Prosthetic joint infections (PJI) are amongst the most feared postoperative complication of total joint replacement (TJR). PJIs are associated with significant morbidity ranging from functional impairment to amputation. Staphylococcus aureus (S. aureus) is one of the most common causative organisms involved in PJI. More than one quarter of the general population are S. aureus carriers, and carrier status has been shown to increase the risk of developing surgical site infections including PJIs. Decolonization of S. aureus carriers prior to surgery has demonstrated promising results in general surgery, however, solid evidence supporting decolonization in orthopaedic patients is lacking. We aimed to seek further evidence supporting pre-operative screening and S. aureus decolonization in patients undergoing primary or revision hip and knee TJR.

A quasi-experimental quality improvement study was conducted to compare the 5-year baseline rates of deep PJIs to a one-year screening and decolonization intervention period. All consecutive patients who underwent primary or revision TJR at one tertiary care hospital in Hamilton, ON, Canada were included in both study periods.

Nasal and throat screening for S. aureus carriage of all eligible TJR patients in the preoperative clinic was implemented as standard of care. Patients who tested positive were contacted and provided with details on the S. aureus decolonization protocol. Decolonization included a standardized treatment protocol of 2% intranasal mupirocin twice daily for five days prior to surgery date (excluding day of surgery), and chlorhexidine gluconate wipes (2%) to be used once daily for 4 days prior to surgery date and on the morning of surgery. Regardless of the colonization status at the visit in the preoperative clinic, all patients were re-swabbed on the day of surgery.

Primary outcome of interest was the rate of deep PJI as per CDC/NHSN at one-year postoperative follow-up. Secondary outcomes included rate of deep PJIs due to S. aureus, adherence to the decolonization protocol, proportion of S. aureus carriers successfully decolonized, and the proportion of patients deemed as non-carriers following preoperative swab subsequently identified as carriers on the day of surgery. A total of 8,505 patients were included in the 5-year control group, and 1,883 during the intervention period, of which 424 (22.5%) were identified as S. aureus carriers.

The deep PJI rate was similar in the two groups, 0.4% (7/1,883) in the intervention group and 0.5% (42/8,505) in the control group (OR 0.75, 95%CI 0.34–1.67, p=0.58). More importantly, we found a significant reduction in PJI due to S. aureus to only one case in the intervention period (0.05%) as compared to 29 cases (0.3%) in the historic control (OR 0.15, 95%CI 0.004–0.94, p=0.0376).

We found a significant reduction in PJIs due to S. aureus by decolonizing S. aureus carriers prior to surgery. However, no significant difference in overall infection rates was observed. In conclusion, routine implementation of active screening for S. aureus and decolonization of carriers before TJR is feasible and helps to reduce PJI due to S. aureus.

Introduction

Early intervention is advocated to prevent long-term work absence due to musculoskeletal (MSK) pain. The SWAP trial tested whether adding a vocational advice (VA) service to best current care led to fewer days work absence over 4 months.

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.

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.

Background: Psychosocial factors are well-known contributors to the suffering and disability associated with common musculoskeletal problems. How to identify salient obstacles to recovery or return to work, and how to manage them effectively remains difficult. This project interpreted the evidence base and presented it as solution-focused guidance for everyday practical use by the key players (clinicians, employers, funders, case managers, etc) to help people remain active and working.

Methods and Results: Two methods were used to identify evidence and practical advice, and synthesize this into use-able statements:

existing reviews;

An extended conceptual development of a ‘flags framework’, based on the earlier approach of Yellow Flags, was used to prepare an easily understood and pragmatic approach. The framework integrates obstacles related to the person (yellow flags), the workplace (blue flags) and the context (black flags). A full-colour 32-page document suitable for distribution as both print and electronic media was developed. This contains a clear explanation of how to identify psychosocial flags, how to develop a plan to address them effectively, and how to take action to overcome the obstacles. Poster-style summaries for clinicians, the workplace, and the individual are included, and are available for download. International consultation was used to ensure system-independent applicability and language.

Conclusion: The new document provides practical guidance on identifying and managing psychosocial issues relevant to common musculoskeletal problems based on the latest evidence and conceptual approaches.

Conflict of Interest: none

Sources of Funding: Society for Back Pain Research, Faculty of Occupational Medicine, BackCare, Transport for London, Royal Mail, HCML, TSO

Background: Many studies have investigated predictors of outcome in low back pain (LBP) patients, including the role of coping. However, the relative importance of different coping strategies is unclear.

Objective: To systematically review prospective cohort studies to determine the role of specific coping strategies in the prediction of LBP outcome in primary care settings.

Methods: Medline, PsychINFO, and Embase electronic databases were searched from inception to April 2008. Prospective cohort studies focusing on aspects of coping with LBP in settings relevant to primary care were included. Studies were excluded if they focused on specific populations (e.g. nursing staff) or patients aged under 18 years, or if they were not published in English. Prior to data extraction, studies were quality assessed and coping strategies were conceptualised as either cognitive or behavioural.

Results: 782 potentially relevant articles were identified, of which 34 were included with an average follow-up of 10 months. There was considerable variability in the prognostic risk factors measured. Fear avoidance beliefs were most frequently associated with outcome. Negative affect, anxiety and depression, use of active or passive coping strategies, and catastrophizing were also commonly associated with outcome. Behavioural coping strategies were measured by only 5 of the 34 studies.

Conclusion: Despite considerable heterogeneity, most studies were of acceptable quality, enabling the identification of several key coping strategies predictive of LBP outcome. However, the majority of studies focused on cognitive coping factors only. Therefore further research is needed, particularly to investigate the influence of behavioural coping strategies on LBP outcome.

Background: Last year we presented the STarT Back Tool, which is validated for use in Primary Care. It subgroups patients into 3 categories (high, medium and low risk) on the basis of modifiable risk factors for chronicity. We are now piloting the feasibility of using the tool as part of a new approach to sub-grouping and targeting back pain in primary care.

Methods: The physiotherapy interventions for the 3 subgroups were developed after reviewing the literature, current guidelines, the content of existing targeted treatment programmes, and convening workshops with internationally recognised experts. Both the intervention training modules, and the targeted treatments were piloted. Consecutive back pain consulters were identified using GP electronic Read Codes (weekly downloads) and invited to attend the study’s back pain clinic. Consenting patients completed a baseline questionnaire and were classified by the tool into one of 3 sub-groups.

Results: 60 patients were recruited. 50 patients were allocated to receive treatment according to their subgroup allocation and 10 patients (control group) received a triage physiotherapy assessment (usual care) to decide if they needed further physiotherapy treatment. Primary outcomes include the Roland Morris Disability Questionnaire and the Pain Catastrophising Scale. Three-month follow-up postal questionnaires are currently being administered and outcomes will be presented at the conference. Clinicians involved (GPs, and physiotherapists) will be interviewed to identify the feasibility of this approach.

Conclusions: Once feasibility is established we will take this developmental work forwards into the clinical trial arena to investigate whether this novel “sub-grouping for targeted treatment” approach provides a cost effective way of reducing long-term risk of chronic disability in patients consulting their GP with back pain.

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.

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.

Purpose of the study: To investigate whether video analysis, in addition to self-reported paper audit, could elucidate expected differences in the content of two interventions.

Background: We have completed a randomised clinical trial comparing two types of physiotherapy for subacute low back pain (“hands on” physiotherapy versus a pain management programme). An essential component in conducting clinical trials is to audit the interventions to check for compliance with the protocol. We use two approached:

self complete proforma

Methods: i) Treatment content was recorded on a proforma by the physiotherapists after each session.

ii) A check-list of treatment modalities was constructed from this proforma. Twelve sessions were recorded on video (one new and one review patient for each therapist). The recordings were rated by 3 blinded, independent observers using the checklist. These were compared with the self-report audit forms relating to the same physiotherapy session.

Results: Analysis of the videos showed good levels of agreement (67%) between the 3 observers. Agreement between the video content and paper audit was also good (84%, _ = 0.59). The complete paper audit revealed clear differences between the treatment arms. Patients undergoing the “handson” treatment received manual therapy, whereas patients in the pain management group had specific issues addressed in the course of the consultation.

Conclusions: Feasible, reliable methods of confirming the content of interventions delivered in pragmatic trials are difficult to achieve. Self report paper audits are simple but rely upon the honesty and accuracy of the completer, and may not pick up subtle differences in approach. Video recording is time consuming, may be threatening to the treating practitioner and patient, and is difficult to analyse. A compromise approach involving sample video recordings along with paper self complete audit was able to validate the content of the treatments delivered.

Study design: Cross-sectional questionnaire-based workforce survey together with collection of retrospective data on work absence.

Objectives: To determine if psychosocial ‘blue flags’ are related to back pain and/or sickness absence due to back pain.

Summary of background: The original description of the psychosocial ‘yellow flags’ for back pain chronicity included a mixture of individual psychological parameters and parameters related to perceptions about work and the workplace. It has recently been suggested that these latter parameters should be considered separate and distinct from the individual parameters , and can be termed ‘blue flags’. To date, however, there has been no attempt to explore the specific relationship between the blue and yellow flags or their relative relationship to symptoms and disability.

Methods: The workforce of a large multi-site company was invited to complete a booklet of questionnaires, which included the standard Nordic instrument for obtaining back pain data, and specific instruments to obtain data on ‘yellow’ and ‘blue’ psychosocial flags. The blue flags included psychosocial aspects of work, attribution and elements from the demand/control model, with psychological distress used as a yellow flag comparator. Of the 7,500 workers, 60% responded. Sickness absence records identified workers who had taken absence for back pain. The exploration of the data involved determining statistically significant relationships between psychosocial scores and both back pain history and absence. Appropriate statistical procedures were then used to establish cut-off points for the psychosocial variables. Odds ratios were calculated for two particular outcome variables: self-reported back pain in the previous 12 months and recorded absence over the same period.

Results: Cut-off points were established for each variable, along with the odds ratio (OR) that this score or a score above or below (depending on the scale direction) is associated with reports of back pain or absence. The ORs for psychological distress were 1.9 and 2.4 respectively for LBP and absence in the last 12 months. The ORs for the blue flag variables varied from 1.1 to 1.5 for LBP and from 1.8 to 3.2 for absence.

Conclusions: The psychosocial blue flags reported here are statistically significantly related both to reported back pain and absence. The effect size is less than that for distress in respect of back pain, but variously higher and lower for absence. Whilst prospective studies are needed to determine cause/effect, the results offer tentative support for the suggestion that blue flags should be addressed in clinical interventions.

Traditional biomedical/ergonomic occupational interventions to reduce work loss show limited success. Attention is now focussing on tackling the psychosocial factors that influence occupational back pain.

A workforce survey of Glaxo Smith Kline (reported to the Society last year) established that clinical and occupational psychosocial factors (yellow & blue flags) act independently and may represent obstacles to recovery. Consequently, a nurse-led intervention was devised. Occupational nurses at two manufacturing sites were trained to identify both clinical and occupational psychosocial factors, and address them using a basic ‘counselling’ technique that reinforces evidence-based messages and advice, along with availability of modified work. The program should ideally be implemented within the first days of absence, with ‘case-management’ by the nurse for a further 4 weeks. Control sites simply offer ‘usual management’. Outcomes at 12-month follow-up are rates for work loss/work retention.

The target for contacting the worker (3 days) was achieved at one site, but not the other (mean 12 days), thus exerting a differential delay in delivering the intervention. The lack of early identification at the second site was due to local reporting/recording mechanisms. This study reveals a third class of obstacles to recovery – black flags – company policies/procedures that can impede occupational rehabilitation programs.

We studied 50 consecutive patients presenting at an accident department after rear-end vehicle collisions and recorded symptoms and psychological test scores within one week of injury, at three months and at two years. The range of neck movement was noted at three months.

Within one week of injury, psychological test scores were normal in 82% of the group but became abnormal in 81% of the patients with intrusive or disabling symptoms at over three months (p < 0.001) and remained abnormal in 69% at two years. The clinical outcome after two years could be predicted at three months with 76% accuracy by neck stiffness, 74% by psychological score and 82% by a combination of these variables.

The severity of symptoms after a whiplash injury is related both to the physical restriction of neck movement and to psychological disorder. The latter becomes established within three months of the injury.