Background: Many studies have investigated predictors of outcome in low back pain (LBP) patients, including the role of coping. However, the relative importance of different coping strategies is unclear.

Objective: To systematically review prospective cohort studies to determine the role of specific coping strategies in the prediction of LBP outcome in primary care settings.

Methods: Medline, PsychINFO, and Embase electronic databases were searched from inception to April 2008. Prospective cohort studies focusing on aspects of coping with LBP in settings relevant to primary care were included. Studies were excluded if they focused on specific populations (e.g. nursing staff) or patients aged under 18 years, or if they were not published in English. Prior to data extraction, studies were quality assessed and coping strategies were conceptualised as either cognitive or behavioural.

Results: 782 potentially relevant articles were identified, of which 34 were included with an average follow-up of 10 months. There was considerable variability in the prognostic risk factors measured. Fear avoidance beliefs were most frequently associated with outcome. Negative affect, anxiety and depression, use of active or passive coping strategies, and catastrophizing were also commonly associated with outcome. Behavioural coping strategies were measured by only 5 of the 34 studies.

Conclusion: Despite considerable heterogeneity, most studies were of acceptable quality, enabling the identification of several key coping strategies predictive of LBP outcome. However, the majority of studies focused on cognitive coping factors only. Therefore further research is needed, particularly to investigate the influence of behavioural coping strategies on LBP outcome.

Bone allograft use in trauma and orthopaedic surgery is limited by the potential for cross infection due to inadequate acceptable decontamination methods. Current methods for allograft decontamination either put the recipient at risk of potentially pathogenic organisms or markedly reduce the mechanical strength and biological properties of bone. This study developed a technique of sterilization of donor bone which also maintains its mechanical properties.

Whole mature rat femurs were studied, as analogous to strut allograft. Bones were inoculated by vortexing in a solution of pathogens likely to cause cross infection in the human bone graft situation. Inoculated bones were subjected to supercritical carbon dioxide at 250 bar pressure at 35 degrees celsius for different experimental time periods until a set of conditions for sterilization was achieved. Decontamination was assessed by vortexing the treated bone in culture broth and plating this on suitable culture medium for 24 hours. The broth was also subcultured. Controls were untreated-, gamma irradiated- and dehydrated bone. Mechanical testing of the bones by precision three-point bending to failure was performed and the dimensions and cross-section digitally assessed so values could be expressed in terms of stress.

Mechanical testing revealed bone treated with supercritical carbon dioxide was consistently significantly stronger than that subjected to gamma irradiation and bones having no treatment (due to the minor dehydrating effect of the carbon dioxide). Terminal sterilization of bone is achieved using supercritical carbon dioxide and this method maintains the mechanical properties.

The new technique greatly enhances potential for bone allograft in orthopaedic surgery.

Introduction: Guidelines for the management of LBP recommend diagnostic triage where most cases are classified ‘non-specific’, although studies have suggested this term is unsatisfactory to patients and practitioners. We aimed to describe the explanations for LBP used by general practitioners (GPs) and physiotherapists (PTs) in the UK.

Methods: Content analysis of an open question in a cross-sectional survey of GPs and PTs, based on a vignette of a patient with non-specific LBP. Respondents provided their explanation for the patient’s LBP in the language they would use with the patient. A coding schedule was developed (AB and NF) and applied to all data (AB).

Results: Survey response was 22% (n=446) for GPs and 55% for PTs (n=1091, 580 had seen a patient with LBP in the preceding 6 months were analysed). Responses to the open question were provided by 430 GPs and 560 PTs. Both professions used predominantly biomedical explanations (68% GPs, 51% PTs) such as tissue labels (e.g. ‘muscle’, ’disc’), ‘degeneration’ and ‘wear and tear’. PTs often gave lifestyle factors as reasons for LBP, with ‘work’ (19% PTs) and ‘posture’ (26% PTs) the most common. Only 2.8% of GPs and 6.4% of PTs would explain that the cause of LBP is unknown and use of the term ‘non-specific LBP’ was rare (0.9% GPs, 1.6% PTs).

Conclusion: Explanations for LBP used by GPs and PTs remain predominantly biomedical. The term ‘non-specific LBP’ is used very rarely. Further research needs to investigate appropriate language that explains non-specific LBP that is acceptable to both practitioners and patients.

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.

Introduction: Previous studies have shown that advice given to patients with low back pain (LBP) by health care practitioners (HCPs) such as physiotherapists (PTs) and general practitioners (GPs) is not in line with guidelines about encouraging early return to work. The aim of this study was to describe the attitudes, beliefs and reported practice behaviour of UK GPs and PTs about LBP and to explore associations between these.

Methods: A national cross-sectional survey of GPs and PTs (n=4000), including an attitudes measure, the Pain Attitudes and Beliefs Scale (PABS.PT), which measures ‘biomedical and behavioural orientations of HCPs. A vignette describing a patient with non-specific LBP, who had a four-week absence from work, was used to capture reported clinical management. This presentation will focus on the findings about work advice.

Results: Response rates were 22% (n=446) for GPs and 55% (n=1091) for PTs. Almost one third of GPs (32%) and one in four PTs (25%) reported that they would advise the vignette patient to remain off work. The HCPs advising the vignette patient to remain off work had significantly higher biomedical (F_1,988=78.85, p< 0.001) and lower behavioural (F_1,981=31.89, p< 0.001) scores on the PABS.PT than those suggesting a return to work.

Conclusion: An association between attitudes and reported practice behaviour was apparent, with HCPs operating within a predominantly biomedical framework being more likely to advise a patient with back pain to stay off work. Further research should explore how HCPs’ attitudes might be changed and whether this results in changes in work recommendations.

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.

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.