Group and individual telehealth for chronic musculoskeletal pain: A scoping review.

BACKGROUND CONTEXT: Musculoskeletal (MSK) pain presents a global challenge. Individual and group pain management programmes (PMPs) are recommended approaches for patients with chronic MSK disorders. With advances in remote healthcare capability, telehealth, and the recent COVID-19 pandemic, the importance of telehealth PMPs has become even more evident. Nevertheless, it is not known how patients perceive PMPs for their MSK complaint when delivered via telehealth. OBJECTIVE: To synthesise the evidence of patients' experiences of group and individual telehealth PMPs for chronic MSK pain. DESIGN: A scoping review informed by the PRISMA extension for scoping reviews. DATA SOURCES: Based on a planned search strategy, modified following initial searches, an electronic search was conducted of key databases: Cochrane Library, Medline, CINAHL, EMBASE, AMED, SportDiscus and APA PsychInfo from 2010 until 11 May 2021. STUDY SELECTION: Any qualitative or mixed methods study reporting patient experiences of telehealth PMPs for patients with MSK disorders. DATA EXTRACTION AND DATA SYNTHESIS: Data were extracted and synthesised using thematic analysis. RESULTS: From 446 identified studies, 10 were included. Just two studies investigated group telehealth PMPs for patients with MSK disorders, with eight delivered individually. Four main themes emerged: (1) Usability of the technology, (2) Tailored care, (3) Therapeutic alliance and (4) Managing behaviour. The findings highlight patient acceptability of telehealth to support self-management for chronic MSK disorders, with appropriate clinical and technical support. Group telehealth has the potential to empower patients with peer support. Remote delivery of PMPs also impacts on how patients and providers interact, communicate and develop a therapeutic relationship. CONCLUSIONS AND IMPLICATIONS: Barriers and enablers to engagement in telehealth PMPs for patients with chronic MSK disorders have been identified. Peer support and group cohesiveness can be achieved remotely to enhance the patient experience. There is a critical need for further research in this area.

Neck pain with radiculopathy: A systematic review of classification systems.

BACKGROUND: Disparities in eligibility criteria for cervical radiculopathy (CR) in clinical trials have been acknowledged previously. The increasing use of CR related neck pain classification systems to inform eligibility criteria in clinical trials warrants evaluation. OBJECTIVE: To evaluate existing neck pain classification systems for CR. DESIGN: Systematic review and critical appraisal, reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. METHODS: Database searches were performed from inception until 31/7/2020. Neck pain classification systems containing CR as a component were included. Methodological quality of each classification system was assessed using seven measurement property domains and scored using a framework developed by Buchbinder and colleagues. Classification criteria for CR from classification systems assessed as moderate or good quality were narratively synthesised using inductive content analysis which consisted of selecting unit of analysis, open coding, grouping and categorisation. RESULTS: Out of 19,975 references, 14,893 remained after elimination of duplicates with 17 articles reporting 11 classification systems included. Five moderate and one good quality classification systems were identified. Nine classification criteria for CR were derived, including dermatomal sensory deficit, positive Spurling's test, positive upper limb tension test. CONCLUSION: All classification systems had methodological limitations with Childs et al. (2008) classification system identified as good quality and most clinically useful. Future studies should investigate the reliability of Childs et al. (2008) classification system as it has the potential to further strengthen its methodological quality and clinical utility. The nine derived classification criteria can inform eligibility criteria in future trials.

Exploring expectations and perceptions of different manual therapy techniques in chronic low back pain: a qualitative study.

BACKGROUND: Chronic low back pain (CLBP) prevalence has steadily increased over the last two decades. Manual therapy (MT) is recommended within a multimodal management approach to improve pain and disability although evidence investigating the patients' experience of MT is scarce. OBJECTIVE: To explore expectations and perceptions of MT techniques in people with CLBP. METHODS: A qualitative study embedded sequential to an experimental trial using semi-structured interviews (SSI) explored participants' experiences of thrust, non-thrust and sham technique. Purposive sampling enabled variance in age and CLBP duration. An evidence informed topic guide was used. Data were analysed using thematic analysis (TA). Respondent validation and peer debriefing enhanced trustworthiness. The Consolidating Criteria for Reporting Qualitative Studies (COREQ) reported methodological rigour. FINDINGS: Ten participants (50% male) with a mean age of 29.1 years (Standard Deviation (SD): 7.9, range: 19-43), a mean pain intensity of 4.5 on a Numeric Rating Scale (NRS) 0-10 (SD: 1.5, range: 2-7), a mean Oswestry Disability Score (ODI) of 9 (SD: 4.6, range: 2-17) and a mean Tampa Scale of Kinesiophobia (TSK) score of 38.6 (SD: 4.8, range: 30-45) participated. Four themes were identified: understanding of pain; forming expectations; perception of care; re-evaluation of body awareness and management. Understanding of CLBP is formed by an individuals' pain perception and exchange with social environment. This, combined with communication with physiotherapist influenced expectations regarding the MT technique. CONCLUSION: Expectations for MT were formed by an individual's social environment and previous experience. A treatment technique is perceived as positive if its characteristics are aligned with the individual's understanding of pain and if care is delivered in an informative and reassuring manner.

Successful recovery following musculoskeletal trauma: protocol for a qualitative study of patients' and physiotherapists' perceptions.

BACKGROUND: Annually in the UK, 40,000-90,000 people are involved in a traumatic incident. Severity of injury and how well people recover from their injuries varies, with physiotherapy playing a key role in the rehabilitation process. Recovery is evaluated using multiple outcome measures for perceived levels of pain severity and quality of life. It is unclear however, what constitutes a successful recovery from injury throughout the course of recovery from the patient perspective, and whether this aligns with physiotherapists' perspectives. METHODS: A qualitative study using two approaches: Interpretive Phenomenological Analysis (IPA) using semi-structured interviews and thematic analysis following the Kreuger framework for focus groups. A purposive sample of 20 patients who have experienced musculoskeletal trauma within the past 4 weeks and 12 physiotherapists who manage this patient population will be recruited from a single trauma centre in the UK. Semi-structured interviews with patients at 4 weeks, 6 and 12 months following injury, and 2 focus groups with physiotherapists will be undertaken at one time point. Views and perceptions on the definition of recovery and what constitutes a successful recovery will be explored using both methods, with a focus on the lived experience and patient journey following musculoskeletal trauma, and how this changes through the process of recovery. Data from both the semi-structured interviews and focus groups will be analysed separately and then integrated and synthesised into key themes ensuring similarities and differences are identified. Strategies to ensure trustworthiness e.g., reflexivity will be employed. DISCUSSION: Recovery following musculoskeletal trauma is complex and understanding of the concept of successful recovery and how this changes over time following an injury is largely unknown. It is imperative to understand the patient perspective and whether these perceptions align with current views of physiotherapists. A greater understanding of recovery following musculoskeletal trauma has potential to change clinical care, optimise patient centred care and improve efficiency and clinical decision making during rehabilitation. This in turn can contribute to improved clinical effectiveness, patient outcome and patient satisfaction with potential service and economic cost savings. This study has ethical approval (IRAS 287781/REC 20/PR/0712).

Digital interventions for promoting exercise adherence in chronic musculoskeletal pain: a systematic review and meta-analysis.

BACKGROUND: Chronic musculoskeletal disorders are the second largest contributor to disability globally. Exercise is typically recommended by physiotherapists to manage symptoms. However, adherence to the prescribed exercise programme is often poor. Adjunctive digital interventions offer potential to enhance exercise adherence. OBJECTIVES: To review evidence on the effectiveness of digital interventions for improving exercise adherence in people with chronic musculoskeletal conditions. The study is reported in line with PRISMA guidance and was registered with PROSPERO (CRD42019124502). DATA SOURCES: MEDLINE, Embase and PsycInfo were searched using a comprehensive search strategy. The reference lists of all included papers and relevant systematic reviews identified during the search were scanned for relevant articles. STUDY APPRAISAL AND SYNTHESIS METHODS: Two researchers independently checked articles for inclusion and extracted data. RESULTS: The search returned a total of 4257 results of which five trials were included in the review and two studies were included in a random effects meta-analysis. There was no statistically significant difference in exercise adherence (SMD: 0.23; 95% CI: -0.10, 0.57). Studies that were not suitable for inclusion in the meta-analysis reported similar results. Heterogeneity of effects was high and study quality ranged from low to moderate. All of the meta-analysed data related to osteoarthritis of the hip and/or knee. CONCLUSION: We found no evidence that digital interventions enhance adherence to therapeutic exercise in patients with chronic musculoskeletal disorders. However, further, high quality research is required to draw definitive conclusions on their effectiveness and to identify key components that are associated with effectiveness. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019124502.

Injury surveillance in elite Paralympic athletes with limb deficiency: a retrospective analysis of upper quadrant injuries.

BACKGROUND: Compared to injury surveillance in Olympic athletes relatively little literature exists for Paralympic athletes. Injury surveillance data underpin design and evaluation of injury prevention strategies in elite sport. The aim of this study is investigate upper quadrant injuries in elite athletes with limb deficiency. METHODS: A retrospective analysis of upper quadrant injuries in elite athletes with limb deficiency with available data (2008-2016) was conducted using medical notes extracted from English Institute of Sport (EIS) records. Eligibility criteria included funded athletes, eligible for EIS physiotherapy support with an upper and/or lower limb disability arising from full or partial limb deficiency. RESULTS: A total 162 injuries from 34 athletes were included. Participant characteristics: 20 males (59%), from 9 sports, with mean age 27 years (range 16-50 years) and 15 with congenital limb loss (44%). Athletes age 20-29 years experienced most injuries, four per athlete. The glenohumeral joint was the reported injury site (23%, n = 38). Index (first) injuries accounted for 77% (n = 128) injuries, 17% (n = 28) a recurrence and 6% (n = 10) an exacerbation. More than half of injuries occurred in training (58%, n = 94), this being slightly higher in those with traumatic limb loss. Athletes with quadruple levels of limb deficiency had double the number of recurrent injuries as those with single or double limb deficiency. CONCLUSION: Elite athletes with limb deficiency experience upper quadrant injuries, with glenohumeral joint the most frequently reported. The quality and consistency of data reported limits definitive conclusions, although findings highlight the importance of precision and accuracy in recording injury surveillance to enable implementation of effective injury prevention strategies.

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis.

PURPOSE: To conduct a meta-analysis to describe clinical course of pain and disability in adult patients post-lumbar discectomy (PROSPERO: CRD42015020806). METHODS: Sensitive topic-based search strategy designed for individual databases was conducted. Patients (> 16 years) following first-time lumbar discectomy for sciatica/radiculopathy with no complications, investigated in inception (point of surgery) prospective cohort studies, were included. Studies including revision surgery or not published in English were excluded. Two reviewers independently searched information sources, assessed eligibility at title/abstract and full-text stages, extracted data, assessed risk of bias (modified QUIPs) and assessed GRADE. Authors were contacted to request raw data where data/variance data were missing. Meta-analyses evaluated outcomes at all available time points using the variance-weighted mean in random-effect meta-analyses. Means and 95% CIs were plotted over time for measurements reported on outcomes of leg pain, back pain and disability. RESULTS: A total of 87 studies (n = 31,034) at risk of bias (49 moderate, 38 high) were included. Clinically relevant improvements immediately following surgery (> MCID) for leg pain (0-10, mean before surgery 7.04, 50 studies, n = 14,910 participants) and disability were identified (0-100, mean before surgery 53.33, 48 studies, n = 15,037). Back pain also improved (0-10, mean before surgery 4.72, 53 studies, n = 14,877). Improvement in all outcomes was maintained (to 7 years). Meta-regression analyses to assess the relationship between outcome data and a priori potential covariates found preoperative back pain and disability predictive for outcome. CONCLUSION: Moderate-level evidence supports clinically relevant immediate improvement in leg pain and disability following lumbar discectomy with accompanying improvements in back pain. These slides can be retrieved under Electronic Supplementary Material.

General group exercise in low back pain management in a military population, a comparison with specific spine group exercise: a service evaluation.

OBJECTIVE: To investigate whether general group exercise (GGE) offers the same outcomes compared with a specific spinal group exercise (SSGE) for chronic low back pain (CLBP) in a military population. DESIGN: Retrospective service evaluation using routine service activity data. SETTING: A UK military rehabilitation centre. PARTICIPANTS: A total of 106 patients with CLBP. INTERVENTIONS: Three-week intensive (5 days per week, 15-day intervention) rehabilitation course for patients with CLBP. Six SSGE groups (n=64); CLBP only. Six GGE groups (n=42); CLBP patients grouped with chronic lower limb (LL) injuries. OUTCOME MEASURES: Oswestry Disability Index (ODI), Numerical Pain-Rating Scores and the Modified Multi-Stage Fitness Test (Mod-MSFT). Long-term effects were measured by Medical Employment Standard (MES) status and physiotherapy follow-up at 3 and 12 months. RESULTS: A between-group analysis showed no significant difference in GGE compared with SSGE. Mean changes (SD) in pain were -2.71±2.35 and -1.20±1.99 (p=0.018), ODI were -3.6±5.7 and -4±8.5 respectively (p=0.649) and Mod-MSFT 28.4±30.8 and 29.7±31.7 respectively (p=0.792). At 3 months, a greater proportion of the GGE were having ongoing physiotherapy; GGE=50%, SSGE=30.2%, (p=0.016) although some differences were evident across MES with 32.5 % of GGE compared with 20.6 % of SSGE being medically fit with no restrictions. At 12 months, groups were largely comparable for follow-up physiotherapy and MES; 22.5% of GGE and 20.6% of SSGE continued to have physiotherapy input; 47.5% of GGE and 50.8% of SSGE were medically fit with no restrictions. CONCLUSION: Patients with CLBP who completed a 3-week rehabilitation programme had comparable outcomes when grouped with patients with LL, although only improvements in pain in the GGE group achieved a meaningful change. Further evaluation of potential costs and savings to service costs is now required.

Vibration sensibility of the median nerve in a population with chronic whiplash associated disorder: Intra- and inter-rater reliability study.

UNLABELLED: Whiplash Associated Disorders (WAD) grade II are the most prevalent group of whiplash patients seen on a regular basis by musculoskeletal physiotherapists. Impairment of vibration sensibility may be an early indicator of nerve pathology and it has previously been demonstrated in individuals with chronic WAD symptoms utilising vibrameters. A less expensive option, such the tuning fork (TF) may assist with these measures, but research regarding its measurement properties is lacking. OBJECTIVES: To investigate the intra- and inter-rater reliability of vibration sensibility of the median nerve in chronic WAD II (CWAD II). METHODS: A double blinded, within day intra- and inter-rater reliability study was undertaken. A convenience sample of 26 individuals (8 males, 18 females, age mean 29.9 ± 10.0 years) with CWADII was recruited. EXCLUSION CRITERIA: WAD I, III & indications of neuropathic pain. Vibration attenuation times were recorded from skin innervated by the median nerve (thenar eminence). RESULTS: Descriptive statistics (mean scores) and reliability statistics [intraclass correlation coefficient (ICC2,1) and Bland and Altman limits of agreement] were undertaken with p = 0.05. Almost perfect intra-rater reliability (Intraclass Correlation Coefficiency (ICC): 0.972-0.955) and inter-rater reliability (ICC: 0.983) were identified. Confidence Intervals (CI) for inter-rater reliability were 95% CI: -1.461 to -0.056. CONCLUSIONS: Almost perfect reliability scores across intra- and inter-rater reliability were found. This provides evidence that, with a standardised testing protocol the TF can be a highly reliable means of vibration sensibility testing. Future studies assessing the validity of the TF in different WAD populations may provide further information about the usefulness of this protocol.

Understanding why the thoracic region is the 'Cinderella' region of the spine.

The thoracic spine has for a long time been the 'Cinderella' region of the spine. There has been a lesser research focus to the thoracic region compared with the cervical and lumbar spine, and there continues to be a limited understanding of the aetiology and epidemiology of a range of neuromusculoskeletal presentations which have an anatomical connection to the thoracic spine. This paper firstly, provides a critical evaluation of the available evidence to provide some understanding for this under-exploration of the thoracic spine. Secondly the paper provides an evaluation of an emerging interest in this spinal region, with a body of evidence supporting the use of thoracic spine manipulation in the management of upper quadrant presentations. This has been linked to the theory of regional interdependence with the thoracic spine being viewed as a silent contributor to clinical presentations where a pain source lies elsewhere. Finally, a case for further research is made. Identified gaps in the current evidence base include, aetiology and epidemiology of thoracic spine pain and thoracic spine dysfunction, and to investigate mechanisms of action of currently used interventions.