Background

Chronic pain is a complex condition that demonstrates better outcomes in multidisciplinary rehabilitation, typically delivered to groups of patients by tertiary healthcare teams. An inter-disciplinary pain management course for individual patients was developed to increase the scope of physical therapists working in primary care by integrating osteopathic manual therapy with psychological interventions from Acceptance and Commitment Therapy (ACT), a form of ‘3rd wave’ Cognitive Behaviour Therapy.

Purpose

The aim of this study was to explore the usefulness and feasibility of comprehensive vocational rehabilitation (C-VR) and less comprehensive vocational rehabilitation (LC-VR) for workers on sick leave due to CMP, from the perspective of patients, professionals, and managers.

Background. Medical Research Council (MRC) guidelines recommend applying theory within interventions to explain how behaviour change occurs. Guidelines endorse self-management of chronic low back pain (CLBP) and osteoarthritis (OA), but evidence for its effectiveness is weak. This literature review aimed to determine the use of behaviour change theory and techniques within group-based self-management randomised controlled trials for chronic musculoskeletal pain, including CLBP and OA. Methods. A two phase search strategy of electronic databases was used to identify systematic reviews and studies relevant to this area. Articles were coded independently for their use of behaviour change theory, and the number of behaviour change techniques (BCTs) was identified using a 93 item taxonomy, Taxonomy (v1). Results. 25 articles of 22 studies met the inclusion criteria, of which only three reported having based their intervention on theory, and all used Social Cognitive Theory. A total of 29 BCTs were coded across all articles with the most commonly identified techniques being ‘instruction on how to perform the behaviour’, ‘demonstration of the behaviour’, ‘behavioural practice’, ‘credible source’, ‘graded tasks’ and ‘body changes’. Conclusion. The findings demonstrate that theoretically driven research within self- management for chronic musculoskeletal pain is lacking, or is poorly reported and may partly explain the weak evidence surrounding its effectiveness, Future research that follows MRC and CONSORT guidelines regarding the use of theory and the importance of its reporting is warranted. Programmes should be theoretically based, and focus on comprehensive reporting of all trial aspects, including the basis of technique and theory selection. Conflicts of interest: No conflicts of interest. Sources of funding: This review was conducted as part of Health Research Award HRA_HSR/2012/24 from the Health Research Board of Ireland

Purpose of Study and Background. Population ageing will facilitate an increase in health problems common in older adults, such as musculoskeletal conditions. Musculoskeletal conditions are the fourth largest contributor to disease burden in older adults; affecting quality of life, physical activity, mental wellbeing and independence. Therefore primary care health services must provide appropriate and efficacious management and treatment. However there are a number of complexities specific to older adults that are essential to address. Methods and Results. In order to identify these complexities, a review of the background literature was undertaken in addition to a Patient and Public Involvement and Engagement (PPIE) session. The PPIE group consisted of eight older adults who experience chronic musculoskeletal pain. This session was used to discuss and explore what factors are important to consider in GP consultations for musculoskeletal pain for older adults, in addition to those identified through background literature. A number of factors were highlighted through these methods, including the difference in mood and aspirations for older adults; taking a holistic approach; the impact of comorbidities; whether the GP is listening and ‘on the same wavelength’, and older adults' expectations regarding their pain and the consultation. Conclusion. Management of musculoskeletal pain for older adults in GP consultations is complex due to a range of factors, reinforcing the importance of taking a holistic approach. The impact of these factors upon the experience and outcomes of GP consultations will be further explored through in depth interviews with older adults with musculoskeletal pain. Conflicts of interest. No conflicts of interest. Sources of funding. This PhD is funded as part of an ACORN studentship awarded by Keele University. This PhD is nested within the Treatment for Aches and Pains Study, funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1211-20010)

Background. Chronic musculoskeletal pain increases an individual's risk of developing many chronic diseases and the risk of all-cause early mortality. There is irrefutable evidence supporting the role of physical activity (PA) in reducing these risks. Sustaining changes to PA behaviours is challenging and efforts are needed to understand the barriers and facilitators of change. Understanding these factors is a vital step in developing behaviour change interventions. Objectives. Explore barriers and facilitators to engaging in PA in adults accessing pain services. Explore barriers and facilitators to promoting PA by healthcare professionals, exercise professionals and charity staff/expert patients. Methods. A qualitative study using the theoretical domains framework (TDF). Two focus groups were conducted with service users (n=18). Three focus groups were held with; healthcare professionals (n=8); exercise professionals (n=6) and charity staff/expert patients (n=8). Two independent reviewers thematically analysed transcripts. Barriers and facilitators were subsequently coded according to the domains of the TDF. Results. For all groups barriers were frequently mapped to the domain ‘environmental context and resources’. Although there was variation across the groups, barriers were also frequently mapped to the domains of ‘knowledge’, ‘beliefs about consequences’, and ‘belief about capabilities’. For service-users' facilitators were frequently mapped to ‘social influences’. Conclusion. The TDF was used to identify deficits that are likely to influence behaviours; targeted intervention strategies have been developed to specifically target these deficits. The interventions that have been developed consider not only the behaviour of those at whom the intervention is targeted, but also those involved in its delivery. No conflicts of interest. Sources of funding: This research was funded by the Public Health Agency, HSC R&D Division through a Doctoral Fellowship awarded to J Marle

Introduction. There has been a recent surge in the interest of the role of vitamin D in chronic musculoskeletal pain however there are limited studies that have investigated the link of vitamin D hypovitaminosis with low back pain. The aim of our study was to determine the prevalence of low vitamin D levels in patients who present with low back pain in an outpatient setting in the UK. Methods. Data was collected retrospectively from computerised databases of all patients who presented with low back pain from a single spinal consultant's outpatient clinic and have had serum levels of 25-hydroxycholecalciferol (25-OH vitamin D) requested. Data of these patients were collected from hospital electronic and paper records and analysed against their serum 25-OH vitamin D levels. Results. Data on 229 patients was collected over an 18 month period. 19.7% of patients presenting to the spinal outpatient clinics had severe 25-OH vitamin D deficiency (less than 15 nmol/L) compared to 2.6% of 3132 non-spinal outpatient clinic patients (p<0.001). However, the percentage of patients with deficient (15 to 30 nmol/L) but not severe deficiency was similar in both groups (37.6% versus 38.3%). There was no significant difference in the incidence of vitamin D deficiency whether a surgical or non-surgical pathology was present or not (p=0.62). Conclusion. We have found no link between vitamin D deficiency and low back pain in this study. Vitamin D deficiency is a common comorbidity in Leicester

Aims/background. Current treatment recommendations advocate various exercise modalities for people with chronic Low Back Pain (cLBP). 1. Walking appears to represent an inexpensive and readily accessible activity for a range of individuals, including those who were previously sedentary. However, the effectiveness of such interventions are uncertain in cLBP. Methods. A systematic review was undertaken to examine the effectiveness of walking interventions across a range of chronic musculoskeletal pain conditions, including LBP. Six electronic databases were searched for relevant studies. Data for pain and self reported function were extracted and where appropriate, results were pooled and analysed using RevMan (v.5). Results. Twenty studies with a total of 1852 participants (Mean: 96) were included in the review. Only two provided data for cLBP, Data from one of these was not analysed as only median values were reported. The remaining study found no effect in favour of the walking intervention for pain (mean difference = −0.50 [95% confidence interval = −16.23, 17.23]) with a moderate improvement in function (−22.56 [−40.84, −4.26]). For osteoarthritis, analysis revealed small to moderate differences for both pain (−6.23 [−11.22, −1.24]; n=7) and function (−10.90 [−20.61, −1.19]; n=5). Discussion. Despite the potential benefits associated with walking, results of this systematic review found limited evidence to support the use of such interventions for people with cLBP. Further studies where walking is the predominant component of an overall intervention and which closely monitor any associated adverse events are required

Background. Emerging research has indicated that ‘significant others’ (spouses/relatives) may have important influences on continued work participation for individuals with chronic non-specific musculoskeletal pain (CMP). In order to expand on this novel area of research, data from studies conducted in The Netherlands and the UK were assimilated. Method. In both studies, worker and significant other perceptions of pain self-efficacy, perceived partner responses to pain, pain catastrophizing, and contribution to work participation were explored in relation to the worker's CMP. In the Netherlands, questionnaire data were collected from workers with CMP and their significant others (n=103), and in the UK, in-depth semi-structured interviews were conducted (n=10). Appropriate quantitative and qualitative analysis techniques were applied. Results. In the Dutch study, moderate to high levels of perceived pain self-efficacy, moderate levels of significant other solicitous and distracting responses, and low levels of significant other punishing responses and catastrophizing were reported by both significant others and workers. Significant others were viewed as crucial in helping maintain continued work participation by workers with CMP. Overall group averages indicated no significant differences, with the exception of greater pain catastrophizing reported by significant others (14.4 versus 11.1 p<0.01), although this was not deemed clinically relevant (ES=0.34). Qualitative data from the UK study supports these findings, further elaborating on the above concepts. Conclusions. This study adds further weight to the evidence which recognizes the importance of social context for successful pain management and vocational rehabilitation interventions. Conflicts of interest: No conflicts of interest. Sources of funding: Funded by Instituut Gak and the BUPA foundation

Chronic pain and psychosocial distress are generally thought to be associated in chronic musculoskeletal disorders such as non-specific neck pain. However, it is unclear whether a raised level of anxiety is necessarily a feature of longstanding, intense pain amongst patient and general population sub-groups. Post-hoc analysis. In a cohort of 70 self-selected female, non-specific neck pain sufferers, we observed relatively high levels of self-reported pain of 4.46 (measured on the 11 point numerical pain rating scale (NRS-101)) and a longstanding duration of symptoms (156 days/year). However, the mean anxiety scores observed (5.49), fell well below the clinically relevant threshold of 21 required by the Beck Anxiety Inventory. The cohort was stratified to further distinguish individuals with higher pain intensity (NRS>6) and longer symptom duration (>90 days). Although a highly statistically significant difference (p=0.000) was subsequently observed with respect to pain intensity, in the resulting sub-groups, none such a difference was noted with respect to anxiety levels. Our results indicate that chronic, intense pain and anxiety do not always appear to be related. Explanations for these findings may include that anxiety is not triggered in socially functional individuals, that individual coping strategies have come into play or in some instances that a psychological disorder like alexithymia could be a confounder. More studies are needed to clarify the specific role of anxiety in chronic non-specific musculoskeletal pain before general evidence-driven clinical extrapolations can be made