Purpose and background:

Implementation fidelity (IF) is the extent to which an intervention is implemented as intended by its developers, and increases confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. The aim of this study was to evaluate the IF within a behaviour-change self-management intervention for people with chronic low back pain and/or osteoarthritis, consisting of six weekly sessions (SOLAS ISRCTN49875385).

Background

Medical Research Council (MRC) guidelines recommend applying theory within interventions to explain how behaviour change occurs. Guidelines endorse self-management of chronic low back pain (CLBP) and osteoarthritis (OA), but evidence for its effectiveness is weak. This literature review aimed to determine the use of behaviour change theory and techniques within group-based self-management randomised controlled trials for chronic musculoskeletal pain, including CLBP and OA.

Background

Implementation fidelity is the extent to which an intervention is delivered as intended by intervention developers, and is extremely important in increasing confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. Growing demands on healthcare services mean that multiple condition interventions involving highly prevalent musculoskeletal pain conditions such as chronic low back pain (CLBP) and/or osteoarthritis (OA) are of increasing clinical interest. This is the first in-depth review of implementation fidelity within self-management interventions for any musculoskeletal pain condition.

Background

Osteoarthritis (OA) and chronic low back pain (CLBP > 12 weeks duration) are two of the most common and costly chronic musculoskeletal conditions globally. Healthcare service demands mean that group-based multiple condition interventions are of increasing clinical interest and a priority for research, but no reviews have evaluated the effectiveness of group-based physiotherapy-led self-management interventions (GPSMI) for both conditions concurrently. Rapid review methodologies are an increasingly valid means of expediting knowledge dissemination and are particularly useful for addressing focused research questions.

Background and purpose

Sleep disturbance is frequently reported by people with chronic low back pain (CLBP >12 weeks), but there is limited knowledge of their sleep quality compared to healthy people. While disturbed sleep influences patients' mood, quality of life and recovery, few studies have comprehensively investigated sleep in CLBP. This study investigated differences in sleep profiles of people with CLBP, compared to age- and gender matched controls over seven consecutive nights.

Purpose

This pilot study tested the feasibility of a self-determination theory-based communication skills training programme designed to increase physiotherapists' psychological needs supportive behaviour when treating patients with chronic low back pain (CLBP>12 weeks).

Background and purpose

Sleep disturbance is a prevalent symptom in people with chronic low back pain (CLBP >12 weeks), but there is currently no knowledge of the effectiveness of physiotherapy for this problem. This study evaluated the feasibility of a randomised controlled trial (RCT) exploring the effects of physiotherapy on sleep disturbance in CLBP [Current controlled trial ISRCTN 54009836].

Background: Activity advice and prescription are commonly used in the management of low back pain (LBP). However, no research has assessed whether objective measurements of physical activity predict outcome, recovery and course of LBP.

Methods: One hundred and one patients with acute LBP were recruited into a longitudinal cohort study. Each participant completed the Roland Morris Disability Questionnaire (RMDQ), Visual Analogue Scale and a “simple” activity question, detailing whether they had resumed full “normal” activities (Y/N), at baseline (T0) and 3 months (T1); Baecke Physical Activity Questionnaire, Fear-Avoidance Beliefs Questionnaire and the 12-item General Health Questionnaire at T0. Physical activity was measured for 7 days at T0 and T1 with an RT3 accelerometer and the seven day physical activity recall questionnaire (7d-PAR).

Results: The only significant predictor of RMDQ change was RMDQ score at T0 (p < .0001). Physical activity change did not predict RMDQ change in both univariate (p = 0.82) and multivariate analysis (p = 0.84). Paired t-tests found a significant change in RMDQ (p < .0001) and return to full “normal” activities (p < .0001) from T0 to T1, but no significant change in activity levels measured with the RT3 (p = 0.56) or the 7d-PAR (p = 0.43). RMDQ change (OR 1.72, p = 0.01) and RMDQ at T1 (OR 0.65, p = 0.04) predicted return to full “normal” activities at T1.

Conclusions: These results question the role of physical activity in LBP recovery and the assumption that activity levels change as LBP symptoms resolve.

Conflicts of Interest: None

Sources of Funding: This research was supported by a University of Otago Establishment Grant

Background and Purpose: Current clinical guidelines recommend supervised exercise as a first-line treatment in the management of low back pain (LBP). To date studies have not used objective forms of measuring changes in free-living physical activity (FLPA). The aim of this study was to compare FLPA between two groups who received either supervised exercise and auricular acupuncture (EAA) or exercise alone (E).

Methods: 51 patients with non-specific LBP [mean±SD=42.8±12.4 years] wore an accelerometer for 7 days at baseline, end of the intervention (week 8) and follow up (week 25). FLPA variables were extracted: % time (hours) spent in postures; daily step count and cadence. Data were analysed using SPSS (v15). Repeated measures ANCOVA were performed using a mixed linear model.

Results: There was no difference in daily step count between the two groups at any time point (E, mean±SD, week 1, 8197±2187; week 8, 8563±2438, week 25, 8149±2800; EAA, mean±SD, week 1, 8103±1942; week 8, 8010±2845, week 25, 8139±1480, p=0.9) or cadence. No differences in postures were noted, apart from time sitting/lying which was shorter at week 25 in the E group (p=0.006).

Conclusions & Implications: Supervised exercise classes, with or without acupuncture, do not produce changes in FLPA in the short term or longer term in people with LBP. This suggests more effective ways should be sought to encourage the patient to incorporate activity into their daily lives. These findings have informed the design of two walking intervention trials for LBP patients.

Conflict of Interest: None

Sources of Funding: Research and Development Office, Northern Ireland, Strategic Priority Fund, Department of Employment and Learning, Northern Ireland.

Background & Purpose: Clinical guidelines support physical activity for people with chronic low back pain (CLBP); walking is an ideal form of physical activity as it is easy to do, requires no special skills and is achievable by virtually all ages with little risk of injury but there are no current evidence-based structured walking programmes (WP) for this population. The purpose of this study was to develop a WP for CLBP patients in preparation for a proposed randomized controlled trial.

Methods: An 8-week structured WP was developed using Intervention Mapping (IM) principles:

literature review,

Results: Both the CLBP patients and physiotherapists interviewed endorsed walking as a suitable form of physical activity, and identified possible barriers as fear avoidance, exacerbation of pain, behavioural change, motivation, time, personal safety and adverse weather. The pilot study found 90% compliance with the WP. Descriptive analysis of change scores showed improvements at 8-weeks in all self reported outcomes and objectively measured physical activity and functional capacity.

Conclusion: Intervention Mapping was successfully used to develop a WP intervention for chronic LBP, the efficacy of which is being evaluated in a randomized controlled trial.

Background & Purpose: This pragmatic randomised clinical trial (RCT) investigated differences in the clinical outcomes of physiotherapy for low back pain (LBP) delivered in

public hospital-based secondary care versus

Methods: Between March 2005 and May 2006, 160 consenting subjects [110F, 50M; mean age (SD) yrs: 41.28 (12.83)] were recruited, stratified (acute: < 3/12; chronic: > 3/12), and randomly allocated to public hospital (H) or private community (P) physiotherapy. Subjects completed clinical outcomes (Roland Morris Disability Questionnaire (RMDQ). SF-36, Fear Avoidance Beliefs & Back Beliefs Questionnaires) at baseline, 3, 6 and 12 months post randomisation and the Patient Satisfaction with Outpatient Physical Therapy (PTOPS) survey at the end of treatment. Intention-to-treat analysis was conducted using the Statistical Package for the Social Sciences (SPSS, Version 12).

Results: There were no significant differences between groups at baseline (p> 0.05). Patient response rates were 85% (n=137), 80% (n=128) and 74% (n=118) at 3, 6, and 12 months. Despite significantly longer waiting times for public hospital physiotherapy, repeated measures ANOVA found no significant differences over time between groups for any of the outcome measures (p> 0.05), except ‘patient satisfaction with outcome,’ which was significantly higher in the P group (median difference: 0.00; p=0.020, Mann Whitney U=1324.50).

Conclusions & Implications: The trial cannot recommend one physiotherapy setting over the other for LBP management. However, the limited adherence to LBP clinical guidelines in both settings and the lack of improvement in psychosocial outcomes in subjects managed in both settings warrant further investigation.

Acknowledgements: Physiotherapists, General practitioners and patients in both settings.

Background & Purpose: Current clinical guidelines support physical activity programmes for people with low back pain (LBP), but a major factor limiting their efficacy is the patient’s level of adherence, difficult to assess using self-report, and the lack of objective data on activity levels in this population. This study investigated differences in the self-report and objective activity levels of LBP patients and age-matched controls.

Methods: 20 patients with non-specific LBP [5 male, 15 female; mean (SD) age = 43.2 (12.1) years] and 20 healthy controls [10 male, 10 female; mean (SD) age = 39.6 (10.9) years] wore the activPAL™ uniaxial accelerometer on the anterior thigh during waking hours for 7 days, and completed the 7-Day Physical Activity Recall Questionnaire (7DRQ). Data were analysed using SPSS (v12).

Results: There was no difference between groups in energy expenditure as measured by the 7DRQ (p> 0.05), but the activPAL™ data showed LBP subjects expended significantly less energy than controls (p=0.004) over the 7-day period, and failed to reach the recommended 10,000 steps per day [mean (SD) = 8067.9 steps (2581.7)] compared to controls [mean (SD)= 10,864 (3,570.3); t = 2.84, p=0.007)]. The LBP subjects also had a significantly lower mean cadence (p=0.004), a lower walking index (p=0.001), and took significantly more short walks (0–100 steps) and less long walks (> 100 steps) than controls (p< 0.05).

Conclusions & Implications: People with LBP are less physically active than age-matched controls, and this is more evident with objective than subjective evaluation. These findings have informed the design of a targeted walking programme for LBP patients.

Background: General practitioners (GPs), orthopaedic surgeons, neurosurgeons, rheumatologists and pain consultants manage the majority of patients with chronic low back pain (CLBP) in the Republic of Ireland. However, little is known about their attitudes and beliefs and the factors that influenced them. This study aimed to investigate factors that influenced doctors’ attitudes and beliefs to CLBP.

Method: A cross-sectional questionnaire was mailed to a random sample of GPs (n=750; 35%), and all orthopaedic surgeons (n=81), neurosurgeons (n=9), rheumatologists (n=26), and pain consultants (n=24) in the republic of Ireland. The questionnaire pack contained a demographic data form, two clinical vignettes, and an attitudes measure, the Pain Attitudes and Beliefs Scale (PABS.PT). Approval was obtained from the UCD Human Research Ethics Committee.

Results: The response rate was 58% (n=523). Doctors were qualified 23.4±9.4 years. Analysis of the vignettes showed there was no significant difference (p> 0.05) between those who had undertaken postgraduate education (PGE) regarding referral rates to physiotherapy, investigations, or secondary care. Prescription rates were significantly lower for those who had undertaken PGE (88% v 94%, χ² =4.95, p< 0.05), as was their biomedical score on the PABS.PT (41.3 v 43.1, df=507, p=0.03). The number of years since qualification was dichotomised (1–23 yrs, > 23 yrs), and there was no significant difference in the management of the vignettes, except referral rates for investigations which was greater for doctors qualified > 23 years (3% v 52%, χ² =10.71, p=0.001).

Conclusion: Demographic factors (PGE and the number of years since qualification) did not significantly influence doctors’ practice behaviour.

Background: General practitioners (GPs), orthopaedic surgeons, rheumatologists and pain consultants manage the majority of patients with chronic low back pain (CLBP) in primary and secondary care settings in the Republic of Ireland. Little is known about their attitudes and beliefs to CLBP, although the existing literature highlights a range of factors influencing such beliefs including: past experience, education, time and resources¹. This study aimed to investigate factors influencing attitudes and beliefs of Irish doctors to the management of CLBP patients.

Method: A multiple case studies design of semi-structured audiotaped interviews (30 minutes) was conducted on a purposeful sample of GPs (n=7) and Consultants (n=7: orthopaedic surgeons, n=2; Pain consultants, n=2; Rheumatologists n=2 Neurosurgeon, n=1) in July 2006. Questions were devised based on the results of a systematic review of the literature of the topic. All interviews were subsequently transcribed, coded and a cross case analysis was constructed. Approval was obtained from the UCD Human Research Ethics Committee.

Results: The main emerging themes included Doctors current holistic management (referral for physical and mental health treatment), the negative impact of lack of resources on treatment options (lack of multidisciplinary services and prolonged waiting times for Consultant appointments), the influence of the medicolegal system on patients (increased stress) and Doctors (increased referral rates for investigations and procedures).

Conclusion: Doctors’ attitudes and beliefs regarding CLBP management may have important influences on both patient outcomes and resource utilization within the health service. These findings will inform a national postal survey of Doctors attitudes to CLBP.

Background: This pragmatic randomised controlled trial aimed to investigate any differences in the clinical outcomes of patients with low back pain (LBP) receiving physiotherapy in (i) the current public hospital-based secondary healthcare model (H) versus (ii) a private community-based primary healthcare model (P)

Participants & Methods: Between March 2005 and May 2006, 160 consenting subjects [110F, 50M; mean age (SD) yrs: 41.28 (12.83}], referred by GPs for physiotherapy for non-specific LBP were recruited across three clinical centres within Ireland Subjects completed a baseline interview and outcome measures (Roland Morris Disability Questionnaire (RMDQ), SF-36 V2 Pain Subscale, Fear Avoidance Beliefs Questionnaire, Back Beliefs Questionnaire), were stratified (acute: < 3/12; chronic: > 3/12), and randomised to one of the two groups (i.e. H: n=80; P: n=80), with follow ups at 3, 6 and 12 months post randomisation.

Analysis: Data were coded and questionnaires scored, then analysed using the Statistical Package for the Social Sciences (SPSS, Version 11). An intention-to-treat analysis was conducted. Patient follow-ups are ongoing: 3-month [completed by 31stth August 2006; current response rate: 82% (n =117/143)].

Results: Both groups were comparable for all baseline demographic variables and questionnaire scores. Current descriptive analysis of mean change scores (SD), from baseline to 3-months, show clinically meaningful improvements in both groups RMDQ: [H=3.95(−1.172); P=4.94(−0.816)] and SF-36 Bodily pain: [H=−7.51(=3.6); P= −10.54(−2.6)]. The complete 3-month data set will be presented at the meeting.

Conclusion & Implications: The findings may influence future health policy regarding the funding of physiotherapy services in Ireland.

Background: In the Republic of Ireland, physiotherapy for low back pain (LBP) is delivered in both public and private sectors via hospital-based departments (H) and community-based private practices (P) respectively. However, there is inequity in access and minimal evidence of the physiotherapy management of LBP in these two settings.

Purpose: To investigate any differences in patient profile and physiotherapy management of LBP in H and P settings.

Methods: A random sample of one Dublin city hospital and neighbouring private practices (n=3) were recruited. A retrospective chart survey of all LBP patients who commenced physiotherapy during 2003 was conducted. Data were analysed using Statistical Package for Social Sciences (SPSS, v.11). Ethical approval was granted by the participating hospital.

Results: In total, 249 charts were identified: H=93 [male n=32, female n=61, mean age (SD) = 46 years (20)]; P =156 [male n=78, female n=78, mean age (SD) = 36 years (10)]. Statistically significant differences between settings were found for:

percentage of patients with ‘acute’ (< 12 weeks) and ‘chronic’ (≥12 weeks) LBP [H: acute LBP = 4.7%, chronic LBP = 95.3%; P: acute LBP= 84.7%, chronic LBP= 15.3%; χ² = 120.34, df=1, p< 0.001];

Conclusion: Findings suggest a two-tier system of health care for LBP patients in Ireland. A randomised controlled trial evaluating patient outcomes in both settings is currently underway by the Research Team.

Background: Patients assessed at the clinic are classified and managed according to the guidelines from The Royal College of General Practitioners. The purpose of this study was to evaluate the differences in initial assessment findings between patients with ‘simple’ LBP and those with probable ‘Nerve Root Pain’ (NRP).

Methods: All 1949 new patients attending over two years were assessed using a range of valid and reliable questionnaires to establish generic health status (Short-Form 36; SF36), self reported disability (Oswestry Disability Index; ODI) and psychological status (Hospital Anxiety and Depression Scale; HADS). The spinal examination was carried out by a Senior Physiotherapist and patients were triaged into the various categories of back pain. Differences between groups were assessed for the questionnaire scores and physical examination findings (SLR and lumbar flexion) using Chi-Square Analysis and unrelated T-Tests.

Results: 908 patients were classified as having ‘Simple’ LBP and 302 were classified as having probable ‘Nerve Root Pain’. A significant difference was detected between the two groups for the mean ODI scores (mean difference: −8.73; 95% CI –11.3 to –6.2; P< 0.001). (mean ODI of 36.73 % (SD 18.88%) for ‘Simple LBP’ and 45.46% (SD 22%) for NRP group. Significant differences were also detected for the SF36-Physical Component scores, lumbar flexion and SLR.

Conclusion: The ODI was found to be the strongest discriminator between the two groups. These findings support the inclusion of this condition specific outcome measure in the triage of back pain patients, as it appears to be sensitive to those patients with ‘NRP’.