Physiotherapy - Research Publications

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    An international core capability framework for physiotherapists delivering telephone-based care.
    Davies, L ; Hinman, RS ; Russell, T ; Lawford, B ; Bennell, K (Elsevier BV, 2022-04)
    QUESTION: What are the core capabilities that physiotherapists need in order to deliver quality telephone-based care? DESIGN: Three-round modified e-Delphi survey. PARTICIPANTS: An international Delphi panel comprising experts in the field, including consumers, physiotherapy researchers, physiotherapy clinicians and representatives of physiotherapy organisations. METHODS: A modified e-Delphi survey was conducted. A draft framework was adapted from a previously developed core capability framework for physiotherapists delivering care via videoconferencing. The panel considered the draft framework of 39 individual capabilities across six domains. Over three rounds, panellists rated their agreement (via Likert or 0-to-10 numerical rating scales) on whether each capability was essential (core) for physiotherapists to deliver telephone-based care. Capabilities achieving consensus, defined as 75% of the panel rating the item at least 7 out of 10 in Round 3, were retained. RESULTS: Seventy-one panellists from 17 countries participated in Round 1, with retention of 89% in Round 2 and 82% in Round 3. The final framework comprised 44 capabilities across six domains: compliance (n = 7 capabilities); patient privacy and confidentiality (n = 4); patient safety (n = 7); telehealth delivery (n = 9); assessment and diagnosis (n = 7); and care planning and management (n = 10). CONCLUSION: This framework outlines the core capabilities that physiotherapists need to provide telephone-based care. It can help inform content of physiotherapy curricula and professional development initiatives in telehealth delivery and provide guidance for physiotherapists providing care over the telephone.
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    Patient-Facing Mobile Apps to Support Physiotherapy Care: Protocol for a Systematic Review of Apps Within App Stores
    Merolli, M ; Francis, JJ ; Vallance, P ; Bennell, KL ; Malliaras, P ; Hinman, RS (JMIR PUBLICATIONS, INC, 2021-12-01)
    BACKGROUND: Care delivered by physiotherapists aims to facilitate engagement in positive health behaviors by patients (eg, adherence to exercise). However, research suggests that behavioral interventions are frequently omitted from care. Hence, better understanding of strategies that can be used by physiotherapists to support patients to engage in positive behaviors is important and likely to optimize outcomes. Digital health interventions delivered via mobile apps are garnering attention for their ability to support behavior change. They have potential to incorporate numerous behavior change techniques (BCTs) to support goals of physiotherapy care, including but not limited to self-monitoring, goal setting, and prompts/alerts. Despite their potential to support physiotherapy care, much is still unknown about what apps are available to consumers, the BCTs they use, their quality, and their potential to change behaviors. OBJECTIVE: The primary aim of this study is to systematically review the mobile apps available in app stores that are intended for use by patients to support physiotherapy care, including the BCTs within these apps. The secondary aims are to evaluate the quality and behavior change potential of these apps. METHODS: A systematic review of mobile apps in app stores will be undertaken. This will be guided by recommendations for systematic reviews in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement but adapted to suit our app store search, consistent with similar systematic reviews of apps published in the Journal of Medical Internet Research. Apple Store and Google Play will be searched with a two-step search strategy, using terms relevant to physiotherapy, physiotherapists, and common physiotherapy care. Key eligibility criteria will include apps that are intended for use by patients and are self-contained or stand-alone without the need of additional wearable devices or other add-ons. Included apps will be coded for BCTs and rated for quality using the Mobile Application Rating Scale (MARS) and for potential to change behavior using the App Behavior Change Scale (ABACUS). RESULTS: App store search and screening are expected to be completed in 2021. Data extraction and quality appraisal are expected to commence by November 2021. The study results are expected to be published in a subsequent paper in 2022. CONCLUSIONS: Knowledge gained from this review will support clinical practice and inform research by providing a greater understanding of the quality of currently available mobile apps and their potential to support patient behavior change goals of physiotherapy care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/29047.
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    An e-Learning Program for Physiotherapists to Manage Knee Osteoarthritis Via Telehealth During the COVID-19 Pandemic: Real-World Evaluation Study Using Registration and Survey Data.
    Jorge, AES ; Bennell, KL ; Kimp, AJ ; Campbell, PK ; Hinman, RS (JMIR Publications Inc., 2021-12-01)
    BACKGROUND: The COVID-19 pandemic necessitated clinicians to transition to telehealth, often with little preparation or training. The Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis (PEAK) e-learning modules were developed to upskill physiotherapists in management of knee osteoarthritis (OA) via telehealth and in-person. In the research setting, the e-learning modules are perceived by physiotherapists as effective when they are part of a comprehensive training program for a clinical trial. However, the effectiveness of the modules on their own in a real-world setting is unknown. OBJECTIVE: This study aims to evaluate the reach, effectiveness, adoption, and implementation of PEAK e-learning modules. METHODS: This longitudinal study was informed by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Participants were clinicians, researchers, educators, and health care students who registered for access to the modules between April 1 and November 30, 2020. Reach was evaluated by outcomes (countries, referral sources, and attrition) extracted from registration data and embedded within precourse surveys in the Learning Management System (LMS). Effectiveness was evaluated by outcomes (confidence with videoconferencing; likelihood of using education, strengthening exercise, and physical activity in a treatment plan for knee OA; usefulness of modules) measured using a 10-point numeric rating scale (NRS; score range from 1=not confident or likely or useful at all to 10=extremely confident or likely or useful) in pre- and postcourse (on completion) surveys in the LMS. Adoption and implementation were evaluated by demographic and professional characteristics and outcomes related to the use of learning and usefulness of program elements (measured via a 4-point Likert scale, from not at all useful to extremely useful) in a survey administered 4 months after module completion. RESULTS: Broad reach was achieved, with 6720 people from 97 countries registering for access. Among registrants, there were high levels of attrition, with 36.65% (2463/6720) commencing the program and precourse survey and 19.61% (1318/6720) completing all modules and the postcourse survey. The program was effective. Learners who completed the modules demonstrated increased confidence with videoconferencing (mean change 3.1, 95% CI 3.0-3.3 NRS units) and increased likelihood of using education, strengthening and physical activity in a knee OA treatment plan, compared to precourse. Adoption and implementation of learning (n=149 respondents) occurred at 4 months. More than half of the respondents used their learning to structure in-person consultations with patients (80/142, 56.3%) and patient information booklets in their clinical practice (75/142, 52.8%). CONCLUSIONS: Findings provide evidence of the reach and effectiveness of an asynchronous self-directed e-learning program in a real-world setting among physiotherapists. The e-learning modules offer clinicians an accessible educational course to learn about best-practice knee OA management, including telehealth delivery via videoconferencing. Attrition across the e-learning program highlights the challenges of keeping learners engaged in self-directed web-based learning.
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    Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial)
    Rebbeck, T ; Evans, K ; Ferreira, P ; Beales, D ; Sterling, M ; Bennell, KL ; Cameron, I ; Nicholas, M ; Ritchie, C ; Jull, G ; Treleaven, J ; Trevena, L ; Refshauge, K ; Connelly, L ; Foster, N ; Black, D ; Hodges, P ; Ferreira, M ; Shaw, TJ ; Simic, M (BMJ PUBLISHING GROUP, 2021-12-01)
    Introduction Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people’s risk of poor outcome. Methods and analysis Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration. Ethics and dissemination Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media. Trial registration number ACTRN12619000871145.
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    Effects of adding aerobic physical activity to strengthening exercise on hip osteoarthritis symptoms: protocol for the PHOENIX randomised controlled trial
    Hall, M ; Allison, K ; Hinman, RS ; Bennell, KL ; Spiers, L ; Knox, G ; Plinsinga, M ; Klyne, DM ; McManus, F ; Lamb, KE ; Da Costa, R ; Murphy, NJ ; Dobson, FL (BMC, 2022-04-18)
    BACKGROUND: Hip osteoarthritis (OA) is a leading cause of musculoskeletal pain. Exercise is a core recommended treatment. Most evidence is based on muscle-strengthening exercise, but aerobic physical activity has potential to enhance clinical benefits. The primary aim of this study is to test the hypothesis that adding aerobic physical activity to a muscle strengthening exercise leads to significantly greater reduction in hip pain and improvements in physical function, compared to a lower-limb muscle strengthening exercise program alone at 3 months. METHODS: This is a superiority, 2-group, parallel randomised controlled trial including 196 people with symptomatic hip OA from the community. Following baseline assessment, participants are randomly allocated to receive either i) aerobic physical activity and muscle strengthening exercise or; ii) muscle strengthening exercise only. Participants in both groups receive 9 consultations with a physiotherapist over 3 months. Both groups receive a progressive muscle strengthening exercise program in addition to advice about OA management. The aerobic physical activity plan includes a prescription of moderate intensity aerobic physical activity with a goal of attaining 150 min per week. Primary outcomes are self-reported hip pain assessed on an 11-point numeric rating scale (0 = 'no pain' and 10 = 'worst pain possible') and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index physical function subscale) at 3 months. Secondary outcomes include other measures of self-reported pain (assessed at 0, 3, 9 months), self-reported physical function (assessed at 0, 3, 9 months), performance-based physical function (assessed at 0, 3 months), joint stiffness (assessed at 0, 3, 9 months), quality of life (assessed at 0, 3, 9 months), muscle strength (assessed at 0, 3 months), and cardiorespiratory fitness (assessed at 0, 3 months). Other measures include adverse events, co-interventions, and adherence. Measures of body composition, serum inflammatory biomarkers, quantitative sensory measures, anxiety, depression, fear of movement and self-efficacy are included to explore causal mechanisms. DISCUSSION: Findings will assist to provide an evidence-based recommendation regarding the additional effect of aerobic physical activity to lower-limb muscle strengthening on hip OA pain and physical function. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN 12619001297112. Registered 20th September 2019.
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    Expert-Moderated Peer-to-Peer Online Support Group for People With Knee Osteoarthritis: Mixed Methods Randomized Controlled Pilot and Feasibility Study.
    Egerton, T ; Lawford, BJ ; Campbell, PK ; Plinsinga, ML ; Spiers, L ; Mackenzie, DA ; Graham, B ; Mills, K ; Eyles, J ; Knox, G ; Metcalf, B ; Maclachlan, LR ; Besomi, M ; Dickson, C ; Abraham, C ; Vicenzino, B ; Hodges, PW ; Hunter, DJ ; Bennell, KL (JMIR Publications Inc., 2022-01-17)
    BACKGROUND: Osteoarthritis (OA) is a major problem globally. First-line management comprises education and self-management strategies. Online support groups may be a low-cost method of facilitating self-management. OBJECTIVE: The aim of this randomized controlled pilot study is to evaluate the feasibility of the study design and implementation of an evidence-informed, expert-moderated, peer-to-peer online support group (My Knee Community) for people with knee OA. The impacts on psychological determinants of self-management, selected self-management behaviors, and health outcomes were secondary investigations. METHODS: This mixed methods study evaluated study feasibility (participant recruitment, retention, and costs), experimental intervention feasibility (acceptability and fidelity to the proposed design, including perceived benefit, satisfaction, and member engagement), psychological determinants (eg, self-efficacy and social support), behavioral measures, health outcomes, and harms. Of a total of 186, 63 (33.9%) participants (41/63, 65% experimental and 22/63, 35% control) with self-reported knee OA were recruited from 186 volunteers. Experimental group participants were provided membership to My Knee Community, which already had existing nonstudy members, and were recommended a web-based education resource (My Joint Pain). The control group received the My Joint Pain website recommendation only. Participants were not blinded to their group allocation or the study interventions. Participant-reported data were collected remotely using web-based questionnaires. A total of 10 experimental group participants also participated in semistructured interviews. The transcribed interview data and all forum posts by the study participants were thematically analyzed. RESULTS: Study feasibility was supported by acceptable levels of retention; however, there were low levels of engagement with the support group by participants: 15% (6/41) of participants did not log in at all; the median number of times visited was 4 times per participant; only 29% (12/41) of participants posted, and there were relatively low levels of activity overall on the forum. This affected the results for satisfaction (overall mean 5.9/10, SD 2.7) and perceived benefit (17/31, 55%: yes). There were no differences among groups for quantitative outcomes. The themes discussed in the interviews were connections and support, information and advice, and barriers and facilitators. Qualitative data suggest that there is potential for people to derive benefit from connecting with others with knee OA by receiving support and assisting with unmet informational needs. CONCLUSIONS: Although a large-scale study is feasible, the intervention implementation was considered unsatisfactory because of low levels of activity and engagement by members. We recommend that expectations about the support group need to be made clear from the outset. Additionally, the platform design needs to be more engaging and rewarding, and membership should only be offered to people willing to share their personal stories and who are interested in learning from the experiences of others. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001230145; http://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377958.
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    Moderators of the Effect of a Self-directed Digitally Delivered Exercise Program for People With Knee Osteoarthritis: Exploratory Analysis of a Randomized Controlled Trial
    Nelligan, RK ; Hinman, RS ; McManus, F ; Lamb, KE ; Bennell, KL (JMIR PUBLICATIONS, INC, 2021-10-29)
    BACKGROUND: A 24-week self-directed digitally delivered intervention was found to improve pain and function in people with knee osteoarthritis (OA). However, it is possible that this intervention may be better suited to certain subgroups of people with knee OA compared to others. OBJECTIVE: The aim of this study was to explore whether certain individual baseline characteristics moderate the effects of a self-directed digitally delivered intervention on changes in pain and function over 24 weeks in people with knee OA. METHODS: An exploratory analysis was conducted on data from a randomized controlled trial involving 206 people with a clinical diagnosis of knee OA. This trial compared a self-directed digitally delivered intervention comprising of web-based education, exercise, and physical activity program supported by automated exercise behavior change mobile phone text messages to web-based education alone (control). The primary outcomes were changes in overall knee pain (assessed on an 11-point numerical rating scale) and physical function (assessed using the Western Ontario and McMaster Universities Osteoarthritis Index function subscale [WOMAC]) at 24 weeks. Five baseline patient characteristics were selected as the potential moderators: (1) number of comorbidities, (2) number of other painful joints, (3) pain self-efficacy, (4) exercise self-efficacy, and (5) self-perceived importance of exercise. Separate linear regression models for each primary outcome and each potential moderator were fit, including treatment group, moderator, and interaction between treatment group and moderator, adjusting for the outcome at baseline. RESULTS: There was evidence that pain self-efficacy moderated the effect of the intervention on physical function compared to the control at 24 weeks (interaction P=.02). Posthoc assessment of the mean change in WOMAC function by treatment arm showed that each 1-unit increase in baseline pain self-efficacy was associated with a 1.52 (95% CI 0.27 to 2.78) unit improvement in the control group. In contrast, a reduction of 0.62 (95% CI -1.93 to 0.68) units was observed in the intervention group with each unit increase in pain self-efficacy. There was only weak evidence that pain self-efficacy moderated the effect of the intervention on pain and that number of comorbidities, number of other painful joints, exercise self-efficacy, or exercise importance moderated the effect of the intervention on pain or function. CONCLUSIONS: With the exception of pain self-efficacy, which moderated changes in function but not pain, we found limited evidence that our selected baseline patient characteristics moderated intervention outcomes. This indicates that people with a range of baseline characteristics respond similarly to the unsupervised digitally delivered exercise intervention. As these findings are exploratory in nature, they require confirmation in future studies.
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    Effects of adding a diet intervention to exercise on hip osteoarthritis pain: protocol for the ECHO randomized controlled trial
    Hall, M ; Hinman, RS ; Knox, G ; Spiers, L ; Sumithran, P ; Murphy, NJ ; McManus, F ; Lamb, KE ; Cicuittini, F ; Hunter, DJ ; Messier, SP ; Bennell, KL (BMC, 2022-03-05)
    BACKGROUND: Hip osteoarthritis (OA) is a leading cause of musculoskeletal pain. Exercise is a core recommended treatment. Despite some clinical guidelines also recommending weight loss for hip OA, there is no evidence from randomised controlled trials (RCT) to substantiate these recommendations. This superiority, 2-group, parallel RCT will compare a combined diet and exercise program to an exercise only program, over 6 months. METHODS: One hundred people with symptomatic and radiographic hip OA will be recruited from the community. Following baseline assessment, participants will be randomly allocated to either, i) diet and exercise or; ii) exercise only. Participants in the diet and exercise group will have six consultations with a dietitian and five consultations with a physiotherapist via videoconferencing over 6 months. The exercise only group will have five consultations with a physiotherapist via videoconferencing over 6 months. The exercise program for both groups will include prescription of strengthening exercise and a physical activity plan, advice about OA management and additional educational resources. The diet intervention includes prescription of a ketogenic very low-calorie diet with meal replacements and educational resources to support weight loss and healthy eating. Primary outcome is self-reported hip pain via an 11-point numeric rating scale (0 = 'no pain' and 10 = 'worst pain possible') at 6 months. Secondary outcomes include self-reported body weight (at 0, 6 and 12 months) and body mass index (at 0, 6 and 12 months), visceral fat (measured using dual energy x-ray absorptiometry at 0 and 6 months), pain, physical function, quality of life (all measured using subscales of the Hip Osteoarthritis Outcome Scale at 0, 6 and 12 months), and change in pain and physical activity (measured using 7-point global rating of change Likert scale at 6 and 12 months). Additional measures include adherence, adverse events and cost-effectiveness. DISCUSSION: This study will determine whether a diet intervention in addition to exercise provides greater hip pain-relief, compared to exercise alone. Findings will assist clinicians in providing evidence-based advice regarding the effect of a dietary intervention on hip OA pain. TRIAL REGISTRATION: ClinicalTrials.gov . Identifier: NCT04825483 . Registered 31st March 2021.
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    Podiatry Intervention Versus Usual General Practitioner Care for Symptomatic Radiographic Osteoarthritis of the First Metatarsophalangeal Joint: A Randomized Clinical Feasibility Study
    Paterson, KL ; Hinman, RS ; Metcalf, BR ; Campbell, PK ; Menz, HB ; Hunter, DJ ; Bennell, KL (WILEY, 2021-02-01)
    OBJECTIVE: To determine the feasibility of a clinical trial comparing a podiatry intervention to usual general practitioner (GP) care for people with first metatarsophalangeal (MTP) joint osteoarthritis (OA). METHODS: A 2-arm, participant- and assessor-blinded, randomized feasibility study was conducted over 12 weeks. Participants were age >40 years and had pain and radiographic OA in the first MTP joint. Participants in the podiatry group had 3 visits and received foot orthoses, exercise, manual therapy, and advice. Participants in the GP group had 1 visit and received medication advice/prescription and the same advice as the podiatry group. Primary outcomes were measures of feasibility (recruitment, attendance, and retention rates; percentage of prescribed exercise sessions completed; orthoses wear hours/day; treatment fidelity). Secondary outcomes included self-reported pain, function, satisfaction, adherence, adverse events, and dropouts. RESULTS: A total of 236 people were screened, and 30 (13%) were included. All except 1 participant in the podiatry group attended the required clinical visits, and retention rates were 93% (podiatry group) and 80% (GP group). Participants completed 66% of the exercise sessions and wore orthoses for an average of 6.3 hours/day. Adherence to medication use was 5.3 on an 11-point numeric rating scale. Both treatment approaches improved pain and function by clinically important differences at 12 weeks. CONCLUSION: A clinical trial comparing a podiatry intervention to usual GP care for people with first MTP joint OA is feasible. Given the improvements in pain and function observed, a larger appropriately powered clinical trial is warranted to evaluate the superiority of one treatment approach over the other.
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    Perceptions About the Efficacy and Acceptability of Telephone and Video-Delivered Allied Health Care for Adults With Disabilities During the COVID-19 Pandemic: A Cross-sectional National Survey.
    Lawford, BJ ; Hinman, RS ; Morello, R ; Oliver, K ; Spittle, A ; Bennell, KL (Elsevier BV, 2022-07)
    OBJECTIVE: To investigate and compare perceptions about the efficacy and acceptability of allied health care delivered via telephone and video call for adults with disabilities during the COVID-19 pandemic. DESIGN: Cross-sectional national survey. SETTING: Participants who accessed occupational therapy, physiotherapy, psychology, or speech pathology care via telephone or via video call from June to September 2020. PARTICIPANTS: Five hundred eighty-one adults with permanent or significant disabilities, or their carers, partners, or family members, who were funded by the Australian National Disability Insurance Scheme. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Experiences (eg, safety, efficacy, ease of use) with telephone and video-delivered care. Data were analyzed by calculating response proportions and chi-square tests to evaluate differences in experiences between allied health professions and between telephone and video modalities. RESULTS: Responses were obtained for 581 adults with disabilities. There was no evidence of differences between experiences with telephone or video-delivered services or across allied health professions. Overall, 47%-56% of respondents found telehealth technology easy to use (vs 17%-26% who found it difficult), 51%-55% felt comfortable communicating (vs 24%-27% who felt uncomfortable), 51%-67% were happy with the privacy and/or security (vs 6%-9% who were unhappy), 74% were happy with the safety (vs 5%-7% who were unhappy), and 56%-64% believed the care they received was effective (vs 17% who believed it was ineffective). Despite this, 48%-51% were unlikely to choose to use telephone or video consultations in the future (vs 32%-36% who were likely). CONCLUSIONS: Adults with disabilities in Australia had generally positive experiences receiving allied health care via telehealth during the COVID-19 pandemic, although some experienced difficulties using and communicating via the technology. Findings indicated no differences between satisfaction with telephone or video modalities, or between physiotherapy, speech pathology, occupational therapy, or psychology services.