Exploring the association between adherence to home-based exercise recommendations and recovery of nonspecific low back pain: a prospective cohort study.

BACKGROUND: Adherence to home-based exercise (HBE) recommendations is critical in physiotherapy for patients with low back pain (LBP). However, limited research has explored its connection with clinical outcomes. This study examined how adherence to HBE relates to changes in physical function, pain intensity, and recovery from LBP in patients undergoing physiotherapy treatment. METHODS: Data from a multicenter cluster randomized controlled trial in the Netherlands involving patients with LBP from 58 primary care physiotherapy practices were used. Adherence to HBE was assessed with the Exercise Adherence Scale (EXAS) at each treatment session. Previously identified adherence trajectories served as a longitudinal measure of adherence and included the classes "declining adherence" (12% of participants), "stable adherence" (45%), and "increasing adherence" (43%). The main outcomes included disability (Oswestry Disability Index), pain (Numeric Pain Rating Scale), and recovery (pain-free for > 4 weeks), which were measured at baseline and after three months. Linear and binomial logistic regression analyses adjusted for confounders were used to examine adherence-outcome relationships. RESULTS: In the parent trial, 208 participants were included. EXAS scores were available for 173 participants, collected over a median of 4.0 treatment sessions (IQR 3.0 to 6.0). Forty-five (28.5%) patients considered themselves to have recovered after three months. The median changes in the Oswestry Disability Index and Numeric Pain Rating Scale were - 8 (IQR - 1 to -20) and - 2 (IQR - 0.5 to -4), respectively. The mean EXAS scores varied among patient classes: "declining adherence" (46.0, SD 19.4), "stable adherence" (81.0, SD 12.4), and "increasing adherence" (39.9, SD 25.3), with an overall mean of 59.2 (SD 25.3). No associations between adherence and changes in physical functioning or pain were found in the regression analyses. CONCLUSIONS: No association between adherence to HBE recommendations and changes in clinical outcomes in patients with LBP was found. These findings suggest that the relationship between adherence to HBE recommendations and treatment outcomes may be more complex than initially assumed. Further research using detailed longitudinal data combined with qualitative methods to investigate patient motivation and beliefs may lead to a deeper understanding of the relationship between adherence and clinical outcomes in patients with LBP.

Characteristics and health outcomes associated with activation for self-management in patients with non-specific low back pain: A cross-sectional study.

BACKGROUND: Research has shown that the course of non-specific low back pain (LBP) is influenced by, among other factors, patients' self-management abilities. Therefore, clinical guidelines recommend stimulation of self-management. Enhancing patients' self-management potentially can improve patients' health outcomes and reduce future healthcare costs for non-specific LBP. OBJECTIVES: Which characteristics and health outcomes are associated with activation for self-management in patients with non-specific LBP? DESIGN: Cross-sectional study. METHOD: Patients with non-specific LBP applying for primary care physiotherapy were asked to participate. Multivariable linear regression analysis was performed to analyze the multivariable relationship between activation for self-management (Patient Activation Measure, range 0-100) and a range of characteristics, e.g., age, gender, and health outcomes, e.g., self-efficacy, pain catastrophizing. RESULTS: The median activation for self-management score of the patients with non-specific LBP (N = 208) was 63.10 (IQR = 19.30) points. The multivariable linear regression analysis revealed that higher self-efficacy scores (B = 0.54), female gender (B = 3.64), and a middle educational level compared with a high educational level (B = -5.47) were associated with better activation for self-management in patients with non-specific LBP. The goodness-of-fit of the model was 17.24% (R2 = 0.17). CONCLUSIONS: Patients with better activation for self-management had better self-efficacy, had a higher educational level, and were more often female. However, given the explained variance better understanding of the factors that influence the complex construct of self-management behaviour in patients who are not doing well might be needed to identify possible barriers to engage in self-management.

Self-management behaviour after a physiotherapist guided blended self-management intervention in patients with chronic low back pain: A qualitative study.

BACKGROUND: Self-management support is considered an important component in the physiotherapeutic treatment of people with chronic low back pain. The stratified blended physiotherapy intervention e-Exercise Low Back Pain is an example of a self-management intervention. More insight may contribute to improving blended interventions to stimulate self-management after treatment and thus hopefully prevent chronicity and/or relapses in patients with chronic low back pain. OBJECTIVES: The aim of this study was to gain an in-depth understanding of the self-management behaviour after a physiotherapist guided blended self-management intervention in people with chronic low back pain. DESIGN: A qualitative study with semi-structured interviews nested within a randomized controlled trial on the (cost-)effectiveness of e-Exercise Low Back Pain was conducted. METHOD: Thematic analysis was used to analyse the transcriptions. A hybrid process of both deductive and inductive approaches was used. RESULTS: After 12 interviews, data saturation was reached. Analysis of the data yielded six themes related to self-management behaviour: illness beliefs, coping, cognitions, social support and resource utilization, physiotherapeutic involvement and motivation. CONCLUSIONS: In our study the majority of the participants seemed to show adequate self-management behaviour when experiencing low back pain. Most participants first try to gain control over their low back pain themselves when experiencing a relapse before contacting the physiotherapist. Participants struggle in continuing health behaviour in pain free periods between relapses of low back pain. Physiotherapists are recommended to encourage long-term behaviour change. Additionally, better facilitation by the physiotherapist or additional functionalities in the app to stimulate social support might have a useful contribution.

Development and proof of concept of a blended physiotherapeutic intervention for patients with non-specific low back pain.

OBJECTIVE: To develop a blended physiotherapeutic intervention for patients with non-specific low back pain (e-Exercise LBP) and evaluate its proof of concept. DESIGN: Focus groups with patients, physiotherapists, and eHealth and LBP experts were conducted to investigate values according to the development of e-Exercise LBP. Proof of concept was evaluated in a multicentre study. SETTING: Dutch primary care physiotherapy practices (n=21 therapists). PARTICIPANTS: Adults with non-specific LBP (n=41). INTERVENTION: e-Exercise LBP was developed based on clinical LBP guidelines and the focus groups, using the Center for eHealth Research Roadmap. Face-to-face physiotherapy sessions were integrated with a web application consisting of 12 information lessons, video-supported exercises and a physical activity module with the option to gradually increase individuals' level of physical activity. The intervention could be tailored to patients' risk of persistent disabling LBP, according to the STarT Back Screening Tool. MAIN OUTCOME MEASURES: Functional disability, pain, physical activity, sedentary behaviour and fear-avoidance beliefs, measured at baseline and 12 weeks. RESULTS: After 12 weeks, improvements were found in functional disability [Quebec Back Pain Disability Scale: mean difference (MD) -12.2/100; 95% confidence interval (CI) 8.3 to 16.1], pain (Numeric Pain Rating Scale: MD -2.8/10; 95% CI 2.1 to 3.6), subjective physical activity (Short Questionnaire to Assess Health Enhancing Physical Activity: MD 11.5minutes/day; 95% CI -47.8 to 24.8) and objective sedentary behaviour (ActiGraph: MD -23.0minutes/day; 95% CI -8.9 to 55.0). Small improvements were found in objective physical activity and fear-avoidance beliefs. The option to gradually increase physical activity was activated for six patients (15%). On average, patients received seven face-to-face sessions alongside the web application. CONCLUSIONS: The results of this study provide the first indication of the effectiveness of e-Exercise LBP, particularly for disability and pain among patients with LBP. Future studies will focus on end-user experiences and (cost-) effectiveness.

Discussing patients' insurance and out-of-pocket expenses during GPs' consultations.

BACKGROUND: Generally, a significant portion of healthcare spending consists of out-of-pocket (OOP) expenses. Patients indicate that, in practice, there are often some OOP expenses, incurred when they receive medical care, which are unexpected for them and should have been taken into account when deciding on a course of action. Patients are often reliant on their GP and may, therefore, expect their GP to provide them with information about the costs of treatment options, taking into consideration their individual insurance plan. This also applies to the Netherlands, where OOP expenses increased rapidly over the years. In the current study, we observed the degree to which matters around patients' insurance and OOP expenses are discussed in the Netherlands, using video recordings of consultations between patients and GPs. METHODS: Video recordings were collected from patient-GP consultations in 2015-2016. In 2015, 20 GPs and 392 patients from the eastern part of the Netherlands participated. In 2016, another eight GPs and 102 patients participated, spread throughout the Netherlands. The consultations were coded by three observers using an observation protocol. We achieved an almost perfect inter-rater agreement (Kappa = .82). RESULTS: In total, 475 consultations were analysed. In 9.5% of all the consultations, issues concerning patients' health insurance and OOP expenses were discussed. The reimbursement of the cost of medication was discussed most often and patients' current insurance and co-payments least often. In some consultations, the GP brought up the subject, while in others, the patient initiated the discussion. CONCLUSIONS: While GPs may often be in the position to provide patients with information about treatment alternatives, few patients discuss the financial effects of their referral or prescription with their GP. This result complies with existing literature. Policy makers, GPs and insurers should think about how GPs and patients can be facilitated when considering the OOP expenses of treatment. There are several factors why this study, analysing video recordings of routine GP consultations in the Netherlands, is particularly relevant: Dutch GPs play a gatekeeper function; OOP expenses have increased relatively swiftly; and patients have both the right to decide on their treatment, and to choose a provider.