Communication style and exercise compliance in physiotherapy (CONNECT): a cluster randomized controlled trial to test a theory-based intervention to increase chronic low back pain patients' adherence to physiotherapists' recommendations: study rationale, design, and methods

Adapting and Evaluating a Theory-Driven, Non-Pharmacological Intervention to Self-Manage Pain

BACKGROUND

The existing literature has limited detail on theory-driven interventions, particularly in pain studies. We adapted Bandura's self-efficacy framework toward a theory-driven, non-pharmacological intervention using auricular point acupressure (APA) and evaluated participants' perceptions of this intervention on their pain self-management. APA is a non-invasive modality based on auricular acupuncture principles.

METHODS

We mapped our study intervention components according to Bandura's key sources of self-efficacy (performance accomplishments, vicarious experience, verbal persuasion, and emotional arousal) to facilitate the self-management of pain. Through a qualitative study design, we conducted virtual interviews at one and three months after a 4-week APA intervention among 23 participants using purposive sampling to describe their experiences in managing their pain based on our theory-driven APA intervention.

RESULTS

Using thematic analyses, we found four themes: the enhanced self-management of pain, improved pain outcomes, the feasibility of technology, and the sustainability of APA.

CONCLUSIONS

Describing how interventions are mapped according to the elements of theoretical frameworks can help to guide intervention development, advance science and knowledge development, and promote the implementation of interventions. As such, using Bandura's self-efficacy theory as a foundation for the APA intervention, APA was found to be feasible and sustainable, improving self-management, pain intensity, and pain-related outcomes. Participants provided recommendations for the further improvement of this theory-driven intervention.

Impact of a training program on hospital pharmacists' patient-centered communication attitudes and behaviors

Background

Effective communication that integrates the value of patient-centered care is important in healthcare encounters. Communication skills training (CST) has been indicated as effective in improving patient-centered communication behaviors. However, there is a paucity of studies on the impact of CST among Malaysian hospital pharmacists.

Objective

This study aimed to evaluate the effects of a patient-centered CST program on patient-centered communication scores, communication self-efficacy, and attitudes toward concordance among pharmacists in public hospitals.

Methods

A communication skills training (CST) program was conducted among hospital pharmacists. This training intervention was developed based on patient-centered communication frameworks and techniques, namely the Four Habits Model and motivational interviewing. A pre-test/post-test quasi-experimental design was implemented for the evaluation. Pharmacists underwent pre-test/post-test audiotaped simulated consultations and completed questionnaires, including the Revised United States-Leeds Attitudes Toward Concordance scale (RUS-LATCon) and Communication Self-Efficacy scale. The Four Habits Coding Scheme (FHCS) was used to evaluate patient-centered communication scores from the audiotapes, and the Wilcoxon signed-rank test was used to analyze for differences in the pre- and post-intervention scores.

Results

A total of 38 pharmacists from four tertiary hospitals participated in this study and completed the pre-test. However, due to the impact of COVID-19, only 23 pharmacists completed the post-test data collection. Improvements were noted in the FHCS scores post-training, including items related to exploring patients' concerns, acceptability, and barriers to treatment. Based on the questionnaire, there was an improvement in recognizing patients' needs and potential medication uncertainty and an increase in the overall communication self-efficacy scores after the training.

Conclusions

CST may help improve the adoption of patient-centered communication in pharmacists' consultations with patients.

Effectiveness of Communication Strategies in the Management of Chronic Postsurgical Pain: Protocol for a Systematic Review and Meta-Analysis

Purpose

To describe the details of a systematic review to assess the current evidence about the efficacy of communication strategies on the prevention of chronic postsurgical pain (CPSP).

Methods

The protocol for this systematic review was based on the Cochrane Handbook methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommendations. A systematic search of the literature on electronic databases Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science (from the inception to 19 June 2022) was carried out using predefined search terms to identify relevant studies. This review will include randomized clinical trials or observational studies. The search strategy consisted of keywords and index terms related to "clinician", "communication" or "post-surgical pain". Inclusion criteria are as follows: randomized clinical trials or observational studies using a parallel group design that assess the efficacy of communication interventions in patients undergoing surgery and that assess pain and pain-related disability. We considered interventions that included any type of written, verbal, and non-verbal communication in combination with other interventions or without. Control groups may include no communication intervention or another intervention distinctly different. We excluded studies with follow-up duration of less than 3 months, patients aged <18 years, and studies for which no reviewer had language proficiency (eg, Chinese, Korean). Descriptive statistics will be used to summarize quantitative findings. Meta-analysis will only be considered if at least three studies used the same outcome with comparable interventions, as we expect a wide heterogeneity of study population and settings.

Conclusion

This systematic review and meta-analysis will be an important source for clinicians and researchers to understand the influence of communication to prevent CPSP.

Study Registration

This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO). Registration number: CRD42021241596.

The comparison between the effects of pain education interventions with online and face-to-face exercise and the control group received biomedical education + standardized physical therapy in patients with chronic nonspecific neck pain during COVID-19: protocol for a parallel-group randomized controlled trial

BACKGROUND

Various psychological issues and serious health concerns during the imposed lockdown by coronavirus disease 2019 (COVID-19) have induced many changes in the treatment of patients. More effective self-management strategies through tele-rehabilitation are suggested to be applied for patients with chronic neck pain to reduce referrals to health cares and disability support through COVID-19. Also, the pain neuroscience education (PNE) approach is an educational method used by health professionals to assist patients in understanding the biology, physiology, and psychosocial factors affecting their pain experience and aligning with the cognitions and beliefs associated with pain and recurrent disability. PNE combined with tele-rehabilitation could be a new solution to encourage patients to manage their condition by themselves and increase the continuity of practice instead of face-to-face sessions.

OBJECTIVE

This randomized control trial (RCT) aims to investigate the effects of PNE with online and face-to-face exercise interventions, and the control group received biomedical education + standardized physical therapy on neck pain and disability, psychological factors, and function in non-traumatic chronic neck pain.

METHODS/DESIGN

Patients with non-traumatic chronic neck pain (patient-centered care and active involvement of patients and the public) will be recruited via flyers displayed in hospitals and universities to participate in an RCT with two experimental and one control group designed to investigate the effects of PNE with online and face-to-face exercise interventions, and the control group received biomedical education + standardized physical therapy on neck pain and disability, psychological factors, and function in non-traumatic chronic neck pain. The outcomes will be measured at baseline, after PNE, and after 3 months of an exercise intervention. All outcomes are presented as mean ± SD, and statistical significance was set at α level of < 0.05. The normal distribution of the variables was verified by the Kolmogorov-Smirnov test, following a descriptive analysis.

DISCUSSION

It seems that PNE plus online and face-to-face exercise interventions are appropriate educational models for the treatment of patients with neck pain during COVID-19. Also, online training seems to encourage patients to continue their treatment.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20150503022068N5. Registered on 09 September 2021.

From the challenge of assessing autonomy to the instruments used in practice: A scoping review

Autonomy is one of the essential components to live a quality life. Monitoring this autonomy is, in effect, essential, to allow the nurses to conceive, implement and evaluate interventions aimed at its promotion or even maintenance. For this reason, this scoping review aims to map the evidence to identify and analyze the instruments used to assess the person’s autonomy, which emerges from scientific production.

Comparing an e-Health program vs home rehabilitation program in patients with non-specific low back pain: A study protocol randomized feasibility trial

BACKGROUND

There is little evidence on the reliability of the web application-based rehabilitation systems to treat chronic low back pain (CLBP).

METHODS

This protocol describes a double-blind, randomized controlled feasibility trial of an e-Health intervention developed to support the self-management of people with CLBP in primary care physiotherapy. Three Hospitals with primary care for outpatients will be the units of randomisation, in each Hospital the participants will be randomized to one of two groups, a pragmatic control group receiving either the usual home program based on electrostimulation and McKenzie Therapy and e-Health intervention. Patients are followed up at 2 and 6 months. The primary outcomes are (1) acceptability and demand of the intervention by GPs, physiotherapists and patients and (2) feasibility and optimal study design/methods for a definitive trial. Secondary outcomes will include analysis in the clinical outcomes of pain, disability, fear of movement, quality of life, isometric resistance of the trunk flexors, lumbar anteflexion and lumbar segmental range of motion.

DISCUSSION

The specific e-Health programs to home could increase adherence to treatment, prevent stages of greater pain and disability, and improve the painful symptomatology.

CONCLUSIONS

The e-Health programs could be an effective healthcare tool that can reach a large number of people living in rural or remote areas.

Kabat Rehabilitation in Facial Nerve Palsy after Parotid Gland Tumor Surgery: A Case-Control Study

Temporary facial nerve palsy after parotid tumor surgery ranges from 14 to 65%, depending on surgery, tumor type, and subsite. The study aimed to evaluate the role of Kabat physical rehabilitation in the outcomes of patients affected by severe facial nerve palsy following parotid gland surgery. The results and clinical data of two groups, Kabat and non-Kabat (control), were statistically compared. Descriptive statistics, the multiple linear regression model, difference in difference approach, and the generalized linear model were used. F-Test, Chi-square test, McFadden R-squared, and adjusted R-squared were used to assess the significance. The results showed that the House–Brackmann (HB) stage of patients who had physiotherapy performed were lower than the control group. The decrease of HB staging in the Kabat group at 3 months was −0.71 on average, thus the probability of having a high HB stage decreased by about 13% using Kabat therapy. The results are statistically significant, and indicated that when the Kabat rehabilitation protocol is performed, mainly in the cases of a high-grade HB score, the patients showed a better and faster improvement in postoperative facial nerve palsy.

Health Care Students' Perspectives on Artificial Intelligence: Countrywide Survey in Canada

BACKGROUND

Artificial intelligence (AI) is no longer a futuristic concept; it is increasingly being integrated into health care. As studies on attitudes toward AI have primarily focused on physicians, there is a need to assess the perspectives of students across health care disciplines to inform future curriculum development.

OBJECTIVE

This study aims to explore and identify gaps in the knowledge that Canadian health care students have regarding AI, capture how health care students in different fields differ in their knowledge and perspectives on AI, and present student-identified ways that AI literacy may be incorporated into the health care curriculum.

METHODS

The survey was developed from a narrative literature review of topics in attitudinal surveys on AI. The final survey comprised 15 items, including multiple-choice questions, pick-group-rank questions, 11-point Likert scale items, slider scale questions, and narrative questions. We used snowball and convenience sampling methods by distributing an email with a description and a link to the web-based survey to representatives from 18 Canadian schools.

RESULTS

A total of 2167 students across 10 different health professions from 18 universities across Canada responded to the survey. Overall, 78.77% (1707/2167) predicted that AI technology would affect their careers within the coming decade and 74.5% (1595/2167) reported a positive outlook toward the emerging role of AI in their respective fields. Attitudes toward AI varied by discipline. Students, even those opposed to AI, identified the need to incorporate a basic understanding of AI into their curricula.

CONCLUSIONS

We performed a nationwide survey of health care students across 10 different health professions in Canada. The findings would inform student-identified topics within AI and their preferred delivery formats, which would advance education across different health care professions.

Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial

BACKGROUND

Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability.

METHODS

We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: ClinicalTrials.gov NCT02647658.

FINDINGS

Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2·1, 95% CI -4.9-0.6; p = 0.12). Opioids and imaging were prescribed in 22%-25% and 23%-26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups.

INTERPRETATION

There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines.

FUNDING

Patient-Centered Outcomes Research Institute (PCORI) contract # PCS-1402-10867.

Developing an mHealth app for post-stroke upper limb rehabilitation: Feedback from US and Ethiopian rehabilitation clinicians

Stroke is the leading cause of adult disability worldwide, with 70 percent of survivors exhibiting residual impairments of the upper limb that require frequent in-person visits to rehabilitation clinic over several months. This study explored rehabilitation clinician's preferences for design features to be included in an mHealth-enabled app for post-stroke upper limb rehabilitation. Data were collected via online survey, sampling participants from Ethiopia (n = 69) and the United States (n = 75). Survey results indicated that Ethiopian and US rehabilitation clinicians have different opinions about the importance of design features that should be included in a stroke tele-rehabilitation system which are likely due to differences in culture, the availability of human and physical resources, and how the field of rehabilitation is organized and managed. Our results, thus, indicate that mHealth technologies must be tailored to the geographical and cultural context of the end users.

Patients' perceptions of recovery following a 6-week exercise intervention for the treatment of patellofemoral pain: A mixed methods study

Background

Patellofemoral pain (PFP) is a common and complex condition. The diagnosis and causal mechanisms are not well understood and therefore the long-term prognosis tends to be poor. Exercise is currently the only evidence-based treatment strategy suggested to improve pain and function in the long term. However, no qualitative studies have been conducted to establish patients’ perceptions of recovery in the long term following an exercise intervention.

Objectives

To measure self-reported recovery on a 7-point Likert scale in 31 participants with PFP 6 months after a 6-week physiotherapy intervention. To explore the subjective accounts of patients who received a physiotherapy intervention for PFP, regarding their expectations and perceptions of recovery.

Method

Semi-structured exit interviews were conducted electronically 6 months after intervention to ascertain the patients’ perspectives on whether expectations of treatment were met, and factors that influenced their recovery experience.

Results

Quantitative analysis of self-reported recovery on a 7-point Likert scale showed that 48.4% of participants felt that they were ‘recovered’. Qualitative analysis showed three main categories: expectations of treatment, perceptions of recovery and changes in functional abilities.

Conclusion

Clinicians should address patients’ expectations of treatment and include the patients in decision-making regarding their treatment. Long-term follow-up is essential to ensure that treatment effects have been maintained, and this should include information about patients’ self-reported recovery.

Clinical implications

This study suggests that patients’ expectations of treatment and perceptions of recovery from PFP may influence prognosis. Clinicians need to collaborate with patients and involve them in decision-making to achieve their goals. An individualised treatment approach is essential to adequately address patients’ experiences, priorities and beliefs.

Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial)

BACKGROUND

Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP.

METHODS AND STUDY DESIGN

The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently.

DISCUSSION

The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT.

TRIAL REGISTRATION

ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.

Assessing physiotherapists' communication skills for promoting patient autonomy for self-management: reliability and validity of the communication evaluation in rehabilitation tool

PURPOSE

To assess the inter-rater reliability and concurrent validity of the Communication Evaluation in Rehabilitation Tool, which aims to externally assess physiotherapists competency in using Self-Determination Theory-based communication strategies in practice.

MATERIALS AND METHODS

Audio recordings of initial consultations between 24 physiotherapists and 24 patients with chronic low back pain in four hospitals in Ireland were obtained as part of a larger randomised controlled trial. Three raters, all of whom had Ph.Ds in psychology and expertise in motivation and physical activity, independently listened to the 24 audio recordings and completed the 18-item Communication Evaluation in Rehabilitation Tool. Inter-rater reliability between all three raters was assessed using intraclass correlation coefficients. Concurrent validity was assessed using Pearson's r correlations with a reference standard, the Health Care Climate Questionnaire.

RESULTS

The total score for the Communication Evaluation in Rehabilitation Tool is an average of all 18 items. Total scores demonstrated good inter-rater reliability (Intraclass Correlation Coefficient (ICC) = 0.8) and concurrent validity with the Health Care Climate Questionnaire total score (range: r = 0.7-0.88). Item-level scores of the Communication Evaluation in Rehabilitation Tool identified five items that need improvement.

CONCLUSION

Results provide preliminary evidence to support future use and testing of the Communication Evaluation in Rehabilitation Tool. Implications for Rehabilitation Promoting patient autonomy is a learned skill and while interventions exist to train clinicians in these skills there are no tools to assess how well clinicians use these skills when interacting with a patient. The lack of robust assessment has severe implications regarding both the fidelity of clinician training packages and resulting outcomes for promoting patient autonomy. This study has developed a novel measurement tool Communication Evaluation in Rehabilitation Tool and a comprehensive user manual to assess how well health care providers use autonomy-supportive communication strategies in real world-clinical settings. This tool has demonstrated good inter-rater reliability and concurrent validity in its initial testing phase. The Communication Evaluation in Rehabilitation Tool can be used in future studies to assess autonomy-supportive communication and undergo further measurement property testing as per our recommendations.

Social psychological aspects of ACL injury prevention and rehabilitation: An integrated model for behavioral adherence

Managing rehabilitation for ACL injury is dependent on uptake of, and compliance with, medical and safety recommendations. In this paper, we propose a multi-theory model that integrates self-determination theory and the theory of planned behavior to identify the motivational determinants ACL injury prevention and management behaviors and the processes involved.

Randomised non-inferiority trial: 1600 mg versus 400 mg tablets of mesalazine for the treatment of mild-to-moderate ulcerative colitis

BACKGROUND

High concentration mesalazine formulations are more convenient than conventional low concentration formulations for the treatment of ulcerative colitis (UC).

AIM

To compare the efficacy and safety of 1600 mg and 400 mg tablet mesalazine formulations.

METHODS

Patients with mild-to-moderate active UC (Mayo Clinic Score >5; N=817) were randomised to 3.2 g of oral mesalazine, administered as two 1600 mg tablets once, or four 400 mg tablets twice daily. We hypothesised that treatment with the 1600 mg tablet was non-inferior (within a 10% margin) to the 400 mg tablet for induction of clinical and endoscopic remission at week 8. Open-label treatment with the 1600 mg tablet continued for 26-30 weeks based on induction response. Predictors of treatment response were also explored.

RESULTS

At week 8, remission occurred in 22.4% and 24.6% of patients receiving the 1600 mg and 400 mg tablets, respectively (absolute difference -2.2%, 95% CI: -8.1% to 3.8%, non-inferiority P=.005). Endoscopic and histopathologic disease activity, leucocyte concentration and age were significantly associated with clinical remission (P=.022, .042, .014 and .023, respectively). At week 38, 43.9% (296/675) of patients who continued treatment with the 1600 mg formulation were in remission, including 70.3% (142/202) of patients who received a reduced dose of mesalazine (1.6 g/d). The overall incidence of serious adverse events was low.

CONCLUSIONS

Induction therapy with 3.2 mg mesalazine using two 1600 mg tablets once-daily was statistically and clinically non-inferior to a twice-daily regimen using four 400 mg tablets (NCT01903252).

What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis

BACKGROUND

Musculoskeletal physical therapy involves both specific and nonspecific effects. Nonspecific variables associated with the patient, therapist, and setting may influence clinical outcomes. Recent quantitative research has shown that nonspecific factors, including patient-therapist interactions, can influence treatment outcomes. It remains unclear, however, what factors influence patient-therapist interaction.

PURPOSE

This qualitative systematic review and meta-synthesis investigated patients' and physical therapists' perceptions of factors that influence patient-therapist interactions.

DATA SOURCES

Eleven databases were searched independently.

STUDY SELECTION

Qualitative studies examining physical therapists' and patients' perceptions of factors that influence patient-therapist interactions in musculoskeletal settings were included.

DATA EXTRACTION

Two reviewers independently selected articles, assessed methodological quality using the Critical Appraisal Skills Programme (CASP), and performed the 3 stages of analysis: extraction of findings, grouping of findings (codes), and abstraction of findings.

DATA SYNTHESIS

Thirteen studies were included. Four themes were perceived to influence patient-therapist interactions: (1) physical therapist interpersonal and communication skills (ie, presence of skills such as listening, encouragement, confidence, being empathetic and friendly, and nonverbal communication), (2) physical therapist practical skills (ie, physical therapist expertise and level of training, although the ability to provide good education was considered as important only by patients), (3) individualized patient-centered care (ie, individualizing the treatment to the patient and taking patient's opinions into account), and (4) organizational and environmental factors (ie, time and flexibility with care and appointments).

LIMITATIONS

Only studies published in English were included.

CONCLUSIONS

A mix of interpersonal, clinical, and organizational factors are perceived to influence patient-therapist interactions, although research is needed to identify which of these factors actually influence patient-therapist interactions. Physical therapists' awareness of these factors could enhance patient interactions and treatment outcomes. Mechanisms to best enhance these factors in clinical practice warrant further study.

Using intervention mapping to develop a theory-driven, group-based complex intervention to support self-management of osteoarthritis and low back pain (SOLAS)

BACKGROUND

The Medical Research Council framework provides a useful general approach to designing and evaluating complex interventions, but does not provide detailed guidance on how to do this and there is little evidence of how this framework is applied in practice. This study describes the use of intervention mapping (IM) in the design of a theory-driven, group-based complex intervention to support self-management (SM) of patients with osteoarthritis (OA) and chronic low back pain (CLBP) in Ireland's primary care health system.

METHODS

The six steps of the IM protocol were systematically applied to develop the self-management of osteoarthritis and low back pain through activity and skills (SOLAS) intervention through adaptation of the Facilitating Activity and Self-management in Arthritis (FASA) intervention. A needs assessment including literature reviews, interviews with patients and physiotherapists and resource evaluation was completed to identify the programme goals, determinants of SM behaviour, consolidated definition of SM and required adaptations to FASA to meet health service and patient needs and the evidence. The resultant SOLAS intervention behavioural outcomes, performance and change objectives were specified and practical application methods selected, followed by organised programme, adoption, implementation and evaluation plans underpinned by behaviour change theory.

RESULTS

The SOLAS intervention consists of six weekly sessions of 90-min education and exercise designed to increase participants' physical activity level and use of evidence-based SM strategies (i.e. pain self-management, pain coping, healthy eating for weight management and specific exercise) through targeting of individual determinants of SM behaviour (knowledge, skills, self-efficacy, fear, catastrophizing, motivation, behavioural regulation), delivered by a trained physiotherapist to groups of up to eight individuals using a needs supportive interpersonal style based on self-determination theory. Strategies to support SOLAS intervention adoption and implementation included a consensus building workshop with physiotherapy stakeholders, development of a physiotherapist training programme and a pilot trial with physiotherapist and patient feedback.

CONCLUSIONS

The SOLAS intervention is currently being evaluated in a cluster randomised controlled feasibility trial. IM is a time-intensive collaborative process, but the range of methods and resultant high level of transparency is invaluable and allows replication by future complex intervention and trial developers.

Theory-driven group-based complex intervention to support self-management of osteoarthritis and low back pain in primary care physiotherapy: protocol for a cluster randomised controlled feasibility trial (SOLAS)

INTRODUCTION

International clinical guidelines consistently endorse the promotion of self-management (SM), including physical activity for patients with chronic low back pain (CLBP) and osteoarthritis (OA). Patients frequently receive individual treatment and advice to self-manage from physiotherapists in primary care, but the successful implementation of a clinical and cost-effective group SM programme is a key priority for health service managers in Ireland to maximise long-term outcomes and efficient use of limited and costly resources.

METHODS/ANALYSIS

This protocol describes an assessor-blinded cluster randomised controlled feasibility trial of a group-based education and exercise intervention underpinned by self-determination theory designed to support an increase in SM behaviour in patients with CLBP and OA in primary care physiotherapy. The primary care clinic will be the unit of randomisation (cluster), with each clinic randomised to 1 of 2 groups providing the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) intervention or usual individual physiotherapy. Patients are followed up at 6 weeks, 2 and 6 months. The primary outcomes are the (1) acceptability and demand of the intervention to patients and physiotherapists, (2) feasibility and optimal study design/procedures and sample size for a definitive trial. Secondary outcomes include exploratory analyses of: point estimates, 95% CIs, change scores and effect sizes in physical function, pain and disability outcomes; process of change in target SM behaviours and selected mediators; and the cost of the intervention to inform a definitive trial.

ETHICS/DISSEMINATION

This feasibility trial protocol was approved by the UCD Human Research Ethics-Sciences Committee (LS-13-54 Currie-Hurley) and research access has been granted by the Health Services Executive Primary Care Research Committee in January 2014. The study findings will be disseminated to the research, clinical and health service communities through publication in peer-reviewed journals, presentation at national and international academic and clinical conferences.

TRIAL REGISTRATION NUMBER

ISRCTN 49875385; Pre-results.

A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation

Background

Clinical practice guidelines for the treatment of low back pain suggest the inclusion of a biopsychosocial approach in which patient self-management is prioritized. While many physiotherapists recognise the importance of evidence-based practice, there is an evidence practice gap that may in part be due to the fact that promoting self-management necessitates change in clinical behaviours. Evidence suggests that a patient’s motivation and maintenance of self-management behaviours can be positively influenced by the clinician’s use of an autonomy supportive communication style. Therefore, the aim of this study was to develop and pilot-test the feasibility of a theoretically derived implementation intervention to support physiotherapists in using an evidence-based autonomy supportive communication style in practice for promoting patient self-management in clinical practice.

Methods

A systematic process was used to develop the intervention and pilot-test its feasibility in primary care physiotherapy. The development steps included focus groups to identify barriers and enablers for implementation, the theoretical domains framework to classify determinants of change, a behaviour change technique taxonomy to select appropriate intervention components, and forming a testable theoretical model. Face validity and acceptability of the intervention was pilot-tested with two physiotherapists and monitoring their communication with patients over a three-month timeframe.

Results

Using the process described above, eight barriers and enablers for implementation were identified. To address these barriers and enablers, a number of intervention components were selected ranging from behaviour change techniques such as, goal-setting, self-monitoring and feedback to appropriate modes of intervention delivery (i.e. continued education meetings and audit and feedback focused coaching). Initial pilot-testing revealed the acceptability of the intervention to recipients and highlighted key areas for refinement prior to scaling up for a definitive trial.

Conclusion

The development process utilised in this study ensured the intervention was theory-informed and evidence-based, with recipients signalling its relevance and benefit to their clinical practice. Future research should consider additional intervention strategies to address barriers of social support and those beyond the clinician level.

Exploring the effect of space and place on response to exercise therapy for knee and hip pain--a protocol for a double-blind randomised controlled clinical trial: the CONEX trial

INTRODUCTION

Context effects are described as effects of a given treatment, not directly caused by the treatment itself, but rather caused by the context in which treatment is delivered. Exercise is a recommended core treatment in clinical guidelines for musculoskeletal disorders. Although moderately effective overall, variation is seen in size of response to exercise across randomised controlled trial (RCT) studies. Part of this variation may be related to the fact that exercise interventions are performed in different physical environments, which may affect participants differently. The study aims to investigate the effect of exercising in a contextually enhanced physical environment for 8 weeks in people with knee or hip pain.

METHODS AND ANALYSIS

The study is a double-blind RCT. Eligible participants are 35 years or older with persisting knee and/or hip pain for 3 months. Participants are randomised to one of three groups: (1) exercise in a contextually enhanced environment, (2) exercise in a standard environment and (3) waiting list. The contextually enhanced environment is located in a newly built facility, has large windows providing abundant daylight and overlooks a recreational park. The standard environment is in a basement, has artificial lighting and is marked by years of use; that is, resembling many clinical environments. The primary outcome is the participant's global perceived effect rated on a seven-point Likert scale after 8 weeks exercise. Patient-reported and objective secondary outcomes are included.

ETHICS AND DISSEMINATION

The Regional Scientific Ethical Committee for Southern Denmark has approved the study. Study findings will be disseminated in peer-reviewed publications and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02043613.

Effect of a self-determination theory-based communication skills training program on physiotherapists' psychological support for their patients with chronic low back pain: a randomized controlled trial

OBJECTIVE

To examine the effects of communication skills training on physiotherapists' supportive behavior during clinical practice.

DESIGN

Randomized trial.

SETTING

Hospital outpatient physiotherapy clinics.

PARTICIPANTS

Physiotherapists (N=24) and patients (N=24) with chronic low back pain.

INTERVENTIONS

Two hospital clinics were randomly assigned to the intervention arm. Physiotherapists (n=12) received 8 hours of communication skills training focused on supporting patients' psychological needs. Physiotherapists (n=12) from 2 other hospital clinics formed a waitlist control arm.

MAIN OUTCOME MEASURES

Verbal communication between each physiotherapist and a patient was recorded on an audiotape, and independent, blinded raters used the Health Care Climate Questionnaire to assess physiotherapists' needs-supportive behavior (primary outcome).

RESULTS

Independent raters' Health Care Climate Questionnaire scores favored the intervention arm (Cohen's d=2.27; P<.01).

CONCLUSIONS

Compared with controls, independent ratings demonstrated that physiotherapists who completed the Communication style and exercise compliance in physiotherapy training were found to provide greater support for patients' needs in a single assessed session. Long-term maintenance of this needs-supportive behavior should be examined.

A cluster-randomised controlled trial of a physical activity and nutrition programme in retirement villages: a study protocol

INTRODUCTION

Physical activity levels of Australia's ageing population are declining and coincidentally rates of overweight and obesity are increasing. Adequate levels of physical activity and a healthy diet are recognised as important lifestyle factors for the maintenance of a healthy weight and prevention of chronic diseases. Retirement village (RV) residents rarely engage in physical activity and nutrition programmes offered, with poor attendance and low use of existing facilities such as on-site fitness centres and classes and nutrition seminars. The RV provides a unique setting to access and engage with this older target group, to test the effectiveness of strategies to increase levels of physical activity, improve nutrition and maintain a healthy weight.

METHOD AND ANALYSIS

This cluster-randomised controlled trial will evaluate a physical activity, nutrition and healthy weight management intervention for insufficiently active ('not achieving 150 min of moderate-intensity physical activity per week') adults aged 60-75 residing in RV's. A total of 400 participants will be recruited from 20 randomly selected RV's in Perth, Western Australia. Villages will be assigned to either the intervention group (n=10) or the control group (n=10) each containing 200 participants. The Retirement Village Physical Activity and Nutrition for Seniors (RVPANS) programme is a home-based physical activity and nutrition programme that includes educational resources, along with facilitators who will motivate and guide the participants during the 6-month intervention. Descriptive statistics and mixed regression models will be performed to assess the intervention effects. This trial will evaluate an intervention for the modification of health risk factors in the RV setting. Such research conducted in RV's has been limited.

ETHICS AND DISSEMINATION

Curtin University Human Research Ethics Committee (approval number: HR128/2012). Dissemination of the study results will occur through publications, reports, conference presentations and community seminars.

TRIAL REGISTRATION NUMBER

Australia and New Zealand Clinical Trial Registry (ACTRN12612001168842).

Pedometer-driven walking for chronic low back pain: a feasibility randomized controlled trial

OBJECTIVES

To evaluate the feasibility of an RCT of a pedometer-driven walking program and education/advice to remain active compared with education/advice only for treatment of chronic low back pain (CLBP).

METHODS

Fifty-seven participants with CLBP recruited from primary care were randomly allocated to either: (1) education/advice (E, n=17) or (2) education/advice plus an 8-week pedometer-driven walking program (EWP, n=40). Step targets, actual daily step counts, and adverse events were recorded in a walking diary over the 8 weeks of intervention for the EWP group only. All other outcomes (eg, functional disability using the Oswestry Disability Questionnaire (ODQ), pain scores, physical activity (PA) measurement etc.) were recorded at baseline, week 9 (immediately post-intervention), and 6 months in both groups.

RESULTS

The recruitment rate was 22% and the dropout rate was lower than anticipated (13% to 18% at 6 mo). Adherence with the EWP was high, 93% (n=37/40) walked for ≥ 6 weeks, and increased their steps/day (mean absolute increase in steps/d, 2776, 95% confidence interval [CI], 1996-3557) by 59% (95% CI, 40.73%-76.25%) from baseline. Mean percentage adherence with weekly step targets was 70% (95% CI, 62%-77%). Eight (20%) minor-related adverse events were observed in 13% (5/40) of the participants. The EWP group participants demonstrated an 8.2% point improvement (95% CI, -13 to -3.4) on the ODQ at 6 months compared with 1.6% points (95% CI, -9.3 to 6.1) for the E group (between group d=0.44). There was also a larger mean improvement in pain (d=0.4) and a larger increase in PA (d=0.59) at 6 months in EWP.

DISCUSSION

This preliminary study demonstrated that a main RCT is feasible. EWP was safe and produced a real increase in walking; CLBP function and pain improved, and participants perceived a greater improvement in their PA levels. These improvements require confirmation in a fully powered RCT.

The effect of regular physical activity on bone mineral density in post-menopausal women aged 75 and over: a retrospective analysis from the Canadian multicentre osteoporosis study

Background

Physical activity is known to benefit many physiological processes, including bone turnover. There are; however, currently no clinical guidelines regarding the most appropriate type, intensity and duration of activity to prevent bone loss.

Methods

To help address this gap in the literature, we performed a retrospective analysis of data from the Canadian Multicentre Osteoporosis Study (CaMos), a prospective cohort of 9423 adult patients, to determine the relationship between the amount of regular daily physical activity performed and bone mineral density. A total of 1169 female participants aged 75 and over provided information regarding their daily activity levels, including the amount of time spent each week performing physical activity at varying levels of intensity. Multiple and linear regression analyses were used to determine the effect of increasing amounts of this regular physical activity on bone mineral density.

Results

The results indicate that a step increase in the amount of physical activity performed each day resulted in a positive effect on bone mineral density at the hip, Ward’s triangle, trochanter and femoral neck (B = 0.006 to 0.008, p < 0.05). Possible confounding factors such as the use of anti-resorptive therapy, body mass index and age were included in the analysis and suggested that age had a negative effect on bone density while body mass index had a positive effect. Anti-resorptive therapy provided a protective effect against loss of bone density.

Conclusions

The data indicate that a step increase in the amount of daily activity, using simple, daily performed tasks, can help prevent decreases in post-menopausal bone mineral density.

Foot orthoses for the management of low back pain: a qualitative approach capturing the patient's perspective

BACKGROUND

The onset of non specific low back pain is associated with heavy lifting, age, female gender, and poor general health, with psychological factors being predictors of it becoming chronic. Additionally, it is thought that altered lower limb biomechanics are a contributory factor, with foot orthoses increasingly being considered as an appropriate intervention by physiotherapists and podiatrists. However, research into the effect of foot orthoses is inconclusive, primarily focusing on the biomechanical effect and not the symptomatic relief from the patient's perspective. The aim of this study was to explore the breadth of patients' experiences of being provided with foot orthoses and to evaluate any changes in their back pain following this experience.

METHOD

Following ethical approval, participants (n = 25) with non-specific low back pain associated with altered lower limb biomechanics were provided with customised foot orthoses. At 16 weeks after being provided with the foot orthoses, conversational style interviews were carried out with each patient. An interpretivistic phenomenological approach was adopted for the data collection and analysis.

RESULTS

For these participants, foot orthoses appeared to be effective. However, the main influence on this outcome was the consultation process and a patient focussed approach. The consultation was an opportunity for fostering mutual understanding, with verbal and visual explanation reassuring the patient and this influenced the patient's beliefs, their engagement with the foot orthoses (physical) and their experience of low back pain (psychological).

CONCLUSION

Clinicians need to adopt 'psychologically informed practice' in relation to the provision of foot orthoses. Likewise, researchers should consider all the influencing factors found in this study, both in relation to their study protocol and the outcomes they plan to measure.