Background and study purpose

Low back pain with no identified underlying cause is categorised as primary musculoskeletal pain by the International Association for the Study of Pain. In April 2021, the National Institute for Care and Excellence (NICE) published updated guidance for the management of primary chronic pain conditions in England. As part of the De-STRESS pain study, we explored the perspectives of GPs on the updated guideline and impact upon clinical practice.

Background and study purpose

Low mood and distress are commonly reported with by people with persistent musculoskeletal pain and may be mislabelled as ‘depression’. In order to understand how pain-related distress is conceptualised and managed in primary care consultations, we explored understanding of pain-related distress and depression from the perspectives of people with persistent musculoskeletal pain and general practitioners (GPs).

Background

Previous research in people with musculoskeletal low back pain (MLBP) in primary care shows that a reliable and valid measure of consultation-based reassurance enables testing reassurance against patient' outcomes. Little is known about the role of reassurance in people with MLBP consulting spinal surgeons, especially in cases where surgeons recommend not to have surgery. There might be several reasons to exclude surgery as a treatment option, that range from positive messages about symptoms resolving to negative messages, suggesting that all reasonable avenue of treatment have been exhausted.

AIM to explore patient's experience of consultation-based reassurance in people with MLBP who have been recently advised not to have surgery.

Purpose of the study and background

Although pain is usually described as a private experience, how pain is understood and responded to by others is important. A crucial feature of this process is empathy. The aim of this study was to examine the relationship between empathy for pain and observers' health anxiety and fear of pain. The role of the observer's sex and age were also examined.

Statement of the purposes of the study and background:

Low back pain (LBP) is the leading cause of disability worldwide, and greater understanding of mechanisms leading to increased disability in LBP is necessary. Pain-related guilt and in particular social guilt (one type of pain-related guilt) has recently been linked to greater depression, anxiety and disability in LBP. Research has also shown that greater acceptance of pain is associated with less pain intensity, depression, pain-related anxiety and disability, and with greater daily activity and overall wellbeing in chronic pain patients. The current study aim was to understand the relationship between pain-related guilt and pain-related acceptance in LBP.

Background:

A distinction has been posited between cognitive (informational) and affective (emotional) reassurance, with a suggestion that affective reassurance may negatively affect patient outcomes by reducing patients' motivation to engage with information conducive to recovery. Cognitive reassurance, though, provides explanations and information to help patients self-manage, and so aids recovery. However, research is lacking on how each actually affects patient outcomes in primary care.

Purpose of the study and background

Patients' beliefs about the origin of their pain and their cognitive processing of pain-related information have both been shown to be associated with poorer prognosis in low back pain (LBP), but the relationship between specific beliefs and specific cognitive processes is not known. The aim of this study was to study the relationship between diagnostic uncertainty and recall bias in two groups of chronic LBP patients, those who were certain about their diagnosis, and those who believed that their pain was due to an undiagnosed problem.

Purpose of the study and background

In the majority of low back pain (LBP) patients a definitive cause for back pain cannot be established; consequently, many patients report feeling uncertain about their diagnosis. They also experience pain-related guilt, which can be divided into: social guilt, managing pain guilt and verification of pain guilt. This study aimed to test a theoretical (causal) model, which proposed that diagnostic uncertainty leads to pain-related guilt, which leads to depression, anxiety and finally to disability.

Purpose of the study and background:

Identifying mechanisms that mediate recovery is imperative to improve outcomes in low back pain (LBP). Qualitative studies suggest that guilt may be such a mechanism, but research on this concept is scarce, and reliable instruments to measure pain-related guilt are not available. We addressed this gap by developing and testing a pain-related guilt scale (PGS) for people with LBP.

Background

Fear avoidance (FA) has been identified as a risk factor for poor prognosis and a target for intervention in patients with low back pain (LBP), but the mechanisms involved need clarification. Experimental studies would benefit from the use of carefully developed and controlled stimuli representing avoided movements in back pain, and matched stimuli of movements to provide a credible control stimuli. Existing stimuli depicting avoided movements in LBP are static, do not include a set of control stimuli, and do not control for possible systematic observer biases.

Background and purpose

There is on-going debate about a possible link between manipulation and stroke in patients, and a growing interest in other treatment reactions such as increased pain. Evidence about manipulation is contradictory. There is little published information about outcomes in osteopathy. We aimed to address this gap.

Purpose and background

Private musculoskeletal practitioners treat a large section of people with back pain, and could play an important role in returning and maintaining patients to work. We aimed to examine practitioners perception of their role quantitatively.

Study purpose and background

There is growing concern that current outcome measures of back pain trials do not comprehensively capture what is important to patients. Some researchers believe we need to incorporate patients in the development of ‘next-generation’ outcomes. As a preliminary step to patient-interviews, we aimed to articulate ‘important change’ from the patients' perspective, as represented in reports of qualitative investigations inadvertently or directly exploring this.

Purpose and background

Effective reassurance is an essential element of treatment for conditions that do not require further investigations, referrals and on-going monitoring. However, research defining what reassurance should consist of and how to deliver it is scarce. The aim of this review was to identify consultation-related processes that improved patients' outcomes, in order to build an evidence-based model of effective reassurance in primary care.

Background and aims: Evidence-based recommendations for practitioners treating back pain emphasize adequate screening of work-related factors, and good communication with employers. It has been argued that getting all the stakeholders onside – including practitioners – could reduce sickness absence. However, expanding the role of clinicians to include exploration of occupational obstacles to recovery, and targeting these within the framework of clinical intervention is controversial. Private musculoskeletal practitioners (MPs) including physiotherapists, chiropractors and osteopaths treat a considerable section of those seeking care for low back pain (LBP). This study aimed to explore how private musculoskeletal practitioners view their role.

Method: A semi-structured interview was carried out with 15 physiotherapists, 16 chiropractors and 14 osteopaths. The interview schedule included questions about the relationship between work & health; communication with employers and GPs; strategies in returning/maintaining patients at work; and sick leave certification. Interviews were audio-taped & transcribed, and content analysis was carried out to extract themes. These were reviewed on a sample of interviews by another researcher, and independently reviewed against verbatim quotes by a third researcher.

Results: There was a consensus that work was in general good for psychological well being, but work-specific issues were also seen as threats to back pain. Most practitioners viewed patients who would not take time off work or moderate work-practices as the strongest threat for further problems. There was very limited communication with employers or GPs, but most practitioners gave advice about moderating work-duties.

In conclusion, private musculoskeletal practitioners explore work-related issues, and see return to work as an important treatment goal.

Conflict of Interest: None

Source of Funding: British Academy and BackCare

Aim of investigation: Fear of movement (avoidance) has been implicated as an obstacle to recovery in back pain. We have argued that the concept of fear-avoidance needs clarifying, to identify sub-groups of avoiders. This study explored the patterns of activation during exposure to previously reported feared movement in patients with chronic back pain. The aim was to explore activation in areas associated with catasrophizing.

Method: 13 chronic back pain patients, who scored above a cut-point on the Tampa Scale of Kinesiophobia selected photographic images representing 5 movements they feared most and five movements they hadno concerns with carrying out. Stimuli were therefore individually selected. Two other sets of stimuli included generally threatening images, and neutral images. These four stimulus types were presented in blocks in a fMRI scanner in random order. Ratings of pain were taken after the presentation of each block.

Results: Analysis of contrasts-of-interest showed that the highly feared movements caused selective activation in areas related to preparation for action, and attentional modulation. The canonical ‘pain matrix’, and areas associated with catasrophizing was not activated.

Conclusion: The activation seen may indicate the involvement of heightened attentional processing and/or response processes (bracing and protecting) when viewing pictures of feared movements. The absence of activity in affective pain areas in the contrast analysis will be discussed in reference to theoretical developments and methodological limitations.

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.

Objective: To improve the quality of prospective cohorts studying the transition from early stages of back pain to persistent problems, in order to allow researchers to improve the predictive quality, and pool data from multi-centre studies.

Summary of background: The progress from early stages of back pain to persistent problems is poorly understood, and only a fraction of the variance at outcome can be accounted for by current prospective cohorts. Standardization of a core set of factors would allow pooling and facilitate comparison between studies.

Method: Teams from 12 nations with expertise in clinical practice, prospective cohorts, epidemiology, social sciences, and health services were appointed.

The steering committee produced checklists of predictors and outcomes based on systematic reviews and a Delphi focus group. The international teams of experts coded each item for inclusion or exclusion, and recommended new items. This process was iterated twice to resolve disagreement between teams, and to receive scores for new items. The steering committee carried out a consensus synthesis and produced the final lists for predictors and outcome. Finally, the measurements for each factor were selected based on:

original systematic review

Results: The checklist for predictors include information about demographics, clinical status, psychosocial status, work, and the first consultation for back pain. The recommendation for outcomes include pain, disability, return to work and sick leave, satisfaction, psychological factors, health care utilization and treatment over the follow up period.

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.

Study Design: To design and test a new questionnaire to assess depression and other mood states.

Summary of Background Data: Measurement of depression and of other mood states in pain patients has been criticised in recent years on the grounds that most questionnaires were not developed in pain populations and suffer from criterion contamination by somatic items. In addition, there is no accepted measurement for positive emotions which are more than the absence of depression.

Objective: To develop a reliable and brief tool to assess mood in pain patients.

Method: Non-somatic items concerning depression, anxiety and positive outlook were extracted using exploratory factor analysis from commonly used instruments (Beck Depression Inventory and Hospital Anxiety and Depression Scale) completed by over 900 chronic pain patients. Confirmatory factor analysis was used to test the internal structure of the final item set. Items were then reworded and presented as a new questionnaire (the Depression, Anxiety and Positive Outlook Scale: DAPOS) to two new samples: patients attending pain management and patients attending osteopathy. The new questionnaire was compared with several well-known questionnaires (SF-36, BDI, PCS). The structure was calibrated and tested using confirmatory factor analysis on both samples. Finally, a sub-set of patients carried out a sorting task to test for face validity.

Results and conclusion: The DAPOS performed well, indicating that it is a reliable measure of the three mood states with good initial evidence of validity in these samples.

Purpose and Background: Despite widespread clinical belief, a previous systematic review found insufficient evidence to substantiate fear avoidance beliefs (FAB) as a risk factor for long-term problems in low back pain. This updated review explores whether there is stronger evidence supporting the role of fear avoidance in early stages of low back pain as a predictor of outcome. In addition, this evidence was examined in reference to current models and knowledge about fear avoidance.

Methods and Results: A systematic literature search for all prospective inception cohorts of low back pain that included psychological factors at baseline between 2000 and 2003 was made. We searched MEDLINE, psychINFO, AMED, CINAHL, Social Science Citation Index, Science Citation Index databases. Included studies had early recruitment of up to three weeks since onset of back pain and an absence of back pain in the previous three months. These studies were coded according to criteria adapted from Pincus et al (2002) blindly by two researchers. A sample of these was coded by a third blinded reviewer. An independent statistician performed statistical conversion of reported results to effect sizes. Out of the six included studies, four included valid and reliable measures of fear avoidance. There was only weak evidence implicating fear avoidance as a predictor of disadvantageous outcome.

Conclusions: There is insufficient evidence to support or refute the basic concept of fear avoidance as a risk factor for poor outcomes in low back pain. Experimental studies indicate that those with high FAB benefit from targeted intervention. To explain this we propose a model of FAB containing two distinct groups.

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: 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.

i. Measurement of depression and of other mood states in pain patients has been criticised in recent years on the grounds that most questionnaires were not developed in pain populations and suffer from criterion contamination by somatic items. In addition, there is no accepted measurement for positive emotions which are more than the absence of depression. The aim of this study was to develop a reliable and brief tool to assess mood in pain patients.

ii. Nonsomatic items concerning depression, anxiety and positive outlook were extracted using exploratory factor analysis from commonly used instruments (the Beck Depression Inventory and the Hospital Anxiety and Depression Scale) completed by over 900 chronic pain patients. Confirmatory factor analysis was used to test the internal structure of the final item set. Items were then reworded and presented as a new questionnaire(the Depression, Anxiety and Positive Outlook Scale: DAPOS) to two new samples: patients attending pain management and patients attending osteopathy. The new questionnaire was compared with several well-known questionnaires (SF36, BDI, PCS). The structure was calibrated and tested using confirmatory factor analysis on both samples. Finally, a sub-set of patients carried out a sorting task to test for face validity. iii. The DAPOS performed well, indicating that it is a reliable measure of the three mood states with good initial evidence of validity in these samples

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.

Study design: A systematic review of prospective cohort studies in low back pain.

Objectives: To evaluate the evidence implicating psychological factors in the development of chronicity in low back pain.

Summary of background: The biopsychosocial model is gaining acceptance in low back pain, and has provided a basis for screening measurements, guidelines and interventions. However, to date, the unique contribution of psychological factors in the transition from an acute presentation to chronicity has not been rigorously assessed.

Methods: A systematic literature search was followed by the application of three sets of criteria to each study: methodological quality, quality of measurement of psychological factors, and quality of statistical analysis. Two reviewers blindly coded each study, followed by independent assessment by a statistician. Studies were divided into three environments: primary care, pain clinics and workplace-based studies.

Results: Twenty-five publications (18 cohorts) included psychological factors at baseline. Six of these met acceptability criteria for methodology, psychological measurement and statistical analysis. Increased risk of chronicity (persisting symptoms and/or disability) from depressive mood and, to a lesser extent, somatisation emerged as the main findings. Acceptable evidence generally was not found for other psychological factors, although weak support emerged for the role of catastrophising as a coping strategy.

Conclusions: Both depressive mood and somatisation are implicated in the transition to chronic low back pain. The development and testing of clinical interventions specifically targeting these factors is indicated. In view of the importance attributed to other psychological factors, there is a need to clarify their role in back-related disability through rigorous prospective studies.

Objectives: To investigate the relationship between recall bias for pain stimuli in chronic low back pain patients and the cost of managing their back pain in primary care.

Design: A retrospective cross-sectional investigation.

Method: Sixty three low back pain patients were interviewed in a primary care setting. Information was gathered on their pain intensity, disability ratings, depression, anxiety, and duration of pain. They were also presented with a surprise recall test for pain descriptors. The cost of each patient’s treatment specifically for back pain in the previous 12 months was calculated. The relationship between the cost of back pain treatment and the scores from the interview were calculated first for total cost, and then for the breakdown of individual cost items.

Results: Results indicated that recall bias for pain stimuli were significantly related to total cost (Rsq. = 8%). A detailed analysis revealed that pain intensity was related to the number of appointments with the general practitioners; depression scores related to the number of appointments with the in-house osteopaths; and recall bias for pain stimuli related to referrals to external experts (outpatients). A minority of patients high on recall bias was found to account for a disproportionate amount of the cost.

Conclusion: Although no causal path can be deduced from the findings, the study provides a novel approach to measuring psychological factors in back pain in reference to health care utilisation. It is limited by its retrospective design, and should be followed by prospective studies to fully understand the relationship between cognitive bias and utilisation of health services.

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.