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.

Background. BANDAIDE aka Back and Neck Discomfort relief with Altered behaviour, Intelligent Postures, Dynamic movement and Exercises (ISBN - 0995676933) is a concise self-help booklet containing strengthening exercises and illustrated information to enable patients self-manage their back and neck pain. The aim of this preliminary audit was to determine patient opinion on BANDAIDE. Institutional audit approval was obtained – No. 8429. Methods and Results. BANDAIDE was distributed to 40 patients, who were asked to evaluate the booklet using the Usefulness Scale for Patient Information Material (USE). USE consists of nine positive statements which are subdivided into three sub-domains; cognition, emotional and behavioural. The cognition sub-domain assesses the knowledge obtained from the material, the emotional sub-domain evaluates the effects of the material on an individual's ability to cope with the illness and the behavioural sub-domain assesses ability to self-manage. Responders were required to rate the extent to which they agreed with each of the nine statements on a scale of 0 to 10, where 0 denotes ‘completely disagree’ and 10 denotes ‘completely agree’. Each subsection is on a scale of 0–30, with a higher score suggesting better usefulness. 23 participants provided their opinions of BANDAIDE through the USE. For the three sub-domains, the mean ratings for cognition, emotional and behavioural were 27.2, 24.7, and 26.4 respectively. Conclusions. This preliminary audit suggests that BANDAIDE provides coherent advice that enables a patient to self-manage their back and neck pain. Nevertheless, the opinions of a larger cohort should be pursued to obtain more robust conclusions. Conflict of Interest: George Ampat sells the BANDAIDE booklet online through Amazon and other platforms. S Rhodes and J Sims are employed by Talita Cumi Ltd, of which Bandaide is a trading name. Shantanu Kundu is a medical student and has no conflict of interest. Sources of funding: No funding was obtained

Statement of purpose of study and background. As the treatment of low back pain (LBP) continues to evolve, there is greater recognition of the importance of optimising the therapeutic relationship to better deliver improved patient outcomes. Contextual effects, such as communication, have been shown to influence the therapeutic relationship, but it is not known how these factors evolve over time. This study analysed interviews from two studies (one cross-sectional and one longitudinal) to explore patients’ and physiotherapists’ perspectives of treatment outcomes and experiences in episodes of LBP in the same dialogic space. The objective was to explore the alignment between these perceptions to identify factors that influence the therapeutic relationship over time. Summary of methods used and results. Two secondary thematic analyses were undertaken, one analysing cross-sectional data and the other analysing longitudinal data, from an existing data set from the programme: “Exploring the relationship between communication and clinical decision-making in physiotherapy consultations for back pain”. All data were thematically analysed and organised using a framework approach. Six themes emerged from the cross-sectional data reporting consistency of opinion in the initial consultation stages, but highlighting inadequate patient involvement in shared decision making. Four main themes emerged from the longitudinal data, all of which reported interactional fears and anxieties identified on both the parts of the patient and the physiotherapist. Conclusion. These findings suggest that failing to involve the patient in adequately personalised treatment from the initial consultation may lead to diagnosis hunting and stereotyping behaviours within the therapeutic relationship, in turn leading to increased health resource usage. Conflicts of interest. None. Sources of Funding. The primary data set was collected in a research programme funded by Arthritis Research UK (now Versus Arthritis)

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. Phone based Physiotherapy is a topical area of investigation. Salisbury, (2013) states it may be as effective as usual care. It is also suggested that satisfaction is similar, but more specific attitudes have not been investigated. This study aims to retrospectively investigate the attitudes of PD vs usual care patients and to identify any differences in the attitudes of spine pain vs peripheral pain patients. Methods and Results. Questionnaires including 6 attitude questions (3 negatively, 3 positively worded) scored between 0–10 were completed by 197 physiotherapy patients discharged between 6 and 12 months previously. n=99 had received usual care, n=19 only PD care and n=79 both PD and usual care. N=61 had been treated for back or neck pain and n=136 had peripheral pain. Overall patients who had received some PD care were more likely to strongly agree (score 8–10) with the positive statements and strongly disagree (score 0–2) with the negative ones than patients who had not had some PD care. Spine patients who had never had PD were more likely to strongly agree with the negative statements than non-spines, but this was only the case with 1-in-3 negative statements in spine patients who had received PD. Compared to spine pain patients who had never had PD care, spine patients who had received PD were far more likely to strongly disagree with negative statements about PD than non-spine patients. Multiple other interesting trends exist. Conclusion. Spine pain patients' attitudes to PD care may differ from non-spine pain patients

Purpose. To establish if the subjective features of both bilateral leg pain and sexual dysfunction are presenting features in cauda equina syndrome (CES). Background. There appears to be conflicting expert opinion ‘red flag’ symptoms in the context of CES with many experts basing clinical decisions on the objective clinical findings only. Bilateral radiculopathy has been suggested as a possible sign of suspected CES, although a consensus statement by BASS and SBNS makes no reference to either this or sexual dysfunction. However, bilateral leg pain is included in the NICE clinical knowledge summary and sexual dysfunction is highlighted within CES guidance by the American Association of Neurological Surgeons. Methods. The clinical documentation of patients undergoing urgent magnetic resonance imaging (MR) due to clinical suspicion of cauda equina syndrome (CES) was reviewed over 12 months. Patients questioned regarding sexual function were included in this retrospective analysis (n=179), along with those with bilateral leg pain (n=294). Patients with confirmed cauda equina compression (CES +ve) were compared to those without (CES -ve). A logistic regression was applied to find the odds ratio. Results. In CES +ve 37.5% had sexual dysfunction, 48% had bilateral leg pain. CES –ve 14% had sexual dysfunction, 27% bilateral leg pain. Both significant to p=0.015 with an odds ratio of 3.6 and 2.5 respectively. Conclusions. Both sexual dysfunction and bilateral leg pain do appear to be ‘red flags’ for CES and should therefore be asked in the ED to aid clinical reasoning when suspecting this diagnosis. No conflicts of interest. No funding obtained

A statement of the purposes of the study and background. Lower back pain (LBP) is one of the ten leading causes of disease burden globally, producing significant detrimental effects on physical and emotional wellbeing whilst having a substantial economic burden for society. There is an inverse relationship between socio-economic status and pain prevalence. The effectiveness of a locally run ‘Back to Fitness Programme’ (6-week education and exercise programme) in the most deprived local authority area in England was evaluated. A summary of the methods used and the results. Patients at Blackpool Hospitals NHS Trust over a 6-month timeframe were included. Initial data were collected from 49 patients (mean age 53.4 years, 67% female). The amount of final data collected varied per outcome measure due to a range of factors. Participants reported the programme had helped with their understanding of pain (n=16, 100%), ability to move around and function (n=15, 94%), and level of pain (n=14, 88%). Looking at Roland Morris Disability Questionnaire scores (n=17), 88% (n=15) of patients indicated a reduction (n=12, 71%) or no change (n=3, 18%) in perceived disability. The Pain Self Efficacy Questionnaire (n=18) showed that 78% (n=14) of participants perceived an increase in their average level of confidence to move despite pain. There was an overall improvement in understanding of pain reflected by Revised Neurophysiology of Pain Questionnaire scores (n=44): 89% (n=39) improved (n=36, 82%) or did not change (n=3, 7%). Regarding lumbar flexion post-programme (n=17), 77% (n=13) of participants demonstrated an improvement (n=9, 53%) or no change (n=4, 24%). Conclusion. The majority of clinical outcomes improved following participation, predominantly in relation to understanding of pain. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by The University of Central Lancashire in partnership with The Blackpool Teaching Hospitals NHS Foundation Trust

Background. Improving primary care management of musculoskeletal (MSK) pain is a priority. A pilot cluster RCT tested prognostic stratified care for patients with common MSK pain presentations, including low back pain, in 8 UK general practices (4 stratified care; 4 usual care) with 524 patients. GPs in stratified care practices were asked to use i) the Keele STarT MSK tool for risk-stratification and ii) matched treatment options for patients at low-, medium- and high-risk of persistent pain. A linked qualitative process evaluation explored patients' and GPs' views and experiences of stratified care. Methods. Individual ‘stimulated-recall’ interviews with patients and GPs in the stratified care arm (n=10 patients; 10 GPs), prompted by consultation-recordings. Data were analysed thematically and mapped onto the COM-B behaviour change model; exploring the Opportunity, Capability and Motivation GPs and patients had to engage with stratified care. Results. Patients reported positive views that stratified care enabled a more ‘structured’ consultation. GPs identified difficulties integrating the STarT MSK tool in their consultation timeframe (Opportunity), but found this easier as it became more familiar. Both groups saw the tool as having added-value, but identified ‘cumbersome’ items which made it more difficult to use (Capability). GPs reported the matched treatment options aided their clinical decision-making, identified several that were not available to them (e.g. pain-management clinics) and suggested additional options (e.g. GP-management of psychosocial issues (Motivation). Conclusion. Changes to the STarT MSK tool and matched treatment options, targeting the COM-B model constructs, were identified and have been implemented in the current main trial. Conflicts of interest statement: No conflicts of interest. Sources of funding: This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1211-20010). 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 and Social Care. Nadine Foster is a NIHR Senior Investigator and was supported through an NIHR Research Professorship (NIHR-RP-011-015). Trial registration: ISRCTN15366334

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.

Aims

This systematic review aims to identify 3D predictors derived from biplanar reconstruction, and to describe current methods for improving curve prediction in patients with mild adolescent idiopathic scoliosis.

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

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Background. Sciatica is common and associated with significant impacts for the individual, health care and society. The SCOPiC randomised controlled trial (RCT) is investigating whether stratified primary care for sciatica is more effective and cost-effective than usual, non-stratified primary care. Stratified care involves subgrouping patients to one of three groups based on a combination of prognostic and clinical indicators. Patients in one of these groups are ‘fast-tracked’ with an MRI scan to spinal specialist opinion. Our aim was to understand the perspectives of clinicians on the acceptability of this ‘fast-track’ pathway. Methods. Qualitative, semi-structured interviews were conducted with general practitioners, spinal specialist physiotherapists and spinal surgeons (n=20 in total). Interviews were fully transcribed, and data were analysed using the constant comparison method. Results. Across all groups, clinicians identified potential added value in ‘fast-tracking’ some sciatica patients in terms of patient reassurance based on MRI scan findings. Whilst spinal physiotherapists felt that most ‘fast track’ patients were appropriate, some spinal physiotherapists and GPs had concerns that patients with symptom durations of less than 6 weeks might be inappropriately fast-tracked since their symptoms may still resolve without the need for invasive treatments. Spinal surgeons felt it was acceptable for patients with short symptom durations to be ‘fast-tracked’, but to provide early reassurance rather than direct treatment. Conclusion. Whilst clinicians saw added value in a group of sciatica patients being ‘fast-tracked’ to specialist opinion, there was some reservation about moving away from the usual stepped care, ‘wait and see’ approach for patients with short symptom duration. Conflicts of interest statement. No conflicts of interest. Sources of funding. This study is funded by the National Institute for Health Research Health Technology Assessment Programme (NIHR HTA project number 12/201/09) and will be published in full in Health Technology Assessment. Funding support is also received from an NIHR Research Professorship for Nadine Foster (NIHR-RP-011-015), who is an NIHR Senior Investigator, and a HEFCE Senior Clinical Lecturer award for Kika Konstantinou. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health and Social Care. The study was approved by the NRES Committee West Midlands – Solihull, 17/03/2015, ref: 15/WM/0078. Trial registration: ISRCTN75449581

Aims

The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

Statement of purpose. We review the current state of development of proton therapy and the implications for beam therapy in the management of primary bone tumours. Introduction. The principle of radiotherapy is to deliver a high dose, accurately, to the tumour. Conventional photon and proton therapy irradiates adjacent tissue significantly. This is reduced with intensity modulation proton therapy (IMPT). This has been demonstrably effective in treating tumours refractory to chemotherapy and conventional radiotherapy such as chrondrosarcomas and chordomas. Case Report. We present a patient with an isolated chondrosarcoma involving the anterior and posterior element of the L3 vertebral body with a significant soft tissue component displacing the IVC. The patient underwent a 2 stage en-bloc excision of the tumour: Stabilisation was achieved by posterior L2-4 instrumented fusion with Peek rods and screws, an anterior Peek cage and bone graft. Post-operatively the patient underwent 12 weeks of bed rest followed by rehabilitation. Due to pedicle involvement (giving a high risk of contamination) and the narrow clear margin found on histology the patient has been accepted for post-operative IMPT. Discussion. The high risk of contamination and the narrow margins presented an ideal case for post-operative IMPT. However, conventionally the stabilisation would have been metallic, distorting the treatment mapping and the delivery of the IMPT, reducing any possible benefit. Thus, we used Peek as it is proven to maintain its properties when subjected to a wide range of conditions while also being tolerant of, and not interfering with, most forms of radiation including proton therapy, maximising the chance of a positive outcome. One concern with Peek is that it is less biomechanically stable then metal, hence the prolonged period of bed rest. Conclusion. This report discusses the current evidence for proton therapy while describing a successful technique for stabilisation to facilitate delivery of proton treatment post-operatively. Ethics approval. None Audit/service standard in trust Ethics committee COREC number:. Interest Statement. None Local grant/National grant Commercial/industry support

A statement of the purposes of the study and background. The biopsychosocial (BPS) model is recommended for managing non-specific low back pain (NSLBP) but the best method for teaching the BPS model is unclear. E-learning is a promising alternative to face-to-face methods. This study was a pilot randomised controlled trial (RCT) with embedded interview study to investigate the feasibility of conducting a main RCT and to explore the impact of an BPS for NSLBP e-learning programme on experienced practitioners' attitudes to back pain. A summary of the methods used and the results. Mixed methods evaluated the impact of an evidence-based e-learning programme on participants' attitudes to back pain. A pilot RCT assessed 45 experienced osteopaths' attitudes before and after the intervention, using the Pain Attitudes and Beliefs Scale (PABS) and the Attitudes to Back Pain Scale (ABS). The qualitative study explored 9 participants' views on the e-learning programme and possible impact on their clinical practice. 91% of participants completed the course and the overall satisfaction was very high. Participants' views on the BPS model ranged between not being structural enough, already done and transformative. The e-learning programme was well accepted. It would be feasible to run a main study using the same recruitment procedures, eligibility criteria, randomisation procedure, consent process, data collection and outcome measures. Conclusion. E-learning is an appropriate tool to deliver CPD to experienced manual therapists. Although a pilot study, the results suggest a shift in practitioners' attitudes towards a more BPS view of back pain. A main trial should be undertaken to test the effectiveness of the intervention. No conflicts of interest. Funding acknowledgements: This research is part of Jerry Draper-Rodi's Professional Doctorate in Osteopathy, partly funded by the British School of Osteopathy

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.

Statement of the purposes of the study and background:. Low back pain (LBP) is the leading cause of disability worldwide, and greater understanding of mechanisms leading to increased disability in LBP is necessary. Pain-related guilt and in particular social guilt (one type of pain-related guilt) has recently been linked to greater depression, anxiety and disability in LBP. Research has also shown that greater acceptance of pain is associated with less pain intensity, depression, pain-related anxiety and disability, and with greater daily activity and overall wellbeing in chronic pain patients. The current study aim was to understand the relationship between pain-related guilt and pain-related acceptance in LBP. Summary of the methods used and the results:. The study examined the relationship between pain-related guilt and pain-related acceptance in a sample of 287 LBP patients. A series of hierarchical multiple regression analyses were conducted in which known correlates of pain-related acceptance (pain intensity, disability, depression and anxiety) were controlled for, with the objective of testing whether pain-related guilt explains any unique variance in pain-related acceptance. Social guilt was the strongest predictor of reduced pain-related acceptance in all analyses. Conclusion:. The findings highlight the role of social guilt in pain-related acceptance and they enable a better understanding of psychological factors associated with acceptance of pain. The study was cross-sectional, thus the direction of these relationships should be further examined using longitudinal designs

A statement of the purposes of the study and background:. Merely publishing clinical guidelines is insufficient to ensure their implementation in clinical practice. We aimed to clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care. A summary of the methods used and the results:. We conducted semi-structured interviews with 53 purposively-sampled clinicians from south-west England. Participants were: 16 General Practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses. Thematic analysis showed that official guidelines comprised just one of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organisational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology - “non-specific LBP” - unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services and sparse commissioning of guideline-recommended treatments. A conclusion:. The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centred care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended therapies; and commissioning guideline-recommended treatments for NHS patients

Aim:. To Determine Whether Maximal Rib Prominence Measured On Lateral Radiographs Can Be Used As A Surrogate To Rib Rotation Determined By Surface Tomography (Quantecscanning) In Assessment Of Spinal Rotation. Method:. Patients With Adolescent Idiopathic Scoliosis Underwent Plain Lateral Radiographs And Quantec Scans. Maximal Rib Prominence On The Lateral Radiograph Was Defined Pre- And Post-Operatively By Distance From Most Posterior Aspect Of The Rib To The Facet Joint And Instrumented Rod, Respectively. Rib Rotation Was Measured By Surface Tomography Quantec Scan Using The Suzuki Method. This Was Then Repeated At A Later Time And By An Additional Investigator To Assess Intra- Observer And Inter-Observer Variability. The Correlation Between Maximal Rib Prominence And The Suzuki Ratio Was Determined. Results:. 20 Patients, Median Age 15 Years, Were Evaluated. The Correlation Coefficient Between Radiograph Determined Maximal Rib Prominence And Quantec Derived Suzuki Ratio Was 0.68, R2=0.46 (See Figure). Discussion:. There Was A Weak Positive Correlation Between Radiograph Determined Maximal Rib Prominence And Quantec Derived Suzuki Ratio. Further Investigation In A Larger Cohort Is Warranted. Conflict Of Interest Statement: No conflict of interest