Patient Expectations of Assigned Treatments Impact Strength of Randomised Control Trials

Improving Rehabilitation Research to Optimize Care and Outcomes for People with Chronic Primary Low Back Pain: Methodological and Reporting Recommendations from a WHO Systematic Review Series

Chronic primary low back pain (CPLBP) is a prevalent and disabling condition that often requires rehabilitation interventions to improve function and alleviate pain. This paper aims to advance future research, including systematic reviews and randomized controlled trials (RCTs), on CPLBP management. We provide methodological and reporting recommendations derived from our conducted systematic reviews, offering practical guidance for conducting robust research on the effectiveness of rehabilitation interventions for CPLBP. Our systematic reviews contributed to the development of a WHO clinical guideline for CPLBP. Based on our experience, we have identified methodological issues and recommendations, which are compiled in a comprehensive table and discussed systematically within established frameworks for reporting and critically appraising RCTs. In conclusion, embracing the complexity of CPLBP involves recognizing its multifactorial nature and diverse contexts and planning for varying treatment responses. By embracing this complexity and emphasizing methodological rigor, research in the field can be improved, potentially leading to better care and outcomes for individuals with CPLBP.

The ‘Rippling’ Waves of Wellbeing: A Mixed Methods Evaluation of a Surf-Therapy Intervention on Patients with Acquired Brain Injury

Dominant psychological models of wellbeing neglect the role that nature connection and other key factors, such as positive health behaviours and behaviour change, play in determining wellbeing. The present mixed-methods evaluation explores the impact of ”Surf-Ability”, an adapted surf therapy intervention delivered in collaboration with a UK neurorehabilitation service, on individuals with acquired brain injury (ABI) as part of an effort to design interventions based on advances in wellbeing science. Following five surf-therapy sessions, within-subjects analysis (n= 15) revealed significant improvements on the Warwick–Edinburgh mental wellbeing scale (t (15) = −2.164, p = 0.048), as well as in anxiety and happiness as measured via a brief visual analogue. No significant changes occurred in the Hospital Anxiety and Depression Scale (HADS) or resting heart rate variability (HRV). A ripple effects mapping (REM) session at 6–10 months follow-up (n = 6) revealed that the physical and psychological experience of a nature-based challenge initiated a mindset shift in participants, which ultimately led to them adopting wellbeing-promoting long-term behaviour changes. These changes occurred at the scale of (1) individual wellbeing—increased mindfulness and physical activity; (2) collective wellbeing—improved relationships, community participation and contribution to organisations; and (3) planetary wellbeing—connection to nature. These findings align with the GENIAL theoretical framework, which defines wellbeing from a biopsychosocial ecological perspective across multiple levels of scale. The findings support the need for healthcare providers—including neurorehabilitation services—to enhance interventions for patients by incorporating novel factors that improve wellbeing, such as nature-connection.

Accounting for Patient Engagement in Randomized Controlled Trials Evaluating Digital Cognitive Behavioral Therapies

Background: Cognitive behavioral therapy (CBT) can be a useful treatment option for various mental health disorders. Modern advances in information technology and mobile communication enable delivery of state-of-the-art CBT programs via smartphones, either as stand-alone or as an adjunct treatment augmenting traditional sessions with a therapist. Experimental CBTs require careful assessment in randomized clinical trials (RCTs). Methods: We investigate some statistical issues for an RCT comparing efficacy of an experimental CBT intervention for a mental health disorder against the control. Assuming a linear model for the clinical outcome and patient engagement as an influential covariate, we investigate two common statistical approaches to inference—analysis of covariance (ANCOVA) and a two-sample t-test. We also study sample size requirements for the described experimental setting. Results: Both ANCOVA and a two-sample t-test are appropriate for the inference on treatment difference at the average observed level of engagement. However, ANCOVA produces estimates with lower variance and may be more powerful. Furthermore, unlike the t-test, ANCOVA allows one to perform treatment comparison at the levels of engagement other than the average level observed in the study. Larger sample sizes may be required to ensure experiments are sufficiently powered if one is interested in comparing treatment effects for different levels of engagement. Conclusions: ANCOVA with proper adjustment for engagement should be used for the for the described experimental setting. Uncertainty on engagement patterns should be taken into account at the study design stage.