Background
The gap between clinical guidelines and their application in clinical practice is reflected in the fact that not the recommended exercise and education, but still non-evidence-based interventions, such as passive modalities and surgery are used as first-line interventions in the management of HK-OA and LBP. GLA:D (Good Life with osteoArthritis in Denmark) translates the international guidelines for hip and knee osteoarthritis (HK-OA) and for persistent or recurrent low back pain (LBP) into standardized but individualized programmes (GLA:D-OA and GLA:D-Back).
Purpose
Given the high prevalence of OA and LBP, the evidence-based GLA:D programmes should be implemented in clinical practice to overcome the evidence-performance gap.
Methods
The three core elements of the GLA:D programmes have been systematically implemented internationally, and in Switzerland, GLA:D-HK-OA since 2019 and GLA:D-Back since 2021: 1) certification of physiotherapists (PTs) for uniform implementation; 2) training of the affected persons by the certified PTs in their institution: 4 individual sessions and 14 group sessions (2 patient education sessions and 12 supervised training sessions); 3) collection of all assessment and questionnaire data in a national registry at entry, after completion, after 6 months (LBP only) and after 1 year. The data are evaluated annually as part of the quality monitoring.
Results
A total of 848 certified GLA:D-PTs for HK-OA and 402 PTs for LBP treated a total of 4662 HK-OA and 574 LBP patients in all three language regions in Switzerland in GLA:D courses. After the intervention, the 2462 KOA and 741 HOA patients with complete data showed improvements in pain of 24% and 23%, walking speed of 12% and 6%, quality of life of 22% and 16%, and pain medication use of 18% and 15%, respectively. Pain, function and quality of life remained substantially improved also after one year. The 300 LBP patients with complete data improved by 30% in pain intensity, 26% in pain medication consumption, 18% in physical function, and 20% in fear of physical activity. These improvements remained after 6 months.
Conclusions:
These evaluations showed that the standardized, individually adapted, and evidence-based GLA:D programme achieved substantial improvements immediately after participation in the programme and at 6 or 12 months. The number of participants is satisfactory, however more effort and systematic implementation strategies are necessary to further and successfully implement the GLA:D programmes in the Swiss health care system.
Implications:
The GLA:D programmes strengthen the importance of exercise and education in HK-OA and LBP and makes an important contribution to best practice. The expertise of PTs is increased by the GLA:D certification and strengthens evidence-based and high-quality physiotherapeutic care.
Background:
Current evidence suggests that the clinical outcomes from health interventions in patients with musculoskeletal (MSK) disorders could be significantly improved by integrating prognostic factors into the decision-making process. The Measures Associated to PrognoStic (MAPS) tool, a set of standardized questionnaires that integrates validated prognostic tools and unique prognostic factors, was developed to systematically identify the various prognostic factors that could influence recovery for patients presenting with MSK disorders. Through this tool, physiotherapists might depict their patients’ prognostic profile and optimize their interventions
Purpose:
The main objectives of this study were to: 1) assess the feasibility of implementation of the MAPS tool within everyday clinical practice; 2) assess the acceptability of the clinical dashboard by the clinicians; 3) assess the acceptability of the MAPS tool by patients.
Methods:
Feasibility study within the context of true clinical practice. Physiotherapists working in outpatient MSK clinics were recruited. Over a period of three months, they were asked to use the MAPS tools as part of the initial assessment of new patients. Patients were invited to complete an acceptability survey about the MAPS tool. At the end of the 3-month period, clinicians were invited to complete an acceptability survey about the dashboard provided by the MAPS tool and to participate to a semi-structured interview about their experience using the tool.
Results:
Eleven physiotherapists completed all portions of the study. One hundred and thirty-six patients accessed the MAPS tool and 78% totally completed the questionnaire. Of them, 106 gave consent to participate to the acceptability survey. 7/10 feasibility criteria (70%) and 19/24 acceptability criteria (79%) reached the a priori threshold for success. The 3 criteria that did not get acceptability from the patients were the: 1) degree of appreciation (73%), 2) pertinence (79%) and 3) perceived usefulness (77%) of the tool. Nine clinicians completed the acceptability survey and the semi-structured interview. The acceptability criterion deemed the most limiting one by 44% of the clinicians was the added administrative burden. The semi-structured interviews provided more insight on the reasons behind the least acceptable elements. Three main themes were identified to facilitate implementation of the tool: 1) limiting the burden, 2) ensuring patients’ understanding of the tool’s purpose and 3) integrating the dashboard as a clinical information tool.
Conclusion(s):
Depicting the patients’ prognostic profile seems feasible and acceptable by both clinicians and patients as our results support the feasibility of implementation and acceptability of the MAPS tool pending minor adjustments. The next step would be to implement the MAPS tool on a large scale in outpatient practice and proceed to an impact study on clinical practice. It would also be relevant to consider its feasibility of implementation in other types of settings (e.g., public sector). In its current form, the MAPS tool comprises prognostic models for MSK conditions, yet other versions could be considered to assess different populations like in neurology, cardiorespiratory or geriatrics.
Implications:
Depicting the patients’ prognostic profile has the potential to help clinicians optimize their interventions for patients presenting with MSK disorders.
Introduction
Many physiotherapists still manage their patients mainly from a biomedical point of view. The purpose of this study was to analyze the effect of two different e-learning interventions on knowledge, attitudes and beliefs of physiotherapists managing low back pain (LBP).
Methods
Physiotherapists were allocated (1/1) either to an experimental or a traditional e-learning. Baseline and post- intervention assessment included the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ) and a clinical vignette. Participants had two weeks to complete the post-intervention assessment. Statistics were processed using ANCOVA and Fisher’s t-tests.
Results
419 physiotherapists were included in the analysis. Mean scores of HC-PAIRS, Back-PAQ and NPQ significantly improved post-intervention in both groups. There was a significant effect of the intervention type (experimental or traditional) on the scores of HC-PAIRS (p < .001; η2p = .243) and Back-PAQ (p < .001; η2p = .135), but not on NPQ scores. Return to work recommendations assessed with the clinical vignette were significantly more guideline-consistent in the experimental group (p < .001) post-intervention.
Conclusion
An interactive e-learning intervention focusing on patient’s reassurance, self-management and importance of psycho-social factors seems the most promising way to enhance physiotherapists’ attitudes, beliefs and work recommendations regarding LBP.
Background
The Center for Disease control reported in 2021 that 59% of individuals over the age of 18 have had an incidence of low back pain (LBP) within the past 3 months. (2021 CDC) Exercise and manual therapy are the interventions currently advocated in published clinical practice guidelines. Implementing guideline-based care in practice is shown to improve outcomes. Risk stratification based and psychologically informed care is also advocated in the treatment of LBP. Hodges (2019) proposed an integrated model of care for those with LBP to blend these approaches.
Use of standardized outcome tools in patient care enables measurement of the impact of LBP on disability. Implementing a systematic approach to use of outcome measures in practice allows the ability to measure change overtime. Failure to improve on a standardized measurement may indicate lack of improvement over time.
Purpose:
The purpose of this quality improvement initiative was to determine if targeted education regarding the hybrid model described by Hodges combined with management controls such as electronic health record modifications enhanced outcomes for patients with non-surgical LBP.
Methods:
An analysis of retrospective patient reported outcomes collected in our center from 9/1/2016 to 12/31/2017, as part of standard care on 664 patients with non-surgical low back pain, identified the probability of meeting the MCID on the Modified Disability Questionnaire (MDQ) was 0.668. A quality improvement initiative was subsequently delivered over the next 14 months that included evidence-based approaches to examination and intervention and management controls to facilitate implementation. A hybrid model as put forth by Hodges (2019) was the framework for improvement alongside content on treatment-based classification, pain mechanisms, OPTIMAL theory, and central sensitization. Development and implementation of a clinical decision algorithm was introduced using stop points in the electronic medical record that facilitated compliance. Following completion of the quality improvement initiative, data collected between 9/1/2021 and 12/31/2021 were analyzed using a logistical regression.
Results:
The “pre” sample included data on 664 patients with a probability of success on the MDQ of 0.668. The “post” sample which encapsulates patients treated after the intervention consisted of 47 patients who demonstrated a probability of success on the MDQ of 0.778 (p-value: 0.06). Additionally, pain measured by the Numeric Pain Rating Scale (NPRS) showed improvement but no significant difference with the “pre” probability of success of 0.520 improving to 0.642 (p-value: 0.10)
Conclusion(s):
The success of this evidence-based quality improvement initiative highlights the importance of continuing to bridge the divide between clinician knowledge gaps and current evidence. Targeted identification of knowledge deficits combined with well researched and implemented education interventions can improve the quality of patient outcomes in individuals with low back pain, specifically in this case in integrating a hybrid model of treating low back pain.
Implications:
This project gives impetus for even a single clinic to embark on steps necessary to become a learning health clinic through systematic collection of patient reported outcomes, focused quality improvement work, and well researched and implemented evidence-based practice.
Musculoskeletal disorders are the leading contributor to disability worldwide. Workforce capacity building to manage this growing burden of disease is crucial. Clinical practice guidelines for the management of musculoskeletal disorders emphasise a biopsychosocial approach. However, healthcare professionals learning about the biopsychosocial model does not necessarily translate to effective adoption of the model in clinical practice. A multitude of biopsychosocial constructs are mediators or moderators to pain. Coupled with gaps about what tools or strategies can be used to effectively translate the biopsychosocial model into musculoskeletal practice, this makes designing effective pain education programs to upskill the physiotherapy workforce challenging.
There are three aims to this research:
(1) Understand the barriers and enablers that influence healthcare professionals’ adoption of a biopsychosocial approach to musculoskeletal pain from a whole-of-health perspective.
(2) Identify the behavioural determinants and behavioural change techniques to support the implementation of high value musculoskeletal pain care.
(3) Investigate physiotherapy educators’ perspectives on what approaches, strategies and tools they adopt in teaching to translate knowledge about the biopsychosocial model into practice.
(i) A qualitative review was undertaken to investigate the experiences of primary healthcare professionals engaged in biopsychosocial pain care for musculoskeletal disorders.
(ii) A five-step process informed by the Behaviour Change Wheel methodology was used to identify the behavioural determinants and behavioural change techniques that may improve the implementation of biopsychosocial pain care.
(iii) Qualitative study using semi-structured interviews were used to gather information from experienced physiotherapy educators across Australia to understand how the biopsychosocial model was taught in undergraduate, postgraduate physiotherapy and health workforce training programs.
1.The review identified barriers and enablers across the whole-of-health.
At the
(i). Micro-level: healthcare professionals’ personal factors, knowledge and skills, and their perception of clinical practice guidelines, perception of patients’ factors and time;
(ii). Meso-level: clinical practice guideline adoption, community factors, funding models, health service provision, resourcing issues and workforce training issues; and
(iii). Macro-level: health policy, organizational and social factors, influenced the adoption of a biopsychosocial approach.
2. Six behaviour change techniques were relevant to facilitate behaviour change to improve training and support for healthcare professionals: “Instruction on how to perform a behaviour”, “behavioural practice/rehearsal”, “social support (unspecified)”, “social support (practical)”, “prompts/cues”, and “restructuring the physical environment”. Behavioural intervention priorities included building effective communication to strengthen therapeutic alliance (clinical-level); re-design of curricula to strengthen interdisciplinary pain competencies (service provision/health workforce training); and encouraging multi-sectoral partnerships (systems-level).
3. A variety of frameworks were used by physiotherapy educators to teach the biopsychosocial model: the Musculoskeletal Clinical Translation Framework, Pain and Movement Reasoning Model, case formulation approach, Clinical Reasoning model, and the International Classification of Functioning, Disability and Health.
Addressing the barriers from a whole-of-health perspective, considering training priorities from a behavioural approach, aligned with current educational practices, can help improve the translation of the biopsychosocial model into clinical practice.
This research can potentially inform better design of biopsychosocial pain education for various musculoskeletal disorders, in scope and at scale. It also highlights the existing gaps in the training and education of musculoskeletal pain.
Background
The global burden of spinal pain has increased significantly over the past two decades to become the leading cause of years lived with disability with high personal and healthcare economic implications; driving a need for physiotherapy. Research to date has had little impact and a new approach is required. Many chronic health conditions benefit from large registries to track health-related metrics, predict outcomes, and inform practice. There is promise for patient reported and clinician collected data to inform predictive modelling and development of complex precision musculoskeletal physiotherapy interventions. Currently, no registry of physiotherapy specific data exists.
Purpose
To create a registry to enable international big data for understanding and development of precision interventions for spinal pain to improve patient care pathways and outcomes. Objectives are to: 1] create a longitudinal minimum core dataset for spinal problems, 2] facilitate extended datasets for spinal problems, 3] establish a source for recruitment of potential participants for research.
Methods
Prospective observational longitudinal registry with data collection (commenced 1st August 2023) at defined intervals (intake, 1 3 6 and 12 months, yearly) through an electronic platform (EmPower Health Research). The minimum core dataset was informed by the Report of the NIH Task Force on Research Standards for Low Back Pain, research-based recommendations for registry construction, literature reviews and authentic partnerships with patients and clinicians. Adults (≥18 years) experiencing spinal pain/symptoms (neck, upper/mid-back, low back) of musculoskeletal cause are eligible to participate and recruited through contact with a physiotherapist or responding to advertisements online/healthcare locations. For patients recruited through physiotherapist contact, parallel clinician data (intake, 1 month) are collected. Patient data include demographics, symptom characteristics, functional interference, resilience, work status etc. Clinician data include nature of spinal pain, physical examination findings, physiotherapy diagnosis etc. Extended datasets include physical measures and biomarkers. A system of reminders including email, text, and phone calls reduces loss to follow up. Planned recruitment is n=20,000 patients over 20 years.
Results
SPINA allows patients and clinicians ownership over their data. Patients download their data trends over time. Physiotherapy clinical sites download their clinic data trends over time. Current recruitment is from Canada, awaiting ethical approval in the UK and Australia. Data analysis will include pre-post physiotherapy intervention analyses, and development and validation of models for predicting outcome from low back, cervical and thoracic problems using a range of outcomes (e.g. pain and disability) and outcomes important to patients, at a range of timepoints.
Conclusion(s)
This physiotherapy-focused registry is the first of its kind to support spine research enabling investigation of clinical phenotypes, recovery pathways, identification of risk, and prediction of outcomes to inform precision intervention. SPINA, for the first time enables research across lumbar, cervical and thoracic regions.
Implications
Longitudinal tracking will allow for care pathways to be visualized through data for model development and systems-based improvement. SPINA also forms the foundation for parallel data-banking of biomarkers and physical measures for comprehensive profiling of spinal pain. It is anticipated that SPINA will be a valuable resource internationally for researchers and clinicians.
Low back pain (LBP) is the leading cause of disability worldwide. Therapeutic exercise is a recommended core treatment for LBP with many randomised controlled trials (RCTs) investigating effectiveness. However, many RCTs are incompletely reported, and the rationale for how the prescribed exercise intervention is anticipated to ‘work’ is poorly described. RCTs which do not include process evaluations and conventional systematic reviews are seldom designed to explain why an intervention ’works’, or to identify the most important components and mechanisms underpinning treatment effects. Realist reviews explore how underlying mechanisms (M) may be active in the context (C) of certain settings or populations to create intended or unintended outcomes (O). Our objective was to explore and understand the mechanisms by which therapeutic exercise prescription creates change in outcomes for people with LBP.
Methods.
This was a realist review reported following RAMESES guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37 studies). Subsequently, an information specialist (AB) designed and undertook an iterative search strategy. We refined, and tested CMO configurations using iterative review with the stakeholder and steering groups.
Results.
Of 522 initial papers identified, 75 papers were included to modify and test the CMO configurations. Twenty-two of the 75 included studies comprised qualitative research designs, followed by quantitative designs (n=15), RCTs (n=15), systematic reviews (n=15), mixed methods (n=3), commentary (n=2), case reports (n=2) and narrative reviews (n=1). Trust emerged as a mechanism and was identified as a key mechanism to all identified outcomes (adherence, engagement, and clinical outcomes)in 27 studies (seven CMOcs high confidence, three CMOcs moderate confidence). Motivation was a key mechanism to engagement and adherence (10 CMOcs high confidence level, 2 CMOcs moderate confidence, 1 low confidence). Confidence was a mechanism to the outcome of adherence to exercise, with high confidence in all six CMOcs). The patient-clinician consultation incorporating therapeutic alliance, holistic assessment and previous experience builds the foundation of and maintains trust, and was related to adherence, engagement, and clinical outcomes. Individualised exercise prescription, including considerations of patient preference, increases motivation to adhere to exercise and thus impacts clinical outcomes. Provision of support such as timely follow-up, education and reassurance, supervision and peer support can further facilitate motivation and confidence to improve adherence to therapeutic exercise for LBP.
Conclusions.
To develop and harness the benefits of a strong therapeutic alliance, clinicians may wish to consider performing a holistic assessment to build and win the patient’s trust, to co-design and individualise the exercise prescription around the patient’s own goals, accounting for their previous experience, preferences, and available time to perform exercises. Engagement and adherence to therapeutic exercise for LBP, and clinical outcomes, are optimised using the mechanisms of trust, motivation, and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription. Further research is required to explore the relationship between adherence and clinical outcomes, and how to implement and optimise these mechanisms in clinical practice.
Background:
There is an ongoing need for scientific validation of the effects of physiotherapeutic interventions and elucidation of the underlying mechanisms. Ultrasound shear wave elastography (SWE) could be a valuable method in this process.
Purpose:
Through a series of studies, we aimed to examine the changes in tendon and muscle stiffness after various exercise and therapeutic interventions. Additionally, we sought to verify if the changes of stiffness measured by SWE coincide with the ones assessed by measuring passive joint torque.
Methods:
In all studies, muscle stiffness was assessed with SWE, using an ultrasound device (Resona 7, Mindray, Shenzen, China). Specifically, sound touch quantification in musculoskeletal mode was utilized to obtain shear modulus values (in kPa), assuming tissue density of 1000 kg/m3.
In the initial study, the effects of eccentric exercise were examined in 14 individuals. SWE measurements of hamstring muscles (biceps femoris, BF, semitendinosus, ST, and semimembranosus, SM) were compared with passive knee extension torque (PKT). PKT was measured on an isokinetic dynamometer device (Humac Norm, Computer Sports Medicine Inc., Massachusetts, USA) at a speed of 5°/s from 35° to 0° knee flexion.
In the second study, the effects of isometric fatigue (three sets of 6/6/3 minutes consisting of 6 seconds exertion at 50% of MVC interspersed with 4 seconds of rest) on the stiffness of the erector spinae and multifidus muscles at rest were measured in 22 participants. Measurements were also taken during two submaximal contractions of the trunk extensors at different intensities: the prone arm lift (low-level contraction) and trunk extension (high-level contraction).
In the third study, employing a crossover study design, 10 participants performed 3 sets of 30 consecutive hops. The following day manual massage or foam rolling (with order randomized between sessions) of the entire lower limb was performed. Changes in stiffness of the Achilles tendon (AT) and gastrocnemius muscle (GM) were measured.
Results:
One-way repeated measures analysis of variance (ANOVA) showed a significant effect of eccentric exercise on stiffness of BF (p=0,009; η2=0,22) and ST (p=0,001; η2=0.31) but not the SM muscle (p=0,096). Unlike with the SWE-based outcomes, there were no statistically significant effects of eccentric exercise on PKT (p=0.096-0.340). There were no correlations between changes in SWE outcomes and changes in passive joint torque at any time point. In the second study, the two-way ANOVA has shown a statistically significant main effect of fatigue for passive shear modulus (p=0.004; η2=0.33) and active shear modulus during high-level contraction (p=0.003; η2=0.37) but not during low-level contraction (p=0.551). In the third study, the two-way ANOVA showed no main effects of time or treatment (p≥0.362) on GM and AT stiffness. There was a trend of interaction effect nearly reaching the level of significance for AT (p=0.069), indicating an opposite effect of foam rolling and massage therapies.
Conclusions:
Our studies indicate that SWE holds promise as a valuable method for evaluating muscular and tendon changes resulting from diverse physiotherapeutic interventions. The potentially contrasting effects of similar therapeutic procedures underscore the necessity for further research in this domain.