Clinical outcomes of surgery for disc herniation and spinal stenosis are variable. Surveys show that postoperative management is inconsistent; spinal surgeons and their patients are uncertain about what best to do post-operatively. Following a focused literature review, a patient-centred, evidence-based booklet was developed, which aims to reduce uncertainty, guide post-operative management and facilitate recovery. Initial peer and patient evaluations were encouraging and the booklet Your back operation (www.tso.co.uk/bookshop) is currently factored into a trial investigating the post-operative management of spinal patients.

To date, 80 patients have been recruited into the study of which 34 have been randomised to receive the booklet. At 6 months post-surgery all of these patients are requested to complete a questionnaire on the booklet. This questionnaire contained forced-choice questions on readability, style, information level, believability, length, content and helpfulness. Further open questions concern the booklet’s messages, giving patients the opportunity to identify anything they did not like or understand, voice any concerns that were not covered, and say if they thought the booklet would change what they did after surgery. Finally, they were asked their overall rating of the booklet on a scale from 1 to 10.

Feedback is very positive. The average overall rating of the booklet was 8.6/10. Over 80% found it easy to read, interesting, and of appropriate length. Over 80% also stated they had learnt new and helpful information. All subjects stated that they would recommend the booklet to a friend, and the majority stated that they frequently referred to the booklet. The predominant messages received and understood by the patients were related to the safe benefits of early activation and return to normal activities.

The results show that spinal surgery patients appreciate evidence-based information in booklet form, and suggest that this booklet may be an important adjunct to post-operative management of spinal patients.

Background/purpose: Clinical outcomes of surgery for disc herniation and spinal stenosis are variable. Surveys show that post-operative management is inconsistent, and spinal surgeons and their patients are uncertain about what best to do during the recovery phase. The aim of this study was to develop a patient-centred, evidence-based booklet that spinal surgeons can give to their patients to reduce uncertainty, guide post-operative management and facilitate recovery.

Methods: A systematic literature search led to a best-evidence synthesis of appropriate information and advice on post-operative activation, restrictions, rehabilitation, and expectations about surgical and functional outcomes. Data were extracted into evidence statements which were graded by consensus for consistency and practicality so as to inform and prioritise the booklet’s messages. Following peer review (n = 16), a sample of patients (n = 11) gave a structured evaluation of the draft text.

Results: The review found scant evidence in favour of post-operative activity restriction, yet an early active approach to post-operative rehabilitation can improve clinical, functional and occupational outcomes. Thus, the text of the booklet presents carefully selected messages to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice to aid self-management. Peer reviewers’ comments were incorporated into the text; all the spinal surgeons (n = 7) said they would find the booklet useful. Patients found it readable, interesting and helpful; they understood and accepted the intended messages.

Conclusions: Following careful development, an evidence-based booklet to aid post-operative management in spinal surgery is now available, and is factored into a RCT of post-surgical rehabilitation.

Purpose of study and background: It is generally accepted that a biopsychosocial model is required to explain the complex phenomenon of whiplash associated disorders, particularly in the development of chronic pain and disability. Because the factors leading to chronicity are present early in the course of the disorder, clinical guidelines and recommendations have stressed the need for appropriate information and advice for patients. Following the success of patient educational material, in the form of an evidence-based booklet, in the management of low back pain, a similar booklet has been produced for whiplash patients. The messages for the booklet were synthesised from a comprehensive review of the available scientific evidence; the resultant text was intended to challenge unhelpful beliefs about whiplash, promote positive attitudes, and stimulate an active approach to recovery.

Methods and results: Using samples of patients and non-patients, the booklet was evaluated for its ability to create a positive shift in beliefs, and for its ability to impart its intended messages about active management. The results showed that the booklet is considered easy to read, understandable, believable, and conveys its intended messages. Furthermore, it created a substantial and highly statistically significant positive shift in attitudes and beliefs about whiplash associated disorders, suggesting its suitability as patient educational material.

Conclusion: This booklet changes beliefs about whiplash, however only a randomised clinical trials will determine whether such a booklet can have an effect on clinical outcomes.

Objective: A review of scientific literature on whiplash associated disorders was conducted to inform appropriate messages for an evidenced-based patient educational booklet – The Whiplash Book. The booklet has been developed for use as both a clinical tool and general health intervention.

Design and Results: A systematic literature search was conducted, using MEDLINE and psychINFO, together with hand searches, reference tracking, and the Internet. The Quebec Task Force report and the British Columbia Whiplash Initiative were taken as the starting point. The new evidence covered the period May 1994 through March 2001 (163 articles). All relevant articles were included, with a particular focus on management and treatment of whiplash associated disorders. The quantity, consistency and relevance of all retrieved articles was evaluated, and rated as:

*** consistent findings in multiple reports

** consensus based on balance of various findings

* limited information (single report)

Conclusions: The main messages from the literature suggest: serious physical injury is rare, reassurance about good prognosis is important, over-medication is detrimental, fastest recovery occurs with early return to normal pre-accident activities; self-exercise/manual therapy and positive attitudes/beliefs are helpful to regain activity levels; collars/rest and negative attitudes/beliefs delay recovery and contribute to chronicity.

Study design: A systematic review of the literature to inform the development of occupational health guidelines for the management of low back pain at work.

Objectives: To evaluate the evidence from occupational health settings or concerning occupational outcomes.

Summary of background: Clinical guidelines for the management of low back pain (LBP) provide only limited guidance on the occupational aspects. Thus the Faculty of Occupational Medicine requested this review in order that a multi-disciplinary working group could develop the first evidence-based UK guidelines for management of LBP at work.

Methods: A systematic literature search was followed by rating of the strength of the evidence plus a narrative review, by agreement between two experienced and independently-minded reviewers. There was no attempt at blinded double review or quality scoring. The final version followed peer-review by four international experts.

Results: More than 2000 titles were considered. 34 systematic reviews, 28 narrative reviews, 52 additional scientific studies, 22 less rigorous scientific studies and 17 previous guidelines were identified and included. The evidence statements (rated for strength) were presented under headings that reflect a logical sequence of occupational health situations (Background, Pre-placement assessment, Prevention, Assessment of the worker presenting with back pain, Management principles for the worker presenting with back pain, Management of the worker having difficulty returning to normal occupational duties at 4–12 weeks). Some important areas were given additional narrative evidence-linked discussion (High risk patients/physically demanding jobs, Return to work with back pain, Rehabilitation programmes). Thirty six evidence-linked statements were developed to inform the guidelines group. The strongest evidence suggests that: generally the physical demands at work have only a modest influence on the incidence of LBP or permanent spinal damage; a history of LBP is not a reason to deny employment; preventive strategies based on the injury model do not reduce LBP or work loss; individual and work-related psychosocial factors play an important role in persisting symptoms and work loss; the management approach should be ‘active’ (including early work return); the combination of clinical, rehabilitation and organisational interventions designed to assist work return is more effective than single elements. However, further research is needed to identify the optimal roles of all stakeholders (clinicians, employers and workers) in case management.

Conclusions: This review consolidates the emerging focus on active management of LBP at work, and indicates that approaches addressing obstacles to recovery will provide greater benefits than attempts at primary prevention. The outcome of the review has resulted in what we believe are the first truly evidence-linked occupational health guidelines for back pain in the world (www.facoccmed.ac.uk).

A review of scientific literature on whiplash associated disorders was conducted to inform appropriate messages for an evidenced based patient educational booklet, “The Whiplash Book.” The booklet is being developed for use as both a clinical tool and general health intervention.

A systematic literature search was conducted, using MEDLINE and psychINFO, together with hand searches, reference tracking, and the Internet. The Quebec Task Force report and the British Columbia Whiplash Initiative were taken as the starting point. The new evidence covered the period May 1994 through March 2001 (147 articles). All relevant articles were included, with a particular focus on management and treatment of whiplash associated disorders. The quantity, consistency and relevance of all retrieved articles was evaluated, and rated as *** for consistent findings in multiple reports, ** for consensus based on balance of various findings, or * for limited information (single report).

The main messages from the literature suggest: physical serious injury is rare, reassurance about good prognosis is important, over-medication is detrimental, fastest recovery occurs with early return to normal pre-accident activities, self-exercise/manual therapy and positive attitudes/beliefs are helpful to regain activities levels, collars/rest and negative attitudes/beliefs delay recovery and contribute to chronicity.

We aimed to develop a better understanding and method of rating the success or failure of low back surgery by studying 185 patients prospectively. Identical pre-operative and postoperative assessment by an independent observer included pain, disability, physical impairment, psychological distress and illness behaviour. Outcome was assessed by the patient, by the observer and by return to work. There was 96% follow-up at two years. Correlation co-efficients varied considerably between the various measures of outcome, both patient and observer appearing to base their assessment mainly on postoperative status rather than on any change produced by surgery. The observer was influenced most by postoperative pain, disability and physical impairment. Patients were influenced most by residual physical impairment, type of surgery and proportional change in disability. Return to work was moderately influenced by postoperative disability and to a larger extent by social and work-related factors. We developed a simple formula to judge overall success or failure which accurately reproduced the combined assessment of patient and observer. If surgical audit is to be meaningful it must be based on an improved understanding of how the outcome of surgery should be assessed.

Clinical localisation of a disc prolapse required dependable knowledge of the muscles supplied by the lumbosacral nerve roots. Localisation is most difficult in the 10 per cent of patients who have lumbosacral bony segmental anomalies. The lumbosacral plexus has been dissected in 11 cadavers with such anomalies and electrical stimulation studies carried out in 15 patients similarly afflicted. It is suggested that whatever the anomaly the "last fully mobile level" should be identified as the lowest level with a fully formed disc space, bilateral facet joints and two free transverse processes which do not articulate with the sacrum or pelvis. In three out of four patients with bony segmental anomalies the fifth lumbar root emerges at the last fully mobile level.