Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain-A Scoping Review and Theoretical Models

Biological Markers of Musculoskeletal Pain: A Scoping Review

Background

Musculoskeletal pain (MSP) is the leading contributor to disability, limiting mobility and dexterity. As research on the determinants of MSP is evolving, biomarkers can probably play a significant role in understanding its causes and improving its clinical management. This scoping review aimed to provide an overview of the associations between biomarkers and MSP.

Methods

This study followed Arksey and O'Malley and PRISMA-ScR recommendations. Keywords related to biomarkers, association, and MSP were searched on PubMed, Embase, Cochrane, and Web of Science databases from inception to September 28th, 2023. Data were systematically retrieved from the retained articles. A narrative synthesis approach - but no quality assessment - was used to map the core themes of biological markers of MSP that emerged from this work.

Results

In total, 81 out of 25,165 identified articles were included in this scoping review. These studies were heterogeneous in many aspects. Overall, vitamin D deficiency, dyslipidemia (or hypercholesterolemia), and cytokines (high levels) were the most studied biomarkers with regards to MSP and were most often reported to be associated with non-specific MSP. Cadmium, calcium, C-reactive protein, collagen, creatinine, hormones, omega-3 fatty acids, sodium, tumor necrosis factor-alpha, and vitamin C were also reported to be associated with MSP syndromes, but the evidence on these associations was sketchier. No conclusions could be drawn as to age and sex.

Conclusions

Our findings suggest that some biomarkers are associated with specific MSP syndromes, while others would be associated with non-specific syndromes. Among all candidate markers, the evidence seems to be more consistent for vitamin D, cytokines and lipids (total cholesterol, triglycerides, low- and high-density lipoproteins). High-quality studies, stratified by age and sex, are needed to advance our understanding on biomarkers of MSP.

Factors associated with self-management in older adults with multiple chronic conditions: a qualitative study

Background and purpose

Recognizing the importance of self-management in older adults with multiple chronic conditions (MCCs) is crucial for their quality of life. This qualitative study explored the factors linked to self-management among older adults with MCCs.

Materials and methods

The present study was conducted in three stages: an integrated review, qualitative interviews, and Delphi. The search used electronic databases including Web of Science, PubMed, Scopus, Magiran, SID, and Iranmedex. The results of 33 studies that met the inclusion criteria were analyzed using conventional content analysis. A data matrix was formed; and purposeful sampling was conducted among older adults with MCCs, family caregivers, and specialists. The data were collected through semi-structured interviews. Data analysis of 29 interviews was conducted simultaneously with data collection using oriented qualitative content analysis and the Elo and Kyngäs approach. Three rounds of Delphi were conducted via email correspondence with a group of 30 experts to develop and validate the proposed variables.

Results

The factors that influence self-management can be categorized into various categories. Biological factors, cognitive factors, co-morbidities, socio-economic factors, health-related behaviors, mental health, interactions with healthcare teams, Family relationships, medical facility resources, employee empowerment, health policy development, and cultural influences.

Conclusion

Self-management in older Iranian adults with MCCs is a complex and multidimensional phenomenon. By identifying the relevant factors, it is possible to design operational plans that promote self-management among the older adult population and are tailored to fit the specific needs of Iranian society.

Physical Activity Supported by Low-Cost Mobile Technology for Back Pain (PAT-Back) to Reduce Disability in Older Adults: Results of a Feasibility Study

OBJECTIVE

The purpose of this study was to evaluate the feasibility of a randomized controlled trial investigating the effectiveness of a multimodal program (PAT-Back) compared to best practice advice on pain and disability in older adults with chronic low back pain (LBP) in primary care.

METHODS

This feasibility study took place in Fortaleza, Northeast Brazil. The PAT-Back intervention consisted of a program including exercises, pain education, and motivational text messages for the in-home component. The control group received an evidence-based educational booklet. Feasibility outcomes were recruitment, adherence and retention rates, level of difficulty of the education and intervention content, perception of utility of mobile technology, and adverse events. The feasibility criteria were previously defined.

RESULTS

A total of 248 people were screened, of which 46 older adults were eligible. The retention rate was high (100% in the PAT-Back group and 95% in the control group). The adherence rate to intervention was partially met (60%), whereas the adherence rate to unsupervised exercises was adequate (75%), and perception about safety to perform home exercise was partially acceptable (70%) in the PAT-Back group. In addition, 100% of older adults reported which text messages motivated them to perform the exercises in the PAT-Back group. Difficulty reported by participants in understanding and performing the intervention was small in both groups. Six participants reported transient adverse events in both groups.

CONCLUSION

Older adults accepted both interventions. Results demonstrated that the program is feasible, although minor changes targeting adherence and safety in home exercise are needed.

IMPACT

This feasibility study supports progression to a full trial investigating the effectiveness of a multimodal program (PAT-Back) on pain and disability in older adults with chronic LBP within a primary health care setting in low to middle income countries where such data from the older population are scarce and the burden of LBP is increasing.

Adding Behaviour-Change Counselling to an Exercise Program for Adults Preparing for Hip and Knee Arthroplasty Improves Psychological and Physical Wellness: Focus Group Reflections

PURPOSE

To explore participant experiences for people on an arthroplasty waitlist, randomised to an exercise and behaviour-change counselling program (ENHANCE). The ENHANCE program for arthroplasty patients was led by an accredited exercise physiologist who delivered an individually tailored and structured exercise program. Included in the exercise program were up to five in-person counselling sessions, based on the Health Action Process Approach (HAPA) applied specifically to people with osteoarthritis. Nine adults (mean 69.4 years) who were on the waiting list for a total hip or knee arthroplasty and who had completed a 12-week program (ENHANCE) as part of a randomised controlled trial were recruited for this study.

METHODS

Two focus groups were conducted to explore participant experiences of ENHANCE. Data were analysed using inductive thematic analysis with constructs of the HAPA (motivational and volitional factors) as a framework.

RESULTS

We identified three themes (1) 'The structured program addressed inactivity and improved feelings of wellness and preparation for the operation'. The benefits were not only physical, but psychological and were contextualised in terms of preparation for the upcoming surgery. (2) 'People as enablers of participation': Participants identified that the attitude, and skill of the experienced instructor were supportive and motivating, especially in tailoring the intervention. Within the program, the support of the group was considered a positive attribute (3) 'Improved awareness changed attitudes to self-efficacy and perceived self-control'. Participants described an increased awareness of their condition and a better understanding of health expectations. They felt more control and ownership over their health journey.

CONCLUSION

Goal setting and social support were identified factors in a behaviour-change counselling program, delivered in conjunction with structured exercise that led to a positive experience. Improved psychological and physical health were described. Participants were better prepared for their upcoming surgery, with increased self efficacy and mastery to support long-term physical-activity engagement.

Behaviour Change Techniques to promote self-management and home exercise adherence for people attending physiotherapy with musculoskeletal conditions: A scoping review and mapping exercise

BACKGROUND

Many patients with musculoskeletal problems do not adhere to home exercises or self-management advice provided by physiotherapists. This is due to numerus factors, many of which can be targeted by Behaviour Change Techniques.

OBJECTIVES

1) Undertake a scoping review to identify the modifiable determinants (barriers and facilitators) of home exercise adherence and self-management for the physiotherapy management of people with musculoskeletal problems and map them to the Theoretical Domains Framework and Behaviour Change Techniques. 2) For determinants with supporting evidence from ≥2 studies, provide examples of Behaviour Change Techniques for clinical practice.

DESIGN

This review follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

METHOD

Four electronic databases were searched from inception to December 2022. Two independent reviewers carried out manuscript selection, data extraction, quality assessment, and mapping, the latter using the Theory and Techniques Tool.

RESULTS

Thirteen modifiable determinants were identified in 28 studies. The most frequently identified were self-efficacy, social support, and task appreciation. Determinants were mapped to 7 of 14 Theoretical Domains Framework categories, which in turn mapped onto 42 of 93 Behaviour Change Techniques, the most common being problem solving and instruction on how to perform behaviour.

CONCLUSIONS

By identifying determinants to home exercise adherence and self-management and mapping these to Behaviour Change Techniques, this review has improved understanding of their selection, targeting, and potential application to musculoskeletal physiotherapy practice. This provides support for physiotherapists targeting the determinants of importance for the patient in front of them.

Digital Rehabilitation Programs Improve Therapeutic Exercise Adherence for Patients With Musculoskeletal Conditions: A Systematic Review With Meta-Analysis

OBJECTIVE: To investigate the effects of digital rehabilitation for improving adherence to therapeutic exercise in people with musculoskeletal conditions. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: Five databases were searched from their inception to March 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials evaluating digital rehabilitation programs to improve adherence to therapeutic exercise for people with musculoskeletal conditions. DATA SYNTHESIS: We calculated standardized mean differences (SMDs) or mean differences (MDs) and 95% confidence intervals (CIs). Certainty of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Bias was assessed using the Cochrane risk of bias tool. RESULTS: Eleven trials were included in the meta-analysis (n = 1144 participants). At short-term follow-up, digital rehabilitation was no better than nondigital rehabilitation (3 trials, adherence rate of prescribed exercise test SMD 0.50, 95% CI: -0.13, 1.13; 2 trials, self-reported exercise adherence test MD 1.07, 95% CI: 0.58, 1.56; 2 trials, assessor-reported exercise adherence test SMD -0.10, 95% CI: -0.56, 0.36). At intermediate-term follow-up, digital rehabilitation improved exercise adherence compared with nondigital rehabilitation (6 trials, adherence rate of prescribed exercise test SMD 0.53, 95% CI: 0.35, 0.70; 2 trials, self-reported exercise adherence test MD 1.50, 95% CI: 0.76, 2.25; 2 trials, Exercise Adherence Rating Scale test MD 5.86, 95% CI: 0.08, 11.65). At long-term follow-up, there was no clinically important difference between digital and nondigital rehabilitation (2 trials, adherence rate of prescribed exercise test SMD 0.28, 95% CI: -0.14, 0.70; 1 trial, self-reported exercise adherence test MD 0.20, 95% CI: -0.91, 1.31). CONCLUSION: Digital rehabilitation was effective at improving therapeutic exercise adherence in musculoskeletal conditions at mid-term follow-up, but not at short- and long-term follow-up. J Orthop Sports Phys Ther 2022;52(11):726-739. Epub: 12 August 2022. doi:10.2519/jospt.2022.11384.

Evaluation of Physical Therapy Interventions for Improving Musculoskeletal Pain and Quality of Life in Older Adults

Background: The ageing process may lead to functional limitations, musculoskeletal pain, and worsened quality of life. The aim of this paper is to evaluate two physical therapy interventions for reducing musculoskeletal pain and improving quality of life in older adults. Methods: A cohort study was carried out with older people (60−75 years old). The Geriatric Physical Therapy group (n = 70) received massage therapy, therapeutic exercise, and therapeutic education program for 5 weeks; the Standardized Therapeutic Exercise group (n = 140) received a standardized therapeutic exercise and therapeutic education program for 3 weeks. Health-related quality of life (SF-36v2) and musculoskeletal pain intensity (VAS) were collected at baseline (A0), post-intervention (A1), and 12 weeks after baseline (A2). Results: There was pain intensity reduction in both groups (p < 0.05) and health-related quality of life improvement, except for Emotional Role (p = 0.34); Physical Function (p = 0.07), Bodily Pain (p = 0.02), and General Health (p = 0.09). At A2 there was a difference (p < 0.05) for neck pain in favor of the Geriatric Physical Therapy Group. Conclusions: Within the limitations of the study, it was possible to conclude that both physical therapy interventions showed a positive effect for reducing non-specific neck pain and low back pain in older adults, which may contribute to health-related quality of life improvement.

From hands-on to remote: Moderators of response to a novel self-management telehealth programme during the COVID-19 pandemic

BACKGROUND

In March 2020, state-wide lockdowns were declared in many countries, including Spain. Citizens were confined to their homes and remotely supported activities were prioritized as an alternative to in-person interactions. Previous data suggest that remote and self-management interventions may be successful at reducing pain and related psychological variables. However, individual factors influencing the effectiveness of these interventions remain to be identified. We aimed to investigate the psychological and motivational factors moderating changes in pain observed in chiropractic patients undertaking a novel telehealth self-management programme.

METHODS

A cohort of 208 patients from a chiropractic teaching clinic was recruited to participate in the study. Patients received telehealth consultations and individualized self-management strategies tailored for their current complaint. They were encouraged to make use of these strategies daily for 2-4 weeks, whilst rating their pain intensity, motivation and adherence. Validated questionnaires were completed online to assess catastrophizing, kinesiophobia and anxiety.

RESULTS

A total of 168 patients completed the first 2 weeks of the programme, experiencing significant reductions in all variables. Kinesiophobia emerged as a key factor influencing pain reduction and moderating the association between motivation and pain relief. In turn, adherence to the programme was associated with lower pain intensity, although moderated by the degree of motivation.

CONCLUSIONS

In the context of COVID-19, when introducing remote and self-management strategies, pain cognitions and motivational factors should be taken into consideration to foster adherence and yield better pain outcomes.

Self-Reported Practices and Emotions in Prescribing Opioids for Chronic Noncancer Pain: A Cross-Sectional Study of German Physicians

Background: The pressure on physicians when a patient seeks pain relief and their own desire to be self-effective may lead to the prescription of strong opioids for chronic noncancer pain (CNCP). This study, via physician self-reporting, aims to identify and measure (i) physician adherence to national opioid prescribing guidelines and (ii) physician emotions when a patient seeks a dosage increase of the opioid. Methods: Within a cross-sectional survey—conducted as part of a randomized controlled online intervention trial (ERONA)—600 German physicians were queried on their opioid prescribing behavior (choice and formulation of opioid, indications) for CNCP patients and their emotions to a case vignette describing a patient seeking an opioid dosage increase without signs of objective deterioration. Results: The prescription of strong opioids in this study was not always in accordance with current guidelines. When presented with a scenario in which a patient sought to have their opioid dose increased, some physicians reported negative feelings, such as either pressure (25%), helplessness (25%), anger (23%) or a combination. The risk of non-guideline-compliant prescribing behavior using the example of ultrafast-acting fentanyl for CNCP was increased when negative emotions were present (OR: 1.7; 95%-CI: 1.2−2.6; p = 0.007) or when sublingual buprenorphine was prescribed (OR: 15.4; 95%-CI: 10.1−23.3; p < 0.001). Conclusions: Physicians’ emotional self-awareness represents the first step to identify such direct reactions to patient requests and to ensure a responsible, guideline-based opioid prescription approach for the long-term well-being of the patient.

Applying the PDSA cycle to a group activity promoting lifestyle change for the active ageing of older Thai adults - a focused ethnography

Background

The proportion of the older Thai population is increasing rapidly. Lifestyle may impact active ageing in later life. Interventions that empower older Thai adults to initiate and carry out lifestyle changes are needed. This study applied the Plan-Do-Study-Act (PDSA) cycle, a tool for improving lifestyle changes, with the aim of exploring interactions among older Thai adults when participating in group activities.

Method

Focused ethnography was used based on participant observations, field notes and video recordings of 15 older Thai adults aged 62–78 years.

Results

Older Thai adults faced difficulties at the beginning since they were unfamiliar with initiating and carrying out lifestyle changes according to the PDSA concept. This provided a learning opportunity enabling older Thai adults to reach their individual goals of lifestyle change.

Conclusions

The PDSA cycle has the potential to empower older adults in group contexts to promote lifestyle changes related to active ageing.

Impacts on patient-centered outcomes of a chronic pain self-management program in a rural community: A feasibility study

This study explored if a self-management training program was feasible for a predominantly older rural Latino adults with chronic pain who had limited access to non-pharmacologically based pain treatment. Physical therapy doctoral students delivered the six-week low-literacy low-cost patient-centered program. The intervention was feasible to the participants (n=38) who showed improvement in a majority of the eight outcome measures at 6-week posttest and three measures at 18-week followup. The changes in pain severity, pain interference and pain-related physical functions reached minimally clinically important difference at follow-up. A randomized controlled trial with long-term follow-up is needed to test the program effectiveness in partnership with community health centers to increase access to pain management in rural communities.