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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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