Purpose: Joint pain due to osteoarthritis (OA) is a major cause of disability, work-loss and reduced quality of life in older adults. NICE clinical guidelines recommend core OA treatment should include education, exercise and weight-loss (when applicable). However, despite the evidence-base, many people with OA do not receive these treatments in primary care. This report describes and evaluates the implementation of a clinical-academic physiotherapist OA clinic embedded into a general practice.

BackgroundOne untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes.Methods1573 adults with back pain (+/− radiculopathy) consulting at 10 general practices in England responded to invitations to attend an assessment clinic, at which 851 eligible participants were randomised (intervention n=568; control n=283). Primary outcome using intention-to-treat analysis was the difference in change in the Roland-Morris Disability Questionnaire (RMDQ) score at 12 months. Secondary outcomes included 4-month RMDQ change between arms overall, and at risk-group level at both time-points. The economic evaluation estimated incremental quality-adjusted life years (QALYs) and back pain-rel...

Source Citation Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-30. 28192789

Background Back pain can have a major impact on someone9s quality of life and ability to return to work. However, getting the right treatment to the right patients at the right time is difficult. Recent research1 showed the effectiveness of a new way of allocating matched treatment to different patient groups based on their risk of poor outcomes (the “STarTBack” approach). It reduces disability, time off work and healthcare costs. STarTBack is recognised internationally as improving the care pathway for back pain patients but the challenge is taking it forward into routine clinical practice. Objectives To describe public involvement (PI) in taking the successful STarTBack research into routine clinical practice. Methods Providing clear and useful patient information was a key feature of the successful rollout of STarTBack. A PI group helped develop: 1) an information sheet on living with back pain given to patients during a GP consultation; 2) public pages of a STarTBack website; 3) a “Making Every Contact Count” manual to help health professionals have a conversation with patients about their back pain; and 4) a questionnaire to collect the patient experience of STarTBack. The project team met with the PI group on three occasions and provided regular feedback about their contribution. Results Six patients with back pain (three males, three females) formed the PI group. 1) Back pain information sheet: PI members highlighted the best aspects of two leaflets on back pain2,3 (e.g. simple advice, useful images, clear layout), and suggested how existing information used in local GP practices for patients about living with back pain (provided by the patient.co.uk) could be adapted to include these. 2) STarTBack Website: PI members suggested content for the public pages of the STarTBack website that patients with back pain would find useful (www.keele.ac.uk/sbst/patients). 3) ‘Making Every Contact Count’ manual: PI members advised on the clarity, appropriateness and phrasing of key messages and example discussion prompts recommended for use by health professionals during conversations with patients with back pain. 4) Patient experience questionnaire: PI members thought existing NICE quality standard statements for patient experience of health services4 were too long for use in a patient questionnaire. Members therefore suggested new items for a brief questionnaire based on their own back pain experiences. Conclusions Public involvement has provided a valuable contribution to the roll out of a successful research study into routine clinical practice to improve the treatment of patients with back pain. The PI group has improved the content and clarity of materials used to provide patient information, aid conversations between health professionals and patients with back pain, and collect the patient experience of STarTBack. The uptake and use of the STarTBack approach in local GP practices will be audited and evaluated during 2015-16. References Hill et al, Lancet,2011;378(9802):1560-1571 www.arthritisresearchuk.org/arthritisinformation/conditions/backpain www.patient.co.uk/pdf/4202.pdf www.nice.org.uk/guidance/qs15 Acknowledgements Supported by West Midlands Academic Health Science Network and NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands. KS is funded by a NIHR Knowledge Mobilisation grant (KS, KMF-2012-01-35). Disclosure of Interest None declared

PURPOSE:We aimed to determine the effects of implementing risk-stratified care for low back pain in family practice on physician's clinical behavior, patient outcomes, and costs. METHODS:The IMPaCT Back Study (IMplementation to improve Patient Care through Targeted treatment) prospectively compared separate patient cohorts in a preintervention phase (6 months of usual care) and a postintervention phase (12 months of stratified care) in family practice, involving 64 family physicians and linked physical therapy services. A total of 1,647 adults with low back pain were invited to participate. Stratified care entailed use of a risk stratification tool to classify patients into groups at low, medium, or high risk for persistent disability and provision of risk-matched treatment. The primary outcome was 6-month change in disability as assessed with the Roland-Morris Disability Questionnaire. Process outcomes captured physician behavior change in risk-appropriate referral to physical therapy, diagnostic tests, medication prescriptions, and sickness certifications. A cost-utility analysis estimated incremental quality-adjusted life-years and back-related health care costs. Analysis was by intention to treat. RESULTS:The 922 patients studied (368 in the preintervention phase and 554 in the postintervention phase) had comparable baseline characteristics. At 6 months follow-up, stratified care had a small but significant benefit relative to usual care as seen from a mean difference in Roland-Morris Disability Questionnaire scores of 0.7 (95% CI, 0.1-1.4), with a large, clinically important difference in the high risk group of 2.3 (95% CI, 0.8-3.9). Mean time off work was 50% shorter (4 vs 8 days, P = .03) and the proportion of patients given sickness certifications was 30% lower (9% vs 15%, P = .03) in the postintervention cohort. Health care cost savings were also observed. CONCLUSIONS:Stratified care for back pain implemented in family practice leads to significant improvements in patient disability outcomes and a halving in time off work, without increasing health care costs. Wider implementation is recommended.

Purpose The objectives of this study were to develop consensus on (i) the content of a clinical assessment for adults presenting to primary care with low back and leg pain, and (ii) the most important items for diagnosing spinal nerve root involvement. Methods Existing literature and expert knowledge was used to compile a list of items pertaining to clinical history questions and examination tests employed in the assessment of patients with low back pain with suspected spinal nerve involvement. A Delphi consensus method was employed to rate the importance of items for clinical assessment and for diagnosis in two web-based rounds. A multidisciplinary group of 42, including GPs, physiotherapists, osteopaths, rheumatologists, spinal orthopaedic surgeons and chiropractors took part. Items were included in the final assessment when over 70% of participants rated them as important. Results Thirty-four items were included in the clinical assessment, and 15 items for diagnosis. History items included pain distribution in the leg, pain quality and behaviour, altered sensation, functional limitations and yellow flags, previous history of similar symptoms and outcome of previous treatment/management. Examination items included typical neurological tests including neural tension and ‘demonstration of movement that produces symptoms’. Conclusions We have developed a clinical assessment schedule for patients with low back pain and leg pain presenting in primary care. History and clinical items considered important for their contribution in the diagnosis of nerve root involvement were also established.

Background Low-back related leg pain with or without nerve root involvement is associated with a poor prognosis compared to low back pain (LBP) alone. Compared to the literature investigating prognostic indicators of outcome for LBP, there is limited evidence on prognostic factors for low back-related leg pain including the group with nerve root pain. This 1 year prospective consultation-based observational cohort study will describe the clinical, imaging, demographic characteristics and health economic outcomes for the whole cohort, will investigate differences and identify prognostic indicators of outcome (i.e. change in disability at 12 months), for the whole cohort and, separately, for those classified with and without nerve root pain. In addition, nested qualitative studies will provide insights on the clinical consultation and the impact of diagnosis and treatment on patients' symptom management and illness trajectory. Methods Adults aged 18 years and over consulting their General Practitioner (GP) with LBP and radiating leg pain of any duration at (n = 500) GP practices in North Staffordshire and Stoke-on-Trent, UK will be invited to participate. All participants will receive a standardised assessment at the clinic by a study physiotherapist and will be classified according to the clinically determined presence or absence of nerve root pain/involvement. All will undergo a lumbar spine MRI scan. All participants will be managed according to their clinical need. The study outcomes will be measured at 4 and 12 months using postal self-complete questionnaires. Data will also be collected each month using brief postal questionnaires to enable detailed description of the course of low back and leg pain over time. Clinical observations and patient interviews will be used for the qualitative aspects of the study. Discussion This prospective clinical observational cohort will combine self-reported data, comprehensive clinical and MRI assessment, together with qualitative enquiries, to describe the course, health care usage, patients' experiences and prognostic indicators in an adult population presenting in primary care with LBP and leg pain with or without nerve root involvement.

Background Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control).Methods 1573 adults (aged >= 18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. This study is registered, number ISRCTN37113406.Findings 851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4.7 [SD 5.9] vs 3.0 [5.9], between-group difference 1.81 [95% CI 1.06-2.57]) and at 12 months (4.3 [6.4] vs 3.3 [6.2], 1.06 [0.25-1.86]), equating to effect sizes of 0.32 (0.19-0.45) and 0.19 (0.04-0.33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0.039 additional QALYs) and cost savings (240.01 pound vs 274.40) pound compared with the control group.Interpretation The results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care.

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.

Background Cardiovascular disease (CVD) is a major cause of death and disability.Effective population-based strategies to reduce CVD morbidity and mortality are needed.Objective To evaluate the effectiveness of a pharmacy-based Cardiovascular Health Awareness Program (CHAP) on cardiovascular disease morbidity.Design: Cluster randomized trial.Setting: Thirty-nine mid-sized communities in Ontario, Canada.Participants: Community-dwelling residents 65 years of age or older, family physicians, pharmacists, volunteers, community nurses and local lead organizations.Intervention: Residents 65 years of age or older were invited to attend volunteer-run cardiovascular risk assessment and education sessions held in community-based pharmacies over a 10-week period.Automated blood pressure readings and self-reported risk factor data were collected and shared with session participants and their family physicians and pharmacists.Main Outcome Measure: A composite of hospital admissions for acute myocardial infarction, stroke and congestive heart failure among all community residents aged 65 years and older.Results All 20 intervention communities successfully implemented CHAP.A total of 1 265 3-hour long sessions were held in 90% (129/145) of pharmacies during the 10-week program.A total of 27 358 CVD assessments were performed on 15 889 unique participants with the assistance of 577 peer-volunteers.Adjusting for hospital admission rates in the year prior to intervention, CHAP was associated with a 9% relative reduction in our composite endpoint (rate ratio 0•91 [95% CI 0•86-0•97], p=0•002).There were statistically significant reductions favouring the intervention communities in hospital admissions for acute myocardial infarction (rate ratio 0•87 [95% CI 0•79 -0•97], p=0•008) and congestive heart failure (rate ratio 0•90 [95% CI 0•81 -0•99], p=0•029), but not for stroke (rate ratio 0•99 [95% CI 0•88 -1•12], p=0•89) (table 3).Conclusions A collaborative, multipronged community-based health promotion and prevention program targeted at older adults can reduce cardiovascular morbidity at the population level.

SUMMARY The importance of atrial fibrillation as a treatable risk factor for stroke is well established. Less is known about how to find previously unidentified cases within the community so that antithrombotic treatment can be offered to a wider group of at-risk patients. The aim of our study was to examine ways to improve the efficiency of practice-based screening for atrial fibrillation, including issues of time and financial cost. We used different combinations of pulse palpation and interpretation of 12-lead and bipolar electrocardiographs as carried out by practice nurses. The best strategy for the detection of atrial fibrillation in a practice population would appear to be to screen all eligible subjects by nurse pulse palpation, followed by 12-lead electrocardiograph readings in those who have a pulse suggestive of atrial fibrillation. The electrocardiograph interpretation can be undertaken effectively by a trained nurse.

Background Most patients seeking help for back pain are managed in primary care.Aim To describe the content and outcome of 'usual care' for low back pain in primary care trials.Design of study A systematic review of randomised controlled trials published since 1998. Setting Primary care.Method Randomised controlled trials of back pain in adults were scrutinised to obtain data on treatment and outcome measures in groups receiving usual primary care. A narrative review of the resulting heterogeneous data was undertaken.Results Thirty-three papers were identified for analysis. Overall the exact nature of the treatment received in the 'usual' primary care group was poorly recorded. Medication was frequently used, and there were suggestions that levels of opioid prescription were higher than might be expected from clinical guidelines. Requesting of plain-film X-rays occurred more often than recommended. There was very little information to suggest that doctors were promoting physical activity for patients with back pain. Disability scores (Roland-Morris Disability Questionnaire) and pain scores improved over time for patients with acute or subacute back pain, but not for those with chronic pain.Conclusion Treatment received by patients with back pain was varied and often not in line with back-pain guidelines, particularly with respect to opioid prescription and X-ray investigation. The content of the 'usual care' arm in trials is crucial to interpreting the outcome of studies, but was poorly described in the papers reviewed. Future trials should more fully describe the 'usual care' arm.

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.