Title: Development and evaluation of the Digital-My Arm Pain Programme (D-MAPP) for improving painful distal upper limb musculoskeletal disorders
Funder: Department of Health and Social Care

Abstract: Research question Is it possible to develop a robust evidence-based, digitally delivered care package to address the deficiencies in treatment and healthcare support for people with distal upper limb (DUL) musculoskeletal disorders (MSDs) in order to optimise recovery; improve long-term functional use and reduce pain? Background DUL-MSDs are highly prevalent and commonly include: hand, wrist and thumb osteoarthritis (OA), carpal tunnel syndrome, tendinitis and epicondylitis. DUL-MSDs cause distressing levels of pain, swelling, loss of function and disability. The effects of living with a DUL-MSD are considerable in terms of personal, social and economic consequences. Primary care consultations for upper limb disorders are high: a UK population survey reported 15% had consulted a GP within the previous year with upper limb pain. There are difficulties in the treatment and management of DUL-MSDs and a lack of national guidelines. Current challenges in our NHS including increasing costs, overburdened musculoskeletal (MSK) services and an unwarranted variation in service provision, all call for innovative ways of delivering rehabilitation. Supporting self-management and personalising treatments, including the use of digital technology are NHS priority areas. Aim The overall aim of this research programme is to co-develop and evaluate a digital rehabilitation programme -Digital-My Arm Pain Programme (D-MAPP) to be prescribed by health professionals for improving DUL-MSDs. Objectives To develop consensus between patients and key clinician stakeholders on the required components of D-MAPP; To explore potential barriers and facilitators to patient engagement; To iteratively co-design and refine D-MAPP with patients and clinical stakeholders, identifying key intervention attributes and specifications for optimising use; To identify the causal mechanisms underpinning D-MAPP, and develop a logic model of the intervention; To explore with patients and key clinical stakeholders the content and usability of D-MAPP and any barriers to usability, adoption and adherence; To examine the clinical and cost-effectiveness of D-MAPP to determine if it will provide clinical and cost-effective improvements in DUL regional pain and physical function and facilitate workability compared to usual care; To explore experience, perceptions, usability and adherence of the D-MAPP by people with DUL-MSDs; To assess the challenges of intervention implementation of D-MAPP with patients and key clinical stakeholders in primary and community care. Methods/Timeline The programme is designed as a mixed methods study with multiple work packages culminating in a randomised controlled trial. Workpackage 1: Modified Delphi study and exploratory qualitative research (Months 1-7) Workpackage 2: Experience Based Co-Design with case study and evaluation (Months 6-28) Workpackage 3: Randomised controlled trial with internal pilot and mixed methods evaluation (Months 24-71) Workpackage 4: Implementation (Months 1-12, 25-36, 61-72) Anticipated Impact and Dissemination We will produce a novel digital intervention (D-MAPP) for people with DUL-MSDs which has the potential to reduce pain control, improve physical function and, if relevant, enhance work participation. The D-MAPP will also reduce burden on over-stretched GPs and musculoskeletal services and likely post-COVID changed working practices. We will ensure that the D-MAPP is widely disseminated to GPs, other health professionals, charity-based organisations and patient groups, including through social media, publications and conference presentations.

Lay abstract: Painful conditions of the elbow, forearm, wrist/hand including tennis elbow, tendon inflammation and hand arthritis are common, affecting over 10% of the population. Around half of people affected have chronic pain and disability. Many find essential daily activities (e.g. using cutlery, writing, opening jars) difficult, resulting in reduced quality-of-life. In severe cases, symptoms threaten jobs. There are few effective treatments, with physiotherapy the main option. Recently we demonstrated that people advised to keep moving their hand/arm became less disabled at 6 months than people advised to rest or having immediate physiotherapy. However, further work is needed to improve treatment. Current NHS challenges include spiralling costs, overburdened services and post-COVID changed working practices. There is therefore a need for innovative approaches to providing care, including remote delivery. The overall aim of this research is to develop and evaluate a digital rehabilitation programme (Digital-My Arm Pain Programme, D-MAPP) to be prescribed by healthcare professionals (e.g. GPs). This will include an exercise programme tailored to the specific condition and the patients current level of function, together with education to help them look after their own condition (self-management). We have gathered an experienced UK team with the relevant clinical, patient and research expertise. Our patient co-applicant will chair a Patient Advisory Group to ensure patient involvement throughout. The 6-year programme includes 4 workpackages (WPs): WP1 will review published evidence and obtain agreement from experts and patients using a series of structured questionnaires (a Delphi study). This will establish the main building blocks for the D-MAPP intervention (e.g. exercise programme content, areas for self-management support). We will use focus groups to explore patients views on barriers and facilitators to using digital programmes. In WP2 we will work closely with patients and healthcare professionals to co-design D-MAPP, using the building blocks identified in WP1. We will test how acceptable D-MAPP is to patients using interviews. In WP3 we will use a large clinical trial to formally test whether D-MAPP has the desired benefit on function and pain for people with these conditions, compared to usual clinical care. We anticipate that we will randomly assign 356 people to either the D-MAPP package-of-care or standard care and follow them for 12 months. We will compare NHS costs between groups, to see whether the intervention is good value-for-money, and learn about participants experiences of using D-MAPP. WP4 ( Implementation ) will consider the practical steps needed to roll-out D-MAPP widely to everybody with these conditions through routine clinical practice. This will include communication, education and publicising D-MAPP. This novel digital rehabilitation programme has potential to provide better pain control, improved physical function and, if relevant, enhanced work participation for many millions. The D-MAPP will also reduce burden on over-stretched healthcare services.

Research activity codes: 6.7 PHYSICAL;5.7 PHYSICAL
Health categories: MUSCULOSKELETAL