Internet delivered interventions may provide a route to rapid support for behavioural self-management for low back pain (LBP) that could be widely applied within primary care. Although evidence is emerging that more complex technologies (mobile apps linked to digital wristbands) can have some impact on LBP-related disability, there is a need to determine the effectiveness of highly accessible, web-based support for self-management for LBP. We conducted a multi-centre pragmatic randomised controlled trial, testing ‘SupportBack’, an accessible internet intervention developed specifically for primary care. We aimed to determine the effectiveness of the SupportBack interventions in reducing LBP-related physical disability in primary care patients. Participants were randomised to 1 of 3 arms: 1) Usual care + internet intervention + physiotherapy telephone support, 2) Usual care + internet intervention, 3) Usual care alone. Utilising a repeated measures design, the primary outcome for the trial was disability over 12 months using the Roland Morris Disability Questionnaire (RMDQ) at 6 weeks, 3, 6 and 12 months. Results: 826 were randomised, with follow-up rates: 6 weeks = 83%; 3 months = 72%; 6 months = 70%; 12 months = 79%. Analysis is ongoing, comparing each intervention arm versus usual care alone. The key results will be presented at the conference.Background
Methods and results
Specifically designed control interventions can account for expectation effects in clinical trials. For the interpretation of efficacy trials of physical, psychological, and self-management interventions for people living with pain, the design, conduct, and reporting of control interventions is crucial. To establish a quality standard in the field, core recommendations are presented alongside additional considerations and a reporting checklist for control interventions.Background
Objectives
Clinical guidelines identify a clear role for managing back pain with structured exercise. Pilates is a commonly recommended modality, however, Pilates-specific research is limited. Research suggests the patient-practitioner relationship may be important in managing persistent low back pain, although further research is needed to evaluate its impact on outcomes. The purpose of this study was to identify the components of the relationship between Pilates teachers and clients with persistent low back pain. This qualitative study used a multi-site, ethnographically-informed methodology. Data collection included observation of 24 Pilates sessions at eight sites across the South of England, and 19 semi-structured interviews with Pilates teachers and clients with persistent low back pain. Data were audio-recorded, transcribed verbatim and analysed thematically. From the interviews and observations, ten themes emerged, of which four related to components of the relationship: (1) ‘being known’; (2) support; (3) teacher expertise; and (4) mastery of exercises, facilitated by the teacher. Key influences on the relationship were identified in four themes: (5) professional identity of Pilates teachers; (6) health perceptions; (7) social influences such as group dynamic; and (8) service perceptions. An additional two themes described the perceived impact of the relationship: (9) feelings of safety; and (10) ‘feeling good’.Purpose
Methods and Results
Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by physiotherapists to patients with back pain at their initial consultation. Twenty-five audio-recordings of patients with back pain and physiotherapists in a primary care outpatient department were collected, transcribed, coded and thematically analysed using a Framework approach to identify the content of advice given.Purpose and background
Patients and methods
Patients with sciatica experience high levels of disability and poor outcomes and treatment has demonstrated, at best, only modest success. To be effective, management strategies must be informed by patients' perceptions about ‘what matters’ about experiencing this condition. The aim of this paper is to explore the lived experience of sciatica and to consider the implications for clinical practice. In this qualitative study, based on the principles of interpretative phenomenological analysis, 14 participants with a clinical presentation of sciatica of likely nerve root origin were purposively recruited from an NHS, Primary Care Musculoskeletal Service in the UK. Individual, semi-structured interviews were used to collect data, which were audio-recorded and transcribed verbatim. Data were managed using a framework approach and analysed thematically. Sciatica was experienced as a protracted journey of acute exacerbations of uncontrolled and incapacitating symptoms that were overwhelming and difficult to make sense of. Adversely affecting almost all aspects of life, participants struggled to maintain their physical, functional and financial independence; their important relationships; social networks and the roles and activities that provided joy and purpose. The impact of sciatica was a ‘life on hold’; an altered sense of self and an uncertain future. For three participants, the experience of sciatica was sufficiently distressing for them to contemplate suicide.Background and purpose of the study
Methods and results
Uncertainty remains regarding the optimal method of diagnosing sciatica. Clinical guidelines currently recommend that investigations be used only when they are likely to change management. In clinical practice, considerable variation can occur between patient and clinician, regarding the perceived importance of investigations such as MRI scans. The aim of this study was to explore patients' experiences of investigations and to consider the impact of concordance between clinical presentation and investigation findings. In this qualitative study, based on the principles of interpretative phenomenological analysis, 14 participants with a clinical presentation of sciatica of likely nerve root origin, who had recently undergone investigations, were purposively recruited from an NHS, Primary Care Musculoskeletal Service in the UK. Individual, semi-structured interviews were used to collect data, which were audio-recorded and transcribed verbatim. Data were managed using a framework approach and analysed thematically. Although patients reported wanting investigations to understand the cause of symptoms and inform management, access to them was difficult and protracted. When investigations revealed potentially relevant findings, patients experienced relief, validation, empowerment and decisive decision-making. Disappointment emerged, however, regarding treatment waiting times and options, and long-term prognosis. When investigations failed to identify relevant findings, patients were unable to make sense of their symptoms, move forward in their management or relinquish their search to identify the cause.Background and purpose of the study
Methods and results
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. Recruitment has taken place over 15 months. Invitation letters or emails were sent to individual practitioners identified using online search tools and professional networks. Recruitment rates were analysed descriptively. Within the private sector, response rates (number participating/number invited) are: acupuncturists 3% (49/1561), osteopaths 6% (53/912), physiotherapists 4% (40/1048). Private sector practitioners have each recruited on average 1, 4, and 2 patients into the study respectively. Within the NHS, the response rates are: acupuncturists 100% (2/2), osteopaths 8% (1/13), physiotherapists 63% (44/70). NHS practitioners have each recruited on average 4, 3, and 2 patients respectively.Purpose and Background
Methods and Results
Internet interventions provide an opportunity to encourage patients with LBP to self-manage and remain active, by tailoring advice and providing evidence-based support for increasing physical activity. This paper reports the development of the ‘SupportBack’ internet intervention, designed for use with usual primary care, as the first stage of a feasibility RCT currently underway comparing: usual primary care alone; usual care plus the internet intervention; usual care plus the internet intervention with physiotherapist telephone support. The internet intervention delivers a 6-week, tailored programme focused on graded goal setting, self-monitoring, and provision of tailored feedback to encourage physical activity/exercise increases or maintenance. 22 patients with back pain from primary care took part in ‘think aloud’ interviews, to qualitatively explore the intervention, provide feedback on its relevance and quality and identify any extraneous content or omissions.Background:
Methods:
To explore clinicians' perceptions of empathy during musculoskeletal clinical consultations. Empathy is considered essential to creating a positive experience within healthcare for both the patient and clinician, improving adherence, creating trust and improving patient experience. However, little is known about how clinicians acquire and display empathic communication skills during musculoskeletal consultations.Purpose:
Background:
To measure the prevalence, type and instigator of verbal interruptions during initial consultations between clinicians and patients with low back pain. During initial consultations, patients take on average, 92 seconds to outline their problem, if given the chance. Few achieve this, with clinicians interrupting (25–69% of cases) in as little as 12 seconds, either with an ‘overlap’, (a projection error of when a turn ends), or an ‘interruption’ (a start-up before the speaker's talk is complete). The prevalence and impact of these in back pain consultations is unknown.Purpose
Background
With a strong political agenda for change towards patient-centred healthcare, the notion of shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. In clinical practice however, observational studies have shown shared decision-making is rarely implemented and patient preferences are seldom met. The aim of this study was to measure the extent of shared decision-making in clinical encounters involving physiotherapists and patients with low back pain. Eighty outpatient encounters (from 12 clinicians) were observed, audio-recorded, transcribed verbatim and analysed using the OPTION instrument. This measures 12 decision-making items, rated on a scale 0–4, which are summated and scaled to give a percentage: The higher the score, the greater the shared decision-making competency. The mean OPTION score was 24.0% (range 10.4%–43.8%). Providing patients with a list of treatment options was the only behaviour exhibited by every clinician, however in 73.8%, this was not demonstrated beyond a perfunctory level. Failure to offer the choice of doing nothing, or deferring the decision precluded clinicians from attaining a higher OPTION score.Purpose of the Study and Background
Methods and Results
To explore the clinical reasoning strategies used by extended scope physiotherapists (ESPs) when assessing patients with low back pain. Extended scope physiotherapists commonly work in back pain services and their training emphasises the acquisition of clinical skills and possible diagnostic tests (including MRI) to aid clinical reasoning and diagnosis. Whilst there has been some exploration of reasoning strategies of other professional groups (notably medically qualified) to date, the clinical reasoning strategies of ESP clinicians have not been reported.Purpose of study
Background
Effective communication between healthcare professionals and patients is key to a successful consultation and is reported to affect both adherence to treatment and outcome. Despite this evidence, research on how best to open consultations is limited and the optimal way, unknown. This study seeks the opinions of physiotherapists on how to open a clinical encounter in an adult musculoskeletal outpatient setting – a topic which has relevance to all clinicians aiming to build rapport with their patients. Forty clinical encounters between physiotherapists in a primary care setting and patients with back pain were observed and audio-recorded. The clinicians' key questions inviting the patient to discuss their back pain were identified, together with a content analysis of the topics discussed prior to the conversation about their back pain. In 2012, a national survey was undertaken, approaching 34,922 physiotherapists from 3 networks on the interactive website hosted by the professional body, the Chartered Society of Physiotherapy asking participants to rank the data from clinical practice, to determine the preferred way to open a clinical encounter.Background and purpose of the study
Methods
Acute Low Back Screening Questionnaire (ALBSQ), designed to assess psychosocial variables identified as risk factors for continued back pain symptoms; Tampa Scale of Kinesiophobia (TSK), measuring fear of movement Clinical Back Pain Questionnaire (CBPQ), measuring pain and function. The patients’ specific responses were used to develop the tailored psychosocial intervention.
Extended Scope Practitioners (ESPs) often assess and manage patients with LSS in orthopaedic and rheumatology clinics. Little is reported about how these patients are managed, variations in practice and the rationale for the clinical decision-making that occurs.
Definition, Clinical presentation Signs and Symptoms Pathology Aetiology The findings from these searches were coded to identify individual aspects of CES. The consistency of each aspect was then classified using The Guidelines Development Groups format (where 100% coverage = ‘unanimity’; 75–99% = ‘consensus’; 51–74% = ‘majority view’; and 0– 50% = ‘no consensus’), and the findings summarized.
From these, there were widely varying descriptions of the definition, clinical presentation and aetiology of CES, and no individual aspects reached 100% agreement. The individual aspect with greatest agreement was found to be bladder dysfunction.
In the ‘Back Home’ study, which was a randomised controlled trial of a patient information leaflet for people with acute low back pain (previously presented to this Society), recruitment of patients was problematic. A total of 28/97 GPs in the New Forest area agreed to recruit patients for the study, but in 22 weeks, only 8 patients emerged. Despite extending the catchment area of the study, and having 51 participating GPs, in 2_ years, only 64 patients were entered from 19 of these GPs. Therefore, we decided to investigate GPs’ perceptions of the reasons for such poor recruitment.
Forty GPs were sent a questionnaire and 24 responded (60%). They gave 47 unprompted reasons for poor recruitment of patients – the most popular being: pressure of work (n=12); difficulty remembering (n=10); feeling ‘over-researched’ (n=4); and few patients fitted the inclusion criteria (n=4). When GPs rated the 12 listed factors, the maximum score for each item = 96 (24x4). According to the GPs, the top 4 factors were: pressure of work (score=60); forgetting to include suitable patients (52); time-consuming process of entering patients (39); GPs are ‘over-researched’ (31).
Low back pain has been described as a 20th century health care enigma. Increasingly, adolescents report back discomfort at an earlier age. In a cross-sectional study amongst a Danish population of 29,424 twins, Leboeuf-Yde reported a rapid increase in back pain prevalence after the age of 12. The link between childhood and adult back pain however, remains controversial. In 1997 the NBPA School Bag Survey reported that 80% of school children carry ‘too much weight’ in ‘poorly designed’ school bags, resulting in postural stress. In response, BackCare (formerly NBPA) designed an ergonomic school bag. This study was undertaken to establish 16-year-olds’ views on the comfort and usability of the ergonomic bag in comparison to their usual school bag. Thirty students, aged 16 years, were recruited from three local sixth form colleges. Each student used the ergonomic bag for one week. They evaluated the comfort and usability of both the ergonomic bag and their usual school bag using self-report questionnaires. Seventy percent of the students reported back pain within the last 12 months. Ratings for the comfort of the ergonomic bag were compared with those for their usual school bag using the Wilcoxon test. There were statistically significant differences between the bags for comfort at the shoulders (p = 0.001) and all regions of the spine: neck (p = 0.000); upper back (p = 0.008); lower back (p = 0.001), with the ergonomic bag more comfortable than the students’ own. No significant differences were found between the bags for comfort in the arms, hands or legs. Despite this improvement in spinal comfort, only 13% of students said they would use the ergonomic bag in preference to their usual bag. This was due to practical aspects such as its appearance and perceived lack of security for valuable items, such as ‘money and mobile phones’. In this population of 16-year-olds, cosmetic and practical aspects of a school bag were more important than comfort. If such bags are to be accepted, manufacturers must create a fusion between ergonomics and fashion.
