Background and purpose. Pilates is a popular exercise approach which is increasingly used in the management of LBP. However, to date the evidence base remains poor with a need to define the Pilates intervention and the outcome measures required for future high quality studies. The objective of this study was to explore the client's view of participating in Pilates classes: in particular the reasons for attendance and its effects. Methods. Purposeful sampling was used to recruit clients (n=25; 4 male and 21 female, age range 28 to 65 years) who had attended Body Control Pilates classes for at least 24 sessions. Focus group discussions were guided by pre-determined questions, these were transcribed verbatim and analysed using the thematic approach. Ethical approval was obtained for the study from the University of Ulster's School of Health Sciences. Results. Clients attended Pilates classes mainly for the management of musculoskeletal conditions particularly low back pain. They reported that Pilates reduced pain, improved strength, flexibility, balance, core stability and body awareness. 5 main themes emerged (1) long-term commitment to Pilates (2) improved health and well-being (3) personalised form of exercise and (4) belief in the Pilates instructor (5) barriers to Pilates. Conclusions. Pilates classes provide individually-modified exercises in a group setting and enable clients in the self-management of long term musculoskeletal conditions. The results of this study informed the design of a UK wide survey to further establish this information. Conflicts of interest: None. Sources of funding: This study is funded by The Department for Education and Learning (DEL). This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Background. There is a 20% dissatisfaction rate with knee replacements. Calls for tools that can pre-operatively identify patients at risk of being dissatisfied postoperatively have been widespread. However, it is unclear what sort of information patients would want from such a tool, how it would affect their decision making process, and at what part of the pathway such a tool should be used. Methods. Using focus groups involving 12 participants and in-depth interviews with 10 participants, we examined the effect outcome prediction has by providing fictitious predictions to patients at different stages of treatment. A qualitative analysis of themes, based on a constant comparative method, is used to analyse the data. This study was approved by the Dyfed Powys Research Ethics Committee (13/WA/0140). Results. Our results demonstrate several interesting findings. Firstly, patients who have received information from friends and family are unwilling to adjust their expectation of outcome down (i.e. to a worse outcome), but highly willing to adjust it up (to a better outcome). This is an example of the optimism bias, and suggests the effect on expectation of any poor outcome prediction would be blunted. Secondly, patients generally wanted a “bottom line” outcome, rather than lots of detail. Thirdly, patients who were earlier in their treatment for osteoarthritis were more likely to find the information useful, and for it to affect their decision, than patients later in their pathway. Conclusion. An outcome prediction tool would have most effect targeted towards people at the start of their treatment pathway, with a “bottom line” prediction of outcome. However, any effect on expectation and decision making of a poor outcome prediction is likely to be blunted by the optimism bias. Level of Evidence. 4

Background. Knee replacement surgery is currently facing three dilemmas: a high dissatisfaction rate; increasing demand with financial constraints; and variation in utilisation. A patient centred approach, usually achieved through shared decision-making, has the potential to help address these dilemmas. However, such an approach requires an understanding of the factors involved in patient decision-making. This is the first study examining decision-making in knee replacements that includes patients at different stages of decision-making – this is critical when considering decision-making as a process. We base our findings in a theoretical model, proposed by Elwyn et al, that highlights the distinction between deliberation and decision-making, and propose modifications to this model specific to knee replacement decision-making. Methods. This study used two focus groups of six patients each and in-depth interviews with 10 patients to examine the factors that affect patient decision-making and their interaction at different points in the decision-making process. A qualitative analysis of themes, based on a constant comparative method, is used to analyse the data. This study was approved by the Dyfed Powys Research Ethics Committee (13/WA/0140). Results. We describe 10 themes that affect patient deliberation over the decision: decision-making style; coping strategies; expectation of outcome; decision-making stress; personal situation; preferred model of care; trust in doctor; sources of information; mental state; and loss of control. We add to Elwyn's model by demonstrating the boundary between deliberation and decision-making is the decision-making threshold. Conclusion. This study provides increased detail on a theoretical model that can be used to describe decision-making, and an understanding of the factors that affect decision-making for patients considering knee replacement. Such an understanding will aid patient centred care, and has particular relevance in developing interventions aimed at delivering information. This is likely to affect the satisfaction rate, demand, and utilisation of knee replacements. Level of evidence. 4

Around 20% of patients who have total knee replacement find that they experience long-term pain afterwards. There is a pressing need for better treatment and management for patients who have this kind of pain but there is little evidence about how to improve care. To address this gap we are developing a complex intervention comprising a clinic to assess potential causes of a patient's long-term pain after knee replacement and onwards referral to appropriate, existing services. The Medical Research Council recommends that development of complex interventions include several stages of development and refinement and involvement of stakeholders. This study comprises the penultimate stage in the comprehensive development of this intervention. Earlier stages included a survey of current practice, focus groups with healthcare professionals, a systematic review of the literature and expert deliberation. Healthcare professionals from diverse clinical backgrounds with experience of caring for patients with long-term pain after knee replacement were sent a study information pack. Professionals who wished to participate were asked to return their signed consent form and completed study questionnaire to the research team. Participants rated the appropriateness of different aspects of the assessment process and care pathway from 1–9 (not appropriate to very appropriate). Data were collated and a document prepared, consisting of anonymised mean appropriateness ratings and summaries of free-text comments. This document was then discussed in 4 facilitated meetings with healthcare professional held at the future trial centres. A summary report and revised care pathway was then prepared and sent to participants for further comments. 28 professionals completed the questionnaire and/or attended a meeting. Participants included surgeons, physiotherapists, nurses, pain specialists and rheumatologists. Mean appropriateness scores ranged from 6.9 to 8.4. Taking a score of 7–9 as agreement, consensus was achieved that the assessment should be performed at 3 months post-operative by an extended scope practitioner/nurse, treatment be guided by a standardised assessment of pain, and treatment individualised. There was also agreement that referrals in the care pathway to surgical review, GP and pain clinics were appropriate. Nurse-led/self-monitoring was rated lower (6.9) because of considerations about the need to ensure that patients receive appropriate support, follow-up and referral to other services. This work demonstrates the research methods that can be used to refine the design of a complex intervention. The process and findings enable refinement of an intervention for patients with long-term pain after knee replacement. The next stage of intervention development will assess the acceptability and reliability of the assessment process, and the usability of the intervention's standard operating procedures. The intervention will then be evaluated by a larger research team in a multi-centre randomised controlled trial, starting in late 2016

Purpose of study. To explore the clinical reasoning strategies used by extended scope physiotherapists (ESPs) when assessing patients with low back pain. Background. Extended scope physiotherapists commonly work in back pain services and their training emphasises the acquisition of clinical skills and possible diagnostic tests (including MRI) to aid clinical reasoning and diagnosis. Whilst there has been some exploration of reasoning strategies of other professional groups (notably medically qualified) to date, the clinical reasoning strategies of ESP clinicians have not been reported. Methods. A qualitative study, with three focus groups, explored clinical reasoning by ESPs and non-ESPs, to compare how these clinicians assess patients' with back pain. This informed a second study, using a ‘think-aloud’ technique with 10 participants from four NHS sites, examining their reasoning strategies, immediately after completing initial consultations. Analysis was informed by a grounded theory approach. Results. Themes identified relating to clinical reasoning were prior thinking, patient interaction, gut-feeling, and formal testing. The differences in practice between ESP and non-ESP appeared to be driven by differences in accountability, safety and external influences. A key difference between the accounts of clinical reasoning provided by ESPs and non-ESPs centred on the role and appropriateness of ‘gut feeling’ in diagnostic decision making. The analysis explores the apparent tension between this instinctive contribution to reasoning and evidence-based practice. The paper explores the legitimacy of gut feeling. Conclusions. Extended scope physiotherapists appear to employ different clinical reasoning strategies to their non-ESP colleagues, highlighting the additional burden of responsibility and tension created by the use of gut feeling. No conflicts of interest. No funding obtained. This abstract has not been previously published in whole or in part; nor has it been presented previously at a national meeting

Aims. 1. To develop a decision aid - Decision Support Package (DSP) - that will provide low back pain (LBP) patients, and their treating physiotherapists with information on the treatment options available to the patients. 2. To develop a training package for physiotherapists on how to use the DSP. 3. To encourage and evaluate the informed shared decision making (ISDM) process between patients and physiotherapists during consultation. Method. We developed a DSP informed by existing research and collaboration with physiotherapists, patients and experts in the field of decision aids and LBP. We did six pieces of exploratory work: literature review; 2009 NICE LBP guidelines review; qualitative screening of transcripts of interviews of LBP patients; focus groups (patients); nominal group (physiotherapists), and Delphi study (experts). We collated these data to develop the DSP. We also developed a training package for physiotherapists. Results. We developed a LBP patient resource for use prior to their first consultation and a training package for physiotherapists. The DSP contained information on acupuncture, structured group exercise, manual therapy and cognitive behavioural approach. LBP patients would expect these treatment options to be offered to them at their initial consultation. The training package for physiotherapists was on DSP use and communication skills during consultation. Conclusion. We have developed an evidence and theory informed Decision Support Package and physiotherapists training. We are currently piloting its use in one NHS Trust prior to running a pilot RCT (N=150) to test is effect on improving patient satisfaction with LBP patients' treatment choices. Conflicts of Interest. None. Source of Funding. National Institute for Health Research- Research for Patient Benefit (NIHR-RfPB). This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Background. Evidence suggests classification system (CS) guided treatments are more effective than generalized and practice guidelines based treatments for low back pain (LBP) patients. This study evaluated clinicians' and managers' attitudes towards LBP classification and its usefulness in guiding LBP management. Methods. Data from 3 semi-structured interviews with physiotherapy service managers and advanced spinal physiotherapy practitioner and a focus group (5 physiotherapists) in two NHS Health Boards, South Wales, UK, was thematically analysed. Results. Five themes emerged. CS knowledge: Clinicians and managers know different CSs and agree with its usefulness. Clinicians have specific CSs knowledge, managers viewed classification related to referral pathways and prognosis. Current CS use: Clinicians classify using their experience and clinical reasoning skills shifting between multiple CSs. Managers are confident that staff provide evidence-based service though believe classification is not always practiced across services. CS advantages/disadvantages: Effectively targeting the right patients for right treatments using evidence-based practice is advantageous. Prevalence of “guru led” CSs developed for research and of limited clinical use is disadvantageous. Barriers: Patients' treatment expectations, threat to clinical autonomy, lack of sufficiently complex CSs, lack of resources to up-skill clinicians and overall CSs fit into complex referral pathways. Enablers: CSs sufficiently complex & placed within clinical reasoning process, mentoring for inexperienced staff, positive engagement with all stakeholders and patients. Conclusion. Clinicians and managers are aware of CSs and agree with its usefulness to guide LBP management. Clinicians classify LBP though there is no formalized CS process in place. Whilst clinicians view classification as the relationship between patients and physiotherapy managers have a broader, whole service view. Conflicts of interest: None. Sources of funding: Wales School of Primary Care Research, Cardiff, UK. This abstract has not been previously published in whole or substantial part nor has been presented previously at a national meeting

Objectives

Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making.