Aims

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform.

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

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 and background. Static plain radiographs at the end of uncontrolled bending are the current standard of care for measuring translatory slip in back pain patients. Quantitative fluoroscopy systems (QF) that employ standardised bending protocols have been found to improve precision and reduce dose, but comparative data are lacking. We compared 4 QF methods with static radiographs in a control population, calculating ranges, population variation and measurement errors over 6 weeks. Methods. Fifty-four healthy controls (F=22, M=23) received passive recumbent and active weight bearing QF screenings during controlled motion, plus still fluoro imaging in neutral, flexion and extension. The translatory slip of all levels from L2-S1 was determined for each condition using bespoke image tracking codes (Matlab) and pooled to provide means and ranges of variation (+/-1.96SD). The pooled measurement error, or minimal detectable change (MDC. 95. ), reflecting the intra subject repeatability over 6 weeks was calculated. Ranges of translation for each level (L2-S1), for each type of motion were also calculated. Results. Static radiographs at the end of uncontrolled flexion gave the greatest variation and the worst repeatability, while QF recumbent passive and active weight bearing motion with flexion recorded during the motion had ¼ less variation and twice the repeatability. For individual levels, L2-3 had significantly higher flexion ranges in controlled motion than uncontrolled motion, whereas the converse was true at L4-5 (P<0.001). Conclusion. Dynamic QF measurement of flexion translatory slip gives ¼ less population variation and half the measurement error of static radiographs when measured in the same participants. No conflicts of interest. No funding obtained

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).

Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

Purpose and background. Over two-thirds of pregnant women experience low back pain (LBP) that interferes with everyday activities, work and sleep. Acupuncture appears a safe, promising intervention but there are no high quality trial data, regarding its clinical or cost-effectiveness in comparison to standard care. Methods. EASE Back was a feasibility and pilot RCT designed to inform a full trial evaluating the addition of acupuncture to standard care for pregnancy-related LBP. In preparation for the pilot trial, phase 1 of EASE Back consisted of semi-structured interviews exploring the views of pregnant women, midwives and physiotherapists about pregnancy-related LBP, use of acupuncture, and participation in clinical trials. Transcript data were anonymised and analysed using thematic analysis. Three members of the team independently coded a sample of transcripts to develop the coding framework. Results. 17 women, 15 midwives and 21 physiotherapists were interviewed (total n=53). Findings highlighted the impact of LBP in pregnancy, the paucity of effective treatment options and the challenges of recruiting pregnant women with LBP into research. Women and midwives expressed few concerns over the use and safety of acupuncture; physiotherapists were more cautious and had concerns about safety. Conclusions. Acupuncture for pregnancy- related LBP appears to be acceptable to women and midwives. Future research needs to consider strategies to support recruitment and retention, and should consider including interviews with eligible women who decline to take part in order to understand their reasons, as well as with women receiving treatment so as to understand their experiences of taking part. This abstract has not been published in whole or substantial part, nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. This project presents independent research funded by the National Institute for Health Research's Health Technology Assessment Programme (Grant Reference Number 10/69/05) and an NIHR Research Professorship for N.E. Foster (NIHR-RP-011-015). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, MRC, CCF, NETSCC, the HTA or the Department of Health

Much has been written about ESP (Extended Scope Practitioners) lead clinical services, the vast majority of which have been developed in secondary care. Little evidence is available on the efficacy of ESP. clinics either for both the patient and weather they stream line back pain treatment. We present an interim audit of an assessment pathway for community management and MDT practice for lower back pain. 56 patients were reviewed with a revised ESP assessment tool and then presented to an MDT meeting. Each, assessment was 45 minutes long and outcome measures used included ODI and STaRT scores. Patients were telephoned at 12 weeks following their appointment and then at 18 weeks, to ascertain the progress they were making and to see if the 18-week target had been met. 56 patients were reviewed from September 2009. The average ODI, was 63%, and 56% at 12 weeks; most patients had a STaRT score of 6, and 3 on the psychological component it the beginning of the study. The EQ-5D scores were observed to show an improvement. MRI rates were 3.8% and the DNA rate was 7%. A total of 11 MRI requests; the results of 7 of these were available for analysis. The scans that were requested all showed a disc lesion that was amenable to surgical decompression or stabilization. Overall patients were very satisfied. Our formatted methodology allowed clinical governance at source to measure the efficacy of patient treatment. Early results suggest an efficient in delivering an acceptable standard of care as long as they are properly supported

Background. Chronic pain is a complex condition that demonstrates better outcomes in multidisciplinary rehabilitation, typically delivered to groups of patients by tertiary healthcare teams. An inter-disciplinary pain management course for individual patients was developed to increase the scope of physical therapists working in primary care by integrating osteopathic manual therapy with psychological interventions from Acceptance and Commitment Therapy (ACT), a form of ‘3rd wave’ Cognitive Behaviour Therapy. Method and Results. A single cohort study with pre-course (n=180) and post-course (n=79) self-report measures (44% response rate) evaluated six week interventions which combined individual manual therapy with self-management, delivered by teams of qualified and student osteopaths. Data included: quality of life (European Quality of Life Questionnaire); pain, mood and coping (Bournemouth Questionnaire); psychological flexibility (Revised Acceptance and Action Questionnaire); and mindfulness (Freiburg Mindfulness Inventory). Participants were predominantly female (68%), unemployed (59%), with an average age of 49 and pain duration of more than 12 months (86%). Commonly reported symptoms were low back pain (82%), neck pain (60%) and multiple sites (86%). At six months, there were statistically significant improvements in all four outcome measures (p<0.0005), with promising effect sizes in quality of life and pain coping (r=0.52) which appeared to be mediated by changes in psychological flexibility. Conclusions. This innovative, integrated, patient-centred chronic pain management course demonstrated promising outcomes when delivered by osteopaths with varying experience. Randomised clinical trials are now needed to assess outcomes in comparison with standard care, and optimal ways of training physical therapists to deliver effective psychological interventions. Conflicts of interest: No conflicts of interest. Sources of funding: A Department of Health ‘Innovation, Excellence and Strategic Development’ (IESD) grant for the Voluntary Sector Investment Programme (AIMS Ref: 2527190; ISRCTN: 04892266). The results of this study are being submitted for publication in the International Journal of Osteopathic Medicine and will be presented at the COME Collaboration Osteopathic Conference in Barcelona on September 30th 2017 and at the Therapy Expo 2017 at the NEC in Birmingham on November 22nd 2017

Purpose and Background:. To identify treatment effect modifiers within the STarT Back Trial which demonstrated prognostic stratified care was effective in comparison to standard care for patients with low back pain. Methods:. Secondary analysis of the STarT Back Trial using 688 patients with available 4-month follow-up data. Disability (baseline and 4 months) was assessed using the Roland Morris Disability Questionnaire (RMDQ) using continuous and dichotomized (>7) outcome scores. Potential treatment effect modifiers were evaluated with group x predictor interaction terms using linear and logistic regression models. Modifiers included: age, gender, education, socio-economic status (SES), employment status, work satisfaction, episode duration, general health (SF-12), number of pain medications, and treatment expectations. Results:. No significant treatment effect modifiers were identified using linear regression, however logistic regression analysis identified SES as a treatment modifier (interaction: OR = 0.65; 95% confidence interval = 0.42 to 0.98). Comparing those receiving stratified care versus best current care, the proportion of patients with poor 4 month outcome was similar for lower SES patients (35.4% vs. 37.2%), yet different for high SES patients (19.3% vs. 38.9%). No other treatment effect modifiers were identified; however exploratory analyses indicated trends for worse outcomes with increased age, patients taking ≥3 medications, those with lower education, and those with poor treatment expectations as potential treatment effect modifiers. Conclusion:. SES was identified as a treatment effect modifier in the STarT Back Trial with patients with lower SES not benefiting from stratified care. The explanations for this finding need further exploration

Aims

The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.