Osteoarthritis (OA) and chronic low back pain (CLBP) are two of the most common musculoskeletal pain conditions in the developed world (WHO, 2003). These conditions place a huge burden on both the health system, in terms of service demand, and the people with the condition, in terms of quality of life and personal wellbeing (Buchbinder et al., 2013). Aiming to reduce this burden both for the individual and the health system in question, international clinical guidelines for the treatment of OA and CLBP have endorsed self-management, education and exercise as important components of the management of these conditions (Pillastrini et al., 2012, Hochberg et al., 2012).
Interventions promoting self-management, involving education and exercise that are delivered in groups of people with a combination of painful joint areas (such as people with CLBP and/or lower limb OA), are an attractive option for healthcare providers as this would potentially enable them to treat more people in less time. Physiotherapists are well-placed to provide such interventions in primary care, and are often the main providers of this type of intervention (Walsh et al., 2006, Patel et al., 2014). No research has previously reviewed the effectiveness of physiotherapy-led self-management interventions for people with these specific conditions combined, as such the overall effectiveness is unclear.
Recently, our research team in University College Dublin undertook a rapid review of the literature on the effectiveness of these types of group-based self-management interventions (GPSMIs) (Toomey et al., 2014a). We searched for published studies involving adult participants with CLBP and/or OA of the hip, knee and/or lower back. To be included, the intervention in question needed to aim to promote self-management and incorporate 1) an educational component, 2) a structured exercise component and 3) the training of participants in self-management skills, such as pain management or coping strategies (e.g. appropriate medication use, physical activity, pacing, goal-setting). The intervention needed to be delivered face-to-face by healthcare professionals (to include at least one physiotherapist) in a group format (two or more participants).
Overall, we found a total of 22 relevant studies; 10 of which involved people with OA, 12 involving people with CLBP but none that included both conditions together. In the 22 studies, the GPSMIs were compared to a number of different treatments (comparator groups) – individual physiotherapy (n=8), unspecified ‘usual medical management’ (n=6), a variety of specific treatments (e.g. spinal manipulation) delivered by general practitioners (n=4), the GPSMIs with an additional component (e.g. GPSMI with acupuncture) (n=4) and other treatments (e.g. group yoga or no treatment) (n=4). To measure effectiveness, studies mostly used questionnaires that measured pain as an outcome followed by disability, quality of life and physical function. The results showed that GPSMIs were just as effective as individual physiotherapy. For the other comparator groups, there was not enough agreement between the findings of the grouped studies to be able to make any clear conclusions. We also felt that there wasn’t enough clarity in terms of what the actual treatment was within the other comparator groups to be able to make conclusions – e.g. what was involved in ‘usual medical management’ in one study may have been completely different to ‘usual medical management’ in another study.
So where does this leave us? Well on first glance, it appears that GPSMIs are no more effective than individual physiotherapy. However, there are a number of factors to be considered. Firstly, it is important to remember that the most commonly used measures of effectiveness in these studies were pain, disability, quality of life and physical function. Although these are very important overall outcomes, interventions that aim to promote self-management are potentially more about improving a person’s ability and confidence to deal with and manage their pain and symptoms. Therefore measures of pain, disability etc., may not be the most appropriate for self-management interventions. In addition, group-based interventions treating people with multiple conditions may be more cost-effective than individual physiotherapy, but this has not been well investigated at this time.
The second part of our review (Toomey et al., 2014b) examined the reported ‘fidelity’ of the 22 included studies, using a checklist developed by the National Institutes for Health (Borrelli et al., 2005) to give each study a % fidelity score. Fidelity relates to how well the interventions were actually carried out as intended by the interventions’ developers (Gearing et al., 2011). For example, a study may be designed to deliver six physiotherapy sessions to a group of eight people, but what actually happens in reality may be different. While this may reflect the difficulties faced by interventions carried out in real life settings, it is important to address and monitor this as it may alter what is actually being tested by the study.
Overall, we found that the average fidelity score across all studies was 36%, with 18 of the studies scoring below 50%, interpreted as ‘low’. Only one study scored above 80%, interpreted as ‘high’. Bearing this in mind, it makes us further question the results of the effectiveness review, as it is possible that the studies did not fully test what they intended to test.
Going forwards, we believe that GPSMIs may be of benefit for people with OA and/or CLBP, but that future research needs to explore both clinical and cost-effectiveness of treating both conditions together, the most appropriate outcome measures for self-management programmes and the implementation fidelity of these interventions.
This review was funded by the Health Research Board of Ireland as part of Health Research Award HRA_HSR/2012/24
About Elaine Toomey
Elaine is currently completing a PhD in University College Dublin. Her work is exploring the area of implementation fidelity within behaviour change interventions. Still a practicing physiotherapist, her research interests lie in linking research with clinical practice and the implementation of good quality evidence into clinical settings.
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