Emergency department use by people with back pain: An investigation.

Background: Demand on emergency departments (EDs) is rising, at least in part due to patients with conditions suitable for management in primary care. Pain experienced in the back region is a common reason for patients to seek help and much of the established literature on back pain suggests serious pathologies are rare and the majority of patients can be safely treated in primary care. Emerging international data suggests that patients who present to ED complaining of back pain do not reflect those in primary care, with a higher rate of serious pathologies and non-spinal causes. This exploratory study seeks to quantify the prevalence of people attending ED with back pain, to describe their characteristics and the characteristics of their attendance. Methods: This observational study is a retrospective analysis of patients attending EDs within an NHS Trust in the North East of England presenting with back pain from 1/10/2017 to 30/09/2018. Results: Of 212,020 attendances, 3872 (2%) patients presented complaining of back pain on arrival. 36% of patients had no official diagnosis recorded, 5% were categorised as having a potentially serious spinal pathology, 22% had a non-spinal pathology diagnosis and 23% were categorised as simple backache. The majority (56%) had no recorded investigations, 19% received plain radiography, 5% received either CT/MRI, 18% had blood investigations and 17% had cardiac monitoring or electrocardiogram. Most individuals self-presented. NHS 111, primary care and community care referrals accounted for 24% of attendances. Conclusion: Back pain was a relatively common ED attendance and represented a variety of conditions including non-spinal causes. This suggests that the population of patients with back pain attending ED are a different subgroup to those presenting to primary care. Care should be taken applying primary care guidance to this group and there may be a need for emergency care specific back pain guidelines.

Ambulance service use by patients with lower back pain: an observational study.

Background: Lower back pain (LBP) is the leading cause of disability globally and can be distressing for patients. It is commonly reported that serious pathologies underlying LBP are rare and most patients would be more appropriately managed in primary care. However, recent literature suggests patients accessing emergency care may differ from those accessing primary care. Currently, little is known about the use of ambulance services by people with LBP. The aim of this study was to investigate the extent and nature of ambulance services utilisation by patients presenting with LBP. Methods: This observational study is a retrospective analysis of ambulance service calls in the North East of England presenting with LBP from 1 August 2016 to 31 July 2017 (Health Research Authority registration 17/WS/0216). Results: Of 484,495 answered calls, 3315 (0.7%) calls were categorised as initially presenting with LBP. Women represented 59% of callers. Most calls were from those aged 41-50 and 71-80 years old. Almost half of patients (48%) initially presenting with LBP were later categorised with a problem elsewhere. Of the patients, 49% received analgesia, including Entonox (24%) and morphine (13%). Most patients (69%) were transported to an emergency department while 28% remained at home. Conclusion: LBP is a relatively common reason to call the ambulance service. Contrary to data from primary care, non-spinal causes, which include medical emergencies, make up a significant proportion of this. Current guidance on back pain focuses on primary care and specialist settings. Future updates may need to consider emergency care as a distinct setting with a potentially different patient population.

Sensory discrimination training for adults with chronic musculoskeletal pain: a systematic review.

BACKGROUND: Sensory discrimination training (SDT) is a form of feedback guided sensory training used in the treatment of chronic musculoskeletal pain (CMP). OBJECTIVE: This systematic review aimed to investigate the efficacy and safety of SDT for CMP. METHODS: MEDLINE, CINAHL, EMBASE, AMED, CENTRAL, PsycINFO, Scopus, OT Seeker, PEDro, ETHOS, Web of Science, and Open Grey were searched for appropriate randomized controlled trials (RCTs). Included papers were assessed for risk of bias, and evidence was graded using the GRADE approach. The protocol was published on PROSPERO (anonymized). RESULTS: Ten RCTs met the inclusion/exclusion criteria. There was conflicting evidence from seven RCTs for the efficacy of SDT for chronic low back pain (CLBP). There was very low-quality evidence from two studies supporting the efficacy of SDT for phantom limb pain (PLP). There was very low-quality evidence from one RCT for the efficacy of SDT for Fibromyalgia. No adverse effects of SDT were identified. CONCLUSIONS: SDT has been delivered in multiple forms in the literature. SDT does not appear to be associated with any adverse effects and shows potential regarding its clinical efficacy. However, there is a lack of high-quality evidence upon which to make any firm clinical recommendations.

USING A BIOPSYCHOSOCIAL APPROACH WITHIN ACL REHABILITATION: AN EXPLORATION OF STUDENT PHYSIOTHERAPISTS` PERCEPTIONS AND EXPERIENCES.

BACKGROUND: Supporting the psychological needs of the patient during Anterior Cruciate Ligament Reconstruction (ACLR) rehabilitation is of paramount importance in order to optimize function and return to sport. Despite this, the amount of psychological training physiotherapists receive is inadequate. PURPOSE: the central aim of this study was to gain valuable insight, through the lens of the student physiotherapist, in relation to biopsychosocial practices used within ACL rehabilitation. METHOD: A phenomenological design using an inductive approach through purposive sampling was used. The study conducted semi-structured interviews, which involved ten undergraduate and postgraduate physiotherapy students from a UK University institution. The study identified perceptions, experiences and training surrounding a biopsychosocial approach within ACL rehabilitation. Data analysis included thematic analysis with triangulation and an audit trail to enhance confirmability and credibility. RESULTS: Participants demonstrated a superficial understanding of the biopsychosocial approach, psychological symptoms and the significance of applying a patient-centered approach. Nonetheless, participants consistently reported barriers to implementing this approach, including the application of theory to practice when working with patients following ACL surgery. DISCUSSION: Findings were consistent with previous research surrounding inadequate biopsychosocial education and training within ACL rehabilitation. The application of theory of the model to clinical practice was absent from the students' training. CONCLUSION: These findings suggest that student physiotherapists are aware of the possible benefits of incorporating psychological interventions but feel inadequately trained, highlighting a need for a review of the curriculum. Future research focusing on pedagogy-based strategies to effectively equip students to apply biopsychosocial theory to practice is of critical importance to prepare students for contemporary ACL rehabilitation and practice.

A THEORETICAL BASED PHYSIOTHERAPY GOAL SETTING MODEL FOR ANTERIOR CRUCIATE LIGAMENT REHABILITATION.

BACKGROUND: Anterior Cruciate Ligament rehabilitation is a lengthy process and requires appropriate goal setting strategies to help optimize patient and athlete outcomes. From a global perspective, ACL injury incidences are continuing to rise, with Australia and the USA having one of the highest incidences of ACL injury rates in the athletic population. In addition, physiotherapists are expected by their professional regulatory body to effectively use goal setting practices. DESIGN: Theoretical Goal Setting Model consisting of three phases: 1) Pre goal setting phase (empower); 2) goal implementation phase (strive); and 3) goal evaluation phase (attain). DISCUSSION: This model provides physiotherapists with a useful process so that key aspects of setting goals are considered and incoporporated. This model showcases a necessary path a physiotherapist and patient must journey together in order to enhance rehabilitation outcomes. This model will also advance the  physiotherapists' awareness of the multi-stages of the patients goal desires, intentions and commitment to their rehabilitation. CONCLUSION: This model is a preliminary attempt to guide both practice, teaching, and research to ensure that goal setting practices in ACL rehabilitation are given an appropriate rehabilitative platform. The next stage is to empirically validate the practical application of the model and how each phase manifests.

Goal setting practices used within anterior cruciate ligament rehabilitation: An exploration of physiotherapists understanding, training and experiences.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are a common injury that occurs in both the sporting and non-sporting population. Goal setting is said to be an effective psychological tool within ACL rehabilitation and is commonly used by physiotherapists. To date, literature surrounding goal setting practices is under analysed in relation to qualitative research. PURPOSE: The central aim of this study was to explore UK physiotherapists understanding, experiences and training towards goal setting practices used in ACL rehabilitation and whether they are effective. METHOD: Semi-structured interviews involving 24 participants across three specific areas including: National Health Service, elite sport and academia were conducted using an inductive approach. Data analysis included thematic analysis with triangulation and a comprehensive multi-staged analysis process to enhance trustworthiness, whilst respecting ethical considerations. RESULTS/DISCUSSION: Participants from all three areas of practice tended to use the same approach which was SMART goals. All participants lacked any theoretical understanding of goals but would welcome further training in the field. Participants were missing important aspects of setting goals such as not addressing expectations and underutilising feedback. CONCLUSION: These findings suggest that a call for more psychological training is clearly warranted in both the physiotherapy curriculum and within post graduate CPD training. Creating a specialist interest group (e.g. physiotherapists interested in psychology) may help share good psychological practices and overall enhance understanding in this field.

The Effects of Unilateral Versus Bilateral Motor Training on Upper Limb Function in Adults with Chronic Stroke: A Systematic Review.

OBJECTIVES: Rehabilitation goals for chronic stroke patients are largely focused around regaining functional ability and independence, with particular focus on upper limb motor function. Unilateral and Bilateral motor training may help achieve this. Our objective was to evaluate and compare the effects of unilateral and bilateral motor training on upper limb motor function in chronic stroke patients. MATERIALS AND METHODS: A comprehensive literature search was conducted until June 2020 through several electronic databases (CENTRAL, Medline, CINAHL, EBSCO, AMED and PEDro) to identify relevant studies. Studies that used the Fugl Meyer Assessment (FMA) as a minimum, to assess upper limb motor function following unilateral versus bilateral training in chronic stroke patients, qualified for inclusion within the review. Randomised controlled trial (RCT), cohort study and cross-sectional study designs were considered. The Cochrane risk of bias tool was used to assess Randomised Controlled Trials (RCTs). The findings were qualitatively synthesised. RESULTS: From a total of 838 studies identified, 7 RCTs were included in this review. All except one of the studies included reported an unclear risk of bias, with one low risk of bias reported. Overall, the studies reported that unilateral and bilateral training improved upper limb function in chronic stroke patients. Improvements between interventions were equivocal. Bilateral upper limb training however may be more efficacious for increasing upper limb strength and quality of movement, with unilateral training more beneficial for recovering functional ability for activities of daily living. CONCLUSION: While the findings of the included studies support the use of unilateral and bilateral motor training post chronic stroke, the seven studies that were included methodologically all presented with limitations, hence strong conclusions cannot be drawn and further research is warranted.

An exploration of UK student physiotherapists' goal setting practices within anterior cruciate ligament rehabilitation.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are a common and complex injury coupled with a lengthy rehabilitation. Goal setting is said to be an effective psychological tool within ACL rehabilitation due to its simplicity and is commonly used amongst sport and health professionals. To date, literature surrounding goal setting practices has only focused on qualified therapists. PURPOSE: The central aim of this study was to explore UK student physiotherapists' perceptions towards goal setting practices used in ACL rehabilitation and whether they feel prepared for practice. METHOD: Semi-structured interviews involving 11 participants from one UK university was conducted using an inductive approach. Data analysis included thematic analysis with triangulation and a comprehensive five-stage analysis process to enhance confirmability and credibility, whilst respecting ethical considerations. RESULTS/DISCUSSION: Participants reported some understanding of goal setting and the importance of involving the patient during this process. However, participants negatively experienced goal setting practices as being mainly therapist/protocol led. The training participants received on goal setting was minimal, but further training was welcomed by all participants. The findings were consistent with previous UK and international research surrounding inadequate education and training across sport and health professionals when applying goal setting practice within ACL rehabilitation. CONCLUSION: These findings suggest that, initially, a review of the psychological content of sport and health professional courses is warranted to clearly identify potential knowledge gaps. There is also an opportunity whereby a global specialist interest group could be designed to share psychological practices and globally connect like-minded sport and health professionals together.

Exploring the origin of pain subclassification, with emphasis on low back pain: a scoping review.

OBJECTIVE: This scoping review aimed to explore the different working definitions for the duration of acute, subacute, and chronic pain, with emphasis on low back pain, and to establish where these definitions originated and the rationale provided for the time frames used. INTRODUCTION: From a global perspective, low back pain is a major social and economic problem. One of the most commonly used methods to stratify and manage low back pain is the traditional duration-based classification (acute, subacute, and chronic). Where these time points lie to differentiate these transitions continues to be debated within the scientific community, which may engender a degree of heterogeneity in study findings. Therefore, applying these findings to clinical practice may be somewhat challenging. This review encapsulates the historical origins of the different duration categories to provide an understanding of how these variations were derived. INCLUSION CRITERIA: Studies that included participants with low back pain were the focus of this review. Sources that included children or other specific pain pathologies, such as cancer pain, were excluded. The main concept of interest was that the publication proposed an original definition of the duration of acute, subacute, or chronic low back pain. All study designs were included provided they gave a rationale for the duration that they used. METHODS: The following databases were searched: MEDLINE, Embase, CINAHL, and PsycINFO, from the inception of each database until September 18, 2019. This review was limited to studies published in English. Two independent reviewers screened the retrieved articles against the eligibility criteria. Additional studies were searched from the reference lists of studies to find the original source. Some original sources overlapped with general pain duration literature. This led to a deviation from the scoping review protocol, which originally intended to focus on definitions of low back pain duration only. Data extraction was undertaken using a charting table developed specifically for the review objectives. The findings were presented using narrative synthesis. RESULTS: Nineteen records were included in this review, and comprised three book chapters, four review articles, four articles that arose following pain expert group discussions, seven primary research studies, and a spinal guideline. Data were extracted from the included studies and categorized into four themes based on the origin of the classification of the duration. The themes included i) work/employment setting, ii) empirical studies, iii) expert reasoning, and iv) pathophysiological explanation. CONCLUSIONS: This scoping review compiled the existing literature on the working definitions of the duration of acute, subacute, and chronic low back pain and found a wide variation. These ranged from seven days, 14 days, and seven weeks for the acute and subacute transition points, and seven weeks to three years for chronic low back pain. The duration definitions specifically referring to the general pain literature focused on three and/or six months for the transition to chronic. Better integration of reasoning between the identified themes could facilitate the establishment of more ideal duration definitions in the future. Although inconclusive, the definition most commonly cited, with most consensus, was three months for the transition to chronic low back pain.

A call for more psychological skills training: Examining the views of qualified and student sports therapists in the United Kingdom.

CONTEXT: Sports therapists can influence an athlete's psychological response to injury. At present it is unclear whether sports therapists are sufficiency trained in psychology. OBJECTIVES: To understand the views both of practising clinicians and students regarding the extent to which sports therapy education addresses psychological factors in injury management. DESIGN: Cross-sectional study. SETTING: Online Questionnaire. PARTICIPANTS: Qualified sports therapists (n = 30) and sports therapy students, (n = 33). INTERVENTIONS: Sports Therapist and Sport Psychology Questionnaire. MAIN OUTCOME MEASURES: The questionnaire included five subsets of questions (5-point Likert scale or multiple-choice). Internal consistency of each subset was rated via Cronbach's alpha (α, 95% confidence interval) as good (questions 5 & 6; α 0.81, 0.68 to 0.88) or as excellent (scale questions 3-4; α 0.91, 0.85-0.95, question 8, α 0.97, 9.6 to 9.8, questions 7, 11 & 12; α 0.94, 0.91-0.96; and questions 9 & 10, α 0.96, 9.4-9.8). RESULTS: Both groups recognised psychological components as either 'important' or 'very important' in rehabilitation. They reported a need for psychological skills in injury management, and more psychology training during education. While 80% of qualified therapists identified a duty to treat psychological components, only 45% of students concurred. CONCLUSIONS: Future sports therapy education should consider placing greater emphasis on the psychological components of injury management in order to sufficiently equip therapists with appropriate skills for practice.

The effects of unimanual and bimanual massed practice on upper limb function in adults with cervical spinal cord injury: a systematic review.

BACKGROUND: Individuals with cervical spinal cord injury (cSCI) have identified improving upper limb function as their most important rehabilitation goal. Unimanual massed practice (UMP) and bimanual massed practice (BMP) may help achieve this. OBJECTIVES: To evaluate and compare the effects of UMP and BMP on upper limb function in adults with cSCI. DATA SOURCES: Cochrane Central Register of Controlled Trials, PubMed, CINAHL, Web of Science and PEDro until April 2016. STUDY SELECTION: Studies investigating the effects of UMP and/or BMP on upper limb function in adults with cSCI. DATA EXTRACTION AND SYNTHESIS: Data was extracted using a standardised form. Studies were appraised using a modified version of the Cochrane risk of bias tool. The findings were qualitatively synthesised. RESULTS: Five randomised controlled trials and 2 case studies were included. Six studies included UMP, three included BMP, and two compared these approaches. Overall the studies reported that UMP and BMP improved upper limb function, particularly when combined with electrical stimulation, with no clear differences between UMP and BMP. These findings should be interpreted with caution however, as 6 studies presented a high or unclear risk of bias for all functional upper limb outcome measures included, and the remaining study was a small pilot study with no control group. CONCLUSION: Although the findings of the included studies support the use of UMP and BMP in adults with cSCI, only 7 studies, all with significant limitations, were included; hence robust conclusions cannot be drawn and further research is warranted. PROSPERO registration number: CRD42016037365.

The Use of Recovery Strategies Among Participants of the BUPA Great North Run: A Cross-Sectional Survey.

OBJECTIVE: To investigate half-marathon runners' frequency of use of recovery strategies, perceptions regarding the most beneficial recovery strategy, and reasons for using recovery strategies. DESIGN: Cross-sectional survey. PARTICIPANTS: 186 participants of the 13.1 mile BUPA Great North Run 2013. METHODS: A questionnaire was developed which required participants to indicate how frequently they used 12 different recovery strategies, identify which recovery strategy they believed to be most beneficial, and rank 6 reasons for using recovery strategies in order of importance. Data were analyzed using a Friedman nonparametric ANOVA and additional nonparametric tests. RESULTS: All participants used recovery strategies. Stretching was the most commonly used recovery strategy (P < .001), whereas the use of nutritional supplements was the most commonly selected most beneficial recovery strategy. More than 50% of respondents indicated that they never used strategies such as kinesio tape (80%), hydrotherapy (78%), or ice baths (71%). A significant difference was observed between reasons for using recovery strategy (χ2 (5) = 292.29, P < .001). Reducing muscle tightness (rank 4.87) and reducing injury (rank 4.35) were the most frequently chosen most important reasons for using recovery strategies. Minor sex and age differences in the responses were identified. CONCLUSION: Recovery strategy usage appears to be widespread among half-marathon runners; however, disparities exist between the frequency of use and perceived effectiveness of different recovery strategies. Further research in this area is needed to facilitate the development of recovery strategy guidelines which are both evidence-based and practically relevant.

Musculoskeletal physiotherapists' use of psychological interventions: a systematic review of therapists' perceptions and practice.

BACKGROUND: Research has demonstrated that incorporating psychological interventions within physiotherapy practice has numerous potential benefits. Despite this physiotherapists have reported feeling inadequately trained to confidently use such interventions in their day-to-day practice. OBJECTIVE: To systematically review musculoskeletal physiotherapists' perceptions regarding the use of psychological interventions within physiotherapy practice. DATA SOURCES: Eligible studies were identified through a rigorous search of AMED, CINAHL, EMBASE, MEDLINE and PsychINFO from January 2002 until August 2013. STUDY ELIGIBILITY CRITERIA: Full text qualitative, quantitative and mixed methodology studies published in English language investigating musculoskeletal physiotherapists' perceptions regarding their use of psychological interventions within physiotherapy practice. STUDY SYNTHESIS AND APPRAISAL: Included studies were appraised for risk of bias using the Critical Appraisal Skills Programme qualitative checklist. Meta-analysis was not possible due to study heterogeneity. RESULTS: Six studies, all with a low risk of bias, met the inclusion criteria. These studies highlighted that physiotherapists appreciate the importance of using psychological interventions within their practice, but report inadequate understanding and consequent underutilisation of these interventions. LIMITATIONS: These results should be noted with some degree of caution due to various limitations associated with the included studies and with this review, including the use of a qualitative appraisal tool for mixed methodology/quantitative studies. CONCLUSION: These findings suggest that musculoskeletal physiotherapists are aware of the potential benefits of incorporating psychological interventions within their practice but feel insufficiently trained to optimise their use of such interventions; hence highlighting a need for further research in this area and a review of physiotherapist training.