Comparative Efficacy of Clinic-Based and Telerehabilitation Application of Mckenzie Therapy in Chronic Low-Back Pain

Effects of Clinic-based and Telerehabilitation-based Motor Control Exercises in Individuals with Chronic Low-back Pain: A Randomized Controlled Trial With 3-Month Follow-up

OBJECTIVE

To evaluate the effectiveness of clinic-based and telerehabilitation-based motor control exercises in individuals with chronic low-back pain 3 months posttreatment.

METHODS

Forty-two participants were randomized to either clinic-based or telerehabilitation-based groups, performing exercises 3 times weekly for 8 weeks. Assessments were conducted pre-intervention, postintervention and 1 and 3 month follow-ups. The primary outcome was pain intensity (Visual Analog Scale) for low-back pain.

RESULTS

Both exercise approaches were found to be similarly effective in improving pain disability, quality of life (except for emotional response, energy level, sleep, and social isolation), and pain catastrophizing at both follow-up time points. The Visual Analog Scale showed statistically significant reductions in pain from baseline at all time points in both groups ( P <0.001), with effect sizes ranging from moderate to strong. Nottingham Health Profile showed significant improvements in physical activity, pain, and total score, with effect sizes ranging from moderate to strong. No statistically significant changes in spatiotemporal gait parameters were observed in either group. According to the postintervention intention-to-treat analysis, lumbar flexion range of motion showed statistically significant improvements in both groups with small effect sizes ( P <0.05).

DISCUSSION

Telerehabilitation-based motor control exercises proved as effective as clinic-based methods in treating chronic low-back pain, offering a viable alternative tailored to individual needs and circumstances.

Exercise-based telerehabilitation in chronic low back pain - a scoping review

BACKGROUND

Low back pain is a major global health problem. Physiotherapy involving exercises is considered first-line treatment. In recent years digital tools including telerehabilitation have increased, but the interventions are diverse. The aim of this study was to map how telerehabilitation approaches are used in studies evaluating exercise-based rehabilitation in patients with chronic low back pain.

METHODS

A systematic literature search was conducted in PubMed, Cinahl and Cochrane Central between January 2017 and January 2024 for original studies on adults, 18 years or older, with chronic low back pain who received exercise-based telerehabilitation.

RESULTS

The database search resulted in 1019 articles. Out of 37 full texts that were screened 28 articles were included in the analysis. The included studies showed a wide variation regarding technological solutions, interventions and outcome measures. The exercise-based telerehabilitation was usually delivered asynchronously via a smartphone application. The most common clinical outcome measure was pain and disability/physical function. Telerehabilitation compared to conventional exercise therapy showed similar clinical improvements.

CONCLUSIONS

This scoping review confirms the heterogeneity within this research area but also contributes by mapping and demonstrating some knowledge gaps in the literature. Further research focusing on synchronous and group interventions are needed. The new technologies described in the included studies provide added value through functional improvements and task redesign.

TRIAL REGISTRATION

OSF https//doi.org/10.17605/OSF.IO/EMKCG.

Impact of 25 Years of Mobile Health Tools for Pain Management in Patients With Chronic Musculoskeletal Pain: Systematic Review

BACKGROUND

Mobile technologies are increasingly being used in health care and public health practice for patient communication, monitoring, and education. Mobile health (mHealth) tools have also been used to facilitate adherence to chronic musculoskeletal pain (CMP) management, which is critical to achieving improved pain outcomes, quality of life, and cost-effective health care.

OBJECTIVE

The aim of this systematic review was to evaluate the 25-year trend of the literature on the adherence, usability, feasibility, and acceptability of mHealth interventions in CMP management among patients and health care providers.

METHODS

We searched the PubMed, Cochrane CENTRAL, MEDLINE, EMBASE, and Web of Science databases for studies assessing the role of mHealth in CMP management from January 1999 to December 2023. Outcomes of interest included the effect of mHealth interventions on patient adherence; pain-specific clinical outcomes after the intervention; and the usability, feasibility, and acceptability of mHealth tools and platforms in chronic pain management among target end users.

RESULTS

A total of 89 articles (26,429 participants) were included in the systematic review. Mobile apps were the most commonly used mHealth tools (78/89, 88%) among the included studies, followed by mobile app plus monitor (5/89, 6%), mobile app plus wearable sensor (4/89, 4%), and web-based mobile app plus monitor (1/89, 1%). Usability, feasibility, and acceptability or patient preferences for mHealth interventions were assessed in 26% (23/89) of the studies and observed to be generally high. Overall, 30% (27/89) of the studies used a randomized controlled trial (RCT), cohort, or pilot design to assess the impact of the mHealth intervention on patients' adherence, with significant improvements (all P<.05) observed in 93% (25/27) of these studies. Significant (judged at P<.05) between-group differences were reported in 27 of the 29 (93%) RCTs that measured the effect of mHealth on CMP-specific clinical outcomes.

CONCLUSIONS

There is great potential for mHealth tools to better facilitate adherence to CMP management, and the current evidence supporting their effectiveness is generally high. Further research should focus on the cost-effectiveness of mHealth interventions for better incorporating these tools into health care practices.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42024524634; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=524634.

Low back pain self-management mobile applications: a systematic review on digital platforms

OBJECTIVE

To identify and analyze the features and quality of self-management support of mobile applications available in Brazil for chronic low back pain in adults.

METHOD

A systematic review on the Apple Store® and Google Play® digital platforms. The Self-Management Support Assessment Tool scale was used to assess self-management support and the Institute for Healthcare Informatics Functionality Score scale was used to assess functionality.

RESULTS

Seventeen applications were selected, which included around seven self-management skills. The applications that met the majority of self-management support skills were Pathways, Branch, Pancea, Pain Navigator, and Curable. The Curable, Branch and MoovButh applications had the highest scores, with ten features on the functionality scale.

CONCLUSION

Some applications have the potential to complement in-person treatment in terms of validity, acceptability and clinical usefulness in pain management. However, barriers such as lack of partnership between healthcare providers and patients, limited evidence-based content, social support, cultural relevance, cost, language, security and privacy can limit their sustained use. PROSPERO Registration: CRD42022382686.

Smartphone applications are used for self-management, telerehabilitation, evaluation and data collection in low back pain healthcare: a scoping review

Background

Smartphone use has grown in providing healthcare for patients with low back pain (LBP), but the literature lacks an analysis of the use of smartphone apps. This scoping review aimed to identify current areas of smartphone apps use for managing LBP. We also aimed to evaluate the current status of the effectiveness or scientific validity of such use and determine perspectives for their potential development.

Methods

We searched PubMed, PEDro and Embase for articles published in English up to May 3 rd, 2021 that investigated smartphone use for LBP healthcare and their purpose. All types of study design were accepted. Studies concerning telemedicine or telerehabilitation but without use of a smartphone were not included. The same search strategy was performed by two researchers independently and a third researcher validated the synthesis of the included studies.

Results

We included 43 articles: randomised controlled trials (RCTs) (n=12), study protocols (n=6), reliability/validity studies (n=6), systematic reviews (n=7), cohort studies (n=4), qualitative studies (n=6), and case series (n=1). The purposes of the smartphone app were for 1) evaluation, 2) telerehabilitation, 3) self-management, and 4) data collection. Self-management was the most-studied use, showing promising results derived from moderate- to good-quality RCTs for patients with chronic LBP and patients after spinal surgery. Promising results exist regarding evaluation and data collection use and contradictory results regarding measurement use.

Conclusions

This scoping review revealed a notable interest in the scientific literatures regarding the use of smartphone apps for LBP patients. The identified purposes point to current scientific status and perspectives for further studies including RCTs and systematic reviews targeting specific usage.

Efficacy of telerehabilitation for spine pain during the Coronavirus pandemic lockdown: a retrospective propensity score-matched analysis

PURPOSE

Despite increased usage of telemedicine to deliver treatment during the coronavirus disease 2019 (COVID-19) pandemic, the efficacy of telerehabilitation for spine pain is unknown. This study aimed to investigate the effect of telerehabilitation on pain and disability in patients with spine pain treated during the COVID-19 pandemic and compare the results to in-clinic rehabilitation.

MATERIALS & METHODS

In this propensity score-matched analysis, 428 patients with spine pain who underwent telerehabilitation during the 6 months of COVID-19 pandemic lockdown and 428 patients who underwent in-clinic multimodal rehabilitation treatment during the 6-month period prior to lockdown were compared. Propensity score matching was done based on gender, age, pre-treatment pain, and disability. Post-treatment numerical pain rating scale (NPRS), Oswestry or Neck disability index (ODI or NDI), and minimal clinical important difference (MCID) achieved for NPRS and ODI/NDI scores were compared between the 2 groups.

RESULTS

Post-treatment, the mean NPRS (mean difference - 1, p < 0.0001) and ODI/NDI (mean difference - 5.8, p < 0.0001) scores, were significantly lower in the telerehabilitation group when compared to control group. Similarly, the percentage of patients who achieved MCID of ≥ 2 for NPRS (mean difference - 6%, p = 0.0007) and MCID of ≥ 10 for ODI/NDI (mean difference - 7.5%, p = 0.005) scores were significantly higher in the telerehabilitation group.

CONCLUSIONS

Telerehabilitation achieved significant reduction in pain and disability among patients with spine pain, better than in-clinic rehabilitation. These encouraging results during the COVID-19 pandemic indicate the need to further explore and test the efficacy and wider application of telerehabilitation for treating spine pain.IMPLICATIONS FOR REHABILITATIONTelerehabilitation can help achieve significant reduction in pain and disability among patients with spine pain.These encouraging results indicate the need to further explore a wider application of telerehabilitation for treating patients with spine pain during non-pandemic times.

Remotely delivered physiotherapy is as effective as face-to-face physiotherapy for musculoskeletal conditions (REFORM): a randomised trial

QUESTION

Is remotely delivered physiotherapy as good or better than face-to-face physiotherapy for the management of musculoskeletal conditions?

DESIGN

Randomised controlled, non-inferiority trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS

A total of 210 adult participants with a musculoskeletal condition who presented for outpatient physiotherapy at five public hospitals in Sydney.

INTERVENTION

One group received a remotely delivered physiotherapy program for 6 weeks that consisted of one face-to-face physiotherapy session in conjunction with weekly text messages, phone calls at 2 and 4 weeks, and an individualised home exercise program delivered through an app. The other group received usual face-to-face physiotherapy care in an outpatient setting.

OUTCOME MEASURES

The primary outcome was the Patient Specific Functional Scale at 6 weeks with a pre-specified non-inferiority margin of -15 out of 100 points. Secondary outcomes included: the Patient Specific Functional Scale at 26 weeks; kinesiophobia, pain, function/disability, global impression of change and quality of life at 6 and 26 weeks; and satisfaction with service delivery at 6 weeks.

RESULTS

The mean between-group difference (95% CI) for the Patient Specific Functional Scale at 6 weeks was 2.7 out of 100 points (-3.5 to 8.8), where a positive score favoured remotely delivered physiotherapy. The lower end of the 95% CI was greater than the non-inferiority margin. Whilst non-inferiority margins were not set for the secondary outcomes, the 95% CI of the mean between-group difference ruled out clinically meaningful differences.

CONCLUSION

Remotely delivered physiotherapy with support via phone, text and an app is as good as face-to-face physiotherapy for the management of musculoskeletal conditions.

TRIAL REGISTRATION

ACTRN12619000065190.

Effectiveness and cost-effectiveness of telerehabilitation for musculoskeletal disorders: A systematic review and meta-analysis

BACKGROUND

Internet-based telerehabilitation could be a valuable option for the treatment of musculoskeletal disorders, with the advantage of providing rehabilitation from anywhere. However, there is no solid and updated evidence demonstrating its effectiveness on relevant clinical and cost outcomes.

OBJECTIVE

This systematic review aims to determine the clinical and cost-effectiveness of internet-based telerehabilitation during the recovery of musculoskeletal disorders.

METHODS

Medline, Web of Science, Scopus and Cochrane databases were systematically searched from inception to June 2023. Trials investigating the effects of internet-based telerehabilitation in any musculoskeletal disorder were selected. Nonoriginal articles and grey literature were excluded. Two independent reviewers conducted the study selection and data extraction. Random effect meta-analyses (standardized mean difference) and further sensitivity analyses were performed.

RESULTS

We selected 37 clinical trials (33 randomized and 4 non-randomized) and 5 health economics studies, which included a total of 4,288 participants. Telerehabilitation was more favourable than control treatments in improving all studied clinical outcomes, although the effectiveness varied depending on the type of musculoskeletal disorder. The standard mean differences (SMD) ranged from 0.24 to 0.91. For physical function, the primary outcome, superior effectiveness was found only in people with hip fractures (SMD, 0.87; 95 % CI, 0.34 to 1.41). The effects for joint replacement, osteoarthritis, and spine pain were similar to those of control treatments. However, the favourable outcomes for telerehabilitation became insignificant when compared specifically to face-to-face rehabilitation. Some results displayed publication bias and a lack of robustness, necessitating cautious interpretation. In terms of health economics studies, telerehabilitation was 89.55$ (95 % CI 4.6 to 174.5) cheaper per individual than conventional treatments.

CONCLUSIONS

Telerehabilitation should be considered in the recovery process of musculoskeletal disorders when optimal face-to-face rehabilitation is not feasible. Moreover, telerehabilitation reduces costs and time.

PROSPERO NUMBER

CRD42022322425.

Effects of Interactive Telerehabilitation Practices in Office Workers with Chronic Nonspecific Neck Pain: Randomized Controlled Study

Aim: Aim of this study is to investigate the effects of interactive telerehabilitation exercises in office workers with chronic nonspecific neck pain. Methods: Office workers (n = 120) were randomly divided into three groups between February and July 2022, taking into account the inclusion and exclusion criteria, and office ergonomics training was given to all of the participants. Group 1 participants were given an interactive telerehabilitation program (strengthening, motor control, and posture correction exercises) for 45 min per day, 3 days a week, for a total of 6 weeks. Group 2 participants were trained to do the home exercise program on their own for 45 min per day, 3 days a week, for a total of 6 weeks. Only office ergonomics training was given to Group 3 patients. Results: Statistically significant improvement in pain (p < 0.001), range of motion (ROM) (p < 0.001), neck disability status (p < 0.001), functional status (p < 0.001), and quality of life (p < 0.001) of 6-week interactive telerehabilitation application in office workers was found. Discussion: In addition to office ergonomics training, interactive telerehabilitation program is the most effective method on pain, ROM, and neck disability compared with home exercise program and office ergonomics training alone, and studies are needed on the long-term effectiveness of telerehabilitation applications and telerehabilitation treatment diversity.

The Added Value of Face-to-Face Supervision to a Therapeutic Exercise-Based App in the Management of Patients with Chronic Low Back Pain: A Randomized Clinical Trial

Low back pain (LBP) is a significant global health challenge due to its high prevalence, and chronicity and recurrence rates, with projections suggesting an increase in the next years due to population growth and aging. The chronic and recurrent nature of LBP, responsible for a significant percentage of years lived with disability, underscores the need for effective management strategies, including self-management strategies advocated by current guidelines, to empower patients and potentially improve healthcare efficiency and clinical outcomes. Therefore, the aim of this study was to analyze the added value of face-to-face visits in patients with chronic LBP undergoing a self-management program based on therapeutic exercises on pain intensity, disability, quality of life and treatment adherence and satisfaction. A randomized clinical trial was conducted, allocating 49 patients into a experimental group with a mobile health (mHealth) app usage and face-to-face sessions and 49 patients into an active control group without face-to-face sessions. Pain intensity, disability and quality of life were assessed at baseline, 4 weeks postintervention and 12 weeks postintervention. Patients' satisfaction and adherence were assessed at the end of the study. The multivariate general model revealed no statistically significant time × group interaction for any outcome (p > 0.0068) but mental quality of life (p = 0.006). Within-group differences revealed significant improvements for all the clinical indicators (all, p < 0.001). Patients allocated to the experimental group reported greater satisfaction and adherence (both, p < 0.001) compared to the control group. The use of mHealth apps such as Healthy Back® as part of digital health initiatives may serve as a beneficial approach to enhance the management of LBP.

Effectiveness of Telerehabilitation for Correcting Posture in Elderly with Thoracic Kyphosis in Urban Thailand

Introduction

Thoracic kyphosis (TK) is an abnormal thoracic spine. Telerehabilitation and conventional physical therapy were compared for correct posture in the thoracic angle, forward head posture, back muscle strength, and cost-effectiveness.

Method

Twenty-two Thai women 60 years of age and over, with thoracic angles over 45 degrees, participated in this study. Participants were randomly allocated into a telerehabilitation group (TG) or a control group (CG). TG and CG underwent a thoracic corrective exercise program for 1 hour each session, three times per week for 8 weeks.

Result

Thoracic angle, forward head posture, and back muscle strength improved (P < .05) in both groups. Furthermore, cost-effectiveness showed the cost of intervention in TG lower than CG, approximately 133.78 US$.

Conclusion

Our study showed no difference in telepractice program efficacy and effectiveness compared to in-person treatment in the clinic. Thus, telerehabilitation may be an alternative treatment for the elderly who cannot travel to the hospital.

Mobile technologies for rehabilitation in non-specific spinal disorders: a systematic review of the efficacy and potential for implementation in low- and middle-income countries

PURPOSE

The aim of this systematic review was primarily to identify the types of mHealth technologies for the rehabilitation of non-specific spinal disorders, second to evaluate their efficacy, and finally to determine their applicability in LMICs.

METHODS

Three databases (Scopus, PubMed, and Web of Science) were searched for randomized controlled trials and clinical trials from January 2012 until December 2022. Studies were found eligible when using mHealth technologies for the rehabilitation of non-specific spinal disorders. To evaluate efficacy, the primary outcome was pain intensity, and the secondary outcomes were disability and quality of life. To evaluate the applicability in LMICs, information about financial and geographical accessibility, offline usability, and languages was extracted.

RESULTS

Fifteen studies were included comprising 1828 participants who suffer from non-specific low back pain (86.05%) and non-specific neck pain (13.95%). Fourteen distinct smartphone-based interventions and two sensor system interventions were found, with a duration ranging from four weeks to six months. All mHealth interventions demonstrated efficacy for the improvement of pain, disability and quality of life in non-specific spinal disorders, particularly low back pain. Five of the evaluated smartphone applications were free of charge accessible and had language features that could be adapted for use in LMICs.

CONCLUSION

mHealth interventions can be used and integrated into the conventional treatment of non-specific spinal disorders in rehabilitation. They have demonstrated efficacy and could be implemented in LMICs with minor adaptations to overcome language barriers and the absolute necessity of the internet.

Effect of the telemedicine-supported multicomponent exercise therapy in patients with knee osteoarthritis: study protocol for a randomized controlled trial

INTRODUCTION

The rising prevalence of knee osteoarthritis is placing a considerable strain on the global healthcare system. To address this issue, telemedicine-supported multicomponent exercise therapy has emerged as a promising approach. This therapy combines exercise, patient education, and health coaching to empower knee osteoarthritis patients to manage their condition from the comfort of their homes. Nevertheless, there are some existing limitations in the current research on this approach, including challenges related to patient compliance and the absence of objective evaluation methods.

METHODS AND ANALYSIS

Patients diagnosed with knee osteoarthritis, who have not undergone knee surgery in the past year, will be recruited for a randomized controlled trial. The trial will include an intervention group and a control group. The intervention group will receive an mHealth app-based multicomponent exercise therapy, consisting of exercise therapy, patient education, and health coaching. Meanwhile, the control group will receive usual care, involving drug therapy and patient education. The primary outcome of the trial will be the measurement of pain intensity, assessed using a visual analog scale at baseline and at 4, 8, and 12 weeks of the post-intervention. To analyze the data, a two-factor, four-level repeated measures ANOVA will be used if the assumptions of homogeneity of variance and sphericity are met. If not, a mixed effects model will be employed.

DISCUSSION

The aim of the study is to evaluate the effectiveness of multicomponent exercise therapy aimed at enhancing pain self-management for knee osteoarthritis patients in the comfort of their own homes. The intervention incorporate wearable devices equipped with advanced deep learning systems to monitor patients' adherence to the prescribed at-home exercise regimen, as well as to track changes in outcomes before and after the exercise sessions. The findings from this trial have the potential to enhance both the accessibility and quality of care provided to knee osteoarthritis patients, offering valuable insights for future improvements in their treatment and management.

TRIAL REGISTRATION

Chinese Clinical Trials Registry, ChiCTR2300073688. Registered on 19 July 2023, https://www.chictr.org.cn/bin/project/edit?pid=199707 . World Health Organization International Clinical Trials Registry Platform, https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2300073688 .

Telerehabilitation for a Non-specific Low Back Pain: A Case Report

One of the most common conditions that affect activities of daily living and make them significantly more difficult to perform is low back pain (LBP). As a result, it is essential to treat LBP at an early stage. Particularly in geographically remote areas where there is a shortage of medical professionals and a lack of rehabilitation services, telerehabilitation is considered a potential alternative. Hence, this case report represents the impact of telerehabilitation on LBP in a 32-year-old female corporate worker who presented to the out-patient department of physiotherapy with the chief complaints of LBP for the last three months with difficulty in performing activities, and being unable to sit for prolonged period of time. The physiotherapeutic rehabilitation was virtually administered through online sessions through the cloud-based application as the patient was not able to visit the outpatient department on a regular basis. Post-intervention results demonstrated increased range of motion and flexibility, reduced pain, increased muscle strength, reduced disability and kinesiophobia, and improved quality of life. Hence, it can be concluded that telerehabilitation offers a novel solution to increase access to rehabilitation services.

Virtually Administered Intervention Through Telerehabilitation for Chronic Non-specific Low Back Pain: A Review of Literature

The most frequent reason for individuals to seek medical attention in both primary care settings and immediate care centers is low back pain (LBP). Over a duration of time, the disability caused by lower back pain has risen enough, particularly in countries with low or moderate incomes. In the coming years, there may be an increase in LBP-related impairment and expenses in countries with low or medium incomes, particularly when fragile medical systems are unable to handle this growing load. Hence, this review focuses on the effectiveness of telerehabilitation (TR) on LBP. The significant advantages of TR may include greater interaction and remote accessibility to medical treatments. The exchange of knowledge and health information is made possible through a more effective interaction, which benefits patients, families, carers, physicians, and researchers. People who live in distant places now have the opportunity to get medical attention assisting families in caring for patients with poor responsiveness. In addition, it provides the potential for prompt detection, the beginning of treatment in the midst of an emergency, a shorter stay in the hospital, ongoing monitoring of those at risk, and overall time and expense savings. Therefore, this study supports the application of TR in conditions of LBP for early management and relief of pain for patients in low-resource areas.

Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain

Low back pain (LBP) is the world's leading cause of years lived with disability. Digital exercise-based interventions have shown great potential in the management of musculoskeletal conditions, promoting access and easing the economic burden. However, evidence of their effectiveness for chronic LBP (CLBP) management compared to in-person physiotherapy has yet to be unequivocally established. This randomized controlled trial (RCT) aims to compare the clinical outcomes of patients with CLBP following a digital intervention versus evidence-based in-person physiotherapy. Our results demonstrate that patient satisfaction and adherence were high and similar between groups, although a significantly lower dropout rate is observed in the digital group (11/70, 15.7% versus 24/70, 34.3% in the conventional group; P = 0.019). Both groups experience significant improvements in disability (primary outcome), with no differences between groups in change from baseline (median difference: -0.55, 95% CI: -2.42 to 5.81, P = 0.412) or program-end scores (-1.05, 95% CI: -4.14 to 6.37; P = 0.671). Likewise, no significant differences between groups are found for secondary outcomes (namely pain, anxiety, depression, and overall productivity impairment). This RCT demonstrates that a remote digital intervention for CLBP can promote the same levels of recovery as evidence-based in-person physiotherapy, being a potential avenue to ease the burden of CLBP.

In non-specific low back pain, is an exercise program carried out through telerehabilitation as effective as one carried out in a physiotherapy center? A controlled randomized trial

BACKGROUND

s:The effectiveness of telerehabilitation (TLRH) in patients with non-specific low back pain (NLBP) remains unknown. No study till date has investigated the efficacy of a mobile-based TLRH in patients with NLBP.

OBJECTIVES

To investigate if a TLRH program is as effective as a clinical exercise programme in improving disability, pain intensity, pain catastrophizing, and hip pain and strength in patients with NLBP.

DESIGN

Single-blind, two-armed, randomized controlled study.

METHOD

A total of 71 individuals with NLBP were randomly allocated to either the TLRH home group (TLRH) or clinic group (CG). The TLRH followed exercise videos and read information on pain neurophysiology. The CG performed the same exercises and received on-site pain education. Both groups performed the exercises twice weekly for 8 weeks. Disability, pain intensity, pain catastrophizing, and hip pain and strength were assessed at baseline, at post-treatment, and at three months.

RESULTS

Statistically significant differences for time-by-group interaction were detected in the strength of left hip flexors (supine [F = 8.356; p = .005]; sitting [F = 9.828; p = .003]), right hip extensors with extended knee [F = 7.461; p = .008], left hip extensors (extended knee [F = 13.175; p = .001]; flexed knee [F = 13.505; p < .001]), pain during flexion of the right [F = 5.133; p = .027] and left [F = 4.731; p = .033] hips in the supine position, disability [F = 4.557; p = .014], and pain catastrophizing [F = 14.132; p < .001].

CONCLUSION

A TLRH mobile-based is as effective as clinical treatment in improving disability, pain catastrophizing, and pain and strength of the hip structures in patients with NLBP.

Engagement and Utilization of a Complete Remote Digital Care Program for Musculoskeletal Pain Management in Urban and Rural Areas Across the United States: Longitudinal Cohort Study

BACKGROUND

Musculoskeletal (MSK) conditions are the number one cause of disability worldwide. Digital care programs (DCPs) for MSK pain management have arisen as alternative care delivery models to circumvent challenges in accessibility of conventional therapy. Despite the potential of DCPs to reduce inequities in accessing care, the outcomes of such interventions in rural and urban populations have yet to be studied.

OBJECTIVE

The aim of this study was to assess the impact of urban or rural residency on engagement and clinical outcomes after a multimodal DCP for MSK pain.

METHODS

This study consists of an ad hoc analysis of a decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were coded according to their zip codes to a specific rural-urban commuting area code and grouped into rural and urban cohorts. Changes in their engagement and clinical outcomes from baseline to program end were assessed. Latent growth curve analysis was performed to estimate change trajectories adjusting for the following covariates: age, gender, BMI, employment status, and pain acuity. Outcomes included engagement, self-reported pain, and the results of the Generalized Anxiety Disorder 7-item, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment scales. A minimum clinically important difference (MCID) of 30% was considered for pain.

RESULTS

Patients with urban and rural residency across the United States participated in the program (n=9992). A 73.8% (7378/9992) completion rate was observed. Both groups reported high satisfaction scores and similar engagement with exercise sessions, with rural residents showing higher engagement with educational content (P<.001) and higher program completion rates (P=.02). All groups showed a significant improvement in all clinical outcomes, including pain, mental health, and work productivity, without statistically significant intergroup differences. The percentage of patients meeting the MCID was similar in both groups (urban: 67.1%, rural: 68.3%; P=.30).

CONCLUSIONS

This study advocates for the utility of a DCP in improving access to MSK care in urban and rural areas alike, showcasing its potential to promote health equity. High engagement, satisfaction, and completion rates were noted in both groups, as well as significant improvements in clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Impact on productivity impairment of a digital care program for chronic low back pain: A prospective longitudinal cohort study

BACKGROUND

Low back pain (LBP) is the leading cause of disability in the United States and the main reason for absenteeism. Successful management of chronic LBP (CLBP) is dependent on multimodal evidence-based interventions. Digital interventions (DI) may ease accessibility to such treatments, increasing adherence, while reducing healthcare-related costs.

OBJECTIVES

Assess the impact of a completely remote multimodal DI on productivity impairment in a real-work context cohort of patients with CLBP.

DESIGN

Longitudinal study.

METHODS

Ad-hoc analysis of an interventional, single-arm study of individuals with CLBP undergoing a DI for 12 weeks. Outcomes included the mean change in work productivity and activity impairment (including overall and non-work related activities), pain, depression, anxiety, fear-avoidance beliefs, analgesic usage, and engagement. Minimal clinically important change (MCIC) was calculated for productivity using anchor- and distribution-based methods.

RESULTS

From 560 patients at program start, 78.4% completed the DI. A significant improvement in overall productivity (20.21, 95%CI: 16.48-23.94) and in non-work related activities (21.36, 95%CI: 17.49-25.22) was observed, corresponding to a responder rate of 57.1-83.3% and 60.5-79.8%, respectively, and depending on the MCIC method. Significant improvements were reported for pain (2.32 points, 95%CI: 2.02-2.61), anxiety (5.24, 95%CI: 4.18-6.29), depression (6.38, 95%CI: 4.78-7.98) and fear-avoidance beliefs (8.11, 95%CI: 6.20-10.02). Both engagement (sessions per week) and patient satisfaction scores were high, 2.9 (SD 1.0) and 8.8/10 (SD 1.6), respectively.

CONCLUSIONS

This study demonstrated the utility of a multimodal DI to address productivity impairment. DIs have great potential to ease the burden of CLBP, providing an accessible and cost-effective modality of care.

TRIAL REGISTRATION

The study was approved by the New England IRB (protocol number 120190313) and prospectively registered in ClinicalTrials.gov, NCT04092946, on September 17th, 2019.

Therapeutic Effects of Metaverse Rehabilitation for Cerebral Palsy: A Randomized Controlled Trial

Metaverse physical therapy (MPT), an adjuvant technology for the rehabilitation of children with cerebral palsy (CP), has gained notoriety in the clinical field owing to its accessibility and because it provides motivation for rehabilitation. The aim is to compare the gross motor function and cardiopulmonary function, the activities of daily living, quality of life (QOL), and the perceived risk of coronavirus disease (COVID)-19 transmission between MPT and conventional physical therapy (CPT). A convenience sample of 26 children with CP (mean age, 11.23 ± 3.24 years, 14 females) were randomized into either the MPT or CPT group and received therapy three days/week for four weeks. Clinical outcomes included gross-motor-function measure 66 (GMFM-66), heart rate (HR), Borg-rating perceived exertion (BRPE), functional independence measure (FIM), pediatric QOL, and the risk of COVID-19 transmission. An analysis of variance showed that compared with CPT, MPT exerted positive effects on GMFM, HR, and BRPE. An independent t-test showed that compared with CPT, MPT exerted positive effects on the perceived transmission risk of COVID-19 but not on FIM and QOL. Our results provide promising therapeutic evidence that MPT improves gross motor function, cardiopulmonary function, and the risk of COVID-19 in children with CP.

Adherence and Effect of Home-Based Rehabilitation with Telemonitoring Support in Patients with Chronic Non-Specific Low Back Pain: A Pilot Study

Home-based exercises have been on the rise recently. This pilot study aimed to assess the adherence and effect of a home-based rehabilitation programme using telemonitoring in patients with chronic non-specific low back pain (CNLBP). Twenty-seven patients with CNLBP were enrolled in the study, each of whom underwent a neurological assessment, including patient-oriented measures and a functional assessment-a battery of tests that comprehensively evaluated trunk muscle function. The rehabilitation programme lasted 18 weeks and included daily home-based exercises. A mobile application or an exercise diary was used to monitor compliance. Adherence to the programme was excellent for both the diary and mobile application groups, with 82.3% in the diary group exercising at least once a day and 72.9% twice a day, and 94.8% in the mobile application group exercising at least once a day and 86.6% twice a day. Both patient-oriented and functional outcomes improved significantly; however, the relative changes of the parameters in these two groups did not correlate, which supports the idea that trunk muscle function does not directly relate to patient complaints and that CNLBP is a multifactorial issue. This model of rehabilitation programme should be used in clinical practice, as its adherence and effectiveness seem noticeable.

Long-term effects of deep-learning digital therapeutics on pain, movement control, and preliminary cost-effectiveness in low back pain: A randomized controlled trial

Objective

The present study aimed to compare the effects of a deep learning-based digital application with digital application physical therapy (DPT) and those of conventional physical therapy (CPT) on back pain intensity, limited functional ability, lower extremity weakness, radicular symptoms, limited range of motion (ROM), functional movement, quality of life, cost-effectiveness, and postintervention questionnaires for perceived transmission risk of COVID-19 and satisfaction results in 100 participants with low back pain (LBP).

Methods

One hundred participants with LBP were randomized into either DPT or CPT groups, three times per week over four weeks. Outcome measures included the (1) Oswestry Disability Index, (2) Quebec Back Pain Disability Scale, (3) Roland-Morris Disability Questionnaire (RMDQ), (4) Numeric Pain Rating Scale, (5) functional movement screen (FMS), (6) short form-12, (7) lower extremity strength, (8) ROM of trunk flexion, extension, and bilateral side bending, (9) questionnaires for perceived transmission risk of COVID-19, (10) preliminary cost-effectiveness, and (11) postintervention satisfaction questionnaire results. The analysis of variance was conducted at p < 0.05.

Results

Analysis of variance showed that DPT showed superior effects, compared to CPT on RMDQ, hip extensor strength, transmission risk of COVID-19, as well as satisfaction. Both groups showed significant improvement pre- and postintervention, suggesting that DPT is as effective as CPT, and was superior in preliminary cost-effectiveness and transmission risk of COVID-19.

Conclusions

Our results provide novel, promising clinical evidence that DPT was as effective as CPT in improving structural and functional impairment, activity limitation, and participation restriction. Our results highlight the successful incorporation of DPT intervention for clinical outcome measures, lower extremity strength, trunk mobility, ADL improvement, QOL improvement, and FMS in LBP.

Efficacy of e-Health Interventions in Patients with Chronic Low-Back Pain: A Systematic Review with Meta-Analysis

Introduction: Low-back pain (LBP) is the leading cause of disability worldwide. Around 75-84% of the world's population will experience LBP at some point, establishing it as a major global health problem. e-Health is the remote delivery of therapeutic services, clinical information, and medical care, and may prove a very useful approach to tackle this pathology. Objectives: To evaluate the efficacy of e-health-based interventions in improving the symptoms of chronic LBP. Methods: A systematic review with meta-analysis was performed in PubMed, Web of Science, and PEDro until January 2022 through the assessment of methodological quality of systematic reviews (AMSTAR). Studies were included in which e-health interventions were used as experimental treatment compared to physical therapy to determine changes in back-specific functional status and pain in patients with chronic LBP. Two reviewers examined the sources individually, calculated the risk of bias, and extracted the data (PROSPERO number CRD42022306130). The effect size was calculated using the standardized mean difference (SMD) and its confidence interval (95% CI). Results: A total of 9 randomized controlled trials with 3,180 participants were included. The results of the findings showed an effect of e-health compared to other physical therapy on short-term (SMD = -0.59, 95% CI: -1.77 to 0.59) and intermediate short-term (SMD = -0.40, 95% CI: -0.91 to 0.11) pain intensity and back-specific functional status in the short term (SMD = -0.20, 95% CI: -0.81 to 0.41) and intermediate short term (SMD = -0.30, 95% CI: -0.74 to 0.14). The effect of e-health compared to minimal intervention on short-term intermediate pain intensity (SMD = -0.64, 95% CI: -1.72 to 0.45) and short-term intermediate back-specific functional status (SMD = -0.39, 95% CI: -0.87 to 0.09). Conclusions: e-Health interventions based on self-maintenance and education are as effective on pain and back-specific functional status as other face-to-face or home-based interventions in patients with chronic LBP, with moderate scientific evidence.

Telerehabilitation proposal of mind-body technique for physical and psychological outcomes in patients with fibromyalgia

Fibromyalgia (FM) syndrome is characterized by the close correlation of chronic widespread pain and other non-pain related symptoms. Aim of this study was to investigate whether telerehabilitation that provides physical and psychological support services of the mind-body techniques can affect the clinical profile and pain relief of FM patients. The study included twenty-eight female FM patients, mean aged 56.61 ± 8.56 years. All patients underwent a rehabilitation treatment (8 sessions, 1/week, 1 h/each) through Zoom platform, with the following principles of rehabilitation treatment: Anchoring to a positive emotion; listen and perceive your “own” body; conscious breathing; improve interoceptive awareness; relax. All patients then underwent clinical assessment of the physical distress and fear of movement for the Numeric Rating Scale (NRS); the Fatigue Assessment Scale (FAS); the Fear Avoidance Belief Questionnaire (FABQ); with measures of physical and mental disability for the Fibromyalgia Impact Questionnaire (FIQ); the 12-Items Short Form Survey; the Resilience Scale for Adults and the Coping Strategies Questionnaire-Revised. The evaluations were performed at T0 (baseline), T1 (after 8 weeks of treatment), and T2 (after 1 month of follow-up). The main finding was that telerehabilitation reduced physical and mental distress, fear, and disability (p < 0.001). Resilience and coping ability were less affected by the rehabilitative treatment. Our attempt of mind-body technique telerehabilitation has shown good results in the improvement of painful symptoms and quality of life for the FM patients but showed fewer positive impacts for the resilience and coping abilities aspects.

Translation, Cross-Cultural Adaptation, and Psychometric Testing of Yoruba Version of the EQ-5D Questionnaire in Patients With Musculoskeletal Disorders

Background

The EuroQol-5 Dimension (EQ-5D) is a generic self-administered questionnaire used for the measurement and economic valuation of a wide range of health conditions, which necessitates its existence and adaptation in different languages. Currently, the tool does not exist in any Nigerian language. This study aimed to translate, cross-culturally adapt, and determine the reliability and validity of the Yoruba version of the EQ-5D-5L questionnaire.

Methods

The International Quality of Life Assessment (IQOLA) project guidelines, involving forward translation, reconciliation and harmonization, backward translation, and reconciliation of problematic items were used in the Yoruba translated version of the EQ-5D-5L (EQ-5D-Yor). A total of 113 and 109 persons with musculoskeletal disorders participated in the validity and 7-day test-retest reliability testing of the EQ-5D-Yor. Convergent and discriminant validity of the EQ-5D-Yor were determined using the Yoruba version of the 12-Item Short-Form Health Survey (SF-12) (SF-12-Y) and Visual Analog Scale (VAS). Data were analyzed using descriptive and inferential statistics of Spearman correlation, Intra-Class Correlation, Cronbach alpha, and multi-trait scaling analysis. Alpha level was set as p < 0.05.

Results

The construct validity of the EQ-5D-Yor yielded Spearman rho ranging from 0.438 to 1.000, with the EQ-VAS having the highest co-efficient (r = 1.000; p = 0.001). The convergent validity of the EQ-5D-Yor index with scales and domains of the SF-12-Y yielded no significant correlations (p < 0.05), except for the physical functioning scale (r = −0.709, p = 0.001). On the other hand, the divergent validity of the EQ-5D-Yor index with VAS yielded a moderate negative correlation (r = −0.482; p = 0.001). The Intra-class Correlation Coefficient (ICC) and Cronbach's alpha for the test-retest reliability of the EQ-5D-Yor were 1.000 and 0.968. The confirmatory factor analysis showed the factor loadings were poor when including VAS in the model.

Conclusion

The EQ-5D-Yor has acceptable validity and reliability and can be used as a valid tool among Yoruba speaking population with musculoskeletal disorders.

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.

Comparison of the effectiveness of an e-health program versus a home rehabilitation program in patients with chronic low back pain: A double blind randomized controlled trial

OBJETIVE

We conducted a randomized double blind clinical trial, to compare the effectiveness of McKenzie exercises and electroanalgesia via an e-Health program versus a home rehabilitation program on functionality, pain, fear of movement and quality of life in patients with non-specific chronic low back pain.

METHODS

Seventy-four participants with non-specific chronic low back pain were randomized to either the e- Health program group (n = 39) or the home rehabilitation program group (n = 35). The interventions consisted of the e-Health program group performing McKenzie exercises and received transcutaneous electrical nerve stimulation, while the home rehabilitation group attended an information session to explain the exercises, which they then performed at home with printed instructions. Both groups performed 3 weekly sessions for 8 weeks. The following were analyzed main measures: pain, disability, fear of movement, quality of life, trunk muscle endurance and trunk anteflexion motion were assessed at baseline and at 2 months.

RESULTS

Independent samples Student's t-tests showed that although the patients who followed the e-Health program showed significantly greater improvement than those who followed the home disability rehabilitation program in terms of intensity of pain, lumbar flexion mobility (P < 0.001), and the following dimensions of quality of life (P < 0.005), both groups improved significantly in the immediate post-treatment follow up compared with baseline scores.

CONCLUSIONS

Patients with chronic low back pain who followed an unsupervised home intervention supported by an individualized video exercise program showed greater post-treatment improvement than those who followed the same program with printed instructions.

Digital Therapeutic Care and Decision Support Interventions for People With Low Back Pain: Systematic Review

BACKGROUND

Low back pain (LBP) is the leading cause of worldwide years lost because of disability, with a tremendous economic burden for health care systems. Digital therapeutic care (DTC) programs provide a scalable, universally accessible, and low-cost approach to the multidisciplinary treatment of LBP. Moreover, novel decision support interventions such as personalized feedback messages, push notifications, and data-driven activity recommendations amplify DTC by guiding the user through the program while aiming to increase overall engagement and sustainable behavior change.

OBJECTIVE

This systematic review aims to synthesize recent scientific literature on the impact of DTC apps for people with LBP and outline the implementation of add-on decision support interventions, including their effect on user retention and attrition rates.

METHODS

We searched bibliographic databases, including MEDLINE, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database, from March 1, 2016, to October 15, 2020, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and conducted this review based on related previously published systematic reviews. Besides randomized controlled trials (RCTs), we also included study designs with the evidence level of at least a retrospective comparative study. This enables the consideration of real-world user-generated data and provides information regarding the adoption and effectiveness of DTC apps in a real-life setting. For the appraisal of the risk of bias, we used the Risk of Bias 2 Tool and the Risk of Bias in Non-Randomized Studies of Interventions Tool for the RCTs and nonrandomized trials, respectively. The included studies were narratively synthesized regarding primary and secondary outcome measures, DTC components, applied decision support interventions, user retention, and attrition rates.

RESULTS

We retrieved 1388 citations, of which 12 studies are included in this review. Of the 12 studies, 6 (50%) were RCTs and 6 (50%) were nonrandomized trials. In all included studies, lower pain levels and increased functionality compared with baseline values were observed in the DTC intervention group. A between-group comparison revealed significant improvements in pain and functionality levels in 67% (4/6) of the RCTs. The study population was mostly homogeneous, with predominantly female, young to middle-aged participants of normal to moderate weight. The methodological quality assessment revealed moderate to high risks of biases, especially in the nonrandomized trials.

CONCLUSIONS

This systematic review demonstrates the benefits of DTC for people with LBP. There is also evidence that decision support interventions benefit overall engagement with the app and increase participants' ability to self-manage their recovery process. Finally, including retrospective evaluation studies of real-world user-generated data in future systematic reviews of digital health intervention trials can reveal new insights into the benefits, challenges, and real-life adoption of DTC programs.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

The Use of Virtual Reality in Back Pain Rehabilitation: A Systematic Review and Meta-Analysis

This systematic review aimed to synthesize the existing evidence of extended reality (XR) on pain and motor function outcomes in patients with back pain. Following the Cochrane guidelines, relevant articles of any language were selected by 2 independent reviewers from CINAHL, Cochrane, Embase, Medline and Web of Knowledge databases. Of 2,050 unique citations, 24 articles were included in our review. These studies included a total of 900 back pain patients. Despite broader XR search, all interventions were virtual reality (VR) based and involved physical exercises (n = 17, 71%), hippotherapy (n = 4, 17%), motor imagery (n = 1, 4%), distraction (n = 1, 4%), and cognitive-behavior therapy (n = 1, 4%). Sixteen controlled studies were included in a meta-analysis which suggested that VR provides a significant improvement in terms of back pain intensity over control interventions (Mean Difference: -0.67; 95% CI: -1.12 to -0.23; I² = 85%). Almost all included studies presented high risk of bias, highlighting the need to improve methodology in the examination of VR interventions. While the specific set of studies showed high heterogeneity across several methodological factors, a tentative conclusion could be drawn that VR was effective improving back pain intensity and tends to have a positive effect on improving other pain outcomes and motion function. PERSPECTIVE: Extended reality technologies have appeared as interesting nonpharmacological options for the treatment of back pain, with the potential to minimise the need for opioid medications. Our systematic review summarised existing applications of extended reality for back pain and proposed a few recommendations to direct further studies in the field.

The effect of video exercise-based telerehabilitation on clinical outcomes, expectation, satisfaction, and motivation in patients with chronic low back pain

BACKGROUND

The efficacy of exercise-based telerehabilitation in chronic low back pain (CLBP) has not been well studied. To our knowledge, no other studies have investigated the efficacy of video exercise-based telerehabilitation software in the remote management of home exercises in patients with CLBP.

AIMS

The purpose of the study was to investigate the effect of the video-based exercise software on pain, function, quality-of-life, expectation, satisfaction, and motivation in individuals with CLBP.

METHODS

A double-blind, two-armed randomized controlled trial was carried out with 50 individuals with CLBP. Participants were randomly allocated to either the telerehabilitation group (n = 25) or the conventional rehabilitation group (n = 25). The telerehabilitation group was followed up with a video exercise-based telerehabilitation software called Fizyoweb. The clinician was able to communicate with the patients through the software. The conventional rehabilitation group was given the same home exercises as the paper-based exercise instruction form. Pain, function, quality-of-life, and kinesiophobia were evaluated at baseline and after 8 weeks of intervention. In addition, patient expectations were questioned at the initial evaluation; afterward, patient satisfaction and motivation were questioned at the eighth week.

RESULTS

After 8 weeks of treatment, the telerehabilitation group achieved significant improvement in pain, function, quality-of-life, kinesiophobia, satisfaction, and motivation (p < 0.05). In addition, the telerehabilitation group reported more significant gains in all parameters compared with the conventional rehabilitation group (p < 0.05).

CONCLUSIONS

The video exercise-based telerehabilitation software positively affects clinical parameters and adherence to rehabilitation in patients with CLBP.

In-Clinic Versus Web-Based Multidisciplinary Exercise-Based Rehabilitation for Treatment of Low Back Pain: Prospective Clinical Trial in an Integrated Practice Unit Model

BACKGROUND

The recent onset of the COVID-19 pandemic has highlighted the need to reduce barriers to access physical therapy and associated care through the use of web-based programs and telehealth for those seeking treatment for low back pain (LBP). Despite this need, few studies have compared the effectiveness of clinic-based versus web-based or telehealth services.

OBJECTIVE

This study aims to compare the clinical outcomes of clinic-based multidisciplinary therapy in an integrated practice unit (C-IPU) model with online integrated multidisciplinary therapy (O-IPU) in individuals undergoing conservative care for LBP.

METHODS

A total of 1090 participants were prospectively recruited to participate in a clinical trial registry (NCT04081896) through the SpineZone rehabilitation IPU program. All participants provided informed consent. Participants were allocated to the C-IPU (N=988) or O-IPU (N=102) groups based on their personal preferences. The C-IPU program consisted of a high-intensity machine-based core muscle resistance training program, whereas the O-IPU program consisted of therapist-directed home core strengthening exercises through a web-based platform. Changes in LBP symptom severity (Numeric Pain Rating Scale), disability (Oswestry Disability Index), goal achievement (Patient-Specific Functional Scale), and frequency of opioid use were compared between the C-IPU and O-IPU groups using multivariate linear regression modeling adjusted for age, gender, treatment number, program duration, and baseline pain and disability.

RESULTS

Approximately 93.03% (1014/1090) of the participants completed their recommended programs, with no group differences in dropout rates (P=.78). The C-IPU group showed greater pain relief (P<.001) and reductions in disability (P=.002) than the O-IPU group, whereas the O-IPU group reported greater improvements in goal achievement (P<.001). Both programs resulted in reduced opioid use frequency, with 19.0% (188/988) and 21.5% (22/102) of participants reporting cessation of opioid use for C-IPU and O-IPU programs, respectively, leaving only 5.59% (61/1090) of participants reporting opioid use at the end of their treatment.

CONCLUSIONS

Both in-clinic and web-based multidisciplinary programs are beneficial in reducing pain, disability, and opioid use and in improving goal achievement. The differences between these self-selected groups shed light on patient characteristics, which require further investigation and could help clinicians optimize these programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04081896; https://clinicaltrials.gov/ct2/show/NCT04081896.

Telemedicine for Musculoskeletal Rehabilitation and Orthopedic Postoperative Rehabilitation

Telehealth visits result in high-quality care, with high patient and provider satisfaction. Strong evidence suggests that virtual physical therapy is noninferior to conventional face-to-face physical therapy for a variety of musculoskeletal disorders. Postoperative telerehabilitation has a strong positive effect on clinical outcomes, and the increased intensity telerehabilitation programs offer is a promising option for patients. Studies demonstrate effective virtual postoperative management. The novel coronavirus disease 2019 pandemic has led to improved reimbursement for telehealth visits and accelerated widespread implementation of telemedicine. This article establishes experience and evidence-based practice guidelines for conducting telemedicine visits, with emphasis on the virtual physical examination.

Remote Versus in-Person Exercise Instruction for Chronic Nonspecific Low Back Pain Lasting 12 Weeks or Longer: A Randomized Clinical Trial

BACKGROUND

Low back pain is a common health problem. We compared the effects of a remote exercise instruction with in-person exercise instruction on the pain and disability of people with nonspecific low back pain for more than 12 weeks.

MATERIAL AND METHODS

We carried out a randomized clinical trial with two study arms in an outpatient clinic at a University Hospital. A total of 56 patients were included and randomly allocated to each study arm. The primary outcome was the intensity of the low back pain. The secondary outcome was the Oswestry Disability Questionnaire score. We measured the outcomes before the intervention and in one and three months after completion of the program. The program consisted of core stability exercises and included flexibility and strengthening for all patients. Participants in the remote exercise group carried out the exercises at home two times a day for four weeks. They were followed by telephone calls. Patients in the in-person exercise group received the same exercises at the clinic, three times a week for four weeks.

RESULTS

Between-group comparisons indicated that there were no significant differences between the two approaches in changing pain (p = 0.93) and disability scores (p = 0.74) from the baseline to three months postintervention values.

CONCLUSIONS

There was no measurable difference between an exercise program delivered remotely compared to in-person.

Development and Feasibility Testing of Video Home Based Telerehabilitation for Stroke Survivors in Resource Limited Settings

Tele-physiotherapy has been shown to be valuable to improve clinical outcomes after stroke. Yet, home-based interventions for stroke survivors (SSVs) who speak indigenous African languages are sparse. This study developed a video-based home exercise programme (VHEP) for SSV speakers of Yoruba. A qualitative descriptive pilot study was conducted in two phases: development and feasibility testing. VHEP development followed the American Stroke Association's recommendations to include demonstrations of task-specific mobility-task and postural training; trunk exercises, and overground walking. The exercise instructions were presented in the Yoruba language. Each exercise was demonstrated for five minutes on video for a total of 30 minutes. The feasibility testing involved ten consenting chronic SSVs. Each imitated the VHEP twice per week for two weeks and thereafter completed a feasibility questionnaire. Criteria for feasibility were: cost of using VHEP, recruitment rate, retention of participants, adherence to the exercises, and intervention delivery. The ten SSVs were recruited within one week, had prior home access to a video player at no-cost, adhered to the exercises as recorded, completed the 30 minute-duration for two weeks, and confirmed intervention delivery of VHEP. Most participants liked the novel use of Yoruba as the language of instruction on VHEP. The VHEP was feasible and acceptable among the studied sample of SSVs. Video based home telerehabilitation for SSVs therefore has the potential to meet the growing need for tele-physiotherapy in resource limited settings.

Rapid Deployment of Chiropractic Telehealth at 2 Worksite Health Centers in Response to the COVID-19 Pandemic: Observations from the Field

OBJECTIVE

The purpose of this paper is to describe the rapid deployment of telehealth, particularly real time video conference, for chiropractic services as a response to COVID-19.

METHODS

Two health centers at 2 campuses of a large California corporation have chiropractic care integrated into physical medicine services. Care was suspended beginning on March 17, 2020 to prevent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among patients and staff. On March 19, the Governor of California issued a stay at home order. With musculoskeletal problems being common in the employee patient population, telehealth services were quickly developed to continue chiropractic care for patients. Using existing infrastructure, several members of the health center team developed chiropractic telehealth operations within 2 days.

RESULTS

Musculoskeletal telehealth services included examinations, risk assessment, advice, and rehabilitative exercises. These telehealth visits facilitated care that would have otherwise been unavailable to employees. Patients reported that the appointments were helpful, addressed their concerns, and provided a safe method to see their doctor. Regular interprofessional teamwork and relations between the clinic operator and client company were key contributors to operationalizing this service in our integrated healthcare environment.

CONCLUSION

We were able to quickly implement real time video conferencing and other forms of telehealth for chiropractic services at 2 worksite health centers. This paper includes information and insights to providers about setting up similar telehealth systems so they may also provide this benefit for patients in their communities during pandemics or disasters.