Chronic Neck Pain and Exercise Interventions: Frequency,Intensity, Time,and Type Principle

Objective

To identify the most effective components in an active exercise physiotherapy treatment intervention for chronic neck pain based on the frequency, intensity, time, and type (FITT) exercise method of tailoring physical activity recommendations to the individual needs and goals of patients.

Data Sources

Databases, including the Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health, MEDLINE, SPORTDiscus, Biomedical Reference Collection, and Academic Search Premier, were searched for relevant articles.

Study Selection

Quantitative design studies that included active exercise as part of a multimodal or stand-alone approach were selected. Only studies scoring ≥6 on the Physiotherapy Evidence Database Scale were included in the review because this reflected a good level of evidence.

Data Extraction

Study methodologies and relevant outcome measures, including isometric strength, Neck Disability Index scores, and pain scores, were extracted from relevant articles and grouped together for appraisal and synthesis.

Data Synthesis

Evidence from selected articles was synthesized according to the FITT exercise principal to determine the most effective exercise type, frequency, and intensity in the treatment of chronic neck pain.

Conclusions

Physiotherapy interventions using a multimodal approach appear to produce more beneficial outcomes in terms of increased strength, improved function, and health-related quality of life and reduced pain scores. Active strengthening exercises appear to be beneficial for all of these outcomes; the inclusion of additional stretching and aerobic exercise components appear to enhance the benefits of an exercise intervention.     

Therapeutic approaches to fibromyalgia syndrome in the United Kingdom: a survey of occupational therapists and physical therapists.

BACKGROUND AND PURPOSE: This study sought information from occupational therapists (OTs) and physical therapists (PTs) working in rheumatology in the UK on their usual methods of treatment and management of patients with fibromyalgia syndrome (FMS). METHODS. Data were gathered by self-completion questionnaire on: work setting; referrals of FMS patients; usual treatment objectives; assessment and treatment approaches; perceived responsiveness of patients; and other perceptions of the management of FMS. Most data were in the form of frequency counts, with some ordinal scales and open responses. RESULTS: Responses were obtained from 142 therapists (71% response rate), of whom 47 OTs and 39 PTs managed patients with FMS. The foremost therapeutic objective was increased functional ability for OTs, and increased exercise tolerance and general fitness for PTs. Pain reduction or management was rated as the second objective for both groups. An endurance-based exercise program and energy conservation techniques were the most frequently utilized interventions. Patients with FMS were thought to be 'moderately responsive' to physical management. Predictors of outcome were considered to be largely psychosocial, rather than physical, in nature. CONCLUSION: These data provide a preliminary profile of current practice in the management of FMS among UK therapists and indicate certain differences in approach between OTs and PTs.     

Land-Based Versus Pool-Based Exercise for People Awaiting Joint Replacement Surgery of the Hip or Knee: Results of a Randomized Controlled Trial

Gill SD, McBurney H, Schulz DL. Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial.

Objective

To compare the preoperative effects of multidimensional land-based and pool-based exercise programs for people awaiting joint replacement surgery of the hip or knee.

Design

Randomized, single-blind, before-after trial.

Setting

Physiotherapy gymnasium and hydrotherapy pool.

Participants

Patients awaiting elective hip or knee joint replacement surgery.

Interventions

Land-based (n=40) or pool-based exercise program (n=42). Each 6-week program included an education session, twice-weekly exercise classes, and an occupational therapy home assessment.

Main Outcome Measures

Participants were assessed immediately before and after the 6-week intervention, then 8 weeks later. Primary outcomes were pain and self-reported function (Western Ontario and McMaster Universities Osteoarthritis Index) and patient global assessment. Secondary outcomes were performance-based measures (timed walk and chair stand) and psychosocial status (Medical Outcomes Study 36-Item Short-Form Health Survey mental component score). Pain was also measured before and after each exercise class on a 7-point verbal rating scale.

Results

Although both interventions were effective in reducing pain and improving function, there were no postintervention differences between the groups for the primary and secondary outcomes. However, the pool-based group had less pain immediately after the exercise classes.

Conclusions

While our multidimensional exercise-based interventions appeared to be effective in reducing disability in those awaiting joint replacement surgery of the hip or knee, there were no large differences in the postintervention effects of the interventions. However, pool-based exercise appeared to have a more favorable effect on pain immediately after the exercise classes.     

A randomized controlled trial of weight-bearing versus non-weight-bearing exercise for improving physical ability after usual care for hip fracture

OBJECTIVE: To compare the effects of weight-bearing and non-weight-bearing home exercise programs and a control program on physical ability (strength, balance, gait, functional performance) in older people who have had a hip fracture. DESIGN: Randomized controlled trial with 4-month follow-up. SETTING: Australian community-dwellers (82%) and residents of aged care facilities who had completed usual care after a fall-related hip fracture. PARTICIPANTS: One hundred twenty older people entered the trial, 40 per group (average age +/- standard deviation, 79+/-9y) and 90% completed the 4-month retest. INTERVENTION: Home exercise prescribed by a physical therapist. MAIN OUTCOME MEASURES: Strength, balance, gait, and functional performance. RESULTS: At the 4-month retest, there were differences between the groups in the extent of improvement since the initial assessment for balance (F(10,196)=2.82, P<.001) and functional performance (F(6,200)=3.57, P<.001), but not for strength (F(12,190)=1.09, P=.37) or gait (F(8,200)=.39, P=.92). The weight-bearing exercise group showed the greatest improvements in measures of balance and functional performance (between-group differences of 30%-40% of initial values). CONCLUSIONS: A weight-bearing home exercise program can improve balance and functional ability to a greater extent than a non-weight-bearing program or no intervention among older people who have completed usual care after a fall-related hip fracture.     

Aerobic exercise training in addition to conventional physiotherapy for chronic low back pain: a randomized controlled trial

Chan CW, Mok NW, Yeung EW. Aerobic exercise training in addition to conventional physiotherapy for chronic low back pain: a randomized controlled trial.

Objective

To examine the effect of adding aerobic exercise to conventional physiotherapy treatment for patients with chronic low back pain (LBP) in reducing pain and disability.

Design

Randomized controlled trial.

Setting

A physiotherapy outpatient setting in Hong Kong.

Participants

Patients with chronic LBP (N=46) were recruited and randomly assigned to either a control (n=22) or an intervention (n=24) group.

Interventions

An 8-week intervention; both groups received conventional physiotherapy with additional individually tailored aerobic exercise prescribed only to the intervention group.

Main Outcome Measures

Visual analog pain scale, Aberdeen Low Back Pain Disability Scale, and physical fitness measurements were taken at baseline, 8 weeks, and 12 months from the commencement of the intervention. Multivariate analysis of variance was performed to examine between-group differences.

Results

Both groups demonstrated a significant reduction in pain (P<.001) and an improvement in disability (P<.001) at 8 weeks and 12 months; however, no differences were observed between groups. There was no significant difference in LBP relapse at 12 months between the 2 groups (χ²=2.30, P=.13).

Conclusions

The addition of aerobic training to conventional physiotherapy treatment did not enhance either short- or long-term improvement of pain and disability in patients with chronic LBP.     

Pain perception after running a 100-mile ultramarathon

OBJECTIVE: To determine if pain perception is affected by an extreme bout of exercise that causes ongoing exercise-related pain. DESIGN: Repeated-measures design. SETTING: Pre-race registration area and finish area of an endurance race. PARTICIPANTS: Twenty-one competitors in the 2005 Western States 100 Mile Endurance Run and 11 control subjects who were assisting at the race but not running. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Overall pain and pain ratings on a pressure pain test before and after the event. RESULTS: Mean overall pain +/- standard deviation on a 100-mm scale increased (P<.05) from 3+/-6mm before the run to 39+/-28mm after the run among the runners. The faster runners showed a mean reduction (P<.05) in pain ratings after the race of 15+/-20mm (on a 100-mm scale), whereas there was no change for the slower runners and controls. Findings were confirmed by model-based analysis. CONCLUSIONS: The faster runners in a 100-mile (161-km) running race experience a modest temporary reduction in pressure pain perception that does not appear to be augmented by ongoing pain related to the exercise. The lack of a reduction in pain perception among the slower runners may be because an extreme bout of exercise of this nature can "exhaust" the systems responsible for exercise-induced analgesia in all but the most well-trained of runners, or that these systems were not activated because the slower runners were unable to maintain a high enough exercise intensity during the later stages of the race.     

Physiotherapy for Sleep Disturbance in People With Chronic Low Back Pain: Results of a Feasibility Randomized Controlled Trial

Objective

To determine the feasibility of a randomized controlled trial investigating the effectiveness of physiotherapy for sleep disturbance in chronic low back pain (CLBP) (≥12wks).

Design

Randomized controlled trial with evaluations at baseline, 3 months, and 6 months.

Setting

Outpatient physiotherapy department in an academic teaching hospital.

Participants

Participants with CLBP were randomly assigned to a walking program (n=20; mean age ± SD, 46.4±13.8y), supervised exercise class (n=20; mean age ± SD, 41.3±11.9y), or usual physiotherapy (n=20; mean age ± SD, 47.1±14.3y). The 3-month evaluation was completed by 44 participants (73%), and 42 (70%) participants completed the 6-month evaluation.

Interventions

Participants received a physiotherapy-delivered 8-week walking program, an 8-week group supervised exercise class (1 class/wk), or 1-to-1 usual physiotherapy (advice, manual therapy, and exercise).

Main Outcome Measures

Sleep was assessed by the self-reported Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Pittsburgh Sleep Diary, and objective actigraphy.

Results

Groups were comparable at baseline. Most (95%, n=57) of the participants had sleep disturbance. The acceptability of actigraphy was excellent at baseline (58 of 60 participants), but dropped at 3 months (26 of 44 participants). There were improvements on the PSQI and ISI in all groups at 3 and 6 months, with predominantly medium effect sizes (Cohen d=0.2–0.5).

Conclusions

The high prevalence of sleep disturbance indicated the feasibility of good recruitment in future trials. The PSQI would be a suitable screening tool and outcome measure alongside an objective nonobtrusive sleep outcome measure. The effectiveness of physiotherapy for sleep disturbance in CLBP warrants investigation in a fully powered randomized controlled trial.     

The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities

OBJECTIVE: To examine the relation between therapy intensity, including physical therapy (PT), occupational therapy (OT), and speech and language therapy (SLT), provided in a skilled nursing facility (SNF) setting and patients' outcomes as measured by length of stay (LOS) and stage of functional independence as measured by the FIM instrument. DESIGN: A retrospective analysis of secondary data from an administrative dataset compiled and owned by SeniorMetrix Inc. SETTING: Seventy SNFs under contract with SeniorMetrix health plan clients. PARTICIPANTS: Patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions (N=4988) covered by Medicare+Choice plans, and admitted to an SNF in 2002. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: LOS and improvement in stage of independence in the mobility, activities of daily living (ADLs), and executive control domains of function as determined by the FIM instrument. RESULTS: Higher therapy intensity was associated with shorter LOS ( P <.05). Higher PT and OT intensities were associated with greater odds of improving by at least 1 stage in mobility and ADL functional independence across each condition ( P <.05). The OT intensity was associated with an improved executive control stage for patients with stroke, and PT and OT intensities were associated with improved executive control stage for patients with cardiovascular and pulmonary conditions ( P <.05). The SLT intensity was associated with improved motor and executive control functional stages for patients with stroke ( P <.05). Therapy intensities accounted for small proportions of model variances in all outcomes. CONCLUSIONS: Higher therapy intensity was associated with better outcomes as they relate to LOS and functional improvement for patients who have stroke, orthopedic conditions, and cardiovascular and pulmonary conditions and are receiving rehabilitation in the SNF setting.     

A randomised controlled trial of wax baths as an additive therapy to hand exercises in patients with systemic sclerosis

ObjectiveThe musculoskeletal features of systemic sclerosis (SSc) are a major cause of disability, causing limitations to movement and function. The study aim was to compare the effects of daily hand exercises with or without daily home wax bath hand treatment in patients with SSc.DesignAssessor-blinded randomised controlled trial of parallel group design.SettingSingle participating centre, undertaken in secondary care and in participants homes.Participants36 participants with hand skin tightening of SSc, two participants lost to follow up.InterventionsParticipants were randomised into wax bath versus no wax bath groups. Both groups in addition performed regular hand exercises as part of standard care. The study period was 9 weeks, with further measures of outcome undertaken at 18 weeks.Main outcome measuresThe primary outcome measure was the Hand Mobility in Scleroderma test (HAMIS). Secondary outcomes measures were the Scleroderma Health Assessment Questionnaire, grip and pinch strength and the Cochin Hand Function Scale.ResultsBetween group comparisons of HAMIS scores showed no evidence of effectiveness of the wax bath treatment at 9-week follow up (adjusted difference in means (95% CI) experimental-control −1.47 (−3.55 to 0.61), P = 0.16) or at 18-week follow up (adjusted difference in means (95% CI) experimental-control 1.94 (−1.07 to 4.95), P = 0.20). Analysis of secondary outcomes also showed no evidence for effectiveness of the wax bath treatment at either 9 or 18 weeks.ConclusionOur findings suggest that the addition of regular wax bath treatment confers no additional beneficial effect to standard care with daily home exercises.Trial registrationISRCTN registry (http://www.isrctn.com) ISRCTN 66736089.     

On a happier note: validation of musical exercise for older persons in long-term care settings

This paper describes a quasi-experimental study of a musical exercise intervention to improve the physical, cognitive, behavioral status and life satisfaction of older residents in a long-term care facility in the United Kingdom. Twenty long-term care residents from three different units (n=60) were recruited and assigned to one of three groups: a control (C) group (no intervention), an occupational therapy (OT) group (comparison group) and a music exercise group (intervention group). Assessments of physical and cognitive status were made pre-intervention and repeated at the end of the 10-week exercise program and again 10 weeks after the completion of the program. The results show that both OT and exercise participation is associated with improvement in physical and cognitive function. However, the exercise group showed significant improvement in more areas than the OT group. The functional benefits from OT and exercise were not sustainable after these activities ceased and showed significant decline 10 weeks after the end of the programs.     

Effectiveness of graded activity versus physiotherapy in patients with chronic nonspecific low back pain: midterm follow up results of a randomized controlled trial

Background

Low back pain (LBP) is a major health and economic problem worldwide. Graded activity and physiotherapy are commonly used interventions for nonspecific low back pain. However, there is currently little evidence to support the use of one intervention over the other in the medium-term.

Rehabilitation and Disability Research Theme: 2009 Colloquium

Abstract

Background:

Self-regulatory mental fatigue (SRF) is commonly experienced after sustained mental and physical effort that requires people to self-regulate behavior, emotion, and movement. Its occurrence suggests that attempts at conscious self-control cause depletion of an exhaustible resource and could lead to decreased quantity and quality of exercises during physical therapy (PT). Patients typically experience fatigue during PT treatment following musculoskeletal or neurological injury, however, SRF has never been applied to PT although there is a strong theoretical link.

Objectives:

This paper aims to critically appraise the evidence and introduce the concept of SRF to PT rehabilitation of musculoskeletal and neurological conditions. Objectives are to review the current evidence linking SRF to motor control and learning of rehabilitation exercises, links to other allied health areas; to examine the role of emotional suppression on SRF and how it affects performance of PT exercises; and to review the evidence concerning potential techniques for clinicians to offset or promote recovery from SRF.

Major findings:

Self-regulatory mental fatigue is a robust concept as shown by the volume of research in the area. However, variable methodology and the novelty of the concept to PT reduce the strength of the body of evidence. Research suggests a theoretical link between SRF and reduced quality and quantity of PT exercise. Self-regulatory mental fatigue can be induced during motor learning and by psychosocial costs of musculoskeletal and neurological conditions. Good-quality evidence indicates that techniques such as quotas and implementation intentions could prove useful clinical tools to decrease the effects of SRF during PT treatment. Glucose mouth rinse or ingestion is supported by the literature but is not a clinically sustainable treatment for SRF.

Conclusions:

There is a theoretical link between SRF and decreased quality and quantity of therapeutic exercise. In order to decrease the effects of SRF this review suggests strategies such as quotas, implementation intentions, rest periods, and glucose supplementation.