A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area

Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations

BACKGROUND

Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists.

METHODS

We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist.

RESULTS

We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons.

CONCLUSIONS

High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.

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.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Identification of subgroup effect with an individual participant data meta-analysis of randomised controlled trials of three different types of therapist-delivered care in low back pain

Background

Proven treatments for low back pain, at best, only provide modest overall benefits. Matching people to treatments that are likely to be most effective for them may improve clinical outcomes and makes better use of health care resources.

Methods

We conducted an individual participant data meta-analysis of randomised controlled trials of three types of therapist delivered interventions for low back pain (active physical, passive physical and psychological treatments). We applied two statistical methods (recursive partitioning and adaptive risk group refinement) to identify potential subgroups who might gain greater benefits from different treatments from our individual participant data meta-analysis.

Results

We pooled data from 19 randomised controlled trials, totalling 9328 participants. There were 5349 (57%) females with similar ratios of females in control and intervention arms. The average age was 49 years (standard deviation, SD, 14).

Participants with greater psychological distress and physical disability gained most benefit in improving on the mental component scale (MCS) of SF-12/36 from passive physical treatment than non-active usual care (treatment effects, 4.3; 95% confidence interval, CI, 3.39 to 5.15). Recursive partitioning method found that participants with worse disability at baseline gained most benefit in improving the disability (Roland Morris Disability Questionnaire) outcome from psychological treatment than non-active usual care (treatment effects, 1.7; 95% CI, 1.1 to 2.31). Adaptive risk group refinement did not find any subgroup that would gain much treatment effect between psychological and non-active usual care. Neither statistical method identified any subgroups who would gain an additional benefit from active physical treatment compared to non-active usual care.

Conclusions

Our methodological approaches worked well and may have applicability in other clinical areas. Passive physical treatments were most likely to help people who were younger with higher levels of disability and low levels of psychological distress. Psychological treatments were more likely to help those with severe disability. Despite this, the clinical importance of identifying these subgroups is limited. The sizes of sub-groups more likely to benefit and the additional effect sizes observed are small. Our analyses provide no evidence to support the use of sub-grouping for people with low back pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04028-8.

Comparing the effectiveness of group-based exercise to other non-pharmacological interventions for chronic low back pain: A systematic review

Background

Low back pain (LBP) is the leading cause of disability worldwide with a substantial financial burden on individuals and health care systems. To address this, clinical practice guidelines often recommend non-pharmacological, non-invasive management approaches. One management approach that has been recommended and widely implemented for chronic LBP is group-based exercise programs, however, their clinical value compared with other non-pharmacological interventions has not been investigated systematically.

Objective

To compare the effectiveness of group-based exercise with other non-pharmacological interventions in people with chronic LBP.

Methods

Four electronic databases were searched by two independent reviewers. Only randomized controlled trials that compared group-based exercise with other non-pharmacological interventions for chronic LBP were eligible. Study quality was assessed using the Cochrane Handbook for systematic reviews of Interventions by two independent reviewers.

Results

Eleven studies were eligible. We identified strong evidence of no difference between group exercise and other non-pharmacologic interventions for disability level and pain scores 3-month post-intervention in people with chronic LBP. We could not find any strong or moderate evidence for or against the use of group-based exercise in the rehabilitation of people with chronic LBP for other time-points and health measurement outcomes. We found no statistically significant differences in disability and quality of life and pain between the group and individual non-pharmacological interventions that included exercise.

Conclusion

With this equivocal finding, group-based exercise may be a preferred choice given potential advantages in other domains not reviewed here such as motivation and cost. Further research in this area is needed to evaluate this possibility.

The longitudinal effects of a physical activity programme on the physical fitness and disability of back pain patients: Service evaluation

OBJECTIVE

To evaluate the longitudinal effect of a group physical activity service to help patients self-manage un-resolving back pain.

BACKGROUND

Back pain is one of the most common and costly conditions. Large scale trials have demonstrated a role for less traditional treatment including exercise, yet the long term effects of patient centred, group physical activity programmes remains unclear.

METHODS

One hundred and eighty-one un-resolving back pain patients (aged 53 ± 17 years) completed a 6 × 2 h physical activity programme. All activities were relevant to activities of daily living and incorporated activities to develop aerobic fitness, flexibility, core activation, and muscular strength and endurance. Dietary advice, home diaries and pedometers were provided.

RESULTS

Measures of back pain, aerobic fitness, muscular endurance and body composition showed significant (p< 0.05) pre-post intervention improvements. Disability rating decreased by 19% alongside improvements in aerobic fitness (15%), back extension (36%) back flexion (16%) and grip strength (5%). Six month follow up identified (p< 0.05) reductions in body fat (6.5%) whilst aerobic fitness, disability rating and muscular strength and endurance remained stable.

CONCLUSION

Group physical activity programmes could contribute to the self-management of back pain, enabling sustained improvements in fitness, physical activity and body fatness.

The Effectiveness of an Upper Extremity Neuromuscular Training Program on the Shoulder Function of Military Members With a Rotator Cuff Tendinopathy: A Pilot Randomized Controlled Trial

INTRODUCTION

Shoulder pain, a leading reason to consult a physician or physiotherapist, continues to be a challenge to rehabilitate, particularly with a military population. A rotator cuff (RC) tendinopathy, the most important source of shoulder pain, is one of the leading reasons for sick leave or a discharge from active military service. Research encourages the use of exercise prescription for the management of a RC tendinopathy, however the ideal method of delivery (group setting versus one-on-one) remains uncertain. The purpose of this single-blind (evaluator) pilot randomized clinical trial was to compare two 6-week rehabilitation programs, a newly developed group-supervised neuromuscular training program and usual one-on-one physiotherapy care, on the pain and symptoms of Canadian soldiers affected by a RC tendinopathy.

MATERIALS AND METHODS

Thirty-one soldiers with the Canadian Armed Forces were randomly assigned to (1) a group-supervised neuromuscular training program (UPEx-NTP) or; (2) one-on-one usual physiotherapy care (UPC). The primary outcome was the Disability of Arm, Hand and Shoulder (DASH) questionnaire. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) Index, pain levels at rest, and maximum isometric voluntary contractions (MIVC) of the abductors and external (lateral) rotators of the affected shoulder. Both were assessed at baseline (T0), 6 (T6) and 12 (T12) weeks. Analysis included two-way repeated measures of variance for intention-to-treat (ITT) and per-protocol analyses.

RESULTS

Eighty military members with a RC tendinopathy were contacted, resulting in 31 participants who were randomized for their active intervention, in the UPEx-NTP or UPC, respectively. No significant group (p ≥ 0.16) or group × time interactions (p ≥ 0.11) were found for either ITT or per-protocol analyses. A statistically significant time effect (p < 0.001) was established for the DASH and WORC, showing that both groups improved over time.

CONCLUSIONS

Our preliminary data demonstrates that both rehabilitation approaches, grounded in active exercises, were not statistically different from each other, and derived similar benefits over time for a military population. This suggests that a group intervention for a RC tendinopathy has potential to be just as effective as a one-on-one approach for a military population, an interesting avenue for an active working population. Larger sample sizes and further investigation are warranted regarding the cost and clinical resource benefits of a supervised group approach.

Effect of Treatment Preference in Randomized Controlled Trials: Systematic Review of the Literature and Meta-Analysis

BACKGROUND

A significant limitation of the traditional randomized controlled trials is that strong preferences for (or against) one treatment may influence outcomes and/or willingness to receive treatment. Several trial designs incorporating patient preference have been introduced to examine the effect of treatment preference separately from the effects of individual interventions. In the current study, we summarized results from studies using doubly randomized preference trial (DRPT) or fully randomized preference trial (FRPT) designs and examined the effect of treatment preference on clinical outcomes.

METHODS

The current systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies using DRPT or FRPT design were identified using electronic databases, including PubMed, Cochrane Library, EMBASE, and Google Scholar between January 1989 and November 2018. All studies included in this meta-analysis were examined to determine the extent to which giving patients their preferred treatment option influenced clinical outcomes. The following data were extracted from included studies: study characteristics, sample size, study duration, follow-up, patient characteristics, and clinical outcomes. We further appraised risk of bias for the included studies using the Cochrane Collaboration's risk of bias tool.

RESULTS

The search identified 374 potentially relevant articles, of which 27 clinical trials utilized a DRPT or FRPT design and were included in the final analysis. Overall, patients who were allocated to their preferred treatment intervention were more likely to achieve better clinical outcomes [effect size (ES) = 0.18, 95% confidence interval (CI) 0.10-0.26]. Subgroup analysis also found that mental health as well as pain and functional disorders moderated the preference effect (ES = 0.23, 95% CI 0.11-0.36, and ES = 0.09, 95% CI 0.03-0.15, respectively).

CONCLUSIONS

Matching patients to preferred interventions has previously been shown to promote outcomes such as satisfaction and treatment adherence. Our analysis of current evidence showed that allowing patients to choose their preferred treatment resulted in better clinical outcomes in mental health and pain than giving them a treatment that is not preferred. These results underline the importance of incorporating patient preference when making treatment decisions.

Cost-effectiveness of exercise therapy in the treatment of non-specific neck pain and low back pain: a systematic review with meta-analysis

OBJECTIVE

To investigate the cost-effectiveness of exercise therapy in the treatment of patients with non-specific neck pain and low back pain.

DESIGN

Systematic review of economic evaluations.

DATA SOURCES

The search was performed in 5 clinical and 3 economic electronic databases.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included economic evaluations performed alongside randomised controlled trials. Differences in costs and effects were pooled in a meta-analysis, if possible, and incremental cost-utility ratios (ICUR) were descriptively analysed.

RESULTS

Twenty-two studies were included. On average, exercise therapy was associated with lower costs and larger effects for quality-adjusted life-year (QALY) in comparison with usual care for subacute and chronic low back pain from a healthcare perspective (based on ICUR). Exercise therapy had similar costs and effect for QALY in comparison with other interventions for neck pain from a societal perspective, and subacute and chronic low back pain from a healthcare perspective. There was limited or inconsistent evidence on the cost-effectiveness of exercise therapy compared with usual care for neck pain and acute low back pain, other interventions for acute low back pain and different types of exercise therapy for neck pain and low back pain.

CONCLUSIONS

Exercise therapy seems to be cost-effective compared with usual care for subacute and chronic low back pain. Exercise therapy was not (more) cost-effective compared with other interventions for neck pain and low back pain. The cost-utility estimates are rather uncertain, indicating that more economic evaluations are needed.

REGISTRATION

PROSPERO, CRD42017059025.

Identifying Treatment Effect Modifiers in the STarT Back Trial: A Secondary Analysis

Identification of patient characteristics influencing treatment outcomes is a top low back pain (LBP) research priority. Results from the STarT Back trial support the effectiveness of prognostic stratified care for LBP compared with current best care, however, patient characteristics associated with treatment response have not yet been explored. The purpose of this secondary analysis was to identify treatment effect modifiers within the STarT Back trial at 4-month follow-up (n = 688). Treatment response was dichotomized using back-specific physical disability measured using the Roland-Morris Disability Questionnaire (≥7). Candidate modifiers were identified using previous literature and evaluated using logistic regression with statistical interaction terms to provide preliminary evidence of treatment effect modification. Socioeconomic status (SES) was identified as an effect modifier for disability outcomes (odds ratio [OR] = 1.71, P = .028). High SES patients receiving prognostic stratified care were 2.5 times less likely to have a poor outcome compared with low SES patients receiving best current care (OR = .40, P = .006). Education level (OR = 1.33, P = .109) and number of pain medications (OR = .64, P = .140) met our criteria for effect modification with weaker evidence (.20 > P ≥ .05). These findings provide preliminary evidence for SES, education, and number of pain medications as treatment effect modifiers of prognostic stratified care delivered in the STarT Back Trial.

PERSPECTIVE

This analysis provides preliminary exploratory findings about the characteristics of patients who might least likely benefit from targeted treatment using prognostic stratified care for LBP.

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

Background

There is good evidence that therapist-delivered interventions have modest beneficial effects for people with low back pain (LBP). Identification of subgroups of people with LBP who may benefit from these different treatment approaches is an important research priority.

Aim and objectives

To improve the clinical effectiveness and cost-effectiveness of LBP treatment by providing patients, their clinical advisors and health-service purchasers with better information about which participants are most likely to benefit from which treatment choices. Our objectives were to synthesise what is already known about the validity, reliability and predictive value of possible treatment moderators (patient factors that predict response to treatment) for therapist-delivered interventions; develop a repository of individual participant data from randomised controlled trials (RCTs) testing therapist-delivered interventions for LBP; determine which participant characteristics, if any, predict clinical response to different treatments for LBP; and determine which participant characteristics, if any, predict the most cost-effective treatments for LBP. Achieving these objectives required substantial methodological work, including the development and evaluation of some novel statistical approaches. This programme of work was not designed to analyse the main effect of interventions and no such interpretations should be made.

Methods

First, we reviewed the literature on treatment moderators and subgroups. We initially invited investigators of trials of therapist-delivered interventions for LBP with > 179 participants to share their data with us; some further smaller trials that were offered to us were also included. Using these trials we developed a repository of individual participant data of therapist-delivered interventions for LBP. Using this data set we sought to identify which participant characteristics, if any, predict response to different treatments (moderators) for clinical effectiveness and cost-effectiveness outcomes. We undertook an analysis of covariance to identify potential moderators to apply in our main analyses. Subsequently, we developed and applied three methods of subgroup identification: recursive partitioning (interaction trees and subgroup identification based on a differential effect search); adaptive risk group refinement; and an individual participant data indirect network meta-analysis (NWMA) to identify subgroups defined by multiple parameters.

Results

We included data from 19 RCTs with 9328 participants (mean age 49 years, 57% females). Our prespecified analyses using recursive partitioning and adaptive risk group refinement performed well and allowed us to identify some subgroups. The differences in the effect size in the different subgroups were typically small and unlikely to be clinically meaningful. Increasing baseline severity on the outcome of interest was the strongest driver of subgroup identification that we identified. Additionally, we explored the application of Bayesian indirect NWMA. This method produced varying probabilities that a particular treatment choice would be most likely to be effective for a specific patient profile.

Conclusions

These data lack clinical effectiveness or cost-effectiveness justification for the use of baseline characteristics in the development of subgroups for back pain. The methodological developments from this work have the potential to be applied in other clinical areas. The pooled repository database will serve as a valuable resource to the LBP research community.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme. This project benefited from facilities funded through Birmingham Science City Translational Medicine Clinical Research and Infrastructure Trials Platform, with support from Advantage West Midlands (AWM) and the Wolfson Foundation.

Person-Centered, Physical Activity for Patients with Low Back Pain: Piloting Service Delivery

Low back pain (LBP) is one of the most common and costly conditions in industrialized countries. Exercise therapy has been used to treat LBP, although typically using only one mode of exercise. This paper describes the method and initial findings of a person-centered, group physical activity programme which featured as part of a multidisciplinary approach to treating LBP. Six participants (aged 50.7 ± 17 years) completed a six-week physical activity programme lasting two hours per week. A multicomponent approach to physical activity was adopted which included aerobic fitness, core activation, muscular strength and endurance, Nordic Walking, flexibility and exercise gaming. In addition, participants were required to use diary sheets to record physical activity completed at home. Results revealed significant (p < 0.05) improvements in back strength (23%), aerobic fitness (23%), negative wellbeing (32%) and disability (16%). Person’s Correlation Coefficient analysis revealed significant (p < 0.05) relationships between improvement in perceived pain and aerobic fitness (r = 0.93). It was concluded that a person-centered, multicomponent approach to physical activity may be optimal for supporting patients who self-manage LBP.

Generic Preference-based Measures for Low Back Pain: Which of Them Should Be Used?

STUDY DESIGN

Systematic review.

OBJECTIVE

This systematic review examines validity and responsiveness of three generic preference-based measures in patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

LBP is a very common incapacitating disease with a significant impact on health-related quality of life (HRQoL). Health state utility values can be derived from various preference-based HRQoL instruments, and among them the most widely ones are EuroQol 5 dimensions (EQ-5D), Short Form 6 Dimensions (SF-6D), and Health Utilities Index 3 (HUI III). The ability of these instruments to reflect HRQoL has been tested in various contexts, but never for LBP populations.

METHODS

A systematic search on electronic literature databases was undertaken to identify studies of patients with LBP where health state utility values were reported. Records were screened using a set of predefined eligibility criteria. Data on validity (correlations and known group methods) and responsiveness (effect sizes, standardized response means, tests of statistical significance) of instruments were extracted using a customized extraction template, and assessed using predefined criteria.

RESULTS

There were substantial variations in the 37 included papers identified in relation to study design and outcome measures used. EQ-5D demonstrated good convergent validity, as it was able to distinguish between known groups. EQ-5D was also able to capture changes of health states as results of different interventions. Evidence for SF-6D and HUI III was limited to allow an appropriate evaluation.

CONCLUSION

EQ-5D performs well in LBP population and its scores seem to be suitable for economic evaluation of LBP interventions. However, the paucity of information on the other instruments makes it impossible to determine its relative validity and responsiveness compared with them.

Individualised cognitive functional therapy compared with a combined exercise and pain education class for patients with non-specific chronic low back pain: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Non-specific chronic low back pain (NSCLBP) is a very common and costly musculoskeletal disorder associated with a complex interplay of biopsychosocial factors. Cognitive functional therapy (CFT) represents a novel, patient-centred intervention which directly challenges pain-related behaviours in a cognitively integrated, functionally specific and graduated manner. CFT aims to target all biopsychosocial factors that are deemed to be barriers to recovery for an individual patient with NSCLBP. A recent randomised controlled trial (RCT) demonstrated the superiority of individualised CFT for NSCLBP compared to manual therapy combined with exercise. However, several previous RCTs have suggested that class-based interventions are as effective as individualised interventions. Therefore, it is important to examine whether an individualised intervention, such as CFT, demonstrates clinical effectiveness compared to a relatively cheaper exercise and education class. The current study will compare the clinical effectiveness of individualised CFT with a combined exercise and pain education class in people with NSCLBP.

METHODS AND ANALYSIS

This study is a multicentre RCT. 214 participants, aged 18-75 years, with NSCLBP for at least 6 months will be randomised to one of two interventions across three sites. The experimental group will receive individualised CFT and the length of the intervention will be varied in a pragmatic manner based on the clinical progression of participants. The control group will attend six classes which will be provided over a period of 6-8 weeks. Participants will be assessed preintervention, postintervention and after 6 and 12 months. The primary outcomes will be functional disability and pain intensity. Non-specific predictors, moderators and mediators of outcome will also be analysed.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Mayo General Hospital Research Ethics Committee (MGH-14-UL). Outcomes will be disseminated through publication according to the SPIRIT statement and will be presented at scientific conferences.

TRIAL REGISTRATION NUMBER

(ClinicalTrials.gov NCT02145728).

Can we convert between outcome measures of disability for chronic low back pain?

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

A range of patient-reported outcomes were used to measure disability due to low back pain. There is not a single back pain disability measurement commonly used in all randomized controlled trials. We report here our assessment as to whether different disability measures are sufficiently comparable to allow data pooling across trials.

SUMMARY OF BACKGROUND DATA

We used individual patient data from a repository of data from back pain trials of therapist-delivered interventions.

METHODS

We used data from 11 trials (n=6089 patients) that had at least 2 of the following 7 measurements: Roland-Morris Disability Questionnaire, Chronic Pain Grade disability score, Physical Component Summary of the 12- or 36-Item Short Form Health Survey, Patient Specific Functional Scale, Pain Disability Index, Oswestry Disability Index, and Hannover Functional Ability Questionnaire. Within each trial, the change score between baseline and short-term follow-up was computed for each outcome and this was used to calculate the correlation between the change scores and the Cohen's κ for the 3-level outcome of change score of less than, equal to, and more than zero. It was considered feasible to pool 2 measures if they were at least moderately correlated (correlation>0.5) and have at least moderately similar responsiveness (κ>0.4).

RESULTS

Although all pairs of measures were found to be positively correlated, most correlations were less than 0.5, with only 1 pair of outcomes in 1 trial having a correlation of more than 0.6. All κ statistics were less than 0.4 so that in no cases were the criteria for acceptability of pooling measures satisfied.

CONCLUSION

The lack of agreement between different outcome measures means that pooling of data on these different disability measurements in a meta-analysis is not recommended.

LEVEL OF EVIDENCE

2.

Context effects and behaviour change techniques in randomised trials: a systematic review using the example of trials to increase adherence to physical activity in musculoskeletal pain

OBJECTIVE

To describe and explore the effects of contextual and behaviour change technique (BCT) content of control and target interventions in clinical trials.

DESIGN

Review and meta-analysis of 42 trials from a Cochrane review of physical activity in chronic musculoskeletal pain.

MAIN OUTCOME MEASURES

Two researchers coded descriptions of target and control interventions for (a) 93 BCTs and (b) whether target and control interventions shared each of five contextual features (practitioners' characteristics, patient-practitioner relationship, intervention credibility, superficial treatment characteristics e.g. delivery modality, and environment). Quality of study reporting was assessed. Effect sizes for adherence to physical activity and class attendance were computed (Cohen's d) and analysed separately.

RESULTS

For physical activity outcomes, after controlling for reporting quality, larger effect sizes were associated with target and control interventions using different modalities (β = -.34, p = .030), target and control interventions involving equivalent patient-practitioner relationship (β = .40, p = .002), and target interventions having more unique BCTs (i.e. more BCTs not also in the control) (β = .008, p = .030). There were no significant effect moderators for class attendance outcomes.

CONCLUSION

Contents of control conditions can influence effect sizes and should be considered carefully in trial design and systematic reviews.

A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder

BACKGROUND

There is little evidence for the optimal form of nonoperative treatment in the management of frozen shoulder. This study assesses the efficacy of current physiotherapy strategies.

METHODS

All primary care referrals of frozen shoulder to our physiotherapy department were included during a 12-month period. Of these referrals, 17% met the inclusion criteria for primary idiopathic frozen shoulder. The 75 patients were randomly assigned to 1 of 3 groups: group exercise class, individual physiotherapy, and home exercises alone. A single independent physiotherapist, who was blinded to the treatment groups, made all assessments. Range of motion, Constant score, Oxford Shoulder Score, Short Form 36, and Hospital Anxiety and Disability Scale (HADS) outcome measures were performed at baseline, 6 weeks, 6 months, and 1 year.

RESULTS

The exercise class group improved from a mean Constant score of 39.8 at baseline to 71.4 at 6 weeks and 88.1 at 1 year. There was a significant improvement in shoulder symptoms on Oxford and Constant scores (P < .001). This improvement was greater than with individual physiotherapy or home exercises alone (P < .001). The improvement in range of motion was significantly greater in both physiotherapy groups over home exercises (P < .001). HADS scores significantly improved during the course of treatment (P < .001). The improvement in HADS anxiety score was significantly greater in both physiotherapy intervention groups than in home exercises alone.

CONCLUSIONS

A hospital-based exercise class can produce a rapid recovery from a frozen shoulder with a minimum number of visits to the hospital and is more effective than individual physiotherapy or a home exercise program.

Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To evaluate the quality, conduct, and reporting of subgroup analyses performed in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain (NSLBP).

SUMMARY OF BACKGROUND DATA

Randomized controlled trials of therapist-delivered interventions for NSLBP to date have, at best, shown small to moderate positive effects. Identifying subgroups is an important research priority. This review evaluates the quality, conduct, and reporting of subgroup analyses performed in the NSLBP literature.

METHODS

Multiple electronic databases were searched for randomized controlled trials of therapist-delivered interventions for NSLBP. Of the identified articles, only articles reporting subgroup analyses (confirmatory or exploratory) were included in the final review. Methodological criteria were used to evaluate the quality of subgroup analyses. The quality of conduct and reporting was also evaluated.

RESULTS

Thirty-nine articles were included in the final review. Of these, only 3 (8%) tested hypotheses about moderators (confirmatory findings), 18 (46%) generated hypotheses about moderators to inform future research (exploratory findings), and 18 (46%) provided insufficient findings. The appropriate statistical test for interaction was performed in 27 of the articles, of which 10 reported results from interaction tests, 4 incorrectly reported results within individual subgroups, and the remaining articles reported either P values or nothing at all.

CONCLUSION

Subgroup analyses performed in NSLBP trials have been severely underpowered, are only able to provide exploratory or insufficient findings, and have rather poor quality of reporting. Using current approaches, few definitive trials of subgrouping in back pain are very likely to be performed. There is a need to develop new approaches to subgroup identification in back pain research.

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

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

Reducing waiting time for community rehabilitation services: a controlled before-and-after trial

OBJECTIVE

To investigate whether a simple alternative (specific timely appointments for triage [STAT]) to the more common approach of managing demand using a waitlist with a triage system could reduce waiting time for a community rehabilitation program (CRP) without adverse impacts on patient care.

DESIGN

A prospective, controlled before-and-after trial. Preintervention and postintervention data were collected for 6 months in 2 consecutive years. STAT was introduced at an intervention site and compared with a control site using a triaged waitlist.

SETTING

Two musculoskeletal CRP teams within a large metropolitan health service.

PARTICIPANTS

All patients referred to both sites during periods preintervention (n=483) and postintervention (n=488).

INTERVENTION

Under STAT, clinicians created a specified number of assessment times each week based on average referral numbers, and patients were immediately allocated an appointment on referral.

MAIN OUTCOME MEASURES

The primary outcome was the time from referral to first appointment; secondary outcomes included program duration, quality-of-life scores (using the EuroQol EQ-5D), and unplanned hospital admissions.

RESULTS

Waiting time decreased from a mean of 17.5 days to 10.0 days (P<.01) at the intervention site, with no significant change at the control site. Intervention site patients were over 3 times more likely to be seen within 7 days than control site patients (odds ratio, 3.3; 95% confidence interval, 2.2-4.9). Secondary outcomes did not differ significantly between groups.

CONCLUSIONS

A simple alternative to using a triaged waitlist to manage CRP referrals reduced waiting time without adversely affecting care. Results were sustained over 6 months with no additional resources.

The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review

BACKGROUND

The effectiveness of multidisciplinary treatment for post-acute (>6 weeks) low back pain (LBP) has been established. Physiotherapists have sufficient training to conduct less intensive functional restoration. The effectiveness of physiotherapy functional restoration (PFR) has not been evaluated using current systematic review methodology.

OBJECTIVES

To determine the effects of PFR for post-acute LBP.

DATA SOURCES

Electronic databases searched include: MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro and Cochrane CENTRAL. TRIAL ELIGIBILITY CRITERIA: Randomised controlled trials of physiotherapy treatment for post-acute LBP combining exercise and cognitive-behavioural intervention compared with other intervention, no intervention or placebo. TRIAL APPRAISAL AND SYNTHESIS METHODS: Two authors independently extracted data. Risk of bias was assessed using the PEDro scale and overall quality of the body of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Treatment effect sizes and 95% confidence intervals were calculated for pain, function and sick leave.

RESULTS

Sixteen trials were included. Heterogeneity prevented meta-analysis for most comparisons. Meta-analyses showed moderate to high quality evidence of significant but small effects favouring PFR compared with advice for intermediate term function and intermediate and long term pain. There was however low to moderate quality evidence that PFR was no more effective than a range of other treatment types. Heterogeneous trials frequently contributed to very low quality evidence.

CONCLUSIONS

Moderate to high quality evidence was found of small effects favouring PFR compared with advice. Preliminary evidence suggested PFR is not different to other treatment types. Further high quality research is required replicating existing trial protocols.

The access randomized clinical trial of public versus private physiotherapy for low back pain

STUDY DESIGN

Pragmatic randomized clinical trial.

OBJECTIVE

This study investigated differences in the clinical outcomes of public physiotherapy (public PT) versus private physiotherapy (private PT) for general practitioner-referred patients with acute and chronic low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Health care setting (i.e., public or private) has been found to influence the course and clinical outcome of common diseases. Despite the international burden of LBP, the effect of health care setting on clinical outcomes has not been investigated in this population.

METHODS

One hundred sixty consenting patients, who were referred for physiotherapy for LBP by their general practitioner, completed the Roland Morris Disability Questionnaire (primary outcome), Short-Form 36 v2, Fear Avoidance Beliefs Questionnaire, Back Beliefs Questionnaire, EuroQol EQ5D, and Patient Satisfaction Questionnaires. The patients were stratified (acute LBP: ≤ 3 months, n = 55; chronic LBP: > 3 months, n = 105), randomly allocated to receive public PT (n = 3 hospitals) or private PT (n = 12 clinics), and followed up at 3, 6, and 12 months postrandomization.

RESULTS

Repeated measures analysis of variance showed significant improvement over time for 9 predominantly biomedical outcomes: (i) Roland Morris Disability Questionnaire at 3 and 6 months, (ii) Short-Form 36 v2 Physical Component Score, Bodily Pain, Role Physical, General Health, Vitality, EQ5D visual analogue scale, and weighted health index scores at 3 months, and (iii) the Back Beliefs Questionnaire at 6 months. The remaining 7 biopsychosocial outcomes showed no change over time, and the "between within" repeated measures analysis of variance showed no significant differences between groups over time for any outcome measures (P > 0.05). Independent samples t tests found no significant differences between groups in the mean changes in outcome measures from baseline at 12 months, apart from SF-36 v2 Role Physical (mean difference, 95% CI = 5.64 [0.860-10.428]; t = 2.337; P = 0.021) in favor of the private PT group. There were significantly higher levels of satisfaction with outcome of treatment in the private PT group (median [IQR]: public PT: 5.0 [2.0]; private PT: 6.0 [2.0]; Mann-Whitney U test = 1324.50; P = 0.020), but no differences in satisfaction with treatment or global perceived improvement (P > 0.05). The private PT group had a significantly shorter waiting time (mean difference = 39.79 days; 95% CI: 26.88-52.69; t = 6.121; P < 0.001) and treatment duration (mean difference: 23.48 days; 95% CI: 7.43-39.52; t = 2.909; P = 0.005) than public PT. Participants in both groups were treated with advice/education, manipulative therapy, and exercise therapy, with minimal use of cognitive behavioral approaches in either group. Physiotherapists in the private PT group had significantly more experience and more postgraduate qualifications than the public PT group (P < 0.005).

CONCLUSION

Despite differences between public and private PT regarding waiting times for treatment and therapist experience, there were no significant differences between groups in the majority of clinical outcome measure scores at follow-up, apart from SF-36 Role Physical and satisfaction with treatment outcome in favor of the private PT group.

Physiotherapy-provided operant conditioning in the management of low back pain disability: A systematic review

BACKGROUND AND PURPOSE

 Non-specific low back pain (LBP) is a leading cause of disability in developed countries. Behavioural interventions have been found efficacious in reducing disability in LBP. Operant conditioning is one type of behavioural intervention being employed by physiotherapists; however, the effectiveness of physiotherapist-provided operant conditioning (POC) in the management of LBP disability is unknown. This review aims to answer the question: is POC more effective than comparison interventions in reducing LBP disability? 

METHOD

 A systematic review of randomized controlled trials was conducted using a qualitative analysis of effect. Participants were adults ≥18 years with non-specific LBP. The intervention was defined as a time contingent, graduated increase in activity including goal setting and the education and reinforcement of positive pain behaviours with the aim of decreasing disability. The primary outcome measure was back pain specific disability. Secondary outcomes included generic functional status, pain intensity, sick leave, fear avoidance beliefs or behaviour and adverse effects. 

RESULTS

 Fifteen trials involving 3737 people were included. Eight studies reported a clinically significant difference. The POC intervention was not found to be inferior to any of the comparison interventions in reducing disability. Moderate evidence was found that POC is more effective than other behavioural interventions in reducing long term disability in chronic LBP. Moderate evidence showed POC may be more effective than other treatments in reducing post-treatment fear avoidance beliefs in a sub-acute population but less effective in reducing short term fear avoidance beliefs in a population with mixed LBP. Moderate evidence showed POC is more effective than a placebo intervention in reducing short term pain in sub-acute LBP. 

CONCLUSION

 POC may be considered efficacious in the treatment of LBP. Physiotherapists may also consider POC for its additional effect of reducing long term disability in chronic LBP.

Assessing the impact of attrition in randomized controlled trials

OBJECTIVES

A survey of randomized controlled trials found that almost a quarter of trials had more than 10% of responses missing for the primary outcome. There are a number of ways in which data could be missing: the subject is unable to provide it, or they withdraw, or become lost to follow-up. Such attrition means that balance in baseline characteristics for those randomized may not be maintained in the subsample who has outcome data. For individual trials, if the attrition is systematic and linked to outcome, then this will result in biased estimates of the overall effect. It then follows that if such trials are combined in a meta-analysis, it will result in a biased estimate of the overall effect and be misleading. The aim of this study was to investigate the impact of attrition on baseline imbalance within individual trials and across multiple trials.

STUDY DESIGN AND SETTING

In this article, we used individual patient data from a convenience sample of 10 trials evaluating interventions for the treatment of musculoskeletal disorders. Meta-analyses using the mean difference at baseline between the trial arms were carried out using individual patient data from these trials. The analyses were first carried out using all randomized participants and secondly only including participants with outcome data on the quality-of-life score. Meta-regression was carried out to evaluate whether the level of baseline imbalance was associated with the level of attrition.

RESULTS

The overall attrition rates for the quality-of-life score ranged between 4% and 28% of the total randomized patients. All trials showed some level of differential attrition between the treatment arms, ranging from 1% to 14%. Attrition within the control group ranged from 3% to 25% and within the intervention group, it ranged from 0% to 31%. For individual trials, there was no indication that attrition altered the results in favor of either the treatment or the control. Forest plots highlighted that the attrition had some impact on the baseline imbalance for the primary outcome score as more heterogeneity was introduced (I-squared value of 0.4% for the initial data set vs. I-squared value of 16.9% for the analyzed data set). However, the standardized mean difference increased only slightly (from 0.01 to 0.03 with 95% confidence interval [CI]: -0.05, 0.10). Meta-regression showed little or no evidence of a significant dose-response relationship between the level of attrition and the baseline imbalance (coefficient 0.73, 95% CI: -0.81, 2.28).

CONCLUSION

Although, in theory, attrition can introduce selection bias in randomized trials, we did not find sufficient evidence to support this claim in our convenience sample of trials. However, the number of trials included was relatively small, which may have led to small but important differences in outcomes being missed. In addition, only 2 of 10 trials included had attrition levels greater than 15% suggesting a low level of potential bias. Meta-analyses and systematic reviews should always consider the impact of attrition on baseline imbalances and where possible any baseline imbalances in the analyzed data set and their impact on the outcomes reported.

Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults

BACKGROUND

Chronic musculoskeletal pain (CMP) is a major health problem, accounting for approximately one-quarter of general practice (GP) consultations in the United Kingdom (UK). Exercise and physical activity is beneficial for the most common types of CMP, such as back and knee pain. However, poor adherence to exercise and physical activity may limit long-term effectiveness.

OBJECTIVES

To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain.

SEARCH STRATEGY

We searched the trials registers of relevant Cochrane Review Groups. In addition, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Science Citation Index and Social Science Citation Index and reference lists of articles to October 2007. We consulted experts for unpublished trials.

SELECTION CRITERIA

Randomised or quasi-randomised trials evaluating interventions that aimed to improve adherence to exercise and physical activity in adults with pain for three months and over in the axial skeleton or large peripheral joints.

DATA COLLECTION AND ANALYSIS

Two of the four authors independently assessed the quality of each included trial and extracted data. We contacted study authors for missing information.

MAIN RESULTS

We included 42 trials with 8243 participants, mainly with osteoarthritis and spinal pain. Methods used for improving and measuring adherence in the included trials were inconsistent. Two of the 17 trials that compared different types of exercise showed positive effects, suggesting that the type of exercise is not an important factor in improving exercise adherence. Six trials studied different methods of delivering exercise, such as supervising exercise sessions, refresher sessions and audio or videotapes of the exercises to take home. Of these, five trials found interventions improved exercise adherence. Four trials evaluated specific interventions targeting exercise adherence; three of these showed a positive effect on exercise adherence. In eight trials studying self-management programmes, six improved adherence measures. One trial found graded activity was more effective than usual care for improving exercise adherence. Cognitive behavioural therapy was effective in a trial in people with whiplash-associated disorder, but not in trials of people with other CMP. In the trials that showed a positive effect on adherence, association between clinical outcomes and exercise adherence was conflicting.

AUTHORS' CONCLUSIONS

Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence. However, high-quality, randomised trials with long-term follow up that explicitly address adherence to exercises and physical activity are needed. A standard validated measure of exercise adherence should be used consistently in future studies.

Cost-effectiveness of interventions based on physical exercise in the treatment of various diseases: A systematic literature review

Objectives:The aim of this study was to review studies reporting cost-effectiveness of exercise-based interventions in treatment of various diseases.

Methods:Systematic literature search using several databases. Abstracts initially screened independently by two authors, full-text articles again evaluated by two authors, who decided whether an article should be included. Included were scientifically valid articles describing controlled studies that included an exercise-based intervention in the treatment of an established medical condition, and also reported on the cost-effectiveness of the intervention, or its effect on the utilization of health services. Quality was assessed with an established approach.

Results:A total of 914 articles were identified, of them 151 were obtained for closer review. Sixty-five articles describing sixty-one studies were included. Most (82 percent) were randomized trials. Twenty-eight studies dealt with musculoskeletal disorders, fifteen with cardiology, four with rheumatic diseases, four with pulmonary diseases, three with urinary incontinence, and two with vascular disorders. There was one study each in the fields of oncology, chronic fatigue, endocrinology, psychiatry, and neurology. Exercise interventions in musculoskeletal disorders were deemed to be cost-effective in 54 percent, in cardiology in 60 percent, and in rheumatic diseases in 75 percent of the cases. There was some evidence that exercise might be cost-effective in intermittent claudication, breast cancer patients, diabetes, and schizophrenia.

Conclusions:The number of studies assessing cost-effectiveness of exercise interventions in various diseases is still limited. The results show large variation but suggest that some exercise interventions can be cost-effective. Most convincing evidence was found for rehabilitation of cardiac and back pain patients; however, even in these cases, the evidence was partly contradictory.

Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice

OBJECTIVE

To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake.

DESIGN

Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes.

SETTING

Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel.

PARTICIPANTS

A consecutive sample of 22,019 adult patients (mean age 51.2 y, standard deviation=15.7, range 18-96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status at discharge.

RESULTS

Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs.

CONCLUSIONS

The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice.

Assessment of the quality of cost analysis literature in physical therapy

BACKGROUND

Policy makers, payers, and other stakeholders increasingly call for greater evidence of the cost-effectiveness of health care interventions.

OBJECTIVE

The purposes of this study were to identify and rate the quality of cost analysis literature in physical therapy and to report summary information on the findings from the reviewed studies.

DESIGN

This study was a targeted literature review and rating of relevant studies published in the last decade using a quality evaluation tool for economic studies.

MEASUREMENTS

The Quality of Health Economic Studies (QHES) instrument was used to obtain quality scores.

RESULTS

Ninety-five in-scope studies were identified and rated using the QHES instrument. The average quality score was 82.2 (SD=15.8), and 81 of the studies received a score of 70 or higher, placing them in the "good" to "excellent" quality range. Investigators in nearly two thirds of the studies found the physical therapy intervention under investigation to be cost-effective.

LIMITATIONS

The small number of studies meeting the inclusion criteria was a limitation of the study.

CONCLUSIONS

The quality of the literature regarding the cost-effectiveness of physical therapy is very good, although the magnitude of this body of literature is small. Greater awareness of the strengths and limitations of cost analyses in physical therapy should provide guidance for conducting high-quality cost-effectiveness studies as demand increases for demonstrations of the value of physical therapy.

A walking programme and a supervised exercise class versus usual physiotherapy for chronic low back pain: a single-blinded randomised controlled trial. (The Supervised Walking In comparison to Fitness Training for Back Pain (SWIFT) Trial)

BACKGROUND

Chronic low back pain (CLBP) is a persistent disabling condition with rising significant healthcare, social and economic costs. Current research supports the use of exercise-based treatment approaches that encourage people with CLBP to assume a physically active role in their recovery. While international clinical guidelines and systematic reviews for CLBP support supervised group exercise as an attractive first-line option for treating large numbers of CLBP patients at low cost, barriers to their delivery include space and time restrictions in healthcare settings and poor patient attendance. The European Clinical Guidelines have identified the need for research in the use of brief/minimal contact self-activation interventions that encourage participation in physical activity for CLBP. Walking may be an ideally suited form of individualized exercise prescription as it is easy to do, requires no special skills or facilities, and is achievable by virtually all ages with little risk of injury, but its effectiveness for LBP is unproven.

METHODS AND DESIGN

This study will be an assessor-blinded randomized controlled trial that will investigate the difference in clinical effectiveness and costs of an individualized walking programme and a supervised general exercise programme compared to usual physiotherapy, which will act as the control group, in people with chronic low back pain. A sample of 246 patients will be recruited in Dublin, Ireland through acute general hospital outpatient physiotherapy departments that provide treatment for people with CLBP. Patients will be randomly allocated to one of the three groups in a concealed manner. The main outcomes will be functional disability, pain, quality of life, fear avoidance, back beliefs, physical activity, satisfaction and costs, which will be evaluated at baseline, and 3, 6 and 12 months [follow-up by pre-paid postage]. Qualitative telephone interviews and focus groups will be embedded in the research design to obtain feedback about participants' experiences of the interventions and trial participation, and to inform interpretation of the quantitative data. Planned analysis will be by intention to treat (quantitative data) and thematic analysis (qualitative data)

DISCUSSION

The trial will evaluate the effectiveness of a walking programme and a supervised general exercise programme compared to usual physiotherapy in people with CLBP.

TRIAL REGISTRATION

Current controlled trial ISRCTN17592092.

Research priorities for non-pharmacological therapies for common musculoskeletal problems: nationally and internationally agreed recommendations

BACKGROUND

Musculoskeletal problems such as low back pain, neck, knee and shoulder pain are leading causes of disability and activity limitation in adults and are most frequently managed within primary care. There is a clear trend towards large, high quality trials testing the effectiveness of common non-pharmacological interventions for these conditions showing, at best, small to moderate benefits. This paper summarises the main lessons learnt from recent trials of the effectiveness of non-pharmacological therapies for common musculoskeletal conditions in primary care and provides agreed research priorities for future clinical trials.

METHODS

Consensus development using nominal group techniques through national (UK) and international workshops. During a national Clinical Trials Thinktank workshop in April 2007 in the UK, a group of 30 senior researchers experienced in clinical trials for musculoskeletal conditions and 2 patient representatives debated the possible explanations for the findings of recent high quality trials of non-pharmacological interventions. Using the qualitative method of nominal group technique, these experts developed and ranked a set of priorities for future research, guided by the evidence from recent trials of treatments for common musculoskeletal problems. The recommendations from the national workshop were presented and further ranked at an international symposium (hosted in Canada) in June 2007.

RESULTS

22 recommended research priorities were developed, of which 12 reached consensus as priorities for future research from the UK workshop. The 12 recommendations were reduced to 7 agreed priorities at the international symposium. These were: to increase the focus on implementation (research into practice); to develop national musculoskeletal research networks in which large trials can be sited and smaller trials supported; to use more innovative trial designs such as those based on stepped care and subgrouping for targeted treatment models; to routinely incorporate health economic analysis into future trials; to include more patient-centred outcome measures; to develop a core set of outcomes for new trials of interventions for musculoskeletal problems; and to focus on studies that advance methodological approaches for clinical trials in this field.

CONCLUSION

A set of research priorities for future trials of non-pharmacological therapies for common musculoskeletal conditions has been developed and agreed through national (UK) and international consensus processes. These priorities provide useful direction for researchers and research funders alike and impetus for improvement in the quality and methodology of clinical trials in this field.

Physiotherapy for low back pain: Differences between public and private healthcare sectors in Ireland—A retrospective survey

OBJECTIVES

European clinical guidelines for low back pain (LBP) recommend early referral of appropriate patients to health services such as physiotherapy. The current study aimed to investigate any differences between the physiotherapy management of LBP, and the physiotherapist and patient profiles in public and private health settings in Ireland.

DESIGN

A retrospective chart survey of all LBP patients referred for physiotherapy to one Dublin City hospital and three neighbouring private practices in 2003 was conducted.

RESULTS

In total, 249 physiotherapy charts (hospital [H] n=93; private practice [Pr] n=156) were identified and demographic, LBP, and management details analysed. Only charts containing full LBP duration and physiotherapy treatment data were included in the analysis of these parameters (LBP duration: H=84, Pr=130; physiotherapy treatment: H=79, Pr=155). There were significantly higher percentages of female (H=66%; Pr=50%: p=0.017), older (H=46 years; Pr=36 years: p<0.001), and chronic LBP patients (>12 weeks; H=50%; Pr=2%: p<0.001) in the public setting. Public patients had significantly longer waiting times for physiotherapy (median H=10 weeks; Pr=0; p<0.001), and more treatment (H=5.1; Pr=2.5: p0.001) than private patients. While treatment approaches were similar for both settings, there was a significantly higher use of advice and spinal stabilisation exercises in the public setting. However, there was minimal difference in the management of acute or chronic LBP in both setting suggesting poor adherence to European guidelines.

CONCLUSIONS

Findings showed longer waiting times, and a higher number and duration of physiotherapy treatments for acute and chronic LBP in the public setting suggesting the need to develop publicly funded primary healthcare in Ireland.

Chronic non-specific low back pain - sub-groups or a single mechanism?

BACKGROUND

Low back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches.

DISCUSSION

Many clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient. An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention.

SUMMARY

The disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed.

Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial

STUDY DESIGN

A randomized controlled trial.

OBJECTIVES

To determine 1) whether, among patients with persistent disabling low back pain (LBP), a group program of exercise and education using a cognitive behavioral therapy (CBT) approach, reduces pain and disability over a subsequent 12-month period; 2) the cost-effectiveness of the intervention; and 3) whether a priori preference for type of treatment influences outcome.

SUMMARY OF BACKGROUND DATA

There is evidence that both exercise and CBT delivered in specialist settings is effective in improving LBP. There is a lack of evidence on whether such interventions, delivered by trained individuals in primary care, result in improved outcomes.

METHODS

The study was conducted in nine family medical practices in East Cheshire, UK. Patients 18 to 65 years of age, consulting with LBP, were recruited; those still reporting LBP 3 months after the initial consultation were randomized between the two trial arms. The intervention arm received a program of eight 2-hour group exercise session over 6 weeks comprising active exercise and education delivered by physiotherapists using a CBT approach. Both arms received an educational booklet and audio-cassette. The primary outcome measures were pain (0-100 Visual Analogue Scale) and disability (Roland and Morris Disability Scale; score 0-24).

RESULTS

A total of 196 subjects (84%) completed follow-up 12 months after the completion of the intervention program. The intervention showed only a small and nonsignificant effect at reducing pain (-3.6 mm; 95% confidence interval, -8.5, 1.2 mm) and disability (-0.6 score; 95% confidence interval, -1.6, 0.4). The cost of the intervention was low with an incremental cost-effectiveness ratio of pound5000 (U.S. $8650) per quality adjusted life year. In addition, patients allocated to the intervention that had expressed a preference for it had clinically important reductions in pain and disability.

CONCLUSIONS

This intervention program produces only modest effects in reducing LBP and disability over a 1-year period. The observation that patient preference for treatment influences outcome warrants further investigation.

Use of groups in pediatric physical therapy: survey of current practices

PURPOSE

This nationwide survey study aimed to examine the use of groups in pediatric physical therapy, including characteristics, effectiveness, and financial considerations of group intervention.

METHODS

Questionnaires were mailed to 500 randomly selected members of the American Physical Therapy Association Section on Pediatrics. Respondents reported on the characteristics of children typically included in group intervention, types of activities used, effectiveness at meeting goals, billing methods, and documentation practices.

RESULTS AND CONCLUSIONS

The response rate was 285 (57%). Only 41.4% of respondents reported using groups. Characteristics of group intervention were variable among respondents, and considerable differences in billing practices and perceived effectiveness were noted. Commonly reported characteristics included use of small groups of young children with developmental delay and use of task specific developmental activities. Perceived benefits and limitations of group intervention were also reported. Implications for further research into the use of groups were explored.

The role of physiotherapy in the management of non-specific back pain and neck pain

This paper provides an overview of best practice for the role of physiotherapy in managing back pain and neck pain, based mainly on evidence-based guidelines and systematic reviews. More up-to-date relevant primary research is also highlighted. A stepped approach is recommended in which the physiotherapist initially takes a history and carries out a physical examination to exclude any potentially serious pathology and identify any particular functional deficits. Initially, advice providing simple messages of explanation and reassurance will form the basis of a patient education package. Self-management is emphasized throughout. A return to normal activities is encouraged. For the patient who is not recovering after a few weeks, a short course of physiotherapy may be offered. This should be based on an active management approach, such as exercise therapy. Manual therapy should also be considered. Any passive treatment should only be used if required to relieve pain and assist in helping patients get moving. Barriers to recovery need to be explored. Those few patients who have persistent pain and disability that interferes with their daily lives and work need more intensive treatment or a different approach. A multidisciplinary approach may then be optimal, although it is not widely available. Liaison with the workplace and/or social services may be important. Getting all players on side is crucial, especially at this stage.