Understanding the barriers and enablers to implementation of a self-managed exercise intervention: a qualitative study

Unravelling interacting barriers and facilitators to adherence and delivery of exercise-based care in the treatment of Subacromial Pain Syndrome - an exploratory qualitative study

PURPOSE

Subacromial Pain Syndrome (SAPS) is a common persistent pain condition. Exercise-based care is first-line recommendation, but an insufficient exercise dose hampers effectiveness. This study explores individual and contextual barriers and facilitators for delivery of and adherence to exercise-based care in people with SAPS.

MATERIALS AND METHODS

Participants in this exploratory qualitative study were involved in the management of SAPS in Denmark. Triangular interviews and analyses were conducted within 3 themes (delivery of recommended services, adherence to recommendations, and frames of the clinical pathways) using the Theoretical Domains Framework (TDF) and the Behavioural Change Wheel model (BCW) to map barriers and facilitators into the Capability, Opportunity, Motivation and Behaviour (COM-B) model.

RESULTS

From interviews with 10 persons with SAPS and 37 healthcare practitioners and double-deductive analyses, 30 subjects of target behaviour within 13 TDF domains emerged across perspectives and COM-B components. Central barriers to delivery and adherence were inconsistencies in diagnostic terminology, cross-professional disagreements, beliefs, and expectations towards pathway services.

CONCLUSION

We identified interrelated individual and contextual barriers to delivery and adherence across all aspects of the BCW, underpinning the complexity of the subject. Findings support that effectiveness of exercise-based care is linked to contextual barriers to delivery and adherence.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Evaluation of a preemptive intervention regimen with hesperidin methyl chalcone in delayed-onset muscle soreness in young adults: a randomized, double-blinded, and placebo-controlled trial study

PURPOSE

Delayed-onset muscle soreness (DOMS) describes an entity characterized by ultrastructural muscle damage. Hesperidin methyl chalcone (HMC) is a synthetic flavonoid presenting analgesic, anti-inflammatory, and antioxidant properties. We evaluated the effects of HMC upon DOMS.

METHOD

In a preventive paradigm, 31 sedentary young men were submitted to a randomized, double-blinded parallel trial and received HMC 500 mg or one placebo capsule × 3 days before an intense dynamic exercise protocol (concentric/eccentric actions) applied for lower limbs for inducing muscle damage. Assessments were conducted at baseline, and 24 and 48 h after, comprising physical performance, and post-muscle soreness and damage, inflammation, recovery of muscle strength, and postural balance associated with DOMS. HMC safety was also evaluated. Thirty participants completed the study.

RESULTS

HMC improved the performance of participants during exercise (40.3 vs 51.3 repetitions to failure, p = 0.0187) and inhibited CPK levels (90.5 vs 57.9 U/L, p = 0.0391) and muscle soreness during passive quadriceps palpation (2.6 vs 1.4 VAS cm, p = 0.0439), but not during active actions, nor did it inhibit IL-1β or IL-10 levels. HMC improved muscle strength recovery, and satisfactorily refined postural balance, without inducing injury to kidneys or liver.

CONCLUSIONS

Preemptive HMC supplementation may be beneficial for boosting physical performance and for the amelioration of clinical parameters related to DOMS, including pain on muscle palpation, increased blood CPK levels, and muscle strength and proprioceptive deficits, without causing adverse effects. These data advance the understanding of the benefits provided by HMC for DOMS treatment, which supports its usefulness for such purpose.

Managing shoulder pain: a meta-ethnography exploring healthcare providers' experiences

OBJECTIVE

To review and synthesize qualitative research studies exploring the experiences of Healthcare Providers (HCPs) of managing shoulder pain.

METHODS

A meta-ethnographic approach was adopted to review and synthesize eligible studies. The findings from each included study were translated into one another using Noblit and Hares' seven-stage process. A systematic search of eleven electronic databases was conducted in February 2021. Methodological quality was assessed using the CASP Appraisal Tool.

RESULTS

Ten studies were included in the meta-synthesis, all deemed of high methodological quality. Three themes were identified; (1) Lack of consensus: "we all have different approaches." (2) Challenges to Changing Practice: It's "really hard to change and switch to a different approach," (3) Getting "Buy in" to Treatment: "…so you have to really sell it early".

CONCLUSION

Healthcare providers working with people with shoulder pain struggle to reconcile, often conflicting, research recommendations with their own clinical experience, beliefs and patient expectations. These findings help explain the continued lack of consensus on how best to manage shoulder pain in clinical practice.IMPLICATIONS FOR REHABILITATIONHealthcare providers (HCPs) working with people with shoulder pain struggle to resolve conflicts between evidence-based recommendations, clinical experience, their own shoulder pain beliefs and patient expectations and preferences.Stronger collaboration across professional disciplines is needed to address the current lack of consensus on the management of shoulder pain.Many HCP's find it difficult to engage patients with shoulder pain in exercise and they work hard to "sell" this approach to patients using strategies such as education, shared decision making and therapeutic alliance.

Barriers and facilitators related to self-management of shoulder pain: a systematic review and qualitative synthesis

OBJECTIVE

The objective of this review was to identify barriers and facilitators related to self-management from the perspectives of people with shoulder pain and clinicians involved in their care.

DATA SOURCES

CINAHL, MEDLINE, PsycINFO, SPORTDiscus, Embase, ProQuest Health, Web of Science, and Scopus were searched from inception to March 2022.

REVIEW METHODS

A meta-aggregative approach to the synthesis of qualitative evidence was used. Two independent reviewers identified eligible articles, extracted the data, and conducted a critical appraisal. Two reviewers independently identified and developed categories, with validation by two further researchers. Categories were discussed among the wider research team and a comprehensive set of synthesized findings was derived.

RESULTS

Twenty studies were included. From the perspective of patients, three synthesized findings were identified that influenced self-management: (1) support for self-management, including subthemes related to patient-centred support, knowledge, time, access to equipment, and patient digital literacy; (2) personal factors, including patient beliefs, patient expectations, patient motivation, pain, and therapeutic response; and (3) external factors, including influence of the clinician and therapeutic approach. From the perspective of clinicians, two synthesized findings were identified that influenced self-management: (1) support for self-management, including education, patient-centred support, patient empowerment, time, and clinician digital literacy; and (2) preferred management approach, including clinician beliefs, expectations, motivation, therapeutic approach, and therapeutic response.

CONCLUSION

The key barriers and facilitators were patient-centred support, patient beliefs, clinician beliefs, pain, and therapeutic response. Most of the included studies focused on exercise-based rehabilitation, and therefore might not fully represent barriers and facilitators to broader self-management.

Experiences of foot and ankle mobilisations combined with home stretches in people with diabetes: a qualitative study embedded in a proof-of-concept randomised controlled trial

Background

The benefits of exercise and staying active are widely reported in the literature, however adherence and engagement with exercise amongst people with long-term illness and diabetes is poor. Physiotherapy aims to promote independence and physical activity using a range of strategies, including manual therapy and education/advice on exercises. However, low adherence impacts negatively on treatment outcomes. In this study, the practicality of physiotherapy interventions in patients who participate in a proof-of-concept (PoC) randomised controlled trial (RCT) will be considered.

Aim

To explore the experiences of people with diabetes who received an intervention package of foot and ankle mobilisations combined with home stretches for a 6-week period.

Design

An embedded qualitative study in a proof-of-concept RCT using semi-structured interviews and thematic analysis.

Participants

Purposive sample of 16 participants (mean age 73 years) with a diagnosis of diabetes (mean duration 13.4 years) were recruited.

Results

Analysis revealed seven themes informing the adherence and non-adherence to the exercise intervention. Themes describing the positive experiences were: 1) support from others to do the exercises; 2) psychological factors to motivate exercise adherence; 2) physical factors contributing to exercise adherence; 4) acceptability of home exercises during and beyond the study. Other themes described barriers: 5) social factors that contributed to exercise disengagement; 6) emotional limitations that influence exercise avoidance; 7) physical circumstances that made exercise participation burdensome. Themes highlighted positive influences by physiotherapists, the motivation of doing exercises while participating in a study, improving the perceived range of motion in their foot and ankle and reducing discomfort in these joints whilst being more active with daily activities.

Conclusion

Our findings highlighted that the intervention of foot and ankle mobilisations combined with home stretches is feasible for study participants. Psycho-social support, self-efficacy, and physiotherapy support are motivational to adhere to the study intervention and might contribute to the success of a full-scale RCT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00512-z.

Development of strategies to support home-based exercise adherence after stroke: a Delphi consensus

OBJECTIVE

To develop a set of strategies to enhance adherence to home-based exercises after stroke, and an overarching framework to classify these strategies.

METHOD

We conducted a four-round Delphi consensus (two online surveys, followed by a focus group then a consensus round). The Delphi panel consisted of 13 experts from physiotherapy, occupational therapy, clinical psychology, behaviour science and community medicine. The experts were from India, Australia and UK.

RESULTS

In round 1, a 10-item survey using open-ended questions was emailed to panel members and 75 strategies were generated. Of these, 25 strategies were included in round 2 for further consideration. A total of 64 strategies were finally included in the subsequent rounds. In round 3, the strategies were categorised into nine domains-(1) patient education on stroke and recovery, (2) method of exercise prescription, (3) feedback and supervision, (4) cognitive remediation, (5) involvement of family members, (6) involvement of society, (7) promoting self-efficacy, (8) motivational strategies and (9) reminder strategies. The consensus from 12 experts (93%) led to the development of the framework in round 4.

CONCLUSION

We developed a framework of comprehensive strategies to assist clinicians in supporting exercise adherence among stroke survivors. It provides practical methods that can be deployed in both research and clinical practices. Future studies should explore stakeholders' experiences and the cost-effectiveness of implementing these strategies.

Adherence to self-managed exercises for patients with persistent subacromial pain: the Ad-Shoulder feasibility study

BACKGROUND

Exercise is recommended for patients with subacromial pain. It has been suggested that good exercise adherence improves clinical outcomes. Despite this, little attention has been paid to the need for behavioural frameworks to enhance adherence to home exercise programmes for patients with subacromial pain.

METHODS

A feasibility study with pre-post design was used. Participants aged > 18 years, with subacromial pain, who had received conservative treatment during the past 6 months, were recruited. The Ad-Shoulder intervention consisted of 1-5 individual sessions provided over 3 months and was based on 5 self-management skills, which aimed to enhance the patients' self-efficacy and adherence to self-managed exercises. The primary objectives were assessed according to predefined progression criteria: (1) the recruitment rate (10 patients enrolled within 12 weeks), (2) follow-up rate (≥ 80% on all self-reported measures), (3) objective physical activity measures (≥ 80% of participants would contribute valid data at each time point), (4) adherence with the self-managed exercises (≥ 80% of the participants would adhere to ≥ 80% of the assigned home exercise programme), (5) fidelity of the delivery of the intervention (the therapists delivered the intervention according to the protocol) and (6) adverse events (< 30% would report adverse events (including mild)). The results were reported using descriptive statistics.

RESULTS

Eleven patients were recruited during 16 weeks. Ten patients completed the self-reported measures at baseline and week 12. Objective physical activity measures were successfully obtained for 100% (11/11) at baseline, 64% (7/11) at week six and 82% at week 12. Fifty-five percent (6/11) of the participants satisfactorily completed at least 80% of their home exercise programme. All sessions were delivered according to the protocol. None of the patients reported any adverse events.

CONCLUSIONS

Objective physical activity data measures at baseline and week 12, follow-up, the physiotherapists' fidelity to the intervention and adverse events met our pre-specified progression criteria. Recruitment and adherence to the self-managed exercise programme were both below the anticipated level. Further intervention development is necessary to understand whether adherence to the self-managed exercises could be enhanced and additional methods of recruitment would need to be considered, including additional recruitment sites, in any planning for a future main trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04190836 , Registered December 9, 2019-retrospectively registered.

Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial

AIM

Clinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement. Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. The aim of this study was to identify perceived facilitators and barriers-among orthopedic surgeons and physical therapists-towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise.

METHODS

This qualitative study is embedded within the QUADX-1 randomized trial that investigates a model of coordinated non-surgical and surgical treatment for patients eligible for knee replacement. Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed (one focus group and four single interviews) to explore their perceived facilitators and barriers related to pre-operative home-based exercise therapy with one exercise-only in patients eligible for knee replacement. Interviews were analyzed using thematic analysis.

RESULTS

From the thematic analysis three main themes emerged: 1) Physical therapists' dilemma with one home-based exercise, 2) Orthopedic surgeons' dilemma with exercise, and 3) Coordinated non-surgical and surgical care.

CONCLUSION

We found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons. The physical therapists were skeptical towards over-simplified exercise therapy. The orthopedic surgeons were skeptical towards the potential lack of (long-term) effect of exercise therapy in patients eligible for knee replacement. The consequence of these barriers and ambivalence in the professional role is important to consider when planning implementation of the model of coordinated non-surgical and surgical treatment.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02931058.

Challenges with strengthening exercises for people with knee osteoarthritis and comorbid obesity: a qualitative study with patients and physiotherapists

OBJECTIVE

Explore challenges associated with implementing a home-based strengthening exercise program for people with knee osteoarthritis and comorbid obesity.

METHODS

Qualitative study embedded within a randomised controlled trial comparing two home-based strengthening programs (weight bearing functional exercise versus non-weight bearing quadriceps strengthening exercise) for people with knee osteoarthritis and comorbid obesity. Patients in both exercise programs attended five consultations with a physiotherapist and undertook a home-based exercise program for 12 weeks. Semi-structured individual telephone interviews were conducted with 22 patients after trial completion, and all seven physiotherapists who delivered trial interventions. Interviews were recorded, transcribed verbatim, and thematically analysed using an inductive approach.

RESULTS

Three themes arose: i) psychological challenges (false assumptions about exercise; fear of pain; disliking exercise; mental effort of weight bearing functional program; underestimating capability) ii) physical challenges (complexity of weight bearing functional program; cuff weights and straight leg raise problematic in non-weight bearing quadriceps program; other health conditions), and; iii) overcoming challenges (incentives to exercise; accountability; education and reassurance; tailoring the exercise program).

CONCLUSION

Patients and physiotherapists experienced numerous psychological and physical challenges to exercise, including a fear of pain, having false assumptions about exercise, difficulties with exercise performance, application of cuff weights, and adverse impacts of other health conditions.

What are the experiences of therapists using the online Back Skills Training and implementing it within clinical practice?

INTRODUCTION

The purpose of the present study was to explore the experiences of physiotherapists using the online Back Skills Training (i-BeST). The aim of the this programme was to enable clinicians to facilitate group-based treatment based on a cognitive behavioural (CB) approach to the treatment of lower back pain (LBP).

METHODS

A qualitative, exploratory approach was chosen. Seven physiotherapists were interviewed. Participants were asked broad, open-ended questions in order to explore: (a) their experiences with the training; (b) the online method; and (c) the implementation of BeST into clinical practice. The interviews were transcribed and analysed manually using interpretive phenomenological analysis.

RESULTS

Four main themes were identified following the analysis: (a) Flexibility but lack of interactivity; (b) CB approach is a new way of working; (c) Facilitating group work after i-BeST training; and (d) The need for managerial support. The flexibility of the online tool was perceived as a major advantage. However, lack of interactivity was identified by most participants as the biggest challenge. Participants found the online tool to be acceptable for attaining knowledge but not adequate for developing skills. After completing BeST, participants reported the application of key principles of the CB approach within routine physiotherapeutic practice, but were reluctant to refer into the group-based treatment programme. Coordination of implementation of the group-based treatment programme throughout a large trust was perceived as necessary, including sufficient staff training for all clinicians.

CONCLUSIONS

I-Best can be implemented within everyday clinical settings but should be enhanced with additional face-to-face support mechanisms to improve effectiveness.

Barriers and facilitators of loaded self-managed exercises and physical activity in people with patellofemoral pain: understanding the feasibility of delivering a multicentred randomised controlled trial, a UK qualitative study

OBJECTIVES

There is an emergent body of evidence supporting exercise therapy and physical activity in the management of musculoskeletal pain. The purpose of this study was to explore potential barriers and facilitators with patients and physiotherapists with patellofemoral pain involved in a feasibility randomised controlled trial (RCT) study. The trial investigated a loaded self-managed exercise intervention, which included education and advice on physical activity versus usual physiotherapy as the control.

DESIGN

Qualitative study, embedded within a mixed-methods design, using semi-structured interviews.

SETTING

A UK National Health Service physiotherapy clinic in a large teaching hospital.

PARTICIPANTS

Purposively sampled 20 participants within a feasibility RCT study; 10 patients with a diagnosis of patellofemoral pain, aged between 18 and 40 years, and 10 physiotherapists delivering the interventions.

RESULTS

In respect to barriers and facilitators, the five overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants' engagement with the loaded self-managed exercises and (5) physiotherapists' clinical development. Locus of control was one overarching theme that was evident throughout. Contrary to popular concerns relating to painful exercises, all participants in the intervention group reported positive engagement. Both physiotherapists and patients, in the intervention group, viewed the single exercise approach in a positive manner. Participants within the intervention group described narratives demonstrating self-efficacy, with greater internal locus of control compared with those who received usual physiotherapy, particularly in relation to physical activity.

CONCLUSIONS

Implementation, delivery and evaluation of the intervention in clinical settings may be challenging, but feasible with the appropriate training for physiotherapists. Participants' improvements in pain and function may have been mediated, in some part, by greater self-efficacy and locus of control.

TRIAL REGISTRATION NUMBER

ISRCTN35272486; Pre-results.

Perceived benefits, rationale and preferences of exercises utilized within Pilates group exercise programmes for people with chronic musculoskeletal conditions: A questionnaire of Pilates-trained physiotherapists

INTRODUCTION

An estimated 29% of the population, around 17.8 million people, live with a musculoskeletal condition in the UK. Pilates exercise has positive benefits, including reducing pain and disability for people with musculoskeletal conditions. The aim of the present study was to explore the views of Pilates-trained physiotherapists in relation to the perceived benefits of, and clinical reasoning for, exercise prescription in Pilates classes.

METHODS

A qualitative approach was taken to both data collection and analysis, using a thematic framework. Data were collected via electronic questionnaires using open-ended questions. Participants included 15 Pilates-trained physiotherapists who regularly ran Pilates exercise classes within seven private physiotherapy clinics for people with a range of chronic musculoskeletal conditions.

RESULTS

The results were organized into six main themes: Perceived benefits 1: Improved function and increased levels of activity. Perceived benefits 2: Improved ability to manage their musculoskeletal condition autonomously; Efficacy of group Pilates exercise; Optimum combination of exercises used within a class; Physiotherapist rationale for the most effective exercises; Precautions with specific exercises.

CONCLUSIONS

The study was the first to investigate perceived benefits, rationale and preference for choice of exercise among Pilates-trained physiotherapists. Physiotherapists felt that the Pilates classes facilitated an active lifestyle and self-management approach. They used a combination of exercises in each class to address all the main muscle groups, but some had specific exercise preferences related to the patients' needs. Exercises were linked to evidence around neuromuscular control, direction preference and biomechanical principles.

The type and pain provoking nature of exercise prescribed for low back pain: A survey of Australian health professionals

OBJECTIVES

To explore the type of exercise prescribed by Australian health professionals for LBP, and whether the exercises prescribed are pain-free or into pain.

METHODS

A survey of physiotherapists and exercise physiologists was conducted from all states/territories in Australia. The survey contained two chronic LBP vignettes with different pain mechanisms (dominant nociceptive or central sensitisation pain) and one acute LBP vignette. Respondents were asked if they would prescribe advice to stay active and exercise. If exercise was prescribed, respondents were asked to specify the type and pain provoking nature (exercise with no pain, exercise to the start of pain, exercise with pain at a tolerable level or exercise irrespective of pain).

RESULTS

The response rate was 17%(218/1276). Most respondents prescribed advice to stay active(≥95%) and exercise(≥90%) for all vignettes. Irrespective of the vignette, several exercises were prescribed [aerobic (57-85% of clinicians), motor control (62-84% of clinicians), range of motion (72-75% of clinicians)]. Strengthening exercise was prescribed more for chronic(>60%) than acute LBP(23%). Irrespective of the exercise, between 20 and 25% of respondents prescribed pain-free exercise, between 71 and 79% of respondents prescribed exercise into pain, and ≤4% prescribed exercise irrespective of pain for acute and chronic LBP.

CONCLUSIONS

Several exercises are prescribed for LBP, irrespective of pain mechanism or duration, with more clinicians prescribing strengthening exercise for chronic than acute LBP. Most clinicians prescribed exercise into pain for acute and chronic LBP, irrespective of the exercise. Further research should determine which exercises are beneficial based on pain mechanism and duration, and whether exercise into pain should be prescribed for LBP.

Perspectives of Dutch Physiotherapists on Self-Management Support: A Q-Methodology Study

Self-management support programs are reported to have positive effects on the health and care of people with physical disabilities. It is unclear how physiotherapists (PTs) view self-management support. A cross-sectional study with mixed-methods design using Q-methodology was conducted to determine the perspectives of Dutch PTs on self-management support. PTs (n = 39) rank-ordered 37 validated statements about self-management support from "most disagree (-3)" to "most agree (+3)." Differences in perspectives on self-management support were explored in a by-person centroid factor analysis on the basis of the explained variance (R²). After having sorted the statements, PTs explained their ranking of -3 and +3 statements in semi-structured interviews. All PTs recognized self-management support as intrinsic part of physiotherapy practice. Nevertheless, four particular perspectives could be identified: (1) the "externally driven educator" (R² = 14%), (2) "internally driven educator" (R² = 9%), (3) "client-centered coach" (R² = 13%), and (4) "client-initiated coach" perspective (R² = 15%). Each perspective reflects particular goals and perceptions of self-management support. Differences were identified with respect to the PTs' role perception (educating or coaching), drive (external or internal), and collaboration with the patient (as partner or not). The identified perspectives can be used in the physiotherapy education curriculum to create awareness about the various ways of practicing self-management support and the skills needed to be able to tailor support to patient needs and to switch between perspectives.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

BACKGROUND

Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient's pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.

METHODS

Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence.

RESULTS

The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference.

CONCLUSION

Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders.

PROSPERO REGISTRATION

CRD42016038882.

Effectiveness of scapula-focused approaches in patients with rotator cuff related shoulder pain: A systematic review and meta-analysis

BACKGROUND

Rotator cuff related shoulder pain (RCSP) is common with a range of conservative treatments currently offered. Evidence supporting superiority of one approach over another is lacking. Scapula focused approaches (SFA) are frequently prescribed and warrant investigation.

OBJECTIVE

To evaluate the effectiveness of SFA in RCSP.

DESIGN

Systematic review of randomised controlled trials.

METHODS

An electronic search including MEDLINE, PEDro, ENFISPO to January 2016 was supplemented by hand searching. Randomised controlled trials were included; appraised using the PEDro scale and synthesised via meta-analysis or narratively, where appropriate.

RESULTS

Four studies (n = 190) reported on pain and three studies (n = 122) reported on disability. Regarding pain, there was statistical but not clinically significant benefit of SFA versus generalised approaches (mean difference (VAS) 0.714; 95% CI 0.402-1.026) in the short term (<6 weeks); regarding disability, there was significant benefit of SFA versus generalised approaches (mean difference 14.0; 95% CI 11.2-16.8) in the short term (<6 weeks). One study (n = 22) reported disability at 3 months, which was not statistically significant. Evidence is conflicting from four studies relating to the effect of SFA on scapula position/movement.

CONCLUSION

SFA for RCSP confers benefit over generalised approaches up to six weeks but this benefit is not apparent by 3 months. Early changes in pain are not clinically significant. With regards to scapula position/movement, the evidence is conflicting. These preliminary conclusions should be treated with significant caution due to limitations of the evidence base.