In a previous blog tiled ‘When Pain Kills’ we discussed new evidence about the link between pain and death through non-communicable disease and lifestyle risks. We also mentioned some trials that our team in Newcastle have been conducting to assess the impact of supporting patients with chronic low back pain and knee osteoarthritis to address lifestyle factors. The results of these trials are in and they showed that using generic lifestyle programs might not adequately support patients with chronic pain to address their lifestyle risks.
What we did
We randomly allocated 160 patients with chronic low back pain (trial 1) and 120 patients with knee osteoarthritis (trial 2) to receive a lifestyle intervention or usual care. In both trials, patients received some initial advice about the benefits of improving physical activity and reducing weight for their pain, and they were then referred to the New South Wales Get Healthy Service (GHS). The GHS is a 6-month telephone-based healthy lifestyle coaching service that supports people to modify eating behaviours, increase physical activity and achieve or maintain a healthy weight. The back pain patients were also offered a physiotherapy appointment where they received detailed education about back pain, about the link with lifestyle factors, and to dispel common myths.
The model was based on self-determination theory and experiential learning. We thought that providing education about pain with a proactive process for supporting behaviour change could act on a number of targets and establish a greater tendency to establish positive health behaviour and self-management. Unfortunately, patients in the 6 month program didn’t lose more weight, improve their diet or increase physical activity, nor did they improve pain beliefs relative to those in the usual care group, and we didn’t see any improvement in pain or disability.
What this means
The first thing to point out is there is some good evidence that weight loss improves symptoms of osteoarthritis of the knee, and this is why clinical practice guidelines recommend that anyone who is overweight and has osteoarthritis should be supported to lose weight. An issue is that many people can’t access the intensive face-to-face clinical treatments previously studied. This is certainly the case for many people who live in the Hunter New England Health District which provides services to around one million people over an area twice the size of Ireland. This means we needed to test a scalable option to support patients.
The GHS service was designed for the general population where because people opt into the service themselves – that is they seem to be motivated to make lifestyle changes, so there is generally a high engagement and positive participant outcomes. Unfortunately, most of the patients we referred to the service dropped out early.
It is likely patients with musculoskeletal conditions face condition specific barriers to making lifestyle changes that are hard to overcome. For example, pain is a known barrier to engaging in physical activity. Pain can also lead to compensatory behaviours like so called ‘eating for analgesia’, alcohol use and use of other drugs, which in the presence of pain may be far more complex to overcome. Interestingly when we ask patients in interviews after the close of the study, if they thought the GHS adequately supported their pain, a theme that emerged was the service typically didn’t consider pain with the support provided, and this was a main reason for drop out.
The bottom line
General lifestyle support approaches like these might not benefit patients with chronic musculoskeletal pain, which at any given time could be up to 25% of the population. Patients in pain appear to need extra support to change lifestyle habits compared to the general population. We need to continue to explore ways to support patients with musculoskeletal conditions to improve their lifestyle. This is important not only to potentially help their painful conditions, but also to improve general health and decrease the risk of developing other chronic diseases.
About Amanda Williams
Amanda is a post-doctoral researcher at the University of Newcastle and Hunter New England Population Health. She has a Bachelor of Nutrition and Dietetics and has recently submitted her PhD. Amanda has a wealth of experience in health promotion, working on a range of research projects focusing on lifestyle risks within various community settings. Her current work looks at the impact of lifestyle risks such as poor diet, physical inactivity and weight gain on chronic pain. Amanda conducts trials that aim to integrate clinical and population health services to provide lifestyle-focused care to at risk patients with musculoskeletal conditions. She is also particularly interested in the complex relationships between musculoskeletal conditions and chronic diseases, reducing waste in the healthcare system and science communication.
About Chris Williams
Chris is a NHRMC Clinical Research Fellow (ECF), population health physiotherapist and aspiring implementation scientist. He leads the Hunter New England Musculoskeletal Health Program, which he established in 2013 with the Hunter New England Population Health, at the Hunter New England Local Health District and Hunter Medical Research Institute, University of Newcastle. The program is a research-practice partnership that focuses on enhancing the organisation of clinical and population health services for chronic pain and associated health risks and chronic disease. Chris’s research interests include the use of novel methods to conduct efficient research trials in real world contexts to test intervention strategies that target patient level and health service level (implementation) outcomes. In 2016, Chris established (with Steve Kamper) the Centre for Pain, Health and Lifestyle, a multi-institutional collaboration, which aims to improve musculoskeletal health and co-morbid health problems across the lifespan, particularly in childhood and adolescence. Chris has qualifications in Exercise Science and Physiotherapy, and completed his PhD in 2013 at the George Institute for Global Health and University of Sydney.
Williams, Amanda; Wiggers, Johna; O’Brien, Kate; Wolfenden, Luke; Yoong, Sze, Lin; Hodder, Rebecca, K.; Lee, Hopin; Robson, Emma, K.; McAuley, James,H; Haskins, Robin; Kamper, Steven, J; Rissel, Chris; Williams, Christopher, M.(2018). Effectiveness of a healthy lifestyle intervention for chronic low back pain: a randomised controlled trial. PAIN: 159(6): 1137–1146
Robin Christensen, Else Marie Bartels, Arne Astrup, and Henning Bliddal (2007) Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta‐analysis. Ann Rheum Dis. 66(4): 433–439
K.M. O’Brien, J. Wiggers, A. Williams, E. Campbell, R.K. Hodder, L. Wolfenden, S.L. Yoong, E.K. Robson, R. Haskins, S.J. Kamper, C. Rissel, C.M. Williams (2018). Telephone-based weight loss support for patients with knee osteoarthritis: a pragmatic randomised controlled trial. Osteoarthritis and cartilage: 26(4): 485–494