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: 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 & Objectives: The physical therapy professions (musculoskeletal physiotherapy, osteopathy and chiropractic) are involved in the management of low back pain (LBP) in approximately 15–20% of all cases in the UK. LBP accounts for between 50% and 67% of the workload of this group. Initiatives to implement evidence-based practice (EBP) in the UK have included the development of national multidisciplinary guidelines for acute LBP, the target audience of which include all three physical therapy professions.

The objective of this study was to explore and identify perceptions, attitudes and beliefs held by practitioners from these three professional groups about their approaches to the care of LBP patients.

Methods & Results: An exploratory study was used to investigate beliefs and attitudes of practitioners, concerning factors that potentially influence practice. Particular attention was given to practitioners’ thoughts on the opportunities and threats of taking an EBP approach to LBP management, and identifying other factors that influence their clinical behaviour with LBP patients. Following ethical approval and informed consent, five focus groups were conducted with members of the physical therapy professions. Audio recordings of each focus group were made, and subsequently transcribed verbatim. Transcript data were analysed in line with a grounded theory approach to produce relevant themes.

Preliminary categories of themes that emerged were: Evidence; Perceived Knowledge; Personality Characteristics; Professional Identity; The Patient; and Motivation. Of particular interest, practitioners seem to have mixed opinions with regard to basing their practice on evidence from external research.

Conclusions: Practitioners’ views of EBP in LBP management are diverse and it cannot be presumed that all practitioners view EBP as desirable. They seem to have mixed opinions with regard to basing their practice on evidence from external research. Practitioner behaviour, and thus the implementation of EBP may relate to practitioners’ beliefs and attitudes.

Background: Psychosocial factors have been shown to be important in the progression from acute low back pain (LBP) to chronic disability. Early identification of individuals at risk of developing chronic disability is important. The aim of this study was to determine if physiotherapists recognise when patients with LBP are at risk of chronicity due to psychosocial factors. A secondary aim was to explore the advice they give to patients about work and activities.

Methods: A cross-sectional, descriptive survey of practising, musculoskeletal physiotherapists was designed and completed. Vignettes were written based on three acute LBP patients at low, moderate or high risk of chronicity due to psychosocial factors as measured by the Acute Low Back Pain Screening Questionnaire. The vignettes were tested by an expert panel (n=6) and incorporated into a postal questionnaire, which was piloted (n=50) and then sent to a simple random sample of experienced musculoskeletal physiotherapists in the UK (n=900). After one reminder, 20% of non-responders were sent a further questionnaire (n=80) to explore the non-response bias. Data were analysed using the Statistical Package for the Social Sciences (SPSS version 11).

Results: The response rate was 57.7% (n=518). The sample consisted of experienced physiotherapists (mean of 18 years postgraduate experience) working across all practice settings. Most correctly rated the chronicity risk of the low and high risk patient cases (56.6% and 89.1 %), but the moderate risk case appeared to cause some difficulty. Chronicity rating appeared to be more highly associated with biomedical factors such as the perceived pathology. Most therapists (95%, 88.6% and 85.8%) reported they would recommend some limitation of activity for each case.

Conclusions: Most physiotherapists recognise when patients are at high and low risk of developing chronicity, but this seems to be influenced more by biomedical than psychosocial factors. Even when therapists recognise that a patient is at high risk of chronicity, many recommend the patient limit their activity levels and not work. Many physiotherapists may be providing advice, which aids the progression to chronicity. Research is needed to explore how to facilitate a change in therapists’ beliefs and practices.

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: It is universally acknowledged that psychological distress in chronic low back pain (LBP) is commonplace and the early identification of such distress is increasingly being advocated as an important aspect of LBP assessment. The Distress and Risk Assessment Method (DRAM) is a screening tool, using the Modified Zung (MZ) and Modified Somatic Perception Questionnaires (MSPQ), developed to provide a simple classification of patients with LBP. Patients are classified as normal, at risk of developing distress, and those who are distressed (Distressed Depressive {DD} and Distressed-Somatic {DS}). The DRAM was used to screen LBP patients for entrance to an RCT examining different physiotherapy regimes for recurrent LBP.

Methods: Patients referred for physiotherapy, at three hospitals within South Birmingham, with a diagnosis of recurrent LBP were screened using the DRAM and Roland Morris Disability Questionnaire (RMDQ). Distressed patients were excluded from the trial as psychological distress has been shown to be associated with an increased risk of poor treatment outcome.

Results: 214 patients were screened for entrance to the trial with 69 (31%) excluded on the basis of their DRAM scores (DD=39, DS=30). Excluded (distressed) patients (n=69) had a mean MZ score of 33.30 (SD: 9.28, range= 7 to 56), with patients entered into the trial (non-distressed, n=95) having a mean of 18.12 (SD: 7.83, range=3 to 36). The mean MSPQ score for the distressed patients was 12.70 (SD: 5.69, range=0 to 26), and for the non-distressed patients was 4.37 (SD: 3.67, range= 0 to 22). RMDQ scores (functional disability) were higher for the distressed group (mean 14.09 [SD: 4.80], range=3 to 23) than the non-distressed group (mean 10.52 [SD: 4.22], range= 5 to 21).

Conclusions: The results indicate that approximately one third of patients referred for physiotherapy at the units studied exhibited a level of distress that increased their relative risk of poor outcome by 3 to 4 times. The impact of these results has been to slow the recruitment to the ongoing RCT. The clinical implications are that screening this group of patients may indicate when liaison with clinical psychologists is appropriate and possibly identify patients who are too distressed to respond to physiotherapy.

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.