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Psychologically informed practice (PiP) includes a special focus on psychosocial obstacles to recovery, but research trials have revealed significant difficulties in implementing PiP outside of research environments. Qualitative studies have identified problems of both competence and confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of care. In PiP, the distinction between assessment and management is not clear-cut. Analysis of the problem is part of the intervention, and guided self-management begins with the initial detective work by the patient, who is encouraged to develop successful and relevant behavior change. This requires a different style and focus of communication that some clinicians find difficult to enact. In this Perspective, the PiP Consultation Roadmap is offered as a guide for clinical implementation to establish a therapeutic relationship, develop patient-centered communication, and guide effective pain self-management. These strategies are illustrated through the metaphor of the patient learning to drive, with the therapist as a driving instructor and the patient as a student driver. For convenience, the Roadmap is depicted in 7 stages. Each stage represents aspects of the clinical consultation in a recommended order, although the Roadmap should be viewed as a general guide with a degree of flexibility to accommodate individual differences and optimize PiP interventions. It is anticipated that the experienced PiP clinician will find it progressively easier to implement the Roadmap as the building blocks and style of consultation become more familiar. [ABSTRACT FROM AUTHOR]

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician–patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions. [ABSTRACT FROM AUTHOR]

Painful musculoskeletal disorders represent an enormous burden at the individual, organizational, and societal levels.[72] In the workplace context, disabling effects of pain are influenced by a wide range of psychosocial factors, including pain beliefs, psychological distress, social support, self-efficacy, and perceptions of organizational support.[[26], [49], [52], [66]] Moreover, a patient's ability to return to work (RTW) or maintain employment can be affected by multiple overlapping systems outside of the clinic. Work and pain: a lifespan development approach.; Oxford: Oxford University Press, 2020. p., 160-77. 9 Bhattacharya A,, Ray T. Precarious work, job stress, and health-related quality of life. In all cases, interventions may need to address workplace and individual issues[82] and prognostic factors that vary by pain duration.[[12], [40], [89]] The effective management of pain-associated limitations in the workplace therefore requires consideration of both physical and psychosocial factors as well as overall management planning.[76] 2.1. [Extracted from the article]

There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples' responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined. [ABSTRACT FROM AUTHOR]

Background: Despite a lack of service provision for people with osteoarthritis(OA), each year 1 in 5of the general population consults a GP about a musculoskeletal condition such as OA. Consequently this may provide an opportunity for practice nurses to take an active role in helping patients manage their condition. A nurse led clinic for supporting patients with OA was developed for the MOSAICS study investigating how to implement the NICE 2014 OA Guideline core recommendations. This paper has two main objectives, firstly to provide an overview of the nurse-led OA clinic, and secondly to describe the development, key learning objectives, content and impact of the training to support its delivery. Methods: A training programme was developed and delivered to provide practice nurses with the knowledge and skill set needed to run the nurse-led OA clinic. The impact of the training programme on knowledge, confidence and OA management was evaluated using case report forms and pre and post training questionnaires. Results: The pre-training questionnaire identified a gap between what practice nurses feel they can do and what they should be doing in line with NICE OA guidelines. Evaluation of the training suggests that it enabled practice nurses to feel more knowledgeable and confident in supporting patients to manage their OA and this was reflected in the clinical management patients received in the nurse-led OA clinics. Conclusions: A significant gap between what is recommended and what practice nurses feel they can currently provide in terms of OA management was evident. The development of a nurse training programme goes some way to develop a system in primary care for delivering the core recommendations by NICE. [ABSTRACT FROM AUTHOR]

The McGill pain questionnaire (MPQ) and its later derivative the short form-MPQ have been used widely both in experimental and clinical pain studies. They have been of considerable importance in stimulating research into the perception of pain and now, with the publication of its latest variant, the short form-MPQ-2, it is appropriate to appraise their utility in the light of subsequent research into the nature of pain and the purpose of pain assessment. Following a description of the content and development of the questionnaires, issues of validity, reliability, and utility are addressed, not only in terms of the individual pain descriptors and the scales, but also in terms of methods of quantification. In addition, other methods of pain depiction are considered. In the second part of the review, advances in pain measurement and methodology, in the elucidation of pain mechanisms and pathways, in the psychology of pain, and in the nature of pain behavior are presented and their implications for pain assessment in general and the MPQ family of measures in particular will be addressed. It is suggested that pain assessment needs to be cast in its social context. We need to understand the influences on pain expression using a socio-communication model of pain that recognizes the function of pain and the importance of both innate pain responses and the effects of social learning. The review concludes with recommendations for future use of the MPQ and identifies a number of research challenges which lie ahead. [ABSTRACT FROM AUTHOR]

In this perspective article, a number of conclusions and recommendations are offered based on the articles in this special issue of PTJ. In this special issue, a new approach to physical therapy, termed "psychologically informed practice," is offered as a "middle way" between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness. This new approach uses the "flags" framework, with psychologically informed practice requiring routine and specific consideration of "yellow flags" and "blue flags" (depending on clinical setting) for determining risk of poor outcome and identifying the potential for treatment modification- but with cognizance of the overall environment or context in which the clinician must operate. This context includes professional culture, health care policy, and insurance reimbursement (potential "black flags"). The primary goal of this approach is to prevent the development of unnecessary pain-associated activity limitations. The approach is based on the identification of normal psychological processes that affect the perception of pain and the response to it as an expected and normal part of the musculoskeletal pain experience and that are potentially modifiable. The potential for linking risk identification with targeted treatment has been discussed, this article focuses on the potential implications for training and implementation, drawing on experience in developing training programs in which the trainees have welcomed this new approach, viewing it as a helpful extension of their basic professional training. Indeed, this new approach can be viewed as evolutionary rather than revolutionary, in that it builds upon the established professional expertise of physical therapists, but incorporates systematic attention to the psychosocial factors that are associated with outcome of treatment. [ABSTRACT FROM AUTHOR]

There is mounting evidence that occupational factors influence the extent of sickness absence following an episode of low back pain, but there have been limited efforts to integrate the identification and management of occupational factors into the routine practice of physical therapists. Systematic reviews suggest that a client's report of heavy physical demands, inability to modify job tasks, work stress, lack of organizational support, job dissatisfaction, poor expectations for resuming usual work, and fear of reinjury are indications of significant barriers to returning to work. Recommended strategies for evaluating and addressing occupational factors are explored with respect to the physical therapist's role in client assessment, development of activity and lifestyle recommendations, therapeutic exercise, communication with other providers, and summary reports. Primary recommendations include: (1) administration of self-report questionnaires to assess a client's perspective of physical job demands, (2) client-centered interviewing to highlight individual return-to- work concerns, (3) early discussions with clients about possible job modifications, and (4) incorporation of clients' workplace concerns in progress reports and summaries. These strategies may improve low back pain outcomes by encouraging effective communication with key stakeholders and by developing clients' ability to resolve obstacles to returning to work. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue including one by Fritz and colleagues on the use of the Subgroups for Targeted Treatment (STarT) Back Screening Tool, Nicholas and colleagues on the original development of the concept of yellow flags as psychosocial obstacles to recovery and Bergbom and colleagues on the relationship between pain catastrophizing and depressed mood in the outcome of physical therapy treatment.

Presents a clinical review of musculoskeletal pain. Idea that musculoskeletal symptoms are a major reason for consultation in primary care; Management of acute back pain; Identification of risk factors for chronic pain; Collaborative management between physicians; Belief that the ideas of the patient concerning the problem must be a part of management.

Examines the normality and reliability in the clinical assessment of backache. Limits of normality; Reliability of nerve function assessment; Determination of the minimum amount of information to be collected for clear diagnosis and management.

The article discusses the management and assessment of psychosocial factors in people with back pain. Topics covered include the undergraduate training of physiotherapists, changes in reimbursement, and an expanded role for physiotherapists. Also mentioned are guided self-management, the challenges facing the development of efficient biopsychosocial management of back pain, and the need to establish the right professional platform.

Abstract: Back pain is a leading cause of disability. Previous research suggests that modifiable risk factors influence recovery from back pain, and practice guidelines recommend integrating such factors within primary care management. Toward this goal, a brief, multidimensional questionnaire, the STarT Back Tool, was designed to facilitate risk assessment by reducing the need to administer multiple, unidimensional questionnaires. However, aspects of this tool’s clinical utility remain unaddressed. For instance, it is unclear whether this tool is responsive to treatment-related changes or whether clinically meaningful information is lost when it replaces multiple risk questionnaires. This study compared the responsiveness of the STarT Back Tool to its corresponding full-length measures, and evaluated its ability to detect clinically meaningful improvement. The study sample included 300 participants that consulted their doctor with disabling back pain. The STarT Back Tool and its reference standard questionnaires (disability, catastrophizing, fear, and depression) were administered at baseline and 4months later. Regression analyses tested whether, after controlling for its reference standard questionnaires, the STarT Back Tool (independent variable) predicted treatment-related changes in global improvement, pain severity, disability, catastrophizing, fear, and depression (dependent variables). Receiver operating characteristic analyses determined the level of STarT Back change needed for clinically meaningful improvement. STarT Back scores predicted changes in all dependent variables except depression. Reductions in STarT Back scores predicted meaningful improvement on all dependent variables. These findings suggest that the STarT Back Tool, instead of multiple risk questionnaires, can be used to measure recovery from back pain. Implications for future research and clinical practice are discussed. [Copyright &y& Elsevier]

Objective. To identify GPs' attitudes towards sickness certification. Design. Systematic search and narrative review identifying themes around attitudes towards sickness certification. Results. Eighteen papers were identified for inclusion in the review; these included qualitative, quantitative, and systematic reviews. The papers were predominantly from Scandinavia and the UK. Three themes were identified from the literature: conflict, role responsibility, and barriers to good practice. Conflict was predominantly centred on conflict between GP and patients regarding the need for a certificate, but there was also conflict between all stakeholders. Role responsibility focused on the multiple roles GPs had to fulfil, and barriers to good practice were identified both within and outside the healthcare system. Conclusion. Any potential for changing the certification system needs to focus on reducing the potential for conflict, clarification of the roles of all stakeholders, and improving access to specialist occupational health and rehabilitation services. [ABSTRACT FROM AUTHOR]

Aim The aim of this study is to examine the effects of an 8-day university-based training course, aimed at identifying and addressing psychosocial prognostic factors during physiotherapy treatment, in shifting therapists towards a more biopsychosocial orientation as measured by changes in beliefs/attitudes, knowledge, skills and behaviour. Method We combined a randomized controlled trail with a pre–post design. Forty-two physiotherapists applied for a university-accredited training course designed to enhance knowledge and management of psychosocial factors in their practice with patients suffering from musculoskeletal pain. The course participants were randomized either to receiving the course or to a waiting list for training. Attitudes and beliefs towards, and knowledge of psychosocial factors, patient vignettes and a video of an imaginary patient were tested before and after training. The patients of the course participants were asked to fill out a questionnaire with background questions at treatment start. The patients also received a questionnaire about the physical therapists' behaviour and patient satisfaction 6 weeks after treatment start. Results The results show that physical therapists' attitudes and believes became more biopsychosocially and less biomedically orientated, they were less convinced that pain justifies disability and limitation of activities, and their knowledge and skills on psychosocial risk factors increased after a university-accredited training course. Yet despite these changes their patients perceived their practice behaviour before and after the course as similar and were equally satisfied with their treatment and treatment result. Conclusion A course, which enhanced biopsychosocial attitudes and beliefs, as well as increased such knowledge and skills did not change the way patients perceived their physical therapists. A future question is whether it improves patient outcome. [ABSTRACT FROM AUTHOR]

Abstract: A novel prognostic approach to defining chronic pain was developed in a US primary care low back pain population, using a combination of information about pain history, current status and likely prognosis. We tested whether this method was generalisable to a UK population. A prospective cohort of 426 patients who consulted with back pain at one of five UK general practices, and who returned follow-up information 1-year later were included. A baseline risk score was calculated based on pain severity and prognostic measures (depression, diffuse pain, pain duration), and cut-points from the US study applied for the risk of future clinically significant back pain, as defined by Chronic Pain Grades 2–4. New cut-points were also derived for the UK population using identical methods. The cut-points for probable and possible chronic pain developed in the US population (80% and 50% probability of future clinically significant back pain, respectively) were appropriate for the UK population, but the cut-point for classifying people at low risk (20% probability) was not replicated in the UK sample. The newly derived cut-points in the UK sample were similar; they remained the same for probable chronic pain, were slightly increased for possible chronic pain, and slightly reduced for those at intermediate or low risk. This method for defining chronic pain prospectively, using risk thresholds for future clinically significant pain, appears to be generalisable to a UK back pain population, particularly for identifying probable chronic pain, and may be generalisable to other primary care low back pain populations. [Copyright &y& Elsevier]

Background Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians' adherence to biopsychosocial guidelines is low. Objective The current study examined the effects of a flags approach–based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients. Design Randomized controlled trial (trial registration number: ISRCTN53670726). Setting University classroom. Subjects Medical students and GP trainees. Methods Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31). Results Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research. Conclusions Short flags approach–based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues. [ABSTRACT FROM AUTHOR]

Background and aims: In the spring of 2019, Professor Steven J. Linton, the founder of the Center for Health and Medical Psychology (CHAMP) at Örebro University, Sweden, formally retired. As a tribute to his scholarly work covering decades of influence and inspiration to the field of pain psychology, the research center organized a topical conference titled "Pain in the 21st century: Where do we come from and where are we going?", which resulted in this state-of the-art synthesis. The aim of this declaration is to highlight lessons learned but not in the least is meant to inspire and guide our continued journey forward, developing pain psychology into the 21st century. Methods: Several collaborators of Professor Linton have summarized and reflected on the current state-of-the-art of pain psychology from the perspective of his input to the field, as well as on developments from the last years of advancements in pain psychology. Results: The topics have been divided into six themed sections covering the fear avoidance model, transdiagnostics, secondary prevention, risk- and protective factors, communication and contextual factors. The sections cover a broad spectrum, from basic experimental studies, integrating emotion and motivational theories into current theoretical models, to applied research on the effect of early interventions as well as sophisticated emotion-focused treatment models for pain patients with concurrent emotional ill-health. Conclusions: There have been major advancements within pain psychology research during the last decades, moving the field towards a more comprehensive picture, taking emotional and motivational aspects into account to understand pain sufferers. Although psychologically informed interventions in general mainly focus on the individual, it has been put forward that pain management is highly influenced by the surrounding environment, including communication with health care providers, and the occupational and social context. Implications: Professor Steven J. Linton has been at the forefront of pain psychology research during the last decades, and inspired by his work this journey will continue into the 21st century, with the ultimate goal of enhancing the understanding and treatment for all people suffering from persistent and disabling pain. [ABSTRACT FROM AUTHOR]

Background: Statistical analysis plans increase the transparency of decisions made in the analysis of clinical trial results. The purpose of this paper is to detail the planned analyses for the PREVENT trial, a randomized, placebo-controlled trial of patient education for acute low back pain. Results: We report the pre-specified principles, methods, and procedures to be adhered to in the main analysis of the PREVENT trial data. The primary outcome analysis will be based on Mixed Models for Repeated Measures (MMRM), which can test treatment effects at specific time points, and the assumptions of this analysis are outlined. We also outline the treatment of secondary outcomes and planned sensitivity analyses. We provide decisions regarding the treatment of missing data, handling of descriptive and process measure data, and blinded review procedures. Conclusions: Making public the pre-specified statistical analysis plan for the PREVENT trial minimizes the potential for bias in the analysis of trial data, and in the interpretation and reporting of trial results. [ABSTRACT FROM AUTHOR]

Abstract: The biopsychosocial model is increasingly accepted in low back pain (LBP) research and clinical practice. In order to assess the role of psychological factors in the development and persistence of pain, a wide array of measures has been developed. Yet there is likely to be considerable conceptual overlap between such measures, and consequently, a lack of clarity about the importance of psychological factors. The aims of this study were to investigate the extent of any such overlap. An observational cohort study of 1591 LBP patients consulting in primary care completed data on a range of psychological instruments. Exploratory and confirmatory factor analyses (EFA and CFA, respectively) were carried out at the subscale level (n=20) to investigate factor structure. The influences of the derived factors on clinical outcomes (pain intensity and self-reported disability) were then tested using linear regression. EFA yielded 4 factors, termed “Pain-related distress,” “Cognitive coping,” “Causal beliefs,” and “Perceptions of the future,” which accounted for 65.5% of the variance. CFA confirmed the validity of these factors models. The pain-related distress factor was found to have the strongest association to LBP patients’ outcomes, accounting for 34.6% of the variance in pain intensity, and 51.1% of the variance in disability. Results confirmed that considerable overlap exists in psychological measures commonly used in LBP research. Most measures tap into patients’ emotional distress. These findings help us to understand how psychological constructs relate together; implications for future research and clinical practice are discussed. [Copyright &y& Elsevier]

Background. The IMPaCT Back study (IMplementation to improve Patient Care through Targeted treatment for Back pain) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain (LBP) in primary care. This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aimed at equipping clinicians to deliver it.The subgrouping and targeted treatment system. This system differs from ‘one-size fits all’ usual practice as it suggests that first contact health care practitioners should systematically allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity. Patients in each subgroup (those at low, medium or high risk of chronicity) are then managed according to a targeted treatment system of increasing complexity.The subgrouping tools. Subgrouping tools help guide clinical decision-making about treatment and onward referral. Two subgrouping tools have been used in the IMPaCT Back study, a 9-item version used by participating physiotherapists and a 6-item version used by GPs.The targeted treatments. The targeted treatments include a minimal intervention delivered by GPs (for those patients at low risk of poor outcome) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability (for those at medium risk) and additional cognitive-behavioural approaches to help address psychological and social obstacles to recovery (for those at high risk).The training packages. Building on previous interventions for other pilot studies and randomized trials, we have developed and delivered clinical training and support programmes for GPs and physiotherapists.Discussion. This paper describes in detail the IMPaCT Back study’s subgrouping for targeted treatment system and the training and mentoring packages aimed at equipping clinicians to deliver it, within the IMPaCT Back study.Study registration. ISRCTN55174281. [ABSTRACT FROM PUBLISHER]

Background: The IMPaCT Back study (IMplementation to improve Patient Care through Targeted treatment for Back pain) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain (LBP) in primary care. This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aimed at equipping clinicians to deliver it. THE SUBGROUPING AND TARGETED TREATMENT SYSTEM: This system differs from 'one-size fits all' usual practice as it suggests that first contact health care practitioners should systematically allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity. Patients in each subgroup (those at low, medium or high risk of chronicity) are then managed according to a targeted treatment system of increasing complexity. THE SUBGROUPING TOOLS: Subgrouping tools help guide clinical decision-making about treatment and onward referral. Two subgrouping tools have been used in the IMPaCT Back study, a 9-item version used by participating physiotherapists and a 6-item version used by GPs. The targeted treatments. The targeted treatments include a minimal intervention delivered by GPs (for those patients at low risk of poor outcome) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability (for those at medium risk) and additional cognitive-behavioural approaches to help address psychological and social obstacles to recovery (for those at high risk). THE TRAINING PACKAGES: Building on previous interventions for other pilot studies and randomized trials, we have developed and delivered clinical training and support programmes for GPs and physiotherapists.Discussion: This paper describes in detail the IMPaCT Back study's subgrouping for targeted treatment system and the training and mentoring packages aimed at equipping clinicians to deliver it, within the IMPaCT Back study.Study Registration: ISRCTN55174281. [ABSTRACT FROM AUTHOR]

The article presents a randomised controlled study which compares the clinical and cost-effectiveness of stratified primary care management for low back pain. The study examined 851 patients who were divided into intervention and control groups. The results show the significant implications of a stratified approach for future primary care management of back pain.

Originally the term "yellow flags" was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability. [ABSTRACT FROM AUTHOR]

Originally the term "yellow flags" was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability. [ABSTRACT FROM AUTHOR]

Abstract: Many psychological factors have been suggested to be important obstacles to recovery from low back pain, yet most studies focus on a limited number of factors. We compared a more comprehensive range of 20 factors in predicting outcome in primary care. Consecutive patients consulting 8 general practices were eligible to take part in a prospective cohort study; 1591 provided data at baseline and 810 at 6months. Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ). The relative strength of the baseline psychological measures to predict outcome was investigated using adjusted multiple linear regression techniques. The sample was similar to other primary care cohorts (mean age 44years, 59% women, mean baseline RMDQ 8.6). The 20 factors each accounted for between 0.04% and 33.3% of the variance in baseline RMDQ score. A multivariate model including all 11 scales that were associated with outcome in the univariate analysis accounted for 47.7% of the variance in 6months RMDQ score; rising to 55.8% following adjustment. Four scales remained significantly associated with outcome in the multivariate model explaining 56.6% of the variance: perceptions of personal control, acute/chronic timeline, illness identify and pain self-efficacy. When all independent factors were included, depression, catastrophising and fear avoidance were no longer significant. Thus, a small number of psychological factors are strongly predictive of outcome in primary care low back pain patients. There is clear redundancy in the measurement of psychological factors. These findings should help to focus targeted interventions for back pain in the future. [Copyright &y& Elsevier]

Background A number of factors influence an individual's decision to take sickness absence or to remain at work while ill. The relationship between health, work characteristics, individual perceptions of work and sickness absence and performance is complex and further clarification of the interactions between these factors is necessary. [ABSTRACT FROM PUBLISHER]

The article focuses on the importance of Work and Organization Assessment Questionnaire (WOAQ) in evaluating public sector development. It cites the cross-sectional survey which is designed to measure demographics, characteristics and work organizations in the public sector. It demonstrates how WOQA, with the scoring method, develops the manufacturing sector. It claims that WOQA is the most useful and potential transferable tool to examine the work and organization factors in the public sector.

The article discusses a study which aims to develop and validate a back pain screening tool relevant to primary care settings. The study assessed the psychometric properties of the tool including concurrent and discriminant validity, internal consistency, and repeatability. Bothersomeness, catastrophizing, fear, anxiety and depression were identified as a psychosocial subscale. It was found that the tool demonstrated good reliability and validity and was acceptable to patients and clinicians.

Background: Back pain is a major health problem and many sufferers develop persistent symptoms. Detecting relevant subgroups of patients with non-specific low back pain has been highlighted as a priority area for research, as this could enable better secondary prevention through the targeting of prognostic indicators for persistent, disabling symptoms. We plan to conduct a randomised controlled trial to establish whether subgrouping using a novel tool, combined with targeted treatment, is better than best current care at reducing long-term disability from low back pain. Methods/Design: We will recruit 800 participants aged 18 years and over with non-specific low back pain from 8-10 GP practices within two Primary Care Trusts in Staffordshire, England. Our primary outcome measures are low back pain disability and catastrophising. Secondary outcomes include back pain intensity, global change, leg pain, fear avoidance, anxiety, depression, illness perceptions, patient satisfaction, overall health status and cost-effectiveness. Data will be collected before randomisation, and 4 and 12 months later. Participants are randomised to receive either newly developed interventions, delivered by trained physiotherapists and targeted according to subgroups defined by tool scores, or best current care. Discussion: This paper presents detail on the rationale, design, methods and operational aspects of the trial. Trial registration: Current Controlled Trials ISRCTN37113406. [ABSTRACT FROM AUTHOR]

As the experience of stigma and its psychological dimensions require careful measurement, the purpose of this study was to examine the psychometric properties and factor structure of the Feelings of Stigmatization Questionnaire (FSQ). A total of 170 participants with psoriasis and 124 with atopic dermatitis (AD) completed the FSQ. AD participants self-rated AD severity, while psoriasis severity was determined by a clinician. Confirmatory (CFA) and exploratory factor analytic (EFA) techniques were used to examine the factor structure of the FSQ. The FSQ total score was not related to age, age at onset, illness duration or psoriasis severity but it was negatively associated with AD severity ( r = −.25, p < .01). The original six-factor structure of the FSQ was not replicated in our sample. Using EFA, a fixed three-factor solution proved the most stable, with the dimensions of feeling flawed, anticipation of rejection and secrecy, and positive attitudes towards skin disease being identified. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The objective of this study was to examine the psychometric properties and clinical correlates of the 20-item Toronto Alexithymia Scale (TAS-20) in patients with psoriasis. Methods: Three hundred patients with psoriasis completed the TAS-20 and had the severity of their psoriasis clinically assessed. Test–retest reliability was assessed over 10 weeks in a subset of 71 patients receiving standard medical treatment for their psoriasis. Examination of the factor structure employed both exploratory (EFA) and confirmatory (CFA) factor analysis techniques. Results: The overall prevalence of alexithymia in this population of psoriasis patients, as indicated by the TAS-20, was 33%. The TAS-20 total score was not related to clinical severity, age, age at onset or duration of psoriasis. The 10-week test–retest reliability on a sample of 71 psoriasis patients, pre- and posttreatment with photochemotherapy, was found to be acceptable (r=.69; P<.001). EFA produced no stable solutions. The three-factor structure of the TAS-20 using CFA was also not replicable in this sample. Conclusions: The findings of this study support the contention that alexithymia is not significantly influenced by either disease severity or chronicity in patients with psoriasis. It is recommended that when employing the TAS-20 in patients with psoriasis, caution is exercised in the interpretation of the scale scores and that further psychometric evaluation of the scale is undertaken as appropriate. [Copyright &y& Elsevier]

Objective: The aim of the study was to assess the influence of general and dermatitis-specific psychological and clinical factors on quality of life in adults with atopic dermatitis (AD).Method: A total of 125 adults recruited through the National Eczema Society of U.K. (NES) completed a number of psychological and dermatological questionnaires, including the Dermatology Life Quality Index (DLQI), the Stigmatisation and Eczema Questionnaire (SEQ), the Hospital Anxiety and Depression Scale (HADS), the Fear of Negative Evaluation Scale (FNE) and the Rosenberg Self-Esteem Scale (RSE).Results: Pearson''s correlational analyses suggested that perceptions of stigma were significantly associated with psychological factors as well as quality of life (Ps<.01). An association was also found between perceived stigma and disease severity (-.28, P<.01). Almost 46% of participants were identified as having probable mood disorder. Regression analysis indicated that perceptions of stigma and depression accounted for 44.5% of the variance in quality of life in this sample [F(3,121)=34.18, P<.001], when disease severity was controlled for.Conclusion: Psychological factors and disease severity were strong predictors of quality of life in adults with AD. AD-related perceptions of stigma were of particular importance in predicting AD-related quality of life over and above more general psychological factors, such as depression. These findings have important implications for the psychological and clinical management of AD. [Copyright &y& Elsevier]

The psychological adjustment of patients with psoriasis has been studied extensively. By comparison, no research has focused on their partners. We examined illness representations of psoriasis held by patients and their partners, and investigated whether divergent beliefs were associated with psychological distress. Fifty-eight patients with chronic plaque psoriasis and their partners completed a range of psychological assessments including beliefs about the condition, anxiety, depression, and worry. Patients also completed a self-assessment of psoriasis severity. Patients with psoriasis had significantly higher levels of anxiety, depression, and worry than their partners ( t's> 2.53, p's<.05). Multiple regression analysis indicated that divergence in patients' and partners' beliefs about emotional impact of psoriasis and chronicity of timeline accounted for a statistically significant (21.3%) proportion of the variance in depression for partners. Differences in views on the consequences of having psoriasis and the cyclical nature of the condition were also significantly associated with increased levels of worry in partners. Dissimilarity in particular aspects of illness representations are associated with increased psychological distress in particular for the partners of patients with psoriasis. The results illustrate the importance of concordance between patients' and partners' models of illness in relation to adjustment, and highlight the need to consider and collaborate with both patients and their partners in managing this challenging condition. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of this study was to investigate the effects of a cognitive-behavioral psoriasis symptom management programme (PSMP) on patient-held perceptions about their condition and patients' use of self-reported coping strategies, and to examine the influence of alexithymia scores at induction on response to treatment. Design. Age- and sex-matched case-controlled prospective study. Methods. A total of 40 patients with psoriasis were treated in the PSMP, and an age-and sex-matched cohort received standard pharmacological care only. The Illness Perception Questionnaire was used to assess patients' beliefs about illness identity, time-line, consequences, cure/control and perceptions of the cause of their psoriasis. Participants also completed the COPE questionnaire and the Toronto Alexithymia Scale (TAS-20). Results. Results suggested that at 6-month follow-up, patients who chose the PSMP showed significant reductions in illness identity (the frequency and severity of symptoms that patients associate with their condition), the strength of belief in severity of consequences of their illness, and their attributions for emotional causes of their psoriasis. Perceptions about the anticipated course of the disease (time-line), its cure or controllability, ideas about physical agents of causation, and coping strategies did not differ between PSMP patients or controls at 6-week or 6-month follow-up. Alexithymia had no effect on response to treatment. Regression analyses demonstrated the importance of both participation in the PSMP and demographic/clinical history variables in accounting for significant variance in illness-perception-change scores. Conclusion. The findings are generally supportive of multivariate models of intervention, but the lack of a demonstrated effect of the intervention on coping may have implications for both the assessment of coping in psoriasis and the nature of psychological interventions proposed ... [ABSTRACT FROM AUTHOR]

Information processing biases relate to the manner in which people attend to particular types of information more readily than others. This bias, which is central to cognitive models of disorder, has not been explored in patients with psoriasis. The purpose of this study was to examine whether patients with psoriasis show an automatic attentional bias to classes o fin formation relative to controls. Sixty patients and 60 age- and sex-matched controls completed a computer-based attentional interference task (the modified Stroop task). Patients with psoriasis showed significant interference for disease-specific, self-referent, and others' behavior stimuli relative to controls. In terms of information processing biases, the relationship between subject status (psoriasis patient vs. control) and color-naming interference was significantly stronger than that between anxiety, depression and worry, and interference. Recall bias was limited to disease-specific stimuli only. The observed bias to threat is more appropriately accounted for by participant's status (i.e., psoriasis patient or control) than by psychological distress. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of this study was to examine the relative contribution of medical variables, illness perceptions, coping and alexithymia to the variance in stress, distress and disability in patients with psoriasis. Design. Cross-sectional study. Method. A group of 225 patients with psoriasis completed the Hospital Anxiety and Depression Scale (HADS), The Penn State Worry Questionnaire (PSWQ), the COPE, the Illness Perception Questionnaire (IPQ), Toronto Alexithymia Scale (TAS-20), and two measures specific to psoriasis, the Psoriasis Disability Index (PDI), and the Psoriasis Life Stress Inventory (PLSI). The severity of patients' psoriasis was clinically assessed by dermatologists on the Psoriasis Area and Severity Index (PASI). Results. In general, demographic variables, clinical history and extent of disease were consistently the least useful variables in terms of explaining variance in stress, distress or disability. Their utility was limited to accounting for small but significant variations in disability, but even in this case, they accounted for just over half as much variance as illness perceptions. Illness perceptions were uniformly the most important variables in terms of the variance accounted for in outcome. Coping varied widely in its explanatory power; its effects were negligible in both disability (PDI) and everyday stress (PLSI), and it was moderately important in accounting for additional variance in depression and anxiety. However, coping was important in explaining the variance in pathological worrying. Alexithymia accounted for significant additional variance chiefly for anxiety and to a lesser extent for depression, worrying and psoriasis-related life stress. Conclusion. The observed importance of cognitive factors in stress, distress and disability invite us to consider the utility of multivariate models of outcome in psoriasis. [ABSTRACT FROM AUTHOR]

Presents letters to the editor concerning medical issues. Debate over withdrawing life sustaining treatment and euthanasia; Cannabinoids in pain management; Rehabilitation for chronic low back pain; Others.

Examines the symptoms and signs of illness behavior. Correlation between physical disease and psychological disturbances; Determination of the time patterns of pain and lumbar flexion; Relevance of microbes in infectious disease.

A response to a letter to the editor about the article on methodological challenges of work environment research and high-quality research on health and work in the previous issue is presented.

Background: There is as yet no evidence on the feasibility of implementing recommendations from the National Institute of Health and Care Excellence (NICE) osteoarthritis (OA) guidelines in primary care, or of the effect these recommendations have on the condition. The primary aim of this study is to determine the clinical and cost effectiveness of a model OA consultation (MOAC), implementing the core recommendations from the NICE OA guidelines in primary care. Secondary aims are to investigate the impact, feasibility and acceptability of the MOAC intervention; to develop and evaluate a training package for management of OA by general practitioners (GPs) and practice nurses; test the feasibility of deriving 'quality markers' of OA management using a new consultation template and medical record review; and describe the uptake of core NICE OA recommendations in participants aged 45 years and over with joint pain.Design: A mixed methods study with a nested cluster randomised controlled trial.Method: This study was developed according to a defined theoretical framework (the Whole System Informing Self-management Engagement). An overarching model (the Normalisation Process Theory) will be employed to undertake a comprehensive 'whole-system' evaluation of the processes and outcomes of implementing the MOAC intervention. The primary outcome is general physical health (Short Form-12 Physical component score [PCS]) (Ware 1996). The impact, acceptability and feasibility of the MOAC intervention at practice level will be assessed by comparing intervention and control practices using a Quality Indicators template and medical record review. Impact and acceptability of the intervention for patients will be assessed via self-completed outcome measures and semi-structured interviews. The impact, acceptability and feasibility of the MOAC intervention and training for GPs and practice nurses will be evaluated using a variety of methods including questionnaires, semi-structured interviews, and observations.Discussion: The main output from the study will be to determine whether the MOAC intervention is clinically and cost effective. Additional outputs will be the development of the MOAC for patients consulting with joint pain in primary care, training and educational materials, and resources for patients and professionals regarding supported self-management and uptake of NICE guidance.Trial Registration: ISRCTN number: ISRCTN06984617. [ABSTRACT FROM AUTHOR]