Keele Aches and Pains Study protocol: validity, acceptability, and feasibility of the Keele STarT MSK tool for subgrouping musculoskeletal patients in primary care

Redesigning the Care of Musculoskeletal Conditions With Lifestyle Medicine

Value-based health care has been accelerated by alternative payment models and has catalyzed the redesign of care delivery across the nation. Lifestyle medicine (LM) is one of the fastest growing medical specialties and has emerged as a high-value solution for root cause treatment of chronic disease. This review detailed a large integrated health care delivery system's value transformation efforts in the nonoperative treatment of musculoskeletal (MSK) conditions by placing patient-centric, team-based, lifestyle-focused care at the foundation. With an economic and treatment imperative to reimagine care, recognizing more intervention is not always better, a collaborative approach was designed, which placed functional improvement of the patient at the center. This article described the process of implementing LM into an MSK model of care. The change management process impacted clinical, operational, and benefit plan design to facilitate an integrated care model. A new understanding of patients' co-occurring physical impairments, medical comorbidities, and behavioral health needs was necessary for clinicians to make the shift from a pathoanatomic, transactional model of care to a biopsychosocial, longitudinal model of care. The authors explored the novel intersection of the implementation of a biopsychosocial model of care using LM principles to achieve greater value for the MSK patient population.

Does the Keele STarT MSK tool predict the risk of poor outcome in non-specific shoulder complaints in primary care in a Dutch population?

OBJECTIVES

The Keele STarT MSK tool is a questionnaire to identify the prognostic factors for musculoskeletal conditions, such as shoulder complaints, developed by Keele University, UK. This study assessed whether the Keele STarT MSK tool can predict the risk of poor outcome in non-specific shoulder complaints in a Dutch population.

DESIGN

Multicentre prospective cohort study.

SETTING

Fourteen primary care physiotherapy clinics in the Netherlands participated in this study.

PARTICIPANTS

In total, 180 patients with non-specific shoulder complaints with complete data from the Keele STarT MSK tool (baseline), Short-Form 12 Health Survey (SF-12), Shoulder Pain and Disability Index (SPADI), Numeric Pain Rating Score (NPRS) and Global Perceived Effect (GPE) scale at week 6, week 12 or endpoint were included. Data were collected from January 2019 to January 2020. Of these, 180 patients were eligible for the study. Of these, 139 completed the study and were included in the analysis.

MAIN OUTCOME MEASURES

Poor outcome was defined as: SF-12 score ≤33 (physical health), SPADI score ≥30% (disability in activity), NPRS score ≥3 (pain intensity) and GPE scale score ≥3 (patient-reported recovery).

RESULTS

The area under the receiver operating characteristic curves for prediction of outcome were excellent for the SF-12, acceptable for the SPADI and NPRS, and showed no discrimination for the GPE scale. The optimal cut-off value for the Keele STarT MSK score to discriminate between low and medium/high risk groups was ≥5.

CONCLUSIONS

The Keele STarT MSK tool is able to predict the risk of poor outcome in patients with non-specific shoulder complaints in primary care physiotherapy clinics. Further research is needed to establish whether stratified care (subgrouping and targeted treatment) is more efficient. CONTRIBUTION OF PAPER.

Implementing good life with osteoArthritis from Denmark (GLA:D®) in australian public hospitals. Part 1: Feasibility

BACKGROUND

Literature reporting positive outcomes from the Good Life with osteoArthritis in Denmark (GLA:D®) program in Australia mainly involves patients attending private physiotherapy services.

OBJECTIVE

Evaluate the feasibility of implementing GLA:D® in Australian public hospitals.

DESIGN

Implementation study in three metropolitan tertiary public hospitals over six months.

METHOD

Patients aged ≥18 years with knee or hip joint-related problems deemed appropriate for non-surgical care were invited to participate in GLA:D®. Feasibility was evaluated using RE-AIM framework components (Implementation, Effectiveness, Maintenance) using service-level metrics, patient-level data, and program fidelity assessment. Findings of qualitative interviews with service providers are presented in Part 2.

RESULTS

Implementation: 70 patients (69 with knee osteoarthritis) participated (13 cohorts). 55 (79%) patients attended both education sessions, and 49 patients (70%) attended 10-12 exercises sessions. Fidelity was met based on environmental, therapist, participant- and program-related criteria.

EFFECTIVENESS

At 3 months, patients reported lower average pain (visual analogue scale [0-100 mm]: effect size -0.56, 95% CI -0.88 to -0.23) and disability (HOOS/KOOS-12 [100-0]: 0.67, 0.28 to 1.05), and improved quality of life (EQ-5D overall score: 0.46, 0.11 to 0.80). No adverse events were reported. All patients who completed 3-month assessment (n = 52) would recommend GLA:D®. Maintenance: All participating services elected to continue delivering GLA:D® beyond the study.

CONCLUSIONS

Implementing GLA:D® in Australian public hospitals is feasible, safe, and acceptable to patients with knee osteoarthritis. Public hospital patients with knee osteoarthritis reported improvements in pain, disability, and quality of life similar to previous GLA:D® cohorts.

Validity and reliability of the Persian version of the STarT musculoskeletal tool

BACKGROUND

The Subgrouping for Targeted Treatment (STarT) musculoskeletal (MSK) tool stratifies patients with MSK disorders (MSDs) into prognostic categories based on poor outcomes.

PURPOSE

This study aimed at investigating the validity and reliability of the Persian STarT MSK tool in people suffering from painful MSDs in Iran.

METHODS

A total of 593 subjects with painful MSDs including neck, shoulder, low back, knee, and multisite pain received and completed the STarT MSK tool, visual analog scale (VAS), EuroQol five-dimensions three-levels questionnaire (EQ-5D-3 L), short form-36 health survey questionnaire (SF-36), and Örebro musculoskeletal pain screening questionnaire (ÖMPSQ) in the first visit. To examine test-retest reliability, 234 patients completed the STarT MSK tool 2 days after the initial visit.

RESULTS

In this study, 139 (23.5%), 266 (44.9%), and 188 (31.7%) participants were classified as low-, medium-, and high-risk groupings for poor outcomes, respectively. Spearman's correlation coefficient showed a strong relationship among Persian STarT MSK tool and EQ-5D-3 L (-0.78), SF-36 (-0.76), and OMPSQ (0.70). The results of known-group validity indicated that this tool could distinguish among the participants in different risk subgroups based on the scores of the ÖMPSQ, VAS, SF36, and EQ-5D-5 L (p < .001). No ceiling and floor effects were observed. Cronbach's alpha and intra-class correlation coefficient (ICC2,1) were acceptable (0.71) and excellent (0.98), respectively.

CONCLUSION

The Persian version of STarT MSK tool has shown to be a valid and reliable instrument to stratify people with painful MSDs into low-, medium-, and high-risk subgroups based on persistent pain disability.

Predicting persisting disability in musculoskeletal pain patients with the STarT MSK screening tool: Results from a prospective cohort study

BACKGROUND

The STarT MSK screening tool aims to categorise musculoskeletal patients into three risk groups for treatment stratification. The tool has been translated and validated into Hebrew. However, its ability to predict persistent disability in patients has yet to be evaluated.

OBJECTIVE

The primary aim of this study was to assess the ability of the Hebrew version of the STarT MSK tool to predict persistent disability in patients experiencing musculoskeletal pain.

METHODS

A prospective observational cohort study was conducted, recruiting 135 patients with musculoskeletal pain in five common areas: back, neck, shoulder, knee, or multisite pain over the age of 21. At the first consultation, all patients completed demographic information, the Focus On Therapeutic Outcomes (FOTO) questionnaire (function, pain, and fear avoidance score), and the STarT MSK questionnaire. The patients completed the FOTO questionnaire again at the end of the physiotherapy treatments.

RESULTS

25 patients (18.5%) were classified into the low-risk group, 68 patients (50.3%) into the medium-risk group, and 42 (31.1%) into the high-risk group. The baseline STarT MSK tool score demonstrated an excellent ability to identify patients at high risk of developing persistent disability (AUC = 0.795, 95% CI 0.716-0.873).

CONCLUSIONS

The Hebrew version of the STarT MSK tool can differentiate between three chronic risk groups and has high predictive validity for chronicity. This may provide a tool to assist clinicians in identifying patients who require more intensive care, and thus, potentially prevent the transition to chronic disabling pain.

Supported self-management for all with musculoskeletal pain: an inclusive approach to intervention development: the EASIER study

BACKGROUND

Supported self-management interventions for patients with musculoskeletal (MSK) conditions may not adequately support those with limited health literacy, leading to inequalities in care and variable outcomes. The aim of this study was to develop a model for inclusive supported self-management intervention(s) for MSK pain that take account of health literacy.

METHODS

A mixed methods study with four work-packages was conducted: work package 1: secondary analysis of existing data to identify potential targets for intervention; work package 2: evidence synthesis to assess effective components of self-management interventions taking into account health literacy; work package 3: views of community members and healthcare professionals (HCPs) on essential components; work package 4: triangulation of findings and an online modified Delphi approach to reach consensus on key components of a logic model.

FINDINGS

Findings identified targets for intervention as self-efficacy, illness perceptions, and pain catastrophizing. A range of intervention components were identified (e.g. information in diverse formats offered at specific times, action planning and visual demonstrations of exercise). Support should be multi-professional using a combination of delivery modes (e.g. remote, face-to-face).

CONCLUSIONS

This research has developed a patient-centred model for a multi-disciplinary, multi-modal approach to supported self-management for patients with MSK pain and varying levels of health literacy. The model is evidence-based and acceptable to both patients and HCPs, with potential for significant impact on the management of MSK pain and for improving patient health outcomes. Further work is needed to establish its efficacy.

Development and feasibility of stratified primary care physiotherapy integrated with eHealth in patients with neck and/or shoulder complaints: results of a mixed methods study

BACKGROUND

Providing individualized care based on the context and preferences of the patient is important. Knowledge on both prognostic risk stratification and blended eHealth care in musculoskeletal conditions is increasing and seems promising. Stratification can be used to match patients to the most optimal content and intensity of treatment as well as mode of treatment delivery (i.e. face-to-face or blended with eHealth). However, research on the integration of stratified and blended eHealth care with corresponding matched treatment options for patients with neck and/or shoulder complaints is lacking.

METHODS

This study was a mixed methods study comprising the development of matched treatment options, followed by an evaluation of the feasibility of the developed Stratified Blended Physiotherapy approach. In the first phase, three focus groups with physiotherapists and physiotherapy experts were conducted. The second phase investigated the feasibility (i.e. satisfaction, usability and experiences) of the Stratified Blended Physiotherapy approach for both physiotherapists and patients in a multicenter single-arm convergent parallel mixed methods feasibility study.

RESULTS

In the first phase, matched treatment options were developed for six patient subgroups. Recommendations for content and intensity of physiotherapy were matched to the patient's risk of persistent disabling pain (using the Keele STarT MSK Tool: low/medium/high risk). In addition, selection of mode of treatment delivery was matched to the patient's suitability for blended care (using the Dutch Blended Physiotherapy Checklist: yes/no). A paper-based workbook and e-Exercise app modules were developed as two different mode of treatment delivery options, to support physiotherapists. Feasibility was evaluated in the second phase. Physiotherapists and patients were mildly satisfied with the new approach. Usability of the physiotherapist dashboard to set up the e-Exercise app was considered 'OK' by physiotherapists. Patients considered the e-Exercise app to be of 'best imaginable' usability. The paper-based workbook was not used.

CONCLUSION

Results of the focus groups led to the development of matched treatment options. Results of the feasibility study showed experiences with integrating stratified and blended eHealth care and have informed amendments to the Stratified Blended Physiotherapy approach for patients with neck and/or shoulder complaints ready to use within a future cluster randomized trial.

Benchmarking community/primary care musculoskeletal services: A narrative review and recommendation

INTRODUCTION

High quality data on service performance is essential in healthcare to evidence efficacy, efficiency, and value. There remains a paucity of publicly reported data in community and primary care musculoskeletal (MSK) services. There is also a lack of guidance on which metrics MSK services should be collecting and reporting, and how this data could be used to directly improve patient outcomes, experiences, and value.

METHOD

A narrative review of the evidence around benchmarking MSK services was undertaken with a focus on how to develop routine data collection within community/primary care settings, and how to develop benchmarking capabilities for the future, looking towards a national MSK audit. This evidence was triangulated with the findings from recent MSK data studies undertaken by the authors and emerging UK policy and guidance in this area.

RECOMMENDATIONS

To enable MSK benchmarking services need to collect consistent, standardised outcomes and, therefore, we have developed a recommendation on a minimum MSK 'core outcome set' of Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) (PROMs: MSK-HQ, NPRS, WPAI; PREMs: National MSK PREM). In addition, we make recommendations on the use of a standardised evidence-based method for case-mix adjustment and outlier identification (using the following baseline demographics and clinical factors; age, sex, ethnicity, pain site, comorbidities, duration of symptoms, previous surgery, previous pain episodes), alongside considerations on how this data should be integrated and reported within NHS systems.

CONCLUSIONS

Capturing high quality MSK data in a standardised, consistent, and sustainable way is a significant challenge. Policy holders, commissioners, managers, and clinicians need to be realistic with expectations, and take time to explore barriers to implementation including, funding, digital infrastructure/intra-operability, data sharing/governance, digital literacy, and local/national leadership. Next steps include developing a national MSK audit programme to provide a benchmarking model to support continuous improvements in care quality for patients living with MSK conditions.

Prognosis of shoulder pain in those with and without a psychological disorder: A prospective cohort study with a six-month follow-up

BACKGROUND

Because shoulder pain can have an unfavorable prognosis, it is important to have a better understanding of factors that may influence recovery.

OBJECTIVE

To determine the association between recovery from shoulder pain and the presence of depression, anxiety, and pain catastrophizing.

METHODS

In a prospective cohort study with a six months follow-up, we included patients visiting an orthopaedic department with shoulder pain. Primary outcome was recovery from shoulder pain measured with the Shoulder Pain and Disability Index at three and six months. Information about depression and anxiety (Hospital Anxiety and Depression Scale), pain catastrophizing (Pain Catastrophizing Scale), and demographic and clinical factors were collected at baseline. A linear mixed model was used to estimate the effects of depression, anxiety, pain catastrophizing, and underlying shoulder disorders on recovery.

RESULTS

We included 190 patients. There were no statistically significant associations between the presence of depression, anxiety, and pain catastrophizing, and three- and six-month recovery. Also between the underlying shoulder disorders and recovery at three and six months, there were no statistically significant associations.

CONCLUSIONS

We could not prove that depression, anxiety, and pain catastrophizing, as well as underlying shoulder disorders, were associated with recovery of shoulder pain at six months.

Validation of the German version of the STarT-MSK-Tool: A cohort study with patients from physiotherapy clinics

BACKGROUND

The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations.

OBJECTIVE

To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity.

METHODS

A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models.

RESULTS

The participants' (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%.

CONCLUSIONS

The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative.

Implementing a Stratified Vocational Advice Intervention for People on Sick Leave with Musculoskeletal Disorders: A Multimethod Process Evaluation

Purpose To perform a process evaluation of a stratified vocational advice intervention (SVAI), delivered by physiotherapists in primary care, for people on sick leave with musculoskeletal disorders participating in a randomised controlled trial. The research questions concerned how the SVAI was delivered, the content of the SVAI and the physiotherapists' experiences from delivering the SVAI. Methods We used qualitative and quantitative data from 148 intervention logs documenting the follow-up provided to each participant, recordings of 18 intervention sessions and minutes from 20 meetings with the physiotherapists. The log data were analysed with descriptive statistics. A qualitative content analysis was performed of the recordings, and we identified facilitators and barriers for implementation from the minutes. Results Of 170 participants randomised to the SVAI 152 (89%) received the intervention and 148 logs were completed. According to the logs, 131 participants received the correct number of sessions (all by telephone) and 146 action plans were developed. The physiotherapists did not attend any workplace meetings but contacted stakeholders in 37 cases. The main themes from the recorded sessions were: 'symptom burden', 'managing symptoms', 'relations with the workplace' and 'fear of not being able to manage work'. The physiotherapists felt they were able to build rapport with most participants. However, case management was hindered by the restricted number of sessions permitted according to the protocol. Conclusion Overall, the SVAI was delivered in accordance with the protocol and is therefore likely to be implementable in primary care if it is effective in reducing sick leave.

Efficient Screening for Fear of Movement in Outpatient Settings: Short Form and Computer Adaptive Tests for Fear Avoidance and Negative Pain Coping

OBJECTIVE

The purpose of this study was to develop screening measures using item response theory (IRT) for 2 factors highly relevant to fear of movement (FoM): fear avoidance and negative pain coping.

METHODS

A total of 431 patients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions seeking physical therapy completed 8 validated psychological questionnaires measuring fear avoidance and negative pain coping, resulting in 97 candidate items for IRT analysis. Unidimensionality and local independence were assessed using exploratory factor analyses followed by confirmatory factor analyses. Items were assessed for model fit to the graded response model for ordinal items. Using the final item bank, a computer adaptive test (CAT) administration mode was constructed, and reduced item sets were selected to create short forms (SFs), including items with highest information (reliability) at the different levels of the trait being measured while also considering clinical content.

RESULTS

The results supported a 28-item bank for fear avoidance and 16-item bank for negative pain coping. A 10-item and 8-item SF were developed for fear avoidance and negative pain coping, respectively. Additionally, 4-item form versions were created to provide options with lower administrative burden. CAT administration used a mean (median) of 7.7 (8) and 7.0 (7) items for fear avoidance and negative pain coping, respectively. All factors demonstrated construct validity by discriminating patient groups in expected clinical patterns.

CONCLUSION

These newly derived SFs and CAT administration modes provide reliable, valid, and efficient options to screen for fear avoidance and negative pain coping in populations with musculoskeletal pain.

IMPACT

These tools, collectively referred to as the Screening for Pain Vulnerability and Resilience tools, address a critical need for standard FoM screening processes that aid in clinical decision-making to identify who might benefit from psychologically informed approaches.

STarT MSK tool: Translation, adaptation and validation in Hebrew

BACKGROUND

The Keele STarT MSK Tool divides musculoskeletal patients into three prognostic groups for risk-stratified care. It has shown good predictive and discriminative ability in development and validation samples.

OBJECTIVES

This study aimed to translate and validate the STarT MSK in a Hebrew version, among Israeli people living with musculoskeletal (MSK) pain.

METHOD

A cross-sectional study, with nested prospective sub-sample. The STarT MSK was translated into Hebrew using published guidelines. A total of 153 adults (18+) who reported living with MSK pain were administered the STarT MSK. Clinical measures included for validity testing included the 12-Item Short-Form Health Survey (SF-12), the Hospital Anxiety and Depression Scale (HADS), the Fear-Avoidance Beliefs Questionnaire (FABQ) and a numerical pain rating scale (NPRS).

RESULTS

The STarT MSK was forward and backward translated, with minor changes to ensure cultural adaptation. The test-retest reliability of the STarT MSK total score was excellent (intraclass correlation coefficient 0.92). Internal consistency for the MSK scale was (α = 0.612). The Spearman's correlation coefficients between STarT MSK total score and the validation measures confirmed the hypotheses and were significant.

CONCLUSION

The Israeli translation and validation of the STarT MSK suggest that it is a valid and reliable instrument. The STarT MSK discriminated low-, medium- and high-risk groups.

Validity and reliability of the Norwegian version of the Musculoskeletal Health Questionnaire in people on sick leave

Background

The Musculoskeletal Health Questionnaire (MSK-HQ) is a recently developed generic questionnaire that consists of 14 items assessing health status in people with musculoskeletal disorders. The objective was to translate and cross-culturally adapt the MSK-HQ into Norwegian and to examine its construct validity and reliability in people on sick leave with musculoskeletal disorders.

Methods

A prospective cohort study was carried out in Norway on people between 18 and 67 years of age and sick leave due to a musculoskeletal disorder. The participants were recruited through the Norwegian Labour and Welfare Administration during November 2018–January 2019 and responded to the MSK-HQ at inclusion and after four weeks. Internal consistency was assessed by Cronbach’s alpha, and structural validity with a factor analysis. Construct validity was assessed by eight “a priori” defined hypotheses regarding correlations between the MSK-HQ and other reference scales. Correlations were analyzed by Spearman’s- or Pearson’s correlation coefficient and interpreted as high with values ≥ 0.50, moderate between 0.30–0.49, and low < 0.29. Reliability was tested with test–retest, standard error of measurement (SEM) and smallest detectable change (SDC).

Results

A total of 549 patients, mean age (SD) 48.6 (10.7), 309 women (56.3%), were included. The mean (SD) MSK-HQ sum scores (min–max 3–56) were 27.7 (8.2). Internal consistency was 0.86 and a three-factor structure was determined by factor analysis. Construct validity was supported by the confirmation of all hypotheses; high correlation with HRQOL, psychosocial risk profile, and self-perceived health; moderate correlation with physical activity, self-perceived work ability, and work presenteeism; and low correlation with the number of sick days. The test–retest reliability was good with an intraclass correlation coefficient of 0.83 (95% CI, 0.74–0.89), SEM was 2.3 and SDC 6.5.

Conclusions

The Norwegian version of the MSK-HQ demonstrated high internal consistency, a three-factor structure, good construct validity and good test–retest reliability when used among people on sick leave due to musculoskeletal disorders.

Integrating clinician support with intervention design as part of a programme testing stratified care for musculoskeletal pain in general practice

Background

Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to early treatment options. The STarT-MSK programme developed and tested a new stratified primary care intervention for patients with common musculoskeletal (MSK) conditions in general practice. Stratified care involves changing General Practitioners’ (GPs) behaviour, away from the current ‘stepped’ care approach to identifying early treatment options matched to patients’ risk of persistent pain. Changing healthcare practice is challenging, and to aid the successful delivery of stratified care, education and support for GPs was required. This paper details the iterative development of a clinician support package throughout the lifespan of the programme, to support GPs in delivering the stratified care intervention. We argue that clinician support is a crucial aspect of the intervention itself, which is often overlooked.

Methods

Qualitative research with patients and GPs identified barriers and facilitators to the adoption of stratified care, which were mapped onto the Theoretical Domains Framework (TDF). Identified domains were ‘translated’ into an educational paradigm, and an initial version of the support package developed. This was further refined following a feasibility and pilot RCT, and a finalised support package was developed for the main RCT.

Results

The clinician support package comprised face-to-face sessions combining adult-learning principles with behaviour change theory in a multimethod approach, which included group discussion, simulated consultations, patient vignettes and model consultation videos. Structured support for GPs was crucial to facilitate fidelity and, ultimately, a successful trial. Clinician support is a two-way process– the study team can learn from and adapt to specific local factors and issues not previously identified. The support from senior clinicians was required to ensure ‘buy in’. Monitoring of GP performance, provision of regular feedback and remedial support are important aspects of effective clinician support.

Conclusion

Designing effective clinician support from the onset of trial intervention design, in an evidence-based, theory-informed manner, is crucial to encourage active engagement and intervention fidelity within the trial, enabling the delivery of a robust and reliable proof-of-principle trial. We offer practical recommendations for future general practice interventions.

Triggers for acute flare in adults with, or at risk of, knee osteoarthritis: a web-based case-crossover study in community-dwelling adults

OBJECTIVE

To identify proximate causes ('triggers') of flares in adults with, or at risk of, knee osteoarthritis (OA), estimate their course and consequences, and determine higher risk individuals.

METHODS

In this 13-week web-based case-crossover study adults aged ≥40 years, with or without a recorded diagnosis of knee OA, and no inflammatory arthropathy who self-reported a knee flare completed a questionnaire capturing information on exposure to 21 putative activity-related, psychosocial and environmental triggers (hazard period, ≤72 h prior). Comparisons were made with identical exposure measurements at four 4-weekly scheduled time points (non-flare control period) using conditional logistic regression. Flare was defined as a sudden onset of worsening signs and symptoms, sustained for ≥24 h. Flare characteristics, course and consequence were analysed descriptively. Associations between flare frequency and baseline characteristics were estimated using Poisson regression.

RESULTS

Of 744 recruited participants (mean age [SD] 62.1 [10.2] years; 61% female), 376 reported 568 flares (hazards) and provided 867 valid control period measurements. Thirteen exposures (eight activity-related, five psychosocial/environmental) were positively associated with flare onset within 24 h (strongest odds ratio estimate, knee buckling: 9.06: 95% confidence interval [CI] 5.86, 13.99; weakest, cold/damp weather: 1.45: 95%CI 1.12, 1.87). Median flare duration was 5 days (IQR 3, 8), less common if older (incident rate ratio [IRR] 0.98: 95%CI 0.97, 0.99), more common if female (IRR 1.85: 95%CI 1.43, 2.39).

CONCLUSIONS

Multiple activity-related, psychosocial and environmental exposures are implicated in triggering flares. This evidence can help inform prevention and acute symptom management for patients and clinicians.

Refinement and validation of a tool for stratifying patients with musculoskeletal pain

BACKGROUND

Patients with musculoskeletal pain in different body sites share common prognostic factors. Using prognosis to stratify and treatment match can be clinically and cost-effective. We aimed to refine and validate the Keele STarT MSK Tool for prognostic stratification of musculoskeletal pain patients.

METHODS

Tool refinement and validity was tested in a prospective cohort study, and external validity examined in a pilot cluster randomized controlled trial (RCT). Study population comprised 2,414 adults visiting U.K. primary care with back, neck, knee, shoulder or multisite pain returning postal questionnaires (cohort: 1,890 [40% response]; trial: 524). Cohort baseline questionnaires included a draft tool plus refinement items. Trial baseline questionnaires included the Keele STarT MSK Tool. Physical health (SF-36 Physical Component Score [PCS]) and pain intensity were assessed at 2- and 6-month cohort follow-up; pain intensity was measured at 6-month trial follow-up.

RESULTS

The tool was refined by replacing (3), adding (3) and removing (2) items, resulting in a 10-item tool. Model fit (R² ) was 0.422 and 0.430 and discrimination (c statistic) 0.839 and 0.822 for predicting 6-month cohort PCS and pain (respectively). The tool classified 24.9% of cohort participants at low, 41.7% medium and 33.4% high risk, clearly discriminating between subgroups. The tool demonstrated model fit of 0.224 and discrimination 0.73 in trial participants. Multiple imputation confirmed robustness of findings.

CONCLUSIONS

The Keele STarT MSK Tool demonstrates good validity and acceptable predictive performance and clearly identifies groups of musculoskeletal pain patients with different characteristics and prognosis. Using prognostic information for stratification and treatment matching may be clinically/cost-effective.

SIGNIFICANCE

The paper presents the first musculoskeletal pain prognostic stratification tool specifically for use among all primary care patients with the five most common musculoskeletal pain presentations (back, neck, knee, shoulder or multisite pain). The Keele STarT MSK Tool identifies groups of musculoskeletal pain patients with clearly different characteristics and prognosis. Using this tool for stratification and treatment matching may be clinically and cost-effective.

Physiotherapist-led treatment for femoroacetabular impingement syndrome (the PhysioFIRST study): a protocol for a participant and assessor-blinded randomised controlled trial

INTRODUCTION

This double-blind, randomised controlled trial (RCT) aims to estimate the effect of a physiotherapist-led intervention with targeted strengthening compared with a physiotherapist-led intervention with standardised stretching, on hip-related quality of life (QOL) or perceived improvement at 6 months in people with femoroacetabular impingement (FAI) syndrome. We hypothesise that at 6 months, targeted strengthening physiotherapist-led treatment will be associated with greater improvements in hip-related QOL or greater patient-perceived global improvement when compared with standardised stretching physiotherapist-led treatment.

METHODS AND ANALYSIS

We will recruit 164 participants with FAI syndrome who will be randomised into one of the two intervention groups, both receiving one-on-one treatment with the physiotherapist over 6 months. The targeted strengthening physiotherapist-led treatment group will receive a personalised exercise therapy and education programme. The standardised stretching physiotherapist-led treatment group will receive standardised stretching and personalised education programme. Primary outcomes are change in hip-related QOL using International Hip Outcome Tool-33 and patient-perceived global improvement. Secondary outcomes include cost-effectiveness, muscle strength, range of motion, functional task performance, biomechanics, hip cartilage structure and physical activity levels. Statistical analyses will make comparisons between both treatment groups by intention to treat, with all randomised participants included in analyses, regardless of protocol adherence. Linear mixed models (with baseline value as a covariate and treatment condition as a fixed factor) will be used to evaluate the treatment effect and 95% CI at primary end-point (6 months).

ETHICS AND DISSEMINATION

The study protocol was approved (La Trobe University Human Ethics Committee (HEC17-080)) and prospectively registered with the Australian New Zealand Clinical Trials Registry. The findings of this RCT will be disseminated through peer reviewed scientific journals and conferences. Patients were involved in study development and will receive a short summary following the completion of the RCT.

TRIAL REGISTRATION NUMBER

ACTRN12617001350314.

Validity and reliability of the Dutch STarT MSK tool in patients with musculoskeletal pain in primary care physiotherapy

Objective

To evaluate the validity and reliability of the Dutch STarT MSK tool in patients with musculoskeletal pain in primary care physiotherapy.

Methods

Physiotherapists included patients with musculoskeletal pain, aged 18 years or older. Patients completed a questionnaire at baseline and follow-up at 5 days and 3 months, respectively. Construct validity was assessed by comparing scores of STarT MSK items with reference questionnaires. Pearson’s correlation coefficients were calculated to test predefined hypotheses. Test-retest reliability was evaluated by calculating quadratic-weighted kappa coefficients for overall STarT MSK tool scores (range 0–12) and prognostic subgroups (low, medium and high risk). Predictive validity was assessed by calculating relative risk ratios for moderate risk and high risk, both compared with low risk, in their ability to predict persisting disability at 3 months.

Results

In total, 142 patients were included in the analysis. At baseline, 74 patients (52.1%) were categorised as low risk, 64 (45.1%) as medium risk and 4 (2.8%) as high risk. For construct validity, nine of the eleven predefined hypotheses were confirmed. For test-retest reliability, kappa coefficients for the overall tool scores and prognostic subgroups were 0.71 and 0.65, respectively. For predictive validity, relative risk ratios for persisting disability were 2.19 (95% CI: 1.10–4.38) for the medium-risk group and 7.30 (95% CI: 4.11–12.98) for the high-risk group.

Conclusion

The Dutch STarT MSK tool showed a sufficient to good validity and reliability in patients with musculoskeletal pain in primary care physiotherapy. The sample size for high-risk patients was small (n = 4), which may limit the generalisability of findings for this group. An external validation study with a larger sample of high-risk patients (≥50) is recommended.

Stratified care integrated with eHealth versus usual primary care physiotherapy in patients with neck and/or shoulder complaints: protocol for a cluster randomized controlled trial

BACKGROUND

Neck and shoulder complaints are common in primary care physiotherapy. These patients experience pain and disability, resulting in high societal costs due to, for example, healthcare use and work absence. Content and intensity of physiotherapy care can be matched to a patient's risk of persistent disabling pain. Mode of care delivery can be matched to the patient's suitability for blended care (integrating eHealth with physiotherapy sessions). It is hypothesized that combining these two approaches to stratified care (referred to from this point as Stratified Blended Approach) will improve the effectiveness and cost-effectiveness of physiotherapy for patients with neck and/or shoulder complaints compared to usual physiotherapy.

METHODS

This paper presents the protocol of a multicenter, pragmatic, two-arm, parallel-group, cluster randomized controlled trial. A total of 92 physiotherapists will be recruited from Dutch primary care physiotherapy practices. Physiotherapy practices will be randomized to the Stratified Blended Approach arm or usual physiotherapy arm by a computer-generated random sequence table using SPSS (1:1 allocation). Number of physiotherapists (1 or > 1) will be used as a stratification variable. A total of 238 adults consulting with neck and/or shoulder complaints will be recruited to the trial by the physiotherapy practices. In the Stratified Blended Approach arm, physiotherapists will match I) the content and intensity of physiotherapy care to the patient's risk of persistent disabling pain, categorized as low, medium or high (using the Keele STarT MSK Tool) and II) the mode of care delivery to the patient's suitability and willingness to receive blended care. The control arm will receive physiotherapy as usual. Neither physiotherapists nor patients in the control arm will be informed about the Stratified Blended Approach arm. The primary outcome is region-specific pain and disability (combined score of Shoulder Pain and Disability Index & Neck Pain and Disability Scale) over 9 months. Effectiveness will be compared using linear mixed models. An economic evaluation will be performed from the societal and healthcare perspective.

DISCUSSION

The trial will be the first to provide evidence on the effectiveness and cost-effectiveness of the Stratified Blended Approach compared with usual physiotherapy in patients with neck and/or shoulder complaints.

TRIAL REGISTRATION

Netherlands Trial Register: NL8249 . Officially registered since 27 December 2019. Date of first enrollment: 30 September 2020. Study status: ongoing, data collection.

Self-efficacy as a prognostic factor and treatment moderator in chronic musculoskeletal pain patients attending pain management programmes: A systematic review

OBJECTIVE

Evidence on the effectiveness of pain management programmes (PMPs) for chronic pain patients is mixed. Self-efficacy may be associated with outcome of PMPs. The purpose of this systematic review was to assess the role of self-efficacy as a (i) prognostic factor and (ii) moderator of treatment, in chronic musculoskeletal pain (CMP) patients attending a PMP.

METHODS

A systematic review of the literature and qualitative synthesis was carried out. Six electronic databases were searched (1989-2020). Studies that measured pain self-efficacy as a prognostic factor or treatment moderator in patients with CMP, who participated in a multidisciplinary PMP were included. Study quality was appraised using the Quality in Prognosis Studies (QUIPS) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Six studies investigating self-efficacy as a prognostic factor were included with a total of 1881 participants. No studies were found assessing self-efficacy as a treatment moderator. Self-efficacy was a prognostic factor for physical functioning in two studies. There was weak evidence for self-efficacy as a prognostic factor for disability, health-related quality of life and pain outcomes and no evidence for psychological variables, disease severity and tender point index following PMPs. Quality of evidence was very low using the GRADE system for each outcome measure.

CONCLUSION

Baseline self-efficacy may play a role in physical function outcomes in CMP patients attending a PMP. Higher quality evidence is needed to determine the influence of self-efficacy on outcomes in this setting.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg

BACKGROUND

Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied.

METHODS

In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients.

INCLUSION CRITERIA

age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy.

EXCLUSION CRITERIA

pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods.

DISCUSSION

NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Study protocol for a randomized controlled trial of the effectiveness of adding motivational interviewing or stratified vocational advice intervention to usual case management on return to work for people with musculoskeletal disorders. The MI-NAV study

Background

Little research exists on the effectiveness of motivational interviewing (MI) on return to work (RTW) in workers on long term sick leave. The objectives of this study protocol is to describe a randomized controlled trial (RCT) with the objectives to compare the effectiveness and cost-effectiveness of usual case management alone with usual case management plus MI or usual case management plus stratified vocational advice intervention (SVAI), on RTW among people on sick leave due to musculoskeletal (MSK) disorders.

Methods

A multi-arm RCT with economic evaluation will be conducted in Norway with recruitment of 450 participants aged 18–67 years on 50–100% sick leave for > 7 weeks due to MSK disorders. Participants will be randomized to either usual case management by the Norwegian Labour and Welfare Administration (NAV) alone, usual case management by NAV plus MI, or usual case management by NAV plus SVAI. Trained caseworkers in NAV will give two MI sessions, and physiotherapists will give 1–4 SVAI sessions depending upon risk of long-term sick leave. The primary outcome is the number of sick leave days from randomization to 6 months follow-up. Secondary outcomes are number of sick leave days at 12 months follow-up, time until sustainable RTW (≥4 weeks of at least 50% of their usual working hours) at 12 months, proportions of participants receiving sick leave benefits during 12 months of follow-up, and MSK symptoms influencing health at 12 months. Cost-utility evaluated by the EuroQoL 5D-5L and cost-benefit analyses will be performed. Fidelity of the interventions will be assessed through audio-recordings of approximately 10% of the intervention sessions.

Discussion

The results from this RCT will inform stakeholders involved in supporting RTW due to MSK disorders such as staff within NAV and primary health care.

Trial registration

ClinicalTrials.gov ID: NCT03871712 registered March 12th 2020.

Validation of the Musculoskeletal Health Questionnaire (MSK-HQ) in primary care patients with musculoskeletal pain

OBJECTIVE

To evaluate the responsiveness, and concurrent validity of the Musculoskeletal Health Questionnaire (MSK-HQ) in UK primary care patients with common musculoskeletal (MSK) pain presentations.

METHODS

A secondary analysis of a primary care pilot randomised trial (STarT MSK) was performed. In 524 people consulting with back, neck, shoulder, knee, or multi-site pain, the following were recorded at 0/6 months: MSK-HQ, EQ-5D-5L, Roland-Morris Disability Questionnaire (RMDQ; back pain), Neck Disability Index (NDI), Shoulder Pain and Disability Index (SPADI), Knee Injury and Outcome Score (KOOS), Short-Form-12 (SF-12; multisite pain). At 6-months, patients self-rated their global change in MSK condition, from -5 ("very much worse") to +5 ("completely recovered"). Receiver operating characteristic curves evaluated abilities of 6-month changes in each patient reported outcome measure (PROM) to discriminate between patients improving/not improving on global change scores, with Minimal Clinically Important Differences (MCID) calculated.

RESULTS

The MSK-HQ had a good ability to discriminate between MSK pain patients reporting global improvement vs. no improvement (area under the curve [AUC] 0.81; 95% CI 0.78, 0.85). Its discriminative ability was higher than the EQ-5D-5L (AUC 0.68; 95% CI 0.62, 0.73) and similar to site-specific PROMs. The MCID for the 6-month change in MSK-HQ was 5.5. The MSK-HQ had strong correlations with all PROMs, except SF-12 scores.

CONCLUSION

In primary care patients with common MSK pain presentations, the MSK-HQ was as good as existing pain-site specific PROMs at identifying people reporting global improvements in their MSK condition, and was better than the EQ-5D-5L.

Risk assessment for prolonged sickness absence due to musculoskeletal disorders: protocol for a prospective cohort study

Background

Musculoskeletal disorders are the leading cause of sickness absence and disability pension in Norway. There is strong evidence that long-term sickness absence due to musculoskeletal disorders are associated with a reduced probability of return to work (RTW). A way to meet the economic and resource-demanding challenges related to individual follow-up of this group is to identify and treat those individuals with a high risk of prolonged sickness. The overall purposes of this project are 1) to determine the most accurate screening tool to identify people at a high risk of prolonged sickness absence due to an musculoskeletal disorder, and 2) to investigate severity of musculoskeletal health, health-related quality-of-life, health care utilization, and costs across different risk profiles in people on sick leave due to a musculoskeletal disorder.

Methods

People older than 18 years of age on sick leave for at least 4 weeks due to a musculoskeletal disorder will be invited to participate in this prospective observational cohort study conducted within the Norwegian Welfare and Labor Administration (NAV) system in collaboration with OsloMet – Oslo Metropolitan University. The main outcome is sickness absence, obtained from the NAV registry. Data on sickness absence will be retrieved prospectively in the period from study inclusion to 12 months follow-up, and retrospectively 12 months before inclusion in the study. Possible risk factors will be self-reported by the participants at inclusion while health care utilization will be retrieved from registry data. To conduct analyses including 15 to 20 predictor variables, we aim at including 500–600 people on sick leave due to musculoskeletal disorders.

Discussion

This study may provide tools that can be used to identify individuals with high risk of prolonged sickness absence and may thus be important from both a socioeconomic and individual perspective. Further, the study may give valuable insight into identification of sickness absence profiles and the associations between these profiles and musculoskeletal health status, health-related quality of life and costs.

Trial registration

Retrospectively registered in ClinicalTrials.gov (NCT04196634, 27.11.2019).

Musculoskeletal ultrasound imaging - Integration with the biopsychosocial model

BACKGROUND AND METHOD

Musculoskeletal ultrasound imaging, (MSKUSI) has become a popular imaging modality in recent years and is being utilised by a variety of professions in clinical environments beyond radiology departments. A previously published study exploring physiotherapists' interests and use of MSKUSI in practice included in-depth interviews of participants, (n = 11). The data from this qualitative study were analysed thematically and five themes were identified; one was 'Application of the biopsychosocial model', the basis of this paper.

RESULT

The theme, 'Application of the biopsychosocial model' drew together three categories of analysed data: clinical reasoning, professional variance and communication opportunity. 'Clinical reasoning' reflected the participants' value on subjective assessment information and the integration of ultrasound imaging with physical examination findings. 'Professional variance' observed the scanning processes undertaken by physiotherapists tended to vary from other professionals, the physiotherapists perceived their use of dynamic imaging was greater, in particular scanning in symptom provoking positions. Another variance observed was the style of communication that physiotherapists used when scanning, this was categorised as a 'communication opportunity' as it represented an event that could be utilised to promote patient understanding of their presentation, link imaging findings to proposed management and enhance compliance with rehabilitation strategies. Participants emphasised their responsibility when communicating with patients to avoid language that could promote unhelpful behaviour, e.g. catastrophisation.

CONCLUSION

Participants placed value on integrating musculoskeletal ultrasound imaging into the biopsychosocial model, further research to explore the impact of this approach on patients' clinical outcomes and reported experiences is required.

RESTORE-Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain: study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability globally and its costs exceed those of cancer and diabetes combined. Recent evidence suggests that individualised cognitive and movement rehabilitation combined with lifestyle advice (cognitive functional therapy (CFT)) may produce larger and more sustained effects than traditional approaches, and movement sensor biofeedback may enhance outcomes. Therefore, this three-arm randomised controlled trial (RCT) aims to compare the clinical effectiveness and economic efficiency of individualised CFT delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling LBP.

METHODS AND ANALYSIS

Pragmatic, three-arm, randomised, parallel group, superiority RCT comparing usual care (n=164) with CFT (n=164) and CFT-plus-movement-sensor-biofeedback (n=164). Inclusion criteria include: adults with a current episode of LBP >3 months; sought primary care ≥6 weeks ago for this episode of LBP; average LBP intensity of ≥4 (0-10 scale); at least moderate pain-related interference with work or daily activities. The CFT-only and CFT-plus-movement-sensor-biofeedback participants will receive seven treatment sessions over 12 weeks plus a 'booster' session at 26 weeks. All participants will be assessed at baseline, 3, 6, 13, 26, 40 and 52 weeks. The primary outcome is pain-related physical activity limitation (Roland Morris Disability Questionnaire). Linear mixed models will be used to assess the effect of treatment on physical activity limitation across all time points, with the primary comparison being a formal test of adjusted mean differences between groups at 13 weeks. For the economic (cost-utility) analysis, the primary outcome of clinical effect will be quality-adjusted life years measured across the 12-month follow-up using the EuroQol EQ-5D-5L .

ETHICS AND DISSEMINATION

Approved by Curtin University Human Research Ethics Committee (HRE2018-0062, 6 Feb 2018). Study findings will be disseminated through publication in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001396213).

Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain

Neck pain, whether from a traumatic event such as a motor vehicle crash or of a non-traumatic nature, is a leading cause of worldwide disability. This narrative review evaluated the evidence from systematic reviews, recent randomised controlled trials, clinical practice guidelines, and other relevant studies for the effects of rehabilitation approaches for chronic neck pain. Rehabilitation was defined as the aim to restore a person to health or normal life through training and therapy and as such, passive interventions applied in isolation were not considered. The results of this review found that the strongest treatment effects to date are those associated with exercise. Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in the short-term. The evidence was of moderate quality at best, indicating that future research will likely change these conclusions. Lower quality evidence and smaller effects were found for other exercise approaches. Other treatments, including education/advice and psychological treatment, showed only very small to small effects, based on low to moderate quality evidence. The review also provided suggestions for promising future directions for clinical practice and research.

Can patients with low health literacy be identified from routine primary care health records? A cross-sectional and prospective analysis

Background

People with low health literacy (HL) are at increased risk of poor health outcomes, and receive less benefit from healthcare services. However, healthcare practitioners can effectively adapt healthcare information if they are aware of their patients’ HL. Measurements are available to assess HL levels but may not be practical for use within primary care settings. New alternative methods based on demographic indicators have been successfully developed, and we aim to test if such methodology can be applied to routinely collected consultation records.

Methods

Secondary analysis was carried out from a recently completed prospective cohort study that investigated a primary care population who had consulted about a musculoskeletal pain problem. Participants completed questionnaires (assessing general health, HL, pain, and demographic information) at baseline and 6 months, with linked data from the participants’ consultation records. The Single Item Literacy Screener was used as a benchmark for HL. We tested the performance of an existing demographic assessment of HL, whether this could be refined/improved further (using questionnaire data), and then test the application in primary care consultation data. Tests included accuracy, sensitivity, specificity, and area under the curve (AUC). Finally, the completed model was tested prospectively using logistic regression producing odds ratios (OR) in the prediction of poor health outcomes (physical health and pain intensity).

Results

In total 1501 participants were included within the analysis and 16.1% were categorised as having low HL. Tests for the existing demographic assessment showed poor performance (AUC 0.52), refinement using additional components derived from the questionnaire improved the model (AUC 0.69), and the final model using data only from consultation data remained improved (AUC 0.64). Tests of this final consultation model in the prediction of outcomes showed those with low HL were 5 times more likely to report poor health (OR 5.1) and almost 4 times more likely to report higher pain intensity (OR 3.9).

Conclusions

This study has shown the feasibility of the assessment of HL using primary care consultation data, and that people indicated as having low HL have poorer health outcomes. Further refinement is now required to increase the accuracy of this method.

Matching treatment options for risk sub-groups in musculoskeletal pain: a consensus groups study

BACKGROUND

Musculoskeletal (MSK) pain represents a considerable worldwide healthcare burden. This study aimed to gain consensus from practitioners who work with MSK pain patients, on the most appropriate primary care treatment options for subgroups of patients based on prognostic risk of persistent disabling pain. Agreement was sought on treatment options for the five most common MSK pain presentations: back, neck, knee, shoulder and multisite pain, across three risk subgroups: low, medium and high.

METHODS

Three consensus group meetings were conducted with multi-disciplinary groups of practitioners (n = 20) using Nominal Group Technique, a systematic approach to building consensus using structured in-person meetings of stakeholders which follows a distinct set of stages.

RESULTS

For all five pain presentations, "education and advice" and "simple oral and topical pain medications" were agreed to be appropriate for all subgroups. For patients at low risk, across all five pain presentations "review by primary care practitioner if not improving after 6 weeks" also reached consensus. Treatment options for those at medium risk differed slightly across pain-presentations, but all included: "consider referral to physiotherapy" and "consider referral to MSK-interface-clinic". Treatment options for patients at high risk also varied by pain presentation. Some of the same options were included as for patients at medium risk, and additional options included: "opioids"; "consider referral to expert patient programme" (across all pain presentations); and "consider referral for surgical opinion" (back, knee, neck, shoulder). "Consider referral to rheumatology" was agreed for patients at medium and high risk who have multisite pain.

CONCLUSION

In addressing the current lack of robust evidence on the effectiveness of different treatment options for MSK pain, this study generated consensus from practitioners on the most appropriate primary care treatment options for MSK patients stratified according to prognostic risk. These findings can help inform future clinical decision-making and also influenced the matched treatment options in a trial of stratified primary care for MSK pain patients.

Acute Flares of Knee Osteoarthritis (the ACT-FLARE Study): Protocol for a Web-Based Case-Crossover Study in Community-Dwelling Adults

Background

The cardinal feature of osteoarthritis (OA) is pain. Although heterogeneity in pain and function have been demonstrated in the long-term course of OA, the more proximate determinants of acute flare-ups remain less clear. How short-term intermittent or transient exposures trigger acute flare-ups has important implications for effective and sustainable self-management strategies.

Objective

The primary objective of this study is to identify potential triggers of acute flares in knee OA. Secondary objectives are to determine their course and consequences and describe high-risk participant profiles.

Methods

We carried out a Web-based case-crossover study. This study aims to recruit 620 community-dwelling adults aged ≥40 years, resident in England, and who have knee pain, with or without a recorded diagnosis of knee OA, and no preexisting diagnosis of inflammatory arthropathy. Participants will be recruited via 3 routes: (1) general practice registers, (2) offline community advertisement, and (3) online social media advertisement. By using questionnaires comparing periods before participants’ self-reported flare-up episodes (hazard periods) with periods during the study when their knee OA symptoms are stable (control periods), triggers preceding flare-ups will be identified and examined using conditional logistic regression. Time-to-resolution of flare-up will be examined by monitoring people’s daily pain, bothersomeness, and medication usage until the participant reports when their flare-up episode ends. Rates of flare-ups will be examined across different participant and flare characteristics using regression models to identify high-risk participant profiles. A study-specific Patient Advisory Group (PAG) is providing suggestion, input, and ongoing support for all stages of the research process.

Results

Participant recruitment opened in July 2018 and is anticipated to continue for 6 months. The study results will be disseminated through a number of channels, including relevant national or international conferences and peer-reviewed publication in a medical journal, via advocacy or charity organizations, such as Versus Arthritis and across social media. Findings will be fed back to members of our PAG, study participants, and clinicians from participating primary care general practices. The PAG will also take an active role in the overall dissemination strategy.

Conclusions

This study will provide empirical evidence to help patients identify common knee OA flare triggers and provide health care professionals with questions to identify patients at most risk of frequent flare-ups.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13428

The Impact of Inadequate Health Literacy in a Population with Musculoskeletal Pain

Musculoskeletal conditions are a major cause of ill health and disability. Inadequate health literacy may partly explain why musculoskeletal self-management programs are not effective for some patients. This study prospectively evaluated the impact of patients' health literacy level on their musculoskeletal pain and physical function (PF) following usual primary care. Primary care patients (N = 4,720) who had consulted for musculoskeletal pain were mailed a baseline questionnaire; responders were sent a 6-month follow-up questionnaire. The measure of health literacy used was the single-item Literary Screener at baseline, and the outcomes were PF and pain intensity at the 6-months follow-up. Analysis was conducted by linear regression. The number of patients who responded was 1,890 (40%); 17.3% (95% CI [15.6%–19%]) of them had inadequate health literacy. Inadequate health literacy was associated with older age (p < .05), lower education, mental health, and comorbidities (all p < .001), but not by gender (p = .642). At the 6-month follow-up stage, patients with inadequate health literacy had lower PF (mean difference −12.2; 95% CI [−16.7, −7.6]) and higher pain intensity (mean difference 1; 95% CI [0.6, 1.4]), which was adjusted for age, gender, education, mental health, and comorbidities. Differences in PF and particularly pain scores between patients with inadequate and adequate health literacy increased over 6 months. Future studies should develop interventions that better support patients who have musculoskeletal pain with inadequate health literacy to successfully manage their pain. [HLRP: Health Literacy Research and Practice. 2018;2(4):e214–e220.]

Acute flares of knee osteoarthritis in primary care: a feasibility and pilot case-crossover study

Background

Osteoarthritis (OA) is a leading cause of persistent pain and disability. Traditionally viewed as a slowly progressive disease, the impact of symptom variability on prognosis remains unclear. 'Acute-on-chronic' episodes are a well-recognised feature of many long-term conditions but only recently formally described in OA. This study aimed to develop a web-based data collection platform and establish key methodological design parameters, to develop a larger community-based study investigating acute flares of knee OA in England.

Methods

The study is a 9-week feasibility and pilot web-based observational case-crossover study. Adults aged ≥ 40 years registered with two general practices who had consulted their general practitioner for knee pain/OA in the last 2 years were recruited. Participants completed a baseline questionnaire and scheduled (control-period) questionnaires at follow-up weeks 1, 5, and 9. Participants were invited to self-declare via the website on any occasion they experienced a knee pain flare-up lasting ≥ 24 h. Upon notification, an event-driven (case-period) questionnaire comparable to the scheduled questionnaires was completed and daily measurements on the course and consequences were taken until resolution. A sub-study of 10 participants logged daily pain measurements. The analysis estimated key parameters including recruitment (selective non-participation, eligibility, consent), retention, and flare-up capture processes. Questionnaire completeness and website usability were evaluated.

Results

Of 442 patients invited, 14 completed baseline questionnaires. Eligibility rate was 26.9% (95% CI 19.3, 36.2), consent rate 53.6% (35.8, 70.5), and overall recruitment rate 3.2% (1.9, 5.2). Compared to those mailed, baseline responders were more likely to be male and ≥ 65 years, as were those reporting ≥ 1 flare-up. Eleven scheduled questionnaires were completed (mean response 35%). Although seven participants (50%) self-declared 11 flare-ups, only one event-driven questionnaire was completed and three participants contributed daily flare measurement for four flares. Missing data was ≤ 3.7% across completed baseline, scheduled, and event-driven questionnaires. Aspects of website usability require minor refinement.

Conclusions

Recruitment was not feasible with the current strategy. An evaluation of processes has suggested several substantial changes in design that may enhance recruitment, retention, and data quality in a future full-scale study.

Advancing practice for back pain through stratified care (STarT Back)

BACKGROUND

Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care.

RESULTS

The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care.

CONCLUSIONS

The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.

'If you can't help me, so help me God I will cut it off myself…' The experience of living with knee pain: a qualitative meta-synthesis

OBJECTIVE

To identify and explore the feelings and experiences of people living with knee pain as a precursor to exploring how this might contribute to improved care in the future.

DESIGN

The qualitative meta-synthesis was undertaken in three parts (1) a systematic search of the literature, (2) a critical appraisal of the relevant studies and (3) meta-aggregation of the findings from the selected studies. A qualitative meta-synthesis is a process that enables researchers to answer a specific research question by combining and summarising a variety of qualitative sources. This was undertaken using a contextualist approach which acknowledges different realities exist but tries to determine an underlying 'truth'.

SETTING

The participants from the selected studies were from a range of settings and ethnic groups, and cultural backgrounds.

PARTICIPANTS

There were nine articles included in the meta-synthesis. Articles focused on the experiences of surgery, return to sport, or other aspects of care were excluded.

RESULTS

No articles were excluded following critical appraisal. Eleven categories were identified from 55 findings which resulted in two synthesised findings being identified: knee pain affects every aspect of life and Searching for the best way forward.

LIMITATIONS

Articles were largely limited to older adults living with osteoarthritis. Many of the findings did not report demographic data. Only English language studies were included.

CONCLUSION

Many people living with knee pain struggle to adapt to living with knee pain and this is often exacerbated by a lack of knowledge and available information to help them plan for the future.

PROSPERO NO

CRD42017070227.

General Practitioners' and patients' perceptions towards stratified care: a theory informed investigation

Background

Stratified primary care involves changing General Practitioners’ (GPs) clinical behaviour in treating patients, away from the current stepped care approach to instead identifying early treatment options that are matched to patients’ risk of persistent disabling pain. This article explores the perspectives of UK-based GPs and patients about a prognostic stratified care model being developed for patients with the five most common primary care musculoskeletal pain presentations. The focus was on views about acceptability, and anticipated barriers and facilitators to the use of stratified care in routine practice.

Methods

Four focus groups and six semi-structured telephone interviews were conducted with GPs (n = 23), and three focus groups with patients (n = 20). Data were analysed thematically; and identified themes examined in relation to the Theoretical Domains Framework (TDF), which facilitates comprehensive identification of behaviour change determinants. A critical approach was taken in using the TDF, examining the nuanced interrelationships between theoretical domains.

Results

Four key themes were identified: Acceptability of clinical decision-making guided by stratified care; impact on the therapeutic relationship; embedding a prognostic approach within a biomedical model; and practical issues in using stratified care. Whilst within each theme specific findings are reported, common across themes was the identified relationships between the theoretical domains of knowledge, skills, professional role and identity, environmental context and resources, and goals. Through analysis of these identified relationships it was found that, for GPs and patients to perceive stratified care as being acceptable, it must be seen to enhance GPs’ knowledge and skills, not undermine GPs’ and patients’ respective identities and be integrated within the environmental context of the consultation with minimal disruption.

Conclusions

Findings highlight the importance of taking into account the context of general practice when intervening to support GPs to make changes to their clinical behaviour. Findings will inform further stages of the research programme; specifically, the intervention format and content of support packages for GPs participating in a future randomised controlled trial (RCT). This study also contributes to the theoretical debate on how best to encourage clinical behaviour change in general practice, and the possible role of the TDF in that process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0511-2) contains supplementary material, which is available to authorized users.