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BACKGROUND: Musculoskeletal (MSK) First Contact Physiotherapists (FCPs) are diagnostic clinicians able to assess and manage undifferentiated and undiagnosed MSK presentations. The FCP role in primary care has been introduced to allow patients with MSK pain to see a FCP directly rather than wait to see a General Practitioner (GP) first, which improves capacity within primary care. A national evaluation was undertaken of the FCP model. This article reports the thematic analysis of the free-text responses of patients who participated in the national evaluation. METHODS: An online platform collected patient-reported experience and outcomes following the FCP consultation and at 1, 2 and 3 months follow-up. Free-text responses to the Friends and Family test, reasons for consulting another health care professional (HCP) and general comments were thematically analysed and grouped according to their responses. RESULTS: Over 13 months, 680 of 2825 registered patients (24%) completed the initial questionnaire and 54% (n = 370) completed the 3-month follow-up. During the course of the evaluation, 785 participants provided free-text responses. Themes identified from free-text responses were: communication and knowledge, clinicians' characteristics, efficiency, treatment provided, assessment skills and service provided in comparison to GP care. Complaints represented 4% (n = 26 comments) of total feedback. The main reasons for consulting other HCPs after seeing a FCP were persistent pain, delays in referrals or already attending NHS physiotherapy. CONCLUSION: Thematic analysis of free-text responses in the national FCP evaluation provides context and detail to the positive outcomes reported by patients after consulting a FCP in primary care.

PURPOSE: Musculoskeletal problems are the leading cause of chronic disability. Most patients in the UK seek initial care from general practitioners (GPs), who are struggling to meet demand. Patient direct access to National Health Service physiotherapy is one possible solution. The purpose of this study was to understand the experiences of patients, GPs, physiotherapists and clinical commissioners on direct access in a region in England with it commissioned. \ud \ud METHODS: The study was informed by Normalisation Process Theory (NTP). Data collection was via semi-structured individual face-to-face and telephone interviews with 22 patients and 20 health care professionals (HCPs). Data were analysed thematically using NPT. \ud \ud RESULTS: Three themes emerged: understanding physiotherapy and the direct access pathway; negotiating the pathway; making the pathway viable. HCPs saw direct access as acceptable. Whilst patients found the concept of direct access, those with complex conditions continued to see their GP as first point of contact. Some GPs and patients reported a lack of clarity around the pathway, reflected in ambiguous paperwork and inconsistent promotion. Operational challenges emerged in cross-disciplinary communication and between HCPs and patients, and lack of adequate resources. \ud \ud CONCLUSION: Direct access to NHS musculoskeletal physiotherapy is acceptable to patients and HCPs. There is need to ensure: effective communication between HCPs and with patients, clarity on the scope of physiotherapy and the direct access pathway, and sufficient resources to meet demand. Patient direct access can free GPs to focus on those patients with more complex health conditions who are most in need of their care.

OBJECTIVE: To explore whether using a single matched or composite outcome might impact the results of previous randomised controlled trials (RCTs) testing exercise for non-specific low back pain (NSLBP). The first objective was to explore whether a single matched outcome generated a greater standardised mean differences (SMD) when compared to the original unmatched primary outcome SMD. The second objective was to explore whether a composite measure, comprised of matched outcomes, generated a greater SMD when compared to the original primary outcome SMD. DESIGN: We conducted exploratory secondary analyses of data. SETTING: Seven RCTs were included, of which two were based in the USA (University research clinic, Veterans Affairs medical centre) and the UK (primary care clinics, nonmedical centres). One each were based in Norway (clinics), Brazil (primary care), and Japan (outpatient clinics). PARTICIPANTS: The first analysis comprised 1) five RCTs (n=1,033) that used an unmatched primary outcome but included (some) matched outcomes as secondary outcomes, and the second analysis comprised 2) four RCTs (n=864) that included multiple matched outcomes by developing composite outcomes. INTERVENTION: Exercise compared to no exercise. MAIN OUTCOME MEASURES: The composite consisted of standardised averaged matched outcomes. All analyses replicated the RCTs' primary outcome analyses. RESULTS: Of five RCTs, three had greater SMDs with matched outcomes (pooled effect SMD 0.30 (95% CI 0.04, 0.56), p=0.02) compared to an unmatched primary outcome (pooled effect SMD 0.19 (95% CI -0.03, 0.40) p=0.09). Of four composite outcome analyses, three RCTs had greater SMDs in the composite outcome (pooled effect SMD 0.28 (95%CI 0.05, 0.51) p=0.02) compared to the primary outcome (pooled effect SMD 0.24 (95%CI -0.04, 0.53) p=0.10). CONCLUSIONS: These exploratory analyses suggest that using an outcome matched to exercise treatment targets in NSLBP RCTs may produce greater SMDs than an unmatched primary outcome. Composite outcomes could offer a meaningful way of investigating superiority of exercise than single domain outcomes.

Objectives Despite several hundred previous randomised controlled trials (RCTs), the key treatment targets of exercise for persistent nonspecific low back pain (NSLBP) remain unclear. This study aimed to generate consensus about the key treatment targets of exercise interventions for patients with NSLBP. Design Consensus was generated using modified nominal group technique in two, sequential, workshops. The results of a previous systematic review informed the first, national, workshop idea generation and the results of this workshop informed the second, international, workshop. The authors generated a starting list of 30 treatment targets from the systematic review. A pre-specified consensus threshold of 75% was used in the voting stage. Participants Workshop participants included people with experience of using exercise to manage their persistent NSLBP, clinicians who prescribe exercise for persistent NSLBP, and researchers who design and evaluate exercise interventions in RCTs. All participants generated, voted and ranked the treatment targets in each workshop using an online platform. Results A total of 39 participants contributed to the consensus (15 in the national workshop and 24 in the international workshop), comprising two people with NSLBP, six clinicians and 31 researchers/clinicians. A total of 40 exercise treatment targets were generated, and 25 were retained after voting and ranking. The prioritised targets of exercise for persistent NSLBP were: improving function, improving quality of life, reducing pain, meeting patient-specific goals and reducing fear of movement. Conclusions Future RCTs of exercise should specify the targets of their exercise intervention and consider assessing these treatment targets as well as including mediation analyses. (c) 2021 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Objective First Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the qualitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against pre-agreed success criteria. Design and setting A mixed-methods 24-month service evaluation involving FCP sites across England. Methods Data were collected at 2 time points, year 1 and year 2. Data were collected using individual interviews and focus groups, transcribed verbatim and analysed using a hybrid inductive and deductive thematic analysis. Participants were recruited from all stakeholder groups; patients, physiotherapists, general practitioners and administration staff. Results A total of 6 sites were recruited over both rounds of data collection demonstrating a wide range of service models. Thirty-nine participants were recruited including fourteen patients. All six qualitative success criteria were met. GPs’ discourse reflected confidence in the FCP service and competence of the FCPs. Patient discourse reflected self-efficacy and confidence in self-management techniques and reported FCP as a positive experience. FCPs saw providing advice about work related issues as integral to their role and patient discourse reflected perceived benefit from the advice offered. Staff discourse reflected a positive experience of working with, and in, the FCP services. Conclusion Ahead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful insights and recommendations to facilitate successful FCP implementation in terms of patient outcome and experience, and staff experience.

Purpose Musculoskeletal (MSK) pain is a common cause of work absence. The recent SWAP (Study of Work And Pain) randomised controlled trial (RCT) found that a brief vocational advice service for primary care patients with MSK pain led to fewer days’ work absence and provided good return-on-investment. The I-SWAP (Implementation of the Study of Work And Pain) initiative aimed to deliver an implementation test-bed of the SWAP vocational advice intervention with First Contact Practitioners (FCP). This entailed adapting the SWAP vocational advice training to fit the FCP role. This qualitative investigation explored the implementation potential of FCPs delivering vocational advice for patients with MSK pain. Methods Semi-structured interviews and focus groups were conducted with 10 FCPs and 5 GPs. Data were analysed thematically and findings explored using Normalisation Process Theory (NPT). Results I-SWAP achieved a degree of ‘coherence’ (i.e. made sense), with both FCPs and GPs feeling FCPs were well-placed to discuss work issues with these patients. However, for many of the FCPs, addressing or modifying psychosocial and occupational barriers to return-to-work was not considered feasible within FCP consultations, and improving physical function was prioritised. Concerns were also raised that employers would not act on FCPs’ recommendations regarding return-to-work. Conclusion FCPs appear well-placed to discuss work issues with MSK patients, and signpost/refer to other services; however, because they often only see patients once they are less suited to deliver other aspects of vocational advice. Future research is needed to explore how best to provide vocational advice in primary care settings.

Background Multiple cohort and systematic review studies exist, reporting independent predictive factors associated with outcome in musculoskeletal populations. These studies have found evidence for a number of "generic" factors that have been shown to predict outcome across musculoskeletal patient cohorts. This review provides a higher level review of the evidence with a focus on generic patient factors associated with functional musculoskeletal outcome with a view to informing predictive modelling. Objectives (a) Identify patient factors found to have evidence to support their association with functional outcome, and (b) review these findings across body areas/conditions to identify generic predictive factors. Databases and data treatment Electronic databases of MEDLINE, AMED, EMBASE, CINAHL and Cochrane were searched for eligible studies. Two reviewers independently extracted data and assessed quality using an established checklist for umbrella reviews. Results Twenty-one systematic reviews met inclusion criteria, all were of moderate/high quality. Six independent predictors were found to have strong evidence of association with worse musculoskeletal functional outcome across anatomical body sites (worse baseline function, higher symptom/pain severity, worse mental well-being, more comorbidities, older age and higher body mass index). Longer duration of symptoms, worse pain coping, presence of workers compensation, lower vitality and lower education were also found to have moderate evidence of association with worse functional outcome across body sites. Conclusions This study identifies a number of factors associated with musculoskeletal functional outcome. The generic predictive factors identified should be considered for inclusion into musculoskeletal prognostic models, including models used for case-mix-adjustment of patient reported outcome measure data. Significance This article identifies "generic" patient factors that predict functional outcome (measured using Patient Reported Outcome Measures (PROMs)) across musculoskeletal conditions. Findings provide support for the development and content of generic musculoskeletal prognostic models including models used to case-mix adjust PROM data for baseline complexity. Generic musculoskeletal models and functional PROMs would facilitate more feasible comparison and benchmarking of musculoskeletal services in order to identify variation and address health inequalities.

Background Case-mix adjustment is an established method to take account of variations across cohorts in baseline patient factors, when comparing health outcomes. Although commonplace, there is a lack of evidence as to the most appropriate case-mix adjustment model to use to enable fair comparisons of PROM data in musculoskeletal services. Objectives To conduct a systematic review summarising evidence of the development, validation, and performance of musculoskeletal case-mix adjustment models, and to make recommendations for future methods. Data Sources Searches included; AMED, CINAHL, EMBASE, HMIC, MEDLINE, and grey literature. Eligibility Criteria Studies; from January 1992-May 2017, English language, musculoskeletal adult population, developing or validating a case-mix adjustment model, using a relevant PROM, and using patient factors feasible for clinical collection. Data Synthesis Two reviewers evaluated selected papers. The CASP Cohort Tool was used to assess quality. Results Fourteen studies were included; eight US studies on the Focus on Therapeutic Outcomes model (pooled n = 546,726 patients (with pre/post treatment data)) and six UK studies related to the UK National PROMs Programme model (pooled n = 282,424 patients (with pre/post treatment data)). The majority used retrospective data, restricted to complete datasets. Both US and UK models showed good predictive ability (R2 18-42%). Common model variables were; baseline PROM score, age, sex, comorbidities, symptom duration, and surgical history. Reduced quality scores were mainly due to acceptability of patient recruitment, and completeness and length of patient follow up. Conclusion Significant methodological crossover was found. Further studies are however needed to externally validate and develop models across musculoskeletal settings. PROSPERO database(CRD42017055948).

Objective: First Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the quantitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against success criteria. Design and setting: A mixed-methods 24-month service evaluation involving 40 FCP sites and 240 FCPs across England. Methods: An online platform collected patient-reported experience and outcomes following the FCP consultation and at 1, 2 and 3-months follow-up. These included the Keele STarT MSK Tool, pain intensity (0–10 NRS scale), Musculoskeletal Health Questionnaire (MSK-HQ, range 0–56), and Friends-and-Family Test. Results: Over 13 months, 2825 patients were invited by email and 24% (n = 680) completed their initial questionnaire. Their mean age was 56.2 (SD 14.9), 61% were female, ethnicity was 97% white, mean pain intensity was 6.1 (SD 2.13) and mean MSK-HQ score was 33.8 (SD 9.5). At 3-months follow-up (n = 370) there was a 2.8 (CI 2.5 to 3.1) mean pain intensity reduction from baseline, a mean 7.1 (6.0 to 8.2) score improvement in MSK-HQ and 64% reporting overall improvement (much better/better) since seeing the FCP. One of the six success criteria was not met; 29% of those in employment reported receiving specific work advice from the FCP (target ≥75%). Conclusion: Ahead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful data on patients who access this service, their short-term clinical outcomes and whether key success criteria are being met.

Exercise is a core treatment for persistent non-specific low back pain (NSLBP), but results from randomised controlled trials (RCTs) of exercise typically show only small to moderate standardised mean differences (SMDs) compared to nonexercise controls. The choice of primary outcome, and relationship to the specific targets of exercise may influence this. This systematic review aimed to explore whether primary outcomes match the exercise treatment targets used in NSLBP RCTs and the potential impact of matching on SMDs. Included RCTs were conducted with patients with persistent NSLBP, compared exercise to no exercise, with sample sizes >60 per arm. Screening, data extraction and risk of bias assessment were independently undertaken by paired reviewers. Of 19272 initial titles, 27 RCTs were included with 31 treatment targets and 6 primary outcome domains identified. Only 25% of included RCTs had primary outcomes that matched the treatment targets. SMDs of exercise versus comparison arms were observed to be larger in the matched (SMD .54 (95% Confidence Interval .23 to.85), P =.0006) compared to the unmatched category (SMD 0.22 (95% Confidence Interval .01, .44) P = .04) but this difference was not statistically significant (P = .10). These exploratory findings may have implications for future teams developing RCTs of exercise for NSLBP and warrant further investigation in larger datasets. Perspective This review was an exploratory study that investigated the primary outcome and treatment targets used in RCTs of exercise for NSLBP. The SMDs of the matched group were descriptively larger than those of the unmatched group, but further analysis with larger sample sizes is required to have confidence in these results.

OBJECTIVES: This study examined the real-world impact of patient direct access to NHS physiotherapy (self-referral) on (a) general practice consultations for musculoskeletal (MSK) conditions and (b) specified clinical management for patients with MSK conditions. \ud \ud DESIGN AND SETTING: Natural experiment in four general practices and the associated physiotherapy service. \ud \ud METHODS: Anonymised routinely collected data were obtained. MSK coded GP consultations, recorded fit notes, MSK-related prescription medication, X-rays and MRI requests, and referrals to secondary care for patients consulting with MSK conditions were identified and trends described across a 6-year period (June 2011 to June 2017). Joinpoint regression analysis was used to identify any significant changes in GP MSK consultation trends before and after the introduction of self-referral to physiotherapy. Physiotherapy service data examined access methods used by patients (GP referred, GP recommended self-referral, true self-referral) and the number of physiotherapy sessions. \ud \ud RESULTS: Direct access resulted in inconsistent impact on general practices. In one arm of the experiment a significant increase in GP consultations was observed and in one arm was stable. Exploratory examination of clinical management showed only requests for X-rays (arm 1) and possibly requests for MRI (arm 2) changed over time. Physiotherapy service referrals showed a low uptake of true self-referral (10% and 6%) in each arm respectively. \ud \ud CONCLUSION: This is the first study to examine the real-world impact of patient direct access to physiotherapy at general practice level. We found no consistent impact of patient direct access on GP MSK workload. Impact on some clinical management was observed but not consistently in the direction suggested by previous studies.

Background The biopsychosocial model is recommended in the management of non-specific low back pain but musculoskeletal practitioners can lack skills in assessing and managing patients using a biopsychosocial framework. Educational interventions have produced equivocal results. There is a need for an alternative educational tool to support practitioners’ development in the application of biopsychosocial model to manage low back pain. Methods A mixed methods study assessed the feasibility and acceptability of an e-learning programme on the biopsychosocial management of non-specific low back pain for osteopaths with more than 15 years’ experience. A sequential explanatory design was conducted, with a feasibility randomised controlled trial and semi-structured interviews explored with thematic analysis. Results A total of 45 participants participated in the RCT of which 9 also participated in the interview study. The a-priori sample size was not met (45 instead of 50). The recruitment strategies, randomisation, retention, data collection and outcome measures worked well and were found to be feasible for a main trial. The retention, satisfaction and participants’ views of the programme demonstrated a good acceptability of the programme. Data from the semi-structured interviews were organised in three themes, the first two were related to the feasibility and acceptability of the e-learning programme (practical experience of following the course and engagement with the content) and the third relates to the impact of the intervention (perception of the BPS model). Conclusion A main RCT is feasible and the intervention was received well by the participants. A main RCT is required to assess the effectiveness of the e-learning programme. This work also provided data on aspects so far unreported, including osteopaths’ views on continuing professional development, on e-learning as a form of continuing professional development and osteopaths’ perceptions and challenges concerning the implementation of the biopsychosocial model in practice.

OBJECTIVES: The assessment of health care professionals' attitudes and beliefs towards musculoskeletal pain is essential because they are key determinants of their clinical practice behaviour. The Pain Attitudes and Beliefs Scale (PABS) biomedical scale evaluates the degree of health professionals' biomedical orientation towards musculoskeletal pain and was never assessed using item response theory (IRT). This study aimed at assessing the psychometric performance of the 10-item biomedical scale of the PABS scale using IRT.METHODS: Two cross-sectional samples (BeBack, n = 1016; DABS; n = 958) of health care professionals working in the UK were analysed. Mokken scale analysis (nonparametric IRT) and common factor analysis were used to assess dimensionality of the instrument. Parametric IRT was used to assess model fit, item parameters, and local reliability (measurement precision).RESULTS: Results were largely similar in the two samples and the scale was found to be unidimensional. The graded response model showed adequate fit, covering a broad range of the measured construct in terms of item difficulty. Item 3 showed some misfit but only in the DABS sample. Some items (i.e. 7, 8 and 9) displayed remarkably higher discrimination parameters than others (4, 5 and 10). The scale showed satisfactory measurement precision (reliability > 0.70) between theta values -2 and +3.DISCUSSION: The 10-item biomedical scale of the PABS displayed adequate psychometric performance in two large samples of health care professionals, and it is suggested to assess group-level professionals degree of biomedical orientation towards musculoskeletal pain.

Background and Aim of Study Despite several hundred RCTs of exercise for persistent non-specific low back pain (NSLBP), the treatment targets of exercise are unclear. In a systematic review we obse...

Short report.

Objectives Our aim was to undertake an economic evaluation of patient direct access to physiotherapy in the UK NHS by comparing the number of patients treated, waiting time, cost and health gain from a direct access pathway versus traditional GP-referral to NHS physiotherapy. Design The authors used a discrete event simulation (DES) model to represent a hypothetical GP practice of 10,000 patients. Costs were measured from the perspective of the NHS and society. Outcomes were predicted waiting times, the total number of patients with musculoskeletal conditions who received physiotherapy and quality adjusted life years (QALYs) gained, each estimated over a one year period. Model inputs were based on a pilot cluster randomised controlled trial (RCT) conducted in four general practices in Cheshire, UK, and other sources from the literature. Results Direct access could increase the number of patients receiving at least one physiotherapy appointment by 63%, but without investment in extra physiotherapist capacity would increase waiting time dramatically. The increase in activity is associated with a cost of £4999 per QALY gained. Conclusions Direct access to physiotherapy services would be cost-effective and benefit patients given current cost per QALY thresholds used in England. This is because physiotherapy itself is cost-effective, rather than through savings in GP time. Direct access without an increase in supply of physiotherapists would increase waiting times and would be unlikely to be cost saving for the NHS owing to the likely increase in the use of physiotherapy services.

Background Pregnancy-related low back pain and pelvic girdle pain (LBP/PGP) are common and negatively impact the lives of many pregnant women. Several patient-based outcome instruments measure treatment effect, but there is no consensus about which measure to use with women who have these pain presentations. Objective The objective was to compare the responsiveness of 3 outcome measures in LBP/PGP: Oswestry Disability Index-version 2.0 (ODI), Pelvic Girdle Questionnaire (PGQ), and 0 to 10 numerical rating scale for pain severity (NRS); and to estimate a minimal important change (MIC) for these measures in pregnancy-related LBP/PGP. Design This was a methodology study using data from a pilot randomized controlled trial. Methods Women (N = 124) with pregnancy-related LBP/PGP were recruited to a pilot randomized controlled trial evaluating the benefit of adding acupuncture to standard care, of whom 90 completed an 8-week follow-up. Responsiveness was evaluated by examining correlation between change score and the external anchor (6-point global perceived effect scale) and by using receiver operating characteristic curve analysis. MIC was estimated using anchor-based methods. Results All measures showed good responsiveness, with areas under the receiver operating characteristic curve ranging from 0.77 to 0.90. The estimated MICs were 3.1, 11.0, 9.4, 13.3, and 1.3 for the ODI, PGQ-total, PGQ-activity, PGQ-symptoms, and NRS, respectively. All the measures, apart from ODI, had MICs larger than the measurement error. Limitations The lack of an optimal “gold standard” or external criterion for assessing responsiveness and MIC was a limitation of this study. Conclusion All 3 outcome measures demonstrated good responsiveness. MICs were derived for each instrument. The PGQ at 8 weeks postrandomization was identified as an appropriate outcome measure for pregnancy-related LBP/PGP because it is specific to these pain presentations and assesses both activity limitations and symptoms. The NRS is an efficient, shorter alternative.

Introduction The demand for musculoskeletal (MSK) care is rising, and is a growing challenge for general practice. Direct access to physiotherapy and other healthcare services may offer appropriate care for MSK pain patients but there is uncertainty regarding the effectiveness or efficiency of this approach in practice. This study aimed to review the evidence regarding characteristics, outcomes, barriers and facilitators of MSK triage and direct access services. Methods A comprehensive search of eight databases (including MEDLINE, EMBASE, and Cochrane library) up to February 2018 was conducted to identify studies (trials, cohorts and qualitative evidence) on direct access services for MSK in primary care settings. Using predefined inclusion and exclusion criteria, titles, abstracts, and subsequent full texts were independently screened by reviewers. Methodological quality of eligible studies was assessed using the mixed methods appraisal tool, and extracted data regarding study characteristics and results were independently reviewed. A narrative synthesis and grading of evidence was undertaken. Approaches to MSK triage and direct access were profiled along with their respective outcomes of care relating to patient-oriented and socioeconomic outcomes. Barriers and facilitators of each model of direct access services were also highlighted. Results 9010 unique citations were screened, of which 26 studies were eligible. Three approaches (open access, combination and service pathway models) to MSK triage and direct access shared similar goals but were heterogeneous in application. MSK patients using direct access showed largely similar characteristics (age, sex and duration of symptoms) compared to GP-led care, although they were often younger, slightly more educated and with better socio-economic status than patients seen through GP-led care. Although many studies showed limitations in design or methods, outcomes of care (patient oriented outcomes of pain, and disability) did not show large differences between direct access and GP-led care. In most studies direct access patients were reported to have lower healthcare utilisation (fewer physiotherapy or GP consultations, analgesics or muscle relaxants prescriptions, or imaging procedures) and less time off work compared to GP-led care. Discussion This study provides insight into the current state of evidence regarding MSK triage and direct access services and highlights potential implications for future research, healthcare services planning, resource utilisation and organising care for MSK patients in primary care. There is consistent, although limited, evidence to suggest that MSK triage and direct access services lead to comparable clinical outcomes with lower healthcare consumption, and can help to manage GP workload. However, due to the paucity of strong empirical data from methodologically robust studies, a scale up and widespread roll out of direct access services cannot as yet be assumed to result in long term health and socio-economic gains. PROSPERO-ID: CRD42018085978.

Background or context Routine imaging for non-specific low back pain is advised against in guidelines yet imaging continues to occur. Patient and public beliefs regarding imaging may be a driving factor contributing to this. Objectives To review the current evidence in relation to patient and public beliefs regarding imaging for low back pain. Data sources A systematic scoping review was conducted in databases Medline, Embase, Cinahl, Psyc info (inception - Jan 2018). Study selection Any method of study including beliefs of adults about imaging for non-specific low back pain. Data Extraction and Data Synthesis Descriptive data was extracted and patient and public beliefs about imaging for low back pain was analysed using conventional qualitative content analysis. Results 12 studies from an initial search finding of 1135 were analysed. 4 main themes emerged; (1) The desire for imaging; (2) Influences on desire for imaging; (3) Reasons for wanting imaging and (4) Patient relationship with clinicians. Limitations Few qualitative studies were found, all studies were in English language, the majority of studies were older than 2003. Conclusion and implications of key findings There is little available evidence on patients and public beliefs about imaging but what evidence there is suggests that imaging is seen as a positive in the management of low back pain and patient desire for a diagnosis is a big driver of this. There is also a suggestion that these beliefs may still be being influenced by health care professionals.

This review lists biopsychosocial factors and assessment methods to use with non-specific low back pain. These should be included in evidence-informed educational interventions. This review supports a biopsychosocial approach in a manual therapy context.

This study aimed to investigate the inter-rater reliability and construct validity of the Scale for the Assessment and Rating of Ataxia (SARA) and Brief Ataxia Rating Scale (BARS) in children with posterior fossa tumours. These scales have been developed for adults with genetic ataxias, and the performance of these scales in children with brain tumours has not previously been described.The participants, who had undergone surgical resection for a posterior fossa tumour (inclusion criteria age 4-18 years), were recruited from the neuro-oncology service at a tertiary children's hospital. Children were assessed using the SARA, BARS and Paediatric Evaluation of Disability Index (PEDI) mobility domain, a measure of function. Children were independently rated by two therapists to determine the inter-rater reliability of the SARA and BARS. The construct validity was determined by assessing the correlation between the two scales with the PEDI.Forty-four children were recruited. Inter-rater reliability was good for both scales, demonstrating the strong correlations (SARA, r = 0.94; BARS, r = 0.91) and the good consistency (93 % of SARA and 90 % of BARS paired scores differing by less than 2 points) between two raters. Both ataxia scales demonstrated a strong negative correlation with the mobility domain of the PEDI (SARA, r = -0.77; BARS, r = -0.76), indicating that more severe ataxia was associated with worse mobility. The mean time for completion of the SARA was 4.5 and 2.7 min for the BARS.The SARA and BARS are reliable and valid measures and appear to be of equal value in determining the severity of ataxia in children with posterior fossa tumours.

Musculoskeletal pain is a common cause of work absence and early intervention is advocated to prevent the adverse health and economic consequences of longer-term absence. This cluster randomised controlled trial investigated the effect of introducing a vocational advice service, into primary care to provide occupational support. Six general practices were randomised, patients were eligible if they were consulting their general practitioner (GP) with musculoskeletal pain, were employed and struggling at work or absent from work

Introduction Around 17% of general practitioner (GP) consultations are for musculoskeletal conditions, which will rise as the population ages. Patient direct access to physiotherapy provides one solution, yet adoption in the National Health Service (NHS) has been slow. Setting A pilot, pragmatic, non-inferiority, cluster randomised controlled trial (RCT) in general practice and physiotherapy services in the UK. Objectives Investigate feasibility of a main RCT. Participants Adult patients registered in participating practices and consulting with a musculoskeletal problem. Interventions 4 general practices (clusters) randomised to provide GP-led care as usual or the addition of a patient direct access to physiotherapy pathway. Outcomes Process outcomes and exploratory analyses of clinical and cost outcomes. Data collection Participant-level data were collected via questionnaires at identification, 2, 6 and 12 months and through medical records. Blinding The study statistician and research nurses were blinded to practice allocation. Results Of 2696 patients invited to complete study questionnaires, 978 participated (intervention group n=425, control arm n=553) and were analysed. Participant recruitment was completed in 6 months. Follow-up rates were 78% (6 months) and 71% (12 months). No evidence of selection bias was observed. The direct access pathway was used by 90% of patients in intervention practices needing physiotherapy. Some increase in referrals to physiotherapy occurred from one practice, although waiting times for physiotherapy did not increase (28 days before, 26 days after introduction of direct access). No safety issues were identified. Clinical and cost outcomes were similar in both groups. Exploratory estimates of between group effect (using 36-item Short Form Health Survey (SF-36) Physical Component Summary (PCS)) at 6 months was −0.28 (95% CI −1.35 to 0.79) and at 12 months 0.12 (95% CI −1.27 to 1.51). Conclusions A full RCT is feasible and will provide trial evidence about the clinical and cost-effectiveness of patient direct access to physiotherapy. Trial registration number ISRCTN23378642.

Background Low back pain (LBP) and pelvic girdle pain (PGP) during pregnancy are common and often accepted as a ‘normal’ part of pregnancy. Many women receive little in the way of treatment, and yet pain interferes with sleep, daily activities and work and leads to increasing requests for induction of labour or elective caesarean section. The aim of this study was to assess the feasibility of a full RCT evaluating the benefit of acupuncture for pregnancy-related back pain. Methods This study is a single-centre, three-arm pilot RCT in one large maternity unit and associated antenatal and physiotherapy clinics. Women were eligible if they had pregnancy-related LBP with or without PGP. Exclusions included a history of miscarriage, high risk of early labour or pre-eclampsia, PGP only and previous acupuncture. Interventions were standard care (SC): a self-management booklet with physiotherapy if needed. SC+TA: the booklet and physiotherapy comprising true (penetrating) acupuncture, advice and exercise. SC+NPA: the booklet and physiotherapy comprising non-penetrating acupuncture, advice and exercise. Remote telephone randomisation used a 1:1:1 allocation ratio stratified by gestational weeks. Three measures of pain/function were compared to inform the primary outcome measure in a full RCT: the Pelvic Girdle Questionnaire (PGQ), Oswestry Disability Index (ODI) and 11-point 0–10 numerical rating scale for pain. Analysis focused on process evaluation of recruitment, retention, descriptive information on outcomes, adherence to treatment, occurrence of adverse events and impact of physiotherapist training. Results One hundred twenty-five women were randomised (45% of those eligible) between April and October 2013; 73% (n = 91) provided 8-week follow-up data. Three of six recruitment methods accounted for 82% of total uptake: screening questionnaire at the 20-week scan, community midwives issuing study cards, and self-referral following local awareness initiatives. Physiotherapists’ self-confidence on managing pregnancy-related LBP improved post training. The PGQ is suitable as the primary outcome in a full trial. The average number of treatment sessions in both SC+TA and SC+NPA was six (in line with treatment protocols). No serious adverse events attributable to the trial treatments were reported. Conclusions A full RCT is feasible and would provide evidence about the effectiveness of acupuncture and inform treatment choices for women with pregnancy-related LBP. Trial registration ISRCTN49955124

Background Despite being a highly prevalent chronic condition managed predominantly in primary care and unlike other chronic conditions, osteoarthritis (OA) care is delivered on an ad hoc basis rather than through routine structured review. Evidence suggests current levels of OA care are suboptimal, but little is known about what general practitioners’ (GPs) consider important in OA care, and, thus, the scope to improve inconsistency or poor practice is, at present, limited. Objectives We investigated GPs’ views on and practice of monitoring OA. Methods This was a cross-sectional postal survey of 2500 practicing UK GPs randomly selected from the Binley's database. Respondents were asked if monitoring OA patients was important and how monitoring should be undertaken. Results Responses were received from 768 GPs of whom 70.8% were male and 89.5% were principals within their practices. Despite 55.4% (n = 405) indicating monitoring patients with OA was important and 78.3% (n = 596) considering GPs the appropriate professionals to monitor OA, only 15.2% (n = 114) did so routinely, and 45% (n= 337) did not monitor any OA patients at all. In total, 61.4% (n = 463) reported that patients should self-monitor. Respondents favored monitoring physical function, pain, and analgesia use over monitoring measures of BMI, self management plans, and exercise advice. Conclusions The majority of respondents felt that monitoring OA was important, but this was not reflected in their reported current practice. Much of what they favored for monitoring was in line with published guidance, suggesting provision of suboptimal care does not result from lack of knowledge and interventions to improve OA care must address barriers to GPs engaging in optimal care provision.

Physiotherapy-led telephone assessment and advice services for patients with musculoskeletal problems have been developed in many services in the UK, but high quality trial data on clinical and cost effectiveness has been lacking. In order to address this ‘The PhysioDirect trial’ (ISRCTN55666618), was a pragmatic randomised trial of a PhysioDirect telephone assessment and advice service. This paper describes the PhysioDirect system used in the trial and how physiotherapists were trained and supported to use the system and deliver the PhysioDirect service. The PhysioDirect system used in the trial was developed in Huntingdon and now serves a population of 350,000 people. When initiating or providing physiotherapy-led telephone assessment and advice services training and support for physiotherapists delivering care in this way is essential. An enhanced skill set is required for telephone assessment and advice particularly in listening and communication skills. In addition to an initial training programme, even experienced physiotherapists benefit from a period of skill consolidation to become proficient and confident in assessing patients and delivering care using the telephone. A computer-based system assists the delivery of a physiotherapy-led musculoskeletal assessment and advice service.Clinical Trials Registration Number (ISRCTN55666618).

BackgroundMany pregnant women experience low back pain. Acupuncture appears to be a safe, promising intervention but evidence is needed about its clinical effectiveness and cost-effectiveness.ObjectivesTo assess the feasibility of a future large randomised controlled trial (RCT) testing the additional benefit of adding acupuncture to standard care (SC) for pregnancy-related back pain.DesignPhase 1: a questionnaire survey described current care for pregnancy-related back pain. Focus groups and interviews with midwives, physiotherapists and pregnant women explored acceptability and feasibility of acupuncture and the proposed RCT. Phase 2: a single-centre pilot RCT. Participants were identified using six methods and randomised to SC, SC plus true acupuncture or SC plus non-penetrating acupuncture.ParticipantsPhase 1: 1093 physiotherapists were surveyed and 15 midwives, 21 physiotherapists and 17 pregnant women participated in five focus groups and 20 individual interviews. Phase 2: 125 women with pregnancy-related back pain participated.InterventionsSC: a self-management booklet and onward referral for one-to-one physiotherapy (two to four sessions) for those who needed it. SC plus true acupuncture: the self-management booklet and six to eight treatments with a physiotherapist comprising true (penetrating) acupuncture, advice and exercise. SC plus non-penetrating acupuncture: the self-management booklet and six to eight treatments with a physiotherapist comprising non-penetrating acupuncture, advice and exercise.Main outcome measuresPilot RCT outcomes included recruitment rates, treatment fidelity, follow-up rate, patient-reported pain and function, quality of life and health-care resource use. Birth and neonatal outcomes were also assessed. Staff overseeing outcome data collection were blind to treatment allocation.ResultsPhase 1: 629 (57.5%) physiotherapists responded to the survey, 499 were experienced in treating pregnancy-related back pain and reported 16 advice and 18 treatment options. Typical treatment comprised two to four individual sessions of advice and exercise over 6 weeks. Acupuncture was reported by 24%. Interviews highlighted the impact of back pain and paucity of effective interventions. Women and midwives strongly supported a RCT and expressed few concerns. Physiotherapists’ concerns about acupuncture in pregnancy informed a training programme prior to the pilot RCT. Phase 2: We recruited 125 of 280 potentially eligible women (45%) in 6 months and randomised 41 to SC and 42 each to the SC plus true acupuncture and SC plus non-penetrating acupuncture arms. Analysis was conducted with 124 participants (41, 42 and 41, respectively) as one participant was randomised in error. Three of six recruitment methods were the most successful. In total, 10% of women (n = 4) randomised to SC alone accessed one-to-one physiotherapy and received an average of two treatments. The average number of treatments was six for both SC plus true acupuncture and SC plus non-penetrating acupuncture. Treatments were in line with protocols. Eight-week follow-up was 74%. Patient-reported outcomes (pain, function and quality of life) favoured the addition of acupuncture. There was no evidence of serious adverse events on mothers or birth and neonatal outcomes. The Pelvic Girdle Questionnaire was found to be an appropriate outcome measure for a future trial.ConclusionsA future main RCT is feasible and would be welcomed by women and clinicians. Longer-term follow-up and further follow-up efforts are recommended for a main trial.Trial registrationCurrent Controlled Trials ISRCTN49955124.FundingThis project was funded by the National Institute of Health Research Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 33. See the NIHR Journals Library website for further project information.

Background Pregnancy-related low back pain (LBP) is very common. Evidence from a systematic review supports the use of exercise and acupuncture, although little is known about the care received by women with pregnancy-related back pain in the UK. Objective To describe current acupuncture and standard care management of pregnancy-related LBP by UK physiotherapists. Design Cross-sectional survey of physiotherapists with experience of treating women with pregnancy-related LBP from three professional networks of the Chartered Society of Physiotherapy. Methods In total, 1093 physiotherapists were mailed a questionnaire. The questionnaire captured respondents’ demographic and practice setting information, and experience of managing women with pregnancy-related back pain, and investigated the reported management of pregnancy-related LBP using a patient case vignette of a specific, ‘typical’ case. Results The overall response rate was 58% (629/1093). Four hundred and ninety-nine physiotherapists had experience of treating women with pregnancy-related LBP and were included in the analysis. Most respondents worked wholly or partly in the UK National Health Service (78%). Most respondents reported that they treat patients with pregnancy-related LBP in three to four one-to-one treatment sessions over 3 to 6 weeks. The results show that a range of management strategies are employed for pregnancy-related LBP, and multimodal management is common. The most common reported treatment was home exercises (94%), and 24% of physiotherapists reported that they would use acupuncture with the patient described in the vignette. Conclusions This study provides the first robust data on the management of pregnancy-related LBP by UK physiotherapists. Multimodal management is common, although exercise is the most frequently used treatment for pregnancy-related LBP. Acupuncture is used less often for this patient group.

Background: There has been much research into factors that can be modified to improve the response rates of general practitioners to surveys and to the demographic characteristics of those who do and do not respond. However, response is yet to be considered with respect to the quality of clinical care provided by GPs. In the UK, one measure of quality of care is the Quality and Outcomes Framework (QOF) score achieved by a general practice. Objective: This study considers the association of QOF score with response to self-completion postal surveys of general practitioners. Methods: Data are taken from two postal surveys of general practitioners (GPs) in the UK regarding their attitudes to osteoarthritis (OA) and sickness certification respectively. Logistic regression was used to assess the association between survey response and QOF score (as a proxy for quality of clinical care), adjusting for other characteristics of GPs and their practices (list size, number of partners, geographical region). Results: There was no significant association of QOF score with survey response in either study, before or after adjustment for the other characteristics. Conclusion: There is no evidence of an association between QOF score and the response of GPs to postal surveys. This gives reassurance that samples for studies of GP attitudes and practices should not suffer from response bias in relation to this core characteristic that represents the clinical achievement of their practice.

Low back pain is a common condition which, although largely self-limiting, is responsible for large personal, societal and financial burdens. A multitude of best practice guidelines now exist for the management of patients with low back pain, with largely consistent messages. Although some guideline recommendations appear to have translated relatively well into clinical practice, studies have identified a relatively poor uptake for other key recommendations. The clear message from published literature is that the mere production and dissemination of guidelines for the management of low back pain does not translate into clear shifts in clinical practice in line with best practice. There are numerous potential obstacles to healthcare practitioners adopting best practice recommendations and these can be categorised in various ways. The attitudes and beliefs that a healthcare practitioner holds can be either obstacles or facilitators to the adoption of best practice recommendations. Individual practi...

Objective \ud \ud To establish the meaning of the term ‘adherence’ (including conceptual and measurement definitions) in the context of therapeutic exercise (TE) for musculoskeletal (MSK) pain.\ud \ud Design \ud \ud Systematic review using a search strategy including terms for: adherence, TE and MSK pain. Identified studies were independently screened for inclusion by two researchers. Two independent researchers extracted data on: study type; MSK pain population; type of TE used; definitions, parameters, measurement methods and values of adherence.\ud \ud Data sources \ud \ud Seven electronic databases were searched from inception to December 2016.\ud \ud Eligibility criteria \ud \ud Any study type featuring TE for adults with MSK pain and containing a definition of adherence, or a description of how adherence was measured.\ud \ud Results \ud \ud 459 studies were identified and 86 were included in the review. Most were prospective cohort studies and featured back and/or neck pain. Strengthening and stretching were the most common types of TE. A clearly identifiable definition of adherence was provided in 40% of the studies, with 12% using the same definition. Exercise frequency was the most commonly measured parameter of adherence, with self-report logs the most common measurement method. The most common value range used to determine satisfactory adherence was 80%–99% of the recommended exercise dose.\ud \ud Conclusion \ud \ud No single definition of adherence to TE was apparent. We found no definition of adherence that specifically related to TE for MSK pain or described the dimensions of TE that should be measured. We recommend conceptualising adherence to TE for MSK pain from the perspective of all relevant stakeholders.

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.

Guidelines for the management of low back pain (LBP) have existed for many years, but adherence to these by health care practitioners (HCPs) remains suboptimal. The aim of this study was to measure the attitudes, beliefs and reported clinical behaviour of UK physiotherapists (PTs) and general practitioners (GPs) about LBP and to explore the associations between these. A cross-sectional postal survey of GPs (n = 2000) and PTs (n = 2000) was conducted that included the Pain Attitudes and Beliefs Scale (PABT.PT), and a vignette of a patient with non-specific LBP (NSLBP) with questions asking about recommendations for work, activity and bedrest. Data from 1022 respondents (442 GPs and 580 PTs) who had recently treated patients with LBP were analysed. Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations, 28% reported they would advise this patient to remain off work. Work advice was significantly related to the PABS.PT scores with higher biomedical (F1,986 = 77.5, p

The attitudes and beliefs that health care practitioners (HCPs) hold about back pain have been shown to affect the advice they provide to patients seeking healthcare. In order to develop a questionnaire for a national survey of attitudes, beliefs and practice behaviour of HCPs about back pain, a systematic review of available measurement tools was undertaken. Measurement tools were identified from a systematic search of databases (Medline, Embase, CINAHL, Psychinfo, AMED and British Nursing Index) in the English language for papers published from January 1990 to October 2006. Quality criteria were applied to each of the tools by two independent reviewers. The initial search strategy generated a total of 5269 references. Following assessment of titles and abstracts, 12 papers describing five tools were identified for inclusion in the review. The tools were the Attitudes to Back Pain scale for musculoskeletal practitioners (ABS.mp), a fear avoidance beliefs tool, the Fear Avoidance Beliefs Questionnaire (FABQ) adapted for HCPs, the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT). The HC-PAIRS and PABS.PT have undergone the most thorough testing to date, but gaps in the properties of all the tools remain, particularly test-retest reliability and responsiveness. This review identified only five tools and demonstrated limited reporting of their validity and reliability. Further development and testing of existing tools should be a priority to ensure they are robust and valid measures of attitudes and beliefs of HCPs about back pain.

Background Musculoskeletal problems are common, accounting for up to 30 % of general practitioner (GP) consultations and are a major cause of chronic disability worldwide. Demand for health care for musculoskeletal conditions is likely to continue to rise given the ageing population and the increasing impact of these common painful conditions. Physiotherapists are well equipped to deliver evidence-based management for these conditions. Direct access allows patients to access physiotherapy without seeing their GP or another referring practitioner first; however, for most patients in the UK, access to National Health Service physiotherapy is controlled through GP referral. Methods/Design The aim of this pilot, pragmatic, cluster trial is to assess the feasibility of a future large trial to compare the clinical and cost-effectiveness of the additional offer of direct access to physiotherapy versus continuing with usual GP-led primary care alone for adults with common musculoskeletal problems. The pilot will focus on process outcomes to assess feasibility, although performance of the likely outcomes of a main trial will also be assessed. This is a two-arm parallel, cluster RCT where GP practices are the units of randomisation (the clusters), yet data are collected from individual patients with musculoskeletal problems (the participants). A direct access service will be set up in the participating physiotherapy service to provide the option of direct access to patients of the intervention arm practices. Inclusion criteria are broad to reflect the ‘real-world’ operation of an NHS physiotherapy direct access service for patients with musculoskeletal pain. Data collection will be through patient self-reported questionnaires at baseline, 2, 6 and 12 months and medical record review. Discussion No previous trials have been conducted into direct access to physiotherapy for patients with musculoskeletal problems. The strengths of the STEMS pilot trial are its size, the length of follow-up, and collection of process, clinical and cost outcomes to fully inform a future main trial to meet calls to provide robust trial evidence of the impact on clinical outcomes, work loss and costs to provide clinicians and service funders with the high quality trial data they need to guide decisions on the best models of care. Trial registration The STEMS pilot trial is registered at Current Controlled Trials: ISRCTN23378642 Electronic supplementary material The online version of this article (doi:10.1186/s40814-015-0020-4) contains supplementary material, which is available to authorized users.

Background Low back pain is often accepted as a “normal” part of pregnancy. Despite research suggesting that quality of life for women who are pregnant is adversely affected, most are advised to self-manage. Although the use of acupuncture for the management of persistent nonspecific low back pain has been recommended in recent UK national guidelines, its use in the management of pregnancy-related low back pain remains limited. Objectives This study aimed to explore the perceptions and experiences of physical therapists involved in treating women who are pregnant and have low back pain with the objective of informing the pretrial training program for a pilot randomized trial (Evaluating Acupuncture and Standard care for pregnant womEn with Back pain [EASE Back]). Design A qualitative phenomenological method with purposive sampling was used in the study. Methods Three focus groups and 3 individual semistructured interviews were undertaken, and an iterative exploratory thematic analysis was performed. To ensure transparency of the research process and the decisions made, an audit trail was created. Results Twenty-one physical therapists participated, and emergent issues included: a lack of experience in treating pregnancy-related complaints, mixed messages from previous acupuncture education, a mistrust of the current evidence for acupuncture safety and effectiveness, and personal and professional fear of causing harm. Conclusions The findings suggest that UK physical therapists are reluctant to use acupuncture in the management of pregnancy-related low back pain. The explanations for these findings include perceived lack of knowledge and confidence, as well as a pervasive professional culture of caution, particularly fears of inducing early labor and of litigation. These findings have been key to informing the content of the training program for physical therapists delivering acupuncture within the pilot EASE Back trial.