The role of self-efficacy and catastrophizing in explaining improvements in disability, pain and fatigue among patients with chronic widespread pain treated with physiotherapy: an exploratory analysis.

OBJECTIVES: Most research exploring the relationship between cognitive factors (catastrophizing and self-efficacy beliefs) and levels of pain, disability and fatigue in patients with chronic widespread pain has been performed in multidisciplinary environments. It is less clear whether these associations are valid in other clinical environments. This study therefore aimed to establish whether changes in cognitive factors were related to changes in pain, disability and fatigue among patients treated in a physiotherapy-led symptom management programme. DESIGN: A longitudinal pre-post treatment study. Regression analyses were performed with change in pain, disability, physical and mental fatigue as the dependent measures. Demographics, change in pain and fatigue (when not dependent variables) and cognitive factors were entered as independent variables. ß values were calculated for the final model. SETTING: Two out-patient physiotherapy departments in Manchester, UK. PARTICIPANTS: Fifty patients with persistent widespread pain. INTERVENTION: A physiotherapist-led symptom management programme. MAIN OUTCOME MEASURES: Disability (Fibromyalgia Impact Questionnaire), Pain (Numeric Pain Rating Scale and Fatigue (Chalder Fatigue Scale) RESULTS: Significant changes in disability, fatigue and cognitive factors were observed after treatment. Changes in self-efficacy beliefs (ß=-0.38, P<0.05) and catastrophizing (ß=0.41, P<0.05) were significantly related to reductions in disability. There was no significant relationship between change in the cognitive variables and change in pain or fatigue. CONCLUSIONS: Self-efficacy beliefs and catastrophizing were important determinants of change in disability, but not pain or fatigue among patients with chronic widespread pain attending physiotherapy. Cognitively-informed physiotherapy appeared to be effective in reducing disability and fatigue and modifying cognitive factors. Such interventions may offer an effective treatment option for patients with chronic widespread pain and future randomised controlled trials are required to fully assess this.

"Pacing does help you get your life back": The acceptability of a newly developed activity pacing framework for chronic pain/fatigue.

OBJECTIVES: We have developed and feasibility tested an activity pacing framework for clinicians to standardise their recommendations of activity pacing to patients with chronic pain/fatigue. This study aimed to explore the acceptability and fidelity to this framework in preparation for a future trial of activity pacing. DESIGN: Acceptability and fidelity were explored using semi-structured interviews. Data were analysed using framework analysis. PARTICIPANTS: Patients who attended a rehabilitation programme for chronic pain/fatigue underpinned by the framework, and clinicians (physiotherapists and psychological wellbeing practitioners) who led the programmes. RESULTS: Seventeen interviews were conducted, involving 12 patients with chronic pain/fatigue and five clinicians. The framework analysis revealed four deductive themes: (1) Acceptability of the activity pacing framework, (2) Acceptability of the feasibility study methods, (3) Processes of change and (4) Barriers and facilitators to activity pacing; and one inductive theme: (5) Perspectives of patients and clinicians. CONCLUSIONS: The activity pacing framework appeared acceptable to patients and clinicians, and adherence to the framework was demonstrated. Processes of behaviour change included patients' regulation of activities through activity pacing. Barriers to pacing included work/social commitments and facilitators included identifying the benefits of pacing on symptoms. Different perspectives emerged between clinicians and patients regarding interpretations of symptom-contingent and quota-contingent strategies. The framework recognises fluctuations in symptoms of chronic pain/fatigue and encourages a quota-contingent approach with flexibility. Future work will develop a patient friendly guide ahead of a clinical trial to explore the effects of pacing.

Testing a newly developed activity pacing framework for chronic pain/fatigue: a feasibility study.

OBJECTIVES: To test the feasibility of using a new activity pacing framework to standardise healthcare professionals' instructions of pacing, and explore whether measures of activity pacing/symptoms detected changes following treatment. DESIGN: Single-arm, repeated measures study. SETTING: One National Health Service (NHS) Pain Service in Northern England, UK. PARTICIPANTS: Adult patients with chronic pain/fatigue, including chronic low back pain, chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis. INTERVENTIONS: Six-week rehabilitation programme, standardised using the activity pacing framework. OUTCOME MEASURES: Feasibility was explored via patients' recruitment/attrition rates, adherence and satisfaction, and healthcare professionals' fidelity. Questionnaire data were collected from patients at the start and end of the programme (T1 and T2, respectively) and 3 months' follow-up (T3). Questionnaires included measures of activity pacing, current/usual pain, physical/mental fatigue, depression, anxiety, self-efficacy, avoidance, physical/mental function and quality of life. Mean changes in activity pacing and symptoms between T1-T2, T2-T3 and T1-T3 were estimated. RESULTS: Of the 139 eligible patients, 107 patients consented (recruitment rate=77%); 65 patients completed T2 (T1-T2 attrition rate=39%), and 52 patients completed T3 (T1-T3 attrition rate=51%). At T2, patients' satisfaction ratings averaged 9/10, and 89% attended ≥5 rehabilitation programme sessions. Activity pacing and all symptoms improved between T1 and T2, with smaller improvements maintained at T3. CONCLUSION: The activity pacing framework was feasible to implement and patients' ability to pace and manage their symptoms improved. Future work will employ a suitable comparison group and test the framework across wider settings to explore the effects of activity pacing in a randomised controlled trial. TRIAL REGISTRATION NUMBER: NCT03497585.

Inter-rater reliability of paediatric emergency assessment: physiological and clinical features.

OBJECTIVE: The Paediatric Admission Guidance in the Emergency Department (PAGE) score is an assessment tool currently in development that helps predict hospital admission using components including patient characteristics, vital signs (heart rate, temperature, respiratory rate and oxygen saturation) and clinical features (eg, breathing, behaviour and nurse judgement). It aims to assist in safe admission and discharge decision making in environments such as emergency departments and urgent care centres. Determining the inter-rater reliability of scoring tools such as PAGE can be difficult. The aim of this study was to determine the inter-rater reliability of seven clinical components of the PAGE Score. DESIGN: Inter-rater reliability was measured by each patient having their clinical components recorded by two separate raters in succession. The first rater was the assessing nurse, and the second rater was a research nurse. SETTING: Two emergency departments and one urgent care centre in the North West of England. Measurements were recorded over 1 week; data were collected for half a day at each of the three sites. PATIENTS: A convenience sample of 90 paediatric attendees (aged 0-16 years), 30 from each of the three sites. MAIN OUTCOME MEASURES: Two independent measures for each child were compared using kappa or prevalence-adjusted bias-adjusted kappa (PABAK). Bland-Altman plots were also constructed for continuous measurements. RESULTS: Inter-rater reliability ranged from moderate (0.62 (95% CI 0.48 to 0.74) weighted kappa) to very good (0.98 (95% CI 95 to 0.99) weighted kappa) for all measurements except 'nurse judgement' for which agreement was fair (0.30, 95% CI 0.09 to 0.50 PABAK). Complete information from both raters on all the clinical components of the PAGE score were available for 73 children (81%). These total scores showed good' inter-rater reliability (0.64 (95% CI 0.53 to 0.74) weighted kappa). CONCLUSIONS: Our findings suggest different nurses would demonstrate good inter-rater reliability when collecting acute assessments needed for the PAGE score, reinforcing the applicability of the tool. The importance of determining reliability in scoring systems is highlighted and a suitable methodology was presented.

Opt-out Consent in Children's Emergency Medicine Research.

There is global acceptance that individuals should be allowed to decide whether or not to take part in research studies, and to do so after being informed about the nature of the research and the risk that might attach to participation. The process of providing detailed information before seeking consent (formalized by signatures) in advance of undertaking research procedures may not be possible in some circumstances, and sometimes an amended approach may be adopted. The use of opt-out consent has been recognized as a valid and ethical means of recruiting participants to studies particularly with large samples and where the risk to participants is small. However, it is sometimes misunderstood and can be a problematic factor in being accepted by research ethics committees and governing authorities. This may be due partly to differing expectations of the amount of information and support offered, together with the nature of the process that is adopted to ensure that a decision has been made rather than consent simply being assumed. In accordance with ongoing discussions with young people, and following consultation with parents, an opt-out consent strategy including varied means of providing information was employed in a large study of 44,501 cases of children attending emergency or urgent care departments. The study was conducted over more than 12 months in dissimilar emergency departments and an urgent care unit, and was designed to support better decision-making in pediatric emergency departments about whether children need to be admitted to hospital or can be discharged home safely. Robust analysis of the factors that exerted the greatest impact on predicting the need to admit or the safety of discharging children led to a revised version of an existing tool. In this article, we review approaches to consent in research, the nature and impact of opt-out consent, the factors that made this an effective strategy for this study, but also more recent concerns which may make opt-out consent no longer acceptable.

Observational cohort study with internal and external validation of a predictive tool for identification of children in need of hospital admission from the emergency department: the Paediatric Admission Guidance in the Emergency Department (PAGE) score.

OBJECTIVES: To devise an assessment tool to aid discharge and admission decision-making in relation to children and young people in hospital urgent and emergency care facilities, and thereby improve the quality of care that patients receive, using a clinical prediction modelling approach. DESIGN: Observational cohort study with internal and external validation of a predictive tool. SETTING: Two general emergency departments (EDs) and an urgent care centre in the North of England. PARTICIPANTS: The eligibility criteria were children and young people 0-16 years of age who attended one of the three hospital sites within one National Health Service (NHS) organisation. Children were excluded if they opted out of the study, were brought to the ED following their death in the community or arrived in cardiac arrest when the heart rate and respiratory rate would be unmeasurable. MAIN OUTCOME MEASURES: Admission or discharge. A participant was defined as being admitted to hospital if they left the ED to enter the hospital for further assessment, (including being admitted to an observation and assessment unit or hospital ward), either on first presentation or with the same complaint within 7 days. Those who were not admitted were defined as having been discharged. RESULTS: The study collected data on 36 365 participants. 15 328 participants were included in the final analysis cohort (21 045 observations) and 17 710 participants were included in the validation cohort (23 262 observations). There were 14 variables entered into the regression analysis. Of the 13 that remained in the final model, 10 were present in all 500 bootstraps. The resulting Paediatric Admission Guidance in the Emergency Department (PAGE) score demonstrated good internal validity. The C-index (area under the ROC) was 0.779 (95% CI 0.772 to 0.786). CONCLUSIONS: For units without the immediate availability of paediatricians the PAGE score can assist staff to determine risk of admission. Cut-off values will need to be adjusted to local circumstance. STUDY PROTOCOL: The study protocol has been published in an open access journal: Riaz et al Refining and testing the diagnostic accuracy of an assessment tool (Pennine Acute Hospitals NHS Trust-Paediatric Observation Priority Score) to predict admission and discharge of children and young people who attend an ED: protocol for an observational study. BMC Pediatr 18, 303 (2018). https://doi.org/10.1186/s12887-018-1268-7. TRIAL REGISTRATION NUMBER: The protocol has been published and the study registered (NIHR RfPB Grant: PB-PG-0815-20034; ClinicalTrials.gov:213469).

Cognitive factors are associated with disability and pain, but not fatigue among physiotherapy attendees with persistent pain and fatigue.

OBJECTIVES: Most research exploring the relationship between cognitive factors and pain, disability and fatigue in patients with persistent pain/fatigue has been performed in multi disciplinary environments. It is unclear whether these associations are consistent in other contexts. This study therefore aimed to establish the relationships between these factors in patients with persistent pain/fatigue referred for physiotherapy treatment. DESIGN: Cross-sectional observational study assessing the association between cognitive factors (self-efficacy and catastrophizing) and levels of pain, disability, mental fatigue and physical fatigue in patients with persistent pain/fatigue disorders. Data were analysed using regression analyses. SETTING: Two out-patient physiotherapy departments, Manchester, UK. PARTICIPANTS: 166 patients with persistent pain and fatigue disorders chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalopathy). MAIN OUTCOME MEASURES: Disability was assessed using the Fibromyalgia Impact Questionnaire, whilst mental and physical fatigue were assessed with the sub-scales of the Chalder Fatigue Scale. Pain intensity was measured with a Numeric Pain Rating Scale, self-efficacy with the Chronic Pain Self-efficacy Questionnaire and catastrophizing with the Pain Catastrophizing Scale. RESULTS: Cognitive factors were significantly associated with pain (self-efficacy beliefs ß=-0.30, P<0.05; catastrophizing ß=0.24, P<0.05) and disability (self-efficacy beliefs ß=-0.62, P<0.05), but not fatigue. CONCLUSIONS: Similar associations were observed in patients referred to physiotherapy as to those observed in patients treated in multi disciplinary clinical environments. Self-efficacy beliefs appear to be particularly strong determinants of disability, but exert a lesser influence over pain or fatigue. Targeting self-efficacy may be an effective method to reduce disability in patients with persistent pain and fatigue disorders.

Engaging stakeholders to refine an activity pacing framework for chronic pain/fatigue: A nominal group technique.

OBJECTIVES: Due to the current absence of a standardized guide for activity pacing, the concept of pacing is interpreted in various ways by healthcare professionals, patients and researchers. Consequently, the effects of pacing across different conditions are unclear. The present study aimed to undertake the second stage in the development of an activity pacing framework for chronic pain/fatigue. METHODS: The newly developed activity pacing framework was refined using a consensus method. A nominal group technique (NGT) was selected to engage stakeholders to reach agreement on the top 10 priorities for inclusion in the framework and accompanying appendices. Participants included patients with diagnoses of chronic pain/fatigue and healthcare professionals working in fields of chronic pain/fatigue. RESULTS: Ten participants were recruited via purposive sampling: four patients, two physiotherapists, two occupational therapists and two psychological wellbeing practitioners. The top priorities for the pacing framework included a clear definition of pacing, and stating the aims and context of pacing. The appendices were refined as a teaching guide, including priorities of detailing the stages of pacing, the overactivity-underactivity cycle/pain cycle and goal setting. CONCLUSIONS: Incorporating a diverse panel of stakeholders was an effective and inclusive method to refine the activity pacing framework. The framework has been purposefully designed for wider use across patients with chronic pain/fatigue and by various healthcare professionals. The framework provides a comprehensive definition, background and manual for healthcare professionals to instruct activity pacing. Further study will test the clinical usability of the framework, to enable the standardization of activity pacing in future investigations.

Survey of activity pacing across healthcare professionals informs a new activity pacing framework for chronic pain/fatigue.

INTRODUCTION: Activity pacing is considered a key component of rehabilitation programmes for chronic pain/fatigue. However, there are no widely used guidelines to standardize how pacing is delivered. This study aimed to undertake the first stage in developing a comprehensive evidence-based activity pacing framework. METHODS: An online survey across pain/fatigue services in English National Health Service trusts explored healthcare professionals' opinions on the types/uses of pacing, aims, facets and perceived effects. Data were analysed using descriptive statistics for closed-ended questions and thematic analysis for open-ended questions. Purposeful recruitment with a snowball effect engaged 92 healthcare professionals (physiotherapists, occupational therapists, nurses, doctors and psychologists) to the study. RESULTS: Pacing was highly utilized, with perceived long-term benefits for patients (n = 83, 90.2% healthcare professionals instructed pacing). The most endorsed aim of pacing was "achievement of meaningful activities" (24.5% of ranked votes). The least endorsed aim was "to conserve energy" (0.1% of ranked votes). The most frequently supported facet of pacing was "breaking down tasks" (n = 91, 98.9%). The least supported facet was "stopping activities when symptoms increase" (n = 6, 6.5%). Thematic analysis showed recurring themes that pacing involved flexibility and sense of choice. CONCLUSIONS: Pacing is a multidimensional coping strategy and complex behaviour. The message is clear that pacing should enable increases in meaningful activities, as opposed to attempting to avoid symptoms. The survey findings have informed the development of an activity pacing framework to guide healthcare professionals on the multiple components of pacing. This will help to standardize and optimize treatments for chronic pain/fatigue and enable future investigations.

Cross-Cultural Adaptation, Reliability, and Validity of the Chinese Version of the Tampa Scale for Kinesiophobia-11 Among Patients Who Have Undergone Total Knee Arthroplasty.

BACKGROUND: The shortened version of the Tampa Scale for Kinesiophobia (TSK-11) has been well characterized in the literature. However, to the best of our knowledge, no previous studies have evaluated the reliability and validity of the TSK-11 for Chinese-speaking patients who have undergone total knee arthroplasty (TKA). Thus, the objectives of this study were to translate and adapt the TSK-11 cross-culturally into Chinese and to evaluate its reliability and validity in a sample of Chinese TKA patients. METHODS: The TSK-11 was translated and cross-culturally adapted into Chinese according to the international guidelines for the cross-cultural adaptation of self-report measures. The Chinese version of TSK-11 was administered to 254 patients following their TKA, along with the Fear-Avoidance Beliefs Questionnaire, Pain Catastrophizing Scale, Numerical Rating Scale, and 12-Item Short Form Health Survey. Psychometric testing included internal consistency, test-retest reliability, floor and ceiling effects, construct validity, and convergent validity. RESULTS: A high completion rate of 95.8% with no floor or ceiling effects was noted in the Chinese version of the TSK-11. The questionnaire also showed good internal consistency (Cronbach's α = 0.883) and test-retest reliability (intraclass correlation coefficient = 0.798). Construct validity was assessed by exploratory factor analysis, and 3 factors were extracted that accounted for 65.2% of the variance. Convergent validity was confirmed by significant Pearson correlations between the Chinese version of the TSK-11 and the Pain Catastrophizing Scale (r = 0.751), Fear-Avoidance Beliefs Questionnaire (r = 0.719) and VAS (r = 0.450), as well as the 12-Item Short Form Health Survey subdomains Bodily Pain (r = -0.391), Mental Health (r = -0.356), Physical Functioning (r = -0.339), Role-Emotional (r = -0.317), and Role-Physical (r = -0.277). CONCLUSION: The Chinese version of the TSK-11 demonstrated satisfactory acceptability, reliability, and validity; therefore, it can be used in clinical practice and research for assessing kinesiophobia in Chinese patients after TKA.

Refining and testing the diagnostic accuracy of an assessment tool (PAT-POPS) to predict admission and discharge of children and young people who attend an emergency department: protocol for an observational study.

BACKGROUND: Increasing attendances by children (aged 0-16 years) to United Kingdom Emergency Departments (EDs) challenges patient safety within the National Health Service (NHS) with health professionals required to make complex judgements on whether children attending urgent and emergency care services can be sent home safely or require admission. Health regulation bodies have recommended that an early identification systems should be developed to recognise children developing critical illnesses. The Pennine Acute Hospitals NHS Trust Paediatric Observation Priority Score (PAT-POPS) was developed as an ED-specific tool for this purpose. This study aims to revise and improve the existing tool and determine its utility in determining safe admission and discharge decision making. METHODS/DESIGN: An observational study to improve diagnostic accuracy using data from children and young people attending the ED and Urgent Care Centre (UCC) at three hospitals over a 12 month period. The data being collected is part of routine practice; therefore opt-out methods of consent will be used. The reference standard is admission or discharge. A revised PAT-POPs scoring tool will be developed using clinically guided logistic regression models to explore which components best predict hospital admission and safe discharge. Suitable cut-points for safe admission and discharge will be established using sensitivity and specificity as judged by an expert consensus meeting. The diagnostic accuracy of the revised tool will be assessed, and it will be compared to the former version of PAT-POPS using ROC analysis. DISCUSSION: This new predictive tool will aid discharge and admission decision-making in relation to children and young people in hospital urgent and emergency care facilities. TRIAL REGISTRATION: NIHR RfPB Grant: PB-PG-0815-20034. ClinicalTrials.gov: 213469. Retrospectively registered on 11 April 2018.

Activity pacing: moving beyond taking breaks and slowing down.

This brief communication responds to the paper by Jeong and Cho (Qual Life Res 26(4):903-911, 2017) that has described activity pacing in limited terms of adjusting activities through going at a slower rate and taking breaks. Activity pacing was reported as not involving goal setting, in comparison to other strategies for long-term conditions such as Acceptance and Commitment Therapy. This brief communication aims to challenge this limited perception of activity pacing in light of numerous studies that recognise pacing to be a more complex strategy. Pacing is considered to be a multifaceted coping strategy, including broad themes of not only adjusting activities, but also planning activities, having consistent activity levels, acceptance of current abilities and gradually increasing activities, and one that includes goal setting as a key facet. It is essential that pacing is both defined and measured as a multifaceted strategy in order to assess the outcomes of pacing, and for meaningful comparisons with other strategies regarding efficacy for the management of long-term conditions.

The processes underpinning reductions in disability among people with chronic neck pain. A preliminary comparison between two distinct types of physiotherapy intervention.

PURPOSE: To establish whether different processes underpin changes in disability in people with neck pain who underwent two types of active physiotherapy intervention. MATERIALS AND METHODS: This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability. RESULTS: In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant ß value in the final model. CONCLUSIONS: Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach. Implications for rehabilitation Certain cognitive factors are known to be related to levels of disability in patients with chronic neck pain Specifically targeting these factors results in more patients making a clinically meaningful reduction in disability Different processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner. Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain.

Acceptance in chronic neck pain: associations with disability and fear avoidance beliefs.

Chronic neck pain can result in significant levels of disability. Physiotherapy treatments often aim to modify cognitive factors and this approach benefits some, but not all, patients. Research from other pain conditions suggests that acceptance may be related to disability; however, it is unclear whether these associations exist in patients with neck pain. Moreover, it is unclear to what extent other cognitive factors are related to acceptance. Feasibly, if these factors are related, existing treatments may already be indirectly modifying acceptance. The aim of this study was therefore to establish the associations between acceptance and disability, and between acceptance and other cognitive factors. Cross-sectional data were collected from 149 patients and regression analyses were carried out. In the first analysis, disability was the dependent variable and the proportion of variance explained by two acceptance subscales (activities engagement and pain willingness) was calculated. In the second analyses, the acceptance subscales were the dependent variables. Measures of pain-related fear, catastrophizing and pain vigilance and awareness were entered as explanatory variables and the proportion of variance explained was calculated. In the first analysis, acceptance explained 18% of variance in disability (P<0.001). In the second analysis, cognitive factors explained 7% (P<0.05) of variance in activities engagement and 58% (P<0.001) of pain willingness. On this basis, treatments that enhance acceptance may reduce disability. Moreover, as cognitive factors were strongly related to pain willingness, but not activity engagement, alternative treatments may be required to maximize acceptance. Further studies are warranted to assess acceptance-based treatments in patients with neck pain.

Activity Pacing is Associated With Better and Worse Symptoms for Patients With Long-term Conditions.

BACKGROUND: Activity pacing has been associated with both improved and worsened symptoms, and its role in reducing disability among patients with long-term conditions has been questioned. However, existing studies have measured pacing according to unidimensional subscales, and therefore the empirical evidence for pacing as a multifaceted construct remains unclear. We have developed a 26-item Activity Pacing Questionnaire (APQ-26) for chronic pain/fatigue containing 5 themes of pacing: activity adjustment, activity consistency, activity progression, activity planning, and activity acceptance. OBJECTIVE: To assess the associations between the 5 APQ-26 pacing themes and symptoms of pain, physical fatigue, depression, avoidance, and physical function. METHODS: Cross-sectional questionnaire study design. Data analyzed using multiple regression. PARTICIPANTS: A total of 257 adult patients with diagnoses of chronic low back pain, chronic widespread pain, fibromyalgia, and chronic fatigue syndrome/myalgic encephalomyelitis. RESULTS: Hierarchical multiple regression showed that activity adjustment was significantly associated with increased physical fatigue, depression, and avoidance, but decreased physical function (all Ps≤0.030). Activity consistency was associated with decreased pain, physical fatigue, depression, and avoidance, but increased physical function (all Ps≤0.003). Activity planning was associated with reduced physical fatigue (Ps=0.025) and activity acceptance was associated with increased avoidance (Ps=0.036). CONCLUSIONS: Some APQ-26 pacing themes were associated with worse symptoms and others with symptom improvement. Specifically, pacing themes involving adjusting/reducing activities were associated with worse symptoms, whereas pacing themes involving undertaking consistent activities were associated with improved symptoms. Future study will explore the causality of these associations to add clarification regarding the effects of pacing on patients' symptoms.

Are fear of movement, self-efficacy beliefs and fear of falling associated with levels of disability in people with osteoarthritis of the knee? A cross sectional study.

INTRODUCTION: Osteoarthritis of the knee (OAK) can result in significant disability and previous authors have suggested that cognitive and falls-related factors may be significant determinants of function. However, no previous studies have considered the relative influence of these factors when the effects of symptoms related to OAK are also considered. Additionally, it is plausible that falls-related factors exert a greater influence in patients who have previously fallen. METHODS: Fifty-eight patients were recruited from an outpatient physiotherapy department. They completed measures of physical function, pain, stiffness, physical symptoms, fear avoidance, perceived consequences of falling, fear of falling and self-efficacy beliefs. Variables exhibiting significant correlations with disability were entered into a regression model. ß Values were also calculated for the final model to allow the relative contribution of each variable to be established when all variables were considered. Sub-analysis was then performed using only data from patients who had previously fallen, to establish whether cognitive and falls-related factors exerted a stronger influence in this group. RESULTS: Pain, stiffness and joint symptoms significantly explained 75% of the variance in disability. The cognitive and falls-related variables did not significantly explain any additional variance. Only pain and stiffness exhibited significant ß values in the final model. Similar findings were observed in the sub-analysis with the participants who had previously fallen, with only pain and stiffness explaining significant variance (77%) or exhibiting significant ß values. DISCUSSION: The current findings suggested that cognitive and falls-related factors are not significantly related to disability in patients with OAK. By contrast, pain and stiffness were strongly associated with disability. This suggests that targeting cognitive and falls-related factors is unlikely significantly to improve outcome in these patients.

Comparison of three types of exercise in the treatment of rotator cuff tendinopathy/shoulder impingement syndrome: A randomized controlled trial.

OBJECTIVES: To assess the efficacy of three different exercise programmes in treating rotator cuff tendinopathy/shoulder impingement syndrome. DESIGN: Parallel group randomised clinical trial. SETTING: Two out-patient NHS physiotherapy departments in Manchester, United Kingdom. PARTICIPANTS: 120 patients with shoulder pain of at least three months duration. Pain was reproduced on stressing the rotator cuff and participants had full passive range of movement at the shoulder. INTERVENTIONS: Three dynamic rotator cuff loading programmes; open chain resisted band exercises (OC) closed chain exercises (CC) and minimally loaded range of movement exercises (ROM). MAIN OUTCOMES: Change in Shoulder Pain and Disability Index (SPADI) score and the proportion of patients making a Minimally Clinically Important Change (MCIC) in symptoms 6 weeks after commencing treatment. RESULTS: All three programmes resulted in significant decreases in SPADI score, however there were no significant differences between the groups. Participants making a MCIC in symptoms were similar across all groups, however more participants deteriorated in the ROM group. Dropout rate was higher in the CC group, but when only patients completing treatment were considered more patients in the CC group made a meaningful reduction in pain and disability. CONCLUSIONS: Open chain, closed chain and range of movement exercises all seem to be effective in bringing about short term changes in pain and disability in patients with rotator cuff tendinopathy. ISRCTN76701121.

Exploring patients' opinions of activity pacing and a new activity pacing questionnaire for chronic pain and/or fatigue: a qualitative study.

OBJECTIVE: Despite the frequent recommendation of activity pacing as a coping strategy for patients with chronic pain and/or fatigue, pacing is interpreted in different ways and there is an absence of a widely accepted pacing scale. We have developed a new Activity Pacing Questionnaire (APQ). The aims of this study were to explore patients' views and beliefs about the concept of pacing, together with the acceptability of the APQ. DESIGN: Qualitative pragmatic study using semi-structured telephone interviews. Data were analysed using Framework analysis. PARTICIPANTS: 16 adult patients attending secondary care physiotherapy out-patient departments were recruited via purposive sampling. Diagnoses included chronic low back pain, chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis. FINDINGS: Pacing emerged as a multifaceted concept from participants' descriptions. The implementation of pacing was influenced by participants' age, the presence of co-morbidities and participants' emotions. The APQ was found to be generally acceptable in comparison to two existing pacing subscales. Participants undertook activities using quota/symptom-contingent approaches. Four behavioural typologies emerged: Task avoidance, Task persistence, Task fluctuation (boom-bust) and Task modification (activity pacing). CONCLUSIONS: The APQ appears to be easy to complete, and acceptable to patients who are attending physiotherapy for the management of long-term conditions. It emerged that individual patients implemented different pacing facets to varying degrees, and that different behavioural typologies were apparent. The relationships between behavioural typologies and facets of pacing warrant further investigation to facilitate the development of effective tailored pacing interventions.

Patient-reported improvements in health are maintained 2†years after completing a short course of cognitive behaviour therapy, exercise or both treatments for chronic widespread pain: long-term results from the MUSICIAN randomised controlled trial.

OBJECTIVES: The MUSICIAN study has previously shown short-term benefit but only marginal cost-effectiveness for two non-pharmacological interventions for chronic widespread pain (CWP). We wished to determine their long-term effectiveness and cost-effectiveness. METHODS: A 2×2 factorial randomised controlled trial based in primary care in the UK. People were eligible if they were aged ≥25 years with CWP for which they had consulted their general practitioner. The interventions were a 6-month telephone cognitive behaviour therapy (tCBT) and/or a tailored exercise programme, in comparison to usual care. The primary outcome was patient-reported change in health. RESULTS: 884 persons were eligible, 442 were randomised and 81.7% were followed up 24 months post-treatment. In comparison to usual care (positive outcome 12.8%), tCBT (35.4%; OR 3.7 95% CI (1.8 to 8.0)), exercise (29.3%; OR 2.8 95% CI (1.3 to 6.0)) and both interventions (31.2%; OR 3.1 95% CI (1.3 to 6.0)) were significantly more effective. There was only a small decrease in effectiveness over time for individual and combined treatments. Those with more intense/disabling pain, higher distress and those who exhibited passive coping at baseline were more likely to have a positive outcome with tCBT than persons without these characteristics. tCBT was associated with the greatest increase in quality of life and lowest costs. Cost per quality adjusted life year was £3957-£5917 depending on method of analysis. CONCLUSIONS: A short course of tCBT for people with CWP was effective long-term and was highly cost-effective. Exercise was also effective but delivered positive outcome for fewer patients at greater cost, and there was no advantage for patients receiving both interventions. TRIAL REGISTRATION NUMBER: ISRCTN67013851.