'A challenge to my professional identity'- resisting the shift from over-management to self-management for back pain within an implementation trial: a qualitative study.

OBJECTIVE: The Enhanced Transtheoretical Model Intervention (ETMI) is based on behavioral models and focuses on guiding Chronic Low Back Pain (CLBP) patients to self-manage symptoms and engage in recreational physical activity. While there is promising evidence that ETMI benefits patients, it is unclear how challenging it might be to implement widely. This investigation focused on the perceptions of physiotherapists trained to deliver ETMI for CLBP. DESIGN: A Qualitative study comprised of semi-structured interviews (July to November 2023). Interviews were audio-recorded, transcribed, coded, and analyzed thematically by two independent researchers. SETTING: Data were obtained as part of a large implementation study evaluating the uptake and impact of ETMI amongst physiotherapists in a large public healthcare setting. PARTICIPANTS: 22 physiotherapists trained to deliver the ETMI approach and chose to use it with at least one patient. RESULTS: While physiotherapists acknowledged the evidence base behind ETMI and the clarity of the approach, they struggled to adapt it to routine delivery. Exploration of the reasons for this identified an overarching meta-theme, 'A challenge to my professional identity', and three main themes consisting of 1) interventions such as ETMI contradicted my training. 2) I am ambivalent/ do not accept evidence that contradicts my habitual practice, and 3) I am under-skilled in psychological and communication skills. CONCLUSION: This study highlights the reluctance of physiotherapists to implement evidence-based interventions such as ETMI, which fundamentally challenge their traditional practice and therapeutic identity. The shift from over-management by experts seeking cures to supporting self-management was not palatable to physiotherapists. The challenge of embracing a new professional identity must be addressed to enable a successful implementation of the approach. CONTRIBUTION OF THE PAPER.

Antidepressants for pain management in adults with chronic pain: a network meta-analysis.

Background: Chronic pain is common and costly. Antidepressants are prescribed to reduce pain. However, there has not been a network meta-analysis examining all antidepressants across all chronic pain conditions, so effectiveness and safety for most antidepressants for pain conditions remain unknown. Objective: To assess the efficacy and safety of antidepressants for chronic pain (except headache) in adults. Our primary outcomes were as follows: substantial pain relief (50%), pain intensity, mood and adverse events. Our secondary outcomes were as follows: moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change, serious adverse events and withdrawal. Design: This was a systematic review with a network meta-analysis. We searched CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS, AMED and PsycINFO databases for randomised controlled trials of antidepressants for chronic pain conditions up until 4 January 2022. The review was registered in PROSPERO (CRD42020171855), and the protocol was published in the Cochrane Library (https://doi.org/10.1002/14651858.CD014682). Setting: We analysed trials from all settings. Participants: We included trials in which participants had chronic pain, defined as longer than 3 months, from any condition excluding headache. Interventions: We included all antidepressants. Main outcome measures: Our primary outcome was substantial pain relief, defined as a reduction ˃ 50%. We also measured pain intensity, mood and adverse events. Secondary measures included moderate pain relief (above 30% reduction), physical function, sleep, quality of life, Global Impression of Change, serious adverse events, and withdrawal from trial. Results: We identified 176 studies with a total of 28,664 participants. Most studies were placebo-controlled (n = 83) and parallel armed (n = 141). The most common pain conditions examined were fibromyalgia (59 studies), neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of randomised controlled trials was 10 weeks. Most studies measured short-term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest-ranked antidepressant with moderate- to high-certainty evidence. Standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that for duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Limitations: The evidence for antidepressants other than duloxetine is poor. For duloxetine, it is not clear whether the effect applies to groups with both pain and low mood, since these groups were excluded from trials. There is also insufficient evidence on long-term outcomes and on adverse effects. Conclusions: There is only reliable evidence for duloxetine in the treatment of chronic pain. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high-quality research is needed to be confident in these conclusions. Data for all other antidepressants were of low certainty. However, the findings should not be read as an encouragement to prescribe antidepressants where other non-pharmacological intervention could be equally effective, especially in the absence of good evidence on side effects and safety. Future work: There is a need for large, methodologically sound trials testing the effectiveness of antidepressants for chronic pain. These trials should examine long-term outcomes (> 6 months) and include people with low mood. There should also be better reporting of adverse events, tolerance of drugs, and long-term compliance. Study registration: This study is registered as PROSPERO CRD42020171855. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128782) and is published in full in Health Technology Assessment; Vol. 28, No. 62. See the NIHR Funding and Awards website for further award information.

Chronic pain is pain that lasts for more than 3 months. Over one-third of people across the world experience chronic pain. This often has a detrimental impact on people's mood, disability and well-being. Antidepressants are often prescribed to reduce pain, but we are not sure which antidepressants work best for different types of pain, or whether they are safe. We wanted to find out whether antidepressants were effective and safe for management of chronic pain. We searched for studies that had compared any antidepressant with any other treatment for any type of chronic pain (except headache). We compared all the treatments against each other using a statistical method called network meta-analysis. This method allows us to rank the treatments in order of best to worst for each outcome. We found 176 studies that included a total of 28,664 people with chronic pain. Most of the studies (83/176) compared an antidepressant with a placebo (which looks like the real medicine but does not have any medicine in it). The evidence from our analysis suggests that: Duloxetine is the antidepressant that we have the most confidence in. It was the best antidepressant for reducing pain and improving physical function. A standard dose of duloxetine was equally as effective for reducing pain as a high dose of duloxetine. Milnacipran was also effective at reducing pain, but we are not as confident in this result as in the one for duloxetine because there were fewer studies with fewer people involved. Aside from duloxetine and milnacipran, we do not have confidence in the results from any other antidepressant included in this review, and even for duloxetine and milnacipran, we do not know the long-term effects. It is important to recognise that the lack of evidence for the majority of antidepressants in this review does not necessarily equal a lack of benefit. Rather, this means that the large, high-quality trials required for us to be certain of an antidepressant's effectiveness have not been undertaken. Altogether, although duloxetine and milnacipran are effective, the results of this review should not be read as an encouragement to prescribe antidepressants where other non-pharmacological intervention could be equally effective, especially in the absence of good evidence on side effects and safety. These conclusions were informed by our patient and public involvement group.

Self-management interventions for chronic widespread pain including fibromyalgia: a systematic review and qualitative evidence synthesis.

ABSTRACT: Supporting behavioural self-management is increasingly important in the care for chronic widespread pain (CWP), including fibromyalgia. Understanding peoples' experiences of these interventions may elucidate processes and mechanisms that lead to or hinder their intended impact. We conducted a systematic review and thematic synthesis of qualitative studies exploring peoples' experiences of self-management interventions for CWP, including fibromyalgia. MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science were searched. Primary qualitative or mixed-methods studies were included if they explored people's self-management intervention experiences for their CWP, including fibromyalgia. Screening, data extraction, and critical appraisal were conducted by 2 reviewers. Data analysis was conducted through thematic synthesis. Twenty-three studies were included, mostly were rated as high or moderate quality. We developed 4 analytic themes: A multifaceted experience of the intervention, potential for transformative experience of group cohesion, a new outlook, and striving for change after the loss of support. Broadly, personalisation was perceived as beneficial and people experienced a range of emotional experiences. These appeared to support positive behavioural and cognitive changes. For most, group activities promoted acceptance and support, fostering new perspectives and improved self-management, although some found aspects of group contexts challenging. Lack of on-going support after interventions led to challenges in applying behavioural strategies, and some struggled without social support from the group. The experiences of self-management interventions for CWP reflect a complex, multifaceted process. Although many reported positive experiences, addressing issues with integration of physical activity, group dynamics and postintervention support may improve effectiveness for a broader range of people.

Acceptability of a proposed practice pharmacist-led review for opioid-treated patients with persistent pain: A qualitative study to inform intervention development.

Introduction: Regular review of patients prescribed opioids for persistent non-cancer pain (PCNP) is recommended but not routinely undertaken. The PROMPPT (Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by clinical Pharmacists in primary care Teams) research programme aims to develop and test a pharmacist-led pain review (PROMPPT) to reduce inappropriate opioid use for persistent pain in primary care. This study explored the acceptability of the proposed PROMPPT review to inform early intervention development. Methods: Interviews (n = 15) and an online discussion forum (n = 31) with patients prescribed opioids for PCNP and interviews with pharmacists (n = 13), explored acceptability of a proposed PROMPPT review. A prototype PROMPPT review was then tested and refined through 3 iterative cycles of in-practice testing (IPT) (n = 3 practices, n = 3 practice pharmacists, n = 13 patients). Drawing on the Theoretical Framework of Acceptability (TFA), a framework was generated (including a priori TFA constructs) allowing for deductive and inductive thematic analysis to identify aspects of prospective and experienced acceptability. Results: Patients felt uncertain about practice pharmacists delivering the proposed PROMPPT review leading to development of content for the invitation letter for IPT (introducing the pharmacist and outlining the aim of the review). After IPT, patients felt that pharmacists were suited to the role as they were knowledgeable and qualified. Pharmacists felt that the proposed reviews would be challenging. Although challenges were experienced during delivery of PROMPPT reviews, pharmacists found that they became easier to deliver with time, practise and experience. Recommendations for optimisations after IPT included development of the training to include examples of challenging consultations. Conclusions: Uptake of new healthcare interventions is influenced by perceptions of acceptability. Exploring prospective and experienced acceptability at multiple time points during early intervention development, led to mini-optimisations of the prototype PROMPPT review ahead of a non-randomised feasibility study.

Designing a primary care pharmacist-led review for people treated with opioids for persistent pain: a multi-method qualitative study.

BACKGROUND: Opioids are frequently prescribed for persistent non-cancer pain despite limited evidence of long-term effectiveness and risk of harm. Evidence-based interventions to address inappropriate opioid prescribing are lacking. AIM: To explore perspectives of people living with persistent pain to understand barriers and facilitators in reducing opioids in the context of a pharmacist-led primary care review, and identify review components and features for optimal delivery. DESIGN & SETTING: A multi-method qualitative study undertaken in the primary care setting in the UK. METHOD: Adults with experience of persistent pain and taking opioids participated in semi-structured interviews (n = 15, 73% female) and an online discussion forum (n = 31). The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis, involving deductive analysis to TDF domains, inductive analysis within domains to generate sub-themes, and sub-theme comparison to form across-domain overarching themes. The behaviour change technique taxonomy (v1) and motivational behaviour change technique classification system were used to systematically map themes to behaviour change techniques to identify potential review components and delivery features. RESULTS: Thirty-two facilitator and barrier sub-themes for patients reducing opioids were identified across 13 TDF domains. These combined into the following six overarching themes: learning to live with pain; opioid reduction expectations; assuming a medical model; pharmacist-delivered reviews; pharmacist-patient relationship; and patient engagement. Sub-themes mapped to 21 unique behaviour change techniques, yielding 17 components and five delivery features for the proposed PROMPPT review. CONCLUSION: This study generated theoretically informed evidence for design of a practice pharmacist-led PROMPPT review. Future research will test the feasibility and acceptability of the PROMPPT review and pharmacist training.

The acceptability and feasibility of conducting a randomised controlled trial to test the effectiveness of a walking intervention for older people with persistent musculoskeletal pain in primary care: A mixed methods evaluation of the iPOPP pilot trial.

INTRODUCTION: Persistent musculoskeletal (MSK) pain is associated with physical inactivity in older people. While walking is an acceptable form of physical activity, the effectiveness of walking interventions in this population has yet to be established. OBJECTIVES: To assess the acceptability and feasibility of conducting a randomised controlled trial (RCT) to test the effectiveness of a healthcare assistant-led walking intervention for older people with persistent MSK pain (iPOPP) in primary care. METHODS: A mixed method, three arm pilot RCT was conducted in four general practices and recruited patients aged ≥65 years with persistent MSK pain. Participants were randomised in a 1:1:1 ratio to: (i) usual care, (ii) usual care plus a pedometer intervention, or (iii) usual care plus the iPOPP walking intervention. Descriptive statistics were used in an exploratory analysis of the quantitative data. Qualitative data were analysed using thematic analysis. A triangulation protocol was used to integrate the analyses from the mixed methods. RESULTS: All pre-specified success criteria were achieved in terms of feasibility (recruitment, follow-up and iPOPP intervention adherence) and acceptability. Triangulation of the data identified the need, in the future, to make the iPOPP training (for intervention deliverers) more patient-centred to better support already active patients and the use of individualised goal setting and improve accelerometry data collection processes to increase the amount of valid data. CONCLUSIONS: This pilot trial suggests that the iPOPP intervention and a future full-scale RCT are both acceptable and feasible. The use of a triangulation protocol enabled more robust conclusions about acceptability and feasibility to be drawn.

Development of a complex exercise rehabilitation intervention for people with pulmonary hypertension: the supervised pulmonary hypertension exercise rehabilitation (SPHERe) trial.

BACKGROUND: People with pulmonary hypertension (PH) are not routinely referred for exercise rehabilitation despite the potential for reducing breathlessness and improving quality of life. We describe the development of a supervised pulmonary hypertension exercise rehabilitation (SPHERe) programme for people with PH. METHODS: Development was completed in three phases: (1) systematic review, (2) stakeholder engagement with consensus from patients and experts and (3) prepilot intervention acceptability testing. We completed systematic reviews to identify international cardiopulmonary rehabilitation guidance and trials of exercise-based interventions for people with PH. Evidence from systematic reviews and stakeholder consensus shaped the SPHERe intervention, including addition of individual behavioural support sessions to promote exercise adherence. The draft SPHERe intervention was ratified through discussions with multidisciplinary professionals and people living with PH. We acceptability tested the centre-based intervention with eight participants in a prepilot development phase which identified a number of condition-specific issues relating to safety and fear avoidance of activity. Comprehensive intervention practitioner training manuals were produced to ensure standardised delivery. Participant workbooks were developed and piloted. Trial recruitment began in January 2020 but was subsequently suspended in March 2020 further to COVID-19 pandemic 'lockdowns'. In response to the pandemic, we undertook further development work to redesign the intervention to be suitable for exclusively home-based online delivery. Recruitment to the revised protocol began in June 2021. DISCUSSION: The final SPHERe intervention incorporated weekly home-based online group exercise and behavioural support 'coaching' sessions supervised by trained practitioners, with a personalised home exercise plan and the optional loan of a stationary exercise bike. The intervention was fully manualised with clear pathways for assessment and individualised exercise prescription. The clinical and cost-effectiveness of the SPHERe online rehabilitation intervention is currently being tested in a UK multicentre randomised controlled trial. TRIAL REGISTRATION NUMBER: ISCRTN10608766.

Antidepressants for pain management in adults with chronic pain: a network meta-analysis.

BACKGROUND: Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well-being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients' global impression of change for certain chronic pain conditions. However, there has not been a network meta-analysis (NMA) examining all antidepressants across all chronic pain conditions. OBJECTIVES: To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. SELECTION CRITERIA: We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double-blind. We included RCTs with active comparators that were unable to be double-blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow-up was less than two weeks and those with fewer than 10 participants in each arm.  DATA COLLECTION AND ANALYSIS: Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta-analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta-Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB-MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. MAIN RESULTS: This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo-controlled (83), and parallel-armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short-term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest-ranked antidepressant with moderate- to high-certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain.  Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate-certainty evidence) and continuous pain intensity (standardised mean difference (SMD) -0.31, 95% CI -0.39 to -0.24; 18 studies, 4959 participants; moderate-certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD -0.22, 95% CI -0.39 to 0.06; 4 studies, 1866 participants; moderate-certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD -0.5, 95% CI -0.78 to -0.22; 1 study, 406 participants; low-certainty evidence), while duloxetine showed a small effect (SMD -0.16, 95% CI -0.22 to -0.1; 26 studies, 7952 participants; moderate-certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest-ranked antidepressants with moderate-certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low-certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. AUTHORS' CONCLUSIONS: Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high-quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long-term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point.

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.

Pediatrician Explanations of Pediatric Pain in Clinical Settings: A Delicate Craft.

Explaining chronic pain to children and families can be challenging, particularly in the absence of an obvious physiologically identifiable cause for the child's pain. In addition to medical intervention, children and families may expect clinicians to provide clarity around the cause of pain. Such explanations are often provided by clinicians who have not received formal pain training. This qualitative study sought to explore the following question: What do pediatricians consider to be important when providing pain explanations to children and their parents? Using semistructured interview methods, 16 UK pediatricians were interviewed regarding their perceptions of explaining chronic pain to children and families in clinical settings. Data were analyzed using inductive reflexive thematic analysis. Analyses generated 3 themes: 1) timing of the explanation, 2) casting a wider net, and 3) tailoring of the narrative. Study findings demonstrated the need for pediatricians to skilfully interpret where children and families are in their pain journey and deliver an appropriate and adaptable explanation relating to individual needs. Analyses identified the importance of providing a pain explanation that could be repeated and understood by others outside the consultation room, to enable children and families to accept the explanation. PERSPECTIVE: Study findings identify the importance of language in addition to familial and broader factors that may influence the provision and adoption of chronic pain explanations provided by pediatricians to children and families. Improving pain explanation provision may influence treatment engagement for children and their parents, subsequently impacting pain related outcomes.

Cross-cultural adaptation, reliability, and validity of the pain self-efficacy questionnaire - Hebrew version.

PURPOSE: This study aims to translate, culturally adapt, and evaluate the psychometric properties of the Hebrew Pain Self-Efficacy Questionnaire (PSEQ). METHODS: The study was designed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) recommendations for patient-reported outcome measurement instruments. The PSEQ was initially translated into Hebrew and cross-culturally adapted. The Hebrew version of the PSEQ (PSEQ-H) was administered to participants suffering from chronic musculoskeletal pain, along with other self-report measures of pain (NPRS, FABQ, HADS, PCS, and SF-12). Eight hypotheses on expected correlations of the PSEQ-H with other instruments were formulated a priori to assess construct validity. Structural validity was assessed using confirmatory factor analysis. Floor and ceiling effects, test-retest, and internal consistency reliability were also assessed. RESULTS: The translation process retained the unidimensional model of the PSEQ. The PSEQ-H demonstrates excellent internal consistency (Cronbach's α = 0.97) and test-retest reliability (ICC = 0.88), and no significant floor and ceiling effects were observed. Construct validity was found satisfactory as 75% (six) of the analyses between the PSEQ-H and the other self-reported measures met the hypotheses. Factor analysis confirmed the single-factor structure of the questionnaire. CONCLUSIONS: The PSEQ-H version was found to have excellent reliability, good construct, and structural validity, and can be used with heterogeneous chronic musculoskeletal pain populations. Future studies should test the PSEQ-H's responsiveness and psychometric properties with specific pain populations.

Physiotherapists' perceptions of implementing evidence-based practice for patients with low back pain through the Enhanced Transtheoretical Model Intervention: a qualitative study.

BACKGROUND: Physiotherapists have been urged to implement evidence-based practice for the management of low back pain (LBP). However, recent evidence suggests that many fail to do so, specifically in accordance with eliciting and addressing psychosocial factors that impact pain. The Enhanced Transtheoretical Model Intervention (ETMI) for the Treatment of patients with LBP was developed in Israel according to the clinical guidelines and demonstrated clinically and cost-effectiveness. OBJECTIVES: This study's purpose is to explore physiotherapists' perceptions of implementing evidence-based practice through the ETMI approach. DESIGN: Qualitative study. METHODS: Qualitative semi-structured interviews were conducted with 26 physiotherapists. The interviews were audio-recorded, transcribed, coded, and analyzed thematically to identify prevalent themes. RESULTS: Three main themes were identified from the transcripts, consisting of barriers and facilitators of implementing the intervention, and a meta-theme referring to shifts in the perceptions of professional role and identity. CONCLUSION: The findings suggest that physiotherapists believed that implementing ETMI and adopting a psychosocial approach to LBP can be achieved by overcoming issues around communication skills, patient reassurance, and inter-professional collaboration. Therapists also highlighted the need for physiotherapy training to gain skills in combined physical and psychological approaches.

Cross-cultural adaptation and validation of the Hebrew version of the Injustice Experience Questionnaire - long and short versions.

PURPOSE: To translate, validate, and culturally adapt the Injustice Experience Questionnaire (IEQ) and IEQ Short Form (IEQ-SF) into Hebrew, as measuring tools for examining feelings of injustice in cases of accidents and chronic pain. METHODS: The translation was performed in several steps following the cross-cultural adaptation process. A sample of 150 patients suffering from traumatic injury fill out a battery of questionnaires: IEQ, IEQ-SF, Hospital Anxiety and Depression Scale (HADS), Numeric Pain Rating Scale (NPRS), and Pain Catastrophizing Scale (PCS), which were used for calculating construct validity. A test-retest was performed on 41 patients. RESULTS: The IEQ and IEQ-SF found Cronbach's alpha of 0.92 and 0.84, respectively. Test-retest reliability for IEQ (ICC: 0.94) was found to be excellent. Spearman's correlation coefficient between IEQ and PCS was 0.68, NPRS (severe pain: 0.45, average pain: 0.51), HADS (anxiety: 0.62, depression: 0.60). The correlation between IEQ-SF and PCS was 0.67, with HADS (anxiety: 0.52, depression: 0.48). A weak correlation was found for NPRS (severe pain: 0.30, average pain: 0.34). CONCLUSIONS: The Israeli translation and cross-cultural adaptation of the IEQ and IEQ-SF questionnaires were found to be valid and reliable.Implications for rehabilitationThe perception of injustice is a significant mental and psychological factor for recovery after accidents and injuries.This study translated, validated and culturally adapted the Injustice Experience Questionnaire (IEQ) and the short form into Hebrew.The questionnaires were found to be valid and reliable in Hebrew.

Slow and Steady But Not Related to HIV Stigma: Physical Activity in South Africans Living with HIV and Chronic Pain.

HIV stigma may influence physical activity in people living with HIV (PLWH) and chronic pain. We prospectively examined the relationship between stigma, activity and chronic pain in a convenience sample of PLWH initiating antiretroviral therapy in an inner-city clinic in Johannesburg, South Africa. Participants wore accelerometers to measure daily duration and intensity of activity for 2 weeks. Stigma was assessed with the Revised HIV Stigma Scale. Participants [n = 81, 89% female, age mean (SD) 42 (8)] were active for a median of 7 h daily (IQR 5.2, 9.2), but at very low intensity, equivalent to a slow walk [median (IQR): 0.39 m s-1 (0.33, 0.50)]. Duration and intensity of activity was not associated with stigma, even after controlling for age, self-assessed wealth, pain intensity and willingness to engage in physical activity (p-values > 0.05). As stigma did not associate with greater activity, drivers of sustained activity in South African PLWH remain unclear.

RESUMEN: El estigma del VIH puede influir en la actividad física de las personas que viven con el VIH (PVVS) y el dolor crónico. Se examinó prospectivamente la relación entre el estigma, la actividad y el dolor crónico en una muestra de conveniencia de PVVS que iniciaba la terapia antirretroviral en una clínica del centro de la ciudad en Johannesburgo, Sudáfrica. Los participantes usaron acelerómetros para medir la duración diaria y la intensidad de la actividad durante dos semanas. El estigma se evaluó con la escala revisada de estigma del VIH. Los participantes [n = 81, 89% mujeres, media de edad (SD) 42 (8)] tenían una actividad de intensidad muy baja, para una mediana de siete horas diarias (IQR 5.2, 9.2), pero, equivalente a una marcha lenta [mediana (IQR): 0.39 m s−1 (0.33, 0.50)]. La duración y la intensidad de la actividad no se asociaron con los niveles de estigma, incluso después de controlar la edad, la riqueza autoevaluada, la intensidad del dolor y la voluntad de participar en la actividad física (valores de p > 0.05). Como el estigma no se asoció con una mayor actividad, los impulsores de la actividad sostenida en las PVVS sudafricanas siguen sin estar claros.

Supportive Self-Management Program for People With Chronic Headaches and Migraine: A Randomized Controlled Trial and Economic Evaluation.

BACKGROUND AND OBJECTIVES: Chronic headache disorders are a major cause of pain and disability. Education and supportive self-management approaches could reduce the burden of headache disability. We tested the effectiveness of a group educational and supportive self-management program for people living with chronic headaches. METHODS: This was a pragmatic randomized controlled trial. Participants were aged 18 years or older with chronic migraine or chronic tension-type headache, with or without medication overuse headache. We primarily recruited from general practices. Participants were assigned to either a 2-day group education and self-management program, a one-to-one nurse interview, and telephone support or to usual care plus relaxation material. The primary outcome was headache related-quality of life using the Headache Impact Test (HIT)-6 at 12 months. The primary analysis used intention-to-treat principles for participants with migraine and both baseline and 12-month HIT-6 data. RESULTS: Between April 2017 and March 2019, we randomized 736 participants. Because only 9 participants just had tension-type headache, our main analyses were on the 727 participants with migraine. Of them, 376 were allocated to the self-management intervention and 351 to usual care. Data from 586 (81%) participants were analyzed for primary outcome. There was no between-group difference in HIT-6 (adjusted mean difference = -0.3, 95% CI -1.23 to 0.67) or headache days (0.9, 95% CI -0.29 to 2.05) at 12 months. The Chronic Headache Education and Self-management Study intervention generated incremental adjusted costs of £268 (95% CI, £176-£377) (USD383 [95% CI USD252-USD539]) and incremental adjusted quality-adjusted life years (QALYs) of 0.031 (95% CI -0.005 to 0.063). The incremental cost-effectiveness ratio was £8,617 (USD12,322) per QALY gained. DISCUSSION: These findings conclusively show a lack of benefit for quality of life or monthly headache days from a brief group education and supportive self-management program for people living with chronic migraine or chronic tension-type headache with episodic migraine. TRIAL REGISTRATION INFORMATION: Registered on the International Standard Randomized Controlled Trial Number registry, ISRCTN79708100 16th December 2015 doi.org/10.1186/ISRCTN79708100. The first enrollment was April 24, 2017. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that a brief group education and self-management program does not increase the probability of improvement in headache-related quality of life in people with chronic migraine.

Patient-centered consultations for persons with musculoskeletal conditions.

Consultations between practitioners and patients are more than a hypothesis-chasing exploration, especially when uncertainty about etiology and prognosis are high. In this article we describe a single individual's account of their lived experience of pain and long journey of consultations. This personal account includes challenges as well as opportunities, and ultimately led to self-awareness, clarity, and living well with pain. We follow each section of this narrative with a short description of the emerging scientific evidence informing on specific aspects of the consultation. Using this novel structure, we portray a framework for understanding consultations for persistent musculoskeletal pain from a position of patient-centered research to inform practice.

Physiotherapy services during the COVID-19 pandemic: A mediated model of physiotherapists' self-efficacy, tele-physiotherapy role stressors, and motivation to provide tele-physiotherapy.

BACKGROUND: Occupational self-efficacy is a stable predictor for professionals' motivation to engage with new methods and tasks. Yet, the delivery of tele-physiotherapy (Tele-PT) by physiotherapists (PTs) during the coronavirus disease of 2019 (COVID-19) outbreak without advance training may have had the potential to increase work stress and damage their motivation, regardless of their occupational self-efficacy. OBJECTIVES: The present study examined whether the relations between PTs' overall occupational self-efficacy and motivation to provide Tele-PT was mediated by role stress (i.e. role conflict and ambiguity). DESIGN AND METHOD: Between February 4 and April 23, 2021, 150 Israeli PTs completed an online survey that measured their overall occupational self-efficacy, their role stress induced by the provision of Tele-PT, their motivation to provide Tele-PT, and their demographic characteristics. RESULTS: PTs' overall occupational self-efficacy was positively associated with PTs' motivation to provide Tele-PT (r= 0.328, p < .01) and fully mediated by role conflict (0.1757, 95% CI = [0.0231, 0.3797]) and by role ambiguity (0.1845, 95% CI = [0.0196, 0.4184]) (components of role stress) caused by the provision of Tele-PT. CONCLUSIONS: It is important to investigate the predictors and mediators of the motivation to provide Tele-PT because in the post-COVID-19 era health organizations are likely to adopt many tele-medicine services, and they need to find ways to mitigate perceived challenges.

Supporting people with pain-related distress in primary care consultations: a qualitative study.

BACKGROUND: Low mood and distress are commonly reported by people who have persistent musculoskeletal (MSK) pain, which may be labelled as 'depression'. It is important to understand how pain-related distress is conceptualised and managed in primary care consultations. AIM: To explore understanding of pain-related distress and depression from the perspectives of people with persistent MSK pain and GPs. DESIGN AND SETTING: Qualitative study with people with persistent MSK pain and GPs from different parts of the UK. METHOD: Semi-structured interviews conducted remotely and data analysed thematically. RESULTS: Most participants reported challenges in distinguishing between distress and depression in the context of persistent MSK pain, but also described strategies to make this distinction. Some people described how acceptance of their situation was key and involved optimism about the future and creation of a new identity. Some GPs expressed 'therapeutic nihilism', with uncertainty about the cause of pain and how to manage people with both persistent MSK pain and distress in primary care consultations, while GPs who could identify and build on optimism with patients described how to help the patient to move forwards. CONCLUSION: This study offers a framework for the primary care consultation with patients presenting with pain-related distress. GPs should recognise the impact of persistent MSK pain on the patient and support the person in coming to terms with their pain, explore how the person feels about the future, encourage optimism, and support self-management strategies.

Implementation of the Enhanced Transtheoretical Model Intervention (ETMI) for Low Back Pain Patients in Primary Care: Study Protocol.

BACKGROUND: Self-management, an active life routine, and adherence to physical activity are effective in the management of low back pain (LBP). However, delivering effective education and reassurance to patients can be a difficult for practitioners. The enhanced transtheoretical model intervention (ETMI) has shown to be successful and cost effective. The intervention focuses on educating practitioners to reassure patients, empower them to increase physical activity, and improve their self-efficacy. OBJECTIVES: To assess whether ETMI can be implemented among primary care practitioners and to examine whether it reduces pain, disability, and fear avoidance as well as decreasing healthcare utilization. This protocol outlines the methodology for the implementation of ETMI through a hybrid implementation-effectiveness design. METHODS: Two qualitative and mixed-method studies provided a basis for an implementation prospective cohort study. Discussions are followed by a prospective cohort study with pre-and post-intervention measures as well as descriptions retrieving economic and therapeutic outcome data from the Maccabi Healthcare Services (MHS) databases. In addition, a fourth qualitative study was conducted at the midpoint of the implementation to evaluate the process by measuring the perceptions and practice of practitioners. The intervention group was 220 primary care practitioners and their patients (~n=10,000) from the central district of MHS. The control data was provided by other care districts with similar socioeconomic makeup (~n=40,000). CONCLUSIONS: We evaluated the process and outcomes of the implementation of ETMI. We investigated the relationship between the care received (ETMI against treatment as usual) and healthcare utilization, costs, and patient-clinical outcomes.