Limitations and generalizability
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This is a pilot clinical trial with a small sample size and carried out in a specific geographic area, which could lead us to under- or overestimate the generalizability of the results. Additionally, this was the first time our therapists carried out a multidisciplinary group videoconferencing approach (even though they all have years of expertise in their fields). The therapists’ expertise can influence on results obtained [The open-label design could also play a limiting role. Patients’ awareness of the randomized treatment received might have influenced their expectations and their subjective responses. The psychological sensitivity and predisposition of participants in the experimental group might have differed from those in the control group, as the former involved trying a new treatment after previous unsuccessful attempts. Consequently, the predisposition to improve in the experimental group may have been greater. Also, unblinded therapists/assessors may raise concerns of bias; however, we used objective tools to assess the study endpoints to keep observer bias to a minimum, and the assessment of candidacy for surgery was performed by an independent surgeon (not a study team member).