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

What are the predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears? Gaining expert consensus using an international e-Delphi study

BACKGROUND

Massive irreparable rotator cuff tears can cause significant shoulder pain and disability. Treatment options include physiotherapy or surgery, with a lack of research comparing treatment options. For physiotherapy there is uncertainty about which patients will have a successful or unsuccessful response to treatment and a lack of consensus on what constitutes the best physiotherapy programme. With these significant gaps in the research, it is challenging for clinicians seeing patients with massive irreparable rotator cuff tears to advise on what is their best treatment pathway.

METHODS

A three round Delphi study was conducted with expert shoulder physiotherapists and orthopaedic surgeons to gain consensus on the important factors associated with response to physiotherapy in this patient population. Round 1 was an information-gathering round to identify predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears. Rounds 2 and 3 were consensus-seeking rounds on the importance and modifiability of the predictors. Consensus criteria were determined a priori using median, interquartile range, percentage agreement and Kendall's Coefficient of Concordance.

RESULTS

Participants were recruited April-October, 2023. 88 experts participated in Round 1 and of these, 70 completed Round 3 (79.54%). In Round 1, content analysis of 344 statements identified 45 predictors. In Round 2, 29 predictors reached consensus as important and 2 additional predictors were identified. In Round 3, of the 31 predictors from Round 2, 22 reached consensus as important and 12 of these reached consensus as modifiable by physiotherapists. Both patient factors and clinician factors from a broad range of domains reached consensus: biomechanical, psychological, social, co-morbidities, communication / healthcare interactions and pain.

CONCLUSIONS

The results of this Delphi study suggest that clinicians assessing patients with massive irreparable rotator cuff tears should assess across all these domains and target the modifiable factors with interventions. Particular emphasis should be placed on optimising modifiable clinician factors including therapeutic alliance, comprehensive explanation of the condition and collaborative and realistic goal-setting. These in turn may influence modifiable patient factors including patient expectations, engagement with the physiotherapy programme, motivation and self-efficacy thus creating the ideal environment to intervene on a biomechanical level with exercises.

A Qualitative Study Identifying Barriers and Enablers to Exercise Adherence in People with Chronic Low Back Pain. "It's a personal journey"

Exercise leads to clinically meaningful pain reductions in people with chronic low back pain and is recommended as a first line treatment. The benefits of exercise for chronic low back pain decrease over time with a lack of long-term exercise adherence as a potential reason for this decreasing effect. We aimed to identify the barriers and enablers to exercise adherence from the perspective of people with chronic low back pain. This qualitative study was underpinned by a constructivist epistemology and used a critical realist ontological perspective. Adults (18-65 years) with chronic low back pain who had exercised since the onset of their back pain were recruited to participate in focus groups and individual interviews. Audio data were transcribed and then analysed in 2 stages 1) inductive coding using reflexive thematic analysis, followed by 2) deductive analysis through mapping codes onto the Theoretical Domains Framework. Five enablers and 3 barriers were identified across 6 of the 14 Theoretical Domain Framework domains. Exercise identity and confidence in deciding to self-manage pain were enablers, whereas beliefs about the consequences of exercise, exercise context, and relationships could function as either barriers or enablers. These barriers and enablers were complex and fluid, with participants reporting conflicting barriers and enablers that varied, depending on context. These findings improve our understanding of the barriers and enablers to exercise adherence from the individual perspective of people with chronic low back pain and can be utilised for more effective exercise treatment in this population. PERSPECTIVE: This article presents the barriers and enablers to exercise adherence from the perspective of people with chronic low back pain. These perspectives may aid to individualise and optimise exercise treatment, improve its long-term adherence and therefore its effectiveness for chronic low back pain.