Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review

Abstract Objective To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy. Methods We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized. Results Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient’s understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls. Conclusion Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain. Study registration Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).


Introduction
Chronic pain is a major cause of disease burden across the globe. 1 Chronic pain is pain that persists beyond 3 months, 2 and it is associated with depression, 3 reduced physical activity, disability, 4 opioid-related harm, 5 and suicidality. 6ndividuals experiencing chronic pain are frequently managed by physiotherapists. 7,8espite evidence supporting contemporary physiotherapy management for common chronic pain conditions, treatments lacking efficacy remain widely implemented. 9,10Examples include manual therapy, acupuncture, taping techniques, and the use of electrophysical agents. 11,12Persistent implementation of such treatments has given rise to the concept of "lowvalue" physiotherapy, which yields little or no benefit relative to cost, or where the risk of adverse impact is greater than the likelihood of benefit. 13Conversely, a recent consensus statement from Australian physiotherapists defined "high-value" physiotherapy (HVP) as "care that delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care" 14 (p.4).As a recent concept, 15 HVP is often considered interchangeable with evidence-based practice (EBP).Although EBP is a key component of HVP, the latter has a clearer emphasis on costeffectiveness and value. 16It is critically important to consider the influence of value, given the high percentage of physiotherapists who deliver care in the private sector (eg, 72% in Australia). 17Indeed, the value proposition of physiotherapy for patients and the broader primary health care system is a key component of a recent strategic plan released by the Australian Physiotherapy Association. 18Value proposition also underpins the international "Choosing Wisely" initiative, which aims to reduce the provision of low-value health care and is subscribed to by multiple national physiotherapy associations. 19The Choosing Wisely initiative aims to reduce the provision of low-value care.
1][22] Exercise therapy independently, and in combination with manipulative therapy and pain neuroscience education, has demonstrated efficacy for CLBP. 20As part of HVP, exercise is also supported for CNP, with moderate effects from strengthening exercises (ie, of the upper quadrant and neck regions) and smaller effects from other forms of exercise (eg, motor control exercises of the head-neck). 23For OA, HVP supports rehabilitation comprising aerobic and resistance-based exercise, weight management where indicated, and self-management. 22atients' perception of value (contributing to their engagement) is pivotal to the success of active and high-value treatment approaches and presents a substantial challenge to the clinical implementation of these approaches. 24,250][31][32] The emergence of consumer-driven health care 33 also highlights the importance of understanding patient-related influences on HVP implementation.

Objectives
This systematic review aims to identify, evaluate, and summarize the patient-related barriers to and enablers of the success of implementing HVP for chronic pain.Furthermore, we aimed to describe the evidence for the efficacy of patientrelated interventions that have been used to facilitate the implementation of HVP for chronic pain.

Methods
As HVP and EBP are similar concepts and have been used interchangeably in the literature, we sought investigations incorporating either.To be eligible for inclusion in this review, studies were required to investigate patient-related barriers to or enablers of the implementation of HVP (or EBP) chronic pain management (review question 1) or interventions aimed at enhancing implementation of HVP (or EBP) for chronic pain (review question 2).Barriers and enablers were considered patient related if they were directly reported by patients; interventions were considered patient related if the focus was to directly engage patients in behavior change.For inclusion, studies were required to be peer reviewed, to be published in English, and to pertain to adult persons 18 years of age or more.The completed eligibility criteria are summarized in Table 1.
A systematic search was conducted within the following databases: APA PsycInfo, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scopus, and PEDro.The search strategy was devised through the use of a logic grid comprising key concepts, related synonyms, and index terms for each database, where required.Key concepts and search terms for each database are detailed in Supplemental Table S1.The search strategy was reviewed by an experienced Medical Librarian and checked against the Peer Review of Electronic Search Strategies checklist. 34The search was completed for titles, keywords, and abstracts on January 25, 2023.As an exemplar, the full search syntax for the Medline database is demonstrated in Supplemental Table S2.
This systematic review was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines 35 and used a framework synthesis approach. 36The Theoretical Domains Framework (TDF), interlinked with the Capability Opportunity Motivation-Behavior (COM-B) model (Figure 1), provided a robust a priori framework for synthesis of our data and reflects the multifactorial nature of HVP. 37The validated TDF and COM-B model have been widely used in implementation science research, including for Table 1.Inclusion and exclusion criteria applied to publications from systematic search.

Inclusion criteria 1
The full article is available for review.2 The article is published in English.3  The article focuses on physiotherapy as the health care provider.4 The study involves adults (ie, 18 years of age).5 The article reports on chronic (>3 months' duration) musculoskeletal pain as the health condition of interest.6 The article is a peer-reviewed publication.7 The article reports on patient-related barriers to or enablers of the implementation of high-value HVP or EBP chronic pain management.a 8 The article reports on an intervention to enhance implementation of HVP or EBP chronic pain management.a Exclusion criteria 1 The article pertains to non-neuromusculoskeletal chronic pain (eg, cancer pain, migraine, neuropathic pain). 2 The article pertains to non-physiotherapeutic management (eg, osteopathy, chiropractic). 3 The full article does not report on analyses of primary data (eg, is an editorial, letter to the editor, short communication, or study protocol).4 The full article is a review of literature.5 The article is a thesis.6 The study involves healthy participants.
Abbreviations: EBP¼ evidence-based practice; HVP¼ high-value physiotherapy.a Inclusion criteria 1-6 were applied to all publications during the screening process.Inclusion criteria 7 and 8 were applied (to publications meeting criteria 1-6) for the purposes of addressing questions 1 and 2, respectively, of the systematic review.[39][40]

Protocol and registration
Consistent with PRISMA requirements, the protocol for this systematic review was registered and made publicly available via Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Study selection
The study selection process is summarized in Figure 2. Results were downloaded into the Endnote X9 reference management software (Clarivate Analytics, Philadelphia, PA, United States) and transferred into the online platform Covidence (Veritas Health Innovation, Melbourne, Australia) with duplicates removed.Title and abstract screening was completed by 2 independent reviewers (C.D. and K.K.C.).A reference list search for included articles was completed by C.D. Full-text screening was completed by authors C.D. and K.K.C.Studies in which exercise and activity levels were the focus of treatment (eg, enhancing activity levels among patients or enhancing adherence to exercise) were included only if the program was led by a physiotherapist.Studies in which the sample of individuals comprised those with acute and chronic pain (and results were not reported separately) were excluded.Studies exploring feasibility / proof-of-concept of interventions were included.

Synthesis of studies
For the studies reporting on barriers and enablers, extraction of data themes and allocation to a domain of the COM-B/ TDF was completed by one author (C.D.) and cross-checked by a second author (P.R.).Disagreements were discussed until consensus was reached.Guidelines for use of the TDF 37 informed the identification and charting of themes, which was completed in the computer program Excel (Microsoft Corporation, Redmond, WA, United States).Overlapping narratives within studies (eg, where patients had reported multiple barriers to or facilitators of the implementation of HVP that were thematically consistent) were merged into common themes and qualitatively synthesized.Outcomes from the studies reporting on interventions were also qualitatively synthesized.

Results
Our search and subsequent screening yielded 23 studies. 24,41- 61,64Summary descriptive data are provided in Table 2 (studies of barriers and enablers) and Table 3 (studies of interventions).[55][56][57][58][59][60][61] One study reported on both.45 Across all studies, a range of patients experiencing chronic pain was represented, including patients with hip OA (n ¼ 3), knee OA (n ¼ 14), patellofemoral pain (n ¼ 1), CLBP (n ¼ 5), rheumatoid arthritis (RA) (n ¼ 1), and CNP (n ¼ 1).Three studies included patients with various (nonspecified) musculoskeletal complaints (Tables 2 and 3).  37 This fire demonstrates the domains of the Capability Opportunity Motivation-Behavior (COM-B) model (inner circle), as it articulates with the Theoretical Domains Framework of Behavior (TDF) on the outer circle.Via an a priori framework synthesis approach, the COM-B and TDF were used to synthesize themes arising from the qualitative studies included in the review.

Studies reporting on barriers and enablers
Of the 14 studies that investigated barriers to and enablers of HVP, alignment was found among 10 domains of the TDF and themes considered as barriers.Themes considered enablers aligned with 9 TDF domains.In total, 55 individual themes were identified as barriers and 40 as enablers.
Domains of the TDF that aligned with themes considered as barriers 1. Knowledge.One study among patients with knee OA 48 found that a lack of understanding of the benefits of exercise and uncertainty about what type and intensity of exercise to do were barriers to adherence.Patients also expressed uncertainty about how weight loss could be helpful for their condition.In patients with patellofemoral pain, 50 some understood that their chronic pain symptoms related to tissue damage, reflecting a biomedical understanding of their pain.Biomedically oriented beliefs about chronic pain have been associated with reduced treatment adherence and fearavoidant behaviors. 65. Memory, attention, and decision processes.One study of patients with CLBP reported that forgetfulness was a barrier to exercise adherence. 52Patients with hip and knee OA also reported difficulty remembering to do their exercises when not supervised. 45Among patients with various chronic pain conditions, 44 one patient reported ". ..I can only absorb one thing . . .Physical therapy for me would work if they taught one thing" (p.21).
3. Beliefs about capabilities.Barriers to exercise adherence reported by patients with knee OA 24 included "the willingness and ability to accommodate the exercises into everyday life" (p.134).One study among patients with back and neck pain reported that insufficient feedback from physiotherapists on exercise performance was a barrier, contributing to a lack of confidence to continue and fear of doing exercises incorrectly. 47Another study of patients with CLBP found that for older persons or those not accustomed to regular physical activity, the perceived burden of exercise (distinct from the time taken to do the exercises) is a barrier to adherence. 46ne patient reported that more than 3 or 4 exercises was too much for them to complete.
4. Optimism.In patients with knee OA, 24 prior health care experiences negatively influenced exercise adherence, including whether previous advice had provided a fatalistic prognosis.With regard to recommended weight loss, patients with knee OA 48 felt this was difficult because of challenges undertaking physical activity and nonmodifiable predisposing factors, such as genetic influences.With regard to resumption or maintenance of work, patients were concerned about potential symptom exacerbation.With regard to structured inperson exercise, patients with RA 51 were pessimistic about committing to programs of 6 weeks or longer, eg, "Twice a week for 6 weeks that's a lot . .." (p.267).

Intentions.
Two studies involving patients with CLBP 52 and hip and knee OA 45 reported that lack of motivation to engage in exercise was a barrier.
6. Beliefs about consequences.Perceived severity was a barrier to exercise adherence among individuals with knee OA. 24 Conversely, one patient reported that they had ". . . got nothing to complain about" (p.135), which also attenuated exercise compliance.Patients were less likely to adhere to exercise if they thought that their condition was caused by nonmodifiable factors, such as age or degenerative changes.Perceived efficacy also influenced exercise adherence: If the treatment was perceived as helpful, adherence was increased, and vice versa.This was a recurring theme in 3 studies involving patients with CLBP 46,47,52 and CNP. 47With regard to patient-reported outcome measures (PROMs), patients thought some aspects were irrelevant, and the prospect of this information being shared with third parties such as insurers was a concern. 53One study of patients with CLBP 46 found that unhelpful or false beliefs (underpinning a fear of movement) were a barrier to exercise.Exercise complexity was a  1 and 2.
barrier for some patients, relating to fear of hurting themselves when unsupervised.This theme also emerged in patients with hip and knee OA and RA. 45,48,51With regard to recommendations to resume or continue exercise, patients with knee OA recognized the importance of this but lacked an understanding of what benefits are associated with it. 48atients with RA reported a preference for exercise programs to commence 6 months after diagnosis to ensure their symptoms were well managed by a stable medication regimen. 51ome patients with patellofemoral pain described an expectation that they would receive hands-on treatment, rather than self-managed exercises. 50Patient expectations (in terms of the treatment modality and effects) are known to influence results for persons with chronic pain, 66 and the need for clinicians to navigate patient expectations has been recognized. 66,67. Reinforcement.Pain subsequent to exercise was a barrier to adherence among patients experiencing CLBP 48 and knee OA. 46 Patients with knee OA expressed frustration that their medication regimen did not provide sufficient pain relief to allow adequate physical activity levels. 48. Emotion.One study of patients with CLBP 46 found that they experienced exercise programs as boring and repetitive.Despondency subsequent to longstanding symptoms, depressive symptoms, and lack of motivation were also considered barriers to adherence. 46Furthermore, transitioning from a supervised to a home-based exercise program resulted in feelings of abandonment from reduced follow-up and communication with clinicians. 46. Social influences.A lack of social support and perceived stigma associated with their condition were barriers to exercise adherence among patients with CLBP. 46Platforms such as social networks and forums to enhance adherence were explored in this study, which for some patients were considered a barrier because of confidentiality concerns. 46Another study of patients with CLBP 41 reported that fragmented care, including insufficient interprofessional communication, was perceived as a barrier to care.Patients described a lack of formal referral between their general practitioner (GP) and physiotherapist, which for some was only done when prompted by the patient. 41Patients also described feelings of anger when no further options or onward referrals were made available to them if they were unresponsive to treatment.Lastly, patients described lack of trust in their physiotherapist as a barrier to reaching agreement on treatment options. 41One patient reported: ". . .I felt like he was doubting me the whole time and he didn't believe that I was truly injured" (p. 7). 41nother study of patients with CLBP 42 reported that a lack of connection between patient and physiotherapist was a barrier, with one patient stating, "The person that I had wasn't really giving me their full attention 'cause she was off doing other things, making phone calls" (p. 6). 41One study of patients with knee OA 48 reported that physiotherapists prescribed exercises didactically, in contrast to recommendations for  1 and 2.
b Technology-enabled telephone-based coaching utilizing a "Fitbit Flex" wearable activity tracker.c Application comprising option for use on smartphone and remote user support.
Pain Medicine, 2024, Vol. 25, No. 2 shared decision-making with patients. 68Patients with RA from one study 51 indicated that exercising in groups (ie, the social context) was a deterrent.One patient reported that: ". . .all we did was sat around and talked about what was wrong with us" (p.268). 510.Environmental context and resources.A study of patients with CNP and CLBP 47 reported that exercise adherence was hampered if programs took too much time to complete.This theme also emerged from patients with knee OA 24 and CLBP. 46,52Some patients also thought that using PROMs reduced treatment time. 53Lack of access to physiotherapy services and cost were barriers arising from 3 studies of patients with various chronic pain (various conditions), CLBP, and knee OA, respectively. 41,43,44In one study, one patient reported, "They only allowed you a total of six visits of physical therapy . . .Without the coaching I just can't make myself do it alone" (p.21). 44Similarly, patients with knee OA often stop attending physiotherapy because of cost. 43mains of the TDF that aligned with themes considered as enablers 1. Knowledge.Patients with CLBP and CNP 47,52 reported that a clear explanation of their condition and treatment rationale was an important motivator of exercise adherence.One study of patients with patellofemoral pain reported that patients expected answers about what was causing their pain. 50Lastly, with regard to exercise programs, patients with RA valued the inclusion of an educational component on medications and how to manage symptoms of pain and fatigue. 51. Behavioral regulation.Patients with knee OA from one study 64 valued a specific exercise plan with explicit parameters and with clear goals related to their function and symptoms.
3. Beliefs about capabilities.The ability of patients to integrate exercise into day-to-day life was (if positive) considered an enabler of adherence among patients with both knee OA and patellofemoral pain. 24,50Among those with patellofemoral pain, a greater internal locus of control was important for exercise adherence, which was fostered by the provision of a manageable single-exercise program. 50Patients with CLBP 42 reported feeling empowered by a combination of exercise and education.
4. Optimism.Patients with CLBP 52 valued the positive influence of exercises on functional activities such as walking and standing.Patients with RA 51 reported that learning of others' positive experiences of a structured in-person exercise program could promote adherence.
5. Goals.With regard to structured in-person exercise programs, patients with RA 51 reported that patient-centered goal setting was important so as to avoid "taxing goals being imposed by professionals and peer pressure" (p.269).The importance of tracking individual progress and goal setting was also echoed by patients with hip and knee OA, for whom competition with oneself served as a motivator. 45. Beliefs about consequences.Patients experiencing severe pain or functional impairment from knee OA were more likely to have greater adherence to exercise. 24This related to the perceived efficacy of exercises, which was also an important influence on adherence among individuals with CNP and CLBP. 47Two studies of patients with CLBP also identified that exercise efficacy (ie, symptom management, functional gains, or as a preferred treatment over others) was an important influence on adherence. 46,52Patients with hip and knee OA were motivated to complete exercises if it was likely to prevent the need for surgical intervention. 45With regard to engagement with physiotherapy generally, perceived efficacy was an important factor reported in one study of individuals with various chronic pain conditions. 44Among patients with patellofemoral pain, 50 treatment expectations reportedly influenced exercise adherence (ie, greater adherence if patients expected exercise as part of their treatment).With regard to PROMs, one study 53 reported that patients viewed them as worthwhile and thought they aided the physiotherapist with assessment and diagnosis.Although some patients expressed concern about their PROM data being shared with third parties, others thought this might have some merit from a quality improvement perspective.
7. Reinforcement.One study involving patients with CLBP 46 found that symptom relief after exercise was an enabler of adherence.Furthermore, patients reported that exchange tools such as social networks and forums were likely to increase exercise adherence, if led by a professional who could answer questions. 46Patients reported that gaming technology was likely to enable exercise adherence, particularly if feedback on performance was provided. 46. Social influences.With regard to PROMs, 53 patients found that they enabled communication with the physiotherapist, ie, if they were new patients or returning patients with a new problem.One study of patients with knee OA 64 reported 3 themes that enabled exercise adherence, including review of progress with the physiotherapist with regard to pain, function, and exercise technique, as well as follow-up consults more than 3 months after the initial session to check on progress.Patients with knee OA also recognized the importance of communicating their needs and expectations to the physiotherapist, 48 and they valued personalized care. 43Rapport and trust in the physiotherapist were also themes among patients with CLBP 42 and knee OA. 43 One patient with CLBP 42 reported, "I was able to talk to them openly . . .I was able to just let them know when I was in pain.They didn't judge me" (p. 6).Patients with RA 51 valued exercising in a safe and supportive environment with social support and also found that telephone-based support fostered motivation and engagement.This was also the case for patients with hip and knee OA. 45 One study among patients with CLBP 41 reported that timely referral (be it to a physiotherapist from a GP, or onward referral to a different physiotherapist if not progressing) was an enabler of more effective management of their condition.
9. Environmental context and resources.Patients with CLBP reported that keeping the exercises simple (and with no additional equipment) was important for ease of implementation. 52Engaging in a structured exercise program also enabled adherence for some of these patients.Patients with RA reported that accessibility of location was important for adherence to a structured in-person exercise program. 51

Studies reporting on interventions
Ten studies reported on interventions aimed at enhancing implementation of HVP, 9 of which aimed to improve exercise adherence (Table 3).Four of these studies used telephonebased coaching, 49,57,59,60 2 of which were technology enabled (ie, included the use of an activity tracker).Two studies used messaging services, 55,61 and 3 used software applications (1 online and 2 smartphone). 45,54,58One study aimed to facilitate EBP through the implementation of a structured model of care for patients with OA, delivered by physiotherapists and GPs. 56our of the intervention studies were randomized controlled trials that tested the efficacy of interventions to enhance the effectiveness of prescribed exercises for persons with knee OA 54,55,57 and upper-or lower-limb musculoskeletal complaints. 58Interventions comprised applications (smartphone and online), 54,58 telephone-based coaching, 57 and messaging services. 55Final intervention follow-up time frames varied in these studies from 4 weeks 58 to 18 months. 55Each of these studies reported improvements in exercise program adherence among intervention groups (compared with controls) up to 6 months' follow-up.One study 57 reported adherence outcomes beyond 6 months (ie, at 12 and 18 months), and no difference was observed between the intervention group and the control group.Functional outcomes were also reported in each of these 4 studies.Functional outcomes favoring the intervention group over the control group were observed in only one of these studies, at 4 weeks' follow-up. 58ain outcomes were also available for 3 of these randomized controlled trials. 54,55,57Pain outcomes favored intervention groups at 6 weeks' follow-up in one study, 54 though no difference was observed between intervention groups and control groups when measured at 6 months, 55,57 12 months, and 18 months. 57f the remaining 6 intervention studies, one was a proofof-concept study of technology-enabled counseling, 60 one was a feasibility study of technology-enabled counseling, 59 and one was a pilot study of a reminder system via multimedia messaging service. 61Each of these studies (aiming to enhance exercise adherence) reported positive outcomes relating to the interventions in terms of preliminary efficacy and feasibility.One study (n ¼ 6) explored experiences of patients with hip and knee OA in using a smartphone application through a participatory study design. 45This study found that the absence of physiotherapist observation, input, and encouragement was a barrier, whereas competition and exercising in a group were enablers.One pilot study 61 comprising 14 individuals with knee OA tested the effectiveness of a multimedia message reminder system (in addition to 6 once-weekly group exercise sessions), compared with a control group who completed the same group exercise program.Preliminary efficacy was assessed through a range of functional, adherence, and pain-related questionnaires.Marginal improvements in adherence and function were demonstrated but were not statistically significant.Two studies investigated integrated care models, one aiming to facilitate exercise adherence of individuals with knee OA 49 and the other to improve the quality of care delivered to persons with hip and knee OA. 56 The former comprised a structured exercise program with five 30-minute consultations over a 6-month period, with up to 12 telephone coaching sessions.Patients in this study valued personalized care and genuine interest and attention, and they experienced a sense of accountability to their physiotherapist (and telephone coach).The second study of persons with hip and knee OA 56 comprised a randomized controlled trial of a structured treatment program that, for the intervention group (n ¼ 284), included a GP consultation and one exercise and education program with a physiotherapist.Both the GP and physiotherapist had received training on OA clinical guidelines.This was followed by up to 12 weeks of twice-weekly group-based exercise led by a physiotherapist.The control group (n ¼ 109) comprised usual care (eg, medication, referral to physiotherapy).Patients in the intervention group reported experiencing higher quality (as measured by the OsteoArthritis Quality Indicator questionnaire out of 100: mean difference ¼ 18.9, 95% CI 12.7-25.1;P < .001)than did those in the control group.

Risk-of-bias assessment of qualitative studies and randomized controlled trials
The risk-of-bias assessment found that 11 of the 14 qualitative studies included did not provide a statement about the researcher's cultural or theoretical position, whereas 13 did not report on the potential influence of the researcher on the respective study (Supplemental Table S3).Of the 8 randomized controlled trials, blinding of the individuals delivering treatment (to the assignment of treatment) was applicable to 5 of them.None of these 5 studies reported doing this (Supplemental Table S4).Blinding of outcome assessors was applicable to 7 studies.It was unclear from 3 of these studies whether or not this was done; one study did not do this (Supplemental Table S4).

Discussion
This review aimed to explore patient-related barriers to and enablers of, as well as interventions to enhance, the implementation of HVP for chronic pain.Our findings demonstrate that patients with chronic pain experience barriers to and enablers of engaging with HVP, which relate to multiple behavior change domains of the TDF.Barriers include cost and the patient's perception of treatment efficacy.Furthermore, barriers and enablers relate to the patient's beliefs (ie, of consequences and their own capability).Intervention studies predominantly focused on enhancing exercise adherence, for which efficacy was demonstrated.
There has been a significant amount of research on barriers to the implementation of HVP (and EBP) experienced by physiotherapists. 69,70Examples of barriers include workload and time pressure, 69,70 knowledge and skills, 70 and funding structures. 70,71Our review considers barriers from the perspective of patients, and similarly, there are multiple factors influencing their engagement with HVP.Perceived treatment efficacy is a notable barrier arising from the present review, given that patient outcomes underpin HVP. 16Previous research has evidenced improvements in perceived treatment efficacy through a multidisciplinary approach, inclusive of pain science education, psychologically informed care, and exercise-based physiotherapy management. 72Therapeutic alliance (ie, where the relationship between patient and clinician is characterized by empathy, rapport, collaboration, and trust and is nonjudgmental) is central to the delivery of such care, 73 which was also identified herein as a bidirectional influence on patient engagement.This is consistent with previous research, which provides evidence that a strong therapeutic alliance can contribute to active engagement from patients 74 and pain-related outcomes. 75ost also emerged from our results as a barrier to accessing HVP.Given that cost-effectiveness is a key component of HVP, 16 this is a significant finding.Hence, the value proposition of HVP treatments needs to be evident to patients to maximize their engagement.A patient's perception of health care service value is also grounded in trust. 76,77This again highlights the importance of the therapeutic alliance in terms of cultivating a perception of value (and hence, engagement) among patients with chronic pain. 78he importance of challenging unhelpful beliefs held by patients with chronic pain was highlighted by the review.Identified themes, including fear of movement and beliefs about the influence of nonmodifiable factors (such as "degeneration of joints"), indicate a need to incorporate approaches to address these.Behavior change principles have been integrated into 4 of the randomized controlled trials reviewed herein, to good effect in terms of improving exercise adherence. 54,55,57,58However, a recent broader review of mobile applications to facilitate exercise adherence 79 found limited integration of behavior change principles and mixed results in terms of improving adherence outcomes.Greater use of these principles in future interventions was suggested, which again might help to challenge unhelpful beliefs held by patients.In a previous study of physiotherapists, 60% reported that patient expectations of low-value treatments precluded implementation of higher-value treatments and that providing treatments counter to these expectations could adversely influence the therapeutic alliance. 71Although treatment expectations were reported as a barrier in one of our included studies, 50 this was not a dominant theme, and this contrasts with these earlier findings. 71This is an important finding that could influence the clinical decision-making of physiotherapists-suggesting that (in the presence of a strong therapeutic alliance) patients are amenable to HVP.
With regard to enablers of HVP, a significant amount of research has again explored these from the perspective of physiotherapists. 69,70Enablers include professional mentorship, 71 support networks, 71 and funding structures that support implementation of HVP. 70Although the literature reflects a focus on enabling physiotherapists to make clinical decisions congruent with HVP, our findings indicate that the process of clinical decision-making needs to be in collaboration with patients, incorporating their perspectives.Patients value rapport with and trust in their physiotherapist, as described herein, which seems an important conduit through which other barriers could be mitigated and the success of interventions optimized.
Exercise adherence was most commonly investigated among the intervention studies included in this review, reflecting the weight of evidence for exercise as an effective component of HVP for chronic pain. 20,22,80Our findings suggest that technology-based interventions are an encouraging approach to enhancing implementation of HVP, in terms of demonstrating efficacy for increasing exercise adherence.Among patients with hip and knee OA, this has previously been shown to improve pain, functional, and perceived efficacy outcomes. 81However, the 4 randomized controlled trials of interventions reviewed 54,55,57,58 demonstrate that improved adherence among intervention groups does not necessarily translate into improved pain and functional outcomes.Lack of effectiveness might reflect the challenges of implementing the optimal type and dosage of self-managed exercise programs. 82Aside from exercise adherence, the breadth and nature of the barriers reported herein, against the backdrop of the reviewed interventions, suggest scope to explore novel approaches to overcome them.
Although exploring terminology differences within the literature was not an aim of this review, we have observed the use of different terms relating to treatments that could be considered EBP or HVP.Examples include high-value, 41 evidence-based, 43 and high-quality. 43,53This might be because EBP is a component of HVP or because HVP recommendations were introduced in Australia only in 2015. 13This observation might also indicate that the term HVP has not yet infiltrated the vernacular of physiotherapists and researchers alike.This seems consistent with recent work, which posits that recommendations seeking to foster HVP have lacked industry-based impact. 19

Strengths and limitations
Studies pertaining to hip or knee OA and CLBP are highly represented compared with other chronic pain conditions, and hence, our findings need to be considered in this context.Furthermore, having included studies of different chronic pain conditions from various settings could have influenced the barriers and enablers reported.
The risk-of-bias assessment demonstrated that the majority of the qualitative studies did not provide a statement on the researcher's cultural or theoretical position or on the potential influence of the researcher on the study itself, which might have impacted the interpretation and presentation of findings.Furthermore, with regard to the randomized controlled trials, blinding of the individuals delivering treatment and outcome assessors was not done or reported in several studies, which could have introduced bias.
Our review of 4 randomized controlled trials predominantly comprised individuals with knee OA, and hence, the most reliable evidence we have reported on pertains mainly to this population.Notably, only one study involved patients with CNP, which, given that CNP is a cause of significant individual and societal burden, 83 indicates a need for further research into this area.Although some chronic pain conditions share common influences on patient engagement with HVP, as shown here, there appears to be a need to better understand this in relation to patients experiencing CNP because of the related comorbidities, such as dizziness, 84 migraine, 85 and whiplash-associated disorders. 86tudies focusing on exercise adherence are also highly represented in this review, which, given the weight of evidence supporting exercise therapy for management of chronic pain, [20][21][22] is a strength.Furthermore, the use of the TDF in our framework synthesis approach is also a strength of this review and provides a construct from which influences on patient engagement with HVP can be understood.This also provides a reference point for future development of interventions seeking to enhance implementation of HVP.Another strength of our review is the focus on HVP.This aligns with the strategic direction of industry stakeholders, such as the Australian Physiotherapy Association 18 and American Physical Therapy Association, 87 and hence, this review contributes to a deeper understanding of this concept in the context of patient-related experiences.

Conclusion
This review shows that patients with chronic pain experience barriers to engaging with HVP, which include the nature of their interaction with their physiotherapist, the perceived efficacy of treatment, and cost.Furthermore, consideration needs to be given to patients' beliefs in order to optimize their engagement with HVP.Patient-related interventions have predominantly aimed to increase adherence to exercise through the use of technology, and they have demonstrated moderate effectiveness.Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain conditions.Doing so could enhance patient engagement and optimize their treatment outcomes.

Figure 1 .
Figure 1.The articulating domains of the COM-B model and TDF. 37This figure demonstrates the domains of the Capability Opportunity Motivation-Behavior (COM-B) model (inner circle), as it articulates with the Theoretical Domains Framework of Behavior (TDF) on the outer circle.Via an a priori framework synthesis approach, the COM-B and TDF were used to synthesize themes arising from the qualitative studies included in the review.

Figure 2 .
Figure 2. Flow chart representing the process of selecting the included studies.This figure demonstrates the study selection process completed for this review after systematic search of the APA PsycInfo, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scopus, and PEDro databases.The central text boxes in the figure denote each stage of the study selection process and the numbers of studies carried forward to each subsequent stage.The adjacent text boxes show the number of studies excluded at each stage and the reasons for doing so.

Table 2 .
Included studies reporting on barriers to and enablers of high-value physiotherapy.

Table 3 .
Included studies reporting on interventions to enhance implementation of high-value physiotherapy.