Do Physical Therapists in the United Kingdom Recognize Psychosocial Factors in Patients With Acute Low Back Pain? Impact of chronic musculoskeletal pathology on older adults: a study of differences between knee OA and low back pain. Integrating Mobile health and Physical Activity to reduce the burden of Chronic low back pain Trial (IMPACT): a pilot trial protocol A controlled study of the effects of an early intervention on acute musculoskeletal pain problems A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement. Individually tailored treatment targeting activity, motor behavior, and cognition reduces pain-related disability: a randomized controlled trial in patients with musculoskeletal pain. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews Point-of-care prognosis for common musculoskeletal pain in older adults. Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial Evaluation of a patient-centred approach in generalized musculoskeletal chronic pain/fibromyalgia patients in primary care. Long-term follow-up of tailored behavioural treatment and exercise based physical therapy in persistent musculoskeletal pain: A randomized controlled trial in primary care. Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the Dutch Transition Project. Cognitive Treatment of Illness Perceptions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial A Tailored Workplace Exercise Program for Women at Risk for Neck and Upper Limb Musculoskeletal Disorders: A Randomized Controlled Trial Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain A physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol
Study Design . A cross-sectional , descriptive vignette survey of practicing , musculoskeletal physical therapists . Objectives . The aim of this study was to determine if musculoskeletal physical therapists , in the United Kingdom , recognize when patients with low back pain ( LBP ) are at risk of chronicity due to psychosocial factors . A secondary aim was to explore the advice they give to patients about  work and activities .  Summary of Background Data . Psychosocial factors have been shown to be important in the progression from acute LBP to chronic disability . Early identification of individuals at risk of developing chronic disability is important to enable targeted intervention . Methods . Three vignettes were written based on acute LBP patients attending for physical therapy  and incorporated into a self-completed postal question naire sent to a simple r and om sample of musculoskeletal physical therapists in the United Kingdom ( n = 900 ) . After one reminder , 20 % of nonresponders were sent a further question naire ( n = 80 ) . Data were analyzed using the Statistical Package for the Social Sciences ( SPSS version 11 ) . Results . The response rate was 57.7 % ( n = 518 ) with 453 meeting all inclusion criteria . The sample consisted of physical therapists working in the musculoskeletal field across all practice setting s. Most correctly rated the chronicity risk of the low- and high-risk patient vignettes . Advice to restrict work and activity was common . Conclusions . Most physical therapists recognize when patients are at high risk of developing chronicity , yet many recommend the patient limit their activity levels and not work . Advice to “ not work ” is associated with more severe perceived spinal pathology , suggesting persistence of the biomedical model for LBP OBJECTIVES The study aim ed to compare the psychological and physical characteristics of older adults with knee osteoarthritis ( OA ) vs those of adults with chronic low back pain ( CLBP ) and to identify psychological and physical predictors of function as measured by gait speed . DESIGN Secondary data analysis . METHOD AND PATIENTS Eighty-eight older adults with advanced knee OA and 200 with CLBP who had participated in separate r and omized controlled trials were selected for this study . MEASURES Inclusion criteria for both trials included age > or = 65 and pain of at least moderate intensity that occurred daily or almost every day for at least the previous 3 months .  Psychological constructs ( catastrophizing , fear avoidance , self-efficacy , depression , affective distress ) and physical measures ( comorbid medical conditions , pain duration , pain severity , pain related interference , self-rated health ) were obtained . RESULTS Subjects with CLBP had slower gait ( 0.88 m/s vs 0.96 m/s , P = 0.002 ) and more comorbid conditions than subjects with knee pain ( mean 3.36 vs 1.97 , P < 0.001 ) . All the psychological measures were significantly worse in the CLBP group except the Multidimensional Pain Inventory-Affective Distress score . Self-efficacy , pain severity , and medical comorbidity burden were associated with slower gait regardless of the location of the pain . CONCLUSIONS Older adults with chronic pain may have distinct psychological and physical profiles that differentially impact gait speed . These findings suggest that not all pain conditions are the same in their psychological and physical characteristics and may need to be taken into consideration when developing treatment plans Background It is well recognised that low back pain is a significant public health problem and engagement in moderate levels of physical activity is associated with positive outcomes .Conservative active care , such as exercise , is effective in reducing pain and disability associated with chronic low back pain . However , a rapid decline in clinical outcomes is commonly seen after discharge from treatment . Methods / Design We will conduct a r and omised controlled trial to investigate the effectiveness of a mobile health supported physical activity intervention ( compared to st and ard care ) in care-seeking , pain and disability in people with chronic low back pain after discharge from treatment . We will recruit 68 patients with chronic low back pain following discharge from an outpatient hospital program , who will be r and omly allocated to the physical activity intervention ( n = 34 ) or the st and ard care group ( n = 34 ) and monitored for 6 months . The physical activity intervention will involve a physical activity advice booklet , a face-to-face health coaching session and 12 fortnightly follow-up telephone-based health coaching sessions . This intervention will be supported by provision of a specifically design ed web app and a physical activity monitoring device ( FitBit ) . The st and ard care group will receive the physical activity advice booklet only . Discussion This pilot trial will investigate a new model to prevent clinical decline in people following conservative treatment for chronic low back pain . If proven to be effective , this approach will constitute a major advance in the management of low back pain . Chronic patients who experience recurrent pain and disability after treatment are prone to seek additional care in the form of physiotherapy , medication , emergency department attendance , specialist consultation or spinal surgery . This model aims to maintain functional levels and reduce care-seeking empowering patients to self-manage their low back pain by offering them a contemporary patient-centred physical activity program with the support of mobile health technology . The outcomes of this trial will have immediate implication s for clinical practice .Trial registration ACTRN12615000189527 ( 26 - 02 - 2015 ) & NA ; Current conceptions of chronic pain clearly suggest that proper care at the acute stage should prevent the development of chronic problems . Patients ( 198 ) seeking help for acute musculoskeletal pain ( MSP ) , e.g. , back and neck pain participated in two studies of the effects of an Early Active intervention which underscored ‘ well ’ behavior and function compared to a Treatment as Usual control group . The quantity of the Early Active treatment was a median of 1 doctor 's appointment and 3 meetings with a physical therapist .  Study I concerned patients with a prior history of sick‐listing for MSP , while study II involved patients with no prior history of MSP . Treatment satisfaction , pain experience , activities and sickness absenteeism were assessed before , after and at a 12‐month follow‐up . In study I ( patients with a history of MSP ) , the results showed significant improvements for both groups , but virtually no differences between the groups . Similarly , in study II ( no history of MSP ) both groups demonstrated significant improvements e.g. , for pain intensity and activity levels . However , the Early Active treatment result ed in significantly less sick‐listing relative to the control group . Moreover , the risk of developing chronic ( > 200 sick days ) pain was 8 times lower for the Early Activation group . This investigation shows that relatively simple changes in treatment result in reduced sickness absenteeism for ‘ first‐time ’ sufferers only . Consequently , the content and timing of treatment for pain appear to be crucial . Properly administered early intervention may therefore decrease sick leave and prevent chronic problems , thus saving considerable re sources Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing UNLABELLED This study compares the outcomes of an individually tailored behavioral medicine intervention ( experimental ) with physical exercise therapy ( control ) . The experimental intervention was systematic ally individualized according to each participant 's behavioral treatment goals and functional behavioral analyses . One hundred twenty-two patients seeking care at 3 primary health care clinics because of musculoskeletal pain were r and omized . Ninety-seven completed the trial . Data were collected at baseline , immediately after treatment , and at a 3-month follow-up . Analyses of data from completers , as well as intention-to-treat analyses , showed that the experimental group experienced lower levels of disability ( P = .01 ) , lower maximum pain intensity ( P = .02 ) , higher levels of pain control ( P = .001 ) , and lower fear of movement ( P = .022 ) as a result of treatment condition . Self-efficacy ( P = .0001 ) and physical performance ( P = .0001 ) increased over time for both groups . Participants in the experimental group generally reported more positive effects after treatment . Treatment fidelity was maintained during the course of the study . Activity can be resumed and pain might be managed by the patients themselves if treatment incorporates the biopsychosocial explanatory model of pain and strategies are tailored according to individual 's priorities of everyday life activities and empirically derived determinants of pain-related disability . PERSPECTIVE This study shows that the biomedical and the psychosocial perspectives of the experiences and consequences of pain complement rather than contradict each other . Primary health care patients with persistent musculoskeletal pain benefit more from a systematic tailoring of treatments according to biopsychosocial factors than from a physically based exercise intervention Abstract Objective : To evaluate effectiveness of an exercise programme in a community setting for patients with low back pain to encourage a return to normal activities . Design : R and omised controlled trial of progressive exercise programme compared with usual primary care management . Patients ' preferences for type of management were elicited independently of r and omisation . Participants : 187 patients aged 18 - 60 years with mechanical low back pain of 4 weeks to 6 months ' duration . Interventions : Exercise classes led by a physiotherapist that included strengthening exercises for all main muscle groups , stretching exercises , relaxation session , and brief education on back care . A cognitive-behavioural approach was used . Main outcome measures : Assessment s of debilitating effects of back pain before and after intervention and at 6 months and 1 year later . Measures included Rol and disability question naire , Aberdeen back pain scale , pain diaries , and use of healthcare services . Results : At 6 weeks after r and omisation , the intervention group improved marginally more than the control group on the disability question naire and reported less distressing pain . At 6 months and 1 year , the intervention group showed significantly greater improvement in the disability question naire score ( mean difference in changes 1.35 , 95 % confidence interval 0.13 to 2.57 ) . At 1 year , the intervention group also showed significantly greater improvement in the Aberdeen back pain scale ( 4.44 , 1.01 to 7.87 ) and reported only 378 days off work compared with 607 in the control group . The intervention group used fewer healthcare re sources . Outcome was not influenced by patients ' preferences . Conclusions : The exercise class was more clinical ly effective than traditional general practitioner management , regardless of patient preference , and was cost effective . Key messages Patients with back pain need to return to normal activities as soon as possible but are often afraid that movement or activity may be harmful An exercise programme led by a physiotherapist in the community and based on cognitive-behavioural principles helped patients to cope better with their pain and function better even one year later Patients ' preferences for type of management did not affect outcome Patients in the intervention group tended to use fewer healthcare re sources and took fewer days off work This type of exercise programme should be more widely Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies IMPORTANCE Many site-specific , multivariable risk models for predicting the outcome of musculoskeletal pain problems have been published . The overlapping content in these models suggests a common set of generic indicators suitable for use in primary care . OBJECTIVE To investigate whether a brief set of generic prognostic indicators can predict the outcome of musculoskeletal pain in older patients presenting to general practitioners . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve observational cohort study conducted from September 1 , 2006 , through March 31 , 2007 , of consecutive patients 50 years or older presenting with noninflammatory musculoskeletal pain to 1 of the 5 participating general practice s in the United Kingdom . MAIN OUTCOME MEASURES During consultation , the treating physician assessed and recorded 5 brief generic items ( duration of present pain episode , current pain intensity , pain interference with daily activities , presence of multiple-site pain , and ultrashort depression screen ) and recorded their overall prognostic judgment . The primary outcome was patient-rated improvement , which was measured 6 months after consultation and cross-vali date d with repeated measures up to 3 years . RESULTS A total of 194 ( 48.1 % ) of 403 participants were classified as having an unfavorable outcome at 6 months . Inclusion of 3 generic prognostic indicators ( duration of present pain episode , pain interference with daily activities , and presence of multiple-site pain ) in the prognostic model improved on reliance on physicians ' prognostic judgment alone ( C statistic = 0.72 vs 0.62 ; net reclassification index = 0.136 ; proportion correctly classified = 69 % ) . The improvement in prognostic accuracy was attributable to correcting physicians ' tendency toward overoptimistic expectations of outcome . CONCLUSIONS AND RELEVANCE Three easy-to-obtain pieces of information followed by systematic recording of the general practitioners ' prognostic judgment provide a simple generic assessment of prognosis at point of care in older persons presenting with musculoskeletal problems to primary care practice s in the United Kingdom . Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions Background The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled . Objective The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain . Design This was a r and omized , placebo-controlled trial . Setting The study was conducted in an outpatient physical therapy department in Australia . Patients The participants were 154 patients with chronic low back pain of more than 12 weeks ’ duration . Intervention Twelve sessions of motor control exercise ( ie , exercises design ed to improve function of specific muscles of the low back region and the control of posture and movement ) or placebo ( ie , detuned ultrasound therapy and detuned short-wave therapy ) were conducted over 8 weeks . Measurements Primary outcomes were pain intensity , activity ( measured by the Patient-Specific Functional Scale ) , and patient 's global impression of recovery measured at 2 months . Secondary outcomes were pain ; activity ( measured by the Patient-Specific Functional Scale ) ; patient 's global impression of recovery measured at 6 and 12 months ; activity limitation ( measured by the Rol and -Morris Disability Question naire ) at 2 , 6 , and 12 months ; and risk of persistent or recurrent pain at 12 months . Results The exercise intervention  improved activity and patient 's global impression of recovery but did not clearly reduce pain at 2 months . The mean effect of exercise on activity ( measured by the Patient-Specific Functional Scale ) was 1.1 points ( 95 % confidence interval [CI]=0.3 to 1.8 ) , the mean effect on global impression of recovery was 1.5 points ( 95 % CI=0.4 to 2.5 ) , and the mean effect on pain was 0.9 points ( 95 % CI=−0.01 to 1.8 ) , all measured on 11-point scales . Secondary outcomes also favored motor control exercise . Limitation Clinicians could not be blinded to the intervention they provided . Conclusions Motor control exercise produced short-term improvements in global impression of recovery and activity , but not pain , for people with chronic low back pain . Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups The aim of this paper is to assess whether patient-centred consultations are more effective than the usual style of consultations used by general practitioners with patients suffering from benign chronic musculoskeletal pain and fibromyalgia . It also seeks to evaluate the differential characteristics of these two clinical groups of symptoms . The study was design ed as a cluster r and omised and simple blind trial . Twenty general practitioners took part and 110 patients were recruited . Compared with patients who received the usual treatment from their family physician , those who received a patient-centred approach showed greater improvement after 1 year in terms of psychological distress ( anxiety ) and number of tender points , as well as showing positive trends in some important outcomes such as pain intensity . Significantly better results were observed in those patients suffering chronic pain than in those with fibromyalgia , particularly as regards associated symptoms , self-rated pain and physical mobility as measured by the Nottingham health profile This study examined long-term effects of a tailored behavioural treatment protocol ( TBT ) , as compared with an exercise based physical therapy protocol ( EBT ) .  One-hundred and twenty-two patients who , due to persistent musculoskeletal pain , consulted physical therapists in primary care were originally r and omized to either of the two conditions . Follow-up assessment s two-year post-treatment were completed by 65 participants . According to per- protocol analyses , short-term effects were maintained in both groups for the primary outcome , pain-related disability . The TBT-group reported lower disability levels compared with the EBT-group . Intention-to-treat analyses ( ITT ) conveyed similar results . Secondary outcomes of pain intensity , pain control , and functional self-efficacy were maintained over the 2-year post-treatment , but previous group differences were levelled out according to the most conservative method of ITT . Fear of movement/(re)injury increased in the EBT-group , and EBT participants reported higher fear of movement/(re)injury two years post-treatment compared to TBT . The study supports tailoring of treatments in concordance with patients ' needs and preferences of activity goals and functional behavioural analyses including predictors of pain-related disability , for successful immediate outcomes and their maintenance in the long run . Exercise-based treatments result ed in somewhat smaller immediate treatment effects but had similar maintenance of effects over the 2-year follow-up period BACKGROUND Better insight into frequent comorbidities in patients with chronic ( ≥ 3 months ) low back pain ( LBP ) may help general practitioners when planning comprehensive care for these patients . OBJECTIVE To prospect ively study the prevalence of psychological , social , musculoskeletal and somatoform disorders in patients presenting with chronic non-specific LBP to general practitioners , in comparison to a contrast group of patients consulting in the same setting . METHODS This case-control study is embedded in a historical cohort , based on a primary care practice -based research network . All the health problems presented by the patients were prospect ively coded according to the international classification of primary care between 1996 and 2013 . The prevalence of psychological , social , musculoskeletal and somatoform disorders presented by the adult patients from 1 year before the onset of chronic LBP to 2 years after onset was compared to that of matched patients consulting without LBP , using conditional logistic regressions . RESULTS The 1511 patients with chronic LBP more often presented musculoskeletal disorders than the contrast group during the year before the onset of LBP and during the second year after it , with odds ratios ( 95%confidence intervals ) of 1.39 ( 1.20 - 1.61 ) and 1.56 ( 1.35 - 1.81 ) , respectively . They did not more often present psychological , social or non-musculoskeletal somatoform disorders . CONCLUSIONS General practitioners should consider all the musculoskeletal symptoms when caring for patients with chronic LBP . Rather than systematic ally screening for specific psychological , social or somatoform disorders , they should consider with the patient how LBP and any type of potential comorbidity interfere with his/her daily functioning Background Illness perceptions have been shown to predict patient activities . Therefore , studies of the effectiveness of a targeted illness-perception intervention on chronic nonspecific low back pain ( CLBP ) are needed . Objective The purpose of this study was to compare the effectiveness of treatment of illness perceptions against a waiting list for patients with CLBP . Design This was a prospect ively registered r and omized controlled trial with an assessor blinded for group allocation . Setting The study was conducted in an outpatient rehabilitation clinic . Participants The participants were 156 patients ( 18–70 years of age ) with CLBP ( > 3 months ) . Intervention Patients were r and omly assigned to either a treatment group or to a waiting list ( control ) group . Trained physical therapists and occupational therapists delivered 10 to 14 one-hour treatment sessions according to the treatment protocol . Measurements The primary outcome measure was change in patient-relevant physical activities ( Patient-Specific Complaints question naire ) . The secondary outcome measures were changes in illness perceptions ( Illness Perceptions Question naire ) and generic physical activity level ( Quebec Back Pain Disability Scale ) . Measurements were taken at baseline ( 0 weeks ) and after treatment ( 18 weeks ) . Results A baseline-adjusted analysis of covariance showed that there were statistically significant differences between intervention and control groups at 18 weeks for the change in patient-relevant physical activities . This was a clinical ly relevant change ( 19.1 mm ) for the intervention group . Statistically significant differences were found for the majority of illness perception scales . There were no significant differences in generic physical activity levels . Limitations Longer-term effectiveness was not studied . Conclusions This first trial evaluating cognitive treatment of illness perceptions concerning CLBP showed statistically significant and clinical ly relevant improvements in patient-relevant physical activities at 18 weeks Objective : The aim of this study was to evaluate a tailored physical activity protocol performed in a work environment with a group of female workers employed in manual precision tasks to reduce upper limb pain . Methods : Sixty female subjects were r and omly assigned to an intervention group or a control group . The IG was administered of a 6-month , twice-a-week , tailored exercise program , whereas the CG received no intervention . Results : The IG showed a reduction on shoulder pain accompanied by increases on the range of motion measures . In addition , reductions in upper limb pain and neck disability were detected with concomitant increases in grip strength . Conclusions : This study indicated positive effects of a tailored workplace exercise protocol in female workers exposed to moderate risk for work-related musculoskeletal disorders , showing clinical ly meaningful reductions of pain symptoms and disability on upper limb and neck regions Osteoarthritis is the leading cause of persistent knee pain , affecting around one quarter of adults ( 1 , 2 ) , and is a major contributor to global disability ( 3 ) . Knee osteoarthritis causes loss of function , reduced quality of life , and psychological disability ( 4 ) . It has no cure and , given the aging population and increasing obesity rates , disease burden is rapidly increasing ( 5 , 6 ) . The urgent need for effective and accessible models of health service delivery that can be provided on a population level has been recognized as a research priority by key stakeholders ( 7 ) . Such models should take a biopsychosocial approach ; emphasize nondrug , nonsurgical treatment ; and foster self-management , of which appropriate educational information is a core component ( 8) . Exercise has well-established benefits for pain and function in persons with knee osteoarthritis ( 911 ) and is recommended by clinical guidelines as the cornerstone of conservative management ( 12 ) . It is often prescribed by a health professional and can be performed effectively at home ( 9 ) . Evidence also supports  pain-coping skills training ( PCST ) , an approach based on cognitive behavioral principles , to target psychological factors , such as low self-efficacy , poor pain coping , and pain catastrophizing , that are common in persons with chronic pain ( 13 , 14 ) . However , for many , accessing specialist clinicians to prescribe and supervise these treatments may be difficult due to cost , transport issues , or geographic location , particularly in regional and rural areas where services may be limited or nonexistent ( 15 , 16 ) . The Internet is a time-efficient and convenient method to deliver health interventions with broad reach ( 17 , 18 ) . Educational material is often accessed online by persons with chronic pain ( 19 ) . Remotely delivered physiotherapy and exercise can benefit persons with knee pain and osteoarthritis ( 2022 ) and those who have undergone knee joint replacement , albeit often using sophisticated technology ( 23 ) . An Internet-based interactive PCST program ( PainCOACH ) , design ed to translate key therapeutic elements of clinician-delivered face-to-face PCST ( 24 ) , showed improved outcomes in persons with hip or knee osteoarthritis ( 25 ) . An online intervention combining these treatments aligns with a biopsychosocial approach to chronic disease management ( 8) but has not been investigated in this patient population . This study aim ed to evaluate the effectiveness of an innovative Internet-based intervention combining physiotherapist-prescribed home exercise delivered via videoconferencing ( Skype [ Microsoft ] ) and automated PCST in addition to educational material in persons with chronic knee pain . Our primary hypothesis was that the intervention would reduce pain and improve physical function after 3 months compared with educational material only . Supplement . Study Protocol Methods Design Overview We conducted a parallel , 2-group pragmatic r and omized , controlled trial . The protocol has been published ( 26 ) . The trial was prospect ively registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12614000243617 ) . Initial registration erroneously listed the Depression , Anxiety and Stress Scale ( DASS-21 ) as a secondary outcome rather than an eligibility screening tool . We amended the registry after enrolling 16 participants but before collecting follow-up data . No interim analyses were performed . The Institutional Human Ethics Committee approved the trial , and participants provided informed consent . Recruitment occurred from March 2014 to May 2015 , with follow-up completed in February 2016 . Participants and physiotherapists were unblinded to group allocation and were aware of the alternative treatment components , but study hypotheses were not disclosed to participants . The statistician was blinded . A nested health economic evaluation and a qualitative study exploring patients ' and physiotherapists ' experiences will be published separately . Setting and Participants We recruited community-dwelling participants from Australia via print , radio , and social media advertisements and our data base .  Eligibility was confirmed using an online survey followed by a telephone interview .  Inclusion criteria were age 50 years or older , knee pain for more than 3 months and on most days of the previous month , knee pain during walking ( score of 4 on an 11-point numerical rating scale [ NRS ] , with terminal descriptors of no pain and worst pain possible ) in the previous week , mild to moderate physical dysfunction ( score > 20 out of 68 on the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [ WOMAC ] ) , and an active e-mail account and a computer with Internet access . Exclusion criteria were joint replacement in the symptomatic knee , awaiting joint replacement surgery , intra-articular corticosteroid injection or knee surgery in the previous 6 months or planned joint surgery in the subsequent 9 months , treatment for knee pain or participation in a strengthening exercise or PCST program in the previous 6 months , systemic arthritic condition , neurologic condition affecting the lower limb or limiting exercise , pain at another site that was worse than knee pain or limited exercise , and high-level depression ( score > 21 on the depression subscale of the DASS-21 [ 27 ] ) . R and omization and Interventions Computer-generated r and omization was conducted by r and om permuted blocks of size 2 to 8 stratified by sex and residence ( metropolitan or regional/rural ) . The r and omization schedule was prepared by an independent biostatistician and concealed from the research er enrolling participants in sequentially numbered , opaque , sealed envelopes . Intervention Participants received 3 Internet-delivered treatments . The first was educational material about exercise and physical activity , pain management , emotions , healthy eating , complementary therapies , and medications ( www.arthritisaustralia.com.au ) . Participants were encouraged to access the material at their leisure . The second was an interactive automated PCST program ( PainCOACH ) ( 24 , 25 ) . Participants were asked to complete eight 35- to 45-minute modules ( 1 per week commencing in week 1 ) and practice pain-coping skills daily ( Appendix Table 1 ) . These skills included progressive relaxation , activityrest cycling , scheduling pleasant activities , changing negative thoughts , pleasant imagery and distraction techniques , and problem solving . The third was 7 Skype sessions with a physiotherapist over 12 weeks ( in weeks 2 , 3 , 4 , 6 , 8 , 10 , and 12 ) . Sessions lasted 45 minutes in weeks 2 and 12 and 30 minutes in the other weeks . Physiotherapists were allocated to participants on the basis of availability , and the same physiotherapist undertook all consultations with any given participant . The physiotherapist performed a brief assessment and prescribed a lower-limbstrengthening home exercise program to be performed 3 times per week ( 26 , 28 ) ( Appendix Table 2 ) . Exercise progression was provided by varying the exercises , repetitions , load , or difficulty to approximate a 10-repetition maximum level and a self-rated effort level of at least 5 out of 10 ( hard ) on a modified Borg Rating of Perceived Exertion scale ( 29 ) . Participants were provided with instructions , video demonstrations , and equipment ( such as resistance b and s and ankle weights ) . They also were encouraged to increase physical activity levels , received written information about how to do so , and were given the option of using a pedometer for motivation ( provided at no cost ) . Appendix Table 1 . Summary of the Internet-Based PainCOACH Content * Appendix Table 2 . Home Exercise Program Protocol * Generic e-mail reminders to complete PainCOACH modules were sent weekly during the first 8 weeks . At week 11 and at monthly intervals from week 13 , participants received e-mails encouraging them to review the final module , revisit useful or meaningful modules , and continue home exercise and pain-coping skills practice .  Eight physiotherapists ( 4 men ) with an average of 16 years ( range , 3 to 28 years ) of clinical musculoskeletal experience were trained to deliver the exercise component . Physiotherapists attended a 1-day training course conducted by the research ers and were given an exercise manual . They also were provided with an overview of PainCOACH and were asked to encourage participants to complete modules and practice skills . Regular telephone and Skype meetings between the physiotherapists and the research ers were held to discuss implementation of the intervention . A brief video showing a mock physiotherapy session is provided in the Supplement Video . Control The control group received access to the same online educational material as the intervention group . Outcomes and Follow-up Participants completed measurements online at baseline , 3 months ( primary time point ) , and 9 months . They received a $ 50AUD gift voucher for completing all question naires . The primary outcomes were valid and reliable self-reported measures of pain and physical function that are recommended for knee osteoarthritis clinical trials ( 30 ) . Overall average pain during walking over the previous week was measured with an NRS , with terminal descriptors of no pain ( score of 0 ) and worst pain possible ( score of 10 ) and a minimum clinical ly important difference ( MCID ) of 1.8 units ( 31 ) . Difficulty with physical function over the previous 48 hours was measured with the WOMAC ( Likert version 3.1 ) physical function subscale ( 32 ) , with total scores ranging from 0 ( no dysfunction ) to 68 ( maximum dysfunction ) and an MCID of 6 units ( 33 ) . Secondary outcomes included knee pain over the previous 48 hours , measured using the WOMAC pain subscale ( 32 ) ( scores range from 0 [ no pain ] to 20 [ maximum pain ] ) ; global change overall , in pain , and in physical function , measured using 7-point Likert scales with terminal descriptors of much worse to much better ( measured at 3 and 9 months ) ; health-related quality of life , Background Knee osteoarthritis ( OA ) is a prevalent chronic musculoskeletal condition with no cure . Pain is the primary symptom and results from a complex interaction between structural changes , physical impairments and psychological factors . Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population . There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training ( PCST ) particularly in other chronic pain conditions . Though typically provided separately , there are symptom , re source and personnel advantages of exercise and PCST being delivered together by a single healthcare professional . Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management . No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population . The primary aim of this multisite r and omised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA . Methods / design This will be an assessor-blinded , 3-arm r and omised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice . Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and r and omized into one of three groups : exercise alone , PCST alone , or integrated PCST and exercise .  R and omisation will be stratified by city ( Melbourne or Brisbane ) and gender . Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale . Secondary outcomes include global rating of change , muscle strength , functional performance , physical activity levels , health related quality of life and psychological factors . Measurements will be taken at baseline and immediately following the intervention ( 12 weeks ) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects . Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42 . Relative cost-effectiveness will be determined from health service usage and outcome data . Discussion The findings from this r and omised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone . Trial registration Australian New Zeal and Clinical Trials Registry reference number :
Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence .
BACKGROUND Chronic musculoskeletal pain ( CMP ) is a major health problem , accounting for approximately one-quarter of general practice ( GP ) consultations in the United Kingdom ( UK ) .
Exercise and physical activity is beneficial for the most common types of CMP , such as back and knee pain .
However , poor adherence to exercise and physical activity may limit long-term effectiveness .
OBJECTIVES To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain .