H. Mitchell

Clinical effectiveness of a rehabilitation program integrating exercise, self‐management, and active coping strategies for chronic knee pain: A cluster randomized trial

Objective Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain. Methods We conducted a single-blind, pragmatic, cluster randomized controlled trial. Participants age ≥50 years, reporting knee pain for >6 months, were recruited from 54 inner-city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participants primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self-reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC-func]) 6 months after completing rehabilitation. Results A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (−3.33 difference in WOMAC-func score; 95% confidence interval [95% CI] −5.88, −0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (−3.53; 95% CI −6.52, −0.55) or group rehabilitation (−3.16; 95% CI −6.55, −0.12). Conclusion ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.

Long‐term outcomes and costs of an integrated rehabilitation program for chronic knee pain: A pragmatic, cluster randomized, controlled trial

Chronic joint pain is a major cause of pain and disability. Exercise and self‐management have short‐term benefits, but few studies follow participants for more than 6 months. We investigated the long‐term (up to 30 months) clinical and cost effectiveness of a rehabilitation program combining self‐management and exercise: Enabling Self‐Management and Coping of Arthritic Knee Pain Through Exercise (ESCAPE‐knee pain).

Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain

Objective To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program. Methods Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness. Results Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost £224 (95% confidence interval [95% CI] £184, £262) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay £1,900 for improvements in functioning. Indiv-rehab cost £314/person and Grp-rehab £125/person. Indiv-rehab cost £189 (95% CI £168, £208) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP £5,500. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome. Conclusion Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.

In osteoarthritis, the psychosocial benefits of exercise are as important as physiological improvements.

HURLEY, M. V., H. L. MITCHELL, and N. WALSH. In osteoarthritis, the psychosocial benefits of exercise are as important as physiological improvements. Exerc. Sport Sci. Rev., Vol. 31, No. 3, pp. 138–143, 2003. Exercise has a major role in the management of osteoarthritis, effecting well-documented physiological improvements on muscle function. However, exercise also has lasting benefits on the complex psychosocial sequelae of osteoarthritis—facilitating appropriate health beliefs, behaviors, pain coping, and self-management strategies—that are as important as its physiological effects.

Oocyte cryopreservation for social reasons: demographic profile and disposal intentions of UK users

A small number of studies from the USA and Europe have provided some data on the profile and characteristics of women who have undergone oocyte cryopreservation for what has been termed elective, social or non-medical reasons; however, little is known in a UK context about which women are undergoing oocyte cryopreservation or their reproductive intentions and actions after the procedure. Drawing on data from an exploratory study of 23 UK resident women who had undergone social oocyte cryopreservation, the demographic profile of these women, their reproductive intentions and actions are discussed, as well as their attitudes and intentions towards their cryopreserved oocytes should they never require them in treatment. The study found that, at the time of oocyte cryopreservation, women were on average 36.7 years of age, were university educated, with 65% of the sample holding further postgraduate or professional qualifications. Fifty-seven per cent of the participants were in professional employment. All participants identified as heterosexual and 87% were not in a relationship at the time of cryopreserving their oocytes. Most (88%) participants stated that they would donate unwanted oocytes to research or to other women for use in fertility treatment should they never require them.

Integrated exercise and self-management programmes in osteoarthritis of the hip and knee: a systematic review of effectiveness

Abstract The aim of this systematic review was to investigate the clinical effects of integrated exercise and self-management programmes on pain and function in patients with hip and knee osteoarthritis, and to determine the cost-effectiveness of these interventions. A multiple database literature search identified randomised controlled trials reporting treatment regimens that combined exercise with interventions promoting self-management. A predetermined protocol was developed by the reviewers who then independently appraised the methodological quality of the studies, and extracted outcome data for pain and function. Of 109 abstracts identified, 10 studies met the inclusion criteria for this review. Outcome data suggested that interventions reduced pain and improved function, but many of the papers had methodological flaws, such as low statistical power, limited blinding and randomisation procedures, short follow-up and protracted treatment regimens. No associated cost analyses were included in any of the studies accepted within the review. Combining exercise and psychological interventions improves pain and function in hip and knee osteoarthritis, although methodological problems limit the ability to extrapolate the findings of these studies into clinical practice. Rigorously designed research studies of typical patients, using clinically applicable and practicable interventions with long-term follow-up and cost-benefit analyses are required to inform management guidelines and clinical practice.

Management of chronic knee pain: a survey of patient preferences and treatment received

AbstractBackgroundA range of interventions exist for the management of knee pain, but patient preferences for treatment are not clear. In this study the management received by people with chronic knee pain, their management preferences and reasons for these preferences were recorded.MethodsAt baseline assessment of a clinical trial of rehabilitation for chronic knee pain, 415 participants were asked about their i) previous management, ii) preferred treatment, if any, iii) whether they would undergo knee surgery and iv) reasons for their preferences.ResultsPrevious management – Medication was the most common treatment, followed by physiotherapy, 39 participants had received no treatment. Preferences – 166 patients expressed no treatment preference. Of those who expressed a preference the most popular option was physiotherapy, whilst not having surgery was the third most frequent response. The most common reason for preferring physiotherapy and not wanting surgery was prior experience. Willingness to accept surgery – 390 participants were not waiting for knee replacement surgery, and overall 81% would not accept surgery if offered, usually because pain was not perceived to be severe enough to warrant surgery.ConclusionMost chronic knee pain is managed with medication despite concerns about safety, efficacy and cost, management guidelines recommendations and peoples management preferences. Previous experience and perceptions of need were major determinants of peoples preferences, but many people were unaware of management options. Appreciating patient preferences and provision of more information about management options are important in facilitating informed patient/clinician discussion and agreement.Trial RegistrationCurrent Controlled Trials, ISRCTN 94658828

Reproductive technology and the life course: Current debates and research in social egg freezing

Abstract While there are currently few confirmed births from previously frozen eggs in the UK, the improved outcomes of new technologies of vitrification and intra-cytoplasmic sperm injection (ICSI) have led to the marketing of egg freezing for non-medical reasons, whereby women are offered the possibility of preserving their eggs until such time as they wish to have a child. Non-academic commentary on this phenomenon has commonly constructed it within a neo-liberal discourse of ‘choice’, whereby women are positioned as choosing to ‘delay motherhood,’ often for reasons relating to their careers. However, there have been relatively few research studies which explore either womens awareness and understandings of social egg freezing or the reasons why women consider or undertake egg freezing. This paper summarises the current academic discussion surrounding social egg freezing and outlines the limited body of empirical literature identified from a systematic search of relevant databases. The potential benefits and harms of social egg freezing and the ethical issues it raises are well rehearsed in existing literature, but there is limited empirical evidence about who is accessing social egg freezing, why they are taking this option and what their experiences and future intentions are.

A qualitative study of the impact of endometriosis on male partners

Abstract STUDY QUESTION What is the impact of endometriosis on male partners of women with the condition? SUMMARY ANSWER Endometriosis significantly impacts men across several life domains and can negatively impact emotional well-being. WHAT IS KNOWN ALREADY Endometriosis has been shown to negatively impact womens quality of life and may strain intimate relationships. Little is known about the impact on male partners. STUDY DESIGN, SIZE, DURATION The ENDOPART study was a cross-sectional, qualitative study of 22 women with endometriosis and their male partners (n = 44) in the UK (2012–2013). PARTICIPANTS/MATERIALS, SETTING, METHODS Inclusion criteria: laparoscopic diagnosis of endometriosis; the presence of symptoms for at least a year; partners living together. Data were collected via face to face, semi structured interviews with partners interviewed separately. Data were analysed thematically, assisted by NVivo 10. MAIN RESULTS AND THE ROLE OF CHANCE Men reported that endometriosis affected many life domains including sex and intimacy, planning for and having children, working lives and household income. It also required them to take on additional support tasks and roles. Endometriosis also had an impact on mens emotions, with responses including helplessness, frustration, worry and anger. The absence of professional or wider societal recognition of the impact on male partners, and a lack of support available to men, results in male partners having a marginalized status in endometriosis care. LIMITATIONS REASONS FOR CAUTION Self-selection of participants may have resulted in a sample representing those with more severe symptoms. Couples included are in effect ‘survivors’ in relationship terms, therefore, findings may underestimate the contribution of endometriosis to relationship breakdown. WIDER IMPLICATIONS OF THE FINDINGS The study extends knowledge about the impact of endometriosis on relationships, which thus far has been drawn largely from studies with women, by providing new insights about how this condition affects male partners. Healthcare practitioners need to take a more couple-centred, biopsychosocial approach toward the treatment of endometriosis, inclusive of partners and relationship issues. The findings demonstrate a need for information and support resources aimed at partners and couples. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the Economic and Social Research Council (reference ES/J003662/1). The authors have no conflicts of interest.

Conducting dyadic, relational research about endometriosis: A reflexive account of methods, ethics and data analysis

Despite a growing literature on the value of relational data in studies of social phenomena, individuals still commonly constitute the basic unit of analysis in qualitative research. Methodological aspects of interviewing couples, particularly interviewing partners separately, and of conducting dyadic analysis have received scant attention. This article describes the experience of conducting separate interviews with both partners in 22 heterosexual couples (n = 44) in a study of the impact of the gynaecological condition endometriosis. In order to advance current methodological thinking regarding interviewing couples, we describe the dyadic, relational approach employed in designing the study and our specific method of dyadic analysis. We argue that utilising separate interviews with dyadic analysis rather than conducting joint interviews, while not without its ethical, practical and analytical challenges, offers considerable methodological benefits. Such an approach allows a unique relational insight into the impact of chronic illness on couples and how they navigate chronic illness by illuminating both shared and individual interpretations, experiences, understandings and meanings.