One-to-one or strength in numbers – is there a best way to deliver exercise based physiotherapy?

Musculoskeletal (MSK) conditions are common and costly, resulting in significant personal, social and economic burden (here and here) [1, 2]. While physiotherapists deliver many interventions (e.g. massage, spinal manipulation, dry needling, etc.), exercise is probably the most commonly used and researched component of physiotherapy, with many RCTs showing some benefits for pain and function (here, here, here and here). [3-6]

Our research group has recently published a systematic review and meta-analysis [7] in the British Journal of Sports Medicine comparing the effectiveness of group and one-to-one physiotherapy interventions including exercise for MSK conditions. The reason we undertook this review was that despite one-to-one appearing to be the most popular mode of  delivering physiotherapy including exercise, there is evidence that groups may be as effective (e.g. here) [8]. The potential benefits of group physiotherapy include peer-to-peer interaction, observational learning, social support and a lower cost compared with one-to-one care. However, it is unclear which mode of delivery has the greatest level of supporting evidence. Furthermore, many people with MSK conditions (e.g. low back pain, neck pain) appear to be either over-treated or treated inefficiently, without improving their clinical outcomes in a big way (e.g. here, here, here and here). [9-12] Therefore, by conducting this systematic review and meta-analysis we wanted to answer the question: What does current research tell us about different modes of delivery for physiotherapy which includes exercise?

We included randomized controlled trials (RCTs) involving participants with MSK conditions (low back, neck, hip, knee, ankle, shoulder, elbow or wrist pain). RCTs had to measure pain and/or disability. RCTs had to compare group and one-to-one physiotherapy. Both group and one-to-one physiotherapy comparisons were required to include exercise. One-to-one physiotherapy was eligible for inclusion whether or not it also involved a passive therapy (e.g. massage, electrotherapy). RCT inclusion was not affected by the addition, or absence of other co-interventions (e.g. manual therapy, relaxation, education).  RCTs were excluded if they compared group physiotherapy with a different group physiotherapy intervention or compared one-to-one physiotherapy with a different one-to-one physiotherapy intervention or if interventions contained a combination of group and one-to-one components, for example if patients first got one-to-one care followed by group rehabilitation. RCTs were also excluded if interventions had multidisciplinary team involvement (e.g. psychology, occupational therapy or dietician). RCTs that compared group or one-to-one physiotherapy to a minimalist control group only (e.g. providing education/advice booklets or a self-directed home exercise programme which did not involve regular tailoring and/or progression) were also excluded. Finally, we excluded RCTs that involved participants with specific pathologies/conditions (e.g. pregnancy, rheumatoid arthritis) or “red flag” disorders.

So what did we find?

We included 14 RCTs. Seven RCTs investigated low back pain, four investigated neck pain, two investigated knee pain, and one investigated shoulder pain. 12 of these RCTs could be included in the meta-analysis

Only small, clinically irrelevant (less than a 1 point change on a 0-10 pain scale) ) differences in pain and disability were found between group and one-to-one physiotherapy including exercise. Of most interest is that when these small differences were apparent, these were in favour of group physiotherapy. It is worth highlighting that, since all but one study included co-interventions together with exercise in the group or one-to-one arm, drawing precise conclusions regarding the unique effect of the way in which exercise is delivered is difficult. However, the results as they stand are very consistent across all body sites, and at the very least challenge suggestions that one-to-one care is always best.

We provide some possible reasons for the lack of differences, and the potentially better results for the groups:

  1. One-to-one physiotherapy interventions in this review spent a significant amount of time on passive therapies. In fact, 12 of the 14 RCTs involved other interventions being provided with exercise. In contrast, group interventions spent the time solely on exercise and education. This review does not seem to suggest that the groups missed out on a key component in this regard.
  2. One-to-one physiotherapy interventions did not seem patient-centered in nature. For example, in the majority of RCTs, patients received the same dose and type of therapy with little attempt to target the intervention (e.g. exercise, education) towards the individual (e.g. baseline fitness capacity, preferences, goals). It might be argued this could be done better – though this has not yet been shown.
  3. MSK conditions involve an interaction of multiple factors across the biopsychosocial spectrum, which varies from individual to individual. These include structural (e.g. soft tissue ‘degeneration’), physical (e.g. movement patterns, deconditioning), psychological (e.g. beliefs, depression, anxiety), lifestyle (e.g. physical activity, sleep) and social (e.g. work and family) factors. Exercise, while shown to have numerous benefits for psychological (e.g. depression, catastrophising) and lifestyle (e.g. sleep) factors, is generally prescribed by physiotherapists to improve physical factors (e.g. posture, muscle timing). Interestingly, physical factors rarely change following exercise in chronic painful conditions. Given the multidimensional and individual nature of MSK conditions, it is possible, though uncertain, that placing emphasis on different aspects of therapy and reframing the objective of exercise (e.g. as a means of reducing stress as opposed to increasing core stability) for certain people with MSK conditions may yield better outcomes.  This is something which we are investigating in our current RCT in a chronic LBP population (here). [13] We are comparing an individualized multidimensional treatment which targets the physical, psychological, lifestyle and social factors deemed to be most relevant to each individual, to generic group exercise and education where each individual gets the same treatment. The possibility that MSK conditions will not respond significantly, even when such an approach is used, cannot be dismissed.

The results of this review and meta-analysis are remarkably in line with the findings of other systematic reviews showing no clinically significant differences in outcomes between different approaches to MSK pain (e.g. manual therapy, exercise, cognitive behavioural therapy, medication) (e.g. here and here). [14, 15] Choosing the most cost-efficient and feasible therapy may therefore be reasonable, based on the evidence to date.  As a result, group interventions may need to be considered more often.

Many physiotherapists reading this may be surprised that one-to-one does not clearly deliver superior results than group. However, as scientists we need to examine what the available data shows us. As can be seen by the current RCT we are undertaking, we are open to the possibility that individualised care which is sufficiently multidimensional could enhance care for people with MSK conditions such as LBP. However, as of right now, the weight of the evidence suggest that if exercise is a primary focus of therapy, group rehabilitation is as effective as one-to-one care.

About Mary O’Keeffe

Mary O'Keeffe

Dr Mary O’Keeffe has recently received her PhD in the University of Limerick, Ireland. Her PhD research examined whether tailoring multidimensional rehabilitation to the individual chronic LBP patient enhances effectiveness, and is worth the additional time (and costs!) involved. Her supervisors were Dr Kieran O’Sullivan from UL and Prof Peter O’Sullivan from Curtin University, Perth.

Email: Mary.OKeeffe@ul.ie ; Twitter: @MaryOKeeffe007

About Kieran O’Sullivan

University of Limerick Kieran O'SullivanDr Kieran O’Sullivan has been a Lecturer in Physiotherapy at the University of Limerick, Ireland for the last 10 years. He recently took up a position as Lead Physiotherapist at the Sports Spine Centre, at Aspetar Orthopaedic and Sports Hospital, Doha, Qatar.

Email:  Kieran.OSullivan@aspetar.comTwitter: @kieranosull

The authors’ research group promotes evidence-based assessment and management of chronic pain through www.pain-ed.com.

References:

[1] Palazzo, C., Ravaud, J.-F., Papelard, A., Ravaud, P. and Poiraudeau, S. (2014) ‘The burden of musculoskeletal conditions’, PloS One, 9(3), e90633.

[2] Woolf, A. D., Erwin, J. and March, L. (2012) ‘The need to address the burden of musculoskeletal conditions’, Best Practice & Research: Clinical Rheumatology, 26(2), 183-224.

[3] Steffens, D., Maher, C., Pereira, L., Stevens, M., Oliveira, V., Chapple, M., Teixeira-Salmela, L. and Hancock, M. (2016) ‘Prevention of Low Back Pain: A Systematic Review and Meta-analysis’, JAMA Internal Medicine, 176(2), 1-10.

[4] Petersen, J., Thorborg, K., Nielsen, M. B., Budtz-Jorgensen, E. and Holmich, P. (2011) ‘Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial’, American Journal of Sports Medicine, 39(11), 2296-303.

[5] Calatayud, J., Borreani, S., Colado, J. C., Flandez, J., Page, P. and Andersen, L. L. (2014) ‘Exercise and ankle sprain injuries: A comprehensive review’, Physician and Sportsmedicine, 42(1), 88-93.

[6] Hanratty, C. E., McVeigh, J. G., Kerr, D. P., Basford, J. R., Finch, M. B., Pendleton, A. and Sim, J. (2012) ‘The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis’, Seminars in Arthritis and Rheumatism, 42(3), 297-316.

[7] O’Keeffe, M., Hayes, A., McCreesh, K., Purtill, H. and O’Sullivan, K. (2016) ‘Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analysis‘, British Journal of Sports Medicine.

[8] Critchley, D. J., Ratcliffe, J., Noonan, S., Jones, R. H. and Hurley, M. V. (2007) ‘Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation’, Spine, 32(14), 1474-1481.

[9] Henry, S. M., Van Dillen, L. R., Ouellette-Morton, R. H., Hitt, J. R., Lomond, K. V., DeSarno, M. J. and Bunn, J. Y. (2014) ‘Outcomes are not different for patient-matched versus nonmatched treatment in subjects with chronic recurrent low back pain: a randomized clinical trial’, Spine J, 14(12), 2799-2810.

[10] Saner, J., Kool, J., Sieben, J. M., Luomajoki, H., Bastiaenen, C. H. G. and de Bie, R. A. (2015) ‘A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A randomised controlled trial with one-year follow-up’, Manual Therapy, 20(5), 672-679.

[11] Rantonen, J., Vehtari, A., Karppinen, J., Luoto, S., Viikari-Juntura, E., Hupli, M., Malmivaara, A. and Taimela, S. (2014) ‘Face-to-face information combined with a booklet versus a booklet alone for treatment of mild low-back pain: a randomized controlled trial’, Scandinavian Journal of Work, Environment and Health, 40(2), 156-166.

[12] Michaleff, Z. A., Maher, C. G., Lin, C. W., Rebbeck, T., Jull, G., Latimer, J., Connelly, L. and Sterling, M. (2014) ‘Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial’, Lancet, 384(9938), 133-41.

[13] O’Keeffe M, Purtill H, Kennedy N, et al. Individualised cognitive functional therapy compared with a combined exercise and pain education class for patients with non-specific chronic low back pain: study protocol for a multicentre randomised controlled trial. British Medical Journal Open 2015; 5(6): e007156.

[14] O’Keeffe, M., Purtill, H., Kennedy, N., Conneely, M., Hurley, J., O’Sullivan, P., Dankaerts, W. and O’Sullivan, K. (2016) ‘Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis’, Journal of Pain, 17(7), 755-74.

[15] Artus, M., van der Windt, D. A., Jordan, K. P. and Hay, E. M. (2010) ‘Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials’, Rheumatology, 49(12), 2346-56.

Commissioning Editor: Neil O’Connell

Comments

  1. I think Jon hits the nail on the head above when he says the important thing is that people get the help they needed, which in my opinion can either be in a 1 to 1 situation or a small group. Though i do feel the group size is important, as too big a group can leave the participants feeling they don’t have enough access to the teacher which can lead to resent.

    Personally i prefer a small group, as seeing improvements in others can act as tremendous motivation and uplift ones spirit. This can snowball so to speak through the members of the group, and of course having like minded souls to talk too about things is always a good thing!

  2. I Like that a group can help with more peer interaction and that it does lower the cost of treatment as a group. Either way, as long as the people get the help they need then I am pretty happy. My son has been doing this stuff for a couple of months now. It really works for him.

    Mary O'Keeffe Reply:

    Hi Jon, glad to hear that for your son 🙂 for sure, giving the person get good evidence based information, free of nonsense and a good understanding of their pain should be the goal regardless of mode. If this can be achieved, in group or one to one- happy days hopefully!