Effectiveness of a cognitive-behavioral group intervention for knee osteoarthritis pain: protocol of a randomized controlled trial

Teaming in Interdisciplinary Chronic Pain Management Interventions in Primary Care: a Systematic Review of Randomized Controlled Trials

BACKGROUND

Current pain management recommendations emphasize leveraging interdisciplinary teams. We aimed to identify key features of interdisciplinary team structures and processes associated with improved pain outcomes for patients experiencing chronic pain in primary care settings.

METHODS

We searched PubMed, EMBASE, and CINAHL for randomized studies published after 2009. Included studies had to report patient-reported pain outcomes (e.g., BPI total pain, GCPS pain intensity, RMDQ pain-related disability), include primary care as an intervention setting, and demonstrate some evidence of teamwork or teaming; specifically, they needed to involve at least two clinicians interacting with each other and with patients in an ongoing process over at least two timepoints. We assessed study quality with the Cochrane Risk of Bias tool. We narratively synthesized intervention team structures and processes, comparing among interventions that reported a clinically meaningful improvement in patient-reported pain outcomes defined by the minimal clinically important difference (MCID).

RESULTS

We included 13 total interventions in our review, of which eight reported a clinically meaningful improvement in at least one patient-reported pain outcome. No included studies had an overall high risk of bias. We identified the role of a care manager as a common structural feature of the interventions with some clinical effect on patient-reported pain. The team processes involving clinicians varied across interventions reporting clinically improved pain outcomes. However, when analyzing team processes involving patients, six of the interventions with some clinical effect on pain relied on pre-scheduled phone calls for continuous patient follow-up.

DISCUSSION

Our review suggests that interdisciplinary interventions incorporating teamwork and teaming can improve patient-reported pain outcomes in comparison to usual care. Given the current evidence, future interventions might prioritize care managers and mechanisms for patient follow-up to help bridge the gap between clinical guidelines and the implementation of interdisciplinary, team-based chronic pain care.

Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review

This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.

Multiple psychological factors predict pain and disability among community-dwelling knee osteoarthritis patients: a five-year prospective study

OBJECTIVE

To identify predictors of long-term pain and disability in knee osteoarthritis.

DESIGN

A longitudinal cohort study of five years.

SETTING

Primary care providers.

SUBJECTS

In all, 108 patients (mean age = 63.6 years, standard deviation (SD) = 7.2 years) with knee pain (⩾40 mm on a 100 mm visual analogue scale in the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index pain scale) and radiographic grading (Kellgren-Lawrence: 2-4) of knee osteoarthritis who participated in a randomized controlled trial.

MAIN MEASURES

Disease-specific pain and functioning were assessed using the corresponding WOMAC subscales. Generic functioning was assessed by the RAND-36 subscales for function and physical and mental component summary scores. Possible baseline predictors for these outcomes were (1) demographic and disease-related variables and (2) psychological variables of mood (anxiety, depression), pain-related cognitions (pain self-efficacy, pain catastrophizing, kinesiophobia), and positive resource factors (life satisfaction, sense of coherence).

RESULTS

Multivariate linear mixed model analyses revealed that minimal anxiety at baseline predicted significantly better results for pain (WOMAC, P = 0.019) and function (WOMAC, P = 0.001, RAND-36 function P = 0.001). High pain self-efficacy predicted significantly better scores in RAND-36 function (P = 0.006), physical (P = 0.004) and mental (P = 0.001) component summaries. Pain catastrophizing predicted higher pain (P = 0.015), whereas fear of movement predicted poorer functioning in RAND-36 physical (P = 0.016) and mental (P = 0.009) component summaries. Those satisfied with life reported higher scores in RAND-36 function (P = 0.002) and mental component summary (P = 0.041). A low number of comorbidities predicted significantly better results in pain (WOMAC P = 0.019) and function (WOMAC P = 0.033, RAND-36 P = 0.009).

CONCLUSION

Anxiety, pain-related cognitions, and psychological resources predict symptoms in knee osteoarthritis in the long term.

Joint pain and osteoarthritis in former recreational and elite cricketers

BACKGROUND

Sport participants are at increased risk of joint pain and osteoarthritis. A better understanding of factors associated with joint pain and osteoarthritis in this population could inform the development of strategies to optimise their long-term joint health. The purpose of the study was to describe the prevalence of joint pain and osteoarthritis in former cricketers, and determine whether playing position, playing standard (i.e. elite or recreational standard) and length-of-play are associated with region-specific joint pain.

METHODS

The data were from the Cricket Health and Wellbeing Study (CHWS), a cohort of 2294 current and former cricketers (played ≥1 season) in England and Wales. For this study, eligible individuals had to be aged ≥30 years and be a former cricket participant. Joint pain was defined as region-specific (hip/knee/ankle/shoulder/hand/back) pain on most days of the last month. Osteoarthritis was defined as joint-specific doctor-diagnosed osteoarthritis. Logistic regression was used to calculate unadjusted and adjusted (for history of joint injury resulting in > 4 weeks of reduced activity +/- age) odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

846 individuals from the CHWS were former cricketers aged ≥30 years (3% female, aged median 62(IQR 54-69) years, 62% played cricket recreationally, median 33(IQR 21-41) cricket seasons). One-in-two (48%) reported joint pain and 38% had been diagnosed with osteoarthritis. Joint pain and OA were most common in the knee (23% pain, 22% osteoarthritis), followed by the back (14% pain, 10% osteoarthritis) and hand (12% pain, 6% osteoarthritis). After adjusting for injury, bowlers had greater odds of shoulder pain (OR (95% CI) 3.1(1.3, 7.4)) and back pain (3.6(1.8, 7.4)), and all-rounders had greater odds of knee (1.7(1.0, 2.7)) and back pain (2.1(1.0, 4.2)), compared to batters. Former elite cricketers had greater odds of hand pain (1.6(1.0, 2.5)) than former recreational cricketers. Playing standard was not related to pain at other sites, and length-of-play was not associated with joint pain in former cricketers.

CONCLUSIONS

Every second former cricketer experienced joint pain on most days of the last month, and more than one in three had been diagnosed with osteoarthritis. Compared with batters, bowlers had higher odds of shoulder and back pain and all-rounders had higher odds of back and knee pain. Elite cricket participation was only related to higher odds of hand pain compared with recreational cricket participation.

Correlates and predictors of pain intensity and physical function among individuals with chronic knee osteoarthritis in Nigeria

BACKGROUND

Little is known about the correlates between pain intensity (PI) and physical function (PF) and psychosocial factors {kinesiophobia (K), Pain Catastrophizing (PC) and Self-efficacy (SE)} among patients diagnosed with knee osteoarthritis in developing countries like Nigeria.

OBJECTIVE

To investigate the correlates of PI and PF and psychosocial factors in patients with knee osteoarthritis in Nigeria.

DESIGN

Eighty-nine consecutively sampled patients diagnosed with knee osteoarthritis from three selected public hospitals in Enugu, South-East Nigeria, participated in this cross-sectional survey.

METHOD

Brief Fear of Movement Scale for Osteoarthritis, Pain Catastrophizing Scale and Arthritis Self-Efficacy Scale-8 item were used to assess kinesiophobia, pain catastrophizing and Self-efficacy respectively. Visual Analogue Scale and Ibadan Knee or Hip Osteoarthritis Measure were used to assess PI and PF respectively. Data were analysed using Pearson's correlation coefficient and multiple regression at p = 0.05.

RESULTS/FINDINGS

Participants were aged 59.11 ± 12.46years involving male (17.9%) and female (82.1%) participants. There were no significant gender differences in the scores of kinesiophobia, PI, PF, PC and self-efficacy. Pain intensity was significantly proportional to kinesiophobia (r = 0.38), and PC(r = 0.39). Better physical function was associated with high self-efficacy (r = 0.35), low kinesiophobia (r = -0.43) and low PC(r = -0.28). Significant predictive markers of PI included kinesiophobia (β = 0.24) and PC(β = 0.11) while that of PF, included kinesiophobia (β = -0.41) and SE(β = 2.39).

CONCLUSIONS

Kinesiophobia and pain catastrophizing correlate and predict PI significantly. Kinesiophobia and SE are significant correlates and predictors of PF among patients with knee osteoarthritis in Nigeria.

Mental Health-Ill Health Differences in Disease Severity and Its Sociodemographic Biobehavioral Predictors Among Patients With Knee Osteoarthritis

Our aim in this cross-sectional study was to investigate mental health-ill health differences in disease severity and its sociodemographic biobehavioral predictors among patients with knee osteoarthritis (OA). Applying convenient sampling, 180 patients with knee OA in Tabriz, Iran, were recruited to participate in completing a three-section questionnaire (SF-12, Lequesne Algofunctional Index and Self-Management Behaviors Scale). Separate hierarchical multiple linear regressions were performed with OA severity as dependent variable: one for OA patients with positive mental health and other for OA patients with mental disorders symptoms. Among the patients with positive mental health, but not those with symptoms of mental disorder, pain management, duration of OA, physical activity management, living alone, and level of education were significant predictors of disease severity. Health care providers with a better understanding on the determinants of disease severity by mental health status may identify vulnerable patients and develop targeted interventions to foster disease management behaviors among OA patients.

Determinants of pain and functioning in knee osteoarthritis: a one-year prospective study

Objective:

To identify predictors of pain and disability in knee osteoarthritis.

Design:

A one-year prospective analysis of determinants of pain and functioning in knee osteoarthritis.

Study setting:

Primary care providers in a medium-sized city.

Patients:

A total of 111 patients aged from 35 to 75 with clinical symptoms and radiographic grading (Kellgren-Lawrence 2–4) of knee osteoarthritis who participated in a randomized controlled trial.

Main measures:

The outcome measures were self-reported pain and function, which were recorded at 0, 3 and 12 months. Disease-specific pain and functioning were assessed using the pain and function subscales of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index. Generic physical and mental functioning were assessed using the RAND-36 subscales for function, and physical and mental component summary scores. Possible baseline predictors for these outcomes were 1) demographic, socioeconomic and disease-related variables, and 2) psychological measures of resources, distress, fear of movement and catastrophizing.

Results:

Multivariate linear mixed model analyses revealed that normal mood at baseline measured with the Beck Anxiety Inventory predicted significantly better results in all measures of pain (WOMAC P=0.02) and function (WOMAC P=0.002, RAND-36 P=0.002) during the one-year follow-up. Psychological resource factors (pain self-efficacy P=0.012, satisfaction with life P=0.002) predicted better function (RAND-36). Pain catastrophizing predicted higher WOMAC pain levels (P=0.013), whereas fear of movement (kinesiophobia) predicted poorer functioning (WOMAC P=0.046, RAND-36 P=0.024).

Conclusions:

Multiple psychological factors in people with knee osteoarthritis pain are associated with the development of disability and longer term worse pain.

Relationship between biological factors and catastrophizing and clinical outcomes for female patients with knee osteoarthritis

AIM

To investigate the correlations between clinical outcomes and biopsychological variables in female patients with knee osteoarthritis (OA).

METHODS

Seventy-seven patients with symptomatic knee OA were enrolled in this study. We investigated the age, body mass index (BMI), pain catastrophizing scale (PCS) and radiographic severity of bilateral knees using a Kellgren-Lawrence (K-L) grading system of the subjects. Subsequently, a multiple linear regression was conducted to determine which variables best correlated with main outcomes of knee OA, which were pain severity, moving capacity by measuring timed-up-and-go test and Japanese Knee Osteoarthritis Measure (JKOM).

RESULTS

We found that the significant contributor to pain severity was PCS (β = 0.555) and BMI (β = 0.239), to moving capacity was K-L grade (β = 0.520) and to PCS (β = 0.313), and to a JKOM score was PCS (β = 0.485) and K-L grade (β = 0.421), respectively.

CONCLUSION

The results suggest that pain catastrophizing as well as biological factors were associated with clinical outcomes in female patients with knee OA, irrespective of radiographic severity.

Effect of stepped care on health outcomes in patients with osteoarthritis: an observational study in Dutch general practice

BACKGROUND

A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands.

AIM

To assess the association between care that is in line with the SCS recommendations and health outcomes.

DESIGN AND SETTING

Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis.

METHOD

Care was considered 'SCS-consistent' if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0-100); active pain coping with the Pain Coping Inventory (range 10-40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12-48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations.

RESULTS

No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, -4.3 (95% confidence interval [CI] = -10.3 to 1.7) and -1.9 (95% CI = -7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping.

CONCLUSION

The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects.

Effectiveness of a cognitive-behavioural group intervention for knee osteoarthritis pain: a randomized controlled trial

OBJECTIVE

To assess the effectiveness of a six week cognitive-behavioural group intervention in patients with knee osteoarthritis pain.

DESIGN

Single-blinded randomized controlled trial.

STUDY SETTING

Primary care providers in a medium-sized city in Finland.

PATIENTS

A total of 111 participants aged from 35 to 75 with clinical symptoms and radiographic grading (Kellgren-Lawrence 2-4) of knee osteoarthritis were included.

INTERVENTIONS

In the intervention group, 55 participants attended a cognitive-behavioural training programme for pain management with six weekly group sessions supervised by a psychologist and a physiotherapist. Concurrently, they and the 56 participants of the control group continued in ordinary GP care that was not altered by the study.

MAIN MEASURES

The primary outcome on three-month and 12-month follow-up was the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis index pain subscale. Secondary outcome measures included self-reports of pain and physical function, health-related quality of life, and a comprehensive set of psychological questionnaires.

RESULTS

Mixed model results showed no significant differences between the intervention and control group for any measures of pain or function. A significant difference between the groups was found in the Pain Self-Efficacy Questionnaire (Pr = 0.022) in favour of the control group, and in the RAND-36 emotional well-being subscale in favour of the intervention group (Pr = 0.038). Conventional group comparisons of mean follow-up values showed no significant differences in any of the outcome variables.

CONCLUSION

This trial could not confirm the hypothesized advantage of a cognitive-behavioural training programme over ordinary GP care in knee osteoarthritis pain patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN64794760.