Steve Woby

Modest Association of Joint Hypermobility With Disabling and Limiting Musculoskeletal Pain: Results From a Large‐Scale General Population–Based Survey

To determine the population prevalence of joint hypermobility (JH) and to test the hypothesis that JH would be associated with reporting musculoskeletal pain.

Patient-reported improvements in health are maintained 2 years after completing a short course of cognitive behaviour therapy, exercise or both treatments for chronic widespread pain: long-term results from the MUSICIAN randomised controlled trial.

Objectives The MUSICIAN study has previously shown short-term benefit but only marginal cost-effectiveness for two non-pharmacological interventions for chronic widespread pain (CWP). We wished to determine their long-term effectiveness and cost-effectiveness. Methods A 2×2 factorial randomised controlled trial based in primary care in the UK. People were eligible if they were aged ≥25 years with CWP for which they had consulted their general practitioner. The interventions were a 6-month telephone cognitive behaviour therapy (tCBT) and/or a tailored exercise programme, in comparison to usual care. The primary outcome was patient-reported change in health. Results 884 persons were eligible, 442 were randomised and 81.7% were followed up 24 months post-treatment. In comparison to usual care (positive outcome 12.8%), tCBT (35.4%; OR 3.7 95% CI (1.8 to 8.0)), exercise (29.3%; OR 2.8 95% CI (1.3 to 6.0)) and both interventions (31.2%; OR 3.1 95% CI (1.3 to 6.0)) were significantly more effective. There was only a small decrease in effectiveness over time for individual and combined treatments. Those with more intense/disabling pain, higher distress and those who exhibited passive coping at baseline were more likely to have a positive outcome with tCBT than persons without these characteristics. tCBT was associated with the greatest increase in quality of life and lowest costs. Cost per quality adjusted life year was £3957–£5917 depending on method of analysis. Conclusions A short course of tCBT for people with CWP was effective long-term and was highly cost-effective. Exercise was also effective but delivered positive outcome for fewer patients at greater cost, and there was no advantage for patients receiving both interventions. Trial registration number ISRCTN67013851.

Does adding cognitive-behavioural physiotherapy to exercise improve outcome in patients with chronic neck pain? A randomised controlled trial

OBJECTIVES To determine whether adding a physiotherapist-led cognitive-behavioural intervention to an exercise programme improved outcome in patients with chronic neck pain (CNP). DESIGN Multicentre randomised controlled trial. SETTING Four outpatient physiotherapy departments. PARTICIPANTS Fifty-seven patients with CNP. Follow-up data were provided by 39 participants [57% of the progressive neck exercise programme (PNEP) group and 79% of the interactive behavioural modification therapy (IBMT) group]. INTERVENTIONS Twenty-eight subjects were randomised to the PNEP group and 29 subjects were randomised to the IBMT group. IBMT is underpinned by cognitive-behavioural principles, and aims to modify cognitive risk factors through interactive educational sessions, graded exercise and progressive goal setting. MAIN OUTCOME MEASURES The main outcome measure was disability, measured by the Northwick Park Questionnaire (NPQ). Secondary outcomes were the Numeric Pain Rating Scale (NPRS), Pain Catastrophising Scale, Tampa Scale for Kinesiophobia (TSK), Chronic Pain Self-efficacy Scale (CPSS) and the Pain Vigilance and Awareness Questionnaire. RESULTS No significant between-group differences in disability were observed (mean NPQ change: PNEP=-7.2, IBMT=-10.2). However, larger increases in functional self-efficacy (mean CPSS change: PNEP=1.0, IBMT=3.2) and greater reductions in pain intensity (mean NPRS change: PNEP=-1.0, IBMT=-2.2; P<0.05) and pain-related fear (mean TSK change: PNEP=0.2, IBMT=-4.7, P<0.05) were observed with IBMT. Additionally, a significantly greater proportion of participants made clinically meaningful reductions in pain (25% vs 55%, P<0.05) and disability (25% vs 59%, P<0.05) with IBMT. CONCLUSIONS The primary outcome did not support the use of cognitive-behavioural physiotherapy in all patients with CNP. However, superior outcomes were observed for several secondary measures, and IBMT may offer additional benefit in some patients. CLINICAL TRIAL REGISTRATION NUMBER ISRCTN27611394.

Defensive coping styles, anxiety and chronic low back pain

Psychological factors, such as anxiety, are associated with ifferences in pain perception and the prevalence of chronic ain conditions [1], such as chronic low back pain (CLBP) 2]. Within other clinical populations, anxiety has also been onsidered in the context of high or low defensiveness to dentify distinct coping styles, which have been associated ith differences in treatment response and health outcomes 3–9]. This has rarely been considered within CLBP. When anxiety and defensiveness are taken together, indiiduals can be classified into four groups [10]: high-anxious, ow-anxious, defensive high-anxious and repressors. Represors are characterised by scoring low on anxiety measures but igh on defensiveness. Although self-reporting low anxiety, epressors tend to exhibit elevated physiological responses, imilar to high-anxious individuals, in stressful situations 11]. Later research has supported the distinctiveness of the our groups, and the apparent discrepancy between selfeport and physiological/behavioural reactivity in repressors 3,7,11]. It is proposed that repressors avoid attending to negtive self-relevant information due to their cognitive biases 11], and are genuine when they report experiencing low anxety (i.e. it is self-deception) [12]. Within clinical populations, repressive coping style is associated with poor prognosis, reluctance to seek social support or engage effectively in sychotherapy [5], and a greater willingness to undertake elf-care health behaviours compared with those perceived as eing outside the individual’s control [4]. In general, defenive patients may not respond well to treatment, perhaps being nwilling to acknowledge issues and challenge beliefs [3]. Chronic illnesses have typically been associated with a igh prevalence of the repressive coping style. One notable

Changes in muscle activity and stature recovery after active rehabilitation for chronic low back pain

Patients with low back pain often demonstrate elevated paraspinal muscle activity compared to asymptomatic controls. This hyperactivity has been associated with a delayed rate of stature recovery following spinal loading tasks. The aim of this study was to investigate the changes in muscle activity and stature recovery in patients with chronic low back pain following an active rehabilitation programme. The body height recovery over a 40-min unloading period was assessed via stadiometry and surface electromyograms were recorded from the paraspinal muscles during standing. The measurements were repeated after patients had attended the rehabilitation programme and again at a six-month follow-up. Analysis was based on 17 patients who completed the post-treatment analysis and 12 of these who also participated in the follow-up. By the end of the six months, patients recovered significantly more height during the unloading session than at their initial visit (ES = 1.18; P < 0.01). Greater stature recovery immediately following the programme was associated with decreased pain (r = -0.55; P = 0.01). The increased height gain after six months suggests that delayed rates of recovery are not primarily caused by disc degeneration. Muscle activity did not decrease after treatment, perhaps reflecting a period of adaptation or altered patterns of motor control.

Are fear of movement, self-efficacy beliefs and fear of falling associated with levels of disability in people with osteoarthritis of the knee? A cross sectional study.

INTRODUCTION Osteoarthritis of the knee (OAK) can result in significant disability and previous authors have suggested that cognitive and falls-related factors may be significant determinants of function. However, no previous studies have considered the relative influence of these factors when the effects of symptoms related to OAK are also considered. Additionally, it is plausible that falls-related factors exert a greater influence in patients who have previously fallen. METHODS Fifty-eight patients were recruited from an outpatient physiotherapy department. They completed measures of physical function, pain, stiffness, physical symptoms, fear avoidance, perceived consequences of falling, fear of falling and self-efficacy beliefs. Variables exhibiting significant correlations with disability were entered into a regression model. β Values were also calculated for the final model to allow the relative contribution of each variable to be established when all variables were considered. Sub-analysis was then performed using only data from patients who had previously fallen, to establish whether cognitive and falls-related factors exerted a stronger influence in this group. RESULTS Pain, stiffness and joint symptoms significantly explained 75% of the variance in disability. The cognitive and falls-related variables did not significantly explain any additional variance. Only pain and stiffness exhibited significant β values in the final model. Similar findings were observed in the sub-analysis with the participants who had previously fallen, with only pain and stiffness explaining significant variance (77%) or exhibiting significant β values. DISCUSSION The current findings suggested that cognitive and falls-related factors are not significantly related to disability in patients with OAK. By contrast, pain and stiffness were strongly associated with disability. This suggests that targeting cognitive and falls-related factors is unlikely significantly to improve outcome in these patients.

Activity pacing: Moving beyond taking breaks and slowing down

This brief communication responds to the paper by Jeong and Cho (Qual Life Res 26(4):903–911, 2017) that has described activity pacing in limited terms of adjusting activities through going at a slower rate and taking breaks. Activity pacing was reported as not involving goal setting, in comparison to other strategies for long-term conditions such as Acceptance and Commitment Therapy. This brief communication aims to challenge this limited perception of activity pacing in light of numerous studies that recognise pacing to be a more complex strategy. Pacing is considered to be a multifaceted coping strategy, including broad themes of not only adjusting activities, but also planning activities, having consistent activity levels, acceptance of current abilities and gradually increasing activities, and one that includes goal setting as a key facet. It is essential that pacing is both defined and measured as a multifaceted strategy in order to assess the outcomes of pacing, and for meaningful comparisons with other strategies regarding efficacy for the management of long-term conditions.

The processes underpinning reductions in disability among people with chronic neck pain. A preliminary comparison between two distinct types of physiotherapy intervention

Abstract Purpose: To establish whether different processes underpin changes in disability in people with neck pain who underwent two types of active physiotherapy intervention. Materials and methods: This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability. Results: In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant β value in the final model. Conclusions: Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach. Implications for rehabilitation Certain cognitive factors are known to be related to levels of disability in patients with chronic neck pain Specifically targeting these factors results in more patients making a clinically meaningful reduction in disability Different processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner. Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain.

Comparison of three types of exercise in the treatment of rotator cuff tendinopathy/shoulder impingement syndrome: A randomized controlled trial

OBJECTIVES To assess the efficacy of three different exercise programmes in treating rotator cuff tendinopathy/shoulder impingement syndrome. DESIGN Parallel group randomised clinical trial. SETTING Two out-patient NHS physiotherapy departments in Manchester, United Kingdom. PARTICIPANTS 120 patients with shoulder pain of at least three months duration. Pain was reproduced on stressing the rotator cuff and participants had full passive range of movement at the shoulder. INTERVENTIONS Three dynamic rotator cuff loading programmes; open chain resisted band exercises (OC) closed chain exercises (CC) and minimally loaded range of movement exercises (ROM). MAIN OUTCOMES Change in Shoulder Pain and Disability Index (SPADI) score and the proportion of patients making a Minimally Clinically Important Change (MCIC) in symptoms 6 weeks after commencing treatment. RESULTS All three programmes resulted in significant decreases in SPADI score, however there were no significant differences between the groups. Participants making a MCIC in symptoms were similar across all groups, however more participants deteriorated in the ROM group. Dropout rate was higher in the CC group, but when only patients completing treatment were considered more patients in the CC group made a meaningful reduction in pain and disability. CONCLUSIONS Open chain, closed chain and range of movement exercises all seem to be effective in bringing about short term changes in pain and disability in patients with rotator cuff tendinopathy. ISRCTN76701121.

Symptoms of chronic fatigue syndrome/myalgic encephalopathy are not determined by activity pacing when measured by the chronic pain coping inventory

OBJECTIVES Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) is a chronic illness which can cause significant fatigue, pain and disability. Activity pacing is frequently advocated as a beneficial coping strategy, however, it is unclear whether pacing is significantly associated with symptoms in people with CFS/ME. The first aim of this study was therefore to explore the cross-sectional associations between pacing and levels of pain, disability and fatigue. The second aim was to explore whether changes in activity pacing following participation in a symptom management programme were related to changes in clinical outcomes. DESIGN Cross-sectional study exploring the relationships between pacing, pain, disability and fatigue (n=114) and pre-post treatment longitudinal study of a cohort of patients participating in a symptom management programme (n=35). SETTING Out-patient physiotherapy CFS/ME service. PARTICIPANTS One-hundred and fourteen adult patients with CFS/ME. MAIN OUTCOME MEASURES Pacing was assessed using the chronic pain coping inventory. Pain was measured using a Numeric Pain Rating Scale, fatigue with the Chalder Fatigue Scale and disability with the Fibromyalgia Impact Questionnaire. RESULTS No significant associations were observed between activity pacing and levels of pain, disability or fatigue. Likewise, changes in pacing were not significantly associated with changes in pain, disability or fatigue following treatment. CONCLUSIONS Activity pacing does not appear to be a significant determinant of pain, fatigue or disability in people with CFS/ME when measured with the chronic pain coping index. Consequently, the utility and measurement of pacing require further investigation.