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Room for improvement: a randomised controlled trial with nested qualitative interviews on space, place and treatment delivery
  1. Louise F Sandal1,
  2. Jonas B Thorlund1,
  3. Andrew J Moore2,
  4. Roger S Ulrich3,
  5. Paul A Dieppe4,
  6. Ewa M Roos1
  1. 1 Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
  2. 2 School of Clinical Science, University of Bristol, Bristol, UK
  3. 3 Department of Architecture, Chalmers University of Technology, Gothenburg, Sweden
  4. 4 Medical School, University of Exeter, Exeter, UK
  1. Correspondence to Louise F Sandal, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark; lsandal{at}


Objective Healthcare-oriented design in hospitals can promote better clinical outcomes. Creating optimal facilities may increase treatment effects. We investigated the influence of the treatment room on effects of exercise therapy.

Methods In a mixed-method randomised controlled double-blind trial, middle-aged individuals reporting knee or hip pain performed 8 weeks of exercise therapy in (1) a newly built physically enhanced environment, (2) a standard environment or (3) were waitlisted, receiving no intervention. Participants and therapists were blind to study aim. Primary outcome was participants’ Global Perceived Effect (GPE; seven-point Likert scale). Six nested focus group interviews with participants (n=25) and individual interviews with therapists (n=2) explored experiences of the environments.

Results 42 people exercised in the physically enhanced environment, 40 in the standard environment, 21 were waitlisted. Contrary to our hypothesis, the treatment response seemed greater in the standard environment for GPE (0.98, 95% CI0.5 to 1.4) than for the physically enhanced environment (0.37, 95% CI −0.2 to 0.9), between-group difference (0.61, 95% CI −0.1 to 1.3) did not reach statistical significance (p=0.07). Waitlist group reported no improvement (−0.05 95% CI −0.5 to 0.4). In interviews, participants from the standard environment expressed greater social cohesion and feeling at home. Qualitative themes identified; reflection, sense of fellowship and transition. Secondary patient-reported outcomes and qualitative findings supported the primary finding, while improvements in muscle strength and aerobic capacity did not differ between exercise groups.

Conclusion Results suggest that the physical environment contributes to treatment response. Matching patients’ preferences to treatment rooms may improve patient-reported outcomes.

Trial registration number identifier: NCT02043613.

  • joint pain
  • treatment delivery
  • context effect
  • physical environment

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  • Contributors LFS, JBT, RSU, PAD and EMR were all involved in the design of the study. All authors contributed to drafting the manuscript or revising it. LFS, JBT and EMR comprise the steering committee for the study. LFS was the trial manager and responsible for the coordinating and conducting the study. LFS recruited, screened and conducted all baseline and follow-up testing and is responsible for the accuracy of the data and data analysis. LFS, PAD and AJM designed the nested qualitative study, LFS performed all interviews, AJM supervised the qualitative data collection process, AJM and PAD contributed to the analysis of the qualitative data. All authors read, commented and approved the manuscript for publication.

  • Funding The trial was supported by The Swedish Research Council (2006-4129), the Faculty of Health at University of Southern Denmark, the research project Good Life with Osteoarthritis and the Danish Rheumatism Association (May 2013). The funding sources had no role in the design, execution, analyses, interpretation or submission of this study.

  • Competing interests None declared.

  • Ethics approval The Regional Scientific Ethical Committee for Southern Denmark.

  • Provenance and peer review Not commissioned; externally peer reviewed.