- Title
- Combined management of musculoskeletal conditions and lifestyle risk factors
- Creator
- Robson, Emma Kate
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2023
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Musculoskeletal conditions are responsible for a huge societal, economic and individual burden worldwide. Lifestyle factors including weight loss, physical activity, diet quality and smoking cessation are potentially important behavioural treatment targets in the management of musculoskeletal conditions, particularly spinal pain and osteoarthritis (OA). There are significant evidence gaps in our understanding of how effective behavioural treatments are in addressing lifestyle factors to improve spinal pain and OA outcomes, the importance of compliance to such treatments and considerations for implementing and integrating lifestyle care into usual musculoskeletal management. This thesis addresses the above evidence gaps in attempt to explore and understand the effectiveness of addressing lifestyle risk factors for the management of musculoskeletal conditions. Weight loss is recommended in all clinical practice guidelines as a core treatment for overweight and obese patients with knee or hip OA. The literature suggests weight loss may also benefit those with spinal pain who are overweight or obese. However, there is a lack of research that synthesises all trials of possible weight loss interventions (including behavioural, pharmaceutical, cognitive/psychological weight loss strategies) for OA, and on the effectiveness of weight loss for spinal pain. Chapter two details a systematic review that synthesised the evidence for effectiveness of weight loss interventions to improve pain and disability in patients with knee and hip OA and spinal pain (low back or neck pain). We searched eight online databases and Clinical Trial Registries up to June 2018 for randomised controlled trials (RCTs) of any intervention that intended to reduce participant weight to improve pain intensity or disability in people with knee or hip OA, or spinal pain. We included 22 RCTs (17 for knee OA, two for knee and hip OA and three for low back pain) with 3,602 participants. We found very low quality evidence that weight loss interventions have a moderate effect on pain intensity (standardised mean difference [SMD] -0.54, 95% confidence interval [CI] -0.86 to -0.22, 10 trials, n=1806) and low quality evidence for a small effect on disability (SMD -0.32, 95% CI -0.49 to -0.14, 11 trials, n=1821) for OA compared to minimal care. For knee OA specifically there was low to moderate quality evidence that weight loss interventions were not more effective than exercise only interventions for pain intensity or disability. For spinal pain there was low quality evidence from two trials that weight loss interventions were not effective for pain intensity or disability compared to controls. Weight loss interventions appeared to be effective for improving pain intensity and disability compared to minimal care for OA, but not more effective than exercise-only interventions. Evidence of the effect of weight loss interventions on spinal pain intensity or disability was limited and inconclusive. At the end of Chapter two is a synopsis of an update of the original review, conducted for the World Health Organization (WHO) in 2022. The purpose of the update was to inform the global guidelines for low back pain and investigate weight management interventions for low back pain. We used similar search terms, inclusion criteria and quality assessment methods as the original review. We found a total of four additional trials of weight loss interventions for low back pain (three lifestyle interventions, one pharmaceutical intervention). We were able to synthesise the evidence for lifestyle weight loss interventions and found there was very low certainty evidence that lifestyle weight loss interventions were effective to reduce low back pain disability (SMD -0.65, 95% CI -1.12 to -0.19, 3 trials, n=249 participants) compared to usual care. The available evidence appears promising that lifestyle weight loss interventions moderately improve low back pain disability compared to minimal or usual care. Interpreting estimates of effect from RCTs is challenging when participants do not fully comply with interventions. Causal average complier effect (CACE) analysis is one method that maintains randomisation and provides an estimate of an intervention’s effect if people comply. In chapter three we conducted CACE analyses to assess the effect of two telephone-based lifestyle weight loss interventions for knee OA and chronic low back pain amongst compliers. Participants from two trials with low back pain (n=160) and knee OA (n=120) with a Body Mass Index (BMI) ≥27kg/m were included. We defined adherence to the telephone-based lifestyle weight loss intervention as completing 60% (six from 10) of intervention telephone health coaching calls. CACE estimates showed potentially clinically meaningful effects for pain intensity (Mean Difference [MD] -1.4, 95% CI -3.1 to 0.4) and small effects for disability (MD -2.1, 95% CI -8.6 to 4.5) amongst compliers in the low back pain trial intervention compared to control. However, effect sizes are uncertain due to wide confidence intervals. There were potentially worse effects found for compliers of the knee OA trial. Results from chapter three found those with chronic low back pain who comply with a telephone-based weight loss lifestyle intervention may benefit, but not those with knee OA. Chronic low back pain is a global problem, and evidence from the literature and the review described in chapter two suggests improving lifestyle factors (physical activity, diet and smoking) may reduce low back pain disability. Chapters four and five present a study protocol and statistical analysis plan respectively for a RCT testing the effectiveness of the Healthy Lifestyle Program (HeLP) for low back pain compared to guideline-based care. Chapter six presents the results of the HeLP RCT. HeLP was a pragmatic, superiority RCT conducted in a tertiary hospital in Newcastle, Australia. We randomly assigned 346 adults with activity limiting chronic low back pain and at least one lifestyle risk factor (overweight, poor diet, inactive, smoker) to the HeLP intervention (n=174) or guideline-based care (n=172). HeLP involved: i) five in-person clinical consultations, ii) educational resources, and iii) referral to a 6-month telephone coaching service. The control group received guideline-based physiotherapy care. The primary outcome was the difference in reported disability between groups at 26 weeks measured on the Roland Morris Disability Questionnaire (RMDQ). We analysed data from 344 trial participants (two post-randomization exclusions) at 26 weeks using intention-to-treat (ITT). There was a between group difference in disability of -1.3 points (95% CI -2.5 to -0.2) in favour of HeLP. CACE results were larger than ITT, with clinically significant reductions in disability in those who complied with the intervention compared to would-be compliers in the guideline-based care group. Our results support healthy lifestyle change being a focus of care for chronic low back pain disability and presents an opportunity to concurrently address chronic disease in an at risk population. Process evaluations can inform intervention adaptations to optimise future delivery and implementation. Information gained from process evaluations can provide greater insight regarding the delivery and implementation of the intervention and understand how an intervention was perceived and functioned in practice. This allows identification of what worked and didn’t work to guide decision making on future adaptations and delivery. Chapter seven presents a mixed methods process evaluation describing implementation outcomes of: i) fidelity, ii) adoption, iii) acceptability, appropriateness and feasibility, and iv) barriers and facilitators to participant engagement and clinician delivery of the HeLP intervention. We used a sequential mixed methods design to evaluate HeLP participant and clinician data. We collected quantitative and qualitative data and analysed the data using descriptive statistics and thematic analyses respectively. We followed triangulation protocol to integrate data and identify meta-themes. We found HeLP was delivered with high fidelity (>90%) and adoption of the intervention components (consultations, resources and telephone support services) varied. Clinicians and participants perceived addressing lifestyle factors for back pain management as appropriate and acceptable. Acceptability and appropriateness of the telephone service varied, and participants expressed a need for greater individualisation of care. Clinician reported barriers pertaining to intervention delivery included low self-efficacy in behaviour change communication skills, while enablers included behaviour change training and practice observation and feedback. Overall, participants and clinicians were satisfied with HeLP, although adoption of intervention components varied. Future adaptations to improve clinicians’ behaviour change communication skills and better individualisation of care is needed. Care for lifestyle risk factors, including weight loss is an important and effective treatment to consider for spinal pain and OA. HeLP as a model of integrated lifestyle low back pain care is effective and feasible to improve both low back pain disability and chronic disease risks. There is a need to further understand the causal mechanisms and cost effectiveness of HeLP and lifestyle interventions, and how to improve patient compliance. Future comparative effectiveness trials of flexible delivery models of HeLP and implementation trials to understand how to integrate lifestyle care into clinical low back pain care is needed.
- Subject
- musculoskeletal conditions; management; lifestyle risk factors; interventions; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1504270
- Identifier
- uon:55488
- Rights
- This thesis is currently under embargo and will be available from 12.06.2025, Copyright 2023 Emma Kate Robson
- Language
- eng
- Full Text
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