Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting (protocol)

Reliability, validity, and cultural adaptation of the Persian version of the Exercise Adherence Rating Scale (EARS) in patients with knee osteoarthritis

OBJECTIVES

The aim of this study was to culturally adapt and assess the validity and reliability of the Exercise Adherence Rating Scale (EARS) in Persian language for patients with knee osteoarthritis.

METHODS

The original English version of the EARS was forward-translated to Persian (by an expert and a non-expert in the field of exercise and health science) and then backward-translated to English by two people, and then by a committee of five, pre-final Persian version of EARS was created. Patients were provided with a three-month exercise program, three times a week, through telerehabilitation. After completion of the exercise program, patients filled out the Persian version of EARS and the Scanlan questionnaire. Three weeks later, patients completed the EARS and Scanlan questionnaire again. During the study, patients recorded the number of exercise sessions weekly in a standardized diary form. Face validity was assessed by ten patients, using the item impact method. Content validity was assessed by five experts and quantified using the content validity ratio and content validity index. Agreement between EARS and Scanlan questionnaire was assessed using Spearman test and Bland-Altman plot. The reliability of the Persian version of EARS was assessed using the intraclass correlation coefficient and Cronbach's α.

RESULTS

A total of 30 patients (3 men, 27 women), with a mean age of 59 years (SD ​= ​10), participated in this study. All items of the Persian version of EARS had item impact method scores above 1.5, indicating acceptable face validity. The scale-content validity index/average for relevancy and simplicity components were calculated as 0.87 and 0.85, respectively, indicating good content validity. Bland-Altman plot showed good agreement between EARS and Scanlan questionnaire at baseline and three weeks later. Cronbach's alpha was 0.96, indicating excellent internal consistency. The intraclass correlation coefficient (95% CI) was 0.996 (0.991, 0.998), indicating excellent reliability.

CONCLUSIONS

The Persian version of EARS demonstrated acceptable cultural adaptation, reliability, and validity in patients with knee osteoarthritis. The use of the Persian version of EARS can be a reliable and valid tool to assess exercise adherence in patients with knee osteoarthritis.

LEVEL OF THE EVIDENCE

II.

Development and Feasibility Testing of a Remote Support Application for Adherence to Home Exercise Programs: A Randomized Pilot Study

Objectives

Poor adherence to home exercise programs (HEPs) is a significant barrier to continuity of care and eventual outcomes, thus requiring innovative mitigating approaches. This study aimed to develop and test the feasibility of a remote support application (RSA) designed to encourage adherence to HEPs.

Methods

Using standard computer programing, an RSA with administrator and user interfaces was developed for mobile phone or tablet. Consenting patients receiving physiotherapy for musculoskeletal conditions (n=19) were randomly assigned into the experimental group (n=10) or the control group (n=9). The experimental group received their customized HEP reminders via the RSA, whereas the control group used conventional paper handouts for HEPs. Adherence to HEPs was assessed over 4 weeks. The feasibility of the RSA was assessed using the Mobile Application Rating Scale and System Usability Scale (SUS) questionnaires. Data were summarized using descriptive and inferential statistics.

Results

The adherence rate of patients in experimental group was significantly higher than that of patients in the control group after 2 weeks [median diff.=-6.0, 95% confidence interval (CI): -8.0 to -5.0; U=5.00; Z=-3.304; P=0.001; r=0.75] and 4 weeks (median diff.=-7.0, 95% CI: -8.0 to -5.0; U=0; Z=-3.695; P<0.001; r=0.84) of intervention. The RSA had a mean SUS score of 82.53±9.04 (out of 100) and a mean app quality rating score of 75.95±4.98 (out of 95).

Conclusions

The use of an RSA to improve adherence to HEPs is feasible for patients with musculoskeletal conditions.

Effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

The objective of the study was to evaluate the effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis (KOA).

METHODS

Five databases (PubMed, Embase, Cochrane Library, CINAHL, Web of Science Core Collection) were searched for relevant randomized controlled trials (RCTs) published from database inception to 2 August 2022. The Cochrane Collaboration's standards were followed for study selection, eligibility criteria, data extraction and statistics, using the Cochrane Collaboration Risk of Bias Tool and PEDro for quality assessment. A meta-analysis and subgroup analyses, stratified by control condition and intervention duration, were conducted using RevMan 5.4. The study was reported in compliance with the PRISMA statement.

RESULTS

A total of 12 independent RCTs with 1442 participants were included. The meta-analysis showed that the home-based exercise interventions significantly reduced pain in individuals with KOA (SMD =  - 0.32, 95% CI [- 0.41, - 0.22], p < .01) and improved physical function (SMD =  - 0.25, 95% CI [- 0.47, - 0.02], p = .03) and quality of life (SMD = 0.63, 95% CI [0.41, 0.85], p < .001). Subgroup analysis revealed that home-based exercise interventions were superior to health education and no treatment, in terms of pain and physical function, and similar to clinic-based exercise and pharmacologic treatment.

CONCLUSIONS

The effect of home-based exercise intervention is significantly better than health education and no treatment for reducing knee pain and improving physical function, and was able to achieve the effects of clinic-based exercise treatment and pharmacologic treatment. With regard to quality of life, the unsupervised home strength exercise intervention showed a significant effect compared with the health education control and combined with cognitive behavioural therapies may produce better results. Although home-based intervention provides effective treatment options for individuals with clinical treatment limitations, individual disease complications and the dosimetry of exercise need to be considered in practice. Furthermore, growing evidence supports the effectiveness of Tai Chi in the rehabilitation of KOA.

What are the unsupervised exercise adherence rates in clinical trials for knee osteoarthritis? A systematic review

BACKGROUND

Exercise is an effective intervention for knee osteoarthritis (OA), and unsupervised exercise programs should be a common adjunct to most treatments. However, it is unknown if current clinical trials are capturing information regarding adherence.

OBJECTIVE

To summarize the extent and quality of reporting of unsupervised exercise adherence in clinical trials for knee OA.

METHODS

Reviewers searched five databases (PubMed, CINAHL, Medline (OVID), EMBASE and Cochrane). Randomized controlled trials where participants with knee OA engaged in an unsupervised exercise program were included. The extent to which exercise adherence was monitored and reported was assessed and findings were subgrouped according to method for tracking adherence. The types of adherence measurement categories were synthesized. A quality assessment was completed using the Physiotherapy Evidence Database (PEDro) scores.

RESULTS

Of 3622 abstracts screened, 176 studies met criteria for inclusion. PEDro scores for study quality ranged from two to ten (mean=6.3). Exercise adherence data was reported in 72 (40.9%) studies. Twenty-six (14.8%) studies only mentioned collection of adherence. Adherence rates ranged from 3.7 to 100% in trials that reported adherence. For 18 studies (10.2%) that tracked acceptable adherence, there was no clear superiority in treatment effect based on adherence rates.

CONCLUSIONS

Clinical trials for knee OA do not consistently collect or report adherence with unsupervised exercise programs. Slightly more than half of the studies reported collecting adherence data while only 40.9% reported findings with substantial heterogeneity in tracking methodology. The clinical relevance of these programs cannot be properly contextualized without this information.

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.

Evaluation of at-home physiotherapy

An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise. A smartwatch was used to collect inertial data from 42 patients performing shoulder physiotherapy exercises for rotator cuff injuries in both in-clinic and at-home settings. A two-stage ML approach was used to detect out-of-distribution (OOD) data (to remove non-exercise data) and subsequently for classification of exercises. We evaluated the performance impact of grouping exercises by motion type, inclusion of non-exercise data for algorithm training, and a patient-specific approach to exercise classification. Algorithm performance was evaluated using both in-clinic and at-home data. The patient-specific approach with engineered features achieved the highest in-clinic performance for differentiating physiotherapy exercise from non-exercise activity (area under the receiver operating characteristic (AUROC) = 0.924). Including non-exercise data in algorithm training further improved classifier performance (random forest, AUROC = 0.985). The highest accuracy achieved for classifying individual in-clinic exercises was 0.903, using a patient-specific method with deep neural network model extracted features. Grouping exercises by motion type improved exercise classification. For at-home data, OOD detection yielded similar performance with the non-exercise data in the algorithm training (fully convolutional network AUROC = 0.919). Including non-exercise data in algorithm training improves detection of exercises. A patient-specific approach leveraging data from earlier patient-supervised sessions should be considered but is highly dependent on per-patient data quality.

Physiotherapy Exercise Classification with Single-Camera Pose Detection and Machine Learning

Access to healthcare, including physiotherapy, is increasingly occurring through virtual formats. At-home adherence to physical therapy programs is often poor and few tools exist to objectively measure participation. The aim of this study was to develop and evaluate the potential for performing automatic, unsupervised video-based monitoring of at-home low-back and shoulder physiotherapy exercises using a mobile phone camera. Joint locations were extracted from the videos of healthy subjects performing low-back and shoulder physiotherapy exercises using an open source pose detection framework. A convolutional neural network was trained to classify physiotherapy exercises based on the segments of keypoint time series data. The model's performance as a function of input keypoint combinations was studied in addition to its robustness to variation in the camera angle. The CNN model achieved optimal performance using a total of 12 pose estimation landmarks from the upper and lower body (low-back exercise classification: 0.995 ± 0.009; shoulder exercise classification: 0.963 ± 0.020). Training the CNN on a variety of angles was found to be effective in making the model robust to variations in video filming angle. This study demonstrates the feasibility of using a smartphone camera and a supervised machine learning model to effectively classify at-home physiotherapy participation and could provide a low-cost, scalable method for tracking adherence to physical therapy exercise programs in a variety of settings.

Artificial Intelligence in the Management of Rotator Cuff Tears

Technological innovation is a key component of orthopedic surgery. Artificial intelligence (AI), which describes the ability of computers to process massive data and "learn" from it to produce outputs that mirror human cognition and problem solving, may become an important tool for orthopedic surgeons in the future. AI may be able to improve decision making, both clinically and surgically, via integrating additional data-driven problem solving into practice. The aim of this article will be to review the current applications of AI in the management of rotator cuff tears. The article will discuss various stages of the clinical course: predictive models and prognosis, diagnosis, intraoperative applications, and postoperative care and rehabilitation. Throughout the article, which is a review in terms of study design, we will introduce the concept of AI in rotator cuff tears and provide examples of how these tools can impact clinical practice and patient care. Though many advancements in AI have been made regarding evaluating rotator cuff tears-particularly in the realm of diagnostic imaging-further advancements are required before they become a regular facet of daily clinical practice.

Adherence to a home physical exercise program in patients with osteoporotic vertebral fractures: A retrospective observational study

BACKGROUND

Adherence to treatment is one of the most common problems in patients suffering from chronic disease such as osteoporosis, and special commitment is required to patients, especially regarding rehabilitation. There is increasing evidence that physical interventions aimed at relieving pain and reducing physical impairments could play a crucial role in improving the quality of life and reducing the risk of fractures in patients with severe osteoporosis.

OBJECTIVE

The aim of this study was to assess the compliance and determine the acceptability of a home-self-managed exercises program in patients with vertebral fractures, one of the most frequent and serious consequences of osteoporosis.

METHODS

We conducted a retrospective observational study of patients undergoing a home exercise program, monitoring them with clinical scales, questionnaires, and routine visits.

RESULTS

62.86% of the patients were compliant with the treatment; the absence of supervision by health personnel was the primary cause of non-compliance, followed by the lack of time and the lack of motivation. Compliant patients showed a significant reduction in lumbar pain (p 0.011), an improvement in posture with a reduction of dorsal kyphosis (occipital-wall distance T0-T1, p-value = 0.02) and an improvement in QoL (p-value = 0.001) and physical performance at the 20 m walking test (p-value = 0.003).

CONCLUSIONS

A home exercise program is feasible and could improve signs and symptoms in patients with vertebral fractures due to OP.

Using Large-Scale Sensor Data to Test Factors Predictive of Perseverance in Home Movement Rehabilitation: Optimal Challenge and Steady Engagement

Persevering with home rehabilitation exercise is a struggle for millions of people in the US each year. A key factor that may influence motivation to engage with rehabilitation exercise is the challenge level of the assigned exercises, but this hypothesis is currently supported only by subjective, self-report. Here, we studied the relationship between challenge level and perseverance using long-term, self-determined exercise patterns of a large number of individuals (N = 2,581) engaging in home rehabilitation with a sensor-based exercise system without formal supervision. FitMi is comprised of two puck-like sensors and a library of 40 gamified exercises for the hands, arms, trunk, and legs that are designed for people recovering from a stroke. We found that individuals showed the greatest perseverance with the system over a 2-month period if they had (1) a moderate level of motor impairment and (2) high but not perfect success during the 1st week at completing the exercise game. Further, a steady usage pattern (vs. accelerating or decelerating use) was associated with more overall exercise, and declines in exercise amount over time were associated with exponentially declining session initiation probability rather than decreasing amounts of exercise once a session was initiated. These findings confirm that an optimized challenge level and regular initiation of exercise sessions predict achievement of a greater amount of overall rehabilitation exercise in a group of users of commercial home rehabilitation technology and suggest how home rehabilitation programs and exercise technologies can be optimized to promote perseverance.

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.

Acceptability and deliverability of an auditory rhythmical cueing (ARC) training programme for use at home and outdoors to improve gait and physical activity post-stroke

BACKGROUND

Although laboratory studies demonstrate that training programmes using auditory rhythmical cueing (ARC) may improve gait post-stroke, few studies have evaluated this intervention in the home and outdoors where deployment may be more appropriate. This manuscript reports stakeholder refinement of an ARC gait and balance training programme for use at home and outdoors, and a study which assessed acceptability and deliverability of this programme.

METHODS

Programme design and content were refined during stakeholder workshops involving physiotherapists and stroke survivors. A two-group acceptability and deliverability study was then undertaken. Twelve patients post-stroke with a gait related mobility impairment received either the ARC gait and balance training programme or the gait and balance training programme without ARC. Programme provider written notes, participant exercise and fall diaries, adverse event monitoring and feedback questionnaires captured data about deliverability, safety and acceptability of the programmes.

RESULTS

The training programme consisted of 18 sessions (six supervised, 12 self-managed) of exercises and ARC delivered by a low-cost commercially available metronome. All 12 participants completed the six supervised sessions and 10/12 completed the 12 self-managed sessions. Provider and participant session written records and feedback questionnaires confirmed programme deliverability and acceptability.

CONCLUSION

An ARC gait and balance training programme refined by key stakeholders was feasible to deliver and acceptable to participants and providers.

TRIAL REGISTRATION

ISCTRN 12/03/2018.

A Pilot Study of a Sensor Enhanced Activity Management System for Promoting Home Rehabilitation Exercise Performed during the COVID-19 Pandemic: Therapist Experience, Reimbursement, and Recommendations for Implementation

Adherence to home exercise programs (HEPs) during physical rehabilitation is usually unmonitored and is thought to be low from self-reports. This article describes exploratory implementation of a Sensor Enhanced Activity Management (SEAM) system that combines HEP management software with a movement sensor for monitoring and motivating HEP adherence. The article also presents results from attempting to gain reimbursement for home use of the system with therapist oversight using Remote Physiologic Monitoring (RPM) codes. Four therapists used the system in their regular practice during the first six months of the COVID-19 pandemic. Therapists filled out surveys, kept notes, and participated in interviews. Billing and reimbursement data were obtained from the treatment facility. Exercise data from the SEAM system were used to understand HEP adherence. Patients were active for a mean of 40% (26% SD) of prescribed days and completed a mean of 25% (25% SD) of prescribed exercises. The therapists billed 23 RPM codes (USD 2353), and payers reimbursed eight of those instances (USD 649.21). The therapists reported that remote monitoring and the use of a physical movement sensor was motivating to their patients and increased adherence. Sustained technical support for therapists will likely improve implementation of new remote monitoring and treatment systems. RPM codes may enable reimbursement for review and program management activities, but, despite COVID-19 CMS waivers, organizations may have more success if these services are billed under supervision of a physician.

Impact of home exercise program on self-efficacy and quality of life among primary knee osteoarthritis patients: a randomized controlled clinical study

Background

Knee osteoarthritis (KOA) is a common joint disorder in elderly individuals, causing pain, loss of physical functioning, disability, and reduction of life quality. Home exercise programs (HEP) serve as a crucial complement to outpatient rehabilitation therapy, as they save the cost of supervised physical therapy sessions, while also offering a high level of treatment. The aim of this study was to evaluate the effectiveness of the 6-month HEP on pain, quality of life, and self-efficacy in patients with primary KOA and to identify the adherence level to exercises and associations with patients’ characteristics and clinical outcomes.

Results

After 6 months of HEP, there were statistically significant differences between groups for self-efficacy (p ≤ 0.001, from 58.29 to 71.5) (p = 0.23, from 55.98 to 57.72), quality of life (p ≤0.001, from 60.1 to 72.2) (p = 0.074, from 60.35 to 60.92), and pain severity (P ≤0.001, from 58.29 to 41.4) (P = 0.88, from 61.2 to 60.9) in favor of exercise group.

Conclusions

Home-based exercise program improves pain score, self-efficacy, and quality of life in patients with knee osteoarthritis. Adherence level to the exercise program may have a positive impact on patient improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43166-021-00073-2.

Client preferences and perceptions regarding a written home exercise program or video self-modeling: A cross-sectional study

STUDY DESIGN

This was a cross-sectional study.

INTRODUCTION

Home exercise programs (HEPs) are frequently prescribed to maximize a patient's recovery and ensure maintenance of therapeutic gains produced during supervised treatment. Improved understanding of patient preferences and incorporation of simple mobile health technologies may be beneficial strategies for improving patient HEP adherence.

PURPOSE

The purpose of this study was to determine client's preferred mode of home exercise program delivery when offered a choice between a cellular video and paper handout.

METHODS

A convenience sample was recruited from clients receiving services at an upper extremity rehabilitation facility. Participants were provided a paper handout with written instructions and an audiovisual recording of themselves performing the exercises. A questionnaire was developed to compare clients' preferences and perceptions. Quantitative data regarding patient preference were gathered and analyzed with descriptive statistics. Collected qualitative data were themed to determine the characteristics of home exercise programs (HEPs) perceived by patients.

RESULTS

A total of 30 patients participated in the study. Of the 29 responses regarding patient preference of HEP mode, 20 (69%) patients preferred a video, 4 (14%) patients preferred a paper handout, and 5 (17%) patients preferred both paper and video HEP. Patients with preference to a paper HEP reported the handout was helpful to be accessed in a simple manner and could be displayed as a visual reminder to perform the exercises. Those who preferred the cellular video reported increased understanding and confidence with accurate performance of exercises using audiovisual instructions.

DISCUSSION

HEP adherence enhancement techniques include improved understanding of patient preferences in order to facilitate customized client-centered treatment.

CONCLUSION

The majority of participants in this study preferred a mobile-based video HEP. Participants perceived the video as visually appealing and a more effective mode of instruction than paper handouts.

How I See Me-A Meta-Analysis Investigating the Association Between Identities and Pro-environmental Behaviour

Prolific research suggests identity associates with pro-environmental behaviours (PEBs) that are individual and/or group focused. Individual PEB is personally driven, self-reliant, and are conducted on one's own (e.g., home recycling). Group focused PEB is other people-reliant and completed as part of a group (e.g., attending meetings of an environmental organisation). A wide range of identities have been related to PEBs. For example, a recent systematic qualitative review revealed 99 different types of identities studied in a PEB context. Most studies were correlational, few had an experimental design. However, the relationships between all these identities and PEBs have so far not been tested quantitatively with meta-analytical techniques. As such, a clear overview of this field is currently lacking. Due to the diverse nature of the field, a priori hypotheses were not possible and relatively broad definitions of identity had to be used to encompass all types of identities and the diverse meanings of identity that have been included in PEB research. What prior theory did allow for was to assess the distinction between two main types of identity, namely how people label, describe, and recognise oneself individually (individual identity), or as part of a group (group identity). Our overall goal was thus to assess the current state of knowledge on identities and PEBs. In 104 studies using a meta-regression following the preferred reporting items for systematic reviews and meta-analyses guidelines, our random-effects meta-analysis showed that the overall concept of identity associated with PEB with a medium Pearson's r (Aim 1). Furthermore, we found that individual identities associated more strongly with PEBs than group identities (Aim 2). The associations between individual and group identities were stronger when the identity and PEB were from the same category (e.g., when both were group-focused; Aim 3). Methodologically, the findings revealed that group identities and group PEBs were most strongly associated for self-reported rather than observed PEBs (Aim 4). Overall identity associated most strongly with group PEBs in the field rather than in the lab (Aim 5) and in student- rather than non-student samples (Aim 6). We discuss the theoretical and practical implications.

Adherence Patterns and Dose Response of Physiotherapy for Rotator Cuff Pathology: Longitudinal Cohort Study

BACKGROUND

Physiotherapy is considered to be essential for the successful operative and nonoperative management of rotator cuff pathology; however, the extent to which patients adhere to assigned physiotherapy activities and how this impacts recovery is unknown.

OBJECTIVE

The purpose of this study was to measure the rate and patterns of participation in physiotherapy for rotator cuff disorders, assess the dose response between physiotherapy activity and recovery, and explore patient factors predictive of physiotherapy participation.

METHODS

We report a prospective longitudinal study of 42 patients undergoing physiotherapy for symptomatic rotator cuff pathology. The patients were issued a smartwatch that recorded inertial sensor data while they performed physiotherapy exercises both in the clinic and in the home setting. A machine learning approach was used to assess total physiotherapy participation from smartwatch inertial data. Primary outcomes were the Disabilities of the Arm Shoulder and Hand and numeric pain rating scale assessed every 4 weeks until 12 weeks follow-up. The relationships between participation, outcomes, and clinical patient variables were assessed in univariable analyses.

RESULTS

Mean physiotherapy exercise participation in clinic and at home were 11 minutes per week and 33 minutes per week, respectively, with patients participating in physiotherapy on 41% of days assigned to treatment. Home physiotherapy participation decreased significantly over time (P=.03). There was a statistically significant and clinically meaningful relationship between cumulative physiotherapy participation and recovery demonstrated by pain scores at 8 weeks (P=.02) and 12 weeks (P=.05) and disability scores at 8 weeks (P=.04) and 12 weeks (P=.04). Low patient expectations and self-efficacy were associated with low rates of physiotherapy participation.

CONCLUSIONS

There was a low rate of participation in home shoulder physiotherapy exercise, and a statistically and clinically significant dose response of physiotherapy on treatment outcome in patients with rotator cuff pathology. The findings highlight the opportunity to develop novel methods and strategies to improve the participation in and efficacy of physiotherapy exercises for rotator cuff disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/17841.

Physical Therapists' Opinion of E-Health Treatment of Chronic Low Back Pain

(1) Background: Using new technologies to manage home exercise programmes is an approach that allows more patients to benefit from therapy. The objective of this study is to explore physical therapists’ opinions of the efficacy and disadvantages of implementing a web-based telerehabilitation programme for treating chronic low back pain (CLBP). (2) Methods: Nineteen physical therapists from academic and healthcare fields in both the public and private sector participated in the qualitative study. Texts extracted from a transcript of semi-structured, individual, in-depth interviews with each consenting participant were analysed to obtain the participants’ prevailing opinions. The interviews lasted approximately 40 min each. The participants’ responses were recorded. (3) Results: The results suggest that telerehabilitation can only be successful if patients become actively involved in their own treatment. However, exercise programmes for LBP are not always adapted to patient preferences. New technologies allow physical therapists to provide their patients with the follow-up and remote contact they demand, but long-term adherence to treatment stems from knowledge of the exercises and the correct techniques employed by the patients themselves. (4) Conclusions: Physical therapists treating patients with chronic non-specific low back pain believe that new technologies can provide highly effective means of reaching a greater number of patients and achieving significant savings in healthcare costs, despite the limitations of a telerehabilitation approach in developing an appropriate and effective patient-based physiotherapy programme.

Effectiveness of Mobile Health-Based Exercise Interventions for Patients with Peripheral Artery Disease: Systematic Review and Meta-Analysis

Background

Peripheral artery disease (PAD) affects over 236 million people worldwide, and exercise interventions are commonly used to alleviate symptoms of this condition. However, no previous systematic review has evaluated the effects of mobile health (mHealth)–based exercise interventions for patients with PAD.

Objective

This study aimed to assess the effect of mHealth-based exercise interventions on walking performance, functional status, and quality of life in patients with PAD.

Methods

A systematic review and meta-analysis were conducted. We searched in seven databases to identify randomized controlled trials of patients with PAD published in English up to December 4, 2020. Studies were included if patients participated in mHealth-based exercise interventions and were assessed for walking performance. We analyzed pooled effect size on walking performance, functional status, and quality of life based on the standardized mean differences between groups.

Results

A total of seven studies were selected for the systematic review, and six studies were included in the meta-analysis. The duration of interventions in the included studies was 12 to 48 weeks. In the pooled analysis, when compared with the control groups, the mHealth-based exercise intervention groups were associated with significant improvements in pain-free walking (95% CI 0.13-0.88), maximal walking (95% CI 0.03-0.87), 6-minute walk test (6MWT) distance (95% CI 0.59-1.24), and walking distance (95% CI 0.02-0.49). However, benefits of the interventions on walking speed, stair-climbing ability, and quality of life were not observed.

Conclusions

mHealth-based exercise interventions for patients with PAD were beneficial for improving pain-free walking, maximal walking, and 6MWT distance. We found that exercise interventions using mHealth are an important strategy for improving the exercise effectiveness and adherence rate of patients with PAD. Future studies should consider the use of various and suitable functions of mHealth that can increase the adherence rates and improve the effectiveness of exercise.

Effectiveness of a Program Combining Strengthening, Stretching, and Aerobic Training Exercises in a Standing versus a Sitting Position in Overweight Subjects with Knee Osteoarthritis: A Randomized Controlled Trial

There is an increasing incidence, prevalence, and burden of knee osteoarthritis due to a global increase in obesity and an aging population. The aim of the present study was to compare the effectiveness of the addition of aerobic exercises performed in an unloaded or loaded position to a conventional exercise program in overweight subjects with knee osteoarthritis. Twenty-four subjects were randomly allocated to receive 36 sessions of 30-min duration of either sitting aerobic exercises (experimental group) or standing aerobic exercises (control group). Pain intensity, knee disability, and quality-of-life data were collected at baseline and at 12, 24, and 36 sessions. Generalized linear mixed models (GLMMs) were constructed for the analysis of the differences. Significant differences were found in the experimental group for self-reported pain and knee pain and disability at 24 and 36 sessions (p < 0.05). Significant between-group differences were observed in change in self-reported knee pain and disability and quality of life from baseline to 24th- and 36th-session measurements in favor of the experimental group. Adherence to treatment was higher in the experimental group. Adding aerobic exercises in an unloaded position to a conventional exercise program produced superior effects over time for self-reported knee pain, knee pain and disability and quality of life compared to loaded aerobic exercises in overweight subjects with knee osteoarthritis.

Do behaviour change techniques increase adherence to home exercises in those with upper extremity musculoskeletal disorders? A systematic review

OBJECTIVES

To investigate whether behaviour change techniques (BCTs) can influence adherence to home exercise in people with upper extremity musculoskeletal disorders (UEMD).

DESIGN

A systematic review of randomised control trials, non-randomised control trials, case-control studies and cohort studies. Results were presented narratively. Participants were those with UEMD. The intervention was any home exercise programme, alongside a BCT designed to increase exercise adherence. Any duration of intervention was accepted. The main outcome sought was adherence to home exercise. A systematic search was performed on four online databases. Grey literature was searched.

RESULTS

The search resulted in 28,755 titles. 77 full-text articles were assessed for eligibility. Six studies were included in the qualitative synthesis. Four studies had Some Concern of Bias, whilst two studies had High Risk of Bias. Three studies found statistically significant differences in exercise adherence (p < 0.05) between the Intervention group and Control group. The BCT 'Social Support (unspecified)' was used within all studies that found significant differences in adherence levels at outcome. However, multiple BCTs were received by the Intervention groups within all studies, making it impossible to identify the effects of any single BCT upon adherence levels.

CONCLUSION

Social support may be relevant in patients' adherence levels to HEPs. However, confidence in the results is uncertain given the small number of studies found, and their High RoB. Future studies should validate their measurement and definition of adherence, as well as the number of BCTs they use, to provide reproducible evidence.

Assessing adherence to physical activity programs post-stroke at home: A systematic review of randomized controlled trials

BACKGROUND

Physical activity at home provides significant benefits post-stroke. Adherence assessments contribute to objective evaluation of treatment effectiveness across settings.

OBJECTIVES

The aims of this study were to (1) conduct a systematic review with focus on analyzing the reporting quality of RCTs that incorporate home physical activity interventions among people post-stroke, and utilize a physical activity adherence assessment and to: (2) identify, group, and critically appraise physical activity adherence assessments within the identified studies.

METHODS

A literature search for RCTs was conducted. Articles needed to (1) study adult, post-stroke participants, (2) include a physical activity intervention at home, (3) utilize a physical activity adherence assessment, (4) be published in English in a peer reviewed journal. Two independent reviewers assessed the reporting quality of each RCT for conformity to 39 Consolidated Standards of Reporting Trials (CONSORT) items, followed by an evaluation of adherence assessment methods.

RESULTS

Eleven studies met the inclusion criteria and none of them reported all CONSORT items. The median number of "fully reported" items was 7 out of 39. Ten of the 11 RCTs employed the adherence diary as an assessment method. The adherence parameters of frequency and duration were applied with greater frequency than intensity and accuracy. No evidence of an objective method of adherence assessment was found.

CONCLUSIONS

This systematic review revealed suboptimal reporting of RCTs of physical activity interventions. The use of a diary with the post-stroke population at home was common, despite the lack of an objective method of adherence assessment. Stricter compliance to CONSORT guidelines and complementary direct adherence measurement is advised to improve activity adherence research.

Does the addition of concurrent visual feedback increase adherence to a home exercise program in people with stroke: a single-case series?

OBJECTIVE

Evidence is accumulating for the potential benefits of technology use in stroke rehabilitation. However, few studies have examined ways in which technology can be used to increase adherence to programs after discharge from rehabilitation. The aim of this study was to determine if the addition of concurrent visual feedback, via a tablet computer, increased adherence to an exercise program following stroke. Ten participants were provided with a self-administered exercise program and were asked to perform 60 min of the exercises daily. After a baseline phase (1 week), participants were given a tablet computer (2 weeks) and were asked to video record each exercise session. The tablet computer was removed during the fourth week of the program.

RESULTS

Exercise duration, measured via wrist-worn accelerometry, was investigated over the 4 weeks using the two-standard deviation (2 SD) band method. A statistically significant effect was observed in four out of ten cases, demonstrated by two successive data points occurring outside the 2 SD band during the intervention phase, suggesting that adherence was increased in response to the tablet computer use. This preliminary study indicates that the use of visual feedback, via a tablet computer, may increase adherence to an exercise program in people with stroke. Trial registration ACTRN: ACTRN12620000252910 (26 February 2020, Retrospectively registered).

Adherence Tracking With Smart Watches for Shoulder Physiotherapy in Rotator Cuff Pathology: Protocol for a Longitudinal Cohort Study

Background

Physiotherapy is essential for the successful rehabilitation of common shoulder injuries and following shoulder surgery. Patients may receive some training and supervision for shoulder physiotherapy through private pay or private insurance, but they are typically responsible for performing most of their physiotherapy independently at home. It is unknown how often patients perform their home exercises and if these exercises are performed correctly without supervision. There are no established tools for measuring this. It is, therefore, unclear if the full benefit of shoulder physiotherapy treatments is being realized.

Objective

The proposed research will (1) validate a smartwatch and machine learning (ML) approach for evaluating adherence to shoulder exercise participation and technique in a clinical patient population with rotator cuff pathology; (2) quantify the rate of home physiotherapy adherence, determine the effects of adherence on recovery, and identify barriers to successful adherence; and (3) develop and pilot test an ethically conscious adherence-driven rehabilitation program that individualizes patient care based on their capacity to effectively participate in their home physiotherapy.

Methods

This research will be conducted in 2 phases. The first phase is a prospective longitudinal cohort study, involving 120 patients undergoing physiotherapy for rotator cuff pathology. Patients will be issued a smartwatch that will record 9-axis inertial sensor data while they perform physiotherapy exercises both in the clinic and in the home setting. The data collected in the clinic under supervision will be used to train and validate our ML algorithms that classify shoulder physiotherapy exercise. The validated algorithms will then be used to assess home physiotherapy adherence from the inertial data collected at home. Validated outcome measures, including the Disabilities of the Arm, Shoulder, and Hand questionnaire; Numeric Pain Rating Scale; range of motion; shoulder strength; and work status, will be collected pretreatment, monthly through treatment, and at a final follow-up of 12 months. We will then relate improvement in patient outcomes to measured physiotherapy adherence and patient baseline variables in univariate and multivariate analyses. The second phase of this research will involve the evaluation of a novel rehabilitation program in a cohort of 20 patients. The program will promote patient physiotherapy engagement via the developed technology and support adherence-driven care decisions.

Results

As of December 2019, 71 patients were screened for enrollment in the noninterventional validation phase of this study; 65 patients met the inclusion and exclusion criteria. Of these, 46 patients consented and 19 declined to participate in the study. Only 2 patients de-enrolled from the study and data collection is ongoing for the remaining 44.

Conclusions

This study will provide new and important insights into shoulder physiotherapy adherence, the relationship between adherence and recovery, barriers to better adherence, and methods for addressing them.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17841

Selecting Evidence-Based Content for Inclusion in Self-Management Apps for Pressure Injuries in Individuals With Spinal Cord Injury: Participatory Design Study

BACKGROUND

Technological solutions, particularly mobile health (mHealth), have been shown to be potentially viable approaches for sustaining individuals' self-management of chronic health conditions. Theory-based interventions are more successful, as evidence-based information is an essential prerequisite for appropriate self-management. However, several reviews have shown that many existing mobile apps fail to be either theoretically grounded or based on evidence. Although some authors have attempted to address these two issues by focusing on the design and development processes of apps, concrete efforts to systematically select evidence-based content are scant.

OBJECTIVE

The objective of this study was to present a procedure for the participatory identification of evidence-based content to ground the development of a self-management app.

METHODS

To illustrate the procedure, we focused on the prevention and management of pressure injuries (PIs) in individuals with spinal cord injury (SCI). The procedure involves the following three steps: (1) identification of existing evidence through review and synthesis of existing recommendations on the prevention and self-management of PIs in SCI; (2) a consensus meeting with experts from the field of SCI and individuals with SCI to select the recommendations that are relevant and applicable to community-dwelling individuals in their daily lives; and (3) consolidation of the results of the study.

RESULTS

In this case study, at the end of the three-step procedure, the content for an mHealth intervention was selected in the form of 98 recommendations.

CONCLUSIONS

This study describes a procedure for the participatory identification and selection of disease-specific evidence and professional best practices to inform self-management interventions. This procedure might be especially useful in cases of complex chronic health conditions, as every recommendation in these cases needs to be evaluated and considered in light of all other self-management requirements. Hence, the agreement of experts and affected individuals is essential to ensure the selection of evidence-based content that is considered to be relevant and applicable.

Use of the nominal group technique to identify UK stakeholder views of the measures and domains used in the assessment of therapeutic exercise adherence for patients with musculoskeletal disorders

OBJECTIVES

The objective was to the undertake nominal group technique (NGT) to evaluate current exercise adherence measures and isolated domains to develop stakeholder consensus on the domains to include in the measurement of therapeutic exercise adherence for patients with musculoskeletal disorders.

DESIGN

A 1-day NGT workshop was convened. Six exercise adherence measures were presented to the group that were identified in our recent systematic review. Discussions considered these measures and isolated domains of exercise adherence. Following discussions, consensus voting identified stakeholder agreement on the suitability of the six offered adherence measures and the inclusion of isolated domains of exercise adherence in future measurement.

SETTING

One stakeholder NGT workshop held in Sheffield, UK.

PARTICIPANTS

Key stakeholders from the UK were invited to participate from four identified populations. 14 participants represented patients, clinicians, researchers and service managers.

RESULTS

All six exercise adherence measures were deemed not appropriate for use in clinical research or routine practice with no measure reaching 70% group agreement for suitability, relevance, acceptability or appropriateness. Three measures were deemed feasible to use in clinical practice. 25 constructs of exercise adherence did reach consensus threshold and were supported to be included as domains in the future measurement of exercise adherence.

CONCLUSION

A mixed UK-based stakeholder group felt these six measures of exercise adherence were unacceptable. Differences in opinion within the stakeholder group highlighted the lack of consensus as to what should be measured, the type of assessment that is required and whose perspective should be sought when assessing exercise adherence. Previously unused domains may be needed alongside current ones, from both a clinician's and patient's perspective, to gain understanding and to inform future measurement development. Further conceptualisation of exercise adherence is required from similar mixed stakeholder groups in various socioeconomic and cultural populations.

The Self-Efficacy for Home Exercise Programs Scale: Development and Psychometric Properties

BACKGROUND

The Self-Efficacy for Home Exercise Programs Scale (SEHEPS) was developed to help clinicians evaluate patients' self-efficacy for performing prescribed home exercise programs. Prior to clinical adoption, the scale's psychometric properties need to be examined.

OBJECTIVE

To determine the psychometric properties of the SEHEPS.

METHODS

Eighty-one patients (32 men, 49 women; mean ± SD age, 42 ± 17 years) with varying musculoskeletal conditions participated in this cohort study. Patients were given a home exercise program at the initial physical therapy visit and completed the SEHEPS and a modified Self-Efficacy for Exercise (SEE) scale. The SEHEPS is a 12-item patient-reported questionnaire designed to assess self-efficacy for prescribed home exercise. Patients rated their confidence on a 7-point scale that ranged from 0 (not confident) to 6 (very confident). Total scores ranged from 0 (low self-efficacy) to 72 (high self-efficacy). We assessed the internal consistency of the SEHEPS using Cronbach's alpha and its test-retest reliability using an intraclass correlation coefficient. Convergent validity between the SEHEPS and SEE scale was evaluated with a Spearman correlation.

RESULTS

High internal consistency (α = .96) and good test-retest reliability (intraclass correlation coefficient = 0.88; SEM, 4; minimal detectable change at the 95% confidence level, 12) were demonstrated. The SEHEPS was strongly correlated with the SEE scale (ρ = 0.83, P<.01), indicating strong convergent validity.

CONCLUSION

The SEHEPS demonstrates excellent internal consistency and convergent validity with the SEE scale. Overall, the SEHEPS is a clinically useful tool to evaluate a patient's self-efficacy in home-based musculoskeletal exercise programs. This scale can be used prior to prescribing a home exercise program for patients with musculoskeletal conditions.

LEVEL OF EVIDENCE

Therapy, level 4. J Orthop Sports Phys Ther 2019;49(9):647-655. Epub 10 Jul 2019. doi:10.2519/jospt.2019.8779.

Heavy-slow resistance training in addition to an ultrasound-guided corticosteroid injection for individuals with plantar fasciopathy: a feasibility study

INTRODUCTION

Plantar fasciopathy, characterised by plantar heel pain, affects one in ten in a lifetime. Heavy-slow resistance training (HSR) is an emerging treatment, but it often takes considerable time before the effect starts to manifest. Combining HSR with a corticosteroid injection (known for its short-term pain relief) could potentially improve outcomes in both short and long term. As this combination is yet to be investigated, we aimed to evaluate the feasibility of combining HSR with a corticosteroid injection for individuals with plantar fasciopathy before investigating the efficacy in a clinical trial.

MATERIALS AND METHODS

We recruited 20 participants with plantar fasciopathy for this prospectively registered feasibility study (ClinicalTrials.gov: NCT03535896). Participants received an ultrasound-guided injection and performed heel raises on a step every second day for 8 weeks. To assess participant acceptability of the combined interventions and exercise compliance, we used a 7-point Likert scale dichotomised to "unacceptable" (categories 1-2) or "acceptable" (categories 3-7) and training diaries. Greater than or equal to 10/20 had to rate the combination "acceptable", ≥ 15/20 had to perform ≥ 20 training sessions, and ≥ 15/20 had to start exercising ≤ 7 days after injection to confirm feasibility.

RESULTS

Eighteen out of 20 rated the combination acceptable. Five training diaries could not be retrieved. Ten out of 15 participants performed ≥ 20 training sessions, and 15/15 started exercising ≤ 7 days after injection.

CONCLUSIONS

Based on participant acceptability and time to exercise start, combining HSR with corticosteroid injection is feasible and the efficacy should be investigated in a future trial. Due to loss of 5/20 training diaries, firm conclusions regarding exercise compliance could not be drawn.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03535896.

Completion and adherence rates to exercise interventions in intermittent claudication: Traditional exercise versus alternative exercise - a systematic review

BACKGROUND

Intermittent claudication, defined as fatigue or pain in the legs while walking, is a common symptom in peripheral arterial disease. Although exercise effectively improves function and manages symptoms, adherence rates are not ideal. The high levels of pain experienced in traditional exercise programmes may explain the suboptimal adherence. Alternative modalities of exercise can elicit similar benefits to traditional walking exercise. The purpose of this systematic review was to compare completion and adherence rates of exercise programmes in traditional exercise interventions versus alternative exercise interventions among patients with intermittent claudication.

DESIGN

Systematic review.

METHODS

The electronic databases of Medline, SPORTDiscus and CINAHL were searched from the earliest records to March 2018. Search terms were based on 'peripheral artery disease' and 'exercise'. Studies were included if they involved structured exercise and explicitly reported the number of participants that commenced and completed the programme.

RESULTS

The search identified 6814 records based on inclusion criteria. Eighty-four full-text records were reviewed in further detail. Out of the 84 studies, there was a total of 122 separate exercise groups, with 64 groups of 'traditional walking exercise' and 58 groups of 'alternative exercise'. Completion and adherence rates for traditional exercise were 80.8% and 77.6%, respectively. Completion and adherence rates for alternative exercise were 86.6% and 85.5%, respectively.

CONCLUSIONS

The use of alternative modalities of exercise, which have been proved to be as effective as traditional exercise, may offer a solution to the poor participation and adherence rates to exercise in this population.

What makes implementation intention interventions effective for promoting healthy eating behaviours? A meta-regression

This study examines the efficacy of implementation intentions (II), a widely used self-regulatory strategy to help people achieve their goals. Although previous research has shown that the effect of II interventions is significantly higher in promoting healthy eating behaviours than in diminishing unhealthy eating behaviours, the factors that can moderate the effectiveness of these interventions remain unclear. In a meta-analysis of 70 interventions (N = 9689), we confirmed that II interventions for healthy eating behaviours yielded a medium significant effect size (d = 0.33) and a low significant effect size for unhealthy eating behaviors (d = 0.18). We show that the moderator variables of II interventions for healthy and unhealthy eating goals are very different. Regarding healthy eating, since moderator variables explain 53% of the variance in the heterogeneity of the effect sizes, the present study helps in gaining an understanding of the previous inconsistent results and offers suggestions for designing more efficient interventions. Effect size was negatively predicted by age, indicating that for younger people the effect size is higher, and II check, showing that if the instructor checks the plan it decreases its efficacy. Moreover, the effect of II interventions on students is significantly smaller than in non-student samples. In contrast, the effect size was positively predicted by initial training, off-line delivered interventions and, specific if-then and action plans versus complex plans. For unhealthy eating behaviours, our results show that there is less room to improve the intervention; there is only one moderator variable (plan formulation), and the heterogeneity found in the studies is lower for unhealthy eating behaviours (I² = 46.70%) than for healthy eating behaviours (I² = 73.25%), indicating that the intervention has low efficacy regardless of the design of the intervention.

A systematic review of measures of adherence to physical exercise recommendations in people with stroke

OBJECTIVE:

To review methods for measuring adherence to exercise or physical activity practice recommendations in the stroke population and evaluate measurement properties of identified tools.

DATA SOURCES:

Two systematic searches were conducted in eight databases (MEDLINE, CINAHL, PsycINFO, Cochrane Library of Systematic Reviews, Sports Discus, PEDro, PubMed and EMBASE). Phase 1 was conducted to identify measures. Phase 2 was conducted to identify studies investigating properties of these measures.

REVIEW METHODS:

Phase 1 articles were selected if they were published in English, included participants with stroke, quantified adherence to exercise or physical activity recommendations, were patient or clinician reported, were defined and reproducible measures and included patients >18 years old. In phase 2, articles were included if they explored psychometric properties of the identified tools. Included articles were screened based on title/abstract and full-text review by two independent reviewers.

RESULTS:

In phase 1, seven methods of adherence measurement were identified, including logbooks ( n = 16), diaries ( n = 18), 'record of practice' ( n = 3), journals ( n = 1), surveys ( n = 2) and questionnaires ( n = 4). One measurement tool was identified, the Physical Activity Scale for Individuals with Physical Disabilities ( n = 4). In phase 2, no eligible studies were identified.

CONCLUSION:

There is not a consistent measure of adherence that is currently utilized. Diaries and logbooks are the most frequently utilized tools.

Clinician perceptions of a prototype wearable exercise biofeedback system for orthopaedic rehabilitation: a qualitative exploration

OBJECTIVES

This study explores the opinions of orthopaedic healthcare professionals regarding the opportunities and challenges of using wearable technology in rehabilitation. It continues to assess the perceived impact of an exemplar exercise biofeedback system that incorporates wearable sensing, involving the clinician in the user-centred design process, a valuable step in ensuring ease of implementation, sustained engagement and clinical relevance.

DESIGN

This is a qualitative study consisting of one-to-one semi-structured interviews, including a demonstration of a prototype wearable exercise biofeedback system. Interviews were audio-recorded and transcribed, with thematic analysis conducted of all transcripts.

SETTING

The study was conducted in the orthopaedic department of an acute private hospital.

PARTICIPANTS

Ten clinicians from a multidisciplinary team of healthcare professionals involved in the orthopaedic rehabilitation pathway participated in the study.

RESULTS

Participants reported that there is currently a challenge in gathering timely and objective data for the monitoring of patients in orthopaedic rehabilitation. While there are challenges in ensuring reliability and engagement of biofeedback systems, clinicians perceive significant value in the use of wearable biofeedback systems such as the exemplar demonstrated for use following total knee replacement.

CONCLUSIONS

Clinicians see an opportunity for wearable technology to continuously track data in real-time, and feel that feedback provided to users regarding exercise technique and adherence can further support the patient at home, although there are clear design and implementation challenges relating to ensuring technical accuracy and tailoring rehabilitation to the individual. There was perceived value in the prototype system demonstrated to participants which supports the ongoing development of such exercise biofeedback platforms.

Shoulder physiotherapy exercise recognition: machine learning the inertial signals from a smartwatch

OBJECTIVE

Participation in a physical therapy program is considered one of the greatest predictors of successful conservative management of common shoulder disorders. However, adherence to these protocols is often poor and typically worse for unsupervised home exercise programs. Currently, there are limited tools available for objective measurement of adherence in the home setting. The goal of this study was to develop and evaluate the potential for performing home shoulder physiotherapy monitoring using a commercial smartwatch.

APPROACH

Twenty healthy adult subjects with no prior shoulder disorders performed seven exercises from an evidence-based rotator cuff physiotherapy protocol, while 6-axis inertial sensor data was collected from the active extremity. Within an activity recognition chain (ARC) framework, four supervised learning algorithms were trained and optimized to classify the exercises: k-nearest neighbor (k-NN), random forest (RF), support vector machine classifier (SVC), and a convolutional recurrent neural network (CRNN). Algorithm performance was evaluated using 5-fold cross-validation stratified first temporally and then by subject.

MAIN RESULTS

Categorical classification accuracy was above 94% for all algorithms on the temporally stratified cross validation, with the best performance achieved by the CRNN algorithm (99.4%). The subject stratified cross validation, which evaluated classifier performance on unseen subjects, yielded lower accuracies scores again with CRNN performing best (88.9%).

SIGNIFICANCE

This proof of concept study demonstrates the technical feasibility of a smartwatch device and supervised machine learning approach to more easily monitor and assess the at-home adherence of shoulder physiotherapy exercise protocols.

Outcome measures for adherence to home exercises among patients with chronic low back pain: a systematic review

[Purpose] The aim of this study was to investigate what outcome measures are reliable in the evaluation of adherence to home exercises among patients with chronic low back pain. [Methods] A systematic review on articles related to adherence to home exercises for patients with chronic low back pain was conducted, and outcome measures and psychometric properties were extracted and evaluated in terms of validity and reliability. [Results] A total of 4,583 articles were identified, and eight articles were finally included after screening. The identified outcome measures were self-reported frequency, duration and intensity of home exercises and Treatment Self-Regulation Questionnaire results. Although the internal consistency and criterion validity of the Treatment Self-Regulation Questionnaire results have been proven in the literature, none of the included articles validated the self-reported frequency, duration, and intensity of the home exercises. [Conclusion] Only the Treatment Self-Regulation Questionnaire results were found to be a reliable measure, and further research to validate self-reported outcome measures is required.

Trajectories of adherence to home-based exercise programs among people with knee osteoarthritis

OBJECTIVE

To investigate the presence of different trajectories of self-reported adherence to home exercise programs among people with knee osteoarthritis (OA), and to compare baseline characteristics across identified groups.

DESIGN

Pooled analysis of data from three randomised controlled trials involving exercise interventions for people aged ≥50 years with clinical knee OA (n = 341). Exercise adherence was self-reported on an 11-point numerical rating scale (NRS; 0 = not at all-10 = completely as instructed). Latent class growth analysis was used to identify distinct trajectories of adherence, at intervals from 12 to 78 weeks from baseline. Baseline characteristics of these groups were compared using chi-squared tests, one-way analysis of variance (ANOVA) and Kruskal Wallis tests where appropriate.

RESULTS

Three distinct adherence trajectories were identified: a "Rapidly declining adherence" group (n = 157, 47.4%) whose adherence was 7.7 ± 1.6 (/10) at 12 weeks, declined to 4.2 ± 2.2 by 22 weeks and remained low thereafter; a "Gradually declining adherence" group (n = 153, 45.1%) whose adherence declined from 8.5 ± 1.5 to 7.8 ± 1.5 over the same period, and continued to decline slowly, and a "Low adherence" group (n = 21, 6.3%) whose adherence was 2.2 ± 1.4 at 12 weeks and remained low. At baseline the "Rapidly declining adherence" group reported significantly lower Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (mean difference (95% Confidence Interval (CI)) -0.8 (-1.4, -0.2)) and better WOMAC function compared to the "Gradually declining adherence" group (-3.1 (-5.2, -1.1)).

CONCLUSION

Three trajectories of self-reported adherence to home exercises were found among people with knee OA. Findings highlight the need for close monitoring of adherence from initiation of a home exercise program in order to identify and intervene when low or rapidly declining adherence is identified.

A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy

Patient adherence to rehabilitation programmes is frequently low - particularly adherence to home exercise programmes. Home exercise programmes have been identified as complementary to clinic-based physical therapy in an orthopaedic setting. Barriers to patient adherence have previously been identified within the literature. Low self-efficacy is a barrier to adherence that clinicians have the ability to have an impact on and improve. The theory of self-efficacy is defined as a person's confidence in their ability to perform a task. This theory examines the ability of a person to change through exerting control over inner processes of goal setting, self-monitoring, feedback, problem solving and self-evaluation. If clinicians are able to identify patients with low self-efficacy prior to the prescription of a home exercise programme, adjustments to individualized care can be implemented. Individualized care based on improving self-efficacy for home exercise programmes may improve patient adherence to these programmes. The purpose of this article was to use the theory of self-efficacy to direct clinicians in providing individualized programmes to patients with varying levels of self-efficacy.

Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

What Adherence Measures Should Be Used in Trials of Home-Based Rehabilitation Interventions? A Systematic Review of the Validity, Reliability, and Acceptability of Measures

OBJECTIVE

To systematically review methods for measuring adherence used in home-based rehabilitation trials and to evaluate their validity, reliability, and acceptability.

DATA SOURCES

In phase 1 we searched the CENTRAL database, NHS Economic Evaluation Database, and Health Technology Assessment Database (January 2000 to April 2013) to identify adherence measures used in randomized controlled trials of allied health professional home-based rehabilitation interventions. In phase 2 we searched the databases of MEDLINE, Embase, CINAHL, Allied and Complementary Medicine Database, PsycINFO, CENTRAL, ProQuest Nursing and Allied Health, and Web of Science (inception to April 2015) for measurement property assessments for each measure.

STUDY SELECTION

Studies assessing the validity, reliability, or acceptability of adherence measures.

DATA EXTRACTION

Two reviewers independently extracted data on participant and measure characteristics, measurement properties evaluated, evaluation methods, and outcome statistics and assessed study quality using the COnsensus-based Standards for the selection of health Measurement INstruments checklist.

DATA SYNTHESIS

In phase 1 we included 8 adherence measures (56 trials). In phase 2, from the 222 measurement property assessments identified in 109 studies, 22 high-quality measurement property assessments were narratively synthesized. Low-quality studies were used as supporting data. StepWatch Activity Monitor validly and acceptably measured short-term step count adherence. The Problematic Experiences of Therapy Scale validly and reliably assessed adherence to vestibular rehabilitation exercises. Adherence diaries had moderately high validity and acceptability across limited populations. The Borg 6 to 20 scale, Bassett and Prapavessis scale, and Yamax CW series had insufficient validity. Low-quality evidence supported use of the Joint Protection Behaviour Assessment. Polar A1 series heart monitors were considered acceptable by 1 study.

CONCLUSIONS

Current rehabilitation adherence measures are limited. Some possess promising validity and acceptability for certain parameters of adherence, situations, and populations and should be used in these situations. Rigorous evaluation of adherence measures in a broader range of populations is needed.

Quality and acceptability of measures of exercise adherence in musculoskeletal settings: a systematic review

Objective

To recommend robust and relevant measures of exercise adherence for application in the musculoskeletal field.

Method

A systematic review of measures was conducted in two phases. Phase 1 sought to identify all reproducible measures used to assess exercise adherence in a musculoskeletal setting. Phase 2 identified published evidence of measurement and practical properties of identified measures. Eight databases were searched (from inception to February 2016). Study quality was assessed against the Consensus-based Standards for the Selection of Health Measurement Instruments guidelines. Measurement quality was assessed against accepted standards.

Results

Phase 1: from 8511 records, 326 full-text articles were reviewed; 45 reproducible measures were identified. Phase 2: from 2977 records, 110 full-text articles were assessed for eligibility; 10 articles provided evidence of measurement/practical properties for just seven measures. Six were exercise adherence-specific measures; one was specific to physical activity but applied as a measure of exercise adherence. Evidence of essential measurement and practical properties was mostly limited or not available. Assessment of relevance and comprehensiveness was largely absent and there was no evidence of patient involvement during the development or evaluation of any measure.

Conclusion

The significant methodological and quality issues encountered prevent the clear recommendation of any measure; future applications should be undertaken cautiously until greater clarity of the conceptual underpinning of each measure is provided and acceptable evidence of essential measurement properties is established. Future research should seek to engage collaboratively with relevant stakeholders to ensure that exercise adherence assessment is high quality, relevant and acceptable.

Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To evaluate whether interventions aimed at increasing adherence to therapeutic exercise increase adherence greater than a contextually equivalent control among older adults with chronic low back pain and/or hip/knee osteoarthritis.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Five databases (MEDLINE (PubMed), CINAHL, SportDISCUS (EBSCO), Embase (Ovid) and Cochrane Library) were searched until 1 August 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials that isolated the effects of interventions aiming to improve adherence to therapeutic exercise among adults ≥45 years of age with chronic low back pain and/or hip/knee osteoarthritis were included.

RESULTS

Of 3899 studies identified, nine studies (1045 participants) were eligible. Four studies, evaluating strategies that aimed to increase motivation or using behavioural graded exercise, reported significantly better exercise adherence (d=0.26-1.23). In contrast, behavioural counselling, action coping plans and/or audio/video exercise cues did not improve adherence significantly. Meta-analysis using a random effects model with the two studies evaluating booster sessions with a physiotherapist for people with osteoarthritis revealed a small to medium significant pooled effect in favour of booster sessions (standardised mean difference (SMD) 0.39, 95% CI 0.05 to 0.72, z=2.26, p=0.02, I²=35%).

CONCLUSIONS

Meta-analysis provides moderate-quality evidence that booster sessions with a physiotherapist assisted people with hip/knee osteoarthritis to better adhere to therapeutic exercise. Individual high-quality trials supported the use of motivational strategies in people with chronic low back pain and behavioural graded exercise in people with osteoarthritis to improve adherence to exercise.

Physical activity as intervention for age-related loss of muscle mass and function: protocol for a randomised controlled trial (the LISA study)

INTRODUCTION

Physical and cognitive function decline with age, accelerating during the 6th decade. Loss of muscle power (force×velocity product) is a dominant physical determinant for loss of functional ability, especially if the lower extremities are affected. Muscle strength training is known to maintain or even improve muscle power as well as physical function in older adults, but the optimal type of training for beneficial long-term training effects over several years is unknown. Moreover, the impact of muscle strength training on cognitive function and brain structure remains speculative. The primary aim of this randomised controlled trial is to compare the efficacy of two different 1 year strength training regimens on immediate and long-lasting improvements in muscle power in retirement-age individuals. Secondary aims are to evaluate the effect on muscle strength, muscle mass, physical and cognitive function, mental well-being, health-related quality of life and brain morphology.

METHODS AND ANALYSIS

The study includes 450 home-dwelling men and women (62-70 years). Participants are randomly allocated to (1) 1 year of supervised, centre-based heavy resistance training, (2) home-based moderate intensity resistance training or (3) habitual physical activity (control). Changes in primary (leg extensor power) and secondary outcomes are analysed according to the intention to treat principle and per protocol at 1, 2, 4, 7 and 10 years.

ETHICS AND DISSEMINATION

The study is expected to generate new insights into training-induced promotion of functional ability and independency after retirement and will help to formulate national recommendations regarding physical activity schemes for the growing population of older individuals in western societies. Results will be published in scientific peer-reviewed journals, in PhD theses and at public meetings. The study is approved by the Regional Ethical Committee (Capital Region, Copenhagen, Denmark, number H-3-2014-017).

TRIAL REGISTRATION NUMBER

NCT02123641.

The effectiveness of home-based exercise programs for low back pain patients

[Purpose] The purpose of this study was to investigate the effectiveness of home-based exercise programs for low back pain (LBP) patients. [Subjects and Methods] The study subjects were 49 volunteer chronic LBP patients. Home-based exercises that had been specifically modified for the individual patients were prescribed for a period of four weeks, and the volunteers were asked to return for a control evaluation at the end of this period. Exercise adherence and correct performance, pain intensity, disability, endurance, and flexibility were compared between pre- and post intervention, and correlations between exercise adherence and correct performance with, pain intensity score, endurance, disability, and flexibility were investigated. [Results] Twenty-eight patients (57.14%) did not return for the control evaluation. The mean age of the patients who participated in this control test was 43.24 ± 10.89 years. The adherence rate of the home exercise program was 54.10 ± 26.01%, and the correctly performed execises score was 2.7 ± 1.9. All of the parameters had improved at the final evaluation; however, there was no correlation among the parameters. [Conclusion] Clinicians should be aware of the patient’s adherence level when recommending home-based exercises, and should also realize that exercises might be performed inaccurately in an unsupervised environment.

Optimising the validity and completion of adherence diaries: a multiple case study and randomised crossover trial

BACKGROUND

Diaries are the most commonly used adherence measurement method in home-based rehabilitation trials, yet their completion and validity varies widely between trials. We aimed to: (1) generate theory to explain this variation, (2) create an optimised diary and (3) evaluate the optimised diary's validity.

METHODS

Stage 1.

DEVELOPMENT

using a multiple case study approach, we collected trialist interviews (n = 7), trial publications (n = 16) and diaries (n = 7) from seven purposively sampled UK rehabilitation trials. We explored return rates, diary designs and trialists' ideas as to what affected diary completion and validity. Using explanatory case study analysis, we developed a diary optimisation model. Stage 2.

EVALUATION

we compared a diary optimised according to several model components to one nonoptimised according to the same components in a randomised AB/BA crossover trial. Healthy adults aged 60+ years without mobility impairments undertook a home-based 8-week walking programme. They recorded walking duration and frequency for 4 weeks per diary. We hypothesised that the optimised diary would possess greater validity for self-reported adherence to walking duration (criterion: the Activpal accelerometer), assessed during each diary's final week. Participants were blinded to the hypothesis. Secondary outcomes included test-retest reliability and acceptability. Ethical approval was granted from Glasgow Caledonian University.

RESULTS

Thirty-two out of 33 participants completed the study. Diaries did not significantly differ in validity, reliability or acceptability. Both diaries agreed closely with the Activpal when assessing duration adherence at a group level, however, inter and intraindividual variation in validity was high (mean difference (95 % limits of agreement (LOA): limits of agreement plot the difference between measurements collected using two different methods against their mean and thus assess the extent to which the two measures agree with each other)) optimised diary = 3.09 % (-103.3 to 109.5 %), nonoptimised diary = -0.34 % (-131.1 to 130.5 %), p = 0.732). We found similarly wide LOA for percentage of days adhered to and percentage of walks taken, whilst frequency adherence was underestimated. Participants rated both diaries as low-burden and equal numbers favoured each diary or were neutral. Preference appeared to impact minimally upon validity.

CONCLUSION

Group-level adherence diary data are likely to be valid. However, individual diary data lack validity, which raises concerns if using this data in calculations such as predicting functional outcomes. Different diary designs are likely interchangeable, though unanticipated high variation meant that this study was underpowered.

TRIAL REGISTRATION

The trial was not eligible for registration in a clinical trial database as diary measurement property outcomes, not clinical health outcomes of participants, were assessed.

New exercise-integrated technology can monitor the dosage and quality of exercise performed against an elastic resistance band by adolescents with patellofemoral pain: an observational study

QUESTION

Is the exercise-integrated Bandcizer™ system feasible for recording exercise dosage (time under tension (TUT) and repetitions) and pain scores among adolescents with patellofemoral pain? Do adolescents practise the exercises as prescribed (TUT and repetitions)? Do adolescents accurately report the exercises they do in an exercise diary?

DESIGN

Observational feasibility study.

PARTICIPANTS

Twenty adolescents between 15 and 19 years of age with patellofemoral pain.

INTERVENTION

Participants were prescribed three exercise sessions per week (one with and two without supervision) for 6 weeks. The exercises included three hip and one knee exercise with an elastic resistance band. Participants were instructed to perform three sets with a predefined TUT (3seconds concentric; 2seconds isometric; 3seconds eccentric; 2seconds pause), equating to 80seconds for 10 repetitions (one set).

OUTCOME MEASURES

The exercise-integrated system consisted of a sensor attached to the elastic resistance band that was connected to the Bandtrainer app on an electronic tablet device. Pain intensity was reported on a visual analogue scale on the app. Participants also completed a self-report exercise diary.

RESULTS

No major problems were reported with the system. Participants performed 2541 exercise sets during the 6 weeks; 5% were performed with the predefined TUT (ie, within 10seconds of the 80-second target) and 90% were performed below the target TUT. On average, the participants received 15% of the instructed exercise dosage based on TUT. The exercise dosage reported in the exercise diaries was 2.3 times higher than the TUT data from the electronic system. Pain intensity was successfully collected in 100% of the exercise sets.

CONCLUSION

The system was feasible for adolescents with patellofemoral pain. The system made it possible to capture detailed data about the TUT, repetitions and sets during home-based exercises together with pain intensity before and after each exercise. [Rathleff MS, Bandholm T, McGirr KA, Harring SI, Sørensen AS, Thorborg K (2016) New exercise-integrated technology can monitor the dosage and quality of exercise performed against an elastic resistance band by adolescents with patellofemoral pain: an observational study.Journal of Physiotherapy62: 159-163].

Exercise in knee osteoarthritis--preliminary findings: Exercise-induced pain and health status differs between drop-outs and retainers

BACKGROUND

Exercise effectiveness is related to adherence, compliance and drop-out. The aim of this study is to investigate if exercise-induced pain and health status are related to these outcomes during two exercise programs in knee osteoarthritis patients.

METHODS

Symptomatic knee osteoarthritis patients were randomly allocated to a walking or strengthening program (N=19/group). At baseline, patients were categorized according to their health status. Exercise adherence and compliance were calculated and drop-out rate was registered. For exercise-induced pain, patients rated their pain on an 11-point numeric rating scale (NRS) before and after each training session. Before each session the maximal perceived pain of the last 24h (NRSmax24) was assessed. Patients rated their global self-perceived effect (GPE) on a 7-point ordinal scale after the intervention period.

RESULTS

53% of the participants felt they improved after the program, 6 patients dropped out. The mean adherence and compliance rates were higher than .83 in both groups. Worse health and higher exercise-induced pain were seen in drop-outs. NRSmax24 during the first 3 weeks did not significantly increase compared to baseline, but correlated negatively with adherence during the home sessions (-.56, p<.05). Lower adherence during supervised sessions was significantly related with higher pre-exercise pain scores (ρ=-.35, p<.05).

CONCLUSION

Patients who drop-out show a worse health condition and higher exercise-induced pain levels compared to patients that retained the program.