The effectiveness of social prescribing in the management of long-term conditions in community-based adults: A systematic review and meta-analysis.

OBJECTIVE: The objective of this systematic review and meta-analysis was to evaluate the effectiveness of social prescribing interventions in the management of long-term conditions in adults. DATA SOURCES: Eleven electronic databases were searched for randomised and quasi-randomised controlled trials. REVIEW METHODS: Outcomes of interest were quality of life, physical activity, psychological well-being and disease-specific measures. Bias was assessed with the Cochrane Risk of Bias 2 tool. A narrative synthesis and meta-analysis were performed. RESULTS: Twelve studies (n = 3566) were included in this review. Social prescribing interventions were heterogeneous and the most common risks of bias were poor blinding and high attrition. Social prescribing interventions designed to target specific long-term conditions i.e., cancer and diabetes demonstrated significant improvements in quality of life (n = 2 studies) and disease-specific psychological outcomes respectively (n = 3 studies). There was some evidence for improvement in physical activity (n = 2 studies) but most changes were within group only (n = 4 studies). Social prescribing interventions did not demonstrate any significant changes in general psychological well-being. CONCLUSION: Social prescribing interventions demonstrated some improvements across a range of outcomes although the quality of evidence remains poor.

Effect of a Home-Based, Walking Exercise Behavior Change Intervention vs Usual Care on Walking in Adults With Peripheral Artery Disease: The MOSAIC Randomized Clinical Trial.

Importance: Home-based walking exercise interventions are recommended for people with peripheral artery disease (PAD), but evidence of their efficacy has been mixed. Objective: To investigate the effect of a home-based, walking exercise behavior change intervention delivered by physical therapists in adults with PAD and intermittent claudication compared with usual care. Design, Setting, and Participants: Multicenter randomized clinical trial including 190 adults with PAD and intermittent claudication in 6 hospitals in the United Kingdom between January 2018 and March 2020; final follow-up was September 8, 2020. Interventions: Participants were randomized to receive a walking exercise behavior change intervention delivered by physical therapists trained to use a motivational approach (n = 95) or usual care (n = 95). Main Outcomes and Measures: The primary outcome was 6-minute walking distance at 3-month follow-up (minimal clinically important difference, 8-20 m). There were 8 secondary outcomes, 3 of which were the Walking Estimated Limitation Calculated by History (WELCH) questionnaire (score range, 0 [best performance] to 100), the Brief Illness Perceptions Questionnaire (score range, 0 to 80 [80 indicates negative perception of illness]), and the Theory of Planned Behavior Questionnaire (score range, 3 to 21 [21 indicates best attitude, subjective norms, perceived behavioral control, or intentions]); a minimal clinically important difference was not defined for these instruments. Results: Among 190 randomized participants (mean age 68 years, 30% women, 79% White race, mean baseline 6-minute walking distance, 361.0 m), 148 (78%) completed 3-month follow-up. The 6-minute walking distance changed from 352.9 m at baseline to 380.6 m at 3 months in the intervention group and from 369.8 m to 372.1 m in the usual care group (adjusted mean between-group difference, 16.7 m [95% CI, 4.2 m to 29.2 m]; P = .009). Of the 8 secondary outcomes, 5 were not statistically significant. At 6-month follow-up, baseline WELCH scores changed from 18.0 to 27.8 in the intervention group and from 20.7 to 20.7 in the usual care group (adjusted mean between-group difference, 7.4 [95% CI, 2.5 to 12.3]; P = .003), scores on the Brief Illness Perceptions Questionnaire changed from 45.7 to 38.9 in the intervention group and from 44.0 to 45.8 in the usual care group (adjusted mean between-group difference, -6.6 [95% CI, -9.9 to -3.4]; P < .001), and scores on the attitude component of the Theory of Planned Behavior Questionnaire changed from 14.7 to 15.4 in the intervention group and from 14.6 to 13.9 in the usual care group (adjusted mean between-group difference, 1.4 [95% CI, 0.3 to 2.5]; P = .02). Thirteen serious adverse events occurred in the intervention group, compared with 3 in the usual care group. All were determined to be unrelated or unlikely to be related to the study. Conclusions and Relevance: Among adults with PAD and intermittent claudication, a home-based, walking exercise behavior change intervention, compared with usual care, resulted in improved walking distance at 3 months. Further research is needed to determine the durability of these findings. Trial Registrations: ISRCTN Identifier: 14501418; ClinicalTrials.gov Identifier: NCT03238222.

Fatigue in adults with primary antiphospholipid syndrome: findings from a mixed-methods study.

OBJECTIVE: This study aimed to explore the experience and impact of fatigue in adults with primary antiphospholipid syndrome (pAPS). METHODS: This sequential, explanatory mixed-methods study enrolled adults with a six-month or more history of pAPS. Consenting participants completed the Functional Assessment of Chronic Illness Therapy-Fatigue subscale (FS), Multi-Dimensional Perceived Social Support Scale, Patient Health Questionnaire (PHQ9), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire (IPAQMETS). Relationships between FS and other variables were explored with multiple linear regression. Interviews were conducted with a subgroup of participants, and the data were analysed thematically. RESULTS: A total of 103 participants were recruited (Mage = 50.3 years; standard deviation = 10.1 years; 18 males). Of these, 62% reported severe fatigue. Greater fatigue was associated with lower mood, physical inactivity, poorer sleep quality and lower perceived social support. The best-fit model explained 56% of the variance in FS (adjusted R2 = 0.560, F(3, 74) = 33.65, p > 0.001) and included PHQ9 and IPAQMETS as significant predictors, and PSQI as a non-significant predictor. Twenty participants completed interviews. Three key themes were identified: characteristics of fatigue, impact on life and coping strategies. CONCLUSION: Fatigue was a common symptom of pAPS and challenging to manage. Other factors, particularly mood and physical activity, influenced fatigue. Evidence-based self-management interventions are needed.

Are Walking Treatment Beliefs and Illness Perceptions Associated With Walking Intention and 6-Min Walk Distance in People With Intermittent Claudication? A Cross-Sectional Study.

Intermittent claudication is debilitating leg pain affecting older people with peripheral arterial disease, which is improved by regular walking. This study evaluated associations between psychosocial variables and 6-min walk distance (6MWD) to identify factors that motivate walking. A total of 142 individuals with intermittent claudication (116 males; Mage = 66.9 years [SD = 10.2]) completed cross-sectional assessments of sociodemographics, walking treatment beliefs and intention (Theory of Planned Behaviour), illness perceptions (Revised Illness Perceptions Questionnaire), and 6MWD. Multiple linear regression was used to evaluate relationships among psychosocial variables (treatment beliefs and illness perceptions) and outcomes (walking intention and 6MWD). Theory of planned behavior constructs were associated with intention (R = .72, p < .001) and 6MWD (R = .08, p < .001). Illness perceptions were associated with 6MWD only (R = .27, p < .001). Intention (ß = 0.26), treatment control (ß = -0.27), personal control (ß = 0.32), coherence (ß = 0.18), and risk factor attributions (ß = 0.22; all ps < .05) were independently associated with 6MWD. Treatment beliefs and illness perceptions associated with intention and 6MWD in people with intermittent claudication are potential intervention targets.

The effect of interactive digital interventions on physical activity in people with inflammatory arthritis: a systematic review.

The aim of this systematic review was to evaluate the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of interactive digital interventions (IDIs) for physical activity (PA) and health related quality of life (HRQoL) in people with Inflammatory Arthritis [rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) axial Spondyloarthritis (AS) and psoriatic arthritis (PsA)]. Seven electronic databases identified published and unpublished studies. Two reviewers conducted independent data extraction and quality assessment using the Cochrane risk of bias tool (RoB). The primary outcome was change in objective PA after the intervention; secondary outcomes included self-reported PA and HRQoL after the intervention and objective or self-reported PA at least 1 year later. Five manuscripts, reporting four RCTs (three high and one low RoB) representing 492 (459 RA, 33 JIA) participants were included. No trials studying PsA or AS met the inclusion criteria. Interventions ranged from 6 to 52 weeks and included 3-18 Behaviour Change Techniques. Due to heterogeneity of outcomes, a narrative synthesis was conducted. No trials reported any significant between group differences in objective PA at end of intervention. Only one low RoB trial found a significant between group difference in self-reported vigorous [MD Δ 0.9 days (95% CI 0.3, 1.5); p = 0.004], but not moderate, PA in people with RA but not JIA. There were no between group differences in any other secondary outcomes. There is very limited evidence for the effectiveness of IDIs on PA and HRQoL in RA and JIA and no evidence for their effectiveness in PsA or AS.

Multidisciplinary team care for people with rheumatoid arthritis: a systematic review and meta-analysis.

The objective of this study was to systematically review the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of multidisciplinary team (MDT) care for the management of disability, disease activity and quality of life (QoL) in adults with rheumatoid arthritis (RA). Data sources identified published (MEDLINE, PsychINFO, EMBASE, CINAHL, Web of Science, CENTRAL) and unpublished (OpenGrey) literature. Independent data extraction and quality assessment, using the Cochrane risk of bias tool, were conducted by two reviewers. The primary outcome was change in disability at 12 months; secondary outcomes included disability at other time points and disease activity and QoL at 12 months. Where possible, the pooled effect sizes were calculated for inpatient or outpatient MDT interventions. Four hundred and fifteen studies were retrieved. Twelve manuscripts, which reported 10 RCTs, representing 1147 participants were included. Only data from five high- or moderate-quality trials were pooled according to clinical setting. There was no difference in disability between inpatient MDT care and any comparison group [mean difference (95% confidence intervals) 0.04, -0.13 to 0.20] or between outpatient MDT care and comparison groups (0.09, -0.07 to 0.25) at 12 months. There was no difference in disability at 2 years or <12 months or disease activity and QoL at 12 months between MDT care and any comparison group. There is limited evidence evaluating the effect of MDT care on disability, disease activity or QoL in people with RA. There is likely to be no effect of MDT care on disability at 12 months or other time points.

Economic evaluation of a brief education, self-management and upper limb exercise training in people with rheumatoid arthritis (EXTRA) programme: a trial-based analysis.

OBJECTIVE: The aim of this study was to conduct a cost-utility analysis of the Education, Self-management and Upper Limb Exercise Training in People with RA (EXTRA) programme compared with usual care. METHODS: A within-trial incremental cost-utility analysis was conducted with 108 participants randomized to either the EXTRA programme (n = 52) or usual care (n = 56). A health care perspective was assumed for the primary analysis with a 36 week follow-up. Resource use information was collected on interventions, medication, primary and secondary care contacts, private health care and social care costs. Quality-adjusted life years (QALYs) were calculated from the EuroQol five-dimension three-level (EQ-5D-3L) questionnaire responses at baseline, 12 and 36 weeks. RESULTS: Compared with usual care, total QALYs gained were higher in the EXTRA programme, leading to an increase of 0.0296 QALYs. The mean National Health Service (NHS) costs per participant were slightly higher in the EXTRA programme (by £82), resulting in an incremental cost-effectiveness ratio of £2770 per additional QALY gained. Thus the EXTRA programme was cost effective from an NHS perspective when assessed against the threshold of £20 000-£30 000/QALY gained. Overall, costs were lower in the EXTRA programme compared with usual care, suggesting it was the dominant treatment option from a societal perspective. At a willingness-to-pay of £20 000/QALY gained, there was a 65% probability that the EXTRA programme was the most cost-effective option. These results were robust to sensitivity analyses accounting for missing data, changing the cost perspective and removing cost outliers. CONCLUSION: The physiotherapist-led EXTRA programme represents a cost-effective use of resources compared with usual care and leads to lower health care costs and work absence. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number Register; http://www.controlled-trials.com/isrctn/ (ISRCTN14268051).

Participants' experiences and acceptability of a home-based walking exercise behaviour-change intervention (MOtivating Structure walking Activity in people with Intermittent Claudication (MOSAIC)).

OBJECTIVES: This study explored the experiences and acceptability of a novel, home-based, walking exercise behaviour-change intervention (MOtivating Structured walking Activity in people with Intermittent Claudication (MOSAIC)) in adults with Peripheral Arterial Disease (PAD). DESIGN AND SETTING: Individual semi-structured audio-recorded interviews were conducted with adults with Peripheral Arterial Disease who had completed the MOSAIC intervention as part of a randomised clinical trial. Data were analysed using inductive reflexive thematic analysis and interpreted using the seven-construct theoretical framework of acceptability of healthcare interventions (TFA). PARTICIPANTS: Twenty participants (mean age (range) 67(54-80) years, 70% male, 55% White British) were interviewed. RESULTS: One central theme was identified: Acceptability of walking exercise as a treatment. This theme was explained by four linked themes: Exploring walking exercise with a knowledgeable professional, Building confidence with each step, Towards self-management-learning strategies to continue walking and The impact of walking exercise. These themes were interpreted using six of the seven TFA constructs: affective attitude, burden, perceived effectiveness, intervention coherence, opportunity costs, and self-efficacy. CONCLUSIONS: Participants perceived MOSAIC as an effective, acceptable, and low burden intervention. Physiotherapists were regarded as knowledgeable and supportive professionals who helped participants understand PAD and walking exercise as a treatment. Participants developed confidence to self-manage their condition and their symptoms. As participants confidence and walking capacity improved, they expanded their activities and gained a more positive outlook on their future. MOSAIC is an acceptable intervention that may facilitate adoption of and access to exercise for people with PAD.

Can social prescribing put the 'social' into the biopsychosocial management of people with long-term musculoskeletal disorders?

BACKGROUND: Chronic musculoskeletal disorders (MSD) are a significant burden on individuals' quality of life and society and are made more complex by the presence of multimorbidity. It is recommended that interventions targeting MSD be sustainable, equitable and incorporate the biopsychosocial model of care (BPS). AIMS: A criticism of the BPS approach is that the social component of this model is not addressed adequately during the management of people with long-term MSD and that a gap exists between theory and implementation. The use of social prescribing (SP) as an intervention to bridge this gap is discussed. RESULTS AND DISCUSSION: Social prescribing is a holistic non-medical person-centered approach to well-being that utilizes link workers (LW) to support individuals with long-term conditions (LTC) in the community. Social prescribing referrals are received from primary healthcare practitioners to LW and range from light touch signposting for employment or financial advice to more intensive support for LTC such as obesity, decreased physical activity and mental health needs. CONCLUSION: There is evidence to suggest that SP interventions are effective in the management of LTC; however, due to the paucity of high-quality evidence, it is difficult to be conclusive. Large-scale randomised controlled trials are recommended to support the use of SP interventions in the management of LTC.

Exploring needs, barriers to, and facilitators of rehabilitation exercise following revision hip replacement - A grounded theory study.

PURPOSE: Evidence on rehabilitation after revision total hip replacement (THR) is inadequate and development of rehabilitation interventions is warranted. Even so, little is known about patients' experiences with revision THR rehabilitation. This study aimed to explore patients' rehabilitation exercise experiences after revision THR. MATERIALS AND METHODS: Using constructivist grounded theory, we conducted semi-structured qualitative interviews with twelve patients with completed or almost completed rehabilitation exercise after revision THR. Data collection and analysis were a constant comparative process conducted in three phases; initial, focused, and theoretical. FINDINGS: From the data, we generated a substantial theory of the participant's circumstances and ability to integrate rehabilitation exercise into their everyday life after revision THR. Four categories were constructed based on patients' experiences in different contexts: hesitance, fear avoidance, self-commitment, and fidelity. CONCLUSIONS: This study highlighted that patients' expectations, past experiences, attitudes, trusts, and circumstances interact to influence engagement and adherence to rehabilitation exercise and described four categories relating to the integration of revision THR rehabilitation exercise into their everyday life. Clinicians should be aware of and account for these categories during rehabilitation exercise. Tailored individual rehabilitation exercise interventions and clinician approaches to optimize engagement and adherence are needed among patients with revision THR.

Patients' rehabilitation exercise experiences after revision total hip replacement may serve as guidance for clinicians.A need exists to tailor individual rehabilitation interventions and clinicians' approaches to optimize patients' engagement and rehabilitation exercise adherence following revision total hip replacement.Clinicians can tailor rehabilitation exercise for patients with revision total hip replacement by focusing on therapeutic relationships, support needs, and physical function while incorporating insights from previous rehabilitation exercise experiences.An important goal of rehabilitation exercise is to enhance patient engagement, thereby facilitating the integration of rehabilitation exercises into the patients' everyday life.

Experience and perceptions of Social Prescribing interventions; a qualitative study with people with long-term conditions, link workers and health care providers.

Background: Long-term conditions (LTC) are a leading cause of reduced quality of life and early mortality. People with LTC are living longer with increasing economic and social needs. Novel patient centred care pathways are required to support traditional medical management of these patients. Social Prescribing (SP) has gained popularity as a non-medical approach to support patients with LTC and their unmet health needs. The current focus group study aims to explore the experiences and perceptions to SP interventions from the perspective of people with long-term conditions, link workers, healthcare providers and community-based services. Methods: Six toeight participants will be recruited into three specific 60 to 90 minute focus groups relative to their role as a patient, link worker and community-based service. 8 to12 participants with a Health care provider and GP background will be interviewed individually online. The participants within these focus groups and semi-structured interviews will be invited to provide opinions on what factors they think are important to the successful implementation of a SP service from their respective stakeholder positions. The data will be recorded and exported to NVivo software for further analysis using Thematic Reflexive analysis methods. Coded categorical data will inform emerging themes from which a narrative summary will be consolidated and presented for dissemination. Conclusion: The conclusions made from this study will help inform the next study, which will aim to develop a pilot SP service for patients with long-term musculoskeletal conditions as part of an overall larger project.

Are patients meeting the updated physical activity guidelines? Physical activity participation, recommendation, and preferences among inner-city adults with rheumatic diseases.

BACKGROUND: Physical activity (PA) improves the health of people with rheumatic diseases. Revised guidelines (published in the United States in 2008 and in the United Kingdom in 2011) recommend that adults complete 150 or more minutes of moderate-intensity PA or 75 or more minutes of vigorous-intensity PA (or equivalent) in bouts of 10 or minutes per week, yet whether people with rheumatic diseases meet these guidelines is unknown. OBJECTIVES: This study evaluates the PA levels of adults with rheumatic diseases attending an inner-city hospital against the updated PA guidelines. It assesses respondents' PA preferences and the proportion who report ever receiving PA advice from a healthcare professional (HCP). METHODS: Five hundred and eight patients (46% response rate) attending the general rheumatology clinics of an inner-city UK hospital completed the self-report International Physical Activity Questionnaire and 3 additional questions: "Has a doctor or other HCP ever suggested PA or exercise to help your arthritis or joint symptoms?" "Would you like help from your doctor or health service to become more physically active?" and "Which physical activities do you enjoy?" RESULTS: Overall, 61% of respondents met the updated PA guidelines, and 39% did not meet the guidelines. Forty-three percent of respondents reported ever receiving PA advice from an HCP, and 50% reported that they would "like help" to become more physically active. Walking was the most preferred PA (65%). CONCLUSIONS: Almost two-thirds of our respondents met the updated PA guidelines; however, many were entirely inactive. Recommending regular PA should be integral to rheumatic disease management, and walking offers a potentially accessible, inexpensive, and acceptable PA intervention.

Using Intervention Mapping in the Systematic Development of a Behaviour Change Intervention to Enhance Exercise Adherence among People with Persistent Musculoskeletal Pain.

Purpose: This article describes the first four steps of the intervention mapping framework used to design a programme aimed at increasing adherence to prescribed exercise by people with persistent musculoskeletal pain. Method: In Step 1, a systematic review and qualitative study was completed to inform Step 2 and the identification of the Health Action Process Approach as an appropriate theoretical framework for establishing two programme objectives: enhancing self-management and providing tailored and accessible exercise instructions. Step 3 encompassed the selection of the programme methods, and the programme is described in Step 4. The resulting programme provides virtually delivered motivational interviewing and an app-based exercise programme to support individuals' adherence to exercise. Results: The resulting intervention was assessed in a proof-of-concept feasibility and acceptability study and was shown to be feasible and acceptable. Refinements to the programme included additional tailoring of the exercise app and modifying the motivational interviewing schedule. Conclusions: Using the intervention mapping approach enabled us to successfully develop an intervention aimed at supporting the development of self-management behaviours and addressing maladaptive beliefs as a means of enhancing individuals' adherence to exercise. Evaluation and implementation of the intervention should now be carried out.

Objectif : décrire les quatre premières étapes du cadre de modélisation d'une intervention, utilisé pour concevoir un programme visant à accroître l'adhésion à une prescription d'exercices chez les personnes souffrant de douleurs musculosquelettiques persistantes. Méthodologie : à la première étape, les chercheurs ont effectué une analyse systématique et une étude qualitative pour étayer la deuxième étape et déterminer le processus d'action en santé dans un cadre théorique approprié qui permettrait de formuler les deux objectifs du programme : améliorer l'autogestion et fournir des directives d'exercices adaptées et accessibles. L'étape trois englobait le choix de la méthodologie du programme, décrite à l'étape quatre. Le programme qui en découle comprend des entrevues motivationnelles virtuelles et un programme d'exercices fondé sur une application pour renforcer l'adhésion à l'exercice. Résultats : l'intervention obtenue, évaluée dans une étude de validation de la faisabilité et de l'acceptabilité, s'est révélée faisable et acceptable. Les améliorations au programme ont inclus de nouvelles adaptations à l'application d'exercices et des modifications au calendrier d'entrevues motivationnelles. Conclusion : grâce à la démarche de modélisation de l'intervention, il a été possible d'élaborer une intervention visant à promouvoir l'acquisition de comportements d'autogestion et à corriger des convictions mésadaptées pour accroître l'adhésion à l'exercice. Il reste maintenant à évaluer et à mettre en œuvre l'intervention.

"It's important to buy in to the new lifestyle": barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain.

INTRODUCTION: Exercise and physical activity may improve pain and function in people with persistent musculoskeletal pain, but adherence is often low. Understanding the barriers and facilitators of exercise adherence could aid in the development of an intervention to promote exercise adherence. This study explored the factors influencing adherence to prescribed exercise in people with persistent musculoskeletal pain. METHODS: Qualitative semi-structured interviews were conducted with patients with persistent musculoskeletal pain. Registered physiotherapists specializing in the treatment of persistent musculoskeletal pain were recruited to two focus groups. Data was analyzed using framework analysis informed by the Theoretical Domains Framework. FINDINGS: Twenty patient participants (mean age = 44 years, standard deviation = 14) and ten physiotherapists (mean duration registered = 11 years, standard deviation = 5) were included. Four themes were identified: the role of environment, the therapeutic relationship, facilitating engagement with self-management and the influence of pain and negative affect. The Health Action Process Approach was identified as an appropriate model to inform intervention development. CONCLUSIONS: Personal, social, and environmental factors as well as the relationship with the physiotherapist influences exercise adherence. These findings may inform practice and the development of theoretically-informed interventions to enhance exercise adherence in people with persistent musculoskeletal pain.Implications for rehabilitationExercise and physical activity can decrease pain while improving mobility in a population with persistent musculoskeletal pain, but adherence to prescribed programs is low.The physical and social environment, the influence of pain, and negative affect may act as barriers to exercise adherence, while fostering a collaborative therapeutic relationship and facilitating self-management may enhance exercise adherence.The findings from the current study align with the constructs theorized by the Health Action Process Approach to support initiation and maintenance of behavior. This may provide a suitable theoretical framework to support the development of a targeted intervention.Healthcare providers, specifically physiotherapists, may find that facilitating self-management strategies that emphasize coping skills to overcome personal, social and environmental barriers may enhance exercise adherence in their patients.

Smartphone Apps Targeting Physical Activity in People With Rheumatoid Arthritis: Systematic Quality Appraisal and Content Analysis.

BACKGROUND: Rheumatoid arthritis (RA) is a disabling, inflammatory joint condition affecting 0.5%-1% of the global population. Physical activity (PA) and exercise are recommended for people with RA, but uptake and adherence tend to be low. Smartphone apps could assist people with RA to achieve PA recommendations. However, it is not known whether high quality, evidence-informed PA apps that include behavior change techniques (BCTs) previously identified as effective for PA adherence are available for people with RA. OBJECTIVE: This study aims to systematically identify apps that include goals to facilitate PA for adults with RA and assess app quality and content for the inclusion of relevant BCTs against recommendations for cardiorespiratory, resistance, flexibility, and neuromotor PA and exercise. METHODS: A systematic search of the Apple App Store and Google Play Store in the United Kingdom was conducted to identify English language apps that promote PA for adults with RA. Two researchers independently assessed app quality (mobile app rating scale [MARS]; range 0-5) and content (BCT Taxonomy version 1, World Health Organization, the American College of Sports Medicine, and the European League against Rheumatism recommendations for PA). The completeness of reporting of PA prescription was evaluated using a modified version of the Consensus on Exercise Reporting Template (CERT; range 0-14). RESULTS: A total of 14,047 apps were identified. Following deduplication, 2737 apps were screened for eligibility; 6 apps were downloaded (2 on the Apple App Store and 4 on the Google Play Store), yielding 4 unique apps. App quality varied (MARS score 2.25-4.17). Only 1 app was congruent with all aspects of the PA recommendations. All apps completely or partially recommended flexibility and resistance exercises, 3 apps completely or partially advised some form of neuromotor exercise, but only 2 offered full or partial guidance on cardiorespiratory exercise. Completeness of exercise reporting was mixed (CERT scores 7-14 points) and 3-7 BCTs were identified. Two BCTs were common to all apps (information about health consequences and instruction on how to perform behavior). Higher quality apps included a greater number of BCTs and were more closely aligned to PA guidance. No published trials evaluating the effect of the included apps were identified. CONCLUSIONS: This review identifies 4 PA apps of mixed quality and content for use by people with RA. Higher quality apps were more closely aligned to PA guidance and included a greater number of BCTs. One high-quality app (Rheumatoid Arthritis Information Support and Education) included 7 BCTs and was fully aligned with PA and exercise guidance. The effect of apps on PA adherence should be established before implementation.

A randomized controlled feasibility trial of a home-based walking behavior-change intervention for people with intermittent claudication.

Walking treatment is recommended for improving intermittent claudication (IC), a debilitating symptom of leg pain caused by peripheral arterial disease. However, center-based exercise programs offered in a community or hospital setting are often not implemented or adhered to. We developed a home-delivered behavior-change intervention, MOtivating Structured walking Activity in Intermittent Claudication (MOSAIC), to increase walking in people with IC. A feasibility randomized controlled trial with nested qualitative interviews involving a subsample of trial participants was conducted. Feasibility criteria evaluated participant recruitment and retention; suitability of proposed outcome measures; and acceptability and adherence to the intervention and trial. Participants (adults aged ≥18 years diagnosed with IC identified from vascular outpatient clinics) were randomized 1:1 to receive MOSAIC treatment (two 60-minute home-based sessions and two 20-minute booster telephone calls incorporating behavior-change techniques) or an attention-control comparison. Outcomes (baseline and 16-week follow-up) included the 6-minute walking distance (meters), pedometer-assessed daily walking activity (steps/d), health-related quality of life, physical functioning, and beliefs about walking treatment, peripheral arterial disease, and self-regulatory processes. Twenty-four participants (mean age: 66.8 ± 9.4 years, 79% male) were included. Feasibility criteria achieved were recruitment rate (25%), participant retention (92%), and adherence to assigned treatment or attention-control sessions (71%). Missing data rates were <10% for all outcomes except for baseline daily walking activity (36%). The trial protocol and interventions were acceptable to participants and the clinician. In conclusion, the MOSAIC trial was feasible to conduct, with the exception of high missing pedometer data. The intervention is an acceptable approach to facilitate walking among people with IC.

Behaviour change techniques associated with adherence to prescribed exercise in patients with persistent musculoskeletal pain: Systematic review.

PURPOSE: Exercise (planned, structured, repetitive movement) improves pain and function in people with persistent musculoskeletal pain (PMSK), but adherence is often poor. This systematic review evaluates the evidence from randomized controlled trials (RCTs) on the effectiveness of interventions to improve exercise adherence in people with PMSK and describes the content, context, and theoretical underpinning of behaviour change interventions designed to increase adherence. METHODS: Nine electronic databases were searched from inception dates to August 2017. Studies were included if they were RCTs that included adults with PMSK ≥3 months; ≥one measure of exercise adherence, exercise prescribed to both groups, and employed ≥one behaviour change technique (BCT) in the treatment group. Independent data extraction, theory coding, BCT taxonomy coding, and quality assessment using Cochrane Risk of Bias (RoB) tool was conducted by two reviewers. RESULTS: Eight RCTs (five low, three high RoB) met inclusion criteria. Five trials reported between-group differences in exercise adherence, favouring the treatment group. Three trials reported theoretical underpinning. There was moderate evidence that five BCTs, social support, goal setting, instruction of behaviour, demonstration of behaviour, and practice/rehearsal, improved exercise adherence. Interventions employing ≤seven BCTs, unique to those included in the control group, were most effective at enhancing exercise adherence. CONCLUSIONS: Limited moderate-quality evidence supports using a small number of BCTs to enhance exercise adherence in people with PMSK. Further research should explore the associations and synergies between BCTs and explicitly report how theory was utilized. This may inform recommendations for health care professionals working with this population. Statement of contribution What is already known on this subject? Exercise (i.e., planned, structured, repetitive movements) improves pain and function in people with persistent musculoskeletal pain (PMSK). Many people with PMSK do not adhere to exercises prescribed by a health care professional. Little research has explored how to enhance adherence to prescribed exercise in people with PMSK. What does this study add? Moderate-quality evidence from eight trials suggests behaviour change interventions enhance exercise adherence. Social support, goal setting, demonstration, instruction, and rehearsal were employed in effective interventions. Interventions with ≤7 behaviour change techniques were more effective at improving adherence than those employing >7.

Non-exercise physical therapies for musculoskeletal conditions.

Management of musculoskeletal conditions by physiotherapy delivers a package of health care designed to reduce pain and improve function. Health-care interventions should be safe, effective, acceptable to patients, deliverable by clinicians, and affordable by health-care providers. Physiotherapy is very safe and popular with patients. While there is good evidence that exercise relieves pain, improves function, and is cost-effective, evidence supporting the use of non-exercise physiotherapeutic interventions is much weaker. There is some support for the efficacy of thermotherapy, transcutaneous electrical neuromuscular stimulation, and massage, all of which are relatively inexpensive and easy to self-administer. There is little evidence to support the efficacy of electrotherapy, acupuncture or manual therapy, which need to be delivered by a therapist, making them expensive and encouraging long-term reliance on others. Despite lack of efficacy, the popularity and powerful placebo effects of physiotherapeutic modalities may have some utility in making more burdensome physiotherapeutic interventions (exercise and self-management advice) more acceptable.