Discussion
e-Exercise LBP, MSK complaints, neck/shoulder pain, pain
In the first phase of this study, matched treatment options were developed for six subgroups as part of the Stratified Blended Physiotherapy approach for patients with neck and/or shoulder complaints. Recommendations about the content and intensity of physiotherapy treatment were matched to the patient’s risk of persistent disabling pain (using the Keele STarT MSK Tool; low, medium, or high risk), and mode of physiotherapy delivery was intended to be matched to the patient’s suitability for blended care (using the Dutch Blended Physiotherapy Checklist (i.e. yes or no). A paper-based workbook and the e-Exercise app modules for patients with neck and/or shoulder complaints were developed as practical tools for the mode of delivery matched treatment options. In the second phase of this study, feasibility of the developed Stratified Blended Physiotherapy approach for patients with neck and/or shoulder complaints was investigated for both patients and physiotherapists. Patients and physiotherapists were ‘a little’ satisfied with the new approach. Of the patients who were willing to participate, they considered the e-Exercise app as ‘best imaginable’ usability. Usability of the physiotherapist dashboard to set up the e-Exercise app was considered ‘OK’ by physiotherapists. This can be largely explained by the lack of a cockpit functionality with an overview of active patients and their progress and a lack of a logical workflow. The paper-based workbook was not used, so there is no data of patients that were unsuitable for blended care. Results of the second phase can be used to develop, improve or implement e-Exercise or other blended interventions.This is the first study to develop and test feasibility of integrated risk stratification and blended care in patients with neck and/or shoulder complaints. Also, no stratification tools to identify patient subgroups and subsequently match them to a treatment are recommended by Dutch physiotherapy guidelines for neck/shoulder pain [In this study, we identified some improvements needed to be made to the Stratified Blended Physiotherapy approach before initiating a cluster randomized trial to determine the clinical effectiveness of the new approach compared to usual physiotherapy. First, patients needed an overview of the steps and possibilities of the e-Exercise app module. Therefore, an instruction sheet called ‘working with the e-Exercise program through MijnZorgApp’ was developed for patients. Second, physiotherapists needed a cockpit functionality in the physiotherapist dashboard of the app module with an overview of active patients and their progress. Therefore, a cockpit functionality was developed for physiotherapists to see which action is needed for which active patient, with the aim to provide a more logical workflow. Third, improvements need to be made to the physical activity module of the app. It is suggested to integrate an activity tracker or personal health environment with the app. The integration of an activity tracking device with a display was also suggested in a previously executed feasibility study on e-Exercise [A strength of this study was the use of knowledge from a previously developed and evaluated stratified blended intervention for patients with other MSK complaints, namely non-specific low back pain (e-Exercise LBP), in which patients and physiotherapists were involved in the participative development, and was conducted by the same research group [Despite the careful execution of this study, there are some methodological considerations. The digital questionnaire was sent three months after the first physiotherapy session. This is a relatively long time gap, especially for patients at low risk, which might have led to recall bias. However, we chose follow-up at 3 months to ensure that all participants would have been able to receive their matched intervention, and to ensure the follow-up time-point was the same for all subgroups. Also, because of the small number of included patients, physiotherapists did not gain the experience to fully familiarize the Stratified Blended Physiotherapy approach. Therefore, there were no physiotherapists which made the Stratified Blended Physiotherapy approach part of their daily work routine, which might have influenced feasibility outcomes. Experiences might have been different in that theoretical group, because behavior change of the physiotherapist will need time and experience. Additionally, no a priori sample size calculations were done. The small sample of physiotherapists and patients, and the fact that only one patient at high risk was included in the feasibility analyses might have led to limited generalizability. Therefore, in the subsequent cluster randomized trial, continuous actions will be taken to maximize inclusion rates.