Factors impacting adherence to an exercise-based physical therapy program for individuals with low back pain

Baseline Participant Characteristics are Associated With Engagement in a Movement-Based RCT for Chronic Low-Back Pain

PurposeExamine whether baseline participant characteristics predict engagement in a movement-based RCT for chronic low back pain (CLBP).DesignLongitudinal study within an RCT.SettingOnline.Subjects138 individuals with CLBP (18-79 years).InterventionParticipants were randomized to a 12-week intervention of twice-weekly synchronous online yoga OR stretching/strengthening classes, and received 20-min pre-recorded home videos to complete daily.MeasuresBaseline questionnaires assessed sociodemographic, psychosocial, and pain factors (100% response rate). Engagement was operationalized as minutes of class attended + minutes of home videos completed.ResultsBivariate correlations were computed between baseline variables and engagement. Three multivariate negative binomial generalized linear models (GLMs) were constructed to simultaneously examine predictors of engagement in the domains of sociodemographic, psychosocial, and pain-related factors. Greater engagement was significantly associated with greater baseline age, educational attainment, energy, and emotional well-being, and less emotion regulation difficulties, cannabis use problems, and pain interference (|rs| = .19-.33). In the domain specific GLMs, education (B = .491, P = .017) and cannabis use problems (B = -.048, P = .027) were the only significant predictors in the sociodemographic and psychosocial models, respectively. Neither pain interference nor pain severity were significant in the pain model.ConclusionFactors identified can inform strategies to increase engagement in movement-based CLBP interventions, potentially improving research validity and outcomes. Limitations include lack of racial diversity and not testing how engagement fluctuates throughout the intervention.

Predictors of treatment adherence in patients with centralized low back pain

BackgroundTreatment adherence is central to treatment success in rehabilitation for musculoskeletal conditions, including low back pain (LBP). Unfortunately, non-adherence to prescribed treatment is common and undermines treatment success.ObjectiveTo identify predictors of treatment adherence in physical therapy for patients with LBP.Methods209 cases of patients receiving physical therapy for a chief complaint of centralized LBP were retrospectively analyzed for predictors of treatment adherence. Symptom duration, pain intensity, level of disability, the presence of an opioid prescription, and patient cost were assessed as predictors of treatment adherence. Patients who completed their prescribed plan of care were classified as adherent.ResultsLogistic regression analysis revealed that individuals who had an opioid prescription were 2.56 (95% CI = 1.25-5.24, p = 0.010) times less likely to be adherent with treatment compared to individuals without an opioid prescription. Individuals who had symptoms for less than 1 month were 3.21 (95% CI = 1.12-9.24, p = 0.030) times less likely to be adherent with treatment compared to individuals who had experienced symptoms for 4 months to 1 year. Finally, individuals who paid greater than $40 per visit were 3.45 (95% CI = 1.31-9.09, p = 0.011) times less likely to be adherent with treatment compared to individuals who did not have to pay each visit.ConclusionThe results of this study may help clinicians quickly identify and address risk factors for lower treatment adherence in patients with LBP to mitigate the impact of suboptimal treatment adherence on patient outcomes.

Barriers and facilitators to exercise-based rehabilitation in people with musculoskeletal conditions: A systematic review

BACKGROUND

Exercise-based rehabilitation is the first line of treatment for people with musculoskeletal conditions. However, uptake and adherence are suboptimal, compromising the success of rehabilitation.

OBJECTIVES

To identify the barriers and facilitators that influence adherence to exercise-based rehabilitation in people with musculoskeletal conditions. Additionally, to identify the methods and instruments used to determine these barriers and facilitators.

DESIGN

Systematic review METHODS: Five databases from inception to May 2024 using terms related to exercise, musculoskeletal conditions, methods, barriers and facilitators. Risk of bias was assessed using either the Newcastle-Ottawa Scale or Cochrane risk of bias tool. Using an inductive thematic approach, barriers and facilitators were grouped into intrapersonal, interpersonal and community factors. Methods/instruments were categorized into three groups, being questionnaires, interviews and focus-groups.

RESULTS

Eighty-one of 8380 studies were included. The majority of studies were of good or fair quality (95%). The most frequently identified barriers were lack of time (53%), pain (45%) and health (40%). The most frequent facilitators were self-efficacy (42%), perceived health benefits (32%) and previous experiences (30%). The methods used were interviews (n = 53), questionnaires (n = 44) and focus groups (n = 10).

CONCLUSION

Most barriers and facilitators to exercise were related to intrapersonal factors. Although there is a lack of consistency in instruments used, the reported barriers and facilitators were similar across studies. Clinicians and researchers should consider intrapersonal factors when promoting exercise-based rehabilitation programs. Applying a theoretical framework to investigate barriers and facilitators to exercise-based rehabilitation in people with musculoskeletal conditions might assist practitioners to prioritize their practice.

Voices from the clinic: a qualitative analysis of physiotherapy strategies in musculoskeletal care for knee osteoarthritis patients

BACKGROUND

Physiotherapy has emerged as an important health strategy to deliver lifestyle, exercise and physical activity for people with knee osteoarthritis. However, little is known about the extent to which physiotherapists adhere to clinical practice guidelines. This study aimed to explore the perspectives and care patterns of physiotherapists in Sydney, Australia on their delivery of knee osteoarthritis care and how this aligns with the 2019 Osteoarthritis Research Society International (OARSI) guidelines.

METHODS

We invited thirty-three physiotherapists from nine private practices in metropolitan Sydney to partake in a semi-structured interview. The interviews were digitally recorded and transcribed verbatim. The data collected were analysed deductively using content analysis, comparing guidelines to current care patterns, while their perspectives were inductively analysed through thematic analysis.

RESULTS

Thirty physiotherapists participated (age range 22-63 years, 17 male and 13 female). Interview responses indicated that most physiotherapists were satisfied with their care of knee osteoarthritis patients. Most physiotherapists delivered "core" guideline-based care of education and land-based exercise. Recommendations of modalities of exercise, including hydrotherapy and manual therapy, were discussed and were perceived to be beneficial despite not being "core" clinical guideline recommendations. Current treatment strategies focussed on disease severity, symptom presentation and/or patient exercise history with little emphasis on education about osteoarthritis pathophysiology and drug-based pain relief. The thematic analysis identified two over-arching themes; (1) capacity to deliver and awareness of evidence-based care and (2) perceived recommendations for future physiotherapy management. Participants identified notable areas of potential service improvement including developing stronger and more effective reimbursement models, increased consult times and improved patient access.

CONCLUSION

The study provided unique insights towards physiotherapists' current usual knee osteoarthritis care and their perceived barriers to delivering guideline-based care. Thus, informing a need for future studies to focus on developing specific and detailed guidelines if physiotherapists are to align more closely to the core guideline-based recommendations.

TRIAL REGISTRATION

This study was part of a larger study, with the full protocol published and registered at ClinicalTrials (ACTRN12620000188932, ACTRN12620000218998) 19/02/2020).

High-Intensity Training Telerehabilitation for Persons with Chronic Low Back Pain: A Pilot Clinical Trial

Background/Objectives: High-intensity training (HIT) has been shown to enhance physical fitness and reduce functional impairments in persons with moderately disabling chronic nonspecific low back pain (CNSLBP). However, sustaining these improvements post-rehabilitation remains a challenge. To address this, a home-based, technology-supported HIT program utilizing telerehabilitation can be implemented at home. This study assesses the feasibility and clinical effectiveness of a telerehabilitation HIT program for persons with CNSLBP. Methods: The pilot clinical trial (NCT05234008) recruited 15 persons with CNSLBP. Participants completed a 6-week multimodal HIT intervention with 12 bi-weekly sessions. The first four sessions were organized at REVAL Research Center, followed by eight home-based sessions using the Physitrack® platform. Assessments were conducted at baseline (PRE), two weeks into the intervention (MID), and immediately post-intervention (POST). Outcome measures included maximal oxygen uptake (VO2max) testing, disease-related outcomes, feasibility, motivation assessed via questionnaires, and system usability and adherence tracked through Physitrack® technology. Results: Fourteen participants (seven females; age: 45.9 years) successfully completed the program without adverse events. Based on PRE-POST comparisons, motivation levels remained high (Motivation Visual Analog Scale: -1.2 ± 0.9, p = 0.043) despite reduced motivation at POST. Improvements were also observed in pain (Numeric Pain Rating Scale: -1.8 ± 0.2, p = 0.026), disability (Modified Oswestry Disability Index: -12.1 ± 10.2, p = 0.002), fear-avoidance (Fear-Avoidance Components Scale: -10.1 ± 5.8, p = 0.005), and exercise capacity (VO2max: 4.4 ± 1.6, p = 0.048). Conclusions: The HITHOME study is the first to investigate the feasibility and effectiveness of a telerehabilitation HIT program for persons with CNSLBP. The results underscore the feasibility of implementing a home-based HIT program to support adherence to vigorous exercise programs and improve clinical outcomes in this population. Additionally, the findings emphasize technology's potential importance in enhancing home-based exercise therapy and lay the groundwork for future studies on blended care and telerehabilitation using HIT in CNSLBP.

Effects of Dynamic Neuromuscular Stabilization/Vojta Therapy on Pain Intensity and Physical Function in Individuals with Low Back Pain: A Systematic Review and Meta-Analysis

Background

Low back pain (LBP) is a prevalent health issue that imposes heavy burdens on personal health status and social healthcare. Dynamic Neuromuscular Stabilization (DNS)/Vojta therapy has demonstrated effectiveness in managing conditions related to musculoskeletal system. However, its effects on individuals with LBP remain incompletely understood. We aimed to evaluate the effects of DNS/Vojta therapy on pain intensity and physical function in individuals with LBP.

Methods

A search of studies was conducted on several academic databases from inception through April 13, 2023. This study included clinical trials that evaluated the effects of DNS/Vojta therapy on the outcomes in individuals with LBP. The methodological quality of studies was assessed using PEDro scale, Cochrane Collaboration tool, and ROBINS-I scale. Meta-analysis was performed using Review Manager software (RevMan version 5.4.1, The Cochrane Collaboration, 2020).

Results

This systematic review and meta-analysis identified twelve eligible studies, which demonstrated that DNS/Vojta therapy significantly alleviated pain intensity (SMD=-1.09; 95%Cl [-1.74, -0.44]; Z=3.28; P=0.001), reduced disability severity (SMD=-0.91; 95%Cl [-1.48, -0.34]; Z=3.12; P=0.002), and improved quality of life (SMD=1.05; 95%CI [0.14, 1.96]; Z=2.27; P=0.02) in individuals with LBP, while no significant improvements were observed in static and dynamic balance ability or spine flexibility.

Conclusion

DNS/Vojta therapy is a promising approach for providing great benefits for individuals with LBP, particularly in terms of reducing pain intensity and disability severity, and improving quality of life, which is worth further in clinical application.

Exploring the association between adherence to home-based exercise recommendations and recovery of nonspecific low back pain: a prospective cohort study

BACKGROUND

Adherence to home-based exercise (HBE) recommendations is critical in physiotherapy for patients with low back pain (LBP). However, limited research has explored its connection with clinical outcomes. This study examined how adherence to HBE relates to changes in physical function, pain intensity, and recovery from LBP in patients undergoing physiotherapy treatment.

METHODS

Data from a multicenter cluster randomized controlled trial in the Netherlands involving patients with LBP from 58 primary care physiotherapy practices were used. Adherence to HBE was assessed with the Exercise Adherence Scale (EXAS) at each treatment session. Previously identified adherence trajectories served as a longitudinal measure of adherence and included the classes "declining adherence" (12% of participants), "stable adherence" (45%), and "increasing adherence" (43%). The main outcomes included disability (Oswestry Disability Index), pain (Numeric Pain Rating Scale), and recovery (pain-free for > 4 weeks), which were measured at baseline and after three months. Linear and binomial logistic regression analyses adjusted for confounders were used to examine adherence-outcome relationships.

RESULTS

In the parent trial, 208 participants were included. EXAS scores were available for 173 participants, collected over a median of 4.0 treatment sessions (IQR 3.0 to 6.0). Forty-five (28.5%) patients considered themselves to have recovered after three months. The median changes in the Oswestry Disability Index and Numeric Pain Rating Scale were - 8 (IQR - 1 to -20) and - 2 (IQR - 0.5 to -4), respectively. The mean EXAS scores varied among patient classes: "declining adherence" (46.0, SD 19.4), "stable adherence" (81.0, SD 12.4), and "increasing adherence" (39.9, SD 25.3), with an overall mean of 59.2 (SD 25.3). No associations between adherence and changes in physical functioning or pain were found in the regression analyses.

CONCLUSIONS

No association between adherence to HBE recommendations and changes in clinical outcomes in patients with LBP was found. These findings suggest that the relationship between adherence to HBE recommendations and treatment outcomes may be more complex than initially assumed. Further research using detailed longitudinal data combined with qualitative methods to investigate patient motivation and beliefs may lead to a deeper understanding of the relationship between adherence and clinical outcomes in patients with LBP.

Optimal Duration of Physical Therapy Following Total Knee Arthroplasty

Aims & Objectives

The purpose of this study was to identify patient characteristics associated with engagement and completion of physical therapy (PT) following total knee arthroplasty (TKA) and examine the relationship between number of PT sessions attended and outcomes during the first 12 weeks after surgery.

Methods

Patients underwent unilateral primary TKA by a single surgeon and were advised to complete 17 PT sessions over 6 weeks at a hospital-affiliated facility. Analyses examined predictors of PT engagement (attendance of ≥2 sessions) and completion (attendance of 17 ± 1 sessions) within 6 weeks and associations between number of PT sessions attended and changes in range of motion (ROM) and Knee Injury and Osteoarthritis Outcome Score (KOOS) values.

Results

Patients living <40 km were more likely to be engaged in PT than those living ≥40 km from the clinic (P < .0001). Among patients who completed PT within 6 weeks, 95.0%, 85.1%, and 56.4% achieved flexion of, respectively, ≥90°, ≥100°, and ≥110°. Among engaged patients, the active flexion thresholds of ≥90°, ≥100°, and ≥110° were achieved by, respectively, 94.4%, 82.5%, and 58.1% by 6 weeks and by 96.7%, 92.1%, and 84.2% by 12 weeks. Improvement in KOOS Symptoms (P = .029), Function in daily living (P = .030) and quality of life (P = .031) linearly decreased as number of PT sessions increased.

Conclusions

These results raise the question of whether patients who meet satisfactory outcomes before completing 6 weeks of prescribed PT and those who attend more PT sessions than prescribed may be over-utilizing healthcare resources without additional benefit.

Demographic and Diagnostic Factors in Physical Therapy Attendance

Introduction Physical therapy (PT) is an effective nonoperative treatment for various orthopedic diagnoses. However, patients may have many reasons to dismiss PT, including favoring another intervention for their injury, time constraints, transportation, and cost. This dismissal of PT may contribute to inadequate patient compliance. This study aimed to elucidate patient compliance with a basic PT prescription and whether PT led to subjective injury improvement. Methods This is a retrospective study of patients observed in Stony Brook Orthopedic clinics from 08/01/2022 to 12/23/2022. Patients prescribed PT received a phone call six weeks after the PT prescription. The primary outcome was patient attendance at PT. Secondary outcomes were subjective; symptomatic improvement was listed as better, worse, or the same. Chi-square testing was used to compare outcomes. Results A total of 100 patients were enrolled in the study. Patients prescribed PT following surgery were more likely to attend compared to patients prescribed PT as a primary treatment (P value=0.027). The association between attendance at PT and a change in subjective symptoms (better, worse, same) was not significant. Patients' age, sex, and chronicity of injury were not significant factors in PT attendance. Of the 40 patients who did not attend PT, 14 cited time constraints, 11 utilized self-directed treatment, three cited insurance, two cited transportation, and 10 cited other reasons. Conclusions Overall, postoperative patients were more likely to attend PT compared to patients prescribed PT as a primary treatment. Factors such as age, sex, and chronicity of injury did not affect whether a patient attended PT. Of the patients enrolled, 71% stated subjective improvement in symptoms, but there was no association between symptoms and PT attendance. This study highlights the characteristics of those patient factors that may influence PT compliance and underscores the importance of further research into the population most likely to attend and benefit from PT.

The potential of a multimodal digital care program in addressing healthcare inequities in musculoskeletal pain management

Digital interventions have emerged as a solution for time and geographical barriers, however, their potential to target other social determinants of health is largely unexplored. In this post-hoc analysis, we report the impact of social deprivation on engagement and clinical outcomes after a completely remote multimodal musculoskeletal (MSK) digital care program managed by a culturally-sensitive clinical team. Patients were stratified in five categories according to their social deprivation index, and cross-referenced with their race/ethnicity, rurality and distance to healthcare facilities. From a total of 12,062 patients from all U.S. states, 8569 completed the program. Higher social deprivation was associated with greater baseline disease burden. We observed that all categories reported pain improvements (ranging from -2.0 95%CI -2.1, -1.9 to -2.1 95%CI -2.3, -1.9, p < 0.001) without intergroup differences in mean changes or responder rates (from 59.9% (420/701) to 66.6% (780/1172), p = 0.067), alongside reduction in analgesic consumption. We observed significant improvements in mental health and productivity across all categories, with productivity and non-work-related functional recovery being greater within the most deprived group. Engagement was high but varied slightly across categories. Together these findings highlight the importance of a patient-centered digital care program as a tool to address health inequities in musculoskeletal pain management. The idea of investigating social deprivation within a digital program provides a foundation for future work in this field to identify areas of improvement.