Harbinder Sandhu

Background and aims: Long‐term strong opioid use for chronic non‐malignant pain (CNMP) represents a significant public health challenge, associated with reduced health‐related quality of life (HRQoL) and increased mortality. The Improving the Wellbeing of people with Opioid Treated CHronic pain (I‐WOTCH) trial demonstrated that a multicomponent intervention supporting opioid withdrawal in people with CNMP successfully reduced opioid consumption compared with best usual care (BUC), without adversely affecting perceived pain levels. This study aimed to assess the value‐for‐money of the strategies tested in the I‐WOTCH trial, from the perspective of the United Kingdom National Health Service (NHS) and Personal and Social Services. Design, setting and participants: Within‐trial cost‐consequence (CCA) and model‐based cost‐effectiveness analyses (CEA), over one year and lifetime horizons, respectively. Data were sourced from the I‐WOTCH trial, which recruited 608 participants from 191 primary care centres in England between May 2017 and January 2019 and followed them up for up to 12 months. Participants received either BUC or 3 group sessions (lasting one day each) led by a trained intervention nurse and by a lay person with CNMP and lived experience with opioid tapering. These sessions, designed to develop self‐management skills, were supplemented by ongoing one‐to‐one support from nursing and lay personnel during follow‐up. We used a probabilistic state‐transition model to predict expected quality‐adjusted life years (QALYs) and costs (in UK £) of each strategy over the lifetime of an individual. Model input parameters were derived mostly from the I‐WOTCH trial. Opioid‐related excess mortality and fracture rates were extracted from the literature. Measurements: Individual‐level healthcare resource use and generic HRQoL [measured using the EuroQOL five dimensions questionnaire (Equation 5D)] were collected at baseline, 4, 8 and 12 months, and analysed to estimate total costs and health consequences for the I‐WOTCH and BUC groups. Findings: I‐WOTCH had higher costs and similar HRQoL outcomes compared with BUC at 12 months. When accounting for long‐term reductions in mortality and morbidity from decreased exposure to strong opioids, our long‐term model predicted I‐WOTCH to yield higher costs and higher QALYs than BUC over the patient's lifetime, resulting in a base case incremental cost‐effectiveness ratio of £29 543/QALY (2019 prices). Results were sensitive to structural assumptions in the model (i.e. cohort starting age, treatment effect weaning rate). Our probabilistic sensitivity analysis found I‐WOTCH to have a 50% probability of being cost‐effective compared with BUC for willingness‐to‐pay thresholds ranging between 0 and £100 000/QALY. Conclusions: The Improving the Wellbeing of people with Opioid Treated CHronic pain intervention supporting opioid withdrawal in people with chronic non‐malignant pain appears to be cost‐effective on average, but further research is warranted to reduce current levels of decision uncertainty.

Aims: To determine the distribution of unhelpful pain beliefs in patients after ankle fracture surgery and investigate their impact, along with other demographic characteristics, on postoperative recovery. Methods: This was an observational cohort study embedded within the Weightbearing in Ankle Fractures (WAX) trial. Adults (≥ 18 years) who underwent operative fixation of unstable ankle fractures were recruited from 23 UK hospitals two weeks post-surgery. Pain beliefs were measured at baseline using the Pain Self-Efficacy Questionnaire (PSEQ-2) and Tampa Scale of Kinesiophobia (TSK-11). Outcomes were the Olerud-Molander Ankle Score (OMAS) and EuroQol five-dimension questionnaire (EQ-5D) index at four months. Associations between pain beliefs and outcomes were examined using multivariable linear regression models adjusted for age, sex, BMI, comorbidity, occupation, and weightbearing allocation. Results: Of 795 eligible patients, 561 were recruited between February 2020 and October 2021 (mean age 48 years, 64% female). At four months, higher BMI, manual labour occupation, and greater kinesiophobia (TSK-11) were associated with poorer OMAS and EQ-5D outcomes, whereas male sex and higher pain self-efficacy (PSEQ-2) predicted better outcomes. Pain beliefs accounted for roughly twice the variability in outcomes compared with other factors. The adjusted R² for the OMAS and EQ-5D models was 0.15, indicating that other unexplored factors contribute to recovery. Conclusion: Unhelpful pain beliefs measured two weeks after ankle fracture surgery were consistently associated with poorer function and quality of life up to 12 months. Pain self-efficacy and fear of movement emerged as stronger predictors than most demographic or clinical factors, highlighting their value as early screening targets. These findings support the integration of biopsychosocial interventions to improve recovery following ankle fracture surgery. Cite this article: Bone Joint J 2026;108-B(3):431–438.

Purpose: Effective rehabilitation following ankle fracture surgery is essential for optimal recovery and patient satisfaction. However, traditional rehabilitation strategies often lack personalisation, leading to suboptimal outcomes. This study aimed to co-design a rehabilitation package, collaborating directly with patients, to understand their individual needs, using the Behaviour Change Wheel (BCW) framework. Methods: Integrated within the larger weight-bearing in ankle fractures (WAX) trial, this study employed the BCW to understand behaviour, intervention options and content implementation. Nominal Group Technique was used to facilitate a workshop with 10 ankle fracture patients, and subsequent surveys were used to gather and prioritise rehabilitation needs and strategies. Participants were aged between 28 and 69, and nine (90%) were female, with representation from seven different NHS hospital trusts. Two experienced patient representatives facilitated the workshop. Results: Rehabilitation strategies were developed focussing on interventions that included education, training, environmental restructuring, persuasion and enablement, delivered through an app or website. Survey results indicated high patient enthusiasm for structured, accessible rehabilitation support, including instructional videos, live chats with physiotherapists and peer support forums. Patients desired advice on returning to hobbies and life roles, and particularly returning to driving, bathing and work. Conclusion: The BCW framework facilitated the development of a patient-centred rehabilitation package, highlighting the importance of tailored, accessible interventions. Patients expressed strong support for the proposed strategies, suggesting potential for improved rehabilitation outcomes through personalised, digitally delivered support. These components will be used to co-design future rehabilitation interventions.

Objectives The aim of the study was to assess the feasibility of conducting a definitive multicentre randomised controlled trial (RCT) testing an online exercise rehabilitation and behavioural/motivational support intervention for people with postural tachycardia syndrome (PoTS). Design Feasibility RCT. Setting Two secondary care centres. Participants Adults aged 18 to 60 years with PoTS. Exclusions were serious mental health/cognitive problem preventing safe participation; currently undertaking physical activity equivalent to the Chief Medical Officer guidelines; pregnancy. Interventions Participants were randomly assigned (1:1) to best-practice usual care (a single 1:1 session of advice) or the ‘postural tachycardia syndrome exercise’ (PULSE) intervention: (1) individual online consultation, (2) 12 weeks of supervised online group exercise and behavioural/motivational support, and (3) home exercise programme with recumbent exercise bike. Outcomes The primary outcome was feasibility: (1) patients screened, eligible, recruited, randomised, withdrawn; (2) adherence; (3) physiological, clinical and patient-reported outcomes (4 and 7 months); and (4) embedded qualitative study to evaluate acceptability. Results 209 patients screened between 5 May 2021 and 1 December 2022, 44 (female 98%; age 29.9 SD, 7.5) were randomised to usual care (n=21) or PULSE (n=23) (71% of target). Follow-up at 4 months was n=12 and n=17 respectively (66% of target). Median live exercise/support session attendance was 15 (IQR 12 to 17) of 18 sessions. Home exercise bike usage was highly variable. There were two serious adverse events in each treatment arm, both unrelated to the trial. Exercise rehabilitation was considered important by participants, and trial procedures, outcomes and interventions were acceptable. Conclusions The PULSE trial procedures and interventions were acceptable, and important design considerations were identified. A definitive RCT testing a remotely supervised exercise rehabilitation and behavioural/motivational support intervention for people with PoTS is feasible in the UK National Health Service. Trial registration number ISRCTN45323485.

Background: This qualitative evaluation was embedded in the Rehabilitation Exercise and psycholoGical support After COVID-19 InfectioN (REGAIN) study, a randomised controlled trial (RCT) for those with post-COVID-19 condition (‘long COVID’) after hospital admission for COVID-19, comparing weekly home-based, live online supervised group exercise and psychological support sessions with ‘best practice usual care’ (a single session of advice).Objective: To increase our understanding of how and why the REGAIN programme might have worked and what helped or hindered this intervention.Design: A qualitative evaluation which utilised interviews with participants and practitioners delivering the intervention. Framework and thematic analysis were used to analyse the findings.Setting: England and Wales, UK.Participants: Adults discharged from National Health Service (NHS) hospitals at least 3 months previously after COVID-19, with ongoing physical and/or mental health sequelae.Results: Twenty intervention participants, 20 control participants and five practitioners were interviewed.The themes from the group support sessions were: (1) you are not alone; (2) sharing experiences and addressing worries; (3) gaining new perspectives; (4) hope for progression; (5) peer support and bonding; (6) integration of facilitation skills; (7) modified activity pacing and goal setting, and (8) giving participants structure. The themes from group exercise were: (1) monitoring and modification of the online exercise; (2) catering for differing abilities; (3) feeling safe and confident to exercise; (4) progression of fitness; (5) optimal timing in the recovery trajectory; (6) group effect; (7) initial apprehension about exercise group; (8) gauging exercise capabilities; (9) translating exercises into life; and (10) on-demand supplementary videos. The 1:1 consultation sessions revealed patients needed to tell their stories.Conclusion: Being listened to and being understood by someone ‘who got it’ was very important to people with post-COVID-19 condition. The group sessions of both exercise and psychological support were valued by participants, working together, and learning from each other in the face of a new disease within a global pandemic.

Post-surgical rehabilitation advice after ankle fracture surgery, particularly regarding weight-bearing, varies significantly, leading to patient frustration and inconsistent recovery outcomes. This study aimed to establish a consensus for ankle fracture rehabilitation advice and identify content and implementation options for future interventions through consultation with healthcare professionals (HCPs). This study was part of the weight-bearing in ankle fractures (WAX) trial, a multicentre, randomised controlled trial. Using the behaviour change wheel (BCW) framework, three online workshops with HCPs were conducted between April 25, 2022, to May 4, 2022, to generate consensus on rehabilitation interventions. Participants completed pre-workshop tasks, and data were collected using an adapted nominal group technique (NGT). Workshop data were collated to create a survey with indicative statements about rehabilitation preferences. An online survey was subsequently disseminated to surgeons and physiotherapists between May 5, 2022, and July 13, 2022. Respondents were asked to indicate how strongly they agreed with various statements by ranking statements on a 5-point Likert scale from "strongly disagree" to "strongly agree”; 75% was used as a threshold for consensus agreement. Eight HCPs participated in the workshops, and 79 HCPs responded to the survey, representing 38 different NHS hospital trusts. Consensus was achieved on several key aspects: Patients could rest their foot on the floor while seated during non-weight-bearing periods and gradually increase weight-bearing based on comfort. It was agreed that orthotic boots are for comfort, and patients can discontinue use as early as two weeks post-operatively if weight-bearing is permitted. Guidelines for wound management, including when to get wounds wet and how to handle numbness, were also established. This study established a consensus for ankle fracture rehabilitation, emphasising patient autonomy and clear, standardised advice. The findings support the development of a tailored, patient-centred rehabilitation interventions, potentially delivered through digital platforms, to enhance recovery outcomes.

Ankle fractures are common injuries that can significantly impact mobility and quality of life. Rehabilitation following ankle fracture treatment is crucial for recovery, yet adherence to regimens remains a challenge. Behaviour Change Techniques (BCTs) have been suggested to improve adherence, but their effectiveness in ankle fracture rehabilitation is not well established. This review aimed to evaluate the effectiveness of BCTs in the rehabilitation of ankle fracture patients. We conducted a comprehensive search across multiple databases, including MEDLINE and EMBASE, focusing on Randomised Controlled Trials (RCTs) that incorporated BCTs into rehabilitation interventions. The effectiveness of BCTs on patient-reported outcomes (PROMs), quality of life, and adverse events was analysed. Nine RCTs met the inclusion criteria, encompassing a range of interventions that employed BCTs, most commonly including goal setting and instruction on how to perform behaviours, specifically physiotherapy exercises. The review found limited evidence supporting their effectiveness in improving PROMs. Only one study showed a significant positive effect, but it was deemed at high risk of bias. The lack of integration of behavioural theory in the design of rehabilitation interventions and the varied nature of the BCTs employed across studies may contribute to these findings. The use of BCTs in ankle fracture rehabilitation is prevalent, but this review highlights a significant gap their role of enhancing patient outcomes. Future research should incorporate a theory-based approach to intervention design, utilising a broader range of BCTs, to fully evaluate their potential in improving rehabilitation adherence and outcomes following ankle fracture .

Background The Improving the Wellbeing of people with Opioid Treated CHronic pain (I-WOTCH) randomised controlled trial found that a group-based educational intervention to support people using strong opioids for chronic non-malignant pain helped a significant proportion of people to stop or decrease opioid use with no increase in pain-related disability. We report a linked process evaluation of the group-based intervention evaluated in comparison to a usual-care control group that received a self-help booklet and relaxation CD. Methods We interviewed 18 intervention facilitators, and 20 intervention and 20 control participants who had chronic non-malignant pain and were recruited from general (family) practices in the UK. Quantitative data included change mechanism questions on the trial questionnaires which explored motivation, expectations and self-efficacy. Fidelity was assessed by listening to a sample of audio-recorded group sessions and nurse consultations. Quantitative and qualitative data were integrated using ‘follow a thread’ and a mixed-methods matrix. Findings Four overarching themes emerged: (1) the right time to taper, (2) the backdrop of a life with chronic pain, (3) needing support and (4) the benefits of being in a group. Delivery fidelity was good, adherence (83%) and competence (79%) across a range of intervention groups. Staff delivering the intervention found three typical responses to the intervention: resistance, open to trying and feeling it was not the right time. The group experience was important to those in the intervention arm. It provided people with a forum in which to learn about the current thinking about opioid usage and its effects. It also gave them examples of how feasible or personally relevant coming off opioids might be. Conclusion The process evaluation data showed that the I-WOTCH intervention was well delivered, well received and useful for most interviewees. Being ‘the right time’ to taper and having support throughout tapering, emerged as important factors within the context of living with chronic pain. Trial registration number ISRCTN49470934.