The Cochrane Collaboration has produced three new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner. These are relevant to a wide range of musculoskeletal specialists, and include reviews in lateral elbow pain, osteoarthritis of the big toe joint, and cervical spine injury in paediatric trauma patients.

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Background. Ankle fractures are extremely common but unfortunately, over 20% fail to obtain good to excellent recovery. For those requiring surgical fixation, usual-care post-surgery has included six-weeks cast immobilisation and non-weightbearing. Disuse atrophy and joint stiffness are detrimental sequelae of this management. While rehabilitation, starting at two-weeks post-surgery is viewed as safe, the literature contains methodological flaws and a lack of focus on early exercise, perpetuating the controversy over the effectiveness of early exercise interventions. Objectives. Our objectives were to determine if following operative fixation for Weber B fracture, the physiotherapy intervention, early motion and directed exercise (EMADE), applied in the clinical setting, were superior to Usual-care at 12-weeks (primary outcome) and 24-weeks. Design and Methods. We undertook a pragmatic-RCT, recruiting 157 surgically fixed Weber B ankle fracture patients, to establish if EMADE was superior to the Usual-care of 6-weeks immobilisation. The EMADE physiotherapy intervention (between week-2 and 4 post-surgery) utilised a removable cast and combined non-weightbearing progressive home exercises with manual therapy, advice and education. The primary outcome measure was the OMAS at 12-weeks. Results. 130 participants returned their 12-weeks post-surgery data, exceeding the 60/group threshold set by the a-priory power calculation. Group OMAS means were; 62.0 and 48.8 (SD 21, 22.5) EMADE, Usual-care respectively, yielding a clinically meaningful mean difference of 13.2 on the OMAS and a statistical difference (95% CI p< 0.001, 5.66 to 20.73). Both clinically meaningful and statistically significant findings were maintained at week-24. There were no intervention related or unexpected adverse events, including instability. Conclusions. This clinic set pragmatic-RCT yielded both clinical and statistical outcomes at week-12 in favour of the EMADE physiotherapy intervention over the Usual-care of 6-weeks immobilisation, in surgically fixed Weber B ankle fracture patients. These positive findings were maintained at week-24 and justify EMADE physiotherapy as a viable treatment option

Aims

Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data.

Aims

A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care.

Background. Evidence supports that dysfunction of descending inhibition (endogenous analgesic (EA) modulation) contributes towards chronic pain conditions. Research suggests that manual therapy may influence EA modulation; however, this is poorly understood. Trials testing the effect of sustained digital pressure, a commonly used manual therapy technique, using pain pressure threshold (PPT) would give us a better understanding of the influence of manual therapy on EA modulation. A measurement of PPT has been shown to be most effective using fingertip pressure due to the palpatory feedback of symptomatic tissues. Design. A cross-sectional observational study, utilizing a repeated measure approach. Aim. The aim of this research study is to provide preliminary data on the variability of pressure in sustained fingertip pressure in comparison to algometer guided pressure. Methods. Utilizing a pressure algometer, 26 participants were used to test the variability of fingertip pressure in comparison to algometer guided pressure, over 120 seconds. In a randomized order and utilizing two sheets of skin, participants tried to attain, and sustain, a targeted pressure. In the fingertip pressure condition, participants were blinded to the exerted pressure. Conclusion. It was determined that, on average, participants were able to attain the target pressure, but this was highly variable from trial to trial. The test-retest measurement concluded that participants' accuracy was reproducible. Participants were not reproducible in variability when completing the test-retest measurement. There was a relatively higher variability with the lower pressures tested. The order in which the trial was performed, and type of skin did not affect the variability. It was concluded that, whilst some practitioners appear to have a high degree of accuracy with low variability of sustained finger-tip pressure, across a sample population this was not the case bringing into question the mechanism of effect of this common manual therapy technique. Conflict of interest: None. Funding: None

Purpose & Background. The ability to jump higher is a key factor for athletic performance and relies on many factors including spinal movement and trunk muscle activity. Manual therapy including Mulligan' Sustained Natural Apophyseal Glide (SNAG) techniques are proposed to increase spinal movement and thus function. The evidence pf the effect of manual therapy on muscle activity is limited. We aimed to determine the immediate effects of an extension SNAG on the lower lumbar spine on jump height and rectus abdominis (RA), external oblique (EO), multifidus (M) and iliocostalis Lumborum (IL) muscle activity during the flight phase of vertical jump compared to a placebo intervention (flat hand pressure). Method. Eighteen healthy participants (16 males, age 28.11±5.01 years, weight 70.58±11.9 kg, height 1.70±0.07m, body mass index 24.28±3.30)from Cardiff University were randomly allocated to either an extension SNAG or placebo intervention. Surface Electromyography was normalised to maximum voluntary contraction and was collected during the flight phase of the jump and jump height was measured using jump and reach test. Results. There was a significant increase (p=0.01) in jump height for the SNAG group. No significant differences in RA, EO, M, IL muscle activity was noted between SNAG and placebo interventions In EO, LES and M descriptive analysis showed a decrease in muscle activity in on average 14 of the subjects. Conclusion. SNAG mobilisation can produce an immediate increase in jump height but no significant changes in muscle activity in healthy subjects. Further work is warranted in subjects with low back pain. No Conflict of Interests. No funding was obtained

Background. Chronic pain is a complex condition that demonstrates better outcomes in multidisciplinary rehabilitation, typically delivered to groups of patients by tertiary healthcare teams. An inter-disciplinary pain management course for individual patients was developed to increase the scope of physical therapists working in primary care by integrating osteopathic manual therapy with psychological interventions from Acceptance and Commitment Therapy (ACT), a form of ‘3rd wave’ Cognitive Behaviour Therapy. Method and Results. A single cohort study with pre-course (n=180) and post-course (n=79) self-report measures (44% response rate) evaluated six week interventions which combined individual manual therapy with self-management, delivered by teams of qualified and student osteopaths. Data included: quality of life (European Quality of Life Questionnaire); pain, mood and coping (Bournemouth Questionnaire); psychological flexibility (Revised Acceptance and Action Questionnaire); and mindfulness (Freiburg Mindfulness Inventory). Participants were predominantly female (68%), unemployed (59%), with an average age of 49 and pain duration of more than 12 months (86%). Commonly reported symptoms were low back pain (82%), neck pain (60%) and multiple sites (86%). At six months, there were statistically significant improvements in all four outcome measures (p<0.0005), with promising effect sizes in quality of life and pain coping (r=0.52) which appeared to be mediated by changes in psychological flexibility. Conclusions. This innovative, integrated, patient-centred chronic pain management course demonstrated promising outcomes when delivered by osteopaths with varying experience. Randomised clinical trials are now needed to assess outcomes in comparison with standard care, and optimal ways of training physical therapists to deliver effective psychological interventions. Conflicts of interest: No conflicts of interest. Sources of funding: A Department of Health ‘Innovation, Excellence and Strategic Development’ (IESD) grant for the Voluntary Sector Investment Programme (AIMS Ref: 2527190; ISRCTN: 04892266). The results of this study are being submitted for publication in the International Journal of Osteopathic Medicine and will be presented at the COME Collaboration Osteopathic Conference in Barcelona on September 30th 2017 and at the Therapy Expo 2017 at the NEC in Birmingham on November 22nd 2017

Background and objectives. Numerous approaches are recommended for the management of non-specific neck pain (NS-NP). However, the extent to which approaches are used is unclear. This survey investigated current UK physiotherapists' measurement and management of patients with NS-NP. Methods and results. Physiotherapists were invited to participate in an online survey if they were practicing in the UK and had experience of managing NS-NP. 2101 responses were received. Analysis of the results indicated the overall popularity of active treatment approaches with 84% and 61% of respondents employing exercise and patient education respectively. 48% of respondents reported using a multimodal approach (that is, combination of exercise and manual therapy with/without patient education). Over a third of respondents reported not using outcome measures (OMs) for NS-NP. Of the two-thirds who reported using OMs, the majority reported using pain and range of motion measures. Physical and functional limitations, psychological distress, and quality of life constructs, which are frequently associated with NS-NP, were rarely measured. Conclusion. The active interventions most frequently used in the management of NS-NP were supported by moderate to strong evidence but a variety of other commonly used approaches have limited, unclear or no evidence of efficacy. Multimodal treatment approaches that are supported by strong evidence of efficacy are less commonly used. Physiotherapists in the UK are inadequately evaluating NS-NP. Research and guidelines are needed to reduce the use of ineffective interventions, promote the use of multimodal care and develop high quality outcome measures that are relevant and feasible for use in clinical practice. Keywords. Health, survey, neck pain, non-specific, rehabilitation. Conflicts of interest: None. Sources of funding: None

Summary. Each patient received Cognitive Reassurance appropriate for and proportionate to his/her capacity through evidence informed explanation/education to enhance effective self-care and realistic self-management. Background and pathway. Changes to back and neck pain commissioning by our CCG required GPs not to refer to manual therapy until six weeks and upgrade GP care beyond that previous. 100 consecutive patients requesting GP appointment reporting back/neck pain were directed to a pragmatic service provided by an experienced manual therapy practitioner. Cognitive Reassurance reflecting evidenced informed biopsychosocial and salutogenic thinking was given at initial consultation/assessment. Patients were contacted at 10 and 20 days to ascertain their status. One sub-group suggested an opportunity for long-term follow-up. Pilot Objectives. Providing Cognitive Reassurance for achieving greater levels of patient engagement with self-management. Demonstrate full clinical triage by primary care providers is effective/practical. Demonstrate a need for appropriate contracting models. ————————–. Outcomes 100 patients. Wait time. 2d. Inappropriate self-referral directed to GPs. 25%. DNAs. 7%. Referral for medication –. 28%. Prescribed AQP manual therapy. 35%. Outcomes 36 patients decided at 20 days no further treatment needed . Treatments averaged. 1.8/pt (Range 0–4). Patients deciding no treatment needed beyond initial consultation. 4%. Patients requesting further consultation during the 12 months following:. 4%. Conclusion. Patient experience measured by an external moderator showed 94% highly satisfied or satisfied. Clinical triage was acceptable to patients and GPs. Adapting to the needs of each patient requires a more pragmatic model of contracting to be created. The opportunity for a further pilot are considered

Background and purpose of the study. Dropped Head Syndrome (DHS) is characterized by a chin on chest flexion neck deformity that is passively correctible. The condition is rare and literature on surgical and conservative management is focused on case studies and theoretical evidence. Purpose of the study. The purpose of this study was to investigate the value of physiotherapy in the treatment of DHS by case series analysis. Methods. The effectiveness of physiotherapy was examined in six patients, some of whom were still under treatment and evaluation. Photographs were taken of some of the patients in order to gain further insight into the condition. Conservative management was provided in the form of physiotherapy and the use of a collar. Physiotherapy treatment involved a focus on sagittal balance and treatment included education, manual therapy, exercises, postural and mirror work and modification of sitting and lying positions. Results. In the first completed case study the patient reported an improvement in the ability to correct their deformity and improved appearance following physiotherapy. Photographs taken before and after treatment appear to support this. At one year follow up this patient still followed the advice given and did the exercises taught and reported to find them beneficial in managing DHS. The same approach was applied with the other patients in the case series with treatment and analysis evolving as further insight into the condition was gained. Conclusion. The case series supports other reported cases in the literature which report benefit from the use of physiotherapy as well as raising questions around the potential causes and management of DHS. Conflicts of interest – No conflicts of interest. Sources of funding – No funding obtained

Background to the study:

The use of Patient Reported Outcome Measures (PROMs) to measure effectiveness of care, and supporting patient management is being advocated increasingly. PROMs data are often collected using hard copy questionnaires. New technology enables electronic PROM data collection.

Background:. Low back pain (LBP) is the most common symptom encountered by osteopaths in the UK and affects a third of the UK population each year. Guidelines recommend using the biopsychosocial (BPS) model for non-specific LBP but it remains unclear what the BPS model actually is and how it applies in osteopathy. The aim of this study was to define the factors included in a BPS approach for non-specific LBP in a manual therapy using a systematic search and scoping review. Methods:. An online search was performed on seven electronic databases. Guidelines and systematic reviews published after 2004 were included. 10% of the articles randomly selected were analysed by second reviewer to assess consistency of information extraction. Disagreements were discussed between the two reviewers. Mediation from the third author was not required. Results:. A total of 539 articles were identified. 37 articles were included: 13 guidelines and 24 systematic reviews. 70 BPS factors were reported, 15 were excluded, resulting in 55 BPS factors identified. The BPS model is helping clinicians to be more aware of the importance of the patients' context in their pain experience and the risk of them developing chronic pain. Psychosocial factors were identified as better predictors of poor recovery than examination findings. Out of the 55 factors drawn from the literature that are predictors of poor recovery, 13 were biological factors. While it is of upmost importance to assess and manage psychosocial issues, it may be time to include biological factors more explicitly as possible obstacles to recovery

Background. A proportion of patients with low back pain fail to respond to conventional medicine, physical therapy or surgery. Neurophysiological changes occur in chronic pain and research shows that Mindfulness and ‘3. rd. wave’ Cognitive Behavioural Therapy can help patients with long-term musculoskeletal conditions to live more actively, despite pain. This paper describes the development of the three year ‘OsteoMAP’ project (Osteopathy, Mindfulness and Acceptance Programme) to expand the scope of primary care by integrating these psycho-educational interventions into osteopathic practice. Methods. A before and after design is being used. Patients with disabling pain for more than six months attend a course of six, individual, one hour sessions, integrating mindfulness and acceptance-based exercises with manual therapy. Questionnaire data collected at the course start and after six months, analysed by an independent group, includes pain-related behaviour (Bournemouth Questionnaire), quality of life (EQ5D), self-efficacy (PSEQ) and mindfulness (MAAS). Results. The project started in June. Follow-up data is not yet available. Qualitative data from a pilot study will be presented. It supports the preliminary hypothesis that touch and osteopathic techniques combined with psycho-education and mindful movement may increase patients' embodied awareness, promote active self-management, and guide more patient-centred manual interventions. Conclusion. Despite the challenges of balancing practitioner-led manual therapy treatment with more collaborative acceptance-based interventions which aim to empower patients' active self-management capabilities, there appear to be potential benefits in expanding the scope of community-based healthcare for patients with long-term low back pain that is unlikely to be resolved by physical interventions alone

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. 2. To develop a training package for physiotherapists on how to use the DSP. 3. To encourage and evaluate the informed shared decision making (ISDM) process between patients and physiotherapists during consultation. Method. We developed a DSP informed by existing research and collaboration with physiotherapists, patients and experts in the field of decision aids and LBP. We did six pieces of exploratory work: literature review; 2009 NICE LBP guidelines review; qualitative screening of transcripts of interviews of LBP patients; focus groups (patients); nominal group (physiotherapists), and Delphi study (experts). We collated these data to develop the DSP. We also developed a training package for physiotherapists. Results. We developed a LBP patient resource for use prior to their first consultation and a training package for physiotherapists. The DSP contained information on acupuncture, structured group exercise, manual therapy and cognitive behavioural approach. LBP patients would expect these treatment options to be offered to them at their initial consultation. The training package for physiotherapists was on DSP use and communication skills during consultation. Conclusion. We have developed an evidence and theory informed Decision Support Package and physiotherapists training. We are currently piloting its use in one NHS Trust prior to running a pilot RCT (N=150) to test is effect on improving patient satisfaction with LBP patients' treatment choices. Conflicts of Interest. None. Source of Funding. National Institute for Health Research- Research for Patient Benefit (NIHR-RfPB). This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting