Video-Game-Based Exercises for Older People With Chronic Low Back Pain: A Randomized Controlledtable Trial (GAMEBACK)

How do non-specific back pain patients think about their adherence to physiotherapy, and what strategies do physiotherapists use to facilitate adherence? A focus group interview study

BACKGROUND

Long-term effectiveness of physiotherapy (PT) for low back pain (LBP) depends on the adherence of patients. Objectives: (1) Identify aspects associated with the adherence of patients with LBP to physiotherapy, and (2) identify factors to facilitate adherence of patients with LBP to PT.

METHOD

Focus group interviews were conducted with 10 patients with LBP (n = 10, 5 women) and 11 physiotherapists (5 women) from Germany and Switzerland, treating patients with LBP. Data analysis was based on structured content analysis. Deductive and inductive categories were identified and coded.

RESULTS

Patients with LBP requested more and effective home programs, long-term rehabilitation management, and individualized therapy to achieve a higher level of adherence. Physiotherapists requested more time for patient education. Communication, quality of the therapist-patient relationship, and individualized therapy were identified as essential factors by both representatives.

CONCLUSION

Patients and physiotherapists identified aspects contributing to adherence. These may guide the development of multidimensional measurement tools for adherence. In addition, this information can be used to develop PT approaches to facilitate the level of adherence.

The effect of self-management techniques on relevant outcomes in chronic low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Among many treatment approaches for chronic low back pain (CLBP), self-management techniques are becoming increasingly important. The aim of this paper was to (a) provide an overview of existing digital self-help interventions for CLBP and (b) examine the effect of these interventions in reducing pain intensity, pain catastrophizing and pain disability.

DATABASES AND DATA TREATMENT

Following the PRISMA guideline, a systematic literature search was conducted in the MEDLINE, EMBASE, PsychInfo, CINAHL and Cochrane databases. We included randomized controlled trials from the last 10 years that examined the impact of digital self-management interventions on at least one of the three outcomes in adult patients with CLBP (duration ≥3 months). The meta-analysis was based on random-effects models. Standardized tools were used to assess the risk of bias (RoB) for each study and the quality of evidence for each outcome.

RESULTS

We included 12 studies (n = 1545). A small but robust and statistically significant pooled effect was found on pain intensity (g = 0.24; 95% CI [0.09, 0.40], k = 12) and pain disability (g = 0.43; 95% CI [0.27, 0.59], k = 11). The effect on pain catastrophizing was not significant (g = 0.38; 95% CI [-0.31, 1.06], k = 4). The overall effect size including all three outcomes was g = 0.33 (95% CI [0.21, 0.44], k = 27). The RoB of the included studies was mixed. The quality of evidence was moderate or high.

CONCLUSION

In summary, we were able to substantiate recent evidence that digital self-management interventions are effective in the treatment of CLBP. Given the heterogeneity of interventions, further research should aim to investigate which patients benefit most from which approach.

SIGNIFICANCE

This meta-analysis examines the effect of digital self-management techniques in patients with CLBP. The results add to the evidence that digital interventions can help patients reduce their pain intensity and disability. A minority of studies point towards the possibility that digital interventions can reduce pain catastrophizing. Future research should further explore which patients benefit most from these kinds of interventions.

Efficacy of serious games for chronic pain management in older adults: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To synthesise and appraise the evidence of the efficacy of serious games in reducing chronic pain among older adults.

BACKGROUND

Chronic pain in older adults generally results in a substantial handicap due to decreased mobility, exercise avoidance and various concerns that affect their overall quality of life. While serious games have been widely used as a pain management approach, no reviews have thoroughly examined their efficacy for chronic pain management in older adult populations.

DESIGN

A systematic review and meta-analysis.

METHODS

The CINAHL, the Cochrane Library, Embase, Medline, PubMed and Web of Science databases were comprehensively searched to find articles published from their inception until 17 April 2023. RoB-2 was used to assess the risk of bias in the included studies. The efficacy of serious games for pain management in older individuals was investigated using pooled standardised mean differences (SMDs) in pain reduction using a random effect model.

RESULTS

The meta-analysis comprised nine randomised controlled trials that included 350 older adult patients with pain. Serious games effectively alleviated pain in this group (pooled SMD = -0.62; 95% confidence interval: -1.15 to -0.10), although pain-related disability and fear require further investigation.

CONCLUSIONS

Serious games tended to effectively reduce pain in this older adult group; however, due to a lack of randomised controlled trials, the analysis found lower effectiveness in reducing pain-related disability and fear. Further studies are accordingly required to confirm these findings.

RELEVANCE TO CLINICAL PRACTICE

The findings of the study emphasise the importance of serious games to increase the motivation of older adults to exercise as one of the safe and extensively used pain management strategies. Serious games that effectively reduce chronic pain in older adults are characterised as consisting of diverse physical activities delivered through consoles, computer-based activities and other technologies.

PATIENT OR PUBLIC CONTRIBUTIONS

Serious games are recommended as being potentially useful and practical for reducing pain in older adults.

Virtual Reality-Based Training in Chronic Low Back Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Low back pain is one of the most prevalent pain conditions worldwide. Virtual reality-based training has been used for low back pain as a new treatment strategy. Present evidence indicated that the effectiveness of virtual reality-based training for people with chronic low back pain is inconclusive.

OBJECTIVE

This study conducted a meta-analysis to evaluate the immediate- and short-term effects of virtual reality-based training on pain, pain-related fear, and disability in people with chronic low back pain.

METHODS

We searched the PubMed, Embase, Web of Science, PEDro, CENTRAL, and CINAHL databases from inception until January 2024. Only randomized controlled trials assessing the effects of virtual reality-based training on individuals with chronic low back pain were selected. The outcomes were focused on pain, pain-related fear measured by the Tampa Scale of Kinesiophobia, and disability measured by the Oswestry Disability Index. The immediate term was defined as the immediate period after intervention, and the short term was defined as 3 to 6 months after intervention. The Cochrane Risk of Bias tool and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach were used to evaluate the quality of the methodology and evidence, respectively.

RESULTS

In total, 20 randomized controlled trials involving 1059 patients were eligible for analysis. Virtual reality-based training showed significant improvements in pain (mean difference [MD] -1.43; 95% CI -1.86 to -1.00; I2=95%; P<.001), pain-related fear using the Tampa Scale of Kinesiophobia (MD -5.46; 95% CI -9.40 to 1.52; I2=90%; P=.007), and disability using the Oswestry Disability Index (MD -11.50; 95% CI -20.00 to -3.01; I2=95%; P=.008) in individuals with chronic low back pain immediately after interventions. However, there were no significant differences observed in pain (P=.16), pain-related fear (P=.10), and disability (P=.43) in the short term.

CONCLUSIONS

These findings indicated that virtual reality-based training can be used effectively for individuals with chronic low back pain in the immediate term, especially to reduce pain, alleviate pain-related fear, and improve disability. However, the short-term benefits need more high-quality trials to be demonstrated.

TRIAL REGISTRATION

PROSPERO CRD42021292633; http://tinyurl.com/25mydxpz.

Virtual reality is effective in the management of chronic low back ache in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chronic low back ache (CLBA) is a common condition that is conventionally managed with physical therapy and analgesics. Recently, virtual reality-based interventions have been tried out in the management of CLBA. Their effectiveness, however has not been established. This meta-analysis aims to find out if the application of VR will lead to better pain relief, as compared to conventional techniques in adults with CLBA.

METHODS

The literature search was carried out in three online databases for potential randomized controlled trials that compared VR-based interventions with conventional treatment in CLBA. Data on outcome parameters were recorded. Meta-analysis was carried out with the help of appropriate software.

RESULTS

Seven studies having data on 507 subjects were included in the meta-analysis. Their mean ages were 48.4 years. There were 252 subjects in the VR group and 255 in the control group. VR-based interventions were found to have a statistically significant improvement in the pain intensity compared with conventional techniques (p - 0.005).

CONCLUSION

VR-based interventions are effective in the management of CLBA in the short term. Further research with longer follow-up is required to evaluate if these improvements are persistent in the long term.

Home-based exercise interventions delivered by technology in older adults: A scoping review of technological tools usage

BACKGROUND

Despite technology-based systems being considered promising tools to stimulate and increase physical function at home, most older adults are unfamiliar with technology, which may pose some difficulties. Technology-related parameters, such as adherence, acceptance, and acceptability, are crucial to achieving higher efficacy levels of home-based exercise interventions delivered by technology. In this scoping review, we aimed to revise the use of home-based technological tools to improve physical function in the older population, focusing on the user's experience and perspective. Methods This scoping review was conducted following PRISMA guidelines. The search was conducted in April 2022 and updated in April 2023. A total of 45 studies were included in the review. Results Most studies (95.5%) met the technology usage levels defined by the research team or reported satisfactory technology usage levels. Positive health-related outcomes were reported in 80% of studies. Although the existence of guidelines to correctly define and use measures associated with technology use, including adherence, acceptance and acceptability, some terms are still being used interchangeably. Some concerns related to the lack of an international consensus regarding technology usage measures and the exclusion of older adults who did not own or have previous experience with technology in a large percentage of the included studies may have limited the results obtained. Conclusions Altogether, home-based exercise interventions delivered through technology were associated with positive health-related outcomes in older adults, and technology usage levels are considered satisfactory. Older adults are willing and able to use technology autonomously if adequate support is provided.

The effects of virtual reality training on postural sway and physical function performance on older women with chronic low back pain: A double-blind randomized clinical trial

BACKGROUND

Chronic low back pain (CLBP) is known as an important debilitating health condition among older women.

OBJECTIVE

This study aimed to evaluate the effects of eight-week virtual reality training (VRT) exercises on postural sway and physical function performance (PFP) among older women suffering from CLBP.

METHODS

Twenty-seven older women presenting with CLBP were randomized into experimental and control groups. The experimental group was instructed to perform 30-minute VRT exercises three times a week for eight weeks. Plantar pressure variables [sway velocity (SV) and anterior-posterior (AP) and medial-lateral (ML) fluctuations of the center of pressure (CoP)], 30-second chair stand test (30CST), and timed up and go (TUG) test were recorded.

RESULTS

The VRT group exhibited significant decreases in SV (p= 0.002), AP (p= 0.008), and ML (p= 0.02) fluctuations. Also, the performance of the VRT group in the 30CST and TUG tests significantly improved after the exercises (P< 0.001).

CONCLUSION

According to the results, VRT and the program used in this study should be used to enhance balance and PFP in older women with CLBP who mostly prefer activities that are accessible and feasible in low-risk environments.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured Exercise Programs for Chronic Primary Low Back Pain in Adults

PURPOSE

Evaluate benefits and harms of structured exercise programs for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.

METHODS

We searched for randomized controlled trials (RCTs) in electronic databases (inception to 17 May 2022). Eligible RCTs targeted structured exercise programs compared to placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of exercise could be isolated). We extracted outcomes, appraised risk of bias, conducted meta-analyses where appropriate, and assessed certainty of evidence using GRADE.

RESULTS

We screened 2503 records (after initial screening through Cochrane RCT Classifier and Cochrane Crowd) and 398 full text RCTs. Thirteen RCTs rated with overall low or unclear risk of bias were synthesized. Assessing individual exercise types (predominantly very low certainty evidence), pain reduction was associated with aerobic exercise and Pilates vs. no intervention, and motor control exercise vs. sham. Improved function was associated with mixed exercise vs. usual care, and Pilates vs. no intervention. Temporary increased minor pain was associated with mixed exercise vs. no intervention, and yoga vs. usual care. Little to no difference was found for other comparisons and outcomes. When pooling exercise types, exercise vs. no intervention probably reduces pain in adults (8 RCTs, SMD = - 0.33, 95% CI - 0.58 to - 0.08) and functional limitations in adults and older adults (8 RCTs, SMD = - 0.31, 95% CI - 0.57 to - 0.05) (moderate certainty evidence).

CONCLUSIONS

With moderate certainty, structured exercise programs probably reduce pain and functional limitations in adults and older people with CPLBP.

Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis

Purpose

Chronic low back pain (CLBP) is an aging and public health issue that is a leading cause of disability worldwide and has a significant economic impact on a global scale. Treatments for CLBP are varied, and there is currently no study with high-quality evidence to show which treatment works best. Exercise therapy has the characteristics of minor harm, low cost, and convenient implementation. It has become a mainstream treatment method in clinics for chronic low back pain. However, there is insufficient evidence on which specific exercise regimen is more effective for chronic non-specific low back pain. This network meta-analysis aimed to evaluate the effects of different exercise therapies on chronic low back pain and provide a reference for exercise regimens in CLBP patients.

Methods

We searched PubMed, EMBASE, Cochrane Library, and Web of Science from inception to 10 May 2022. Inclusion and exclusion criteria were used for selection. We collected information from studies to compare the effects of 20 exercise interventions on patients with chronic low back pain.

Results

This study included 75 randomized controlled trials (RCTs) with 5,254 participants. Network meta-analysis results showed that tai chi [standardized mean difference (SMD), -2.11; 95% CI, -3.62 to -0.61], yoga (SMD, -1.76; 95% CI -2.72 to -0.81), Pilates exercise (SMD, -1.52; 95% CI, -2.68, to -0.36), and sling exercise (SMD, -1.19; 95% CI, -2.07 to -0.30) showed a better pain improvement than conventional rehabilitation. Tai chi (SMD, -2.42; 95% CI, -3.81 to -1.03) and yoga (SMD, -2.07; 95% CI, -2.80 to -1.34) showed a better pain improvement than no intervention provided. Yoga (SMD, -1.72; 95% CI, -2.91 to -0.53) and core or stabilization exercises (SMD, -1.04; 95% CI, -1.80 to -0.28) showed a better physical function improvement than conventional rehabilitation. Yoga (SMD, -1.81; 95% CI, -2.78 to -0.83) and core or stabilization exercises (SMD, -1.13; 95% CI, -1.66 to -0.59) showed a better physical function improvement than no intervention provided.

Conclusion

Compared with conventional rehabilitation and no intervention provided, tai chi, toga, Pilates exercise, sling exercise, motor control exercise, and core or stabilization exercises significantly improved CLBP in patients. Compared with conventional rehabilitation and no intervention provided, yoga and core or stabilization exercises were statistically significant in improving physical function in patients with CLBP. Due to the limitations of the quality and quantity of the included studies, it is difficult to make a definitive recommendation before more large-scale and high-quality RCTs are conducted.

Effects of exercise/physical activity on fear of movement in people with spine-related pain: a systematic review

Background

Kinesiophobia (i.e., fear of movement) can be an important contributor for ongoing pain and disability in people with spine-related pain. It remains unclear whether physical activity interventions/exercise influence kinesiophobia in this population. A systematic review was therefore conducted to synthesize the available evidence on whether physical activity interventions/exercise influence kinesiophobia in people with chronic non-specific spine-related pain.

Methods

The study protocol was registered prospectively with PROSPERO (CRD42021295755). The following databases were systematically searched from inception to 31 January 2022 and updated on 22 June 2023: PubMed, MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, ZETOC, PROSPERO and Google Scholar. Inclusion criteria were randomized or non-randomized controlled studies investigating adults aged ≥18 years, reporting the effect of exercise or physical activity on kinesiophobia in individuals with chronic non-specific spine-related pain. Two reviewers independently extracted data and assessed the quality of the included studies. Bias was assessed using the Cochrane ROB2 tool and evidence certainty via Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

Seventeen studies from seven countries involving a total of 1,354 individuals were selected for inclusion. The majority of studies (n = 13) involved participants with chronic low back pain (LBP), and Pilates was the most common form of exercise evaluated. Most of the studies reported a positive direction of effect in favor of exercise reducing kinesiophobia when compared to a control group. There was moderate to high risk of bias among the studies and the overall certainty of the evidence was very low.

Conclusion

This review supports the use of exercise for reducing kinesiophobia in people with chronic LBP albeit with very low certainty of evidence; Pilates (especially equipment-based) was shown to be effective as were strengthening training programmes. There was limited evidence available on the effects of exercise on kinesiophobia for people with chronic neck or thoracic pain and further research is required.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295755.

Which aspects facilitate the adherence of patients with low back pain to physiotherapy? A Delphi study

BACKGROUND

The effectiveness of physiotherapy to reduce low back pain depends on patient adherence to treatment. Facilitators and barriers to patient adherence are multifactorial and include patient and therapist-related factors. This Delphi study aimed to identify an expert consensus on aspects facilitating the adherence of patients with back pain to physiotherapy.

METHOD

International experts were invited to participate in a three-round standard Delphi survey. The survey contained 49 items (32 original and 17 suggested by experts) which were rated on 5-point Likert scales. The items were assigned to six domains. The consensus level was defined as 60%.

RESULTS

Of 38 invited experts, 15 followed the invitation and completed all three rounds. A positive consensus was reached on 62% of the 49 proposed items to facilitate adherence. The highest consensus was achieved in the domains "Influence of biopsychosocial factors" (89%) and "Influence of cooperation between physiotherapists and patients" (79%). Additional important domains were the "Influence of competencies of physiotherapists" (71%) and "Interdisciplinary congruence" (78%). "Administration aspects" and the "Use of digital tools" did not reach expert consensus.

CONCLUSIONS

Biopsychosocial factors, therapeutic skills, and patient-physiotherapist collaboration should be considered in physiotherapy practice to facilitate adherence in patients with LBP. Future studies should prospectively evaluate the effectiveness of individual or combined identified aspects for their influence on patient adherence in longitudinal study designs.

Strategies to facilitate and tools to measure non-specific low back pain patients' adherence to physiotherapy - A two-stage systematic review

BACKGROUND

Sustainable management for non-specific low back pain relies on adherence. This requires effective strategies to facilitate but also tools to measure adherence to physiotherapy.

OBJECTIVE

This two-stage systematic review aims to identify (1) tools to measure non-specific back pain patients' adherence to physiotherapy and (2) the most effective strategy to facilitate patients' adherence to physiotherapy.

METHOD

PubMed, Cochrane, PEDro, and Web of Science were searched for English language studies measuring adherence in adults with low back pain. Following PRISMA recommendations, scoping review methods were used to identify measurement tools (stage 1). The effectiveness of interventions (stage 2), followed a predefined systematic search strategy. Two independent reviewers selected eligible studies (software Rayyan), analyzed these for risk of bias using the Downs and Black checklist. Data relevant to assess adherence were collected in a predesigned data extraction table. Results were heterogeneous and hence summarized narratively.

RESULTS

Twenty-one studies were included for stage 1 and 16 for stage 2. Identified were 6 different tools to measure adherence. The most used tool was an exercise diary; the most common more multidimensional tool was the Sports Injury Rehabilitation Adherence Scale. Most included studies were not designed to improve or measure adherence but used adherence as a secondary outcome for new exercise programs. The most promising strategies for facilitating adherence were based on cognitive behavioral principles.

CONCLUSION

Future studies should focus on the development of multidimensional strategies to facilitate adherence to physiotherapy and appropriate tools to measure all aspects of adherence.

Commercial exergames for rehabilitation of physical health and quality of life: a systematic review of randomized controlled trials with adults in unsupervised home environments

Background

Commercial exergames are widely available tools that can support physical rehabilitation at home. However, the effects of the unsupervised use of commercial exergames in home environments are not yet clear. Hence, we provide a systematic review on the effects of unsupervised commercial exergaming at home on adults' physical health (RQ1) and quality of life (RQ2). We also scrutinize adults' experiences with exergaming at home regarding participant support, adherence, and adverse outcomes (RQ3).

Methods

We searched Web of Science, PsycINFO, PubMed, Embase, and CINAHL for peer-reviewed randomized controlled trials with adults in need of rehabilitation. Overall, 20 studies (1,558 participants, 1,368 analyzed) met our inclusion criteria. The quality of evidence was assessed with the Cochrane risk of bias tool.

Results

Effects of unsupervised commercial exergaming at home on physical health were higher in seven studies and similar in five studies regarding the respective comparison or control conditions; eight studies reported non-significant findings. Of the 15 studies that also examined effects on quality of life, improvements were higher in seven studies and similar in two studies regarding the respective comparison or control conditions; results were non-significant in six studies. Participant support consisted of setup of the exergaming system, instructions, training, and contact with participants. Adherence was high in eight studies, moderate in six studies, and low in one study. Adverse outcomes related to exergaming were found in four studies and were at most moderate. Concerning the quality of evidence, six studies were related to a high risk of bias due to outcome reporting bias or ceiling effects in the primary outcome. Additionally, 10 studies yielded some concerns, and four studies were related to a low risk of bias.

Discussion

This systematic review summarizes promising evidence that the unsupervised use of commercial exergames can support and complement rehabilitation measures in home environments. Still, future studies based on larger samples and using more recent commercial exergames are needed to obtain more high-quality evidence on the effects of different exercise prescriptions. Overall, considering the necessary precautions, the unsupervised use of commercial exergames at home can improve the physical health and quality of life in adults with needs for physical rehabilitation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022341189, identifier: PROSPERO, Registration number: CRD42022341189.

Patient Adherence With At-Home Hand and Wrist Exercises: A Randomized Controlled Trial of Video Versus Handout Format

BACKGROUND

Patient adherence is important for maximizing patient outcomes. The purpose of this randomized controlled trial was to determine patient adherence and confidence in home therapy exercises of the hand and wrist at multiple time points when distributed by either paper handout or video.

METHODS

Patients were prospectively enrolled and randomized in orthopedic clinics to either the handout or video exercise group. Exclusion criteria included patients less than 18 years old. Questionnaires were electronically distributed each week for 4 weeks following enrollment. Questionnaires assessed the frequency of exercise performance, percentage of exercises utilized, and confidence in performing the exercises correctly. The handout and video groups were compared via 2-sample t tests for continuous data and χ2 tests for categorical data.

RESULTS

Of the 89 patients enrolled, 71 patients responded to the initial follow-up survey (80% of randomized patients), and 54 of these patients (76%) completed all surveys at each time point. The handout group (37 patients) and the video group (34 patients) had no differences in response rate or demographics. There were no differences in frequency, exercise utilization rate, or confidence in performing exercises between groups at week 1. However, the video group reported higher exercise utilization and confidence than the handout group at subsequent time points.

CONCLUSIONS

Video-format distribution of home therapy exercises is superior to that of paper handout distribution for the distal upper extremity rehabilitation. Patients in the video group utilized more exercises and had higher confidence in completing them correctly following initiation of the exercise program.

Digital self-care in the management of spine musculoskeletal disorders: A systematic review and meta-analysis

to analyze the effectiveness of digital self-care in the management of pain and functional disability among people with spine musculoskeletal disorders. a systematic literature review, developed with the PRISMA checklist, of randomized clinical trials of people with spine musculoskeletal disorders and digital interventions accessed by means of computers, smartphones or other portable devices. Databases researched: National Library of Medicine, Excerpta Médica dataBASE, SciVerse Scopus, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Science Citation Indexes, Cumulative Index to Nursing and Allied Health Literature and Physiotherapy Evidence Database. The descriptive synthesis of the results and by means of meta-analyses (fixed-effects model) was performed with the Review Manager software. The methodological quality was evaluated with the Physiotherapy Evidence Database scale. a total of 25 trials were selected (5,142 participants), which showed statistically significant improvements (p <0.05) in 54% (12/22) in the pain levels and 47% (10/21) in functional disability in the Intervention Group. The meta-analyses showed moderate effects on pain intensity and small effects on functional disability. There was a predominance of medium quality studies. the digital care interventions showed a beneficial result in pain intensity and in functional disability, mainly for chronic low back pain. Digital care emerges as promising to support self-management of the spine musculoskeletal conditions. PROSPERO registry number CRD42021282102.

Effects of Exergaming on Musculoskeletal Pain in Older Adults: Systematic Review and Meta-analysis

BACKGROUND

Exercise is effective for musculoskeletal pain. However, physical, social, and environmental factors make it difficult for older adults to persist in exercising. Exergaming is a new pathway that combines exercise with gameplay and may be helpful for older adults to overcome these difficulties and engage in regular exercise.

OBJECTIVE

This systematic review aimed to determine the efficacy of exergaming to improve musculoskeletal pain in older adults.

METHODS

The search was performed in 5 databases (PubMed, Embase, CINAHL, Web of Science, and Cochrane Library). The risk of bias for randomized controlled studies was assessed using the revised Cochrane Risk of Bias tool in randomized trials (RoB 2), and the methodological quality was assessed using the Physiotherapy Evidence-Based Database scale. Standardized mean difference and 95% CI were calculated using fixed-effects model meta-analyses in the Review Manager version 5.3 (RevMan 5.3).

RESULTS

Seven randomized controlled studies were included, which contained 264 older adults. Three of the 7 studies reported significant improvements in pain after the exergaming intervention, but only 1 reported a significant difference between groups after adjustment for baseline (P<.05), and another reported a significant improvement in thermal pain between the 2 groups (P<.001). The results of the meta-analysis of the 7 studies showed no statistically significant improvement in pain compared to the control group (standardized mean difference -0.22; 95% CI -0.47 to 0.02; P=.07).

CONCLUSIONS

Although the effects of exergames on musculoskeletal pain in older adults are unknown, exergame training is generally safe, fun, and appealing to older adults. Unsupervised exercise at home is feasible and cost-effective. However, most of the current studies have used commercial exergames, and it is recommended that there should be more cooperation between industries in the future to develop professional rehabilitation exergames that are more suitable for older adults. The sample sizes of the studies included are small, the risk of bias is high, and the results should be interpreted with caution. Further randomized controlled studies with large sample sizes, high quality, and rigor are needed in the future.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022342325; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342325.

Effects of Resistance Training on Pain Control and Physical Function in Older Adults With Low Back Pain: A Systematic Review With Meta-analysis

BACKGROUND AND PURPOSE

Low back pain (LBP) has a high prevalence in older adults and is associated with elevated health care costs. This systematic review and meta-analysis examines the effects of progressive resistance training (PRT) interventions on physical function (PF) and pain control in community-dwelling older adults with chronic LBP.

METHODS

A meta-analysis applying the quality effect method was performed by calculating the effect sizes (ESs) using the Cohen d with a 95% CI. A subgroup analysis was performed according to the participant and intervention characteristics. The statistical significance of differences between subgroups was calculated using a Z-test. Study bias was estimated using the version 2 of the Cochrane risk of bias tool for randomized trials (RoB 2.0) and quality of evidence (Qi) index. Small study effect/publication bias was estimated using the Doi plot and Luis Furuya-Kanamori (LFK) index. The systematic search was conducted in major databases for clinical trials published between January 1, 1990, and January 9, 2021. The inclusion criteria were articles that (1) were peer-reviewed; (2) had participants' mean age of more than 60 years; (3) studied PRT interventions; (4) had participants with LBP; (5) measured LBP or PF outcomes; (6) measured PF in terms of functionality; (7) were randomized controlled trials; (8) and non-randomized controlled trials. The exclusion criteria were (1) articles not written in English, (2) nonexperimental studies, and (3) repeated publications.

RESULTS AND DISCUSSION

Twenty-one studies were included (n = 1661). Clear improvements were found in PF (ES = 0.32 [95% CI, 0.05-0.58]; I2 = 75.1%; P < .001), but results on LBP decrease were inconclusive (ES = 0.24 [95% CI, -0.05 to 1.10]; I2 = 75.7%; P < .001). The overall evidence of this aggregated data meta-analysis of clinical trials is level C+. Main limitations are the use of aggregated data and the large heterogeneity between studies.

CONCLUSIONS

The Qi of this meta-analysis is level I (C+). We concluded that PRT interventions are useful for PF improvement in older adults with generalized LBP, LBP not arising from lumbar spinal stenosis, and having body mass index less than 27. In older adults with LBP not arising from lumbar spine stenosis, PRT interventions also decrease LBP. Interventions should have a frequency of at least 3 sessions per week. In addition, at a lower level of evidence IV (C+), we recommend that interventions with a duration of more than 12 weeks should be considered, whenever possible.

A Systematic Review and Meta-Analysis of the Effectiveness of Virtual Reality-Based Rehabilitation Therapy on Reducing the Degree of Pain Experienced by Individuals with Low Back Pain

BACKGROUND

The concept of virtual reality (VR)-based rehabilitation therapy for treating people with low back pain is of growing research interest. However, the effectiveness of such therapy for pain reduction in clinical settings remains controversial.

METHODS

The present study was conducted according to the reporting guidelines presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We searched the PubMed, Embase, CENTRAL, and ProQuest databases for both published and unpublished papers. The Cochrane risk of bias tool (version 2) was used to evaluate the quality of the selected studies. GRADEprofiler software (version 3.6.4) was used to evaluate the level of evidence. We analyzed the included research results using RevMan software (version 5.4.1).

RESULTS

We included a total of 11 articles in the systematic review and meta-analysis, with a total of 1761 subjects. Having assessed the quality of these studies, the risk of bias was generally low with high heterogeneity. The results revealed a small to medium effect (standardized mean difference = ±0.37, 95% confidence interval: 0.75 to 0) based on evidence of moderate overall quality.

CONCLUSION

There is evidence that treatment using VR improves patients' pain. The effect size was small to medium, with the studies presenting evidence of moderate overall quality. VR-based treatment can reduce pain; therefore, it may help in rehabilitation therapy.

The Effects of Interactive Virtual Reality in Patients with Chronic Musculoskeletal Disorders: A Systematic Review and Meta-Analysis

Objective: Interactive virtual reality (iVR) has been widely used for treatment purposes in patients with chronic musculoskeletal disorders. However, no consensus has been reached on the effects of iVR on pain, psychological distress, and functional disability. Therefore, this study aims to investigate the effects of iVR on pain, psychological distress, and functional disability in patients with chronic musculoskeletal disorders compared with no rehabilitation and conventional rehabilitation. Methods: Five electronic databases (PubMed, Cochrane CENTRAL, Scopus, EMBASE, and Web of Science) were searched from January 2016 to December 2021. All randomized controlled trials using iVR for treating pain, psychological distress, and functional disability in patients with chronic musculoskeletal disorders were included. A subgroup analysis was conducted to compare the effects of nonimmersive and immersive types of iVR on the outcomes of interest. Results: Our study provides good quality evidence that iVR reduced overall pain by 9.28 points as compared with no rehabilitation and by 8.09 points as compared with conventional rehabilitation. In the subgroup analysis, nonimmersive iVR showed a reduction in psychological distress (standardized mean differences = -0.35) as compared with no rehabilitation. However, no statistically significant difference in the outcomes existed between nonimmersive and immersive iVR. Furthermore, there were no statistically significant differences in the outcomes of functional disability. Conclusions: iVR is recommended for reducing pain intensity more than no rehabilitation or conventional rehabilitation. Meanwhile, nonimmersive iVR has been proposed for psychological distress improvement, with effects similar to those of conventional rehabilitation. However, iVR may not be an effective intervention in the case of functional disability.

Acute effects of game-based biofeedback training on trunk motion in chronic low back pain: a randomized cross-over pilot trial

Background

Improving movement control might be a promising treatment goal during chronic non-specific low back pain (CLBP) rehabilitation. The objective of the study is to evaluate the effect of a single bout of game-based real-time feedback intervention on trunk movement in patients with CLBP.

Methods

Thirteen CLBP patients (8female;41 ± 16 years;173 ± 10 cm;78 ± 22 kg) were included in this randomized cross-over pilot trial. During one laboratory session (2 h), participants performed three identical measurements on trunk movement all including: first, maximum angle of lateral flexion was assessed. Secondly, a target trunk lateral flexion (angle: 20°) was performed. Main outcome was maximum angle ([°]; MA). Secondary outcomes were deviation [°] from the target angle (angle reproduction; AR) and MA of the secondary movement planes (rotation; extension/flexion) during lateral flexion. The outcomes were assessed by an optical 3D-motion-capture-system (2-segment-trunk-model). The measurements were separated by 12-min of intervention and/or resting (randomly). The intervention involved a sensor-based trunk exergame (guiding an avatar through virtual worlds). After carryover effect-analysis, pre-to-post intervention data were pooled between the two sequences followed by analyses of variances (paired t-test).

Results

No significant change from pre to post intervention for MA or AR for any segment occurred for the main movement plane, lateral flexion (p > .05). The upper trunk segment showed a significant decrease of the MA for trunk extension/flexion from pre to post intervention ((4.4° ± 4.4° (95% CI 7.06–1.75)/3.5° ± 1.29° (95% CI 6.22–0.80); p = 0.02, d = 0.20).

Conclusions

A single bout of game-based real-time feedback intervention lead to changes in the secondary movement planes indicating reduced evasive motion during trunk movement.

Trial registration No. DRKS00029765 (date of registration 27.07.2022). Retrospectively registered in the German Clinical Trial Register.

Movement characteristics during customized exergames after total knee replacement in older adults

Introduction

There is limited understanding of how older adults can reach kinematic goals in rehabilitation while performing exergames and conventional exercises, and how similar or different the kinematics during exergaming are when compared with conventional therapeutic exercise with similar movement. The aim of this study was to describe the movement characteristics performed during exercise in custom-designed exergames and conventional therapeutic exercises among patients who have undergone unilateral total knee replacement (TKR). In addition, the secondary aim was to assess the relation of these exercise methods, and to assess participants' perceived exertion and knee pain during exergaming and exercising.

Materials and methods

Patients up to 4 months after the TKR surgery were invited in a single-visit exercise laboratory session. A 2D motion analysis and force plates were employed to evaluate movement characteristics as the volume, range, and intensity of movement performed during custom-designed knee extension-flexion and weight shifting exergames and conventional therapeutic exercises post TKR. The perceived exertion and knee pain were assessed using the Borg Rating of Perceived Exertion and Visual Analog Scale, respectively.

Results

Evaluation of seven patients with TKR [age median (IQR), 65 (10) years] revealed that the volume and intensity of movement were mostly higher during exergames. Individual goniometer-measured knee range of motion were achieved either with exergames and conventional therapeutic exercises, especially in knee extension exercises. The perceived exertion and knee pain were similar after exergames and conventional therapeutic exercises.

Conclusions

During custom-designed exergaming the patients with TKR achieve the movement characteristics appropriate for post-TKR rehabilitation without increasing the stress and pain experienced even though the movement characteristics might be partly different from conventional therapeutic exercises by the volume and intensity of movement. Physical therapists could consider implementing such exergames in rehabilitation practice for patients with TKR once effectiveness have been approved and they are widely available.

Effect of virtual reality technology as intervention for people with kinesiophobia: A meta-analysis of randomised controlled trials

AIMS AND OBJECTIVE

To explore the effectiveness of Virtual Reality Technology in reducing kinesiophobia in people.

BACKGROUND

Kinesiophobia is an important psychosocial factor affecting the pain experience and has a significant negative impact on rehabilitation. Virtual reality technology has been widely used in the treatment of phobias, mental disorders and anxiety disorders. However, the effect of virtual reality technology on people with kinesiophobia has been reported with inconsistent results.

DESIGN

A meta-analysis of randomised controlled trials.

METHODS

This study systematically searched PubMed, Web of Science, PsycINFO, CINAHL, Embase, Cochrane Library, Medline, Scopus and four Chinese databases. The standardised mean difference (SMD) was calculated using random-effects models, and the Cochrane Collaboration's tool was used to assess the risk of bias in each study. The PRISMA 2020 checklist provided by the EQUATOR network was used.

RESULTS

Eleven randomised controlled trials involving a total of 488 subjects were included. Meta-analysis showed the effect sizes of virtual reality intervention on kinesiophobia (SMD = -0.53, 95% CI [-0.90, -0.17], p = .004). Virtual reality intervention was more effective in reducing kinesiophobia in people with chronic low back pain (SMD = -1.00, 95% CI [-1.71, -0.29], p = .006). Compared with fully immersive virtual reality (SMD = -0.29, 95% CI [-0.62, 0.05], p = 0.09), non-immersive virtual reality was more effective in reducing kinesiophobia (SMD = -0.66, 95% CI [-1.24, -0.09], p = 0.02). Compared with virtual reality intervention alone (SMD = -0.35, 95% CI [-1.40, 0.71], p = 0.52), virtual reality combined with exercise was more effective in reducing kinesiophobia (SMD = -0.59, 95% CI [-0.95, -0.22], p = 0.002).

CONCLUSIONS

Virtual reality technology has the potential to reduce the degree of kinesiophobia in people. In addition, virtual reality technology was more effective in people with chronic low back pain; non-immersive virtual reality was more effective in reducing kinesiophobia; and virtual reality technology combined with exercise was more effective in reducing kinesiophobia than virtual reality intervention alone. Clinical nursing staff should be encouraged to use virtual reality to speed up patient recovery. However, to achieve immersion and apply this technology to different diseases, more studies are required to provide clearer suggestions.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that healthcare staff should pay attention to kinesiophobia, and early identification and intervention of kinesiophobia can help patients recover their health and improve the quality of nursing.

Feedback on Trunk Movements From an Electronic Game to Improve Postural Balance in People With Nonspecific Low Back Pain: Pilot Randomized Controlled Trial

Background

Postural balance is compromised in people with low back pain, possibly by changes in motor control of the trunk. Augmenting exercising interventions with sensor-based feedback on trunk posture and movements might improve postural balance in people with low back pain.

Objective

We hypothesized that exercising with feedback on trunk movements reduces sway in anterior-posterior direction during quiet standing in people with low back pain. Secondary outcomes were lumbar spine and hip movement assessed during box lift and waiter bow tasks, as well as participant-reported outcomes. Adherence to the exercising intervention was also examined.

Methods

A randomized controlled trial was conducted with the intervention group receiving unsupervised home exercises with visual feedback using the Valedo Home, an exergame based on 2 inertial measurement units. The control group received no intervention. Outcomes were recorded by blinded staff during 4 visits (T1-T4) at University Hospital Zurich. The intervention group performed 9 sessions of 20 minutes in the 3 weeks between T2 and T3 and were instructed to exercise at their own convenience between T3 and T4. Postural balance was assessed on a force platform. Lumbar spine and hip angles were obtained from 3 inertial measurement units. The assessments included pain intensity, disability, quality of life, and fear of movement questionnaires.

Results

A total of 32 participants with nonspecific low back pain completed the first assessment T1, and 27 (84%) participants were randomized at T2 (n=14, 52% control and n=13, 48% intervention). Intention-to-treat analysis revealed no significant difference in change in anterior-posterior sway direction during the intervention period with a specified schedule (T2-T3) between the groups (W=99; P=.36; r=0.07). None of the outcomes showed significant change in accordance with our hypotheses. The intervention group completed a median of 61% (55/90; range 2%-99%) of the exercises in the predefined training program. Adherence was higher in the first intervention period with a specified schedule.

Conclusions

The intervention had no significant effect on postural balance or other outcomes, but the wide range of adherence and a limited sample size challenged the robustness of these conclusions. Future work should increase focus on improving adherence to digital interventions.

Trial Registration

ClinicalTrials.gov NCT04364243; https://clinicaltrials.gov/ct2/show/NCT04364243

International Registered Report Identifier (IRRID)

RR2-10.2196/26982

The ESCAPE trial for older people with chronic low back pain: Protocol of a randomized controlled trial

Background

Low-back pain is one of the most common health conditions worldwide. It is defined as pain below the costal margin and above the inferior gluteal folds. Current guidelines recommend management of chronic health (e.g., low back pain) conditions in older people at primary health care settings using active strategies (e.g., exercise). In non-specific low back pain, high quality evidence supports active strategies for general population. However, the management of non-specific low back pain in the older people has been overlooked and evidence is limited to a small number of low powered randomized controlled trials with high risk of bias.

Methods

This is a prospectively registered, open, two-arm randomised controlled trial comparing the group-based exercise and waiting list in pain intensity (11-item Pain Numerical Rating Scale) and disability (Roland Morris questionnaire) of older people (i.e., 60 years old or over) with chronic non-specific low back pain. One hundred and twenty patients will be recruited from Diamantina, Brazil. Follow-ups will be conducted in post-treatment (8 week) and 6- and 12-months post-randomisation.

Discussion

Our hypothesis is that group-based exercise will be better than waiting list in reducing pain intensity and disability in older people with chronic non-specific low back pain.

Impact

The practice of individualized exercise has been studied for the management of chronic non-specific low back pain in older people. However, the group exercise, even showing high quality evidence for the improvement of several important outcomes in this population, has been ignored until now. Thus, the results of this study have the potential to indicate a viable and accessible strategy for managing chronic non-specific low back pain in the older people.

Trial registration

The study was prospectively registered at www.ensaiosclinicos.gov.br (RBR-9j5pqs). Date-11/18/2020.

Effects of Gaming on Pain-Related Fear, Pain Catastrophizing, Anxiety, and Depression in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

The aim was to systematically review the effects of gaming on pain-related fear, pain catastrophizing, anxiety, and depression in patients with chronic musculoskeletal pain. Databases (Medline, EMBASE, PsycInfo, CINAHL, Cochrane Central Register for Controlled Trials [CENTRAL], Web of Science, and SCOPUS) were searched from inception up to October 2021. Two reviewers independently selected randomized controlled trials that compared the effects of any gaming modality with other interventions or no treatment on pain-related fear, pain catastrophizing, anxiety, and depression. For data synthesis, Standardized Mean Differences (SMDs) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model for meta-analysis according to the outcome of interest, comparison group, and follow-up period. The level of evidence was synthesized using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Thirteen studies were included with a total sample of 680 patients. Gaming was superior to other treatments and no treatment on reducing pain-related fear (SMD: -1.23; 95% CI: -2.02 to -0.44) and anxiety (SMD: -0.55; 95% CI: -1.01 to -0.09), respectively. Gaming was not superior to other treatments on reducing pain catastrophizing, anxiety, and depression, and it was not superior to no treatment on reducing pain-related fear, pain catastrophizing, and depression. Those findings were based on very low or low-quality evidence. In a conclusion, gaming modalities may have positive effects on some mental health outcomes. However, there were conflicting results with low-quality evidence, which indicates that more high-quality randomized controlled trials are needed.

Virtual Reality Assisted Non-Pharmacological Treatments in Chronic Pain Management: A Systematic Review and Quantitative Meta-Analysis

Virtual reality (VR) is a developing technology that has recently attracted the attention of healthcare practitioners. Recently, VR systems have been used to treat pain symptoms. The present study aims to evaluate the VR effectiveness on chronic pain management. A systematic literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords were used to discover the potentially eligible studies. The primary focus of the present investigation was to evaluate the possible effect of VR-assisted treatments on chronic pain, especially in the commonly occurring low back and neck pain. Nine studies reporting randomized controlled trials were included in the present study. VR-mediated interventions demonstrated significant improvement for pain symptoms in patients experiencing chronic pain. In addition, VR-mediated therapy decreased pain intensity and disability in the case of chronic neck pain compared to control conditions. However, the VR interventions showed a statistically non-significant improvement in chronic low back pain when experimental groups were compared with controls. VR therapy positive effect on chronic pain did not differ from the one reported for other types of interventions for pain management, as physical exercise and laser therapy. Taken together, these findings showed that currently available lines of evidence on the effect of VR-mediated therapy in chronic pain management, despite pointing towards possible therapeutical benefits of the VR-based intervention, are overall inconclusive and that more research on VR-assisted therapy for chronic pain is needed.

Is Telerehabilitation a Viable Option for People With Low Back Pain? Associations Between Telerehabilitation and Outcomes During the COVID-19 Pandemic

OBJECTIVE

The aims of this study were to examine associations between frequency of telerehabilitation (TR) and outcomes of functional status (FS), number of visits, and patient satisfaction during COVID-19 and to compare FS outcomes by TR delivery mode for individuals with low back pain.

METHODS

Propensity score matching was used to match episodes of care with or without TR exposure by the probability of receiving TR. FS, visits, and satisfaction were compared for individuals without TR and those who received care by TR for "any," "few," "most," or "all" frequencies (4 matched samples), and FS was compared for individuals receiving synchronous, asynchronous, and mixed TR modes (3 matched samples). Standardized differences were used to compare samples before and after matching. Outcomes between matched samples were compared using z tests with 95% CI.

RESULTS

The sample consisted of 91,117 episodes of care from 1398 clinics located in 46 states (58% women; mean age = 55 [SD = 18]). Of those, only 5013 episodes (5.5%) involved any amount of TR. All standardized differences between matched samples were <0.1. There was no significant difference in FS points (range = 0-100, with higher representing better FS) between matched samples, except for episodes that had ``few'' (-1.7) and ``all'' (+2.0) TR frequencies or that involved the asynchronous (-2.6) TR mode. These point differences suggest limited clinical importance. Episodes with any TR frequency involved significantly fewer visits (0.7-1.3) than episodes with no TR, except that those with the "most" TR frequency had non-significantly fewer visits (0.6). A smaller proportion of individuals with TR (-4.0% to -5.0%) than of individuals with no telerehabilitation reported being very satisfied with treatment results, except for those with the "all" TR frequency.

CONCLUSIONS

A positive association between TR and rehabilitation outcomes was observed, with a trend for better FS outcomes and fewer visits when all care was delivered through TR. Satisfaction tended to be lower with TR use. Overall, this observational study showed that for people with low back pain, physical therapy delivered through TR was equally effective as and more efficient than in-person care, with a trend of higher effectiveness when used for all visits during the episode of care. No differences in FS outcomes were observed between care delivered with synchronous and mixed TR delivery modes and care delivered with no TR. However, the asynchronous mode of TR was associated with worse functional outcomes than no TR. Although the majority of people were very satisfied with their treatment results with and without TR, very high satisfaction rates were reported by a slightly smaller proportion of individuals with TR versus those without TR. Our results suggest that TR is a viable option for rehabilitation care for individuals with low back pain and should also be considered in the post-COVID-19 era.

A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With Chronic Neck Pain: Development, Suitability, and Crossover Pilot Study

Background

There is sparse research on the effectiveness of therapeutic exercise for the treatment of neck pain in older adult populations. Moreover, there is a lack of research on the use of serious games or virtual reality for the treatment of neck pain in this population.

Objective

The primary aim of this study was to develop and assess the suitability of a serious game for performing task-oriented cervical exercises in patients with neck pain.

Methods

A serious game was designed based on the key features identified by previous studies that designed serious video games for physical and cognitive rehabilitation or exercise. The game in this study was designed to provide an interactive scenario, with the main functionality of the software solution to control a virtual airplane to reach targets using head motions. At the end of the exercise, the application stores the targets reached and missed and the airplane’s trajectory. A crossover pilot study was carried out for preliminary evaluation of the suitability of the technology in the older adult population. Men and women over 65 years of age with chronic neck pain were included. Subjects were randomly assigned to two study arms; each arm consisted of a sequence of two 4-week treatments with an intermediate washout period of 4 weeks. The total study duration was 16 weeks due to a final follow-up measure 4 weeks after the end of all treatments. Treatment A consisted of the use of the serious game developed in this study, and treatment B consisted of conventional exercises. Subjects allocated to the A-B study arm received treatment A first, followed by treatment B, and vice versa in the B-A arm. The following variables were assessed: Suitability Evaluation Questionnaire (SEQ) scores, Visual Analog Scale scores, and the number of targets reached in the serious game.

Results

A total of 18 subjects were assessed for eligibility. A total of 13 subjects, aged between 71 and 92 years (mean 81.85, SD 6.82), were finally included and completed the study protocol. The global mean SEQ score was 50.38 (SD 5.35) out of 65 points, showing good suitability of the serious game. Most patients considered the experience very enjoyable and “real” in terms of the virtual environment and found the information provided to be clear. Also, they believed that the game could be very helpful for their rehabilitation. None of the patients felt any neck pain or discomfort when playing the game, and only 2 patients out of 13 (15%) reported some degree of dizziness, eye discomfort, or disorientation, which did not limit their capacity to finish the session.

Conclusions

The serious game developed in this study showed good suitability for use in adults over 70 years of age with chronic neck pain. The game was a safe method for performing task-oriented cervical exercises, and patients reported very high levels of satisfaction and acceptance after the use of this technology.

Using Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This study aimed to assess the effectiveness of virtual reality (VR) in managing different types of pain in different age groups and to provide evidence for the clinical application of new alternative strategy for pain management.

METHODS

Electronic databases, including the Cochrane Library, PubMed, EMBASE, and the Web of Science, were searched for studies published up to October 2020. Randomized controlled trials that reported on VR for pain management were included.

RESULTS

A total of 31 randomized controlled trials were included. As for the pain intensity, the increase of visual analog scale score in the VR group was 1.62 scores less than that in the control group. In juvenile patients, the VR group had 1.79 scores lower than that in control group. For adult patients, the VR group had 1.34 scores lower than that in control group. As for other pain-related indicators, the VR group had lower levels of anxiety, lower pain unpleasantness, lower pulse rate, and shorter duration of dressing change and spent less time thinking about pain. Nevertheless, there was no statistical difference in pain tolerance. VR can effectively alleviate acute pain. In terms of chronic low back pain and cancer-related pain, there was no statistical difference between VR therapy and standard therapy.

CONCLUSIONS

VR is a feasible alternative therapy for both juveniles and adults in pain management, and it has a greater potential for juveniles. VR can effectively alleviate acute pain. Nevertheless, VR showed little effectiveness in increasing pain tolerance, which may explain in part the ineffectiveness of VR therapy in pain management for chronic pain.

The Effect of Video Game-Based Interventions on Performance and Cognitive Function in Older Adults: Bayesian Network Meta-analysis

Background

The decline in performance of older people includes balance function, physical function, and fear of falling and depression. General cognitive function decline is described in terms of processing speed, working memory, attention, and executive functioning, and video game interventions may be effective.

Objective

This study evaluates the effect of video game interventions on performance and cognitive function in older participants in terms of 6 indicators: balance function, executive function, general cognitive function, physical function, processing speed, and fear of falling and depression.

Methods

Electronic databases were searched for studies from inception to June 30, 2020. Randomized controlled trials and case-controlled trials comparing video game interventions versus nonvideo game control in terms of performance and cognitive function outcomes were incorporated into a Bayesian network meta-analysis. All data were continuous variables.

Results

In total, 47 studies (3244 participants) were included. In pairwise meta-analysis, compared with nonvideo game control, video game interventions improved processing speed, general cognitive function, and depression scores. In the Bayesian network meta-analysis, interventions with video games improved balance function time (standardized mean difference [SMD] –3.34, 95% credible interval [CrI] –5.54 to –2.56), the cognitive function score (SMD 1.23, 95% CrI 0.82-1.86), processing speed time (SMD –0.29, 95% CrI –0.49 to –0.08), and processing speed number (SMD 0.72, 95% CrI 0.36-1.09), similar to the pairwise meta-analysis. Interventions with video games with strong visual senses and good interactivity ranked first, and these might be more beneficial for the elderly.

Conclusions

Our comprehensive Bayesian network meta-analysis provides evidence that video game interventions could be considered for the elderly for improving performance and cognitive function, especially general cognitive scores and processing speed. Games with better interactivity and visual stimulation have better curative effects. Based on the available evidence, we recommend video game interventions for the elderly.

Trial Registration

PROSPERO CRD42020197158; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197158

What is the effect of low back pain self-management interventions with exercise components added? A systematic review with meta-analysis

BACKGROUND

Best practice guidelines endorse self-management and exercise in chronic low back pain (CLBP) management. The majority of existing self-management interventions (SMIs) do not include exercise components, and the effect of SMIs with exercises on CLBP and disability remains unclear.

OBJECTIVES

To systematically review the evidence for the effect of SMIs with an exercise component added, on pain and disability in people with CLBP.

DESIGN

Systematic review with meta-analysis.

METHOD

An electronic search of randomized controlled trials (RCTs) with SMIs with exercises was performed in 5 databases. Standardised Mean Difference (SMD) and 95% confidence interval (CI) were calculated using a random-effects model for meta-analysis at short-term, intermediate, and long-term follow-up points. The level of evidence was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

09 RCTs were included in the review and the GRADE quality assessment revealed low-quality evidence for all meta-analyses across 3 follow-up points. Effect sizes (ESs) for pain were -0.28, -0.36 and -0.21 for short-term, intermediate, and long-term respectively, and -0.30, -0.25 and -0.20 for short-term, intermediate, and long-term for disability, respectively. 6 out of 09 studies included tailored exercise programmes and exercise components differed widely in their content and delivery.

CONCLUSIONS

There is low-quality evidence that SMIs with exercises added have moderately positive effects on pain and disability in patients with CLBP compared to control interventions involving usual care, typically consisting of access to medication, exercise, advice, education, and manual therapy.

Telehealth Treatment for Non-Specific Low Back Pain: A Review of the Current State in Mobile Health

INTRODUCTION

Non-specific low back pain (LBP) is an idiopathic musculoskeletal condition that affects 4 out of 5 individuals in their lifetime and is the leading cause of job-related disability in the United States (US). The interest in interactive and dynamic telehealth treatments for LBP continues to grow, and it is important for the medical community to remain up-to-date on the state of the science.

LITERATURE SURVEY

Relevant studies published from March 2016 until March 2021 were identified through a systematic search of EMBASE, MedLine and Web of Science. The search strategy combined the concepts of back pain, telehealth and mobile applications.

METHODOLOGY

Titles and abstracts were screened to select full text randomized controlled trials or protocols and methodological quality and risk of bias was assessed using the Cochrane risk-of-bias tool. Data were synthesized narratively.

SYNTHESIS

We included seven concluded randomized controlled trials and two study protocols reporting mobile health (mHealth) solutions for LBP. Six of the seven concluded trials found a significant improvement in self-reported numerical pain rating scale compared to the control group. A single trial compared a mHealth solution to physical therapy, with the majority of studies comparing interventions to "usual care." Substantial heterogeneity in reporting of sample characteristics was found, indicating a lack of standardization through the field.

CONCLUSIONS

mHealth solutions may positively impact people with LBP. Larger trials should be encouraged and the field should coalesce around a set of baseline variables for collection and reporting. As many interventions involve patient engagement, future trials should aim to further quantify adherence levels and begin to define telehealth 'doses' associated with better outcomes. This article is protected by copyright. All rights reserved.

Virtual Reality in the Treatment of Adults with Chronic Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Virtual reality (VR) can present advantages in the treatment of chronic low back pain. The objective of this systematic review and meta-analysis was to analyze the effectiveness of VR in chronic low back pain. This review was designed according to PRISMA and registered in PROSPERO (CRD42020222129). Four databases (PubMed, Cinahl, Scopus, Web of Science) were searched up to August 2021. Inclusion criteria were defined following PICOS recommendations. Methodological quality was assessed with the Downs and Black scale and the risk of bias with the Cochrane Risk of Bias Assessment Tool. Fourteen studies were included in the systematic review and eleven in the meta-analysis. Significant differences were found in favor of VR compared to no VR in pain intensity postintervention (11 trials; n = 569; SMD = −1.92; 95% CI = −2.73, −1.11; p < 0.00001) and followup (4 trials; n = 240; SDM = −6.34; 95% CI = −9.12, −3.56; p < 0.00001); and kinesiophobia postintervention (3 trials; n = 192; MD = −8.96; 95% CI = −17.52, −0.40; p = 0.04) and followup (2 trials; n = 149; MD = −12.04; 95% CI = −20.58, −3.49; p = 0.006). No significant differences were found in disability. In conclusion, VR can significantly reduce pain intensity and kinesiophobia in patients with chronic low back pain after the intervention and at followup. However, high heterogeneity exists and can influence the consistency of the results.

Using Postmarket Surveillance to Assess Safety-Related Events in a Digital Rehabilitation App (Kaia App): Observational Study

Background

Low back pain (LBP) affects nearly 4 out of 5 individuals during their lifetime and is the leading cause of disability globally. Digital therapeutics are emerging as effective treatment options for individuals experiencing LBP. Despite the growth of evidence demonstrating the benefits of these therapeutics in reducing LBP and improving functional outcomes, little data has been systematically collected on their safety profiles.

Objective

This study aims to evaluate the safety profile of a multidisciplinary digital therapeutic for LBP, the Kaia App, by performing a comprehensive assessment of reported adverse events (AEs) by users as captured by a standardized process for postmarket surveillance.

Methods

All users of a multidisciplinary digital app that includes physiotherapy, mindfulness techniques, and education for LBP (Kaia App) from 2018 to 2019 were included. Relevant messages sent by users via the app were collected according to a standard operating procedure regulating postmarket surveillance of the device. These messages were then analyzed to determine if they described an adverse event (AE). Messages describing an AE were then categorized based on the type of AE, its seriousness, and its relatedness to the app, and they were described by numerical counts. User demographics, including age and gender, and data on app use were collected and evaluated to determine if they were risk factors for increased AE reporting.

Results

Of the 138,337 active users of the Kaia App, 125 (0.09%) reported at least one AE. Users reported 0.00014 AEs per active day on the app. The most common nonserious AE reported was increased pain. Other nonserious AEs reported included muscle issues, unpleasant sensations, headache, dizziness, and sleep disturbances. One serious AE, a surgery, was reported. Details of the event and its connection to the intervention were not obtainable, as the user did not provide more information when asked to do so; therefore, it was considered to be possibly related to the intervention. There was no relationship between gender and AE reporting (P>.99). Users aged 25 to 34 years had reduced odds (odds ratio [OR] 0.31, 95% CI 0.08-0.95; P=.03) of reporting AEs, while users aged 55 to 65 years (OR 2.53, 95% CI 1.36-4.84, P=.002) and ≥75 years (OR 4.36, 95% CI 1.07-13.26; P=.02) had increased odds. AEs were most frequently reported by users who had 0 to 99 active days on the app, and less frequently reported by users with more active days on the app.

Conclusions

This study on the Kaia App provides the first comprehensive assessment of reported AEs associated with real-world use of digital therapeutics for lower back pain. The overall rate of reported AEs was very low, but significant reporting bias is likely to be present. The AEs reported were generally consistent with those described for in-person therapies for LBP.

Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.

The Unknown Prevalence of Postrandomization Bias in 15 Physical Therapy Journals: A Methods Review

OBJECTIVES

To determine the prevalence of prospective clinical trial registration and postrandomization bias in published musculoskeletal physical therapy randomized clinical trials (RCTs).

DESIGN

A methods review.

LITERATURE SEARCH

Articles indexed in MEDLINE and published between January 2016 and July 2020 were included.

STUDY SELECTION CRITERIA

Two independent blinded reviewers identified the RCTs using Covidence. We included RCTs related to musculoskeletal interventions that were published in International Society of Physiotherapy Journal Editors member journals.

DATA SYNTHESIS

Data were extracted independently for the variables of interest from the identified RCTs by 2 blinded reviewers. The data were presented descriptively or in frequency tables.

RESULTS

One hundred thirty-eight RCTs were identified. One third of RCTs were consistent with their prospectively registered intent (49/138); consistency with prospectively registered intent could not be determined for two thirds (89/138) of the RCTs. Four RCTs (8%)reported inconsistent results with the primary aims and 7 (14%) with the outcomes from the prospective clinical trial registry, despite high methodological quality (Physiotherapy Evidence Database [PEDro] scale score). Differences between prospectively registered and non-prospectively registered RCTs for PEDro scale scores had a medium effect size (r = 0.30). Two of 15 journals followed their clinical trial registration policy 100% of the time; in 1 journal, the published RCTs were consistent with the clinical trial registration.

CONCLUSION

Postrandomization bias in musculoskeletal physical therapy RCTs could not be ruled out, due to the lack of prospective clinical trial registration and detailed data analysis plans. J Orthop Sports Phys Ther 2021;51(11):542-550. Epub 21 Sep 2021. doi:10.2519/jospt.2021.10491.

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.

Attempting to Separate Placebo Effects from Exercise in Chronic Pain: A Systematic Review and Meta-analysis

BACKGROUND

Pain is the most disabling characteristic of musculoskeletal disorders, and while exercise is promoted as an important treatment modality for chronic musculoskeletal conditions, the relative contribution of the specific effects of exercise training, placebo effects and non-specific effects such as natural history are not clear. The aim of this systematic review and meta-analysis was to determine the relative contribution of these factors to better understand the true effect of exercise training for reducing pain in chronic primary musculoskeletal pain conditions.

DESIGN

Systematic review with meta-analysis DATA SOURCES: MEDLINE, CINAHL, SPORTDiscus, EMBASE and CENTRAL from inception to February 2021. Reference lists of prior systematic reviews.

ELIGIBILITY CRITERIA

Randomised controlled trials of interventions that used exercise training compared to placebo, true control or usual care in adults with chronic primary musculoskeletal pain. The review was registered prospectively with PROSPERO (CRD42019141096).

RESULTS

We identified 79 eligible trials for quantitative analysis. Pairwise meta-analysis showed very low-quality evidence (GRADE criteria) that exercise training was not more effective than placebo (g [95% CI]: 0.94 [- 0.17, 2.06], P = 0.098, I² = 92.46%, studies: n = 4). Exercise training was more effective than true, no intervention controls (g [95% CI]: 0.99 [0.66, 1.32], P < 0.001, I² = 92.43%, studies: n = 42), usual care controls (g [95% CI]: 0.64 [0.44, 0.83], P < 0.001, I² = 76.52%, studies: n = 33), and when all controls combined (g [95% CI]: 0.84 [0.64, 1.04], P < 0.001, I² = 90.02%, studies: n = 79).

CONCLUSIONS

There is very low-quality evidence that exercise training is not more effective than non-exercise placebo treatments in chronic pain. Exercise training and the associated clinical encounter are more effective than true control or standard medical care for reductions in pain for adults with chronic musculoskeletal pain, with very low quality of evidence based on GRADE criteria.

The Use of Virtual Reality in Back Pain Rehabilitation: A Systematic Review and Meta-Analysis

This systematic review aimed to synthesize the existing evidence of extended reality (XR) on pain and motor function outcomes in patients with back pain. Following the Cochrane guidelines, relevant articles of any language were selected by 2 independent reviewers from CINAHL, Cochrane, Embase, Medline and Web of Knowledge databases. Of 2,050 unique citations, 24 articles were included in our review. These studies included a total of 900 back pain patients. Despite broader XR search, all interventions were virtual reality (VR) based and involved physical exercises (n = 17, 71%), hippotherapy (n = 4, 17%), motor imagery (n = 1, 4%), distraction (n = 1, 4%), and cognitive-behavior therapy (n = 1, 4%). Sixteen controlled studies were included in a meta-analysis which suggested that VR provides a significant improvement in terms of back pain intensity over control interventions (Mean Difference: -0.67; 95% CI: -1.12 to -0.23; I² = 85%). Almost all included studies presented high risk of bias, highlighting the need to improve methodology in the examination of VR interventions. While the specific set of studies showed high heterogeneity across several methodological factors, a tentative conclusion could be drawn that VR was effective improving back pain intensity and tends to have a positive effect on improving other pain outcomes and motion function. PERSPECTIVE: Extended reality technologies have appeared as interesting nonpharmacological options for the treatment of back pain, with the potential to minimise the need for opioid medications. Our systematic review summarised existing applications of extended reality for back pain and proposed a few recommendations to direct further studies in the field.

Design and evaluation of mobile scenario based learning in the self-management of chronic pain

Chronic pain is a lifelong issue, being one of the main causes of disability, affecting a great number of people worldwide, many of which often avoid seeking medical advice from pain experts and/or demonstrate poor adherence to their therapeutic plan. One of the most important steps in achieving a manageable course of disease, is the ability of self-management. We aimed at applying a method of systematic patient education and self-management through the use of Virtual Patients (VPs), a well-established method for educating medical doctors and students but never before targeting patients. Two VPs scenarios were designed, tested and evaluated by patients with rheumatic disorders, achieving a SUS score of 88/100 "Best Imaginable", alongside with positive reviews from the participants. The positive feedback from the patients supports the potential of VP educational paradigm to educate these patients and equip them with disease coping skills and strategies.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

The effect of video exercise-based telerehabilitation on clinical outcomes, expectation, satisfaction, and motivation in patients with chronic low back pain

BACKGROUND

The efficacy of exercise-based telerehabilitation in chronic low back pain (CLBP) has not been well studied. To our knowledge, no other studies have investigated the efficacy of video exercise-based telerehabilitation software in the remote management of home exercises in patients with CLBP.

AIMS

The purpose of the study was to investigate the effect of the video-based exercise software on pain, function, quality-of-life, expectation, satisfaction, and motivation in individuals with CLBP.

METHODS

A double-blind, two-armed randomized controlled trial was carried out with 50 individuals with CLBP. Participants were randomly allocated to either the telerehabilitation group (n = 25) or the conventional rehabilitation group (n = 25). The telerehabilitation group was followed up with a video exercise-based telerehabilitation software called Fizyoweb. The clinician was able to communicate with the patients through the software. The conventional rehabilitation group was given the same home exercises as the paper-based exercise instruction form. Pain, function, quality-of-life, and kinesiophobia were evaluated at baseline and after 8 weeks of intervention. In addition, patient expectations were questioned at the initial evaluation; afterward, patient satisfaction and motivation were questioned at the eighth week.

RESULTS

After 8 weeks of treatment, the telerehabilitation group achieved significant improvement in pain, function, quality-of-life, kinesiophobia, satisfaction, and motivation (p < 0.05). In addition, the telerehabilitation group reported more significant gains in all parameters compared with the conventional rehabilitation group (p < 0.05).

CONCLUSIONS

The video exercise-based telerehabilitation software positively affects clinical parameters and adherence to rehabilitation in patients with CLBP.

Horse-riding simulators in treatment of chronic low back pain: A meta-analysis

BACKGROUND

The use of horse-riding simulators in the treatment of chronic low back pain has drawn considerable attention for its efficacy and acceptability to reduce chronic low back pain; because of the similarities in movements provided by equine-assisted therapies and the possible accessibility advantages. However, the results are conflicting. This study aimed to perform a meta-analysis of randomised controlled trials to assess the impact of treatments based on horse-riding simulators on chronic low back pain.

METHODS

A systematic literature search up to January 2021 was performed and 11 studies were detected with 543 subjects with chronic low back pain at the baseline of the study, 257 of them were using horse-riding simulators, and 255 of them were inactive control group who continued their usual care, and similar kind of physical therapy (control). They reported a comparison between horse-riding simulators and control to reduce chronic low back pain. Mean differences (MD) with 95% confidence intervals (CIs) were calculated assessing the impact of treatments based on horse-riding simulators on chronic low back pain using the continuous method with a random or fixed-effect model.

RESULTS

Significantly higher change-from-baseline pain outcomes was observed in Visual Analogue Scale (MD, -4.36; 95% CI, -6.24 to -2.30, P < .001), and Roland Morris Disability Questionnaire change-from-baseline (MD, -2.32; 95% CI, -3.52 to -1.12, P < .001) with horse-riding simulators compared with control.

CONCLUSIONS

Using horse-riding simulators may lower the risk of chronic low back pain. This relationship forces us to recommend the use of horse-riding simulators to avoid any complications that could occur with chronic low back pain.

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

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

What makes a great clinical trial in physiotherapy?

Objective: To identify common characteristics of landmark physiotherapy clinical trials.Methods: The Physiotherapy Evidence Database (PEDro) top five trials were compared to 91 physiotherapy trials published in top medical journals and 99 trials randomly selected from PEDro on the following characteristics: PEDro score, sample size, number of trial sites, use of prospective registration, positive or negative trial, citations, citations in guidelines, Altmetric score, impact factor, publications and citations of first and last author, and PEDro codes (sub-discipline, topic, problem, therapy, and body part). Trials were published from 2014 to 2019. One-way independent ANOVA and Chi-squared test evaluated between-group differences.Results: Compared to a random sample of physiotherapy trials, the PEDro top five trials and trials in top medical journals have higher PEDro scores, larger sample sizes, more study sites, more citations (including in guidelines), higher Altmetric scores, more likely to be prospectively registered, less likely to be positive trials, and have first and last authors with more citations and publications. The problem was the only PEDro code was distributed differently across the trial groups.Conclusion: The PEDro top five trials and physiotherapy trials published in the top medical journals have characteristics that may inform the design, conduct, and reporting of future physiotherapy trials.

Effect of a Multimodal Movement Intervention in Patients With Neurogenic Claudication Based on Lumbar Spinal Stenosis and/or Degenerative Spondylolisthesis-A Pilot Study

Chronic low-back pain is a major individual, social, and economic burden. The impairment ranges from deterioration of gait, limited mobility, to psychosocial distress. Due to this complexity, the demand for multimodal treatments is huge. Our purpose is to compare the effects of a multimodal movement intervention (MI) (coordinative–cognitive exercises and dancing program) with standard physical therapy (PT) on gait, physical function, and quality of life in patients with lumbar spinal stenosis (LSS). The study design is based on a 6-week intervention with a two (group: MI/PT) by two (measurement time points: pre-/post-test) parallel group design with random assignment. Twenty-four subjects (18 female/6 male, 70.8 ± 10.6 years old) diagnosed with LSS were included and randomly allocated to the MI or PT group. The primary outcomes are minimum toe clearance (MTC) and double step length (DSL) variability and the Timed “Up & Go” test (TUG). Secondary outcomes are the Brief Pain Inventory, the short Fall Efficacy Scale–International (sFES-I), and the Oswestry Disability Index. Nine subjects for each group could be analyzed. The MTC variability revealed a significant between-group difference in the posttest (p = 0.008) showing a lower MTC variability for the MI compared to the PT group. The MI group displayed an improved TUG (p = 0.031) and a reduced sFES-I (p = 0.044). The decreased MTC variability and fear of falling as well as the improved functional mobility may contribute to a reduced risk of falling. For the subsequent study, further kinematic and cognitive parameters should be analyzed, and the number of participants has to be increased.

Clinical Trial Registration: German Clinical Trial Register (ID: DRKS00021026/URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021026).

Effects of Exercise Training on Fear-Avoidance in Pain and Pain-Free Populations: Systematic Review and Meta-analysis

BACKGROUND

Fear of pain and movement is an important factor in the development of hypervigilance and avoidance behaviours.

OBJECTIVE

We examined the effectiveness of exercise training on improving fear-avoidance beliefs.

METHODS

A systematic review (data sources: MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL) and metaanalysis of randomised controlled/clinical trials of exercise training in adults versus relevant nonexercise comparators that quantified fear-avoidance was conducted.

RESULTS

After screening 4603 identified records, 17 (2014 participants) and 13 (1152 participants) studies were eligible for qualitative and quantitative synthesis, respectively. Pairwise meta-analysis showed exercise training was more effective than all non-exercise comparators (standardised mean difference (SMD) [95% CI] - 0.378 [- 0.623, - 0.133], P = 0.002, Grading of Recommendations Assessment, Development and Evaluation [GRADE]: very low) for reducing fear-avoidance. Exercise training was more effective than true control for reducing fear avoidance (- 0.407 [- 0.750, - 0.065], P = 0.020, GRADE: very low), however it was not more effective than other interventions (- 0.243 [- 0.614, 0.128], P = 0.199, GRADE: very low). In people with low back pain, exercise training was more effective than non-exercise comparator groups for reducing fear-avoidance (- 0.530 [- 0.755, - 0.304], P < 0.001, GRADE: very low). For individuals with neck pain, exercise training was not more effective than non-exercise comparator groups for reducing fear-avoidance (0.061 [- 0.360, 0.482], P = 0.777, GRADE: very low).

CONCLUSION

There is very low to low-quality evidence that exercise training is effective for reducing fear-avoidance, including in people with low back pain. Exercise training may be more effective than no intervention for reducing fear avoidance, but there is very low-quality evidence that non-exercise interventions are as effective as exercise for fear avoidance. Few studies with low risk of bias is a limitation.

TRAIL REGISTRATION

PROSPERO Registration Number: CRD42019139678.