Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials.

OBJECTIVE: To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function. DESIGN: Systematic review and meta-analysis. METHODS: We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures. ELIGIBILITY CRITERIA: RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET. RESULTS: 30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident. CONCLUSIONS: Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small. PROSPERO REGISTRATION NUMBER: CRD42018082703.

The effect on work presenteeism of job retention vocational rehabilitation compared to a written self-help work advice pack for employed people with inflammatory arthritis: protocol for a multi-centre randomised controlled trial (the WORKWELL trial).

BACKGROUND: Work problems are common in people with inflammatory arthritis. Up to 50% stop work within 10 years due to their condition and up to 67% report presenteeism (i.e. reduced work productivity), even amongst those with low disease activity. Job retention vocational rehabilitation (JRVR) may help prevent or postpone job loss and reduce presenteeism through work assessment, work-related rehabilitation and enabling job accommodations. This aims to create a better match between the person's abilities and their job demands. The objectives of the Workwell trial are to test the overall effectiveness and cost-effectiveness of JRVR (WORKWELL) provided by additionally trained National Health Service (NHS) occupational therapists compared to a control group who receive self-help information both in addition to usual care. METHODS: Based on the learning from a feasibility trial (the WORK-IA trial: ISRCTN76777720 ), the WORKWELL trial is a multi-centre, pragmatic, individually-randomised parallel group superiority trial, including economic evaluation, contextual factors analysis and process evaluation. Two hundred forty employed adults with rheumatoid arthritis, undifferentiated inflammatory arthritis or psoriatic arthritis (in secondary care), aged 18 years or older with work instability will be randomised to one of two groups: a self-help written work advice pack plus usual care (control intervention); or WORKWELL JRVR plus a self-help written work advice pack and usual care. WORKWELL will be delivered by occupational therapists provided with additional JRVR training from the research team. The primary outcome is presenteeism as measured using the Work Limitations Questionnaire-25. A comprehensive range of secondary outcomes of work, health, contextual factors and health resource use are included. Outcomes are measured at 6- and 12- months (with 12-months as the primary end-point). A multi-perspective within-trial cost-effectiveness analyses will also be conducted. DISCUSSION: This trial will contribute to the evidence base for provision of JRVR to people with inflammatory arthritis. If JRVR is found to be effective in enabling people to keep working, the findings will support decision-making about provision of JRVR by rheumatology teams, therapy services and healthcare commissioners, and providing evidence of the effectiveness of JRVR and the economic impact of its implementation. TRIAL REGISTRATION: Clinical Trials.Gov: NCT03942783 . Registered 08/05/2019 ( https://clinicaltrials.gov/ct2/show/NCT03942783 ); ISRCTN Registry: ISRCTN61762297 . Registered:13/05/2019 ( http://www.isrctn.com/ISRCTN61762297 ). Retrospectively registered.

Development and Pragmatic Evaluation of a Rapid Response Team.

In response to national and local drivers, a clinical emergency response system (CERS) incorporating an intensivist-led rapid response team (RRT) was implemented at a Sydney (Australia) hospital. The authors present a pragmatic evaluation of the 5 years since this major initiative was commenced. A "partner not conquer" philosophy was adopted. Implementation of the RRT was based on a collaborative pragmatic quality improvement approach. A team of intensive care specialist trained medical doctors (n = 2) and clinical nurse consultants (n = 2) set up the service with executive support and funding. Roles and responsibilities were clearly detailed, reinforcing a positive, partnership-driven culture. A constantly evolving education strategy was a critical element of implementation and maintenance. Ongoing evaluation includes process and patient outcome data. Serious patient deterioration-related incidents have decreased significantly (from 7 to 1 per year) and the RRT has been universally accepted by clinicians. Key lessons learned include the need for specific protected funding, a partnership approach ensuring hospital clinicians retain responsibility of patient treatment, ongoing education and reinforcement, and strong nursing leadership. However, generalizations cannot be made about the implementation of the CERS. It is important to consider context; "one size does not fit all."

Job retention vocational rehabilitation for employed people with inflammatory arthritis (WORK-IA): a feasibility randomized controlled trial.

BACKGROUND: Inflammatory arthritis leads to work disability, absenteeism and presenteeism (i.e. at-work productivity loss) at high cost to individuals, employers and society. A trial of job retention vocational rehabilitation (VR) in the United States identified this helped people keep working. The effectiveness of this VR in countries with different socioeconomic policies and conditions, and its impact on absenteeism, presenteeism and health, are unknown. This feasibility study tested the acceptability of this VR, modified for the United Kingdom, compared to written advice about managing work problems. To help plan a randomized controlled trial, we tested screening, recruitment, intervention delivery, response rates, applicability of the control intervention and identified the relevant primary outcome. METHODS: A feasibility randomized controlled trial with rheumatoid, psoriatic or inflammatory arthritis patients randomized to receive either job retention VR or written information only (the WORK-IA trial). Following three days VR training, rheumatology occupational therapists provided individualised VR on a one to one basis. VR included work assessment, activity diaries and action planning, and (as applicable) arthritis self-management in the workplace, ergonomics, fatigue and stress management, orthoses, employment rights and support services, assistive technology, work modifications, psychological and disclosure support, workplace visits and employer liaison. RESULTS: Fifty five (10%) people were recruited from 539 screened. Follow-up response rates were acceptable at 80%. VR was delivered with fidelity. VR was more acceptable than written advice only (7.8 versus 6.7). VR took on average 4 h at a cost of £135 per person. Outcome assessment indicated VR was better than written advice in reducing presenteeism (Work Limitations Questionnaire (WLQ) change score mean: VR = -12.4 (SD 13.2); control = -2.5 (SD 15.9), absenteeism, perceived risk of job loss and improving pain and health status, indicating proof of concept. The preferred primary outcome measure was the WLQ, a presenteeism measure. CONCLUSIONS: This brief job retention VR is a credible and acceptable intervention for people with inflammatory arthritis with concerns about continuing to work due to arthritis. TRIAL REGISTRATION: ISRCTN 76777720 . Registered 21.9.12.

The use of telephone and video consultations in upper limb musculoskeletal rehabilitation: A scoping review.

Introduction: In 2020, the COVID-19 pandemic caused a rapid uptake of virtual consultations (VCs) to minimise disease transmission and for this reason, research into telerehabilitation has been expanding. This review aimed to map and synthesize evidence on the use of VCs in upper limb musculoskeletal rehabilitation, describe key characteristics, and identify gaps in the research. Methods: This scoping review investigated synchronous rehabilitation consultations performed over VC. All asynchronous, wearable or pre-recorded technology was excluded. CINAHL Complete, Medline, PEDro, Google Scholar and grey literature sources were searched. Screening and data extraction were done by a single researcher. Frequency counts were used to analyse the data. Results: Nineteen studies were identified, with patients with shoulder injury/pain most frequently studied. Most sources (n = 9) used bespoke video programmes. Range of motion (ROM) was the most common assessment (n = 10) and exercise prescription (n = 7) was the most common treatment. Benefits included time and cost savings, maintaining therapeutic relationships and increasing patient independence. Most diagnostic assessments, except joint and nerve tension tests, were found to be reliable and valid. Studies noted increased function in activities, decreased pain and increased ROM after VCs. Limitations included restricted 'hands-on' treatment, resource and training concerns and limiting patient factors. Conclusions: This review mapped available evidence and identified several gaps in the literature. Further robust research into VCs for hand/wrist disorders, ROM assessment and cost-effectiveness is needed.

The Work Experience Survey - Rheumatic conditions (United Kingdom): Psychometric properties and identifying the workplace barriers of employed people with inflammatory arthritis receiving vocational rehabilitation.

OBJECTIVE: The aims were to: revise the Work Experience Survey-Rheumatic Conditions (WES-RC- UK), a work assessment listing 142 workplace barriers; investigate content validity, reliability, and concurrent validity; update the accompanying WES-RC and WORKWELL Solutions Manuals; and investigate workplace barriers of people with inflammatory arthritis. METHODS: Rheumatology therapists, following vocational rehabilitation (VR) training, assessed participants in the WORKWELL VR trial using the WES-RC. Data were extracted from the WES-RC to identify the frequency of workplace barriers, and from trial baseline questionnaires (e.g., Work Limitations Questionnaire-25 (WLQ-25). Barriers reported by ≤5 participants were considered for removal. WES-RC content validity was assessed by linking to the International Classification of Functioning, Health, and Disability Core Set for VR (ICF-VR). Reliability was assessed using Cronbach's α and concurrent validity by correlating the total number of workplace barriers reported with WLQ-25 scores. RESULTS: WES-RCs were completed with 116 employed participants: 79% women, age 48.72 (SD 9.49) years, and 57% working full-time. The WES-RC was reduced to 121 barriers. Content validity was good, with 73/90 ICF-VR items linked. Cronbach's α = 0.92, that is, suitable for individual use. Concurrent validity was moderate: WLQ-25 (rs  = 0.40). The three most common barriers were Physical Job Demands (100%: e.g., mobility 99%; hand use 74%), Mental, Time, Energy, Emotional Job Demands (91%, e.g., concentration 47%, remembering 41%); Getting Ready for and Travel to Work (87%, e.g., driving 60%). CONCLUSION: The WES-RC (UK) has good content validity, reliability, and concurrent validity. The wide range of barriers emphasises the need for biopsychosocial work rehabilitation.

The Workwell trial: protocol for the process evaluation of a randomised controlled trial of job retention vocational rehabilitation for employed people with inflammatory arthritis.

BACKGROUND: The Workwell trial is a multi-centre randomised controlled trial with the aims of evaluating the effectiveness and cost-effectiveness of job retention vocational rehabilitation for employed people with inflammatory arthritis, who are experiencing work difficulties due to their arthritis. Vocational rehabilitation is delivered by health service occupational therapists, who have received additional training in providing this Workwell intervention. A process evaluation will be undertaken alongside the main trial to investigate implementation fidelity; understand key stakeholders' perspectives of the intervention and the social and structural context in which the intervention is provided; and explore issues related to future implementation in clinical practice. This protocol describes the aims, objectives, and methodology of the Workwell trial process evaluation. METHODS: This mixed methods process evaluation will follow the Medical Research Council's Guidance on process evaluations for complex interventions. It will be underpinned by the conceptual framework for implementation fidelity (CFIF) and normalisation process theory (NPT). We will analyse treatment records, work assessments, and treatment notes to ascertain implementation fidelity. Semi-structured interviews with trial participants, their employer/line managers, treating therapists, and their therapy service managers will be undertaken to explore perceptions of the intervention, contextual factors, and potential for future implementation in practice. Interview topic guides will be informed by NPT. Therapists' views about Workwell training will be explored via questionnaires following training, and interviews and focus groups following treatment delivery to inform future implementation. Quantitative data will be analysed descriptively. Qualitative data will be analysed using thematic analysis. NPT will guide data analysis and interpretation. Findings from the different elements of this embedded design process evaluation will be reported separately and then the elements integrated. The process evaluation data will be analysed independently of the Workwell trial outcome evaluation. The process evaluation data will then be reviewed in the light of the trial findings. DISCUSSION: Few trials of job retention vocational rehabilitation in arthritis have included process evaluations. This process evaluation will assist in understanding factors influencing trial outcomes and identifying potential contextual barriers and facilitators for the potential implementation of Workwell vocational rehabilitation into clinical services. TRIAL REGISTRATION: ClinicalTrials.gov NCT03942783 . Registered on 08 May 2019. ISRCTN Registry ISRCTN61762297 . Registered on 13 May 2019. Retrospectively registered.

The development and evaluation of a vocational rehabilitation training programme for rheumatology occupational therapists.

People with inflammatory arthritis rapidly develop work disability, yet there is limited provision of vocational rehabilitation (VR) in rheumatology departments. As part of a randomized, controlled trial, ten occupational therapists (OTs) were surveyed to identify their current VR provision and training needs. As a result, a VR training course for OTs was developed which included both taught and self-directed learning. The course included: employment and health and safety legislation, work assessment and practical application of ergonomic principles at work. Pre-, immediately post- and two months post-training, the ten OTs completed a questionnaire about their VR knowledge and confidence On completion, they reported a significant increase (p < 0.01)in their knowledge and confidence when delivering vocational rehabilitation. They rated the course as very or extremely relevant, although seven recommended more practical sessions. The preference for practical sessions was highlighted, in that the aspects they felt most beneficial were role-playing assessments and sharing ideas through discussion and presentations. In conclusion, the course was considered effective in increasing both knowledge and confidence in using VR as an intervention, but, due to time constraints within the working day, some of the self-directed learning should be incorporated into the training days.