research topics in physical therapy

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Effectiveness of photobiomodulation in reducing pain and disability in patients with knee osteoarthritis: a systematic review with meta-analysis.

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Diversity, Equity, Inclusion, and Antiracism Research in Physical Therapy over the Last 25 Years: A Scoping Review

Long-term follow-up of a person-centered prehabilitation program based on cognitive-behavioral physical therapy for patients scheduled for lumbar fusion, the targeted motor control screening tool is valid for four-year-old children., instructing to impact: exploration of doctor of physical therapy education instruction of social determinants of health and health equity for people with disabilities, prognostic factors and treatment effect modifiers for physical health, opioid prescription, and health care utilization in patients with musculoskeletal disorders in primary care: exploratory secondary analysis of the stems randomized trial of direct access to physical therapist–led care, relationship among falls, fear of falling, and physical activity level in patients on hemodialysis, the effect of total knee replacement on dual-task gait performance in older adults, inspiratory muscle training in patients living with chronic kidney disease and receiving hemodialysis: meta-analysis of randomized controlled trials, inspiratory muscle training in phase 1 and 2 postoperative cardiac rehabilitation following coronary artery bypass graft surgery: systematic review with meta-analysis, lgbtqia+ cultural competence in physical therapist education and practice: a qualitative study from the patients’ perspective, unlocking patient voices: advancing physical therapist practice with discrete choice experiments, factors associated with physical inactivity of recipients of a kidney transplant: results from the adhere brazil multicenter study., validation of the cervical torsion test and head neck differentiation test in patients with peripheral vestibular hypofunction, on “is clinical research as helpful to clinicians as it could be” turolla a, guccione aa, tedeschi r, pillastrini p. phys ther . 2023;103(8):pzad060. https://doi.org/10.1093/ptj/pzad060, prognosis of pain after stroke during rehabilitation depends on the pain quality, efficacy of physical activity promoting interventions in physical therapy and exercise therapy for persons with noncommunicable diseases: an overview of systematic reviews, attitudes and beliefs of physical therapists and physical therapist students towards working with older adults: a systematic review, efficacy of rehabilitative techniques on pain relief in patients with vulvodynia: a systematic review and meta-analysis, accreditation can advance excellence in physical therapist education: a call to action, concurrent validity and reliability of video-based approach to assess physical function in adults with knee osteoarthritis, igniting the fire of discovery: creating partnerships between research, education, and practice, a call to action: develop physical therapist practice guidelines to affirm people who identify as lgbtqia+, accumulative assessment of upper extremity, national benchmarks to understand how doctor of physical therapy learners from minoritized race and ethnicity groups perceive their physical therapist education program, early mobilization dose reporting in randomized clinical trials with patients who were mechanically ventilated: a scoping review, telerehabilitation in physical therapist practice: a clinical practice guideline from the american physical therapy association, decline in mobility and balance in persons with post–covid-19 condition.

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Exploring Symptom Responses to Upper Limb Neural Test Variations of the Radial Nerve in Patients With Lateral Epicondylalgia: An Observational Study

Online exercise programs for chronic nonspecific neck pain: a randomized controlled trial reveals comparable effects of global, local, and combined approaches, orthopaedic manual physical therapy: a modern definition and description, author response to sahrmann, on “concerns on the science and practice of a movement system.” joyce ct, beneciuk jm, george sz. phys ther . 2023;103:pzad087. https://doi.org/10.1093/ptj/pzad087, blood flow restriction and veterans with multiple sclerosis (brave-ms) and advanced disability: protocol for a randomized controlled trial, functional recovery of adults following acute covid-19: a systematic review and meta-analysis, when east meets west: considerations in physical therapist care for the asian american population, constraint-induced movement therapy promotes myelin remodeling and motor function by mediating sox2/fyn signals in rats with hemiplegic cerebral palsy, introducing mechanically assisted cough for patients with progressive neurological disease: patient-physical therapist interaction and physical therapist perspective, differences in pain experience among different racial and ethnic groups, community mobility among older adults who are socioeconomically disadvantaged: addressing the poverty penalty, queering the physical therapy curriculum: competency standards to eliminate lgbtqia+ health disparities, email alerts.

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Best 60 Physical Therapy Research Topics

Physical therapists specialize in improving the quality of life through movements by prescribed physical exercise, care, and education of patients. They diagnose and treat people of various ages, from adults to small children and even older patients.

Different individuals suffer injuries, disabilities, and all other physical conditions that require hospitalization or treatment. Physical therapists are responsible for nursing these people back to health and individuals who want to become even healthier and prevent physical complications in the future.

They carry this out by examining each patient and creating a treatment plan to improve movement ability and reduce or manage pain, prevent disability, and gradually restore normal mobility functions. Physical therapists are sometimes underrated, but they can affect profound positive changes in people’s lives.

To ensure the best treatment outcomes, it is essential for physical therapists to stay updated with the latest research and advancements in the field. If you’re in need of assistance in exploring physical therapy research topics or require support in writing your thesis, consider reaching out to professional experts who can help you. With their expertise, they can guide you in selecting relevant research topics and provide valuable insights to enhance your thesis.

Physical therapy research topics aid and guide physical therapists to help people achieve a better style and standard of healthy living. By seeking professional assistance, such as writing services that offer “ write my thesis ” support, you can ensure that your thesis reflects the latest research and contributes to the field of physical therapy.

What Are Some Physical Therapy Research Topics?

Physical therapists practice across different works of life. Significant examples are schools, workplaces, clinics, hospitals, sports environments, and nursing homes. The demand for physical therapies differs in various regions of the world. In countries or nations with a higher and older population, the need for physical therapists is ever increasing.

Research topics for physical therapy provide insight into the various ways and methods of fulfilling healthy living through physical therapy and fitness. These topics can range from research education to health administration and consultation. Fundamentally, physical therapy is given as a means of primary care or in addition to other medical services.

In most countries, physical therapists also possess the authority to issue lifestyle routines and prescribe medications. Some research topics in physical therapy include;

• The systemic review of health promotion in physical therapy
• The influence of hip strength and core endurance on recurrent dislocations
• Influence of fatigue and knee kinetics
• Effects of fatigue of jumping and leg movement
• Role of physical therapists in health promotion
• The accuracy of sensors in the detection of kicks in young infants

Current Physical Therapy Research Topics

Current physical therapy research topics mostly dwell on the trending and impactful issues that presently concern the physical health and fitness of the general population. They compare previous experiences and formulate ideas and physical movement methods to improve individuals’ physical wellbeing.

Students can write research papers about the latest developments in the sector of physical therapy. Some of these research topics can even address current setbacks in the sector. Some good research topics for physical therapy currently being talked about include;

• Physical therapy for rheumatoid arthritis
• Physical therapy and mental health
• Physical therapy and Foucault
• The pain barrier and physical therapy
• Physical therapy for cancer patients
• A study of the benefits of physical therapy on physical and psychological health

Pediatric Physical Therapy Research Topics

Pediatric physical therapy research topics talk about topics that involve patients requiring pediatric care. These types of physical therapy topics encompass how physical therapy affects both mother and child. These topics are perfect for students who intend on specializing in pediatric physical therapy.

However, the choice of any subject in this category should principally depend on the students’ passion and interest and the instructions of the tutors in charge. Examples of pediatric research topics in physical therapy are;

• How does physical therapy impact a child?
• The significant differences between occupational therapy and physical therapy
• The function and features of pediatric therapy research
• Who is a pediatric physical therapist, and what is their obligation?
• Disparities between a physical therapy for children of different age ranges
• Is pediatric research for children with injuries vital?

Interesting Physical Therapy Topics

Interesting physical therapy topics lean towards those topics on physical therapy that pique the interest of individuals and are extensive in terms of providing specific and compelling information on various points of improved physical health. These physical therapy topics are often discussed and induce great anticipation and interest upon their explanation or study. Some exciting research topics on physical therapy are;

• The science of pain and physical therapy
• Compliance and consistency in physical therapy
• Significant signs of burnout in physical therapy
• Travel therapy: A form of physical therapy
• Physical therapists and their handling of musculoskeletal issues
• The science behind physical therapy

Hot Topics in Physical Therapy

To think up hot topics in physical therapy research, students should brainstorm or explore the available problems or developments. Potential ideas in physical therapy such as the issues affecting routine and the growth and development or success of physical therapy can be written and thoroughly examined to generate hot topics in physical therapy. Hot research topics for physical therapy students include;

• Interaction between physical therapists and mentally challenged patients
• Physical therapy for both mind and body
• Physical disability and its psychological impact
• Physical therapy as a means of empowerment for surmounting pain
• Abuse and tortured patients’ treatment in physical therapy
• The effect of slow-progressing physical therapy

Controversial Topics Physical Therapy

Controversial topics in physical therapy research concern methods and techniques used by physical therapy experts which are deemed ineffective and unnecessary. These topics have differing opinions on their efficacy and contribution to overall physical wellbeing. Some controversial physical therapy topics are;

• Is ultrasound effective in the diagnosis of sports injuries?
• The reason behind self-myofascial techniques
• Is icing a good treatment for physical injuries?
• The process of dry needling
• Is hemp-derived CBD successful in treating sport-related injuries?
• The most effective strategies for targeting neuro-musculoskeletal injuries.

Acute Care Physical Therapy Topics

This topic revolves around patients who require acute physical care due to the nature of their physical impairments. Some of these topics include;

• Treatment of bone and muscle disorders in the musculoskeletal system
• Walking analysis and kinetics
• Primary effects of physical therapy intervention in the cardiovascular system
• Physiological responses to the musculoskeletal system
• Secondary effects of physical therapy intervention in the pulmonary system
• Measurements and tests in physical therapy.

Physical Therapy Topics for Presentation

These physical therapy research topics can be employed for presentation purposes. They intensively explain some direct aspects of physical therapy. These physical therapy presentation topics include;

• Prevention and identification of injuries during physical therapy
• Acute care and assessment of sports injuries
• Education of athletes on injury prevention
• Treatment and techniques that speed up physical therapy
• Best processes for the rehabilitation and management of injuries
• The pharmacology of musculoskeletal systems.

Physical Therapy Research Paper Topics

Physical therapy research paper topics delve into the extensive explanation and research of physical therapy methods and techniques used to treat physical impediments or disorders. Some of them are;

• The musculoskeletal system’s response to the environment
• Mobility and joint functions in the body
• Exercise and the musculoskeletal system
• Practicing physical therapy: A professionals perspective
• The benefits of an effective physical therapy
• Similarities in occupational and physical therapy.

Get Your Physical Therapy Paper from Experts

To get physical therapy from experts, you simply need to identify efficient and trusted therapy platforms with experienced therapists to aid your recovery or improve your physical health. As a student, many professional writers can assist you in writing a therapy paper. Some physical therapy paper topics experts can help you to write on are;

• Code of ethics for physical therapy
• The roles which challenge physical therapists
• Rehabilitation guidelines for physical therapists
• Dimensions of physical therapy
• Ethical issues in the practice of physical therapy
• The relationship of patients and physical therapists

Conclusion 

Research papers on physical therapy essentially encompass health problems that make movement and daily tasks difficult for individuals. The principal reason for this is because physical therapy is about pain relief and physical rehabilitation. All the topics highlighted here can easily be used for research and paper writing.

If you’re pursuing a thesis in the field of physical therapy and find yourself in need of expert guidance, our reputable academic writing services available to write the thesis for you . DissertationTeam provide valuable assistance in crafting a well-researched and structured thesis. Professional writers with subject matter expertise can help you navigate the complexities of the research process, refine your ideas, and ensure that your thesis meets the highest academic standards. By seeking the support of our company and having us write the thesis for you, you can enhance your thesis writing experience and increase your chances of success.

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105+ Most Amazing Physical Therapy Research Topics – Full Guide!

Many age groups and medical conditions across individuals are helped by physiotherapy, which helps to relieve pain, restore movement, and improve the quality of life. 

This area constantly changes, creating new areas for physical therapy research. It introduces new techniques and groundbreaking interventions while revealing the complexity of how the human body functions during rehabilitation. 

It offers a fascinating tapestry of intellectual curiosity and a profound impact on human well-being in various aspects, ranging from discovering neuroplasticity’s intricate mechanisms to investigating cutting-edge technologies that redefine the limits of recovery in physical therapy research. 

This blog offers an assortment of interesting research subjects that could interest you, challenge your intellect, or even help contribute to this noble profession.

Recommended Reading: “ Top 111+ Forensic Science Research Topics – Interesting Ideas! “.

Importance of Choosing the Right Physical Therapy Research Topic

Table of Contents

The most important thing is choosing the right research topic for physical therapy. It is not just a mere formality, but it is also an ultimate decision that can either make or break your entire journey in conducting research. 

What is worth noting here is that finding the right subject to study will keep you engaged and curious throughout your research process, keeping you going even when things become difficult.

However, this goes beyond personal motivation. Indeed, the topic you choose can propel physical therapy forward as a discipline. The purpose here would be to explore unchartered territories or difficult issues, and your investigation may reveal new treatments, question old assumptions, or improve our understanding of bodily healing mechanisms. This kind of work changes lives.

Moreover, crossing disciplines to pursue ambitious topics leads to exciting partnerships. Physical therapy is a unique convergence between medicine, biomechanics, and neuroscience. 

At this juncture, such approaches blend that magic occurs—those ‘Eureka’ moments redefining medicinal care.

Therefore, do not select a subject because it sounds cool or it’s an easy grade booster. Instead, go for something that ignites and can affect individuals around you positively. 

Therefore, this single attribute differentiates great difference-making investigative studies from ordinary ones; hence, one should take their time and get things right at the beginning before moving any further steps.

Top 105+ Physical Therapy Research Topics

The list of top 105+ physical therapy research topics is organized by category. 

Topics on Helping Muscles and Bones

• How hands-on therapy helps muscle and bone problems.
• Comparing different exercises for back pain.
• How therapy helps achy joints.
• Using special machines for sports injuries.
• Exercise programs to help older people keep their balance.
• Using special tape to help injuries.
• Different ways to stretch to stay flexible.
• Comparing different exercises for shoulder injuries.
• Helping people recover after surgery.
• How therapy helps with neck pain.

Topics on Helping the Brain and Nervous System

• How therapy helps people after a stroke.
• Helping people with Parkinson’s disease.
• Learning to walk again after brain or spine injuries.
• Using video games for therapy.
• Assisting people to move better after a stroke.
• Assisting people with multiple sclerosis to keep their balance.
• Using water therapy for nerve problems.
• Special machines to help people move their arms.
• Helping people with brain injuries exercise.
• Using therapy for stiff muscles after a spine injury.

Topics on Helping Heart and Lungs

• Exercise programs for breathing problems.
• Exercising for a healthier heart.
• Using therapy to stay out of the hospital for heart problems.
• Breathing exercises to make lungs stronger.
• Special ways to clear mucus from the lungs.
• Different exercises after heart problems.
• Helping people breathe better.
• Using special exercises for stronger breathing muscles.
• Using exercise after heart surgery.
• Exercise to lower the risk of heart problems.

Topics on Helping Kids

• Helping kids who develop slowly.
• Helping kids with stiff muscles from birth.
• Using play to help kids exercise.
• Assisting babies to learn to move.
• Helping kids with spine problems walk better.
• Using water play for kids with autism.
• Helping babies with stiff necks.
• Helping kids who don’t like certain sensations.
• Helping kids with Down syndrome move better.
• Helping kids use their arms better.

Topics on Helping Older Adults

• Helping older people keep their balance.
• Exercise to stay strong as you age.
• Making life better for older people in nursing homes.
• Stopping older people from falling.
• Helping older people with long-term pain.
• Keeping muscles strong as you get older.
• Exercises for older people at home.
• Keeping the mind sharp with exercise.
• Using water therapy for older people.
• Helping older people keep their balance with tai chi.

Topics on Helping After Surgery or Injuries

• Helping before surgery to recover faster.
• Using special needles for muscle pain.
• Assisting people to stand up straight.
• Using special exercises for tendon pain.
• Helping with jaw pain.
• Using hands-on therapy to relax muscles.
• Assisting ankles to stay strong to prevent sprains.
• Helping kids with crooked backs.
• Using hands-on treatment for wrist pain.
• Using special exercises for knee pain.

Topics on Helping Athletes

• Stopping athletes from getting hurt.
• Helping athletes with head injuries.
• Using science to stop athlete injuries.
• Assisting knees to stay strong for athletes.
• Using special bands for healing muscles.
• Assisting athletes in getting back to their sport after knee surgery.
• Assisting athletes with overuse injuries.
• Using special exercises for sports recovery.
• Assisting athletes with tape for injuries.
• Using tape to stop ankle injuries in athletes.

Topics on Helping Women’s Health

• Helping with bladder problems.
• Assisting women with organs that move out of place.
• Exercising safely during pregnancy.
• Assisting women in recovering after having a baby.
• Helping with pain in private areas.
• Helping after having a baby belly.
• Exercising safely during pregnancy for a sore belly.
• Assisting women with menopause symptoms.
• Assisting women with weak bones after menopause.
• Exercising to prevent diabetes during pregnancy.

Topics on Learning in Physical Therapy

• Learning in real-life situations during training.
• Using pretend situations to learn in therapy school.
• Learning with different types of healthcare workers.
• Think about what you’ve learned after helping patients.
• Using computers to learn in therapy school.
• Testing what you’ve learned in therapy school.
• Learning by teaching others during training.
• Going to other countries to learn during training.
• Learning from someone experienced during training.
• Learning from classmates during training.

Topics on Staying Healthy

• Exercising for a healthier body.
• Changing your lifestyle to stay healthy.
• Exercising to stay strong as you get older.
• Exercising for a happier mind.
• Staying healthy at work.
• Exercising to save money on healthcare.
• Learning how to move well.
• Exercising with friends in your community.
• Using technology to help you exercise.
• Assisting others to be healthy.

Topics on New Technology and Ideas

• Talking to a therapist online.
• Using special watches to track your health.
• Using phone apps to follow exercises.
• Playing games to feel less pain.
• Using smart computers to make therapy better.
• Playing games to make therapy more fun.
• Using robots to help people move.
• Using machines to make special body parts.
• Using a screen to see how you’re moving.
• Wearing a special machine to walk better.

Physical therapy, as a wide field, has many topics to discuss. They allow exploration and improvement of the area. Physical therapy researchers can study these topics deeply to bring out important ideas that will help improve the practice.

Closing Up 

As wide as it is, the subject matter of physical therapy contains several promising and critical areas for investigation. In addition to novel approaches to treating chronic pain and neurological diseases, they also study how physical therapy can help maintain healthy aging and prevent falls. 

These topics may improve patient outcomes significantly and further develop this profession. As researchers uncover more about these fields, practitioners must be updated with the latest information and ready to use evidence-based practice in their clinical decision-making. 

Through lifelong learning and contributing new knowledge to the vast storehouse of facts that form the backbone of this discipline, therapists can mold their future contributions to positively impact their patients’ lives.

What are some unique research topics in forensic science?

Some unique research topics in forensic science include the analysis of digital evidence in cybercrimes, using plant evidence in forensic botany, and applying geospatial analysis in forensic geology.

How does forensic science research contribute to solving cold cases?

Forensic science research contributes to solving cold cases by reanalyzing existing evidence using advanced techniques, developing new methods for analyzing forensic evidence and applying interdisciplinary approaches to uncover new leads and information.

What role does forensic anthropology play in criminal investigations?

Forensic anthropology plays a crucial role in criminal investigations by analyzing skeletal remains to determine the identity, age, sex, and ancestry of individuals, as well as identifying trauma or injuries that may provide clues about the cause of death.

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TheScholarsRepository@LLU: Digital Archive of Research, Scholarship & Creative Works

Home > SAHP > PT > ETD-PT

Theses, Dissertations and Projects - Physical Therapy

Theses/dissertations from 2022 2022.

High-Intensity Interval Training and Biological Age , Trevor Lohman

Theses/Dissertations from 2021 2021

The Impact of Intraneural Facilitation Therapy on Diabetic Peripheral Neuropathy , Kyan Zhra-Sahba Alnajafi

The Influence of Strength and Mobility on Lumbar Biomechanics During Lifting , Christopher S. Patterson

Theses/Dissertations from 2019 2019

Spine Kinematics and Muscle Activities in Non-specific Chronic Low Back Pain Subgroups in Sitting , Mansoor Ahmed Alameri

Relationship between Balance and Physical Activity in Subjects with Non-Specific Chronic Low Back Pain , Muhsen B. Alsufiany

Does self-evaluation and education in students change attitudes and beliefs towards Weight Stigma? , Henry A. Garcia

Effects of Head Motion on Balance in Middle-Aged and Young Adults with Chronic Motion Sensitivity , Ammar E. Hafiz

Effect of Pediatric Ear Infections on Postural Stability , Ohud A. Sabir

Biomechanics and Postural Control Characteristics in Low Back Pain Subgroups During Dynamic Task , Amjad Shallan

Theses/Dissertations from 2018 2018

Effect of Adding Stretching Techniques to Standardized Intervention on Nonspecific Mechanical Neck Pain , Saad S. Alfawaz

Theses/Dissertations from 2017 2017

Effects of Head Motion on Postural Stability in Participants with Chronic Motion Sensitivity , Abdulaziz A. Albalwi

Relationship between Vestibular System, Vision, Anxiety, and Chronic Motion Sensitivity , Ahmad A. Alharbi

The Effects of Frequent Smartphone Use on Children’s Upper Posture and Pulmonary Function , Asma Alonazi

The Effects of Wearing Headscarves on Cervical Spine Proprioception and Range of Motion , Samiah Alqabbani

A Comparison of Neuromuscular Control between Subjects with and without Chronic Ankle Instability , Hatem Jaber

Theses/Dissertations from 2016 2016

Effects of Adjustments to Wheelchair Seat to Back Support Angle on Head, Neck, and Shoulder Postures , Afnan M. Alkhateeb

Effect of Jet Lag on Postural Stability , Faisal M. Al Mubarak

Effect of Heavy Lifting with a Head Strap on the Pelvic Floor across the Menstrual Cycle , Yvonne Biswokarma

Theses/Dissertations from 2015 2015

Physical Therapy after Triangular Fibrocartilage Injuries and Ulnar Wrist Pain , Mohamed A. Abdelmegeed

The Effect of Cervical Muscle Fatigue on Postural Stability during Immersion Virtual Reality , Mazen M. Alqahtani

The Effects of a Novel Therapeutic Intervention in Diabetic Peripheral Neuropathy Patients , Adel M. Alshahrani

Cross-cultural Adaption and Psychometric Properties Testing of The Arabic Anterior Knee Pain Scale , Abdullah S. Alshehri

Effect of Tai Chi Exercise Combined with Mental Imagery in Improving Balance , Abdulrahman Alsubiheen

Effect of Vestibular Adaptation Exercises on Chronic Motion Sensitivity , Danah Alyahya

Muscle Dynamics as the Result of Whole Body Vibration and Plyometrics , Richard Jeremy Hubbard

Theses/Dissertations from 2014 2014

Effect of Monophasic Pulsed Current on the Treatment of Plantar Fasciitis , Abdullah Alotaibi

Screening for Torticollis and Plagiocephaly: The Role of the Pediatrician , Lisa Ann Change-Yee Hwang

Effect of 17β Estradiol & Foot Strike Patterns on Physiological & Biomechanical Changes in Runners , Iman Akef Khowailed

Theses/Dissertations from 2013 2013

Inter-rater Reliability of Lumbar Segmental Instability Tests and the Subclassification , Faisal Mohammad Alyazedi

Sleep-wake Cycle Assessment in Type 2 Diabetes and Salivary Melatonin Correlates , Paula Regina Aguiar Cavalcanti

Anterior Cruciate Ligament Elasticity and Force for Knee Flexion during the Menstrual Cycle in Women , Haneul Lee

Effect of Passive Vibration on Skin Blood Flow in Good Glycemic Control and Poor Glycemic Control Type 2 Diabetics , Kanikkai Steni Balan Sackiriyas

Theses/Dissertations from 2012 2012

Co-diagnosis Frequency of Peripheral Vestibular Disorders and Physical Therapy , Summer M. San Lucas

Postural Sway, EEG and EMG Analysis of Hip and Ankle Muscles during Eight Balance Training Tasks , Yuen Yi Florence Tse

Effect of a Single High-Fat Meal and Vitamins on the Circulatory Response to Local Heat in Koreans and Caucasians , JongEun Yim

Theses/Dissertations from 2011 2011

Virtual Reality Gaming as a Tool for Rehabilitation in Physical Therapy , Abel A. Rendon

Theses/Dissertations from 2010 2010

Aerobic Exercise and Bone Turnover in Trained and Untrained Premenopausal Women , Michelle Prowse

Theses/Dissertations from 2008 2008

Effect of 3-Electrode Electrical Stimulation on Current Delivery and Healing in Chronic Wounds , HyeJin Suh

Theses/Dissertations from 2007 2007

Is Electrical Stimulation a Predictive Tool for Autonomic Dysfunction in Males with Diabetes? , Susan Dorothy Rand

Theses/Dissertations from 2005 2005

The Effect of Posterior Versus Anterior Glide Joint Mobilization on External Rotation Range of Motion of Patients with Shoulder Adhesive Capsulitis , Andrea J. Johnson

The Effect of Electrical Stimulation on Blood Flow in Chronic Wounds in Patients with and without Diabetes , Daryl J. Lawson

Isokinetic Knee Strength in Females with Fibromyalgia , Flora F. Shafiee

Difference in Transverse Plane Scapular Position of Professional Baseball Players Relative to Baseball Field Position , James M. Syms

The Effect of Positioning on Pelvic Floor Muscle Activity as Evaluated with Surface Electromyography in Normals , Karen R. Whitter-Brandon

Theses/Dissertations from 2004 2004

Orthopedic Treatment Outcomes and Physical Therapists' Orthopedic Clinical Specialist Status , Karin Granberg

The Effectiveness of a Physical Therapy Intervention for Children with Hypotonia and Flatfeet , Charmayne G. Ross

Theses/Dissertations from 2003 2003

The Role of Health Promotion in Physical Therapy , Brenda L. Rea

Predicting Sacroiliac Syndrome: The Association Between Noninvasive Sacroiliac Joint Tests and Sacroiliac Joint Injections , Lorraine D. Webb

Theses/Dissertations from 2002 2002

Prevalence of various Upper Extremity Disorders in Patients with Carpal Tunnel Syndrome versus Patients without Carpal Tunnel Syndrome , Daniel C. Buda

Effect of Electrode Size, Shape, and Placement on Electrical Current and Subject Comfort During Electrical Stimulation , Bonnie J. Forrester

Patterns of Scholarly Productivity in Physical Therapy Faculty , Ardith L. Williams-Meyer

Theses/Dissertations from 2001 2001

The Effects of Education on Fear-Avoidance Behavior of Subjects with Work-Related Low Back Pain , Marie A. Anger

Toward the Optimal Waveform for Electrical Stimulation , Scott Douglas Bennie

Factors in Predicting the Number of Home Care Physical Visits , Bruce D. Bradley

A Practice Analysis Survey: Defining the Clinical Practice of Primary Care Physical Therapy , Edsen Bermudez Donato

Disability Self-Assessment and Upper Quarter Muscle Balance in Females , Eric Glenn Johnson

Theses/Dissertations from 2000 2000

Comparison of Elderly Non-Fallers and Fallers on Performance Measures of Functional Reach, Sensory Organizations, and Limits of Stability , Harvey W. Wallmann

Theses/Dissertations from 1999 1999

Patient participation in physical therapy goal-setting , Susan M. Baker

Theses/Dissertations from 1998 1998

Prediction of Discharge Destination from Initial Physical Therapy Assessment using the Physical Assessment Key (PAK) , Wendy L. Chung and Kimberly A. Vieten

Does the Oswestry or SF-36 Help a Therapist to Predict Treatment Classification , Amy Crawford and Denese D. Kaufeldt-Soliz

Reliability and Validity of Assessing Student Performance of Psychomotor Skills in Entry Level Physical Therapy Curricula , Nancy Sue Darr

Theses/Dissertations from 1997 1997

Reference Serum Chemistry and Hematological Values for Spinal Cord Injured Patients , Michael S. Laymon and Antone L. Davis II

Discharge Outcomes : An Evaluation of a Functional Index of Physical Assistance , Jan R. Snell

Theses/Dissertations from 1985 1985

A Comparison of Strength Improvement on Free Weights and the Universal Centurion , David J. Davies

Theses/Dissertations from 1984 1984

The effect of dextrose ingestion on cardiovascular endurance , Judith M. Axford

Theses/Dissertations from 1980 1980

The Ingestion of Garlic and its Effect on Cardiovascular Endurance , Thomas G. Blackwelder

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• 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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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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The Top 100 Most-Cited Publications in Musculoskeletal Rehabilitation: A Bibliometric Analysis

Division of Interventional Pain Management, OrthoAlabama Spine and Sports, AB Birmingham, USA

Musculoskeletal conditions are the leading contributor to global healthcare expenditure and with an increase in ageing global population, this number is projected to rise further.

To determine the top 100 most-cited studies in field of musculoskeletal rehabilitation and to conduct their bibliometric analysis.

Scopus was used for identification of studies, published in the field of musculoskeletal rehabilitation over last five decades.

Literature search was conducted in February 2021 with final Boolean search phrases being: [(musculoskeletal) and (rehabilitation) and (musculoskeletal rehabilitation)]. In addition to number of citations, data was also collected for other variables such as title of study, topic of discussion, subdivisions of clinical and applied science involved in conduction of study, study design, journal and its impact factor, year of publication, and country where study was conducted.

The top 100 most-cited articles in musculoskeletal rehabilitation over the last 50 years were published between 1973 and 2015. Total number of citations was 24,366, with an average of 243.66 citations per paper. Highest citation was reported by a paper on treatment of low back pain by Waddell G. The decade of 2000–2009 contributed maximum articles with highest number of publications from journal “Archives of Physical Medicine and Rehabilitation”. Most of the publications were from United States and most common topic to feature among these articles was “Strength training”.

Conclusions

This study identifies the top 100 most-cited articles in musculoskeletal rehabilitation and provides insight into its historical trends while serving as a guide for future research.

Introduction

Musculoskeletal conditions are among the largest contributors to the need for rehabilitation services globally, with a recent analysis by Global Burden of Disease stating that approximately 1.71 billion people worldwide have musculoskeletal disorders [ 1 ]. Musculoskeletal rehabilitation has often been construed to be a very specialized and exorbitant service for the few, but this narrative is constantly being challenged by the enormous number of people afflicted with musculoskeletal diseases worldwide. The WHO Rehabilitation Need Estimator tool (2019) states that approximately 1 in 3 people globally could benefit from musculoskeletal rehabilitation with highest need in the Western Pacific Region, where 610 M people could benefit from rehabilitation. Equally important is the fact that there has been a 69.4% worldwide increase in years lived with disability between 1990 and 2019 with 570 M people been affected by low back pain alone [ 2 ].

As different aims and objectives drive research, an analytical evaluation of progress in musculoskeletal rehabilitation research is important for scientists and physicians to understand various trends over the decades. Based on bibliometrics, secondary analysis of the knowledge unit characteristics and relationships of published literature can help researchers understand the past and current statuses of musculoskeletal rehabilitation effectively and anticipate future areas of research. Analysis of the citations incurred by a publication has proven to be an effective and useful way to objectively determine its impact on a specific topic or in a particular field [ 3 – 6 ]. Publications with the most citations represent the highest impact work in a given field and could constitute the background for future research and development [ 7 ]. However, scientometric analysis of musculoskeletal rehabilitation is rare. A literature search failed to reveal any study with top cited articles on musculoskeletal rehabilitation. Hence, this study was designed to delineate the 100-most cited articles published on musculoskeletal rehabilitation.

This study analyzed the top 100-cited articles in musculoskeletal rehabilitation. Since there was no use of human subjects, this study was exempt from the institutional review board approval. A single author independently conducted the search and identification of articles.

The literature search took place on February 24, 2021 and made use of Scopus for acquisition of all possible publications related with musculoskeletal rehabilitation. Scopus is the largest abstract and citation database of peer-reviewed literature, delivering a comprehensive overview of the world's research output in the different fields of science and technology. It features smart tools to track, analyze and visualize research while allowing the researcher to search both forward and backward in time. The database is updated on a daily basis and comprises of 27 million abstracts with citations dating back to the year 1966. [ 8 ]

The final Boolean search phrases were: [(musculoskeletal) AND (rehabilitation) AND (musculoskeletal rehabilitation)]. Only articles in the English language from 1970 onwards were included. No journal or country of origin restrictions were placed on this search. This resulted in 11,097 total articles (Fig.  1 ). The search list was organized in such a way that articles were arranged in descending order based on the number of citations. The title and abstract of each article were then reviewed to determine its relevance to musculoskeletal rehabilitation. A publication was considered for inclusion only when it focused on a facet of musculoskeletal rehabilitation as the primary objective (Fig.  1 ). Subsequently, complete manuscripts of the selected publications were reviewed before including them in the study.

Flow diagram illustrating the selection process of the top 100 most-cited articles

In addition to the number of citations, the following data were extracted: title, topic of discussion, subdivision of science, where the study was conducted (in case of collaboration between multiple departments, department of corresponding author was chosen), study design (systematic review, original article, randomized controlled trial/RCT, observational study, clinical trial, comparative study, research report, conference paper, clinical commentary, clinical opinion), journal and its impact factor, year of publication, and country, where the study was conducted. If an article had multiple institutions and country affiliations, the corresponding author information was taken as primary affiliation. Data in this study is presented as descriptive statistics.

The final list of the top 100 most-cited articles on musculoskeletal rehabilitation along with their citations is illustrated in Table ​ Table1. 1 . In addition, the distribution of articles according to their study type/design along-with the citations in each study design is illustrated in Fig.  2 . The most commonly observed study designs were systematic reviews ( n  = 40; 40%), RCTs ( n  = 14; 14%), original articles ( n  = 13; 13%), observational studies ( n  = 11; 11%) and clinical trials ( n  = 9; 9%). Other less commonly included study designs were comparative studies ( n  = 6; 6%), research reports ( n  = 3; 3%), conference papers ( n  = 2; 2%), clinical commentary ( n  = 1; 1%) and clinical opinion ( n  = 1; 1%). For these 100 studies, the total number of citations was calculated to be 24,366, with an average of 243.66 citations per paper. The most frequently cited article was “A new clinical model for the treatment of low-back pain” by Waddell G with 1052 citations and was awarded “Volvo award in clinical sciences” in the year 1987. The second- and third-most cited articles were cited 1022 and 683 times, respectively. There existed a wide range between the most cited ( n  = 1052) and the least cited article ( n  = 132).

Top 100 most-cited articles in musculoskeletal rehabilitation

Distribution of the top 100 most-cited articles according to the study type along-with number of citations in each study type

Across these 100 most-cited studies included in the analysis, maximum citations occurred in the publication years 2000–2009 (61 articles with 14,275 citations) followed by publication years 1980–1989 (15 articles with 4549 citations) (Fig.  3 ). On further analysis of total number of citations with respect to the number of articles, highest mean was observed for the publication years 1980–1989 (303.27) followed by publication years 2010–2019 (241.75) and publication years 2000–2009 (234.02), respectively. For the 100 included studies, the earliest year of publication was 1973 and the latest was 2015. Of these studies, 69 studies were published after the year 2000; however, most studies with the greatest number of lifetime citations were published during 2000–2009 ( n  = 61).

Distribution of the top 100 most-cited articles over 10-year intervals along-with number of citations in each time interval

In addition to analyzing the articles by total number of citations, they were also analyzed by the citation density or the number of citations divided by the number of years since publication (Table ​ (Table1). 1 ). The top 3 articles by citation density can be attributed to Horak FB/rank 2 (68.13 citations/year), Ma VY et al./rank 9 (58.71 citations/year) and Liu CJ et al./rank3 (56.92 citations/year). The article with the lowest citation density was attributed to Eriksson E/rank 68 with 3.76 citations/year. These top 100 cited articles were published in a variety of American and European journals with an impact factor ranging from 0.724 to 74.699 (Table ​ (Table2). 2 ). Of these journals, Archives of Physical Medicine and Rehabilitation was the most represented with 15 articles followed by Spine and Sports Medicine with 7 articles each.

Journals in which top 100 most-cited articles were published

a Relaunched in 2017 as Musculoskeletal Science and Practice

b Impact factor as of 2018

The 100 most-cited musculoskeletal rehabilitation articles originated from 13 different countries of the North American and European region (Fig.  4 ) with United States contributing maximum number of articles ( n  = 45) followed by Canada ( n  = 10) and Australia ( n  = 8). In these 100 most-cited articles the number of authors per article varied from a single author to ten with a mean of 3.97. Twelve of these publications had a single author; forty publications had ≥ 5 authors and only one publication ( “ Control strategies for active lower extremity prosthetics and orthotics: a review ” by Tucker MR et al./rank 19) had ten authors. Eighty-two of these publications had the same author as the first and corresponding author.

Number of top 100 most-cited articles related to musculoskeletal rehabilitation by the country of origin

Across these top 100 most-cited articles, three most popular areas of clinical science involved with research in musculoskeletal rehabilitation were Physical Medicine and Rehabilitation ( n  = 29), Physical Therapy ( n  = 18) and Orthopaedics ( n  = 12) (Table ​ (Table3). 3 ). The major topic of interest in the top 100 most-cited articles was strength training ( n  = 22) followed by gait analysis ( n  = 11) and musculoskeletal pain ( n  = 10) (Table ​ (Table4 4 ).

Most popular domains/fields ranked by number of articles

Most popular topics ranked by number of articles

This review article helps to identify the top 100 most-cited articles of musculoskeletal rehabilitation over the last 5 decades. Bibliometric analysis helps to measure the impact of a paper by quantifying the frequency of citations and also highlights contribution of that article in the evolution of a topic [ 9 ]. Assessing the significance which an individual article makes within its area of expertise is quite challenging, but the total number of citations accumulated by a paper can definitely be used as a benchmark of its impact [ 10 ]. In this study, highest citation was reported by a paper on treatment of low back pain by Waddell G (“ A new clinical model for the treatment of low-back pain ”;1052 citations) which was published in the year 1987 in the journal Spine . This paper was also awarded with “Volvo award in clinical sciences” in the year 1987. In it, Waddell G expressed his apprehension with regards to low-back disability and attempted to construct a new theoretic framework for treatment. He stressed upon the role of active rehabilitation as compared to bed rest for the treatment of low back pain and advocated for robust controlled trials to determine the treatment protocols for various types of low-back pain. [ 11 ] Maximum citations accumulated by this article could be attributed to the fact that low back pain still continues to be an enigma for clinicians worldwide, besides being a main contributor to the burden of musculoskeletal conditions and a predominant reason for premature exit from workforce [ 2 ]. Similar conclusions could also be drawn from the work of Hartvigsen J which predicts an increase in the number of people with low back pain in the future, and even more rapid increase of low-back disability in low-income and middle-income countries [ 12 ]. Notably, the large number of years since its publication and the fact that it was published in a peer-reviewed, internationally recognized journal ( Spine) could have also made a significant contribution towards its citations.

The reasons for citing a paper continue to be multifactorial and are as diverse as geographic location of authors, direction of results or conclusions among other factors [ 13 , 14 ]. It is noteworthy that sometimes refutation and controversy around a paper might also contribute to its higher number of citations [ 15 ]. Another study has suggested use of citation density as a proxy measure to assess the impact made by an article [ 16 ]. On application of citation density in our study, interesting details were noticed as the article with highest citation density was ranked 2 nd with 1022 citations and a citation density of 68.13 citations/year, whereas the article ranked 1 st in the list had 1052 citations but a citation density of only 30.94 citations/year. Similarly, article with the second highest citation density (58.91 citations/year) was ranked at 9th position. It further reinforces the belief that more definitive measures need to be devised for measuring scientific relevance of a publication.

This cross-sectional analysis of top 100 citation classics demonstrated that more than half of the articles ( n  = 61) were published during 2000–2009, suggesting it as the most productive decade in the history of musculoskeletal rehabilitation. On comparing the articles published before and after the year 2000, it was evident that scientific research in the field of musculoskeletal rehabilitation has significantly accelerated in the last two decades with 69 articles from the list being published post 2000. In addition, contrary to the common perception that earlier published articles have an advantage at generating more citations, only two articles published before the year 2000 could feature among the top 10 articles in this list. One of those two articles was the article ranked first (“ A new clinical model for the treatment of low-back pain ” by Waddell G) which was published in 1987 and the other article was ranked tenth ( “ Walking to health ” by Morris JN) with publication in 1997. The higher number of impactful publications post year 2000 could be attributed to the extensive use of technology and interventions in the field of musculoskeletal rehabilitation over the last two decades. In addition, the integration of social media platforms with clinical research by clinicians could have also attributed to more citations, for articles published post year 2000. [ 17 ]

The study designs commonly noticed in this list of 100 most-cited articles were review studies ( n  = 40, total = 11,161 citations with an average of 279.03 citations/paper) followed by RCT ( n  = 14, total = 3025 citations with an average of 216.07 citations/paper) followed by original articles ( n  = 13, total = 3171 citations with an average of 243.92 citations/paper). Review studies (traditional narrative reviews or systematic reviews) address a well-defined clinical question while making use of an explicit strategy for locating relevant evidence and evaluates the retrieved studies using prospectively defined methodologic criteria along-with synthesis of results [ 18 – 20 ]. They are deemed to be of undeniable importance to clinicians as they provide unbiased summaries of knowledge of a topic [ 21 ]. Similarly, RCTs are the benchmark of evidence-based medicine and form the basis for translating research data into clinical practice. [ 22 ] The high proportion of review articles in this list suggests that review studies command more attention with regards to the impact they have on scientific progress. Similarly, several other empirical studies have also documented high citation rate of review studies while acknowledging the fact that systematic reviews and meta-analyses performed with rigorous scientific methods get more citations than non-systematic reviews [ 23 ].

Despite the compilation of list of top-100 citation classics from 44 journals, almost half of these articles were concentrated in 7 journals. These journals were Archives of Physical Medicine and Rehabilitation ( n  = 15) , Spine ( n  = 7), Sports Medicine ( n  = 7), American Journal of Sports Medicine ( n  = 6), Clinical Biomechanics ( n  = 6), Manual Therapy ( n  = 4) and Journal of Biomechanics ( n  = 4). All of these journals are leading journals in their respective fields of Physical Medicine and Rehabilitation, Spine, Sports Medicine, Orthopaedics, Biomechanics and Manual therapy. These all are international, peer-reviewed journals with monthly publications except for Spine which has a bi-weekly publication. All these factors play a pivotal role in increasing the accessibility of their publications versus those from other journals which publish less frequently, thereby, contributing to their higher number of frequently cited articles. These findings are in tandem with Bradford’s law which states that the concentration of scientific information is skewed to a handful of journals who publish greater number of articles and these articles end up receiving maximum citations [ 23 ]. When few journals cover most of the influential literature irrespective of the total number of journals circulating in that particular field, it tends to produce a strong tendency for centralization of the key literature. The existing high-quality, highly competitive multidisciplinary journals mentioned above also contribute to this concept of centralization and could explain the concentration of almost half of the articles from the final list in only seven journals. Callahan M et al. also reported that the journal of a publication is its most important factor in receiving citations—even more important than its content and quality, which are also pivotal for predicting future citation impact [ 24 ].

Most of the articles in this analysis were contributed by United States ( n  = 45) which corroborates with literature search in other disciplines [ 25 – 27 ]. It could be attributed to the fact that United States has a large scientific community comprising of more than 400 university hospitals [ 26 ]. Further, in another study, authors argued that United States tends to be at the forefront of research owing to its large population base and huge financial resources available to the scientific community [ 28 ]. Another interesting pattern noticed among the countries featured in this list was that all have developed economies and rank near the top in health care expenditures. Similar findings were observed by Rahman and Fukui who stated that biomedical research productivity worldwide is directly proportional to their per capita gross national product and the expenditure allotted for research and development in each country [ 29 ].

This article also attempts to identify the most popular topics in the field of musculoskeletal rehabilitation which have made the most impact over the last five decades. Through this bibliometric analysis, it was observed that the articles in the final list were centered around “strength training” followed by “gait analysis” and “musculoskeletal pain”. Maximum interest was focused on strength training which mirrors the changing perception regarding importance of exercising in treatment of musculoskeletal conditions. Similar conclusions have been reported by Suchomel et al. [ 30 ] who concluded that greater muscle strength not only reduces risk of future injury but also allows an individual to recover earlier; Kitsuda et al. [ 31 ] who suggested that high load resistance training could be instrumental in increasing BMD in patients with osteoporosis and osteopenia; Furtado et al. [ 32 ] who concluded that exercises improve functional-fitness performance, decrease feelings of stress and induce clinically relevant hormonal and immune responses. The next important topics identified were gait analysis followed by musculoskeletal pain. Co-ordinated and efficient gait has been proven to be of utmost significance in the field of rehabilitation and similar views have been echoed by Blumen et al. [ 33 ] who stressed upon the association between poor gait and disability, falls, increased morbidity, and mortality; LeBrasseur [ 34 ] who described the association of gait disturbances with a multitude of health-related events.

This article also tries to focus on the fields involved with research on musculoskeletal rehabilitation. There was relatively higher contribution observed from clinical sciences with PM&R at the forefront followed by department of Physical therapy and Orthopaedics. Nevertheless, the contribution made by applied sciences was also noteworthy, further stressing upon the importance of integration of clinical science with technological advances in the field of engineering for continuous improvisation in the health services. Wu et al. [ 35 ] also shares similar views that while clinical science helps in formalizing and testing innovations, it is engineering which customizes and optimizes how that innovation would be applied while tailoring to accommodate local conditions and these two domains together have the potential to accelerate the creation of an evidence-based healthcare system that would work effectively in specific health care settings.

Study Limitations

This study used only one search engine for the bibliometric analysis and could not identify studies not included in Scopus, hence articles and otherwise published research, could not be identified. This study might have missed recent milestones in the field of musculoskeletal rehabilitation as citations usually accumulate over time and this particular method of assessment by citation classics tends to underestimate recently published articles irrespective of their true impact. The author also believes that the inability to incorporate other objective tools such as H-index, local citation score and global citation score limit the external and internal validity of this study.

This is the first study to discuss the top 100 most-cited articles in the field of musculoskeletal rehabilitation. Although the articles in the final list span over 5 decades, yet they continue to provide substantial clinical relevance to future researchers while forming an integral part of the foundation for subsequent publications. Furthermore, it would be prudent to state that though the number of citations is a valid and legitimate indicator for clinical relevance of a publication, it is by no means an absolute measure. This study points out that the absolute number of citations might not be a true reflection of the scientific importance of published medical literature and further studies delineating their correlation with citation density, H-index or local and global citation score should be undertaken. However, while other complementary measures of impact clearly are being developed, citations revel in wide acceptance despite criticisms [ 19 ].

Abbreviations

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations

On behalf of all authors, the corresponding author states that there is no conflict of interest.

This article does not contain any studies with human or animal subjects performed by the any of the authors.

For this type of study, informed consent is not required.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

100+ Research Topics for Physiotherapy Students in 2022

Team Desklib

Published: 2022-08-18

The physiotherapy profession has addressed the significance of teaching students the fundamentals and applications of research through its published educational accreditation criteria and normative model of professional education.

The goal of Research Topics for Physiotherapy Students  is to conduct a long-term study of students in relation to their perception of research knowledge, perception of the best source to use when making clinical decisions, and their perception of the best tools to use when managing patients in a clinical setting.

How Physiotherapy Students can Choose Manageable Research Topics?

Discover what is already known about your issue and what unanswered research questions exist after reviewing it. The most recent literature will likely be the source of your research question.

What details and research remain on your problem? Which publications you discovered have you had "implications for future research"? Research Topics for Physiotherapy  Students  can take many different forms. Let's go through these topics one by one -

Top 25 Interesting Physiotherapy Research Topics

• Knee osteoarthritis can be treated with quadriceps workouts and Kinesio taping.
• Knee osteoarthritis can be treated with ultrasound therapy and knee joint mobilization.
• Effectiveness of resistance training and therapeutic ultrasonography in rheumatoid arthritis.
• Effect of nerve mobilization and gliding procedures in carpal tunnel syndrome.
• Contrasting the effects of conventional physical therapy methods with phonophoresis in osteoarthritis.
• Shoulder exercises for people who have had CABG.
• Effects of strengthening exercises and Kinesio taping for diastasis recti in postpartum women.
• Techniques for mobilization and hold relaxation for limited knee range of motion.
• Exercises that increase strength and use an alternating current to treat knee osteoarthritis
• Exercises that build muscle are used to treat shoulder pain in diabetics.
• Effectiveness of strengthening exercises and interferential current in the treatment of cervical discomfort.
• Effect of Kinesio taping and therapeutic ultrasonography on knee injuries.
• A randomized control experiment evaluating the effectiveness of Kinesio taping in treating shoulder discomfort.
• Contrasting the results of therapeutic ultrasound and dry needling for the relief of trapezius trigger points.
• Exercise's effects on a premenopausal woman's bone health.
• Effects of strengthening exercises and lumbar traction on chronic radicular lumbar back pain
• Exercises for strengthening and cervical traction for persistent neck discomfort
• A randomized control experiment using dry needling for cervical discomfort.
• A randomized control experiment evaluating the effectiveness of cervical mobilization in migraine.
• A randomized control experiment evaluating the effectiveness of stretching activities for treating low back pain.  
• Exercises for strengthening help with neck pain.
• Effects of pelvic floor exercises and therapeutic ultrasonography on the relief of persistent pelvic pain
• In an ankle injury, therapeutic ultrasound and Kinesio taping are used.
• Computer users' neck pain can be reduced using therapeutic ultrasound and trigger point release.
• Trigger point release helps female patients with lumbar back discomfort.

Top 25 Physiotherapy Research Topics for College Students

• Effect of trigger point release and therapeutic ultrasonography on the relief of neck discomfort in university students.
• An RCT looked at the impact of lumbar traction on calf muscle soreness.
• Impact of trigger point release in treating student thoracic back discomfort.
• Therapeutic ultrasonography with trigger point release for the treatment of persistent pelvic pain.
• Therapeutic ultrasound and trigger point release for piriformis muscle discomfort.
• Trigger point release's effects on reducing biceps discomfort.
• Scapular mobilization for shoulder pain relief.
• The effectiveness of therapeutic ultrasound and quadriceps muscle trigger point release in reducing knee pain
• Trigger point release and therapeutic ultrasound's effects on calf muscle discomfort.
• Effects of therapeutic ultrasound and trigger point release on treating tennis elbow discomfort.
• Effects of therapeutic ultrasound and trigger point release on golfer's elbow pain.
• Randomized controlled trial contrasting the benefits of therapeutic ultrasound and shock wave on heel spur pain.
• Impact of trigger point release and therapeutic ultrasound on reduction of SI joint discomfort.
• The effectiveness of cervical neck mobilization and therapeutic ultrasonography.
• Effect of mobilization in experiencing dizziness again.
• The ability of therapeutic ultrasonography to ease knee pain
• Techniques for easing shoulder discomfort
• Mobilization and therapeutic ultrasound for postpartum women with carpal tunnel syndrome.
• Comparison of the effects of shock wave therapy versus the standard physiotherapy routine for treating fibromyalgia.
• Contrasting the effects of transcutaneous electrical nerve stimulation and interferential current for the treatment of chronic low back pain.
• Effectiveness of prenatal exercise program for sacroiliac joint treatment
• Interferential current in a randomized controlled trial for the treatment of rotator cuff muscle rupture pain.
• Contrasting the effects of transcutaneous electrical nerve stimulation and interferential current for the treatment of neck discomfort.
• The effectiveness of therapeutic ultrasound and mobilization in easing wrist discomfort.
• Therapeutic ultrasound's effect on reducing lumbar back pain.

Top 25 Current Physiotherapy Research Topics 

University students who suffer from thoracic back discomfort can benefit from therapeutic ultrasound treatments.

• Impact of therapeutic ultrasound and mobilization in easing pain in the SI joint.
• Contrasting the effects of conventional physiotherapy and shock wave therapy on cervical discomfort.
• Effects of conventional physical therapy and shock wave therapy for plantar fasciitis.
• Shock wave therapy and conventional physical therapy methods are used to treat lateral epicondylitis.
• Medical epicondylitis treatment procedure using physiotherapy.
• Contrasting the results of standard physiotherapy and shock wave therapy.
• Contrasting the effects of shock wave therapy and conventional physical therapy methods for treating trapezius trigger points
• Protocol used in conventional physical therapy to address low back pain.
• Treatment plan for piriformis syndrome.
• Contrasting the effects of shock wave therapy and conventional physical therapy methods for treating shoulder discomfort
• For the treatment of knee osteoarthritis, interferential current and transcutaneous electrical nerve stimulation is used.
• Interferential current in a randomized controlled trial for the treatment of pain following complete hip replacement.
• Comparative analysis For the treatment of bicep muscle pain, interferential current effects and transcutaneous electrical nerve stimulation are used.
• Effects of phonophoresis on bicipital tendinitis in a randomized controlled experiment.
• A randomized control experiment on the effects of phonophoresis for De Quervain's tenosynovitis.
• Effects of phonophoresis for the treatment of Achilles tendinitis in a randomized controlled experiment.
• A randomized control experiment evaluating the effects of phonophoresis for the treatment of lateral epicondylitis.
• Using transcutaneous electrical nerve stimulation, carpal tunnel syndrome can be treated.
• Interferential current under controlled study to treat pain following a shoulder replacement.
• Contrasting the effects of transcutaneous electrical nerve stimulation and interferential current for the treatment of piriformis syndrome.
• A trial-based investigation of phonophoresis's effects in the treatment of coccydynia.
• A Randomized Controlled Trial using the interferential current to treat meniscal tear pain
• Contrasting the effects of transcutaneous electrical nerve stimulation and interferential current for the treatment of lumbar back muscle spasm.
• Exercises that improve posture and build muscle are used to treat acute occupational neck pain.

Some Advance Physiotherapy Research Topics 

• A randomised control experiment evaluating the effectiveness of shortwave diathermy in treating knee osteoarthritis.
• A randomized control trial of manual therapy for treating vertigo.
• Kinesiotaping is used to treat persistent low back pain.
• Manual therapy's effects on the treatment of SI joint pain in postpartum women
• Low back pain management with infrared therapy.
• A controlled trial evaluating the effectiveness of short-wave diathermy with infrared therapy for the treatment of chronic low back pain.
• Exercises for stretching and strengthening to address forward head position.
• Kinesiotaping for female population bladder issues
• Kinesiotaping's effectiveness in treating patellofemoral pain syndrome.
• Results of a randomized control experiment on the effects of shock wave therapy for migraine management.
• A comparison of the effects of transcutaneous electrical nerve stimulation with the interferential current for the treatment of shoulder pain.
• Phonophoresis for the treatment of osteoarthritis of the knee: a randomized control trial study.
• Prenatal exercise program's effectiveness in treating neck and shoulder discomfort
• Contrasting the results of transcutaneous electrical nerve stimulation with the interferential current.
• An analysis of the effectiveness of a prenatal exercise program for the treatment of low back pain.
• Competitive research on the effects of transcutaneous electrical nerve stimulation and interferential current for the treatment of lateral epicondylitis.
• Effects of phonophoresis for the treatment of neck pain: a randomized control experiment.
• For the treatment of medial epicondylitis, transcutaneous electrical nerve stimulation is used, and the effects of interferential current are compared.
• A comparison of the effects of transcutaneous electrical nerve stimulation with the interferential current for the treatment of persistent pelvic pain.
• A randomized control experiment evaluating the effects of phonophoresis on the treatment of SI joint discomfort.
• Contrasting the effects of transcutaneous electrical nerve stimulation and interferential current for the treatment of sacroiliac joint pain.
• Interferential current in a randomized controlled trial for the treatment of pain following total knee replacement.
• Exercises to strengthen the core and correct posture are used to address acute occupational low back pain.
• Frozen shoulder treatment with transcutaneous electrical nerve stimulation and a comparative investigation of the effects of interferential current.
• A Study at an Indian Primary School on Inclusive Education Environments from the Teachers' Perspective.
• Learning methodologies and their relationship to self-study time are compared between students in a lecture-based curriculum and those who use problem-based learning.

Conclusion -

In this descriptive study of professional physiotherapy students, we sought to evaluate the students' self-reported feelings of comfort and confidence in reading and apply research findings published in the literature, their personal reading habits, and their general beliefs about the value of research to their professional careers and of basing clinical practise on research findings.

Research Topics for Physiotherapy Students show that although there were noticeable improvements by the program's conclusion, attitudes about research have not changed permanently in areas like individual motivation for participation in research and the importance that physical therapists accord to research.

Further Readings - 

• 120 Hot Research Topics for Nursing Students
• Top 50+ Research Topics for High School Students in 2022
• A Thorough Analysis of Market Research
• Research for Psychology and Personality Disorder
• Mental Health Research Topics for Students in 2022
• 4 Tips on How to Find Homework Answers Quickly
• How to Write Different Types of Research Paper ?
• Desklib: Designed to solve plagiarism issues
• 10 Tips to Motivate with Desklib Homework Help  

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Advances in Imaging of Microenvironment in Oncological and Non-oncological Disease by Nuclear Medicine

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About this Research Topic

The cellular microenvironment refers to the immediate surroundings of a cell. Its physical (temperature, pH, oxygen concentration, and mechanical forces), chemical (nutrients, growth factors, signalling molecules, and waste products), and biological components (neighbouring cells, extracellular matrix, and the immune system) interplay in determining and regulating cellular behaviour and functions. It is well-known the pivotal role of the microenvironment in both oncological and non-oncological diseases. Thus, neoangiogenesis represents the prominent phenomenon of pathological microenvironment, aimed at promoting tumoral overgrowth. The possibility of understanding the microenvironment, i.e., distinguishing from pathological to healthy ones, is essential in the era of personalized medicine. Many targets are successfully exploited in recent years, e.g. FAP, VEGF, and PSMA, for imaging and therapy purposes, paving the way for a new chapter of personalized medicine, i.e., theragnostic approach. The scope of this section is to provide an overview of advanced tools for imaging the pathological microenvironment by nuclear medicine. The following contributions will have high priority: • Tracer development and new radiochemistry for developing imaging tools. • Preclinical studies aimed to introduce feasible animal models aimed to display novel molecular pathological processes by targeting the microenvironment as the basis for human application. • Translational studies from pre-clinical/in vitro to in vivo application in diagnostic/therapeutic/theragnostics field. • Clinical research studies about novel or existing radiopharmaceuticals targeting the microenvironment to improve the management of patients.

Keywords : Imaging, Nuclear Medicine, Oncology, Microenvironment, Theragnostics, Radiopharmaceuticals

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To lead you have to work within the rules.

2 Netflix Shows With Spot-On Mental Health Representation

Mark Travers Ph.D. on May 26, 2024 in Social Instincts

These two must-see Netflix shows brilliantly portray psychological concepts.

The Future of Sex

Marianne Brandon Ph.D. on May 26, 2024 in The Future of Intimacy

Adolescents and the more vulnerable among us may need help in metabolizing increasingly potent and accessible artificial lovers.

• Positive Psychology

Why Disagreement Is a Stubborn Enemy of Listening

Guy Itzchakov Ph.D. on May 26, 2024 in The Listening Lens

A family dinner argument left me frustrated yet reflective. Discover how improving our listening skills can make our disagreements more constructive, and strengthen relationships.

Why Personal Growth Is Not Selfish

Stephen Joseph Ph.D. on May 26, 2024 in What Doesn't Kill Us

By making ourselves matter, we are making others matter.

Neurodiversity

Neurodiversity on campus: are colleges affirming.

Jennifer Gerlach LCSW on May 26, 2024 in Beyond Mental Health

Neurodiversity has become a buzzword on college campuses as more and more students and faculty identify as neurodivergent. How are colleges meeting this need?

“Be Strong!”: What Not to Say to a Grieving Person

Tamara Goldsby Ph.D. on May 26, 2024 in Less Stress, More Peace

You don’t need to “Be Strong” when you’re grieving but reach out to others for support. If the grief gets too much, consider talking to a counselor.

Do Doctors and Patients Understand Uncertainty in the Same Way?

Sara Gorman, Ph.D., MPH, and Jack M. Gorman, MD on May 26, 2024 in Denying to the Grave

Do frank conversations between healthcare professionals and patients about medical uncertainty improve trust? There's still a lot we don't know.

What Can We Do to Improve Concert Goers’ Experience?

Lu Wang Ph.D. on May 25, 2024 in Music Is Number in Space

Can new technology help classical music appeal to a broad contemporary audience?

Artificial Intelligence

The shift from analog to digital to cognitive.

John Nosta on May 25, 2024 in The Digital Self

As AI and LLMs usher in The Cognitive Age, humanity faces an existential question: will our own cognition become obsolete, or will we evolve alongside our digital partners?

Why We Like Cryptic Word Puzzles

Marcel Danesi Ph.D. on May 25, 2024 in Brain Workout

The clues used for creating cryptic crosswords constitute in themselves a genre of word puzzles. Solving these invariably produces a sense of pleasure that is exceptional.

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• Self Tests NEW
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• Types of Therapy

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience