BACKGROUND: Chronic pain (CP) is detrimental to physical and psychological function frequently resulting in work-absence which in turn is associated with reduced wellbeing. Patients with negative cognitive representations of pain are less likely to engage in re-employment oriented activities. OBJECTIVE: To explore patients' beliefs and attitudes towards return to work (RTW) and understand how these may impact on RTW readiness. METHODS: Patients attending a 3-week high intensity pain management rehabilitation programme (PMP) at the Royal National Orthopaedic Hospital were recruited to participate in semi-structured focus group discussions. The sample consisted of 17 patients (M:F 8:9, age range 18-65+ years). Data was digitally recorded and transcribed verbatim to permit a thematic analysis. RESULTS: Four superordinate themes emerged from the data: (1) living with CP, (2) the fine balance between CP and RTW, (3) work is a beautiful thing... when you have it and (4) the luck of the draw. The first two imparted patients' coping strategies towards maintaining employment or RTW. The second two reflected participants' cognitions on factors that facilitate or obstruct RTW. CONCLUSIONS: The need for vocational support in chronic pain rehabilitation programmes was identified. Several recommendations are presented for vocational rehabilitation intervention targets.

SummaryObjective: In Britain, consent for surgery is documented using a Department of Health form signed by the surgeon and the patient. In contrast, anaesthetic procedures have no formalised consent process. Evidence on the process of consent for regional anaesthesia, and patient perceptions of this, is scarce outside obstetric practice. We aimed to determine patient recall and perceptions of consent for interscalene brachial plexus block and compared this to surgical consent for shoulder arthroplasty. Design: Prospective observational survey. Setting: A specialist musculoskeletal centre, UK. Participants: Forty-six patients (female:male 30:16, mean age 61 years) undergoing shoulder arthroplasty with interscalene brachial plexus block. Main outcome measures: Recall and understanding of consent for regional anaesthesia and surgery was examined using a semi-structured questionnaire 1-2 days after arthroplasty. Surgical consent forms and discussions recorded by the anaesthetist were examined in participants' medical notes to compare against the level of recall. Analysis to determine statistical significance was conducted using McNemar's test. Results: Recall of surgical risks was overall significantly better than recall of brachial plexus block risks. Compared to their recollections of surgical risk, patients remembered fewer specific risks for brachial plexus block (p < 0.001). There were more patients unable to recall any risks when questioned about brachial plexus block than about their surgery (p < 0.05). One-third of patients did not regard the consent discussion about regional anaesthesia as important as consent for surgery and over one-quarter had not recognised the preoperative discussion about the brachial plexus block as a consent process similar to that conducted for surgery. Conclusions: Fundamental misunderstandings about the consent process are prevalent. Future work in this area should seek to investigate how documentation of the consent process and patients' understanding of consent for regional anaesthesia can be improved.

Background: The COVID-19 pandemic interrupted the delivery of face-to-face pain services including pain management programmes in the United Kingdom with considerable negative impact on patients with chronic musculoskeletal pain. We aimed to develop and implement a remotely delivered pain management programme (PMP) using video-conferencing technology that contains all the core components of a full programme: the ‘virtual PMP’ (vPMP). By reporting on the process of this development, we endeavour to help address the paucity of literature on the development of remote pain management programmes. Methods: The vPMP was developed by an inter-disciplinary group of professionals as a quality improvement (QI) project. The Model for Improvement Framework was employed with patient involvement at the design phase and at subsequent improvements. Improvement was measured qualitatively with frequent and repeated qualitative data collection leading to programme change. Quantitative patient demographic comparisons were made with a patient cohort who had been on a face-to-face PMP pathway. Results: Sixty-one patients on the PMP waiting list were contacted and 43 met the criteria for the programme. Fourteen patients participated in three vPMP cycles. Patient involvement and comprehensive stakeholder consultation were essential to a robust design for the first vPMP. Continued involvement of patient partners during the QI process led to rapid resolution of implementation problems. The most prominent issues that needed action were technical challenges including training needs, participant access to physical and technological resources, participant fatigue and concerns about adequate communication and peer support. Conclusion: This report demonstrates how a remotely delivered PMP, fully in line with national guidance, was rapidly developed and implemented in a hospital setting for patients with chronic musculoskeletal pain. We also discuss the relevance of our findings to the issues of cost, patient experience, patient preferences and inequities of access in delivering telerehabilitation for chronic pain.

Our objective was to investigate the effectiveness of booster sessions after self-management interventions as a means of maintaining selfmanagement behaviours in the treatment of chronic musculoskeletal pain. We searched MEDLINE, EMBASE, Science Citation Index, Cochrane Central Register of Controlled Trials, and PsychINFO. Two authors independently identified eligible trials and collected data. We calculated the odds ratio for the analyses of dichotomous data and standardised mean differences (SMDs) with 95% confidence interval (CI) for continuous variables. Our search identified 14 studies with a total of 1695 patients. All studies were at high risk of bias and provided very low quality evidence. For the primary outcomes, booster sessions had no evidence of an effect on improving patient-reported outcomes on physical function (SMD 20.13, 95% CI 20.32 to 20.06; P 5 0.18), pain-related disability (SMD 20.16, 95% CI 20.36 to 0.03; P 5 0.11), and pain self-efficacy (SMD 0.15, 95% CI 20.07 to 0.36; P 5 0.18). For the secondary outcomes, booster sessions caused a significant reduction in patient-reported pain catastrophising (SMD 20.42, 95% CI 20.64 to 20.19; P 5 0.0004) and no evidence of an effect on patient-reported pain intensity, depression, coping, or treatment adherence. There is currently little evidence that booster sessions are an effective way to prolong positive treatment effects or improve symptoms of long-term musculoskeletal conditions after self-management interventions. However, the studies were few with high heterogeneity, high risk of bias, and overall low quality of evidence. Our review argues against including booster sessions routinely to self-management interventions for the purpose of behaviour maintenance.

Introduction Remotely delivered pain management programmes have been offered in place of in-person programmes by many chronic pain services since the onset of the COVID-19 pandemic. There is a lack of evidence regarding the acceptability of these programmes. In this evaluation, we have explored patients’ acceptability of a remotely delivered pain management programme for patients with persistent musculoskeletal pain. Methods Qualitative data were collected using focus groups with participants who had previously attended the remote pain management programme. Data were analysed using abductive analysis. Results Three focus groups were conducted with a total of 13 participants. The programmme was either entirely acceptable, had some acceptable components or was not acceptable to patients. Factors leading to the programme being acceptable include learning to manage pain from home, receiving high quality care from home, enhancing the potential of rehabilitation using technology, enabling attendance on a pain management programme from home, overcoming social distancing requirements of COVID-19 using technology, and virtual peer support. Factors leading to the programme not being acceptable include having an inappropriate home environment for virtual therapy, communication challenges with virtual therapy, technological issues and concerns regarding the quality of care. Conclusions There is a spectrum of acceptability with respect to the remote programme. The factors that influence this are dynamic, individual and situational. Hybrid programmes have the potential to enhance access to pain management programmes and improve patient experience and programme outcomes in the future.