Background

Specifically designed control interventions can account for expectation effects in clinical trials. For the interpretation of efficacy trials of physical, psychological, and self-management interventions for people living with pain, the design, conduct, and reporting of control interventions is crucial.

Aims

Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Purpose of the study and background

A 2011 Cochrane review concluded that spinal manipulative therapy (SMT) is no better than other interventions for reducing pain and improving function in chronic low back pain (CLBP). Using individual participant data (IPD) from trials has advantages, among others: a more precise estimate of the effect and the potential to identify moderators. Our objective was to assess the effect of SMT in adults with CLBP and to identify relevant moderators.

Objectives

The evidence base to inform the management of Achilles tendon rupture is sparse. The objectives of this research were to establish what current practice is in the United Kingdom and explore clinicians’ views on proposed further research in this area. This study was registered with the ISRCTN (ISRCTN68273773) as part of a larger programme of research.

Background

The available treatments for NSLBP (Non-Specific Low Back Pain) provide, typically, small to moderate average benefits to patients. The aim of this pilot cluster RCT was to test the hypothesis that the use of a patient decision aid together with an informed shared decision making consultation would produce better outcomes in satisfaction with treatment at four month follow-up.

Study Purpose

To review systematically review literature on the early diagnosis of spinal metastases and prediction of spinal cord compression (SCC) due to spinal metastases

Background

We have developed a LBP (low back pain) repository with IPD (individual patient data) from therapist-delivered intervention RCT's from various institutions, nationally and internationally (19 trials, 9328 patients). We will perform IPD meta-analyses to identify and determine the most effective and cost-effective treatments for subgroups of patients. Disability due to LBP is a key outcome of interest. However, there was no common disability measurement that was used in all the RCT's. We report here our assessment as to whether different disability measures are sufficiently comparable to allow pooling across trials.

Background and purpose

There is on-going debate about a possible link between manipulation and stroke in patients, and a growing interest in other treatment reactions such as increased pain. Evidence about manipulation is contradictory. There is little published information about outcomes in osteopathy. We aimed to address this gap.

Study purpose and background

There is growing concern that current outcome measures of back pain trials do not comprehensively capture what is important to patients. Some researchers believe we need to incorporate patients in the development of ‘next-generation’ outcomes. As a preliminary step to patient-interviews, we aimed to articulate ‘important change’ from the patients' perspective, as represented in reports of qualitative investigations inadvertently or directly exploring this.

Purpose and background

Effective reassurance is an essential element of treatment for conditions that do not require further investigations, referrals and on-going monitoring. However, research defining what reassurance should consist of and how to deliver it is scarce. The aim of this review was to identify consultation-related processes that improved patients' outcomes, in order to build an evidence-based model of effective reassurance in primary care.

Aims

1.

To develop a decision aid - Decision Support Package (DSP) - that will provide low back pain (LBP) patients, and their treating physiotherapists with information on the treatment options available to the patients

Background and Purpose: How outcomes of clinical trials are reported alters the way treatment effectiveness is perceived. Clinicians interpret outcomes of trials more favourably when results are presented in relative rather than in absolute terms. However, the face validity of different methods is unclear. We aimed to explore which methods clinicians find clearest, most interpretable, and useful.

Methods and Results: We purposively sampled clinicians who see patients with low back pain (LBP) and presented them with summary reports of a hypothetical trial, reporting the results using a variety of different methods. We explored participants’ preferences for these different methods and how they would like to see future trials reported. We interviewed 14 clinicians (GPs, manual therapists, psychologists, a rheumatologist, and surgeons). Participants felt that clinical trial reports were not written with them in mind. They were familiar with mean differences, proportion improved, and number needed to treat (NNT); and unfamiliar with standardised mean difference (SMD), odds ratios and relative risk. They found the proportion improved, relative risk and NNT more intuitively understandable, and were concerned that between-group mean difference, relative risk and odds ratios may mislead. Participants thought each method uniquely contributed to their overall understanding, and that using a variety of methods to report future trials may prevent erroneous portrayal of treatment effect.

Conclusion: Clinicians who see patients with low back pain currently find it difficult to interpret LBP trials. Using a suite of methods to report outcomes may aid clinicians’ interpretation and the transition of research into practice.

Conflict of Interest: None

Sources of Funding: Barts and the London Charity

Background and Purpose: Clinicians have expressed frustration at the difficulty of interpreting low back pain (LBP) trial outcomes. Using a suite of methods to report outcomes may aid interpretation and transition of research into practice. We aimed to facilitate consensus between LBP experts on how future trials are reported.

Methods and Results: We invited SBPR and LBP Forum members, and authors of LBP trials to participate. In the first round, participants were presented with results of a qualitative study on clinicians’ preferences for different reporting methods. They were asked to rate and comment on the appropriateness of including different reporting methods in a standardised set. In the second round, they reviewed other participants’ ratings and comments, re-rated methods, and edited a statement of recommendation for future reporting. In the final round, participants were asked if they approved of a revised statement. Consensus was measured using the RAND/UCLA appropriateness method and ratified in a meeting at LBP Forum X. Sixty-three experts participated in the study. Ninety-eight percent of participants approved a statement recommending that, where possible, results of LBP trials are reported using between-group mean differences (including advice on clinically important difference), proportion of patients improving in each group, NNT to achieve a minimally important change, and the proportion of deteriorating in each group (all with 95% CIs). Also, additional reporting methods were recommended according to needs of particular trials.

Conclusion: A high level of consensus was reached amongst LBP experts on a statement recommending a standardised set of reporting methods.

Conflict of Interest: None

Source of Funding: Barts and the London Charity

Background: We aimed to explore the incidence and risk of adverse events associated with manual therapies.

Method: The main health electronic databases, plus those specific to allied medicine and manual therapy professions, were searched. Our inclusion criteria for relevant studies were: manual therapies only; administered by regulated therapists; a clearly described intervention; adverse events reported. We performed a meta-analysis using incident estimates of proportions and random effects models from relevant prospective cohort studies and randomised controlled trials (RCTs) published after 1997.

Results: Eight prospective cohort studies and 31 manual therapy RCTs were identified and analysed. The incidence estimate of proportions of minor or moderate transient adverse events after manual therapy was ~41% (CI 95% 17–68%) in the cohort studies and 22% (CI 95% 11.1–36.2%) in the RCTs. The estimate for major adverse events was between 0.007 and 0.13%. No deaths or vascular accidents occurred in any studies. The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham, passive or control interventions compared to manual therapy was similar, but compared to drug therapies greater (RR 0.05, CI 95% 0.01–0.20) and less when compared to general practitioner or usual care (RR 1.91, CI 95% 1.39–2.64).

Conclusions: Our data indicate a very low risk of major adverse events with manual therapy, but around half manual therapy patients may experience minor to moderate adverse events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual medical care.

Conflicts of Interest: D Carnes & T Mars

Source of Funding: National Council for Osteopathic Research

Background and Purpose: A number of authors have calculated thresholds of individually minimally important individual change (MIC) for the Roland Morris Disability Questionnaire (RMDQ). However, at an individual level, the imprecision of the measurement instrument often exceeds the MIC. In recognition of this, there is some consensus on appropriate individual change thresholds (absolute and baseline-specific) for the RMDQ. These were intended to be re-evaluated as further data become available. With this in mind, we calculated the MIC and minimally detectable change (MDC) of the RMDQ in the UK BEAM population.

Method and Results: 1,334 patients enrolled in the UK BEAM trial completed the RMDQ. We calculated MIC using ROC curves from three and 12 month follow-up data, and using a seven-point health transition question as the external criterion. We performed sub-analyses of MIC for bands of baseline severity and considered adjusting these for regression to the mean (RTM). We calculated MDC based on within-person and residual error variances of stable patients’ repeated measurements. The overall MIC was four points and the MDC 7.6 points. These values fall around the centre of the ranges considered by the consensus study team. Higher MIC values were observed for more disabled patients; this may be partially an artefact of RTM. In our positively skewed population, more disabled patients required more than the consensus recommendation of 30% change from baseline.

Conclusion: This is further evidence that five RMDQ points is an appropriate threshold by which to judge individual change on the RMDQ. Proportional change from baseline may be more population-specific than previously thought.

Background and Purpose: Using numbers needed to treat (NNT) to report trial outcomes has been publicised as improving the interpretability of trial results. However, authors of back pain trials rarely report continuous outcomes using NNT, and if they do, rarely consider deteriorating patients. We performed a reanalysis of the UK BEAM dataset to explore the effects of reporting NNT on interpretation, and articulate difficulties with this approach.

Method and Results: 1,334 patients consulting for low back pain were randomised to receive either best GP care alone, or best GP care and exercise, manipulation or combined exercise and manipulation. The primary outcome was Roland Morris Disability Questionnaire (RMDQ) score at three and 12 months. Patient-response to a health transition question (TQ) was used as a secondary outcome. Using consensus thresholds for individual change on the RMDQ, and using the TQ, we calculated NNTs for improvement, and for benefit (incorporating one additional improvement gained or an additional deterioration prevented). In contrast to the small-to-moderate mean differences originally reported, NNTs were low, ranging from two to eight. Detailed results have been submitted for publication and will be presented at the meeting. Estimating NNT can be challenging due to difficulties in defining thresholds of individual change on continuous scales. However, using a TQ avoids some of these challenges.

Conclusion: In contrast to the small-to-moderate mean effects originally reported, corresponding numbers needed to treat for the interventions are attractive. Where possible, NNT should be considered for future use alongside more conventional reporting methods.

Background: Chronic musculoskeletal pain is a major and costly health problem which is difficult to treat from both patients’ and practitioners’ perspectives. Gaining a greater understanding of patients’ and practitioners’ decision making may be one way of achieving more successful chronic pain consultations.

Aim: To explore the influences on patients’ decision making regarding care seeking, and practitioners’ decision making regarding care delivery for chronic musculoskeletal pain.

Method: In-depth qualitative interview study of chronic musculoskeletal pain patients and of NHS and private, mainstream and CAM practitioners who treat patients. Topic guides were developed which explored, patients’ and practitioners’ beliefs about the causes of pain and expectations of treatment, and the factors influencing decision making within the consultation. All interviews were audio taped and transcribed for analysis, and data was analysed using Framework.

Results: Fifteen patients and 21 practitioners (two GPs, five chiropractors, five osteopaths and 10 physiotherapists) were interviewed. Themes identified as influencing the process of care and decision making, were the level of trust within the patient-practitioner relationship, beliefs about whom should be responsible for patients’ health, the role of patients’ self identity on the management of pain, and beliefs about whom should hold the expertise within the consultation.

Conclusions: To improve primary care for chronic musculoskeletal pain, the level of trust within the patient-practitioner relationship may need to be increased. This may help practitioners to recognise and accept patients’ growing expertise within the consultation, which in turn may facilitate patients in taking more responsibility for their pain.

Background: Societal, clinician and patient expectations of treatment outcomes may differ due to different measures of success. This may have implications for measuring progress, monitoring treatment success and patient satisfaction.

Aim: To explore patient expectations about outcome

Method: A qualitative study using in depth interviews with people with chronic pain.

Results: Thirteen chronic pain patients were interviewed, five males and eight females. Age ranged between 24 and 83 years and all had chronic pain in at least one location. Ten interviewees had low back pain. We found that the most important outcome markers for patients were functional tasks that affected every day living. The achievement of these tasks became personal goals. Patients used task achievement to determine treatment success, regardless of whether they had to modify the way they achieved these tasks.

Conclusion: Treatment progress can be monitored using patient determined goals, rather than clinical outcomes which are relatively meaningless to the patient. The additional use of aids or encouraging adaptive behaviour should not be under estimated as part of the treatment process. Patient criteria for success were determined by achieving functional tasks/goals that had previously been difficult. However realistic goal setting remains an important issue that patients and clinicians can jointly negotiate and address.

Background – Patients with chronic musculoskeletal pain seek care from a wide range of practitioners, both mainstream and complementary and alternative (CAM). Previous research suggests that patients’ social class and educational level may strongly influence their consulting behaviour. The role of health outcomes in influencing patients’ consulting behaviour has been less frequently studied.

Aims – To explore the relationship between health outcomes and consulting behaviour of chronic musculoskeletal pain patients.

Method – Secondary analysis of data collected as part of a population questionnaire survey of chronic pain. Univariate and multi variate analyses were undertaken to explore the relationship between health outcomes (e.g. health related quality of life) and consulting behaviour.

Results – The survey response rate was 62% and the prevalence of chronic pain was 38% (987/2504). 53% of patients had consulted mainstream practitioners only, 4% CAM practitioners only, 18% mainstream and CAM practitioners and 25% no one.

Patients’ who had consulted both mainstream and CAM practitioners reported the poorest health outcomes (EQ 5D = 0.55), followed by those who consulted just mainstream practitioners (EQ 5D = 0.61), and those who had consulted no one (EQ 5D = 0.72). The best health outcomes were reported amongst those who had just consulted CAM practitioners (EQ 5D =0.78). In multivariate analyses, the most powerful predictors of consulting both mainstream and CAM practitioners were working and having high levels of pain related disability.

Conclusions – This analysis suggests that poorer health outcomes may be powerful predictors of consulting CAM practitioners, in some cases, amongst those who do not have access to the financial resources to pay for such treatment.

Randomised controlled trials (RCTs) of non-specific low back pain (LBP) interventions commonly estimate sizes of treatment effect from subjective scales. It is not clear which scales are most commonly used. Moreover, the standardized effect sizes, d, of interventions are typically small (d ≈0.3) and many trials may be underpowered to detect d at this magnitude, regardless of scale used. We identified RCTs reported between 1980 and 2000 from the European guidelines for low back and extended the search to 2006 using MEDLINE, EMBASE, PsycINFO, Cochrane, and Lilacs. We extracted data from identified studies concerning outcome measure use and power to detect d. Following analysis of 222 papers, the most commonly used outcome measure was the visual analogue pain scale (VAS-P), used by 42% of trials, followed by the Roland Morris disability questionnaire (RMDQ), used by 34% of trials. Secondary measure use was diverse; 5% of trials included 10 or more measures and 40% involved at least one objective measure. 57% of the trials were powered to detect d = 0.8, only 37% could detect d = 0.5, only 6% were able to detect d = 0.3 and only one trial could detect Cohen’s definition of a small effect, d = 0.2. In sum, the VAS-P is the most commonly used outcome measure in trials of non-specific LBP and the majority of trials are too small to show effect sizes that might realistically occur.

Background: Low back pain is a common symptom in the general population. There is considerable evidence for the effectiveness of exercise for chronic low back pain but long-term adherence rates can be poor. It may be important to gain a greater understanding of patients’ beliefs about exercise for low back pain and their adherence to it.

Objectives: To systematically review studies exploring low back pain patients’ beliefs about exercise as a treatment for their pain.

Method: We searched Medline, Web of Science, National Research Register, PEDro, PsycINFO, AMED, CINAHL and EMBASE. Retrieved titles and abstracts were combined and screened for inclusion in the review. We quality appraised the included papers and did a thematic analysis of the data extracted from them.

Results: Three studies were eligible for inclusion in the review. The main themes identified were barriers and motivators to exercise. Time was the main barrier patients perceived. Fear of pain acted both as a barrier and a motivator to exercise. Health professionals motivated patients to exercise when the patient had regular contact and felt they understood their situation. Exercise had both physical and mental benefits, with responders feeling enabled to self manage their pain.

Conclusions: The impact of the health professional on beliefs about exercise and adherence is already acknowledged in the recommendations for supervised exercises. There is a lack of exploratory research in the area of exercise beliefs, especially in primary care. Further research is needed to understand how people with low back pain view physical activity more generally especially prior to receiving exercise as a treatment.

Objective: To improve the quality of prospective cohorts studying the transition from early stages of back pain to persistent problems, in order to allow researchers to improve the predictive quality, and pool data from multi-centre studies.

Summary of background: The progress from early stages of back pain to persistent problems is poorly understood, and only a fraction of the variance at outcome can be accounted for by current prospective cohorts. Standardization of a core set of factors would allow pooling and facilitate comparison between studies.

Method: Teams from 12 nations with expertise in clinical practice, prospective cohorts, epidemiology, social sciences, and health services were appointed.

The steering committee produced checklists of predictors and outcomes based on systematic reviews and a Delphi focus group. The international teams of experts coded each item for inclusion or exclusion, and recommended new items. This process was iterated twice to resolve disagreement between teams, and to receive scores for new items. The steering committee carried out a consensus synthesis and produced the final lists for predictors and outcome. Finally, the measurements for each factor were selected based on:

original systematic review

Results: The checklist for predictors include information about demographics, clinical status, psychosocial status, work, and the first consultation for back pain. The recommendation for outcomes include pain, disability, return to work and sick leave, satisfaction, psychological factors, health care utilization and treatment over the follow up period.

Objective: To explore the views of patients’ differing treatments received within a randomised controlled trial of physical treatments for low back pain.

Methods: Within a randomised controlled trial, that found small to moderate benefits from adding a manipulation package or an exercise programme to General Practice care, we elicited participants’ views on their treatment from free text responses to an open question completed by respondents at the end of baseline and follow-up questionnaires. These data were organised and analysed using an adapted ‘Framework’ approach.

Results: We received a total of 1,259 comments from 1,334 participants. Participants randomised to general practice care reported dissatisfaction with only receiving ‘usual care’ that consisted of no more that providing analgesic medication without providing an explanation for their pain. Those randomised to a manipulation package felt the intervention was appropriate to their needs, commonly reporting quite striking benefits. Participants assigned to the exercise programme developed a sense of self reliance in managing back pain although some failed to be sufficiently motivated to continue their exercise regimen outside of the classes.

Conclusions: This qualitative analysis has found much more dramatic differences between the groups than the main quantitative analysis. This suggests that some of the ‘value added’ to general practice care from being allocated to additional physical treatment for low back pain is not being captured by existing methods of measurement. Improved methods of assessment that consider a wider range of domains may be needed when interpreting the added value to individual patients of such treatments.

Background: Pain is complex and multifaceted. We can convey information about pain by communicating verbally, textually and non-verbally. We investigated the use of pain drawings as an aide to communication and compared it with verbal and other pain measurement tools.

Method: We conducted a qualitative study using in-depth interviews with a purposive sample of pain patients. Data were analysed using the ‘Framework Approach’.

Results: Aches and pains are seen as an increasing continuum, aches distract people, pain stops them doing things. As pain progresses along the continuum patients pain reports progress from verbal through textual to visual representation. Verbal and textual communication about pain was inconsistent, especially for those with multi site pain. Visual communication was more about significant pain, verbal covered the range. As pain worsened so did the complexity, the need for help, life change and communication all increased. Current measuring tools do not seem adequate to assess multi site pain, transient pain and pain with movement.

Conclusions: Two methods of describing pain exist, clinical (physical symptoms) and behavioural (effect on life). Patients felt confident communicating about the latter but perceived a need for active help by the clinician for the former.

The effect of pain on lifestyle is paramount to the patient, physical symptoms for the clinician. Acknowledging this disparity may reduce frustration experienced in consultations as both have different communication and management needs. Indicating treatment success by focusing on lifestyle improvement in patients rather than reductions in physical symptoms may be more appropriate.

Background: Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain patients in the UK In our previous work we used mixed methods to investigate theor cognitions and attitudes to treating back pain. We developed and tested a scale, the Attitudes to Back Pain- Musculoskeletal Practitioners Scale, which includes both a personal and professional dimensional

Purpose: The purpose of this study was to investigate the differences between the attitudes of three professional groups: Chiropractors, Osteopaths and Physiotherapists.

Methods: A cross-sectional questionnaire survey was sent to 300 practitioners randomly selected from the registers of each profession. The returned questionnaires (N=465, response rate 61%), including the new ABS-mp and a questionnaire about personal and professional factors were analysed, using ANOVA, to compare the responses from the three groups.

Results: Physiotherapists tend to limit the number of treatment sessions offered to LBP patients. They work more clearly within a re-activation approach than their colleagues in the either of the other two professional groups. When practice setting (NHS versus private practice) was considered, the differences in personal interaction attitudes were unchanged but the differences in treatment orientation attitudes become less marked.

Conclusions: Aspects associated with practice settings, and especially those concerned with working within the NHS or privately impact on practitioners attitudes. There are also some professional differences, indicating that physiotherapists hold attitudes more closely in line with current guidelines.

Background: The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy are involved in the management of 15–20% of all people with low back pain (LBP) in the UK. Exploratory and descriptive research suggests that the management of non-specific LBP by some members of these groups does not follow best available evidence.

Purpose: To test the short-term effectiveness of a directly-posted, contextualised, printed educational package about the evidence-based management of acute LBP on changing UK chiropractors’, osteopaths’ and musculoskeletal physiotherapists’:

reported practice (based on a vignette of a patient with non-specific LBP)

Methods: A prospective, pragmatic randomised trial was designed to test the effectiveness of the printed educational package versus a no-intervention control. Questionnaires were posted to simple random samples of UK registered chiropractors (n=611), osteopaths (n=1368) and physiotherapists (n=1625). Intervention packages were sent to consenting practitioners in March 2004, and follow-up questionnaires were sent 6 months later.

Results: Good response rates to the baseline questionnaire were obtained, and most respondents were willing to participate in the RCT. Following exclusions based on criteria determined a priori, 1758/3380 (52.0%) consenting practitioners were recruited for the RCT: chiropractors 335/601 (55.7%), osteopaths 600/1335 (44.9%) and physiotherapists 823/1444 (57.0%). Overall response to the 6 month follow-up was 1557/1758 (88.6%): chiropractors 280/335 (83.6%), osteopaths 520/600 (86.7%) and physiotherapists 757/823 (92.0%).

Conclusions: Data analysis is now being carried out. The main trial results will be presented at the meeting.

We conducted a community survey of the prevalence, health impact and location of chronic pain. We explored the relationship and patterns of chronic pain that commonly occur, with a view to understanding why some treatment approaches may be more appropriate than others for particular patterns of pain.

In 2002, 2504 randomly sampled patients from 16 General Practices in the South East of England responded to a postal questionnaire about chronic pain. Those with chronic pain completed a pain drawing. We calculated descriptive statistics, relative risk and correlations to identify the associations and risks of having linked pain.

The highest prevalences were low back (23%), shoulder (20%) and knee (18%) pain. The number of pain sites experienced was age related in men but less so in women. Lower body pain was more age related than upper body and non musculoskeletal pain. Multi site pain was more common than single site pain. Of those with low back, knee and shoulder pain, 14%, 4.5 % and 1.9% had only low back, knee and shoulder pain respectively. Correlations and minimum spanning trees showed that chronic upper and lower body pain are distinct and axial pain link the two.

Chronic pain is more likely to be multi site, especially at middle age. Research, physical treatments and approaches to managing chronic pain are often site specific, therefore specialising treatment to one area eg low back pain often negates the bigger issue. This may help explain the self perpetuating problem of persistent chronic pain.

Background – Chronic musculoskeletal pain (CMP) is a major health problem, for which patients consult a wide range of practitioners often with little success. This may be due to the sometimes different explanatory models for pain held by patients and practitioners. Gaining an understanding of these models may improve care. An area of conflict may be the identification and management of the psychological aspects of pain.

Purpose – To explore patients’ and practitioners’ beliefs and expectations of treatment for CMP, in relation to the identification and management of the psychological aspects to pain.

Method – In-depth qualitative interview study of 24 practitioners (osteopaths, chiropractors, physiotherapists and GPs) and 24 patients with CMP which explored their beliefs about causation and treatment of CMP. Maximum variety purposive samples of both groups were selected. All interviews were audio-taped and transcribed for analysis. Data was analysed using FRAMEWORK.

Results – Patients and practitioners believed that stress influenced pain perception, however some patients believed that stress could also cause pain. In terms of the consultation, practitioners felt pressure from patients to provide them with emotional / psychological support which on the whole they felt ill-equipped to provide. Patients operated with a physical model of illness and felt dismissed if practitioners focused too much attention on the psychological aspects of their pain.

Conclusion– Practitioners expressed confusion over what they were expected to provide patients in terms of psychological support. They also expressed a need for training in the management of behavioural / psychological aspects to pain. Patients may also require education to increase their awareness of the psychological aspects to their pain.

Purpose and background: Practitioners’ beliefs about their professional role, their patients and the nature of back pain can impact on clinical decisions. These attitudes are likely to affect their choice to implement guidelines, whether they engage with their patients’ psychological problems, and their decisions about referral. We aimed to develop, test and explore the underlying dimensions of a new questionnaire, ‘The Attitudes to Back Pain Scale’ (ABS), in a specific group of clinicians, practitioners who specialise in musculoskeletal therapy: chiropractors, osteopaths and physiotherapists (COPs).

Methods and Results: We used a mixed methods study design. Using transcripts of interviews with 42 practitioners, we constructed 54 attitudinal statements, grouped theoretically into six sub-headings. We tested the validity of our categorization on 14 practitioners, who carried out a sorting task, including a rating of difficulty in cat-egorising each item. We sent the draft questionnaires to a large random sample of practitioners (300 COPs). 546 questionnaires were returned (61%). Exploratory and confirmatory factor analyses were performed on split samples of the dataset. Separate exploratory analyses were done for attitudes concerned with personal interaction (34 items) and attitudes about treatment orientation (18 items), producing six domains ‘Limitations on sessions’, ‘Psychological’, ‘System and Void’, ‘Clinical Limitations’, ‘Reactivation’, and ‘Biomedical’. Confirmatory analyses indicated that the model tested presented a good fit. Validity interviews revealed high agreement of categorisation and low levels of difficulty in categorising the items.

Conclusions: A new questionnaire for measuring clinicians’ attitudes towards back pain has been developed. Further work is required to assess the impact of these factors on practitioners’ behaviour and patient outcomes.

Background – Patients with unexplained chronic musculoskeletal pain (CMP) can be difficult to help, consulting a range of services before consulting specialist pain services. Conflicts between the explanatory models for illness used by patients and health professionals might contribute to this complex ‘career path’, increasing the likelihood of unsatisfactory outcomes for both practitioners and patients.

Purpose – To explore the understanding of the experiences of diagnosis and management amongst patients who attended a specialist musculoskeletal pain clinic.

Method – Potential participants were sent a postal questionnaire 6–20 months after their first clinic attendance. Data was collected on pain presence, severity and location, health related quality of life and care seeking behaviour. Questionnaire data was used to inform combined purposive and theoretical sampling. In-depth interviews were conducted which probed participants’ understanding of their CMP and its management. Data was analysed using FRAMEWORK.

Results – 15 patients were interviewed. Four main themes were identified; a) spoiled identity – were pain limited patients activities so much that this affected their sense of self; b)Diminishing faith in medicine – Patients were disappointed with aspects of their care seeking experience; c) Making sense of pain – Patients made sense of their pain by locating their pain within the context of their lives; d) Learning to live with the pain – An issue for all patients was whether or not their pain would go.

Conclusion – Developing, implementing and evaluating approaches to address patients’ spoiled identity might allow us to improve patient centred outcomes in CMP.

Background – Chronic musculoskeletal pain (CMP) is a major health problem treated by a wide range of health professionals. Complementary therapies are likely to become more readily available on the NHS. Therefore a greater understanding of current service use may be helpful in ensuring appropriate targeting of services in the future.

Purpose – To describe current service use for CMP in a UK representative population. To examine predictors of CMP use.

Methods – Population questionnaire survey to 4100 patients registered with 17 Medical Research Council General Practice Research Framework general practices. The questionnaire collected data on demographics, presence of pain, pain location and severity, health related quality of life (HRQOL), care seeking and beliefs about pain. Univariate and multivariate analyses was undertaken to examine predictors of care seeking.

Results – Response rate of 61% of whom 47% reported CMP use. 77% consulted for their CMP; 60% mainstream medicine only, 17% mainstream and / or complementary and 22% no-one.

Patients who consulted complementary practitioners were more likely to be female, to be psychologically distressed, to work, to have left school aged over 16 and to have severe pain (p< 0.05 in all cases). Working was independently associated with consulting a complementary practitioner (Exp (B) = 2.0, p=0.00)

Conclusion – Complementary therapies are currently only available to those patients who can afford them. If such therapies become available on the NHS it may be important to provide patients and health professionals with appropriate information to inform their choices about these care options.

i Background and Purpose. Typically systematic reviews and guidelines consider chronic and acute/sub-acute back pain (< 3 months). However, LBP’s clinical course is often untidy, making this distinction difficult to apply in practice. We did a secondary analysis of the UK BEAM data-set to decide pain duration affected treatment outcome.

ii Method and results: We recruited 1,334 participants with four weeks or more of LBP to a trial of manipulation and exercise for low back pain. We found small sustained benefit from the manipulation package and a small short term benefit for the exercise package. One third of our participants reported that their pain had lasted for less than 90 days (range 4 weeks to 40 years). For this analysis the dependent variable was the Roland Morris Disability Questionnaire score at 12 months. Independent variables were treatment group and episode length, an interaction term between treatment (usual care, exercise, manipulation, and manipulation followed by exercise) and duration of current episode. Preliminary analysis indicates that the significance of the interaction terms for manipulation vs GP care, exercise vs. GP care and manipulation followed by exercise vs GP care are, 0.409, 0.037 and 0.889 respectively. The statistically significant result for the interaction between exercise and episode duration is a positive interaction, indicating that exercise may be more effective for those with shorter episodes of back pain and GP care more effective for longer episodes.

iii Conclusion: It is possible that duration of episode affects effectiveness of the UK BEAM exercise package, but not the UK BEAM manipulation package.

Background and Significance. The minimally important difference (MID) in outcome, at an individual patient or population level, is crucial to interpreting the outcome of randomised controlled trials (RCTs). We have used the UK BEAM dataset to define a minimally important difference in outcome for the Roland Morris Disability Questionnaire (RMDQ) for different baseline values of the RMDQ.

Method and Results: . We recruited 1,334 participants to UK BEAM. In addition to the RMDQ we included a specific health transition question on satisfaction with current health state that consists of a five point ordinal scale.. We used mean changes and ROC curves to identify the whole number of points change in RMDQ that represented a MID, defined as an improvement of one category on the satisfaction scale, using six bands of baseline RMDQ score 4–24, 4–7, 5–12, 9–16, 13–20 & 17–24, three months after randomization. Rounding up our data give values for the MID, for improvement, in each of these groups of 2,1,2,4,4,6 respectively

Conclusions: The MID, to an individual, is different at different baseline values of RMDQ. Interpretation of MID at high baseline values is difficult because of small numbers. Because of difference in methodological approach our analysis has produced smaller values than the previous study of MID. However, different values for MID should be used at different levels of baseline severity. The use of this approach would allow the number of individual gaining at least a minimally important benefit (or harm) from interventions tested in randomised controlled trials.

Background and Significance: Pain drawings could be a means of easily identifying sub-groups of patients who might benefit from different treatment approaches. In particular it has been suggested that they can be used to identify the psychological ‘state’ of patients in terms of distress, depression, somatisation and anxiety.

Purpose/Hypothesis: To systematically appraise data from the literature about the validity and reliability of using pain drawings to evaluate psychological ‘state’.

Method: We searched 12 medical and social science databases, using key words and their derivatives; pain; drawings; diagrams; vis(z)ualisation; body mapping; mannequins and homunculi. We appraised studies directly evaluating the utility of pain drawings and psychological state.

Results: We selected 19 for final inclusion. The majority of studies reviewed focused on low back pain (79%) and secondary and tertiary care (90%). Pain drawings were evaluated against psychological tools testing personality (MMPI), somatisation (MSPQ, IBQ) and psychological states such as depression (Zung) anxiety (SF36) and distress (GHQ).

11/19 studies reported inconclusive results, 8/19 showed a statistical association between drawings and the psychological assessment tool. However the more clinically relevant, sensitivity data ranged from 24–93%, specificity 44–91%, positive predictive values 28–93%, and negative predictive values 35–92%. The range of this data is too wide to be acceptable clinically as predictive of psychological state.

Conclusions: There is insufficient evidence to support the assumption that unusual pain drawings indicate a disturbed psychological state, therefore pain-drawing use as a psychological assessment tool is not recommended.

Background: Chronic musculoskeletal pain (CMP) is a major health problem for the individual and the NHS. It is important to examine the prevalence of and factors associated with it, to identify unmet need and inform the development of interventions.

Purpose: To describe the prevalence of CMP in a community based sample, overall and by location; To describe the factors associated with presence of CMP.

Methods: Population questionnaire survey to 4100 patients registered with 17 Medical Research Council General Practice Research Framework practices. We collected questionnaire data on demographics, presence and location of pain, pain severity, health related quality of life, care seeking and beliefs about pain. We then did univariate and multivariate analyses to identify factors associated with CMP.

Results: Survey response rate was 61% (2509/4100); mean age 52 years (range 18–101); 56% female. CMP prevalence was 47%. One month period prevalence by area was; Lower back 23%; Knee 19%%; Shoulder 16%; Hip/thigh 14% and Upper back 6%. The majority of sufferers consulted their GP (61%), but a large minority (21%) consulted no-one. Factors associated with presence of CMP were being older, leaving school aged 16 or less, not working, having poorer quality of life and experiencing psychological distress (P< 0.05). In a multivariate analysis no factors were independently associated with presence of CMP.

Conclusion: Results demonstrate the significant burden CMP presents in the community and the need to focus interventions on those individuals who may be more likely to suffer. It may be particularly important to consider the needs of those who have not consulted anyone.

Background The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy are involved in the management of 15–20% of people with low back pain (LBP) in the UK (CSAG 1994). Exploratory and descriptive research suggests that the management of non-specific low back pain (LBP) by some members of these groups does not follow best available evidence (RCGP 1999).

Purpose To test the short-term effectiveness (at 6 months) of a directly-posted, contextualised, printed educational package about the evidence-based management of acute back pain on changing UK chiropractors’, osteopaths’ and musculoskeletal physiotherapists’:

1) beliefs and attitudes about LBP

2) reported practice (using a clinical vignette)

Methods A prospective, pragmatic randomised trial was designed to test the effectiveness of the printed educational package versus a no-intervention control. MREC approval was gained and a questionnaire was developed and piloted (n=150). Information was gathered on practitioners’ demographics, their beliefs about LBP (using the HC-PAIRS, Rainville et al 1995) and reported practice based on a vignette of a patient with non-specific LBP (adapted from Bombardier et al 1995, Buchbinder 2001).

A total of 3602 questionnaires were posted to simple random samples of UK registered chiropractors (n=611), osteopaths (n=1367) and physiotherapists (n=1624). Intervention packages were sent to consenting practitioners in March 2004, and the follow-up is planned for September 2004.

Results Good response rates to the baseline questionnaire were obtained, and most respondents were willing to participate in the RCT. Following exclusions based on a priori criteria, 1773/3402 (52.1%) participants were recruited for the RCT: chiropractors 335/604 (55.4%), osteopaths 600/1338 (44.8%) and physiotherapists 838/1460 (57.4%). The RCT methodology and some baseline data will be presented.

Conclusions It is possible to recruit large numbers of healthcare practitioners, within and outside the NHS, to RCTs conducted by post. Whilst the results will be specific to these three professional groups in the UK, this study is believed to be the largest RCT of printed, evidence-based educational material in healthcare, to incorporate a no-intervention control group.

Background: A wide variety of practitioners with different belief systems and approaches treat chronic musculoskeletal pain. In trials of treatments for musculoskeletal pain the focus has tended to be on outcome rather than on understanding the process of care of these treatments. Gaining greater understanding of the process of care in consultations for chronic musculoskeletal pain may shed light on ways to improve patient care, as despite the range of options available many patients are still dissatisfied with their treatment.

Aim: To undertake a systematic review to explore how the beliefs and expectations of patients with chronic musculoskeletal pain and their treating primary and community care practitioners / therapists influence the process of care

Method: A comprehensive search strategy was developed. Databases including MEDLINE, PSYCHINFO, AMED, and MANTIS were searched by two members of the review group working independently. Two members of the group again working independently screened the title and abstract of each reference retrieved for inclusion. Studies were included if they Reported original research

Explored patient’s or practitioners; beliefs and expectations, or both.

Studied patients with chronic musculoskeletal pain, which does not have a known systemic, inflammatory or malignant origin treated in primary or community care.

The full review group resolved disagreements. Full text articles meeting the inclusion criteria will be obtained and coded further into non-randomised studies, randomised studies and qualitative studies. Data abstraction forms will be developed for each type of study. Data abstraction will be undertaken by two members of the group working independently.

Results: 12, 667 articles were identified from the searches of bibliographic databases. At the present time 10 papers have been identified for potential inclusion in the review. The number of full papers to be considered for the review will be reported in this presentation along with the methods for data abstraction and synthesis. This study is ongoing.

Background: Chronic low back pain (CLBP) is a complex health problem often resulting in difficult consultations for both patients and practitioners. Triggers for consultation may include pain severity, impact of pain on health-related quality of life and troublesomeness of pain. Troublesomeness of CLBP may be influenced by patients’ beliefs about their health, such as beliefs about what is acceptable for their age or lifestyle and their perceptions of risk. Therefore, troublesomeness may be a powerful trigger for consultation for CLBP.

Aim: To explore whether troublesomeness of CLBP is associated with consultation.

To determine the most powerful predictors of consultation for CLBP from pain severity, troublesomeness, health related quality of life and psychological distress

Method: Postal questionnaire survey to randomly sampled patients registered with 18 MRC General Practice Research Framework general practices (5400 patients) with two reminders. Questionnaire measures persistent pain (presence and location), pain severity (using the Chronic Pain Grade questionnaire), health related quality of life (EQ5D), psychological distress (GHQ12), troublesomeness of pain on a simple five point Likert scale and patient demographics.

Chi square tests will be undertaken to explore the relationship between troublesomeness of CLBP and consultations for pain in general and with whether consulted mainstream or complementary practitioners. Multiple logistic regression will be undertaken to explore the most powerful predictors of consultation for CLBP.

Results: The survey is ongoing. A full data-set will be available for the presentation. So far 354 questionnaires have been returned, 48% (167/347) of participants report persistent pain of these 62% (104/167) reported at least moderately troublesome CLBP. Of those reporting troublesome CLBP, 74% (76/103) had consulted their GP, 87% (90/103) had consulted other practitioners including physiotherapists, osteopaths and chiropractors, 27% (28/103) had seen a hospital consultant and 17% (18/103) had consulted no one.

Conclusions: These data suggest that troublesomeness is a simple way to improve the ability of epidemiological studies of back pain to contribute to health needs assessment.

Background: Chronic back pain is a complex and costly health problem, treated by a wide range of practitioners, with different belief systems and approaches. Despite the range of options available, many patients appear to be dissatisfied with the treatment that they receive. This may be due to a mismatch between patients’ and practitioners’ beliefs about the cause of the pain and their expectations for treatment.

Objectives: To explore patients’ beliefs about the causes of their chronic back pain and their expectations regarding treatment.

Methods: Group interviews were held with two sample groups of individuals (experiencing moderate and severe chronic pain) to inform a series of qualitative individual interviews with patients and practitioners, exploring beliefs about the causation of chronic pain and expectations for treatment.

Participants were identified from respondents reporting chronic pain in a postal questionnaire survey administered through a local general practice. Participants were allocated to groups according to the severity of their pain, as measured by the Chronic Pain Grade. Those with grades II and I were allocated to group one and those with grades III and IV to group two.

Results: Participants presented sophisticated accounts of their pain and their care seeking. General practitioners were seen as the most appropriate first ‘port of call’, as chronic back pain was viewed as a medical problem requiring a medical solution such as X-rays, referral to hospital specialist and eventually operations. Participants presented to their GP in hope of a medical solution, which was seldom realised. Participants appeared to be resolved to this situation, yet sustained the belief that a different way of communicating their problem to their GP may lead to appropriate action.

Conclusion: There was a marked contrast between the groups on some issues, which will be explored further within this presentation.

Background: Current orthodoxy in the management of acute back pain is that GPs should refer their patients for physical therapy when it does not resolve. Guidelines from the National Institute of Clinical Excellence (NICE) state that patients with simple back pain who have not resumed their normal activities in 3 months should be referred ‘soon’ to a specialist. The evidence underpinning these recommendations was reassessed to consider the question, ‘Is there evidence to justify diverting health service resources to provide these facilities’.

Methods and results: Existing Cochrane and other systematic reviews for commonly recommended conservative treatments for acute back pain were identified through the Cochrane and DARE databases. Where available the Cochrane review was considered definitive. Reviews were identified for ‘advice to stay active’, ‘back schools’, ‘exercise’, ‘massage’, ‘multidisciplinary psychosocial rehabilitation’, ‘manipulation and ‘drug treatments’. Where reviews considered acute back pain and long-term clinical outcomes (not workloss) in studies comparing intervention with no treatment or placebo the reviewers’ conclusions were accepted. In other cases, the reviewers’ assessment of individual relevant papers was considered to be definitive. Massage was the only treatment with evidence of a clinically important long-term effect. This conclusion was based on one small study.

Conclusions: There appears to be inadequate randomised controlled trial (RCT) evidence to justify diversion of NHS resources from proven interventions to expand services for acute simple back pain. An RCT to show that an intervention for acute back pain decreases the proportion disabled at one year from 10% to 5% requires 1,250 randomised participants (a = 0.05, b=0.2). Obtaining RCT evidence to confirm or refute that these interventions will have meaningful health impact may be impossible. We need to consider other ways of obtaining evidence to inform the development of models of care for those with acute back pain.

The traditional biomedical model of managing musculoskeletal problems, such as low back pain (LBP), tends to be pathology driven, in which the aim is to locate an objectively identified disturbance. Appropriate treatment is conceptualised as a physical intervention that will compensate for or correct the identified disturbance. There is growing appreciation of the need to consider other factors, e.g. the meaning of the problem to the patient and professional, his/her experiences, cognitions, motivations and preferences. Improving the understanding about the beliefs and expectations of patients and health professionals is fundamental, since a better understanding of these factors, and any mismatch between professionals and patients, will facilitate improved management.

A multidisciplinary group of researchers (chiropractor, GP, osteopath, physiotherapist, psychologist, sociologist) have developed a collaborative research programme to investigate the decision-making processes in the care of patients with musculoskeletal pain. The programme uses mixed methods, including systematic reviews, survey research, focus groups and semi-structured interviews with patients and practitioners.

Three studies have already started: patient and health professional beliefs and expectations for the causes and treatment of chronic musculoskeletal pain. 1) Funded by the ARC, the purpose is to develop an understanding of the relationships between the different, professional and lay, theoretical frameworks used to diagnose and treat chronic musculoskeletal pain, and how these affect care. 2) Clinicians cognitions in apparently ineffective treatment of low back pain: funded by the ESRC, the purpose is to identify the reasons clinicians continue to treat LBP in the absence of improvement. Research on risk factors for the transition from acute to chronic LBP has concentrated on patient characteristics (psychological and social). It is possible that clinicians’ behaviour, advice and even treatment contribute to maintaining the problem indirectly. 3) Overcoming barriers to evidence-based practice (EBP) in LBP management in the physical therapy professions; funded by the Department of Physiotherapy Studies, Keele University, this study aims to explore the perceptions of physiotherapists, chiropractors and osteopaths, about the opportunities and threats of taking an EBP approach to LBP management and identify methods by which implementation of evidence can be facilitated.

This collaboration is the first of its kind and was developed through shared interests in the decision-making processes in the healthcare of people with musculoskeletal pain. We are keen to share the ideas and work in progress with the wider musculoskeletal pain research community.

There is some evidence to suggest that, spinal manipulation, and general exercise may help patients with back pain.

We are conducting a randomised controlled trial to compare usual care in general practice for low back pain patients with exercise classes, a package of treatment by a manipulator, manipulation followed by exercise and to compare manipulation’s effect in private and NHS facilities.

Participants were recruited from 167 general practices belonging to the Medical Research Council General Practice Research Framework in 15 sites across the UK with a total registered population of 1,140,000 patients. A total of 1,334 correctly randomised participants have been recruited. Mean age of participants is 43 years, 55% are female and Mean Roland Morris score 8. Follow up rates at one and three months are 83% and 78% respectively. Follow up finishes in May 2002

It is possible to recruit large numbers of back pain patients for trials of physical therapy in primary care.

There is a desire to reduce the economic burden of low back pain. This in is part because of the 226% increase in invalidity benefits paid out for spinal disorders in the ten years to 1994/5. This paper examines the effect of the change from Invalidity Benefit to Incapacity Benefit in 1995, and considers the utility of these figures as a means of assessing changing patterns of back pain disability.

Data were obtained from the DSS on how benefit data were collected and numbers of days of Invalidity/Incapacity Benefits that were paid from 1983/4 to 1998/9. The data suggest that since 1995 that the rate of spinal disability has fallen and has now been stable at 90 million days per year for four years. The headline Incapacity Benefit figures have a very loose relationship with health impact of low back pain. Around 30,000 people per year make the transition to claiming long term Incapacity Benefit from claiming short term Incapacity Benefit.

Incapacity Benefit figures are of little utility in assessing changes in low back pain disability. Numbers making the transition to Long Term Incapacity Benefit may be a more useful indicator.