Limited use of virtual reality in primary care physiotherapy for patients with chronic pain.

BACKGROUND: Chronic pain is a disabling condition which is prevalent in about 20% of the adult population. Physiotherapy is the most common non-pharmacological treatment option for chronic pain, but often demonstrates unsatisfactory outcomes. Virtual Reality (VR) may offer the opportunity to complement physiotherapy treatment. As VR has only recently been introduced in physiotherapy care, it is unknown to what extent VR is used and how it is valued by physiotherapists. The aim of this study was to analyse physiotherapists' current usage of, experiences with and physiotherapist characteristics associated with applying therapeutic VR for chronic pain rehabilitation in Dutch primary care physiotherapy. METHODS: This online survey applied two rounds of recruitment: a random sampling round (873 physiotherapists invited, of which 245 (28%) were included) and a purposive sampling round (20 physiotherapists using VR included). Survey results were reported descriptively and physiotherapist characteristics associated with VR use were examined using multivariable logistic regression analysis. RESULTS: In total, 265 physiotherapists participated in this survey study. Approximately 7% of physiotherapists reported using therapeutic VR for patients with chronic pain. On average, physiotherapists rated their overall experience with therapeutic VR at 7.0 and "whether they would recommend it" at 7.2, both on a 0-10 scale. Most physiotherapists (71%) who use therapeutic VR started using it less than two years ago and use it for a small proportion of their patients with chronic pain. Physiotherapists use therapeutic VR for a variety of conditions, including generalized (55%), neck (45%) and lumbar (37%) chronic pain. Physiotherapists use therapeutic VR mostly to reduce pain (68%), improve coordination (50%) and increase physical mobility (45%). Use of therapeutic VR was associated with a larger physiotherapy practice (OR = 2.38, 95% CI [1.14-4.98]). Unfamiliarity with VR seemed to be the primary reason for not using VR. DISCUSSION: Therapeutic VR for patients with chronic pain is in its infancy in Dutch primary care physiotherapy practice as only a small minority uses VR. Physiotherapists that use therapeutic VR are modestly positive about the technology, with large heterogeneity between treatment goals, methods of administering VR, proposed working mechanisms and chronic pain conditions to treat.

The association of the STarT Back Screening Tool and type of leg pain with low back pain disability trajectories: a prospective cohort study.

BACKGROUND: Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of prognostic factors might contribute to a better understanding of the course of LBP. The purpose of this study is to investigate the association of the STarT Back Screening Tool (SBST) risk score and the type of leg pain (non-radiating LBP, referred non-radicular, and radicular radiating leg pain) with the disability trajectory (at baseline, the slope, and recovery at one year) in adults with low back pain. METHODS: This is a prospective cohort study in 347 patients with low back pain who sought physiotherapy care at three primary care practices in the Netherlands. Linear mixed models were estimated to describe the association of the SBST risk score and the type of leg pain with disability at baseline, the slope in the disability trajectory, and at twelve months follow-up. RESULTS: A medium/high risk score on the SBST is associated with higher baseline disability scores on the Oswestry Disability Index (ODI), faster initial recovery, and still a higher disability ODI score at 12 months follow-up. Non-radicular referred and radicular radiating leg pain were associated with worse baseline disability ODI scores in LBP. This association was not present for the initial recovery or at the 12 months follow-up. CONCLUSION: The SBST is associated with the LBP recovery trajectory. The SBST might be a useful tool to predict the disability trajectory in a heterogeneous group of people with low back pain in primary care and might, therefore, be recommended in future clinical practice guidelines. The type of leg pain was not associated with the recovery trajectory of LBP. Future research might focus on evaluating different types of leg pain. TRIAL REGISTRATION: Clinicaltrials.gov: 109,643.

Facilitators and Barriers to Implementing Interventions to Prevent Musculoskeletal Disorders in Blue-Collar Workers: A Scoping Review.

PURPOSE: Blue-collar workers generally have less healthy lifestyles, poorer health, and a lower life expectancy than white-collar workers. At least in part this may be attributed to their work and working conditions. Employers increasingly provide interventions to improve health and wellbeing and prevent musculoskeletal disorders. However, they often do not reach blue-collar workers. The aim of this scoping review was to identify the facilitators for and barriers to implementing such interventions among blue-collar workers. METHODS: A scoping review in which the study population of the selected studies consists of blue-collar workers (≥ 18 years old) in paid employment. Furthermore, included studies should report facilitators and barriers to implementing interventions to prevent musculoskeletal disorders. The literature search was conducted in six databases. The resulting studies were extracted with the help of the updated Consolidated Framework for Implementation Research. RESULTS: 15 articles were included; these were reviews, intervention studies, qualitative studies and process evaluations. A main facilitator was a participatory approach, which involves the blue-collar worker in the entire process of defining, developing, and implementing a multidimensional preventive intervention. The main barriers on the worker level were unfavorable worker characteristics and unsupportive behavior/attitudes. The main barriers on the organization level were a culture with a high production standard, a hierarchical culture, inflexible work, and an unsupportive attitude from the employer. CONCLUSION: This review showed the multifaceted nature of implementation. A tailored implementation plan that involves the stakeholders (including workers) is important.

Predictors of poor outcome following lumbar spinal fusion surgery: a prospective observational study to derive two clinical prediction rules using British Spine Registry data.

PURPOSE: Lumbar spinal fusion surgery (LSFS) is common for lumbar degenerative disorders. The objective was to develop clinical prediction rules to identify which patients are likely to have a favourable outcome to inform decisions regarding surgery and rehabilitation. METHODS: A prospective observational study recruited 600 (derivation) and 600 (internal validation) consecutive adult patients undergoing LSFS for degenerative lumbar disorder through the British Spine Registry. Definition of good outcome (6 weeks, 12 months) was reduction in pain intensity (Numerical Rating Scale, 0-10) and disability (Oswestry Disability Index, ODI 0-50) > 1.7 and 14.3, respectively. Linear and logistic regression models were fitted and regression coefficients, Odds ratios and 95% CIs reported. RESULTS: Lower BMI, higher ODI and higher leg pain pre-operatively were predictive of good disability outcome, higher back pain was predictive of good back pain outcome, and no previous surgery and higher leg pain were predictive of good leg pain outcome; all at 6 weeks. Working and higher leg pain were predictive of good ODI and leg pain outcomes, higher back pain was predictive of good back pain outcome, and higher leg pain was predictive of good leg pain outcome at 12 months. Model performance demonstrated reasonable to good calibration and adequate/very good discrimination. CONCLUSIONS: BMI, ODI, leg and back pain and previous surgery are important considerations pre-operatively to inform decisions for surgery. Pre-operative leg and back pain and work status are important considerations to inform decisions for management following surgery. Findings may inform clinical decision making regarding LSFS and associated rehabilitation.

Physiotherapy with integrated virtual reality for patients with complex chronic low back pain: protocol for a pragmatic cluster randomized controlled trial (VARIETY study).

BACKGROUND: Chronic low back pain (CLBP) is the most common chronic pain condition worldwide. Currently, primary care physiotherapy is one of the main treatment options, but effects of this treatment are small. Virtual Reality (VR) could be an adjunct to physiotherapy care, due to its multimodal features. The primary aim of this study is to assess the (cost-)effectiveness of physiotherapy with integrated multimodal VR for patients with complex CLBP, compared to usual primary physiotherapy care. METHODS: A multicenter, two-arm, cluster randomized controlled trial (RCT) including 120 patients with CLBP from 20 physiotherapists will be conducted. Patients in the control group will receive 12 weeks of usual primary physiotherapy care for CLBP. Patients in the experimental group will receive treatment consisting of 12 weeks of physiotherapy with integrated, immersive, multimodal, therapeutic VR. The therapeutic VR consists of the following modules: pain education, activation, relaxation and distraction. The primary outcome measure is physical functioning. Secondary outcome measures include pain intensity, pain-related fears, pain self-efficacy and economic measures. Effectiveness of the experimental intervention compared to the control intervention on primary and secondary outcome measures will be analyzed on an intention-to-treat principle, using linear mixed-model analyses. DISCUSSION: This pragmatic, multicenter cluster randomized controlled trial, will determine the clinical and cost-effectiveness of physiotherapy with integrated, personalized, multimodal, immersive VR in favor of usual physiotherapy care for patients with CLBP. TRIAL REGISTRATION: This study is prospectively registered at ClinicalTrials.gov (identifier: NCT05701891).

Development and feasibility of stratified primary care physiotherapy integrated with eHealth in patients with neck and/or shoulder complaints: results of a mixed methods study.

BACKGROUND: Providing individualized care based on the context and preferences of the patient is important. Knowledge on both prognostic risk stratification and blended eHealth care in musculoskeletal conditions is increasing and seems promising. Stratification can be used to match patients to the most optimal content and intensity of treatment as well as mode of treatment delivery (i.e. face-to-face or blended with eHealth). However, research on the integration of stratified and blended eHealth care with corresponding matched treatment options for patients with neck and/or shoulder complaints is lacking. METHODS: This study was a mixed methods study comprising the development of matched treatment options, followed by an evaluation of the feasibility of the developed Stratified Blended Physiotherapy approach. In the first phase, three focus groups with physiotherapists and physiotherapy experts were conducted. The second phase investigated the feasibility (i.e. satisfaction, usability and experiences) of the Stratified Blended Physiotherapy approach for both physiotherapists and patients in a multicenter single-arm convergent parallel mixed methods feasibility study. RESULTS: In the first phase, matched treatment options were developed for six patient subgroups. Recommendations for content and intensity of physiotherapy were matched to the patient's risk of persistent disabling pain (using the Keele STarT MSK Tool: low/medium/high risk). In addition, selection of mode of treatment delivery was matched to the patient's suitability for blended care (using the Dutch Blended Physiotherapy Checklist: yes/no). A paper-based workbook and e-Exercise app modules were developed as two different mode of treatment delivery options, to support physiotherapists. Feasibility was evaluated in the second phase. Physiotherapists and patients were mildly satisfied with the new approach. Usability of the physiotherapist dashboard to set up the e-Exercise app was considered 'OK' by physiotherapists. Patients considered the e-Exercise app to be of 'best imaginable' usability. The paper-based workbook was not used. CONCLUSION: Results of the focus groups led to the development of matched treatment options. Results of the feasibility study showed experiences with integrating stratified and blended eHealth care and have informed amendments to the Stratified Blended Physiotherapy approach for patients with neck and/or shoulder complaints ready to use within a future cluster randomized trial.

The effect of movement representation techniques on ankle function and performance in persons with or without a lateral ankle sprain: a systematic review and meta-analysis.

BACKGROUND: Lateral ankle sprains are highly prevalent and result in tissue damage, impairments of muscle strength, instability, and muscle activation. Up to 74% will experience ongoing symptoms after a lateral ankle sprain. In healthy subjects, motor imagery might induce neural changes in the somatosensory and motor areas of the brain, yielding favourable enhancements in muscular force. However, during motor imagery, difficulties in building a motor image, no somatosensory feedback, and the absence of structural changes at the level of the muscle might explain the differences found between motor imagery and physical practice. In rehabilitation, motor imagery might be supportive in rebuilding motor networks or creating new networks to restore impairments in muscle activation and movement patterns. This systematic review was undertaken to summarize the current body of evidence about the effect on motor imagery, or action observation, on lower leg strength, muscle performance, ankle range of motion, balance, and edema in persons with, and without, a lateral ankle sprain compared to usual care, a placebo intervention, or no intervention. METHODS: A systematic review with meta-analysis of randomized controlled trials was conducted in healthy participants and participants with a lateral ankle sprain. Motor imagery or action observation in isolation, or in combination with usual care were compared to a placebo intervention, or no intervention. An electronic search of MEDLINE, EMBASE, Cinahl, Psychinfo, Sportdiscus, Web of Science, Cochrane and Google Scholar was conducted, and articles published up to 7th June 2023 were included. Two reviewers individually screened titles and abstracts for relevancy using the inclusion criteria. Variables related to muscle strength, muscle function, range of motion, balance, return to sports tests, or questionnaires on self-reported function or activities were extracted. A risk of bias assessment was done using the Cochrane Risk-of-Bias tool II by two reviewers. Meta-analysis using a random effects model was performed when two or more studies reported the same outcome measures. The Standardized Mean Difference (SMD) was calculated over the change from baseline scores. Review manager 5.4 was used to perform analysis of subgroup differences and test for statistically significant differences. Confidence intervals were visually checked for overlap between subgroups. RESULTS: Nine studies, six examining healthy participants and three examining participants with an acute lateral ankle sprain, were included. All studies were rated with moderate to high risk of bias overall. Quality of the motor imagery interventions differed largely between studies. Meta-analysis showed a large and significant effect of motor imagery on lower leg strength (SMD 1.47, 95% CI 0.44 to 2.50); however, the evidence was downgraded to very low certainty due to substantial heterogeneity (I2 = 73%), limitations in the studies (some concerns in risk of bias in all studies), and imprecision (n = < 300). Evidence showed no association with ankle range of motion (SMD 0.25, 95% CI -0.43 to 0.93), edema (SMD -1.11, 95% CI -1.60 to 3.81), the anterior reach direction of the Star Excursion Balance Test (SEBT) (SMD 0.73, 95% CI -0.62 to 2.08), the posterolateral direction (SMD 0.32, 95% CI -0.94 to 1.57), and the posteromedial direction (SMD 0.52, 95% CI -0.07 to 1.10). The certainty of evidence for the different comparisons was very low. CONCLUSIONS: There is a low certainty, significant, positive effect for motor imagery being able to improve lower leg muscle strength in healthy participants. The effect on balance, range of motion and edema was uncertain and of very low certainty. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021243258.

Evidence and consensus-based recommendations for non-pharmacological treatment of fatigue, hand function loss, Raynaud's phenomenon and digital ulcers in patients with systemic sclerosis.

OBJECTIVE: SSc is a complex CTD affecting mental and physical health. Fatigue, hand function loss, and RP are the most prevalent disease-specific symptoms of systemic sclerosis. This study aimed to develop consensus and evidence-based recommendations for non-pharmacological treatment of these symptoms. METHODS: A multidisciplinary task force was installed comprising 20 Dutch experts. After agreeing on the method for formulating the recommendations, clinically relevant questions about patient education and treatments were inventoried. During a face-to-face task force meeting, draft recommendations were generated through a systematically structured discussion, following the nominal group technique. To support the recommendations, an extensive literature search was conducted in MEDLINE and six other databases until September 2020, and 20 key systematic reviews, randomized controlled trials, and published recommendations were selected. Moreover, 13 Dutch medical specialists were consulted on non-pharmacological advice regarding RP and digital ulcers. For each recommendation, the level of evidence and the level of agreement was determined. RESULTS: Forty-one evidence and consensus-based recommendations were developed, and 34, concerning treatments and patient education of fatigue, hand function loss, and RP/digital ulcers-related problems, were approved by the task force. CONCLUSIONS: These 34 recommendations provide guidance on non-pharmacological treatment of three of the most frequently described symptoms in patients with systemic sclerosis. The proposed recommendations can guide referrals to health professionals, inform the content of non-pharmacological interventions, and can be used in the development of national and international postgraduate educational offerings.

Prognostic factors for outcome following lumbar spine fusion surgery: a systematic review and narrative synthesis.

PURPOSE: The objective of this study was to identify and evaluate the value of prognostic factors related to disability, pain and quality of life (QoL) for adult patients undergoing lumbar spine fusion surgery (LSFS). METHODS: Two reviewers independently searched the literature, assessed eligibility, extracted data and assessed risk of bias and certainty of evidence. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e.g. LSFS] to 20/9/2020; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥ 12-month follow-up after LSFS were included. Narrative synthesis was based on recommendations by Cochrane Consumers and Communication Review Group. The GRADE tool enabled assessment of certainty of evidence. Prognostic factors and outcome were analysed and summarised when examined in ≥ 2 studies and when results pointed in the same direction in ≥ 75% of studies. RESULTS: Sixteen studies (n = 8388, 2 low and 14 high risk of bias) were included with 39 prognostic factors identified. There is low certainty evidence that higher pre-operative severity of leg pain predicts greater improvement of leg pain and that pre-operative working predicts less post-operative disability both at 1-2-year follow-up. Other found associations were of very low certainty evidence. CONCLUSION: No moderate to high certainty evidence exists. Use of leg pain and pre-operative working may be valuable predictors of outcome to inform clinical decision-making and advice regarding LSFS surgery. There is need for adequately powered low-risk-of-bias prospective observational studies to further investigate candidate prognostic factors.

Immediate patient perceptions following lumbar spinal fusion surgery: semi-structured multi-centre interviews exploring the patient journey and experiences of lumbar fusion surgery (FuJourn).

PURPOSE: To understand the patient journey to Lumbar Spinal Fusion Surgery (LSFS) and patients' experiences of surgery. METHODS: Qualitative study using interpretive phenomenological analysis. Adult participants following LSFS were recruited from 4 UK clinical sites using purposive sampling to ensure representation of key features (e.g. age). Semi-structured interviews informed by a piloted topic guide developed from the literature were audio-recorded and transcribed verbatim. Framework analysis for individual interviews and then across participants (deductive and inductive) identified emerging themes. Trustworthiness of data analyses was enhanced using multiple strategies (e.g. attention to negative cases). RESULTS: Four emerging themes from n = 31 patients' narratives were identified: decision for surgery, coping strategies, barriers to recovery and recovery after surgery. Decision for surgery and recovery after surgery themes are distinguished by the point of surgery. However, barriers to recovery and coping strategies are key to the whole patient journey encompassing long journeys to surgery and their initial journey after surgery. The themes of coping strategies and barriers to recovery were inter-related and perceived by participants as parallel concepts. The 4 multifactorial themes interacted with each other and shaped the process of an individual patient's recovery. Factors such as sporadic interventions prior to surgery, time-consuming wait for diagnosis and surgery and lack of information regarding recovery strongly influenced perceptions of outcome. CONCLUSION: Patient driven data enables insights to inform research regarding surgery/rehabilitation through depth of understanding of the patient journey. Awareness of factors important to patients is important; ensuring that patient-driven data informs research and patient care.

Opening the black box of non-pharmacological care in systemic sclerosis: a cross-sectional online survey of Dutch health professionals.

The objective is to describe the spectrum of the health professional (HP) treatment approach for systemic sclerosis (SSc) from the perspective of Dutch HPs, including alignment of treatment goals set by HPs with self-reported referral reasons, coverage of patient-reported unmet care needs, and quality of communication between HPs and rheumatologists. Dutch HPs were invited through their patients with SSc to complete an anonymous online survey. The survey covered referral reasons, treatment goals, and interventions of the last patient treated, as well as the perceived quality of communication between HPs and rheumatologists. Referral reasons and treatment targets were linked to the International Classification of Functioning, Disability and Health following the refined ICF Linking Rules. Seventy-nine HPs from 8 professions (including 58 physiotherapists, 73%) completed the survey. One hundred and thirty-three different referral reasons were reported, yielding 58 different ICF codes, with 41 (70.7%) being linked to the ICF domain "body structures and functions." The reported interventions focused on body functions/structures (27.9%), training of daily activities (25.6%), education and advice (26.3%), and psychosocial interventions (20.2%). The quality of communication between HPs and rheumatologists was perceived as low. Our findings revealed numerous treatment options offered by Dutch HPs addressing the unmet care needs of patients with SSc. There is an overlap in the content of the various HP disciplines, and HP treatment goals are not sufficiently aligned with referrals of rheumatologists. HP treatment offer seemed inefficiently organized, possibly precluding rheumatologists from making targeted referrals. Communication between rheumatologists and HPs should be improved.

Stratified care integrated with eHealth versus usual primary care physiotherapy in patients with neck and/or shoulder complaints: protocol for a cluster randomized controlled trial.

BACKGROUND: Neck and shoulder complaints are common in primary care physiotherapy. These patients experience pain and disability, resulting in high societal costs due to, for example, healthcare use and work absence. Content and intensity of physiotherapy care can be matched to a patient's risk of persistent disabling pain. Mode of care delivery can be matched to the patient's suitability for blended care (integrating eHealth with physiotherapy sessions). It is hypothesized that combining these two approaches to stratified care (referred to from this point as Stratified Blended Approach) will improve the effectiveness and cost-effectiveness of physiotherapy for patients with neck and/or shoulder complaints compared to usual physiotherapy. METHODS: This paper presents the protocol of a multicenter, pragmatic, two-arm, parallel-group, cluster randomized controlled trial. A total of 92 physiotherapists will be recruited from Dutch primary care physiotherapy practices. Physiotherapy practices will be randomized to the Stratified Blended Approach arm or usual physiotherapy arm by a computer-generated random sequence table using SPSS (1:1 allocation). Number of physiotherapists (1 or > 1) will be used as a stratification variable. A total of 238 adults consulting with neck and/or shoulder complaints will be recruited to the trial by the physiotherapy practices. In the Stratified Blended Approach arm, physiotherapists will match I) the content and intensity of physiotherapy care to the patient's risk of persistent disabling pain, categorized as low, medium or high (using the Keele STarT MSK Tool) and II) the mode of care delivery to the patient's suitability and willingness to receive blended care. The control arm will receive physiotherapy as usual. Neither physiotherapists nor patients in the control arm will be informed about the Stratified Blended Approach arm. The primary outcome is region-specific pain and disability (combined score of Shoulder Pain and Disability Index & Neck Pain and Disability Scale) over 9 months. Effectiveness will be compared using linear mixed models. An economic evaluation will be performed from the societal and healthcare perspective. DISCUSSION: The trial will be the first to provide evidence on the effectiveness and cost-effectiveness of the Stratified Blended Approach compared with usual physiotherapy in patients with neck and/or shoulder complaints. TRIAL REGISTRATION: Netherlands Trial Register: NL8249 . Officially registered since 27 December 2019. Date of first enrollment: 30 September 2020. Study status: ongoing, data collection.

Therapists' experiences and needs with regard to providing work-focused care: a focus group study.

BACKGROUND: Musculoskeletal disorders (MSDs) can create a temporary or permanent disability that reduce a person's ability to work. Physiotherapists (PTs), occupational therapists (OTs) and exercise therapists (ETs) are often involved in the early management of MSDs. There is a need for additional insights into therapists' experiences, barriers and needs to work-focused care. Moreover, there is no evidence on how OTs and ETs address work participation. Therefore, the aim of this qualitative study was 1) to investigate how generalist PTs, OTs and ETs provide work-focused healthcare and 2) to obtain insight into their perceived barriers and needs that affect their ability to address occupational factors. METHODS: An exploratory qualitative study using three focus groups. Generalist PTs, OTs and ETs were eligible to participate if they treated working patients with MSDs. A semi-structured interview guide with open-ended questions was developed. Two moderators facilitated each focus group using the interview guide, and all the groups were audio recorded. Data were analysed using inductive thematic analysis. RESULTS: Sixteen therapists (mean age 44 years, range 25-59) participated in this study. Participants were aware of the importance of taking occupational factors into account. Whether they address occupational factors is largely dependent on the patient's request for help. However, ETs and OTs consider it normal to ask about occupational factors during the diagnostic process, while PTs often address this in later consultations. Almost all participants were unaware of the existence of PTs, OTs or ETs who are specialised in occupational health. Moreover, almost all participants struggled with when to refer a patient to other (occupational) healthcare professionals. This study identified several needs of therapists. These included knowledge about laws and legislation and skills for identifying and addressing work-related or work-relevant complaints. CONCLUSIONS: Participants in this qualitative study were aware of the importance of taking occupational factors into account. However, how PTs, OTs and ETs address work participation and the extent to which they do so can be improved. There was a lack of knowledge about and cooperation with occupational health professionals, including PTs, OTs or ETs specialised in occupational health.

The decline in physical activity in aging people is not modified by gender or the presence of cardiovascular disease.

BACKGROUND: A physically active lifestyle decreases the progression of atherosclerosis and consequently reduces cardiovascular mortality. However, activity levels are hampered by aging. The association between aging and physical inactivity might be gender-specific or be modified by the presence of cardiovascular disease (CVD). In this study, we investigated if the association between aging and physical inactivity was different between men and women and between primary and secondary prevention patients. METHODS: We performed a cross-sectional analysis of three primary care samples including primary and/or secondary prevention patients (total n = 4726). Baseline data for sample 1 were collected in the years 2013-14, for sample 2 in 2009-10 and for sample 3 in 2009. Activity levels were measured by the patient reported Rapid Assessment of Physical Activity questionnaire. A multilevel regression analysis was used to explore the association between aging and physical inactivity, adjusted for confounders. We examined potential effect modification by gender and the presence of CVD on the association between aging and physical inactivity. RESULTS: Multilevel regression revealed that aging was consistently associated with physical inactivity in three out of three samples. This association was, however, not modified by gender or the presence of CVD. CONCLUSIONS: Cardiovascular risk management interventions should aim at increasing or maintaining physical activity levels in aging primary care population. This study does not support the notion that extra emphasis should be put in targeting men or women, or people with or without the presence of CVD.

The effects of integrating work-related factors and improving cooperation in musculoskeletal physical therapy practice: protocol for the 'WORK TO BE DONE' cluster randomised controlled trial.

BACKGROUND: Musculoskeletal disorders (MSDs) are the primary cause of disability worldwide and a major societal burden. Recent qualitative research found that although a patient's work is considered important, physical therapists take work participation insufficiently into account as a determining factor in the treatment of patients with MSDs. Therefore, the aim of this study is to improve the effectiveness of physical therapy (in primary healthcare) with respect to the work participation of employees with MSDs by increasing the knowledge and skills of generalist physical therapists and by improving the collaboration between generalist physical therapists and physical therapists specialised in occupational health. METHODS/DESIGN: This trial is a two-arm non-blinded cluster randomised controlled trial. Working patients with MSDs visiting a physical therapy practice are the target group. The control group will receive normal physical therapy treatment. The intervention group will receive treatment from a physical therapist with more knowledge about work-related factors and skills in terms of integrating work participation into the patients' care. Data are gathered at baseline (T0), at four months (T1) and eight months (T2) follow-up. Most outcomes will be assessed with validated patient-reported questionnaires. Primary outcomes are the limitations in specific work-related activities and pain during work. Secondary outcomes include limitations in general work-related activities, general pain, quality of life, presenteeism, sick leave (absenteeism), estimated risk for future work disability, work-related psychosocial risk factors, job performance, and work ability. Based on a sample size calculation we need to include 221 patients in each arm (442 in total). During data analysis, each outcome variable will be analysed independently at T1 and at T2 as a dependent variable using the study group as an independent variable. In addition to the quantitative evaluation, a process evaluation will be performed by interviewing physical therapists as well as patients. DISCUSSION: The trial is expected to result in a more effective physical therapy process for working patients with MSDs. This will lead to a substantial reduction of costs: lower costs thanks to a more effective physical therapy process and lower costs due to less or shorter sick leave and decreased presenteeism. TRIAL REGISTRATION: Netherlands Trial Register, registration number: NL8518, date of registration 9 April 2020, URL registration: https://www.trialregister.nl/trial/8518.

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II).

OBJECTIVES: To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction. DESIGN: Systematic review of CPGs (PROSPERO number: CRD42017020407). DATA SOURCES: Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018. ELIGIBILITY CRITERIA: English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction. RESULTS: Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was 'applicability' (can clinicians implement this in practice?) (29%) and the highest 'scope and purpose' (78%) and 'clarity of presentation' (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing. CONCLUSION: The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials.

BACKGROUND: Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise. METHODS: In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers. RESULTS: We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics. CONCLUSIONS: This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

Symptoms of depression are associated with physical inactivity but not modified by gender or the presence of a cardiovascular disease; a cross-sectional study.

BACKGROUND: Depressive symptomatology may act as a barrier to enhance physical activity. This phenomenon is predominantly found in patients with an established cardiovascular disease (CVD) and in female patients. This cross-sectional study investigated (1) the association between symptoms of depression and physical inactivity, and (2) whether this association is different between primary and secondary prevention patients, and between men and women. METHODS: The study design concerns a secondary analysis of baseline data from a randomized clinical trial, including primary and secondary prevention patients (n = 2184; mean age 71.6 ± 8.94), from 34 general practitioner panels. The Rapid Assessment of Physical Activity questionnaire (RAPA) was used to measure patient reported activity levels. Symptoms of depression were determined using the Patient Health Questionnaire (PHQ-9). Multilevel linear regression analysis was used to explore the association between symptoms of depression and physical activity while adjusting for confounders. Gender and whether or not having a CVD were considered as potential effect modifiers for the association between symptoms of depression and inactivity. RESULTS: Symptoms of depression were associated with lower levels of physical activity. This association was neither different for men and women nor for primary and secondary prevention patients. CONCLUSION: In primary care patients' symptoms of depression were associated with physical inactivity. This association was not modified by gender or the presence of a CVD. Future research should focus on lifestyle interventions aiming at the increase of physical activity levels, while emphasizing on improving symptoms of depression in men, women, and patients both with and without a history of CVD.

Effectiveness of Supervised Home-Based Exercise Therapy Compared to a Control Intervention on Functions, Activities, and Participation in Older Patients After Hip Fracture: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this review was to investigate whether supervised home-based exercise therapy after hospitalization is more effective on improving functions, activities, and participation in older patients after hip fracture than a control intervention (including usual care). Furthermore, we aimed to account the body of evidence for therapeutic validity. DATA SOURCES: Systematic searches of Medline, Embase, and CINAHL databases up to June 30, 2016. STUDY SELECTION: Randomized controlled trials studying supervised home-based exercise therapy after hospitalization in older patients (≥65y) after hip fracture. DATA EXTRACTION: Two reviewers assessed methodological quality (Physiotherapy Evidence Database) and therapeutic validity (Consensus on Therapeutic Exercise Training). Data were primary analyzed using a best evidence synthesis on methodological quality and meta-analyses. DATA SYNTHESIS: A total of 9 articles were included (6 trials; 602 patients). Methodological quality was high in 4 of 6 studies. One study had high therapeutic validity. We found limited evidence in favor of home-based exercise therapy for short- (≤4mo) and long-term (>4mo) performance-based activities of daily living (ADL) and effects at long-term for gait (fast) and endurance. Evidence of no effectiveness was found for short- and long-term effects on gait and self-reported (instrumental) ADL and short-term effects on balance, endurance, and mobility. Conflicting evidence was found for strength, long-term balance, short-term gait (comfortable), long-term self-reported ADL, and long-term mobility. CONCLUSIONS: Research findings show no evidence in favor of home-based exercise therapy after hip fracture for most outcomes of functions, activities, and participation. However, trials in this field have low therapeutic validity (absence of rationale for content and intensity and reporting of adherence), which results in interventions that do not fit patients' limitations and goals.

Pain and disability after first-time spinal fusion for lumbar degenerative disorders: a systematic review and meta-analysis.

PURPOSE: Lumbar spinal fusion (LSF) is frequently and increasingly used in lumbar degenerative disorders despite conflicting results and recommendations. A thorough understanding of patient outcomes after LSF is required to inform decisions regarding surgery and to improve post-surgery management. The current study aims to evaluate the course of pain and disability in patients with degenerative disorders of the lumbar spine after first-time LSF. METHODS: A systematic review and meta-analysis of pain and disability outcomes in prospective cohort studies up to 31 March 2017 is identified in four electronic databases. Two independent researchers determined study eligibility, extracted data, and assessed risk of bias (modified Quality in Prognostics tool). A random effects model (maximum likelihood) was used to calculate means and 95% confidence intervals. The primary analysis was performed on complete data, and a sensitivity analysis was performed on all data. RESULTS: Twenty-five studies (n = 1777 participants) were included. The mean (95% confidence interval) Visual Analogue Scale (VAS) back pain (n = 9 studies) decreased from 64 (57-71) pre-surgery to 20 (16-24) at 24-month follow-up. Leg pain (n = 9 studies) improved from VAS 70 (65-74) pre-surgery to 17 (12-23) at 24-month interval. Disability (n = 12 studies), measured with the Oswestry Disability Index, decreased from 44.8 (40.1-49.4) pre-surgery to 17.3 (11.9-22.8) at 24-month follow-up. The sensitivity analysis yielded similar results. CONCLUSION: There is a substantial improvement in pain and disability after first-time LSF for degenerative disorders. However, long-term outcomes indicate that leg pain might be more reduced and for a longer period of time than axial back pain and disability. Registration PROSPERO CRD42015026922. These slides can be retrieved under Electronic Supplementary Material.