Research to encourage exercise for fibromyalgia (REEF): use of motivational interviewing, outcomes from a randomized-controlled trial

Global mapping of physical activity promotion strategies in Fibromyalgia- A comprehensive methodological scoping review protocol

Fibromyalgia Syndrome (FMS) is a chronic, broad, diffuse, and non-inflammatory musculoskeletal condition. Several studies were conducted on the effects of physical activity (PA) and strategies to promote it in people with FMS. The resulting scoping review will provide an analysis of the strategies being researched and executed. This study outlines the protocol for a scoping review to collect, analyse and compile the promotion strategies for PA in FMS. The proposed protocol will be guided by Arksey and O'Malley's framework and advanced methodology study by Levac et al. The search method will comprise of terms pertaining to FMS, PA, and its promotion. To ascertain relevant studies, predetermined inclusion and exclusion criteria will be used. Studies included must be performed on FMS patients with PA as the intervention with an outcome related to quality of life, pain, and fatigue. Data extraction of the included studies will be done through three investigators using Rayyan software. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) will be used to describe the study.

Effectiveness of motivational interviewing on pain-related outcomes in patients with musculoskeletal pain: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of motivational interviewing (MI) in the treatment of adult patients with musculoskeletal (MSK) pain.

MATERIALS AND METHODS

A comprehensive search strategy without date or language restrictions was performed in five scientific databases. Manual searches and reference tracking were also carried out. Two reviewers independently performed title and abstract as well as full-text screening, data extraction, assessment of risk of bias, and evaluation of overall certainty with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Where possible, a meta-analysis was performed to identify effects across multiple studies.

RESULTS

Ten studies reported in 16 manuscripts met the previously defined eligibility criteria. Many outcomes could be extracted and analyzed. Nine of the ten studies were considered to have a high risk of bias according to the revised Cochrane RoB 2.0. The majority of comparisons were based on low to very low overall certainty of the evidence.

CONCLUSIONS

The existing literature did not allow a reliable statement about the effectiveness of MI on pain-related outcomes in people with MSK pain. Only tendencies towards a positive influence of MI were recognisable. However, this must be confirmed by high-quality randomized controlled trials in the future.IMPLICATIONS FOR REHABILITATIONMotivational interviewing appears to be an option for patients with chronic musculoskeletal pain which presumably has few to no adverse effects.Motivational interviewing could represent an opportunity, particularly for patients for whom other treatment strategies have been ineffective so far.Motivational interviewing can safely be combined with other forms of treatment such as an active exercise therapy.

Adherence Support Strategies for Physical Activity Interventions in People With Chronic Musculoskeletal Pain-A Systematic Review and Meta-Analysis

BACKGROUND

Chronic musculoskeletal (MSK) pain significantly impacts individuals' quality of life. Regular physical activity is an important key to therapy. However, adherence to exercise is often below the intended levels. This systematic review aims to assess the effectiveness of adherence support strategies in physical activity randomized controlled trials (RCTs) for patients with chronic MSK pain, to address the challenge of motivation and adherence in this population.

METHODS

Ovid and CINAHL databases were searched for MSK "chronic pain," "adherence" and "physical activity" (in various synonyms) for RCTs with a follow-up of at least 6 months. After a screening process that included several team members, a narrative synthesis and a meta-analysis on adherence and effect sizes of different outcomes were performed.

RESULTS

An initial database output of 5816 articles resulted in 76 RCTs that remained for analysis. These RCTs showed high heterogeneity of intervention design and outcome data. Adherence to exercise varied widely, with 21 RCTs achieving rates of 80% or higher using strategies like education, goal setting, self-monitoring, and personal feedback. The meta-analysis, based on 29 out of 76 RCTs, indicated a nonsignificant correlation between adherence levels and an improved outcome (eg, pain or quality of life). No individual strategy emerged as superior, emphasizing the complexity and diversity of intervention designs.

CONCLUSIONS

This review offers strategies, such as information/education and individual goal setting/feedback that may be beneficial for enhancing physical activity in patients with chronic MSK pain. Future research should focus on including promising adherence support strategies and providing data for adherence calculations.

Virtual Motivational Interviewing (VIMINT) to support physical activity: Experiences of older adults and counsellors

The aim of this study was to explore the experiences of older adults and counsellors involved in virtual motivational interviewing (MI). This study was part of the Virtual Motivational INTerviewing (VIMINT) feasibility trial of virtual MI for physical activity in older adults. A descriptive qualitative design utilized content analysis. Seven older adults and three counsellors were interviewed. Four categories were developed: (i) Benefits and limitations of using technology (ii) Relationships between older adults and counsellors (iii) MI skills and spirit and (iv) Effects of virtual MI. Older adults and counsellors reported that receiving/delivering MI virtually was convenient and flexible. They described reduced non-verbal communication in virtual MI. Virtual MI facilitates interpersonal relationships, and counsellors reported that MI skills and spirit can be applied virtually. This study showed that virtual MI offers potential benefits with some limitations. The findings could inform future research involving virtual delivery of MI.

Effectiveness of behavioural interventions with motivational interviewing on physical activity outcomes in adults: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of behavioural interventions that include motivational interviewing on physical activity outcomes in adults.

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

A search of seven databases for randomised controlled trials published from inception to 1 March 2023 comparing a behavioural intervention including motivational interviewing with a comparator without motivational interviewing on physical activity outcomes in adults. Outcomes of interest were differences in change in quantitative measures of total physical activity, moderate to vigorous physical activity (MVPA), and sedentary time.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data and assessed risk of bias. Population characteristics, intervention components, comparison groups, and outcomes of studies were summarised. For overall main effects, random effects meta-analyses were used to report standardised mean differences (SMDs) and 95% confidence intervals (CIs). Differential effects based on duration of follow-up, comparator type, intervention duration, and disease or health condition of participants were also examined.

RESULTS

129 papers reporting 97 randomised controlled trials totalling 27 811 participants and 105 comparisons were included. Interventions including motivational interviewing were superior to comparators for increases in total physical activity (SMD 0.45, 95% CI 0.33 to 0.65, equivalent to 1323 extra steps/day; low certainty evidence) and MVPA (0.45, 0.19 to 0.71, equivalent to 95 extra min/week; very low certainty evidence) and for reductions in sedentary time (-0.58, -1.03 to -0.14, equivalent to -51 min/day; very low certainty evidence). Evidence for a difference in any outcome compared with comparators of similar intensity was lacking. The magnitude of effect diminished over time, and evidence of an effect of motivational interviewing beyond one year was lacking. Most interventions involved patients with a specific health condition, and evidence of an effect of motivational interviewing to increase MVPA or decrease sedentary time was lacking in general population samples.

CONCLUSIONS

Certainty of the evidence using motivational interviewing as part of complex behavioural interventions for promoting total physical activity in adults was low, and for MVPA and sedentary time was very low. The totality of evidence suggests that although interventions with motivational interviewing increase physical activity and decrease sedentary behaviour, no difference was found in studies where the effect of motivational interviewing could be isolated. Effectiveness waned over time, with no evidence of a benefit of motivational interviewing to increase physical activity beyond one year.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020219881.

Duloxetine and cognitive behavioral therapy with phone-based support for the treatment of chronic musculoskeletal pain: study protocol of the PRECICE randomized control trial

BACKGROUND

Chronic musculoskeletal pain (CMP) is the most common, disabling, and costly of all pain conditions. While evidence exists for the efficacy of both duloxetine and web-based cognitive behavioral therapy (CBT) as monotherapy, there is a clear need to consider study of treatment components that may complement each other. In addition, given the reported association between patient's adherence and treatment outcomes, strategies are needed to enhance participant's motivation to adopt and maintain continued use of newly learned pain coping skills from CBT.

METHODS

Two hundred eighty participants will be recruited from the primary care clinics of a large academic health care system in North Carolina. Participants with CMP will be randomized to one of three treatment arms: (1) combination treatment (duloxetine + web-based self-guided CBT) with phone-based motivational interviewing (MI), (2) combination treatment without phone-based MI, and (3) duloxetine monotherapy. Participants will be in the study for 24 weeks and will be assessed at baseline, week 13, and week 25. The primary outcome is the Brief Pain Inventory (BPI)-Global Pain Severity score, which combines BPI pain severity and BPI pain interference. Secondary measures include between-group comparisons in mean BPI pain severity and BPI pain interference scores. Data collection and outcome assessment will be blinded to treatment group assignment.

DISCUSSION

This randomized controlled trial (RCT) will determine if combination treatment with duloxetine and web-based CBT is superior to duloxetine monotherapy for the management of CMP. Furthermore, this RCT will determine the effectiveness of phone-based motivational interviewing in promoting the continued practice of pain coping skills, thereby enhancing treatment outcomes.

TRIAL REGISTRATION

NCT04395001 ClinicalTrials.gov. Registered on May 15, 2020.

Duloxetine and Cognitive Behavioral Therapy with Phone-based Support for the Treatment of Chronic Musculoskeletal Pain: Study Protocol of the PRECICE Randomized Control Trial

Background

Chronic musculoskeletal pain (CMP) is the most common, disabling, and costly of all pain conditions. While evidence exists for the efficacy of both duloxetine and web-based cognitive behavioral therapy (CBT) as monotherapy, there is a clear need to consider study of treatment components that may complement each other. In addition, given the reported association between patient's adherence and treatment outcomes, strategies are needed to enhance participant's motivation to adopt and maintain continued use of newly learned pain coping skills from CBT.

Methods

Two hundred eighty participants will be recruited from the primary care clinics of a large academic health care system in North Carolina. Participants with CMP will be randomized to one of 3 treatment arms: (1) combination treatment (duloxetine + web-based self-guided CBT) with phone-based motivational interviewing (MI), (2) combination treatment without phone-based MI and (3) duloxetine monotherapy. Participants will be in the study for 24 weeks and will be assessed at baseline, week 13, and week 25. The primary outcome is the Brief Pain Inventory (BPI)-Global Pain Severity score, which combines BPI pain severity and BPI pain interference. Secondary measures include between-group comparisons in mean BPI pain severity and BPI pain interference scores. Data collection and outcome assessment will be blinded to treatment group assignment.

Discussion

This randomized controlled trial (RCT) will determine if combination treatment with duloxetine and web-based CBT is superior to duloxetine monotherapy for the management of CMP. Furthermore, this RCT will determine the effectiveness of phone-based motivational interviewing in promoting the continued practice of pain coping skills; thereby, enhancing treatment outcomes.

Trial Registration

NCT04395001. Registered in ClinicalTrials.gov on May 15, 2020.

Health coaching improves physical activity, disability and pain in adults with chronic non-cancer pain: a systematic review

QUESTION

What is the effect of health coaching on physical activity, disability, pain and quality of life compared with a non-active control in adults with chronic non-cancer pain?

DESIGN

Systematic review and meta-analysis of randomised controlled trials. Evidence was synthesised as standardised mean differences with 95% confidence intervals using random-effects models. Risk of bias was assessed using the revised Cochrane risk of bias tool. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to determine evidence certainty.

DATA SOURCES

MEDLINE, Embase, CENTRAL, CINAHL, Scopus and PEDro were searched from inception to November 2023.

PARTICIPANTS

Adults with chronic non-cancer pain.

INTERVENTION

Health coaching to increase physical activity.

OUTCOME MEASURES

Measures of physical activity, disability, pain and quality of life.

RESULTS

Twenty-six randomised trials (n = 4,403) were included. Trials had moderate to high risk of bias. Health coaching had a trivial to small effect on improving physical activity compared with control (15 trials; SMD 0.21, 95% CI 0.07 to 0.35; low certainty evidence). Health coaching had a small effect on improving disability (19 trials; SMD 0.25, 95% CI 0.17 to 0.32; moderate certainty evidence) and pain (19 trials; SMD 0.31, 95% CI 0.18 to 0.43; very low certainty evidence) compared with control. The effect of health coaching on quality of life was unclear due to significant imprecision in the effect estimate (five trials; SMD 0.19, 95% CI -0.14 to 0.53; moderate certainty evidence).

CONCLUSION

Health coaching promotes a trivial to small improvement in physical activity and small improvements in disability and pain in adults with chronic non-cancer pain. The effect of health coaching on quality of life remains unclear.

REGISTRATION

PROSPERO CRD42020182740.

How to Generate Self-Efficacy despite Pain: The Role of Catastrophizing and Avoidance in Women with Fibromyalgia

BACKGROUND AND OBJECTIVE

Fibromyalgia-related pain is influenced by numerous factors, including severity, as well as cognitive profiles based on pain catastrophizing or activity patterns. In this context, self-efficacy is identified as a potential predictor for explaining certain health outcomes. This study aimed to contribute to exploring the role of pain avoidance (as activity pattern) between pain severity and self-efficacy along pain catastrophizing.

METHODS

Through a cross-sectional study, a total of 264 women with fibromyalgia completed self-report measures of pain severity, pain avoidance, pain catastrophizing, and self-efficacy. The severity of the symptoms, the time elapsed since diagnosis, and the time elapsed since the onsets of symptoms were included as covariates to control. Regression-based moderated-mediation analysis was used to test the conditional effect of pain severity on self-efficacy via pain avoidance at varying levels of pain catastrophizing.

RESULTS

Pain avoidance mediated the effect of pain severity on self-efficacy. The indirect effects showed a moderated effect when patients scored high on the pain catastrophizing scale. The model evaluated, where catastrophic pain moderates the indirect effect of pain intensity on self-efficacy through pain avoidance, explained 49% of the variance.

CONCLUSIONS

Catastrophic beliefs associated with pain as being uncontrollable increase the relationship between pain severity and pain avoidance. In turn, pain avoidance is associated with a low perception of capacity.

Motivate-to-move: development of an intervention promoting parental adherence to early power mobility programs

PURPOSE

Parental/caregiver adherence has been identified as a barrier to implementation of early power mobility programs. Motivational interviewing (MI) may help in addressing this barrier. Two scoping reviews were conducted to gather concepts pertaining to parent-based or rehabilitation-based MI interventions and to develop a parent-based MI intervention to address parental/caregiver adherence to home-based early power mobility interventions for infants and young children.

MATERIALS AND METHODS

Separate literature searches for parent-based MI and rehabilitation-based MI were conducted in PubMed, CINAHL Complete, PsycInfo, and Web of Science Core Collection. Inclusion criteria were [1]: focussed on/use of either a parent-based or a rehabilitation-based MI intervention and [2] MI interventions described in sufficient detail to be reproduced. Articles focussed on vaccinations, child abuse and neglect, mental health, or technology-based MI were excluded. Data regarding MI interventions and strategies were extracted from included articles.

RESULTS

A total of 1130 unique titles were screened and 150 full-text articles were assessed for inclusion. Nineteen articles met the inclusion/exclusion criteria. Using a collaborative, consensus-based approach, a parent-based MI intervention incorporating specific MI strategies identified in the review was developed in collaboration with a psychologist. Future research exploring the application of this parent-based MI intervention is indicated.

CONCLUSIONS

The parent-based MI interventions developed in this project may help to increase parental adherence to home-based early power mobility programs, thereby potentially addressing an identified barrier to implementation of early power mobility programs.IMPLICATIONS FOR REHABILITATIONTo our knowledge, this is the first study to develop MI scripts for the purpose of increasing parental/caregiver adherence to a power mobility training program for children.The MI interventions developed in this study are consistent with published suggestions to address perceived barriers to the implementation of early power mobility programs.Given the strategies of collaboration, autonomy, and empowerment embedded within the spirit of MI, parent-based MI interventions are congruous with and inclusive of the principles of family-centered care.

Distress as a mediator for pain and activities of daily living in older adults with fibromyalgia

Introduction

Pain, distress, and activities of daily living impact the lives of those with chronic pain. This study investigated distress (depressive symptoms, anxiety) on the relationship between pain (intensity and pain interference) and activities of daily living in individuals with fibromyalgia while controlling for age.

Methods

The current cross-sectional investigation focused on data from 123 men and women with fibromyalgia. Pain intensity, pain interference and anxiety were measured on 0-10 Likert type scales from the National Fibromyalgia Assessment Questionnaire. Depressive symptoms were assessed using the Beck Depression Inventory II. Activities of daily living (basic, instrumental) were measured with the Physical Activity Inventory Scale.

Results

It was hypothesized that the relationships between pain intensity and pain interference and activities of daily living in individuals with fibromyalgia would be mediated by the construct of distress while controlling for age. Mediation significantly occurred in both models as predicted. However, those who were older reported lower levels of pain intensity and distress than their younger counterparts, which may be related to time since diagnosis or other factors.

Discussion

Results of this study suggest that individuals with chronic pain conditions would benefit from treatment options which address distress, specifically depressive symptoms and anxiety.

Physical Activity Assessment and Promotion in Clinical Settings in the United States: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to systematically examine interventions that focused on physical activity assessment and promotion in clinical settings in the United States.

DATA SOURCES

A literature search was performed in 6 major databases to extract published peer-reviewed studies from 2008 to 2019.

INCLUSION AND EXCLUSION CRITERIA

Interventions with practicing health professionals in the United States who performed physical activity assessment and promotion with adult patients 18 years of age and older. Studies were excluded if they were published in non-English, observational or case study designs, or gray literature.

DATA EXTRACTION

Studies were screened and coded based on the population, intervention, comparison, outcomes and study setting for scoping reviews (PRISMA-ScR) framework. Of 654 studies that were identified and screened for eligibility, 78 met eligibility criteria and were independently coded by two coders.

DATA SYNTHESIS

Data were synthesized using qualitative and descriptive methods.

RESULTS

Forty-three of the included studies were randomized controlled trials with a majority being delivered by physicians and nurses in primary care settings. Fifty-six studies reported statistically significant findings in outcome measures such as anthropometrics and chronic disease risk factors, with 17 demonstrating improvements in physical activity levels as a result of the interventions.

CONCLUSION

The assessment and promotion of physical activity in clinical settings appears to be effective but warrants continued research.

Pain-Related Worrying and Goal Preferences Determine Walking Persistence in Women with Fibromyalgia

Physical activity and exercise are relevant behaviors for fibromyalgia health outcomes; however, patients have difficulties undertaking and maintaining an active lifestyle. With a cross-sectional design, this study explored the role of pain-related worrying and goal preferences in the walking persistence of women with fibromyalgia. The sample included 111 women who attended a tertiary health setting. We adapted the Six-Minute Walk Test where participants decided either to stop or continue walking in five voluntary 6 min bouts. Women who were categorized higher in pain-related worrying reported higher preference for pain avoidance goals (t = -2.44, p = 0.02) and performed worse in the walking task (LongRank = 4.21; p = 0.04). Pain avoidance goal preference increased the likelihood of stopping after the first (OR = 1.443), second (OR = 1.493), and third (OR = 1.540) 6 min walking bout, and the risk of ending the walking activity during the 30 min task (HR = 1.02, [1.0-1.03]). Influence of pain-related worrying on total walking distance was mediated by goal preferences (ab = -3.25). In interventions targeting adherence in physical activity and exercise, special attention is needed for women who are particularly worried about pain to help decrease their preference for short-term pain avoidance goals relative to long-term goals such as being active through walking.

Predictors of Physical Activity in Patients With Fibromyalgia: A Path Analysis

BACKGROUND/OBJECTIVE

The aim of this study was to identify psychological factors that influence moderate-vigorous physical activity (MVPA) participation in patients with fibromyalgia.

METHODS

In this secondary data analysis, 170 patients received personalized exercise plans and completed baseline and follow-up assessments of self-reported physical activity at weeks 12, 24, and 36. Structural equation modeling was used to examine the predictive strengths of psychological factors (exercise self-efficacy, perceived barriers, and intention) on MVPA participation.

RESULTS

Using a threshold increase in MVPA of 10 or greater metabolic equivalent hours per week (MET h/wk), 3 groups were defined based on subjects who achieved a minimum increase of 10 MET h/wk that was sustained for at least 12 weeks (SUS-PA), achieved an increase of 10 MET h/wk that was not sustained for at least 12 weeks (UNSUS-PA), and did not achieve an increase of 10 MET h/wk (LO-PA). Increases in exercise self-efficacy and intention and reductions in perceived barriers were associated with increased volume of PA, showing the greatest change in the SUS-PA, followed by UNSUS-PA. For the LO-PA group, there was no change in exercise self-efficacy, a decrease in intention, and an increase in barriers. Using path analysis, exercise self-efficacy and perceived barriers were associated with higher volumes of physical activity via greater intention to engage in MVPA.

CONCLUSIONS

For patients with fibromyalgia, exercise self-efficacy, perceived barriers, and intention to exercise are important constructs for increasing physical activity. Our findings provide guidance for practitioners who seek to promote physical activity in fibromyalgia and suggestions for researchers aiming to improve prediction models.

Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme

Background

Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.

Objectives

To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.

Design

Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.

Setting

Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).

Participants

Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.

Interventions

Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.

Main outcome measures

Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.

Results

Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.

Limitations

The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.

Conclusion

The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.

Future work

Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.

Trial registration

Current Controlled Trials ISRCTN70160382.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain-A Scoping Review and Theoretical Models

(1) Background: Adherence to and the maintenance of treatment regimens are fundamental for pain self-management and sustainable behavioural changes. The first aim was to study older adults' (>65 years) levels of adherence to and maintenance of musculoskeletal pain self-management programmes in randomized controlled trials. The second aim was to suggest theoretical models of adherence to and maintenance of a behaviour. (2) Methods: The study was conducted in accordance with the recommendations for a scoping review and the PRISMA-ScR checklist. Capability, motivation and opportunity were used to categorize the behavioural change components in the theoretical models. (3) Results: Among the four studies included, components targeting adherence were reported in one study, and maintenance was reported in two studies. Adherence was assessed by the treatment attendance rates, and maintenance was assessed by the follow-up data of outcome measures. For adherence, the capability components were mostly about education and the supervision, grading and mastery of exercise to increase self-efficacy. The motivation components included the readiness to change, self-monitoring and goal setting; and the opportunity components included booster sessions, feedback and social support. For maintenance, the capability components consisted of identifying high-risk situations for relapse and problem-solving skills. The motivation components included self-regulation and self-efficacy for problem solving, and the opportunity components included environmental triggers and problem solving by using social support. (4) Conclusion: There are several behavioural change components that should be used to increase older adults' levels of adherence to and maintenance of a pain self-management behaviour.

The Effectiveness of Strategies to Promote Walking in People With Musculoskeletal Disorders: A Systematic Review With Meta-analysis

OBJECTIVE

To evaluate the effect of walking promotion strategies on physical activity, pain, and function in people with musculoskeletal disorders.

DESIGN

Intervention systematic review with meta-analysis.

LITERATURE SEARCH

We performed the searches in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Physiotherapy Evidence Database (PEDro) from inception to August 2019.

STUDY SELECTION CRITERIA

We included randomized controlled trials evaluating interventions that promote walking in people with musculoskeletal disorders.

DATA SYNTHESIS

We used the PEDro scale for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. We expressed pooled effects for between-group differences as mean differences or standardized mean differences and 95% confidence intervals, or as risk ratios and 95% confidence intervals, using random-effects meta-analyses.

RESULTS

Twelve eligible trials (n = 1456 participants) were identified. There was moderate- to very low-quality evidence of no difference in physical activity levels for walking promotion interventions when compared to minimal interventions, and a significant effect favoring walking promotion when compared with usual care in the short term. There was moderate-quality evidence that walking promotion was modestly effective for reducing pain and improving function compared with minimal intervention and usual care. There was no difference in pain and function for walking promotion compared to supervised exercise. Walking promotion was not associated with different rates of adverse events compared to control conditions.

CONCLUSION

Strategies to promote walking did not increase physical activity in people with musculoskeletal disorders. Walking promotion was associated with small improvements in pain and function compared to minimal intervention and usual care. J Orthop Sports Phys Ther 2020;50(11):597-606. doi:10.2519/jospt.2020.9666.

Promoting unsupervised walking in women with fibromyalgia: a randomized controlled trial

The objective of this study is to test the efficacy of a group motivational plus implementation intentions intervention in promoting adherence to an unsupervised walking program recommended for fibromyalgia, compared to an implementation intentions condition and to an active control condition. A triple-blind, randomized, longitudinal study with measures at baseline, short (seven weeks post-intervention), mid (12 weeks) and long-term (36 weeks) is performed. Data are analyzed using multilevel longitudinal growth curve two-level modelling. Participants are 157 women with fibromyalgia. In the short-term, adherence to the minimum and to the standard walking program (primary outcome measures) is explained by time (both p <.001), motivational plus implementation intentions intervention (both p <.001) and by their interaction (both p <.001). Regarding the secondary outcomes, only physical function is explained by time (p <.001), motivational plus implementation intentions intervention (p <.05) and by their interaction (p <.05). Motivational plus implementation intentions intervention achieve the promotion of walking as an exercise in the short-term; furthermore, physical function of the women in this condition is better than in the other two intervention groups, which is a relevant outcome from a rehabilitation point of view. However, more studies are needed to maintain the exercise at mid and long-term.

Fibromyalgia

Fibromyalgia is characterized by chronic, widespread musculoskeletal pain and associated fatigue, sleep disturbances, and other cognitive and somatic symptoms. For many patients, these symptoms persist for years and lead to frequent health care use; for some, fibromyalgia and its symptoms can be debilitating. Although many treatments are available, management remains challenging. This article highlights the clinical features of fibromyalgia, discusses diagnostic criteria and their evolution, and reviews treatment options.

The effects of behavioural counselling on the determinants of health behaviour change in adults with chronic musculoskeletal conditions making lifestyle changes: A systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis of controlled trials was carried out to examine the effect of behavioural counselling on determinants of behaviour change in adults with chronic, painful musculoskeletal conditions.

METHODS

Seven databases were searched up to January 2019. Two reviewers independently screened title/abstracts and full texts. Eligible trials included those including participants over 18 years of age with a chronic, painful musculoskeletal condition, a measurement of at least one behavioural determinant and lifestyle behaviour, and where behavioural counselling was the distinguishing intervention. Two reviewers independently extracted data and assessed for risk of bias using the Cochrane Risk of Bias Tool. Meta-analyses were conducted, using standardized mean differences and 95% confidence intervals (CIs) when at least two trials examined the same outcome. The quality of the evidence was evaluated using the Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

Fourteen unique trials, reported in 16 publications, were included. Low-quality evidence showed that behavioural counselling has a small effect on increasing self-reported physical activity (standardized mean difference 0.26; 95% CI 0.00, 0.53). Very-low-quality evidence showed that behavioural counselling has a moderate effect on self-efficacy related to physical activity (standardized mean difference 0.69; 95% CI 0.19, 1.18). Low-quality evidence suggested that behavioural counselling has no effect on symptoms of depression and anxiety.

CONCLUSIONS

Behavioural counselling may help to increase self-reported physical activity levels in adults with chronic painful musculoskeletal conditions. Self-efficacy may be a behavioural determinant in an underlying causal pathway explaining positive lifestyle change.

Postural counseling represents a novel option in pain management of fibromyalgia patients

Background

Chronic pain is a key symptom in fibromyalgia (FM), and its management is still challenging for rheumatologists in daily practice. FM patients show psychological and psychiatric manifestations, going from mood and emotional disorders to depression and alexithymia that negatively impact their quality of life, limiting their daily activities. Since pharmacological strategies have a limited efficacy in FM pain, alternative or complementary non-pharmacological approaches have been introduced in the clinical management of FM.

Patients and methods

This is a retrospective study on FM patients (n=52) treated with a novel integrated postural counseling (PC) rehabilitation program carried out by a counselor physiotherapist. The clinical impact of PC was evaluated by 1) a semi-structured interview using an ad hoc modified questionnaire McGill Illness Narrative Interview (MINI) 1 to obtain data on pain management by highlighting everyday experience of living with pain and 2) an FM impact questionnaire (FIQ) total score.

Results

Two main structures of narrative emplotment of FM illness were recognized: 1) the cumulative life narrative structure (46.15%) and 2) the broken life (53.85%) narrative structure. Baseline FIQ score was 77.38±7.77, and it was significantly reduced after PC to 39.12±13.27 (P<0.0001). Although well-being still requires further definition as outcome in pain management, it is important for FM patients, dealing with pain-related sensations, thoughts and feelings and limiting their daily activities. In our study, 87.5% of interviewed FM patients reported an improvement in their well-being after PC.

Conclusion

Our data suggest that an integrated PC program positively impacts chronic pain and fatigue based on self-management strategies. PC allows FM patients to resume their own life and regenerate their own image. Finally, we propose the introduction of the evaluation of the ability to resume daily activities as the target of rehabilitation programs in FM.

Target population's requirements on a community-based intervention for stimulating physical activity in hard-to-reach physically disabled people: an interview study

Purpose: To explore ideas of the target population about a community-based intervention to stimulate physical activity in hard-to-reach physically disabled people. Materials and methods: Semi-structured interviews were performed with 21 physically disabled people, and analyzed using thematic analyses. Findings were interpreted using the integrated Physical Activity for People with a Disability and Intervention Mapping model. Results: The intervention should aim to stimulate intrinsic motivation and raise awareness for the health effects of physical activity. It should provide diverse activities, increase visibility of these activities, and improve image of physical activity for physically disabled people. Participants suggested to provide individual coaching sessions, increase marketing, present role models, and assign buddies. Potential users should be approached personally through intermediate organizations, or via social media and word of mouth promotion. Participants suggested that users, government, sponsors, and health insurers should finance the intervention. Self-responsibility for being physically active was strongly emphasized by participants. Conclusions: An intervention to stimulate physical activity in hard-to-reach physically disabled people should be individualized, include personal support, and should include marketing to improve image of physical activity of physically disabled people. The intervention that fulfills these requirements should be developed and tested for effects in future research. Implications for rehabilitation An intervention to stimulate physical activity in physically disabled people should aim to raise awareness for the health effects of physical activity, stimulate intrinsic motivation, offer diverse activities, increase the visibility of the possible activities, and improve the image of physical activity for physically disabled people. An intervention should include both individual- and environmental-level intervention methods. Physically disabled people most emphasized individual-level characteristics of an intervention. For intervention development, professionals should take into account that physically disabled people believe that being physically active is a person's own responsibility.

Rating motivational interviewing fidelity from thin slices

Monitoring fidelity to psychosocial treatments is critical to dissemination, process and outcome research, and internal validity in efficacy trials. However, the costs required to behavior code fidelity to treatments like motivational interviewing (MI) over many therapists and sessions quickly become intractable. Coding less of a session accelerates the process, but it is not clear how much of a session must be evaluated to capture the fidelity of the entire session. The present study used a "thin slice" (Ambady & Rosenthal, 1992) paradigm to explore the degree to which variously sized thin slices of MI fidelity related to fidelity ratings for a full session. We randomly selected contiguous and noncontiguous segments of MI sessions at each whole percent of sessions (i.e., a slice consisting of 1% of session utterances, another at 2%, etc.). We then computed MI fidelity scores from these segments and calculated agreement with fidelity ratings obtained from the full session. We compared thin slice agreement with full sessions against interrater agreement and found that approximately a third of a session (9 min, 26 seconds in our sample) had sufficient agreement to approach interrater levels. These results provide a reference for researchers and clinicians to make efficient and informed use of their behavior coding resources. In addition, our results add to the behavior slicing literature, indicating that small therapist behavior samples adequately describe overall session behavior. (PsycINFO Database Record

A scoping review on interventions to promote physical activity among adults with disabilities

BACKGROUND

Despite the strong evidence that physical activity (PA) is a key determinant of health, there is limited knowledge on the content and outcomes of PA promotion interventions among individuals with disabilities.

OBJECTIVE

To conduct a scoping review in order to examine the published literature on PA promotion interventions among adults with disabilities.

METHODS

A scoping review following the methodological framework provided by Arksey and O'Malley used electronic databases (MEDLINE, PsycINFO, and CINAHL), reference lists, and journals to locate studies. Inclusion criteria were based on study aim, outcome measures, and a disability definition by the WHO International Classification of Functioning, Disability and Health. The Behavior Change Techniques Taxonomy version 1 and Furlan and collaborators' risk of bias assessment were utilized during the data charting stage.

RESULTS

Thirty-eight articles met the inclusion criteria. Most of the studies (70%) reported a significant increase in PA behavior immediately following intervention. However, less than half of the studies (46%) examined the maintenance of pre-/post-test differences. The number of identified behavior change techniques was significantly higher for successful PA promotion interventions than for interventions with no effects on PA. Approximately one-third of studies (32%) were rated as having a high risk of bias.

CONCLUSIONS

Although findings support the idea that PA promotion interventions produce positive changes in PA behavior for a variety of disability conditions, risk of bias assessment calls for prudence. There are opportunities for continued development of the area of PA promotion among individuals with disabilities through systematic reviews and meta-analyses.

Obesity Moderates the Effects of Motivational Interviewing Treatment Outcomes in Fibromyalgia

OBJECTIVE

Obesity is a common comorbid condition among patients with fibromyalgia (FM). Our objective was to assess if obesity moderates the treatment benefits of exercise-based motivational interviewing (MI) for FM.

MATERIALS AND METHODS

This is a secondary data analysis of a completed clinical trial of 198 FM patients who were randomized to receive either MI or attention control (AC). Using body mass index (BMI) to divide participants into obese (BMI≥30 kg/m) and nonobese (BMI<30 kg m) groups, mixed linear models were used to determine interaction between treatment arms and obesity status with regards to the primary outcome of global FM symptom severity (Fibromyalgia Impact Questionnaire, FIQ). Secondary measures included pain intensity (Brief Pain Inventory), 6-Minute Walk Test, and self-reported physical activity (Community Health Activities Model Program for Seniors).

RESULTS

Of the 198 participants, 91 (46%) were nonobese and 107 (54%) were obese. On global FM symptom severity (FIQ), the interaction between treatment arms and obesity status was significant (P=0.02). In the nonobese group, MI was associated with a greater improvement in FIQ than AC. In the obese group, MI participants reported less improvement in FIQ compared with AC. The interaction analysis was also significant for Brief Pain Inventory pain intensity (P=0.01), but not for the walk test and self-reported physical activity.

DISCUSSION

This is the first study to show that obesity negatively affects the treatment efficacy of MI in patients with FM. Our findings suggest that exercise-based MI may be more effective if initiated after weight loss is achieved.

The Complex Relationship between Pain Intensity and Physical Functioning in Fibromyalgia: The Mediating Role of Depression

PURPOSE

Fibromyalgia (FM) is typically associated with the experience of diffuse pain and physical impairment. Depression also commonly co-exists in patients with FM, and has been correlated with pain intensity and physical functioning. Previous research suggests an association between pain intensity and physical functioning; however, the direct causal relationship between improvements in pain intensity and in functioning is not observed in many FM patients. This may suggest that another factor such as depression is mediating this relationship. The present work examined mediating role of depression.

METHODS

216 patients with FM completed measures of pain intensity, depression, and physical function as part of a larger longitudinal study. Assessments were completed at baseline, 12, 24, and 36 weeks.

RESULTS

Longitudinal mediational analyses indicated that depression is a partial mediator of the relationship between pain intensity and physical functioning at all four assessment points. Beta coefficients for the path from pain to physical functioning ranged from 0.18 - 0.36, with attenuated path coefficients ranging from 0.03 - 0.08, still showing significant but decreased associations when depression was added as a mediator.

CONCLUSIONS

Clinical implication includes the importance of treating co-morbid depression in patients with fibromyalgia early in the course of treatment to prevent engagement in the cycle of disability.

Determining the Minimal Clinically Important Difference for 6-Minute Walk Distance in Fibromyalgia

OBJECTIVE

The aim of this study was to estimate the minimal clinically important difference (MCID) for 6-min walk distance (6MWD) in patients with fibromyalgia.

DESIGN

Data from a recently completed trial that included 187 patients who completed the 6-min walk test, Fibromyalgia Impact Questionnaire (FIQ), and Short-Form 36 (SF36) at 12 and 36 wks were used to examine longitudinal changes in 6MWD. An anchor-based approach that used linear regression analyses was used to determine the MCID for 6MWD, using the total FIQ score (FIQ-Total) and SF36-physical function domain as clinical anchors.

RESULTS

The mean (SD) change in 6MWD from baseline to week 36 was 34.4 (65.2) m (P < 0.001). The anchor-based MCIDs for the 6MWD were 156 and 167 m for the FIQ and SF36-physical function domain, respectively. These MCIDs correspond with clinically meaningful improvements in FIQ (14% reduction) and SF36-physical function domain (10-point increase).

CONCLUSION

The MCID for 6MWD in patients with fibromyalgia was 156 to 167 m. These findings provide the first evidence of the change in 6MWD that is perceived by patients to be clinically meaningful. Further research using other MCID calculation methods is needed to refine estimates of the MCID for 6MWD in patients with fibromyalgia.

Effectiveness of Occupational Therapy Interventions for Adults With Fibromyalgia: A Systematic Review

OBJECTIVE

This systematic review addresses the effectiveness of occupational therapy-related interventions for adults with fibromyalgia.

METHOD

We examined the literature published between January 2000 and June 2014. A total of 322 abstracts from five databases were reviewed. Forty-two Level I studies met the inclusion criteria. Studies were evaluated primarily with regard to the following outcomes: daily activities, pain, depressive symptoms, fatigue, and sleep.

RESULTS

Strong evidence was found for interventions categorized for this review as cognitive-behavioral interventions; relaxation and stress management; emotional disclosure; physical activity; and multidisciplinary interventions for improving daily living, pain, depressive symptoms, and fatigue. There was limited to no evidence for self-management, and few interventions resulted in better sleep.

CONCLUSION

Although the evidence supports interventions within the scope of occupational therapy practice for people with fibromyalgia, few interventions were occupation based.

The Associations Between Pain-related Beliefs, Pain Intensity, and Patient Functioning: Hypnotizability as a Moderator

OBJECTIVES

On the basis of the idea that thoughts held about pain may represent "self-suggestions" and evidence indicating that people with higher levels of trait hypnotizability are more responsive to suggestions, the current study evaluated hypothesized moderating effects of hypnotizability on the associations between pain-related thoughts and both pain intensity and pain interference.

METHODS

Eighty-five individuals with chronic pain were given measures of hypnotizability, pain intensity, pain interference, and pain-related thoughts (control beliefs, catastrophizing).

RESULTS

Analyses supported a moderating role of hypnotizability on the association between control beliefs and pain interference. Specifically, the negative association between pain control beliefs and pain interference were stronger among those with higher trait hypnotizability than between those with lower trait hypnotizability.

DISCUSSION

The study findings, if replicated in additional samples of individuals with chronic pain, have important clinical and theoretical implications. For example, if trait hypnotizability is found to predict an individual's response to a particular technique of cognitive therapy-such as focusing on and repeating pain control belief self-statements-measures of hypnotizability could be used to identify individuals who might be most responsive to this technique. The current findings indicate that research to further examine this possibility is warranted.

Sustained Benefits of Exercise-based Motivational Interviewing, but Only among Nonusers of Opioids in Patients with Fibromyalgia

OBJECTIVE

Given the known side effects of opioids and their potential effects on cognition, we sought to evaluate the benefits of motivational interviewing (MI) to promote physical activity on 2 subsets of participants with fibromyalgia (FM): nonusers and users of opioids.

METHODS

This was a secondary data analysis of a 36-week randomized controlled trial to assess the efficacy of MI to promote physical activity among participants with FM. Participants were randomized to 1 of 2 treatment arms: 6 phone-based MI sessions (n = 107) or 6 sessions of FM self-management instructions [attention control (AC), n = 109]. The primary outcomes were changes in physical function (Medical Outcomes Study Short Form-36), pain severity (Brief Pain Inventory), global FM symptom severity (Fibromyalgia Impact Questionnaire), and the amount of light to moderate physical activity (LMPA) from baseline to each followup visit. At study entry, subjects were categorized as opioid nonusers versus users. Repeated measures ANOVA was used to assess treatment effects adjusting for potential confounders.

RESULTS

Of the 216 participants, 145 (67%) were nonusers and 71 (33%) were opioid users. Among nonusers, MI was associated with improved physical function, reduced pain severity, and global FM severity, and increased LMPA at 6-month followup. Among opioid users, there were no significant differences in any outcome measures between the MI and AC groups.

CONCLUSION

Exercise-based MI was associated with sustained clinical benefits 6 months after completion of therapy, but only for those who were not taking opioids.

Motivational interviewing: relevance in the treatment of rheumatoid arthritis?

Advances in pharmacological treatment options in RA have led to a dramatic potential for improvement in patients' physical and psychological status. Despite advances, poor outcomes, including fatigue, pain, reduced physical activity and quality of life, are still observed. Reasons include non-adherence to medication, insufficient knowledge about the disease and lack of support in coping and effectively self-managing their condition. Motivational interviewing (MI) is a person-centred approach that relies on collaboration and empathy aiming to elicit a person's own motivation for behaviour change. It has been implemented in a variety of long-term conditions, addressing issues such as lifestyle changes with beneficial effects, but it is yet to be widely recognized and adopted in the field of rheumatology. This review will explain the techniques underpinning MI and the rationale for adopting this approach in rheumatology with the aim to increase medication adherence and physical activity and improve patients' coping strategies for pain and fatigue.

A behavioral intervention promoting physical activity in people with subacute spinal cord injury: secondary effects on health, social participation and quality of life

OBJECTIVE

To assess, for people with subacute spinal cord injury, if rehabilitation that is reinforced with the addition of a behavioral intervention to promote physical activity leads to a better health, participation and quality of life.

DESIGN

Randomized controlled trial.

SETTING

Rehabilitation centers.

PARTICIPANTS

A total of 39 participants analyzed (45 included), with subacute spinal cord injury in inpatient rehabilitation, dependent on a manual wheelchair (33% tetraplegia, 62% motor complete, 150 ±74 days postinjury).

INTERVENTION

A behavioral intervention promoting physical activity after discharge, involving 13 individual sessions delivered by a coach trained in motivational interviewing, beginning two months before and ending six months after discharge from inpatient rehabilitation.

MAIN MEASURES

Physical capacity as determined during a maximal exercise test, body mass index, blood pressure, fasting lipid profile, and social participation (IMPACT-S) and quality of life (SF-36) were determined using questionnaires. Measurements were performed two months before discharge, at discharge, and six and 12 months after discharge from inpatient rehabilitation. B represents the between-group difference.

RESULTS

Twelve months after discharge, significant intervention effects were found for diastolic blood pressure (B = -11.35 mmHg, 95% CI = -19.98 to -2.71), total cholesterol (B = -0.89 mmol/L, 95% CI = -1.59 to -0.20), low-density lipoprotein cholesterol (B = -0.63 mmol/L, 95% CI = -1.25 to -0.00) and participation (B = 9.91, 95% CI = 3.34 to 16.48).

CONCLUSIONS

A behavioral intervention promoting physical activity after discharge from inpatient rehabilitation improves social participation and seems to reduce risk factors for cardiovascular disease in people with subacute spinal cord injury.

Management of fibromyalgia syndrome in 2016

Fibromyalgia syndrome is a chronic pain disorder and defies definitively efficacious therapy. In this review, we summarize the results from the early treatment research as well as recent research evaluating the pharmacological, interventional and nonpharmacological therapies. We further discuss future directions of fibromyalgia syndrome management; we specifically focus on the issues that are associated with currently available treatments, such as the need for personalized approach, new technologically oriented and interventional treatments, the importance of understanding and harnessing placebo effects and enhancement of patient engagement in therapy.

Pain Catastrophizing and EEG-α Asymmetry

OBJECTIVES

Pain catastrophizing is thought to play a causal role in the development and maintenance of chronic pain and its negative impact on functioning. However, few studies have examined the factors that might contribute to the development and maintenance of catastrophizing. The Anterior Asymmetry and Emotion (AAE) model hypothesizes that more activity in left anterior brain regions is associated with a tendency to engage in approach responses (often, but not always, associated with positive valance), and that more right anterior activity is associated with a tendency to engage in more withdrawal responses (often associated with negative valance). Given the consistent associations found between catastrophizing and both (1) approach versus avoidance pain coping style; and (2) affective responses to pain, the AAE model would predict that more left (vs. right) anterior brain activity would prospectively predict future catastrophizing.

METHODS

Anterior asymmetry measures computed using electroencephalogram data from 30 individuals with spinal cord injury were correlated with catastrophizing scores obtained 2 years after the electroencephalograph recording.

RESULTS

Consistent with the AAE model, anterior asymmetry scores reflecting greater left than right anterior activity were negatively associated with subsequent catastrophizing.

CONCLUSIONS

The study findings identify a biological factor that may be associated with greater vulnerability to pain-related catastrophizing. If replicated in future research, the findings suggest new possibilities for treating catastrophizing, which may then contribute to improved pain treatment outcomes.

How to Measure Motivational Interviewing Fidelity in Randomized Controlled Trials: Practical Recommendations

Many randomized controlled trials in which motivational interviewing (MI) is a key intervention make no provision for the assessment of treatment fidelity. This methodological shortcoming makes it impossible to distinguish between high- and low-quality MI interventions, and, consequently, to know whether MI provision has contributed to any intervention effects. This article makes some practical recommendations for the collection, selection, coding and reporting of MI fidelity data, as measured using the Motivational Interviewing Treatment Integrity Code. We hope that researchers will consider these recommendations and include MI fidelity measures in future studies.

Mind and body therapy for fibromyalgia

BACKGROUND

Mind-body interventions are based on the holistic principle that mind, body and behaviour are all interconnected. Mind-body interventions incorporate strategies that are thought to improve psychological and physical well-being, aim to allow patients to take an active role in their treatment, and promote people's ability to cope. Mind-body interventions are widely used by people with fibromyalgia to help manage their symptoms and improve well-being. Examples of mind-body therapies include psychological therapies, biofeedback, mindfulness, movement therapies and relaxation strategies.

OBJECTIVES

To review the benefits and harms of mind-body therapies in comparison to standard care and attention placebo control groups for adults with fibromyalgia, post-intervention and at three and six month follow-up.

SEARCH METHODS

Electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), AMED (EBSCO) and CINAHL (Ovid) were conducted up to 30 October 2013. Searches of reference lists were conducted and authors in the field were contacted to identify additional relevant articles.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) of mind-body interventions for adults with fibromyalgia were included.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted the data and assessed trials for low, unclear or high risk of bias. Any discrepancy was resolved through discussion and consensus. Continuous outcomes were analysed using mean difference (MD) where the same outcome measure and scoring method was used and standardised mean difference (SMD) where different outcome measures were used. For binary data standard estimation of the risk ratio (RR) and its 95% confidence interval (CI) was used.

MAIN RESULTS

Seventy-four papers describing 61 trials were identified, with 4234 predominantly female participants. The nature of fibromyalgia varied from mild to severe across the study populations. Twenty-six studies were classified as having a low risk of bias for all domains assessed. The findings of mind-body therapies compared with usual care were prioritised.There is low quality evidence that in comparison to usual care controls psychological therapies have favourable effects on physical functioning (SMD -0.4, 95% CI -0.6 to -0.3, -7.5% absolute change, 2 point shift on a 0 to 100 scale), pain (SMD -0.3, 95% CI -0.5 to -0.2, -3.5% absolute change, 2 point shift on a 0 to 100 scale) and mood (SMD -0.5, 95% CI -0.6 to -0.3, -4.8% absolute change, 3 point shift on a 20 to 80 scale). There is very low quality evidence of more withdrawals in the psychological therapy group in comparison to usual care controls (RR 1.38, 95% CI 1.12 to 1.69, 6% absolute risk difference). There is lack of evidence of a difference between the number of adverse events in the psychological therapy and control groups (RR 0.38, 95% CI 0.06 to 2.50, 4% absolute risk difference).There was very low quality evidence that biofeedback in comparison to usual care controls had an effect on physical functioning (SMD -0.1, 95% CI -0.4 to 0.3, -1.2% absolute change, 1 point shift on a 0 to 100 scale), pain (SMD -2.6, 95% CI -91.3 to 86.1, -2.6% absolute change) and mood (SMD 0.1, 95% CI -0.3 to 0.5, 1.9% absolute change, less than 1 point shift on a 0 to 90 scale) post-intervention. In view of the quality of evidence we cannot be certain that biofeedback has a little or no effect on these outcomes. There was very low quality evidence that biofeedback led to more withdrawals from the study (RR 4.08, 95% CI 1.43 to 11.62, 20% absolute risk difference). No adverse events were reported.There was no advantage observed for mindfulness in comparison to usual care for physical functioning (SMD -0.3, 95% CI -0.6 to 0.1, -4.8% absolute change, 4 point shift on a scale 0 to 100), pain (SMD -0.1, CI -0.4 to 0.3, -1.3% absolute change, less than 1 point shift on a 0 to 10 scale), mood (SMD -0.2, 95% CI -0.5 to 0.0, -3.7% absolute change, 2 point shift on a 20 to 80 scale) or withdrawals (RR 1.07, 95% CI 0.67 to 1.72, 2% absolute risk difference) between the two groups post-intervention. However, the quality of the evidence was very low for pain and moderate for mood and number of withdrawals. No studies reported any adverse events.Very low quality evidence revealed that movement therapies in comparison to usual care controls improved pain (MD -2.3, CI -4.2 to -0.4, -23% absolute change) and mood (MD -9.8, 95% CI -18.5 to -1.2, -16.4% absolute change) post-intervention. There was no advantage for physical functioning (SMD -0.2, 95% CI -0.5 to 0.2, -3.4% absolute change, 2 point shift on a 0 to 100 scale), participant withdrawals (RR 1.95, 95% CI 1.13 to 3.38, 11% absolute difference) or adverse events (RR 4.62, 95% CI 0.23 to 93.92, 4% absolute risk difference) between the two groups, however rare adverse events may include worsening of pain.Low quality evidence revealed that relaxation based therapies in comparison to usual care controls showed an advantage for physical functioning (MD -8.3, 95% CI -10.1 to -6.5, -10.4% absolute change) and pain (SMD -1.0, 95% CI -1.6 to -0.5, -3.5% absolute change, 2 point shift on a 0 to 78 scale) but not for mood (SMD -4.4, CI -14.5 to 5.6, -7.4% absolute change) post-intervention. There was no difference between the groups for number of withdrawals (RR 4.40, 95% CI 0.59 to 33.07, 31% absolute risk difference) and no adverse events were reported.

AUTHORS' CONCLUSIONS

Psychological interventions therapies may be effective in improving physical functioning, pain and low mood for adults with fibromyalgia in comparison to usual care controls but the quality of the evidence is low. Further research on the outcomes of therapies is needed to determine if positive effects identified post-intervention are sustained. The effectiveness of biofeedback, mindfulness, movement therapies and relaxation based therapies remains unclear as the quality of the evidence was very low or low. The small number of trials and inconsistency in the use of outcome measures across the trials restricted the analysis.

Protocol of a longitudinal cohort study on physical activity behaviour in physically disabled patients participating in a rehabilitation counselling programme: ReSpAct

INTRODUCTION

Stimulating physical activity behaviour in persons with a physical disability is important, especially after discharge from rehabilitation. A tailored counselling programme covering both the period of the rehabilitation treatment and the first months at home seems on the average effective. However, a considerable variation in response is observed in the sense that some patients show a relevant beneficial response while others show no or only a small response on physical activity behaviour. The Rehabilitation, Sports and Active lifestyle (ReSpAct) study aims to estimate the associations of patient and programme characteristics with patients' physical activity behaviour after their participation in a tailored counselling programme.

METHODS AND ANALYSIS

A questionnaire-based nationwide longitudinal prospective cohort study is conducted. Participants are recruited from 18 rehabilitation centres and hospitals in The Netherlands. 2000 participants with a physical disability or chronic disease will be followed during and after their participation in a tailored counselling programme. Programme outcomes on physical activity behaviour and patient as well as programme characteristics that may be associated with differences in physical activity behaviour after programme completion are being assessed. Data collection takes place at baseline and 14, 33 and 52 weeks after discharge from rehabilitation.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Medical Ethics Committee of the University Medical Centre Groningen and at individual participating institutions. All participants give written informed consent. The study results will provide new insights into factors that may help explain the differences in physical activity behaviour of patients with a physical disability after they have participated in the same physical activity and sports stimulation programme. Thereby, it will support healthcare professionals to tailor their guidance and care to individual patients in order to stimulate physical activity after discharge in a more efficient and effective way.

TRIAL REGISTRATION NUMBER

NTR3961.

Does increasing steps per day predict improvement in physical function and pain interference in adults with fibromyalgia?

OBJECTIVE

To examine the concurrent and predictive associations between the number of steps taken per day and clinical outcomes in patients with fibromyalgia (FM).

METHODS

A total of 199 adults with FM (mean age 46.1 years, 95% women) who were enrolled in a randomized clinical trial wore a hip-mounted accelerometer for 1 week and completed self-report measures of physical function (Fibromyalgia Impact Questionnaire-Physical Impairment [FIQ-PI], Short Form 36 [SF-36] health survey physical component score [PCS], pain intensity and interference (Brief Pain Inventory [BPI]), and depressive symptoms (Patient Health Questionnaire-8 [PHQ-8]) as part of their baseline and followup assessments. Associations of steps per day with self-report clinical measures were evaluated from baseline to week 12 using multivariate regression models adjusted for demographic and baseline covariates.

RESULTS

Study participants were primarily sedentary, averaging 4,019 ± 1,530 steps per day. Our findings demonstrate a linear relationship between the change in steps per day and improvement in health outcomes for FM. Incremental increases on the order of 1,000 steps per day were significantly associated with (and predictive of) improvements in FIQ-PI, SF-36 PCS, BPI pain interference, and PHQ-8 (all P < 0.05). Although higher step counts were associated with lower FIQ and BPI pain intensity scores, these were not statistically significant.

CONCLUSION

Step count is an easily obtained and understood objective measure of daily physical activity. An exercise prescription that includes recommendations to gradually accumulate at least 5,000 additional steps per day may result in clinically significant improvements in outcomes relevant to patients with FM. Future studies are needed to elucidate the dose-response relationship between steps per day and patient outcomes in FM.

Effect of Pregabalin on Cardiovascular Responses to Exercise and Postexercise Pain and Fatigue in Fibromyalgia: A Randomized, Double-Blind, Crossover Pilot Study

Pregabalin, an approved treatment for fibromyalgia (FM), has been shown to decrease sympathetic nervous system (SNS) activity and inhibit sympathetically maintained pain, but its effects on exercise responses have not been reported. Methods. Using a randomized double-blind crossover design, we assessed the effect of 5 weeks of pregabalin (versus placebo) on acute cardiovascular and subjective responses to moderate exercise in 19 FM patients. Blood pressure (BP), heart rate (HR), and ratings of perceived exertion (RPE) during exercise and ratings of pain, physical fatigue, and mental fatigue before, during, and for 48 hours after exercise were compared in patients on pregabalin versus placebo and also versus 18 healthy controls. Results. On placebo, exercise RPE and BP were significantly higher in FM patients than controls (p < 0.04). Pregabalin responders (n = 12, defined by patient satisfaction and symptom changes) had significantly lower exercise BP, HR, and RPE on pregabalin versus placebo (p < 0.03) and no longer differed from controls (p > 0.26). Cardiovascular responses of nonresponders (n = 7) were not altered by pregabalin. In responders, pregabalin improved ratings of fatigue and pain (p < 0.04), but negative effects on pain and fatigue were seen in nonresponders. Conclusions. These preliminary findings suggest that pregabalin may normalize cardiovascular and subjective responses to exercise in many FM patients.

Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis

Objective:

A systematic review and meta-analysis of randomized controlled trials to determine if motivational interviewing leads to increased physical activity, cardiorespiratory fitness or functional exercise capacity in people with chronic health conditions.

Data sources:

Seven electronic databases (MEDLINE, PsychINFO, EMBASE, AMED, CINHAL, SPORTDiscus and the Cochrane Central Register of Controlled trials) were searched from inception until January 2014.

Trial selection:

Two reviewers independently examined publications for inclusion. Trials were included if participants were adults (>18 years), had a chronic health condition, used motivational interviewing as the intervention and examined physical activity, cardiorespiratory fitness or functional exercise capacity.

Data extraction:

Two reviewers independently extracted data. Risk of bias within trials was assessed using the Physiotherapy Evidence Database Scale.

Data synthesis:

Meta-analyses were conducted with standardized mean differences and 95% confidence intervals (CIs) were calculated. The Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of the evidence.

Results:

Eleven publications (of ten trials) were included. There was moderate level evidence that motivational interviewing had a small effect in increasing physical activity levels in people with chronic health conditions relative to comparison groups (standardized mean differences = 0.19, 95% CI 0.06 to 0.32, p = 0.004). Sensitivity analysis based on trials that confirmed treatment fidelity produced a larger effect. No conclusive evidence was observed for cardiorespiratory fitness or functional exercise capacity.

Conclusion:

The addition of motivational interviewing to usual care may lead to modest improvements in physical activity for people with chronic health conditions.

Combining motivational and volitional strategies to promote unsupervised walking in patients with fibromyalgia: study protocol for a randomized controlled trial

Background

Fibromyalgia patients are often advised to engage in regular low- to moderate-intensity physical exercise. The need of fibromyalgia patients to walk has been stressed in previous research. Behavioral self-regulation theories suggest that a combination of motivational aspects (to develop or strengthen a behavioral intention: Theory of Planned Behavior) and volitional aspects (engagement of intention in behavior: implementation intentions) is more effective than a single intervention. In this paper, we describe a protocol for identifying the motivational processes (using the Theory of Planned Behavior) involved in the practice of walking (phase I) and for studying the efficacy of an intervention that combines motivational and volitional contents to enhance the acquisition and continuation of this exercise behavior (phase II). The paper also shows the characteristics of eligible individuals (women who do not walk) and ineligible populations (women who walk or do not walk because of comorbidity without medical recommendation to walk). Both groups consist of members of any of four patients’ associations in Spain who are between 18 and 70 years of age and meet the London Fibromyalgia Epidemiology Study Screening Questionnaire criteria for fibromyalgia. Furthermore, using this study protocol, we will explore the characteristics of participants (eligible women who agreed to participate in the study) and nonparticipants (eligible women who refused to participate).

Methods/design

Two studies will be conducted: Phase I will be a cross-sectional study, and phase II will be a triple-blind, randomized longitudinal study with two treatment groups and one active control group. The questionnaires were sent to a total of 2,227 members of four patients’ associations in Spain. A total of 920 participants with fibromyalgia returned the questionnaires, and 582 were ultimately selected to participate.

Discussion

The first data gathered have allowed us to identify the characteristics of the study population and they support the appropriateness of the inclusion criteria.. When the study is complete, the results will enable us to establish whether this kind of intervention can be used as a self-regulation tool for increasing and maintaining walking as unsupervised physical exercise of low to moderate intensity in fibromyalgia patients.

Trial registration

Trial registration number: ISRCTN68584893