Purpose and Background

Traditional physiotherapy methods utilised in the management of NSCLBP have small effects on pain and disability and this is reflected by data previously collected by the host physiotherapy service. O'Sullivan has validated a novel classification system and matching treatment strategy known as Classification Based–Cognitive Functional Therapy (CB-CFT) for people with NSCLBP. Briefly, CB-CFT is a behavioural and functional management approach to NSCLBP. A recent RCT employing CB-CFT has demonstrated superior outcomes in comparison to traditional physiotherapy methods advocated by clinical practice guidelines. It was unknown if CB-CFT improved outcomes for people with NSCLBP attending an NHS physiotherapy service, therefore an evaluation of practice was proposed.

Background

Doubt has been cast over the accuracy of dermatome charts. This study investigated a large group of patients with known lumbar nerve root compression (NRC), and identified whether their radicular pain corresponded with the predicted distribution on a dermatome chart.

Introduction

Previous work(1) has suggested that Spectral Colour Mapping (SCM) may have potential as an objective measurement tool for analysing Electromyography (EMG) data from spinal muscles, but the production and analysis of these maps is a complex undertaking. It would be beneficial for a system to create these maps and be useable with a minimum of training.

Background: Psychosocial factors are well-known contributors to the suffering and disability associated with common musculoskeletal problems. How to identify salient obstacles to recovery or return to work, and how to manage them effectively remains difficult. This project interpreted the evidence base and presented it as solution-focused guidance for everyday practical use by the key players (clinicians, employers, funders, case managers, etc) to help people remain active and working.

Methods and Results: Two methods were used to identify evidence and practical advice, and synthesize this into use-able statements:

existing reviews;

An extended conceptual development of a ‘flags framework’, based on the earlier approach of Yellow Flags, was used to prepare an easily understood and pragmatic approach. The framework integrates obstacles related to the person (yellow flags), the workplace (blue flags) and the context (black flags). A full-colour 32-page document suitable for distribution as both print and electronic media was developed. This contains a clear explanation of how to identify psychosocial flags, how to develop a plan to address them effectively, and how to take action to overcome the obstacles. Poster-style summaries for clinicians, the workplace, and the individual are included, and are available for download. International consultation was used to ensure system-independent applicability and language.

Conclusion: The new document provides practical guidance on identifying and managing psychosocial issues relevant to common musculoskeletal problems based on the latest evidence and conceptual approaches.

Conflict of Interest: none

Sources of Funding: Society for Back Pain Research, Faculty of Occupational Medicine, BackCare, Transport for London, Royal Mail, HCML, TSO

Background: Low back pain (LBP) can affect work ability. Retention of employment relies on appropriate management by employer and employee, and the healthcare that the employee may access. Healthcare in the UK has historically not been work-focused. The UK government has directed the NHS to play a greater role in enabling people with health conditions to remain in work.

Purpose: The aim of this study was to explore patients’ experiences of healthcare interventions regarding the management of work problems due to LBP.

Method: Individual semi-structured interviews were conducted with twenty-five LBP patients who had been referred for multidisciplinary back pain rehabilitation. All were in employment and concerned about their ability to work with LBP.

Findings: Although the participants had received a range of healthcare interventions, these had failed to alleviate their concerns about working with LBP. There was little evidence of work-related advice or interventions provided by any of the clinicians treating the participants. In a number of cases, patients had remained at work despite the recommendations they had received. Clinicians depended on the patient as an information channel rather than creating opportunities for ‘stakeholder’ dialogue and joint problem-solving.

Conclusions: Healthcare professionals need to improve their ability to explain the nature of persistent and recurrent LBP and to explore their patients’ concerns about working with pain. They should take more active steps to address those concerns, e.g. by communicating directly with employers where necessary, by advising patients how to address actual or perceived negative attitudes at work, and how to access modifications if required.

Conflicts of Interest: None

Source of Funding: Arthritis Research Campaign

Purpose and Background: Physiotherapeutic management of lumbar disorders often incorporates specific manual therapy techniques of which McKenzie’s lumbar extension exercises (EIL) and segmental rotational grade V manipulation are popular options. The use of proxy measures of sympathetic nervous system (SNS) activity (skin conductance) is a recognised method of ascertaining neurophysiological responses to physiotherapy treatment but have yet to be used to assess magnitude of response to lumbar techniques. This preliminary study aimed to investigate the neurophysiological effects of these two treatment techniques.

Methodology: A quasi-experimental, independent group’s design was utilised, with random allocation of 50 normal, healthy participants (25 per group) into a manipulation group or an EIL group. Non-invasive neurophysiological measurements of skin conductance were taken as a proxy-measure of sympathetic nervous system (SNS) activity in the lower limbs before, during and after the administration of the techniques. Results were calculated using Area Under the Curve readings and converted into percentage change calculations for the intervention and the post-intervention periods.

Results: Both treatments increased SNS activity during the intervention period, 76% for the manipulation group (p=0.0005) and 35% for EIL group (p=0.0005) with the manipulative technique having significantly greater effect (p=0.012). Further analysis of the manipulation group found no difference between the ‘opening’ and the ‘closing’ side of the technique (p=0.76).

Conclusion: Preliminary evidence now exists supporting the neurophysiological effects of two lumbar techniques and that manipulation has a greater magnitude of effect over the EIL technique. Future research, on a low back pain patient population, is proposed and projected sample size calculations computed.

Background: Each year, 7% of the adult population consult their General Practitioner (GP) with low back pain (LBP). Approximately half of these patients still experience disabling pain after three months. Evidence suggests a biopsychosocial approach may be effective at reducing long-term pain and disability. This study aimed to evaluate, for persistent disabling LBP, the effectiveness of an exercise, education and cognitive behavioural therapy intervention compared to usual GP care plus educational material, and to investigate the effect of patient preference.

Method: Design: randomised controlled trial. Patients, aged 18–65yrs, consulting their GP with LBP were recruited. After 3 months those still reporting disabling LBP (≥20mm on 100mm pain visual analogue scale (VAS) and ≥5 Roland and Morris Disability Questionnaire (RMDQ) points) were randomised, having first established preference, to 2 groups. VAS and RMDQ were assessed at 0, 6, and 12-months post-intervention.

Results: 234 patients were randomised; 116 to the intervention. The intervention showed small non-significant effects at reducing pain (3.6mm) and disability (0.6points RMDQ) over one year. Preference showed significant interaction with treatment effect at one-year; patients had better outcomes if they received their preferred treatment.

Conclusion: The above intervention program produces only a modest effect in reducing LBP and disability over a one-year period. These results add to accumulating evidence that interventions for LBP produce, at best, only moderate benefits. The challenge for future research is to evaluate interventions tailored for specific LBP sub-populations. These results suggest that if patients receive treatment which they believe is beneficial their outcome can be optimised.

Purpose of the study: To investigate whether video analysis, in addition to self-reported paper audit, could elucidate expected differences in the content of two interventions.

Background: We have completed a randomised clinical trial comparing two types of physiotherapy for subacute low back pain (“hands on” physiotherapy versus a pain management programme). An essential component in conducting clinical trials is to audit the interventions to check for compliance with the protocol. We use two approached:

self complete proforma

Methods: i) Treatment content was recorded on a proforma by the physiotherapists after each session.

ii) A check-list of treatment modalities was constructed from this proforma. Twelve sessions were recorded on video (one new and one review patient for each therapist). The recordings were rated by 3 blinded, independent observers using the checklist. These were compared with the self-report audit forms relating to the same physiotherapy session.

Results: Analysis of the videos showed good levels of agreement (67%) between the 3 observers. Agreement between the video content and paper audit was also good (84%, _ = 0.59). The complete paper audit revealed clear differences between the treatment arms. Patients undergoing the “handson” treatment received manual therapy, whereas patients in the pain management group had specific issues addressed in the course of the consultation.

Conclusions: Feasible, reliable methods of confirming the content of interventions delivered in pragmatic trials are difficult to achieve. Self report paper audits are simple but rely upon the honesty and accuracy of the completer, and may not pick up subtle differences in approach. Video recording is time consuming, may be threatening to the treating practitioner and patient, and is difficult to analyse. A compromise approach involving sample video recordings along with paper self complete audit was able to validate the content of the treatments delivered.

Background: Prospective population studies demonstrate that poor paraspinal muscle endurance increases the risk of developing first-time LBP and many CLBP studies also document excessive paraspinal muscle fatigability. The question arises as to whether this could have predisposed to chronic symptoms, through impaired spinal instability, especially in light of the wide inter-individual variation observed in the constitutionally determined paraspinal muscle fibre-type composition, which governs contractile performance.

Objective: To determine whether CLBP-associated excessive paraspinal fatigue results from a paucity in the type I fibre content.

Design: Control comparison using male subjects.

Subjects: Thirty-five CLBP patients with Von-Korff Chronic Pain Scores of ≤ III (high level of residual function, despite pain, to negate effects of disuse atrophy), and 32 controls of similar age.

Outcome measures: Fatigue-induced median frequency (MF) declines in the surface EMG signal, monitored bilaterally at L4 level during Biering-Sorensen- and 60%MVC- isometric fatigue tests. Percutaneous para-spinal muscle biopsies permitted histomorphometric comparisons.

Results: Between-group differences were assessed using independent t-tests (p < 0.05). There were no differences for MF decline during the Biering-Sorensen -0.37(0.16) vs. -0.36(0.12), and the 60% MVC test −0.42(0.31) vs −0.51(0.29), and in the percentage number of type I fibres, 63.6% vs 64.3%, or percentage area occupied by type I fibres, 69.4% vs 67.2%, in the paraspinal muscles for patients and controls respectively (p> 0.05).

Conclusion: Impaired CLBP-associated endurance is not the result of a constitutionally ‘adverse’ fibre-type composition.

Study design: Cross-sectional questionnaire-based workforce survey together with collection of retrospective data on work absence.

Objectives: To determine if psychosocial ‘blue flags’ are related to back pain and/or sickness absence due to back pain.

Summary of background: The original description of the psychosocial ‘yellow flags’ for back pain chronicity included a mixture of individual psychological parameters and parameters related to perceptions about work and the workplace. It has recently been suggested that these latter parameters should be considered separate and distinct from the individual parameters , and can be termed ‘blue flags’. To date, however, there has been no attempt to explore the specific relationship between the blue and yellow flags or their relative relationship to symptoms and disability.

Methods: The workforce of a large multi-site company was invited to complete a booklet of questionnaires, which included the standard Nordic instrument for obtaining back pain data, and specific instruments to obtain data on ‘yellow’ and ‘blue’ psychosocial flags. The blue flags included psychosocial aspects of work, attribution and elements from the demand/control model, with psychological distress used as a yellow flag comparator. Of the 7,500 workers, 60% responded. Sickness absence records identified workers who had taken absence for back pain. The exploration of the data involved determining statistically significant relationships between psychosocial scores and both back pain history and absence. Appropriate statistical procedures were then used to establish cut-off points for the psychosocial variables. Odds ratios were calculated for two particular outcome variables: self-reported back pain in the previous 12 months and recorded absence over the same period.

Results: Cut-off points were established for each variable, along with the odds ratio (OR) that this score or a score above or below (depending on the scale direction) is associated with reports of back pain or absence. The ORs for psychological distress were 1.9 and 2.4 respectively for LBP and absence in the last 12 months. The ORs for the blue flag variables varied from 1.1 to 1.5 for LBP and from 1.8 to 3.2 for absence.

Conclusions: The psychosocial blue flags reported here are statistically significantly related both to reported back pain and absence. The effect size is less than that for distress in respect of back pain, but variously higher and lower for absence. Whilst prospective studies are needed to determine cause/effect, the results offer tentative support for the suggestion that blue flags should be addressed in clinical interventions.

Traditional biomedical/ergonomic occupational interventions to reduce work loss show limited success. Attention is now focussing on tackling the psychosocial factors that influence occupational back pain.

A workforce survey of Glaxo Smith Kline (reported to the Society last year) established that clinical and occupational psychosocial factors (yellow & blue flags) act independently and may represent obstacles to recovery. Consequently, a nurse-led intervention was devised. Occupational nurses at two manufacturing sites were trained to identify both clinical and occupational psychosocial factors, and address them using a basic ‘counselling’ technique that reinforces evidence-based messages and advice, along with availability of modified work. The program should ideally be implemented within the first days of absence, with ‘case-management’ by the nurse for a further 4 weeks. Control sites simply offer ‘usual management’. Outcomes at 12-month follow-up are rates for work loss/work retention.

The target for contacting the worker (3 days) was achieved at one site, but not the other (mean 12 days), thus exerting a differential delay in delivering the intervention. The lack of early identification at the second site was due to local reporting/recording mechanisms. This study reveals a third class of obstacles to recovery – black flags – company policies/procedures that can impede occupational rehabilitation programs.

Augmentation of the acetabular component of total hip replacements is a method of increasing stability and preventing recurrent dislocation. We report a series of mechanical experiments designed to evaluate the turning moments and angles required to dislocate standard, long posterior wall and two different augmented prostheses.