Jacobus Bart Staal

1. In recent years, virtual reality (VR) has become an increasingly popular treatment for both acute and chronic pain conditions. It has also received more and more attention from researchers. A bi...

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of physical prehabilitation (i.e. exercise-based interventions delivered before surgery) alone or as part of a multimodal programme compared with no exercise-based intervention, usual care, or a different intervention in people undergoing major abdominal surgery.

To evaluate the (cost-)effectiveness of a physiotherapist-led, multimodal vocational intervention compared to usual care in adults with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) experiencing reduced work ability. (Self-)employed people with RA or axSpA and reduced work ability were randomized to a 12-month vocational intervention or usual care. Assessments were conducted at baseline, 3, 6, and 12 months. Primary outcome was the Work Ability index Single-item Scale (WAS) at 12 months. Secondary outcomes included additional work-related and clinical outcomes. Cost-effectiveness was evaluated using the EuroQol to estimate quality-adjusted life years (QALYs), alongside healthcare use and productivity data. Primary analyses followed an intention-to-treat approach. A total of 140 participants (80 RA, 60 axSpA) were randomized 1:1 to the intervention or control group. At 12 months, the intervention showed no significant benefits over usual care on the WAS (estimated mean difference (MD): 0.40, 95% confidence interval (CI): − 0.22, 1.01) or any of the secondary outcomes. The QALYs were in favor of the intervention group by 0.05. The mean intervention costs were €395 per participant (90% usage, mean 9.5 sessions). After 12 months, the societal costs were €4324 lower in the intervention group (95% CI €-8169, €-479), mainly due to higher medication and presenteeism costs in the control group. At a willingness-to-pay threshold of €20.000/QALY, the intervention had a 99% probability of being cost-effective compared to usual care. While the intervention did not affect work ability in individuals with RA or axSpA, it outperformed usual care from a health-economic perspective, demonstrating its cost-effectiveness and potential value. International Clinical Trial Registry Platform (ICTRP) registration link: ICTRP Search Portal.

Low back pain is the leading cause of global disability for which exercise therapy is a widely recommended treatment. Research indicates that contextual factors may also influence treatment outcomes in low back pain. Examples include the patient-therapist relationship and other treatment-related circumstances that affect patient expectations. By focusing on the specific treatment effect, clinical trials often ignore the effect of contextual factors, thereby contributing to the so-called efficacy paradox. This means that treatment effects observed in clinical practice are often greater than those reported in clinical trials. This systematic review aims to investigate the proportion of improvement in pain and disability that can be attributed to contextual effects in the outcome of exercise therapy for patients with low back pain. A meta-analysis was conducted. PubMed, Embase, and the Cochrane database were searched for eligible articles reporting randomized controlled trials that compared exercise therapy to placebo interventions. Risk of bias was assessed with the Revised Cochrane Risk of Bias Tool. Outcomes of interest were pain and disability. Meta-analysis was carried out to calculate the proportion attributable to contextual effects for both pain and disability. The body of evidence was assessed using the GRADE methodology. Eight studies met the inclusion criteria and were included in the meta-analysis. Five studies were rated as having a moderate risk of bias and two studies had a low risk of bias. Proportion attributable to contextual effects was 0.60 (95% CI 0.40–0.89) for pain and 0.69 (95% CI 0.48–1.00) for disability. Certainty of the evidence as assessed with the GRADE methodology was low. A large extent of pain and disability improvement after exercise therapy in low back pain is attributable to contextual effects although this conclusion is based on low certainty evidence.

Background: In recent years, the effectiveness and cost-effectiveness of digital health services for people with musculoskeletal conditions have increasingly been studied and show potential. Despite the potential of digital health services, their use in primary care is lagging. A thorough implementation is needed, including the development of implementation strategies that potentially improve the use of digital health services in primary care. The first step in designing implementation strategies that fit the local context is to gain insight into determinants that influence implementation for patients and health care professionals. Until now, no systematic overview has existed of barriers and facilitators influencing the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting. Objective: This systematic literature review aims to identify barriers and facilitators to the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting. Methods: PubMed, Embase, and CINAHL were searched for eligible qualitative and mixed methods studies up to March 2024. Methodological quality of the qualitative component of the included studies was assessed with the Mixed Methods Appraisal Tool. A framework synthesis of barriers and facilitators to implementation was conducted using the Consolidated Framework for Implementation Research (CFIR). All identified CFIR constructs were given a reliability rating (high, medium, or low) to assess the consistency of reporting across each construct. Results: Overall, 35 studies were included in the qualitative synthesis. Methodological quality was high in 34 studies and medium in 1 study. Barriers (–) of and facilitators (+) to implementation were identified in all 5 CFIR domains: “digital health characteristics” (ie, commercial neutral [+], privacy and safety [–], specificity [+], and good usability [+]), “outer setting” (ie, acceptance by stakeholders [+], lack of health care guidelines [–], and external financial incentives [–]), “inner setting” (ie, change of treatment routines [+ and –], information incongruence (–), and support from colleagues [+]), “characteristics of the healthcare professionals” (ie, health care professionals’ acceptance [+ and –] and job satisfaction [+ and –]), and the “implementation process” (involvement [+] and justification and delegation [–]). All identified constructs and subconstructs of the CFIR had a high reliability rating. Some identified determinants that influence implementation may be facilitators in certain cases, whereas in others, they may be barriers. Conclusions: Barriers and facilitators were identified across all 5 CFIR domains, suggesting that the implementation process can be complex and requires implementation strategies across all CFIR domains. Stakeholders, including digital health intervention developers, health care professionals, health care organizations, health policy makers, health care funders, and researchers, can consider the identified barriers and facilitators to design tailored implementation strategies after prioritization has been carried out in their local context.