Acute Whiplash Injury Study (AWIS): a protocol for a cluster randomised pilot and feasibility trial of an Active Behavioural Physiotherapy Intervention in an insurance private setting

Active behavioural physiotherapy intervention for acute non-specific neck pain: a cluster randomised double-blind pilot and feasibility clinical trial

PURPOSE

To evaluate the feasibility of an active behavioural physiotherapy intervention (ABPI) and procedures to prevent the transition to chronicity in patients with acute non-specific neck pain (ANSNP).

MATERIALS AND METHODS

A cluster-randomised double-blind (assessors and participants), parallel 2-arm (ABPI versus standard physiotherapy intervention [SPI]) pilot and feasibility clinical trial was conducted owing to a pre-specified published protocol. Six public hospitals were recruited and cluster-randomised (computer-generated randomisation with block sampling). Sixty participants (30 in each arm, 10 per hospital) were assessed at baseline and 3 months following baseline for neck disability index, numerical pain rating scale, cervical range-of-motion, fear-avoidance beliefs questionnaire and EuroQol 5-dimension 5-level.

RESULTS

All procedures worked well. The participants' median age was 36.5 (range 21-59, interquartile range: 20.75) years. Participants in the ABPI demonstrated better improvement in all outcomes compared to SPI. Furthermore, the number of fully recovered participants following ABPI (27/30, 90.00%) was higher than SPI (16/30, 53.33%) with fewer treatment sessions and lower costs of management.

CONCLUSIONS

The findings suggest that the ABPI is feasible and valuable (e.g. a high number of fully recovered participants, fewer treatment sessions and reduced management costs compared to the SPI) in conducting a future definitive trial to evaluate the effectiveness of the ANSNP management.

TRIAL REGISTRATION

TCTR20180607001.

Effectiveness of psychological interventions delivered by physiotherapists in the management of neck pain: a systematic review with meta-analysis

Physiotherapists are increasingly using psychological treatments for musculoskeletal conditions. We assessed the effects of physiotherapist-delivered psychological interventions on pain, disability, and quality of life in neck pain. We evaluated quality of intervention reporting. We searched databases for randomized controlled trials (RCTs) comprising individuals with acute or chronic whiplash-associated disorder (WAD) or nontraumatic neck pain (NTNP), comparing physiotherapist-delivered psychological interventions to standard care or no treatment. Data were extracted regarding study characteristics and outcomes. Standardised mean difference (SMD) was calculated by random-effects meta-analysis. We evaluated certainty of evidence using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) and intervention reporting using TIDieR. Fourteen RCTs (18 articles-4 detail additional outcome/follow-up data) were included comprising 2028 patients, examining acute WAD (n = 4), subacute/mixed NTNP (n = 3), chronic WAD (n = 2), and chronic NTNP (n = 5). Treatment effects on pain favoured psychological interventions in chronic NTNP at short-term (SMD -0.40 [95% CI -0.73, -0.07]), medium-term (SMD -0.29 [95% CI -0.57, 0.00]), and long-term (SMD -0.32 [95% CI -0.60, -0.05]) follow-up. For disability, effects favoured psychological interventions in acute WAD at short-term follow-up (SMD -0.39 [95% CI -0.72, -0.07]) and chronic NTNP at short-term (SMD -0.53 [95% CI -0.91, -0.15]), medium-term (SMD -0.49 [95% CI -0.77, -0.21]), and long-term (SMD -0.60 [95% CI -0.94, -0.26]) follow-up. GRADE ratings were typically moderate, and intervention reporting often lacked provision of trial materials and procedural descriptions. Psychological interventions delivered by physiotherapists were more effective than standard physiotherapy for chronic NTNP (small-to-medium effects) and, in the short term, acute WAD.

Effectiveness of interventions for middle-aged and ageing population with neck pain: a systematic review and network meta-analysis protocol

INTRODUCTION

Neck pain (NP) is a common musculoskeletal complaint and is increasing in prevalence. Current clinical practice guidelines and systematic reviews recommended conservative, pharmacological and invasive interventions for individuals with NP. However, optimal management specifically for those who are middle-aged or older adults (≥45 years) is not available; and important considering our ageing population.

METHODS AND ANALYSIS

A systematic review with network meta-analysis (NMA) will be conducted following the Cochrane guidelines. Eligibility criteria include randomised controlled/clinical trials evaluating any of acute (<3 months) or chronic (≥3 months) non-specific NP, whiplash associated disorders, cervical radiculopathy and cervicogenic headache. Any interventions and outcome measures detailed within The International Classification of Functioning, Disability and Health domains will be included. Two independent reviewers will search key databases (AMED, CENTRAL, CINAHL, Embase, MEDLINE, PEDro and PsycINFO), grey literature, key journals and reference lists in May 2022. Two reviewers will decide eligibility and assess risk of bias (ROB) of included studies. The kappa statistic will be used to evaluate agreement between the reviewers at each stage. Data will be extracted by one reviewer and checked for accuracy by a second reviewer. Descriptive data and ROB will be summarised and tabulated. Traditional pairwise meta-analysis using random-effect model will be performed for all direct comparisons, and NMA using a frequentist random-effect model then performed based on NP classification where possible. A network of traditional pairwise meta-analysis allows comparisons of multiple interventions from both direct and indirect evidence to provide a hierarchal establishment for enhancing decision making of clinical practitioners.

ETHICS AND DISSEMINATION

Ethic approval is not required as the study is a literature review. The findings will be shared with the national and international researchers, healthcare professionals and the general public through publishing in a peer-reviewed journal and presentations at conferences.

PROSPERO REGISTRATION NUMBER

CRD42021284618.

Translation, cross-cultural adaptation and psychometric evaluation of the Thai version of the fear-avoidance beliefs questionnaire in patients with non-specific neck pain

OBJECTIVES

Fear-avoidance beliefs questionnaire (FABQ) is a self-report, valid and reliable questionnaire to quantify fear and avoidance beliefs related to physical activity and work. Furthermore, it can be used to predict prolong disability in patients with non-specific neck pain. Although it was originally developed to manage patients with low back pain, it has also been studied in individuals with neck pain. This questionnaire was translated into several languages following reports of potential benefits in patients with neck pain. Recently, Thai neck clinical trials, international multi-centre trials and data sharing are growing throughout the world but no validated Thai version of the FABQ is available for clinical and research uses. Our objectives were to translate and cross-culturally adapt the FABQ into Thai version and evaluate its psychometric properties in Thai patients with non-specific neck pain.

METHODS

Cross-cultural translation and adaptation of the FABQ were conducted according to standard guidelines. A total of 129 participants with non-specific neck pain were invited to complete the Thai versions of the FABQ (FABQ-TH), neck disability index and visual analogue scale for pain intensity. Psychometric evaluation included exploratory factor analysis, internal consistency, test-retest reliability, agreement, and convergent validity. Thirty participants completed the FABQ-TH twice with a 48-h interval between tests to assess the test-retest reliability.

RESULTS

Factor analysis identified four components for the FABQ-TH (66.69% of the total variance). The intraclass correlation coefficient of test-retest reliability was excellent for the total score (0.986), work attitudes (0.995), physical activity attitudes (0.958), physical activity experiences (0.927), and expected recovery (0.984). Cronbach's alpha for internal consistency was excellent (range 0.87-0.88) for all items. The minimal detectable change of the FABQ-TH was 5.85. The FABQ-TH correlated to its subscales (range 0.470-0.936), indicating the strongest association with work attitude. The weakest correlation was observed between the FABQ-TH and disability (r _s =0.206, p=0.01). Missing data and significant floor or ceiling effects were not found.

CONCLUSIONS

The Thai version of the FABQ for non-specific neck pain was successfully adapted. It is a valid and reliable instrument to quantify fear and avoidance beliefs among patients with non-specific neck pain who speak and read Thai.

Pragmatic cluster randomised double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute non-specific neck pain: a mixed-methods protocol

INTRODUCTION

Non-specific neck pain causes pain and disability and contributes substantial socioeconomic burden internationally. Up to 50% of adults experience neck pain annually, leading to reduced the quality of life. An active behavioural physiotherapy intervention (ABPI) may be feasible to manage patients with acute non-specific neck pain to prevent transition to chronicity. A recent pilot and feasibility trial investigating an acute whiplash-associated disorder population found potential value of the ABPI with 95% of participants fully recovered (Neck Disability Index: NDI ≤4, compared with 17% in the standard physiotherapy arm); supporting a definitive trial. Qualitative findings from the physiotherapists supported the potential of the ABPI in a non-specific neck pain population.

METHODS AND ANALYSIS

Two phases: (1) Pragmatic cluster randomised double-blind, parallel 2-arm (ABPI vs standard physiotherapy intervention) pilot and feasibility trial to evaluate the procedures and feasibility of the ABPI for the management of acute non-specific neck pain. Six physiotherapy departments from six public hospitals in Thailand will be recruited and cluster randomised by a computer-generated randomisation sequence with block sampling. Sixty participants (30 each arm, 10 per hospital) will be assessed at baseline and 3 months following baseline for NDI, Numerical Rating Scale for pain intensity, cervical range of motion, fear-avoidance beliefs questionnaire and EuroQol-5 dimensions 5 levels outcomes, and (2) Embedded qualitative study using semistructured interviews to explore acceptability of the ABPI to participants (n=12) and physiotherapists (n=3). Descriptive analysis of the quantitative data and interpretative phenomenological analysis to code and analyse qualitative data (deductive and inductive) will inform feasibility for a future definitive trial.

ETHICS AND DISSEMINATION

This trial is approved by the Naresuan University Institutional Review Board (NUIRB_0380/61).

TRIAL REGISTRATION NUMBER AND STATUS

TCTR20180607001; Recruiting commenced 1 February 2019.

A cluster randomised, double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute whiplash-associated disorder (WAD)II

Whiplash-associated disorder (WAD) causes substantial social and economic burden, with ≥70% patients classified as WADII (neck complaint and musculoskeletal sign(s)). Effective management in the acute stage is required to prevent development of chronicity; an issue for 60% of patients. An Active Behavioural Physiotherapy Intervention (ABPI) was developed to address both physical and psychological components of WAD. The ABPI is a novel complex intervention designed through a rigorous sequential multiphase project to prevent transition of acute WAD to chronicity. An external pilot and feasibility cluster randomised double-blind (assessor, participants) parallel two-arm clinical trial was conducted in the UK private sector. The trial compared ABPI versus standard physiotherapy to evaluate trial procedures and feasibility of the ABPI for managing acute WADII in preparation for a future definitive trial. Six private physiotherapy clinics were recruited and cluster randomised using a computer-generated randomisation sequence. Twenty-eight (20 ABPI, 8 standard physiotherapy) participants [median age 38.00 (IQR = 21.50) years] were recruited. Data were analysed descriptively with a priori establishment of success criteria. Ninety-five percent of participants in the ABPI arm fully recovered (Neck Disability Index ≤4, compared to 17% in the standard physiotherapy arm); required fewer treatment sessions; and demonstrated greater improvement in all outcome measures (pain intensity, Cervical Range of Motion, Pressure Pain Threshold, EuroQol-5 Dimensions) except for the Impact of Events Scale and Fear Avoidance Beliefs Questionnaire. The findings support the potential value of the ABPI, and that an adequately powered definitive trial to evaluate effectiveness (clinical, cost) is feasible with minor modifications to procedures.

Development of an active behavioural physiotherapy intervention (ABPI) for acute whiplash-associated disorder (WAD) II management: a modified Delphi study

OBJECTIVE

To develop an active behavioural physiotherapy intervention (ABPI) for managing acute whiplash-associated disorder (WAD) II using a modified Delphi method to develop consensus for the basic features of the ABPI.

DESIGN

Modified Delphi study. Our systematic review and meta-analysis evaluating conservative management for acute WADII found that a combined ABPI may be a useful intervention to prevent patients progressing to chronicity. No previous research has considered a combined behavioural approach and active physiotherapy in the management of acute WADII patients. The ABPI was therefore developed using a rigorous consensus method using international research and local clinical whiplash experts. Descriptive statistics were used to assess consensus in each round.

SETTING

Online international survey.

PARTICIPANTS

A purposive sample of 97 potential participants (aiming to recruit n=30) consisting of international research whiplash experts, UK private physiotherapists and UK postgraduate musculoskeletal physiotherapy students were invited to participate via electronic mail with an attached participant information sheet and consent form.

RESULTS

36 individuals signed and returned the consent form. In round 1, 32/36 participants (response rate=89%, mean age±SD=36.03±13.22 years) across 8 countries (Australia, Finland, Greece, India, Netherlands, Norway, Sweden and UK) contributed to round 1 questionnaire. Response rates were 78% and 75% for rounds 2 and 3, respectively. Following round 3, 12 underlying principles (eg, return to normal function as soon as possible, pain management, encouragement of self-management, reduce fear avoidance and anxiety) achieved consensus. The treatment components reaching consensus included behavioural (eg, education, reassurance, self-management) and physiotherapy components (eg, exercises for stability and mobility). No passive intervention achieved consensus.

CONCLUSIONS

Experts suggested and agreed the underlying principles and treatment components of the ABPI for the management of acute WADII. The ABPI was underpinned by social cognitive theory focusing on self-efficacy enhancement prior to conducting a phase II trial.