Physiotherapists' barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice in patients at risk of recurrence of low back pain: a qualitative study.

BACKGROUND: Recurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists' perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain. METHODS: Two focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements. RESULTS: In total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists' implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources. CONCLUSIONS: This study identified modifiable barriers and facilitators to physiotherapists' implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention.

Minimal Intervention of Patient Education for Low Back Pain: A Systematic Review With Meta-analysis.

OBJECTIVE: To explore the effects of minimal intervention of patient education (MIPE) for reducing disability and pain intensity in patients with low back pain (LBP). DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials. LITERATURE SEARCH: We searched the MEDLINE, Embase, CENTRAL, CINAHL, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Trials comparing MIPE, consisting of a single session of patient education, to no or other interventions in patients with LBP. DATA SYNTHESIS: Random effects meta-analysis was conducted where possible. A noninferiority margin of 5 points (0-100 scale) was considered for noninferiority hypotheses. We assessed risk of bias using the revised Cochrane risk-of-bias tool (RoB 2), and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. RESULTS: A total of 21 trials were included. There were no differences between MIPE and no intervention for effects on disability and pain intensity. There was low-certainty evidence that MIPE had inferior effects on short-term disability (mean difference = 3.62; 95% CI: 0.85, 6.38; 15 trials; n = 3066; I2 = 75%) and pain intensity (mean difference = 9.43; 95% CI: 1.31, 17.56; 10 trials; n = 1394; I2 = 90%) than other interventions. No differences were found for subsequent time points. CONCLUSION: As an intervention delivered in isolation, and without tailoring (ie, one-size-fits-all intervention), MIPE on average did not provide benefits for reducing disability and pain intensity over no or other interventions. We encourage clinicians to consider using additional/other or more tailored treatments when helping people manage LBP. J Orthop Sports Phys Ther 2024;54(2):1-13. Epub 16 November 2023. doi:10.2519/jospt.2023.11865.

Network topology and movement cost, not updating mechanism, determine the evolution of cooperation in mobile structured populations.

Evolutionary models are used to study the self-organisation of collective action, often incorporating population structure due to its ubiquitous presence and long-known impact on emerging phenomena. We investigate the evolution of multiplayer cooperation in mobile structured populations, where individuals move strategically on networks and interact with those they meet in groups of variable size. We find that the evolution of multiplayer cooperation primarily depends on the network topology and movement cost while using different stochastic update rules seldom influences evolutionary outcomes. Cooperation robustly co-evolves with movement on complete networks and structure has a partially detrimental effect on it. These findings contrast an established principle from evolutionary graph theory that cooperation can only emerge under some update rules and if the average degree is lower than the reward-to-cost ratio and the network far from complete. We find that group-dependent movement erases the locality of interactions, suppresses the impact of evolutionary structural viscosity on the fitness of individuals, and leads to assortative behaviour that is much more powerful than viscosity in promoting cooperation. We analyse the differences remaining between update rules through a comparison of evolutionary outcomes and fixation probabilities.

Beyond pain and disability: an explanatory mixed methods study exploring outcomes after physiotherapy intervention in patients with chronic low back pain.

PURPOSE: The primary aim of this study was to explore relevant outcome domains for patients with chronic low back pain (CLBP) undergoing physiotherapy. A secondary aim was to examine potential discrepancies between meaningful changes in pain and disability and the global perception of improvement. METHODS: An explanatory mixed methods design was employed. Twenty-two patients with CLBP completed self-reported measures before and after a physiotherapy programme. After the intervention, three focus groups were conducted with patients who perceived an overall improvement. Discussions were recorded, transcribed and analysed using thematic analysis. RESULTS: Quantitative analysis showed an inconsistent relationship between changes in pain and disability measures and global improvements as perceived by patients. Two main themes emerged from the thematic analysis: "pain relief" (subthemes: reducing pain intensity and other symptoms; reducing medication intake; improving sleep quality) and "gaining control over the LBP condition" (subthemes: ability to self-manage; return to function; and sense of well-being and normality). CONCLUSION: Patients with CLBP perceived multiple outcomes from physiotherapy treatment that cover the domains of global, physical, mental and social health. These study findings suggest that the targets of measurement for physiotherapy need to be expanded in order to reflect outcome domains valued by patients.Implications for rehabilitationMinimum important changes in pain intensity and disability were not valid indicators of global improvements as perceived by patients.Patients with chronic low back pain undergoing physiotherapy perceived gains in multiple health domains that ranged beyond pain and disability domains.Physiotherapy outcome assessment needs to integrate other patient-relevant outcomes such as medication intake, sleep quality, ability to self-manage and sense of well-being.

Minimum important change values for pain and disability: which is the best to identify a meaningful response in patients with chronic nonspecific low back pain?

PURPOSE: To examine the association between different minimum important change (MIC) values for pain and disability and a successful response in global perception of improvement in patients with chronic nonspecific low back pain (CNLBP). METHODS: A prospective cohort study was conducted. At baseline, all participants completed a sociodemographic and clinical questionnaire, the Numeric Pain Rating Scale and the Quebec Back Pain Disability Scale (QBPDS). After a physiotherapy program, the Global Perceived Effect Scale (GPES) was completed together with pain and disability measures. The association of the different literature MIC values for pain and disability with a successful response on the GPES was analyzed using logistic regression models. The discrimination power, sensitivity, specificity and predictive values were computed. RESULTS: A total of 183 patients with CNLBP participated in this study. A reduction of 30% on the QBPDS (OR = 7.8; area under the curve = 0.73; sensitivity = 0.72; specificity = 0.76) most accurately identified patients who perceived a global improvement on the GPES. Composite criteria using both pain and disability MIC values presented high odds ratios and specificity values, but failed to identify patients who perceived a meaningful improvement. CONCLUSION: A 30% reduction on the QBPDS is recommended to identify patients with CNLBP who achieve a clinical improvement with physiotherapy treatment.

3D Antenna Characterization for WPT Applications.

The main goal of this paper is to present a three-dimensional (3D) antenna array to improve the performance of wireless power transmission (WPT) systems, as well as its characterization with over-the-air (OTA) multi-sine techniques. The 3D antenna consists of 15 antenna elements attached to an alternative 3D structure, allowing energy to be transmitted to all azimuth directions at different elevation angles without moving. The OTA multi-sine characterization technique was first utilized to identify issues in antenna arrays. However, in this work, the technique is used to identify which elements of the 3D antenna should operate to transmit the energy in a specific direction. Besides, the 3D antenna design description and its characterization are performed to authenticate its operation. Since 3D antennas are an advantage in WPT applications, the antenna is evaluated in a real WPT scenario to power an RF-DC converter, and experimental results are presented.

Cross-cultural adaptation and psychometric properties of the European Portuguese version of the Global Perceived Effect Scale in patients with chronic low back pain.

PURPOSE: To cross-culturally adapt the Global Perceived Effect Scale (GPES) into Portuguese and investigate its psychometric properties in patients with chronic low back pain. METHODS: Cross-cultural adaptation was carried out according to published guidelines. Along with measures for pain and disability, GPES was administered at baseline, 48-h later and post-intervention. To estimate test-retest reliability, the intraclass correlation coefficient was used. The validity was examined through the correlation between the GPES and the Patient Global Improvement Change Scale and the contribution of baseline status to GPES scores. Responsiveness was assessed by analyzing hypotheses regarding areas under the curve and correlations with changes in other measures. RESULTS: The test-retest reliability, the convergent validity and the contribution of the baseline status to GPES scores were demonstrated. The EPES correlated strongly with global perception of change (r = 0.677), and moderately with pain and disability changes (r = 0.457 and r = 0.452, respectively). Areas under the curve values of 0.71(95% CI = 0.607-0.825) and 0.83 (95% CI = 0.749-922) were found. CONCLUSION: The GPES demonstrated adequate psychometric properties. This study's findings supported its use in clinical and research studies with patients with chronic low back pain.IMPLICATIONS FOR REHABILITATIONThe European Portuguese version of the Global Perceived Effect Scale demonstrated adequate reliability, validity and responsiveness. This instrument is suitable to evaluate meaningful changes in patients with chronic low back pain.The contribution of baseline status to GPES scores was confirmed by specific and recommended methods. The use of the GPES as external criterion of change in clinimetric studies was supported.The minimum important change was 2.5 points out of 11 of the GPES. Only improvements above this point should be considered as relevant to patients with chronic low back pain undergoing physiotherapy.

How Do Physical Therapists Measure Treatment Outcomes in Adults With Chronic Low Back Pain? A Systematic Review.

BACKGROUND: There is an increasing recognition of the importance of using a conceptual framework covering the full range of relevant health domains and outcome measures addressed by physical therapy modalities in patients with chronic low back pain (CLBP). However, little is known about what outcome domains have been measured and through what measures in physical therapy research. OBJECTIVE: The purpose of this review was to synthesize outcome domains, instruments, and cutoff values reported in published randomized controlled trials and their compliance with the original Patient-Reported Outcomes Measurement Information System (PROMIS) framework. DATA SOURCES: Embase, MEDLINE, Cochrane Library, and Physiotherapy Evidence Database electronic databases were systematically searched from January 2008 to April 2019. STUDY SELECTION: Randomized controlled trials that compared physical therapy with any other intervention for adults with CLBP were included. DATA EXTRACTION: Study characteristics, outcome domains, instruments, and cutoff values were extracted by 2 reviewers. The PROMIS framework was used for domain categorization. DATA SYNTHESIS: One hundred ninety-five studies were included, with 52 outcome domains and 45 cutoff values identified from 182 instruments reported. Only 14 of 195 studies assessed all PROMIS health core areas, whereas the PROMIS physical health core area was assessed in all included studies. Pain intensity and disability were the most frequently used domains. LIMITATIONS: Only studies for which full texts were available in English were included. CONCLUSIONS: This review identified a poor overlap between the PROMIS framework and outcome domains used to define the effectiveness of physical therapy in adults with CLBP. This finding suggests that other potential benefits resulting from physical therapy modalities are not being measured. Furthermore, a large diversity in the outcome domains and instruments was found.

The role of pain and disability changes after physiotherapy treatment on global perception of improvement in patients with chronic low back pain.

BACKGROUND: The effectiveness of physiotherapy in patients with chronic low back pain is usually measured through changes in pain and disability domains. However, recent research has suggested that these two domains are not sufficient to capture all the physiotherapy benefits when patients' perspective is considered. OBJECTIVE: The aim of this study was to investigate the role of pain and disability changes in explaining the global perception of improvement in patients with chronic low back pain undergoing physiotherapy. DESIGN: Prospective cohort study. METHODS: The study was conducted on183 patients who were referred to physiotherapy treatment due to low back pain lasting more than 12 weeks. Sociodemographic and clinical characteristics were measured at baseline, together with pain intensity and disability. Eight (post-intervention) and twelve weeks later, global perception of improvement was measured together with pain and disability. The Pearson correlation coefficient and linear regression models were used for analyses. RESULTS: Of the 183 participants included, 144 completed the 12-weeks follow-up. Significant and moderate correlation was found between pain and disability changes and the global perception of improvement after intervention and at the 12-weeks follow-up. Pain and disability changes explained 20.7%-36.3% of the variance in the global perception of improvement. CONCLUSIONS: Pain and disability changes are related and contributed to explaining a partial proportion of variance in the global perception of improvement. The findings suggest that these domains are not sufficient to explain and measure all of the benefits of physiotherapy when patients' global perception of improvement is considered.

Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: a randomized controlled trial.

OBJECTIVE: The aim of this study was to compare the effectiveness of a combination of aquatic exercise and pain neurophysiology education with aquatic exercise alone in chronic low back pain patients. DESIGN: Single-blind randomized controlled trial. SETTING: Outpatient clinic. SUBJECTS: Sixty-two chronic low back pain patients were randomly allocated to receive aquatic exercise and pain neurophysiology education (n = 30) or aquatic exercise alone (n = 32). INTERVENTIONS: Twelve sessions of a 6-week aquatic exercise programme preceded by 2 sessions of pain neurophysiology education. Controls received only 12 sessions of the 6-week aquatic exercise programme. MAIN MEASURES: The primary outcomes were pain intensity (Visual Analogue Scale) and functional disability (Quebec Back Pain Disability Scale) at the baseline, 6 weeks after the beginning of the aquatic exercise programme and at the 3 months follow-up. Secondary outcome was kinesiophobia (Tampa Scale of Kinesiophobia). RESULTS: Fifty-five participants completed the study. Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favoring the education group (mean SD change: -25.4± 26.7 vs -6.6 ± 30.7, P < 0.005). Although participants in the education group were more likely to report perceived functional benefits from treatment at 3 months follow-up (RR=1.63, 95%CI: 1.01-2.63), no significant differences were found in functional disability and kinesiophobia between groups at any time. CONCLUSIONS: This study's findings support the provision of pain neurophysiology education as a clinically effective addition to aquatic exercise.