Background and purpose. The STarT Back trial demonstrated benefits from a stratified primary care model that targets low back pain (LBP) treatment according to patient prognosis (low-, medium-, or high-risk). The current IMPaCT Back study implemented this approach in everyday primary care to investigate; i) changes in GPs' and physiotherapists' attitudes, confidence and behaviours, ii) patients' clinical outcomes, and iii) cost-effectiveness. Method. This quality improvement study involved 5 GP practices (65 GPs and 34 physiotherapists) with before and after implementation cohorts of consecutive LBP consulters using an intention to treat analysis to compare patient data. Phase 1: Usual care data collection from clinicians and patients (pre-implementation). Phase 2: Introduction of prognostic screening and targeted treatment including a minimal GP intervention (low-risk group), systematic referral to physiotherapy (medium-risk group) and to psychologically informed physiotherapy (high-risk group). Phase 3: Post-implementation data collection from clinicians and patients. Results. 922 patients participated (368 in Phase 1 and 554 in Phase 3) with similar baseline characteristics (mean age 53 v 54 years, disability (RMDQ) 8.7 v 8.4). Significant differences in favour of targeted treatment were demonstrated in clinicians' attitudes and confidence, and RMDQ 6-month change scores (mean difference 0.7 [95% CI 0.1, 1.4]). Health care cost savings were also identified, in addition to an average of 3.5 fewer days off work during study follow-up. Conclusion. A stratified model of LBP management can be successfully introduced into real-life primary care, improving clinicians' attitudes and confidence and patient disability outcomes and reducing the economic burden of LBP. Conflicts of Interest. None. Source of Funding. The Health Foundation. This abstract has not been previously published in whole or substantial part, it has been presented at international meetings in 2011, but not yet a national meeting

Background. People with back pain often experience long-term pain with recurrences and fluctuations. However, few studies have considered which factors predict long-term outcomes. Purpose. To determine the prognostic factors, measured around the time of a primary care back pain consultation, that predict clinically significant pain in both the short (6 months) and long-term (5 years). Methods. Back pain consulters at 8 GP practices received a questionnaire shortly after consultation. Information was collected on potential prognostic factors: demographics (age, gender, educational, social class), physical (pain, disability, pain duration, distal leg pain), psychological (illness perceptions, coping, fear avoidance, pain self-efficacy, depression, anxiety) and occupational (work status). Patients were followed-up by postal questionnaire 6 months and 5 years later. The Chronic Pain Grade was used to define clinically significant pain at outcome. Results. Baseline pain intensity (Relative Risk (RR) 1.12, 95% CI 1.03, 1.20) and a strong patient belief that their LBP would last a long time (RR 1.04, 95% CI 1.01, 1.07) predicted outcome at 6 months. Outcome at 5 years was best predicted by a similar model: pain intensity (RR 1.09, 95% CI 0.997, 1.20) and a strong belief that their back pain would persist (RR 1.06, 95% CI 1.03, 1.09). Conclusion. Pain intensity and a belief by the patient that their back pain will last a long time predicted clinically significant pain in both the short and long-term. Both predictors have the potential for clinical intervention at the consultation stage. No conflicts of interest. Source of funding: The baseline and 6-month follow-up phases of this study was supported financially by a Programme Grant awarded by the Arthritis Research UK [13413] and the 5-year follow-up phase was completed as part of Dr KM Dunn's Wellcome Trust Grant [083572]. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Background. One untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes. Methods. 1573 adults with back pain (+/− radiculopathy) consulting at 10 general practices in England responded to invitations to attend an assessment clinic, at which 851 eligible participants were randomised (intervention n=568; control n=283). Primary outcome using intention-to-treat analysis was the difference in change in the Roland-Morris Disability Questionnaire (RMDQ) score at 12 months. Secondary outcomes included 4-month RMDQ change between arms overall, and at risk-group level at both time-points. The economic evaluation estimated incremental quality-adjusted life years (QALYs) and back pain-related health care costs. Results. Overall, between-group differences in RMDQ adjusted mean change scores significantly favoured stratified care; 1·8 (95%CI 1·1, 2·6) at 4-months and 1·1 (95%CI 0·3, 1·9) at 12-months. Stratified care was associated with an increase in generic health benefit (0.039 additional QALYs) and cost savings. Low-risk patients had non-inferior outcomes compared with controls, and there were significant between-group differences in RMDQ adjusted mean change scores for medium-risk patients at 4 (1·99 [95%CI 0·75, 3·22]) and 12 months (1·33 [95%CI 0·15, 2·52]), and high-risk patients at 4 months (2·53 [95%CI 0·90, 4·16]). Conclusion. A stratified approach of prognostic screening with treatment matched pathways for patients in primary care with back pain provides significant improvements in clinical and economic outcomes compared to current best practice. Conflicts of Interest. None. Source of Funding. Arthritis Research UK. This abstract has been presented at 3 international conferences but not yet at a national conference. It has also been accepted for publication in the Lancet – but is not yet published

Background. Evidence suggests classification system (CS) guided treatments are more effective than generalized and practice guidelines based treatments for low back pain (LBP) patients. This study evaluated clinicians' and managers' attitudes towards LBP classification and its usefulness in guiding LBP management. Methods. Data from 3 semi-structured interviews with physiotherapy service managers and advanced spinal physiotherapy practitioner and a focus group (5 physiotherapists) in two NHS Health Boards, South Wales, UK, was thematically analysed. Results. Five themes emerged. CS knowledge: Clinicians and managers know different CSs and agree with its usefulness. Clinicians have specific CSs knowledge, managers viewed classification related to referral pathways and prognosis. Current CS use: Clinicians classify using their experience and clinical reasoning skills shifting between multiple CSs. Managers are confident that staff provide evidence-based service though believe classification is not always practiced across services. CS advantages/disadvantages: Effectively targeting the right patients for right treatments using evidence-based practice is advantageous. Prevalence of “guru led” CSs developed for research and of limited clinical use is disadvantageous. Barriers: Patients' treatment expectations, threat to clinical autonomy, lack of sufficiently complex CSs, lack of resources to up-skill clinicians and overall CSs fit into complex referral pathways. Enablers: CSs sufficiently complex & placed within clinical reasoning process, mentoring for inexperienced staff, positive engagement with all stakeholders and patients. Conclusion. Clinicians and managers are aware of CSs and agree with its usefulness to guide LBP management. Clinicians classify LBP though there is no formalized CS process in place. Whilst clinicians view classification as the relationship between patients and physiotherapy managers have a broader, whole service view. Conflicts of interest: None. Sources of funding: Wales School of Primary Care Research, Cardiff, UK. This abstract has not been previously published in whole or substantial part nor has been presented previously at a national meeting

Introduction. Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM: EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI. Methods. A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from the previous INFORM research programme. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385). Result. The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development. Conclusions. This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems

Virtual physiotherapy has been provided to hundreds of patients at the Holland Centre during the COVID pandemic. As we plan for virtual care to be one part of our care delivery we want to evaluate it and ensure the care delivery is safe and effective. The objectives of this project was two-fold: 1) to examine the outcome of virtual physiotherapy and/ or a hybrid of virtual and in-person care in patients who received post-operative treatment following total knee replacement at the Holland Centre, 2) to explore the challenges of virtual care participation in the joint replacement population. Patients who received either virtual care or a combination of in-person and virtual care (hybrid model) based on the patients’ needs were included. Patient-related outcomes were the Patient Specific Functional Scale (PSFS) and pain scale. Flexion and extension range of motion were measured before and after treatment. A modified Primary Care Patient Experience Virtual Care Survey was used to examine barriers for virtual care. Sixty patients, mean age 68(8), ranging between 45-83 years, 34(57%) females, who received either virtual care or a combination of in-person and virtual care based on the patients’ needs were included. Patients showed improvement in the PSFS and pain scores (p<0.0001). Flexion (p<0.0001) and extension (p=0.02) improved at a statistically significant level. A separate sample (N=54) (age range 50-85 years) completed the patient experience survey. A well-designed post-operative virtual physiotherapy program, initially implemented to maintain continuity of care during the pandemic, continues to be an important part of our model of care as we normalize our activities. Clear understanding of barriers to virtual care and mitigation strategies will help us create virtual care standards, meet our patient needs, optimize our care delivery and potentially increase the use of virtual rehab in the future

Abstract. Objectives. Magnetic resonance imaging (MRI) is one of the most widely used investigations for knee pain as it provides detailed assessment of the bone and soft tissues. The aim of this study was to report the frequency of each diagnosis identified on MRI scans of the knee and explore the relationship between MRI results and onward treatment. Methods. Consecutive MRI reports from a large NHS trust performed in 2017 were included in this study. The hospital electronic system was consulted to identify whether a patient underwent x-ray prior to the MRI, attended an outpatient appointment or underwent surgery. Results. 4466 MRI knees were performed in 2017 with 71.2% requested in primary care and 28.1% requested in secondary care. The most common diagnosis was signs of arthritis (55.2%), followed by meniscal tears (42.8%) and ACL tears (8.3%). 49.4% of patients who had an MRI attended outpatients and 15.6% underwent surgery. The rate of knee surgery was significantly higher for patients who had their scans requested in secondary care (32.9% vs 8.9%, p < 0.001). Conclusion. The rate of surgical intervention following MRI is low and given these results it seems unlikely that the scan changes practice in most cases. The rate of surgery and outpatient follow up was significantly higher in scans requested by secondary care. We urge clinicians avoid wasteful use of MRI and recommend the use of plain radiography prior to MRI where arthritis may be present

Aims and objectives. Our aim was to evaluate the indications for patients undergoing magnetic resonance imaging (MRI) of the knee prior to referral to an orthopaedic specialist, and ascertain whether these scans altered initial management. Materials and Method. We retrospectively reviewed all referrals received by a single specialist knee surgeon over a 1-year period. Patient demographics, relevant history, examination findings and past surgical procedures were documented. Patients having undergone MRI prior to referral were identified and indications for the scans recorded. These were reviewed against The NHS guidelines for Primary Care Physicians to identify if the imaging performed was appropriate in each case. Results. A total of 261 patients were referred between 1. st. July 2018 and 30. th. June 2019. 87/261 patients underwent MRI of the knee joint prior to referral. The mean patient age was 53 years with predominance of male patients (52 verses 35 females). 21/87 patients (24%) underwent the appropriate imaging prior to referral with only 13% of patients undergoing x-ray imaging before their MRI. In cases where MRI was not indicated, patients waited an average of 12 weeks between their scan and a referral being sent to the specialist knee surgeon. Conclusion. 76% of patients referred to orthopaedics had inappropriate MRI imaging arranged by their primary care physician. For a single consultant's referrals over 1 year these unnecessary MRI scans cost the NHS £13,200. Closer adherence to the guidelines by primary care physicians would result in a financial saving for the NHS, faster referral times and a more effective use of NHS resources

Purpose and background. Effective reassurance is an essential element of treatment for conditions that do not require further investigations, referrals and on-going monitoring. However, research defining what reassurance should consist of and how to deliver it is scarce. The aim of this review was to identify consultation-related processes that improved patients' outcomes, in order to build an evidence-based model of effective reassurance in primary care. Method and results. A literature search identified prospective observational studies that explicitly measured consultation-related factors in appropriate primary care patient groups. The findings from empirical studies were combined with theoretical and systematic reviews to develop a model of effective reassurance. Scrutiny of 8193 Abstracts yielded 29 empirical studies fitting inclusion criteria, and 64 reviews. The majority of studies measured patient satisfaction. Clinical outcomes (e.g. health status / symptom reduction) appear to improve with patients' active participation in the consultation. Behavioural outcomes (e.g. adherence/ health care utilization) were only measured in a handful of studies, but may improve when information was given in the final stage of the consultation. Psychological outcomes (e.g. health concerns) were consistently improved by patient-centred approaches. Conclusion. The synthesis of empirical evidence and theory resulted in a model with two distinct stages: Affective reassurance, which focuses on eliciting patient concerns empathically and leads to trust in the clinician. Cognitive reassurance should then follow, involving iterative and interactive education, leading to enablement and impacting on medium and long term outcomes. Conflicts of Interest. None. Source of Funding. None

The Cochrane Collaboration has produced three new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner. These are relevant to a wide range of musculoskeletal specialists, and include reviews in lateral elbow pain, osteoarthritis of the big toe joint, and cervical spine injury in paediatric trauma patients.

The Cochrane Collaboration has produced five new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner These reviews are relevant to a wide range of musculoskeletal specialists, and include reviews in Morton’s neuroma, scoliosis, vertebral fractures, carpal tunnel syndrome, and lower limb arthroplasty.

Background. There is a paucity of long term data concerning the pre and postoperative patient reported function of total knee replacement. The aim of this study was to determine the mortality, implant survivorship, patient reported function and satisfaction in a cohort of 114 patients, from a single centre, who received a Kinemax total knee replacement more than 15 years ago. Methods. Patients completed a questionnaire incorporating validated disease- and joint-specific scores, patient satisfaction and overall health preoperatively, at 3 months, 1 year, 2 years and a minimum of 15 years following surgery. NHS National Strategic Tracing Service, hospital and primary care records were used to establish mortality and for implant survivorship in deceased patients. Results. 45 patients were alive at final follow up. The survivorship of the cohort with revision of the TKR as the endpoint was 84%. Four cases were revised for wear, three for loosening and one for peri-prosthetic fracture. There was a significant improvement in WOMAC Pain, Function and Stiffness Scores, Oxford Knee Score and Self-Administered Patient Satisfaction Scale between pre-operative and all post-operative time points, although patient satisfaction had decreased significantly by the time of final follow up. Conclusion. In this cohort, the Kinemax TKR showed satisfactory long term survivorship with functional scores demonstrating a high level of patient satisfaction at all follow up time points. Level of Evidence. 2

GIRFT was published in the United Kingdom with the aim of streamlining primary care pathways, secondary care, creating a network of hospitals and treatment centres and to better regulate introduction of new implants. It also proposed the use of Orthopaedic Devices Evaluation Panel (ODEP) 10A* rated cemented implants in hip arthroplasty. Aim: The purpose of this study was to assess the effects of adopting GIRFT on surgical time, length of stay, changes to the implants used and number of cases per surgical list. Prior to adopting GIRFT, elective primary total hip replacement (THR) was predominantly uncemented THR. Age, sex, Body Mass Index (BMI), American Society of Anesthetiss (ASA), closure technique and surgical time of 50 consecutive primary uncemented THR were analysed to identify the appropriate statistical methods. Mean and standard deviation for surgical time were identified. Threshold increase in surgical time was set at 20 minutes. Based on expected difference of 20 minutes and standardised difference, minimum sample size was calculated to be 19. Prospective data on 60 consecutive uncemented THR and 30 consecutive cemented primary THR were included in this study. Inclusion criteria – primary THR for arthritis by single surgeon. Exclusion criteria – previous hip surgery, complex primary, abnormal anatomy. No differences in age, sex, BMI, ASA and length of stay between the two groups. Surgical time was significantly increased by 28 minutes (p<0.001). Implants used changed from 7A*/5A* uncemented THR to 10A* (18/30) and 7A*(12/30) cemented THR. There was a reduction in number of THR done per surgical list due to the increase in surgical time (3 instead of 4). GIRFT compliance improved from 0% cemented to 100% cemented. 0% 10A* rated implants to 66% 10A* rated implants. Undertaking cemented THR instead of uncemented THR is associated with significantly increased surgical time. Hence, number of THR surgeries performed in a day's list is accordingly reduced. There is potential for financial loss when the savings in the implants used is compared with the reduction in the number of surgeries performed

Background and purpose of the study. Effective communication between healthcare professionals and patients is key to a successful consultation and is reported to affect both adherence to treatment and outcome. Despite this evidence, research on how best to open consultations is limited and the optimal way, unknown. This study seeks the opinions of physiotherapists on how to open a clinical encounter in an adult musculoskeletal outpatient setting – a topic which has relevance to all clinicians aiming to build rapport with their patients. Methods. Forty clinical encounters between physiotherapists in a primary care setting and patients with back pain were observed and audio-recorded. The clinicians' key questions inviting the patient to discuss their back pain were identified, together with a content analysis of the topics discussed prior to the conversation about their back pain. In 2012, a national survey was undertaken, approaching 34,922 physiotherapists from 3 networks on the interactive website hosted by the professional body, the Chartered Society of Physiotherapy asking participants to rank the data from clinical practice, to determine the preferred way to open a clinical encounter. Results. Form the 40 recorded consultations eleven opening questions were identified. In these encounters fourteen other topics were discussed before the key opening question about back pain. In the national survey, the top 5 openings were identified. Conclusion. Knowing how clinicians and patients communicate, and specifically, how clinical encounters are opened, is important for teaching and professional development to assist clinicians in optimising their non-specific treatment effects. No Conflict of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Background. The physiotherapy profession has experienced a paradigm shift in recent years where mounting research evidence, indicating better patient outcomes, has led to an increase in popularity of a biopsychosocial model of care. In turn physiotherapists have begun to address psychosocial ‘obstacles’ to recovery, as means of improving outcomes for patients. To date, research has not examined how this change has affected the perceptions of physiotherapists about delivering care. The aim of this study was to explore these perceptions through exploratory interviews with physiotherapists in the UK. Methods. A qualitative interview study using a purposive sample of physiotherapists (n=12), nested within a larger study, exploring the attitudes and behaviours of UK general practitioners and physiotherapists about managing patients with low back pain. Interview transcripts were coded by the lead researcher and independently validated by a further team member. Transcripts were coded thematically using the constant comparative method to identify similarities and differences between the data and to determine fit and relevance. Results. The findings demonstrate that a combination of traditional physical therapy with a biopsychosocial approach presented significant challenges for professionals during the consultation. Physiotherapists perceived a number of ‘obstacles to recovery’ and responded to these through adoption of ‘health corrective’ strategies and by imposing limits around the management of these concerns with patients. Conclusion. A model of care combining a biopsychosocial approach with traditional physiotherapy can increase pressure on physiotherapists to use consultation strategies which appear to be patient-centred but may fail to shift from a professional-led agenda. Conflicts of interest. None. Sources of funding. Arthritis Research UK and the North Staffordshire Primary Care Research Consortium. We confirm that this abstract has not been previously published in whole or part nor has it been presented at a national meeting

Background. A wide array of measures has been developed to assess the role of psychological factors in the development and persistence of pain. Yet there is likely to be considerable conceptual overlap between such measures, and consequently a lack of clarity about the importance of psychological factors. Purpose. To investigate whether conceptual overlap exists within psychological measures used in back pain research. Methods. An observational cohort study of 1591 back pain primary care consulters provided data on anxiety, depression, self-efficacy, coping, illness perceptions, fear avoidance and catastrophising. Exploratory and confirmatory factor analysis (EFA and CFA) was carried out at the sub-scale level (n=20) to investigate factor structure. Derived factors were then tested using hierarchical linear regression in relation to clinical outcomes (pain intensity and disability). Results. EFA derived 4 factors from the sub-scale measures. Factors were termed ‘distress’ (comprising depression, anxiety, pain self-efficacy, fear avoidance, catastrophising), ‘cognitive’ (cognitive coping strategies), ‘causes’ (psychological, immunity, risk factors) and ‘future’ (expectancies of potential treatment and recovery), and accounted for 65.5% of the data. CFA confirmed the validity of these factors. The distress factor was found to have the strongest association with patients' outcomes, accounting for 28.7% of the variance in pain intensity, and 53.6% in disability. Conclusion. Considerable overlap exists in psychological measures used in back pain research. Most measures tap in to patients' emotional distress; this factor was shown to have the greatest association with clinical outcomes. These findings have implications for the way psychological measures are used in back pain research. No conflicts of interest. Source of funding: Programme Grant awarded by the Arthritis Research UK [13413] and Dr KM Dunn's Wellcome Trust Grant [083572]. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Summary Statement. This study assesses the service provision of viscosupplementation within an NHS (British National Health System) hospital. The results of this study show long term efficacy of the treatment, when provided by a dedicated, orthopaedic unit. Introduction. The service provision of viscosupplementation for osteoarthritis within the National Health System (NHS) remains controversial. The treatment was recommended in the 2007 NICE guidelines but support was withdrawn the following year. Furthermore, whether it should be provided by orthopaedic surgeons or in primary care is also a matter of debate. St Helens and Knowsley Trust, runs an orthopaedic outpatient clinic dedicated to the administration of viscosupplementation to patients with symptomatic knee osteoarthritis. This study aims to assess the efficacy of viscosupplementation for knee osteoarthritis when that is provided by a highly specialised, orthopaedic, dedicated service. Patients and Methods. Between January 2011 and June 2011, 103 patients underwent Ostenil® intra articular knee injections in our clinic. The viscosupplement used is Ostenil®, a 20mg/2ml sodium hyaluronate as an isotonic solution contained in a single syringe. Patients are given a regimen of 3 × 20mg/2ml Ostenil® injections. The time interval between injections is two weeks. They were all given a “pain diary” and were asked to document their pain score on a Visual Analogue Scale (from 0 to 10), prior to the treatment, the day of procedure and up to 3 months after the procedure. 72 patients (M:F 34:38, Mean age: 60.3 years) participated in the study (Right knee 31, Left 22 and Bilateral 19). Mean pre treatment and post treatment score amongst all patients were calculated up to three months post treatment. Results. Results show a continuous decreasing trend in pain scores up to three months after the procedure. Indicatively, mean pre treatment pain score was 6.88, mean pain score on day 3 (2 days post first injection) is 4.89, mean pain score on Day 31 (2 days after 3rd injection) is 4.37. Pain levels are maintained low at Week 6 after treatment (4.43) and Month 3 (4.37). A small peak in pain score was identified up to 48hrs after the injections but that has been already identified in current literature as a result of short term inflammation due to the injection process. Conclusion. Viscosupplementation for knee osteoarthritis is an efficient treatment when provided by an orthopaedic, dedicated service. The duration of the reduction in pain with a three injection course is at least 3 months. This study also demonstrates that an overall 3 injection course with a time interval of 2 weeks between injections is sufficient to produce long lasting results

Summary Statement. Applying appropriate upper limb regional-specific and joint-specific tools along with suitable psychologic tools provides an effective assessment of supportive, interventional, and treatment strategies in TE. Background. Tennis elbow (TE) is a painful pathologic condition with its origin in the common wrist extensor muscles at the lateral epicondyle. As the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting, with an annual incidence of 4 to 7 cases per 1000 patients in general practice (with a peak at 35 to 54 yrs of age), TE has considerable socioeconomic costs. As pain relief and improvement in functional performance are the 2 common aims of all treatment strategies, the importance of using appropriate tools for the assessment of pain and functional disability in TE is evident. In view of the high prevalence of TE, uncertainties about its treatment, and its substantial socioeconomic consequences, using more specific, patient-centred assessment tools is essential for providing more useful information on the level of pain and functional disability in TE. The Study aimed to: 1) compare pain and functional disability in tennis elbow (TE) patients with healthy controls; and 2) evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. Methods. Sixteen consecutive TE patients were recruited at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localised lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. Results. Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). Discussion. TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of “upper limb” and “psychologic” assessment tools

Purposes of the study and background. Smaller studies indicate that yoga may be an effective treatment for chronic low back pain. We conducted a randomised trial to evaluate if yoga compared to usual care improves back function in patients with chronic or recurrent low back pain. Summary of the methods used and the results. Outcomes were assessed by postal questionnaires. The setting was 13 non-National Health Service premises. We recruited 313 adults with chronic or recurrent low back pain from primary care. 157 were randomised to usual care. 156 were randomised to a 12-class, gradually-progressing programme of yoga delivered by 12 teachers over three months. All received The Back Book. Primary outcome was back function (Roland Morris Disability Score) at three months. Secondary outcomes: back function at six and 12 months, back pain, pain self-efficacy and general health. Back function improved more in the yoga group: mean difference in changes from baseline at three (−2.17, 95% CI −3.31 to −1.03, p<0.001), six (−1.48, 95% CI −2.62 to −0.33, p=0.011) and 12 months (−1.57, −2.71 to −0.42, p=0.007). Improvement in pain self-efficacy at three and six months in the yoga group. No differences in general health and pain reduction. Two adverse events were reported by controls and 12 by the yoga group – 8 out of 12 reported pain which may have been due to yoga. 63 (40%) were not fully compliant with treatment and 23 (15%) did not attend any yoga classes. Conclusion. At all time points Yoga was more effective than usual care at improving back function. Conflicts of Interest. AT, AS and JDA are self-employed yoga practitioners and may benefit if there is a demand for the yoga programme. AT, AS, the funders and the University of York would share any royalties from the future sale of the yoga manuals and CD.” AT, AS AND JDA had no involvement in the collection of data and in the analysis of the trial. Source of funding. Arthritis Research UK