research paper about physical therapy

The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature

Affiliations.

• 1 Outpatient Physical Therapy Department, BreakThrough Physical Therapy , Wake Forest, NC, USA.
• 2 Outpatient Physical Therapy Department, Select Physical Therapy , Arlington, VA, USA.
• 3 Department of Physical Therapy and Occupational Therapy, Adult Ambulatory Division, Duke University Health System , Durham, NC, USA.
• 4 Outpatient Physical Therapy Department, Back to Work Physical Therapy , Tampa, FL, USA.
• 5 Outpatient Physical Therapy Department, Korunda Medical LLC , Naples, FL, USA.
• 6 Doctor of Physical Therapy Division, Department of Orthopaedics, Duke University , Durham, NC, USA.
• PMID: 30265840
• DOI: 10.1080/09593985.2018.1516015

To systematically determine the specific impact of therapeutic alliance (TA) on chronic musculoskeletal pain, identify factors influencing TA between physical therapists and patients with chronic musculoskeletal pain, and determine the working definition of TA across studies. Data Sources : Databases, including PubMed, CINHAL, and Embase, were searched from inception to January 2017. Study Selection : The initial search resulted in 451 papers. After screening, seven studies were identified that examined the role of TA on chronic pain (> 12 weeks) management in physical therapy settings. Data Extraction : Authors extracted data into tables. Risk of bias was assessed using Cochrane Collaboration methodology. Data Synthesis : Three studies examined the influence of a strong TA coupled with physical therapy on pain outcomes. Four studies identified factors that positively and negatively influenced TA. The working definition of TA was identified in each study. Conclusions : Emerging evidence suggests that for individuals participating in physical therapy for chronic musculoskeletal pain, a strong TA may improve pain outcomes. In order to facilitate a strong TA, physical therapists must understand factors that positively and negatively influence the relationship. Studies demonstrate that the definition of TA remains consistent as it transitions to the physical therapy setting.

Keywords: Chronic Pain; Pain Management; Physical Therapy Specialty; Professional-Patient Relations; Therapeutic Alliance.

Publication types

• Systematic Review
• Musculoskeletal Pain / therapy*
• Physical Therapy Modalities*
• Therapeutic Alliance*

• Open access
• Published: 21 May 2024

Efficacy of interventions and techniques on adherence to physiotherapy in adults: an overview of systematic reviews and panoramic meta-analysis

• Clemens Ley   ORCID: orcid.org/0000-0003-1700-3905 1 &
• Peter Putz   ORCID: orcid.org/0000-0003-2314-3293 2  

Systematic Reviews volume  13 , Article number:  137 ( 2024 ) Cite this article

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Adherence to physiotherapeutic treatment and recommendations is crucial to achieving planned goals and desired health outcomes. This overview of systematic reviews synthesises the wide range of additional interventions and behaviour change techniques used in physiotherapy, exercise therapy and physical therapy to promote adherence and summarises the evidence of their efficacy.

Seven databases (PEDro, PubMed, Cochrane Library, Web of Science, Scopus, PsycINFO and CINAHL) were systematically searched with terms related to physiotherapy, motivation, behaviour change, adherence and efficacy (last searched on January 31, 2023). Only systematic reviews of randomised control trials with adults were included. The screening process and quality assessment with AMSTAR-2 were conducted independently by the two authors. The extracted data was synthesised narratively. In addition, four meta-analyses were pooled in a panoramic meta-analysis.

Of 187 reviews identified in the search, 19 were included, comprising 205 unique trials. Four meta-analyses on the effects of booster sessions, behaviour change techniques, goal setting and motivational interventions showed a significantly small overall effect (SMD 0.24, 95% CI 0.13, 0.34) and no statistical heterogeneity ( I 2  = 0%) in the panoramic meta-analysis. Narrative synthesis revealed substantial clinical and methodological diversity. In total, the certainty of evidence is low regarding the efficacy of the investigated interventions and techniques on adherence, due to various methodological flaws. Most of the RCTs that were included in the reviews analysed cognitive and behavioural interventions in patients with musculoskeletal diseases, indicating moderate evidence for the efficacy of some techniques, particularly, booster sessions, supervision and graded exercise. The reviews provided less evidence for the efficacy of educational and psychosocial interventions and partly inconsistent findings. Most of the available evidence refers to short to medium-term efficacy. The combination of a higher number of behaviour change techniques was more efficacious.

Conclusions

The overview of reviews synthesised various potentially efficacious techniques that may be combined for a holistic and patient-centred approach and may support tailoring complex interventions to the patient’s needs and dispositions. It also identifies various research gaps and calls for a more holistic approach to define and measure adherence in physiotherapy.

Systematic review registration

PROSPERO CRD42021267355.

Peer Review reports

Adherence to physiotherapeutic1 treatment and recommendations is crucial to achieving the planned goals and desired effects [ 1 , 2 ]. This is because the desired effects are usually only achieved in the long term if the recommended treatment and home-based exercises are carried out regularly. However, non-adherence in physiotherapy can be as high as 70%, particularly in unsupervised home exercise programmes [ 1 , 3 ] and may differ among medical conditions [ 4 ]. The World Health Organization defines adherence to therapy as ‘the extent to which a person’s behaviour—taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider’ [ 5 ]. Long-term adherence often requires lifestyle changes, which can be supported by behaviour change techniques (BCTs). BCTs are considered the ‘active, replicable and measurable component of any intervention designed to modify behaviour’ ([ 6 ],cf. [ 7 ]). BCTs are defined and operationalised in the behaviour change taxonomy [ 8 ], based on theoretical underpinnings and a Delphi study. Theoretical models to explain (non-)adherence and (a) motivation as well as techniques to promote behaviour change have been extensively studied in health and exercise psychology [ 9 , 10 , 11 ]. Rhodes and Fiala [ 12 ] argue that despite several strong psychological theories that have been developed to explain behaviour, few provide guidance for the design and development of interventions. Furthermore, theories may not be equally applicable to all behavioural domains, therapeutic regimes and settings. For example, the factors determining adherence to (passive) medication use differ from those influencing adherence to (active) physical therapies and exercise behaviour (cf. [ 5 ]). This review specifically addresses the domain of physiotherapy and therapeutic exercise.

Existing reviews of predictive studies identified factors influencing adherence positively or negatively, showing the predominately conflicting and low evidence of a wide range of predictive factors for adherence [ 1 , 2 , 13 ]. Moderate to strong evidence was shown for some factors, referring to previous (adherence) behaviour and treatment experiences, physical activity level, social support and psychosocial conditions, number of exercises and motivational dispositions. Such predictive studies have identified the possible targets for intervention but do not provide evidence on the efficacy of interventions. In contrast, randomised control trials (RCTs) are recognized as the preferred study design for investigating the efficacy of interventions. Thus, this overview of reviews Footnote 1 aimed at providing a synthesis of reviews that examined RCTs, allowing for the discussion of the efficacy of different interventions and BCTs on adherence-related outcomes.

There are numerous reviews on adherence to physiotherapy and (home-based) exercise, and on BCTs to increase physical activity levels, therapeutic exercise or self-organised exercise [ 1 , 2 , 3 , 14 , 15 , 16 , 17 , 18 ]. Yet, no systematic overview of reviews has been identified that specifically synthesised the efficacy of interventions and techniques to enhance adherence to physiotherapy.

Objectives and research questions

Therefore, the aim of this overview of reviews was to synthesise the evidence on the efficacy of interventions and techniques on adherence in physiotherapy, to explore heterogeneity regarding the theoretical underpinnings, types of interventions used, and the adherence-related measures and outcomes reported, and finally to identify research gaps. Thus, the primary research question is the following: How efficacious are interventions and techniques in increasing adherence to physiotherapy? Secondary research questions are as follows: What types of intervention and behaviour change techniques were investigated? Which theoretical underpinning was reported? How was adherence defined and related outcomes measured?

This overview of reviews is guided by the research questions and aligns with the common purposes of overviews [ 19 , 20 ] and the three functions for overviews proposed by Ballard and Montgomery [ 21 ], i.e. to explore heterogeneity, to summarize the evidence and to identify gaps. This overview approach is appropriate for addressing the research questions specified above by exploring different types of interventions and behaviour change techniques and by synthesising the evidence from systematic reviews of RCTs on their efficacy. The review protocol was registered ahead of the screening process in PROSPERO (reg.nr. CRD42021267355). The only deviations from the registration were that we excluded reviews of only cohort studies, due to the already broad heterogeneity of intervention and outcome measures, and that we additionally performed a panoramic meta-analysis.

Information sources, search strategy and eligibility criteria

The search in seven databases, PEDro, PubMed, Cochrane Library, Web of Science, Scopus, PsycInfo and CINAHL (Cumulative Index to Nursing and Allied Health Literature), was last updated on January 31, 2023. The search strategy was structured according to the PICOS (Population, Intervention, Comparison, Outcome and Study Type) scheme. The search terms related to physiotherapy and motivation or behaviour change and adherence and effectiveness/efficacy (details on the searches are listed in Additional file 1 ). A filter was applied limiting the search to (systematic) reviews. No publication date restrictions were applied.

Table 1 outlines the study inclusion and exclusion criteria. Only studies published in peer-reviewed journals were included. The review addressed adult patients, with any illness, disease or injury, and thus excluded studies on healthy populations. Reviews in the field of physiotherapy, physical therapy or the therapeutic use of exercise or physical activity were included if they investigated adherence as a primary outcome. Studies measuring adherence as a secondary outcome were excluded as they do analyse interventions that were not primarily designed to promote adherence and thus are outside the scope of this overview. Reviews that analysed only studies on digital apps or tools (e.g. virtual reality, gamification, exergames or tele-rehabilitation) were excluded from this overview, as they were outside of the scope of this overview. Only systematic reviews that appraised RCTs were included. Reviews appraising RCTs and other study designs were included if RCT results could be extracted separately. Systematic reviews are in our understanding literature reviews of primary studies with a comprehensive description of objectives, materials and methods; considering the risk of bias and confidence in the findings; and reporting according to the PRISMA statement [ 22 , 23 , 24 ]. Adherence is defined as the extent to which a person’s behaviour corresponds with treatment goals, plans or recommendations [ 5 ]. Related terms used in the literature are compliance, maintenance, attendance, participation and behaviour change or lifestyle modification and were thus included in the search strategy.

Screening and selection process

Author CL conducted the search in the seven different databases and removed duplicates, using the Zotero bibliography management tool. Following this, authors CL and PP both independently screened the titles and abstracts of the resulting sources (see Fig.  1 Flow diagram). After removing the excluded studies, PP and CL independently screened the remaining full texts in an unblinded standardised manner. Reasons for exclusion were noted in a screening spreadsheet. Any discrepancy was discussed, verified and resolved by consensus.

Data collection process and data items

Data extraction was done by CL after agreeing with PP on the criteria. A spreadsheet was created with the following data extraction components: (i) objectives and main topic of the review; (ii) study design(s) and number of studies included and excluded; (iii) search strategies (incl. PICO); (iv) population including diagnosis, sample sizes and age; (v) intervention and comparison, theoretical foundations and models used for designing the intervention; (vi) time frames, including follow-up; (vii) adherence-related outcome and outcome measures; (viii) key findings; (ix) analysis of primary studies (meta-analytical, other statistical or narrative analysis); and (x) tools used for the quality assessment, risk of bias and evidence grading. Primary outcomes on adherence included, adherence rates or categories, engagement, attendance and participation, and accomplished physical activity levels. PP verified the data extraction results. The data was extracted as reported in the systematic reviews, then reformatted and displayed in the tables and used for the narrative synthesis.

Assessment of risk of bias across reviews

Systematic reviews of RCTs are ranked highest in the evidence level [ 25 ], but are subjected to risk of bias (RoB). In an overview of reviews of systematic reviews, there are further risks of bias, in addition to those deriving from the primary studies and those deriving from the review of those studies. Particularly, the overlap of reviews regarding the included individual studies may bias the findings. According to the purpose of this overview, i.e. to synthesise the wide range of interventions and behaviour change techniques used to promote adherence and to summarise the evidence of their efficacy, the overlap of reviews regarding intervention or population was not an exclusion criterion. For considering the overlap of primary studies among the reviews, CL extracted the primary RCTs from the included reviews, identified the unique trials and compared the frequency of their use across the reviews (see results overlap of review and Additional file 2 ). Furthermore, where two or more reviews provided findings on the same technique (e.g. on the efficacy of behavioural graded activities), the overlap of primary studies was assessed specifically for that finding. If the evidence came from the same study, this was taken into account and marked accordingly in Table  5 to avoid double counting and overestimation of evidence.

Assessment of risk of bias within the reviews

CL and PP independently assessed the quality and risk of bias of the systematic reviews included, using the AMSTAR-2 tool [ 26 ]. Any discrepancy was discussed and resolved by consensus. AMSTAR (A MeaSurement Tool to Assess systematic Reviews) was developed to evaluate systematic reviews of randomised trials. The AMSTAR-2 revision enables a more detailed assessment of systematic reviews which may also include non-randomised studies of healthcare interventions. The applied AMSTAR-2 checklist consists of 16 items, whereof seven are classified as critical, and the appraisal results in an overall confidence rating distinguishing between critically low, low, moderate or high [ 26 ]. In addition, the overall confidence in the review was stipulated by the number of positive assessments in relation to the applicable domains (depending if meta-analysis was performed or not) and considering whether an item represents a critical domain or not [ 26 ].

Synthesis methods

Panoramic meta-analysis.

Among the included reviews, there were four meta-analyses [ 7 , 16 , 27 , 28 ], which were pooled as a panoramic meta-analysis based on the reported effect sizes and standard errors using IBM SPSS Version 29 (IBM Corp., Armonk, NY, USA). All four meta-analyses used the standardized mean difference as effect size. Standard errors were calculated from the reported 95% CI as \(\frac{\mathrm{upper bound }-\mathrm{ lower bound}}{3.92}\) . Inverse variance was used to weight the meta-analyses, statistical heterogeneity was assessed by I -squared and a fixed-effects model was selected based on the absence of statistical heterogeneity of true effects. Eisele et al. [ 7 ] included 15 primary trials that examined the effect of BCTs on physical activity adherence. They pooled results for medium-term (3–6 months) and long-term (7–12 months) interventions, from which we selected the medium-term model that best matched the eligibility criteria of the other included meta-analyses. Levack et al. [ 27 ] included nine primary trials that examined the effect of goal-setting strategies on engagement in rehabilitation. Among models with other outcomes, we selected this model because it best matched the aim of this overview, and it was most consistent with the outcomes of the other included meta-analyses. McGrane et al. [ 28 ] included six primary trials, representing 378 subjects that examined the effects of motivational interventions on physiotherapy session attendance. They reported another model with perceived self-efficacy as an outcome, but we selected the attendance model because it best matched the aim of this overview, and it was most consistent with the outcomes of the other included meta-analyses. Nicolson et al. [ 16 ] included two primary trials that examined the effect of booster sessions on self-rated adherence. Results were summarized by a forest plot and publication bias was assessed graphically by a funnel plot, although the small number of individual meta-analyses included limits its interpretability. Alpha was set at 0.05.

Narrative synthesis

The narrative synthesis was performed by CL in constant dialogue with and verification of PP. Guided by the research questions, the narrative synthesis of the extracted data was manifold. First, we explored the heterogeneity of interventions, measures and adherence-related outcomes across and within the reviews using the data extraction table. Definitions and measures of adherence were compared among the reviews and discussed. Second, analysis of the descriptions of the interventions and their respective components/techniques, their theoretical underpinning and their objectives was used to classify the interventions according to different types of intervention, namely the informational/educational, the cognitive/behavioural/motivational and the relational/psychosocial intervention. Consequently, for each type of intervention, the results on the efficacy were narratively synthesised. In addition, reported differences in efficacy among medical conditions, theoretical underpinnings and physiotherapeutic settings were summarised based on the data extraction table. Third, the results on the efficacy of the interventions and BCTs were further summarised in a table and then restructured according to the evidence level as reported in the systematic reviews and the confidence in the reviews as analysed by the AMSTAR-2. Therefore, the levels of evidence were extracted as reported in the reviews, which are based on different evidence appraisal schemes: GRADE (high, moderate, low, very low certainty of evidence), Cochrane Collaboration Back Review Group Evidence Levels (strong, moderate, conflicting, limited, no evidence) and self-developed tools. Afterwards, they were compared for the respective intervention/technique across the relevant reviews, considering the confidence in the review and the comprehensiveness of the review as well. The levels of evidence are presented in the table with the categories high, moderate, low and very low. The efficacy supported by the evidence is also based on the results reported in the reviews. In case of overlapping reviews or discrepancies between the reviews, the primary studies were consulted. The category yes refers to results of merely positive effects, and inconsistent refers to findings of positive and no effects of the intervention (techniques) analysed. The category no indicates that the intervention was not efficacious. No negative effects (i.e. favouring the control condition) were reported for the intervention (techniques) shown.

The reporting of findings followed the PRIOR reporting guideline for overviews of reviews of healthcare interventions [ 29 ].

Study selection results

Of the 187 records screened, 19 were included (see Fig.  1 ). Main reasons for exclusion were not a systematic review of RCTs ( n  = 79), adherence not the primary outcome ( n  = 60), and lack of physiotherapy relevance ( n  = 39) (see Fig.  1 ).

Flow diagram, based on PRISMA [ 24 ] and PRIOR [ 29 ] guidelines. Legend: *Multiple reasons for exclusion were possible

Characteristics and diversity of included reviews

The selection strategy resulted in a broad heterogeneity of included reviews. The 19 included reviews differed in their eligibility criteria of the primary studies as well, resulting in substantial clinical diversity, i.e. the inclusion of heterogenous conditions, intervention types and settings (see Table  2 ) and methodological diversity, i.e. the variability in study design, outcome measurements and risk of bias (see Tables 3 , 4 and 5 ). Musculoskeletal diseases [ 6 , 7 , 17 , 30 , 31 , 32 ] and pain [ 13 , 16 , 33 , 34 , 35 ] were the most investigated medical conditions. Those reviews that did not limit their search to a specific disease [ 12 , 27 , 28 , 36 , 37 , 38 , 39 , 40 ] yielded predominantly studies on musculoskeletal diseases. All reviews included adults only (18 and older). One focused on elderly (65 and older) people [ 40 ] and one on older (45 and older) adults [ 16 ]. Fourteen of the 19 reviews analysed RCTs only [ 6 , 7 , 16 , 17 , 27 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 39 , 40 ]; one also included besides RCT cohort studies [ 13 ] and three [ 12 , 37 , 38 ] also included any other quantitative study design (see Table  3 ). Four reviews performed a meta-analysis [ 7 , 16 , 27 , 28 ], and two studies were Cochrane Reviews [ 27 , 35 ]. Four reviews [ 6 , 7 , 17 , 40 ] analysed the use of BCTs and rated the interventions according to a BCT taxonomy [ 8 ].

Results of the individual reviews

The 19 reviews contained a total of 205 unique RCTs. Table 3 shows the main results of each review.

Results of quality assessment and confidence in the reviews

The critical appraisal with the AMSTAR-2 tool (see Table  4 ) showed that four reviews were rated with moderate to high quality [ 7 , 16 , 27 , 35 ], whereas all others resulted in a critically low to low overall confidence in the review. Frequent shortcomings were not explaining the reasons for the inclusion of primary study designs, and an insufficient discussion of the heterogeneity observed. Furthermore, as many reviews did not explicitly mention a pre-established, published or registered protocol or study plan, it is uncertain whether the research followed a pre-specified protocol and whether there were changes and/or deviations from it, and, if so, whether decisions during the review process may have biased the results [ 26 ].

Risk of bias and evidence assessment within reviews

The reviews used various approaches to appraise the evidence, particularly the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system [ 13 , 16 , 26 , 27 ], the evidence levels by the Oxford Centre for Evidence-Based Medicine [ 28 ] or the system by Cochrane Collaboration Back Review Group [published by 25,30] [ 31 , 32 , 33 , 34 ]. Three reviews modified existing or developed their own tool or checklist [ 12 , 35 , 36 ]. For the assessment of the risk of bias and/or quality of the individual studies, the reviews used the following tools: PEDro Scale [ 7 , 13 , 26 , 32 , 37 ], Cochrane Collaboration Back Review Group Quality Assessment Tool [ 31 , 34 ], Cochrane Risk of Bias criteria [ 6 , 16 , 17 , 27 , 33 , 37 , 38 , 39 ], the Delphi List [ 40 ] or modified or developed own tools [ 12 , 35 , 36 ].

A recurring concern regarding potential performance bias was the lack of therapist blinding, which is almost impossible to implement in this research field [ 7 ]. Attrition bias, due to low sample size or drop-outs, and measurement bias, due to the mere use of subjective measures, were also highlighted in the reviews. Another concern was the availability and selection of adequate control groups. Control groups, such as usual practice, unspecific exercise group or alternative intervention commonly include varying numbers of BCTs which must be considered when assessing and comparing contents of interventions [ 7 ]. The comparability of the intervention and control group regarding adherence-related outcomes is further hindered by poor descriptions of the intervention, uncertainty about treatment fidelity and implementation processes, varying competences and proficiency of the therapist, and the diverse translation of theoretical models and use of intervention techniques [ 7 , 34 , 39 ]. Rhodes and Fiala [ 12 ] pointed out that procedures of RCTs, such as several pre-screenings and measurement batteries, may lead to a potential self-selecting of only the most motivated individuals. This may limit the ability to compare intervention to the control group, as both groups are (already) highly motivated, and to detect changes, due to the already high motivation and disposition to adhere. This may explain in part, that the reviews reported many studies that failed to provide evidence for intervention efficacy on adherence. In addition, the restricted timeline (limited duration for observation and follow-up) of the studies may confound/skew the results, as drop-out may occur shortly after the end of the study and long-term adherence is not measured [ 12 ].

Overlap of reviews

The 19 reviews included from 3 to 42 individual RCTs. In sum, the reviews included 261 RCTs (multiple publications on the same trial were counted as one; thus, the number of trials was counted), whereby 34 trials were included in various reviews (see Additional file 2 , Overlap of reviews), resulting in 205 unique RCTs. Of these 34 trials included in multiple reviews, 25 were included in two different reviews. The following trials were included more than twice: Basler et al. 2007 (8x), Friedrich et al. 1998 (7x), Schoo et al. 2005 (4x), Vong et al. 2011 (4x), Asenlof et al. 2005 (3x), Bassett and Petrie 1999 (3x), Brosseau et al. 2012 (3x), Bennell et al. 2017 (3x), Gohner and Schlicht 2006 (3x) and Duncan and Pozehl 2002, 2003 (3x).

In total, the overlap of primary trials in the reviews is considered low; except among reviews [ 27 , 39 ] and among reviews [ 12 , 16 , 28 , 30 ]. Two reviews [ 27 ] and [ 39 ] were conducted by the same authors, within the same field, i.e. goal planning and setting, however with a different approach and research question. Reviews [ 12 , 16 , 28 , 30 ] have a considerable amount of overlap. Still, each of these reviews included unique RCTs, not analysed in any of the other reviews, and they do focus on different research questions, foci and analyses. Therefore, we did not exclude an entire review due to an overlap of studies.

Synthesis of results

The synthesis focused on answering the research questions. We began by presenting the narrative synthesis findings on how adherence was measured, what types of intervention and BCTs were investigated, and which theoretical underpinnings were reported. Afterwards, we synthesised the evidence on the efficacy of the interventions and BCTs, both meta-analytically and narratively.

Measures of adherence and related outcomes

The reviews included studies with a heterogeneous use, breadth and measures of adherence. Mostly, they refer to adherence as the extent to which a person’s behaviour corresponds with treatment goals, plans or recommendations ([ 30 ],cf. [ 5 ]). McLean and colleagues [ 30 ] expressed that within physiotherapy, the concept of adherence is multi-dimensional and could refer to attending appointments, following advice or undertaking prescribed exercises. The terms adherence and compliance were sometimes used interchangeably, referring to the degree of treatment attendance or accomplishment of physical activity levels, participation and recommendations, irrespective of how the treatment goals and plans were established. Yet, for definition purposes, the distinction between agreed and prescribed goals and plans was occasionally used in the reviews to distinguish adherence from compliance .

For analytical purposes, adherence was frequently dichotomised, establishing a cutoff point or percentage used to distinguish adherence from non-adherence. One was considered adherent, for example, if he/she achieved more than 70% or 80% of the targeted, recommended or prescribed sessions. Few studies graded the degree of adherence according to multi-categorical cut-off points (e.g. very low, low, moderate and high adherence). Only in one review [ 13 ], one study was named that distinguished a certain fluctuation in the adherence pattern, i.e. Dalager et al. [ 41 ] included besides the minutes exercised in a week the regularity of participation, distinguishing regular from irregular participation. Self-reported diaries, exercise logs and attendance lists were the most commonly used data recording instruments [ 33 , 35 , 37 ]. Adherence to home-based programmes was mainly measured with self-reported diaries, which are problematic as the only source, due to poor completion rates, and the possibility of inaccurate recall and self-presentation bias [ 18 , 33 ]. Digital devices (e.g. accelerometers or pedometers) may be used additionally to measure adherence; however, their use may also be problematic, as they require certain adherence to a systematic use of the device and the mere use of the device also may increase adherence [ 18 , 33 ]. One study reported the use of the Sport Injury Rehabilitation Adherence Scale (SIRAS) [ 42 ], which measures the patients’ degree and manner of participation in a session and compliance with the therapist’s instructions and plan. Thus, it does not measure adherence over a certain period of time nor adherence to recommendations or home-based exercise, but it can be used to assess the intensity of rehabilitation exercises, the frequency with which they follow the practitioner’s instructions and advice, and their receptivity to changes in the rehabilitation programme during that day’s appointment [ 42 ].

Interventions used to promote adherence

The reviews included a wide range of different interventions, which we grouped into three different intervention types:

Information provision and patient education were investigated in seven reviews [ 12 , 13 , 30 , 31 , 33 , 34 , 36 ], including (i) video- and audio-assisted patient education, (ii) phone calls, (iii) use of supporting materials and spoken or graphically presented information or (iv) other didactical interventions. Patient education has been defined as ‘any combination of learning experiences designed to facilitate voluntary adoption of behaviour conducive to health’ [ 43 ]. Niedermann et al. [ 31 ] distinguished between ‘purely’ educational programs based on knowledge transfer and psychoeducational programs. In the latter, motivational techniques and shared knowledge-building processes are added to the educational programme, which is done similarly in health coaching [ 34 ], and thus also relate to the cognitive, behavioural and relational/psychosocial interventions.

Cognitive and behavioural motivational interventions were relating frequently to cognitive-behavioural and social-cognitive theories, and applied (i) behavioural graded exercise; (ii) booster sessions, refresher or follow-up in situ by the therapist or via phone call; (iii) behavioural counselling (focusing on readiness to change); (iv) psychoeducational counselling; (v) supervision; (vi) (unspecified) motivational intervention; (vii) positive reinforcement; (viii) action and coping planning; and (ix) goal setting [ 7 , 12 , 13 , 16 , 27 , 28 , 30 , 32 , 33 , 34 , 39 ].

Relational and psychosocial interventions were less investigated overall. Related aspects included (i) social support; (ii) patient-centeredness, in particular patient-led goal setting, motivational interviewing and the therapeutic or working alliance; and (iii) emotional components [ 6 , 13 , 17 , 33 ].

The included reviews focused either on one particular or several types of intervention. Particularly, four reviews [ 6 , 7 , 17 , 40 ], which used a BCT taxonomy to analyse the interventions of the primary studies, described BCTs relating to all three intervention types. While this distinction of different types of interventions is useful to showcase the range of diverse interventions and techniques, they do have a great overlap and include a mix of different BCTs. For example, the way of facilitation of information, supervision or goal setting was approached differently according to the relational approach, i.e. being more instructive, directive or more collaborative, participatory, patient-led ([ 31 ],cf. [ 34 ]).

Theoretical underpinning of interventions

No review focused on only one theoretical foundation or excluded studies based on any theoretical model or not underpinning the intervention. In total, the reviews included studies with diverse theoretical models and varying degrees of theoretical underpinning. References to the cognitive behavioural theory (CBT) and to the social-cognitive theory were frequent in the individual studies. Furthermore, the self-determination theory, the transtheoretical model, the health belief model, the social learning theory and the socioemotional selectivity theory were used in some individual studies (cf. [ 11 ]). The heterogeneity in the theoretical underpinning of the interventions is reinforced by the given overlap of the theories and models (cf. [ 11 ],[ 28 ]) and various BCTs are key components of several theories [ 17 ]. Furthermore, theories were not used enough to explicitly inform and underpin interventions and they were translated into practise in different ways; thus, interventions based on the same theory may differ substantially [ 17 ].

The BCT Taxonomy v1 [ 8 ], which relates to various theoretical models, was used in four reviews [ 6 , 7 , 17 , 40 ] to identify BCTs in interventions in a standardized manner. The Behaviour Change Wheel [ 44 ], which is linked to the BCT Taxonomy v1, was referred to in one review [ 40 ] pointing to its usefulness for designing a behaviour change intervention. The number of BCTs used appears to be relevant, as interventions using a higher number (≥ 8) of BCTs achieved a significant effect (pooled SMD = 0.29, 95% CI 0.19–0.40, p  < 0.001), whereas interventions using a lower number (< 8) of BCTs did not (pooled SMD = 0.08, 95% CI -0.11 to 0.27, p  = 0.41).

Overall efficacy and heterogeneity according to the panoramic meta-analysis

Although there was statistical heterogeneity ( I 2 from 41 to 63%) between the primary studies included in each meta-analysis [ 7 , 16 , 27 , 28 ], there was no heterogeneity between the pooled effects of these four meta-analyses ( I 2 0%). This means that all variability in the effect size estimates (SMD from 0.20 to 0.39) was attributable to sampling error, but there was no variability in the true effects. Although the interventions were selected based on different eligibility criteria (BCTs, goal-setting strategies, motivational interventions and booster sessions), they appear to be very similar in terms of the effects they trigger. There was no overlap between the primary trials included in the meta-analyses. The pooled SMD was 0.24 (95% CI 0.13, 0.34) (Fig.  2 ). Effect size estimates were somewhat larger in those meta-analyses with less weight in the model (i.e. due to a larger standard error). However, no obvious publication bias could be detected in the funnel plot (Fig.  3 ). Sensitivity analyses in the meta-analysis in Eisele et al. [ 7 ], considering only studies with PEDro scores of 6 or more, revealed slightly lower effect sizes but still statistically significant effect sizes regarding medium-term effects (SMD PEDro>=6 0.16, 95% CI 0.04–0.28, p  < 0.01 versus SMD all 0.20, 95% CI 0.08–0.33, p  < 0.01) and higher numbers of BCTs (SMD PEDro>=6  = 0.26, 95% CI 0.16–0.37, p  < 0.001 versus SMD all  = 0.29, 95% CI 0.19–0.40, p  < 0.001), indicating that low-quality studies may tend to overestimate the efficacy ([ 7 ],cf. [ 31 ]).

Forest plot of panoramic meta-analysis: interventions aiming at improving adherence, adherence-related outcomes

Legend: Eisele 2019. Intervention: Interventions aiming at improving physical activity levels or adherence, containing at least one BCT. Comparison: Usual care, minimal intervention, placebo or no intervention. Outcome: Any measure of physical activity level or adherence to any kind of physical activity. Levack 2015. Intervention: Goal setting (with or without strategies to enhance goal pursuit). Comparison: No goal setting. Outcome: Engagement in rehabilitation. McGrane 2015. Intervention: Motivational interventions as part of a package, psychological strategies, theory-based instructional manuals, Internet-based behavioural programmes and relapse prevention, and re-inforcement strategies. Comparison: Any comparison (not specified). Outcome: Attendance at physiotherapy sessions/exercise classes. Nicolson 2017. Intervention: Booster sessions to increase adherence to therapeutic exercise. Comparison: Contextually equivalent control treatments. Outcome: Self-rated adherence

Funnel plot of publication bias

Efficacy of informational and educational interventions

The results of five—partly overlapping—reviews [ 12 , 30 , 31 , 34 , 36 ] showed, with a very low evidence base, that interventions that primarily aimed at information provision and knowledge transfer to the patient had limited efficacy on adherence-related outcomes. There was conflicting evidence and inconsistent efficacy of video-assisted patient education [ 36 ] and individualised exercise videos [ 12 , 30 ] in modifying behaviour or adherence. However, the authors identified the format in which the educational information is presented and the complexity of the addressed behaviour as crucial factors [ 36 ]. Videos that provide only spoken or graphically presented health information are inappropriate tools for changing patient behaviour. However, videos with a narrative format appear to be a powerful education tool [ 36 ]. Low evidence based on one study [ 12 , 30 ] indicates that additional written information seems superior to verbal instructions alone (mean difference between groups 39.3%, p  < 0.001). With a high overlap of studies, two reviews [ 30 , 31 ] showed that there is limited evidence for long-term effects of patient education targeting knowledge acquisition. While the informative and instructive educational approach is an essential part of patient education, patient education often involves more than the transfer of knowledge [ 30 , 31 , 34 ]. Niedermann et al. [ 31 ] compared educational and psychoeducational interventions and provided arguments in favour of psychoeducational approaches that enrich patient education with motivational strategies and techniques (cf. [ 34 ]).

Efficacy of cognitive and behavioural motivational interventions

Several (though partly overlapping) reviews [ 12 , 16 , 28 , 30 , 33 , 37 ] examined studies on additional motivational interventions that were based on social-cognitive or cognitive-behavioural theories. McGrane et al. [ 28 ] concluded heterogeneity of motivational interventions, outcomes and measurements as potential causes for conflicting evidence regarding effects on exercise attendance and PT adherence, as they found no significant difference ( p  = 0.07) in exercise attendance between additional motivational intervention groups and their controls (pooled SMD 0.33, 95% CI -0.03 to 0.68, I 2 62%), but a significant ( p  < 0.01) medium-sized effect of additional motivational interventions on self-efficacy beliefs (pooled SMD 0.71, 95% CI 0.55 to 0.87, I 2 41%). The heterogeneity hindered in this meta-analysis the statistical analysis of subgroups to determine and compare the efficacy of different components and approaches to motivational interventions [ 28 ]. Another meta-analysis [ 16 ] found moderate-quality evidence that booster sessions with a physiotherapist helped people with hip/knee osteoarthritis to better adhere to therapeutic exercise (pooled SMD 0.39, 95% CI 0.05 to 0.72, p  = 0.02, I 2 35%). Moderate evidence for the efficacy of supervision (2 studies, n  = 193) favouring adherence was shown [ 13 , 33 , 35 ].

In four reviews [ 16 , 32 , 33 , 35 ], four unique high-quality trials supported the use of motivational strategies and behavioural graded exercise to improve adherence to exercise (effect sizes 0.26–1.23)[ 16 ]. Behavioural graded exercise includes a preset gradual increase of the physical activity through facility-based interventions followed by booster sessions [ 45 ] and uses principles of operant conditioning and self-regulation [ 16 ].

While cognitive behavioural programmes seem superior to exercise alone for short-term adherence and clinical attendance [ 30 ], behavioural counselling focusing on readiness to change, action and coping plans and/or audio/video exercise cues seem not to improve adherence significantly [ 16 ]. Holden [ 34 ] concludes inconsistent evidence for health coaching based on the transtheoretical model of change, with one RCT showing some efficacy on exercise compliance (SMD = 1.3). However, the frequently referred to study of Göhner and Schlicht [ 46 ], who analysed a cognitive-behavioural intervention with a strong emphasis on action and coping planning [ 12 ], showed no difference between experimental and control groups in the first 11 weeks, but a significant difference 5 months later on behaviour (SMD = 0.83) as well as differences over all time-points on self-efficacy (interaction effect of time by group, F (3, 43) 10.36, p  < 0.001, n  = 47) favouring the intervention [ 46 ]. Motivational interventions, including positive reinforcement, increased (i) adherence to home exercise in one RCT [ 33 ], (ii) reported frequency of exercise in two RCTs [ 35 ] and (iii) self-efficacy beliefs in two RCTs, in the short-term (SMD = 1.23) and in the long-term (SMD = 0.44) ([ 16 ],cf. [ 30 ]). Self-efficacy beliefs relate to the trust in one’s capacities/competencies to cope with daily demands [ 47 ] and are associated (moderate evidence) with adherence [ 13 , 48 ].

Levack et al. [ 27 ] conclude some evidence that goal planning/setting improves engagement in rehabilitation (motivation, involvement and adherence) over the duration of the programme (9 studies, 369 participants, SMD 0.30, 95% CI -0.07 to 0.66). Furthermore, they show a low-quality evidence for effects on patient self-efficacy from more structured goal setting compared to usual care with or without goal setting (2 studies, 134 participants; SMD 0.37, 95% CI 0.02 to 0.71) and from goal setting compared to no goal setting (3 studies; 108 participants; SMD 1.07, 95% CI 0.64 to 1.49). The review did not detect differences in efficacy between the approach taken to goal planning. However and similar to patient education [ 34 ], the review authors argue that the lack of clarity about the effects and the low evidence is due to the heterogeneity of the implementation of goal planning, lack of detailed descriptions of the goal-setting process in the intervention groups but also in the control groups, and methodological flaws ([ 27 , 39 ],cf. [ 13 ]).

The BCTs from the cluster goals and planning showed various positive effects, although not fully consistently [ 6 , 7 , 40 ]. Eisele et al. [ 7 ] identified goal setting (behaviour) , problem-solving , goal setting (outcome) , action planning and reviewing behaviour goal(s) as often used in non-effective interventions but also in effective ones. A trial that showed negative effects included problem-solving and goal setting (outcome) as well. Room et al. [ 40 ] found one study on older people and Thacker et al. [ 6 ] two home-exercise-related studies that used BCTs from the goals and planning cluster (i.e. problem-solving and action planning), but none of the studies found differences in favour of the intervention. Willett et al. [ 17 ] adjusted the BCTv1 taxonomy to differentiate patient-led and therapist-led goal setting and showed that patient-led goal setting (behaviour) achieved among the highest efficacy ratios across time points.

Efficacy of relational and psychosocial interventions

The BCT Social Support (unspecified) refers to ‘advise on, arrange or provide social support (e.g. from friends, relatives, colleagues, ’buddies’ or staff) or non-contingent praise or reward for the performance of the behaviour . It includes encouragement and counselling, but only when it is directed at the behaviour’ [8, Supplementary Material]. Eisele et al. [ 7 ] identified this BCT in 19 interventions and 10 control conditions. They found this BCT in three trials supporting efficacy and in seven trials supporting inefficacy. In contrast, Thacker et al. [ 6 ] found this BCT in all effective interventions but not in the non-effective ones. Willet et al. [ 17 ] concluded from their review that this BCT has among the highest efficacy ratios across time points to promote adherence to physical activity.

Social support may come along with monitoring and feedback, which can be graphically or narratively presented by the therapist. Willett et al. [ 17 ] recommend that self-monitoring (e.g. activity diaries), feedback on behaviour as well as social support should be used—beyond monitoring purposes—for explicit intervention purposes (e.g. to foster self-efficacy beliefs). Feedback on behaviour alone does not seem to be efficacious [ 6 ], but feedback can be efficacious for instance in combination with social support or goal setting and planning [ 17 , 40 ].

Patient-centred approaches were also included in the relational/psychosocial intervention type. Motivational interviewing, which is a collaborative, patient-centred communication style to promote behaviour change [ 49 ], was used in three studies, indicating positive effects on exercise compliance, physical activity and exercise at home in two trials, whereas no effect in a pilot study [ 28 ]. There is low evidence from three RCTs for positive effects of the therapist-patient alliance on global assessments; however, the efficacy on adherence-related outcomes is unclear [ 36 ]. The terms working or therapeutic alliance refer to the social connection or bond between therapist and patient/client, including reciprocal positive feelings, (assertive) communication, empathy, and mutual respect as well as collaboration, shared decision-making, agreement on the treatment goals and tasks [ 36 , 50 ]. The therapeutic alliance is a patient-centred approach as well. Patient-led goal setting was more often a component within efficacious interventions than therapist-led goal setting [ 17 ].

None of the included reviews focused specifically on affective interventions. However, some interventions relate to affective components, for example patient-led goal setting or motivational interviewing may cover emotional needs [ 27 ]; health coaching, therapeutic alliance or social support may include emotional support [ 13 , 34 , 35 , 38 ]; monitoring may consider emotional consequences [ 6 ]; or messaging and information provision may include emotional components [ 36 ]. Room et al. [ 40 ] included one RCT [ 51 ], comparing emotionally meaningful messages against factual informational messages, but with no significant differences between the groups.

Efficacy according to the theoretical underpinning

McGrane et al. [ 28 ] provide a narrative analysis of the efficacy of interventions according to the different theoretical underpinnings. In their review, the cognitive-behavioural theory (CBT) was the most popular theory (4 primary studies) and showed to be efficacious in improving self-efficacy and activity limitations, but not consistently regarding attendance and attrition [ 28 ]. The social-cognitive theory was used in three studies, showing improvements in self-efficacy, action and coping planning, and attendance, but conflicting results for exercising in the short and long term. One intervention [ 52 ] based on self-determination theory showed to be efficacious to improve adherence to physical activity. In contrast to McGrane et al. [ 28 ], the reviews [ 12 , 30 , 35 ] point to moderate to conflicting evidence for no or inconsistent efficacy of CBT-based approaches to physiotherapy programmes (see Efficacy of cognitive and behavioural motivational interventions ). Jordan [ 35 ] concluded that the addition of transtheoretical model-based counselling to physiotherapy is no more effective than physiotherapy and a sham intervention (GRADE: High (high quality); Silver). Notably, the interventions may not be representative of the theory described due to diverse translations of the theory into practice and the overlap of the same BCTs among the theories.

Various theories (e.g. the transtheoretical model or the Health Action Process Approach [ 53 ]) and studies [ 54 ] distinguish the action or adoption phase from the maintenance phase at 6 months. Interestingly, Willet et al. [ 17 ] found in total higher short (< 3 months) and long-term (12 months and more) than medium-term (around 6 months) efficacy ratios, pointing to the risk of drop-out when changing from the (short-term) adoption phase to the (long-term) maintenance phase [ 17 ]. Eisele et al. [ 7 ] divided in their meta-analysis the short-term (< 3 months), medium-term (3–6 months) and long-term (7–12 months post-intervention) differently, showing a small medium-term overall effect (pooled SMD 0.20, 95% CI 0.08–0.33, p  < 0.01), but no significant long-term effect of interventions comprising BCTs in enhancing physical activity adherence (pooled SMD 0.13, 95% CI 0.02–0.28, p  = 0.09).

Efficacy according to the different types of exercise, physiotherapeutic settings and medical condition

In their Cochrane review, Jordan et al. [ 35 ] compared the evidence for the efficacy of different types of exercises and physiotherapy settings. Graded exercise is beneficial for adherence (moderate evidence). The exercise type does not appear to play an important role (moderate evidence). Whether water-based exercise favours adherence is unclear (low evidence and inconsistent results). Furthermore, the supervision of exercising (moderate evidence) is beneficial for adherence, but also self-management programmes improve exercise frequency compared to waiting list or no-intervention control groups (moderate evidence). Exercising individually seems to improve attendance at exercise classes more than exercising in a group (moderate evidence), as individual sessions could be scheduled at more convenient times and missed sessions could be rescheduled, whereas group sessions were scheduled at relatively inflexible times, and missed sessions could not be rescheduled [ 35 ]. However, adding group exercise to a home exercise programme can increase overall physical activity levels (moderate evidence) [ 35 ]. While the results of home- versus clinic-based interventions were conflicting and confounded by the intervention approaches, a combination of home- and clinic-based approaches may be promising [ 12 ] and aligns with the moderate-quality evidence that self-management programmes, refresher or booster sessions with a physiotherapist assist people to better adhere to therapeutic exercise [ 16 ].

No study was identified in the reviews that compared other settings, such as private- and public-funded physiotherapy or primary care and rehabilitation settings regarding adherence outcomes. No review and no study comparing the same educational, motivational, or BCT-based intervention across different conditions were identified.

This overview of systematic reviews addresses adherence in the physiotherapy and therapeutic exercise domain, aiming to summarise the evidence on the efficacy of interventions, to explore heterogeneity and to identify research gaps. The overview of reviews provided an adequate approach to generate answers to the research questions. Nineteen reviews, covering 205 unique trials, were included and narratively synthesised. In addition, four meta-analyses were pooled in a panoramic meta-analysis. The findings provide an overview of the diverse interventions and techniques aiming to enhance adherence, ranging from informational/educational to cognitive/behavioural/motivational and to relational/psychosocial intervention types. Furthermore, it synthesised their efficacy in physiotherapy for adults.

Confidence in the reviews was rated moderate or high in four reviews [ 7 , 16 , 27 , 35 ], but low or very low in the others (Table  3 ). The individual reviews considered the evidence levels as mostly low or very low (Table  4 ; see Risk of bias and evidence assessment ). Table 5 summarizes the evidence on the efficacy of each intervention and technique according to (a) whether the evidence supports efficacy, (b) the evidence level based on the report in the systematic reviews and (c) the confidence in the reviews as assessed with AMSTAR-2. It must be noted that the components of the intervention which caused the efficacy were not always clear. Some interventions lacked detailed definitions and descriptions of the specific BCTs included [ 33 ]. A single technique or mechanism of action was not always identifiable; moreover, various techniques seem to influence each other in such a way that they achieved efficacy only jointly [ 17 , 40 ].

No clear conclusion can be drawn on the efficacy of informational/educational interventions. Five reviews [ 12 , 30 , 31 , 34 , 36 ] showed low evidence for the efficacy of interventions on knowledge acquisition and low evidence for limited short-term efficacy on adherence. Providing knowledge alone seems not enough and should be complemented with supportive material (very low evidence) and combined with other interventions (low evidence). Patient education should also include social-cognitive or cognitive-behavioural approaches, psychoeducational interventions and collaborative processes as it is included in the therapeutic alliance approach [ 31 , 34 , 36 ]. Patient education with a more constructive educational approach builds upon the knowledge of the patient, supporting him/her in exploring and co-constructing knowledge which is very relevant in physiotherapy as research has shown [ 55 , 56 ].

The reviews on additional motivational, cognitive and behavioural interventions showed findings ranging from non-efficacy of behavioural counselling based on readiness to change (with low to moderate evidence) to moderate efficacy for booster sessions and behavioural graded physical activity (with moderate evidence) (see Table  5 ). Overall, a small overall effect size (SMD 0.24) for motivational interventions is indicative of the findings of the panoramic meta-analysis. The four pooled meta-analyses [ 7 , 16 , 27 , 28 ] included studies analysing interventions with a considerable amount of content overlap (e.g. goal-setting and booster sessions are BCTs and often part of motivational interventions), and no statistical heterogeneity of the true effect was found. Nevertheless, the diversity of interventions and techniques included constrain the explanatory power for potential components responsible for the efficacy of adherence. The sensitivity analyses in the meta-analysis of Eisele et al. [ 7 ] indicate that low-quality studies tend to overestimate the efficacy (cf. [ 31 ]). While some evidence exists on short- and medium-term effects of motivational programmes on adherence, no clear evidence for long-term effects can be concluded [ 7 , 30 ]. Furthermore, there is moderate and low evidence that additional motivational interventions and goal planning/setting improve adherence to self-efficacy beliefs [ 27 , 28 , 39 ]. Since self-efficacy beliefs play an important role in motivation and adherence [ 13 , 48 ], the results are relevant for physiotherapists to promote motivation and adherence. Experiencing that one can reach the set goals and manage daily challenges, complemented with feedback and reinforcement from the therapist (or important others), may increase self-efficacy beliefs and human agency [ 48 , 57 , 58 , 59 ].

A closer look at how and in which manner goals and actions are planned and reviewed seems crucial. The patient-led approach was only reported in 5 of the 26 interventions that incorporated the BCT goal setting (behaviour) , although it is associated with greater engagement and achievement than goals which are set by the therapist [ 17 ]. Goal setting and action planning should be informed by the patient’s motives, interests and values in order to promote intrinsic motivation, self-determination and subsequently better adherence ([ 17 ],cf. [ 27 , 28 , 60 , 61 ]). The reviews on the BCTs displayed various positive effects relating to the BCT cluster goals and planning ; however, they point out that the BCT goal setting is not used alone but in connection with several other BCTs. Feedback on outcomes of behaviour , behavioural contract and non-specific reward as well as patient led-goal setting , self-monitoring of behaviour and social support (unspecified) was included in efficacious interventions [ 17 ]. Social support seems to have an important influence on adherence [ 6 , 7 , 17 , 40 ], for example through regular phone-calls or home visits, encouraging messaging, supervision or community-based group programs (cf. [ 1 , 2 , 3 ],[ 37 , 62 ]). Social support also relates to the promotion of self-efficacy beliefs, if it endorses confidence in own abilities and competences [ 6 ].

Some BCTs seem inherent to standard practices of physiotherapy [ 6 ] even though physiotherapists seem to use rather a small number of BCTs [ 15 ]. Control groups also contained BCTs [ 6 , 7 ]; in particular instruction on how to perform a behaviour , generalisation of the target behaviour and social support (unspecified) were frequently coded [ 6 ]. Thus, it seems difficult to identify those BCTs that are (most) efficacious in promoting adherence ([ 7 ],cf. [ 50 ]). Unsurprisingly, the reviews revealed conflicting results and a high risk of bias in the individual studies. However, combining a greater number of BCTs (≥ 8) can be highly recommended, as this achieved a larger effect than interventions using fewer BCTs [ 7 ]. It is fairly unlikely that any single BCT changes adherence [ 6 , 7 , 17 , 40 ]. In that regard, Ariie et al. [ 63 ] argue that not only the amount of BCTs but also the quality, appropriateness and feasibility of the use of the BCTs is crucial.

Meaningful combinations of several BCTs are required. However, the combinations of BCTs may also differ among conditions, personal factors and therapeutic interventions ([ 7 ],cf. [ 63 , 64 ], [ 64 , 65 , 66 ]), and over the time. Two reviews consistently point to the same crucial time point (i.e. after 6 months) when BCT efficacy seems to drop, and more attention is required to maintain adherence [ 7 , 17 ]. Action planning , feedback on behaviour and behavioural practice/rehearsal seem efficacious particularly on short-term. Patient led-goal setting , self-monitoring of behaviour and social support (unspecified) are among those BCTs that seem more efficacious at long-term [ 17 ]. These findings are also in line with findings in non-clinical adults [ 54 ] and with motivational theories (e.g. the Health Action Process Approach [ 53 ]).

Limitations

Conducting an overview of reviews is per se associated with methodological limitations. A limitation is that reviews were analysed and not the original RCTs, which adds further risks of bias domains such as selection, analysis and reporting bias. A specific potential source of bias in overviews of reviews is the overlap of primary studies among the included reviews. The small overlap, caused by a few reviews with similar thematic scope, was controlled for in the data analysis. The substantial non-overlap of primary studies across the reviews reflects the clinical and methodological diversity of the included reviews and showcases the efforts to address (a) motivation and (non-)adherence as complex phenomena and from various perspectives.

Another methodological limitation originates from the search strategies. Considering different health-care systems and delimitations of the physiotherapy profession among countries, divergences among the definitions of terms and the use of diverse approaches to physical therapy, physiotherapy or the therapeutic use of exercise and physical activity, made a clear delimitation in the search strategy and inclusion/exclusion criteria difficult. Therefore, we may have missed out some relevant reviews by reducing our search to the two terms physiotherapy and physical therapy. Equally, we may also have included some aspects that were not primarily investigated for physiotherapists or physical therapists. Including only studies with adults, the findings may not be applicable to promote adherence among children.

While we did not exclude reviews from another language, the search was conducted only in English, which may omit important reviews in other languages. All included reviews (and as far as reported, also the original RCTs) were conducted in economically developed countries; however, social-cultural and context-specific factors influence participation and adherence [ 67 , 68 , 69 , 70 , 71 ]. Furthermore, we are aware that our own cultural background and experiences may have influenced the analysis and synthesis of the results and that conclusions drawn in this overview of reviews may not be suitable for every setting around the world. Therefore, we encourage the readers to critically assess the applicability of the findings to their specific context.

Another gap in coverage of this overview is that interventions that were analysed in RCTs but not included in any systematic review are not considered in this overview. Thus, there may be new or alternative intervention approaches that resulted efficacious but were not covered by this overview. Furthermore, reviews that focused only on the use of digital apps or tools, e.g. virtual reality, gamification, exergames or tele-rehabilitation, were excluded from this overview. Several reviews in this field include adherence-related outcomes, showing potential efficacy as well as limitations of the use of digital tools [ 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 ].

Research gaps, recommendations and measuring adherence

This overview of reviews highlighted some gaps in the existing knowledge. First, there is a lack of clear evidence on the efficacy of the interventions. The use of BCTs in the intervention as well as in the control groups may be a reason for inconsistent findings and conflicting evidence. Furthermore, the clinical and methodological heterogeneity constrains drawing clear conclusions on the efficacy. Second (and related to the previous), interventions are insufficiently described regarding their theoretical underpinning and active ingredients/techniques and thus limit the comparison of interventions. Theoretical underpinnings were used partly and translated into practise differently. Difficulties concerning the derivation or deduction of concrete, practical techniques or strategies from the theories were reported. A broader use of the BCT taxonomies would make interventions more comparable. Recently, the BCT Ontology was published, which claims to provide a standard terminology and a comprehensive classification system for the content of behaviour change interventions, suitable for describing interventions [ 84 ]. Third, there is a need for studies on holistic approaches, complex interventions based on integrative theories and the combination of multiple BCTs. While many theories are based on cognitive and behavioural approaches, affective and psychosocial factors are hardly investigated, overlooked and probably underestimated. Rhodes and Fiala [ 12 ] call for studying the influences of affective attitudes on adherence (e.g. enjoyment and pleasing behaviour) which may oppose the more cognitive, instrumental attitudes (e.g. the utility of behaviour). Jordan et al. [ 35 ] refer to a meta-analysis in another therapeutic regime [ 85 ] to explicit the potential efficacy of affective interventions (e.g. appealing to feelings, emotions or social relationships and social supports) in combination with educational and behavioural interventions on patient adherence [ 35 ]. Fourth, more research in patient-led approaches to goal setting and action planning and the relationship of patient-centeredness to adherence is promising [ 60 , 61 , 86 , 87 ].

Fifth, the reviews reported many studies that failed to provide evidence for intervention efficacy on adherence, particularly on long-term adherence. There is a need for prolonged observation to investigate long-term effects on adherence. Probably, intervention or follow-up interventions (e.g. booster sessions) must also be prolonged or repeated to avoid drop out to medium-term follow-ups (around 6 months) and to maintain participation. Sixth, studies should pay more attention to the actual efficacy of adherent behaviour on the desired therapeutic outcomes.

Seventh, another research gap lies in the analysis of the potential variation of the intervention efficacy across medical conditions, physiotherapeutic settings, personal characteristics (e.g. age, gender, sociocultural background) and dispositions (e.g. motives, affective attitudes, previous behaviour) and diverse context-related factors. Huynh et al. [ 79 ] showed for the case of multiple sclerosis that the efficacy of BCTs is not investigated in all disease stages or throughout the disease course; participants with mild-to-moderate level disability were more frequently included in the studies (cf. [ 18 ]). Ariie et al. [ 73 ] stated that the response to BCTs may be different according to the condition (cf. [ 76 ]). On the one hand, studies analysing the use of the same intervention or same combination of BCTs in different intervention groups (according to the categories mentioned above) could be beneficial for comparison purposes. On the other hand, studies should analyse how to find the ‘right’ (ideally, the ‘most efficacious’) adherence promotion intervention for the patient or target group. Qualitative studies may explore adequate combinations of BCTs and contribute to the understanding of complex intervention processes. The findings showcased that different interventions and BCTs may contribute to adherence and that the BCT Taxonomy defines a wide range of techniques, providing the physiotherapists with an overview of which techniques are useable and thus may inspire and support them to develop additional interventions and to enrich their current physiotherapeutic practise. The physiotherapist may use this knowledge to tailor interventions in a patient-centred manner to promote adherence, and to adapt to the condition, characteristics, dispositions and context-related factors of the patient. Hence, experimental studies could compare the efficacy of tailored to not-tailored interventions.

Finally, the outcome adherence should be better defined and holistically assessed. The definition of adherence (as the extent to which a person’s behaviour corresponds with treatment goals or plans) and calculation of adherence rates (by reported exercise or attended sessions divided by the recommended or prescribed exercise or sessions) are simplifying a complex phenomenon. The average or the percentages of attended or completed sessions do not picture interruptions, regularity or periods of more and less adherence. Attendance regularity can change over the time and different participation and fluctuation patterns can be identified [ 88 , 89 ]. For example, an adherence rate of 50% can imply (a) that a person attended regularly every second session throughout the period of observation or (b) that a person attended all sessions of the first half of the observation period and then stopped attending. The underlying reasons and motivational factors may be quite different in these two cases. Besides assessing participation and fluctuation patterns, the three dimensions of the SIRAS scale [ 42 ], i.e. frequency, intensity and reciprocity, could be considered for a holistic account of adherence. The findings of this overview emphasized the importance of a patient-led goal setting and planning, which includes a shared decision-making process and the mutual agreement to adhere to the jointly established plan (cf. WHO definition of adherence, [ 5 ]). The measurement of adherence should be able to distinguish a patient-led approach from a therapist-led approach (cf. [ 17 ]) and to appraise the extent of a shared decision-making process. In conclusion, a holistic approach to measure adherence in physiotherapy may include measures of the frequency of attendance/exercising (e.g. attended sessions out of the prescribed/recommended sessions), the regularity of participation and fluctuation (e.g. timeline with pauses and interruptions, visualizing more and less adherent periods), the intensity of attendance/exercising (e.g. the number or the increment of exercises and repetitions performed in comparison to the plan), reciprocity and fidelity to the agreed goals and plan (e.g. therapist’s and patient’s subjective appraisal of the degree of accomplishment of the agreed plan) and persistence/perseverance over the time (e.g. measuring volition via questionnaires or rating persistence in participation in spite of the experienced challenges and barriers).

We conclude that moderate certainty of evidence supports that (i) additional motivational interventions and behaviour change programmes can increase adherence and patients’ self-efficacy beliefs and (ii) interventions applying BCTs increase adherence, particularly when using a greater number of BCTs and combining various BCTs, and particularly on short to medium term. The BCTs’ patient-led goal setting , self-monitoring of behaviour and social support seem promising to promote maintenance; (iii) graded activities, booster sessions with a physiotherapist and supervision foster adherence.

There is low certainty of evidence that (i) goal setting and planning improves adherence to treatment regimens, particularly if a patient-centred approach is taken; (ii) motivational interventions including various techniques, such as positive reinforcement, social support, monitoring or feedback, can foster adherence; (iii) social support seems to play an important role in promoting adherence; however, evidence is low as this BCT is frequently found in the control group; and (iv) information provision and transfer of knowledge to the patient may improve adherence-related outcomes when combined with motivational techniques, as in psychoeducational programmes. Additional written information is superior to verbal instructions alone; (v) a combination of home-based exercise programmes with clinical supervision, refresher or booster sessions, or/and self-management programmes seems promising to increase adherence.

Regarding the implications for future research, a holistic approach to measure adherence in physiotherapy and the investigation of clearly defined interventions combining multiple BCTs is recommended.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Overview of reviews, umbrella review and reviews of reviews are considered as synonyms in this article (cf. [ 19 ]).

Abbreviations

Behaviour change technique

Cognitive behavioural/cognitive behavioural theory

Control/comparator group

Grades of Recommendation, Assessment, Development and Evaluation

Intervention/experimental group

Physical activity

Preferred Reporting Items for Overviews of Reviews

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Physiotherapy

Randomised controlled trial

Standardised mean difference

Systematic review

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CL and PP conceived and designed the review. CL did the database search and data extraction. CL and PP did screening and quality assessment. CL did the narrative synthesis and drafted the manuscript. PP conducted the panoramic meta-analysis and critically revised and substantially contributed throughout the writing of the manuscript. The authors read and approved the final manuscript.

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Ley, C., Putz, P. Efficacy of interventions and techniques on adherence to physiotherapy in adults: an overview of systematic reviews and panoramic meta-analysis. Syst Rev 13 , 137 (2024). https://doi.org/10.1186/s13643-024-02538-9

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Home > School of Health > Physical Therapy > DPT Research Papers

Doctor of Physical Therapy Research Papers

Research papers from 2017 2017.

A Systematic Mapping Review of Health Promotion and Well-being Concepts in Physical Therapy , Andrew Amundson, Jesse Klein, Bailey Ringold, and Aaron Theis

The Influence of Hip Strength and Core Endurance on Recurrent Patella Dislocations: A Pilot Study , Samuel Arnold, Emily Bradshaw, Anna Hansen, Jessica Knutson, and Mackenzie Newman

The Impact of Walker Style on Gait Characteristics in Non-assistive Device Dependent older Adults , Matthew Bennett, Taylor Hutchins, and Kaci Platz

The Impact of a Community based Exercise Program on Somali Immigrants Residing in Subsidized Housing in Minnesota , Kimberly Berggren, Meghan Gerardi, and Laura Mueller

Comparison of Three-Dimensional Motion of the Scapula during the Hawkins-Kennedy Test and the Sidelying Sleeper Stretch , Alyssa Buchner, Tami Buus, Brittany Evans, Kirsten Lambert, and Lisandra Scheevel

Influence of Fatigue and Anticipation on Knee Kinematics and Kinetics during a Jump-cut Maneuver , Sara Buermann, Erica Gloppen, Regan Kriechbaum, Dani Potter, and Nicole Sheehan

The Accuracy of Wireless Sensors in Detecting the leg Movements and Kicks of Young Typically Developing Infants: A Pilot Study , Bri Coulter, Julia Johnson, Molly Koch, and Christina Ramsdell

Research Papers from 2016 2016

The Effects of an On-Site Exercise Program on Health and Health Behaviors in Community Dwelling Adults Living in a Subsidized Apartment Building , Alexandra Anders, Chad McNutt, and Sarah Whitmore

Influence of Fatigue on Jump and Land Movement Patterns , Sarah Bard, Beth Anne Cooper, Kevin Kosel, Owen Runion, and Kristi Thorwick

Hip Strength and Core Endurance in Female Adolescent Runners With and Without Knee Pain , Brandon Boeck, Emily Kammerer, Lisa Kelley, Cody Misuraca, and Mitchell Peterson

Factors Impacting Adherence to a Multifactorial Fall Prevention Program - a Matter of Balance , Megan Dean, Justine Eggers, Brittany Stevens, and Gunther Wolff

Chemotherapy Induced Peripheral Neuropathy and Foot Posture in Pediatric Cancer Patients , Parker Deutz, Magdalena Hoelmer, Sarah Knilans, and Abigail Semlak

The Effect of Hip and Hamstring Pathology on Sacroiliac Joint Dysfunction: A Case Series , Sarah DuPlissis, Rachel Hedden, Nicholas Manning, Josh Patterson, and Luke Wahlstrom

Goal-directed Leg Movements and Kicks in Infants with Spina Bifida , Emily Goracke, Kelsey Jacobs, Elizabeth Pilney, and Katherine Shephard

The Role of the Physical Therapist in Health Promotion as Perceived by Patients with Neurological Pathologies: A Descriptive Study , Ariel Hansen, Gabrielle McGurran-Hanson, Kayla LeDuc, and Hannah Von Arb

Research Papers from 2015 2015

Proximal Strength and Functional Testing Applicable to Patellofemoral Instability: A Preliminary Study , Samantha Alschlager, Danielle Honnette, Katelyn Ley, Brianna Ludtke, and Kristen Reed

Recovery of Nerve Function after Treatment for Childhood Cancer , Allison Baker, Alison Bottke, Maria Leider, and Timothy Mann

The Effects of Electrical Stimulation on Chronic Wound Healing: A Systematic Review , Elena Campea, Alice Fasnacht, and Allison Kirkvold

Glenohumeral Osteoarthritis: Patient Profiles and Outcomes of Shoulder Arthroplasty , Lisa Carlson, Katie Kruger, Callie Larsen, and Kim Ruehlmann

The Effect of Conjugate Reinforcement on the Leg Movements of Infants with Spina Bifida , Sarah DeRosier, Jeremy Martin, Anna Payne, Kelly Swenson, and Elisabeth Wech

Recovery from Central Cord Syndrome: A Case Report , Katie Jacobson

Cerebral Vascular Accident Confounded by Parkinson's Disease: A Case Report , Jacqueline Moseman

Physical Therapy for Mobilization of a Patient with a Prolonged Intensive Care Unit Stay: A Case Report , Jennifer Pulscher

Physical Therapy Management of a Patient with Diffuse Pigmented Villonodular Synovitis: A Case Report , Christa Schutte

Research Papers from 2014 2014

Fairview Cancer Rehab Program Outcomes and Effectiveness: a Pilot Study , Kaeleigh Adami, Elizabeth Koch, Allie Meier, and Laura Vaughn

Core Strength Testing: Developing Normative Data for Three Clinical Tests , Alexis Anderson, Jessica Hoffman, Brent Johnson, Anna Simonson, and Laurel Urquhart

Hip Strength and Core Endurance Among Female Adolescent Runners , Jenna Batchelder, Angela Everson, Leah Paquin, and Heidi Sande

Effect of Lower Extremity Sensory Amplitude Electrical Stimulation on Motor Recovery and Function after Stroke: a Pilot Study , David Bowman, Rebecca Nelson, Kelsey Shearen, and Emily Wizykoski

Volunteering as an Occupation in African-American Women in a Rural Community , Kayla Clafton, Melissa Danielson, Danielle Glenn, and Samuel Vukov

The Influence of Age, Position, and Timing of Surgical Repair on the Kicks of Infants with Spina Bifida , Ann Engstrom, Shannon Lucken, Kayla Sis, and Sarah Wehrheim

Facilitators and Barriers to Health Promotion Perceived by Minnesota Physical Therapists Working in Outpatient Settings , Ashley Fisher, Marit Otterson, and Sarah Pitzen

Establishment of Normative Shoulder Internal Rotation Passive Range of Motion Values in the Sidelying and Semi-sidelying Positions , Alisse Indrelie, Shannon Kelly, Hugo Klaers, Tatia Nawrocki, and Michael Stelzmiller

Research Papers from 2013 2013

Core Strength Testing: Developing Normative Data for Three Clinical Tests , David Anderson, Lindsay Barthelemy, Rachel Gmach, and Breanna Posey

The Effects of Walking Poles and Training on Gait Characteristics and Fear of Falling in Community Dwelling Older Adults , Sarah Becker, Lisa Glad, Kelsie Nebelsick, and Katie Yernberg

Effects of a Therapeutic Dance Program on Balance and Quality of Life in Community Dwelling Older Adults , Krista Berger, Julie Kaminski, Lindsey Kolnik, and Jennifer Miller

Physical Therapists’ Role in Health Promotion as Perceived by the Patient: A Descriptive Study , Jessica Berglund and Erin Poepping

Findings of the Lower Extremity Dynamic Screen in Patients with Patellofemoral Pain Syndrome: A Pilot Study , Jake Foley, Meghan Grathen, Lindsey Johnson, and Elizabeth Volk

Prevention of Work-Related Shoulder and Neck Injuries: A Systematic Review , Daniel Frush, Kimberly Redlin, and Jacob Cruze

The Impact of Chemotherapy on the Neuromuscular Components of Gait , Kari Johnson, Britta Schwartzhoff, Sandy Silva, and Rina Terk

Reentry Home after Disaster Relief Work in Haiti: A Mixed Methods Study of the Reentry Process of Medical Professionals , Kelsey Leeman, Andrea Olson, Abby Rassat, and Rita White

Physical Therapy Interventions and Outcomes for a Patient Following Hospitalization for Viral Gastroenteritis and Resulting Hospital-Acquired Pneumonia: A Case Report , Rachel Lewis

Research Papers from 2012 2012

Comparison of the Proprioceptive and Motion Reduction Effects of Shoulder Braces in Individuals With and Without Anterior Shoulder Dislocations: A Pilot Study , Evan Boldt, Marci Burg, Leah Jackson, and Lana Prokop

Risk Factors for Patellofemoral Pain Syndrome , Scott Darling, Hannah Finsaas, Andrea Johnson, Ashley Takekawa, and Elizabeth Wallner

Experiences of Physical Therapists who Participate in Disaster Relief Work in Haiti , Erin Faanes, Andrea Guggenbuehl, Ellen Johnston, Katie Larsen, and Crystal Stien

The Sensitivity of Infants with Spina Bifida to Sensory Information , Katie Gulsvig, Christina Hawn, James Plummer, and Ann Schmitz

Physical Therapists' Knowledge, Beliefs, and Practices Pertaining to Health Promotion and Fitness Testing , Megan Johnson, Allison Fisher, Megan Wiemann, Jenna Laska, and Andrea Eckstrom

Clinical Decision Making and Physical Therapy Management of Knee Pain Following Total Hip Arthoplasty: A Case Report , Lisa Marais

Physical Therapy Management Following Femoroacetabular Impingment Correction and Acetabular Labral Repair: A Case Report , Jessica Walker

Unraveling the Mystery of Knee Pain: A Case Report , Nicole L. Zehnder

Research Papers from 2011 2011

3D Knee Kinematics and Kinetics With Visual Disruption in Subjects With ACL Reconstruction , Brittni Baune, Jennifer Henderson, Jenna Merchant, and Kristian Olson

Lower Extremity Functional Screen for Biomechanical Faults in Female Athletes , Jacqueline Carpenter, Ann Donner, Kristine Hoff, and Naomi Johnson

The Effect of Training on Novice Raters When Performing Radiographic Measurement of Humeral Retroversion: a Follow-up Study , Ryan Christensen, Danielle Grambo, Erin Ingram, and Lyna Menezes

The Effect of Walking Poles on Gait Characteristics and Fear of Falling in Community Dwelling, Four-Wheel Walker Dependent and Non-Assistive Device Dependent Older Adults , Jennifer Gonnerman, Ellen Guerin, Karen Koza, and Courtney Tofte

Physical Therapy Intervention for a Patient with Bilateral Achilles Tendinopathy Following Periods of Immobilization: a Case Report , Alyssa Hageman

An Outpatient Physical Therapy Intervention Program , Rebecca K. Henderson

Functional Recovery in a 67-Year-Old Male with Staphylococcus Aureus Spinal Cord Abscess: a Case Report , Andrea Hokanson

Lower Extremity Activity of Infants with Spina Bifida: Does Context Still Matter , Sarah Meissner, Megan Ogaard, Jeanna Shirley, and Kristin Warfield

Clinical Use of the Nintendo WII for Balance Rehabilitation: a Case Report , Jasey Olsen

Safety of Physical Therapy Using Symptomatic Blood Value Guidelines in Children Being Treated for Cancer , Katie Peters and Jessica Tice

Research Papers from 2010 2010

Political Participation in Physical Therapy: Attitudes and Perceptions Across the Practice Spectrum , Cole Kampen, Nicholas Schneider, Miranda Swensen, and Amy Thompson

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Article Contents

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Physical Therapy and Mental Health: A Scoping Review

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Sophie E Heywood, Joanne Connaughton, Rita Kinsella, Susie Black, Nadia Bicchi, Jenny Setchell, Physical Therapy and Mental Health: A Scoping Review, Physical Therapy , Volume 102, Issue 11, November 2022, pzac102, https://doi.org/10.1093/ptj/pzac102

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Coexistence of mental and physical health conditions is prevalent. To achieve optimal physical therapy outcomes, neither should be treated in isolation. This review aimed to map intersections between physical therapy and mental health.

This was a scoping review searching MEDLINE, CINAHL, PsycInfo, Cochrane, and PEDro databases. Two independent researchers screened studies of physical therapy practice with adolescents/adults with mental health disorders or research using primary mental health outcomes in physical health conditions or clinicians’ perspective. Data were extracted on study type, participants, topics, publication year, and country.

The search yielded 3633 studies with 135 included. Five studies included adolescents. More than one-half were published since 2015. Studies specific to participants with mental health diagnoses included schizophrenia (n = 12), depressive disorders (n = 8), eating disorders (n = 6), anxiety disorders (n = 4), bipolar disorders (n = 1), somatic disorders (n = 5), and trauma and stressor-related disorders (n = 8) or varied mental health diagnoses (n = 14). Forty-one studies had primary mental health outcomes or clinical practice approaches with a mental health emphasis with participants with physical health conditions (musculoskeletal [n = 13], neurological [n = 7], other [n = 21]). Systematic reviews or randomized controlled trials predominantly involved exercise therapy and/or physical activity. Descriptions of physical therapists as participants (n = 35) included 4 main topics: (1) mental health screening; (2) knowledge, attitudes, and experiences; (3) key practice components; and (4) research priorities.

Physical therapy intersects with people experiencing mental health disorders across a broad spectrum of diagnoses, covering a range of interventions with a small but growing evidence base.

Exercise and physical activity studies dominated the highest levels of evidence and future focus, although economic evaluations and consumer-driven or patient experience studies are needed. There is a contrast between the confidence and knowledge of specialized physical therapists working within mental health settings and those in general practice settings. Inspiring, integrated education is required to further improve health care outcomes following physical therapy for people with mental health disorders or symptoms.

The increasing prevalence and impact of mental health disorders in society highlights the importance of its comprehensive consideration alongside physical health for optimal health care outcomes. 1–3 In recent years, there has been greater acknowledgement of the key role mental health plays in enhancing quality of life. 1 The impact of mental health has been particularly highlighted during the COVID-19 pandemic 2 related to widespread emotional distress and increased risk for psychiatric illness. 4

Physical therapists often have a primary focus on helping people to maintain or improve their movement, strength, and functional ability. 5 Interconnected to physical function is the aim of maximizing a person’s quality of life, well-being, and sense of empowerment. This includes psychological and mental health as well as physical aspects of health. 6 There is a high prevalence of coexistence of mental and physical health conditions. 7 , 8 Four out of every 5 people living with mental health disorders have a coexisting physical health issue and are also twice as likely to have a chronic health condition such as cardiovascular disease, respiratory disease, or diabetes. 9 Similarly, people with chronic physical health conditions are often also living with a mental health disorder. 8 The joint effect of mental health disorders and chronic conditions, for example the combination of major depression interacting with physical illness, amplifies functional disability. 10 To achieve optimal outcomes, neither mental nor physical health should be treated in isolation in physical therapy management. 11 , 12

Physical therapists work across a wide range of services, including those with a mental health focus, often as part of a multidisciplinary team. 13 In all settings, regardless of focus, understanding the synergy of mental and physical health is critical. However, physical therapists’ confidence may be limited when working with people with mental illness. 14–16 Geographical variations may play a part in confidence and experience, with physical therapists in some countries having longer histories of engagement with mental health than others, 11 potentially leading to greater opportunities. Despite physical therapists utilizing biopsychosocial approaches—including goal setting, positive and motivational talk, cognitive behavioral therapy strategies, and offering social support 17 —there remain concerns about the narrow focus on biological factors and cognitive behavioral change. 18 This limited application of the biopsychosocial approach may be inadequate to address the complexities of some health conditions. 18 To ultimately enhance patient care, it is critical to better understand the scope of current research so that it can help inform professional practice and the future direction in physical therapy.

With a strong focus on physical health and function, the role of physical therapy regarding peoples’ mental health may be less obvious. To our knowledge, the crossover between physical therapy and mental health has not been explored in a broader context. This scoping review aimed to quantify the volume and distribution of the research literature describing the intersection of physical therapy and mental health disorders or physical therapy in physical health conditions with a primary focus including mental health outcomes or treatment approach.

Our specific research questions were:

What are the study types, volume, publication year distribution, and country of origin of peer-reviewed research encompassing the intersection between physical therapy and mental health disorders?

Which topics and participant groups are the focus of research about physical therapy for people with mental health disorders?

Which topics and participant groups are the focus of research about physical therapy for people with physical health conditions using a primary mental health outcome (ie, depressive symptoms) or clinical practice approach with an emphasis on mental health?

What are the views, knowledge, and experiences of physical therapists working with people with mental health disorders?

Scoping review methodology was chosen to provide an overview of the published academic research on mental health and physical therapy, including key topics, types of evidence, and main sources. Scoping reviews can map and establish the scope of the existing literature in areas of emerging evidence in physical therapy, taking a broad approach. 19 This review employed the methodology described by Arksey and O’Malley and followed PRISMA-Scoping review guidelines. 20 , 21 The protocol was registered in the Open Science Framework ( https://doi.org/10.17605/OSF.IO/WD6ZN ).

Data Sources and Searches

MEDLINE, CINAHL, PsycInfo, Cochrane, and PEDro databases from inception to November 2020 were searched for publications in peer-reviewed journals pertaining to physical therapy and mental health. Search terms related to physical therapy (“physiotherapy” OR “physical therapy” OR “physiotherapist” OR “physical therapist” OR “mind and body therapies”) and overview mental health terms and the most prevalent disorders or outcomes (“mental health” OR “mental illness” OR “psychology” OR “psychiatry” OR “anxiety” OR “depression” OR “schizophrenia” OR “body image” OR “bipolar affective disorder” OR “behavioral disorder” OR “mood disorder” OR “psychotic disorder” OR “eating disorder”). Key words were used across multiple search fields to return the broadest range of results. A grey literature search included research included in the newsletters from 2011 to 2020 of the International Organization of Physical Therapy in Mental Health (IOPTMH) available online. 6 For feasibility, studies were limited to English language only.

Study Selection

The details of inclusion and exclusion criteria for studies are outlined in Table 1 .

Inclusion and Exclusion Criteria a

DSM-5 = Diagnostic and Statistical Manual of Mental Disorders; ICD = International Statistical Classification of Disease and Related Health Problems.

Data Extraction

All yielded studies were imported into Covidence systematic review software ( https://www.covidence.org ). Two reviewers (S.H., N.B.) independently evaluated all identified titles and abstracts against established eligibility criteria. Full texts of all remaining studies were screened independently for inclusion by the same 2 reviewers, with disagreements resolved by a third reviewer (J.C.). For included studies, the following data were extracted and charted to a standardized spreadsheet: year and type of study, authors, country of origin (first named author), title, diagnosis of participants or description of population, outcomes and / or intervention (as appropriate), and key findings or conclusions.

Data Synthesis and Analysis

Although neither mental nor physical health should be treated in isolation in physical therapy, 11 , 12 for the purposes of this scoping review a framework to identify and group information separating the population or diagnosis of participants was developed. Data were synthesized in table form with subgroups related to either (1) the primary mental health or physical diagnosis of the patient population/participants or (2) clinician participants or service review studies.

Role of Funding Source

The funder played no role in the study design, conduct, or reporting of this study.

The search yielded 3633 articles (including 29 articles from the grey literature search not identified in the database search) that were screened for inclusion (see Fig. 1 for the Prisma flowchart), with 135 publications from peer-reviewed journals included in the review (see Tab. 2 for an overview; see Suppl. Tabs. 1 – 13 , for further details and references: Suppl. Tab. 1 Depressive Disorders, 24–31   Suppl. Tab. 2 Anxiety Disorders, 32–35   Suppl. Tab. 3 Schizophrenia Spectrum and Other Psychotic Disorders, 36–47   Suppl. Tab. 4 Bipolar and Related Disorders, 48   Suppl. Tab. 5 Trauma- and Stressor-Related Disorders, 49–56   Suppl. Tab. 6 Eating Disorders, 57–62   Suppl. Tab. 7 Somatic Disorders, 63–67   Suppl. Tab. 8 Mental Health Disorders, 15 , 68–80   Suppl. Tab. 9 Musculoskeletal Conditions, 81–93   Suppl. Tab. 10 Neurological Conditions, 94–100   Suppl. Tab. 11 Other Physical Conditions or Across Multiple Diagnoses, 8 , 101–120   Suppl. Tab. 12 Clinicians, 14–16 , 75 , 121–152   Suppl. Tab. 13 Service Reviews 153–154 ).

PRISMA flowchart.

Participants in Included Studies a

Two studies had both patient and clinician participants, 15 , 75 1 study involved psychiatric nurses as partcipants, 1 , 35 and a further 2 studies were physical therapy service reviews. 153 , 154

Distribution of Papers Published by Year

An increasing number of studies have been published about physical therapy and mental health in recent years, with 54% of studies in the review published since 2015 (see Fig. 2 ).

Distribution of papers by year of publication.

Distribution of Papers Published by Country

The 135 studies included in the review were published by first authors from 25 different countries. The greatest contributions to number of studies were from the United Kingdom (n = 28 studies), Sweden (n = 27), Belgium (n = 16), Australia (n = 11), United States (n = 9), Norway (n = 7), Denmark (n = 6), and Canada (n = 6).

Physical Therapy for People With Mental Health Disorders

This section provides an overview of the focus of studies specific to participants with mental health diagnoses, including depressive disorders (n = 8), anxiety disorders (n = 4), schizophrenia and related disorders (n = 12), bipolar and related disorders (n = 1), trauma and stressor-related disorders (n = 8), eating disorders (n = 6), and somatic disorders (n = 5) and studies with participants across a range of mental health diagnoses (n = 14) (see Fig. 3 ).

Type and number of studies of participants with a mental health diagnosis (size of bubble represents total number of studies including reviews and protocols).

Participants With Depressive Disorders

Eight studies (3 systematic reviews, 3 randomized controlled trials [RCTs], 1 non-randomized study, and 1 qualitative study) included participants with depressive disorders with a focus on exercise in many of the investigations. All 3 systematic reviews investigated exercise in different ways. One systematic review evaluated the effectiveness of exercise therapy in improving symptoms of depression compared with medications or psychological interventions, 28 another investigated optimal exercise parameters on clinician or self-rated depression scales 29 and the third explored dropout rates in exercise studies among people with depression. 30 Of the 3 RCTs with a control group, the intervention groups covered 2 forms of exercise in 1 study, 27 a rehabilitation program in another, 24 and a more upright posture and taping in the third. 31 A non-randomized study compared aerobic exercise or basic body awareness therapy (BBAT) with a single consultation with advice on physical activity for improvements in fitness and self-rated depression, 25 and 1 qualitative study exploring participants with depressive disorders’ experiences in physical therapist guided aerobic exercise program. 26

Participants With Anxiety Disorders

Four studies (1 non-randomized study, 2 qualitative studies, and 1 case series) included participants with anxiety disorders across a range of settings and specific clinical presentations. One cohort study examined breathing retraining for those with hyperventilation syndrome 34 ; of the 2 qualitative studies, 1 described attitudes towards, and preferences for, social and physical features of the rehabilitation environment of women with social physique anxiety, 33 and the other qualitative study explored participants’ experiences of group treatment in a psychiatric outpatient care setting. 35 In a fourth study, a case series measured fear of falling for those who underwent earlier desensitization treatment. 32

Participants With Schizophrenia and Related Disorders

There were 12 studies investigating people with schizophrenia included in this scoping review, including 7 systematic reviews, 1 randomized trial, 2 cross-sectional studies, and 2 qualitative studies. The systematic reviews covered topics related to physical activity participation 40 , 46 and benefits, 44 , 47 walk test distance, 36 and physical therapy approaches, including aerobic, strength, and other types of exercise. 44 , 45 , 47 One review evaluated whether there is an elevated risk of fractures potentially linked to the use of anti-psychotic medication and discussed the implications that physical therapists may add value in improving fitness, leg strength, and balance to reduce both falls and hospital length of stay. 41 The 1 pilot RCT investigated anxiety, psychological stress, and well-being responses to a single session of yoga and aerobic exercise. 43 Of the 2 cross-sectional studies, 1 investigated headache prevalence, characteristics, impact, and management, outlining that no one was receiving best-practice care and physical therapists could be employed within mental health services to address this problem. 37 The other investigated inpatients’ physical activity participation, functional exercise capacity, and self-esteem. 42 Qualitative studies included interviews of people with schizophrenia about barriers to and incentives for physical activity 39 or experiences and perceived main treatment effects of BBAT. 38

Participants With Bipolar and Related Disorders

One non-randomized study investigated the effects of physical therapy techniques on people diagnosed with mania, measuring levels of arousal and perceived need for mechanical restraint. 48

Participants With Trauma and Stressor-Related Disorders

Of the 8 studies of participants with posttraumatic stress disorder, 2 systematic reviews focused on physical fitness 56 and physical activity. 53 Five studies (1 mixed methods and 4 qualitative) evaluated aspects of BBAT, including changes in quality of movement and pain, 49 compliance and satisfaction, 55 and the BBAT experiences of people with a history of trauma from a refugee background 50 and women who have experienced abuse. 51–52 One further qualitative study explored the reactions of adult female survivors of childhood sexual abuse to physical therapy and their views on how physical therapists could be more sensitive to their needs. 54

Participants With Eating Disorders

Six studies in participants with eating disorders included 2 systematic reviews, 1 RCT, 2 non-randomized studies, and a cross-sectional study. The 2 systematic reviews evaluated physical therapy interventions for binge eating disorder 62 and for anorexia and bulimia nervosa. 61 A randomized pilot trial investigated the effect of BBAT in patients with eating disorders. 59 In an inpatient setting, physical therapy and exercise sessions were evaluated for participants with anorexia nervosa. 60 Two studies evaluated body awareness or body image; 1 pilot program investigated a body image intervention program including touch, massage, and drawing exercises for inpatients with eating disorders 58 ; and another observational study evaluated body awareness of persons living with eating disorders. 57

Participants With Somatic Disorders

Functional motor disorders were investigated in 5 studies, including a pilot trial in telehealth physical therapy, 63 an evaluation of anxiety and depression following a 5-day inpatient stay of education and movement retraining, 65 and a protocol for a randomized controlled trial for a specialist physical therapy program. 66 Patients in primary care with medically unexplained symptoms were surveyed and interviewed in a mixed method study of physical therapy and physical activity in a psychiatric specialist treatment setting. 67 In a case study, the details of an adolescent with conversion disorder who presented with an ataxic gait pattern were described. 64

Participants With Various Mental Health Disorders

Fourteen studies did not define participant groups by mental health diagnosis but rather invited participants with a range of mental health diagnoses, including 4 systematic reviews, 3 RCTs, 3 non-randomized studies, 1 observational study, and 3 qualitative studies. In 2 of these studies, physical activity and aerobic exercise were systematically reviewed for changes in symptoms that characterize the included psychiatric disorders. 77–78 Sedentary behavior, 79 physical activity, and cardiorespiratory fitness 80 were evaluated in 2 further reviews. In 3 randomized studies, people with a depressive disorder and/or anxiety disorder evaluated learning-oriented physical therapy compared with standard psychiatric treatment, 68 8 weeks of work-oriented rehabilitation was compared with physical activity and access to a local gym, 70 and weekly BBAT was evaluated for 12 weeks compared with usual care of psychotherapy and medications. 72 One non-randomized study evaluated participants’ depressive symptoms following 6 weeks of a physical fitness program for patients with psychiatric disorders, 69 and a further non-randomized study investigated the addition of physical therapy aiming to increase physical activity in sedentary or inactive patients. 73 One qualitative study explored experiences of people attending an outpatient psychiatric service and the relationship with the physical therapist following BBAT, 71 and 1 study assessed the reliability and validity of a body awareness scale. 74 Two further qualitative studies involved interviewing people with mental illness regarding their understanding of the role and relevance of physical therapy for physical health in mental health care settings 15 and experiences of physical therapy, including barriers and facilitators to care. 75

Physical Therapy for People With Physical Health Conditions

This section provides an overview of the literature that focused on participants with physical health conditions with interventions or outcomes with a mental health focus. Of the 41 studies included, 13 evaluated mental health outcomes for participants with musculoskeletal disorders; 7 for those with neurological disorders; and 21 for those with various other physical health diagnoses, including women’s health, and burns as well as gastrointestinal, respiratory, and chronic conditions (see Fig. 4 ). The research centered around observing whether a physical therapy or exercise therapy intervention helped improve an existing mental health disorder/symptom or observing whether existing mental health disorders/symptoms affected the outcome of the intervention.

Studies of participants with physical health conditions (size of bubble represents total number of studies).

Participants With Musculoskeletal Disorders

Of the 13 studies with participants with musculoskeletal disorders, 8 had a diagnosis of spinal (neck or low back) pain, 81 , 82 , 85 , 86 , 88–91 1 had knee osteoarthritis, 87 1 had generalized pain, 92 2 had fibromyalgia, 83 , 84 and 1 had shoulder pain. 93 The studies investigating people with spinal pain focused on a range of outcomes and treatment approaches including psychological outcomes in response to spinal manipulation 91 ; anxiety and depression outcomes in non-specific low back pain following an exercise intervention 82 ; depressive symptoms following general strength and conditioning or motor control training and manual therapy 89 ; changes in anxiety and depression, sleep, and mood on waking in people with chronic non-specific neck and back pain following acupuncture treatment 85 ; symptoms of depression in participants with work-related back or neck injury following a rehabilitation program 90 ; illness acceptance and depression in people with degenerative spinal disease 86 ; anxiety and depression in a protocol for an RCT including the addition of “somatic experiencing” to physical therapy in participants with low back pain and following trauma 81 and stress; and depression and anxiety in a protocol for an RCT including “stress inoculation training” in addition to supervised exercise in participants with whiplash associated disorder. 88 Anxiety and depression were evaluated in people with knee pain following exercise therapy 87 and in a further study, depressive and somatization symptoms were assessed for those receiving outpatient physical therapy for a variety of common spinal, and peripheral joint musculoskeletal diagnoses. 92 Mental health outcomes of participants with fibromyalgia were evaluated in a systematic review of body awareness interventions 84 and an RCT, 83 consisting of a pharmacology intervention plus BBAT. Finally, a case report of an outpatient with shoulder pain but an undiagnosed psychiatric illness described the presentation and symptoms of the person. 93

Participants With Neurological Disorders

Seven articles evaluated participants with neurological conditions. Four systematic reviews evaluated outcomes of depressive symptoms following exercise or rehabilitation interventions in participants with multiple sclerosis, 94 stroke, 96 , 97 or varying neurological diagnoses. 100 Both cross-over RCTs evaluated the effect of a physical intervention in patients with traumatic brain injury, 1 evaluating depression and stress responses following a walking or nutrition intervention 98 and the other evaluating sleep, stress, and chronic fatigue responses to yoga-based physical therapy. 99 The pilot RCT evaluated depressive outcomes in participants with Parkinson disease 95 who were randomized to either aquatic therapy or dry land control.

Participants With Other Physical Health Conditions

Another 21 articles evaluated mental health outcomes or interventions in various other physical health conditions ( Fig. 3 ). Ten of these studies involved female participants being evaluated for anxiety and depressive symptoms following physical therapy after breast cancer surgery (1 RCT 115 and 2 non-randomized studies 105 , 119 ), women’s health conditions (1 systematic review, 104 3 RCTs, 113 , 114 , 117 1 protocol for an RCT, 103 1 non-randomized study 109 ), or stress disorder (non-randomized study). 118 Three studies evaluated people with respiratory disorders. These included a breathing training intervention in 2 studies: the first, a pilot RCT measuring anxiety and depression for those with hyperventilation syndrome, 106 and the second, a case controlled study measuring panic and anxiety symptoms in people with asthma. 110 The third non-randomized study in people with hyperventilation and exhaustion measured anxiety and depression following a grounding intervention including dance, breathing, and body awareness. 116 Two studies included participants with burn injuries and physical therapy interventions; 1 survey measured pain and anxiety during treatment, 112 and a non-randomized study evaluated depression following a home exercise program. 120 Two studies included participants with gastrointestinal conditions (irritable bowel syndrome): 1 study was an RCT 107 and 1 was a non-randomized study, 108 with both measuring symptoms and body awareness. The remaining studies involved a systematic review evaluating depression and chronic physical conditions 8 and patients with non-specific diagnoses, including 2 RCTs following 6 months of Norwegian Psychomotor Physical Therapy in outpatients evaluating depression and anxiety 101 or general health, pain, coping, and self-esteem, 102 and a pilot study in measuring “psychophysiological parameters” following 10 sessions of connective tissue massage. 111

Physical Therapists’ Views, Knowledge, or Experiences and Service Reviews

Of the 135 studies included in this review, 35 recruited physical therapists as participants from general, musculoskeletal, or outpatient settings or from specialized mental health settings in cross-sectional surveys or qualitative or mixed-methods studies (see Suppl. Fig. 1 ). These studies fell into 4 main topic areas: (1) screening for mental health disorders or symptoms; (2) knowledge, attitudes, beliefs, and experiences of physical therapists; (3) descriptions of key practice components of physical therapy or using specific interventions; and (4) research priorities. Two further studies described physical therapy service reviews within mental health settings. 153 , 154 One study exploring psychiatric nurses’ views of physical therapy for people with schizophrenia fell outside these topics. 135

Screening Studies

There were 5 survey studies related to screening in physical therapy practice. The 4 studies about screening for mental health issues 125 , 130 , 134 , 138 came mainly from general practice musculoskeletal outpatient settings. Findings indicated a lack of onward referrals to psychology despite recognizing depression, 134 poor screening frequency 125 and identification symptoms of depression, 130 and underestimation of mental health issues. 125 , 138 Further education was recommended in all studies. One further screening study investigated physical therapists’ experience and recognition of domestic violence. 121

Knowledge, Attitudes, Beliefs, and Experiences of Physical Therapists

Seven qualitative or mixed methods studies explored the knowledge, attitudes, and perceptions of physical therapists working with people with mental health disorders in both general practice (6 studies) and specialized mental health services (1 study). Reoccurring topics reported in the findings of surveys of physical therapists working in general practice settings from Ireland, 16 Australia, 14 , 15 , 122 and South Africa 133 were the value of the profession to health care, growing exposure to psychological distress, importance and influence of mental health on overall health outcomes, and addressing both physical and mental health issues. Across these studies physical therapists reported varying levels of confidence in addressing mental health issues (often connected to limited training). Enablers to improving capacity in physical therapy practice were primarily related to education but also included funding and service models. For physical therapists working in specialist mental health contexts, Hemmings and Soundy found results similar to those working in general practice, that clinicians believe in the benefit of physical therapy, with communication and holistic care important. 75 One further study with sports physical therapists in the United Kingdom found that negative psychological reactions to sports injury were common, and more education regarding the role of sport psychology in injury rehabilitation is required. 132

Key Practice Components of Physical Therapy

Twenty survey, qualitative, or mixed methods studies included in the review covered a variety of clinicians’ perspectives on key physical therapy practice components when working with people with mental health disorders (including, schizophrenia, eating disorders, anxiety disorders, survivors of torture, and people who are refugees). Four international studies explored views of physical therapists on key practice components, the role of physical therapists, and treatment approaches or services. In surveys of IOPTMH members, physical therapists were identified as physical health experts in the multidisciplinary team in schizophrenia, key workers in bridging the gap between physical and mental health, considered to be integral in health promotion efforts by encouraging healthier lifestyle choices and higher levels of habitual physical activity, 145 and with the necessary knowledge and skills to develop and monitor delivery of physical activity programs. 146 Another survey of international physical therapists, this time working with people with eating disorders, 142 identified the importance of physical therapists (within the multidisciplinary team) in providing interventions aimed at management of distorted body image, programs to control excessive exercise, and anxiety reduction. A mixed methods study developed a consensus statement connected to the IOPTMH concluding there was insufficient evidence for the relative contribution of physical activity reducing cardio-metabolic risks in people with schizophrenia. 148

Specific approaches were also explored. Norwegian Psychomotor Physical Therapy was explored in interviews related to the therapists’ experience of the phenomenon of “listening to the body.” 124 Components of BBAT were examined in international qualitative studies 127 , 129 and explored experience and views on core phenomena in BBAT practiced in Norway 139 and Sweden 128 and with people with schizophrenia. 131

Physical therapists who were members of the Chartered Society of Physiotherapy were surveyed on their views on physical interventions to manage aggression 143 , 144 and interviewed about their role in the management of anorexia nervosa. 137

Studies about physical therapy approaches to working with people with anxiety disorders included 1 survey from the United Kingdom that found that exercise was used more frequently than any other treatment approach 147 and another study using interviews from Sweden suggesting that physical therapy works through immediate, tangible bodily experiences to help a person understand and handle anxiety. 123 One survey study described from the perspective of physical therapists the barriers and facilitators for people with schizophrenia in psychiatric services to engage in physical activity. 141 Barriers included the effects of antipsychotic medication, lack of motivation, fluctuation of an individual’s illness, and negative symptoms. Support from health care professionals and peers, involvement of the multidisciplinary team, and positive relationships between therapist and patient were considered facilitators. Physical therapists’ views from a survey on the value and dimensions in social support were also described in people with schizophrenia. 140

Several studies explored the therapeutic relationship. One study reported personal characteristics, professional and therapeutic competence, and support, language factors, time, and frames were prerequisites for a good interaction by a physical therapist with persons who had undergone torture. 126 With an aim to develop core competencies for physical therapists working with people from a refugee background, 136 a scoping review identified 3 key themes: understanding refugee health (including determinants of health, physical health, and mental health), cultural competence (sensitivity and communication), and the health care system (as it relates to refugees). In 1 study, specialized vestibular physical therapists reported using a range of behavioral and cognitive techniques and adapting their therapeutic approach to manage anxiety. 152

Research Priorities

Three studies surveyed physical therapist participants from IOPTMH member countries on research priorities and questions on physical activity in schizophrenia, 150 bipolar disorder, 151 and binge eating disorder. 149 The top 3 questions in each study related to the benefits of physical activity, safety issues, and optimal exercise prescription.

Physical Therapy Service Review

Two cross-sectional studies described physical therapy service provision. Staff members of 48 different psychiatric hospitals in Switzerland completed a survey on physical activity and exercise, with 85% of hospitals providing physical therapy (85%). 153 In Nigeria, an audit found that in over 200,000 patients in a mental health service, 3% received physical therapy (14% of total inpatients), with low back pain, osteoarthritis, stroke, and shoulder pain the most common coexisting health problems referred for physical therapy. 154

This scoping review sought to map a broad area of clinical practice by considering where physical therapy intersects with mental health. The review identified a relatively small but growing body of literature with a range of topics of research and participant groups. Exercise and physical activity were the most common interventions explored for people with mental health disorders. Research on this topic was generally efficacy-focused, including systematic reviews and randomized controlled trials. In terms of the range of mental health diagnoses attended to in the research, the most common condition was schizophrenia, but depression and anxiety were also key foci. People with musculoskeletal and neurological conditions were the most common participant groups with a primary physical health diagnosis in alignment with the largest focus of studies in physical therapy research outside of the mental health context. 155 Literature exploring people’s experiences within the intersection between physical therapy and mental health was more often physical therapist focused than consumer driven or patient experience studies. These studies generally explored clarifying the role of physical therapists in relation to mental health. There was an unequal geographical distribution of research, which was in agreement with a scoping review in physical therapy in refugees. 136 Unequal distribution may reflect countries or regions with a greater mental health care system integration of physical therapy, interest in specific methods, more academic and clinical support for investigators, or a local “champion” driving a particular stream of research.

The volume of research published about the intersection of physical therapy and mental health is growing. This growth may reflect the global movement toward better awareness and destigmatization of mental health conditions 156 and the impact of mental health in health care and society being recognized more widely. 1 Growth of research in mental health and physical therapy may also be linked to the relatively recent expansion of international mental health physical therapy interest groups. However, the research volume is very small compared with research produced in the core rehabilitation fields physical therapists most commonly contribute to. 155 , 157 For example, indexed to 2014 in the Physiotherapy Evidence Database, the largest number of randomized controlled studies, systematic reviews, and clinical guidelines in the musculoskeletal subdiscipline totaled 7676. 157 There were only 51 randomized controlled trials, systematic reviews, and consensus statements found in our review.

This scoping review identified diversity in participants and types of research, with exercise and physical activity studies dominating the highest levels of evidence. Mental health physical therapists also identified research in exercise as the greatest priority as the focus of further investigations. 149–151 Benefits, barriers, fitness, optimal program variables, and strategies to assist successful implementation of programs all have strong interest as research areas. Despite the benefits of the biomedical diagnosis segmentation and specialty practice in health care, physical therapists are likely to be most successful at improving outcomes for patients when considering the whole person. 11 Research about models of care, the integration of exercise professionals into mental health teams, economic evaluations, and translation of research into practice have been identified as high priorities for future studies for people with mental health disorders. 158 This review found an absence of studies covering these high-priority topics. There is a need for physical therapists to be innovative in service delivery and to avoid professional protectionism and isolation to increase the likelihood that health care users receive evidence-based, high-quality care as part of multidisciplinary pathways. 159 Further to this, qualitative or mixed method studies with mental health care users are also required to heighten the relevance of research by drawing on unique lived experiences. 160

The scoping review findings suggest that physical therapists’ experiences of working with patients with mental health conditions varied considerably. There is a contrast between the confidence levels of specialized physical therapists working within mental health settings and physical therapists in general practice settings (who highlight knowledge gaps and low confidence). However, there is clear acknowledgment within the profession of the prevalence of mental health disorders and their influence on health outcomes by physical therapists working in general practice. 12 , 161 Our findings, like other literature, 11 , 12 , 155 suggest that physical therapy in mental health and psychiatry is still in its early stage of development, with education required to address lack of confidence in general practice settings. Given the widespread stigmatization of people living with mental health conditions 156 and its negative effects on people’s health and well-being, it is imperative that clinicians learn to provide respectful care that does not (unintentionally) reinforce such stigma. Educational experiences that are positive 162 and promote a coherent, integrated approach to mental illness and psychiatry 163 are needed. A re-imagination of physical therapy education is required to produce clinicians adept to meet the challenges of the real world context 164 including mental health.

Limitations

Limitations of this review include the difficulties associated with subdividing complex, overlapping concepts such as “psychosocial well-being” and “mental health” into discrete groups. Further complexity included the variety of language used in mental health and psychology fields across the globe. All authors of the review were from 1 country (Australia) and as a result may have similar perspectives of physical therapy practice with potential effects on interpretation of results. Additionally, only English language articles were included in this review, limiting the inclusion of studies in other languages from countries with extensive contributions to the topic. Only the more prevalent mental health diagnoses were used as specific search terms, which may have also limited identifying participants with less common conditions. To counter this, effort was put into producing clear inclusion criteria while trying to remain open to breadth of practice and an international perspective. It is likely that not all relevant papers are included in the review related to the chosen search terms. Physical therapists may make more significant contributions to health care outcomes related to mental health within multidisciplinary teams compared with independent practice, and although this review did not examine such contexts, they could be the subject of future research. Similarly, physical therapists have made further significant contributions to studies focused on topics excluded from this review, including the prevalence of pain 165 or chronic metabolic conditions, 166 quality of life, 167 paediatrics, 168 and the validity of questionnaires 169 for people with mental health conditions. Physical therapists are making significant contributions to more recent, large RCTs 170 published after the date of the current search, demonstrating that research in this area continues to expand.

Research that involves intersections between physical therapy and mental health is sparse but growing. Exercise and physical activity are a key topic focus of research, but more possibilities exist, including more collaborative and consumer-driven research. Physical therapists in general practice settings recognize a need for more training to enhance their work with people with mental health comorbidities. The challenge for the profession is to continue to develop the research base to guide visionary education and contemporary practice toward optimal outcomes for people with mental health disorders.

Concept/idea/research design: S. Heywood, J. Connaughton, J. Setchell

Writing: S. Heywood, J. Connaughton, R. Kinsella, S. Black, J. Setchell

Data collection: S. Heywood, R. Kinsella, S. Black, N. Bicchi

Data analysis: S. Heywood, J. Connaughton, R. Kinsella, S. Black, N. Bicchi, J. Setchell

Project management: S. Heywood, S. Black, J. Setchell

Fund procurement: S. Heywood

Consultation (including review of manuscript before submitting): S. Heywood, R. Kinsella, S. Black, N. Bicchi, J. Setchell

This study was supported by a grant from the Inclusive Health Fund, St Vincent’s Health, Australia.

The protocol was registered in the Open Science Framework ( https://doi.org/10.17605/OSF.IO/WD6ZN ).

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

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Stubbs   B , Soundy   A , Probst   M , et al.    The assessment, benefits and delivery of physical activity in people with schizophrenia: a survey of members of the International Organization of Physical Therapists in Mental Health . Physiother Res Int . 2014 ; 19 : 248 – 256 .

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Vancampfort   D , De Hert   M , Skjerven   LH , et al.    International Organization of Physical Therapy in Mental Health consensus on physical activity within multidisciplinary rehabilitation programmes for minimising cardio-metabolic risk in patients with schizophrenia . Disabil Rehab . 2012 ; 34 : 1 – 12 .

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Vancampfort   D , Rosenbaum   S , Probst   M , et al.    Top 10 research questions to promote physical activity in bipolar disorders: a consensus statement from the International Organization of Physical Therapists in Mental Health . J Affect Disord . 2016 ; 195 : 82 – 87 .

Walker   A , Kantaris   X , Chambers   M . Understanding therapeutic approaches to anxiety in vestibular rehabilitation: a qualitative study of specialist physiotherapists in the UK . Disabil Rehabil . 2018 ; 40 : 829 – 835 .

Brand   S , Colledge   F , Beeler   N , et al.    The current state of physical activity and exercise programs in German-speaking, Swiss psychiatric hospitals: results from a brief online survey . Neuropsychiatr Dis Treat . 2016;12:1309–1317.

Gbiri   CA , Akinpelu   AO , Odole   AC . Description of physiotherapy services in a mental health institution in Nigeria . S Af J Physiother . 2011 ; 67 : 15 – 18 .

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The Career of a Physical Therapist Research Paper

Introduction, education and university training, financing education, works cited.

Physical therapists are medical experts who handle cases dealing with impairments, disability, immobility, or any other critical change of physical function of the body and healthiness as a result of injury.

Their job include but is not restricted to diagnosis procedures, assessments, evaluations and conducting intervention duties so as to attain the highest functional results for every patient. In their daily work, physical therapists are charged with the responsibility of assisting patients suffering from a multitude of illnesses, and victims of accidents as well.

In 2008, it is estimated that the physical therapist were holding about 185,500 positions in the employment register of the US. Some of the physical therapist worked two or more jobs and that made the job statistic greater than they actually are. Most of the therapies do their job is hospital settings, Offices and other health facilities. The physical therapist assist in relieving pain to patients, enhance mobility of their body, reducing physical disability and re-establishing use (Coppola para. 4).

Through the assistance of a patient’s medical history, a medical therapist is in a position to examine the patient’s strength, posture, coordination, breathing capability, and motor and body balancing function. Plans are the executed in treating patients that have exhibited specific medical conditions.

Physical therapy is a challenging career that needs greater responsibility and dedication. The therapist often faces challenging situations that test their ability to do the job. For this reason, this paper shall address the career of a physical therapist. The physical therapist usually plan and work to treat physically disabled people of all divides regardless of the source of the problem (Jensen et al1256).

Therapists are further required to offer counseling to these patients and even to their families (Curtis 56). The therapist coordinates the processes of consultation and rehabilitation. This can be one at service groups, clinics and hospitals.

There are several universities across the united states that are offering Physical Therapy degrees. One of the best colleges is the University of Delaware. Basically interested students study a degree in Physical Therapy and then proceed to masters of the same when they want to have more expertise (Curtis 56). A better preparation to become a physical therapist has to begin with deed dedication to the job. Students who wish to become therapists should start their preparation while still in high school.

This means that they should take course like physics, biology; psychology among other related subjects so that they can use this as a solid foundation for the future career (Curtis 56). The next step here would be to join a university that offers the training in Physical therapy. Students can study an associate degree or a higher degree in this field.

Students that are in such colleges study social sciences, mathematics, physiology, biochemistry, psychology, physics and other courses that ate considered lifesaving. For the degree, the students increase their scope to cover more specialized courses including neuroscience, physiology, metal issues and pathology (Krumhansl 87). Choosing University of Delaware for study is so critical to anyone wanting to study therapy course.

This is because the university has been ranked number four in the country. Here, the students get the best facilities that are at the cutting edge. This means that their education is great and that they have the best quality of research and better facilities (Krumhansl 87). To be better at the job, graduates that have been in the program can then advance to do their masters degrees. Students take part in the study of the intensive care courses and they are also expected to go through an internship program.

From here, students then still have a choice for further specialization in either neurological therapy or musculoskeletal therapy among other needs (Jensen et al 20011258). In order for a student to be granted the license to practice, he/she is first required to have studied medical imaging, kinesiology, as well as to have undertaken professional and physiology course during their internship period. Upon graduation, the candidate could get the license.

The undergraduate take a minimum of four years while the post graduate programs take only about a year and a half. Basically there is no need to relocate because there are online studies but for practical course like Physical Therapy, one needs to attend classes and online is not a better option (Langenberghe 522).

The cost of attaining a degree in Physical therapy at the University of Delaware is estimated to be about 9,486 dollars for the in-state tuition fee and 23,186 for the out-of-state. There is some financial aid for some students in Delaware University. The fellowships offer full tuition reimbursement and this is averaged at 14,600 dollar for one academic year (Chilsolm 67). This is for the students in degree programs.

For the post graduate and research assistants, there is a reimbursement of 20,772 dollars for every student’s tuition. Assistants in physical therapy get the same amount as degree students and opportunities for internships. Some important statistics are that the percentage of children that get financial aid is 60% and those on Federal grants are 9% (Chilsolm 2002 67). The average grant that the Federal government gives is 3,704 dollars.

The percentage of students that get state aid is 9% and the average amount that is often given is 3,334 dollars. The numbers of students that get this are 37%. Loans are also offered to the students and on average, students get a loan of 6,947 dollars and 48% of the students get these loans. More assistance comes in the name of institutional aid and on average the eligible students get 6,947 dollars.

There is a body known as the Physical Therapy association of America which offers financial assistance to physical therapy studies and research in universities. Application is simple as one only needs to enroll for the graduate degree program (Chilsolm 67). Then search for opportunities in their databases. After that, one can sign out for the internships and apply for funding.

Application process can take a lot of time. However, first it is important that a student determines what type of degree she/he wants in the field of physical therapy. Second is to check the geographical region that one would like to live in. this way, one can narrow down program search and even carry out assessment of cost of living while studying (Jensen et al 1258).

Most of the programs in universities will demand a degree. However, master’s degree would be very appropriate at a later stage. It’s very important to ensure that you are clear with many of or all of the requirements. Minimum GPA is usually a 3.0. It is estimated that the cost of living in Delaware at the university ranges from 12,657 to 15,821 dollars.

The tuition fee is usually the same for people living at the campus and those living at home. The differences are mainly on food, accommodation and transport (Langenberghe 522). Living on campus means that students will pay about 9,894 dollar for the accommodation. Those that live outside the campus can get expensive or cheaper house depending on the place they choose to live (Sneed et al 1287). Credit per hour for the students who stay in state is 377 dollars and out of state credit hour is 1,010 dollars.

Career Development

Getting a degree in medical courses particularly physical therapy is a great investment. This degree allows people to be experts in this subject area. Traditionally, students who decide to pursue the career have three alternatives to choose from as they advance to doctoral level (Krumhansl 89). One is that they can pursue professional physical therapy, two, to pursue transitional therapy of three, to work on physical therapy.

There are some courses that are very important in therapeutic clinical practice. They include palpations, neuroscience, pathology, diagnostic imaging and clinical anatomy among others (Langenberghe 522). When students complete their studies in the subject and hand over their dissertations which are publishable, then they have fulfilled the procedure of being licensed to practice (Krumhansl 90).

The graduates have to meet the requirements by the association of physical therapist of America. The course presents a good opportunity to venture into medical practice because there are job opportunities readily available for people who study physical therapy (Blau et al 649). As projected by the government of the United States, the need for physical therapists is bound to increase through 2013.

This is because the population increases and as a consequence people suffering from physical disability also increase. Notable is the increase in the number of senior member of the society, the baby-boom generation who need therapy for relieve of pain and management of physical problems that in most cases result from heart attacks and strokes (Blau et al 649).

These conditional are increasingly becoming common among older people. Furthermore, it’s been noted that, more babies nowadays are being born with birth defects and the technology today has seen more victims of traumatic conditions survive (Sneed et al 1287).

As a result, this new technology is going to permit increase of debilitating conditions to me managed by specialist in this field (Krumhansl 95). As American become more conscious about their health, the will definitely require more physical therapist and more specialized treatment. Therefore the employment for these experts is expected to increase faster than average growth of the entire medical care needs.

In an effort to do their job, therapists get to move around a lot and seek new pastures. These relocations are often very influencing on their lives.

Though the government encourages people to work with bigger organizations and also to adopt practices that allow work-life balance doctrine, relocation at times is inevitable (Blau et al 652). Workers tend to link relocation with great achievement or career development (Frankl para. 5). This can impact on families in a negative manner. Family responsibilities are affected and its stability shaken.

Parents move away from children and spouses away from each other (Green and Canny Para. 4). Most impact is on school going children because their education is disrupted. Young adults loose friends or financial resources that had already started establishing. For the elderly and their declining health, they can lose friendship networks and this can seriously affect their condition (Green and Canny Para. 4).

Blau, Rosemary, et al. (2002). The Experience of Providing Physical Therapy in a Changing Health Care Environment, Phys Ther journal, 82(2002): 648-657.

Chilsolm, Stephanie. The Health Professions: Trends And Opportunities In U.S. Health Care , Sudbury, MA, Jones & Bartlett, 2002. Print.

Coppola, Stephen. Interview with a Physical Therapist. Projects by Students for Students. 2005. Web.

Curtis, Katherine. Physical Therapy Professional Foundations: Keys To Success In School And Career , Thorofare, NJ, SLACK Inc, 2003. Print.

Frankl, Daniel. Interview with a Physical Therapist. 2003. Web.

Green, Anne and Canny, Angela. The Effects on Families of Job Relocations , Joseph Rowntree Foundation. 2003. Web.

Jensen, Gail et al. Expert Practice in Physical Therapy. Journal of the American physical therapy association , 280.14(2001): 1256–63.

Krumhansl, Bernice. Opportunities in Physical Therapy Careers , New York, McGraw Hill Professional, 2006. Print.

Langenberghe, Harry. Evaluation of Students’ Approaches to Studying in a Problem-based Physical Therapy Curriculum, Phys Ther, 68(2010): 522-527.

Sneed, Robert et al Physicians’ Reliance on Specialists, Therapists, and Vendors When Prescribing Therapies and Durable Medical Equipment for Children With Special Health Care Needs Pediatrics, 107(2001):1283-1290.

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IvyPanda. (2018, July 14). The Career of a Physical Therapist. https://ivypanda.com/essays/physical-therapy/

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IvyPanda . (2018) 'The Career of a Physical Therapist'. 14 July.

IvyPanda . 2018. "The Career of a Physical Therapist." July 14, 2018. https://ivypanda.com/essays/physical-therapy/.

1. IvyPanda . "The Career of a Physical Therapist." July 14, 2018. https://ivypanda.com/essays/physical-therapy/.

Bibliography

IvyPanda . "The Career of a Physical Therapist." July 14, 2018. https://ivypanda.com/essays/physical-therapy/.

Search Inova

Lisa siano, dpt, clt.

14605 Potomac Branch Drive Suite 200 Woodbridge , VA 22191

About Lisa Siano, DPT, CLT

Lisa earned her Bachelor of Science degree in Kinesiology from The Pennsylvania State University in 2009. She graduated with her Doctor of Physical Therapy in 2012 from the University of Pittsburgh. She moved to Northern Virginia and worked for another company before joining the IPTC Woodbridge family in June 2014. She is currently applying to become a Senior PT. She has been a Clinical Instructor and intends on mentoring more DPT students in the future.

Lisa has earned her certification in lymphedema therapy, is trained in Kinesiotaping, and is working towards a certification in manual therapy. She enjoys spending time outdoors with her family, friends, and dog. She is an avid Pittsburgh sports fan.

Inova Provider Referral Services

Please make note of the following information. This Find a Doctor referral service is sponsored by Inova. It includes Inova employed providers (indicated by the Inova mark and referred to as an "Inova provider") and independent practitioners who have obtained the appropriate medical staff privileges at an Inova facility or care site. Independent practitioners are not Inova employees, agents or representatives of Inova and are solely responsible for their provision of medical care to you. There is no charge or fee to you or for the participating provider for our service.

Physical Therapy

If you have pain or physical limitations after illness or injury, or want to prevent injury, physical therapy can help. Count on the specialists at Sentara for personalized care to help you heal and feel better.

Physical Therapy: Why Choose Sentara?

We offer physical therapy programs tailored to your unique needs. Program highlights include:

• Expert providers : Our physical therapists have years of training and take certification exams to prove their knowledge. Team members have passed the National Physical Therapy Examination Board through the Federation of State Boards of Physical Therapy. Meet our experts .
• Leading-edge therapies : We use the most advanced therapy techniques to promote your recovery and prevent injury. We provide a wide variety of specialty therapies to meet your unique needs. Our therapists complete hours of additional training each year to further their knowledge and skills.
• Convenient locations : We offer physical therapy at our Sentara Therapy Centers throughout Virginia and eastern North Carolina. Count on us for prompt service, including same-day and next-day appointments.

Physical Therapy Treatments and Services

Our therapists help you manage pain, recover after injury and maintain physical strength. We offer:

Amputee rehabilitation

Our physical therapists provide a comprehensive rehab program after amputation. We help you:

• Build strength
• Care for your prosthesis (artificial limb)
• Improve mobility

Diabetes fitness program

Our physical therapy experts create personalized exercise programs to help you manage diabetes and lower the risk of complications. We help you:

• Control body weight
• Increase insulin sensitivity (reduce insulin resistance)
• Lower glucose levels
• Reduce blood pressure

Exercise can also help you control cholesterol and reduce stress and anxiety. Ask your doctor if our diabetes fitness program is right for you.

Dry needling

We offer dry needling  to release trigger points (knots) in muscles that make moving painful. Therapists insert thin, flexible needles into the skin and muscle at the trigger point to loosen tissue and reduce pain.

Joint protection training

Some conditions and injuries cause pain, swelling or weakness in the joints. Our therapists teach you how to protect your joints as you go about your daily activities. We help you:

• Build muscle strength
• Change how you work or move to avoid putting stress on the joint
• Plan rest periods throughout your day
• Use supportive devices like braces or splints to strengthen the joint

Kinesio taping®

Using specialized techniques, therapists apply Kinesio tape, special adhesive tape that mimics skin, to support soft tissue without limiting movement. This taping technique helps to:

• Decrease swelling
• Enhance muscle function
• Reduce pain

Specialists analyze your gait (how you walk) to recommend custom devices or braces to support and strengthen your muscles and bones. We also recommend off-the-shelf options that you can buy in a store or online.

Pain management

Our specialists help reduce pain using various therapy treatments. We offer Swedish, deep tissue and sports massage therapy to improve range of motion and reduce muscle soreness.

We use the McKenzie Method®  for spine injury and back pain rehabilitation . Therapists teach you specific movements and positions to ease pain and help with mobility.

Personalized workouts

We design a treatment plan to help you meet your goals. Our therapists create specific exercises to overcome your movement limitations and build strength, flexibility and endurance.

Physical Therapy for pulmonary patients

Our pulmonary therapy team teaches you breathing techniques, exercises and stress management in one-on-one or group settings. We’ll monitor your blood pressure and oxygen saturation levels to track your health as you complete the program.

Working with us, you’ll gain: 

• Improved strength to complete everyday and fun activities
• A sense of security from breathing more easily
• Confidence in managing stress

To get started, please talk with your physician, internist or pulmonologist.

Soft tissue mobilization

We use manual physical therapy to move soft tissues (nerves, muscles, tendons and ligaments) in the body. In soft tissue mobilization , our therapists knead, push and pull tissues in specific ways.

This therapy improves range of motion, decreases pain and breaks down adhesions (scar-like areas that form after tissue injury). Soft tissue mobilization also helps treat swelling (lymphedema). Learn more about lymphedema therapy .

Conditions We Treat With Physical Therapy

We use physical therapy for musculoskeletal injuries and other conditions that limit motion and cause pain. We treat:

• Bone and muscle injuries and conditions

We offer neurological rehabilitation  after stroke or traumatic brain injury, or for conditions such as multiple sclerosis and Parkinson's disease. We also offer cancer rehabilitation  after cancer treatment and orthopedic rehabilitation  before and after surgery.

Benefits of Physical Therapy

Physical therapy improves the way your body moves and functions. Rehabilitation therapy can help you:

• Correct imbalances in strength
• Manage chronic health conditions
• Reduce pain and soreness

Request an Appointment

Learn more about physical therapy at Sentara Therapy Centers. Visit our locations .

Mission Statement

Our mission is to help improve the lives of the people in our community and provide a safe and friendly environment to do so. to enrich the profession, our staff, and our patients with the highest standards of quality care and compassion., fusion rehab and wellness, rated “best rehabilitation/physical therapy services” multiple years running in multiple regions, is continuously reimagining how to run and build impactful physical therapy  practices while striving to expand as an industry-leading healthcare provider and  premier employer in the state of virginia and beyond., core values, learning and teaching.

A commitment to growing not only professionally, but also personally to constantly strive for the best version of ourselves.  We achieve this through continuing education, reading, and communication with everyone in the company.  This allows us to teach each other, students, and patients.

Responsibility

We feel a responsibility to our fusion family, our patients, and our community.  We are responsible for providing the absolute best care, fostering positive relationships, and giving back to our community.  We achieve this through community events, fundraising efforts, and being accountable to ourselves and each other through chart audits.  We are responsible for holding true to health care standards, ethical standards, and moral standards. We have a responsibility to take care of ourselves by eating right, exercising, and holding ourselves to the same instruction we give our patients and the community.

Authenticity

Nothing hidden, nothing secret.  We are open and transparent about all our interactions, costs, and our professional titles.  Most importantly, we are true to ourselves and do not pretend to be anyone else or anything else.  We are also unapologetic for who we are, how we conduct ourselves, and for our superior outcomes.  If we are true to ourselves and truly authentic, we have the courage to stand up for who we are without remorse.

We should all have trust, respect, and affection for each other and our patients and our community.  Hate, mistrust, disrespect, and bullying have no place in our family.  With love, we do not have any desire to mistreat each other, or if harsh words or actions happen, we are quick to apologize.  We respect each other for the value they bring as people, colleagues, and friends.  Love does not need to be romantic only, it is a feeling deep down, a desire even, to be good for the people around you.  If you love your community, you’re happy to help clean it up.  Think of a parent who is bedridden and needs fed or cleaned up; you love them so you assist them in their care, so it should be with our community.

Administration Team

Dr. Travis H. Stoner, PT, DPT, OCS, COMT, FAAOMPT

CEO and Founder

Bachelor of Science : Kinesiology with Biology Minor Shenandoah University 2002

Doctor of Physical Therapy: Shenandoah University 2005

Board Certified Clinical Specialist in Orthopedic Physical Therapy (OCS) Certified Orthopedic Manual Therapist (COMT) Certified Functional Dry Needling Practitioner Fellow American Academy of Orthopedic Manual Physical Therapists (FAAOMPT)

Senior Faculty Member and Fellowship Advisor for Maitland Australian Physiotherapy Seminars

Dr. Travis Stoner hails from western Maryland and began his career working with patients with neurological and vestibular disorders at the Winchester Rehabilitation Center as well as serving as the Director of the Aquatic Therapy Program there. After moving to northern Virginia to pursue orthopedics in 2010, he moved to the Fredericksburg area with his wife, Jennifer, in 2017.

Fun Facts about Travis: He played lacrosse in college, loves ATV riding, boating on Lake Anna, and sim racing. He also named his son Alex after Alexander Ovechkin when his favorite sports team, the Washington Capitals, finally won the Stanley Cup in 2018.

“I started Fusion Rehab and Wellness to serve the community and help grow my amazing profession. Through work and patient experiences, I began to see a gap not just in the way Physical Therapy was treating patients, but also the providers. Fusion, at its core, is built on the mission of providing an area of learning, development, and growth for patients and providers alike. I believe in treating each person as an individual, not a diagnosis or an employee number, and helping each person meet his or her specific goals and creating a conducive environment for that to happen.”

In addition to his practice experience, he has also served as an Adjunct Instructor at Shenandoah University’s Division of Physical Therapy and Germanna Community College and has performed physical screening for officer candidates at Quantico Marine Base.

Travis is a faculty member for Maitland Australian Physiotherapy Seminars teaching continuing education courses across the country as well as a Senior Fellowship Advisor, training other physical therapists advanced manual techniques and clinical reasoning.

Specializes in Orthopedic Manual Therapy, Dry Needling, Post-Concussion Syndrome and Vestibular Rehabilitation, and Chronic Pain

Jennifer M. Stoner, LPTA

Chief Operations Officer

Bachelor of Science: Exercise Science  Radford University 2008

Associates Degree: Physical Therapy Assistant Northern Virginia Community College 2011

Jenn has been working in orthopedics for over 5 years and has completed McKenzie and Mulligan courses. Jenn is a native of Fredericksburg and has returned to the area to lay down roots with her husband Travis and children Alex and Abby. She greatly enjoys being a mother to Alex and Abby and her dog, Stella. In her free time she loves spending time with her family and especially enjoys hanging out on the water.

Rebecca Hundemer

Director of Marketing

Coming soon!

Lisa Long CPT ISSA

Rocksteady Boxing Program Director, Certified Personal Trainer

Lisa has a BS in Medical Technology from Elon University. She is certified as a personal trainer through the International Sports Science Administration and is our Rock Steady Boxing Coach. Helping clients who live with Parkinson’s Disease be the best they can be through functional movement fitness that includes intense circuit-based training. Lisa believes exercise is a celebration of what your body can do, not a punishment for what you ate. Lisa has been living with Type 1 diabetes for 51 years as well as rheumatoid arthritis and she is a cancer survivor. She is an example of how exercise can benefit your well-being and encourages her clients to exceed their goals.

When Lisa is not in the gym she enjoys cooking and baking. She can also be seen at Mary Washington Hospital doing Pet Therapy with her Old English Sheepdog Bentley. One of her favorite things to do includes boating around the Northern Neck of Virginia and taking in the sunsets with her husband, children, and her new grandson, Jacob.

Billing Team

Anna Robinson

Director of Billing

Bachelor of Science: Psychology Longwood University 2011  

Anna Robinson has been with Fusion since it first opened its doors in February 2017. She has worked her way up at the company, starting as an office assistant at our Spotsylvania location and is now the director of billing. 

Anna is our go to person when it comes to training on all administrative tasks.  She makes a point to assist all of our patients with billing questions with kindness and details.  

In her spare time, she loves hunting, fishing, and spending time with friends and family. She has an avid interest in paleontology, with her favorite from the Late Cretaceous Period being the mighty carnivorous theropod Tyrannosaurus Rex, often referred to as the T-rex.

She prides herself in being a wonderful fur mama to her beautiful dog, Lola, and loving girlfriend to her long-time boyfriend, Chris.

Regina Pettit

Billing Assistant

Regina was looking to start a new chapter in her life when she joined Fusion Rehab and Wellness. She comes to us with a background in childcare, and experience with small business ownership. 

When she decided to join our Fusion family she started out as a Physical Therapy Technician. Even though she enjoyed assisting our therapists in helping our patients on their road to recovery, she decided it was best to expand her experience with Fusion, and has joined our Billing team as an assistant to the Director of Billing.

Fun facts about Regina:  She enjoys spending her summers soaking up the sun rays boating on the waters at Lake Anna, VA, and her winters playing in the mud/snow ATV Riding on the trails at Hatfield and McCoy in West Virginia.

Regina decided to join our Fusion family because she has a true understanding of the aches and pains that our patients deal with daily, as she has experience with physical therapy as a patient herself, due to being in a motorcycle accident in 2011.

Regina occupies her free time by creating as many memories as she can with her husband, children, and grandchildren.

Colleen Kimble

Certification in Professional Billing, AAPC August 2023

Colleen comes to us with a background in retail sales.  She is always happy to go above and beyond to assist patients. She brings a positive “can do” attitude and keeps things moving smoothly for both the patients and therapists.

In her spare time, Colleen loves to create art, play video games, and spend time with her two dogs, Nikki and Daisy.

What's New?

Recovery services.

What benefits could our recovery services have for you? We are pleased to offer three new Recovery Services at our Fusion Rehab and Wellness clinics.

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• Biomol Biomed
• v.23(5); 2023 Oct 1
• PMC10494843

Exploring the latest advancements in physical therapy techniques for treating cervical spondylosis patients: A narrative review

Quanzheng chen.

1 Department of Physical Education and Health, Guangxi Normal University, Guilin, China

Zhenshan Wang

Shuna zhang.

Cervical spondylosis is a widespread medical condition that significantly impacts patients’ quality of life. Treatment options include surgical and conservative approaches, with conservative treatment often being the preferred choice. Rehabilitation therapy is an essential component of conservative treatment, and advancements in technology have the way to the development of new physical therapy techniques. The effectiveness of treatment largely hinges on the patient’s ability to improve their dysfunction. This study aims to provide valuable insights into the use of new physical therapy techniques, such as sling exercises training, fascia manipulation, muscle energy technique, and proprioceptive neuromuscular facilitation that aid the rehabilitation of cervical spondylosis. By scrutinizing the current research status of these techniques, this study aims to present innovative ideas enhancing the rehabilitation process and outcomes for patients suffering from cervical spondylosis.

Introduction

Cervical spondylosis is a degenerative disease that typically develops as a consequence of ligament and facet joint disorders. Its common symptoms include neck pain, numbness in the nerve root innervation area, nausea, vomiting, vertigo, and other related symptoms [ 1 ]. Cervical spondylosis commonly affects the C5-C6 and C6-C7 levels of the cervical spine. However, this condition can also result in high cervical spine lesions in some patients. The severity of the symptoms may vary based on the location and extent of the spinal damage [ 2 ]. Neck pain has been found to have a wide incidence rate ranging from 0.4% to 86.8% [ 3 ]. The prevalence of neck pain is higher among individuals who are at a higher risk of developing this condition. It is currently estimated that approximately 349 million people worldwide are affected by neck pain and related conditions [ 4 ]. Numerous studies have demonstrated that repetitive movements that exceed the normal range of motion in the joint can result in mechanical compression of the cervical spine, which may increase the risk of secondary injury [ 5 ]. Maintaining poor neck posture over an extended period can increase the burden on the cervical spine and accelerate the formation of chronic strain. Additionally, it can cause a forward head posture and lead to an increased incidence of neck pain [ 6 , 7 ]. The treatment of cervical spondylosis typically involves surgical and conservative options, with conservative treatment being the primary approach. Recent research, both domestically and internationally, has proven physical therapy as an effective method for the prevention and treatment of cervical spondylosis, while also improving the quality of life for patients [ 8–10 ]. As rehabilitation medicine continues to advance, new physical therapy techniques have been developed and built upon traditional methods, offering unique advantages in the treatment of cervical spondylosis. This study explores the effectiveness of emerging physical therapy techniques in the rehabilitation of cervical spondylosis, including sling exercises training (SET), fascia manipulation (FM), muscle energy technique (MET), and proprioceptive neuromuscular facilitation (PNF). By examining the potential benefits of these techniques, this paper aims to offer novel insights and ideas for the diagnosis, treatment, and further research of cervical spondylosis.

Anatomical basis of cervical spondylosis

The human cervical spine is the most flexible joint in the body, but it also has poor stability due to its structure. The vertebrae are interconnected by intervertebral discs (IVDs) and ligaments, except for the atlas (C1) and axis (C2) vertebrae and the sacral and coccygeal bones. The IVD is composed of the nucleus pulposus, annulus fibrosus, and cartilaginous vertebral endplate. As people age, IVDs become more susceptible to damage from external forces that compress and twist them. This can cause the annulus fibrosus to rupture, leading to cervical spondylosis. Normally, IVDs can withstand significant pressure, but age-related changes make them more vulnerable to damage [ 11 , 12 ]. Some studies have found receptors similar to Golgi bodies in cervical discs [ 13 ]. There is some evidence to suggest that Ruffini bodies, which are mechanoreceptors found in the annulus fibrosus of IVDs, may play a role in causing dizziness in patients with cervical spondylosis [ 14 ]. Studies have shown that patients with cervical spondylosis often exhibit changes in their muscle structure and function. Paliwal et al. [ 15 ] found that these patients may experience reduced innervation of the relevant neck muscles and decreased nerve conduction velocity, which can ultimately lead to secondary muscle degeneration. Damage to the corresponding vertebral segments and adjacent facet muscles can lead to the development of neck pain [ 16 , 17 ]. At the same time, a decrease in spinal stability can lead to degenerative changes in the spine, therefore, strengthening spinal stability is considered an effective treatment [ 18 ]. Cui et al. also discovered that patients with cervical spondylosis, poor posture, and forward head posture often have abnormal shoulder posture, resulting in upper cross syndrome (UCS) [ 19 , 20 ]. Usually, UCS shows asymmetrical muscle strength of weak and strong muscles, decreased muscle strength of deep cervical flexors, lower trapezius, and anterior serratus; excessive tension of upper trapezius, scapular lift, and pectoralis major; crossover of tight and weak muscle chains, and imbalance of muscle chains, resulting in abnormal posture [ 21 ] ( Figure 1 ) . If left untreated, these symptoms greatly impact a patient’s quality of life and worsen the progression of cervical spondylosis [ 22 ].

Muscle strength imbalance in the upper crossed syndrome. An example of strained and weakened muscles caused by superior cross syndrome: decreased muscle strength of deep cervical flexors, lower trapezius, and anterior serratus; excessive tension of upper trapezius, scapular lift, and pectoralis major; crossover of tight and weak muscle chains, and imbalance of muscle chains, resulting in abnormal posture [ 21 ].

Traditional physical therapy techniques

Traditional physical therapy techniques have been utilized for many years and have been effective in aiding patients in their recovery from various ailments. These techniques include strength training, skill training, heat therapy, acupuncture, tai chi, functional reconstruction, physical factor therapy, and many others. In the treatment of cervical spondylosis, traditional physical therapy has shown to be particularly effective in improving patient outcomes [ 23 ]. While traditional physical therapy techniques have been widely used for years to treat cervical spondylosis, they have some drawbacks. One important shortcoming is that the effects of traditional physical therapy may not be immediately noticeable, and patients may require ongoing treatment sessions to achieve relief of pain and other symptoms. This can make the treatment process quite lengthy [ 24 ]. In addition, traditional physical therapy can be quite costly, making it inaccessible to many people who do not have the financial means to undergo such treatment. Furthermore, traditional physical therapy may not focus on long-term prevention or resistance training, which can limit the long-term benefits for patients.

Overview and application of the novel physical therapy techniques and technology

Novel rehabilitation physical therapy techniques integrate the latest technology to help enhance patient outcomes. For instance, suspension technology utilizes rope structure training to boost the connection between the patient and therapist [ 25 ], resulting in a more engaging and interactive rehabilitation experience. Advanced technology allows therapists to develop personalized treatment plans based on each patient’s unique needs and progress, leading to more targeted therapy that can accelerate the recovery process and improve overall outcomes. Additionally, patients tend to be more engaged due to the interactive nature of the therapy sessions, which can help them stay motivated and committed to achieving their recovery goals. Although some of these new rehabilitation techniques may come with a higher cost, in the long run, they can help speed up recovery time and decrease the need for additional treatment, making it more cost-effective for patients.

Sling exercises training

Sling exercises training overview.

SET is a unique physical therapy technique that was first introduced by Meier and further developed by Kirkesola. Originally, it was used to treat orthopedic conditions, but it has since been expanded to address rehabilitation training for sports injuries in humans [ 26 ]. The SET method maximizes the patient’s motor control by utilizing various tools and objects during the rehabilitation process. This allows the patient to move their body within a range that is free from pain or discomfort. The therapist provides assistance with both hands during the treatment to alleviate any pain or discomfort that the patient may experience [ 27 ]. Research has shown that SET is effective in improving muscle activity [ 28 ]. During upper limb exercise training assisted by SET, therapists conduct open and closed chain exercises on an unstable plane, while adjusting the patient’s body angle and gradually increasing the training difficulty. This activates the deep muscles, improves coordination between superficial and deep muscles, and uses postural reflexes to regulate muscle tension. The abnormal neuromuscular control mode of muscle groups is corrected, resulting in improved balance, sensation, and motor control abilities. Furthermore, this can aid in weight loss and core strengthening, ultimately improving core stability [ 25 , 29 ]. The innovative weight loss technique utilized in SET can minimize the impact of gravity on the muscles and reduce the stimulation of pain receptors on the annulus fibrosus. This results in an increased range of joint movement, muscle relaxation, improved blood circulation, and enhanced elimination of inflammatory factors and metabolites, ultimately reducing pain. Additionally, the suspension belt provides additional stimulation to the joint capsule and ligament proprioceptors, enhancing their sensitivity and ensuring accurate sensory input, thereby improving neuromuscular control [ 30 ].

Sling exercises training application research

The majority of studies indicate that SET is effective in addressing muscle imbalances and improving core stability, particularly, in the neck region. In a randomized controlled trial involving women with neck pain, Park et al. [ 31 ] found that after four weeks of SET twice a week, there was a significant decrease in both cervical disability index and pain index, suggesting that SET can effectively alleviate neck pain and enhance quality of life in women. In a study conducted by Yan et al. on female patients with neck pain, it was discovered that four weeks of SET training could improve the condition of the neck muscle group and alleviate neck pain. This improvement may be attributed to better control of the neck nerves [ 32 ]. Wang et al. [ 33 ] discovered that SET training has the ability to activate deep neck muscles and enhance core stability, which can strengthen the weak chain that contributes to UCS (muscle weakness), weaken the strong chain, restore the balance of muscle tension, improve abnormal posture, and enhance the cervical spine’s anti-fatigue ability. Several studies have indicated that SET exercises are effective in improving the cervical range of motion, although some angles may not be as effective as traditional stretching exercises [ 34 ]. Research has demonstrated that SET is more effective in relieving neck pain compared to other treatments, however, it may not be as effective in improving the cervical range of motion as other techniques. While SET has been extensively used to treat patients with lower back pain and stroke, there is still a dearth of high-quality studies on its effectiveness in treating cervical spondylosis. As the joint with the largest range of motion in the human body, it is essential to improve the stability of the cervical spine and reduce pain while maintaining its flexibility [ 18 ]. Studies have suggested that SET is effective in enhancing core stability, which can effectively treat cervical spondylosis. Therefore, it is important to further explore the feasibility and mechanisms of SET as a treatment option for cervical spondylosis. Currently, there is a lack of sufficient research on the relationship between SET and neuromuscular control mechanisms. In future studies, it may be beneficial to use precision instruments such as electromyography to investigate the neural plasticity of SET.

Fascia manipulation

Fascia manipulation overview.

Fascia is a type of connective tissue that includes tendons, ligaments, and joint capsules, among other structures. Cervical spondylosis is often accompanied by symptoms, such as dizziness, neck pain, and eye pain. According to the fascia theory, the proximal posterior fascia chain is made up of the deep fascia of the neck and the fascia sheath of the eye. Therefore, when the fascia is damaged, it can cause discomfort in the corresponding areas [ 35 , 36 ]. Additionally, neck pain and other issues may result from irritation of joints, ligaments, fascia, and other tissues. Studies have found that the myofascial membrane is capable of transmitting force to other muscle groups. From a physiological perspective, the sarcolemma efficiently transfers force through transmembrane substances to the extracellular matrix, which ultimately terminates in the tendon [ 37 ]. The conduction of fascia is not solely dependent on itself, but it can also be influenced by external forces. Manipulative treatments can apply internal forces that may alter its tension [ 38 ]. FM enhances muscle elasticity by improving the flexibility of fascia. It can also enhance Ca 2+ reactivation while reducing muscle pain caused by delayed onset muscle soreness that occurs 24 h after exercise [ 39 ]. The therapist uses their elbow or knuckle to manipulate the fascia in a specific area, restoring its ability to glide smoothly [ 40 ].

Fascia manipulation application research

FM has recently acquired popularity in the treatment of sports injuries and has shown promising results. Among the various types of cervical spondylosis, radicular cervical spondylosis is a common occurrence, accounting for about 60%–70%. Its primary symptoms include upper limb weakness and limb numbness. In the case of limb numbness, the pressure on the adjacent tissues in the innervated area of brachial plexus is considered a crucial factor. The brachial plexus is enveloped by a sheath, which plays a vital role in determining the speed and recovery of nerve conduction. In a study conducted by Turazza et al., it was shown that FM can impact the sheath tone of the brachial plexus, improve patients’ proprioceptive ability, and thereby promote nerve restoration, leading to an improvement in the symptoms of upper limb numbness [ 41 ]. Dos Santos Amorim et al. employed near-infrared spectroscopy to assess the level of oxygenated hemoglobin in the trapezius muscle tissue of the subjects. The results showed that FM could enhance the blood circulation in the local treated area, leading to a significant increase in the oxygenated value of the trapezius muscle in the treated patients. These findings suggest that FM has remarkable benefits in this area [ 42 ]. Rodriguez-Huguet et al. discovered that patients with neck pain experienced significant improvements in pressure pain threshold and digital pain score after undergoing two weeks of fascia therapy. Furthermore, the efficacy of this treatment was found to be superior to that of conventional standard physical therapy [ 43 ]. Fascia therapy is a relatively new field, and there is limited research on its effectiveness for treating cervical spondylosis. The physiological and biochemical mechanisms involved in the treatment of cervical spondylosis with fascia therapy are still poorly understood. Further research can be conducted to investigate the physiological and biochemical processes involved in the treatment, and to better understand the mechanisms through which the muscle pain can be alleviated.

Muscle energy technique

Muscle energy technique overview.

MET is an energy-based therapy that aims to adjust abnormal muscle tone by training specific muscles, enhance muscle strength and stability in corresponding areas, improve the musculoskeletal system’s function, and ultimately improve patients’ quality of life [ 44 ]. Common techniques used in MET include centrifugal contraction, reciprocal inhibition, contraction–relaxation, contraction–relaxation–contraction, and others. MET not only improves muscle strength and elasticity but also enhances core stability and motor control [ 45 ]. During MET, patients follow the therapist’s instructions and engage in antagonist exercises with the therapist to relax spasmodic muscles, strengthen weakened muscles, adjust the tension balance, and reduce pain [ 46 ]. Numerous studies have indicated that MET can effectively promote cell synthesis, blood flow, lymphatic circulation, accelerate substance metabolism, improve tissue excitability, and prevent muscle atrophy [ 47 ]. MET stimulates the Golgi tendon organ through active muscle isometric contraction, and the Golgi tendon organ that converts the signal into impulses that are transmitted to the α motor neuron controlling the muscle. This process inhibits the muscle spindle receptor and relaxes the muscle through negative feedback regulation [ 48 ]. Isometric contraction of muscles leads to sliding of coarse and fine muscle filaments against each other in the sarcomere, generating heat and increasing the ductility and elasticity of surrounding tissues. This leads to an increase in muscle malleability, reduction in muscle tension, and relief from body pain.

Muscle energy technique application research

In a study conducted by Sbardella et al., it was observed that patients suffering from acute and chronic neck pain showed significant improvement in cervical range of motion after undergoing MET training. The improvement was even greater when combined with traditional treatment methods [ 49 ]. This suggests that MET can be an effective technique in correcting abnormal posture and improving body function, particularly in patients with neck pain. In a study by Joshi et al. on neck pain, it was found that after three weeks of MET training, patients showed significant improvements in cervical disability scores and cranial vertebral angle. However, because there was no separate group for MET training in literature, it is difficult to determine the effectiveness of this treatment compared to other treatments [ 50 ]. Despite the positive results of MET in improving cervical range of motion and reducing neck pain, its application in treating cervical spondylosis is still limited, with little research available. Currently, there is no standardized protocol for the application of MET in the treatment of cervical spondylosis, including the direction and angle of application, resistance, total repetitions, and extent of application. Although the improvement of muscle function by MET training may be related to the nervous conduction system, further research is needed to clarify the specific conduction system involved and its effects and future studies should focus on the neurological effects of MET. Moreover, while MET is often used in combination with other physical therapy methods for treating cervical spondylosis, there is insufficient evidence to determine its effectiveness compared to other approaches. Therefore, the next step in further research should be the comparison between the short-term and long-term efficacy of MET with other physical therapy methods.

Proprioceptive neuromuscular facilitation

Proprioceptive neuromuscular facilitation overview.

PNF is a treatment technique that was developed in the 1950s by Tedla and Sangadala [ 51 ]. PNF is a rehabilitation technique that involves stimulating proprioceptors in a spiral diagonal pattern to enhance the neuromuscular response and improve muscle contraction ability. It also involves adjusting abnormal sensory nerve excitability to normalize muscle tension and movement patterns [ 52 , 53 ]. PNF can be applied in various areas, such as the pelvis, upper limbs, and lower limbs, to improve patients’ motor function and aid in their rehabilitation. The basic techniques of PNF include rhythmic initiation, contract–relaxation, isotonic combination, dynamic reversal, and many other techniques. These techniques can help stimulate weak muscles and promote muscle contraction in various ways [ 54 ]. Resistance training in PNF can help increase the strength of respiratory muscles, activate proprioceptors in the respiratory muscles, induce reflex breathing movements, and improve blood circulation [ 55 ]. PNF can improve the range of motion of patients with soft tissue injuries by using a multi-level and multi-directional upper limb movement mode. Additionally, it can effectively enhance muscle strength, balance ability, coordination ability, and promote nerve recovery [ 56 , 57 ]. PNF works on the principle of increasing stimulus intensity leading to an increase in the body’s response intensity. Even after the stimulus stops, the response continues to exist due to the effects of continuous static contraction. This is likely why PNF exercises have been shown to improve joint motion, establish new neural pathways, promote neural plasticity, enhance limb function, and facilitate limb rehabilitation, especially in shoulder joint PNF exercises according to existing research.

Proprioceptive neuromuscular facilitation application research

As a treatment technique commonly used in the field of musculoskeletal rehabilitation, PNF was initially developed for use in neurological diseases, such as stroke, multiple sclerosis, and poliomyelitis, but it has recently gained attention for its unique effectiveness in treating cervical spondylosis [ 58 , 59 ]. A study conducted by Ashfaq et al. on patients with neck pain randomly assigned subjects to three groups: PNF+vertebral passive movement (PVM), PVM+conventional physical therapy (RPT), and RPT alone. After four weeks of intervention, the PNF+RPT group showed less improvement in the patients’ daily life quality compared to the PVM+RPT group [ 60 ]. In this study, since no separate PNF treatment group was established, it was not possible to determine the effectiveness of PNF compared to routine physical therapy. However, Yang and Qiao [ 61 ] found that when PNF was combined with massage, release, and routine physical therapy, it effectively alleviated neck and shoulder muscle imbalance and improved poor postures, such as rounded shoulders and hunchbacks in college students. This improvement may be due to the unique spiral diagonal crossover pattern of PNF. By challenging the core through upper limb movements, distal activity training emphasizes proximal stability, weakens tense muscles, strengthens weak muscles, and restores muscle symmetry [ 62 ], thereby improving poor postures, such as rounded shoulders and hunchback. The duration of treatment was not specified in the study, so it is unclear whether the effects of PNF were short term or long term. In summary, future research could focus on comparing the effectiveness of PNF with other treatments, as well as investigating both short-term and long-term outcomes.

PNF is a physical therapy technique that aims to improve neuromuscular function, flexibility, and strength [ 63 ]. Sling exercise training uses a suspension system to support the body and help practice, which can enhance core strength improve posture, balance, and reduce pain [ 25 ]. Fascial manipulation targets connective tissue to improve range of motion and reduce pain [ 64 ]. MET uses isometric contractions to lengthen tight muscles and improve joint mobility, enhancing the body’s strength and flexibility through muscle contraction [ 65 ]. Compared to conventional physical therapy, SET, FM, MET, and PNF appear to have several advantages in terms of safety, efficacy, and cost-effectiveness. However, SET, FM, and MET may have a slightly limited treatment scope compared to conventional treatment and PNF. For instance, while conventional treatment and PNF cover both musculoskeletal and neurological diseases, SET, FM, and MET may primarily target musculoskeletal diseases or some specific conditions [ 34 , 49 , 66–73 ], as shown in Table 1 . Although the new treatment options represent new hope for patients with cervical spondylosis, their potential advantages and shortcomings need to be carefully considered. PNF, fascial manipulation, and MET require skilled medical personnel, and improper operation may lead to muscle strains. Suspension training requires special suspension devices that may not be readily available and may be less flexible. There are also few relevant studies with small number of subjects, and the evaluation indexes are mostly scales, which are not measured with more sophisticated instruments. Most of the treatment protocols are combined treatments, and it is unclear which treatments are more effective for which types of cervical spondylosis. Therefore, more high-quality randomized controlled trials are needed to study these treatments in the next step. Although the causes and mechanisms underlying the development of cervical spondylosis are not yet clear, it is well known that the painful distress caused by cervical spondylosis can be effectively resolved through a combination of various physical treatments that regulate the balance of muscle tone, strengthen core stability, and correct abnormal biological force lines. It is likely that new physical therapy technologies for the treatment of whiplash will be developed and refined in the future, such as virtual reality (VR) and wearable devices. In recent years, VR technology has been used in the field of pain management [ 74 ]. VR can be used to assess cervical spine range of motion and motion capacity by collecting information on angular velocity and displacement during movement of cervical spine patients [ 75 ]. Interactive modes using games or real-time feedback can reduce pain, improve joint range of motion and facilitate guidance for further rehabilitation of patients [ 76 ]. This may be related to the fact that VR effectively improves the coordination of deep and superficial neck muscle groups [ 77 ]. VR technology has a remote control function, which can to some extent overcome the space limitations of the new physical therapy technologies, facilitate the rehabilitation of patients at home, and reduce time costs. This demonstrates the promising potential of combining VR with new physical therapy technologies for the treatment of cervical spondylosis. VR can improve patient compliance and treatment effectiveness through an immersive experience. Additionally, VR provides information monitoring during treatment, allowing the real-time feedback and adjustment of treatment strategies for more precise and personalized treatment. Furthermore, it may reduce the burden of medical care, as VR technology applications may reduce the need for therapist assistance or specialized medical equipment.

Comparison of conventional and novel treatments for cervical spondylosis. Comparative analysis of traditional and new therapies in terms of safety, cost-effectiveness, treatment, application range, and therapeutic effect

“–” represents unclear data; PNF: Proprioceptive neuromuscular facilitation; SET: Sling exercises training; FM: Fascia manipulation; MET: Muscle energy technique.

Overall, the combination of VR technology and other novel technologies has the potential to improve the field of pain management. However, further research is needed to explore the feasibility of these options and to compare their efficacy with traditional techniques. The development of technology has facilitated the faster dissemination of various technical ideas, and the integration of these ideas has given rise to various novel technologies. However, many of the mechanisms underlying the effects of these new technologies on the treatment of cervical spondylosis are still unknown. Therefore, it is necessary to focus on the study of their theoretical mechanisms and their effective application in the clinic to improve the rehabilitation treatment of cervical spondylosis.

Acknowledgments

We thank the Figdraw for supporting the production of the figure.

Conflicts of interest: Authors declare no conflicts of interest.

Funding: Authors received no specific funding for this work.

Data availability: The data that support the findings of this study are available from the corresponding authors upon reasonable request