Non-specific mechanisms in orthodox and CAM management of low back pain (MOCAM): theoretical framework and protocol for a prospective cohort study.

INTRODUCTION: Components other than the active ingredients of treatment can have substantial effects on pain and disability. Such 'non-specific' components include: the therapeutic relationship, the healthcare environment, incidental treatment characteristics, patients' beliefs and practitioners' beliefs. This study aims to: identify the most powerful non-specific treatment components for low back pain (LBP), compare their effects on patient outcomes across orthodox (physiotherapy) and complementary (osteopathy, acupuncture) therapies, test which theoretically derived mechanistic pathways explain the effects of non-specific components and identify similarities and differences between the therapies on patient-practitioner interactions. METHODS AND ANALYSIS: This research comprises a prospective questionnaire-based cohort study with a nested mixed-methods study. A minimum of 144 practitioners will be recruited from public and private sector settings (48 physiotherapists, 48 osteopaths and 48 acupuncturists). Practitioners are asked to recruit 10-30 patients each, by handing out invitation packs to adult patients presenting with a new episode of LBP. The planned multilevel analysis requires a final sample size of 690 patients to detect correlations between predictors, hypothesised mediators and the primary outcome (self-reported back-related disability on the Roland-Morris Disability Questionnaire). Practitioners and patients complete questionnaires measuring non-specific treatment components, mediators and outcomes at: baseline (time 1: after the first consultation for a new episode of LBP), during treatment (time 2: 2 weeks post-baseline) and short-term outcome (time 3: 3 months post-baseline). A randomly selected subsample of participants in the questionnaire study will be invited to take part in a nested mixed-methods study of patient-practitioner interactions. In the nested study, 63 consultations (21/therapy) will be audio-recorded and analysed quantitatively and qualitatively, to identify communication practices associated with patient outcomes. ETHICS AND DISSEMINATION: The protocol is approved by the host institution's ethics committee and the NHS Health Research Authority Research Ethics Committee. Results will be disseminated via peer-reviewed journal articles, conferences and a stakeholder workshop.

Patients' perceptions and satisfaction with treatment in a UK osteopathic training clinic.

This study was a descriptive and exploratory investigation of patient perceptions of treatment at an osteopathic training clinic. An open text questionnaire survey was administered by post in 2000 to all 292 patients attending the clinic in south-east England in 1998-2000. The response rate was 62%. The data were transcribed and the concepts within the data were coded using grounded theory, within an interpretive phenomenological approach. The emergent core theme "underlying personal values" describes how patients manage their search for health. Four main themes were associated with the therapeutic relationship: hope, communication, respect, and trust. Two further themes emerged: one related to the environment of a teaching clinic; and a cross-checking theme described comparisons of the clinic with NHS services and other services. The majority of patients expressed satisfaction with treatment, the explanations they received and their perceived health outcomes. The question about comfort with the manner of treatment drew out important issues around undressing, privacy and gender. This was the first study of patient attitudes in an osteopathic training clinic and has implications for their organization and service delivery. Recommendations are made for the design of future studies in this area.

First impressions in complementary practice: the importance of environment, dress and address to the therapeutic relationship.

The aim of the study was to explore patients' views of the importance of environmental and social factors within a complementary and alternative medicine (CAM) practice. A cross-sectional patient survey was conducted in 37 CAM practices across nine geographical areas of the UK using a structured questionnaire. The 219 responders (response rate 59%) were 65% female. The most common treatment modalities were osteopathy and acupuncture. Patients rated telephone manner, practitioner appearance and explanatory literature as very important factors in shaping first impressions and influencing their confidence in the complementary practice. Patients' preferences for practitioner dress code were highly variable. Overall 65% preferred a white coat to casual dress. A multivariate analysis revealed that this preference was statistically significantly greater in two geographical regions and in patients over 70 years old. It was not influenced by gender or treatment modality. Further research is recommended in order to understand how the complex verbal and non-verbal communication implicit in the CAM setting may affect the therapeutic relationship.