"We get them up, moving, and out the door. How do we get them to do what is recommended?" Using behaviour change theory to put exercise evidence into action for rehabilitation professionals

Adherence to neck and low back pain clinical practice guidelines based on clinical specialization: a survey of physical therapists

OBJECTIVE

To investigate physical therapist adherence to the Academy of Orthopaedic Physical Therapy's (AOPT) clinical practice guidelines (CPGs) for the management of neck and low back pain (LBP) and to compare adherence among varying clinical specializations.

DESIGN

Electronic cross-sectional survey.

METHODS

The survey was sent to 17,348 AOPT members and 7,000 American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) members. Participants selected the best diagnosis and intervention(s) for six case vignettes based on the current AOPT CPGs for neck and LBP. Diagnostic and intervention adherence rates were reported as total percentages and delineated by the highest level of clinical specialization - fellowship training (PTFs), orthopedic residency training (PTRs), Board Certified Clinical Specialist in Orthopaedic Physical Therapy (PTSs), orthopedic background without clinical specialization (PTOs). Binary logistic regression analyses were performed to determine the effects of clinical specialization (PTFs, PTRs, or PTSs) compared to PTOs on the likelihood of guideline adherence for all six cases.

RESULTS

Of the 159 participants who responded to the survey, 152 were eligible and 145 completed demographic data. Participant responses declined as the survey progressed from 125 completing case one to 106 completing case six. The odds ratio from binary logistic regression analyses were not significant for any specialization in all six cases (OR = 0.16; 95% CI: 0.02, 1.11; p = 0.064).

CONCLUSIONS

The results of this manuscript demonstrated variable adherence rates across subgroups of patients with neck and LBP with no significant association between clinical specialization and adherence. Adherence to CPGs is dependent on the clinical presentation of various patient cohorts.

Finding the Optimal Resistance Training Intensity for Your Bones: Protocol for a Randomized Controlled Trial

OBJECTIVE

The purpose of this trial is to evaluate the effect of twice-weekly, moderate-to-high intensity progressive resistance training (PRT) for 1 year on lumbar spine bone mineral density (BMD) in individuals with low BMD, compared to attention control. Secondary analyses will examine if resistance training improves other health outcomes; if high intensity is more effective than moderate intensity resistance training for all outcomes; the cost of intervention versus benefit; the willingness to pay; and harms.

METHODS

For this study, 324 men or postmenopausal women aged ≥50 years with a femoral neck, total hip, or lumbar spine BMD T-score of ≤-1, or a Fracture Risk Assessment Tool probability of ≥20% for major osteoporotic fracture or ≥ 3% for hip fracture are being recruited to participate in a randomized controlled trial with 1:1:1 randomization. Participants will be stratified by site (3 centers) to twice-weekly, supervised PRT at moderate intensity (about 10 repetitions maximum), to high intensity PRT (≤6 repetitions maximum), or to a home posture and balance exercise program (attention control) for 1 year (resistance training to comparator allocation ratio of 2:1). The primary outcome is lumbar spine BMD via dual-energy X-ray absorptiometry. Secondary outcomes include trabecular bone score, proximal femur and total hip BMD and structure, bone-free and appendicular lean mass, physical functioning, falls, fractures, glucose metabolism, cost per life-year gained, adverse events, and quality of life. Between-group differences will be tested in intention-to-treat and per-protocol analyses using analysis of covariance, chi-square tests, or negative binomial or logistic regression, adjusting for site and baseline values.

IMPACT

The Finding the Optimal Resistance Training Intensity For Your Bones trial will support decision making on resistance training for people at risk of fracture.

Researchers' Perspectives on Adverse Event Reporting in Resistance Training Trials: A Qualitative Study

The objectives of our study were to understand researchers' current practices and perspectives on adverse event (AE) reporting in clinical trials of resistance training (RT), and identify barriers and facilitators of AE reporting. We conducted web conference or telephone-based one-on-one semi-structured interviews with 14 researchers who have published RT studies in individuals with or without health conditions. We audio-recorded and transcribed the interviews, and analyzed data using the thematic framework method. Four themes were identified in the context of RT studies: 1) researchers lack guidance and/or motivation for rigorous AE reporting; 2) researchers who undertake AE reporting educate and value participants, use trained personnel, and implement standardized guidelines; 3) suboptimal implementation of existing AE reporting standards and the perception that available guidelines do not apply to exercise trials; and 4) acceptability and feasibility of an exercise-specific guide for AE reporting depends on its content and format. In conclusion, AE reporting methods in the field of exercise science do not align with best practice. Strategies to reduce inconsistent and suboptimal AE reporting in RT trials are urgently needed and could be based on the barriers and facilitators identified in this study.

An Interpretive Descriptive Approach to Understanding Osteoporosis Management from the Perspective of People at Risk of Fracturing

PURPOSE

Adherence to both non-pharmacological and pharmacological fracture prevention interventions is often low in people with osteoporosis. Understanding how patients acquire information about osteoporosis management is important for understanding both the initial decision-making and ongoing adherence. This study explored the narrative of people living with osteoporosis and their personal experience getting information about their osteoporosis management.

METHODS

An interpretive descriptive method was used for this qualitative study. In-depth interviews were conducted with 13 Canadian participants (age range 51-90) who knew that they had osteoporosis or osteopenia. Participants were asked to participate in one-on-one interviews to address the type of health professionals providing osteoporosis management advice focusing specifically on advice received about exercise, nutrition, and falls prevention. Interviews were transcribed verbatim and coded sentence-by-sentence.

RESULTS

People with osteoporosis rely on physicians for advice related to pharmacological treatment needs, and other health professionals for non-pharmacological needs such as exercise advice, nutrition advice, and falls prevention advice. People value non-professionals, such as family members and close friends, who may or may not have osteoporosis, to discuss or corroborate health professional advice, or to validate their belief system.

CONCLUSION

Training patients to more effectively engage in conversations with their healthcare providers may be a strategy to improve the quality of communication and its translation into adherence to best practices in managing osteoporosis.

Exercise for improving age-related hyperkyphosis: a systematic review and meta-analysis with GRADE assessment

We reviewed exercise trials in men and women ≥ 45 years with hyperkyphosis at the baseline and performed meta-analyses for kyphosis and health-related outcomes.

PURPOSE

To determine the effects of exercise interventions on kyphosis angle, back extensor muscle strength or endurance, physical functioning, quality of life, pain, falls, and adverse events in adults 45 years or older with hyperkyphosis.

METHODS

Multiple databases were searched to May 2020. Randomized controlled trials (RCTs), non-RCT, and pre-post intervention studies that had at least one group with a mean kyphosis angle of at least 40° at the baseline were included.

RESULTS

Twenty-four studies were included. Exercise or physical therapy improved kyphosis outcomes (SMD - 0.31; 95% confidence intervals [CI] - 0.46, - 0.16; moderate certainty evidence), back extensor muscle strength (MD 10.51 N; 95% CI 6.65, 14.38; very low certainty evidence), and endurance (MD 9.76 s; 95% CI 6.40, 13.13; low certainty evidence). Meta-analyses showed improvements in health-related quality of life (HRQoL) (SMD 0.21; 95% CI 0.06, 0.37; moderate certainty of evidence), general pain (MD - 0.26; 95% CI - 0.39, - 0.13; low certainty of evidence), and performance on the timed up and go (TUG) test (MD - 0.28 s; 95% CI - 0.48, - 0.08; very low certainty of evidence). The effects on the rate of falls (incidence rate ratio [IRR] 1.15; 95% CI 0.64, 2.05; low certainty evidence) or minor adverse events (IRR 1.29; 95% CI 0.95, 1.74; low certainty evidence) are uncertain. No serious adverse events were reported in the included studies.

CONCLUSIONS

Interventions targeting hyperkyphosis may improve kyphosis outcomes in adults with hyperkyphosis.

The Effects of Walking or Nordic Walking in Adults 50 Years and Older at Elevated Risk of Fractures: A Systematic Review and Meta-Analysis

Walking is a common activity among older adults. However, the effects of walking on health-related outcomes in people with low bone mineral density (BMD) are unknown. The authors included randomized controlled trials comparing walking to control in individuals aged ≥50 years with low BMD and at risk of fractures. The authors identified 13 randomized controlled trials: nine multicomponent interventions including walking, one that was walking only, and three Nordic walking trials. Most studies had a high risk of bias. Nordic walking may improve the Timed Up-and-Go values (1.39 s, 95% CI [1.00, 1.78], very low certainty). Multicomponent interventions including walking improved the 6-min walk test (39.37 m, 95% CI [21.83, 56.91], very low certainty) and lumbar spine BMD (0.01 g/cm2, 95% CI [0.00, 0.03], low certainty evidence). The effects on quality of life or femoral neck BMD were not significant. There were insufficient data on fractures, falls, or mortality. Nordic walking may improve physical functioning. The effects on other outcomes are less certain; one may need to combine walking with other exercises to be of benefit.