Purpose and background

Recent research has identified possible functional biomarkers in chronic, nonspecific back pain (CNSLBP) based on intervertebral kinematics. Although excessive IV-RoM is no longer regarded as a clear motion abnormality, some studies have found subtle kinematic measures such as mid-range laxity and motion sharing inequality to be greater in CNSLBP patients. We studied a group of such patients who were investigated following failed interventions in terms of these subtle measures.

Purpose and background

Static plain radiographs at the end of uncontrolled bending are the current standard of care for measuring translatory slip in back pain patients. Quantitative fluoroscopy systems (QF) that employ standardised bending protocols have been found to improve precision and reduce dose, but comparative data are lacking. We compared 4 QF methods with static radiographs in a control population, calculating ranges, population variation and measurement errors over 6 weeks.

Background

Dynamic measurement of continuous intervertebral motion in low back pain (LBP) research in-vivo is developing. Lumbar motion parameters with the features of biomarkers are emerging and show promise for advancing understanding of personalised biometrics of LBP. However, measurement of changes over time inevitably involve error, due to subjects' natural variation and/or variation in the measurement process. Thus, intra-subject repeatability of parameters to measure changes over time should be established.

Background and Purpose:

The inability of intervertebral joints to resist perturbation due to laxity is traditionally measured in cadaveric specimens as their neutral zones (NZ). However in patients, quantitative fluoroscopic (QF) examinations substitute the Initial Attainment Rate for this. If these two measures correspond sufficiently, a clinical method for measuring segmental instability is possible. This study explored this by determining the criterion validity of the Initial Attainment Rate against the Dynamic NZ in an unloaded multilevel porcine spine.

Purpose and Background:

Despite the rise of back pain disability, objective mechanical assessment is generally lacking. Quantification of intervertebral kinematics using fluoroscopy provides objective measurement, but its use in clinical practice has not been assessed. This study reviewed cases referred to one UK site for lumbar spine quantitative fluoroscopic (QF) examinations and compared the reasons for referral with the findings reported.

Purpose and Background:

The spread of upright MRi scanning is a relatively new development in the UK. However, there is a lack of information about whether weight bearing scans confer any additional useful information for low back conditions.

Purpose and Background:

To compare static and dynamic lumbar intervertebral ranges of motion (IV-RoM) in patients with chronic, nonspecific low back pain with upper and lower cut off values derived from healthy controls when variability and measurement errors were reduced.

Measurements from functional radiographs suffer from high variability and measurement errors, making cut off values for excessive or insufficient motion problematical. This study compared maximum lumbar IV-RoM and maximum IV-RoM at any point in continuous motion sequences in patients with chronic, non-specific back pain with upper and lower cut off values for L2 to L5 from matched controls using quantitative fluoroscopy, where variation and measurement errors were reduced.

Background and purpose

Investigating inter-vertebral biomechanics in vivo using end-of-range imaging is difficult due to high intra subject variation, measurement errors and insufficient data. Quantitative fluoroscopy (QF) can reliably measure continuous motion but may suffer from contamination from uncontrolled loading and muscle contraction which compromises comparisons between studies and limits interpretation of results. This study presents the methods used to overcome these limitations.

Study Purpose

A preliminary study to compare continuous sagittal plane lumbar inter-vertebral kinematics in 10 healthy volunteers in recumbent and weight bearing configurations using quantitative fluoroscopy.

Background and Purpose: The majority of non-specific low back pain is presumed to be mechanical in origin. Many interventions, including manipulation, mobilisation, core strengthening and rigid/motion preserving surgery rely on the premise that intervertebral motion is related to pain in some patients, however, there is no reliable in vivo experimental evidence for this. We compared continuous intervertebral motion from quantitative digital fluoroscopic sequences in asymptomatic controls and patients with chronic non-specific low back pain to investigate associations between pain and intervertebral motion.

Methods: Thirty asymptomatic volunteers and 21 patients with chronic non-specific low back pain underwent passive, controlled, recumbent lateral bending motion during video-fluoroscopic screening. These provided 90 and 44 intervertebral levels from L2-L5 respectively for analysis. Vertebrae were registered digitally and automatically tracked throughout the motion. Inter-vertebral rotation phenotypes for each left-right sequence were obtained and analysed for stiffness (inter-vertebral motion of less than 3o), lax appearance and paradoxical motion. A similar population underwent sEMG studies to determine if muscle activity was present during controlled passive recumbent motion. Associations between pain and stiffness, lax appearance and paradoxical motion were calculated from chi-squared distributions. A subset of patients also had MR scans to assess disc degeneration.

Conclusion: Stiffness was observed significantly more frequently in patients with pain, as was paradoxical motion and lax appearance. sEMG activity was very small throughout motion in both groups. MR degeneration was not associated with stiffness in patients. Results must, however, be regarded as preliminary as greater normative referencing, group matching, more extensive kinematic analysis, flexion-extension, weight-bearing, and clinical outcomes studies are needed.

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 – 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.

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.

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.

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 – 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.

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.

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: 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.