Background
Fibromyalgia is a chronic primary pain syndrome, characterized by widespread pain, sleep disturbances, cognitive dysfunction, fatigue, and functional symptoms. It exerts a significant impact on health quality of life, resulting in a substantial number of medical visits, a higher average count of missed workdays and early retirements.
Guidelines recommend the combination of pharmacological and non-pharmacological approaches, emphasizing the relevance of self-management and exercise programmes. EHealth interventions hold the potential to facilitate the implementation of these programmes, ensuring their efficacy and safety, while enhancing the accessibility and sustainability of care. The successful development of an eHealth solution requires a deep understanding of patients` needs and perceptions, as well as the involvement of relevant stakeholders.
Purpose
This study is part of a community-based participatory research project aiming to develop an eHealth supported self-management programme for individuals diagnosed with fibromyalgia. Following a framework for mapping the full process of co-creation, this study was focused on the initial stage of contextual inquiry. It aimed to explore the perceived needs, facilitators, and barriers to engage in such a programme, from the perspective of patients, patient representatives and health professionals.
Methods
A qualitative study supported by two focus groups with different stakeholders was completed. The focus groups were based on a semi-structured interview schedule, were audio recorded and videotaped, transcribed verbatim and thematically analysed. Interview transcripts were coded independently by two researchers. Codes were compared and emerged themes were identified and refined by those two researchers. The preliminary analysis was shared with the research team and further refined with the collaboration of eight researchers from different backgrounds (health and computer sciences).
Results
Each focus group session lasted for ninety minutes. A total of fifteen participants were included: eight patients diagnosed with fibromyalgia; two patient representatives from national patient associations; two physiotherapists; two psychologists; one rheumatologist.
Three major themes were identified: 1) needs, 2) facilitators, and 3) barriers. Within the first theme, the need for individualized and personalized approaches was identified, with a strong preference for a flexible hybrid programme that combines traditional in-person care with digital options. In the second theme, the easy access, and the potential to integrate exercise, supervised by a physiotherapist, into their daily routines were considered important facilitators. In the third theme, several anticipated barriers were noted, including concerns about digital literacy, uncertainty about the efficacy and safety of digital health solutions, and fear about the ability to establish a therapeutic relationship.
Conclusion
This study focused on conducting a contextual inquiry, serving as the first stage of a research project that aims to create an eHealth supported self-management programme for individuals diagnosed with fibromyalgia. The insights gained here may provide valuable input for subsequent studies focused on the co-creation, usability testing and clinical effectiveness of the eHealth supported self-management programme.
Implications
Identifying the perceived needs, facilitators, and barriers to engage in an eHealth supported self-management programme, from the perspective of patients diagnosed with fibromyalgia, patient representatives and health professionals can contribute to developing a user-friendly, clinically relevant, and tailored solution.

Background
Neck pain is one of the most common musculoskeletal conditions globally. Disturbed cervical range of motion and reduced movement velocity are often seen in people with neck pain. Objective assessments of movement functions are important to identify dysfunctions, for tailored interventions and evaluation of treatment effect.

Purpose
The aim was to investigate the concurrent validity of a newly developed VR-technology for assessment of cervical range of motion and cervical movement velocity, by comparing VR-technology against a gold standard 3-dimensional optical motion capture system.

Methods
A quantitative cross-sectional study design was used. Twenty people with a natural variation of neck status participated, 10 women, 10 men, 18-65 years old. Participants performed VR-based tests, being cervical range of motion in right/left rotation, flexion, extension, right/left lateral flexion, and four diagonal directions. Velocity was assessed in fast cervical rotation to the right and left, respectively. Kinematics were obtained from VR-headset (Curest VR) and the gold standard Qualisys Motion Capture system simultaneously. The agreement between VR-technology and Motion capture system was analyzed using Bland-Altman plots with 95% Limits of agreement [LOA], as well as the Intraclass Correlation Coefficient [ICC].

Results
The correlation between Curest VR and Qualisys Motion Capture system for cervical range of motion and velocity was excellent, with ICC-values > 0,95. All ROM-variables except right rotation showed a mean bias < 1° (smallest LOA -1,65° to 1,23°, highest LOA -5,36° to 6,84°). Right rotation was the only ROM variable where VR was significantly different from Qualisys, with a mean bias 2,07° (LOA -0,88° to 5,03°). Max velocity variables showed a mean bias < 12 °/s (smallest LOA -40,93°/s to 25,54°/s, highest LOA -71,61°/s to 48,2°/s). Bland Altman plots for max velocity showed largest differences at values above 500 °/s. Mean velocity had mean biases < 3,1°/s (smallest LOA -14,59°/s to 13,03°/s, highest LOA -17,2°/s to 20,15°/s).

Conclusion(s)
Curest VR-headset is a useful assessment device for range of motion measurements in the traditional and diagonal movement directions, with clinically acceptable biases. Movement velocity measurements had clinically acceptable biases for mean velocity. Max velocity measurements had limits of agreement up to ±60°/s indicating larger spread of differences, where largest differences were seen in very fast movements with values above 500 °/s, where extra caution should be taken. Future studies should investigate the reliability and discriminant validity of the VR-based cervical range of motion and velocity tests.

Implications
The VR-device enables for accurate objective assessment of cervical range of motion and movement velocity, with instant test results. VR can be used in the clinical setting or at patients' homes, as a "mini-lab", as it can assess cervical range of motion with good precision and now also velocity which previously was mainly doable in the advanced laboratory setting. A great advantage of the VR is that it can be used in digital health rehabilitation, as test results can be monitored from a distance, making rehabilitation possible for people in remote areas or for people who cannot come to a physical clinic.

Purpose: Mentored clinical practice is central to enabling achievement of educational standards in advanced musculoskeletal physiotherapy, including IFOMPT Educational Standards. Whilst traditionally delivered face-to-face, telehealth e-mentoring is a novel alternative to offering this unique pedagogy, to facilitate mentee critical reflection, deeper learning and enhanced knowledge translation to optimise patient care. With Covid-19 resulting in widespread adoption of telehealth and access to mentors often limited by geography or cost, the potential value of telehealth e-mentoring needs investigating. The purpose of this study was to understand the experiences and outcomes of multiple stakeholders (student-mentees, mentors and patients) engaged in musculoskeletal physiotherapy telehealth e-mentoring. Methods: Using case study design, sequential mixed methods involving qualitative (interviews/focus group) and quantitative components explored stakeholder experience of a 20-week telehealth e-mentoring service in a UK University. Semi-structured interviews exploring experiences of telehealth e-mentoring, including influence on critical thinking, clinical reasoning, communication skills, confidence, motivation, career enhancement etc. with mentee participants and a focus group with mentor participants (topic guide informed by earlier analysis) were audio recorded and transcribed verbatim. Using validated outcome measures, patient participant experiences for care and empathy, patient empowerment and change in musculoskeletal health were collected at baseline and following discharge. Quantitative data was analysed using descriptive statistics (median and IQR) and qualitative data analysed following the Framework Method. Trustworthiness was assured through reflexivity and code/recode audits with experts. Results: Data from patients participants (n=90), mentee participants (n=10) and a mentor focus group (n=6,) contributed to the developed analytic framework. Patient participants had a median age 42 years (18-73 years) with a range of musculoskeletal complaints, with n=52 receiving follow up appointments. Of those returning participants improvements were seen with MSK-HQ increasing 11 points (MCID 6), Patient Specific Functional Scores improving by 4 points (MCID 2.7), and high scores for the Consultation and Relational Empathy and Patient Enablement Instrument. Mentor and mentee participants provided rich descriptions of their experiences. Mentor participants main themes (sub-themes) related a) preparedness (telehealth skills, relationship building, managing perceptions/expectations etc.), b) journey of development (formative feedback, peer discussions, mimicking behaviours etc.) and c) challenges (non-verbal communication, home environment, exercise prescription/goal-setting etc.) and specifically for mentee participants a) social learning (group mentorship, feedback, individualisation etc.), b) advanced professional practice (communication, clinical reasoning, reflective practice etc.), c) learner experience (expectation/acceptance, enjoyment/motivation etc.) and c) limitations of telehealth (caseloads, therapeutic relationship etc.). Conclusions: Data afforded understanding of the experiences of multiple stakeholders (patients, mentors and mentees) in telehealth e-mentoring. Findings illustrate that telehealth e-mentoring is an appropriate alternative to conventional approaches to mentored clinical practice to develop and fulfil the requirements of educational standards in advanced musculoskeletal physiotherapy (skills, knowledge and attributes). Planning for telehealth e-mentoring requires multi-stakeholder preparation, relating to setting expectations, creativity in practice and acquisition of technical skills and literacy. Impact: Adoption of telehealth e-mentoring may usefully enhance capacity to support profession specific skill development and service capability to meet planned growth in advanced musculoskeletal physiotherapists. In particularly, evidence based mentorship provision that considers the preparation, planning and setting expectations

Background: As demand exceeds capacity in primary care, internet interventions have the potential to provide rapid and scalable support for behavioral self-management of low back pain.

Purpose: To determine the clinical and cost-effectiveness of an internet intervention with and without physiotherapy support, on low back pain-related disability in UK primary care.

Methods: A three-arm, multicenter, pragmatic, randomized controlled trial, comparing: 1) usual primary care; 2) usual care + internet intervention; 3) usual care + internet intervention with additional telephone support (3 calls from a senior musculoskeletal physiotherapist, up to 30, 15 and 15 minutes each, designed to provide reassurance, address concerns, problem-solve, and encourage engagement with activity goals, using a standardized support manual).
SupportBack 2 is an evidence-based, self-tailored, 6-week internet intervention, designed to help patients self-manage their back pain, set weekly goals, receive feedback, and access different modules including mood, sleep, managing flare-ups, medication, daily living and work. The intervention, developed with 22 patient representatives, was underpinned by social cognitive, self-regulatory and self determination theories.
The primary outcome was LBP-related disability over 12 months using the Roland Morris Disability Questionnaire (RMDQ) measured at 6 weeks, 3, 6 and 12 months. Analysis was by intention-to-treat and used 97.5% confidence intervals (CIs).

Results: 825 patients were randomised (274 to usual care, 275 to usual care + internet intervention, 276 to the physiotherapist-supported arm). Their mean age was 54 years, 58% were female, 58% were in paid employment. Their average reported pain over the last two weeks was 4.8 (0=no pain, 10=maximum pain), and reported baseline disability (RMDQ) was 7 (0=no disability, 24=maximum disability).
Patients in the intervention + telephone support group accessed the website more often. With a follow-up rate of 79% at 12 months, the results showed a small reduction in RMDQ compared to usual care: internet intervention without support (-0.5, 97.5% CI -1.2 to 0.2, p=0.085); and the internet intervention with support (-0.6, 97.5% CI -1.2 to 0.1, p=0.048). These differences were not statistically significant at the 0.025 level. Both interventions however, led to the majority of participants reporting clinically important benefit (30% reduction in RMDQ) at 12 months compared with usual care (61% in both intervention arms versus 51% in usual care alone). Base case results indicated both intervention groups could be considered cost-effective compared to usual care, at £20,000 per QALY. Whilst the additional benefit of adding physiotherapy telephone support was limited, the effects were present sooner (by 3 months), however by 12 months, the effects were larger in the unsupported group. No harms were reported.

Conclusions: The internet intervention SupportBack 2, used with and without telephone support from a physiotherapist, had a small and clinically important impact on LBP-related disability in a heterogenous primary care population. It was safe and is highly scalable. The benefit of additional physiotherapy telephone support although limited, was present sooner.

Implications: High quality interventions that are evidence-based, goal-oriented and co-designed with service-users can be a cost-effective adjunct in primary care, empowering behavioural self-management, without requiring additional support from health professionals.

Background:
Improving access to evidence-based information for people living with musculoskeletal conditions is likely to enhance patients’ ability to discuss treatment options with health providers. Our earlier analysis of common websites relating to shoulder pain showed that these were limited to information about the pathoanatomy, without considering the psychosocial and neurophysiological influences.
Purpose
(1) To co-create a website to improve health literacy and self-management for people with shoulder pain in Aotearoa New Zealand.
(2) To explore the participants’ experiences of the research process.
Methods
We used participatory action research (PAR) with five cycles to design, develop and produce the website. Participants were recruited from the community, organisations and professional email distribution lists. Six physiotherapists and 7 people with shoulder pain participated as PAR members (2 Māori, 2 Pacifika, 5 New Zealand European, 2 Asian, 2 European). During the PAR meetings, break-out groups were formed for people with shoulder pain, physiotherapists and a mixed group for Māori and Pacifika. A process evaluation was held in the form of a final focus group. PAR meetings 2 to 4 and the focus group for process evaluation were recorded, transcribed and thematically analysed. PAR themes were used to plan and construct the website, and to summarise participants’ perspectives. The University’s Office of Māori Development provided Te Reo (sub)headings. We used the Flesch Kincaid Reading Ease Scale to ensure acceptable readability level. The research team worked with a local website provider to design the website and PAR members assessed two iterations of the drafts, accepting the final product. The final website was peer reviewed by two international physiotherapy experts.
Results
Main PAR themes were grouped as (1) Content (Understanding medical terminology for the shoulder girdle; Why do we feel pain?; Whole body health; Common conditions; and Treatment options), (2) Presentation (images reflecting Aotearoa people) and (3) Further Support (links to relevant health professional groups, Frequently Asked Questions). Culturally important concepts were interwoven with research-based evidence to enhance inclusivity.
The process evaluation had three main themes about the participants’ experiences of the research process: (1) Uncertainty to Empowerment (about shoulder pain, self-management, searching online information, final product), (2) Diversity (ethnicity, culture, professional versus consumer) and (3) Logistics (organisational, inclusivity, hybrid delivery within post-pandemic challenges).
Conclusion(s)
PAR was effective to identify content considered important by people with shoulder pain and physiotherapists, guiding construction of the website.
Implications:
Co-constructing patient resources with health providers and people living with musculoskeletal conditions is likely to enhance external validity and accessibility, encourage use and collaborative decision making. The website is being used as a patient support (education) tool in a randomised clinical trial. Continuous feedback and updates for the website will be needed to maintain relevance.

Final website: https://shoulderpain.org.nz/

Background: Exergames are interactive technology-based exercise programs. By combining physical and cognitive training components, they aim to preserve independence in older adults and reduce their risk of falling.
Purpose: This study explored whether primary end users (PEU, healthy older adults and patients with neurological and geriatric diagnoses) and secondary end users (SEU, health professionals) evaluated the ExerG functional model to be usable, providing a positive experience and therefore acceptable.
Methods: We conducted a mixed-methods study using several assessments to quantify usability and enjoyment outcomes, along with semi-structured interviews to gain an in-depth understanding of the users’ experiences. Descriptive statistics were used for quantitative outcome measures. For qualitative data, a thematic analysis (TA) using an inductive, data-driven approach was carried out to develop themes for each user group.
Results: We interviewed 20 PEUs (13 healthy older adults, 7 patients) and 22 SEUs at two rehabilitation centres in Austria and Switzerland. Users' scores of over 70 on the System Usability Scale denoted good usability. On the Physical Activity Enjoyment Scale-16, both PEU groups rated the ExerG highly. Our TA approach identified four themes per user group. Themes from both PEU groups confirmed their enjoyment of training with the ExerG, however more variety and greater challenges were requested. Whilst the patient group appreciated the security given by the harness system, the healthy older adults reported feeling restricted. SEU themes reflected their approval of this novel training device, although a desire for increased difficulty and more individualisation was expressed. Clear instructions and an easy-to-use harness system were acknowledged and useful feedback for the developers emerged.
Conclusions: The ExerG is usable, provides a positive experience and is thus considered an acceptable solution for the combined physical and cognitive training of the elderly. Our findings contribute to the ongoing development of the ExerG, which will be a welcome addition to current training options for the elderly.
Implications: Further research is needed to confirm its effectiveness in preserving or improving functional independence in daily life and reducing the risk of falling.

Abstract:
Background
Digital self-management platforms have been proposed as a solution to better support people manage their musculoskeletal (MSK) condition. However, there is a lack of evidence supporting its effectiveness and trials often explicitly exclude people who can’t access internet connected devices. An important consideration is that digital exclusion (for people without access to an internet connected device) from these new digital options will worsen already existing inequality in healthcare. The importance of this is highlighted by the fact that MSK pain and disability has a disproportionate impact in areas of economic deprivation and on minor ethnic groups

Aim
To evaluate the acceptability and potential causes of digital exclusion of the South West London (SWL) MSK self-management app.

Objectives
1 a) Explore why some patients are not using the app and any barriers they have.
b) Explore why some clinicians are not prescribing the app.
2 Make recommendations, based on these findings, to improve digital inclusion.


Methods

Design
An explanatory sequential mixed methods service evaluation consisting of initial questionnaires to identify suitable collaborators followed by structured interviews of patients and clinicians
Phase 1.
A questionnaire was developed to assess the ‘acceptability’ of the SWL MSK app for patients and clinicians. We used the London Office of Technlogy & Innovation data, map and personas to identify areas with SWL with high levels of potential digital exclusion, and matched people who found getUBetter less acceptable to these areas. Clinician Interviews were targeted by questionnaire returns and prescription rates.
Phase 2 .
Interviews were then carried out to gain a deeper understanding for potential reasons for digital exclusion.

Results
256 people responded to the initial questionnaire. Of these we took 11 patients and 11 clinicians to interview. Following a comprehensive data analysis, 10 sub-themes were grouped into 4 main themes:
1) Beliefs: Importance of understanding the role of digital; Face to face consultation is still valued and needed.
2) Barriers: Lack of digital literacy; Lack of physical examination/contact with a clinician.
3) Enablers: Immediate access to advice/information; Perceived better control over health; Ease of use; No appointment needed
4) Solutions: Support and training; Greater awareness

Conclusion(s)
The project will enable an existing digital technology to be adopted by more patients as the technology design and delivery can be adapted to address the causes of digital exclusion we have identified from the perspective of people using the technology and clinicians prescribing it. Although service providers and digital health technology companies have a duty to address health inequalities and digital inclusion, a broader response is needed at a societal level.

Implications
We were able to propose several areas for development to improve digital inclusion. The recommendations are as follows:
1. Signposting to local support services available to improve general digital skills.
2. Increase awareness of the app in the community such as GP surgeries, pharmacies, library and community centres.
3. More training around the app and its capability as well as a demonstration of the app (for both practice staff and patients).
4. Better communication that the app is a supportive tool and not intended to replace seeking clinical advice when indicated.
5. If possible, clinicians should give a more in-depth discussion about the app before prescribing it.
6. Access to video demonstration of the app in various languages.
7. Better accessibility options with clearer larger fonts.
8. A dedicated helpline for queries was recommended by patients to help with engagement, motivation and reassurance when using the app.

Aim: To evaluate patient experience and identify if there are barriers to using a mobile health (mHealth) exercise application (app) in musculoskeletal (MSK) Physiotherapy

Methods: An online patient experience survey was sent to 10,287 MSK Physiotherapy patients who had appointments between January 17th and April 9th, 2022. The survey was open for 25 days, with a reminder sent after 14 days.

Results: The survey received 1,447 responses (response rate: 14.07%), with 954 (65.93%) respondents previously provided the mHealth exercise app (PhysiApp). Most participants used PhysiApp (83.06%), found PhysiApp easy to use (82.20%) and had positive perceptions on how PhysiApp added value to their Physiotherapy treatment through its functionality (increased motivation, supported exercise adherence, helped achievement of treatment goals and reduced hospital visits). However, qualitative feedback revealed negative impacts on patient-centred care and practical demonstration of exercises. Key barriers to PhysiApp use included suboptimal explanation, digital exclusion, registration/ login issues and opinion that PhysiApp was superfluous to Physiotherapy treatment. These differed to the main barriers of why participants stopped using/ used PhysiApp less; if they were confident exercising without it, their condition improved/ resolved, loss of motivation, their exercise programme ended or if they found their exercise programme was unsuitable.

Conclusion: Despite multiple interdependent factors influencing patient experience and barriers of using PhysiApp, the survey results revealed the significant influence that is exerted by MSK Physiotherapists. The patient-physiotherapist interaction can positively or negatively impact upon many barriers of use and the subsequent potential added value of PhysiApp to MSK Physiotherapy treatment. Future qualitative research on patient experience and barriers to using mHealth exercise apps in MSK Physiotherapy, with a possible focus on those who are at greatest risk of digital exclusion and health inequalities, is recommended.