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

Purpose and background. Nearly 70% of UK physiotherapists experience work-related musculoskeletal disorders (WRMSDs) during their career, with a significant proportion occurring in the back and being attributed to patient handling tasks. Evidence suggests that manual handling training alone is ineffective and interventions among nurses indicate that a tailored approach, including targeted exercise (TE), can reduce WRMSD rates. This study aimed to explore physiotherapists’ perspectives of WRMSDs, patient handling, and the role of TE in reducing WRMSDs among physiotherapists. Methods and Results. Key informant interviews were conducted with 4 physiotherapy operational leads and 1 manual handling trainer from NHS Grampian. Interviews were transcribed and Framework Analysis was utilised to identify key themes, including challenges, barriers, and facilitators. Following this, two online focus groups were conducted with 7 qualified NHS physiotherapists across the UK. Views of manual handling training varied across specialities, with some finding it comprehensive and adaptable, and others finding it less applicable to patients in their speciality or community setting. Physiotherapist views on fitness for work varied, with some highlighting the necessity of TE to ensure workforce health whilst others considered exercise to be a personal matter. Facilitators to implementation identified by participants were having support from management and a strong justification for the exercise content. Varied work schedules and facilities were identified as barriers to implementation of a work-based TE intervention. Conclusion. Varying perspectives on TE interventions and barriers to implementation were identified. This work will inform future research to develop TE interventions in consultation with key stakeholders. Conflicts of Interest. No conflicts of interest. Source of Funding. NHS Endowment Research Grant 22/001

Purpose and background of the study. Self-management and behaviour change is at the core of back pain management. Despite the high-rate of recurrence and healthcare utilisation, clinical guidelines do not include guidance for clinicians on return consultations. This project aimed to identify primary care clinicians’ reported practices and experiences of delivering self-management advice for people returning with persistent low back pain (LBP), to inform future delivery of self-management care. Methods and Results. In this qualitative study involving 27 primary care clinicians, four focus groups and two semi-structure interviews were conducted online. GPs (n=5) and physiotherapists working in primary care roles (First contact practitioners n=7, community and interface roles n=7, and mixed roles n=8) in England and Scotland shared their experience of delivering self-management advice to people returning with persistent LBP. Video recordings were transcribed verbatim and analysed with reflexive thematic analysis. Clinicians unanimously shared their frustrations identifying the challenges involved in supporting people who return with LBP. Helpful strategies to support self-management in return consultations were identified by clinicians in addition to service and system-level changes vital to optimise care. Patient-factors affecting delivery of care, lack of defined responsibility and challenges in meeting patients’ expectations illustrated the tensions that exist in return consultations. Conclusion. This novel study provides insight into the experiences and practices of the frontline primary care workforce seeing patients return with persistent or recurrent LBP. It identifies the tensions that exist between services, professional roles and between clinicians and patients regarding self-management. Important practice implications have been identified to improve information-sharing, agenda-setting, and exploring expectations. No conflicts of interest.  . Source of funding. Lisa Osborn-Jenkins is funded by University Hospital Southampton NHS Foundation Trust (UHS) Research & Development PhD Fellowship [GRT0723]

Background. Chronic low back pain (CLBP) is the leading cause of disability worldwide. Immersive virtual reality (IVR) can be delivered using head mounted display (HMD) to interact with 3D virtual environment (VE). IVR has shown promising results in management of chronic pain conditions, using different mechanisms (e.g., exposure to movement and distraction). However, it has not been widely tested for CLBP. Future development of IVR intervention needs inputs from gatekeepers to determine key considerations, facilitators and barriers. This qualitative study aimed to explore views and opinions of physiotherapists about IVR intervention for adults with CLBP. Methods. Four focus groups were conducted online, with 16 physiotherapists. A demonstration of existing IVR mechanisms was presented. The data were transcribed and analysed through descriptive thematic analysis. Results. IVR was thought to be a suitable adjunct for a subgroup of patients who are reluctant to engage with standard care. Motivation to perform challenging physical tasks was believed to be a potential benefit. Safety, possibility of addiction, and transferability of acquired skills from VE to ‘real world’ and hygiene were concerns and the intervention was preferred to be used under clinical supervision. VE personalisation to patient's goal and preference with delivery and progression being gradual depending upon patient's abilities was suggested. Technical knowledge was seen as a facilitator, while cost and technology acceptance were barriers for future implementation. Conclusion. Future studies would need to consider the reported views of physiotherapists to inform development and implementation of IVR intervention for CLBP. Conflicts of interest: No conflict of interest. Sources of funding: Funded by the government of Saudi Arabia

Purpose of the study. The purpose of this project was to evaluate whether OHEIs could facilitate student physiotherapy placement training in their educational outpatient clinics. Background. The National Health Service (NHS) is actively promoting Allied Health Professionals (AHPs) to have a greater role in supporting healthcare delivery. There are challenges to increasing AHP numbers and one of these is providing enough student training placements to meet demand. Methods. This evaluation used quantitative and qualitative methods. The OHEI clinical tutors and students collected activity data Anonymised questionnaires for physiotherapy students examining expectation were completed online before placement and an experience questionnaire after placement. Interviews and focus groups were conducted to investigate the experiences of stakeholders involved in the project. This included physiotherapy and osteopathy students, clinic tutors, and placement coordinators in OHEIs and physiotherapy HEIs. Results. Four universities with physiotherapy courses participated, and 37 students in 2 cohorts completed either five- or six-week placements at three OHEI clinics between April and August 2021. Cohort 1 expressed uncertainties about roles and integration in clinic and with patients. Concerns were addressed for Cohort 2 and physiotherapy student learning experiences were much better with 83% of physiotherapy students satisfied or very satisfied with their placement. Conclusion. The placement of physiotherapists in OHEI clinics is feasible. Careful expectation management is essential. Future sustainability is dependent upon managing costs to the OHEIs as it is unlikely placements will generate income. The learning environment could be made more reciprocal with time and experience leading to better understanding of the different professions and enhanced multidisciplinary working. Conflicts of interest: Dawn Carnes and Carol Fawkes are both trained osteopaths. Sources of funding: Health Education England grant to the Institute of Osteopathy (the professional association for UK osteopaths)

Purpose. This research project explored the experiences, attitudes, beliefs, and perceptions of healthcare professionals (physiotherapists and orthopaedic surgeons) and people with chronic low back pain (CLBP) regarding the barriers and facilitators to activity normalisation following physiotherapy. Methods. A qualitative study of the perspectives of patients, physiotherapists and orthopaedic surgeons on CLBP was undertaken in Saudi Arabia. One focus group discussion was conducted with seven patients who had received physiotherapy for CLBP, along with one focus group discussion with eight physiotherapists and seven individual interviews with orthopaedic surgeons. The focus group discussions and interviews were transcribed and analysed using framework analysis. Results. We identified seven factors facilitating or hindering activity normalisation following physiotherapy: symptom control, patient education and awareness, adherence to treatment plan, psychosocial factors, role of the clinician, social support, and issues relating to the healthcare system. Conclusion. Clinicians stressed the importance of exercise and regular activity in spite of pain as an important factor hindering activity normalisation. Patients appreciated reassurance and advice from clinicians but also noted that conflicting and ambiguous advice and diagnosis was common. This may contribute to poor adherence with advice and exercise. Fear of pain and recurrence of injury were highlighted as important factors hindering activity normalisation, particularly since some patients did not take active steps to control pain. Finally, whilst multidisciplinary teams may support patient recovery and activity normalisation, this is often expensive and intensive and may be beyond the reach of a healthcare system without a properly functioning referral system and insufficient specialised clinics and physicians. Conflicts of interest: None. Sources of funding: This research was supported through a PhD scholarship from Prince Sattam bin Abdulaziz University, Saudi Arabia, at the University of Nottingham, United Kingdom

Background. Chronic musculoskeletal pain increases an individual's risk of developing many chronic diseases and the risk of all-cause early mortality. There is irrefutable evidence supporting the role of physical activity (PA) in reducing these risks. Sustaining changes to PA behaviours is challenging and efforts are needed to understand the barriers and facilitators of change. Understanding these factors is a vital step in developing behaviour change interventions. Objectives. Explore barriers and facilitators to engaging in PA in adults accessing pain services. Explore barriers and facilitators to promoting PA by healthcare professionals, exercise professionals and charity staff/expert patients. Methods. A qualitative study using the theoretical domains framework (TDF). Two focus groups were conducted with service users (n=18). Three focus groups were held with; healthcare professionals (n=8); exercise professionals (n=6) and charity staff/expert patients (n=8). Two independent reviewers thematically analysed transcripts. Barriers and facilitators were subsequently coded according to the domains of the TDF. Results. For all groups barriers were frequently mapped to the domain ‘environmental context and resources’. Although there was variation across the groups, barriers were also frequently mapped to the domains of ‘knowledge’, ‘beliefs about consequences’, and ‘belief about capabilities’. For service-users' facilitators were frequently mapped to ‘social influences’. Conclusion. The TDF was used to identify deficits that are likely to influence behaviours; targeted intervention strategies have been developed to specifically target these deficits. The interventions that have been developed consider not only the behaviour of those at whom the intervention is targeted, but also those involved in its delivery. No conflicts of interest. Sources of funding: This research was funded by the Public Health Agency, HSC R&D Division through a Doctoral Fellowship awarded to J Marle

Purpose:. To explore clinicians' perceptions of empathy during musculoskeletal clinical consultations. Background:. Empathy is considered essential to creating a positive experience within healthcare for both the patient and clinician, improving adherence, creating trust and improving patient experience. However, little is known about how clinicians acquire and display empathic communication skills during musculoskeletal consultations. Methods:. In this qualitative study, 11 physiotherapists and 6 students participated in three focus groups, separated by clinical grade. The definition of empathy, its acquisition and impact on clinical practice were discussed, audio-recorded, transcribed verbatim and analysed. Data were managed using a Framework approach, and key themes identified. Results:. The data from 17 participants comprised 149 minutes of audio recording. Six key themes and 48 sub-themes were identified. Empathy was considered a key component of communication and similarly defined in all three focus groups; however divergence surrounded how it is acquired, the extent it can be taught and whether a clinician's personality influences their career pathway. Experienced clinicians highlighted greater importance and impact of empathic communication in practice than novices, whilst novices considered a lack of time a key barrier in preventing empathic communication. Discussion:. There is a mismatch between the importance attributed to empathic communication in the literature and by clinicians, compared with the time and energy spent acquiring and developing these skills. Conclusion:. Displaying genuine empathy is considered essential to building rapport and optimising non-specific treatment effects in clinical practice, however clinicians need greater awareness and engagement to further these skills for patient benefit

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.

Background. Evidence-based practice advocates utilising best current research evidence, while reflecting patient preference and clinical expertise in decision making. Successfully incorporating this evidence into practice is a complex process. Based on recommendations of existing guidelines and systematic evidence reviews conducted using the GRADE approach, treatment pathways for common spinal pain disorders were developed. Aims. The aim of this study was to identify important potential facilitators to the integration of these pathways into routine clinical practice. Methods. A 22 person stakeholder group consisting of patient representatives, clinicians, researchers and members of relevant clinical interest groups took part in a series of moderated focus groups, followed up with individual, semi-structured interviews. Data were analysed using content analysis. Results. Participants identified a number of issues which were categorized into broad themes. Common facilitators to implementation included continual education and synthesis of research evidence which is reflective of everyday practice; as well as the use of clear, unambiguous messages in recommendations. Meeting additional training needs in new or extended areas of practice was also recognized as an important factor. Different stakeholders identified specific areas which could be associated with successful uptake. Patients frequently defined early involvement in a shared decision making process as important. Clinicians identified case based examples and information on important prognostic indicators as useful tools to aiding decisions. Conclusion. A number of potential implementation strategies were identified. Further work will examine the impact of these and other important factors on the integration of evidence-based treatment recommendations into clinical practice

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.

Purpose of the study and background. The CONNECT trial evaluated a theory-based intervention to increase low back pain patients' adherence to treatment recommendations through physiotherapists' communication behaviour. Bridging the gap between evidence and evidence-based practice, we aimed to develop an implementation intervention to support physiotherapists in translating the CONNECT communication training into practice. Methods and results. A systematic approach was used to develop this intervention. 1. Focus groups underpinned by the Theoretical Domains Framework were conducted to assess CONNECT trained physiotherapists' (n = 9) perceptions of the barriers and enablers to implementing these strategies in practice; the results of which yielded four main domains; two related to factors outside the individual (i.e. social influences and environmental resources), and two related to individuals' motivation and capabilities (i.e. self –efficacy and behavioural regulation). 2. Intervention components (i.e., behavior change techniques (BCT) and mode of delivery) were chosen. BCTs were mapped to the identified domains (e.g., the BCT of self-monitoring mapped to the self-efficacy domain) and audit and feedback focused coaching was selected as the main mode of delivery based on empirical evidence and feasibility. 3. Outcome measures were selected to evaluate the proposed changes in physiotherapist practice (i.e., Health Care Climate Questionnaire). This intervention was trialed with physiotherapists (n = 2) using a case-study design. Results from patient consultation audio-recordings and follow-up interviews revealed this intervention supported the translation of evidence-based training into practice and is considered feasible and acceptable to physiotherapists. Conclusion. Findings provide support for the systematic development and implementation of an intervention to translate evidence-based communication training into practice