Objective. Functional neuroimaging studies have shown that experimentally induced acute pain is processed within at least 2 parallel networks of brain structures collectively known as the pain matrix. The relevance of this finding to clinical pain is not known, because no direct comparisons of experimental and clinical pain have been performed in the same group of patients. The aim of this study was to compare directly the brain areas involved in processing arthritic pain and experimental pain in a group of patients with osteoarthritis (OA).Methods. Twelve patients with knee OA underwent positron emission tomography of the brain, using 18 F-fluorodeoxyglucose (FDG). Scanning was performed during 3 different pain states: arthritic knee pain, experimental knee pain, and pain-free. Significant differences in the neuronal uptake of FDG between different pain states were investigated using statistical parametric mapping software.Results. Both pain conditions activated the pain matrix, but arthritic pain was associated with increased activity in the cingulate cortex, the thalamus, and the amygdala; these areas are involved in the processing of fear, emotions, and in aversive conditioning.Conclusion. Our results suggest that studies of experimental pain provide a relevant but quantitatively incomplete picture of brain activity during arthritic pain. The search for new analgesics for arthritis that act on the brain should focus on drugs that modify this circuitry.

IntroductionSelf-management has received growing attention as an effective approach for long-term condition management. Little is known about which outcomes of supported self-management are valued by patients, their families, health professionals and those who commission self-management services. This study systematically reviewed published empirical evidence in accordance with PRISMA guidelines to determine the outcomes of self-management valued by these key stakeholder groups, using three prominent exemplar conditions: colorectal cancer, diabetes and stroke.AimTo systematically review the literature to identify which generic outcomes of self-management have been targeted and are considered important using three exemplar conditions (colorectal cancer, diabetes and stroke), which collectively have a range of features that are likely to be representative of generic self-management issues.MethodsSystematic searching of nine electronic databases was conducted in addition to hand searches of review articles. Abstracts were identified against inclusion criteria and appraised independently by two reviewers, using a critical appraisal tool. Synthesis of findings was conducted using mixed research synthesis.ResultsOver 20,536 abstracts were screened. 41 studies which met the review criteria were fully retrieved and appraised. The majority of evidence related to diabetes. Few studies directly focussed on stakeholders’ views concerning desired self-management outcomes; the majority of evidence was derived from studies focusing upon the experience of self-management. The views of health care commissioners were absent from the literature. We identified that self-management outcomes embrace a range of indicators, from knowledge, skills, and bio-psychosocial markers of health through to positive social networks.ConclusionsPatients’, families’, health professionals’ and commissioners’ views regarding which outcomes of self-management are important have not been clearly elicited. The extent to which bio-psychosocial indicators relate to successful self-management from the perspectives of all groups of stakeholders is unknown. Further investigation regarding which self-management outcomes are considered important by all stakeholders is necessary to guide the commissioning and design of future self-management services.

9Healthcare policy in developed countries has, in recent years, promoted self-10 management among people with long-term conditions. Such policies are underpinned 11 by neoliberal philosophy, as seen in the promotion of greater individual responsibility 12 for health through increased support for self-management. Yet still little is known about 13 how self-management is understood by commissioners of healthcare services, 14 healthcare professionals, people with long-term conditions and family care-givers. The 15 evidence presented here is drawn from a two-year study, which investigated how self-16 management is conceptualised by these stakeholder groups. Conducted in the UK 17 between 2013-2015, this study focused on three exemplar long-term conditions, stroke, 18 diabetes and colorectal cancer, to explore the issue. Semi-structured interviews and 19 focus groups were carried out with 174 participants (97 patients, 35 family care-givers, 20 20 healthcare professionals and 22 commissioners). The data is used to demonstrate 21 how self-management is framed in terms of what it means to be a 'good' self-manager. 22The 'good' self-manager is an individual who is remoralised; thus taking responsibility 23 for their health; is knowledgeable and uses this to manage risks; and, is 'active' in using 24 information to make informed decisions regarding health and social wellbeing. This 25 paper examines the conceptualisation of the 'good' self-manager. It demonstrates how 26 the remoralised, knowledgeable and active elements are inextricably linked, that is, how 27 action is knowledge applied and how morality underlies all action of the 'good' self-28 manager. Through unpicking the 'good' self-manager the problems of neoliberalism are 29 also revealed and addressed here. 30

Successful stroke self-management consists of features which may be modifiable at the individual level, in addition to the presence of external support and an environment which supports and facilitates people following stroke to self-manage. These findings extend current conceptualisations of stroke self-management.

PurposeTo systematically review the psychometric properties of outcome measures used in stroke self-management interventions (SMIs) to (1) inform researchers, clinicians and commissioners about the properties of the measures in use and (2) make recommendations for the future development of self-management measurement in stroke.MethodsElectronic databases, government websites, generic internet search engines and hand searches of reference lists. Abstracts were selected against inclusion criteria and retrieved for appraisal and systematically scored, using the COSMIN checklist.ResultsThirteen studies of stroke self-management originating from six countries were identified. Forty-three different measures (mean 5.08/study, SD 2.19) were adopted to evaluate self-SMIs. No studies measured self-management as a discreet concept. Six (46%) studies included untested measures. Eleven (85%) studies included at least one measure without reported reliability and validity in stroke populations.ConclusionsThe use of outcome measures which are related, indirect or proxy indicators of self-management and that have questionable reliability and validity, contributes to an inability to sensitively evaluate the effectiveness of stroke self-SMIs. Further enquiry into how the concept of self-management in stroke operates, would help to clarify the nature and range of specific self-management activities to be targeted and aid the selection of existing appropriate measures or the development of new measures.Implications for RehabilitationThe evaluation of complex interventions such as self-management interventions is aided by clear outcome expectations and valid and reliable measurement.This review demonstrates a lack of outcome measures that specifically measure self-management of stroke. A minority of outcome measures that were used as proxy indicators for SM fulfill some of the criteria for quality outlined in the COSMIN checklist.Clinicians should select measures which appropriately reflect expected outcomes, giving due consideration to the theoretical underpinnings of the intervention. Further work is required to establish which measures currently in use, if any, accurately reflect stoke self-management.In the meantime, researchers should seek to develop psychometrically sound measures of stroke self-management to assist effective evaluation of such interventions in stroke.