Susan Carolyn Slade

People with non-specific chronic low back pain who have participated in exercise programs have preferences about exercise: a qualitative study

QUESTION What factors do participants in exercise programs for chronic low back pain perceive to be important for engagement and participation? DESIGN Qualitative study of three focus groups. PARTICIPANTS 18 adults with chronic low back pain who had participated in exercise programs for chronic low back pain. RESULTS All focus group results concurred and two significant themes emerged from the focus group data. The first was that the experience of exercise informed participant preferences with respect to exercise environment and type of exercise. Participants described a range of positive and negative experiences, a desire to master exercise techniques, and a preference for exercise that matched their abilities and prior skills. The second significant theme was the helpful and empowering skills of the care-provider, and care-seeker ability to identify and articulate their own needs. Participants regarded carer expertise favourably when positive results were achieved early in the interaction, but were frustrated when they were not listened to and symptoms were aggravated. The relationship was enhanced by effective communication. Participants also recognised they needed to be aware of their own skills and abilities and, and that financial or family support incentives encouraged their adherence to a program. CONCLUSION People are likely to prefer and participate in exercise programs that are designed with consideration of their preferences, circumstances, and past exercise experiences. We propose that information about patient exercise preferences should be collected systematically.

Consensus on Exercise Reporting Template (CERT): Explanation and Elaboration Statement

Exercise is effective for prevention and management of acute and chronic health conditions. However, trial descriptions of exercise interventions are often suboptimal, leaving readers unclear about the content of effective programmes. To address this, the 16-item internationally endorsed Consensus on Exercise Reporting Template (CERT) was developed. The aim is to present the final template and provide an Explanation and Elaboration Statement to operationalise the CERT. Development of the CERT was based on the EQUATOR Network methodological framework for developing reporting guidelines. We used a modified Delphi technique to gain consensus of international exercise experts and conducted 3 sequential rounds of anonymous online questionnaires and a Delphi workshop. The 16-item CERT is the minimum data set considered necessary to report exercise interventions. The contents may be included in online supplementary material, published as a protocol or located on websites and other electronic repositories. The Explanation and Elaboration Statement is intended to enhance the use, understanding and dissemination of the CERT and presents the meaning and rationale for each item, together with examples of good reporting. The CERT is designed specifically for the reporting of exercise programmes across all evaluative study designs for exercise research. The CERT can be used by authors to structure intervention reports, by reviewers and editors to assess completeness of exercise descriptions and by readers to facilitate the use of the published information. The CERT has the potential to increase clinical uptake of effective exercise programmes, enable research replication, reduce research waste and improve patient outcomes.

What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies.

Objectives:The global burden of low back pain is the highest ranked condition contributing to years of living with disability. Exercise is moderately effective, and adherence to exercise may improve if participants are engaged. Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions. The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain. Methods:Two independent reviewers conducted a structured review and metasynthesis informed by Cochrane and Campbell Collaboration guidelines and the PRISMA statement. Fifteen papers were included for data extraction, method quality assessment, and thematic analysis. Results:Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue. Discussion:People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study.

Background Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice. Objective The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT). Design and Methods Using the EQUATOR Networks methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used. Results There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion. Limitations The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts. Conclusions The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

Standardised method for reporting exercise programmes : protocol for a modified Delphi study

Introduction Exercise is integral to health across the lifespan and important for people with chronic health conditions. A systematic review of exercise trials for chronic conditions reported suboptimal descriptions of the evaluated interventions and concluded that this hinders interpretation and replication. The aim of this project is to develop a standardised method for reporting essential exercise programme details being evaluated in clinical trials. Methods and analysis A modified Delphi technique will be used to gain consensus among international exercise experts. We will use three sequential rounds of anonymous online questionnaires to refine a standardised checklist. A draft checklist of potentially relevant items was developed based on the results of a systematic review of exercise systematic reviews. An international panel of experts was identified by exercise systematic review authorship, established international profile in exercise research and practice and by peer referral. In round 1, the international panel of experts will be asked to rate the importance of each draft item and provide additional suggestions for revisions or new items. Consensus will be considered reached if at least 70% of the panel strongly agree/disagree that an item should be included or excluded. Where agreement is not reached or there are suggestions for altered or new items, these will be taken to round 2 together with an aggregated summary of round 1 responses. Following the second round, a ranking of item importance will be made to rationalise the number of items. The final template will be distributed to panel members for approval. Ethics and dissemination Ethics approval was received from The Cabrini Institute Ethics Committee, Melbourne, Australia (HREC 02-07-04-14). We plan to use a stepwise process to develop and refine a standardised and internationally agreed template for explicit reporting of exercise programmes. The template will be generalisable across all types of exercise interventions. The findings will be disseminated through peer-reviewed publications and conference presentations.

Exercise prescription: a case for standardised reporting

Background Structured, regular exercise is recommended to improve health outcomes. Exercise takes many forms and varies in type, intensity, duration and frequency. The authors used the example of exercise for chronic health conditions to examine how exercise programmes are described and summarised in systematic reviews. Methods Two independent reviewers conducted a review of exercise reporting practices using the evidence of exercise effects for chronic conditions as the source material. Inclusion criteria: systematic reviews that summarised the effects of exercise programmes for adults with chronic health conditions. Exclusion criteria: reviews of studies of children and adolescent populations, and non-English publications. Results Seventy-three reviews were included. Data on sample size, number of included trials, interventions, comparisons, programme characteristics, exercise components, author conclusions and recommendations were extracted. Seventy-one per cent of reviews reported being unable to adequately describe the exercise programmes, because the required information was not reported in included trials. Using key exercise descriptors from the included reviews, the authors developed criteria for reporting to a level that enables replication. Conclusions All included reviews recommended better and standardised reporting. Incomplete exercise programme descriptions limit confidence in the accurate replication of effective interventions and limits critical appraisal of interventions when conflicting outcomes are reported. The evaluation and implementation of physical activity and exercise research would be facilitated if exercise programmes are comprehensively described. The authors propose that systematic reviews/meta-analysis and clinical application of the outcomes of exercise therapy research would be enhanced if authors used an exercise reporting grid that includes a detailed description of the programme components.

The dilemma of diagnostic uncertainty when treating people with chronic low back pain: a qualitative study:

Objective: To investigate how physiotherapists prescribe execise for people with non-specific chronic low back pain in the absence of definitive or differential diagnoses. Design: Four guided focus groups were conducted to gather the views of physiotherapists working in primary care. Subjects and setting: Twenty-three primary care physiotherapists from metropolitan Melbourne, Australia, were identified from professional organization member lists and publicly available records. They were recruited via email and assembled for focus groups based on eligibility, availability and location. Main measures: Discussions were audio-taped, transcribed verbatim and analysed for themes by three independent researchers. Results: The ‘dilemma created by diagnostic uncertainty’ emerged as a significant overarching theme with the following subthemes. Physiotherapists: 1) perceive that care-seekers want a clear diagnosis, 2) are challenged by diagnostic uncertainty, 3) are critical when patients fail to improve, 4) feel unprepared by traditional education models and 5) seek support from experienced colleagues. Physiotherapists report needing to: 1) educate care-seekers about their injury/diagnosis, despite diagnostic uncertainty, and 2)observe rapid health outcome improvements. They exhibit potentially negative behaviours, including blame attribution, when this does not occur. Conclusions: Physiotherapists appear under-prepared for the challenges of working with people with chronic conditions. Quality research is warranted to determine best practice in supporting practitioners in the development of suitable therapeutic behaviours to deal with this challenging patient interface.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies

Introduction Low back pain is the highest ranked condition contributing to years lived with disability, and is a significant economic and societal burden. Evidence-based clinical practice guidelines are designed to improve quality of care and reduce practice variation by providing graded recommendations based on the best available evidence. Studies of low back pain guideline implementation have shown no or modest effects at changing clinical practice. Objectives To identify enablers and barriers to adherence to clinical practice guidelines for the management of low back pain. Methods and analysis A systematic review and meta-synthesis of qualitative studies that will be conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Eight databases will be searched using a priori inclusion/exclusion criteria. Two independent reviewers will conduct a structured review and meta-synthesis, and a third reviewer will arbitrate where there is disagreement. This protocol has been registered on PROSPERO 2014. Ethics and dissemination Ethical approval is not required. The systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically, in print and at conferences. Updates of the review will be conducted to inform and guide healthcare translation into practice. Trial registration number PROSPERO 2014:CRD42014012961. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014012961

Systematic review methodology in higher education

Systematic review methodology can be distinguished from narrative reviews of the literature through its emphasis on transparent, structured and comprehensive approaches to searching the literature and its requirement for formal synthesis of research findings. There appears to be relatively little use of the systematic review methodology within the higher education sector. This paper outlines the systematic review methodology, including variations, explores debates regarding systematic reviews from the educational literature and describes particular issues for its application within higher education. We conclude that thoughtful use of the systematic review methodology may be of benefit to the sector.

Measurement of Participant Experience and Satisfaction of Exercise Programs for Low Back Pain: A Structured Literature Review

OBJECTIVES The objective of this review was to identify measuring instruments that might be suitable for assessment of satisfaction and experience of exercise programs designed to help people with persistent, recurrent low back pain. DESIGN The review was designed as a structured literature review adapted from the Cochrane Collaboration Systematic Review and the Quality of Reporting of Meta-analyses and Preferred Reporting Items for Systematic Reviews and Meta-analyses Guidelines. METHODS A priori inclusion and exclusion criteria were established and electronic databases were searched without limits until February 2009. Data extraction guidelines were developed to extract the same information from each included article. Thematic analysis, conducted by two independent reviewers, was applied to identify emergent codes and themes from the questionnaires. The relevant questions were then evaluated for applicability to the back pain population. RESULTS Ten potentially useful instruments were described in the 11 included articles. The following domains of experience were common to the included instruments: care-provider qualities, support staff, governance, access, and facilities. The answers to questions based on these themes may give valuable insights into the experience of exercise programs in general and for low back pain. CONCLUSIONS Important information that would inform researchers and clinicians regarding the components of successful exercise programs may be gained from the development of an instrument that assesses experience of exercise program participation. Research into the experience of people who have participated in exercise programs may be a key to understanding their motivation, engagement, compliance or noncompliance and success or failure.