Pulmonary rehabilitation research highlights

A group of Australian physiotherapists, including clinicians, researchers and academics, conducted a narrative review on recent research in pulmonary rehabilitation. First author Tiffany Dwyer answers some questions here. 

Despite strong evidence for pulmonary rehabilitation, relatively few eligible people access and complete programs. What are the major barriers and what can physiotherapists do to improve referral, uptake and completion? 

Barriers to pulmonary rehabilitation (PR) occur at both system and individual levels. Limited availability of PR programs and trained staff, particularly in rural and low-resource settings, restricts access. 

Even where programs exist, eligible patients may not be referred at all or may decline because of misconceptions about PR, uncertainty about its benefits or fears that exercise will worsen symptoms. 

Transport, work and caring responsibilities can further reduce attendance and completion. 

Effective communication and strong therapeutic relationships may improve participation throughout the PR pathway (from initial referral to uptake and completion of the PR program). 

Physiotherapists can support uptake by identifying appropriate patients; introducing PR early and positively; clearly explaining the exercise, education and self-management components; and linking benefits to a patient’s individual goals (such as walking further, managing breathlessness, maintaining independence or reducing hospitalisation frequency). 

Addressing concerns and practical barriers, such as transport and competing responsibilities, can help patients find solutions, including options for alternative models of PR other than the traditional hospital-based programs. 

Shared decision-making, including encouraging questions and involving patients in care decisions, can further increase confidence, acceptance and engagement with PR. 

Pulmonary rehabilitation has traditionally been strongly associated with chronic obstructive pulmonary disease (COPD). Which other chronic respiratory conditions now have evidence supporting rehabilitation and where do important evidence gaps remain?

The benefits and safety of PR are established or emerging after acute exacerbations of COPD and in interstitial lung disease, pulmonary hypertension, bronchiectasis, lung cancer, asthma and post-tuberculosis lung disease. 

Important evidence gaps remain in evaluating the efficacy of PR after acute exacerbations in non-COPD populations and adapting PR programs to the specific needs of non-COPD populations and/or a treatable traits approach to optimise personalised rehabilitation. 

Telerehabilitation, home-based, community-based and minimal-equipment programs are increasingly available. How should physiotherapists decide which model is appropriate for an individual patient? 

Through shared decision-making, which takes patient preferences and available resources into account, we should offer participants a choice of program model because the most effective program is the one the person completes. 

Telerehabilitation, home-based and community-based PR are appropriate for those who are safe to exercise unsupervised or remotely and where travel to hospital-based PR is not feasible or recommended (eg, severely immunocompromised patients). 

Assessment of confidence and willingness to use technology, and rating of the importance of the social benefits of group exercise, may help decide which of those models is most suitable. 

Minimal-equipment PR is appropriate for all non-hospital-based PR and in low-resource settings. 

We need to ensure that alternative models retain the essential components of PR and include exercise training equivalent in intensity, duration and frequency to hospital-based programs. 

The benefits of pulmonary rehabilitation can decline without ongoing exercise. What does the evidence tell us about helping people maintain exercise and other health-enhancing behaviours after completing a program? 

The optimal strategy to help people maintain the benefits achieved in the initial PR program remains unclear. 

However, maintenance programs that were supervised, home-based and longer than 12 months all reported increased exercise capacity compared to usual care. 

Such resource-intensive maintenance programs may not be feasible for clinicians, so lower-resource strategies are now being studied. 

Behaviour change techniques and self-management strategies (such as action planning and motivational interviewing to support habit formation) implemented during and/or following PR are also successful in helping people maintain their health-related quality of life and exercise capacity at 12 months post-PR. 

There is growing evidence about the economic value of pulmonary rehabilitation. What are the implications of this evidence for physiotherapists, health services and policymakers seeking to expand access to programs? 

The strongest message is that PR represents an investment in both health outcomes and health-system efficiency. 

Physiotherapists have a central role in making that investment effective by delivering high-quality rehabilitation. 

The role of health services is to enable the provision of accessible and evidence-based program models, while policymakers need to create sustainable funding arrangements to allow PR to reach more people who could benefit. 

>>Dr Tiffany Dwyer is an associate professor in the cardiopulmonary teaching team at the University of Sydney and senior physiotherapist and clinical trials coordinator in the Department of Respiratory Medicine at Royal Prince Alfred Hospital. Her work focuses on physical activity, exercise and airway clearance in chronic respiratory conditions.

Active inference and low back pain 

A new editorial explores active inference and how understanding the relationship between messaging and patient expectations can help clinicians support people with pain. First author Mervyn Travers answers some questions here. 

For physiotherapists unfamiliar with active inference, how would you explain the concept and why it may be useful for understanding chronic non-specific low back pain?

Active inference is a framework that seeks to explain planning, attention, cognition, memory, action and perception as serving the need to reduce errors between expected incoming sensory information and predicted incoming sensory information. 

Based on this perspective, conscious experiences like pain involve the interaction of predictions and sensory information. 

This means chronic non-specific low back pain is neither a direct readout of what is happening in the tissues nor simply ‘of the brain’; it emerges from the whole person interacting with their world. 

Your editorial suggests that a person’s expectations and internal model of their back can influence how they experience pain. How might the language and explanations used by physiotherapists inadvertently reinforce a ‘pain-expectant’ model? 

We believe our predictions (which shape our conscious experiences) are based on models that are informed, in part, by our understanding of our back and the consequences of pain. 

Back care messaging commonly presents the back as weak and easily injured. 

Every ‘Be careful’ or ‘Don’t push it’ is another piece of evidence for a vulnerable back. 

Labels such as ‘degeneration’ or ‘slipped disc’ increase a person’s perception of the severity of the problem and lower their expectations of recovery. 

A pain-expectant model is a term we use to describe a scenario where a person’s mental model is likely to predict a dominance of noxious over non-noxious information from the body. 

A painexpectant model may be hard to avoid for people navigating a world of negative messages and labels about back pain. 

What should physiotherapists be listening for when exploring a patient’s beliefs, expectations and previous experiences of low back pain? 

We need to try to deeply understand the person and their models. 

Listen for what they’ve been told, what their scans supposedly showed, what they think will happen if they bend or lift and what they expect for the future. 

Language of damage, fragility and protection hints at a pain-expectant model. 

Movement and loading play an important role in your active inference framework. How can physiotherapists use movement experiences to help challenge a patient’s expectations that their back is vulnerable or that movement will cause pain or damage?

Movement is how we test our predictions. 

Common behaviours such as breath-holding or bracing when bending might look maladaptive but through this lens they may be viewed as ways of reducing error between predictions and incoming sensory information. 

These strategies may be a non-conscious way of matching the sensory evidence with an expectation of pain or nociception. 

In this way the person may be confirming their model or ‘self-evidencing’. 

Movement experiments provide an opportunity to create positive surprisal and to strengthen their model of the back as more fit for purpose than expected. 

You discuss approaches such as graded sensorimotor retraining and cognitive functional therapy. How does active inference help us understand why interventions combining education with movement and sensory experience might be effective? 

Educational components of both treatments are intended to challenge and update the cognitive models of what pain means and how safe the back is. 

Graded sensorimotor retraining aims to reset the precision of incoming sensory input and movement to sharpen non-noxious information coming from the back, which seems to be downweighted in those with chronic low back pain (think decreased tactile acuity and reduced ability to detect postural drift). 

Graded feedback-enriched movement and progressive loading aim to confirm and strengthen models showing that the back is capable via experiential learning. 

Cognitive functional therapy’s idea of ‘exposure with control’ maps onto the same idea. 

What are the important limitations of applying active inference clinically at this stage and what research is needed before we can be more confident about its implications for physiotherapy practice? 

Active inference has gained significant traction as we seek to understand many health conditions. 

We have specifically looked to translate this framework to the context of chronic non-specific low back pain. 

Our translation is largely based on the interpretation of theoretical and fundamental research and observational data from people in pain but some specific assumptions about active inference need to be tested. 

>>Mervyn Travers is a physiotherapist, educator and researcher. His research focuses on understanding and managing persistent pain. He teaches in the musculoskeletal and sports postgraduate programs at Curtin University and lectures internationally on optimising rehabilitation for people living with pain.

Stressmodex for acute whiplash 

Researchers from the University of Queensland’s RECOVER Injury Research Centre have conducted a trial-based economic evaluation involving 108 people with whiplash to examine how to integrate stress-management strategies into an exercise-based treatment program. One of the researchers, Chris Papic, agreed to answer some questions about the trial. 

What does StressModEx involve and how can physiotherapists integrate stress-management strategies into an exercisebased treatment program? 

StressModEx (Stress-Modulation and Exercise) is a physiotherapistdelivered intervention that integrates stress-management skills with exercise-based physiotherapy for acute whiplash. 

Physiotherapists support patients to develop, practise and apply active coping skills, such as abdominal breathing, positive coping statements and problem-solving, alongside exercise rehabilitation. 

These skills can help manage stress related to the crash and uncertainty about recovery or returning to work, driving and everyday activities. 

The approach is integrated into usual care rather than delivered separately. 

Physiotherapists incorporate stress-management strategies into discussions throughout the session, between exercises and in response to concerns raised by the patient. 

Physiotherapists are trained by clinical psychologists to deliver these strategies in a patient-led way. 

As with exercise, regular practice and reflecting on what works helps patients build these skills into everyday life. 

From a health system perspective, StressModEx produced better outcomes while costing slightly less than exercise alone. What do you think is driving that result? 

StressModEx was specifically developed to target stress-related symptoms that contribute to persistent pain and disability. 

An analysis of the original trial confirmed that reducing stress directly contributed to reductions in disability. In essence, it targeted one of the key contributors to poor recovery. 

Improving early recovery may reduce the need for ongoing care, benefiting patients and the health system through lower disability and healthcare costs. 

Our new economic evaluation also showed that StressModEx meaningfully improved health-related quality of life: patients receiving StressModEx experienced around 26 additional days in perfect health over 12 months compared with exercise alone. 

Given that around 80 per cent of patients at risk of poor recovery do not fully recover within this timeframe, these improvements are important and help explain the high probability of cost-effectiveness. 

The picture was less certain when lost work productivity and other societal costs were considered. Why is that distinction important when interpreting the findings? 

Cost-effectiveness considers how much society is willing to pay for health benefits, known as a willingness-to-pay threshold. 

StressModEx remained within commonly used Australian thresholds from a societal perspective but there was considerably more uncertainty. 

The societal analysis included estimated lost work productivity costs over 12 months. 

We did not have actual earnings data, so we estimated productivity losses using average Australian weekly earnings. 

While this approach is consistent with other studies and improves generalisability, it may have contributed to greater uncertainty in our findings. 

Importantly, we do not know why lost work productivity was higher in the StressModEx group despite observed health improvements. 

The StressModEx group (versus exercise only) had lower health-related quality of life at baseline, indicating greater health impairment before the intervention.

Differences in work requirements and other factors influencing return to work, including compensation, may also have contributed. 

These findings therefore need to be interpreted more cautiously. 

Your study focused on people with acute whiplash who had signs that they were at risk of poor recovery. How important is identifying these patients early rather than offering the intervention routinely to everyone with whiplash? 

Critically important. Our new guidelines strongly recommend using risk stratification tools, WhipPredict or the Örebro Musculoskeletal Pain Screening Questionnaire Short Form to identify those at risk of poor recovery after whiplash and guide treatment. 

The StressModEx trial focused on these patients because they present with greater pain-related disability and hyperarousal stress symptoms, making them appropriate for targeted intervention. 

There is also an important health system and economic rationale. 

Not everyone requires the same level of care, so identifying those at higher risk allows resources to be directed towards patients most likely to benefit, while avoiding unnecessary treatment for those more likely to recover with less care. 

What would need to happen for psychologically informed approaches such as StressModEx to become more widely available in routine physiotherapy practice? 

While physiotherapists recognise the influence of psychological factors on musculoskeletal pain and recovery, uptake of psychologically informed approaches varies and training opportunities for student and graduate physiotherapists remain limited. 

We need effective and scalable training programs to support physiotherapists to deliver this care as part of routine practice. 

Our new implementation trial, PICOT, is testing whether a blended online training program can improve uptake of psychologically informed care in routine practice and overcome scalability limitations of in-person training. 

Following successful evaluation in acute whiplash, we are now assessing the feasibility and effectiveness of StressModEx for chronic whiplash. 

We are seeking physiotherapists who work with people with chronic whiplash to participate in training and implement the program as part of routine care. Contact us at picot@uq.edu.au if you are interested in participating. 

>>Dr Chris Papic is an exercise physiologist and research fellow at RECOVER Injury Research Centre at the University of Queensland, with an interest in recovery after traumatic injury. His research focuses on translation and implementation science, including developing and implementing Australian whiplash guidelines.

PBMT plus exercise for back pain

A randomised trial involving 148 people with chronic non-specific low back pain looked at whether photobiomodulation therapy provides any benefit as an adjunct to exercise. One of the authors, Shaiane Silva Tomazoni, agreed to answer some questions about the research. 

What prompted you to investigate whether photobiomodulation therapy (PBMT) adds any benefit when combined with motor control exercise for chronic nonspecific low back pain? 

This study was part of a broader research program examining the role of PBMT in chronic non-specific low back pain. 

Our previous systematic review found no clinically meaningful benefits for pain or disability, although the evidence was uncertain, and a subsequent placebo-controlled trial found that PBMT alone was not superior to placebo. 

However, that left an important clinical question unanswered. 

Exercise is a cornerstone of contemporary low back pain management so we wanted to know whether PBMT could add something when used alongside an evidence-based exercise program. 

In other words, rather than asking whether PBMT works in isolation, we wanted to test whether it improves outcomes beyond those achieved with exercise. 

Your trial found no clinically important additional improvements in pain or disability when PBMT was added to exercise. What should physiotherapists take from this finding in everyday practice? 

The practical message is quite straightforward. With the treatment parameters we investigated, routinely adding PBMT to motor control exercise did not improve pain or disability to a clinically worthwhile extent. 

Our study specifically examined whether PBMT provides additional benefit when patients are already receiving structured motor control exercise. 

For this population and treatment combination, our findings do not support the routine addition of PBMT to exercise. 

The study followed participants for 12 months. What did the longer-term results add to our understanding of whether PBMT has a role alongside exercise? 

The long-term follow-up gave us greater confidence that we were not simply missing a delayed or sustained benefit of adding PBMT. 

Between-group differences in pain and disability remained small and below our predefined thresholds for clinical importance at one, three, six and 12 months. 

Retention was lower at the later followups, which should be considered when interpreting those results, but the overall pattern was remarkably consistent across time. 

How do these findings fit with the broader evidence on PBMT for chronic low back pain and are there still circumstances in which further research is warranted? 

Our findings add to an increasingly consistent body of evidence suggesting that PBMT does not provide clinically meaningful benefits for people with chronic non-specific low back pain. 

Previous evidence has shown little or no benefit of PBMT when used as a standalone treatment and our trial extends this by showing no clinically important additional benefit when PBMT is combined with a structured exercise program. 

Other sham-controlled trials examining PBMT alongside exercise have reported similar findings. 

Although PBMT can be delivered using many different combinations of treatment parameters, the existence of numerous possible protocols is not, in itself, sufficient justification for continuing to test them. 

Future research would need a strong biological and clinical rationale for a substantially different approach rather than simply evaluating further variations in treatment parameters. 

Overall, the accumulating evidence does not currently support PBMT as a treatment for chronic non-specific low back pain, either alone or as a routine adjunct to exercise. 

Your paper raises the issue of high-value care. How can physiotherapists make decisions about adjunctive treatments when an intervention is biologically plausible but does not appear to add clinically meaningful benefit to an evidencebased exercise program? 

Biological plausibility is a good reason to investigate an intervention but it is not enough on its own to justify routine clinical use. 

Our study is a good example: there are plausible biological mechanisms for PBMT, yet we found no clinically meaningful additional benefit when it was combined with exercise. 

For physiotherapists, I think the key question is: what does this treatment add to what I am already providing? 

If an adjunct requires additional time, resources or cost, the evidence should demonstrate that it adds clinically meaningful value. 

That is an important part of delivering high-value physiotherapy care. 

>>Shaiane Silva Tomazoni is a physiotherapist and researcher with a PhD in pharmacology from the University of São Paulo, Brazil. She has conducted postdoctoral research at the University of Bergen, Norway, where she has been involved in research on musculoskeletal conditions and evidence-based physiotherapy. Her research interests include chronic low back pain, PBMT, randomised controlled trials and systematic reviews.