O15 Maintaining musculoskeletal health: a randomised controlled trial of cognitive behaviour therapy among people at high risk of developing chronic widespread pain

Background

Cognitive behaviour therapy (CBT) is effective in the management of fibromyalgia (and its characteristic feature chronic widespread pain (CWP). CBT is recommended in all recent major fibromyalgia management guidelines. From large-scale epidemiological studies, prediction models are available which identify groups at high-risk of developing CWP. We now test whether it is possible to prevent onset of CWP and/or change factors associated with its onset.

Methods

A randomised controlled trial of CBT delivered by telephone plus usual care (tCBT) was tested against usual care alone (UC). Eligible adults aged at least 25 years were identified by a survey of persons registered with sixteen general practices across Scotland. Respondents reporting regional pain (not CWP) for which they had recently consulted their GP and at least 2 items from a previously validated ‘high risk’ profile (Somatic Symptom Scale, Sleep Problem Scale, Illness Behaviour Scale) were invited to participate. tCBT was delivered across 6 sessions over 8 weeks with booster sessions 3 and 6 months after treatment start. Primary outcome was CWP at 12 months. Secondary outcomes were risk profile measures: fatigue (Chalder Fatigue Scale), Patient Global Impression of Change (PGIC: 7 categories), psychological distress (General Health Questionnaire) and quality of life (EQ-5D-5L) also at 12 months. Analysis used logistic, ordinal logistic or linear regression depending on outcome variable type; expressed as an effect size with 95% confidence interval.

Results

1,002 people were randomised, with equal numbers assigned to each arm of the trial: 59% of participants were female, with a median age of 59 (range 25-91) years. 66% of tCBT participants completed treatment and 83% of all participants provided follow-up data at 12 months. There was no difference in the proportion with CWP at 12 months (tCBT 18.0% v. UC 17.5%). There were improvements (all favouring tCBT) in Illness Behaviour Score (mean difference (md) -0.83; -1.55,-0.11), Sleep Problem Scale (md -0.90; -1.45,-0.36), psychological distress (Odds Ratio (OR) per category 0.65; 0.50, 0.85), EQ-5D-5L (md 0.024; 0.009, 0.039), Chalder Fatigue Scale (md -1.05; -1.66,-0.44) and PGIC (OR per category 0.51;0.39,0.67). Specifically 30.2% of those receiving tCBT reported their health as much or very much better, compared to 17.3% of those receiving UC.

Conclusion

This first-ever large-scale trial of prevention, aimed at persons at high risk, has shown tCBT does not change the likelihood of CWP onset but does improve the underlying risk profile for developing the condition as well as improving distress , fatigue and quality of life. Those receiving tCBT were, 12 months later, significantly more like to consider their health was better. This trial provides evidence for extending the group of people considered to benefit from CBT.

Disclosures

G.J. Macfarlane None. M. Beasley None. N. Scott None. P. McNamee None. J. McBeth None. G. Prescott None. G.T. Jones None. P. Hannaford None. N. Basu None. P. Keeley None. K. Lovell None.

Engagement and Participant Experiences With Consumer Smartwatches for Health Research: Longitudinal, Observational Feasibility Study

BACKGROUND

Wearables provide opportunities for frequent health data collection and symptom monitoring. The feasibility of using consumer cellular smartwatches to provide information both on symptoms and contemporary sensor data has not yet been investigated.

OBJECTIVE

This study aimed to investigate the feasibility and acceptability of using cellular smartwatches to capture multiple patient-reported outcomes per day alongside continuous physical activity data over a 3-month period in people living with knee osteoarthritis (OA).

METHODS

For the KOALAP (Knee OsteoArthritis: Linking Activity and Pain) study, a novel cellular smartwatch app for health data collection was developed. Participants (age ≥50 years; self-diagnosed knee OA) received a smartwatch (Huawei Watch 2) with the KOALAP app. When worn, the watch collected sensor data and prompted participants to self-report outcomes multiple times per day. Participants were invited for a baseline and follow-up interview to discuss their motivations and experiences. Engagement with the watch was measured using daily watch wear time and the percentage completion of watch questions. Interview transcripts were analyzed using grounded thematic analysis.

RESULTS

A total of 26 people participated in the study. Good use and engagement were observed over 3 months: most participants wore the watch on 75% (68/90) of days or more, for a median of 11 hours. The number of active participants declined over the study duration, especially in the final week. Among participants who remained active, neither watch time nor question completion percentage declined over time. Participants were mainly motivated to learn about their symptoms and enjoyed the self-tracking aspects of the watch. Barriers to full engagement were battery life limitations, technical problems, and unfulfilled expectations of the watch. Participants reported that they would have liked to report symptoms more than 4 or 5 times per day.

CONCLUSIONS

This study shows that capture of patient-reported outcomes multiple times per day with linked sensor data from a smartwatch is feasible over at least a 3-month period.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10238.

Investigating multisite pain as a predictor of self-reported falls and falls requiring health care use in an older population: A prospective cohort study

Older people are continuing to fall despite fall prevention guidelines targeting known falls’ risk factors. Multisite pain is a potential novel falls’ risk factor requiring further exploration. This study hypothesises that: (1) an increasing number of pain sites and widespread pain predicts self-reported falls and falls recorded in primary and secondary healthcare records; (2) those relationships are independent of known falls’ risk factors and putative confounders. This prospective cohort study linked data from self-completed questionnaires, primary care electronic health records, secondary care admission statistics and national mortality data. Between 2002–2005, self-completion questionnaires were mailed to community-dwelling individuals aged 50 years and older registered with one of eight general practices in North Staffordshire, UK(n = 26,129) yielding 18,497 respondents. 11,375 respondents entered the study; 4386 completed six year follow-up. Self-reported falls were extracted from three and six year follow-up questionnaires. Falls requiring healthcare were extracted from routinely collected primary and secondary healthcare data. Increasing number of pain sites increased odds of future 3 year (odds ratio 1.12 (95% confidence interval: 1.01–1.24)) and 6 year self-reported fall (odds ratio 1.02 (1.00–1.03)) and increased hazard of future fall requiring primary healthcare (hazard ratio 1.01 (1.00–1.03)). The presence of widespread pain increased odds of future 3 year (odds ratio 1.27 (0.92–1.75)) and 6 year fall (odds ratio 1.43(1.06–1.95)) and increased hazard of future fall requiring primary healthcare (hazard ratio 1.27(0.98–1.65)). Multisite pain was not associated with future fall requiring secondary care admission. Multisite pain must be included as a falls’ risk factor in guidelines to ensure clinicians identify their older patients at risk of falls and employ timely implementation of current falls prevention strategies.

P37 Exploring the experience of pain flares in adolescent inflammatory and non-inflammatory musculoskeletal disorders: a phenomenological study

Background

Adolescents with inflammatory and non-inflammatory rheumatic musculoskeletal disorders (RMD) experience acute exacerbations in pain, referred to as pain flares in the adult literature. But little remains known about what pain flares are, why they occur, how they are managed and what lasting effects they have during adolescence. This study explored the lived experience of pain flares in adolescents with RMD.

Methods

Adolescents with juvenile idiopathic arthritis (JIA) or chronic idiopathic pain syndromes (CIPS) were recruited from a UK tertiary paediatric and adolescent rheumatology centre. Data were collected using semi-structured interviews and visual aids, and analysed using interpretative phenomenological analysis.

Results

Participants were eight females and two males aged between 13 and 17 years (M = 14.7, SD = 1.25). Four participants had JIA and six had CIPS. All participants experienced periods when pain deviates from their usual variation in pain, but none reported using the term pain flare to describe these experiences. These experiences were conceptualised as a journey of change from their 1) daily life with pain, 2) pre-flare period, 3) flare period, to their 4) post-flare period. 1) In daily life, adolescents report a level of pain that is usual for them which they manage and continue their daily routines around. 2) Pain, at times, increased beyond usual levels and adolescents reported noticing when a pain flare was coming on (e.g. due to physical exertion). They employed strategies for managing the pre-flare period, however, if they did not succeed in preventing a flare, or when flares occurred without a trigger or controllable cause, pain began to intrude on their lives. 3) All pain flares were described as an increase in the intensity of their usual pain, and were also associated with an increase in the location, duration and/or quality of pain; an increase in other unpleasant symptoms such as fatigue, psychological symptoms, headaches and/or sickness; and a reduction in physical, emotional, cognitive and/or social functioning. The frequency of flares was variable, ranging from weekly flare events to less than two a year. Flares were generally short lived, lasting a few hours to a few days. The majority of flares were managed with parental input, with adolescents seeking medical support when a flare was perceived to be associated with infection in JIA. 4) As flares were brought under control, the pain returned to usual levels but the psychological symptoms outstayed the pain. Participants took actions to regain the level of normality experienced in daily life.

Conclusion

Participants had varying interpretations of what constitutes a flare, but the key finding was that flares are not only an increase in pain intensity, but other features are also required to change. These findings help to differentiate flares from normal variation in pain.

Conflicts of Interest

The authors declare no conflicts of interest.

P36 Adolescents’ experiences of fluctuating pain in musculoskeletal disorders: a qualitative systematic review and thematic synthesis

Background

Adolescents with chronic musculoskeletal pain experience pain that fluctuates within and across days. The aim of this review was to (i) synthesise the qualitative literature on adolescents’ experiences of fluctuating pain in musculoskeletal disorders, (ii) identify the concept of pain flare and how this may differ from daily fluctuation of pain, and (ii) identify knowledge gaps to inform the design of future research.

Methods

Six electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, OpenGrey and Scopus) and reference lists of relevant articles were searched from inception to June 2018. Articles were eligible for inclusion if they were qualitative studies exploring the experiences of pain in adolescents, aged between 10–19 years, diagnosed with juvenile idiopathic arthritis (JIA) and chronic idiopathic pain syndromes (CIPS). Comprehensiveness of reporting was assessed using the Consolidated Criteria for Reporting Qualitative Health Research (COREQ) framework, and studies were analysed using thematic synthesis.

Results

Of the 3,787 records identified, 32 studies were included from 11 countries. 536 young people with JIA or CIPS participated in the studies, of which 509 had a diagnosis of JIA, and 27 with CIPS. Interviews were conducted in 29 studies, with 9 studies also combining interviews with focus groups, observations, questionnaires, researcher journaling, visual depictions and diaries. Although all included studies reported adolescent’s experience of pain, only 19 studies provide insight into the impact of fluctuating pain on an individual’s life and lived experience. 21 studies included data from parents, siblings, health professionals and/or individuals with other chronic illnesses, but efforts were made to only extract data referring to or expressed by adolescents with JIA or CIPS. Ages of patients ranged from 3 to 23 years, but all studies averaged within the adolescent range. Principal findings were synthesised under three themes: 1) symptom experience, 2) disruption and loss, and 3) regaining control. These themes can be seen to describe a journey through which the adolescent experiences fluctuating pain and associated symptoms, encounters the challenges to lifestyle that fluctuating pain presents, followed by employing coping strategies to regain a sense of control of their lives and pain. Each stage is experienced differently depending on individual factors such as adolescents’ developmental status, pain condition, and duration of the pain experience.

Conclusion

Adolescents with chronic musculoskeletal pain live with a daily background level of symptoms which frequently fluctuate and are associated with functional and emotional difficulties. It is not clear whether these symptoms and challenges are experienced as part of normal fluctuations in pain, or whether they reflect symptom exacerbations classified as flares. Further research is needed to explore the frequency and characteristics of pain flares, and how they differ from their normal fluctuations in pain.

Conflicts of Interest

The authors declare no conflicts of interest.

Multisite pain and self-reported falls in older people: systematic review and meta-analysis

Background

Multisite pain and falls are common in older people, and isolated studies have identified multisite pain as a potential falls risk factor. This study aims to synthesise published literature to further explore the relationship between multisite pain and falls and to quantify associated risks.

Methods

Bibliographic databases were searched from inception to December 2017. Studies of community-dwelling adults aged 50 years and older with a multisite pain measurement and a falls outcome were included. Two reviewers screened articles, undertook quality assessment and extracted data. Random-effects meta-analysis was used to pool the effect estimate (odds ratio (OR) and 95% confidence interval (95%CI)). Heterogeneity was assessed by I²; sensitivity analyses used adjusted risk estimates and exclusively longitudinal studies.

Results

The search identified 49,577 articles, 3145 underwent abstract review, 22 articles were included in the systematic review and 18 were included in the meta-analysis. The unadjusted pooled OR of 1.82 (95%CI 1.55–2.13), demonstrating that those reporting multisite pain are at increased risk of falls, is supported by the adjusted pooled OR of 1.56 (95%CI 1.39–1.74). Multisite pain predicts future falls risk (OR = 1.74 (95%CI 1.57–1.93)). For high-quality studies, those reporting multisite pain have double the odds of a future fall compared to their pain-free counterparts.

Conclusion

Multisite pain is associated with an increased future falls risk in community-dwelling older people. Increasing public awareness of multisite pain as a falls risk factor and advising health and social care professionals to identify older people with multisite pain to signpost accordingly will enable timely falls prevention strategies to be implemented.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1847-5) contains supplementary material, which is available to authorized users.

Collecting Symptoms and Sensor Data With Consumer Smartwatches (the Knee OsteoArthritis, Linking Activity and Pain Study): Protocol for a Longitudinal, Observational Feasibility Study

BACKGROUND

The Knee OsteoArthritis, Linking Activity and Pain (KOALAP) study is the first to test the feasibility of using consumer-grade cellular smartwatches for health care research.

OBJECTIVE

The overall aim was to investigate the feasibility of using consumer-grade cellular smartwatches as a novel tool to capture data on pain (multiple times a day) and physical activity (continuously) in patients with knee osteoarthritis. Additionally, KOALAP aimed to investigate smartwatch sensor data quality and assess whether engagement, acceptability, and user experience are sufficient for future large-scale observational and interventional studies.

METHODS

A total of 26 participants with self-diagnosed knee osteoarthritis were recruited in September 2017. All participants were aged 50 years or over and either lived in or were willing to travel to the Greater Manchester area. Participants received a smartwatch (Huawei Watch 2) with a bespoke app that collected patient-reported outcomes via questionnaires and continuous watch sensor data. All data were collected daily for 90 days. Additional data were collected through interviews (at baseline and follow-up) and baseline and end-of-study questionnaires. This study underwent full review by the University of Manchester Research Ethics Committee (#0165) and University Information Governance (#IGRR000060). For qualitative data analysis, a system-level security policy was developed in collaboration with the University Information Governance Office. Additionally, the project underwent an internal review process at Google, including separate reviews of accessibility, product engineering, privacy, security, legal, and protection regulation compliance.

RESULTS

Participants were recruited in September 2017. Data collection via the watches was completed in January 2018. Collection of qualitative data through patient interviews is still ongoing. Data analysis will commence when all data are collected; results are expected in 2019.

CONCLUSIONS

KOALAP is the first health study to use consumer cellular smartwatches to collect self-reported symptoms alongside sensor data for musculoskeletal disorders. The results of this study will be used to inform the design of future mobile health studies. Results for feasibility and participant motivations will inform future researchers whether or under which conditions cellular smartwatches are a useful tool to collect patient-reported outcomes alongside passively measured patient behavior. The exploration of associations between self-reported symptoms at different moments will contribute to our understanding of whether it may be valuable to collect symptom data more frequently. Sensor data-quality measurements will indicate whether cellular smartwatch usage is feasible for obtaining sensor data. Methods for data-quality assessment and data-processing methods may be reusable, although generalizability to other clinical areas should be further investigated.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/10238.

Update on the epidemiology, risk factors and disease outcomes of osteoarthritis

Osteoarthritis (OA) is the most frequent form of arthritis and a leading cause of pain and disability worldwide. OA can affect any synovial joint, although the hip, knee, hand, foot and spine are the most commonly affected sites. Knowledge about the occurrence and risk factors for OA is important to define the clinical and public health burden of the disease to understand mechanisms of disease occurrence and may also help to inform the development of population-wide prevention strategies. In this article, we review the occurrence and risk factors for OA and also consider patient-reported outcome measures that have been used for the assessment of the disease.

The associated features of multiple somatic symptom complexes

OBJECTIVE

To assess whether two or more functional somatic symptom complexes (SSCs) showed stronger association with psychosocial correlates than single or no SSC after adjustment for depression/anxiety and general medical disorders.

METHODS

In a population-based sample we identified, by standardised questionnaire, participants with chronic widespread pain, chronic fatigue and irritable bowel syndrome, excluding those with a medical cause for pain/fatigue. We compared psychosocial variables in three groups: multiple (>1), single or no FSS, adjusting for depression/anxiety and general medical disorders using ordinal logistic regression. We evaluated whether multiple SSCs predicted health status 1 year later using multiple regression to adjust for confounders.

RESULTS

Of 1443 participants (58.0% response) medical records were examined in 990: 4.4% (n = 44) had 2 or 3 symptom complexes, 16.2% a single symptom complex. Many psychosocial adversities were significantly associated with number of SSCs in the expected direction but, for many, statistical significance was lost after adjustment for depression/anxiety and medical illness. Somatic symptoms, health anxiety, impairment and number of prior doctor visits remained significantly associated. Impaired health status 1 year later was predicted by multiple somatic symptom complexes even after adjustment for depression, anxiety, medical disorders and number of symptoms.

CONCLUSIONS

Depression, anxiety, medical illness and health anxiety, demonstrated an exposure-response relationship with number of somatic symptom complexes. These may be core features of all Functional Somatic Syndromes and may explain why number of somatic symptom complexes predicted subsequent health status. These features merit inclusion in prospective studies to ascertain causal relationships.

Representativeness of a digitally engaged population and a patient organisation population with rheumatoid arthritis and their willingness to participate in research: a cross-sectional study

Objectives

To describe (1) the representativeness of (a) users of an online health community (HealthUnlocked.com (HU)) with rheumatoid arthritis (RA) and (b) paid members of an RA patient organisation, the National Rheumatoid Arthritis Society (NRAS), compared with the general RA population; and (2) the willingness of HU users with RA to participate in types of research (surveys, use of an app or activity tracker, and trials).

Methods

A pop-up survey was embedded on HU to determine the characteristics of users and their willingness to participate in research. An anonymous data set of NRAS member characteristics was provided by the NRAS (N=2044). To represent the general RA population, characteristics of people with RA were identified from the Clinical Practice Research Datalink (CPRD) (N=20 594). Cross-sectional comparisons were made across the three groups.

Results

Compared with CPRD, HU respondents (n=615) were significantly younger (49% aged below 55 years compared with 23% of CPRD patients), significantly more deprived (21% in the most deprived Townsend quintile compared with 12% of CPRD patients) and had more recent disease, with 62% diagnosed between 2010 and 2016 compared with 37% of CPRD patients. NRAS members were more similar to the CPRD, but significantly under-represented those aged 75 years or over and over-represented those aged 55–75 years compared with the CPRD. High proportions of HU users were willing to participate in future research of all types.

Conclusions

NRAS members were broadly representative of the general RA population. HU users were younger, more deprived and more recently diagnosed. HU users were willing to participate in most types of research.

Psychosocial factors partially mediate the relationship between mechanical hyperalgesia and self-reported pain

Background and aims:

Amplification of sensory signalling within the nervous system along with psychosocial factors contributes to the variation and severity of knee pain. Quantitative sensory testing (QST) is a non-invasive test battery that assesses sensory perception of thermal, pressure, mechanical and vibration stimuli used in the assessment of pain. Psychosocial factors also have an important role in explaining the occurrence of pain. The aim was to determine whether QST measures were associated with self-reported pain, and whether those associations were mediated by psychosocial factors.

Methods:

Participants with knee pain identified from a population-based cohort completed a tender point count and a reduced QST battery of thermal, mechanical and pressure pain thresholds, temporal summation, mechanical pain sensitivity (MPS), dynamic mechanical allodynia (DMA) and vibration detection threshold performed following the protocol by the German Research Network on Neuropathic Pain. QST assessments were performed at the most painful knee and opposite forearm (if pain-free). Participants were asked to score for their global and knee pain intensities within the past month (range 0–10), and complete questionnaire items investigating anxiety, depression, illness perceptions, pain catastrophising, and physical functioning. QST measures (independent variable) significantly correlated (Spearman’s rho) with self-reported pain intensity (dependent variable) were included in structural equation models with psychosocial factors (latent mediators).

Results:

Seventy-two participants were recruited with 61 participants (36 women; median age 64 years) with complete data included in subsequent analyses. Tender point count was significantly correlated with global pain intensity. DMA at the knee and MPS at the most painful knee and opposite pain-free forearm were significantly correlated with both global pain and knee pain intensities. Psychosocial factors including pain catastrophising sub-scales (rumination and helplessness) and illness perceptions (consequences and concern) were significant partial mediators of the association with global pain intensity when loaded on to a latent mediator for: tender point count [75% total effect; 95% confidence interval (CI) 22%, 100%]; MPS at the knee (49%; 12%, 86%); and DMA at the knee (63%; 5%, 100%). Latent psychosocial factors were also significant partial mediators of the association between pain intensity at the tested knee with MPS at the knee (30%; 2%, 58%), but not for DMA at the knee.

Conclusions:

Measures of mechanical hyperalgesia at the most painful knee and pain-free opposite forearm were associated with increased knee and global pain indicative of altered central processing. Psychosocial factors were significant partial mediators, highlighting the importance of the central integration of emotional processing in pain perception.

Implications:

Associations between mechanical hyperalgesia at the forearm and knee, psychosocial factors and increased levels of clinical global and knee pain intensity provide evidence of altered central processing as a key mechanism in knee pain, with psychological factors playing a key role in the expression of clinical pain.

Quality of life, sleep and rheumatoid arthritis (QUASAR): a protocol for a prospective UK mHealth study to investigate the relationship between sleep and quality of life in adults with rheumatoid arthritis

INTRODUCTION

People with rheumatoid arthritis (RA) frequently report reduced health-related quality of life (HRQoL), the impact one's health has on physical, emotional and social well-being. There are likely numerous causes for poor HRQoL, but people with RA have identified sleep disturbances as a key contributor to their well-being. This study will identify sleep/wake rhythm-associated parameters that predict HRQoL in patients with RA.

METHODS AND ANALYSIS

This prospective cohort study will recruit 350 people with RA, aged 18 years or older. Following completion of a paper-based baseline questionnaire, participants will record data on 10 symptoms including pain, fatigue and mood two times a day for 30 days using a study-specific mobile application (app). A triaxial accelerometer will continuously record daytime activity and estimate evening sleep parameters over the 30 days. Every 10 days following study initiation, participants will complete a questionnaire that measures disease specific (Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF)) and generic (WHOQOL-BREF) quality of life. A final questionnaire will be completed at 60 days after entering the study. The primary outcomes are the AIMS2-SF and WHOQOL-BREF. Structural equation modelling and latent trajectory models will be used to examine the relationship between sleep/wake rhythm-associated parameters and HRQoL, over time.

ETHICS AND DISSEMINATION

Results from this study will be disseminated at regional and international conferences, in peer-reviewed journals and Patient and Public Engagement events, as appropriate.

Consumer Smartwatches for Collecting Self-Report and Sensor Data: App Design and Engagement

Longitudinal data from patients' natural environments would benefit chronic disease care, yet most devices cannot collect sensor data alongside patient-reported outcomes. Here we describe Koalap, a consumer cellular smartwatch application that collects patient-reported outcomes alongside physical activity data from various sensors. Additionally, we show preliminary results indicating high engagement of our 26 participants with knee osteoarthritis. Our future work will show whether data collection with consumer smartwatches is feasible in terms of user engagement, acceptability, data quality and consistency.

The feasibility and acceptability of a physical activity intervention for older people with chronic musculoskeletal pain: The iPOPP pilot trial protocol

INTRODUCTION

This pilot trial will inform the design and methods of a future full-scale randomized controlled trial (RCT) and examine the feasibility, acceptability and fidelity of the Increasing Physical activity in Older People with chronic Pain (iPOPP) intervention, a healthcare assistant (HCA)-supported intervention to promote walking in older adults with chronic musculoskeletal pain in a primary care setting.

METHODS AND ANALYSIS

The iPOPP study is an individually randomized, multicentre, three-parallel-arm pilot RCT. A total of 150 participants aged ≥65 years with chronic pain in one or more index sites will be recruited and randomized using random permuted blocks, stratified by general practice, to: (i) usual care plus written information; (ii) pedometer plus usual care and written information; or (iii) the iPOPP intervention. A theoretically informed mixed-methods approach will be employed using semi-structured interviews, audio recordings of the HCA consultations, self-reported questionnaires, case report forms and objective physical activity data collection (accelerometry). Follow-up will be conducted 12 weeks post-randomization. Collection of the quantitative data and statistical analysis will be performed blinded to treatment allocation, and analysis will be exploratory to inform the design and methods of a future RCT. Analysis of the HCA consultation recordings will focus on the use of a checklist to determine the fidelity of the iPOPP intervention delivery, and the interview data will be analysed using a constant comparison approach in order to generate conceptual themes focused around the acceptability and feasibility of the trial, and then mapped to the Theoretical Domains Framework to understand barriers and facilitators to behaviour change. A triangulation protocol will be used to integrate quantitative and qualitative data and findings.

Evidence for strategies that improve recruitment and retention of adults aged 65 years and over in randomised trials and observational studies: a systematic review

Background

adults aged ≥65 years are often excluded from health research studies. Lack of representation reduces generalisability of treatments for this age group.

Objective

to evaluate the effectiveness of strategies that improve recruitment and retention of adults aged ≥65 in observational studies and randomised controlled trials (RCTs).

Methods

searches conducted in 10 databases for RCTs of recruitment and retention strategies in RCTs or observational studies. Two reviewers screened abstracts and full-text articles for eligibility and extracted data. Studies without separate data for adults aged ≥65 were discarded. Risk of bias assessed using the Cochrane Risk of Bias tool. Results were synthesised narratively.

Results

thirty-two studies were included in the review (n = 75,444). Twelve studies had low risk of bias, of which 10 had successful strategies including: Opt-out versus opt-in increased recruitment (13.6% (n = 261)-18.7% (n = 36) difference; two studies); Advance notification increased retention (1.6% difference, OR 1.45; 95% CI 1.01, 2.10, one study (n = 2,686); 9.1% difference at 4 months, 1.44; 1.08, 1.92, one study (n = 753)); Hand-delivered versus postal surveys increased response (25.1% difference; X2 = 11.40, P < 0.01; one study (n = 139)); Open randomised design versus blinded RCT increased recruitment (1.56; 1.05, 2.33) and retention (13.9% difference; 3.1%, 24.6%) in one study (n = 538). Risk of bias was high/unclear for studies in which incentives or shorter length questionnaires increased response.

Discussion

in low risk of bias studies, few of the strategies that improved participation in older adults had been tested in ≥1 study. Opt-out and advance notification strategies improved recruitment and retention, respectively, although an opt-out approach may have ethical limitations. Evidence from single studies limits the generalisability of other strategies.

Recruitment and Ongoing Engagement in a UK Smartphone Study Examining the Association Between Weather and Pain: Cohort Study

BACKGROUND

The huge increase in smartphone use heralds an enormous opportunity for epidemiology research, but there is limited evidence regarding long-term engagement and attrition in mobile health (mHealth) studies.

OBJECTIVE

The objective of this study was to examine how representative the Cloudy with a Chance of Pain study population is of wider chronic-pain populations and to explore patterns of engagement among participants during the first 6 months of the study.

METHODS

Participants in the United Kingdom who had chronic pain (≥3 months) and enrolled between January 20, 2016 and January 29, 2016 were eligible if they were aged ≥17 years and used the study app to report any of 10 pain-related symptoms during the study period. Participant characteristics were compared with data from the Health Survey for England (HSE) 2011. Distinct clusters of engagement over time were determined using first-order hidden Markov models, and participant characteristics were compared between the clusters.

RESULTS

Compared with the data from the HSE, our sample comprised a higher proportion of women (80.51%, 5129/6370 vs 55.61%, 4782/8599) and fewer persons at the extremes of age (16-34 and 75+). Four clusters of engagement were identified: high (13.60%, 865/6370), moderate (21.76%, 1384/6370), low (39.35%, 2503/6370), and tourists (25.44%, 1618/6370), between which median days of data entry ranged from 1 (interquartile range; IQR: 1-1; tourist) to 149 (124-163; high). Those in the high-engagement cluster were typically older, whereas those in the tourist cluster were mostly male. Few other differences distinguished the clusters.

CONCLUSIONS

Cloudy with a Chance of Pain demonstrates a rapid and successful recruitment of a large, representative, and engaged sample of people with chronic pain and provides strong evidence to suggest that smartphones could provide a viable alternative to traditional data collection methods.

Patient perceptions of glucocorticoid side effects: a cross-sectional survey of users in an online health community

OBJECTIVES

To identify the side effects most important to glucocorticoid (GC) users through a survey of a UK online health community (Healthunlocked.com).

DESIGN

Online cross-sectional survey.

SETTING

Participants were recruited through Healthunlocked.com, an online social network for health.

PARTICIPANTS

Adults who were currently taking GCs, or had taken GCs in the past month.

METHOD

Responders scored the importance of listed side effects from 1 to 10, with 10 being of high importance to them. For each side effect, histograms were plotted, and the median rating and IQR were determined. Side effects were ranked by median ranking (largest to smallest) and then IQR (smallest to largest). The scores were categorised as low (scores 1-3), medium (scores 4-7) and high (scores 8-10) importance.

RESULTS

604 responders completed the survey. Histograms of side effect scores showed a skew towards high importance for weight gain, a U-shaped distribution for cardiovascular disease (CVD), diabetes, eye disease and infections, and a skew towards low importance for acne. When ranked, the side effect of most importance to responders was weight gain (median score=9, IQR 6-10) followed by insomnia and moon face with equal median score (8) and IQR (5-10). Three serious side effects, CVD, diabetes and infections, were ranked of lower importance overall but had wide ranging scores (median score=8, IQR 1-10).

CONCLUSIONS

The three most highly rated side effects were not clinically serious but remained important to patients, perhaps reflecting their impact on quality of life and high prevalence. This should be taken into consideration when discussing treatment options and planning future GC safety studies.

Cloudy with a Chance of Pain: Engagement and Subsequent Attrition of Daily Data Entry in a Smartphone Pilot Study Tracking Weather, Disease Severity, and Physical Activity in Patients With Rheumatoid Arthritis

BACKGROUND

The increasing ownership of smartphones provides major opportunities for epidemiological research through self-reported and passively collected data.

OBJECTIVE

This pilot study aimed to codesign a smartphone app to assess associations between weather and joint pain in patients with rheumatoid arthritis (RA) and to study the success of daily self-reported data entry over a 60-day period and the enablers of and barriers to data collection.

METHODS

A patient and public involvement group (n=5) and 2 focus groups of patients with RA (n=9) supported the codesign of the app collecting self-reported symptoms. A separate "capture app" was designed to collect global positioning system (GPS) and continuous raw accelerometer data, with the GPS-linking providing local weather data. A total of 20 patients with RA were then recruited to collect daily data for 60 days, with entry and exit interviews. Of these, 17 were loaned an Android smartphone, whereas 3 used their own Android smartphones.

RESULTS

Of the 20 patients, 6 (30%) withdrew from the study: 4 because of technical challenges and 2 for health reasons. The mean completion of daily entries was 68% over 2 months. Patients entered data at least five times per week 65% of the time. Reasons for successful engagement included a simple graphical user interface, automated reminders, visualization of data, and eagerness to contribute to this easily understood research question. The main barrier to continuing engagement was impaired battery life due to the accelerometer data capture app. For some, successful engagement required ongoing support in using the smartphones.

CONCLUSIONS

This successful pilot study has demonstrated that daily data collection using smartphones for health research is feasible and achievable with high levels of ongoing engagement over 2 months. This result opens important opportunities for large-scale longitudinal epidemiological research.

Musculoskeletal pain and co-morbid insomnia in adults; a population study of the prevalence and impact on restricted social participation

Background

Comorbidity is common in patients consulting in primary care. Musculoskeletal pain and insomnia each increase the risk of the other. Co-occurrence may pose an increased burden on well-being. However, the prevalence and impact of co-existing pain and insomnia in adults living in the community who may present to primary care is unclear. The aim of this study was to report the prevalence of pain and insomnia in adults registered with primary care, and to examine the impact of co-occurrence on social activities.

Methods

This population-based prospective cohort study of adults aged ≥18 years (n = 1181) used health survey data collected via baseline and 12 month follow-up questionnaires. Baseline data on pain, insomnia (4 symptoms: delayed sleep onset, difficulty maintaining sleep, early waking and non-restorative sleep) and putative confounders and social activity restriction at follow up was collected. Associations between baseline pain, insomnia and restricted social activities (RSA) at 12 months were examined using logistic regression, with adjustment for confounders. Interaction terms between pain and each insomnia symptom were examined in final models.

Results

Mean respondent age was 49.6 (SD ± 15.2) years, 55.7% were female. At baseline, 880 (74.5%) reported pain, 122 (10.3%) delayed sleep onset, 298 (25.2%) difficulty maintaining sleep, 188 (15.9%) early wakening, and 215 (18.2%) reported non-restorative sleep. At follow-up 200 (16.9%) reported RSA. Pain and each insomnia symptom were associated with RSA at 12 month follow-up; pain [unadjusted odds ratio (OR:2.3;95%CI:1.5,3.5), delayed sleep onset (OR:6.1;95%CI:4.0,9.1), difficulty maintaining sleep (OR:3.2;95%CI:2.3,4.4), early wakening (OR:4.1;95%CI:2.9,5.9), and non-restorative sleep (OR:4.0; 95%CI:2.8,5.8). Only delayed sleep onset (OR:2.6;95%C:1.5,4.5) remained significantly associated with restricted social activities in the fully adjusted model. There was a significant interaction between pain and delayed sleep onset (OR:0.3;95%CI:0.1,0.99; p = .049) and restricted social activity at 12 months in the final multivariable model.

Conclusions

Pain and insomnia commonly co-occur, resulting in greater impact upon subsequent functional ability. Delayed sleep onset is the insomnia symptom most strongly associated with reduced functional ability. Clinicians should be aware of the common co-occurrence of insomnia symptoms, inquire about sleep in patients consulting with pain, and offer interventions that target both sleep and pain.