Physical activity supported by mobile technology program (PAT-Back) for older adults with back pain at primary care: a feasibility study protocol

Jesus-Moraleida, Fabianna Resende de; Santos, Ana Ellen do Nascimento; Máximo Pereira, Leani Souza; Ferreira, Manuela Loureiro; Ferreira, Paulo Henrique; Macedo, Luciana Gazzi; Nunes, Ana Carla Lima

doi:10.1590/s1980-657420220020321

Fabianna Resende de Jesus-Moraleida

Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Fisioterapia, Programa de Pós-Graduação em Fisioterapia e Funcionalidade, Fortaleza, CE, Brazil

https://orcid.org/0000-0002-3797-949X

Ana Ellen do Nascimento Santos

Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Fisioterapia, Programa de Pós-Graduação em Fisioterapia e Funcionalidade, Fortaleza, CE, Brazil

https://orcid.org/0000-0001-8429-324X

Leani Souza Máximo Pereira

Universidade Federal de Minas Gerais, Departamento de Fisioterapia, Programa de Pós-Graduação em Ciências da Reabilitação, Belo Horizonte, MG, Brazil

https://orcid.org/0000-0001-7253-4392

Manuela Loureiro Ferreira

University of Sydney, Sydney Medical School, The Kolling Institute, Institute of Bone and Joint Research, Sydney, New South Wales, Australia

https://orcid.org/0000-0002-3479-0683

Paulo Henrique Ferreira

University of Sydney, Faculty of Health Sciences, Sydney, New South Wales, Australia

https://orcid.org/0000-0002-5861-7770

Luciana Gazzi Macedo

McMaster University, School of Rehabilitation Science, Hamilton, Ontario, Canada.

https://orcid.org/0000-0002-1840-2951

Ana Carla Lima Nunes

Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Fisioterapia, Fortaleza, CE, Brazil

https://orcid.org/0000-0002-7380-6537

Associate Editor: Angelina Zanesco0000-0002-2515-1871. ¹Universidade Metropolitana de Santos, Faculdade de Medicina, Santos, SP, Brazil; ²Universidade Estadual Paulista “Júlio de Mesquita Filho”, Departamento de Educação Física, Instituto de Biociências, Rio Claro, SP, Brazil. E-mail: angelina.zanesco@unesp.br.

Corresponding author
Fabianna Resende de Jesus-Moraleida,Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Fisioterapia, Programa de Pós-Graduação em Fisioterapia e Funcionalidade, Fortaleza, CE, Brazil. E-mail: fabiannamoraleida@ufc.br.

Week	Educational component	Exercise component	Mobile technology component
1	Theme: Understanding low back pain. Objective: To clarify the patient about his condition;Topics: Definition of pain, factors that influence pain, types of pain and transition, neurophysiology of chronic pain, pain ≠ injury, prognosis in the older adults, myths about low back pain. Exercise booklet delivery	Group training: diaphragmatic breathing, lumbar-pelvic mobility exercise, global stretching, and progressive muscle relaxation; Home exercises: group-trained exercises	Messages: reminder for attitudes of relaxation and pain relief techniques
2	Theme: The importance of moving. Objective: Highlight exercise as a remedy for low back pain and encourage engagement in physical activity. Topics: Definition of movement, body repercussions, ways of moving, the cycle of pain - fear avoidance, effects of inactivity, benefits of physical exercise for pain, walking program, 1st line of care for LBP	Group training: exercises from week 1, bridge and walking circuit; Home exercises: group-trained exercises	Messages: Reminder of benefits of becoming active and effects of inactivity, and incentive to exercise
3	Theme: Gradual exposure to the activity. Objective: To present gradual exposure as a resource to overcome fear, dysfunctional beliefs of movement, or dysfunctional behaviors. Topics: Belief in fear and behavioral avoidance, pain effects, the impact of LBP in daily activities, definition, aims, and strategies of gradual exposure	Group training: exercises for week 2, gradual exposure to the specific activity indicated and exercise of sitting and standing; Home exercises: group-trained exercises	Messages: Reminder for personalized gradual exposure strategies
4	Theme: Management of biopsychosocial factors in low back pain and aging. Objective: To promote an understanding of the contribution of relevant biopsychosocial factors that impact LBP and how to control them. Topics: Common comorbidities and the importance of their management in the care of LBP; sleep quality and measures for restful sleep, measures for reducing stress and distraction, and leisure	Group training: exercises for week 3, abduction of lower limbs, truck extension; Home exercises: group-trained exercises	Messages: a reminder to control biopsychosocial factors.
5	Theme: The importance of planning. Objective: Organize the exercise routine at home, guide rhythm, micro pause, and division of tasks. Topics: What is and why to plan, strategies for organizing activities and exercises, the balance between activity and rest, respect for the appropriate limit and pace, the definition of goals, and action plan based on the SMART system	Group training: week 4 exercises and, partial curl exercise; Home exercises: group-trained exercises	Messages: Reminder and incentive to set goals and achieve objectives.
6	Theme: How to do self-management in pain? Objective: To reinforce LBP self-management skills and strategies for implementation; Topics: Problems of implementation and solutions in acute exacerbation of pain through the principles of resolution problems, decision-making, use of resources, goal setting and action planning, and self-adaptation, therapist-patient partnership	Group training: progression of week 5 exercises and step up and down exercises; Home exercises: group-trained exercises	Messages: Reminder for self-management implementation strategies
7	Theme: What have we learned so far? Objective: To establish an important intervention. Topics for the confrontation and continuous management of DLC; Topics: Exercise benefits and impairment of inactivity, reinforcement of planning, and importance of progressing exercises	Group training: progression of week 6 exercises and plantar flexion exercises. Home exercises: group-trained exercises	Messages: Encouraging exercises and monitoring them to achieve objectives
8	Theme: You are in control, but you are not alone! Objective: Obtain feedback on changes, help resolve doubts and problems, provide positive reinforcement of advances, and assist in facing barriers	Group training: progression of exercises for week 7; Home exercises: group-trained exercises	Messages: Encouraging exercises and monitoring them

Exercise	Initial approach	Progression
Diaphragmatic breathing	Starting position: supine position with bent knees. Description: inhalation / exhalation with abdominal movement. (5 min)	After performing the pattern properly, the participant evolves to a sitting, standing, and double task. Home frequency recommendation: 7x/ week, 1x/day
Pelvic Tilt	Starting position: sitting in a comfortable position Avel. Description: Execution of retroversion before pelvis version within non-painful range (2 min).	The participant can evolve to standing and four supports, with the addition of repetitions. Home frequency recommendation : 3x / week, 1x / day
Progressive muscle relaxation	Starting position: supine position Description: With his eyes closed, the participant is guided to think about pleasant situations and to breathe calmly. Contract, maintain muscle contraction for a few moments and relax areas of the face, arms, hands, legs, and feet (10 min).	No progression Home frequency recommendation: 7x / week, 1x / day
Overall stretch	Position: Standing or sitting Description: stretching of the posterior and anterior trunk chair, and upper and lower limbs (30 s each muscle group). (5 min)	The participant is oriented to reach greater amplitudes Home frequency recommendation: 7x / week, 1x / day
Bridge	Initial position: Participant in the supine position, knee and arm flexion in pronation extended to the side of the body. Description: And hip lift and return to the initial position, associated with diaphragmatic breathing (repetitions in 1 min).	The participant will evolve, in order, with several repetitions, lift, load, and unipodal support according to perceived effort on the BORG scale. Target recommendation: 2x10 repetitions Home frequency recommendation: 3x / week, 1x / day
Sit and stand	Starting position: Participant sitting in a firm chair. Description: Get up and sit again without using your arms (repetitions in 1 min).	The participant will evolve, in order, with several repetitions, series, and speed according to the perception of effort on the BORG scale. Target recommendation: 3x10 repetitions with speed increase. Home frequency recommendation: 3x/week, 1x/day
Gradual exposure	Activity-dependent, guided by the principles of reinforcement, and rhythm. Safely repeats in 1 min.	The participant will evolve to a more challenging position and/or range. Target: Complete the task safely. Home target recommendation: 3x/week, 1x/day
Abduction of lower limbs	Starting position: Standing participant, positioned in front of a firm support surface. Description: Request that you lift one leg to the side and return to the center, slowly. The same is done on the contralateral leg after the initial leg series (repetitions per member in 1 min).	The participant will evolve, in order, with several repetitions, series, change to lateral decubitus, and speed according to the perception of effort on the BORG scale. Target recommendation: 3x10 repetitions with speed increase. Home frequency recommendation: 3x / week, 1x/day
Step up and down	Starting position: Participant standing, with a close support surface. Description: ask to go up a step and go down, alternating legs (repetitions in 1 min).	The participant will evolve, in order, with several repetitions, series, and speed according to the perception of effort on the BORG scale. Target recommendation: 3x10 repetitions with increased speed. Home frequency recommendation: 3x/week, 1x/day
Partial Curl	Initial position: Patient supine, knees bent, feet flat on the surface Description: trunk partial flexion raising the scapular waist to its limit.	The participant will evolve, in order, with several repetitions, amplitude, series, and load according to the perception of effort on the BORG scale. Target recommendation: 3x10 repetitions with increased load and speed. Home frequency recommendation: 3x/ week, 1x/ day
Tiptoe (plantar flexion)	Initial position: The participant is standing, positioned in front of a support surface. Description: ask him to lift his heel and stand on his toes, then request the return, slowly (repetitions in 1 min)	The participant will evolve, in order, with several repetitions, support, and series according to the perception of effort on the BORG scale. Target recommendation: 3x10 repetitions. Home frequency recommendation: 3x / week, 1x / day
Trunk extension	Initial position: Participant in the prone position, with the support of the elbows, extends the trunk, up to its limit. Description: Raise the trunk and return.	The participant will evolve, in order, with several repetitions, support, and series according to the perception of effort. Home frequency recommendation: 3x/week, 1x/day
Walking circuit	Make sure that the participant has adequate footwear, HR, and PA in normal parameters. Pay attention to the effort and complaints to stop at any time. Description: The participant will walk on a circuit that will involve free walking, with speed obstacles to perceive moderate effort for 10 min. Training at home: Free walk for a minimum of 10 min.	The participant will be instructed to increase the walking pace to perform a greater number of walking cycles when the perceived exertion is less than moderate. Home target recommendation: 90 min/week. Progressing time and walking pace for moderate perceived effort.

Outcomes	Instruments / measures	Analyze	Feasibility criteria
Recruitment rate	Electronic registration of participants recruited in 12 months	Number of participants recruited	Proceed ≥ 100 Proceed with change 99-61 Proceed with significant changes ≤ 60
	Electronic registration of eligible participants who agreed to participate in 12 months	Percentage of eligible people who consented to participate and were randomized	Proceed ≥ 50% Proceed with change 49-26% Proceed with significant changes ≤ 25%
Retention rate	Registrations allocated participants who completed follow-up action immediately	Percentage of participants who completed follow-up measures after randomization	Proceed ≥ 85% Proceed with change 84-61% Proceed with significant changes ≤ 60%
Adherence rate to program	Electronic weekly attendance record	Percentage of individuals who completed 75% of attendance in 8 weeks	Proceed x ≥ 75% Proceed with change 74-51% Proceed with significant changes ≤ 50%
Adherence to unsupervised exercises	Brazilian Portuguese version of the Exercise Adherence Rating Scale (EARS-Br)³⁷37. de Lira MR, de Oliveira AS, França RA, Pereira AC, Godfrey EL, Chaves TC. The Brazilian Portuguese version of the Exercise Adherence Rating Scale (EARS-Br) showed acceptable reliability, validity, and responsiveness in chronic low back pain. BMC Musculoskelet Disord. 2020;21(1):294. doi doi...	Percentage of participants who score 17 points or more	Proceed ≥ 70% Proceed with change 69-51% Proceed with significant changes ≤ 50%
	Written journal of frequency of execution of the prescribed exercises completed by the participant himself	Percentage of participants who performed 75% of training in group	-
Difficulty understanding the intervention	Feasibility forms through the question: How much difficulty did you have understanding any content/instruction at the time of training?	Percentage of participants with a mean response s on a Likert scale (0-10) equal to or greater than 5	Proceed ≤ 50% Proceed with change 51-74% Proceed with many changes ≥ 75%
Difficulty performing exercises at home	Feasibility forms through the question: How much difficulty did you have performing the exercises at home?	Percentage of participants with a mean response on a Likert scale (0-10) equal to or greater than 5	Proceed ≤ 50% Proceed with change 51-74% Proceed with significant changes ≥ 75%
Safety to perform exercises at home	Feasibility forms through the question: How safe did you feel to perform the exercises at home?	Percentage of participants with an average of responses on a Likert scale (0-10) equal to or greater than 5	Proceed x ≥ 75% Proceed with change 74-51% Proceed with significant changes ≤ 50%
Perception of the use of mobile technology	Feasibility forms through the question: How much do you believe that text messages will motivate you to perform the exercises?	Percentage of participants with an average of responses on a Likert scale (0-10) equal to or greater than 5	Proceed ≥ 75% Proceed with change 74-51% Proceed with significant changes x ≤ 50%
Compliance with the accelerometer protocol	Use of the accelerometer on the right side of participants' waist (Actigraph, model wGT3X-BT) for at least 10 h a day for at least four days (removing the first and last days and disregarding days with less than 600 min, and periods of less than 90 min of no activity record)³⁸38. Choi L, Liu Z, Matthews CE, Buchowski MS. Validation of accelerometer wear and non-wear time classification algorithm. Med Sci Sports Exerc. 2011;43(2):357-64. doi doi...	Percentage of participants using it according to the minimum established period.	-
Adverse events	Electronic registration of event reporting by patients	-	-

[1] Associate Editor: Angelina Zanesco0000-0002-2515-1871. ¹Universidade Metropolitana de Santos, Faculdade de Medicina, Santos, SP, Brazil; ²Universidade Estadual Paulista “Júlio de Mesquita Filho”, Departamento de Educação Física, Instituto de Biociências, Rio Claro, SP, Brazil. E-mail: angelina.zanesco@unesp.br.

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Physical activity supported by mobile technology program (PAT-Back) for older adults with back pain at primary care: a feasibility study protocol

Abstract

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Discussion: