Personalisation in Physiotherapeutic Care: Insights from Developing and Evaluating a Stratified Blended Physiotherapy Approach for patients with neck and shoulder pain

Neck and shoulder complaints are among the most common musculoskeletal conditions treated in primary care physiotherapy. They often result in pain, functional limitations, reduced participation in daily activities, and substantial societal costs. With ageing populations, increasingly sedentary lifestyles, and rising levels of multimorbidity, the burden of these conditions is expected to increase. This highlights the need for physiotherapy approaches that are both effective and efficient, while also being tailored to individual patient needs.

This thesis investigated whether physiotherapy for patients with neck and shoulder complaints could be improved through a Stratified Blended Physiotherapy Approach (SBPA). The SBPA combines two innovations. First, stratified care aims to match treatment intensity and content to a patient’s risk of developing persistent disabling pain. Second, blended physiotherapy integrates face-to-face treatment with digital support tools when patients are considered suitable for this mode of care delivery. By promoting self-management and extending care beyond the clinic, this approach was expected to contribute to more personalised and efficient care.

The first part of the thesis focused on the development of the SBPA. Using a participatory design process, physiotherapists, patients, and experts collaborated to develop tailored treatment options for different patient subgroups. To support treatment delivery, a digital application and a paper-based workbook were created. Feasibility testing showed that patients generally considered the digital modules useful and easy to use. However, physiotherapists experienced difficulties integrating the digital tools into their daily practice, and the workbook was rarely used. These findings were used to refine the intervention.

The effectiveness and cost-effectiveness of the SBPA were subsequently evaluated in a multicentre cluster-randomised controlled trial in Dutch primary care physiotherapy. Patients receiving the SBPA were compared with patients receiving usual physiotherapy care. Both groups showed clinically relevant improvements in pain and disability over time. However, no statistically significant differences were found between the groups. Similarly, the economic evaluation showed no clear evidence that the SBPA was more cost-effective than usual physiotherapy. Although some indications of greater efficiency were observed among low-risk patients, these effects were small.

To better understand the implementation of digital physiotherapy, this thesis also included a qualitative systematic review of factors influencing the adoption of digital care for musculoskeletal conditions. Important facilitators included usability, flexibility, stakeholder acceptance, and organisational support. Key barriers included technical issues, workflow misalignment, privacy concerns, limited financial incentives, and variation in digital literacy.

Overall, the findings show that structured patient subgrouping and digital support do not automatically lead to better outcomes or lower costs. Physiotherapists in Dutch primary care already appear to personalise treatment to a considerable extent through clinical reasoning and shared decision-making. The thesis concludes that personalised physiotherapy is best viewed as an ongoing process of tailoring care to individual patients and their context. Digital tools can support this process, but successful implementation requires careful integration into routine practice, adequate professional support, and favourable organisational conditions.