic VR for patients with chronic pain is in its infancy in Dutch primary care physiotherapy practice as only a small minority uses VR. Physiotherapists that use therapeutic VR are modestly positive about the technology, with large heterogeneity between treatment goals, methods of administering VR, proposed working mechanisms and chronic pain conditions to treat.

Experiences of physiotherapists considering virtual reality for shoulder rehabilitation: A focus group study

Introduction

Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR.

Methods

A qualitative interpretive design was used to explore physiotherapists' experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis.

Results

Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention.

Conclusion

Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

Effectiveness and Cost-Effectiveness of a Stratified Blended Physiotherapy Intervention Compared With Face-to-Face Physiotherapy in Patients With Nonspecific Low Back Pain: Cluster Randomized Controlled Trial

BACKGROUND

Nonspecific low back pain (LBP) is a leading contributor to disability worldwide, and its socioeconomic burden is substantial. Self-management support is an important recommendation in clinical guidelines for the physiotherapy treatment of patients with LBP and may support cost-effective management. However, providing adequate individually tailored self-management support is difficult. The integration of web-based applications into face-to-face care (ie, blended care) seems promising to optimize tailored treatment and enhance patients' self-management and, consequently, may reduce LBP-related costs.

OBJECTIVE

We aimed to evaluate the long-term effectiveness and cost-effectiveness of stratified blended physiotherapy (e-Exercise LBP) compared with face-to-face physiotherapy in patients with nonspecific LBP.

METHODS

An economic evaluation was conducted alongside a prospective, multicenter, cluster randomized controlled trial in primary care physiotherapy. Patients with nonspecific LBP were treated with either stratified blended physiotherapy (e-Exercise LBP) (n=104) or face-to-face physiotherapy (n=104). The content of both interventions was based on the Dutch physiotherapy guidelines for nonspecific LBP. Blended physiotherapy was stratified according to the patients' risk of developing persistent LBP using the STarT Back Screening Tool. The primary clinical outcome was physical functioning (Oswestry Disability Index version 2.1a). For the economic evaluation, quality-adjusted life years (QALYs; EQ-5D-5L) and physical functioning were the primary outcomes. Secondary clinical outcomes included fear avoidance beliefs and self-reported adherence. Costs were measured from societal and health care perspectives using self-report questionnaires. Effectiveness was estimated using linear mixed models. Seemingly unrelated regression analyses were conducted to estimate total cost and effect differences for the economic evaluation.

RESULTS

Neither clinically relevant nor statistically substantial differences were found between stratified blended physiotherapy and face-to-face physiotherapy regarding physical functioning (mean difference [MD] -1.1, 95% CI -3.9 to 1.7) and QALYs (MD 0.026, 95% CI -0.020 to 0.072) over 12 months. Regarding the secondary outcomes, fear avoidance beliefs showed a statistically significant improvement in favor of stratified blended physiotherapy (MD -4.3, 95% CI -7.3 to -1.3). Societal and health care costs were higher for stratified blended physiotherapy than for face-to-face physiotherapy, but the differences were not statistically significant (societal: €972 [US $1027], 95% CI -€1090 to €3264 [US -$1151 to $3448]; health care: €73 [US $77], 95% CI -€59 to €225 [US -$62 to $238]). Among the disaggregated cost categories, only unpaid productivity costs were significantly higher for stratified blended physiotherapy. From both perspectives, a considerable amount of money must be paid per additional QALY or 1-point improvement in physical functioning to reach a relatively low to moderate probability (ie, 0.23-0.81) of stratified blended physiotherapy being cost-effective compared with face-to-face physiotherapy.

CONCLUSIONS

The stratified blended physiotherapy intervention e-Exercise LBP is neither more effective for improving physical functioning nor more cost-effective from societal or health care perspectives compared with face-to-face physiotherapy for patients with nonspecific LBP.

TRIAL REGISTRATION

ISRCTN 94074203; https://www.isrctn.com/ISRCTN94074203.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12891-020-3174-z.

Blended Care in Patients With Knee and Hip Osteoarthritis in Physical Therapy: Delphi Study on Needs and Preconditions

BACKGROUND

Osteoarthritis is a major public health concern. Despite existing evidence-based treatment options, the health care situation remains unsatisfactory. Digital care options, especially when combined with in-person sessions, seem to be promising.

OBJECTIVE

The aim of this study was to investigate the needs, preconditions, barriers, and facilitators of blended physical therapy for osteoarthritis.

METHODS

This Delphi study consisted of interviews, an online questionnaire, and focus groups. Participants were physical therapists, patients with hip and/or knee osteoarthritis with or without experience in digital care, and stakeholders of the health care system. In the first phase, interviews were conducted with patients and physical therapists. The interview guide was based on the Consolidated Framework For Implementation Research. The interviews focused on experiences with digital and blended care. Furthermore, needs, facilitators, and barriers were discussed. In the second phase, an online questionnaire and focus groups served the process to confirm the needs and collect preconditions. The online questionnaire contained statements drawn by the results of the interviews. Patients and physical therapists were invited to complete the questionnaire and participate in one of the three focus groups including (1) patients; (2) physical therapists; and (3) a patient, a physical therapist, and stakeholders from the health care system. The focus groups were used to determine concordance with the results of the interviews and the online questionnaire.

RESULTS

Nine physical therapists, seven patients, and six stakeholders confirmed that an increase of acceptance of the digital care part by physical therapists and patients is crucial. One of the most frequently mentioned facilitators was conducting regular in-person sessions. Physical therapists and patients concluded that blended physical therapy must be tailored to the patients' needs. Participants of the last focus group stated that the reimbursement of blended physical therapy needs to be clarified.

CONCLUSIONS

Most importantly, it is necessary to strengthen the acceptance of patients and physical therapists toward digital care. Overall, for development and usage purposes, it is crucial to take the needs and preconditions into account.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023386; https://drks.de/search/en/trial/DRKS00023386.

Tele-assessment of core performance and functional capacity: Reliability, validity, and feasibility in healthy individuals

INTRODUCTION

Many assessment methods are used in physiotherapy to analyze the fitness level and injury risk in athletes, and to determine the general health status and the effectiveness of the treatment applied in patients. Considering the need for telehealth use, it is essential to determine the usability of tests performed as tele-assessment. This study aimed to examine the intra-rater reliability, validity, and feasibility of the tele-assessment version of core strength and endurance and functional capacity assessments in healthy individuals.

METHODS

"Curl-up," "Modified Push-up," "Plank," and "Lateral Bridge" tests were used for core strength and endurance performance assessment, and "Timed Up and Go," "30 second Sit to Stand," and "Functional Reach Test" tests were used for functional capacity assessment in healthy individuals. Participants were evaluated first by tele-assessment, then one hour later on the same day, all assessments were repeated face-to-face procedures by the researchers thus the validity of the tele-assessment method was determined. All tests were applied as tele-assessment one week later to determine the intra-rater reliability of the tele-assessment method. The system usability scale was applied to evaluate the usability of our tele-assessment method.

RESULTS

Eighty healthy people were enrolled. Intraclass correlation coefficients ranged between 0.91 and 0.97 for core performance tests and between 0.95 and 0.97 for functional tests. All tele-assessment versions of the core performance and functional tests were highly correlated with the face-to-face versions.

DISCUSSION

Core strength-endurance and functional tests performed via tele-assessment were reliable, valid, and feasible for practically measuring the performance of healthy young adults. This study supports the tele-assessment versions of these tests.

TRIAL REGISTRATION NUMBER AND TRIAL REGISTER

Clinicaltrials.gov: NCT04899804.

Barriers and facilitators perceived by healthcare professionals for implementing lifestyle interventions in patients with osteoarthritis: a scoping review

OBJECTIVE

To provide an overview of barriers and facilitators that healthcare professionals (HCPs) perceive regarding the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA).

DESIGN

Scoping review.

DATA SOURCES

The databases PubMed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception up to January 2021.

ELIGIBILITY CRITERIA

Primary research articles with a quantitative, qualitative or mixed-methods design were eligible for inclusion if they reported: (1) perceptions of primary and/or secondary HCPs (population); (2) on implementing LIs with physical activity and/or weight management as key components (concept) and (3) on conservative management of hip and/or knee OA (context). Articles not published in English, German or Dutch were excluded.

DATA EXTRACTION AND SYNTHESIS

Barriers and facilitators were extracted by two researchers independently. Subsequently, the extracted factors were linked to a framework based on the Tailored Implementation for Chronic Diseases checklist.

RESULTS

Thirty-six articles were included. In total, 809 factors were extracted and subdivided into nine domains. The extracted barriers were mostly related to non-optimal interdisciplinary collaboration, patients' negative attitude towards LIs, patients' low health literacy and HCPs' lack of knowledge and skills around LIs or promoting behavioural change. The extracted facilitators were mostly related to good interdisciplinary collaboration, a positive perception of HCPs' own role in implementing LIs, the content or structure of LIs and HCPs' positive attitude towards LIs.

CONCLUSIONS

Multiple individual and environmental factors influence the implementation of LIs by HCPs in patients with hip and/or knee OA. The resulting overview of barriers and facilitators can guide future research on the implementation of LIs within OA care. To investigate whether factor frequency is related to the relevance of each domain, further research should assess the relative importance of the identified factors involving all relevant disciplines of primary and secondary HCPs.

PROSPERO REGISTRATION NUMBER

CRD42019129348.

Web Portals for Patients With Chronic Diseases: Scoping Review of the Functional Features and Theoretical Frameworks of Telerehabilitation Platforms

Background

The COVID-19 pandemic has required an increased need for rehabilitation activities applicable to patients with chronic diseases. Telerehabilitation has several advantages, including reducing clinic visits by patients vulnerable to infectious diseases. Digital platforms are often used to assist rehabilitation services for patients in remote settings. Although web portals for medical use have existed for years, the technology in telerehabilitation remains a novel method.

Objective

This scoping review investigated the functional features and theoretical approaches of web portals developed for telerehabilitation in patients with chronic diseases.

Methods

PubMed and Web of Science were reviewed to identify articles associated with telerehabilitation. Of the 477 nonduplicate articles reviewed, 35 involving 14 portals were retrieved for the scoping review. The functional features, targeted diseases, and theoretical approaches of these portals were studied.

Results

The 14 portals targeted patients with chronic obstructive pulmonary disease, cardiovascular, osteoarthritis, multiple sclerosis, cystic fibrosis diseases, and stroke and breast cancer survivors. Monitoring/data tracking and communication functions were the most common, followed by exercise instructions and diary/self-report features. Several theoretical approaches, behavior change techniques, and motivational techniques were found to be utilized.

Conclusions

The web portals could unify and display multiple types of data and effectively provide various types of information. Asynchronous correspondence was more favorable than synchronous, real-time interactions. Data acquisition often required assistance from other digital tools. Various functions with patient-centered principles, behavior change strategies, and motivational techniques were observed for better support shifting to a healthier lifestyle. These findings suggested that web portals for telerehabilitation not only provided entrance into rehabilitation programs but also reinforced participant-centered treatment, adherence to rehabilitation, and lifestyle changes over time.

Usability and Acceptance of an Interactive Tablet-Based Exercise Application: A Mixed Methods Study

Purpose: To investigate usability and acceptance of a newly developed interactive, tablet-based exercise application (app) and to explore personal opinions of therapists when using this app in the clinical setting.

Methods: Twenty participants (10 therapists and 10 inactive healthy adults) tested usability of this app performing different test tasks, using the think aloud method, and rated overall satisfaction with the System Usability Scale and acceptance with a modified Technology Acceptance Model Questionnaire. For a secondary objective, personal opinions of therapists were evaluated with two focus groups, one for team leaders and one for team members.

Results: Overall, the app was judged to be usable. Effectiveness varied between 73 and 90%, overall satisfaction between 70.5 and 85.5/100 points and acceptance between 74 and 80%. Team leader and team member focus groups considered the app as providing a great opportunity for therapy extension, especially because of its blended character. Barriers to its implementation were seen in the existing clinical working processes, personal attitudes of therapists and uncertainty of who would cover expenses for this new form of therapy. Some improvements such as using videos instead of photos, the integration of more interactive tools and the possibility to add additional exercises were suggested in both settings.

Conclusion: The app showed high acceptance and usability in trainees and therapists, although some ideas for upgrading functions were formulated. Before this app can be used in clinical practice, feasibility of this blended approach should be evaluated in a clinical setting.

Applications of Digital Health Technologies in Knee Osteoarthritis: A Narrative Review (Preprint)

Background

With the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR).

Objective

This study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR.

Methods

In this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included.

Results

Digital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively.

Conclusions

For people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.

Feasibility randomised controlled trial comparing TRAK-ACL digital rehabilitation intervention plus treatment as usual versus treatment as usual for patients following anterior cruciate ligament reconstruction

Objectives

To evaluate the feasibility of trialling taxonomy for the rehabilitation of knee conditions—ACL (TRAK-ACL), a digital health intervention that provides health information, personalised exercise plans and remote clinical support combined with treatment as usual (TAU), for people following ACL reconstruction.

Methods

The study design was a two-arm parallel randomised controlled trial (RCT). Eligible participants were English-speaking adults who had undergone ACL reconstruction within the last 12 weeks, had access to the internet and could provide informed consent. Recruitment took place at three sites in the UK. TRAK-ACL intervention was an interactive website informed by behaviour change technique combined with TAU. The comparator was TAU. Outcomes were: recruitment and retention; completeness of outcome measures at follow-up; fidelity of intervention delivery and engagement with the intervention. Individuals were randomised using a computer-generated random number sequence. Blinded assessors allocated groups and collected outcome measures.

Results

Fifty-nine people were assessed for eligibility at two of the participating sites, and 51 were randomised; 26 were allocated to TRAK-ACL and 25 to TAU. Follow-up data were collected on 44 and 40 participants at 3 and 6 months, respectively. All outcome measures were completed fully at 6 months except the Client Service Receipt Inventory. Two patients in each arm did not receive the treatment they were randomised to. Engagement with TRAK-ACL intervention was a median of 5 logins (IQR 3–13 logins), over 18 weeks (SD 12.2 weeks).

Conclusion

TRAK-ACL would be suitable for evaluation of effectiveness in a fully powered RCT.

Stratified care integrated with eHealth versus usual primary care physiotherapy in patients with neck and/or shoulder complaints: protocol for a cluster randomized controlled trial

BACKGROUND

Neck and shoulder complaints are common in primary care physiotherapy. These patients experience pain and disability, resulting in high societal costs due to, for example, healthcare use and work absence. Content and intensity of physiotherapy care can be matched to a patient's risk of persistent disabling pain. Mode of care delivery can be matched to the patient's suitability for blended care (integrating eHealth with physiotherapy sessions). It is hypothesized that combining these two approaches to stratified care (referred to from this point as Stratified Blended Approach) will improve the effectiveness and cost-effectiveness of physiotherapy for patients with neck and/or shoulder complaints compared to usual physiotherapy.

METHODS

This paper presents the protocol of a multicenter, pragmatic, two-arm, parallel-group, cluster randomized controlled trial. A total of 92 physiotherapists will be recruited from Dutch primary care physiotherapy practices. Physiotherapy practices will be randomized to the Stratified Blended Approach arm or usual physiotherapy arm by a computer-generated random sequence table using SPSS (1:1 allocation). Number of physiotherapists (1 or > 1) will be used as a stratification variable. A total of 238 adults consulting with neck and/or shoulder complaints will be recruited to the trial by the physiotherapy practices. In the Stratified Blended Approach arm, physiotherapists will match I) the content and intensity of physiotherapy care to the patient's risk of persistent disabling pain, categorized as low, medium or high (using the Keele STarT MSK Tool) and II) the mode of care delivery to the patient's suitability and willingness to receive blended care. The control arm will receive physiotherapy as usual. Neither physiotherapists nor patients in the control arm will be informed about the Stratified Blended Approach arm. The primary outcome is region-specific pain and disability (combined score of Shoulder Pain and Disability Index & Neck Pain and Disability Scale) over 9 months. Effectiveness will be compared using linear mixed models. An economic evaluation will be performed from the societal and healthcare perspective.

DISCUSSION

The trial will be the first to provide evidence on the effectiveness and cost-effectiveness of the Stratified Blended Approach compared with usual physiotherapy in patients with neck and/or shoulder complaints.

TRIAL REGISTRATION

Netherlands Trial Register: NL8249 . Officially registered since 27 December 2019. Date of first enrollment: 30 September 2020. Study status: ongoing, data collection.

Telerehabilitation for Patients With Knee Osteoarthritis: A Focused Review of Technologies and Teleservices

Background

Telerehabilitation programs are designed with the aim of improving the quality of services as well as overcoming existing limitations in terms of resource management and accessibility of services. This review will collect recent studies investigating telerehabilitation programs for patients with knee osteoarthritis while focusing on the technologies and services provided in the programs.

Objective

The main objective of this review is to identify and discuss the modes of service delivery and technologies in telerehabilitation programs for patients with knee osteoarthritis. The gaps, strengths, and weaknesses of programs will be discussed individually.

Methods

Studies published in English since 2000 were retrieved from the EMBASE, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Physiotherapy Evidence Database (PEDro), and PsycINFO databases. The search words “telerehabilitation,” “telehealth,” “telemedicine,” “teletherapy,” and “ehealth” were combined with “knee” and “rehabilitation” to generate a data set of studies for screening and review. The final group of studies reviewed here includes those that implemented teletreatment for patients for at least 2 weeks of rehabilitation.

Results

In total, 1198 studies were screened, and the full text of 154 studies was reviewed. Of these, 38 studies were included, and data were extracted accordingly. Four modes of telerehabilitation service delivery were identified: phone-based, video-based, sensor-based, and expert system–based telerehabilitation. The intervention services provided in the studies included information, training, communication, monitoring, and tracking. Video-based telerehabilitation programs were frequently used. Among the identified services, information and educational material were introduced in only one-quarter of the studies.

Conclusions

Video-based telerehabilitation programs can be considered the best alternative solution to conventional treatment. This study shows that, in recent years, sensor-based solutions have also become more popular due to rapid developments in sensor technology. Nevertheless, communication and human-generated feedback remain as important as monitoring and intervention services.

A Blended Physiotherapy Intervention for Persons With Hemophilic Arthropathy: Development Study

Background

Joint bleeds are the hallmark of hemophilia, leading to a painful arthritic condition called as hemophilic arthropathy (HA). Exercise programs are frequently used to improve the physical functioning in persons with HA. As hemophilia is a rare disease, there are not many physiotherapists who are experienced in the field of hemophilia, and regular physiotherapy sessions with an experienced physiotherapist in the field of hemophilia are not feasible for persons with HA. Blended care is an innovative intervention that can support persons with HA at home to perform the advised physical activities and exercises and provide self-management information.

Objective

The aim of this study was to develop a blended physiotherapy intervention for persons with HA.

Methods

The blended physiotherapy intervention, namely, e-Exercise HA was developed by cocreation with physiotherapists, persons with HA, software developers, and researchers. The content of e-Exercise HA was compiled using the first 3 steps of the Center for eHealth Research roadmap model (ie, contextual inquiry, value specification, and design), including people with experience in the development of previous blended physiotherapy interventions, a literature search, and focus groups.

Results

A 12-week blended intervention was developed, integrating face-to-face physiotherapy sessions with a web-based app. The intervention consists of information modules for persons with HA and information modules for physiotherapists, a graded activity program using a self-chosen activity, and personalized video-supported exercises. The information modules consist of text blocks, videos, and reflective questions. The patients can receive pop-ups as reminders and give feedback on the performance of the prescribed activities.

Conclusions

In this study, we developed a blended physiotherapy intervention for persons with HA, which consists of information modules, a graded activity program, and personalized video-supported exercises.

Feasibility of a stratified blended physiotherapy intervention for patients with non-specific low back pain: a mixed methods study

INTRODUCTION

Integrating web-based or mobile components and face-to-face components within a treatment process is called blended care. As part of the participatory development of a blended physiotherapeutic intervention for patients with low back pain (e-Exercise LBP), a proof of concept study was carried out and showed promising results.

OBJECTIVE

To investigate the feasibility of the e-Exercise LBP prototype for patients and physiotherapists to improve the intervention.

METHODS

A mixed methods study was executed, embedded in the development phase of e-Exercise LBP. 21 physiotherapists treated 41 patients with e-Exercise LBP. Quantitative data consisted of: patients' satisfaction on a five-point Likert Scale; patients' and physiotherapists' experienced usability of the web-based application (System Usability Scale) and; patients' experiences with e-Exercise LBP (closed-ended questions and statements related to the elements and goals of e-Exercise LBP). Semi-structured interviews about experiences with e-Exercise LBP were conducted with seven patients and seven physiotherapists. Qualitative data were analyzed by a phenomenological approach. Quantitative data were analyzed with descriptive statistics.

RESULTS

Patients were satisfied with e-Exercise LBP (mean: 4.0; SD:0.8; range: extreme dissatisfaction (1)-extreme satisfaction (5)). Usability of the web-based application was acceptable (patients: mean: 73.2 (SD:16.3); physiotherapists: mean: 63.3 (SD:12.0); range: 0-100). Interviews revealed that physiotherapists' training is essential to successfully integrate the web-based application and face-to-face sessions within physiotherapy treatment. Also, patients addressed the need of reminder messages to support long-term (exercise) adherence.

CONCLUSION

e-Exercise LBP appeared to be feasible. However, various prerequisites and points of improvement were mentioned to improve physiotherapists' training and the prototype.

Effectiveness and cost-effectiveness of stratified blended physiotherapy in patients with non-specific low back pain: study protocol of a cluster randomized controlled trial

BACKGROUND

Patient education, advice on returning to normal activities and (home-based) exercise therapy are established treatment options for patients with non-specific low back pain (LBP). However, the effectiveness of physiotherapy interventions on physical functioning and prevention of recurrent events largely depends on patient self-management, adherence to prescribed (home-based) exercises and recommended physical activity behaviour. Therefore we have developed e-Exercise LBP, a blended intervention in which a smartphone application is integrated within face-to-face care. E-Exercise LBP aims to improve patient self-management skills and adherence to exercise and physical activity recommendations and consequently improve the effectiveness of physiotherapy on patients' physical functioning. The aim of this study is to investigate the short- (3 months) and long-term (12 and 24 months) effectiveness on physical functioning and cost-effectiveness of e-Exercise LBP in comparison to usual primary care physiotherapy in patients with LBP.

METHODS

This paper presents the protocol of a prospective, multicentre cluster randomized controlled trial. In total 208 patients with LBP pain were treated with either e-Exercise LBP or usual care physiotherapy. E-Exercise LBP is stratified based on the risk for developing persistent LBP. Physiotherapists are able to monitor and evaluate treatment progress between face-to-face sessions using patient input from the smartphone application in order to optimize physiotherapy care. The smartphone application contains video-supported self-management information, video-supported exercises and a goal-oriented physical activity module. The primary outcome is physical functioning at 12-months follow-up. Secondary outcomes include pain intensity, physical activity, adherence to prescribed (home-based) exercises and recommended physical activity behaviour, self-efficacy, patient activation and health-related quality of life. All measurements will be performed at baseline, 3, 12 and 24 months after inclusion. An economic evaluation will be performed from the societal and the healthcare perspective and will assess cost-effectiveness of e-Exercise LBP compared to usual physiotherapy at 12 and 24 months.

DISCUSSION

A multi-phase development and implementation process using the Center for eHealth Research Roadmap for the participatory development of eHealth was used for development and evaluation. The findings will provide evidence on the effectiveness of blended care for patients with LBP and help to enhance future implementation of blended physiotherapy.

TRIAL REGISTRATION

ISRCTN, ISRCTN94074203. Registered 20 July 2018 - Retrospectively registered.

Cost-effectiveness of a blended physiotherapy intervention compared to usual physiotherapy in patients with hip and/or knee osteoarthritis: a cluster randomized controlled trial

Background

Blended physiotherapy, in which physiotherapy sessions and an online application are integrated, might support patients in taking an active role in the management of their chronic condition and may reduce disease related costs. The aim of this study was to evaluate the cost-effectiveness of a blended physiotherapy intervention (e-Exercise) compared to usual physiotherapy in patients with osteoarthritis of hip and/or knee, from the societal as well as the healthcare perspective.

Methods

This economic evaluation was conducted alongside a 12-month cluster randomized controlled trial, in which 108 patients received e-Exercise, consisting of physiotherapy sessions and a web-application, and 99 patients received usual physiotherapy. Clinical outcome measures were quality-adjusted life years (QALYs) according to the EuroQol (EQ-5D-3 L), physical functioning (HOOS/KOOS) and physical activity (Actigraph Accelerometer). Costs were measured using self-reported questionnaires. Missing data were multiply imputed and bootstrapping was used to estimate statistical uncertainty.

Results

Intervention costs and medication costs were significantly lower in e-Exercise compared to usual physiotherapy. Total societal costs and total healthcare costs did not significantly differ between groups. No significant differences in effectiveness were found between groups. For physical functioning and physical activity, the maximum probability of e-Exercise being cost-effective compared to usual physiotherapy was moderate (< 0.82) from both perspectives. For QALYs, the probability of e-Exercise being cost-effective compared to usual physiotherapy was 0.68/0.84 at a willingness to pay of 10,000 Euro and 0.70/0.80 at a willingness to pay of 80,000 Euro per gained QALY, from respectively the societal and the healthcare perspective.

Conclusions

E-Exercise itself was significantly cheaper compared to usual physiotherapy in patients with hip and/or knee osteoarthritis, but not cost-effective from the societal- as well as healthcare perspective. The decision between both interventions can be based on the preferences of the patient and the physiotherapist.

Trial registration

NTR4224 (25 October 2013).

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5975-7) contains supplementary material, which is available to authorized users.