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Objective. Reduced knee confidence is common in people with knee osteoarthritis (OA) and is likely to influence how people with knee OA engage with movement and activities. However, there is conflicting evidence surrounding the association between confidence and function. This may be because knee confidence has been assessed via a single questionnaire item that was not developed for people with knee OA and thus may not provide an accurate or comprehensive assessment of confidence in this population. A better understanding of knee confidence could inform a more thorough assessment of the construct both in clinical and research contexts. Therefore, the aim of this study was to explore the meaning of knee confidence from the perspective of people with knee OA. Methods. Fifty-one people with a clinical diagnosis of knee OA took part in a one-to-one semistructured interview. Interviews explored how each participant conceptualized knee confidence. Reflexive thematic analysis was selected as a flexible approach for identifying patterns of meaning across cases through a combination of data-driven and theory-informed coding of the transcribed data. Results. People with knee OA conceptualized confidence with reference to 1 or more of 4 themes: (1) symptoms, (2) functional ability, (3) the internal structure of the knee, and (4) knowledge about knee OA and its management. Each conceptualization of confidence was associated with present and future concerns. Conclusion. Because people with knee OA conceptualize knee confidence in different ways, a single-item measure is unlikely to capture all of the aspects of this construct in this population. This may explain the conflicting evidence around the association between reduced knee confidence and function in people with knee OA. Impact. This study showed that a multi-item measure is needed to measure knee confidence in people with knee OA. Clinicians and researchers need to understand what knee confidence means to people with knee OA, because it is likely to influence how these individuals engage with movement and activities. Understanding this relationship can enable more targeted education and functional rehabilitation for people with knee OA. Keywords: Activity, Confidence, Function, Knee Osteoarthritis, Movement, Introduction Reduced knee confidence is common in people with knee osteoarthritis (OA). (1-3) Given the role of the knee in weight-bearing activity, reduced confidence in the knee is likely to [...]

Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety-learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing Cognitive Functional Therapy to promote safety learning. A process is described in which experiential learning combined with 'sense making' disrupts a person's unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning. Keywords: Fear of Movement, Musculoskeletal Pain, Recovery, Rehabilitation, Background Chronic musculoskeletal pain is now a leading cause of disability worldwide, with the disability burden predicted to grow exponentially in the next 2 decades, placing unsustainable strain on health [...]

Objective. Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions. Methods. A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included. Results: Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed. Conclusions. Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions. Impact. This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist--delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist--delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life. Keywords: Behavior Therapy, Education: Professional, Education: Postprofessional, Musculoskeletal Pain, Pain Management, Physical Therapists, Introduction Musculoskeletal pain conditions are a leading contributor to the global health burden. (1) Traditionally, musculoskeletal pain has been treated under a biomedical model of care; however, there is now [...]

Objective. Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe/high-impact cLBP. Such programs are expensive, not easily accessible, and have limited effect; therefore, new cost-effective strategies are warranted. Cognitive functional therapy (CFT) has shown promising results but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed) is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care). Methods. This pragmatic, 2-arm, parallel-group randomized controlled trial will randomly allocate patients (n = 176) aged 18 to 75 years referred to an interdisciplinary pain center due to severe cLBP to 1 of 2 groups (1:1 ratio). Participants randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed), and participants randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual's situation, needs, and resources. The primary outcome is the proportion of participants with an 8-point improvement in the Oswestry Disability Index score at 12 months. Exploratory outcomes are change in Oswestry Disability Index scores over time and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D. Impact. The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for individuals with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system. Keywords: Costs and Cost Analysis, Cognitive Functional Therapy, Health Care Costs, Interdisciplinary Pain Management, Low Back Pain, Introduction Chronic low back pain (cLBP) is one of the leading causes of disability around the world. (1,2) Because various biopsychosocial factors contribute to cLBP, (3) clinical guidelines recommend referral [...]

Objective. The purpose of this study was to determine whether sagittal neck sitting posture subgroup membership in late adolescence was a risk factor for persistent neck pain (PNP) in young adults. Methods. There were 686 participants enrolled in the Raine Study at the 17- and 22-year follow-ups. At 17 years of age, posture was measured by photographs, and 4 subgroups of sitting neck posture were determined by cluster analysis. Height and weight were measured, and exercise frequency, depression, and PNP were assessed by questionnaire. At 22 years of age, participants answered questions about neck pain and occupation type. Logistic regression examined if neck posture subgroups at 17 years of age were a risk factor for PNP at 22 years of age, taking into account other factors. Results. Female sex (odds ratio [OR] = 1.75, 95% CI = 1.16-2.65) and PNP at 17 years of age (OR = 3.78, 95% CI = 2.575.57) were associated with PNP at 22 years of age. In females, neck posture subgroup at 17 years of age was a risk factor for PNP at 22 years of age. Compared with the upright subgroup, both the slumped thorax/forward head subgroup groups and the intermediate subgroup had decreased odds for PNP at 22 years of age (OR = 0.24, 95% CI = 0.08-0.76; OR = 0.38, 95% CI = 0.15-0.99, respectively). No association was found in males. Conclusion. After taking into account PNP at 17 years, sitting neck posture at 17 was not a risk factor for PNP at 22 years of age in males, whereas in females, more relaxed postures (slumped thorax/forward head and Intermediate postures) were protective of neck pain compared with upright posture. Impact. Females in late adolescence who sat in slumped thorax/forward head or intermediate posture rather than upright sitting posture had a lower risk of PNP as a young adult. The practice of generic public health messages to sit up straight to prevent neck pain needs rethinking. Keywords: Posture, Neck Pain, Risk Factors, Adolescent, Young Adult, Raine Study, Introduction Neck pain (NP) is the fourth-ranked disorder for numbers of years lived with disability worldwide. (1) NP often originates in childhood, (2) with prevalence reported to increase through adolescence, [...]

Objective. Persistent low back pain (PLBP) is a common and costly health problem worldwide. Better strategies to manage it are required. The purpose of this study was to longitudinally evaluate absenteeism, pain, and disability in nurses with PLBP following a cognitive functional therapy (CFT) intervention. Methods. In this case series pilot study, 33 eligible nurses with PLBP were recruited. During the baseline phase (phase A; no intervention), outcome measures were collected on 2 occasions 6 months apart (A1 and A2). During phase B, participants received an individualized CFT intervention for 14 weeks. During phase C (no intervention), outcomes were measured immediately after the intervention, as well as 3, 6, 9, 12, and 36 months after the intervention (secondary outcomes only until 12 months). LBP-related work absenteeism, pain intensity (numerical pain rating scale) and disability (Oswestry Disability Index) were the primary outcomes. Health care seeking, a range of psychological and lifestyle variables, and global perceived effect were secondary outcomes. Results. Days of absenteeism due to LBP were significantly reduced in the first and second calendar years after the CFT intervention but not the third and fourth. Disability was significantly reduced immediately after (-4.4; 95% CI = - 6.5 to -2.2) and at 3 months (-4.3; 95% CI = -6.6 to -2.0), 9 months (-6.0; 95% CI = -8.1 to -3.9), and 12 months (-4.9; 95% CI = - 7.0 to -2.8) after the intervention. Pain was significantly reduced immediately after (-1.2; 95% CI = -1.7 to -0.8) and at 3 months (-1.5; 95% CI = -2.0 to -0.9), 9 months (-1.1; 95% CI = -1.9 to -0.3), and 12 months (-0.9; 95% CI = -1.5 to -0.2) after the intervention. Total health care seeking (consults and proportion of participants) was significantly reduced after the intervention. All psychosocial variables, except for 1, demonstrated significant improvements at all follow-up assessments. Conclusions. This case series pilot study demonstrated significant reductions in LBP-related absenteeism, pain intensity, disability, health care seeking, and several psychological and lifestyle behaviors until the 1-year follow-up among nurses with PLBP following an individualized CFT intervention. Further evaluation of the efficacy of CFT in high-quality randomized clinical trials among nurses is recommended. Keywords: Low Back Pain, Nursing, Nurses, Cognitive Functional Therapy, Intervention, Treatment, Introduction Persistent low back pain (PLBP) is a common and costly health problem worldwide. (1,2) Nurses report higher rates of LBP than those employed in heavy industry. (3) The annual [...]