Competing for Pixels: A Self-play Algorithm for Weakly-supervised Semantic Segmentation.

Weakly-supervised semantic segmentation (WSSS) methods, reliant on image-level labels indicating object presence, lack explicit correspondence between labels and regions of interest (ROIs), posing a significant challenge. Despite this, WSSS methods have attracted attention due to their much lower annotation costs compared to fully-supervised segmentation. Leveraging reinforcement learning (RL) self-play, we propose a novel WSSS method that gamifies image segmentation of a ROI. We formulate segmentation as a competition between two agents that compete to select ROI-containing patches until exhaustion of all such patches. The score at each time-step, used to compute the reward for agent training, represents likelihood of object presence within the selection, determined by an object presence detector pre-trained using only image-level binary classification labels of object presence. Additionally, we propose a game termination condition that can be called by either side upon exhaustion of all ROI-containing patches, followed by the selection of a final patch from each. Upon termination, the agent is incentivised if ROI-containing patches are exhausted or disincentivised if a ROI-containing patch is found by the competitor. This competitive setup ensures minimisation of over- or under-segmentation, a common problem with WSSS methods. Extensive experimentation across four datasets demonstrates significant performance improvements over recent state-of-the-art methods. Code: https://github.com/s-sd/spurl/tree/main/wss.

Running is acceptable and efficacious in adults with non-specific chronic low back pain: the ASTEROID randomised controlled trial.

OBJECTIVES: Running is one of the most accessible forms of exercise, yet its suitability for adults with chronic low back pain (LBP) is unknown. This study assessed the efficacy and acceptability of running in adults with chronic LBP. METHODS: This two-arm parallel (1:1) individually randomised controlled trial allocated 40 participants (mean (SD) age: 33 (6) years, female: 50%) with non-specific chronic LBP to a 12-week intervention or waitlist control. The intervention was a progressive run-walk interval programme comprising three 30-min sessions per week that were digitally delivered and remotely supported by an exercise physiologist. Efficacy outcomes were self-reported pain intensity (100-point visual analogue scale) and disability (Oswestry Disability Index). Acceptability outcomes were attrition, adherence and adverse events. RESULTS: At 12-week follow-up, the intervention improved average pain intensity (mean net difference (95% CI): -15.30 (-25.33, -5.27) points, p=0.003), current pain intensity (-19.35 (-32.01, -6.69) points, p=0.003) and disability (-5.20 (-10.12, -0.24) points, P=0.038), compared with control. There was no attrition, and mean (SD) training adherence was 70% (20%; ie, 2.1 of 3 sessions per week). Nine non-serious adverse events deemed likely study-related were reported (lower limb injury/pain: n=7, syncope associated with an underlying condition: n=1, LBP: n=1). CONCLUSIONS: A run-walk programme was considered an acceptable intervention by the participants to improve the pain intensity and disability in individuals aged 18-45 years with non-specific chronic LBP when compared with the control. An individualised and conservative run-walk programme should be considered a suitable form of physical activity for adults with chronic LBP. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry: ACTRN12622001276741. Registered on 29 September 2022.

Comparing adaptations from blood flow restriction exercise training using regulated or unregulated pressure systems: A systematic review and meta-analysis.

OBJECTIVE: No study has examined outcomes derived from blood flow restriction exercise training interventions using regulated compared with unregulated blood flow restriction pressure systems. Therefore, we used a systematic review and meta-analyses to compare the chronic adaptations to blood flow restriction exercise training achieved with regulated and unregulated blood flow restriction pressure systems. DATA SOURCES: The electronic database search included using the tool EBSCOhost and other online database search engines. The search included Medline, SPORTDiscus, CINAHL, Embase and SpringerLink. METHODS: Included studies utilised chronic blood flow restriction exercise training interventions greater than two weeks duration, where blood flow restriction was applied using a regulated or unregulated blood flow restriction pressure system, and where outcome measures such as muscle strength, muscle size or physical function were measured both pre- and post-training. Studies included in the meta-analyses used an equivalent non-blood flow restriction exercise comparison group. RESULTS: Eighty-one studies were included in the systematic review. Data showed that regulated (n = 47) and unregulated (n = 34) blood flow restriction pressure systems yield similar training adaptations for all outcome measures post-intervention. For muscle strength and muscle size, this was reaffirmed in the included meta-analyses. CONCLUSION: This review indicates that practitioners may achieve comparable training adaptations with blood flow restriction exercise training using either regulated or unregulated blood flow restriction pressure systems. Therefore, additional factors such as device quality, participant comfort and safety, cost and convenience are important factors to consider when deciding on appropriate equipment to use when prescribing blood flow restriction exercise training.

Using A Disentangled Neural Network to Objectively Assess the Outcomes of Midfacial Surgery in Syndromic Craniosynostosis.

BACKGROUND: Advancements in artificial intelligence and the development of shape models that quantify normal head shape and facial morphology provide frameworks by which the outcomes of craniofacial surgery can be compared. In this work, we will demonstrate the use of the Swap Disentangled Variational Autoencoder (SD-VAE) to objectively assess changes following midfacial surgery. MATERIALS AND METHODS: Our model is trained on a dataset of 1405 3D meshes of healthy and syndromic patients which was augmented using a technique based on spectral interpolation. Patients with a diagnosis of Apert and Crouzon syndrome who had undergone sub- or trans-cranial midfacial procedures utilising rigid external distraction were then interpreted using this model as the point of comparison. RESULTS: A total of 56 patients met our inclusion criteria, 20 with Apert and 36 with Crouzon syndrome. By using linear discriminant analysis to project the high-dimensional vectors derived by SD-VAE onto a 2D space, the shape properties of Apert and Crouzon syndrome can be visualised in relation to the healthy population. In this way, we are able to show how surgery elicits global shape changes in each patient. To assess the regional movements achieved during surgery, we use a novel metric derived from the Malahanobis distance to quantify movements through the latent space. CONCLUSION: Objective outcome evaluation, which encourages in-depth analysis and enhances decision making, is essential for the progression of surgical practice. We have demonstrated how artificial intelligence has the ability to improve our understanding of surgery and its effect on craniofacial morphology.

Latent disentanglement in mesh variational autoencoders improves the diagnosis of craniofacial syndromes and aids surgical planning.

BACKGROUND AND OBJECTIVE: The use of deep learning to undertake shape analysis of the complexities of the human head holds great promise. However, there have traditionally been a number of barriers to accurate modelling, especially when operating on both a global and local level. METHODS: In this work, we will discuss the application of the Swap Disentangled Variational Autoencoder (SD-VAE) with relevance to Crouzon, Apert and Muenke syndromes. The model is trained on a dataset of 3D meshes of healthy and syndromic patients which was increased in size with a novel data augmentation technique based on spectral interpolation. Thanks to its semantically meaningful and disentangled latent representation, SD-VAE is used to analyse and generate head shapes while considering the influence of different anatomical sub-units. RESULTS: Although syndrome classification is performed on the entire mesh, it is also possible, for the first time, to analyse the influence of each region of the head on the syndromic phenotype. By manipulating specific parameters of the generative model, and producing procedure-specific new shapes, it is also possible to approximate the outcome of a range of craniofacial surgical procedures. CONCLUSION: This work opens new avenues to advance diagnosis, aids surgical planning and allows for the objective evaluation of surgical outcomes. Our code is available at github.com/simofoti/CraniofacialSD-VAE.

Surgical-DeSAM: decoupling SAM for instrument segmentation in robotic surgery.

PURPOSE: The recent segment anything model (SAM) has demonstrated impressive performance with point, text or bounding box prompts, in various applications. However, in safety-critical surgical tasks, prompting is not possible due to (1) the lack of per-frame prompts for supervised learning, (2) it is unrealistic to prompt frame-by-frame in a real-time tracking application, and (3) it is expensive to annotate prompts for offline applications. METHODS: We develop Surgical-DeSAM to generate automatic bounding box prompts for decoupling SAM to obtain instrument segmentation in real-time robotic surgery. We utilise a commonly used detection architecture, DETR, and fine-tuned it to obtain bounding box prompt for the instruments. We then empolyed decoupling SAM (DeSAM) by replacing the image encoder with DETR encoder and fine-tune prompt encoder and mask decoder to obtain instance segmentation for the surgical instruments. To improve detection performance, we adopted the Swin-transformer to better feature representation. RESULTS: The proposed method has been validated on two publicly available datasets from the MICCAI surgical instruments segmentation challenge EndoVis 2017 and 2018. The performance of our method is also compared with SOTA instrument segmentation methods and demonstrated significant improvements with dice metrics of 89.62 and 90.70 for the EndoVis 2017 and 2018 CONCLUSION: Our extensive experiments and validations demonstrate that Surgical-DeSAM enables real-time instrument segmentation without any additional prompting and outperforms other SOTA segmentation methods.

Active learning using adaptable task-based prioritisation.

Supervised machine learning-based medical image computing applications necessitate expert label curation, while unlabelled image data might be relatively abundant. Active learning methods aim to prioritise a subset of available image data for expert annotation, for label-efficient model training. We develop a controller neural network that measures priority of images in a sequence of batches, as in batch-mode active learning, for multi-class segmentation tasks. The controller is optimised by rewarding positive task-specific performance gain, within a Markov decision process (MDP) environment that also optimises the task predictor. In this work, the task predictor is a segmentation network. A meta-reinforcement learning algorithm is proposed with multiple MDPs, such that the pre-trained controller can be adapted to a new MDP that contains data from different institutes and/or requires segmentation of different organs or structures within the abdomen. We present experimental results using multiple CT datasets from more than one thousand patients, with segmentation tasks of nine different abdominal organs, to demonstrate the efficacy of the learnt prioritisation controller function and its cross-institute and cross-organ adaptability. We show that the proposed adaptable prioritisation metric yields converging segmentation accuracy for a new kidney segmentation task, unseen in training, using between approximately 40% to 60% of labels otherwise required with other heuristic or random prioritisation metrics. For clinical datasets of limited size, the proposed adaptable prioritisation offers a performance improvement of 22.6% and 10.2% in Dice score, for tasks of kidney and liver vessel segmentation, respectively, compared to random prioritisation and alternative active sampling strategies.

The distinct roles of reinforcement learning between pre-procedure and intra-procedure planning for prostate biopsy.

PURPOSE: Magnetic resonance (MR) imaging targeted prostate cancer (PCa) biopsy enables precise sampling of MR-detected lesions, establishing its importance in recommended clinical practice. Planning for the ultrasound-guided procedure involves pre-selecting needle sampling positions. However, performing this procedure is subject to a number of factors, including MR-to-ultrasound registration, intra-procedure patient movement and soft tissue motions. When a fixed pre-procedure planning is carried out without intra-procedure adaptation, these factors will lead to sampling errors which could cause false positives and false negatives. Reinforcement learning (RL) has been proposed for procedure plannings on similar applications such as this one, because intelligent agents can be trained for both pre-procedure and intra-procedure planning. However, it is not clear if RL is beneficial when it comes to addressing these intra-procedure errors. METHODS: In this work, we develop and compare imitation learning (IL), supervised by demonstrations of predefined sampling strategy, and RL approaches, under varying degrees of intra-procedure motion and registration error, to represent sources of targeting errors likely to occur in an intra-operative procedure. RESULTS: Based on results using imaging data from 567 PCa patients, we demonstrate the efficacy and value in adopting RL algorithms to provide intelligent intra-procedure action suggestions, compared to IL-based planning supervised by commonly adopted policies. CONCLUSIONS: The improvement in biopsy sampling performance for intra-procedure planning has not been observed in experiments with only pre-procedure planning. These findings suggest a strong role for RL in future prospective studies which adopt intra-procedure planning. Our open source code implementation is available here .

PitSurgRT: real-time localization of critical anatomical structures in endoscopic pituitary surgery.

PURPOSE: Endoscopic pituitary surgery entails navigating through the nasal cavity and sphenoid sinus to access the sella using an endoscope. This procedure is intricate due to the proximity of crucial anatomical structures (e.g. carotid arteries and optic nerves) to pituitary tumours, and any unintended damage can lead to severe complications including blindness and death. Intraoperative guidance during this surgery could support improved localization of the critical structures leading to reducing the risk of complications. METHODS: A deep learning network PitSurgRT is proposed for real-time localization of critical structures in endoscopic pituitary surgery. The network uses high-resolution net (HRNet) as a backbone with a multi-head for jointly localizing critical anatomical structures while segmenting larger structures simultaneously. Moreover, the trained model is optimized and accelerated by using TensorRT. Finally, the model predictions are shown to neurosurgeons, to test their guidance capabilities. RESULTS: Compared with the state-of-the-art method, our model significantly reduces the mean error in landmark detection of the critical structures from 138.76 to 54.40 pixels in a 1280 × 720-pixel image. Furthermore, the semantic segmentation of the most critical structure, sella, is improved by 4.39% IoU. The inference speed of the accelerated model achieves 298 frames per second with floating-point-16 precision. In the study of 15 neurosurgeons, 88.67% of predictions are considered accurate enough for real-time guidance. CONCLUSION: The results from the quantitative evaluation, real-time acceleration, and neurosurgeon study demonstrate the proposed method is highly promising in providing real-time intraoperative guidance of the critical anatomical structures in endoscopic pituitary surgery.

3D Generative Model Latent Disentanglement via Local Eigenprojection.

Designing realistic digital humans is extremely complex. Most data-driven generative models used to simplify the creation of their underlying geometric shape do not offer control over the generation of local shape attributes. In this paper, we overcome this limitation by introducing a novel loss function grounded in spectral geometry and applicable to different neural-network-based generative models of 3D head and body meshes. Encouraging the latent variables of mesh variational autoencoders (VAEs) or generative adversarial networks (GANs) to follow the local eigenprojections of identity attributes, we improve latent disentanglement and properly decouple the attribute creation. Experimental results show that our local eigenprojection disentangled (LED) models not only offer improved disentanglement with respect to the state-of-the-art, but also maintain good generation capabilities with training times comparable to the vanilla implementations of the models. Our code and pre-trained models are available at github.com/simofoti/LocalEigenprojDisentangled.

Long-term Dependency for 3D Reconstruction of Freehand Ultrasound Without External Tracker.

OBJECTIVE: Reconstructing freehand ultrasound in 3D without any external tracker has been a long-standing challenge in ultrasound-assisted procedures. We aim to define new ways of parameterising long-term dependencies, and evaluate the performance. METHODS: First, long-term dependency is encoded by transformation positions within a frame sequence. This is achieved by combining a sequence model with a multi-transformation prediction. Second, two dependency factors are proposed, anatomical image content and scanning protocol, for contributing towards accurate reconstruction. Each factor is quantified experimentally by reducing respective training variances. RESULTS: 1) The added long-term dependency up to 400 frames at 20 frames per second (fps) indeed improved reconstruction, with an up to 82.4% lowered accumulated error, compared with the baseline performance. The improvement was found to be dependent on sequence length, transformation interval and scanning protocol and, unexpectedly, not on the use of recurrent networks with long-short term modules; 2) Decreasing either anatomical or protocol variance in training led to poorer reconstruction accuracy. Interestingly, greater performance was gained from representative protocol patterns, than from representative anatomical features. CONCLUSION: The proposed algorithm uses hyperparameter tuning to effectively utilise long-term dependency. The proposed dependency factors are of practical significance in collecting diverse training data, regulating scanning protocols and developing efficient networks. SIGNIFICANCE: The proposed new methodology with publicly available volunteer data and code for parametersing the long-term dependency, experimentally shown to be valid sources of performance improvement, which could potentially lead to better model development and practical optimisation of the reconstruction application.

Image-guidance in endoscopic pituitary surgery: an in-silico study of errors involved in tracker-based techniques.

Background: Endoscopic endonasal surgery is an established minimally invasive technique for resecting pituitary adenomas. However, understanding orientation and identifying critical neurovascular structures in this anatomically dense region can be challenging. In clinical practice, commercial navigation systems use a tracked pointer for guidance. Augmented Reality (AR) is an emerging technology used for surgical guidance. It can be tracker based or vision based, but neither is widely used in pituitary surgery. Methods: This pre-clinical study aims to assess the accuracy of tracker-based navigation systems, including those that allow for AR. Two setups were used to conduct simulations: (1) the standard pointer setup, tracked by an infrared camera; and (2) the endoscope setup that allows for AR, using reflective markers on the end of the endoscope, tracked by infrared cameras. The error sources were estimated by calculating the Euclidean distance between a point's true location and the point's location after passing it through the noisy system. A phantom study was then conducted to verify the in-silico simulation results and show a working example of image-based navigation errors in current methodologies. Results: The errors of the tracked pointer and tracked endoscope simulations were 1.7 and 2.5 mm respectively. The phantom study showed errors of 2.14 and 3.21 mm for the tracked pointer and tracked endoscope setups respectively. Discussion: In pituitary surgery, precise neighboring structure identification is crucial for success. However, our simulations reveal that the errors of tracked approaches were too large to meet the fine error margins required for pituitary surgery. In order to achieve the required accuracy, we would need much more accurate tracking, better calibration and improved registration techniques.

The value of Augmented Reality in surgery - A usability study on laparoscopic liver surgery.

Augmented Reality (AR) is considered to be a promising technology for the guidance of laparoscopic liver surgery. By overlaying pre-operative 3D information of the liver and internal blood vessels on the laparoscopic view, surgeons can better understand the location of critical structures. In an effort to enable AR, several authors have focused on the development of methods to obtain an accurate alignment between the laparoscopic video image and the pre-operative 3D data of the liver, without assessing the benefit that the resulting overlay can provide during surgery. In this paper, we present a study that aims to assess quantitatively and qualitatively the value of an AR overlay in laparoscopic surgery during a simulated surgical task on a phantom setup. We design a study where participants are asked to physically localise pre-operative tumours in a liver phantom using three image guidance conditions - a baseline condition without any image guidance, a condition where the 3D surfaces of the liver are aligned to the video and displayed on a black background, and a condition where video see-through AR is displayed on the laparoscopic video. Using data collected from a cohort of 24 participants which include 12 surgeons, we observe that compared to the baseline, AR decreases the median localisation error of surgeons on non-peripheral targets from 25.8 mm to 9.2 mm. Using subjective feedback, we also identify that AR introduces usability improvements in the surgical task and increases the perceived confidence of the users. Between the two tested displays, the majority of participants preferred to use the AR overlay instead of navigated view of the 3D surfaces on a separate screen. We conclude that AR has the potential to improve performance and decision making in laparoscopic surgery, and that improvements in overlay alignment accuracy and depth perception should be pursued in the future.

Prototypical few-shot segmentation for cross-institution male pelvic structures with spatial registration.

The prowess that makes few-shot learning desirable in medical image analysis is the efficient use of the support image data, which are labelled to classify or segment new classes, a task that otherwise requires substantially more training images and expert annotations. This work describes a fully 3D prototypical few-shot segmentation algorithm, such that the trained networks can be effectively adapted to clinically interesting structures that are absent in training, using only a few labelled images from a different institute. First, to compensate for the widely recognised spatial variability between institutions in episodic adaptation of novel classes, a novel spatial registration mechanism is integrated into prototypical learning, consisting of a segmentation head and an spatial alignment module. Second, to assist the training with observed imperfect alignment, support mask conditioning module is proposed to further utilise the annotation available from the support images. Extensive experiments are presented in an application of segmenting eight anatomical structures important for interventional planning, using a data set of 589 pelvic T2-weighted MR images, acquired at seven institutes. The results demonstrate the efficacy in each of the 3D formulation, the spatial registration, and the support mask conditioning, all of which made positive contributions independently or collectively. Compared with the previously proposed 2D alternatives, the few-shot segmentation performance was improved with statistical significance, regardless whether the support data come from the same or different institutes.

Enhanced Surgeons: Understanding the Design of Augmented Reality Instructions for Keyhole Surgery.

It is important to understand how to design AR content for surgical contexts to mitigate the risk of distracting the surgeons. In this work, we test information overlays for AR guidance during keyhole surgery. We performed a preliminary evaluation of a prototype, focusing on the effects of colour, opacity, and information representation. Our work contributes insights into the design of AR guidance in surgery settings and a foundation for future research on visualisation design for surgical AR.

The Effect of Luminance on Depth Perception in Augmented Reality Guided Laparoscopic Surgery.

Depth perception is a major issue in surgical augmented reality (AR) with limited research conducted in this scientific area. This study establishes a relationship between luminance and depth perception. This can be used to improve visualisation design for AR overlay in laparoscopic surgery, providing surgeons a more accurate perception of the anatomy intraoperatively. Two experiments were conducted to determine this relationship. First, an online study with 59 participants from the general public, and second, an in-person study with 10 surgeons as participants. We developed 2 open-source software tools utilising SciKit-Surgery libraries to enable these studies and any future research. Our findings demonstrate that the higher the relative luminance, the closer a structure is perceived to the operating camera. Furthermore, the higher the luminance contrast between the two structures, the higher the depth distance perceived. The quantitative results from both experiments are in agreement, indicating that online recruitment of the general public can be helpful in similar studies. An observation made by the surgeons from the in-person study was that the light source used in laparoscopic surgery plays a role in depth perception. This is due to its varying positioning and brightness which could affect the perception of the overlaid AR. We found that luminance directly correlates with depth perception for both surgeons and the general public, regardless of other depth cues. Future research may focus on comparing different colours used in surgical AR and using a mock operating room (OR) with varying light sources and positions.

Evaluation of a calibration rig for stereo laparoscopes.

BACKGROUND: Accurate camera and hand-eye calibration are essential to ensure high-quality results in image-guided surgery applications. The process must also be able to be undertaken by a nonexpert user in a surgical setting. PURPOSE: This work seeks to identify a suitable method for tracked stereo laparoscope calibration within theater. METHODS: A custom calibration rig, to enable rapid calibration in a surgical setting, was designed. The rig was compared against freehand calibration. Stereo reprojection, stereo reconstruction, tracked stereo reprojection, and tracked stereo reconstruction error metrics were used to evaluate calibration quality. RESULTS: Use of the calibration rig reduced mean errors: reprojection (1.47 mm [SD 0.13] vs. 3.14 mm [SD 2.11], p-value 1e-8), reconstruction (1.37 px [SD 0.10] vs. 10.10 px [SD 4.54], p-value 6e-7), and tracked reconstruction (1.38 mm [SD 0.10] vs. 12.64 mm [SD 4.34], p-value 1e-6) compared with freehand calibration. The use of a ChArUco pattern yielded slightly lower reprojection errors, while a dot grid produced lower reconstruction errors and was more robust under strong global illumination. CONCLUSION: The use of the calibration rig results in a statistically significant decrease in calibration error metrics, versus freehand calibration, and represents the preferred approach for use in the operating theater.

Assessing safety and treatment efficacy of running on intervertebral discs (ASTEROID) in adults with chronic low back pain: protocol for a randomised controlled trial.

Poor intervertebral disc (IVD) health is associated with low back pain (LBP). This 12-week parallel randomised controlled trial will evaluate the efficacy of a progressive interval running programme on IVD health and other clinical outcomes in adults with chronic LBP. Participants will be randomised to either a digitally delivered progressive interval running programme or waitlist control. Participants randomised to the running programme will receive three individually tailored 30 min community-based sessions per week over 12 weeks. The waitlist control will undergo no formal intervention. All participants will be assessed at baseline, 6 and 12 weeks. Primary outcomes are IVD health (lumbar IVD T2 via MRI), average LBP intensity over the prior week (100-point visual analogue scale) and disability (Oswestry Disability Index). Secondary outcomes include a range of clinical measures. All outcomes will be analysed using linear mixed models. This study has received ethical approval from the Deakin University Human Research Ethics Committee (ID: 2022-162). All participants will provide informed written consent before participation. Regardless of the results, the findings of this study will be disseminated, and anonymised data will be shared via an online repository. This will be the first study to evaluate whether a progressive interval running programme can improve IVD health in adults with chronic LBP. Identifying conservative options to improve IVD health in this susceptible population group has the potential to markedly reduce the burden of disease. This study was registered via the Australian New Zealand Clinical Trials Registry on 29 September 2022 (ACTRN12622001276741).

The Effectiveness of Exercise Physiology Services During the COVID-19 Pandemic: A Pragmatic Cohort Study.

BACKGROUND: The COVID-19 pandemic markedly changed how healthcare services are delivered and telehealth delivery has increased worldwide. Whether changes in healthcare delivery borne from the COVID-19 pandemic impact effectiveness is unknown. Therefore, we examined the effectiveness of exercise physiology services provided during the COVID-19 pandemic. METHODS: This prospective cohort study included 138 clients who received exercise physiology services during the initial COVID-19 pandemic. Outcome measures of interest were EQ-5D-5L, EQ-VAS, patient-specific functional scale, numeric pain rating scale and goal attainment scaling. RESULTS: Most (59%, n = 82) clients received in-person delivery only, whereas 8% (n = 11) received telehealth delivery only and 33% (n = 45) received a combination of delivery modes. Mean (SD) treatment duration was 11 (7) weeks and included 12 (6) sessions lasting 48 (9) minutes. The majority (73%, n = 101) of clients completed > 80% of exercise sessions. Exercise physiology improved mobility by 14% (ß = 0.23, P = 0.003), capacity to complete usual activities by 18% (ß = 0.29, P < 0.001), capacity to complete important activities that the client was unable to do or having difficulty performing by 54% (ß = 2.46, P < 0.001), current pain intensity by 16% (ß = - 0.55, P = 0.038) and goal attainment scaling t-scores by 50% (ß = 18.37, P < 0.001). Effectiveness did not differ between delivery modes (all: P > 0.087). CONCLUSIONS: Exercise physiology services provided during the COVID-19 pandemic improved a range of client-reported outcomes regardless of delivery mode. Further exploration of cost-effectiveness is warranted.