Purpose and Background. Guidelines recommend biopsychosocial care for chronic, complex musculoskeletal conditions, including non-specific low back pain. The aims were: 1/ to assess how patients with low back pain respond to osteopathic treatment, both before and after an osteopath has completed a Biopsychosocial Pain Management (BPM) course; and 2/ to assess if it is feasible and acceptable for osteopath participants to receive weekly SCED data and use it to guide patient management. Methods and Results. A multiple baseline single case experimental design trial (. clinicaltrials.gov. , on 18/10/2021, ID number NCT05120921) with 11 UK osteopaths was conducted. Patients were randomised to early, middle or late treatment start dates. Statistical analysis assessed the change between baseline, intervention and follow-up periods. Primary outcomes were the Numeric Pain Rating (NPR) and Patient Specific Function Scales (PSFS), measured during the baseline, the 6-week intervention, and during a 12-week follow-up period. At baseline, the osteopaths reported stronger biopsychosocial attitudes to pain, compared to biomedical beliefs (PABS: 34 behavioural scale; 29 biomedical scale). Overall, patient participants showed daily increases in symptoms during the pre-treatment phase (+0.24/day, p<0.001), and daily decreases during treatment (−2.94 over the treatment phase, p<0.001), which continued post-treatment (−3.36 over 12 weeks, p=0.04). Similar improvements were observed for function. Conclusion. Osteopathic care was shown to help patients with persistent low back pain. Patient recruitment was challenging because of the randomisation. With further development, the method shows feasibility as a means of enhancing research activity among practising clinicians. Previous presentations or publications of the work. The protocol was published (. https://doi.org/10.1016/j.ijosm.2023.100660. ) and presented at SBPR in 2022. The results were presented to an osteopathic conference in October 2023. Ethics approval was received from the University College of Osteopathy Research Ethics Committee. Conflicts of interests. Jerry Draper-Rodi receives fees from the sales of the e-learning course on the biopsychosocial management on the UCO CPD platform. Sources of funding. The research was funded by the Osteopathic Foundation

Purpose and Background. Back pain impinges upon all aspects of life, has a reported UK lifetime prevalence as high as 84% and considering approximately a third of our lives are spent asleep the paucity of research into the effect a mattress has on back pain and sleep is surprising. Mood changes, effecting an increase in pain perception, due to sleep loss may also lead to a downward spiral of increasing back pain and greater sleep loss. A controllable factor in this spiral, affecting both aspects, is the mattress but to the authors' knowledge none currently available on the market have any robust, published research to objectively support any claims made and at best being ‘endorsed’ by experts. This may lead to possible misinterpretation of efficacy and leave professionals at a loss with what to advise when questioned. Methods and Data collection. Method:. A three month, randomised, controlled, double blind crossover field study is proposed to take place in the participants own homes, ensuring the most natural sleep environment. Data collection:. Three 28 day phases. 1 - Baseline data, participants sleeping on their own mattress. 2 - Random allocation of mattresses, half allocated test and half control. 3 - Crossover of test and control mattress. Subjective measures of back pain and sleep quality will be collected utilising a daily sleep diary and visual analogue scales. Objective measures of sleep quality using activity monitors during sleep. Conclusion. Minimal evidence is available suggesting the optimal sleep surface for people with back pain. This research hopes to generate evidence to help this group with mattress selection. To confirm: this abstract has not previously been published in whole or part nor has it been presented previously at a national meeting. Conflicts of interest: All mattresses will be designed in conjunction with and provided by Innovative Health Organisation Caerphilly. Sources of funding: This work is part-funded by the European Social Fund (ESF) through the European Union's Convergence programme administered by the Welsh Government and is in conjunction with the Knowledge Economy Skills Scholarship (KESS) project

Background. Osteopathy has been shown to be effective in the management of chronic low back pain. Guidelines recommend biopsychosocial care for chronic, complex musculoskeletal conditions, including non-specific low back pain but there is a lack of evidence comparing standard osteopathic care, which has traditionally been based on dated and disputed biomechanical theories of dysfunction, with more contemporary biopsychosocial approaches. Methods and results. A multiple baseline single case experimental design trial with 11 UK osteopaths and 60 patients is currently assessing effectiveness of osteopathic treatment for patients with non-specific low back pain of more than 12 weeks’ duration. Patients are randomised to early, middle, or late treatment start dates to increase the validity of inferences about the effects of treatment. Osteopaths have participated in one course on the study protocol and processes pre-participation and will take an e-learning course on the biopsychosocial management of patients with low back pain after the first patient recruitment stage. Statistical analysis will assess the degree and rate of change between baseline, intervention and follow-up periods, and whether differences in effect are observed after the osteopaths have completed the biopsychosocial patient management training course. Primary outcomes will be the Numeric Pain Rating and Patient Specific Function Scales, measured daily at baseline and for 6 weeks during the intervention stage, and weekly or fortnightly during a 12-week follow-up period. Conclusion. This experimental design will offer osteopaths in practice the opportunity to engage in research evaluating the effectiveness of osteopathic care and the influence of a training programme to augment biopsychosocial osteopathic care. Study registration: . https://clinicaltrials.gov/ct2/show/NCT05120921. Sources of funding: The Osteopathic Foundation. Conflict of interest: The authors declare no competing interests. Previous publication of work: This protocol is under review with a peer-reviewed journal

Aims. Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS. Methods. POSE was offered to 150 prospective patients over ten months (December 2018 to November 2019) Some chose to attend (Attend-POSE) and some did not attend (DNA-POSE). A third independent retrospective group of 150 patients (mean age 57.9 years (SD 14.8), 50.6% female) received surgery prior to POSE (pre-POSE). POSE consisted of an in-person 60-minute education with accompanying literature, specified using the RTSS as psychoeducative treatment components designed to optimize cognitive/affective representations of thoughts/feelings, and normalize anxieties about surgery and its aftermath. Across-group age, sex, median LOS, perioperative complications, and readmission rates were assessed using appropriate statistical tests. Results. In all, 65 (43%) patients (mean age 57.4 years (SD 18.2), 58.8% female) comprised the Attend-POSE, and 85 (57%) DNA-POSE (mean age 54.9 years (SD 15.8), 65.8% female). There were no significant between-group differences in age, sex, surgery type, complications, or readmission rates. Median LOS was statistically different across Pre-POSE (5 days ((interquartile range (IQR) 3 to 7)), Attend-POSE (3 (2 to 5)), and DNA-POSE (4 (3 to 7)), (p = 0.014). Pairwise comparisons showed statistically significant differences between Pre-POSE and Attend-POSE LOS (p = 0.011), but not between any other group comparison. In the Attend-POSE group, there was significant change toward greater surgical preparation, procedural familiarity, and less anxiety. Conclusion. POSE was associated with a significant reduction in LOS for patients undergoing spinal fusion surgery. Patients reported being better prepared for, more familiar, and less anxious about their surgery. POSE did not affect complication or readmission rates, meaning its inclusion was safe. However, uptake (43%) was disappointing and future work should explore potential barriers and challenges to attending POSE. Cite this article: Bone Jt Open 2022;3(2):135–144

Study Aim. To design an educational resource for people with lower back pain (LBP) using creative co-production. Background. Beliefs associated with a traditional biomedical view of LBP can be a barrier to recovery. Education that reframes the problem as complex and multifactorial may help patients except and engage with more positive attitudes and behaviours. Creative co-production provides a different approach to research intervention development. It encourages a collaborative problem-solving and non-hierarchical approach to knowledge mobilisation. Method. A four-phased approach to creative co-production was used based on methods developed by the Translating Knowledge into Action (TK2A) theme of NIHR CLAHRC YH. Service users and providers were brought together in a series of workshops. Initially the lived experience of LBP was explored to generate a shared understanding of the complexities of living with and managing LBP. Then activities designed to promote divergent and convergent thinking were used for idea generation. From these ideas a series of contextually sensitive prototypes were developed and tested on a small scale. Following further iterations the final prototype, ready for implementation, was presented to all key stake holders. Results. The project produced a new interactive educational resource prototype to promote positive behaviours and attitudes for people living with LBP that can be accessed early on in the health care journey. Conclusion. The creative methods applied in this project allowed patients and staff to work together, flattening hierarchies to produce pragmatic and contextually specific outputs fit for purpose in the complex clinical environment. Project funding: Sheffield Teaching Hospitals Charitable Trust supported by National Institute for Health Research Collaborations for Leadership in Applied Research and Care Yorkshire and Humber (NIHR CLAHRC YH). No conflicts of interest

Introduction. Low back pain (LBP) is the top leading global cause of years lived with disability. In order to examine LBP, researchers have typically viewed the spine in isolation. Clinically, it is imperative that the lower limbs are also considered. The aim of this study was to design a holistic and reliable multi-segmental kinematic model of the spine and lower limbs. Method. The spine was modelled according to easily identifiable anatomical landmarks, including upper thoracic (T1-T6), lower thoracic (T7-T12) and lumbar (L1-L5) segments. Pelvis, thigh, shank and foot segments were included. A 10-camera 3D motion capture system was used to track retro-reflective markers, which were used to define each segment of 10 healthy participants as they walked 3 times at a comfortable speed over a 6km walkway. The relative peak angles between each segment were calculated using the Joint Coordinate System convention and Intraclass Correlation Coefficients (ICCs) were used to determine intra-rater and inter-rater reliability (between an experienced clinician and biomechanical scientist). Results. Intra-rater and inter-rater ICCs were good to excellent (0.6–0.99). This implies that the system could be used reliably by one tester or by testers with limited anatomical expertise. Subjective participant reports implied that the system was acceptable and suitable for patient use (average application time of 10 minutes). Conclusion. The ‘Imperial Spinal Model’ is a holistic and reliable multi-segmental model. It is suitable for the kinematic assessment of the spine and could be used to enhance our understanding of a variety of spinal conditions. No conflicts of interest. Funding: Janet Deane is funded by an Allied Health Professional Doctoral Fellowship awarded by Arthritis Research U.K. (ARUK). Enrica Papi is funded by the National Centre of Excellence for Musculoskeletal Health and Work funded by ARUK and the Medical Research Council

The footplate in the current available TDR is flat without any allowance for endplate concavity in the sagittal plane.

To assess the morphology of the endplates of the lower lumbosacral in the sagittal plane, and to identify the frequently occurring shape patterns of the end plates at each level.

Retrospective Study

200 consecutive magnetic reasonance imaging (MRI) scans of patients between the age of 30 and 60 years were analysed. In each endplate, the anteroposterior width, the height of concavity of the endplate, and the distance of the summit from the anterior vertebral body margin were noted. The shape of the endplate was noted as oblong (o) if the curve was uniform starting from the anterior margin and finishing at the posterior margin, eccentric (e) if the curve started after a flat portion at the anterior border and then curving backwards, and flat (f) if there is no curve in the sagittal plane.

The shape of the end plate is mostly oblong at L3 IEP(59%), equally distributed between oblong and eccentric at L4 SEP (o=43.5%, e=46.5%), eccentric at L4 IEP (e=62.5%), eccentric at L5 SEP (e = 59.0%), eccentric at L5 IEP (e=94.0%), and flat at S1 SEP (f=82.5%).

As there is a difference in the shape of the endplate at each level and they are not uniform, there is a need to focus on the sagittal shape of the footplate to avoid subsidence and mismatch of the footplate in cases of endplate concavity.

Background. Advice and education are considered vital components of back pain care within national guidelines. However, a recent systematic review only found low grade evidence for a small average effect. They also reported wide heterogeneity in intervention design and delivery. This review aimed to understand why intervention design varied and what limited effectiveness by examining the underlying theoretical foundations of the studies from that review. Method. Population, context, selection criteria, intervention(s), control, outcome measures, how the intervention was hypothesised to produce outcomes and author recommendations based on results of the study were extracted from text records. The extent to which the advice included matched a published international consensus statement on evidence-based advice for back pain was recorded. Whether interventions or settings were complex was determined using the Medical Research Council complex intervention development and evaluation guidance and the extent to which they met complexity reporting criteria was recorded. Results. The review included 26 trials conducted over 25 years. Differences In causal pathways could explain diversity in intervention design but these were not clearly described or evaluated. All studies were complex in terms of intervention and setting. This was rarely considered in intervention and trial design or when discussing the results. Although interventions were frequently described in detail only a few explained the process and justification of the design. Theories of education or behaviour change were rarely applied. Conclusion. These studies have not deepened our understanding of how education improves outcomes. Future RCTs should engage more with theory and other theory-based research methods should to be considered. Conflict of interest: No conflicts of interest. Sources of funding: No funding

Background. Specifically designed control interventions can account for expectation effects in clinical trials. For the interpretation of efficacy trials of physical, psychological, and self-management interventions for people living with pain, the design, conduct, and reporting of control interventions is crucial. Objectives. To establish a quality standard in the field, core recommendations are presented alongside additional considerations and a reporting checklist for control interventions. Methods. Three Delphi rounds with 64 experts in placebo research and/or non-pharmacological clinical trials were conducted. The panel was presented with a systematic review and meta-analysis of control and blinding methods. A draft guidance document included 63 consensus items (≥80% agreement) and was discussed with patient partners. Finally, the draft guidance and results from stakeholder interviews were discussed at consensus meetings with Delphi participants and patient representatives. Results. Forty-four experts completed the process. When treatment efficacy or mechanisms are to be studied, the advocated principle is to design control interventions as similar as possible to the tested intervention, apart from the components that the study examines. Structured reasoning in the planning phase, early engagement with stakeholders, feasibility work, and piloting will enhance the quality and acceptability of control interventions. With participant blinding being a primary objective, blinding effectiveness should be routinely assessed and reported. Transparent and detailed reporting will improve interpretability and repeatability of clinical trials. Conclusion. This guideline provides the much-needed standards to enhance the quality of efficacy clinical trials in physical, psychological, and self-management intervention research, ultimately improving patient care. Study registration: . https://osf.io/jmyhq/. Conflict of interest: The authors declare no competing interests. Sources of Funding: Alain and Sheila Diamond Charitable Trust PhD Studentship

Aims. Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS). Methods. UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion. The primary outcome is ‘treatment failure’ (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or ‘treatment success’ (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry. Cite this article: Bone Jt Open 2023;4(11):873–880

Aims. Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted. Methods. As part of the SpInOuT-F study, a pilot randomized trial was carried out across five NHS hospitals. Patients were randomized to either spinal decompression alone or spinal decompression plus instrumented fusion. Patient-reported outcome measures were collected at baseline and three months. The intended sample size was 60 patients. Results. Of the 90 patients screened, 77 passed the initial screening criteria. A total of 27 patients had a PI-LL mismatch and 23 had a dynamic spondylolisthesis. Following secondary inclusion and exclusion criteria, 31 patients were eligible for the study. Six patients were randomized and one underwent surgery during the study period. Given the low number of patients recruited and randomized, it was not possible to assess completion rates, quality of life, imaging, or health economic outcomes as intended. Conclusion. This study provides a unique insight into the prevalence of dynamic spondylolisthesis and PI-LL mismatch in patients with symptomatic spinal stenosis, and demonstrates that there is a need for a definitive RCT which stratifies for these groups in order to inform surgical decision-making. Nonetheless a definitive study would need further refinement in design and implementation in order to be feasible. Cite this article: Bone Jt Open 2023;4(8):573–579

Aims. Anchorage of pedicle screw rod instrumentation in the elderly spine with poor bone quality remains challenging. Our study aims to evaluate how the screw bone anchorage is affected by screw design, bone quality, loading conditions, and cementing techniques. Methods. Micro-finite element (µFE) models were created from micro-CT (μCT) scans of vertebrae implanted with two types of pedicle screws (L: Ennovate and R: S. 4. ). Simulations were conducted for a 10 mm radius region of interest (ROI) around each screw and for a full vertebra (FV) where different cementing scenarios were simulated around the screw tips. Stiffness was calculated in pull-out and anterior bending loads. Results. Experimental pull-out strengths were excellently correlated to the µFE pull-out stiffness of the ROI (R. 2. > 0.87) and FV (R. 2. > 0.84) models. No significant difference due to screw design was observed. Cement augmentation increased pull-out stiffness by up to 94% and 48% for L and R screws, respectively, but only increased bending stiffness by up to 6.9% and 1.5%, respectively. Cementing involving only one screw tip resulted in lower stiffness increases in all tested screw designs and loading cases. The stiffening effect of cement augmentation on pull-out and bending stiffness was strongly and negatively correlated to local bone density around the screw (correlation coefficient (R) = -0.95). Conclusion. This combined experimental, µCT and µFE study showed that regional analyses may be sufficient to predict fixation strength in pull-out and that full analyses could show that cement augmentation around pedicle screws increased fixation stiffness in both pull-out and bending, especially for low-density bone. Cite this article: Bone Joint Res 2021;10(12):797–806

Background. A local authority approached us, for a cost-beneficial solution to their increasing low back pain referrals. We proposed developing a student-led clinic – an intervention delivered by students but supervised by clinicians. We then conducted scoping reviews on student-led clinics in the management of health conditions and on the self-management of back pain. The findings suggested that student-led self-management interventions for low back health should be feasible. The next step was to co-construct the intervention with key stakeholders. Co-Construction. A hybrid of Action Research and Design Science methodology was used to co-construct the intervention with five key stakeholder groups (council staff, managers and human resources, employee healthcare, students, and lecturers). Three rounds of focus groups explored the ‘problem’, the possible solutions, the process, and the content. Themes were taken from each of these focus groups and the similarities and differences were analysed. This analysis and subsequent synthesis with the evidence base created potential intervention models, which were discussed and refined with the stakeholder groups. Intervention. The proposed intervention is focused on providing evidence informed biopsychosocial support for work-relevant back pain, based on identifying obstacles and solutions to improve coping with back health at work. An onboarding workshop challenges positively their thinking around back pain and work. This is followed by up to three 1:1 sessions that support the individual to identify work-relevant back health goals and agree a plan to achieve them using techniques to facilitate behaviour change. Conclusion. The intervention is evidence informed and aims to address the prioritised needs of the stakeholders. Conflicts of interest. No conflicts of interest. Sources of funding. National Health Service Education

Background. Immersive virtual reality (VR) demonstrates potential benefits in patients with chronic low back pain (CLBP). However, few studies have investigated the feasibility and the acceptability of introducing immersive VR for use with patients with CLBP and in the Kingdom of Saudi Arabia (KSA). Aim. To investigate immersive VR's feasibility, tolerability, and acceptability as a rehabilitation intervention for adult patients with CLBP and explore the views of relevant Health Care Practitioners (HCPs) in the KSA. Methodology and Methods. A multi-centre, mixed-methods, explanatory sequential design was adopted to test immersive VR's feasibility, tolerability, and acceptability. An uncontrolled feasibility trial was conducted. The immersive VR intervention involved a training session followed by three sessions over one week using commercially available hardware and software. Feasibility outcomes were collected from patients immediately post-intervention. Patients and HCPs were recruited for semi-structured interviews. Results. Thirty-three patients and three HCPs were recruited. The feasibility a priori criteria were met for recruitment, retention, dropout, completeness of questionnaire data, treatment compliance and fidelity. Adverse events included one who reported aggravation of tinnitus, whereas two experienced dizziness. Qualitative data suggested that entertainment and motivation were key enablers. Barriers included technological capability and HCPs’ perceptions that immersive VR was time-consuming. Conclusion. The results suggested that immersive VR was feasible, acceptable, and tolerable among patients with CLBP and HCPs in clinical settings in the KSA. Further research focusing on the effectiveness is warranted in this field. Conflicts of Interest. None. Sources of Funding. None. Trial registration number. ISRCTN14434517

Purpose and background. Cauda Equina Syndrome (CES), a rare (<1 per 100,000) and potentially devasting condition, involves compression of the lumbosacral nerve roots. If not quickly identified and treated, it can lead to lasting disability, and high medicolegal costs (>£186 million in the decade to 2018). This study identified why people with suspected CES attend the emergency department (ED) and explored any delays in attending. Methods and Results. The design was a secondary analysis of a qualitative dataset comprising patients with back pain who attended the ED, undertaken using an interpretivist approach. Fourteen patients (8M:6F, aged 23–63 years) with suspected CES were purposively sampled from 4 EDs (2 Northern and 2 Southern) in England between August and December 2021. Semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed thematically. Acopia with pain was the biggest factor in a participant's decision to attend the ED, along with the need for a diagnosis. This pain was the worst ever experienced and debilitating, leaving people unable to cope and desperate for relief. 12/14 were advised to attend the ED following identification of red flags by: GPs (n=9); physiotherapists (n=2); surgical colleague (n=1); and 111 (n=1). Factors such as guilt, previous experience of being disregarded, and symptom misattribution were seen to cause delays in seeking care. Conclusion. This paper revealed a disconnect between the priorities of patients and clinicians prior to attending the ED. Clinicians need to validate the pain experience, communicate clearly why signs and symptoms are concerning, and convey the urgency and potential impact of CES. Conflicts of interest. None. Sources of funding. Funding for primary data: Health Education England & National. Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Purpose and background. Understanding patients’ expectations of back pain treatment can help improve their experiences, adherence and outcomes. Patients typically expect a diagnosis and exercise-based physiotherapy, but often undervalue the role of psychological factors. This study explored patients’ expectations of outpatient physiotherapy treatment for back pain in primary care. Methods and Results. The design, a secondary analysis of a qualitative cross-sectional study, involved 25 patients (13M:12F), aged 20–81, referred with low back pain (duration 7 weeks to 9 years). This sample did not include patients with serious spinal pathologies, known psychological disorders, or those unable to communicate without assistance. Face-to-face interviews were undertaken in patients’ homes, which were audio-recorded, transcribed verbatim and analysed using the six stages of thematic analysis outlined by Braun and Clarke. Patients expected a caring clinician and a strong therapeutic relationship, where they felt believed, openly communicated with and valued as an individual. Most patients expected a diagnosis and credible explanation for their pain. There was an almost equal split between those keen to take responsibility for their care and those who felt this was the clinicians’ role. Expectations of passive therapies were slightly higher in this study than existing research. Most patients were realistic about outcomes and expected treatment to reduce their pain, but not cure it. Conclusion. A positive experience mattered most to patients, valuing the relational aspects of their care more than the clinical content provided. Patients saw back pain through a biomedical lens, and most failed to recognise the role of psychosocial factors in their condition or treatment. Conflicts of interest. None. Sources of funding. Funding for primary data: Arthritis Research UK (now Versus Arthritis)

Purpose and background. Low back pain burdens individuals, society and services, including Emergency Departments (ED), straining services and prolonging wait times. Despite reported personal influences on deciding to attend ED, the role of third-party advice remains underexplored. Sparse guidance for clinicians and service-users highlights the need for effective back pain management strategies, to alleviate system pressure and optimise patient outcomes. This study explored how advice influences the decision to attend the ED for back pain. Methods and Results. From a subtle realist stance, the design was a secondary analysis of qualitative data, where 47 patients (26M:21F, aged 23–79 years) with back pain were purposively sampled from four EDs (2 Northern and 2 Southern) in England between August and December 2021. Eight patients had previously visited ED for this episode of back pain. As this was during the pandemic, semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed using a reflective thematic analysis. Three themes were identified as crucial in making the decision to attend ED: The Healthcare professional; Trusted others; and the Individual. Healthcare professionals often dictated decisions, leaving participants feeling powerless. Trusted others provided varying support levels, often acting as allies. Individuals grappled with anxieties around their condition and treatment expectations. Conclusion. This study highlights the need for clinicians to provide clarity and guidance to individuals and their Trusted others, seeking advice regarding escalation to visit the ED with back pain. There was evidence that worrying about pain was a significant motivator for attending ED, resulting in malalignment with current practice guidelines. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Purposes of the study and background. Cognitive Functional Therapy (CFT) is a complex intervention that targets the biopsychosocial nature of low back pain (LBP). The barriers and facilitators to CFT have not previously been researched in the United Kingdom National Health Service (NHS). This study aimed to explore the barriers and facilitators of CFT in the NHS ahead of a future clinical trial. Methods and results. Participants who had completed a CFT intervention for persistent LBP and physiotherapists who had previously attended a CFT training workshop were recruited. Data were collected using one to one semi-structured interviews and were analysed thematically using framework method. Eight people with LBP and ten physiotherapists consented to participate. The key findings were that UK NHS physiotherapists can be trained to deliver CFT, they valued the training and felt confident to deliver CFT successfully to patients in NHS physiotherapy departments. Peer support and mentorship from a CFT practitioner was necessary for the physiotherapists to sustain changes to their clinical practice. Participants with LBP welcomed CFT as they felt it was beneficial and enabled them to self-manage their LBP and they could recognise the difference between CFT and usual care. The barriers, mainly related to the healthcare system, included short appointment times and poor availability of follow-up appointments. Conclusion. This is the first study to establish the barriers and facilitators to the implementation of CFT in the NHS. The findings of this study were used to inform the planning, design and delivery of a feasibility randomised controlled trial. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose of study and background. Psychological factors are considered to play a role in development and maintenance of chronic low back pain (CLBP). Stress or anxiety can change pain sensitivity; however, this has predominantly been studied in healthy individuals with limited work in individuals with musculoskeletal pain. The objective of this study was to quantify the effect of acute exposure to a psychosocial stressor on mechanical pain sensitivity in individuals with and without CLBP. Summary of methods and results. Six individuals with CLBP and 10 individuals without CLBP performed a 10-minute computer task under conditions of low and high psychosocial stress. Psychosocial stress was manipulated using mental maths and memory tasks combined with social evaluative threat. The effect of the stressor was evaluated using blood pressure, heart rate and the state anxiety component of the Spielberger State-Trait Anxiety Index. Mechanical pressure pain threshold (PPT) was recorded on the tibialis anterior muscle using a handheld digital pressure algometer. The stress manipulation increased self-reported anxiety (p<0.001), but not blood pressure or heart rate (p>0.06). Change in PPT from low to high stress was greater in the CLBP group (median ΔPPT = −0.5 kg/cm. 2. ) than in the control group (−0.15 kg/cm. 2. ; p=0.005). Conclusion. Individuals experienced an increase in pain sensitivity after acute exposure to a stressor designed to mimic low-level workplace stressors, and this increase was greater in individuals with CLBP than asymptomatic individuals. These results indicate that this experimental model can be used to study links between pain sensitivity and psychosocial stressors and increase our understanding of their potential role in CLBP. Conflicts of Interest: No conflicts of interest. Sources of funding: No funding obtained

Background. Intervertebral disc degeneration (DD) is a complex age-related condition that constitutes the main risk factor for disabling back pain. DD is assessed using different traits extracted from MR imaging (MRI), normally combined to give summary measures (e.g. Pfirmann score). The aetiology of DD is poorly understood and despite its high heritability (75%), the precise genetic predisposition is yet to be defined. Genome wide association study (GWAS) is used to discover genetic variants associated with a disease or phenotype. It tests variants across the whole genome. It requires large samples to provide adequate but unfortunately there is poor availability of spine imaging data due to the high cost of MRI. We have adopted new methods to examine different MRI traits independently and use the information of those traits to boost GWAS power using specialized statistical software for jointly analyse correlated traits. Methods/Results. We examined DD MRI features disc narrowing, disc bulge, disc signal intensity and osteophyte formation in the TwinsUK cohort who had undergone T2-weighted sagittal spine MRI. GWAS were performed on the four traits. MTAG software was used to boost single trait GWAS power using the information in the other trait GWAS. 9 different loci were identified. Conclusions. Preliminary results suggest genes GDF6, SP1/SP7 are associated with individual trait signal intensity. In addition, novel associated genes with potential for shedding new light on pathogenic mechanisms are identified. Additional cohorts will be included in the design as a replication to test reproducibility of the results. Conflicts of interest: No conflicts of interest. Sources of funding: Funded by Disc4All, EU Horizon 2020, MSCA-2020-ITN-ETN GA: 955735