Background

The BACK To Health programme is part of the wider North of England back pain and radicular pain pathway. The purpose of this programme is to provide a CPPP approach based on the NICE guidelines CG88 for those with back pain that has not responded to early management and simpler therapies. The purpose of this study is to present preliminary results of this programme.

Introduction

The advent of ambulatory total joint replacements has called for measures to reduce postoperative length of stay, while improving patient function and postoperative satisfaction. This prospective, randomized trial evaluated the efficacy of one-on-one preoperative physical therapy (PT) education with a supplemental web-based PT web-portal on discharge disposition, postoperative function and patient satisfaction after total joint replacement.

Introduction

Previous work(1) has suggested that Spectral Colour Mapping (SCM) may have potential as an objective measurement tool for analysing Electromyography (EMG) data from spinal muscles, but the production and analysis of these maps is a complex undertaking. It would be beneficial for a system to create these maps and be useable with a minimum of training.

Background context: It is frequently stated that referred pain does not travel below the knee. However, for many years studies provoking referred pain have demonstrated pain radiating below the knee.

Methods: Over a twelve month period, 643 patients with mechanical back pain and 185 patients with nerve root compressions were seen. For each patient two body map images (front and back) were obtained. Some patients attended for review, at a minimum of six weeks after their first visit. These images were also analysed.

Composite images were created by combining all images from patients in one diagnosis group. Colour based overlays were used to analyse the body map images, to locate the locations of pain. Colour density was scaled so that the site with the most hits had a pure colour, reducing down to zero colour for sites with no hits.

Results: There were 720 nerve root compression images. 216 (30%) showed no leg pain, 91 (12.6%) showed upper leg pain, 134 (18.6%) showed lower leg pain and 279 (38.8%) showed upper and lower leg pain.

There were 1964 mechanical back pain images. 674 (34.3%) showed no leg pain, 528 (26.9%) showed upper leg pain, 308 (15.7%) showed lower leg pain and 454 (23.1%) showed upper and lower leg pain.

Conclusion: A large proportion (39%) of the mechanical back pain images indicated that the patient experienced referred pain below the knee. This has significant implications in the diagnosis of nerve root compressions, potentially leading to inappropriate surgery.

Conflicts of Interest: None

Source of Funding: None

Introduction: The delivery of healthcare in the 21st Century is based on evidence based practice with an increasing call to listen to the voice of the patient this research was conducted to identify patient views on this topic.

Methodology and Results: A cross sectional descriptive postal survey on patients with mechanical low back pain from 2006. Analysis was conducted statistical for quantitative data and thematic analysis (Burnard 1991) on qualitative data.

The reality of living with back pain was considered and patients were asked to rate the interference in aspects of Activities of daily living (ADL). They were then asked which type of support or encouragement they would find useful and how this should be provided. The effect of living with back pain was evaluated using PPMCC in relation to limitation to ADL against age, gender and exercise with no statistical significance demonstrated. However comparison was conducted with employment as a variable against pain on average day (r = −0.155 n=135) satisfaction (r= −0.153 n =132) expressed need for support (r = −1.05 n = 114). The question as to what style of support was clearly defined by the patients this was graphically analysed, demonstrating times and locations they would prefer.

Conclusion: There is opportunity to use this data as part of the recommendations in current discussions with PCT colleagues on the local spinal pathway. The re-shaping of services will then include expressed views and preferences of patients.

Introduction: Back pain patients have an informal record of multiple attendances as they “shop around” a triage clinic for LBP patient’s has enabled evaluation of this phenomenon via the database. All patients are given advice on the importance of some form of exercise and activity as part of managing the condition, but adherence is variable.

Method: A select query was executed on the database and over a period of 13 years 12684 patients were seen of which 8.2% have been seen more than once. Of these 7.2% were seen twice, 0.8 were seen three times and one patient had been seen five times.

Results: Extracting details from those who had two visits and completed the LBOS demonstrated no sick benefit either visit 65%, on benefit both visits 10%, altered status 10% on visit one but 15% on visits two. Patient working on all visits 48%, not working 18% altering work status between visits 18% both times. Sports on both visits 50%, none at either 22% but 20% were doing sports on visit one but on visit 2 had stopped and 9% had started sports on visit two that were not involved in visits one.

Question:

This data suggests that there is a low but significant number of patients who attend twice. Although advice is to increase activity this is not always demonstrated so how had their understanding been evaluated.

Conclusion: If the condition is best managed in primary care alternative resources/staff should be identified who can then provide the service required.

Introduction: Delay in active management reduces the prognosis for simple low back pain. The aim of this project was to develop a tool for use in GP surgeries to assist the doctor in his/her diagnosis of lower back pain and allow prompt management with confidence.

Methods: Three different systems for the automated diagnosis of low back pain were developed. With each, the patient answered a series of questions presented by the system. Three different strategies were employed, one using variable weighting, one a logic tree and one an inference engine. For the purpose of testing the systems against each other, a database was constructed containing the answers to all possible questions from each system for one hundred patients attending a low back pain clinic. The “true” diagnosis was that made by the treating clinician who saw the patients.

The original data contained a number of diagnoses:

Spinal Stenosis (central or lateral)

For the purpose of the comparison two groups were considered – patients with radicular symptoms (groups 1 to 4) and patients with pure MBP.

Conclusions: The different approaches to development showed that a number of factors play a crucial role for the accuracy of the systems, including the number of rules used to try to cover every possibility, the interpretation of the questions by the patients and the weighting and approach taken for the different Certainty Factors. The use of any of these three approaches did not allow the development of a system accurate enough for clinical use and it seems that successful development of such a system might require a wholly different approach.

Introduction: Outcome data is essential for clinical governance and research purposes, and will inform decisions on resource re-distribution. The Spinal Assessment Clinic (SAC) treats patients with low back pain referred by their GPs.

Method: Low Back Outcome Score (LBOS) data was collected at presentation (Q1) for 691 patients and on review (Q2) for 98 patients. At presentation further administrative information is also collected. At review Q2 patient satisfaction is recorded as well as the patient’s perception of the status of their LBP. Results were compared between three clinic locations; inner city (CIT), urban (URB) and semi-rural (RUR).

Results: Significantly more patients at the inner city clinic cancelled and re-appointed, and significantly fewer could be discharged after the first consultation. Equal numbers were employed in the three locations.

Despite failure of improvement of perceived LBP, many patients reported an improvement of LBOS.

Conclusion: Social and environmental factors influence behaviour within a treatment program. Patients can appreciate the difference between a satisfactory treatment experience and an actual change in their low back pain. Function can increase even when reported pain does not.

We reviewed, retrospectively, 13 patients who had undergone open anterograde autologous bone grafting of the talus for symptomatic osteochondral defects of the dome of the talus. The mean age of the seven men and six women was 38.4 years. The defects included the full thickness of articular cartilage, extended through the subchondral plate and were associated with subchondral cysts. Six patients (46%) were clinical failures requiring further surgery. Of the remaining seven, functional outcome results were obtained at a mean of 51.9 months after surgery. The mean outcome scores for the Musculoskeletal Outcomes Data Evaluation and Management System foot and ankle questionnaire and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale were 87.0 and 84.3, respectively. There was an overall 46.2% patient satisfaction rate.

We believe that the technique of autologous bone grafting presented should be used with extreme caution, when considered as the primary treatment for the adult patient with a symptomatic advanced osteochondral defect of the talus.

Aims: This in vitro study investigates the use of Collagen/PRP Hydrogels as a biological matrix for containing genetically modified human ACL cells, and supporting transgene expression. Methods: Adenoviral vectors encoding marker genes (green fluorescent protein (GFP)) and bioactive) where used to infect cultured human ACL cells?genes (TGF- ex vivo. The cells were seeded in Collagen/PRP Hydrogels and maintained in culture. To expression over time, ELISA was performed at days 4, 8, 15, 23,?measure TGFand 29. GFP positive cells within the gel were viewed by fluorescence microscopy at the same time points. After 29 days, the cultures were fixed, sectioned and various sections were stained with H& E, toluidine blue to detect proteoglycans and by immunhistocemistry for collagen type I and II. Results: Collagen/PRP Hydrogels were transgenes for up to 29 days.?able to support expression of GFP and TGF- expressing gel/cell constructs produced an abundant?Compared to controls, TGF- amount of type I collagen, consistent with the ligament phenotype and appeared more cellular. Little or no proteoglycan staining was observed in either group. Conclusion: These results demonstrate that genetically modified human ACL cells can support persistent transgene expression in vitro, sufficient to stimulate growth of ligamentlike tissue within a Collagen/PRP Hydrogel. The high levels of transgene expression suggest that the Collagen/PRP Hydrogel can function as an effective gene delivery system for tendon repair in vivo.

Introduction : The ultimate aim of any treatment for low back ache is to improve the quality of life as perceived by the patient. Changes in the condition specific disability measures like the Low Back Outcome Score are used as a measure for this purpose and the results interpreted in terms of statistical significance. It is not known, however, if these changes are considered to be clinically significant by the patients.

Objective: To quantifies the Minimum Clinically Important Difference (MCID) of Low Back Outcome Score in patient’s treated conservatively for Mechanical Low Back Pain.

Design & Subject: Postal questionnaire was sent to a randomly selected cohort of 300 individuals who were treated in the Spinal Assessment Clinic (SAC) for low back pain.

Outcome measures: Patient’s perception of the outcome of the rehabilitation programme was compared with the changes in LBOS from the time of initial presentation to the postal questionnaire.

Results: 186 forms (62 % response rate) were returned. Data from 170 forms were analysed, as 16 forms were incomplete. An average improvement of 17.96(p=0.001) in 75-point LBOS was noticed in those (n = 61) who reported complete recovery. Those who reported Good but incomplete recovery ( n =61) improved their LBOS by 12.37 points( p=0.001). LBOS improvement of 7.52 points ( p = 0.002) was noticed in patients reporting a minimal improvement( n= 38). Ten patients had no change in their clinical condition ( LBOS change 2.8, p =0.485).Age and gender distribution of four groups remained same ( chi square = 1.39, df = 3,p > 0.5).

Conclusions: The Minimum Clinically Important Difference for patients with Low Back Pain is a 7.5 (10%) change in the 75 point LBOS. An average change of 12 (16%) and 18(24%) can be considered to be Good and Excellent responses respectively to the treatment as perceived by the patients. This data will help to determine whether a statistically significant result is clinically meaningful.

Introduction: The ultimate aim of any treatment for low back ache is to improve the quality of life as perceived by the patients. Changes in the condition specific disability measures like the Low Back Outcome Score are used as a measure for this purpose and the results interpreted in terms of statistical significance. It is not known, however, if these changes are considered to be clinically significant by the patients. This study quantifies the Minimum Clinically Important Difference (MCID) of Low Back Outcome Score from the patient’s perspective that were treated conservatively for Mechanical Low Back Pain.

Method: In August and September 1999, a postal questionnaire was sent to a randomly selected cohort of 300 individuals who were treated in the Spinal Assessment Clinic (SAC) for low back pain.

Patient’s perception of the outcome of the rehabilitation programme was compared with the changes in LBOS from the time of initial presentation to the postal questionnaire.

Results: 186 forms (62 % response rate) were returned. Data from 170 forms were analysed, as 16 forms were incomplete. An average improvement of 17.96(p=0.001) in 75-point LBOS was noticed in those (n = 61) who reported complete recovery. Those who reported Good but incomplete recovery ( n =61) improved their LBOS by 12.37 points( p=0.001). LBOS improvement of 7.52 points ( p = 0.002) was noticed in patients reporting a minimal improvement( n= 38). Ten patients had no change in their clinical condition ( LBOS change 2.8, p =0.485).Age and gender distribution of four groups remained same ( chi square = 1.39, df = 3,p > 0.5).

Conclusion: The Minimum Clinically Important Difference for patients with Low Back Pain is a 7.5 (10%) change in the 75 point LBOS. An average change of 12 (16%) and 18(24%) can be considered to be Good and Excellent responses respectively to the treatment as perceived by the patients. This data will help to determine whether a statistically significant result is clinically meaningful.

Introduction: After a year in post, the waiting time to see the spinal surgeon in a large hospital had risen from 0–62 weeks. A nurse-led assessment clinic was inaugurated to triage patients, cut waiting times and accelerate treatment.

Methods: Referrals were taken directly from general practitioners, and patients triaged using proforma history and examination systems into five categories: mechanical back pain, nerve root entrapment, potentially serious pathology, unknown diagnosis and suitable manipulative therapy.

Audit based on direct patient entry with a light pen interface was integrated into the process. Seventy percent of patients were referred complaining of mechanical back pain, and an Educational Rehabilitation Programme was provided within the clinic.

Results: Following the inauguration of the spinal assessment clinic, waiting times in the consultant clinic fell from 62 weeks to 26 weeks; waiting times in the assessment clinic were between four and six weeks. Emergencies may be seen the same week.

The time from GP referral to surgery for routine nerve root compression fell from 92 weeks to 24 weeks (of which 12 weeks was waiting time for scanning).

Detailed audit of scanning requests in 127 patients demonstrated confirmation of clinical diagnosis in 80 percent of whom half went on to surgery. Of the 20 percent with negative scans, a fifth were subsequently found to have trochanteric bursitis.

An audit of 94 patients revealed reduced analgesic consumption, increased return to work and reduced consultation rates at one year. Five patients were referred to other clinics for further consultation. The satisfaction of the clinic amongst general practitioners was 94 percent. Referrals to the clinic have risen from 403 in 1993 to 1511 in 1999, necessitating the appointment of three further nurse practitioners. Prospective review of 104 patients revealed 95 percent satisfaction rate of the clinic and 67 percent satisfaction rate with rehabilitation. Average low back outcome score increased from 29 to 35 (p< 0.001).

A training programme for nurse practitioners has been established and, to date, ten of the clinics have been inaugurated nation-wide using this model.

Conclusions: A nurse-led clinic for triage of back pain patients has had major impact on waiting times, has produced measurable improvements in patients’ outcome and is associated with high satisfaction ratings in both patients and general practitioners.

The aim of this study was to compare implementation of RCGP guidelines in patients in Primary Care with acute low back pain between GP and Nurse Practitioner. This report presents preliminary results.

The intention was to recruit 200 patients presenting to GP with new episode of back pain. 50% randomised to NP care, 50% to GP care. Outcome measured by documentation audit and patient feedback. Individuals complete a questionnaire which includes a Low Back Outcome Score (LBOS) at 14 weeks, 6,12 and 24 months. All patients in NP arm given back book and advised against bed rest.

Initial Findings: (n = 145): The LBOS score was identical (30) for the 73 patients randomised to nurse practitioner care and the 72 with routine GP care. There were no significant differences between the scores at 14 weeks and 6 months, with an increase in LBOS to 45–49, but numbers dropping to 28 in the NP group and 26 in the GP group.

Process audit at 14 weeks: Only 10 of NP patients were not given the back book compared with 74% for GP care. 13% of NP patients were prescribed bed rest against 18 for GP care.

Initial results suggest no significant difference in outcome between GP and Nurse Practitioner patients. Of interest is that 10% and 13% of patients failed to recall important features of management. This implies that audit of healthcare processes by patient questionnaire may be unsatisfactory.