Introduction

Globally, the prevalence of chronic disease is high. In Australia in 2020–21, 79% of all Australians had a chronic condition with 47% reporting one or more chronic conditions [1]. The burden of disease changes over the life course, increasing in people aged over 45 [2]. The chronic conditions contributing to greatest burden of disease in 2018 were coronary heart disease, back pain and musculoskeletal problems, dementia, and lung cancer [2]. Many of these conditions are amenable to evidence-based allied health interventions, especially musculoskeletal issues and respiratory conditions. There is a higher prevalence and burden, of these chronic diseases in Aboriginal and Torres Strait Islander people compared to other Australians and considerable geographic variation [3].

Most people with chronic conditions are managed by their general practitioner (GP) with approximately 70% of Australian GP encounters primarily associated with the management of chronic conditions [4]. Of those who present with at least one chronic condition, more than two thirds have multimorbidity [5]. Primary care in Australia is healthcare that people seek in the community from a GP, allied health professional, or nurse and it is a fee for service model. The Enhanced Primary Care (EPC) package was introduced in 1999 and extended in 2005 with the introduction of the GP Management Plan (GPMP) and Team Care Arrangement (TCA) to support Australian GPs to better manage people with chronic conditions. These plans aimed to facilitate Medicare subsidised longer appointments and multidisciplinary team care, the TCA provides subsidies for five allied health visits per year with allied health professionals such as physiotherapists, exercise physiologists, occupational therapists, dietitians, or podiatrists. Medicare-subsidised group interventions for people with type-2 diabetes by exercise physiologists, dietitians and diabetes educators were introduced in 2007 to further support multi-disciplinary team care [6].

There has been a steady increase in uptake of the TCA item numbers since their introduction in Australia, with an associated improvement in health outcomes, however care remains poorly co-ordinated with limited information sharing between the service providers and is expensive for the patient [7]. The proportion of people with a GPMP or TCA who claim an allied health item in the subsequent 12-months, has steadily increased from 4% in 2006 to 21% in 2014 [8]. In 2021–2022, 37% of Australians had claimed Medicare subsidised allied health service. Physiotherapy and podiatry [8,9,10] have had the highest uptake of the TCA item numbers, particularly for those aged 80–84, with diabetes, more severe physical limitations, and from low socioeconomic status background. The Medicare data for allied health group services (only available for exercise physiologists and dietitians) have shown a steady increase since 2007 for exercise physiology, but minimal uptake of the items for diabetes educators and dietitians [11]. In 2016, one in three people with a chronic condition had used a general practice chronic disease management item number, but only one in five had used an associated allied health item number [12]. There is a need to ensure affordable access to allied health to optimise health outcomes and reduce the burden on the health system.

Current evidence suggests that access to allied health interventions in Australian primary care results in a reduction in hospital admissions and emergency department use [10]. Those people with five or more physiotherapy claims in the previous 12-month period had a statistically significant reduction in both potentially preventable hospital admissions of 21% and emergency department use of 17% [10]. Increasing access to evidence-based allied health interventions by expanding the range of group allied health interventions subsidised through Medicare is potentially a cost-effective option to improve health outcomes and reduce demands on hospital services. Therefore, the aim of this umbrella review was to determine the effectiveness of allied health group therapy services to improve the health-related outcomes for community dwelling adults with one or more chronic conditions.

Methods

An umbrella review of systematic reviews provides an overview of systematic reviews and was the chosen methodology because of the large number of systematic reviews on group allied health interventions [13]. The review was commenced prior to the publication of the Preferred Reporting Items for Overviews of Reviews (PRIOR) statement [14] and was informed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [15].

A search of Medline, Embase, Scopus, AMED, JBI Database of Systematic Reviews, Cochrane Database of Systematic Reviews, Database of Abstracts or Reviews and Effects (DARE) and PROSPERO was conducted from 2000 up until July 2022. (Supplementary File 1). The review was registered with PROSPERO (CRD42022324827).

Inclusion criteria

Published systematic reviews synthesising quantitative data with meta-analysis or narrative synthesis were included. The systematic reviews were eligible if they included randomised controlled and/or quasi-randomised controlled trials. Where there was a Cochrane Systematic Review and associated co-publication from the same Cochrane review, only the Cochrane Systematic Review was included. Only reviews published in English from 2000 to 2022 were included. The choice to only include English language is justified. The evidence shows that inclusion of studies published in other languages rarely changes the result [16].

Population

  • Community dwelling adults ≥ 18 years.

  • With at least one of the following long-term health conditions (from the eligibility for Medicare subsidised GPMP and TCA) :

    1. 1.

      Chronic respiratory disease (chronic obstructive pulmonary disease (COPD), bronchiectasis, asthma).

    2. 2.

      Cancer.

    3. 3.

      Cardiovascular disease (hypertension, coronary heart disease, heart failure).

    4. 4.

      Diabetes (Type 1 and 2).

    5. 5.

      Chronic kidney disease.

    6. 6.

      Musculoskeletal conditions (osteoarthritis, back pain, high risk of falls).

    7. 7.

      Chronic stroke.

Intervention

Data from systematic reviews were included if:

  • An intervention that was or could be delivered by an appropriately credentialed allied health professional and was either delivered as a group program or could be delivered in a group format.

  • The intervention were delivered by an allied health professional who was eligible to provide Medicare subsidised services for people with chronic conditions in Australia [15]:

    1. 1.

      Aboriginal health worker / Torres Strait Islander health practitioner.

    2. 2.

      Audiologist.

    3. 3.

      Chiropractor.

    4. 4.

      Diabetes educator.

    5. 5.

      Dietitian.

    6. 6.

      Exercise physiologist.

    7. 7.

      Occupational therapist.

    8. 8.

      Osteopath.

    9. 9.

      Physiotherapist.

    10. 10.

      Podiatrist.

    11. 11.

      Speech pathologist.

    12. 12.

      Genetic Counsellor.

  • The group intervention was delivered to > 1 person at a time in a clinic or, community setting or via telehealth. Where the review contained individual and group programs, the review was excluded unless the group program results were presented separately.

  • For walking training intervention: data were included if the walking training was prescribed and supervised, i.e., studies of advice about walking were excluded.

Comparator

  • Comparator: any comparator, including home programs.

Outcomes

  • The review reported any outcomes listed in Table 1. The primary and secondary outcomes from the included reviews were grouped according to the International Classification of Functioning, Disability and Health (ICF) framework [17].

Table 1 International Classification of Functioning, Disability and Health (ICF) framework
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Exclusion criteria

Systematic reviews and meta-analyses were excluded if:

  • They were adults living in residential aged care or currently admitted to hospital.

  • The intervention was provided in an in-patient setting or was a home-based program.

  • The intervention or comparator were provided by psychologists or pharmacists (because these are funded by different schemes in Australia) [18].

  • Systematic review protocols were excluded.

Screening and quality assessment

All titles and abstracts were screened by one reviewer (SD) with other authors (JA, WK, GN, KR, AW) screening a sample each using Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). Full-text articles were reviewed by one reviewer (SD), with other authors (JA, WK, GN, KR, AW) screening a sample each. Team discussions addressed cases of uncertainty and disagreements were resolved by two reviewers (WK and SD). Data were extracted by one reviewer (SD) and summary tables checked by all reviewers. Where there were multiple reviews on the same type of group intervention, the list of included studies of the older systematic reviews were checked against those of the more recent reviews. Data were not extracted from the older reviews if the majority of studies were included in the more recent systematic reviews.

Risk of bias assessment

The included systematic reviews were assessed using the AMSTAR 2 tool [19]. A summary of the risk of bias assessment of included trials reported in the systematic review was also extracted.

Strategy for data synthesis

It was not possible to perform a meta-analysis of the included reviews because of the diverse range of reviews included. The included systematic reviews were grouped according to condition, type of group intervention, and chronologically. The quantitative findings for each included systematic review were presented in a summary format [20]. The outcomes reported in the systematic review were presented using a traffic light system, see Table 2.

Table 2 Summary of traffic light system
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Results

A total of 2385 articles (2381 studies) were identified. Once duplicates were removed 2220 studies were screened, 507 full text systematic reviews were screened and a total of 154 systematic reviews were included (see Fig. 1). From these 154 reviews, data were extracted from 90 reviews (see Table 3 for a summary of the included and extracted reviews and Supplementary File 2 for a reference list of reviews not extracted). A summary of the extracted reviews are presented in Supplementary File 3 and the detailed summary of all extracted reviews is available in Supplementary file 4.

Fig. 1
figure 1

PRISMA flowchart

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Table 3 Summary of the number of systematic reviews identified and extracted for each chronic condition
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Most of the included systematic reviews reported on the outcomes for group exercise programs. A small number (n = 11) were included that reported on the effectiveness of group lifestyle education and dietary advice.

Cancer

Data were extracted from 15 systematic reviews [21,22,23,24,25,26,27,28,29,30,31,32,33,34,35]. Group exercise programs consisting of 50 to 60 min, two to four times per week for 9 to 19 weeks were effective in improving body composition, physical function, cardiovascular fitness, sleep quality and fatigue in people with a range of cancers [21, 22, 24, 27, 28, 30, 32,33,34,35]. The design of group programs and prescription of exercise is in scope for exercise physiologists and physiotherapists.

Examples of effective exercise interventions for people living with cancer included prescribed gym-based resistance [21, 23] or aerobic exercise training [22] or both [24, 27,28,29,30,31,32,33,34,35]; and prescribed walking programs [22].

Cardiovascular disease

Data were extracted from six systematic reviews [36,37,38,39,40,41]. Group exercise programs consisting of 60 min, two to three times per week for 12 weeks were effective for reducing cardiovascular mortality, hospital admission and improving exercise capacity and some physiological measures [36,37,38,39,40,41]. Effective exercise interventions were prescribed to ensure the participants were exercising at a moderate intensity (≥ 60% heart rate maximum (HRmax)). Group centre-based exercise programs had similar outcomes to equivalent home-based programs with regular telephone support. The design of group programs and prescription of exercise is in scope for exercise physiologists and physiotherapists.

Chronic conditions (mixed)

Data were extracted from three systematic reviews which included people with chronic conditions in general [42,43,44]. There is not clear evidence for the effectiveness of group self-management education delivered by allied health [42], and group upper limb resistance training for the management of general chronic conditions to improve postural tremor [44].

Chronic kidney disease

Data were extracted from one systematic review. There is limited evidence regarding the benefits of dietary interventions that focus on diet quality and are delivered by dietitians in relation to outcomes associated with chronic kidney disease [45].

Chronic low back pain

Data were extracted from 12 systematic reviews [46,47,48,49,50,51,52,53,54,55,56,57]. Group exercise programs delivered over a period of eight weeks (interquartile range (IQR) 6 to 12) for a median total duration of 12 h (IQR 8 to 20) were effective for reducing pain intensity and functional limitation associated with chronic low back pain. It was unclear whether the addition of self-management (education, booklets) or psychological approaches (Cognitive Behavioural Therapy (CBT), relaxation techniques) conferred additional benefit [48, 53, 54]. The design of group programs and prescription of exercise is in scope for chiropractors, osteopaths and physiotherapists.

Two network analyses [56, 57] identified the most effective exercises for different outcomes in the management of low back pain, but not whether exercises were provided in group format. However, the following could be delivered effectively in a group format:

  • Group exercise to reduce functional limitation (physical function, return to work, sick leave) include McKenzie exercises, Pilates, exercise that focuses on restoration exercises, flexibility, resistance and stabilisation, water-based exercise, and yoga.

  • Group exercise to improve mental health associated with low back pain (resistance and aerobic training).

Chronic lung disease

Data were extracted from eight systematic reviews [58,59,60,61,62,63,64,65]. A group exercise program consisting of 45 to 60 min, 1 to 3 times per week for 8 to 12 weeks, was effective for improving exercise capacity, quality of life and reducing the number of hospital admissions for people living with chronic asthma or chronic obstructive pulmonary disease (COPD) [58, 59, 61, 64, 65]. The design of group programs and prescription of exercise is in scope for physiotherapists and exercise physiologists.

An exercise program that combined aerobic exercise and resistance training was the most effective [58, 61, 64, 65] for improving quality of life, exercise capacity and reducing hospital admissions. There was weak evidence for the effectiveness of group programs of resistance training only, compared to control of no exercise training for improving quality of life or exercise capacity [59].

There was no evidence of effectiveness for stand-alone self-management education programs in increasing quality of life or self-efficacy [62]. There was no evidence of effectiveness of relaxation programs delivered by a physiotherapist in reducing anxiety for people living with a chronic lung disease [60].

Diabetes

Data were extracted from 14 systematic reviews [66,67,68,69,70,71,72,73,74,75,76,77,78,79]. A group exercise program consisting of 45 to 60 min, 3 times per week for 12 to 16 weeks, was effective for improving glycaemic control and blood lipids (See supplementary Table 5 for details). Exercise at higher intensity was more effective compared to lower intensity exercise at improving functional outcomes, aerobic fitness and glycaemic control [66, 71,72,73,74,75,76,77,78,79]. The design of group programs and prescription of exercise is in scope for exercise physiologists and physiotherapists.

Two network analyses comparing different types of exercise ranked the exercise modalities in terms of their effectiveness on glycaemic control [75, 78]. The exercises with the most effect on glycaemic control were supervised combined aerobic and resistance training, followed by supervised aerobic or resistance training separately. For weight loss, supervised aerobic and resistance training, either combined or separately, were effective.

Culturally tailored group education (from 1 to 30 h in total) was effective in improving glycaemic control for people from culturally and linguistically diverse backgrounds [67, 70]. This is in scope for dietitians. There was insufficient evidence regarding whether education tailored to the prevention of foot ulceration was effective [69]. The design of group programs is in scope for podiatrists.

Lifestyle intervention including dietary advice and exercise plus at least one other lifestyle intervention showed some improvement in glycaemic control at the end of the intervention but was not sustained beyond this [68]. The design of group programs is in scope for dietitians, exercise physiologists, and physiotherapists.

Heart failure

Data were extracted from nine systematic reviews [80,81,82,83,84,85,86,87,88]. A group exercise program consisting of 45 to 60 min, 3 times per week for 10 to 14 weeks was effective for improving aerobic fitness and quality of life, but there was no evidence of impact on mortality [80,81,82,83,84,85,86, 88]. The design of group programs and prescription of exercise is in scope for physiotherapists and exercise physiologists.

High risk of falls

Data were extracted from five systematic reviews [89,90,91,92,93,94]. A group exercise program consisting of 45 to 60 min, 1 to 3 times per week for 12 to 30 weeks was effective in reducing the number of falls and rate of falls in older people who were at a high risk of falls [90,91,92, 94]. The design of group programs and prescription of exercise is in scope for exercise physiologists, physiotherapists, occupational therapists, and osteopaths. There was evidence that programs delivered by trained health professionals such as physiotherapists and exercise physiologists were more effective than those provided by a non-health professional (e.g. fitness trainer) [91].

A network analysis [93] indicated that a group exercise class should contain exercises that focus on: anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility.

Hypertension

Data were extracted from four systematic reviews [95,96,97,98]. A group exercise program consisting of aerobic exercise, 45 min, 3 times per week, improved aerobic fitness and both systolic and diastolic blood pressure in adults with hypertension [95, 96, 98]. The design of group programs and prescription of exercise is in scope for exercise physiologists and physiotherapists.

Osteoarthritis

Data were extracted from six systematic reviews [49, 99,100,101,102,103]. A group exercise program consisting of 45 to 60 min, 1 to 3 times per week for 12 to 16 weeks was effective in reducing pain and increasing physical function in people with osteoarthritis of the hip or knee.

Examples of effective exercise interventions for osteoarthritis included: prescribed gym-based resistance and aerobic exercise; prescribed walking programs; and conditioning exercises [100,101,102,103]. Group physiotherapy programs were comparable in effectiveness to individual physiotherapy programs for pain reduction and increased physical function for people with osteoarthritis [49]. The design of group programs and prescription of exercise is in scope for physiotherapists and exercise physiologists.

Stroke

Data were extracted from eight systematic reviews [104,105,106,107,108,109,110,111]. A group exercise program (or interventions that can be provided in a group setting consisting of 20 to 60 min, 1 to 3 times per week for between 12 weeks up to six months was effective in improving function in people living with chronic stroke. In particular, walking speed and endurance, balance, function, and aerobic fitness improved with a range of exercise modalities [104, 106, 109,110,111].

Motivational interviewing and counselling, as well as individualised physical activity counselling may increase participation in physical activity longer-term [106]. The design of group programs and prescription of exercise is in scope for physiotherapists and exercise physiologists.

Risk of bias

The quality of the evidence included in the systematic reviews was moderate as determined by the different assessment tools used. The most commonly used assessment tools were the Cochrane Risk of Bias tool and the Physiotherapy Evidence Database (PEDro) scale. The factors that influenced the overall quality scores were lack of blinding of both the participants and the clinicians delivering the intervention, which is unavoidable in randomised controlled trials of human delivered interventions. The quality of the systematic reviews as measured by the AMSTAR score ranged from 3–14 out of 16, with a mean of 9 indicating moderate quality systematic reviews [19]. The main issues identified by the AMSTAR checklist were that some authors did not include a list of excluded studies, reasons for exclusion (usually exclusions only published in Cochrane reviews) and funding sources of the included studies. If authors did not conduct a meta-analysis their review received a lower score because several AMSTAR items relate to the conduct of meta-analysis.

Discussion

The majority of the 90 included systematic reviews addressed group exercise delivered by an allied health professional as an intervention for the management of a range of long-term chronic conditions, and a small number addressed lifestyle education, dietary advice and self-management support. Overall, group exercise programs, with individualised assessment and tailored exercise prescription by a suitably qualified allied health professional were found to be effective in improving health outcomes for community dwelling adults with a broad range of chronic conditions. Lifestyle education and support for people with type-2 diabetes was effective, especially for adults from culturally and linguistically diverse backgrounds.

Overall, the findings presented in Table 1 support group exercise of 45 to 60 min per session, two to three times per week for 12 weeks for community dwelling adults experiencing a range of long-term conditions. These findings support published Australian clinical practice guidelines that recommend prescribed exercise as a key component of management, including the COPD-X guidelines [112], Royal Australian College of General Practitioners guidelines for arthritis [113], Australian Commission on Safety and Quality in Health Care clinical standard for low back pain [114], falls prevention [115] and heart failure [116]. For many chronic conditions this type of intervention has been provided in the hospital outpatient setting, but uptake and attendance is often low [117]. In addition, the high service demands on the secondary care system results in many people referred to a group exercise program being placed on a long waitlist. Options for referral in the primary health care setting have been limited and expensive unless a person has access to private health insurance [118,119,120].

A key feature of all the group exercise programs was that each patient had a baseline assessment so that the exercise program could be prescribed and progressed according to their symptoms. This requires the input of health professionals who are trained in exercise assessment and prescription, and understand the impact of co-morbidities on the person’s ability to exercise safely at the intensity required. This is in contrast to more general group exercise programs delivered in the community which are still beneficial but not targeted specifically to address a person’s impairments. Those credentialed to provide exercise programs for people with chronic conditions in primary care are physiotherapists and accredited exercise physiologists. Once a patient has completed the group program and increased their exercise capacity, in most cases they should be encouraged, and ideally supported, to continue to exercise through suitable community-based options, for example Lungs in Action, Heart Foundation programs, or community falls prevention exercise programs.

Group programs delivering lifestyle education and support for people with type-2 diabetes, especially people from culturally and linguistically diverse backgrounds were found to improve patient outcomes. Whilst not explored in this umbrella review, research has shown that to facilitate patient engagement targeted strategies are an essential component of group programs to develop patient self-efficacy [121]. These strategies include shared decision making with the patient, using techniques such as motivational interviewing and counselling to identify goals and work with patients to overcome barriers to lifestyle modification in addition to the benefits of group settings. Furthermore, those programs developed for people from culturally and linguistically diverse backgrounds are more effective at improving HbA1c if they are culturally appropriate for the community [122]. There is limited evidence to support extension to people with chronic kidney disease [45].

Some of the included reviews evaluated the evidence for other forms of exercise such as Pilates, yoga and traditional Chinese exercises. These interventions can be provided by exercise physiologists and physiotherapists but are often provided by instructors who do not have an allied health qualification. These may be suitable maintenance options for patients once they have completed a prescribed group exercise program.

A strength of this review is that we set out to examine extensive evidence for group programs applicable to delivery by allied health clinicians in the community. However, a limitation is that the included reviews primarily addressed exercise interventions and did not always address the effectiveness of a group allied health intervention in the community and some reviews were excluded as data for inpatient and community programs could not be separated. Despite this, the results of the reviews addressing group exercise interventions are broadly consistent across the diverse range of conditions included. The narrative synthesis approach used does not allow us to explore the effect of potential confounding variables on the outcomes, further complicated by the fact that there was no consistency in the reporting of these variables in the included systematic reviews. This review only focused on interventions for adults with chronic conditions and interventions for people with mental health conditions were excluded because in the Australian system they are funded be different Medicare funding streams. A further limitation is that the database search was conducted in 2022 and there has been a considerable time lapse prior to publication which has reduced the currency of the information. The authors are currently working on an update of the umbrella review. However, the findings of the current review address a gap in the knowledge base concerning the effectiveness of group programs. There were also a number of studies that were included in multiple systematic reviews, where possible reviews were excluded if the majority of studies had been included in a more recent review, but some studies would still have been included in multiple reviews. There were very few systematic reviews included that reported the costs of the interventions, this information is important for policy makes with competing priorities to determine how to allocate scarce resources.

The interventions described in the included systematic reviews are complex interventions. They comprise multiple components such as exercises, education, interventions delivered by different types of health professionals, patient groups and in a range of settings and this context impacts effectiveness. There are frameworks for describing complex interventions including the MRC Complex Intervention Framework [123] and TIdieR checklist [124]. These frameworks are used when reporting the results of randomised controlled trials but less so when reporting the interventions in systematic reviews [125]. A limitation of this umbrella review is that the group allied health interventions summarised could not be described in detail using one of these frameworks without going back to the authors of the original randomised controlled trials. There is a need to better report complex interventions in systematic reviews of complex interventions.

In summary, this systematic review provides a comprehensive summary of group interventions, that could be delivered by allied health for a broad range of chronic conditions commonly managed in primary care. In Australia, group exercise programs, with individualised assessment and tailored exercise prescription by a suitably qualified allied health professional, are currently only supported by an MBS item number for people with, or at risk of, type-2 diabetes provided by exercise physiologists or dietitians. Extending this for people with cancer, cardiovascular disease, chronic low back pain, chronic lung disease, heart failure, high risk of falls, hypertension, osteoarthritis and chronic stroke and to include a wider range of allied health professionals is likely to realise health benefits. A key feature of the group exercise programs is that the person undergoes a suitable baseline assessment, and the exercise is prescribed according to the findings of the assessment and progressed during the program.