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Aim:The aim of this study is to investigate the benefits and harms of therapeutic exercise in people with multimorbidity defined as the combination of two or more of the following conditions: knee and hip osteoarthritis, hypertension, diabetes type 2, depression, heart failure, ischaemic heart disease and chronic obstructive pulmonary disease, by performing a systematic review of randomized controlled trials (RCTs).Methods:This study will be performed according to the recommendations from the Cochrane Collaboration and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We will search for RCTs investigating the effect of therapeutic exercise in multimorbidity, as defined above, in MEDLINE, EMBASE, CENTRAL and CINAHL from 1990. Cochrane reviews on the effect of therapeutic exercise for each of the aforementioned conditions and references of the included studies will be checked for eligible studies and citation tracking will be performed in Web of Science. We will assess the risk of bias of the included studies using the Cochrane ‘Risk of Bias Tool’ 2.0 and the Grading of Recommendations Assessment, Development and Evaluation assessment for judging the overall quality of evidence. Meta-analyses will be performed, if possible, using a random-effects model as heterogeneity is expected due to differences in interventions and participant characteristics and outcome measures. Subgroup and meta-regression analyses will be performed to explore potential predictors of outcomes.Dissemination:The results of this systematic review will be published in a peer-review journal, presented at national and international conferences and made available to end users via infographics, podcasts, press releases and videos.

Persistent pain is considered a complex biopsychosocial phenomenon whose understanding and management is yet to be improved. More research is needed to determine the common paths that lead to developing persistent pain, to identify the populations most at risk and to develop and evaluate interventions. The last decades have seen a shift in pain management, from the biomedical model to a biopsychosocial model. There is also a significant body of evidence emphasizing the effects of osteopathy in persistent pain management. Given the relevance of psychosocial factors in aetiology and maintenance of pain, it is essential to investigate whether osteopathy has an influence on depression, anxiety, fear avoidance or pain catastrophyzing. This review will identify and synthesize relevant primary research focused on the effects of osteopathic interventions on psychosocial factors in patients living with different pain conditions. Studies were identified by searching seven databases (Medline complete, CINAHL, Cochrane Library, Psychinfo, Psycharticles, Web of Science and Scopus) between 1980 and 2017. Peer reviewed articles reporting effects of: Osteopathic manual therapy, Osteopathic Manipulation, Mobilization, Spinal manipulation, high velocity and low amplitude manipulation, massage and soft tissue treatment were extracted. A total of 16 RCTs were selected. Two out of five reported significant differences in depression; in regards to anxiety, all the four trials found significant effects; two out of three trials reported a significant reduction in fear avoidance while six out of seven trials found a significant enhancement of health status and three out of four found an increase in quality of life. The findings of this review are encouraging; suggesting that osteopathic treatment may have some effects on anxiety, fear avoidance, quality of life and general health status in populations living with persistent pain.

IntroductionPersistent pain affects a large percentage of the UK population and its burden has wide ramifications that affect physical, psychological, socioeconomic and occupational status. Pain has a significant impact on people’s well-being and quality of life. Some of the most common comorbidities found in this population are depression and anxiety and also maladaptive behaviours such as fear avoidance and catastrophising.Methods and analysisThis is a protocol for a study assessing the feasibility and acceptability of a novel Acceptance and Commitment Therapy (ACT)-based intervention for people from Southwest Wales who live with persistent pain. A group of 12 participants will be recruited through the Health and Wellbeing Academy (Swansea University). After being referred by an Osteopath, and attending a brief meeting with the researcher, the participants will take part in six sessions over six consecutive weeks. ‘A Mindful Act’ is an ACT-based group programme aiming to teach people how to develop more acceptance and self-compassion, be more mindful and clarify personal values in order to live a more rich and meaningful life. The main outcomes will include the feasibility of the recruitment process and the measurement tools, the acceptability of the intervention for both the participants and the Osteopaths and the adherence to the programme. In order to measure acceptability of the intervention, qualitative interviews will be conducted to provide an insight into peoples’ experiences of taking part. Data will be analysed using Thematic Analysis, with the use of NVIVO 10. In addition, quantitative data will be collected at baseline, on completion of the programme and at 1 month and 3 months follow-up to reveal any differences in psychological flexibility, depression, anxiety, fear avoidance and general health status. The findings will help enhance the intervention by making appropriate modifications to the processes and procedures involved, following the recommendations made by the Medical Research Council framework. A larger scale study is envisaged to follow, in order to investigate the full effectiveness and cost-effectiveness of ‘A Mindful Act’.Ethics and disseminationThis study was approved by the College of Human and Health Sciences Research Ethics Committee at Swansea University in December 2017. The findings will be disseminated through various means including: the first author’s PhD thesis, peer-reviewed journals as well as well as national and international conferences and public events.