Background and Purpose: Current clinical guidelines recommend supervised exercise as a first-line treatment in the management of low back pain (LBP). To date studies have not used objective forms of measuring changes in free-living physical activity (FLPA). The aim of this study was to compare FLPA between two groups who received either supervised exercise and auricular acupuncture (EAA) or exercise alone (E).

Methods: 51 patients with non-specific LBP [mean±SD=42.8±12.4 years] wore an accelerometer for 7 days at baseline, end of the intervention (week 8) and follow up (week 25). FLPA variables were extracted: % time (hours) spent in postures; daily step count and cadence. Data were analysed using SPSS (v15). Repeated measures ANCOVA were performed using a mixed linear model.

Results: There was no difference in daily step count between the two groups at any time point (E, mean±SD, week 1, 8197±2187; week 8, 8563±2438, week 25, 8149±2800; EAA, mean±SD, week 1, 8103±1942; week 8, 8010±2845, week 25, 8139±1480, p=0.9) or cadence. No differences in postures were noted, apart from time sitting/lying which was shorter at week 25 in the E group (p=0.006).

Conclusions & Implications: Supervised exercise classes, with or without acupuncture, do not produce changes in FLPA in the short term or longer term in people with LBP. This suggests more effective ways should be sought to encourage the patient to incorporate activity into their daily lives. These findings have informed the design of two walking intervention trials for LBP patients.

Conflict of Interest: None

Sources of Funding: Research and Development Office, Northern Ireland, Strategic Priority Fund, Department of Employment and Learning, Northern Ireland.

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%.