Background and study purpose. Low mood and distress are commonly reported with by people with persistent musculoskeletal pain and may be mislabelled as ‘depression’. In order to understand how pain-related distress is conceptualised and managed in primary care consultations, we explored understanding of pain-related distress and depression from the perspectives of people with persistent musculoskeletal pain and general practitioners (GPs). Method and results. Semi-structured interviews with 21 GPs and 21 people with persistent musculoskeletal pain were conducted. The majority of people with pain had back pain (15/21). Data were analysed thematically using constant comparison techniques. Participants described challenges distinguishing between distress and depression in the context of persistent pain but described strategies to make this distinction. Some people with pain described how acceptance of their situation was key, involving optimism about the future and creation of a new identity. Some GPs expressed ‘therapeutic nihilism’, with uncertainty about the cause of pain and thus how to manage people with both pain and distress, whilst GPs who could identify and build on optimism with patients described how this could help the patient to move forwards. Conclusion. This study offers a model for the primary care consultation with patients presenting with pain-related distress. GPs should recognize the impact of pain on the patient, support the person in acceptance of the pain, explore how the person feels about the future, encourage optimism, and support self-management strategies. Conflicts of Interest: No conflict of interests. 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. Internet delivered interventions may provide a route to rapid support for behavioural self-management for low back pain (LBP) that could be widely applied within primary care. Although evidence is emerging that more complex technologies (mobile apps linked to digital wristbands) can have some impact on LBP-related disability, there is a need to determine the effectiveness of highly accessible, web-based support for self-management for LBP. Methods and results. We conducted a multi-centre pragmatic randomised controlled trial, testing ‘SupportBack’, an accessible internet intervention developed specifically for primary care. We aimed to determine the effectiveness of the SupportBack interventions in reducing LBP-related physical disability in primary care patients. Participants were randomised to 1 of 3 arms: 1) Usual care + internet intervention + physiotherapy telephone support, 2) Usual care + internet intervention, 3) Usual care alone. Utilising a repeated measures design, the primary outcome for the trial was disability over 12 months using the Roland Morris Disability Questionnaire (RMDQ) at 6 weeks, 3, 6 and 12 months. Results: 826 were randomised, with follow-up rates: 6 weeks = 83%; 3 months = 72%; 6 months = 70%; 12 months = 79%. Analysis is ongoing, comparing each intervention arm versus usual care alone. The key results will be presented at the conference. Conclusion. We believe this to be the largest trial of it's kind internationally. The trial will extend knowledge regarding the effectiveness of highly accessible internet interventions to support self-management and activity in people with LBP consulting in primary care. Conflicts of interest: No conflicts of interest. Source of funding: NIHR HTA Project number 16/111/78

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

Background: Patients with LBP, ‘at risk’ of persistent symptoms, require targeted treatment in primary care. We have therefore developed and validated a new screening tool to classify these patients into appropriate management groups. Methods: A list of LBP prognostic indicators was compiled by reviewing published studies and analysing existing datasets. Indicators were selected for the tool according to face and construct validity, consistency and strength of association. For each indicator outcome measure (e.g. Pain Catastrophising Scale) an individual question (e.g. ‘I feel that my back pain is terrible and that it is never going to get an better’) was selected for inclusion (ROC analysis). The tool was modelled to classify patients into 3 categories of risk. The screening tool and corresponding complete scales were mailed to 244 consecutive primary care LBP consulters. Individual items were validated against complete scales. Reliability was examined on 53 responders. Results: This new screening tool classifies patients using 9-items to cover 8 key prognostic indicators. The questionnaires returned by 131 consulters demonstrated excellent construct validity for all individual items. 33% of patients were classified as ‘high risk’ (psychosocial and physical factors), 44% ‘intermediate risk’ (physical factors alone) and 23% ‘low risk’. Discrimination between groups across relevant constructs such as pain, disability, days off work and psychological distress was highly significant. Test-retest reliability was moderate (kappa = 0.54). Conclusions: A novel LBP screening tool has been validated in primary care and effectively classifies patients ‘at risk’ of persistent symptoms. This will facilitate appropriate targeting of treatment

Background. Medication prescribing patterns for patients with neuropathic low back-related leg pain (LBLP) in primary care are unknown. Purpose. To estimate the proportion of patients prescribed pain medications, describe baseline characteristics of patients prescribed neuropathic pain (NP) medication and estimate the proportion of LBLP patients with refractory NP. Methods. General practice electronic medical and prescribing records of a large (n=609), prospective, primary-care cohort of LBLP patients were analysed. Cases of NP were identified using the self-report version of the NP scale, Leeds Assessment for Neurological Symptoms and Signs (score of ≥12 indicates possible NP) (n=293). Patients with leg pain intensity ≥ 5 (mean of three 0–10 NRSs) or <30% reduction in disability (RMDQ 0–23) at 4-months compared to baseline and who were prescribed ≥ 2 NP medications were considered to have refractory NP. Results. 82% (223/273) of patients with NP were prescribed at least one pain medication; 29% (80/273) of patients were prescribed one first-line NP medication (for example Amitriptyline). Patients who were prescribed NP medication(s) had higher leg pain intensity and disability. There was evidence that patients improved with (61%, 41/67) and without (75%, 76/102) having been prescribed NP medication. Few patients (4%, 7/169) met the criteria for refractory NP suggesting that the scale of the problem in primary care is limited. Conclusion. Patients with NP were commonly prescribed pain medication, under a third were prescribed NP medication and many patients improved without such medication. Future research is needed to determine the effectiveness of NP medication. No conflicts of interest. Sources of funding: Sarah Harrisson is a Clinical Doctoral Fellow funded through a National Institute for Health Research (NIHR) Research Professorship awarded to Nadine Foster (NIHR-RP-011-015). Nadine Foster is a NIHR Senior Investigator. Kika Konstantinou is supported by a Higher Education Funding Council for England/ National Institute for Health Research Senior Clinical Lectureship. The views expressed in this publication are those of the author(s), not necessarily those of the NHS, NIHR or the Department of Health and Social Care. This work relates to an Education and Continued Professional Development (level 2) award by the Musculoskeletal Association of Chartered Physiotherapists to Sarah Harrisson (June 2016)

Background:. Internet interventions provide an opportunity to encourage patients with LBP to self-manage and remain active, by tailoring advice and providing evidence-based support for increasing physical activity. This paper reports the development of the ‘SupportBack’ internet intervention, designed for use with usual primary care, as the first stage of a feasibility RCT currently underway comparing: usual primary care alone; usual care plus the internet intervention; usual care plus the internet intervention with physiotherapist telephone support. Methods:. The internet intervention delivers a 6-week, tailored programme focused on graded goal setting, self-monitoring, and provision of tailored feedback to encourage physical activity/exercise increases or maintenance. 22 patients with back pain from primary care took part in ‘think aloud’ interviews, to qualitatively explore the intervention, provide feedback on its relevance and quality and identify any extraneous content or omissions. Results:. Valuable feedback and suggested amendments from patients included individually-tailoring the activity programme, using the individual's current pain or activity level. Patients reported that the goal setting module was helpful, and were content with the range of activities offered by ‘SupportBack’. The majority of patients reported they would accept their GP's recommendation and use a credible internet intervention such as this programme to help improve self-management. Conclusions:. The development of the ‘SupportBack’ internet intervention has worked with patients to create an acceptable online tailored resource to supplement primary care management for patients with low back pain. The intervention is currently being trialled to determine feasibility and the most appropriate way to support its delivery

Hypothesis: Patients with mono-trauma to an extremity often consult primary care prior to being referred to orthopedics services. Appropriate pain control, immobilization and walking aids are not always given to ambulatory patients. Methods: The study used a prospective trauma database of all new ambulatory cases with an isolated injury to an extremity referred to an orthopedic trauma clinic at a level-one trauma center. Patients arriving by ambulance and those that were not able to filled questionnaires were excluded. Data were collected at the initial visit regarding the type of trauma, the medical consultations prior to orthopedic evaluation, the initial management (cast, walking aids, pain control), patient’s socio-demographic characteristics, and patient satisfaction (Visit-Specific Satisfaction Questionnaire: VSQ). Results: Our sample consisted of 166 consecutives patients referred for fracture (85%) and soft tissue injury(15%) to an orthopedic trauma clinic. Nearly two-thirds (65%) had upper limb injuries. 47% of patients were referred from the same hospital emergency, while 53% were referred from other hospitals or clinics. In terms of patient perceptions, 50% considered their injury as a serious health problem. The average satisfaction score (VSQ) was 84%. However, 50% of patients had a substantial degree of pain (> 5/10) at the time of orthopaedic consultation. In addition, 30% of patients received no prescription for analgesics and declared that they missed it and 21% who received a prescription claimed it was not sufficient to decrease their pain. Of those who required immobilization following the type of injury, 30% received none or it was unsuitable. 1/6 of patients who required crutches/cane/wheelchair for a lower limb injury had none prescribed. Conclusion: Primary care for persons with mono-trauma was suboptimal in terms of pain control and immobilization for more then 40% of patients. General practitioners showed a lack of basic knowledge on the importance of initial treatment of isolated limb injury. Significance: Isolated fractures are a common problem affecting a large amount of the population. This study identified unacceptable rate of poor initial management for simple injury. Orthopedic trauma surgeon must be informed of this reality and then, becoming more involved in primary care education in their own health care network

In Britain 8 million people consult their general practitioner annually with musculoskeletal conditions leading to referral of 1.5 million patients to Orthopaedics/ Rheumatology. Northern Ireland has the highest waiting lists for outpatients in Britain. The demand on orthopaedics continues to rise despite past attempts to reduce waiting lists. Trauma and orthopaedics accounted for 14% of the excess waiters for outpatients at June 2002. (DHSSPS Sept 2002) Roland et al 1991, etc. demonstrated that 43% of all orthopaedic referrals were inappropriate. In Belfast, G.P.s and Physiotherapists in partnership with the Regional Orthopaedic Service decided to pilot a Primary Care Orthopaedic Triage Service. The vast majority of orthopaedic referrals relate to three main body parts: lumbar spine 28%, knees 34% and hips 25% and these were chosen to be triaged for the pilot. Approval was sought and granted from Queen’s University Belfast Ethics Committee. Phase 1 involved the training of 2 GPs and 2 physiotherapists at the Musgrave Park and Royal Victoria Hospital with the full cooperation of the orthopaedic surgeons. Phase 2 tested independently the diagnostic capability of the trained professionals and assessed the appropriateness and management of orthopaedic referrals against the consultants decision as ‘gold standard’. 95 patients participated in the study. 55.8% of referrals were deemed appropriate by the consultants, compared to 44.6% by the GP/physio team. The Kappa statistical score was 0.79 reflecting a good level of agreement and is comparable to other clinical specialties (Sackett 1991). The sensitivity of the trained professionals on orthopaedic referrals was 83% and the specificity was 97%. Kappa value for management of inappropriate referrals was 0.83. Orthopaedic referral can be acceptably triaged by primary care professionals reducing the number of onward referrals to outpatients by 40% and increasing the appropriate referrals from 56% to 97%

Purpose and background. Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by physiotherapists to patients with back pain at their initial consultation. Patients and methods. Twenty-five audio-recordings of patients with back pain and physiotherapists in a primary care outpatient department were collected, transcribed, coded and thematically analysed using a Framework approach to identify the content of advice given. Results. The mean duration of consultation was 38 minutes 59 seconds (range 26:21–53:16). Advice was given in 88% (n=22/25) consultations and 96% included additional exercise instruction. Cognitive reassurance was evident, focussing on getting people confident to ‘move your back’ despite pain and encouraging active lifestyle changes. Beyond reassurance and discussion to enhance confidence, the key topics of advice given were: activity promotion; postural changes; practical self-help advice regarding ways to sit; pain-management advice including medication and the use of heat. Gaps were identified in the completeness of the advice given and there was a lack of specificity, especially relating to the frequency of recommended tasks and activities. Conclusion. Advice and reassurance are integral to enabling people to self-manage their back pain. Despite its importance, little is known about the advice offered by clinicians. This novel, observational study identifies the topics of advice given by clinicians in back pain consultations and recognises the need for guidance to be patient-centred and specific. No conflicts of interest. Sources of funding: The data were collected as part of Lisa Roberts's Arthritis Research UK academic fellowship [17830]. Lisa Roberts currently holds an NIHR senior clinical lectureship (round 3)

Purpose: This study aimed to determine the level of pre-assessment distress in patients referred to an outpatient physical therapy department from primary care. (This work was undertaken alongside a pilot randomised controlled trial, designed to test the feasibility of a tailored psychosocial intervention). Background: Research has shown that psychosocial factors are more important than physical factors for patients with back pain, in predicting outcome from physical therapy. Methods: 300 patients reporting low back pain +/− referred leg pain were consecutively sampled. They completed 3 self-report questionnaires prior to attending the hospital department:. Acute Low Back Screening Questionnaire (ALBSQ), designed to assess psychosocial variables identified as risk factors for continued back pain symptoms;. Tampa Scale of Kinesiophobia (TSK), measuring fear of movement. Clinical Back Pain Questionnaire (CBPQ), measuring pain and function. The patients’ specific responses were used to develop the tailored psychosocial intervention. Results: The majority of the 91 respondents (51%) were distressed and at risk of poor outcome after their primary care consultation. (A score of 112 or greater on the ALBPSQ suggests patients have an 80% chance of not returning to their usual employment or pre-morbid functional level). These distressed patients were also shown to have significantly higher levels of fear-avoidance beliefs, pain and reduced function (p=0.000). Conclusion: Following a consultation in primary care, the majority of patients with back pain score above the cut-off level for distress. To ensure optimal outcome, clinicians must develop strategies to recognise and reduce these high levels of distress

Background. Patients with low back-related leg pain (LBLP) can present with neuropathic pain; it is not known but is often assumed that neuropathic pain persists over time. This research aimed to identify cases with neuropathic pain that persisted at short, intermediate and longer-term time points, in LBLP patients consulting in primary care. Methods. LBLP patients in a primary care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible neuropathic pain) at baseline, 4-months, 12-months and 3-years. S-LANSS scores and percentages of patients with score of ≥12 are described at each time-point. Multiple imputation was used to account for missing data. Results. At baseline, 48.3% (293/606) of patients presented with neuropathic pain, 25.0% (94/376) at 4-months, 22.6% (79/349) at 12-months and 21.6% (58/268) at 3-years. A small proportion (6.6%) scored ≥ 12 at all four time-points. Those who scored ≥ 12 at baseline and 4-months reported higher disability (RMDQ (0–23) 15.2) and depression scores (HADS (0–21) 8.6), and lower pain self-efficacy (PSEQ (0–60) 27.2), compared to those with neuropathic pain at one other time-point at most. Conclusion. Few LBLP patients in primary care present with long-term persistent neuropathic pain. Patients with neuropathic pain at baseline and short-term follow-up present with greater morbidity in terms of disability, depression and lower confidence to manage their pain. This is important because these patients may benefit the most from early intervention using neuropathic pain medication. These findings will inform research investigating potential prognostic indicators of persistent neuropathic pain. Conflicts of interest: None. Sources of funding: Support for SA Harrisson, a National Institute for Health Research (NIHR) Clinical Doctoral Fellow and NE Foster, an NIHR Senior Investigator, was provided by an NIHR Research Professorship awarded to NE Foster (NIHR-RP-011-015). K Konstantinou is supported by a Higher Education Funding Council for England/ NIHR Senior Clinical Lectureship. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Primary care trusts (PCTs) are encouraged to create musculoskeletal services to improve access and reduce pressure on orthopaedic clinics. Previous reports have suggested problems can arise. A PCT with a population of 100,000 launched a musculoskeletal service in July 2004. The foot and ankle component was in partnership with the local secondary care foot team. Treatment and referral guidelines were agreed. The PCT staff reviewed GP referrals to orthopaedic clinics. They could forward letters to the acute trust orthopaedic department or initially treat the patients in primary care. We audited referrals from October-December 2004, allowing 3 months to establish the service and 6 months follow-up. 617 orthopaedic referrals were received, including 123 (19.9%) adult foot and ankle problems. 82 patients were treated initially in primary care: 54 by the podiatrist, 20 by the physiotherapist and 8 by the specialist GP. Commonest problems were metatarsalgia (12), hallux valgus (10), Achilles tendonopathy (9), plantar heel pain (9), generalised foot pain (8) and arthritis (6). The commonest intervention was attendance at a physiotherapy programme (26) followed by advice (22), usually about shoewear, insoles (14) and injections (8). Ten patients were referred to secondary care after initial treatment in the community, all in accordance with guidelines; four were listed for surgery. Four patients failed to attend and information was missing on six. 31 referrals were sent directly to secondary care, 29 of which were according to guidelines. 9 were offered surgery, 9 had other specialist care, 6 required services which could not be accessed directly by the PCT team and 3 failed to attend. Primary and secondary care can work together successfully to deliver services for patients with foot and ankle problems, though waiting time remains a challenge

Aims. Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data. Methods. In the UK, the National Institute for Health and Care Excellence (NICE) advises that prompt early management of frozen shoulder is initiated in primary care settings with analgesia, physiotherapy, and joint injections; most people can be managed without an operation. Currently, there is variation in the type of joint injection: 1) CSI, thought to reduce the inflammation of the capsule reducing pain; and 2) HD, where a small volume of fluid is injected into the shoulder joint along with the steroid, aiming to stretch the capsule of the shoulder to improve pain, but also allowing greater movement. The creation of musculoskeletal hubs nationwide provides infrastructure for the early and effective management of frozen shoulder. This potentially reduces costs to individuals and the wider NHS perhaps negating the need for a secondary care referral. Results. We will conduct a multicentre RCT comparing CSI and HD in combination with CSI alone. Patients aged 18 years and over with a clinical diagnosis of frozen shoulder will be randomized and blinded to receive either CSI and HD in combination, or CSI alone. Feasibility outcomes include the rate of randomization as a proportion of eligible patients and the ability to use routinely collected data for outcome evaluation. This study has involved patients and the public in the trial design, dissemination methods, and how to include groups who are underserved by research. Conclusion. We will disseminate findings among musculoskeletal clinicians via the British Orthopaedic Association, the Chartered Society of Physiotherapy, the Royal College of Radiologists, and the Royal College of General Practitioners. To ensure wide reach we will communicate findings through our established network of charities and organizations, in addition to preparing dissemination findings in Bangla and Urdu (commonly spoken languages in northeast London). If a full trial is shown to be feasible, we will seek additional National Institute for Health and Care Research funding for a definitive RCT. This definitive study will inform NICE guidelines for the management of frozen shoulder. Cite this article: Bone Jt Open 2024;5(3):162–173

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

Introduction: Detecting relevant clinical subgroups of patients with non-specific LBP is a priority for research as it has potential for improving treatment effectiveness. The STarT Back Tool (SBT) was recently developed and validated to subgroup LBP patients into targeted treatment pathways in primary care. This study tested the SBT’s criterion validity against a popular existing LBP subgrouping tool – the Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ). Methods: 244 consecutive ‘non-specific’ LBP consulters at 8 GP practices aged 18–59 years were invited to complete a questionnaire. Measures included the OMPSQ & SBT; disability (RMDQ); pain intensity (11-item NRS); duration of symptoms; and demographics. Instruments were compared using Spearman’s rank correlation, discriminant analysis of subgroups, tests for allocation agreement and predictive validity using published data. Results: Completed SBT (9-items) and OMPSQ (24-items) data was available for 130/244 patients (53%). The correlation of SBT and OMPSQ scores was ‘excellent (rs = 0.80, p=< 0.001). Subgroup characteristics from both tools were similar particularly among the ‘low’ risk groups, however, the proportion of patients allocated to ‘low’, ‘medium’ and ‘high’ risk groups were different, with more distressed patients in the SBT’s high risk group. The SBT better predicted pain and disability at 6 months and both equally predicted time off work. Conclusion: The SBT psychometric properties perform as well or better than the OMPSQ, but the SBT is shorter and easier to score. It is therefore an appropriate alternative for screening LBP patients in primary care

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

Purpose of Study and Background. Population ageing will facilitate an increase in health problems common in older adults, such as musculoskeletal conditions. Musculoskeletal conditions are the fourth largest contributor to disease burden in older adults; affecting quality of life, physical activity, mental wellbeing and independence. Therefore primary care health services must provide appropriate and efficacious management and treatment. However there are a number of complexities specific to older adults that are essential to address. Methods and Results. In order to identify these complexities, a review of the background literature was undertaken in addition to a Patient and Public Involvement and Engagement (PPIE) session. The PPIE group consisted of eight older adults who experience chronic musculoskeletal pain. This session was used to discuss and explore what factors are important to consider in GP consultations for musculoskeletal pain for older adults, in addition to those identified through background literature. A number of factors were highlighted through these methods, including the difference in mood and aspirations for older adults; taking a holistic approach; the impact of comorbidities; whether the GP is listening and ‘on the same wavelength’, and older adults' expectations regarding their pain and the consultation. Conclusion. Management of musculoskeletal pain for older adults in GP consultations is complex due to a range of factors, reinforcing the importance of taking a holistic approach. The impact of these factors upon the experience and outcomes of GP consultations will be further explored through in depth interviews with older adults with musculoskeletal pain. Conflicts of interest. No conflicts of interest. Sources of funding. This PhD is funded as part of an ACORN studentship awarded by Keele University. This PhD is nested within the Treatment for Aches and Pains Study, funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1211-20010)

Background: Most reports of sickness absence come either from company records, which are limited to specific workforces, or rely on self-report. Electronic recording of sickness certification in primary care medical records provides an alternative source of information. Purpose: To investigate the validity of electronic sickness certification records in primary care. Methods: Analysis included 292 primary care LBP consulters, who returned a questionnaire including self-reported work absence, and consented to medical record review. Sickness certification records for 2001–2 were downloaded. Self-reported sickness absence for the previous 2-weeks was matched with electronic records for the same time period. Records were considered to match if there was no reported absence and no certificate, if there was reported absence > =7 days and a certificate, or if reported absence was < 7 days and no certificate was issued. Results: Overall, 84% of records matched; 87% of employed consulters and 90% of unemployed consulters. Among the employed, 100% of reports of no absence did not have a certificate, 49% of reported absences > =7 days were matched by a certificate for the same time period and lastly, 80% of reported absences of < 7 days did not have a certificate. Conclusion: We have demonstrated that people with none or short self-reported work absences do not have sickness certificates in their records, but only a small proportion of people with longer self-reported absences appear to have certificates. Further work will investigate possible reasons for non-matching, these may include non-requirement of a certificate, recall errors or incomplete recording of sickness certificates

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

Background. In 2009, NICE CG 88 guideline on the management of non-specific low back pain was published. We looked at whether the introduction of these guidelines has had an impact on the management of back pain within primary care. Methods. Patients with non-specific low back pain (> 6 weeks but < 12 months) attending spinal outpatient clinic in UHL between 2008 and 2011 were asked to complete questionnaires. Two groups were studied, the first prior to the publication of NICE guidelines, and the second afterwards. Patients with radicular, stenotic and red flag symptoms were excluded. Key audited treatment standards assessed included manual therapy, acupuncture, focused structured back exercise program, supervised group exercise program and lastly referral to a combined physical and psychological treatment program. Compliance with not using X-ray or MRI and treatment modalities such as injections, laser therapy, ultrasound therapy, lumbar supports, traction and TENS therapy was assessed. Secondary outcomes included VAS (back, leg pain), Oswestry Disability Index, MSP and MZD. Primary outcomes analyzed using 1-sided Fisher's exact test and secondary outcomes using two sample t tests. Results. 46 patients (pre-guidelines) and 34 patients (post-guidelines) were studied. Key findings showed significant deterioration in the institution of manual therapy in the post guidelines group (p value = 0.032) and an increase in use of MRI scan in post guidelines group (p value = 0.005). Deterioration in the mean presenting VAS for leg pain in post guidelines group noted. No significant difference between groups in the mean scores for VAS for back pain, ODI, MSP and MZDI. Conclusion. Our study suggests that the introduction of NICE guidelines on the management of low back pain has not yet influenced management in primary care. This may be due to lack of awareness of its implementation or due to adherence to local guidelines