A new measure of exercise adherence: the ATEMPT (Adherence To Exercise for Musculoskeletal Pain Tool).

OBJECTIVES: This study aimed to (1) develop a new measure of adherence to exercise for musculoskeletal (MSK) pain (Adherence To Exercise for Musculoskeletal Pain Tool: ATEMPT) based on previously conceptualised domains of exercise adherence, (2) report the content and structural validity, internal consistency, test-retest reliability, and measurement error for the ATEMPT outcome measure in patients managed with exercise for MSK pain. METHODS: ATEMPT was created using statements describing adherence generated by patients, physiotherapists and researchers, with content validity established. Baseline and retest questionnaires were distributed to patients recommended exercise for MSK pain in 11 National Health Service physiotherapy clinics. Items demonstrating low response variation were removed and the following measurement properties assessed: structural validity, internal consistency, test-retest reliability and measurement error. RESULTS: Baseline and retest data were collected from 382 and 112 patients with MSK pain, respectively. Confirmatory factor analysis established that a single factor solution was the best fit according to Bayesian Information Criterion. The 6-item version of the measure (scored 6-30) demonstrated optimal internal consistency (Cronbach's Alpha 0.86, 95% CI 0.83 to 0.88) with acceptable levels of test-retest reliability (intraclass correlation coefficient 0.84, 95% CI 0.78 to 0.88) and measurement error (smallest detectable change 3.77, 95% CI 3.27 to 4.42) (SE of measurement 2.67, 95% CI 2.31 to 3.16). CONCLUSION: The 6-item ATEMPT was developed from the six domains of exercise adherence. It has adequate content and structural validity, internal consistency, test-retest reliability and measurement error in patients with MSK pain, but should undergo additional testing to establish the construct validity and responsiveness.

Musculoskeletal Health and Work: Development and Internal-External Cross-Validation of a Model to Predict Risk of Work Absence and Presenteeism in People Seeking Primary Healthcare.

PURPOSE: To develop and validate prediction models for the risk of future work absence and level of presenteeism, in adults seeking primary healthcare with musculoskeletal disorders (MSD). METHODS: Six studies from the West-Midlands/Northwest regions of England, recruiting adults consulting primary care with MSD were included for model development and internal-external cross-validation (IECV). The primary outcome was any work absence within 6 months of their consultation. Secondary outcomes included 6-month presenteeism and 12-month work absence. Ten candidate predictors were included: age; sex; multisite pain; baseline pain score; pain duration; job type; anxiety/depression; comorbidities; absence in the previous 6 months; and baseline presenteeism. RESULTS: For the 6-month absence model, 2179 participants (215 absences) were available across five studies. Calibration was promising, although varied across studies, with a pooled calibration slope of 0.93 (95% CI: 0.41-1.46) on IECV. On average, the model discriminated well between those with work absence within 6 months, and those without (IECV-pooled C-statistic 0.76, 95% CI: 0.66-0.86). The 6-month presenteeism model, while well calibrated on average, showed some individual-level variation in predictive accuracy, and the 12-month absence model was poorly calibrated due to the small available size for model development. CONCLUSIONS: The developed models predict 6-month work absence and presenteeism with reasonable accuracy, on average, in adults consulting with MSD. The model to predict 12-month absence was poorly calibrated and is not yet ready for use in practice. This information may support shared decision-making and targeting occupational health interventions at those with a higher risk of absence or presenteeism in the 6 months following consultation. Further external validation is needed before the models' use can be recommended or their impact on patients can be fully assessed.

Matching the Outcomes to Treatment Targets of Exercise for Low Back Pain: Does it Make a Difference? Results of Secondary Analyses From Individual Patient Data of Randomised Controlled Trials and Pooling of Results Across Trials in Comparative Meta-analysis.

OBJECTIVE: To explore whether using a single matched or composite outcome might affect the results of previous randomized controlled trials (RCTs) testing exercise for non-specific low back pain (NSLBP). The first objective was to explore whether a single matched outcome generated greater standardized mean differences (SMDs) when compared with the original unmatched primary outcome SMD. The second objective was to explore whether a composite measure, composed of matched outcomes, generated a greater SMD when compared with the original primary outcome SMD. DESIGN: We conducted exploratory secondary analyses of data. SETTING: Seven RCTs were included, of which 2 were based in the USA (University research clinic, Veterans Affairs medical center) and the UK (primary care clinics, nonmedical centers). One each were based in Norway (clinics), Brazil (primary care), and Japan (outpatient clinics). PARTICIPANTS: The first analysis comprised 1) 5 RCTs (n=1033) that used an unmatched primary outcome but included (some) matched outcomes as secondary outcomes, and the second analysis comprised 2) 4 RCTs (n=864) that included multiple matched outcomes by developing composite outcomes (N=1897). INTERVENTION: Exercise compared with no exercise. MAIN OUTCOME MEASURES: The composite consisted of standardized averaged matched outcomes. All analyses replicated the RCTs' primary outcome analyses. RESULTS: Of 5 RCTs, 3 had greater SMDs with matched outcomes (pooled effect SMD 0.30 [95% confidence interval {CI} 0.04, 0.56], P=.02) compared with an unmatched primary outcome (pooled effect SMD 0.19 [95% CI -0.03, 0.40] P=.09). Of 4 composite outcome analyses, 3 RCTs had greater SMDs in the composite outcome (pooled effect SMD 0.28 [95% CI 0.05, 0.51] P=.02) compared with the primary outcome (pooled effect SMD 0.24 [95% CI -0.04, 0.53] P=.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.

First Contact Practitioners' (FCPs) and General Practitioners' Perceptions Towards FCPs Delivering Vocational Advice to Patients with Musculoskeletal Conditions: A Qualitative Investigation of the Implementation Potential of the I-SWAP Initiative.

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.

Defining adherence to therapeutic exercise for musculoskeletal pain: a systematic review.

OBJECTIVE: To establish the meaning of the term 'adherence' (including conceptual and measurement definitions) in the context of therapeutic exercise (TE) for musculoskeletal (MSK) pain. DESIGN: 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. DATA SOURCES: Seven electronic databases were searched from inception to December 2016. ELIGIBILITY CRITERIA: Any study type featuring TE for adults with MSK pain and containing a definition of adherence, or a description of how adherence was measured. RESULTS: 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. CONCLUSION: 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.

Perceptions of health professionals towards the management of back pain in the context of work: a qualitative study.

BACKGROUND: Musculoskeletal complaints have a significant impact on work in terms of reduced productivity, sickness absence and long term incapacity for work. This study sought to explore GPs' and physiotherapists' perceptions of sickness certification in patients with musculoskeletal problems. METHODS: Eleven (11) GPs were sampled from an existing general practice survey, and six (6) physiotherapists were selected randomly using 'snowball' sampling techniques, through established contacts in local physiotherapy departments. Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes. The interviews were audio recorded and transcribed verbatim, following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology, where themes were identified and contrasted between and within both groups of respondents. RESULTS: Three themes were identified from the analysis: 1) Approaches to evaluating patients' work problems 2) Perceived ability to manage 'work and pain', and 3) Policies and penalties in the work-place. First, physiotherapists routinely asked patients about their job and work difficulties using a structured (protocol-driven) approach, whilst GPs rarely used such structured measures and were less likely to enquire about patients' work situation. Second, return to work assessments revealed a tension between GPs' gatekeeper and patient advocacy roles, often resolved in favour of patients' concerns and needs. Some physiotherapists perceived that GPs' decisions could be influenced by patients' demand for a sick certificate and their close relationship with patients made them vulnerable to manipulation. Third, the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption, and over which GPs and physiotherapists could exercise only limited control. CONCLUSION: We conclude that healthcare professionals need to take account of patients' work difficulties, their own perceived ability to offer effective guidance, and consider the 'receptivity' of employment contexts to patients' work problems, in order to ensure a smooth transition back to work.

Rationale, design and methods of the Study of Work and Pain (SWAP): a cluster randomised controlled trial testing the addition of a vocational advice service to best current primary care for patients with musculoskeletal pain (ISRCTN 52269669).

BACKGROUND: Musculoskeletal pain is a major contributor to short and long term work absence. Patients seek care from their general practitioner (GP) and yet GPs often feel ill-equipped to deal with work issues. Providing a vocational case management service in primary care, to support patients with musculoskeletal problems to remain at or return to work, is one potential solution but requires robust evaluation to test clinical and cost-effectiveness. METHODS/DESIGN: This protocol describes a cluster randomised controlled trial, with linked qualitative interviews, to investigate the effect of introducing a vocational advice service into general practice, to provide a structured approach to managing work related issues in primary care patients with musculoskeletal pain who are absent from work or struggling to remain in work. General practices (n = 6) will be randomised to offer best current care or best current care plus a vocational advice service. Adults of working age who are absent from or struggling to remain in work due to a musculoskeletal pain problem will be invited to participate and 330 participants will be recruited. Data collection will be through patient completed questionnaires at baseline, 4 and 12 months. The primary outcome is self-reported work absence at 4 months. Incremental cost-utility analysis will be undertaken to calculate the cost per additional QALY gained and incremental net benefits. A linked interview study will explore the experiences of the vocational advice service from the perspectives of GPs, nurse practitioners (NPs), patients and vocational advisors. DISCUSSION: This paper presents the rationale, design, and methods of the Study of Work And Pain (SWAP) trial. The results of this trial will provide evidence to inform primary care practice and guide the development of services to provide support for musculoskeletal pain patients with work-related issues. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52269669.

Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems.

STUDY QUESTION: Are PhysioDirect services, based on initial telephone assessment and advice from a physiotherapist, as effective as usual care involving patients waiting for a face-to-face appointment? SUMMARY ANSWER: Patients allocated to PhysioDirect received treatment more quickly than those allocated to usual care, and had equivalent clinical outcomes.

Biopsychosocial care and the physiotherapy encounter: physiotherapists' accounts of back pain consultations.

BACKGROUND: The physiotherapy profession has undergone a paradigmatic shift in recent years, where a 'biopsychosocial' model of care has acquired popularity in response to mounting research evidence indicating better patient outcomes when used alongside traditional physiotherapy. However, research has not examined how this new dimension to traditional physical therapy is implemented within the therapeutic consultation. METHODS: The study aimed to investigate physiotherapists' reported approaches to back pain care in the context of increasing pressure to address patients' psychosocial concerns. A secondary analysis of semi-structured qualitative interviews with 12 UK physiotherapists was conducted. Respondents were sampled from a national survey, to include a broad mix of physiotherapists. Data were analysed thematically, adopting the constant comparative methodology. RESULTS: The combination of traditional physical therapy with a broader biopsychosocial approach presented significant challenges. Physiotherapists responded by attempting to navigate patients' biopsychosocial problems through use of various strategies, such as setting boundaries around their clinical role and addressing lay health beliefs of patients through the provision of reassurance and lifestyle advice. CONCLUSIONS: As psychosocial issues, alongside biomechanical factors, command a prominent place within the back pain consultation, physiotherapists may benefit from further specific training and mentoring support in identifying specific strategies for combining the best of traditional physiotherapy approaches with greater focus on patients' beliefs, fears and social context.

Should there be a Quality and Outcomes Framework domain for osteoarthritis? A cross-sectional survey in general practice.

BACKGROUND: Despite being a chronic condition with a high prevalence and significant associated morbidity that is managed predominantly in primary care, osteoarthritis (OA) does not feature in the Quality and Outcomes Framework (QOF) component of the UK general practice contract. The aim of this study was to determine whether general practitioners (GPs) thought OA should be added as a QOF domain, and the potential items for inclusion. METHODS: A cross-sectional postal survey of 2500 UK GPs randomly selected from Binley's database of currently practising GPs was conducted. The survey asked if OA should be added as a domain to QOF, how many points should be allocated to it and what indicators should be included. RESULTS: Responses were received from 768 GPs, of whom 70.4% were male and 89.1% were partners in their practice. The majority (82.6%; n = 602) felt that OA should not be included as a QOF domain. Significant predictors of support for the addition of an OA domain to QOF included having a special interest in musculoskeletal disease (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.26-3.03), a higher research degree (OR 3.98, 95% CI 1.31-12.10) and having read the National Institute for Health and Clinical Excellence (NICE) guidance on the management of OA (OR 1.62, 95% CI 1.04-2.54). Being a GP principal was the only negative association (OR 0.48, 95% CI 0.23-0.99). Preferred potential indicators for an OA QOF were analgesia review, exercise advice and patient education. CONCLUSIONS: The majority of respondents felt that OA should not be included as a QOF domain, although it is unclear whether this reflected views particular to OA, or on the addition of any new domain to QOF. Those supporting an OA QOF domain tended to prefer potential indicators that are in line with current published guidance, despite a significant proportion reporting that they had not read the NICE guidelines on the management of OA.

Patient satisfaction with the first contact physiotherapy service: Results from the national evaluation survey.

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.

Effects of an e-learning programme on osteopaths' back pain attitudes: a mixed methods feasibility study.

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.

Exercise Interventions for Persistent Non-Specific Low Back Pain - Does Matching Outcomes to Treatment Targets Make a Difference? A Systematic Review and Meta-Analysis.

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.

Economic evaluation of patient direct access to NHS physiotherapy services.

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.

Implementing patient direct access to musculoskeletal physiotherapy in primary care: views of patients, general practitioners, physiotherapists and clinical commissioners in England.

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. 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. 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. 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.

Treatment targets of exercise for persistent non-specific low back pain: a consensus study.

OBJECTIVES: Despite several hundred previous randomised controlled trials (RCTs), the key treatment targets of exercise for persistent non-specific 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.

Providing patients with direct access to musculoskeletal physiotherapy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study.

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. DESIGN AND SETTING: Natural experiment in four general practices and the associated physiotherapy service. 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. 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. 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.

Patient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review.

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. 3 main themes emerged; (1) The Desire for imaging; (2) Influences on patient desire for imaging including (a) clinical presentation, (b) past experience and (c)relationships with care professionals and (3) Negative consequences of imaging. 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 patient and public beliefs about imaging but what evidence there is suggests that imaging is seen as 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.

Costing Methodology and Key Drivers of Health Care Costs Within Economic Analyses in Musculoskeletal Community and Primary Care Services: A Systematic Review of the Literature.

Background: Identifying variation in musculoskeletal service costs requires the use of specific standardized metrics. There has been a large focus on costing, efficiency, and standardized metrics within the acute musculoskeletal setting, but far less attention in primary care and community settings. Objectives: To (a) assess the quality of costing methods used within musculoskeletal economic analyses based primarily in primary and community settings and (b) identify which cost variables are the key drivers of musculoskeletal health care costs within these settings. Methods: Medline, AMED, EMBASE, CINAHL, HMIC, BNI, and HBE electronic databases were searched for eligible studies. Two reviewers independently extracted data and assessed quality of costing methods using an established checklist. Results: Twenty-two studies met the review inclusion criteria. The majority of studies demonstrated moderate- to high-quality costing methods. Costing issues included studies failing to fully justify the economic perspective, and not distinguishing between short- and long-run costs. Highest unit costs were hospital admissions, outpatient visits, and imaging. Highest mean utilization were the following: general practitioner (GP) visits, outpatient visits, and physiotherapy visits. Highest mean costs per patient were GP visits, outpatient visits, and physiotherapy visits. Conclusion: This review identified a number of key resource use variables that are driving musculoskeletal health care costs in the community/primary care setting. High utilization of these resources (rather than high unit cost) appears to be the predominant factor increasing mean health care costs. There is, however, need for greater detail with capturing these key cost drivers, to further improve the accuracy of costing information.

Predictors of functional outcome in musculoskeletal healthcare: An umbrella review.

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.