Identification of subgroup effect with an individual participant data meta-analysis of randomised controlled trials of three different types of therapist-delivered care in low back pain

Background: Proven treatments for low back pain, at best, only provide modest overall benefits. Matching people to treatments that are likely to be most effective for them may improve clinical outcomes and makes better use of health care resources. Methods: We conducted an individual participant data meta-analysis of randomised controlled trials of three types of therapist delivered interventions for low back pain (active physical, passive physical and psychological treatments). We applied two statistical methods (recursive partitioning and adaptive risk group refinement) to identify potential subgroups who might gain greater benefits from different treatments from our individual participant data meta-analysis. Results: We pooled data from 19 randomised controlled trials, totalling 9328 participants. There were 5349 (57%) females with similar ratios of females in control and intervention arms. The average age was 49 years (standard deviation, SD, 14). Participants: with greater psychological distress and physical disability gained most benefit in improving on the mental component scale (MCS) of SF-12/36 from passive physical treatment than non-active usual care (treatment effects, 4.3; 95% confidence interval, CI, 3.39 to 5.15). Recursive partitioning method found that participants with worse disability at baseline gained most benefit in improving the disability (Roland Morris Disability Questionnaire) outcome from psychological treatment than non-active usual care (treatment effects, 1.7; 95% CI, 1.1 to 2.31). Adaptive risk group refinement did not find any subgroup that would gain much treatment effect between psychological and non-active usual care. Neither statistical method identified any subgroups who would gain an additional benefit from active physical treatment compared to non-active usual care. Conclusions: Our methodological approaches worked well and may have applicability in other clinical areas. Passive physical treatments were most likely to help people who were younger with higher levels of disability and low levels of psychological distress. Psychological treatments were more likely to help those with severe disability. Despite this, the clinical importance of identifying these subgroups is limited. The sizes of sub-groups more likely to benefit and the additional effect sizes observed are small. Our analyses provide no evidence to support the use of sub-grouping for people with low back pain

A survey of physical activity (PA) across the stroke pathway of care: physiotherapists’ routine practice and knowledge

Background: Stroke research mainly focuses on ambulant participants attending supervised exercise interventions, delivered by physiotherapists, that are not informed by behaviour change theory or measured accurately. It is not clear whether the findings are reflected in clinical practice across the stroke pathway. Objective: This survey investigated physiotherapists’ practice, knowledge, training and understanding of PA interventions across the stroke pathway of care. Design: An online self -administered 26-item survey was completed by physiotherapists working in the stroke population across the United Kingdom (UK) and Republic of Ireland (ROI). Results: 77 valid responses were analysed. Tailored individual exercise (28% n = 21) was the most common PA intervention description and Treadmill training, the least common. Walking ability (68%) and Berg balance scale (62%) were the most common outcome measures reported to measure PA. Lack of time (n = 50) and services to signpost to (n = 48) were the most reported barriers to providing PA interventions. Conclusions: We showed that physiotherapists have good awareness of, but mixed knowledge on, the PA guidelines, and valid measures of daily PA. In terms of implementation, there continues to be a focus on tailored exercise, particularly in non-ambulant people with stroke. Common barriers to the implementation of PA interventions across the stroke pathway were lack of time, limited community services to signpost to, and low patient responsiveness. Future studies should explore knowledge gaps in more detail, and address the barriers to implementation of PA in people with stroke.</p

Virtual reality design for stroke rehabilitation

Stroke is a leading cause of disability, and with the stroke survivor population rising in most countries it is increasingly difficult to provide optimal treatment to patients once they return home. Assistive technology solutions can potentially contribute to meeting demand, and also be cost effective. In this chapter, we consider the design and development of engaging serious virtual reality (VR) games for upper arm stroke rehabilitation. Fundamental design principles are summarised and related to our experience of creating game-based VR rehabilitation. The application of ideas from psychology, particularly behavioural change and flow theory are discussed, as well as related learning and gamification principles. We address how to manage differences between people through design, user profiling, and intelligent dynamic system behaviour, and we also explore how to account for variation in stroke survivor capability and personality. The idea of a hero's journey as a metaphor for stroke recovery is introduced and we discuss how this metaphor may guide system design, its relationship to game design principles, and how patient narratives and embedded stories might support engagement with treatment. An overview of our previous work is summarised and we discuss how our experience and increased knowledge and capability has informed improved approaches to development processes. Finally, our approach is illustrated with reference to a recent EU project. </p

Assisted standing for Duchenne muscular dystrophy.

Background: Duchenne muscular dystrophy (DMD) is the most common X-linked neuromuscular disorder. When boys with DMD reach the second decade of life, they lose their ability to walk and become wheelchair dependent. Standing devices and orthoses are considered to be an essential component in the therapy management of DMD. Clinical opinion and research from other neurological conditions highlight the proposed benefits of standing device use, however, its effect within this population is currently unknown. A review of the evidence for the use of standing devices and orthoses is necessary to inform all stakeholders, including people with DMD, clinicians, decision makers and funders, and to guide future research.Objectives: To assess the effects of standing devices and orthoses on musculoskeletal impairments (such as pain, contracture, scoliosis development and bone density) in boys and men with DMD, and secondarily to determine their effect on quality of life, participation in activities, and patient experience (satisfaction). We also considered any adverse events associated with their use.Search methods: We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, PsycINFO, CINAHL Plus, PEDro, and ProQuest Dissertations & Theses Global up to 5 September 2019. We checked references in identified trials, handsearched journal abstracts, and searched trials registries.Selection criteria: We planned to include randomised controlled trials (RCTs) and quasi-RCTs of any model of standing device for use in DMD. The control interventions would have been any other comparison group, including no standing device, a different model of standing device, usual care, or an alternative form of assistive weight bearing.Data collection and analysis: We used standard Cochrane methodological procedures.Main results: Although we identified 13 potentially relevant studies, none met the inclusion criteria for this review.Authors' conclusions: Since there were no RCTs or quasi-RCTs available to evaluate the effectiveness of standing devices in people with DMD, studies are needed to investigate the effectiveness of standing devices in this population.</p

Changes in physical activity predict changes in a comprehensive model of balance in older community-dwelling adults. A longitudinal analysis of the TILDA study.

Objective: Falls due to poor balance can cause injury, disability, and death in older adults. The relationship between free-living physical activity (PA) and balance over time is poorly understood. The aim of this study is to explore the association between PA and balance in older adults over time.Methods: Using two waves of data from the TILDA study (n=8,504 participants) a structural equation model was used to identify a composite measure of balance that incorporated measures of Timed Up and Go; handgrip strength; Mini Mental State Exam; vision; hearing; and steadiness. The patterns of change in PA and balance were then compared over time (controlling for covariates).Results: The results showed that one extra metabolic equivalent of task (MET) minute of PA improves balance by 4% over one week (Est=-0.10, SE=0.12), and by 5% cumulatively over two years (Est=-0.13, SE=0.02). Medication, alcohol consumption, sex, age, fear of falling, education, pain, and problems performing activities of daily living (ADL) were risk factors for balance.Conclusion: This study provides a novel and robust model that should guide comprehensive balance assessment. PA promotion should engage older adults in more free-living PA that may be more relevant to them.</p

A qualitative study of physiotherapy educators’ views and experience of practice education and simulation-based learning

Background: Globally, practice education is a core component of physiotherapy training. Physiotherapy educators struggle to find sufficient workplace placements to ensure adequate clinical experience. Simulation-based learning (SBL) could complement clinical workplace experiences and bridge the gap between demand and provision. This study explores academic physiotherapy educators’ views and experiences of practice education and the potential contribution of SBL. Methods: Representatives from all six Schools of Physiotherapy on the island of Ireland participated in focus groups. Interviews were audio-recorded and transcribed. Qualitative data were analysed using interpretive description methodology. Results: We conducted seven focus groups with 29 academic educators (26 females and 3 males). Three core themes were identified: (i) challenges in practice education, (ii) the potential for SBL in practice education and (iii) barriers and enablers to integrating SBL in practice education. COVID-19 had dual impacts, both exacerbating challenges and precipitating innovations in practice education. Analysis revealed guidance for how to fit SBL within practice education although varied understanding and limited experience with using SBL remained. Barriers to SBL included cost, time, logistics and stakeholder buy-in, while collaboration represented a key facilitator. Perceived benefits of SBL included enhanced student capacity and experience. Conclusions: A number of contributing factors threaten traditional workplace-based physiotherapy practice education in Ireland. SBL may reduce this threat and solicit ever better performances from students. Future research should examine the feasibility of proposed SBL deployment and foster buy-in from key stakeholders.</p

Older adults' experience of active computer gaming for falls prevention exercise: a mixed methods study

PURPOSE: This mixed methods study explored older adults' experience using a bespoke active computer gaming (ACG) system designed to deliver falls prevention exercise.  METHODS: Usability, acceptability and safety were evaluated through observation of system use, questionnaires, in-system ratings, and semi-structured interviews. Quantitative and qualitative data were synthesised concurrently to provide a deeper understanding of older adults' experience with the system.  RESULTS: N=7 older adults (aged 73-88 years, most with increased fear of falling, and over half with reduced physical functioning) completed up to six uses of the system. Observations and qualitative feedback suggested that older adults' experience with the system was influenced by physical health changes associated with ageing. Overall feedback after using the system was positive. Social support, from either the clinician or a peer, was a key theme influencing experience.  CONCLUSIONS: Findings suggested that autonomous use of the system may not be feasible given the requirement and preference for social support.</p

Physical activity, exercise capacity and sedentary behavior in people with alpha-1 antitrypsin deficiency: a scoping review

Alpha-1 antitrypsin deficiency (AATD) is a hereditary disorder and a genetic risk factor for chronic obstructive pulmonary disease (COPD). Physical activity (PA) is important for the prevention and treatment of chronic disease. Little is known about PA in people with AATD. Therefore, we aimed to map the research undertaken to improve and/or measure PA, sedentary behaviour (SB) or exercise in people with AATD. Searches were conducted in CINAHL, Medline, EMBASE and clinical trial databases for studies published in 2021. Databases were searched for keywords (physical activity, AATD, exercise, sedentary behavior) as well as synonyms of these terms, which were connected using Boolean operators. The search yielded 360 records; 37 records were included for review. All included studies (n = 37) assessed exercise capacity; 22 studies reported the use of the six-minute walk test, the incremental shuttle walk test and cardiopulmonary exercise testing were reported in three studies each. Other objective measures of exercise capacity included a submaximal treadmill test, the Naughton protocol treadmill test, cycle ergometer maximal test, endurance shuttle walk test, constant cycle work rate test, a peak work rate test and the number of flights of stairs a participant was able to walk without stopping. A number of participant self-reported measures of exercise capacity were noted. Only one study aimed to analyze the effects of an intensive fitness intervention on daily PA. One further study reported on an exercise intervention and objectively measured PA at baseline. No studies measured SB. The assessment of PA and use of PA as an intervention in AATD is limited, and research into SB absent. Future research should measure PA and SB levels in people with AATD and explore interventions to enhance PA in this susceptible population. </p

Physical activity, exercise capacity and sedentary behavior in people with alpha-1 antitrypsin deficiency: a scoping review

Alpha-1 antitrypsin deficiency (AATD) is a hereditary disorder and a genetic risk factor for chronic obstructive pulmonary disease (COPD). Physical activity (PA) is important for the prevention and treatment of chronic disease. Little is known about PA in people with AATD. Therefore, we aimed to map the research undertaken to improve and/or measure PA, sedentary behaviour (SB) or exercise in people with AATD. Searches were conducted in CINAHL, Medline, EMBASE and clinical trial databases for studies published in 2021. Databases were searched for keywords (physical activity, AATD, exercise, sedentary behavior) as well as synonyms of these terms, which were connected using Boolean operators. The search yielded 360 records; 37 records were included for review. All included studies (n = 37) assessed exercise capacity; 22 studies reported the use of the six-minute walk test, the incremental shuttle walk test and cardiopulmonary exercise testing were reported in three studies each. Other objective measures of exercise capacity included a submaximal treadmill test, the Naughton protocol treadmill test, cycle ergometer maximal test, endurance shuttle walk test, constant cycle work rate test, a peak work rate test and the number of flights of stairs a participant was able to walk without stopping. A number of participant self-reported measures of exercise capacity were noted. Only one study aimed to analyze the effects of an intensive fitness intervention on daily PA. One further study reported on an exercise intervention and objectively measured PA at baseline. No studies measured SB. The assessment of PA and use of PA as an intervention in AATD is limited, and research into SB absent. Future research should measure PA and SB levels in people with AATD and explore interventions to enhance PA in this susceptible population. </p

Study protocol for a feasibility study of an online educational programme for people working and living with persistent low back pain

Background: Low back pain (LBP) is the main cause of activity limitation and work absence across the world, leading to a high social and economic burden for individuals, families, the labour market and society. The overall aim of this multicentre study is to test the usability, acceptability and feasibility of an evidence-based, digital education programme for people living and working with persistent LBP who are in sedentary or physically demanding jobs and need advice on ergonomics, self-management of pain and healthy behavioural strategies. Methods: This is the protocol of a multinational, multicentre, prospective uncontrolled feasibility study targeting people with persistent LBP in Lithuania, Northern Ireland, Italy, Sweden and Portugal. Eligible participants will be offered the opportunity to use the MyRelief educational platform as part of their care and will undergo evaluations at baseline (enrollment) and 1-month follow-up. Feasibility will be assessed using measures of recruitment and retention, intervention engagement, outcome measure completion rates and within-group effect sizes in response to the digital education programme. Discussion: This study will identify the challenges and implications of delivering a digital training programme in advance of potentially delivering the programme via an online educational platform available on mobile devices. The findings will inform the design of a future randomised controlled trial if it proves feasible. Trial registration: ClinicalTrials.gov, NCT04673773 . Registered 17 December 2020.</p