Background and study purpose. Low back pain with no identified underlying cause is categorised as primary musculoskeletal pain by the International Association for the Study of Pain. In April 2021, the National Institute for Care and Excellence (NICE) published updated guidance for the management of primary chronic pain conditions in England. As part of the De-STRESS pain study, we explored the perspectives of GPs on the updated guideline and impact upon clinical practice. Methods and results. Semi-structured interviews were conducted with 21 GPs in England. Data were analysed using thematic analysis and constant comparison techniques. GPs agreed with the recommendations restricting pharmacological options for pain management and reflected that they now had an expert reference to back-up their decision-making and could use the guidance in potentially difficult conversations with patients. Frustration was expressed by GPs about the lack of alternative options to medication, as the non-pharmacological recommendations were difficult to implement, had lengthy waiting lists, or were unavailable in their locality. Conclusion. Although GPs discussed benefits of the updated NICE guideline in potentially reducing prescriptions of ineffective and potentially harmful medications, frustration about the lack of alternative strategies added to the difficulties encountered in managing people with persistent back pain in primary care. Conflicts of interest: No conflicts of interest. Sources of funding: This study was funded by Versus Arthritis – grant number 22454; Carolyn A Chew-Graham is part-funded by NIHR Applied Research Collaboration (ARC) West Midlands

Background. NHS improvement advocates same day emergency care (SDEC) for patients requiring additional specialism than can be provided in an Emergency Department. A novel physiotherapist-led spinal SDEC unit was established in January 2020, integrated within the on-call spinal service. The aim of this paper was to evaluate patient and peer satisfaction with the spinal SDEC. Methods. Patient satisfaction questionnaires and/or friends and family tests were collected from patients over a six-month period. Questionnaires evaluated satisfaction with recommendations given, service given, staff friendliness. Anonymous, completed questionnaires were uploaded onto a spreadsheet. Peer satisfaction was assessed using a google sheets document emailed to interface, primary care and community services. The questionnaire captured the respondents’ role, how many patients they had referred to the SDEC, reasons for referral, ease of referral, and compared this new pathway with the previous pathway. All patient's satisfaction responses recommended the service to family and friends (n=110 extremely likely, 8 likely) (6% total seen). All respondents were satisfied with the service they received (n=80 very satisfied, n=12 satisfied) and recommendations made (n=86 very satisfied, n=6 satisfied). Of peer satisfaction, 26 respondents (n=12 (46%) physiotherapists, n=6 (23%) first contact practitioners, n=6 (23%) advanced practice physiotherapists, n=1 (4%) GP, n=1 (4%) nurse) reported the SDEC delivered a better pathway and outcomes (n=25, 96%), and 20 (77%) respondents reported favourable comments of the service and its impact on patients and referrers. Conclusion. Peer and patient satisfaction data support the use of a physiotherapist-led spinal SDEC in emergency and urgent spinal care pathways. Conflicts of interest: No conflicts of Interest. Sources of interest: No sources of funding

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

Background and aims. The EU-funded Back-UP project aims to develop a cloud computer platform to guide the treatment of low back and neck pain (LBNP) in first contact care and early rehabilitation. In order to identify evidence-based treatment options that can be recommended and are accessible to people with LBNP across Europe, we conducted a systematic review of recently published guidelines. Methods. Electronic databases, including Medline, Embase, CINAHL, PsycINFO, HMIC, Epistemonikos, PEDro, TRIP, NICE, SIGN, WHO, Guidelines International Network (G-I-N) and DynaMed Plus were searched. We searched for guidelines published by European health professional or guideline development organisations since 2013, focusing on the primary care management of adult patients presenting with back or neck pain (including whiplash associated symptoms, radicular pain, and pregnancy-related LBP). The AGREE-II tool was used to assess the quality of guideline development and reporting. Results. Searches generated 3098 unique citations that were screened for eligibility. A total of 189 full-texts were retrieved, and 18 guidelines were included in the review (from the UK, Germany, France, Italy, Denmark, Poland, Belgium, and the Netherlands). Data extraction showed considerable variation in guideline development processes, especially regarding the methods used for identifying, appraising, and synthesising evidence, and for formulating, agreeing, and grading recommendations. Conclusions. Recommendations for the management of LBNP cover a wide range of treatment options, with self-management advice, analgesics, and exercise proposed as core treatments by most guidelines. A narrative synthesis, taking into account consistency, strength, and quality of guideline recommendations, will be presented. No conflicts of interest. Funding: This abstract presents independent research within the Back-UP project, which has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 777090. This document reflects only the views of the authors, and the European Commission is not liable for any use that may be made of its contents. The information in this document is provided “as is”, without warranty of any kind, and accept no liability for loss or damage suffered by any person using this information

Background. Work disability due to low back pain (LBP) is a global concern, resulting in significant healthcare costs and welfare payments. In recognition of this, recent UK policy calls for healthcare to become more ‘work-focused’. However, an ‘evidence-policy’ gap has been identified, resulting in uncertainty about how this is to be achieved. Clear, evidence-based recommendations relevant to both policy-makers and healthcare practitioners are required. Methods. A policy theory approach combining scientific evidence with governance principles in a pragmatic manner was undertaken. This entailed extracting evidence from a recent review of the system influences on work disability due to LBP* (focused specifically on the healthcare system) and appraising it alongside the most recent review evidence on the implementation of clinical guidance, and policy material aimed at developing work-focused healthcare. Results. It was found that further resources are needed to assist healthcare professionals (HCPs) to engage in work discussions with LBP patients, which can often be complex and challenging. HCPs themselves often have misconceptions about the work-health relationship and the related evidence-based guidance. System-level barriers that reduce access to suitable healthcare at the right time, and those that increase conflict with other key stakeholders (e.g. the workplace and welfare/compensatory systems) were found to be significant obstacles. Supportive policy and legislation that (a) embeds work as a health outcome, and (b) enables all key stakeholders to collaborate would be a major vehicle to facilitate work-focused healthcare for LBP. Conclusions. Accepting that work-focused healthcare for LBP is required does not diminish the challenge it presents. Evidence-based recommendations relevant for both policy and practice would enable a better understanding of what works for whom, and at what cost. *A full description and results of the evidence synthesis were presented at the Society's Annual Meeting 2016 and will be presented at the 15th International Forum for Back and Neck Pain Research in Primary Care 2017. These results also form part of a chapter in ISSLS Online Textbook 2017. Conflicts of interest; None. Sources of funding: None

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

Purpose and background. Lower back pain is a leading cause of disability and a common condition seen by osteopaths. Evidence and advice for the safest lifting posture vary, as do healthcare practitioners' attitudes towards back pain. The aim of this study was to understand osteopaths' beliefs about safe lifting postures, their attitudes towards back pain, and to compare these findings with published data from physiotherapists and manual handling advisors. Methods and results. A cross-sectional electronic survey was used to invite a sample of UK osteopaths to select images that best represent their perception of safe lifting posture (straight or rounded back), and to complete the Back Pain Attitudes Questionnaire (Back-PAQ, Appendix 1). Data was analysed to assess lifting posture selection and relationship to back pain attitudes. 46 (85.2%) out of 54 osteopaths selected straight back posture as safest, these participants had significantly more negative attitudes to back pain injury (i.e. higher Back-PAQ scores), than the 8 osteopaths who selected a rounded back posture (p = 0.007). Data from 266 physiotherapists and 132 manual handling advisors revealed an overall agreement about straight back lifting posture, however revealed differences in Back-PAQ attitude between the professions. Conclusion. Despite a lack of evidence base and inconsistent recommendations, osteopaths in this survey and other healthcare practitioners believe that straight back lifting posture is the safest. Practitioners' attitudes vary and are known to influence their patients' attitudes and recovery behaviour. Further research is recommended to identify reasons for different beliefs, and their impact on advice-giving and patient outcomes. Conflicts of interest: None. Sources of funding for the research: None

Introduction. Analgesic drugs are often prescribed to patients with low back pain (LBP). Recommendations for non-invasive pharmacological management of LBP from recent clinical practice guidelines were compared with each other and with the best available evidence on drug efficacy. Methods. Guideline recommendations concerning opioids, non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, antidepressants, anticonvulsants and muscle relaxants from national primary care guidelines published within the last 3 years were included in this review. For each pharmacotherapy, the most recent systematic review was included as the best available evidence on drug efficacy and common adverse effects were summarized. Results. Eight recent national clinical practice guidelines were included in this review (from Australia, Belgium, Canada, Denmark, The Netherlands, UK and US). Guidelines are universally moving away from pharmacotherapy due to the limited efficacy and the risk of adverse effects. NSAIDs have replaced paracetamol as the first choice analgesics for LBP in many guidelines. Opioids are considered to be a last resort in all guidelines, but prescriptions of these medications have been increasing over recent years. Only limited evidence exists for the efficacy of antidepressants and anticonvulsants in chronic LBP. Muscle relaxants are one of the analgesics of first choice in the US, but aren't widely available and thus not widely recommended in most other countries. Conclusions. Upcoming guideline updates should shift their focus from pain to function and from pharmacotherapy to non-pharmacologic treatment options. No conflicts of interest. Sources of funding: This review has been supported by a program grant of the Dutch Arthritis Foundation

Aims

The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

Purposes and Background. Musculoskeletal disorders including as back and neck pain are leading causes of work disability. Effective interventions exist (i.e. functional restoration, multidisciplinary biopsychosocial rehabilitation, workplace-based interventions, etc.), but it is difficult to select the optimal intervention for specific patients. The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed using machine learning to help select interventions. The WATT algorithm categorizes patients based on individual, occupational, and clinical characteristics according to likelihood of successful return-to-work following rehabilitation. Internal validation showed acceptable classification accuracy, but WATT has not been tested beyond the original development sample. Our purpose was to externally validate the WATT. Methods and Results. A population-based cohort design was used, with administrative and clinical data extracted from a Canadian provincial compensation database. Data were available on workers being considered for rehabilitation between January 2013 and December 2016. Data was obtained on patient characteristics (ie. age, sex, education level), clinical factors (ie. diagnosis, part of body affected, pain and disability ratings), occupational factors (ie. occupation, employment status, modified work availability), type of rehabilitation program undertaken, and return-to-work outcomes (receipt of wage replacement benefits 30 days after assessment). Analysis included classification accuracy statistics of WATT recommendations for selecting interventions that lead to successful RTW outcomes. The sample included 5296 workers of which 33% had spinal conditions. Sensitivity of the WATT was 0.35 while specificity was 0.83. Overall accuracy was 73%. Conclusion. Accuracy of the WATT for selecting successful rehabilitation programs was modest. Algorithm revision and further validation is needed. No conflicts of interest. Sources of funding: Funding was provided by the Workers' Compensation Board of Alberta

Aims

To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

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.

Aims

This study aimed to evaluate rasterstereography of the spine as a diagnostic test for adolescent idiopathic soliosis (AIS), and to compare its results with those obtained using a scoliometer.

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Background. In the USA more than half the states have legislated scoliosis school screening with the remaining states having either voluntary screening or no recommendations. The four primary care providers for adolescents with idiopathic scoliosis in the USA (AAOS, SRS, POSNA, AAP) do not support any recommendation against scoliosis screening, given the available literature. In Australia a national self detection program is implemented but in the UK school screening has been abolished since the 1980's. Opponents to scoliosis screening have focused on concerns about a low predictive value of screening, the cost effectiveness of referral, the possibility of unnecessary brace treatment and the effect of exposure to radiation when radiographs are obtained. Objectives. The purpose of this review was to evaluate the evidence for and against scoliosis screening. Methods. The following databases were searched: Cochrane Library, ARIF, TRIP, MEDLINE, EMBASE and CINAHL. Reference lists of articles were searched for relevant systematic reviews and research articles. Results. One systematic review (2008). 1. suggests that there is evidence (level 1B) that intensive scoliosis specific exercise methods can reduce the progression of mild scoliosis (<30 degrees Cobb). Further a Cochrane review (2010). 2. suggests that there is low quality evidence for the effectiveness of bracing. Conclusions. Based on the evidence of this review, a 4 tier model for school screening is proposed that includes the distribution of information leaflets, screening by a school nurse, topographical assessment, referral to the primary care doctor and finally if the patient is still screening positive, referral to a scoliosis surgeon. Category: Deformity/screening. Ethics approval: none needed for a review. Interest statement: none

Scoliosis school screening is either mandatory or recommended in 32 states in the USA. The remaining states having either got voluntary screening or no recommendations. The four primary care providers for adolescents with idiopathic scoliosis in the USA do not support any recommendation against scoliosis screening, given the available literature. In Australia a national self detection program is implemented but in the UK school screening has been abolished since the 1980's. Opponents to scoliosis screening have focused on concerns about a low predictive value of screening, the cost effectiveness of referral, the possibility of unnecessary brace treatment and the effect of exposure to radiation when radiographs are obtained. The purpose of this review was to evaluate the evidence for and against scoliosis screening. The following databases were searched: Cochrane Library, ARIF, TRIP, MEDLINE, EMBASE and CINAHL. Reference lists of articles were searched for relevant systematic reviews and research articles. One systematic review (2008). 1. suggests that there is evidence (level 1B) that intensive scoliosis specific exercise methods can reduce the progression of mild scoliosis (<30 degrees Cobb). Further a Cochrane review (2010) suggests that there is low quality evidence for the effectiveness of bracing. Based on the evidence of this review, a 4 tier model for school screening is proposed that addresses the “opponents” concerns. The model includes the distribution of information leaflets, screening by a school nurse, topographical assessment, referral to the primary care doctor and finally if the patient is still screening positive, referral to a scoliosis surgeon. Exercises reduce the progression rate of adolescent idiopathic scoliosis:

Purpose and background. Lumbar spinal fusion (LSF) is frequently and increasingly used in lumbar degenerative disorders despite conflicting results and recommendations. Further understanding of patient outcomes after LSF is required to inform decisions regarding surgery and to improve post-surgery management. The objective was to evaluate the course of pain and disability in patients with degenerative disorders of the lumbar spine (spinal stenosis, spondylolisthesis, disc herniation, discogenic low back pain) after first-time LSF. Methods and results. A systematic review and meta-analysis of pain and disability outcomes in prospective cohort studies after first time LSF for degenerative disorders. Two independent researchers searched key databases, determined study eligibility, extracted data and assessed risk of bias (modified Quality in Prognostic Studies tool). A third reviewer mediated at each stage. N weighted pooled estimates were calculated. Twenty-five articles (n=1,777 participants) were included. 17 studies were at unclear risk of bias and 8 at high risk. Back pain (12 studies) decreased modestly and irregularly at follow-up intervals. The n weighted mean VAS back pain decreased from 65.4 (±3.3) pre-surgery to 22.2 (±3.1) at 23 months, but then 45.0 (±not reported; 2 studies at risk of bias) at 42 months. In contrast, leg pain (12 studies) improved substantially short and long-term. Disability (20 studies) improved steadily over time with the exception of the 42-months and 48-months intervals. Conclusion. The overall improvement of leg pain and disability after first-time LSF in degenerative disorders is promising in contrast to back pain outcomes. Further research is needed to analyse outcomes in patients of different diagnostic subgroups. Conflicts of interest. None. Sources of funding. None

Purpose and Background. Strengthening the lumbar extensor musculature is a common recommendation for CLBP. Although reported as effective, variability in response in CLBP populations is not well investigated. This study investigated variability in responsiveness to isolated lumbar extension (ILEX) resistance training in CLBP participants by retrospective analysis of 3 RCTS. Methods and Results. Data from 77 intervention participants was available (males = 43, females = 34) 37 control participants (males = 20, females = 17). Intervention participants all underwent 12wks of ILEX resistance training and changes in ILEX strength, pain (VAS) and disability (ODI) measured. True inter-individual response variability was examined through calculation of difference in the standard deviation of change scores for both control and intervention. Intervention participants were classified into using k-means cluster analysis for strength changes and using MCIC cut-offs for VAS and ODI. Analysis suggested true inter-individual responses to the intervention existed. Participants were classified for strength changes as low (n = 31), medium (n = 36), and high responders (n = 10). Participants were classified for VAS changes as negative (n = 3), non-responders (n = 34), responders (n = 15), and high responders (n = 19). Participants were classified for ODI changes as negative (n = 2), non-responders (n = 21), responders (n = 29), and high responders (n = 25). Conclusion. Considerable variation exists in response to ILEX resistance training in CLBP. Future work should identify factors prognostic of successful outcomes. Conflicts of interest: None. Funding obtained: None

Background & purpose. Measurement inconsistency across clinical trials is tackled by the development of a core outcome measurement set. Four core outcome domains were recommended for clinical trials in patients with non-specific LBP (nsLBP): physical functioning, pain intensity, health-related quality of life (HRQoL), and number of deaths. This study aimed to reach consensus on core instruments to measure the first three domains. Methods & Results. The Steering Committee overseeing this project selected 17 potential core instruments for physical functioning, three for pain intensity, and five for HRQoL. Evidence on their measurement properties in nsLBP was synthesized in three systematic reviews using COSMIN methodology. Researchers, clinicians, and patients (n = 208) were invited in a Delphi survey to seek consensus on which instruments to endorse as core. Consensus was a-priori set at 67% of participants agreeing on endorsing an instrument. Two Delphi rounds were run (response rates = 44% and 41%). Agreement was reached on endorsing the Oswestry Disability Index (ODI 2.1a) for physical functioning, the Numeric Rating Scale (NRS) for pain intensity, but not on other instruments. Several participants demanded to have free of charge core instruments. Taking these results into account, the steering committee formulated the following recommendations: ODI 2.1a or 24-item Roland Morris Disability Questionnaire for physical functioning, NRS for pain intensity, Short-Form 12 or 10-item PROMIS Global Health for HRQoL. Conclusion. A core outcome measurement set is available for clinical trials in patients with nsLBP. High quality clinimetric studies directly comparing recommended and not recommended instruments are required. Conflict of interest: None. Source of funding: EUROSPINE, The Spine Society of Europe