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Objective We explored patients' experiences of using Internet-based self-management support for low back pain (LBP) in primary care, with and without physiotherapist telephone guidance. Design Exploratory descriptive qualitative study using thematic analysis, nested within a randomized feasibility trial. Methods Patients with LBP who participated in a feasibility trial of the SupportBack Internet intervention (ISRCTN: 31034004) were invited to take part in semistructured telephone interviews after the three-month intervention period (a convenience sample from within the trial population). Fifteen participants took part (age range = 36–87 years, 66.7% female, characteristics representative of the trial population). Data were analyzed thematically. Results Analysis resulted in the development of six themes (subthemes in parentheses): Perceptions of SupportBack's design (Clarity and ease of use, Variety and range of information provided, Need for specificity and flexibility), Engaging with the SupportBack intervention, Promoting positive thought processes (Reassurance, Awareness of self-management), Managing behavior with SupportBack (Motivation and goal setting, Using activity as a pain management strategy, Preferences for walking or gentle back exercises), Feeling supported by telephone physiotherapists (Provision of reassurances and clarity, Physiotherapists are motivating), Severity and comorbidity as barriers (Preexisting condition or severity acting as a barrier, Less useful for mild low back pain). Conclusions The Internet intervention SupportBack appeared to feasibly support self-management of LBP. Reassurance and ongoing support to implement behavioral changes were central to reported benefits. The addition of physiotherapist telephone support further enhanced the patient experience and the potential utility of the intervention. [ABSTRACT FROM AUTHOR]

Objective. The aims of this study were to determine the feasibility of introducing a computerized template for identifying quality of care during an OA consultation, describe quality of OA care in practices in which the template was introduced and assess the effect of the template on routinely recorded clinician behaviour in those practices. Methods. A computerized template to assist the recording of care in consultations for patients with OA was installed in eight general practices. Eligible patients were those ⩾45 years of age consulting for clinical OA during a 6 month period. The main outcomes were frequency of template triggering, achievement of quality indicators during the consultation (assessment of pain and function, assessment for first-line analgesics, provision of information, exercise advice, consideration of physiotherapy referral, weight loss advice) and change in routinely recorded clinician behaviour (diagnostic coding, prescribing, referral, use of radiography, weight records) compared with the 12 months prior to template installation. Results. The template was triggered for 1730 patients. Achievement of indicators ranged from 36% (for consideration of physiotherapy referral) to 63% (for pain assessment), with substantial variability between clinicians. There was an increase in prescription of recommended first-line analgesics following the template installation: paracetamol [odds ratio (OR) 1.49 (95% CI 1.22, 1.82) compared with pre-template] and topical NSAIDs [OR 1.95 (95% CI 1.61, 2.35)]. Conclusion. This new template is a feasible tool for capturing data during OA consultations to aid assessment of quality of care. It was associated with significant improvements in recommended care processes. However, strategies are needed to ensure consistent approaches between clinicians. Trial registration. http://www.controlled-trials.com/ISRCTN06984617/mosaics. [ABSTRACT FROM AUTHOR]

Objectives. Evidence regarding the cost-effectiveness of joint protection and hand exercises for the management of hand OA is not well established. The primary aim of this study is to assess the cost-effectiveness (cost-utility) of these management options. In addition, given the absence of consensus regarding the conduct of economic evaluation alongside factorial trials, we compare different analytical methodologies. Methods. A trial-based economic evaluation to assess the cost-utility of joint protection only, hand exercises only and joint protection plus hand exercises compared with leaflet and advice was undertaken over a 12 month period from a UK National Health Service perspective. Patient-level mean costs and mean quality-adjusted life years (QALYs) were calculated for each trial arm. Incremental cost-effectiveness ratios (ICERs) were estimated and cost-effectiveness acceptability curves were constructed. The base case analysis used a within-the-table analysis methodology. Two further methods were explored: the at-the-margins approach and a regression-based approach with or without an interaction term. Results. Mean costs (QALYs) were £58.46 (S.D. 0.662) for leaflet and advice, £92.12 (S.D. 0.659) for joint protection, £64.51 (S.D. 0.681) for hand exercises and £112.38 (S.D. 0.658) for joint protection plus hand exercises. In the base case, hand exercises were the cost-effective option, with an ICER of £318 per QALY gained. Hand exercises remained the most cost-effective management strategy when adopting alternative methodological approaches. Conclusion. This is the first trial evaluating the cost-effectiveness of occupational therapy-supported approaches to self-management for hand OA. Our findings showed that hand exercises were the most cost-effective option. [ABSTRACT FROM AUTHOR]

Objectives. To describe and explore current exercise and physical activity behaviour in older adults with knee pain in the UK. Methods. A survey was mailed to 2234 adults ≥50 years of age registered with one general practice within the UK to determine the presence and severity of knee pain and levels of physical activity. Semi-structured interviews were conducted with 22 questionnaire responders with knee pain. Results. The questionnaire response rate was 59% ( n = 1276) and 611 respondents reported knee pain. Only ∼40% of individuals with knee pain were sufficiently active to meet physical activity recommendations. Interviews revealed individual differences in the type and setting of physical activity completed and some self-monitored their symptoms in response to physical activity in order to guide future behaviour. Conclusion. Innovative interventions that can be adapted to suit individual needs and preferences are required to help older adults with knee pain become more physically active. [ABSTRACT FROM AUTHOR]

Background. The STarT Back Screening Tool (SBT) was recently developed for primary care providers to use as a screening tool for subgrouping people with low back pain (LBP) on the basis of modifiable prognostic factors. The use of the SBT in physical therapy has not been described. Objective. The aims of this study were to describe the use of the SBT in people receiving physical therapy for LBP and to describe patterns of change in clinical outcomes across the episode of care and among SBT categories. Design. This study was a prospective case series. Methods. A total of 214 patients receiving physical therapy for LBP were administered the SBT at the initial evaluation. Treatment was at the physical therapist's discretion. Clinical outcomes included pain intensity and disability scores collected at each session. Descriptive statistics were calculated, and baseline characteristics among SBT categories were compared. Hierarchical linear mixed models were used to examine patterns of change in predicted outcomes across the episode of care. Results. The patients' mean age was 44.3 years (SD=15.8), and 56.5% were women. The SBT categorized 33.2% of the patients as being at low risk, 47.7% as being at medium risk, and 19.2% as being at high risk. The high-risk category corresponded to the highest initial pain intensity and disability scores. The low-risk category corresponded to the lowest initial pain intensity and disability scores. Linear mixed models indicated different patterns of change in outcome scores for pain intensity (F=3.99) and disability (F=3.49) among SBT categories. Relative to the low-risk category, the high-risk category had larger improvements in predicted outcomes and the medium-risk category had similar improvements in predicted outcomes. Limitations. The SBT was not administered to 24% of eligible patients. The timing of follow-up assessments was variable. Conclusions. The SBT may provide important prognostic information for physical therapists. [ABSTRACT FROM AUTHOR]

Background. The delivery of acupuncture alongside mainstream interventions and the cost-effectiveness of "alternative" treatments remain areas of controversy. Objective. The aim of this study was to assess the cost-utility of adding acupuncture to a course of advice and exercise delivered by UK National Health Service (NHS) physical therapists to people with osteoarthritis of the knee. Design. A cost-utility analysis was performed alongside a randomized controlled trial. Methods. A total of 352 adults (aged 50 years or older) were randomly assigned to receive 1 of 3 interventions. The primary analysis focused on participants receiving advice and exercise (AE) or advice and exercise plus true acupuncture (AE+TA). A secondary analysis considered participants receiving advice and exercise plus nonpenetrating acupuncture (AE+NPA). The main outcome measures were quality-adjusted life years (QALYs), measured by the EQ-5D, and UK NHS costs. Results were expressed as the incremental cost per QALY gained over 12 months. Sensitivity analyses included a broader cost perspective to incorporate private out-of-pocket costs. Results. NHS costs were higher for AETA (£314 [British pounds sterling]) than for AE alone (£229), and the difference in mean QALYs favored AE+TA (mean difference=0.022). The base-case cost per QALY gained was £3,889; this value was associated with a 77% probability that AE+TA would be more cost-effective than AE at a threshold of £20,000 per QALY. Cost-utility data for AE+NPA provided cost-effectiveness estimates similar to those for AE+TA. Limitations. As with all trial-based economic evaluations, caution should be exercised when generalizing results beyond the study perspectives. Conclusions. A package of AE+TA delivered by NHS physical therapists provided a cost-effective use of health care resources despite an associated increase in costs. However, the economic benefits could not be attributed to the penetrating nature of conventional acupuncture; therefore, further research regarding the mechanisms of acupuncture is needed. An analysis of alternative cost perspectives suggested that the results are generalizable to other health care settings. [ABSTRACT FROM AUTHOR]

Objectives. To assess overall responses to treatments among non-specific low back pain (NSLBP) patients in clinical trials to examine the pattern following a wide range of treatments.Methods. We conducted a systematic review of published trials on NSLBP and meta-analysis of within-group responses to treatments calculated as the standardized mean difference (SMD). We included randomized controlled trials that investigated the effectiveness of primary care treatments in NSLBP patients aged ≥18 years. Outcome measures included the visual analogue scale for pain severity, Roland Morris Disability Questionnaire and Oswestry Disability Index for physical functioning.Results. One hundred and eighteen trials investigating a wide range of primary care treatment for NSLBP were included. Plots of response to treatments showed that there was a similar pattern of initial improvement at 6 weeks followed by smaller improvement for both pain and functional disability at long-term follow-up. This was also shown by the pooled SMD for pain which was 0.86 (95% CI 0.65, 1.07) at 6 weeks, 1.07 (95% CI 0.87, 1.27) at 13 weeks, 1.03 (95% CI 0.82, 1.25) at 27 weeks and 0.88 (95% CI 0.60, 1.1) at 52 weeks. There was a wide heterogeneity in the size of improvement. This heterogeneity, however, was not explained by differences in the type of treatment classified as active, placebo, usual care or waiting list controls or as pharmacological or non-pharmacological treatment.Conclusions. NSLBP symptoms seem to improve in a similar pattern in clinical trials following a wide variety of active as well as inactive treatments. It is important to explore factors other than the treatment, that might influence symptom improvement. [ABSTRACT FROM PUBLISHER]

Background and Purpose. Physical therapists have an important role in the management of clinical knee osteoarthritis (OA) through designing and supervising exercise programs. This study explored whether their current use of therapeutic exercise for patients with this condition is in line with recent recommendations. Subjects and Methods. A cross-sectional survey was conducted with a random sample of chartered (licensed) physical therapists (N=2,000) practicing in the United Kingdom. This survey included a vignette describing a patient with clinical knee OA as well as clinical management questions relating to the respondents' use of therapeutic exercise. Results. The questionnaire response rate was 58% (n=l,152), with 538 respondents stating they had treated a patient ¦with clinical knee OA in the preceding 6 months. In line with recent recommendations, 99% of the physical therapists stated they would use therapeutic exercise for this patient population, although strengthening exercises were favored over aerobic exercises. Although nearly all physical therapists would monitor exercise adherence, only 12% would use an exercise diary. Seventy-six percent of physical therapists would provide up to 5 treatment sessions, and only 34% would offer physical therapy follow-up after discharge. Discussion and Conclusions. The measure of physical therapists' current clinical practice was self-reported clinical behavior on the basis of a vignette. Although this is a valid measure of clinical behavior, in practice, physical therapists may use therapeutic exercise differently. There are disparities between physical therapists' current use of therapeutic exercise for clinical knee OA and recent recommendations. Identifying potential ways to overcome these disparities is an important step toward optimizing the outcome from therapeutic exercise for patients with clinical knee OA. [ABSTRACT FROM AUTHOR]

Background and Purpose Knee pain is a common disabling condition for which older people seek primary care. Clinicians depend on the history and physical examination to direct treatment. The purpose of this study was to examine the associations between simple physical examination tests and serf-reported physical functional limitations. Subjects and Methods A population sample of 819 older adults underwent a standardized physical examination consisting of 24 tests. Associations between the tests and self-reported physical functional limitations (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning subscale [WOMAC-PF] scores) were explored. Results Five of the tests showed correlations with WOMAC-PF scores, corresponding to an intermediate effect (r≥.30). These were tenderness on palpation of the infrapatellar area, timed single-leg standing balance, maximal isometric quadriceps femoris muscle strength (force-generating capacity), reproduction of symptoms on patellofemoral compression, and degree of knee flexion. Each of these tests was able to account for between 7% and 13% of the variance in WOMAC-PF scores, after controlling for age, sex, and body mass index. Three of these tests are indicative of impairments that may be modifiable by exercise interventions. Discussion and Conclusion Self-reported physical functional limitations among older people with knee pain are associated with potentially modifiable physical impairments that can be identified by simple physical examination tests. [ABSTRACT FROM AUTHOR]