Purpose of the study

The purpose of this project was to evaluate whether OHEIs could facilitate student physiotherapy placement training in their educational outpatient clinics.

Background to the study

The use of Patient Reported Outcome Measures (PROMs) to measure effectiveness of care, and supporting patient management is being advocated increasingly. When evaluating outcome it is important to identify a PROM with good measurement properties.

Purpose and Background

The MOCAM study is a major prospective questionnaire-based study investigating the relationship between low back pain (LBP) patient outcomes and non-specific treatment components, i.e., therapeutic relationship, healthcare environment, incidental treatment characteristics, patients' beliefs and practitioners' beliefs. Participating acupuncturists, osteopaths, and physiotherapists from the NHS and private sector have been asked to recruit at least 10 patients into the study. This paper aims to analyse current recruitment rates from MOCAM and identify barriers and facilitators to effective recruitment.

Background to the study:

The use of Patient Reported Outcome Measures (PROMs) to measure effectiveness of care, and supporting patient management is being advocated increasingly. PROMs data are often collected using hard copy questionnaires. New technology enables electronic PROM data collection.

Background to the study:

The use of Patient Reported Outcome Measures (PROMs) is being increasingly advocated but data are still being collected using paper systems. This is costly and environmentally challenging. New innovations are required to balance the challenges of capturing PROM data while considering budgets, and access to IT, and patient choice.

Background: Mind body therapies are being used increasingly to manage chronic musculoskeletal pain. We aimed to systematically review studies to explore the effectiveness of these mind-body therapies (MBTs).

Method: The following databases were searched MEDLINE, Psychinfo, AMED and CINAHL. Randomised controlled trials (RCTs), cohort studies, and case series studying adults with chronic musculoskeletal disorders were included. MBTs of interest were biofeedback, hypnosis, guided imagery, meditation, and progressive muscle relaxation. Papers of any language were included. Selection, data extraction and methodological evaluation of the studies were done independently. Narrative and meta-analyses were conducted where appropriate.

Results: The search identified 766 articles, 15 were selected for review, three were before and after studies, 12 were either RCTs or clinical controlled trials. The majority of the studies were of a low quality methodologically, with few participants. Fifteen of the studies reported MBTs reduced pain, this was significant for 7 studies post treatment and for five at follow up. MBTs generally had a positive effect on depression, quality of life, acceptance of pain, use of health care and medication. MBTs were as effective as active interventions such as CBT or education and superior to passive control groups.

Conclusion: MBTs may have the potential to reduce pain, depression and improve quality of life. There is not enough evidence to conclude that MBTs are more effective than standard medical care or which type of MBT is more effective. Data suggests that a bio-psychological approach may be beneficial in the treatment of chronic musculoskeletal conditions.

Conflicts of Interest: None

Source of Funding: Queen Mary University of London

Background: We aimed to explore the incidence and risk of adverse events associated with manual therapies.

Method: The main health electronic databases, plus those specific to allied medicine and manual therapy professions, were searched. Our inclusion criteria for relevant studies were: manual therapies only; administered by regulated therapists; a clearly described intervention; adverse events reported. We performed a meta-analysis using incident estimates of proportions and random effects models from relevant prospective cohort studies and randomised controlled trials (RCTs) published after 1997.

Results: Eight prospective cohort studies and 31 manual therapy RCTs were identified and analysed. The incidence estimate of proportions of minor or moderate transient adverse events after manual therapy was ~41% (CI 95% 17–68%) in the cohort studies and 22% (CI 95% 11.1–36.2%) in the RCTs. The estimate for major adverse events was between 0.007 and 0.13%. No deaths or vascular accidents occurred in any studies. The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham, passive or control interventions compared to manual therapy was similar, but compared to drug therapies greater (RR 0.05, CI 95% 0.01–0.20) and less when compared to general practitioner or usual care (RR 1.91, CI 95% 1.39–2.64).

Conclusions: Our data indicate a very low risk of major adverse events with manual therapy, but around half manual therapy patients may experience minor to moderate adverse events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual medical care.

Conflicts of Interest: D Carnes & T Mars

Source of Funding: National Council for Osteopathic Research

Background: Societal, clinician and patient expectations of treatment outcomes may differ due to different measures of success. This may have implications for measuring progress, monitoring treatment success and patient satisfaction.

Aim: To explore patient expectations about outcome

Method: A qualitative study using in depth interviews with people with chronic pain.

Results: Thirteen chronic pain patients were interviewed, five males and eight females. Age ranged between 24 and 83 years and all had chronic pain in at least one location. Ten interviewees had low back pain. We found that the most important outcome markers for patients were functional tasks that affected every day living. The achievement of these tasks became personal goals. Patients used task achievement to determine treatment success, regardless of whether they had to modify the way they achieved these tasks.

Conclusion: Treatment progress can be monitored using patient determined goals, rather than clinical outcomes which are relatively meaningless to the patient. The additional use of aids or encouraging adaptive behaviour should not be under estimated as part of the treatment process. Patient criteria for success were determined by achieving functional tasks/goals that had previously been difficult. However realistic goal setting remains an important issue that patients and clinicians can jointly negotiate and address.

Background: Pain is complex and multifaceted. We can convey information about pain by communicating verbally, textually and non-verbally. We investigated the use of pain drawings as an aide to communication and compared it with verbal and other pain measurement tools.

Method: We conducted a qualitative study using in-depth interviews with a purposive sample of pain patients. Data were analysed using the ‘Framework Approach’.

Results: Aches and pains are seen as an increasing continuum, aches distract people, pain stops them doing things. As pain progresses along the continuum patients pain reports progress from verbal through textual to visual representation. Verbal and textual communication about pain was inconsistent, especially for those with multi site pain. Visual communication was more about significant pain, verbal covered the range. As pain worsened so did the complexity, the need for help, life change and communication all increased. Current measuring tools do not seem adequate to assess multi site pain, transient pain and pain with movement.

Conclusions: Two methods of describing pain exist, clinical (physical symptoms) and behavioural (effect on life). Patients felt confident communicating about the latter but perceived a need for active help by the clinician for the former.

The effect of pain on lifestyle is paramount to the patient, physical symptoms for the clinician. Acknowledging this disparity may reduce frustration experienced in consultations as both have different communication and management needs. Indicating treatment success by focusing on lifestyle improvement in patients rather than reductions in physical symptoms may be more appropriate.

We conducted a community survey of the prevalence, health impact and location of chronic pain. We explored the relationship and patterns of chronic pain that commonly occur, with a view to understanding why some treatment approaches may be more appropriate than others for particular patterns of pain.

In 2002, 2504 randomly sampled patients from 16 General Practices in the South East of England responded to a postal questionnaire about chronic pain. Those with chronic pain completed a pain drawing. We calculated descriptive statistics, relative risk and correlations to identify the associations and risks of having linked pain.

The highest prevalences were low back (23%), shoulder (20%) and knee (18%) pain. The number of pain sites experienced was age related in men but less so in women. Lower body pain was more age related than upper body and non musculoskeletal pain. Multi site pain was more common than single site pain. Of those with low back, knee and shoulder pain, 14%, 4.5 % and 1.9% had only low back, knee and shoulder pain respectively. Correlations and minimum spanning trees showed that chronic upper and lower body pain are distinct and axial pain link the two.

Chronic pain is more likely to be multi site, especially at middle age. Research, physical treatments and approaches to managing chronic pain are often site specific, therefore specialising treatment to one area eg low back pain often negates the bigger issue. This may help explain the self perpetuating problem of persistent chronic pain.

Background and Significance: Pain drawings could be a means of easily identifying sub-groups of patients who might benefit from different treatment approaches. In particular it has been suggested that they can be used to identify the psychological ‘state’ of patients in terms of distress, depression, somatisation and anxiety.

Purpose/Hypothesis: To systematically appraise data from the literature about the validity and reliability of using pain drawings to evaluate psychological ‘state’.

Method: We searched 12 medical and social science databases, using key words and their derivatives; pain; drawings; diagrams; vis(z)ualisation; body mapping; mannequins and homunculi. We appraised studies directly evaluating the utility of pain drawings and psychological state.

Results: We selected 19 for final inclusion. The majority of studies reviewed focused on low back pain (79%) and secondary and tertiary care (90%). Pain drawings were evaluated against psychological tools testing personality (MMPI), somatisation (MSPQ, IBQ) and psychological states such as depression (Zung) anxiety (SF36) and distress (GHQ).

11/19 studies reported inconclusive results, 8/19 showed a statistical association between drawings and the psychological assessment tool. However the more clinically relevant, sensitivity data ranged from 24–93%, specificity 44–91%, positive predictive values 28–93%, and negative predictive values 35–92%. The range of this data is too wide to be acceptable clinically as predictive of psychological state.

Conclusions: There is insufficient evidence to support the assumption that unusual pain drawings indicate a disturbed psychological state, therefore pain-drawing use as a psychological assessment tool is not recommended.