Staff experiences of integrating community and secondary care musculoskeletal services: A qualitative investigation.

INTRODUCTION: Integrated models of care intend to provide seamless and timely access to health and social care services. This study investigated the integration of musculoskeletal services across community and secondary care boundaries, including the introduction of a single point of access from which patients were triaged. METHODS: Staff (n = 15) involved in service development and delivery were interviewed about how, why and to what extent integration impacted service delivery. The analysis focused on staff experiences of using an on-line patient self-referral form and co-located clinics to enhance decision-making in triage, and on the provision of educational materials and de-medicalising language in patient consultations to support self-management. RESULTS: Single point of access, including online self-referral, were operationalised during data collection, but co-located clinics were not. Triage staff explained that the volume of referrals and quality of information provided in online self-referrals sometimes constrained decision-making in triage. Secondary care staff discussed concerns that the single point of access might not consistently identify patients with hard to diagnose conditions that require timely surgical intervention. This concern appeared to constrain staff engagement with integration, potentially inhibiting the delivery of co-located clinics. However, triage staff accessed support to inform secondary care referral via alternate modes. Patient circumstances, for example, need for reassurance, necessitated multiple self-management strategies and innovative approaches were developed to provide patients ongoing and professionally led support. CONCLUSION: Findings emphasise that restructuring services requires engagement from diverse stakeholders. Collaborating with stakeholders to address their concerns about the impact of restructures on well-established pathways may help cultivate this engagement.

Lumbar disc disease: the effect of inversion on clinical symptoms and a comparison of the rate of surgery after inversion therapy with the rate of surgery in neurosurgery controls.

[Purpose] We have previously shown inversion therapy to be effective in a small prospective randomised controlled trial of patients with lumbar disc protrusions. Our purpose now was to measure symptoms and to compare the surgery rate following inversion for 85 participants with the surgery rate in 3 control groups. [Participants and Methods] Each of the 85 inverted participants acted as their own control for the "symptomatic" part of the study. In the "Need for surgery" part of the study, one control group was made up of similar patients with leg pain and sciatica who were referred to the same clinic in the same year. Two additional control groups were examined: the original control group from the pilot trial and the lumbar disc surgery waiting list patients. [Results] Inversion therapy relieved symptoms: there were improvements in the Visual Analogue Score, Roland Morris and Oswestry Disease indices and Health Utility Score compared with their pre-treatment status. Also, the 2 year surgery rate in the inversion participants in the registry (21%) was significantly lower than in the matched control group (39% at two years and 43% at four years). It was also lower than the surgery rate in the other 2 control groups. [Conclusion] Inversion therapy relieved symptoms and avoided surgery.

Inversion therapy in patients with pure single level lumbar discogenic disease: a pilot randomized trial.

PURPOSE: Backache and sciatica due to protuberant disc disease is a major cause of lost working days and health expenditure. Surgery is a well-established option in the management flowchart. There is no strong evidence proving that traction for sciatica is effective. We report a pilot prospective randomized controlled trial comparing inversion traction and physiotherapy with standard physiotherapy alone in patients awaiting lumbar disc surgery. This study sought to study the feasibility of a randomized controlled trial on the effect of inversion therapy in patients with single level lumbar discogenic disease, who had been listed for surgery. METHODS: This was a single centre prospective randomized controlled trial undertaken at the Regional Neurosciences Centre, Newcastle Upon Tyne, UK. It was a prospective randomized controlled trial where patients awaiting surgery for pure lumbar discogenic disease within the ambit of the prestated inclusion/exclusion criteria were allocated to either physiotherapy or physiotherapy and intermittent traction with an inversion device. Post-treatment assessment made by blinded observers at 6 weeks for various outcome measures included the Roland Morris Disability Questionnaire (RMDQ) Score, Short Form 36 (SF 36), Oswestry Disability Index (ODI), Visual Analogue Pain Score (VAS), magnetic resonance imaging (MRI) appearance and the need for surgery. Avoidance of surgery was considered a treatment success. RESULTS: Twenty-six patients were enrolled and 24 were randomized [13 to inversion + physiotherapy and 11 to physiotherapy alone (control)]. Surgery was avoided in 10 patients (76.9%) in the inversion group, whereas it was averted in only two patients (22.2%) in the control group. Cancellation of the proposed operation was a clinical decision based on the same criteria by which the patient was listed for surgery initially. There were no significant differences in the RMDQ, SF 36, ODI, VAS or MRI results between the two groups. CONCLUSION: Intermittent traction with an inversion device resulted in a significant reduction in the need for surgery. A larger multicentre prospective randomized controlled trial is justified in patients with sciatica due to single level lumbar disc protrusions. [ IMPLICATIONS FOR REHABILITATION: • Resolution of impairment and diasability due to radiculopathy is the aim of any intervention.• Avoidance of surgery meant satisfactory resolution of impairment and disability due to radiculopathy. This happened more often in the inversion group to the extent of reaching statistical significance.• The 12-point improvement in disability by the Oswestry Disability Index in the inversion group suggests a role for this intervention in disability reduction.• Inversion may form part of the conservative rehabilitation of patients with single level unilateral lumbar disc protrusion alongside other forms of physiotherapy.• There is a potential secondary impact in the reduction of rehabilitation following surgery.]