Background & Purpose: Clinical guidelines support physical activity for people with chronic low back pain (CLBP); walking is an ideal form of physical activity as it is easy to do, requires no special skills and is achievable by virtually all ages with little risk of injury but there are no current evidence-based structured walking programmes (WP) for this population. The purpose of this study was to develop a WP for CLBP patients in preparation for a proposed randomized controlled trial.

Methods: An 8-week structured WP was developed using Intervention Mapping (IM) principles:

literature review,

Results: Both the CLBP patients and physiotherapists interviewed endorsed walking as a suitable form of physical activity, and identified possible barriers as fear avoidance, exacerbation of pain, behavioural change, motivation, time, personal safety and adverse weather. The pilot study found 90% compliance with the WP. Descriptive analysis of change scores showed improvements at 8-weeks in all self reported outcomes and objectively measured physical activity and functional capacity.

Conclusion: Intervention Mapping was successfully used to develop a WP intervention for chronic LBP, the efficacy of which is being evaluated in a randomized controlled trial.

Background: The purpose of this study was to investigate the relationship between neck pain and upper limb disability.

Methodology: This was a secondary analysis of neck pain patients participating in an RCT comparing usual physiotherapy with graded exercise treatment, to investigate the correlation between baseline neck pain and baseline upper limb disability. 151 neck pain patients from High Wycombe, Nottingham, Grimsby and Hull participated in the study. The measure used to assess baseline neck pain/disability was the Northwick Park Neck Pain Questionnaire (NPQ). The measure of baseline upper limb disability was the Disabilities of Arm, Shoulder, Hand (DASH). A range of variables were also measured at baseline as potential confounding variables. These included pain self efficacy, anxiety, depression, fear avoidance beliefs, coping strategies, age, gender, current smoking status, material and social deprivation and activity level. The measures were validated self administered questionnaires.

Results: Pair wise analysis revealed a strong positive correlation between NPQ score and DASH score (Pearsons’ r=0.799, p< 0.001 (2 tailed), n=142). Stepwise linear regression indicated that increased severity of upper limb disability was predicted by two baseline variables: higher NPQ scores (B=0.743) and lower pain self efficacy scores (B= – 0.489) {Adjusted R2=0.708; n=100, p< 0.001}. After adjusting for potential confounding variables there remains a strong positive association between NPQ score and DASH score.

Conclusions: Patients presenting with high levels of neck pain may also have high levels of upper limb disability. Upper limb disability may need to be assessed and addressed as part of the neck management process.

Background: The main aim of this study was to compare the effectiveness of a brief intervention based on cognitive-behavioural principles (Solution Finding Approach – SFA) with the McKenzie approach (McK). A secondary aim was to determine if there were any clinical characteristics that distinguished patients who responded best to the McKenzie method.

Methods: Eligible patients who were referred by GPs to physiotherapy departments in the UK with neck or back pain were randomly allocated to McK (n= 161) or to SFA (n=154) and their outcome compared at 6 weeks, 6 and 12 months. In addition, putative predictors within the McKenzie group were compared using univariate analysis to examine the relationship between variables and outcomes. Significant variables were assessed using multiple logistic regression analyses.

Results: Both groups demonstrated modest improvements in outcomes. There were no statistically significant differences in outcomes, except 2 small but significant differences at 6 weeks. At 6 weeks, patient satisfaction was greater for McK (median 90% compared with 70% for SFA). The number of treatment successes in the McK group depended upon the definition used, but were limited. Less chronic back pain (rather than neck pain) in patients demonstrating centralisation responded best.

Conclusion: In the original RCT there were few differences between McK and SFA though modest improvements in both. In a secondary analysis of the results for the McK group there were few treatment successes according to our definition of success; these were most likely to occur in back pain patients with shorter duration symptom who demonstrated centralisation response.

i Background and Purpose. Typically systematic reviews and guidelines consider chronic and acute/sub-acute back pain (< 3 months). However, LBP’s clinical course is often untidy, making this distinction difficult to apply in practice. We did a secondary analysis of the UK BEAM data-set to decide pain duration affected treatment outcome.

ii Method and results: We recruited 1,334 participants with four weeks or more of LBP to a trial of manipulation and exercise for low back pain. We found small sustained benefit from the manipulation package and a small short term benefit for the exercise package. One third of our participants reported that their pain had lasted for less than 90 days (range 4 weeks to 40 years). For this analysis the dependent variable was the Roland Morris Disability Questionnaire score at 12 months. Independent variables were treatment group and episode length, an interaction term between treatment (usual care, exercise, manipulation, and manipulation followed by exercise) and duration of current episode. Preliminary analysis indicates that the significance of the interaction terms for manipulation vs GP care, exercise vs. GP care and manipulation followed by exercise vs GP care are, 0.409, 0.037 and 0.889 respectively. The statistically significant result for the interaction between exercise and episode duration is a positive interaction, indicating that exercise may be more effective for those with shorter episodes of back pain and GP care more effective for longer episodes.

iii Conclusion: It is possible that duration of episode affects effectiveness of the UK BEAM exercise package, but not the UK BEAM manipulation package.

Background: Neck pain is a common problem accounting for up to 22% of the workload of physiotherapists. Many different approaches are used and the evidence for these is unclear.

Purpose: To evaluate the effectiveness of a brief physiotherapy intervention (1–3 sessions) for patients with neck pain in the primary care setting, taking preferences into account.

Method: A Randomised controlled trial (n=268) compared a brief physiotherapy intervention based on cognitive-behavioural principles with ‘usual’ physiotherapy. Patients from physiotherapy waiting lists aged 18 – 87 years with neck pain of musculoskeletal origin of more than 2 weeks duration were invited to participate. Their preferences for type of treatment were elicited independently of randomisation.

The brief intervention aimed to facilitate problem-solving, encourage self-management and early return to normal function. Physiotherapists undertook a one-day training programme in communication skills and cognitive-behavioural approaches. In the ‘Usual’ physiotherapy intervention treatment was provided at the discretion of the individual physiotherapist.

The main outcome measures were the Neck Pain Questionnaire, a specific measure of functional disability due to neck pain, the SF-36 a generic health-related quality of life measure, the Tampa Scale for Kinesophobia, a measure of fear- and-avoidance of movement and the use of healthcare services. Data was collected at baseline, at 3 months and at 12 months.

Results: Patients randomised to the ‘Usual’ physiotherapy group were significantly improved compared with the Brief Intervention group, 12 months after randomisation. However, the differences were small and patients randomised to the Brief Intervention who preferred that arm of the study also improved to a similar degree. In contrast, patients who wanted ‘Usual’ physiotherapy but got the brief Intervention did not improve.

Conclusions: The Brief intervention may be effective for patients who prefer the option of a one-off treatment of advice. It is also cheaper and should therefore be offered as an option.ot

Background and Purpose: The purpose of this study was to find out if a sub group of patients might particularly benefit from a structured programme of exercise classes. Such a programme originally designed for chronic back patients, has been further developed for use in the community, and has been shown to have a small but significant effect in reducing disability¹. Recent evidence points to the potentially important role of fear, distress and depression in predicting outcome.

Method and results: A subgroup analysis was carried out on patient outcomes from a randomised controlled trial comparing a ‘Back to Fitness’ programme of exercise classes with usual GP care, in order to test whether patients with high scores on measures of fear-avoidance and distress/depression benefit the most. Data from 179 back pain patients were analysed after categorising baseline scores on fear-avoidance beliefs (high/low) and distress/depression (at risk/normal). The main outcome measure was the Roland Disability Questionnaire. Outcomes were compared between the intervention and control groups at 6 weeks, 6 months and 12 months.

High fear-avoiders fared significantly better in the exercise programme than in usual GP care at 6 weeks and at 1 year. Low fear-avoiders did not. Patients who were distressed or depressed were significantly better off at 6 weeks but the benefits were not maintained long-term.

Conclusion: Patients with high levels of fear-avoidance beliefs could significantly benefit from the Back to Fitness programme. In the clinical setting, it might be worth screening patients for high fear avoidance beliefs and making such a programme available to them.