Usual Physiotherapy Treatment Research Articles

Effectiveness of digital Cognitive-Behavioural Therapy for Insomnia in patients with musculoskeletal complaints and insomnia in primary care physiotherapy: study protocol for a randomised controlled trial

IntroductionInsomnia is prevalent among patients visiting physiotherapists due to musculoskeletal complaints and associated with poorer pain prognosis. Cognitive-Behavioural Therapy for Insomnia (CBT-I) may be effective for improving sleep quality and...

Optimising physiotherapy for people with lateral elbow tendinopathy – Results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE)

BackgroundThe OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET). ObjectivesTo assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET. DesignA mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK. MethodPatients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria. Results50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27–75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time. ConclusionsIt is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research.

Efectividad de la entrevista motivacional en la atención fisioterápica de los trastornos musculoesqueléticos de la espalda

ObjectiveTo evaluate the effectiveness of motivational interviewing (MI) combined with the usual physiotherapy treatment in patients with back musculoskeletal disorders (MSD) in primary care (PC). MethodsQuasi-experimental study with 2groups with therapeutic action (control group and experimental group) and prospective follow-up, in a physiotherapy unit in PC, in patients who began their treatment in 2020, with a medical diagnosis of MSD in the back. MI was used only in the face-to-face visits of the experimental group. Both groups were interviewed by telephone about 3and 6months after finishing the physiotherapy treatment. For this purpose, the Barthel scale was used for the subjective perception of the state of health, and the scale of compliance with home guidelines. Linear (regression coefficient, 95% CI) and logistic (OR, 95% CI) regression models were fitted. ResultsThe study population was 154 people (76.6% women). Perceived health was significantly better (P<.001) in the experimental group than in the control group, both at 3(7.4 versus 5.0, respectively) and at 6months of follow-up (7.1 versus 4.6, respectively). There was a strong association between perceived health and compliance (regression coefficient 3.0 [95% CI=2.5–3.4]). The strong association between MI and treatment adherence was maintained after multivariate adjustments (6-month OR=383.6 [95% CI 31.0–4742.4]). ConclusionsMI is a feasible and effective complement to physiotherapy treatments to improve compliance with home recommendations and subjective perception of health.

The effectiveness of low-dosed outpatient biopsychosocial interventions compared to active physical interventions on pain and disability in adults with nonspecific chronic low back pain: Asystematic review with meta-analysis.

To evaluate the effectiveness of low-dosed outpatient biopsychosocial interventions versus active physical interventions on pain intensity and disability in adults with nonspecific chronic low back pain. Research has shown that primary care biopsychosocial interventions (PCBI) can reduce pain intensity and disability. While scattered studies support low-dosed (≤ 15 treatment hours) PCBI, no systematic review exists comparing the effectiveness of low-dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP). Randomized controlled trials that evaluate low-dosed PCBI compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older), who suffer from CLBP were included. Not recommended interventions that feature only passive therapies, spinal surgery or pharmacological treatment, and studies with inpatient multidisciplinary-based rehabilitation (MBR) were excluded. Databases were searched from inception to December 31, 2021. Language was restricted to English or German. Keywords and derivatives of "chronic back pain", "exercise intervention", "cognitive-behavioral therapy", "primary care" and "randomized controlled trials" were used. Sources were CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science. Search was finished on March 08, 2022. Data appraisal, extraction and synthesis followed JBI guidance for systematic reviews of effectiveness. Risk of Bias was assessed using JBI 13-item checklist for randomized controlled trials. The GRADE approach for grading the certainty of evidence was followed. PROSPERO 2022 CRD42022302771. Eighteen RCTs were found eligible and 15 trials comprising a total of 1531 participants suffering from CLBP were entered in the meta-analyses. Risk of Bias was low. Overall evidence was moderate. Significant effects in favor of PCBI were found for pain intensity post-treatment (standardized mean difference (SMD)=-1.09, 95% confidence interval (CI)=-1.84 to -0.34, I2 =97%, p=0.004) as well as at short-term (SMD=-0.23, 95% CI=-0.39 to -0.08, I2 =0%, p=0.004), long term (SMD=-0.79, 95% CI=-1.42 to -0.17, I2 =96%, p=0.01) and very long-term (SMD=-1.13, 95% CI=-1.93 to -0.33, I2 =94%, p=0.005) follow-up. Significant effects in favor of PCBI for physical function were found post-treatment (SMD=-1.33, 95% CI=-2.17 to -0.49, I2 =97%, p=0.002) at short-term (SMD=-0.20, 95% CI=-0.36 to -0.04, I2 =0%, p=0.01) and at long-term follow-up (SMD=-1.17, 95% CI=-2.06 to -0.28, I2 =98%, p=0.01). The results were characterized by high heterogeneity due to different types (cognitive behavioral therapy, pain-neuroscience education, mindfulness, and motivation), delivery modes (individual and/or group), durations (3-12 weeks) and contact times (2-15 h) of PCBI. In sensitivity analysis outliers were removed to reduce heterogeneity. The results remained significant for pain intensity at short-term (SMD=-0.23, 95% CI=-0.39 to -0.08, I2 =0%, p=0.004) and long-term follow-up (SMD=-0.22, 95% CI=-0.41 to -0.03, I2 =39%, p=0.02). This meta-analysis suggests that low-dosed PCBI has favorable effects in terms of disability and pain intensity compared to active physical treatments alone. All conducted meta-analyses indicate that biopsychosocial interventions produce better outcomes than active physical treatment alone. Therefore, we strongly recommend decision makers and clinical practitioners to analyze how psychosocial elements can be introduced into outpatient (low-dosed) CLBP interventions.

The effectiveness of low-dosed outpatient biopsychosocial interventions compared to active physical interventions on pain and disability in adults with nonspecific chronic low back pain: A protocol for a systematic review with meta-analysis

Best outpatient treatment of nonspecific chronic low back pain is high-dosed exercise that is maintained after therapy. Primary care biopsychosocial intervention (PCBI) is an outpatient multicomponent intervention that includes an active component (exercise, physical activity, or physiotherapy) and at least one psychological, social, or occupational component. Research has shown that PCBI can reduce pain intensity and disability. While scattered studies support low-dosed (<15 treatment hours) PCBI, there is no systematic review comparing the effectiveness of low-dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP). Randomised controlled trials that evaluate low-dosed outpatient biopsychosocial interventions compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older) who suffer from nonspecific CLBP will be included. A comprehensive search of multiple databases will be used to find relevant studies. The databases will be searched from inception to December 2021, with English or German language restrictions imposed. Keywords and derivatives of "chronic back pain", "exercise intervention", "cognitive-behavioral therapy", "primary care" and "randomized controlled trials" will be used. Sources will include CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science. To our knowledge, this will be the first systematic review and meta-analysis of narrowly defined low- dosed PCBI across populations with nonspecific chronic low back pain. The objective of this review is to evaluate the effectiveness of low-dosed outpatient biopsychosocial interventions versus physical active interventions on pain intensity and disability in adults with CLBP. This study will provide evidence that could improve treatment options for patients with nonspecific CLBP. Systematic review registration number: PROSPERO 2022 CRD42022302771. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022302771.

The effectiveness of diacutaneous fibrolysis on pain, range of motion and functionality in musculoskeletal disorders: A systematic review and meta-analysis

Objective: To assess the effectiveness of diacutaneous fibrolysis in reducing musculoskeletal disorders symptoms such as pain, range of motion and functionality. Data sources: A systematic review of MEDLINE, Cochrane, PEDro and Science Direct was conducted until September 2020. Review methods: Computerized search strategy was performed to identify randomized controlled trials applying diacutaneous fibrolysis, on subjects with musculoskeletal disorders. Eligible articles and data extraction were conducted independently by two reviewers. Methodology quality and risk of bias were assessed by Risk of Bias 2 tool from the Cochrane Collaboration and Physiotherapy Evidence Database. Outcomes assessed were pain intensity, range of motion and functionality. Results: Search strategy identified 98 potential randomized control trials and six studies involving 386 participants, were finally included. Diacutaneous fibrolysis intervention added to usual physiotherapy treatment was compared to control group. Pain intensity immediately after treatment showed a pooled Standard Mean Difference (SMD) of –0.58 with 95% confidence interval (CI) from –1.12 to –0.04, and in the longest follow-up SMD was –0.63 with 95% CI (–1.21 to –0.05). Functionality showed a pooled SMD of –1.02 with 95% CI (–1.67 to –0.36) immediately after intervention and a SMD of –0.84 with 95% CI (–1.54 to –0.14). Range of motion could not be included in the quantitative synthesis. Conclusion: Diacutaneous fibrolysis is an effective treatment, when combined with conventional physiotheraphy, reducing pain immediately after treatment and long term follow-up and improving function in both, short and long term in musculoskeletal disorders.

RabbitRun: An Immersive Virtual Reality Game for Promoting Physical Activities Among People with Low Back Pain

Low back pain (LBP) is one of the most common problems among adults. The usual physiotherapy treatment is to perform physical exercises. However, some LBP patients have false beliefs regarding their pain and they tend to avoid physical movements which might increase their pain and disability. Virtual reality (VR) has proven to be an effective intervention in improving motor functions and reducing pain perception. Existing VR interventions for LBP rehabilitation were based on a non-immersive VR, whereas to effectively reduce the pain intensity, we need an immersive VR. In this paper, we introduce the development and evaluation of a serious game called RabbitRun with an immersive experience to engage the patients in a virtual environment and distract them from the pain while performing LBP exercises. The initial usability evaluation results suggest that RabbitRun game is enjoyable and acceptable. The game is easy to play and learn and most of the participants are willing to play the game at home. This solution will enhance the rehabilitation outcome since the patients who are suffering from LBP can use the system at their home and train more for long period of time using a smartphone and low-cost virtual reality device, such as Google Cardboard.

Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial

Background: Non-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor outcome. MMT includes a) neurophysiological education on the perception of pain to decrease self-limitation due to catastrophizing believes about the nature of NSCLBP, b) sensory training of the lower trunk because these patients predominantly show poor sensory acuity of the trunk, and c) motor training to regain definite movement control of the trunk. A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients’ adherence and the evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy. Method: We conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student’s t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated. (Continued on next page)

A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study)

Objectives: To evaluate the clinical effectiveness of a self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy. Design: Multi-centre pragmatic unblinded parallel group randomised controlled trial. Setting: UK National Health Service. Participants: Patients with a clinical diagnosis of rotator cuff tendinopathy. Interventions: The intervention was a programme of self-managed exercise prescribed by a physiotherapist in relation to the most symptomatic shoulder movement. The control group received usual physiotherapy treatment. Main outcome measures: The primary outcome measure was the Shoulder Pain & Disability Index (SPADI) at three months. Secondary outcomes included the SPADI at six and twelve months. Results: A total of 86 patients (self-managed loaded exercise n=42; usual physiotherapy n=44) were randomised. Twenty-six patients were excluded from the analysis because of lack of primary outcome data at the 3 months follow-up, leaving 60 (n=27; n=33) patients for intention to treat analysis. For the primary outcome, the mean SPADI score at three months was 32.4 (SD 20.2) for the self-managed group, and 30.7 (SD 19.7) for the usual physiotherapy treatment group; mean difference adjusted for baseline score: 3.2 (95% Confidence interval -6.0 to +12.4 P = 0.49). By six and twelve months there remained no significant difference between the groups. Conclusions: This study does not provide sufficient evidence of superiority of one intervention over the other in the short-, mid- or long-term and hence a self-management programme based around a single exercise appears comparable to usual physiotherapy treatment.

Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial.

BackgroundNon-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor outcome. MMT includes a) neurophysiological education on the perception of pain to decrease self-limitation due to catastrophizing believes about the nature of NSCLBP, b) sensory training of the lower trunk because these patients predominantly show poor sensory acuity of the trunk, and c) motor training to regain definite movement control of the trunk.A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients’ adherence and the evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy.MethodWe conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student’s t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated.ResultsTwenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients’ adherence to treatment was >80% in both groups. Pain reduction (NRS; [95% CI]) was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0 to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The required sample size for a RCT with six months follow-up was estimated at 170 patients.ConclusionsMMT was found to be feasible and to significantly reduce pain in the short term when compared with UPT. A future RCT with a six-month follow-up would require approximately 170 patients.Trial registrationCurrent Controlled Trials ISRCTN66262199. Registered 8 January 2014.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-015-0533-2) contains supplementary material, which is available to authorized users.

Self-managed loaded exercise versus usual physiotherapy treatment for rotator cuff tendinopathy: a pilot randomised controlled trial

ObjectivesRotator cuff tendinopathy is a common source of shoulder pain characterised by persistent and/or recurrent problems for a proportion of sufferers. The aim of this study was to pilot the methods proposed to conduct a substantive study to evaluate the effectiveness of a self-managed loaded exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy. DesignA single-centre pragmatic unblinded parallel group pilot randomised controlled trial. SettingOne private physiotherapy clinic, northern England. ParticipantsTwenty-four participants with rotator cuff tendinopathy. InterventionsThe intervention was a programme of self-managed loaded exercise. The control group received usual physiotherapy treatment. Main outcomesBaseline assessment comprised the Shoulder Pain and Disability Index (SPADI) and the Short-Form 36, repeated three months post randomisation. ResultsThe recruitment target was met and the majority of participants (98%) were willing to be randomised. 100% retention was attained with all participants completing the SPADI at three months. Exercise adherence rates were excellent (90%). The mean change in SPADI score was −23.7 (95% CI −14.4 to −33.3) points for the self-managed exercise group and −19.0 (95% CI −6.0 to −31.9) points for the usual physiotherapy treatment group. The difference in three month SPADI scores was 0.1 (95% CI −16.6 to 16.9) points in favour of the usual physiotherapy treatment group. ConclusionsIn keeping with previous research which indicates the need for further evaluation of self-managed loaded exercise for rotator cuff tendinopathy, these methods and the preliminary evaluation of outcome offer a foundation and stimulus to conduct a substantive study.