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INTRODUCTION: There is little research on identifying modifiable risk factors that predict future interference of pain with daily activity in people with joint pain, and the estimation of the corresponding population attributable risk (PAR). The present study therefore investigated modifiable predictors of pain interference and estimated maximum potential gain from intervention in adults with joint pain. METHODS: A population-based cohort aged ≥50 years was recruited from eight general practices in North Staffordshire, UK. Participants (n = 1878) had joint pain at baseline lasting ≥3 months and indicated no pain interference. Adjusted associations of self-reported, potentially modifiable prognostic factors (body mass index, anxiety/depressive symptoms, widespread pain, inadequate joint pain control, physical inactivity, sleep problems, smoking and alcohol intake) with onset of pain interference 3 years later were estimated via Poisson regression, and corresponding PAR estimates were obtained. RESULTS: Inadequate joint-specific pain control, insomnia and infrequent walking were found to be independently significantly associated with the onset of pain interference after 3 years, with associated PARs of 6.3% (95% confidence interval -0.3, 12.4), 7.6% (-0.4, 15.0) and 8.0% (0.1, 15.2), respectively, with only the PAR for infrequent walking deemed statistically significant. The PAR associated with insomnia, infrequent walking and inadequate control of joint pain simultaneously was 20.3% (8.6, 30.4). CONCLUSIONS: There is potential to reduce moderately the onset of pain interference from joint pain in the over-50s if clinical and public health interventions targeted pain management and insomnia, and promoted an active lifestyle. However, most of the onset of significant pain interference in the over-50s, would not be prevented, even assuming that these factors could be eliminated.

Background\ud Osteoarthritis (OA) is the most common long-term condition in primary care and is one of the most frequent causes of pain, loss of function and disability. Research evidence alone does not always lead to changes in practice that benefit patients, and OA is often not treated as per evidenced-based guidelines. The aims of this thesis were: (i) to identify lessons learnt from a research study and implementation project regarding OA best care, in order to provide insight into the knowledge mobilisation (KM) process in primary care (ii) to develop a toolkit to optimise KM for OA in primary care.\ud Methods\ud A systematic review and thematic synthesis were conducted to explore the factors affecting the implementation of evidence-based guidelines for OA in primary care. Analysis of data from three focus groups (n=21), and qualitative interviews (n=13), were conducted with key stakeholders to understand KM in primary care. A triangulation protocol of the empirical findings was used to generate draft recommendation statements which were subsequently refined in a consensus exercise with stakeholders (n=27), at a national knowledge mobilisation event. This informed the development of a toolkit to optimise KM for OA in primary care.\ud Results\ud KM of research evidence for OA in primary care is complex and multifaceted and influenced by a range of patient and clinician motivators. KM is optimised with consideration of specific primary care contextual factors. Adopting a whole practice approach was beneficial in circumnavigating potential implementation challenges and co-producing implementation plans relevant to the local context. The nature and impact of facilitation in optimising KM by mediating both internal and external contextual factors was shown. Clinical-academic collaboration and engaging in ‘knowledge networks’ optimised the uptake of evidence for OA. The knowledge mobiliser role was central to driving knowledge into practice in a contextualised way and was adopted by people with different characteristics (in terms of status, power and role). The perceived importance of patient and public involvement and engagement (PPIE) in KM was highlighted, yet uncertainty exists regarding the impact and role of PPIE in KM.\ud Triangulation of the three data sets produced a typology of six key empirical domains and a draft set of recommendation statements. The statements were refined following a consensus exercise with stakeholders (n=27) and the final toolkit developed.\ud Conclusions\ud This empirical study of KM demonstrated the importance of the knowledge mobiliser, underpinned by a strong academic collaboration (and infrastructure for KM) to overcome contextual barriers to KM in primary care. Further work is needed to better understand the role of PPIE in KM and evaluate the utility and transferability of the implementation toolkit.

Health Care Professionals and patients report that hydrotherapy is valuable in managing inflammatory arthritis and musculoskeletal pain. However, clinical services are increasingly required to justify the clinical and cost effectiveness of hydrotherapy.\ud The aims of this thesis were to:\ud 1. Identify the best available evidence for hydrotherapy in adults and children with musculoskeletal pain and inflammatory arthritis for uptake by clinical services using a Critically Appraised Topic (CAT) methodology.\ud 2. Explore how this evidence could be useful in clinical practice and services, through a knowledge mobilisation Community of Practice with a range of stakeholder representatives using a Focus Group study.\ud Firstly, the CAT methodology determined the best empirical research evidence for the clinical and cost effectiveness of hydrotherapy, producing a clinical bottom line for further exploration. A facilitated discussion was subsequently undertaken with a range of stakeholders in a Community of Practice, and analysed using focus group methodology, to establish how to increase uptake of this evidence, exploring barriers and enablers to implementation.\ud Seven studies were identified that led to the CAT clinical bottom line. Systematic reviews (n=4) and clinical trials (n=3) show that hydrotherapy improves pain and function for patients with inflammatory arthritis in the short term and is comparable with land based exercises. There was limited evidence to justify cost effectiveness and return to work or school.\ud Eight members of a stakeholder group attended a community of practice. Eight key themes were highlighted such as the limitation of existing evidence, the need for qualitative studies and the importance of understanding barriers and facilitators in providing hydrotherapy services.\ud In conclusion this thesis has identified an evidence to practice gap for hydrotherapy as a complex intervention, and suggestions for closing this gap for the management of inflammatory arthritis and musculoskeletal pain.