DOCUMENT 17

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Manual therapy to address neuromusculoskeletal function

The content of this document is OFFICIAL.

Please note:

The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research questions:

Is manual therapy delivered by AHPRA recognised professionals effective in improving functional outcomes for people presenting with neuromusculoskeletal symptoms?

Date: 08/08/2023

Requestor: Karyn redacted: s47F - personal privacy

Endorsed by: n/a

Researcher: Aaron redacted: s47F - personal privacy

Cleared by: Stephanie redacted: s47F - personal privacy

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1. Contents

Manual therapy to address neuromusculoskeletal function……………………………………………….. 1

1. Contents ……………………………………………………………………………………………………….. 2

2. Summary ………………………………………………………………………………………………………. 2

3. Scope and terminology ……………………………………………………………………………………. 3

4. Efficacy of manual therapy ……………………………………………………………………………….. 5

4.1  Pain .................................................................................................................          6

4.2   Functional outcomes.................................................................................................. 7

5. Clinical practice guidelines ……………………………………………………………………………….. 7

5.1  Simultaneous active exercise .................................................................................... 8

5.2   Functional outcomes.................................................................................................. 8

6. References ………………………………………………………………………………………………….. 9

2. Summary

This paper addresses the efficacy of manual therapy delivered by physiotherapists, chiropractors and osteopaths on functional outcomes for people experiencing neuromusculoskeletal symptoms.

Manual therapy comprises a variety of hands-on techniques primarily aimed to reduce pain and discomfort or improve range of motion in people with musculoskeletal disorders. It can be delivered by a variety of medical and allied health professionals or associated providers (Manual Therapy). Manual therapy may also address functional difficulties including impairment, activity limitation or participation restrictions for people experiencing neuromusculoskeletal symptoms (Functional outcome). Neuromusculoskeletal symptoms are associated with diseases, conditions or disorders of the neuromuscular system or the musculoskeletal system and can include discomfort, pain, paralysis or other loss of function (Neuromusculoskeletal symptoms).

There is evidence suggesting manual therapy can be effective at managing pain and discomfort and improving physical functioning for people with musculoskeletal-related pain conditions, especially low back pain and neck pain. Minimal evidence exists related to improvements in function for people with non-pain related conditions. While some evidence points to improvements in quality of life, most functional outcomes relate to improving range of motion or mobility. No evidence was found that manual therapy leads to a reduction in other activity limitations or participation restrictions.

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Due the wide scope of practice of manual therapy, research papers pooling results can make it difficult to identify individual trends. Many therapeutic techniques utilise mixed modalities, so it is difficult to determine whether one or all of the modalities taken together are producing an effect. In addition, the current literature is largely of low or very low quality with significant risk of bias. Refer to 4. Efficacy of manual therapy for further details.

Despite the number of existing studies, the quality of the literature has prevented many clinical practice guidelines from offering strong endorsement of manual therapy techniques. Clinical practice guidelines generally offer conditional acceptance of manual therapy. Stronger evidence exists for the benefits of short-term manual therapy, with less evidence that it is efficacious as a long-term management strategy. Further, evidence suggests manual therapy is most optimally delivered alongside active exercise treatment. However, there is also some suggestion that manual therapy, as a form of passive exercise, may be offered as an alternative to patients who are unable to engage in an active exercise program. Refer to 5. Clinical practice guidelines for further details.

Other TAB research

For further examination of the evidence-base for chiropractic, refer to RES 264 Efficacy of chiropractic treatment. RES 316 Melillo Method describes chiropractic-related method aimed to address neurodevelopmental conditions.

RES 276 Sensory based therapy contains discussion of some evidence that massage may target behaviours of concern. RES 191 Massage Therapy as a Treatment for Multiple Sclerosis provides a literature review of massage therapy for use in that cohort.

General information on physiotherapy interventions for various conditions can be found in RES 203 Therapy Best Practice.

Acupuncture is sometimes referred to as a manual therapy. For a consideration of acupuncture refer to:

• RES 190 Acupuncture as a treatment for Mitochondrial Encephalopathy Lactic Acidosis Stroke-like Episodes
• RES 175 Treatment of Chronic Migraine
• RES 211 Therapy Programs for Lupus.

3. Scope and terminology

The efficacy of manual therapy delivered by physiotherapists, chiropractors and osteopaths on functional outcomes for people experiencing neuromusculoskeletal symptoms is explored through discussion of clinical practice guidelines and systematic reviews of manual therapy interventions.

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Neuromusculoskeletal symptoms

Neuromusculoskeletal symptoms are associated with diseases, conditions or disorders of the neuromuscular system or the musculoskeletal system and can include discomfort, pain, paralysis or other loss of function.

Conditions leading to neuromusculoskeletal symptoms can include:

• pain conditions such as chronic back or neck pain, arthritis, fibromyalgia or headache disorders
• significant injury such as spinal cord injury, stroke or traumatic brain injury
• neurological conditions such as Parkinson’s disease, cerebral palsy, or multiple sclerosis (World Health Organisation, 2023a; Wang et al, 2022; Briggs et al, 2018).

Manual therapy

Manual therapy refers to a variety of hands-on physical therapy techniques. The aim is usually to reduce pain, swelling and inflammation, induce relaxation or improve joint range of motion and muscle flexibility. Manual therapy can involve soft tissue techniques, manipulation or mobilisation (NICE, 2021; Young and Argaez, 2020), though the distinctions between these practices may break down in some cases (NICE, 2021b).

Soft tissue techniques target muscles, tendons, or ligaments. This can include massage, muscle energy technique, strain/counterstrain and myofascial/trigger point release (NICE, 2021; Locher & Beyer, 2021; Franke et al, 2015).

Manipulation and mobilisation target joints. Manipulation is the application of force to affect short, quick movements near the end of or beyond the normal range of a joint (LaPelusa & Bordoni, 2023; NICE, 2021). In contrast, mobilisation is often defined as application of force leading to longer, slower movements of target joints (NICE, 2021; Gross et al, 2015). Mobilisation is also sometimes used to refer to the movement of joints regardless of amplitude or velocity (Krøll et al, 2021).

These are often thought of as passive techniques because the therapist or practitioner moves the tissue, joint or limb while client is relaxed. They are distinguished from active techniques such as exercise programs (Ganderton & King, 2020; Canadian Agency for Drugs and Technologies in Health (CADTH), 2016). However, this distinction is challenged by some researchers and clinicians who point out that some manual therapy techniques require the client’s active participation, such as pushing back or tensing in response to the practitioner’s movements (Physio Network, 2021).

Manual therapy techniques are commonly used by physiotherapists, chiropractors, osteopaths and massage therapists (NICE, 2021; Franke et al, 2015; Gross et al, 2015) but may also be used by:

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• other allied health professionals such as occupational therapists or exercise physiologists
• medical professionals such as general practitioners, physiatrists, osteopathic doctors (in the USA)
• traditional or alternative medicine practitioners uses practices such as myotherapy, Chinese medicine, acupuncture/acupressure, or the Melillo Method
• others such as personal trainers and coaches (Locher & Beyer, 2021; Canadian Agency for Drugs and Technologies in Health, 2016).

This paper will focus on manual therapy as it is employed by allied health professionals regulated by AHPRA including physiotherapists, chiropractors, and osteopaths.

Functional outcome

A functional outcome generally contrasts with a clinical outcome. This distinction aims to highlight the differences between an intervention having some observable effect on bodily systems and an intervention improving a person’s functioning. However, the distinction is not often clearly drawn and may be used differently in different contexts. For example, reduction in pain is a common clinical outcome though it may have significant functional implications. Pain may even count as an impairment in cases of chronic or neuropathic pain (Health Direct, 2022; Young and Argaez, 2020; Franke et al, 2015; Gross et al, 2015).

The World Health Organisation’s (WHO) International Classification of Functioning, Disability and Health (ICF) distinguishes three levels of functioning: of bodily systems and structures; of the whole person; of the whole person in their social context. Interruptions to functioning can occur at either level and are referred to as impairments, activity limitations and participation restrictions respectively (WHO, 2023b).

The National Disability Insurance Scheme Act 2013 and the National Disability Insurance Scheme (Supports for Participants) Rules 2016 signals the NDIA’s focus on activity limitations and participation restrictions (e.g. NDIS Act, s24; NDIS Rules, s5.8). Where possible, this paper will focus on whether an intervention is able to achieve functional outcomes as measured by a reduction in activity limitations or participation restrictions in domains including communication, social interaction, learning, mobility, self‑care, self‑management (NDIS Act, s24.1(c)). However, where this information is not available, this paper will examine pain or functional outcomes in reducing impairment of bodily systems or structures.

4. Efficacy of manual therapy

Most evidence regarding the efficacy of manual therapies relates to the treatment of pain conditions. Generally, where evidence of improvement in function exists, it is also for pain conditions. However, according to a recent systematic review, the evidence is equivocal:

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In most cases, treatment with manual therapy did not result in statistically significant differences when compared to sham therapy or no treatment in adults with persistent or chronic non-cancer back and neck pain; however, there was some evidence that suggested treatment with manual therapies improved pain, functional status, and health-related quality of life (Young and Argaez et al, 2020, p.4).

An evidence review informing the NICE guideline for osteoarthritis (2022a) notes:

while there were some benefits due to manual therapy this was often in outcomes that were imprecise or heterogenous with inconsistency that could not be resolved by subgroup analysis. … [There] was insufficient evidence to indicate a benefit from manual therapy alone. However, there was evidence of benefit for manual therapy when combined with exercise.

Evidence suggests manual therapy is most effective if performed as an adjunct to active exercise treatment (Runge et al, 2022; Ganderton & King, 2020).

4.1 Pain

Comparing mixed modality manual therapy with standard treatment, an evidence review informing the NICE guideline for chronic pain found low quality evidence showing no reduction in pain up to 3 months, but some reduction in pain after 3 months (NICE, 2021a). This contrasts with other reviews which find little evidence of benefit in the long term (Runge et al, 2022; Ganderton & King, 2020).

Franke et al (2015) found low quality evidence suggesting muscle energy techniques are not effective in the treatment of low back pain. Chen et al (2020) did not find evidence that myofascial release therapy reduces pain for people with lower back pain. There is some evidence that massage is an effective pain relief for people with multiple sclerosis. However, the evidence is of consistently low or critically low quality with serious risk of bias (NICE, 2022c).

Rubenstein et al (2012) found low quality evidence that spinal manipulation treatment is no more effective than sham control, and no more effective than any other therapy in the treatment of lower back pain. Gross et al (2015) found conditional support for the use of manipulation and mobilisation in the treatment of neck pain. NICE’s review of chronic pain management (2021a) found low quality evidence of reduction in pain for soft tissue techniques compared with usual care and manipulation / mobilisation compared with usual care up to 3 months. A recent narrative review (Licciardone et al, 2021) argues there is sufficient evidence for the effectiveness of osteopathic manipulative treatment (OMT) for lower back pain, citing large effect sizes comparable to some pain medications. However, the authors do not report the quality of these studies. They also note insufficient evidence for the effectiveness of OMT for any other condition. A recent review of systematic reviews of OMT found evidence of possible reduction in lower back and neck pain (Bagagiolo et al, 2022). However, all systematic reviews included in Bagagiolo et al were rated as low or critically low quality.

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4.2 Functional outcomes

Some evidence exists that manual therapy can improve the physical functioning of people experiencing acute or chronic pain conditions. Low or very low quality evidence shows mixed modality manual therapy can improve physical functioning (as measured by either 5 minute walk, sit to stand, Roland Morris Disability Questionnaire, Oswestry Disability Index, Canadian Occupational Performance Measure) compared to usual care for people with chronic pain (NICE, 2021a). Multiple sessions utilising manipulation of the cervical spine may lead to improvement in function and quality of life for people with neck pain and may be more effective than some analgesics (Gross et al, 2015). Bagagiolo et al (2022) report promising evidence that OMT improves functional status in patients with lower back pain and neck pain. However, there was notable heterogeneity due to use of different outcome measures. preventing making firm conclusions.

Runge et al (2022) determined there is evidence for improvement on some measures of physical function after manual therapy for people with hip and knee arthritis, but not for performance-based measures of function.

Very little research was found to show improvements in function after manual therapy for conditions not associated with pain. Some studies show improvements in mobility and range of motion for people with Parkinson’s disease after OMT, though the studies generally have small sample sizes and show inconsistent effects (Li et al, 2021).

5. Clinical practice guidelines

No guidelines were found that recommended manual therapy should not be offered in any circumstance. Some guidelines withhold a recommendation for or against due to lack of evidence (NICE, 2022c; 2021b; 2019a; CADTH, 2016). Most guidelines offer conditional recommendations for manual therapy, with some indicating circumstances in which manual therapy should not be offered (Lin et al, 2020; Hawk et al, 2020; Oliveira et al, 2018; CADTH, 2016). Recommendations concerning manual therapy can vary depending on:

• technique (spinal manipulation, massage, traction etc.)

• condition (chronic pain, Parkinson’s disease, cerebral palsy etc.)

• target outcome (pain, spasticity, mobility etc.)

• chronicity (e.g., acute or chronic pain)

• intended duration (short- or long-term pain management)

• effectiveness of other treatments

• simultaneous treatments (with or without active exercise) (Lin et al, 2020; Hawk et al, 2020; Oliveira et al, 2018; CADTH, 2016).

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Some clinical guidelines recommend against manual therapy in the treatment of pain in some circumstances. NICE (2020) recommend against offering traction for people with lower back pain or sciatica. Other guidelines may recommend manual therapy for acute pain but not chronic pain (Oliveira et al, 2018) or against its long-term use (CADTH, 2016).

5.1 Simultaneous active exercise

Many guidelines recommend offering manual therapy with simultaneous active exercise intervention for the management of pain. Lin et al (2020) note a consensus strongly in favour of simultaneous active exercise to treat musculoskeletal pain. This is also the NICE approach to manual therapy for lower back pain (2020) and for osteoarthritis (2022a) but not for chronic pain in general (2021b). Their guideline for people with spondyloarthritis over 16 years recommends an exercise program delivered by a specialist physiotherapist. The guideline does not clarify whether the exercises should include active, passive or a combination of modalities (NICE, 2017c). The American Academy of Orthopaedic Surgeons (AAOS) offers a limited recommendation in favour of manual therapy with simultaneous exercise for knee arthritis (AAOS, 2021).

Hawk et al (2020) report on a Delphi consensus statement of 58 Doctors of Chiropractic regarding best practice treatment for musculoskeletal pain. They recommend clinicians emphasise the importance of active exercise alongside passive manual therapy for their clients. However, Hawk et al assume manual therapy will be prescribed and suggest active exercise is also prescribed where possible. This contrasts with the consensus described in Lin et al (2020), who suggest manual therapy should only be prescribed if active exercise is also prescribed.

Recommendations in favour of simultaneous active exercise treatment should be considered in the context of clear consensus on the benefits of active exercise and maintaining physical activity for most populations (NICE, 2022a; 2022b; 2022c; 2021; 2020; 2019b; 2017a; 2017b; 2017c; 2016). For example, the NICE guideline for osteoarthritis provides a rationale for this recommendation:

The committee acknowledged recent evidence that showed some clinical benefits of manual therapy for hip and knee osteoarthritis, with no evidence being identified for other joint sites. However, the benefits were stronger if manual therapy was combined with exercise. Clinical and economic evidence showed that exercise alone was more effective than both manual therapy alone and the combination of manual therapy and exercise. So, the committee concluded that manual therapy should only be considered alongside therapeutic exercise (NICE, 2022a, p.42).

5.2 Functional outcomes

Few guidelines offer recommendations for outcomes other than pain management. NICE guidelines for treatment of spasticity (2016) and management of cerebral palsy (2017b; 2019a) do not make recommendations around manual therapy due to lack of evidence. The NICE

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guideline for Parkinson’s disease (2017a) suggests clinicians can consider the Alexander technique to address balance and motor function problems.

The NICE guideline for people with motor neurone disease (2019b) suggests clinicians can consider a tailored exercise program to address range of movement, contractures, stiffness and discomfort, function and quality of life. The programme can include passive exercises depending on the client’s needs and abilities. The guideline does not refer to any evidence that passive exercise programmes can address any of the outcomes cited.

For people recovering after a traumatic injury, NICE (2022b) suggests that clinicians:

• offer a gait training program that includes passive stretches
• consider both passive and active exercises to maintain or improve range of movement
• offer massage for management of scar tissue.

Passive stretching after traumatic injury is described in the context of controlled motion devices or continuous passive motion machines. It is not clear whether the recommendations cover manual therapy without such devices.

6. References

American Academy of Orthopaedic Surgeons. (2021). Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline (3rd Edition). https://www.aaos.org/oak3cpg

Bagagiolo, D., Rosa, D., & Borrelli, F. (2022). Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews. BMJ open, 12(4), e053468. https://doi.org/10.1136/bmjopen-2021-053468

Briggs, A. M., Woolf, A. D., Dreinhöfer, K., Homb, N., Hoy, D. G., Kopansky-Giles, D., Åkesson, K., & March, L. (2018). Reducing the global burden of musculoskeletal conditions. Bulletin of the World Health Organization, 96(5), 366–368. https://doi.org/10.2471/BLT.17.204891

Canadian Agency for Drugs and Technologies in Health. (2016). Physical Therapy Treatments for Chronic Non-Cancer Pain: A Review of Guidelines. https://www.ncbi.nlm.nih.gov/books/NBK409574

Franke, H., Fryer, G., Ostelo, R. W., & Kamper, S. J. (2015). Muscle energy technique for non-specific low-back pain. The Cochrane database of systematic reviews, (2), CD009852. https://doi.org/10.1002/14651858.CD009852.pub2

Ganderton, C. & King, M. (2020, November). Physio, chiro, osteo and myo: what’s the difference and which one should I get? The Conversation.

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https://theconversation.com/physio-chiro-osteo-and-myo-whats-the-difference-and-which-one-should-i-get-149993

Gross, A., Langevin, P., Burnie, S. J., Bédard-Brochu, M. S., Empey, B., Dugas, E., Faber-Dobrescu, M., Andres, C., Graham, N., Goldsmith, C. H., Brønfort, G., Hoving, J. L., & LeBlanc, F. (2015). Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. The Cochrane database of systematic reviews, (9), CD004249. https://doi.org/10.1002/14651858.CD004249.pub4

Hawk, C., Whalen, W., Farabaugh, R. J., Daniels, C. J., Minkalis, A. L., Taylor, D. N., Anderson, D., Anderson, K., Crivelli, L. S., Cark, M., Barlow, E., Paris, D., Sarnat, R., & Weeks, J. (2020). Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline. Journal of alternative and complementary medicine, 26(10), 884–901. https://doi.org/10.1089/acm.2020.0181

HealthDirect. (2022). Nerve pain (neuralgia). https://www.healthdirect.gov.au/nerve-pain

Krøll, L. S., Callesen, H. E., Carlsen, L. N., Birkefoss, K., Beier, D., Christensen, H. W., Jensen, M., Tómasdóttir, H., Würtzen, H., Høst, C. V., & Hansen, J. M. (2021). Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta-analysis. The journal of headache and pain, 22(1), 96. https://doi.org/10.1186/s10194-021-01298-4

LaPelusa, A., & Bordoni, B. (2023). High-Velocity Low-Amplitude Manipulation Techniques. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK574527/

Licciardone, J. C., Schultz, M. J., & Amen, B. (2020). Osteopathic Manipulation in the Management of Chronic Pain: Current Perspectives. Journal of pain research, 13, 1839–1847. https://doi.org/10.2147/JPR.S183170

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G., & O’Sullivan, P. P. B. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British journal of sports medicine, 54(2), 79–86. https://doi.org/10.1136/bjsports-2018-099878

Locher, H. & Beyer, L. (2021).Manual medicine, manual therapy. Manuelle Medizin 59, 254–266. https://doi.org/10.1007/s00337-021-00817-3

National Disability Insurance Scheme (Supports for Participants) Rules 2016 (Cth). https://www.legislation.gov.au/Details/F2018C00165

National Disability Insurance Scheme Act 2013 (Cth). https://www.legislation.gov.au/Details/C2022C00206

National Institute of Health Care Excellence. (2022a). Osteoarthritis in over 16s: diagnosis and management (NG226). www.nice.org.uk/guidance/ng226

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National Institute of Health Care Excellence. (2022b). Rehabilitation after traumatic injury (NG211). www.nice.org.uk/guidance/ng211

National Institute of Health Care Excellence. (2022c). Multiple sclerosis in adults: management (NG220). www.nice.org.uk/guidance/ng220

National Institute of Health Care Excellence. (2021a). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain (NG193) - Evidence review for manual therapy for chronic primary pain. https://www.nice.org.uk/guidance/ng193/evidence/i-manual-therapy-for-chronic-primary-pain-pdf-326591532180

National Institute of Health Care Excellence. (2021b). Chronic pain (primary and secondary) in over 16s: assessment and management (NG193). www.nice.org.uk/guidance/ng193

National Institute of Health Care Excellence. (2020). Low back pain and sciatica in over 16s: assessment and management (NG59). www.nice.org.uk/guidance/ng59

National Institute of Health Care Excellence. (2019a). Cerebral palsy in adults (NG119). www.nice.org.uk/guidance/ng119

National Institute of Health Care Excellence. (2019b). Motor neurone disease: assessment and management (NG42). www.nice.org.uk/guidance/ng42

National Institute of Health Care Excellence. (2017a). Parkinson’s disease in adults (NG71). www.nice.org.uk/guidance/ng71

National Institute of Health Care Excellence. (2017b). Cerebral palsy in under 25s: assessment and management (NG62). www.nice.org.uk/guidance/ng62

National Institute of Health Care Excellence. (2017c). Spondyloarthritis in over 16s: diagnosis and management (NG65). www.nice.org.uk/guidance/ng65

National Institute of Health Care Excellence. (2016). Spasticity in under 19s: management (CG145). www.nice.org.uk/guidance/ng145

Oliveira, C. B., Maher, C. G., Pinto, R. Z., Traeger, A. C., Lin, C. C., Chenot, J. F., van Tulder, M., & Koes, B. W. (2018). Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 27(11), 2791–2803. https://doi.org/10.1007/s00586-018-5673-2

Physio Network. (2021). Manual Therapy: Always a Passive Treatment? https://www.physio-network.com/blog/manual-therapy-passive/

Runge, N., Aina, A., & May, S. (2022). The Benefits of Adding Manual Therapy to Exercise Therapy for Improving Pain and Function in Patients With Knee or Hip Osteoarthritis: A Systematic Review With Meta-analysis. The Journal of orthopaedic and sports physical therapy, 52(10), 675–A13. https://doi.org/10.2519/jospt.2022.11062

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Wang, Y., Hu, M., Li, L., Xu, D., Liu, H., Wang, X., & Li, K. (2022). Editorial: Physical exercise for age-related neuromusculoskeletal disorders. Frontiers in aging neuroscience, 14, 1099417. https://doi.org/10.3389/fnagi.2022.1099417

World Health Organization. (2023a). Neuromusculoskeletal and movement-related functions. International Classification of Functioning, Disability and Health, 11th revision. https://icd.who.int/dev11/l- icf/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f161488596

World Health Organization. (2023b). International Classification of Functioning, Disability & Health. International Classification of Diseases for Mortality and Morbidity Statistics, 11th revision, Reference Guide. https://icdcdn.who.int/icd11referenceguide/en/html/index.html#international-classification-of-functioning-disability-health-icf

Young, C., & Argáez, C. (2020). Manual therapy for chronic, non-cancer back and neck pain: a review of clinical effectiveness. Canadian Agency for Drugs and Technologies in Health. https://www.ncbi.nlm.nih.gov/books/NBK562937/pdf/Bookshelf NBK562937.pdf

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Physiotherapy and exercise for progressive neurological conditions

The content of this document is OFFICIAL.

Please note:

The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research questions:

What is considered best practice for the frequency and duration of physiotherapy and exercise physiology for progressive neurological conditions?

Are there any contraindications for use of a delegated care model for these supports with this population (e.g. using therapy assistants)?

What are the risks and contraindications of physiotherapy and exercise physiology based on disease progression with these populations (i.e. is there a time when hands on therapy should not be provided as risks outweigh benefits)?

Date: 29/4/2024

Requestor: Sarah redacted: s47F - personal priv

Endorsed by: Shannon redacted: s47F - personal pri

Researcher: Aaron redacted: s47F - personal privacy

Cleared by: Aaron redacted: s47F - personal privacy

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1. Contents

Physiotherapy and Exercise physiology for progressive neurological conditions ………………….. 1

1. Contents ……………………………………………………………………………………………………….. 2

2. Summary ………………………………………………………………………………………………………. 3

3. Previous TAPIB research …………………………………………………………………………………. 3

4. Therapy assistants ……………………………………………………………………………………. 4

5. Amyotrophic lateral sclerosis / motor neuron disease …………………………………………… 5

5.1  Frequency and duration ............................................................................................. 5

5.2  Risks .......................................................................................................................... 5

5.3  Stage of progression.................................................................................................. 5

6. Parkinson’s Disease ……………………………………………………………………………………. 6

6.1  Frequency and duration ............................................................................................. 6

6.2  Risks .......................................................................................................................... 7

6.3  Stage of progression................................................................................................  8

7. Multiple Sclerosis ……………………………………………………………………………………. 8

7.1  Frequency and duration ............................................................................................. 8

7.2  Risks .......................................................................................................................... 9

7.3  Stage of progression................................................................................................ 10

8. Muscular dystrophy ……………………………………………………………………………………. 10

8.1  Frequency and duration ........................................................................................... 10

8.2  Risks ........................................................................................................................ 11

8.3  Stage of progression................................................................................................ 11

9. References ………………………………………………………………………………………………….. 11

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2. Summary

This paper considers the use of physiotherapy and exercise interventions for people with progressive neurological conditions including amyotrophic lateral sclerosis (ALS) and motor neuron disease (MND), Parkinson’s disease (PD), multiple sclerosis (MS), and muscular dystrophy (MD). This paper focusses on evidence of optimal frequency and duration of physiotherapy and exercise interventions, risks associated with interventions, differing care for early or late stages of progression and the use of therapy assistants through a delegated care model.

No studies were found that address the role of therapy assistants in the delivery of physiotherapy or exercise interventions for people with progressive neurological conditions. Some evidence suggests that the use of therapy assistants in acute hospital settings and general community settings is safe and effective. This evidence is uncertain and further research is required.

There is limited evidence regarding optimal dosage of physiotherapy and exercise interventions for people with progressive neurological conditions. Clinical practice guidelines for PD and MS provided recommendations for frequency and duration of physiotherapy and exercise interventions. However, it is likely that these recommendations are based primarily on clinical judgement rather than published evidence. One 2023 systematic review was able to determine that at least twice weekly sessions of more than 40 minutes is an effective dose of exercise intervention for the improvement of balance in MS (Corrini et al, 2023). No other studies could provide evidence-based dosage recommendations.

Where evidence is not clear, guidelines generally recommend that type, frequency, duration and intensity of physiotherapy or exercise interventions should be determined individually based on the needs and preferences of the person receiving treatment.

Despite some issues with the proper reporting of adverse events in experimental studies, exercise interventions for people with progressive neurological conditions are generally believed to be safe, provided that standard safety precautions are observed.

There is little evidence regarding safety and effectiveness of physiotherapy and exercise interventions for people at late stages of progressive neurological conditions. Most research focusses on people with mild to moderate symptom severity.

3. Previous TAPIB research

Other relevant TAPIB research papers include:

• RES 322 Manual therapy to address neuromusculoskeletal function

• RES 321 Osteopathy

• RES 318 Exercise physiology and stroke

• RES 289 Lokomat Therapy

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• RES 264 Chiropractic
• RES 233 Virtual reality as a support tool
• RES 191 Massage Therapy as a Treatment for Multiple Sclerosis

4. Therapy assistants

Therapy assistants are

support staff who complete clinical and non-clinical tasks under the supervision and delegation of an allied health professional. Clinical tasks include any direct therapeutic interventions provided to patients such as exercise therapy and education, while non-clinical tasks may include administration duties (eg, completing paperwork for equipment hire), maintenance of equipment and cleaning the clinical environment. Because allied health assistants cannot perform clinical tasks that involve diagnosing or assessing patient health conditions, allied health professionals must perform a comprehensive assessment of the patient and prescribe appropriate therapy prior to delegating the allied health assistant to perform any clinical tasks. (Snowdon et al, 2024, p.2).

In a survey of 232 UK-based physiotherapists, 81% of respondents indicated that they at least sometimes delegate the supervision of prescribed exercises to therapy assistants (Sarigiovannis et al, 2022). The authors also found that delegation of clinical tasks to therapy assistants was more likely in less complex cases where there is a straightforward treatment plan. There is a perception that increased reliance on therapy assistants may compromise the quality or safety of the intervention (Snowdon et al, 2024). However, existing evidence suggests that physiotherapy or exercise interventions delivered by a therapy assistant are likely safe (Lau et al, 2024; Snowdon et al, 2020).

No studies were found that address the role of therapy assistants in the delivery of physiotherapy or exercise interventions for people with progressive neurological conditions. Where there is minimal research to date, there is a growing interest in the role of therapy assistants in completing clinical physiotherapy tasks (Snowdon et al, 2024; Sarigiovannis et al, 2023). Current research mostly considers the addition of therapy assistants to usual care rather than a model where physiotherapy or exercise interventions are primarily delivered by a therapy assistant (Snowdon et al, 2024; Lau et al, 2024; Snowdon et al, 2020). Some evidence points to the efficacy and safety of physiotherapy or exercise interventions delivered by therapy assistants. Additional supervised exercise sessions may improve outcomes regardless of whether it is delivered by a physiotherapist or therapy assistant (Snowdon et al, 2024; Lau et al, 2024; Baumann et al, 2023a-b; Sarigiovannis et al, 2023; Sarigiovannis et al, 2022; Sarigiovannis et al, 2021). Much of the research is based in a hospital setting and the roles of physiotherapist and therapy assistant are frequently poorly reported, so results may not generalise across all models of therapy assistance or patient cohorts (Sarigiovannis et al, 2021; Snowdon et al, 2020).

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5. Amyotrophic lateral sclerosis / motor neuron disease

5.1 Frequency and duration

We did not find any reviews able to determine optimal frequency or duration of exercise or physiotherapy interventions for people with ALS/MND. One review (Zhou et al, 2022) showed inconsistent evidence that more intensive exercise training could slow the decline in functional capacity. However, the authors do not specify what they mean by ‘intensive’.

A 2023 meta-analysis including 17 studies was unable to determine optimal exercise dosage due to the variability of intervention: “frequency ranged from 2×/week to 3×/day, up to 7 days/week, with repetitions of sets ranging from 20 to 25, intensity ranging from 30 to 60% of a patient’s maximum value, and treatment duration ranging from 2 weeks to 2 years” (Donohue et al, 2023, p.19). Meng et al (2020) and Papadopolou et al (2024) were similarly unable to determine the most effective frequency, intensity, type, timing or duration of exercise-based interventions.

5.2 Risks

Researchers report some reluctance to prescribe exercise for people with ALS/MND due to possibility that exercise might lead to fatigue and faster progression of symptoms (MND Australia, 2021). However, recent reviews have found no serious adverse events in studies of exercise or physiotherapy intervention for people with ALS/MND (Papadopolou et al, 2024; Donohue et al, 2023; Meng et al, 2020). Researchers suggest that physiotherapy or exercise-based interventions are likely safe for people with ALS/MND.

5.3 Stage of progression

Minimal evidence is available for the efficacy of physiotherapy or exercise programs for people with more advanced ALS/MND. Donahue et al (2023) find some low certainty evidence that exercise programs are beneficial in early stages of disease progression. However, all of the studies included in their review explore exercise intervention only on those with low to moderate symptom severity.

Ireland’s Guidelines for the physiotherapy management of Motor Neuron Disease (O’Callaghan, 2014), suggests physiotherapy treatment plans differentiate early, middle and late stages of progression. During the late stage, strategies to maintain function and manage symptoms may include:

• a stretching program

• active and passive range of movement exercises

• the use of assistive technology such as motomed or tilt table.

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While evidence is presented for the efficacy of exercise at the early stages of MND, recommendations for strategies at the middle and late stages are based on clinical judgment of the authors.

6. Parkinson’s Disease

6.1 Frequency and duration

There is no consensus on optimal frequency or duration of physiotherapy or exercise interventions for people with Parkinson’s disease. Reviews report average frequency and duration of interventions used in studies but are unable to determine best practice timing (Ernst et al, 2024; El Hayek et al, 2023; Osborne et al, 2022; Grimes et al, 2019; NICE, 2017; Keus et al, 2014).

El Hayek et al (2023) reviewed 46 studies to determine most effective types, timing, frequency, duration, and outcomes of physiotherapy and exercise for people with Parkinson’s disease. They found no significant difference between interventions and comparisons for frequency, duration or number of sessions.

A 2024 Cochrane review of studies on exercise intervention for people with Parkinson’s disease was unable to draw conclusions regarding the optimal frequency of exercise intervention (Ernst et al ,2024). The authors observed a beneficial effect on functional mobility and balance in studies lasting longer than 12 weeks. However, they did not observe a significant effect of intervention duration on other outcomes.

Of four clinical practice guidelines that recommend the use of physiotherapy, exercise or physical activity for people with Parkinson’s disease, only one provides recommendations regarding frequency and duration of activity (Osborne et al, 2022; Grimes et al, 2019; NICE, 2017; Keus et al, 2014). The European Physiotherapy Guideline for Parkinson’s Disease (Keus et al, 2014) includes recommendations for minimum treatment period for seven physiotherapy modalities (refer to Table 1). However, the Guideline Development Group (GDG) responsible for the recommendations also note:

Evidence-based information on the optimal number of sessions a week, session time and length of a treatment period are unavailable. These decisions will depend on the treatment goal, the selected intervention, the potential of the [person with Parkinson’s disease] and the response to the treatment. GDG recommendations for minimum treatment period, frequency and session duration for each intervention category provided in this chapter are based on the averages of controlled clinical trials (CCTs) supportive to the ‘for’ recommendations (Keus et al, 2014, p.64)

Further, the GDG suggests that the optimal treatment period, duration and intensity will most likely never be determined due to the varied fitness levels, functional capacity and preferences of people with Parkinson’s disease (Keus et al, 2014, p.72). This judgement is implicitly supported by the most recent clinical guideline from the American Physical Therapy

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Association (Osborne et al, 2022). Osborne et al review 11 physiotherapy interventions and concludes there is still insufficient evidence to determine optimal dosing for any of the reviewed interventions.

Table 1 Minimum recommended treatment period for physiotherapy interventions (source: Keus et al, 2014)

Note: This table contains recommended minimum treatment periods from the European Physiotherapy Guideline for Parkinson’s Disease. These recommendations are not the optimal dosage, but rather the average treatment period of studies that found beneficial effects of the intervention.

Intervention	Minutes	Per week	Weeks
Conventional physiotherapy	45	3	8
Treadmill training	30	3	4
Dance	60	2	10
Tai chi	60	2	24
Trigger point massage	45	2	8
Cueing	30	3	3
Complex motor sequences	30	3	3

6.2 Risks

Ernst et al (2024) reviewed 154 controlled studies of exercise interventions for people with Parkinson’s disease. They found only 85 studies reported on presence or absence of adverse events. Falls were reported in 18 studies and pain in 10 studies. The authors note “although our review pointed out the difficulties in synthesizing the evidence on the comparative safety of different types of physical exercise, our results are consistent with previous research suggesting that, in general, physical exercise seems to be relatively safe” (p.64)

Osborne et al (2022) reviewed risks reported in studies of aerobic exercise, resistance training, balance training, flexibility training, external cueing, community-based exercise, gait training, task specific training, and a behaviour change approach. They note that there is minor risk if standard safety procedures are in place. People prescribed exercise should be screened for heart issues or other health concerns that would preclude moderate to high intensity exercise. If intensity and duration of exercise is increased, it should be done gradually to prevent injury. Minor musculoskeletal injuries were reported in studies of aerobic exercise, but these resolved. Falls and other adverse effects were reported in some studies, though no study

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reported a more significant rate of adverse effects in the intervention group compared to the control group.

6.3 Stage of progression

Li et al (2023) suggest that exercise interventions are beneficial for people at advanced stages of Parkinson’s disease to maintain function and health. However, this suggestion was not based on the results of their review, which found no evidence that exercise could limit progression of symptoms for people at advanced stages.

Other reviews have also been unable to determine whether exercise interventions are effective or safe for people at advanced at stages of Parkinson’s progression (stages 4 or 5 of the Hoehn & Yahr scale). Ernst et al (2024) reviewed 154 studies and found most studies included participants at stages 1 – 3. No studies included participants at stage 5, while only 17 studies included participants at stage 4. Therefore, the authors note that their results may not apply to people at advanced stages of Parkinson’s disease progression.

For most physiotherapy interventions reviewed by Osborne et al (2022), studies supporting the intervention focussed on mostly those with mild to moderate symptoms covering Hoehn & Yahr stages 1 to 3. Studies investigating external cueing and resistance, balance and flexibility training included participants at stages 1 to 4. None of the recommendations made by Osborne et al are relevant to people showing advanced stage 5 symptoms.

7. Multiple Sclerosis

7.1 Frequency and duration

A 2019 systematic review of clinical practice guidelines for exercise interventions for people with Multiple Sclerosis found consistent dosage recommendations for aerobic and resistance training:

The literature we summarized consistently indicated that moderate-intensity aerobic training should be performed 2 to 3 days per week in 10- to 40-minute bouts. By achieving these guidelines, people with MS can potentially improve their cardiovascular fitness, mobility and symptoms of fatigue and depression. This should be complemented by 2 to 3 days of weekly resistance training, from which anticipated benefits could include: improved strength, balance, mobility, performance of activities of daily living, and symptoms of fatigue (Kim et al, 2019, p.9).

These recommendations may be based on a combination of experimental evidence and clinical judgement. However, considering the difficulty of deriving optimal dosage levels from the current evidence, it is likely that the recommendations in Kim et al represent a professional consensus rather than an evidence-based conclusion (Taul-Madsen et al, 2021; Edwards & Pilutti, 2017).

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Corrini et al (2023) reviewed 20 randomised controlled trials looking at the effect of balance training programs for people with Multiple Sclerosis. They found high quality evidence that physiotherapy targeting balance has a moderate effect on improving balance as measured by the Berg Balance Scale. In addition, their meta-analysis was able to show that sessions lasting 40 minutes or longer produced a significant and clinically meaningful improvement in balance scores, while sessions lasting under 40 minutes did not produce statistically significant results. The authors concluded that:

intense treatments lasting at least 40 [minutes] were associated with a better and more clinically meaningful improvement, and greater results can be reached when rehabilitation is provided over a short period (duration) and for a few sessions per week (frequency) (Corrini et al, 2023, p.20).

7.2 Risks

Learmonth et al (2023) searched for information on relapse and adverse events after exercise interventions for people with Multiple Sclerosis. They reviewed 40 randomised controlled trials including 1780 participants. The authors found no significant difference in adverse events between exercise intervention and comparison groups. The analysis

did not reveal any significant variability in risk of exercise training across the potentially important factors of exercise type, delivery style (e.g. supervised, independent or remotely supervised), participant disability level or the prescription of exercise consistent with minimal exercise guidelines for persons with MS (Learmonth, 2023, p.1624).

While exercise interventions are generally considered safe for people with Multiple Sclerosis, safety precautions and modifications may be required depending on the needs of the individual. A 2019 systematic review of guidelines produced the following advice:

An exercise prescription for people with MS should promote a safe and individualized exercise regimen. Thus, before prescribing an exercise routine, MS specific symptoms/characteristics (i.e., fatigue and heat sensitivity) should be identified and discussed, and the exercise prescription should include appropriate modifications. For example, individuals with high heat sensitivity should exercise in a cool environment, and a cooling fan should be readily available for the person during the exercise sessions. When individuals experience symptom exacerbation, either daily variation in symptoms or relapse, the exercise program may require modification or be temporarily discontinued until the symptoms are stable. Risk of falling should be considered for individuals with MS, and individuals with high risk of falls should perform both aerobic and strength exercises in a seated position (e.g., recumbent bike, weight machines) and under supervision (Kim et al, 2019, p.6)

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7.3 Stage of progression

Learmonth et al (2023) did not find any significant difference in risk or safety of exercise interventions between levels of disability. However, it should also be noted that participants with advanced stages of MS were minimally represented in the studies reviewed. Of 40 randomised controlled trials, only 3 were focussed on people with severe symptoms of Multiple Sclerosis. In fact, most evidence for the efficacy of exercise intervention for people with Multiple Sclerosis lacks generalisability for people with severe symptoms (Corrini et al, 2023; Taul-Madsen et al, 2021; Kim et al, 2019; Edwards & Pilutti, 2017).

Two systematic reviews have examined the effectiveness of physiotherapy or exercise interventions in people with Multiple Sclerosis (Binshalan et al, 2022; Edwards & Pilutti, 2017). A 2017 review found limited and very low certainty evidence that exercise interventions could improve fitness, function, balance, fatigue, mood and quality of life (Edwards & Pilutti, 2017). The authors also suggest exercise interventions are safe for people with severe symptoms. More recently, Binshalan et al (2022) found low quality evidence that robot assisted gait therapy may be effective at improving walking speed and endurance in people with severe symptoms of Multiple Sclerosis. The authors speculate on possible reasons robot assisted gait therapy may be more effective than other modes of physiotherapy or exercise intervention:

Appropriate PT intervention programs must be tailored to the patient’s abilities with sufficient stimulus to push present competence to produce effect [49]. Therefore, it possible that RAGT is less demanding for severely disabled pwMS, who might not be able to complete other forms of PT effectively (p.13).

8. Muscular dystrophy

8.1 Frequency and duration

Hammer et al (2022) is the most recent systematic review of physiotherapy or exercise interventions for people with muscular dystrophy. They reviewed 12 studies with 282 participants and found exercise intervention may improve strength and endurance for people with MD. No conclusions regarding frequency, duration or intensity were possible with the available evidence.

A 2019 Cochrane review of exercise training in muscle disease (including MD), notes:

The most effective dose of exercise for people with muscle diseases is currently unknown, making it difficult to prescribe exercise in this population. This is reflected in the large variation in the frequency, duration and intensity of exercise prescribed (Voet et al, 2019, p.42).

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8.2 Risks

The most recent review of physiotherapy or exercise interventions for MD noted that none of the studies included in the review adequately reported on adverse events. However, the authors noted that “intensive eccentric muscle exercise, where the muscle is both activated and lengthened, in addition to high-resistance exercise, may exacerbate muscle damage and should be avoided” (Hammer et al, 2022, p.2).

Voet et al (2019) report no evidence of safety concerns in appropriately structured exercise programmes, though they also note that “included studies were small and the evidence was largely low or low certainty; therefore, we can make no definitive statements regarding safety” (p.42).

8.3 Stage of progression

No studies were able to discriminate benefits or risks of exercise based on severity of symptoms or stage of progression.

9. References

Binshalan, T., Nair, K. P. S., & McNeill, A. (2022). The Effectiveness of Physiotherapy Interventions for Mobility in Severe Multiple Sclerosis: A Systematic Review and Meta-Analysis. Multiple sclerosis international, 2022, 2357785. https://doi.org/10.1155/2022/2357785

Baumann, A. N., Curtis, D. P., Chen, M., & Baldwin, K. D. (2023a). The Impact of the Addition of a Physical Therapy Assistant to the Treatment Team for Management of Neck Pain: A Retrospective Analysis of Outpatient Physical Therapy Clinics. Cureus, 15(7), e42751. https://doi.org/10.7759/cureus.42751

Baumann, A. N., Indermuhle, T., Oleson, C. J., Callaghan, M. E., Rogers, H., Pennacchio, C., Baldwin, K. D., & Leland, J. M., 3rd (2023b). Clinical Outcomes Associated With the Addition of a Physical Therapist Assistant to a Rehabilitation Team When Treating Musculoskeletal Shoulder Pain in the Outpatient Setting: A Retrospective Cohort Study. Cureus, 15(7), e42680. https://doi.org/10.7759/cureus.42680

Corrini, C., Gervasoni, E., Perini, G., Cosentino, C., Putzolu, M., Montesano, A., Pelosin, E., Prosperini, L., & Cattaneo, D. (2023). Mobility and balance rehabilitation in multiple sclerosis: A systematic review and dose-response meta-analysis. Multiple sclerosis and related disorders, 69, 104424. https://doi.org/10.1016/j.msard.2022.104424

Edwards, T., & Pilutti, L. A. (2017). The effect of exercise training in adults with multiple sclerosis with severe mobility disability: A systematic review and future research directions. Multiple sclerosis and related disorders, 16, 31–39. https://doi.org/10.1016/j.msard.2017.06.003

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El Hayek, M., Lobo Jofili Lopes, J. L. M., LeLaurin, J. H., Gregory, M. E., Abi Nehme, A. M., McCall-Junkin, P., Au, K. L. K., Okun, M. S., & Salloum, R. G. (2023). Type, Timing, Frequency, and Durability of Outcome of Physical Therapy for Parkinson Disease: A Systematic Review and Meta-Analysis. JAMA network open, 6(7), e2324860. https://doi.org/10.1001/jamanetworkopen.2023.24860

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Hammer, S., Toussaint, M., Vollsæter, M., Nesbjørg Tvedt, M., Drange Røksund, O., Reychler, G., Lund, H., & Andersen, T. (2022). Exercise Training in Duchenne Muscular Dystrophy: A Systematic Review and Meta-Analysis. Journal of rehabilitation medicine, 54, jrm00250. https://doi.org/10.2340/jrm.v53.985

Keus, S., Munneke, M., Graziano, M., Paltamaa, J., Pelosin, E., Domingos, J., … & Bloem, B. (2014). European physiotherapy guideline for Parkinson’s disease. The Netherlands: KNGF/ParkinsonNet.

Kim, Y., Lai, B., Mehta, T., Thirumalai, M., Padalabalanarayanan, S., Rimmer, J. H., & Motl, R. W. (2019). Exercise Training Guidelines for Multiple Sclerosis, Stroke, and Parkinson Disease: Rapid Review and Synthesis. American journal of physical medicine & rehabilitation, 98(7), 613–621. https://doi.org/10.1097/PHM.0000000000001174

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Learmonth, Y. C., P Herring, M., Russell, D. I., Pilutti, L. A., Day, S., Marck, C. H., Chan, B., Metse, A. P., & Motl, R. W. (2023). Safety of exercise training in multiple sclerosis: An updated systematic review and meta-analysis. Multiple sclerosis (Houndmills,

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Motor Neuron Disease Australia. (2021). Physical Activity and MND. https://www.mndaustralia.org.au/mnd-connect/information-resources/physical-activity-and-mnd

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O’Callaghan, G., Murray, D. & Vance, R. (2014). Guidelines for the physiotherapy management of Motor Neuron Disease. Irish Hospice Foundation. https://d2khofxhx95v1k.cloudfront.net/b1fdb917f1fea268a7a1b7b502dcd172.pdf

Osborne, J. A., Botkin, R., Colon-Semenza, C., DeAngelis, T. R., Gallardo, O. G., Kosakowski, H., Martello, J., Pradhan, S., Rafferty, M., Readinger, J. L., Whitt, A. L., & Ellis, T. D. (2022). Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association. Physical therapy, 102(4), pzab302. https://doi.org/10.1093/ptj/pzab302

Papadopoulou, M., Papapostolou, A., Dimakopoulos, R., Salakou, S., Koropouli, E., Fanouraki, S., Bakola, E., Moschovos, C., & Tsivgoulis, G. (2024). Non-Pharmacological Interventions on Pain in Amyotrophic Lateral Sclerosis Patients: A Systematic Review and Meta-Analysis. Healthcare (Basel, Switzerland), 12(7), 770. https://doi.org/10.3390/healthcare12070770

Sarigiovannis, P., Foster, N. E., Jowett, S., & Saunders, B. (2023). Developing a best practice framework for musculoskeletal outpatient physiotherapy delegation: the MOPeD mixed-methods research study protocol. BMJ open, 13(3), e072989. https://doi.org/10.1136/bmjopen-2023-072989

Sarigiovannis, P., Foster, N. E., Jowett, S., & Saunders, B. (2022). Delegation of workload from musculoskeletal physiotherapists to physiotherapy assistants/support workers: A UK online survey. Musculoskeletal science & practice, 62, 102631. https://doi.org/10.1016/j.msksp.2022.102631

Sarigiovannis, P., Jowett, S., Saunders, B., Corp, N., & Bishop, A. (2021). Delegation by Allied Health Professionals to Allied Health Assistants: a mixed methods systematic review. Physiotherapy, 112, 16–30. https://doi.org/10.1016/j.physio.2020.10.002

Snowdon, D. A., Wang, Y. T., Callisaya, M. L., Collyer, T. A., Jolliffe, L., Johns, N., Vincent, P., Pragash, N., & Taylor, N. F. (2024). Staying Active with Multimorbidity In Acute hospital settings (StAMInA) trial: protocol for a feasibility randomised controlled trial of allied

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Taul-Madsen, L., Connolly, L., Dennett, R., Freeman, J., Dalgas, U., & Hvid, L. G. (2021). Is Aerobic or Resistance Training the Most Effective Exercise Modality for Improving Lower Extremity Physical Function and Perceived Fatigue in People With Multiple Sclerosis? A Systematic Review and Meta-analysis. Archives of physical medicine and rehabilitation, 102(10), 2032–2048. https://doi.org/10.1016/j.apmr.2021.03.026

Voet, N. B., van der Kooi, E. L., van Engelen, B. G., & Geurts, A. C. (2019). Strength training and aerobic exercise training for muscle disease. The Cochrane database of systematic reviews, 12(12), CD003907. https://doi.org/10.1002/14651858.CD003907.pub5

Zhou, B., Wei, J., Zhang, Y., Liu, Y., Shan, S., Ye, S., Li, B., Fan, D., & Luo, Y. (2022). Different observation period of exercise training in amyotrophic lateral sclerosis patients: A meta-analysis. Frontiers in neurology, 13, 986882. https://doi.org/10.3389/fneur.2022.986882

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