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

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. 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. Chronic pain is a significant burden and represents a major issue for world healthcare systems. Interventions include medication, surgery, pain management programmes, and social support through peer support groups. These groups are often informal, providing informational, emotional, and social support to members. The aim of this project is to co-produce guidance on how to establish a peer support programme for people living with chronic, non-cancer pain that is informed by evidence, theory, and stakeholder experience. Methods. This project is using Steps 1–4 of the Intervention Mapping (IM) approach to inform the research. Online workshops consisting of people living with chronic pain, third sector representatives, healthcare professionals, and researchers are being used to co-produce the guidance. Results. To date, 2 of the 4 planned workshops have been conducted. These have identified the needs of people living with chronic pain, goals for the peer support programme, and expectations of how a peer support programme should be executed. Topics for inclusion in the programme and their content have been identified, with further workshops to refine this planned. The final stage of this project will identify methods of delivery, specific resources that should be developed, and the training to be provided to peer support volunteers. Conclusion. The project has identified the diverse needs of people living with chronic pain and how these may be addressed by a peer support programme. It has identified flexible options that can be recommended to those who want to set up a programme and a variety content that may be included. Conflicts of Interest. None. Sources of Funding. Robert Gordon University

Background. Our current research aims to develop technologies to predict spinal loads in vivo using a combination of imaging and modelling methods. To ensure the project's success and inform future applications of the technology, we sought to understand the opinions and perspectives of patients and the public. Methods. A 90-minute public and patient involvement event was developed in collaboration with Exeter Science Centre and held on World Spine Day 2023. The event involved a brief introduction to the project goals followed by an interactive questionnaire to gauge the participants’ background knowledge and interest. The participants then discussed five topics: communication, future directions of the research, concerns about the research protocol, concerns about data, and interest in the project team and research process. A final questionnaire was used to determine their thoughts about the event. Results. Twelve adults attended the event, many motivated by their experience or interest in back pain. A thematic analysis was used to review participant comments on the research project, identifying the need to relate the research to everyday life, present risks in various ways, and be transparent about funding and data sharing. In terms of future applications, participants felt the technology should be used to understand normal spine behaviour, prevent problems, and improve treatment. Participants agreed that they had got something positive out of engaging in the event. Conclusion. Engagement with public and patient stakeholders is an essential activity that can generate vital information to inform and add value to technology development projects. Conflicts of interest. No conflicts of interest. Sources of funding. EPSRC grants EP/V036602/1 (Meakin, Holsgrove & Javadi) and EP/V032275/1 (Holt & Williams)

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. The purpose of this study was to discover if student led clinics (SLC) are feasible delivery mechanisms for Low back pain (LBP) self-management support and to develop a service model. Background. LBP is the most commonly reported musculoskeletal disorder worldwide. The increasing service and workforce demands of LBP are challenging for providers and policy makers. self-management is appropriate for many people living with LBP yet guidance for self-management is lacking. One potential delivery mechanism is through SLC. These are ‘clinics’ run by students, supervised by clinicians. Methods and Results. A scoping review has found that SLC can be effective for supporting self-management of various long-term conditions and can provide cost benefits compared with traditional clinical services. In principle, their use for providing LBP services could have similar advantages as well as mitigating the clinical placement shortage. A further scoping review of self-management support for LBP was used to develop a model for student-led LBP clinics. The proposed model is a student led LBP supported self-management service. The service users will be triaged using the Psychosocial Flags Framework to identify obstacles to participation, followed by 1–6 sessions of self-management support comprising of; 1) empathetic listening and education to build a therapeutic relationship and to dispel LBP myths; 2) collaboratively setting meaningful goals; 3) imparting knowledge and skills to overcome the identified obstacles; 4) developing an evidence-informed plan for self-management, agreed with relevant stakeholders. Conclusion. Previous experience and the evidence-base suggest that SLC are feasible for delivering self-management support for LBP. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Background. Involving research users in setting priorities for research is essential to ensure research outcomes are patient-centred and to maximise research value and impact. The Musculoskeletal (MSK) Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across MSK disorders. Methods. The Child Health and Nutrition Research Initiative (CHRNI) method of setting research priorities with a range of stakeholders were utilised. The MSKD RAG identified, through consensus, four research Domains: Mechanisms of Disease; Diagnosis and Impact; Living Well with MSK disorders and Successful Translation. Following ethical approval, the research priority exercise involved four stages and two surveys, to: 1) gather research uncertainties; 2) consolidate these; 3) score uncertainties using agreed criteria of importance and impact on a score of 1–10; and 4) analyse scoring, for prioritisation. Results. The first survey had 209 respondents, who described 1290 research uncertainties, which were refined into 68 research questions. 285 people responded to the second survey. The largest group of respondents represented patients and carers, followed by researchers and healthcare professionals. A ranked list was produced, with scores ranging between 12 and 18. Key priorities included developing and testing new treatments, better targeting of treatments, early diagnosis, prevention and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. Conclusions. For the first time, we have summarised priorities for research across MSKD, from discovery science to applied clinical and health research, including translation. We present a call to action to researchers and funders to target these priorities. Conflict of Interest: None. Sources of funding: We thank the funder, Versus Arthritis for their support of the research advisory groups and this activity

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)

Aim. To develop a clinical core set of outcome measures that is accepted for relevance, feasibility and validity by stakeholders and useful for a) interaction between patient and professional, b) internal quality improvement, and c) external transparency in patients with NSLBP in primary care physical therapy. Method. We used a consensus-driven modified RAND-UCLA Delphi technique. We conducted seven separate steps with panellists (physical therapists, patient representatives, health insurers) to select accepted outcomes. These seven steps consisted of a literature search, two online surveys, patient interviews, an experts meeting, a consensus meeting and final approval of an advisory board. Results of previous steps were discussed during the consensus meeting, and then panellists voted for inclusion per measure. The final core set was rated on relevance and feasibility on a 9-point Likert scale, when the median was ≥7 the core set was accepted. Results. 34 panellists in two online surveys, five panellists in an expert committee, ten patients for semi-structured interviews and 26 panellists in a consensus meeting participated in the study. 12 outcome measures were rated and discussed and finally six outcome measures were accepted. The final core set was accepted with a median of 7. Conclusion. This study present an outcome set that is accepted by stakeholders as having added value for a) interaction between patient and professional, b) internal quality improvement, and c) external transparency in patients with NSLBP in primary care physical therapy. In a next project this outcome set will be tested on his reliability and feasibility in a large pilot. No conflicts of interest. Sources of funding: Health insurance company CZ, the Netherlands

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

Aims. Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery. Methods. A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed. Results. The greatest gains in productivity were in avoiding repeat intraoperative scans (a mean of 248 minutes for patients who had two scans, and a mean 180 minutes for those who had a single scan). Optimizing accuracy was the biggest factor influencing this, which was reliant on incremental changes to the operating setup and technique. Conclusion. The application of lean principles to the introduction of ION for AIS surgery helps assimilate this method into the environment of the operating theatre. Data and stakeholder analysis identified a reproducible technique for using ION for AIS surgery, reducing operating time, and radiation exposure. Cite this article: Bone Joint J. 2020;102-B(1):5–10

Background and Aim of Study. Despite several hundred RCTs of exercise for persistent non-specific low back pain (NSLBP), the treatment targets of exercise are unclear. In a systematic review we observed 30 direct and indirect treatment targets of exercise described across 23 RCTs for persistent NSLBP. Since not all treatment targets and outcomes can be assessed in all RCTs, it is therefore important to prioritise these treatment targets through consensus from key stakeholders. These consensus workshops aimed to agree treatment targets for the use of exercise interventions in randomised controlled trials (RCTs) in persistent NSLBP using nominal group workshop (NGW) methodology. Methods and Results. The first UK workshop included people who had experience of exercise to manage their persistent NSLBP, clinicians who prescribe exercise for persistent NSLBP, and researchers who design exercise interventions tested in RCTs. The second workshop included participants attending an international back and neck pain research workshop. Twelve participants took part in the UK NGW and fifteen took part in the final ranking of the exercise treatment targets. In addition to the original list of 30 treatment targets, a further 26 ideas were generated. After grouping and voting, 18 treatment targets were prioritised. The top five ranked targets of exercise interventions for persistent NSLBP were: pain reduction, improvement in function, reduction of fear of movement, encouragement of normal movement and improvement of mobility. The results of the international NGW will also be presented. Conclusion. Future RCTs of exercise should consider more consistent assessment of these treatment targets. Sources of Funding: This PhD is funded by the Research Institute for Primary Care and Health Sciences, Keele University. Prof NE Foster is a UK National Institute for Health Research Senior Investigator, and was supported by a UK National Institute for Health Research Professorship (NIHR-RP-011-015). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Conflicts of Interest: No conflicts of interest

Background. Current policy and practice aimed at tackling work disability due to low back pain is largely aligned with the Psychosocial Flags Framework, which focuses on addressing individual beliefs and behaviours (yellow and blue flags). However, our understanding of the systemic and contextual factors (black flags) that are also proposed to act as obstacles within this Framework is under-represented, resulting in a disproportionate evidence base and suboptimal interventions. Methods. A ‘best-evidence’ synthesis was conducted to collate the evidence on those ‘black flags’ proposed to be the most important: compensatory systems (worker's compensation and disability benefits), healthcare provider systems and ‘significant others’ (spouse/partner/close family members). A systematic search of scientific and grey literature databases was performed, and the validity and merit of the available evidence was assessed using a system adapted from previous large-scale policy reviews conducted in this field. Results. Following a systematic exclusion process, 65 articles were selected from 1,762 records. Robust, credible and meaningful evidence was found to show that inflexible compensatory systems, a lack of ‘work-focused’ healthcare and communication amongst return-to-work stakeholders, along with inappropriate support from ‘significant others’ are obstacles to work participation for those with low back pain. Conclusions. This is the first attempt at synthesising the evidence on the ‘social’ factors proposed to be important influences on work disability due to low back pain within the Psychosocial Flags Framework. Results have relevance to researchers, policy makers, clinicians and employers, with wider implications for the revision of current psychosocial policy and practice. No conflicts of interest; no funding obtained

Aim. To identify patterns in referral and the management pathway of patients with primary bone tumours of the spine referred to the Orthopaedic Spine Unit in order to recommend ways to improve the service. Methods and Results. A retrospective notes and imaging review to evaluate the referral pathway undertaken by patients ending up in the orthopaedic spine unit over a 5 year period according to the recommendations for primary bone tumours. Significant events leading to potential improvement in outcomes were assessed. Recommendations for improvements are suggested. None of the 38 patients evaluated were referred within two weeks of presentation, and only 6 were referred directly to the bone tumour service. Almost half (15/32) of the patients who had an indirect referral pathway had a prior intervention. Five of these had non-surgical, while 10 had surgical interventions outside the tumour centre before their referral. Of these, seven had malignant tumours. Conclusion. In order to optimise outcome, patients with potentially malignant primary tumours of the spine should be referred directly to tumour services. Prior procedures should be limited to biopsy procedures and discussed with the tumour service before this is undertaken having appropriate investigation and imaging available. Guidelines for this should be directed at streamlining the referral pathway and encouraging communication between stakeholders. Further research should assess the impact of patient-related delay in presentation contributes to overall delay in referral to tumour service; how early radiological assessment may augment timely referral; and how indirect referral and prior intervention affect patient outcomes

Aims

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

Aims

The aim of this study was to evaluate improvements in the quality and safety of paediatric spinal surgery following the implementation of a specialist Paediatric Spinal Surgical Team (PSST) in the operating theatre.