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Considering the need to study the experiences of individuals with musculoskeletal problems in contexts that have not yet been investigated as well as the relevance of fostering a research agenda towards person-centred care, this study aimed to explore the experiences of non-specific chronic low back pain from the perspective of Portuguese individuals living with it. An interpretative phenomenological analysis was employed to explore the experiences of eight participants, who were recruited purposefully from two primary care centres and one clinic. Semi-structured one-to-one interviews were carried out, audio-recorded and transcribed verbatim. Three themes were generated as interrelated parts of an extended account that explored the participants’ meaning making of their experience: “Non-specific chronic low back pain as a disruptive experience”; “Searching for the meaning of non-specific chronic low back pain”; and, “Clinical encounters that perpetuate the lack of understanding about non-specific chronic low back pain.” This study offers insight into the Portuguese individuals’ experiences of non-specific chronic low back pain. Particularly, it suggests that clinical encounters may not be aligned with patients’ needs and expectations. These findings may help clinicians in transferring this knowledge to therapeutic approaches to individuals with similar experiences/contexts.IMPLICATIONS FOR REHABILITATIONPatients with NSCLBP need to understand their pain and to retain a sense of control over their lives.Encounters with health professionals may perpetuate the lack of understanding about pain and strategies to control it, as patients consider themselves unable to have an active role in the decision-making and are disempowered to deal with their pain.Health professionals should involve patients and promote the co-construction of an explanation that integrates both health professionals’ knowledge and patients’ narratives.There is a need to align both the patients’ and health professionals’ perspectives regarding health care in order to implement patient-centred and individually tailored treatment. Patients with NSCLBP need to understand their pain and to retain a sense of control over their lives. Encounters with health professionals may perpetuate the lack of understanding about pain and strategies to control it, as patients consider themselves unable to have an active role in the decision-making and are disempowered to deal with their pain. Health professionals should involve patients and promote the co-construction of an explanation that integrates both health professionals’ knowledge and patients’ narratives. There is a need to align both the patients’ and health professionals’ perspectives regarding health care in order to implement patient-centred and individually tailored treatment.

SAICT-POL/23439/2016| LISBOA-01-0145-FEDER-023439). This Grant covers all the planned activities for this study including, the design of the study, data collection, data analysis and interpretation and the writing of this manuscript.The funder did not play any role in the study design, data collection and analysis, decision to publish, or preparation of this manuscript Background Non-specific low back pain (NSLBP) is the most prevalent musculoskeletal condition in western countries and is associated with persistent disability and high consumption of health care resources. NSLBP patients first seek primary health care services but the outcomes are often uncertain. This study aimed to examine the clinical course of the outcomes and to identify prognostic indicators for poor outcomes in NSLBP patients who consulted primary care. Methods A prospective cohort study of 115 patients seeking treatment for NSLBP in primary care was conducted. Participants were consecutively recruited by their General Practitioners (GPs) and then assessed at baseline and 2 and 6 months later. Baseline assessment included socio-demographic and clinical data, psychosocial factors, pain, disability, and health related quality of life (HRQoL). Pain, disability, HRQoL and global perception of change were also assessed at 2 and 6-months’ follow-up. In addition, information regarding the GP’ practice was collected. Poor outcomes were determined according to the cut-off point used to define a persistent disabling condition and the minimal important change established for disability, pain and for global perception of change. The relationship between variables on baseline and poor outcomes was modulated through binary logistic regression analysis. The significance of associations was evaluated at ≤ 0.05 p-value with 95% confidence intervals (CI) and adjusted odds ratios (AOR). Results 110 (94.8%) and 104 (89.7%) participants completed the follow-up assessment at 2 and 6 months, respectively. The mean age (±SD) was 48.06 ± 11.41, with 53.9%, (N = 62) reporting an acute presentation of NSLBP. Six months after GP consultation, 53.8% (N = 56) of the participants reported a persistent disabling condition. An “LBP episode of less than 12 weeks” [AOR: 0.26; 95% CI (0.10, 0.65); AOR: 0.34; 95% CI (0.14, 0.81); AOR: 0.21; 95% CI (0.09, 0.53)],”maladaptive psychosocial factors” [AOR: 2.06; 95% CI (1.40, 3.04); AOR: 1.82; 95% CI (1.27, 2.59); AOR: 1.72; 95% CI (1.20, 2.47)] were significantly associated with poor outcomes on disability, pain and global perception of change, respectively. Besides these factors, being employed reduces the chances of poor outcomes on disability [AOR 0.31; 95% CI (0.11, 0.92)]. Conclusions A large proportion of LBP patients seeking primary health care reported poor outcomes 6 months after GP consultation. Patients who report chronic LBP, maladaptive psychosocial factors and are unemployed have a significant increase in the risk of poor outcome. These findings suggest the need of implementing effective models of care able to provide early screening and appropriate treatment to those at greatest risk of a poor outcome. publishersversion published

Background: Low back pain (LBP) is the leading cause of disability in Portugal and worldwide. The majority of the patients use primary health care services but the treatment outcomes are unknown. Findings of prognostic studies indicate that a marked reduction in mean pain and disability is expected in the first 6-8 weeks, for acute or persistent LBP. Beyond that time frame period, improvement slows and thereafter the probability to develop a persistent disabling back pain condition improves. Therefore, it seems important to measure the patients’ outcomes at this time-point to better assess the effectiveness of the care provided. Objectives: This study aims to describe the short-term outcomes for LBP patients treated in a primary health care centre in Portugal and to identify the prognostic factors for non-recovery and poor health related quality of live (HRQoL). Methods: 116 patients with LBP were consecutively recruited from 7 different primary care units in Portugal. Baseline assessment includes socio-demographic and clinical data, psychosocial factors, pain, disability, and HRQoL. Pain, disability and HRQoL were then assessed at 8-weeks follow-up. A Global Rating of Change Scale to assess patient perception of improvement with treatment was added in the follow-up reassessment. Recovery criteria were determined according to the Minimal Clinically Important Difference established for pain and disability (reduction of ≥30% from baseline). The EQ-5D,3L index was dichotomised into ‘poor’ HRQoL ( Results: Of the 116 participants enrolled, 110 completed the 8-weeks follow-up. (mean age of 48,06±11,41). Approximately half of the participants (53.4%) were acute presentations of LBP. The main treatment strategy was medication (83.5%), with only 8.3% of patients having been referred for physiotherapy. At 8 weeks follow-up, there were statistically significant improvements on pain, disability and HRQoL (p≤ 0.05). However, 38% of the patients reported they felt the same or worse, 76.4% had a poor HRQoL, and only half of the patients reached the established recovery criteria (49% in disability and 50% in pain). In the adjusted model, the probability of non-recovery (p≤0.05) was associated with the presence of maladaptive psychosocial factors (OR: 1.65, 95% CI 1.13-2.40, for pain; OR: 1.61, 95% CI 1.15-2.24, for disability), a chronic pain condition (OR: 1.71, 95% CI 1.33-1.88, for pain; OR: 1.76, 95%CI 1.43-1.89, for disability), and high levels of pain at baseline for pain (OR: 1.26, 95%CI 1.09-1.39). Poor HRQoL was associated to the female gender (OR: 1.88, 95%CI 1.61-1.96), chronic pain condition (OR: 1.68, 95%CI 1.03-1.89) and high levels of pain intensity at baseline (OR: 1.36, 95%CI 1.11-1.67). Conclusion: These results suggest there is a room for improvement in the healthcare delivered to LBP patients in the Portuguese primary healthcare setting. Disclosure of Interests: None declared

Background The results of a recent study have suggested that the current clinical practice is not in line with clinical guideline recommendations and may not be delivering the best outcomes to Low Back Pain (LBP) Portuguese patients. Since the stratified primary care approach has demonstrated clinical and cost-effectiveness in the UK and other countries, the SPLIT project aimed to introduce a similar approach that involves general practitioners (GPs) and physiotherapists (PTs) in the triage and targeted treatment for LBP patients, in Portugal. In order to facilitate the implementation of this project a training program for GPs and PTs was delivered by rheumatologists and PTs. Considering the specific organization of the Portuguese primary care, it was important to explore the perceptions of the GPs and PTs, who attended to the training, regarding the implementation of the SPLIT stratified model of care in the Portuguese context. Objectives Identify and understand the potential barriers and facilitators to the implementation of the SPLIT stratified model of care. Methods After obtaining ethical approval, two focus groups (one for each professional group) were carried out. The focus groups were based on a semi-structured interview schedule, audio-recorded and transcribed verbatim. A thematic analysis was conducted. Firstly, two researchers independently coded the transcripts. Secondly, these researchers discussed the codes and examined their scope and relevance. Thirdly, the researchers developed a coding scheme that included the main themes and sub-themes, as well as the connections among them. Results The potential barriers were identified and explored by both professional groups. The introduction of change into the routine delivery care was identified as one of the most important barriers. According to the GPs` perspective, the possibility of inadequate referral was considered as an issue. The PTs highlighted the challenges inherent to the psychosocial informed physiotherapy treatment of patients classified with high risk of developing persistent and disabling pain. More specifically, they emphasised the need to receive mentoring sessions in clinical practice, in order to develop competences for the management of psychosocial issues. In what concerns to the potential facilitators to the implementation of the model, the participants` personal motivation was considered as one of the most important factors. The alignment of the SPLIT model with the mission and goals of the health care units where the project was going to be piloted was also identified as an important facilitator. Finally, both professionals groups considered that the SPLIT model may facilitate the interdisciplinary approach to the management of this condition, as it clarifies the specific contribution of GPs and PTs in the approach to LBP patients Conclusion The knowledge about the potential barriers and facilitators to the implementation of the SPLIT stratified model of care may contribute to the successful implementation of stratified care for LBP patients in Portugal. References [1] Foster, N., et al. (2018) Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 10137(391): 2368-2383. [2] Gouveia, N., et al. (2016) Prevalence and social burden of active chronic low back pain in the adult Portuguese population: results from a national survey. Rheumatology International. 36(2): 183-97. Disclosure of Interests None declared

Background Research on non-pharmacological treatments for fibromyalgia patients has demonstrated that exercise and education have positive effects on pain and disability1. However, the traditional approach of studying treatment effectiveness based exclusively on quantitative measures has been questioned. There is growing recognition of the importance of integrating patients` perspectives into clinical research. Outcome measures focused on patients` perceptions of improvement have been increasingly used, however they do not offer expanded definitions of what constitutes a “successful” outcome2. The further exploration of patients` perspectives about treatment benefits may contribute to the development of treatments that better match patients` needs. Objectives The aim of this study was twofold: firstly, to examine the effectiveness of a group physiotherapy programme (incorporating exercise and education) on pain intensity, disability and global impression of change in fibromyalgia patients; and, to explore how patients, who achieved success in pain and/or disability (according to the score from the Patient Global Impression of Change Scale - PGIC), understand and make sense of the results. Methods A sequential explanatory mixed methods approach, combining quantitative (1 st phase) and qualitative methods (2nd phase), was carried out. In the 1 st phase, the participants underwent an 8 week (3 times weekly) standardised group programme. Participants were assessed at baseline, 4 and 8 weeks later. Outcome measures included the Numeric Pain Rating Scale (NPRS), the Revised Fibromyalgia Impact Questionnaire (FIQR) and the PGIC. Participants who had scored ≥5 in the PGIC were invited to participate in a focus group. In the 2nd phase, 2 focus groups meetings were carried out to collect data. A semi-structured interview schedule was used and the sessions were audiotaped and transcribed verbatim. Results Thirty-seven participants (females; 49.3±10.2 years) completed the 1 st phase. Analysis using SPSS revealed statistically significant improvements on pain intensity (mean SD change:−1.38±2.363,p=0.001) and disability (−21.577±21.02,p Conclusions The combination of data from both phases provided detailed information about the participants` perceptions regarding the key elements for achieving success with a physiotherapy programme. Further research on patients` perspectives regarding treatment effectiveness is recommended since it may contribute to the design of more effective and patient-centred treatments. References [1] Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases2017;76:318–328. [2] Evans R, et al. “‘I Know It’s Changed’: a Mixed-Methods Study of the Meaning of Global Perceived Effect in Chronic Neck Pain Patients. European Spine Journal2014;23(4):888–97. Disclosure of Interest None declared

Objective: The aim of this study was to compare the effectiveness of a combination of aquatic exercise and pain neurophysiology education with aquatic exercise alone in chronic low back pain patients. Design: Single-blind randomized controlled trial. Setting: Outpatient clinic. Subjects: Sixty-two chronic low back pain patients were randomly allocated to receive aquatic exercise and pain neurophysiology education ( n = 30) or aquatic exercise alone ( n = 32). Interventions: Twelve sessions of a 6-week aquatic exercise programme preceded by 2 sessions of pain neurophysiology education. Controls received only 12 sessions of the 6-week aquatic exercise programme. Main measures: The primary outcomes were pain intensity (Visual Analogue Scale) and functional disability (Quebec Back Pain Disability Scale) at the baseline, 6 weeks after the beginning of the aquatic exercise programme and at the 3 months follow-up. Secondary outcome was kinesiophobia (Tampa Scale of Kinesiophobia). Results: Fifty-five participants completed the study. Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favoring the education group (mean SD change: −25.4± 26.7 vs −6.6 ± 30.7, P < 0.005). Although participants in the education group were more likely to report perceived functional benefits from treatment at 3 months follow-up (RR=1.63, 95%CI: 1.01–2.63), no significant differences were found in functional disability and kinesiophobia between groups at any time. Conclusions: This study’s findings support the provision of pain neurophysiology education as a clinically effective addition to aquatic exercise.

The use of arts, literature and reflective writing has becoming increasingly popular in health professionals education. However, research examining its contribution as an educational strategy to promote narrative reasoning capabilities is limited, particularly from the students' perspective.This study aimed to explore the final year physiotherapy students' perspectives about the contribution of arts, literature and reflective writing in facilitating narrative reasoning capabilities.Three focus group meetings using a semi-structured interview schedule were carried out to collect data. Focus group sessions were audiotaped and transcribed verbatim. Interpretative phenomenological analysis was used to conduct the study and analyze the transcripts.Three themes emerged: (1) developmental understanding of the patients' experiences; (2) developmental understanding about the self; and (3) embedding reflection in clinical practice. Students emphasized an increasing capability to be sensitive and vicariously experience the patient's experience. Through reflective writing, students reported they became more capable of thinking critically about their practice and learning needs for continuous professional development. Finally, students highlighted the contribution of these strategies in making reflection part of their practice.Final year physiotherapy students reported enhanced skills of narrative reasoning. The findings support the inclusion of these strategies within the undergraduate physiotherapy curricula.

Background and objectiveThe SPLIT project aims to introduce an interdisciplinary stratified model of care for patients with low back pain. This study aimed to explore the acceptability and identify potential barriers and facilitators regarding the upcoming implementation of this project, based on the general practitioners' and physiotherapists' perceptions.MethodsA qualitative study was carried out supported by two focus groups, which were conducted by two researchers. A focus group was carried out with each professional group. One focus group included six general practitioners and the other included six physiotherapists. The focus groups were based on a semi-structured interview schedule, audio-recorded and transcribed verbatim. A thematic analysis was conducted.ResultsThe participants explored aspects related to the acceptability of the SPLIT project, emphasising the satisfactory amount of effort that is expected to be required for its implementation. Potential facilitators to the implementation of the model were identified, such as the participants`motivation. Potential barriers were also explored, with particular emphasis on the challenges related to the change of routine care. Lastly, the need for particular adjustments in the health services was also highlighted.ConclusionsThis study`s participants highlighted the feasibility and acceptability of the SPLIT project. The identification of potential barriers and facilitators to its implementation also attained major relevance to better prepare the upcoming implementation of this project. The generalizability of findings to the larger population of relevant practitioners is limited, since only two focus groups were carried out. Therefore, this study`s findings should be considered in terms of transferability to contexts that may have some similarities to the context where the study was carried out.

Narrative reasoning has been presented as a core component of the health professionals' competencies.This study aimed to explore the students' perspectives about the contribution of a narrative reasoning course to promote patient-centred practice.An interpretative phenomenological analysis (IPA) was undertaken through focus groups. Eighteen volunteer final year students participated in three focus groups. Data analysis followed the IPA principles.Three themes emerged: (1) "developing distinctive competencies"; (2) "shifting students' focus" and (3) "challenging students' professional identity". In the first theme, students distinguished their capability to better understand patients' experiences and needs and to be aware of the importance of a collaborative therapeutic relationship. In the second theme, students emphasized a shift from themselves as clinicians towards their patients. Finally, in the third theme participants shared the perspective that they have developed a different clinical profile, and that their reasoning and clinical actions have changed.Students recognized the contribution of the course in developing competencies to facilitate patient-centred practice. Future research is needed to inform lecturers on how to best integrate narrative reasoning within the physiotherapy undergraduate curricula.

Background: Chronic low back pain (CLBP) is a common health problem to which a large number of types of treatments seem to produce similar mean improvement in patient’s symptoms. Individual responder analyses offer the possibility of providing patients and clinicians with supplementary information about the chance of achieving particular degrees of pain relief, which may improve the decision-making process as well as communication with patients. Purpose: To examine the effectiveness of a combined programme of pain neuroscience education and aquatic exercise (EDU+EXE) versus aquatic exercise alone (EXE) in pain intensity in CLBP patients, and to determine the time course of response in pain intensity and the time course of effectiveness for clinically significant improvements. Methods: A single blind randomized trial, was conducted in patients with CLBP lasting >3 months. The EDU+EXE group (n=30) received 2 sessions of pain neuroscience education followed by 12 sessions of a 6-week aquatic exercise programme, whereas the EXE group (n=32) received 12 sessions of the aquatic exercise programme alone. Patients were assessed at baseline, 3 and 6 weeks after the beginning of the aquatic exercise programme and then at a 12 weeks follow-up. The primary outcome was pain intensity (Visual Analogue Scale). Clinically significant treatment response was defined as a pain relief over baseline of >50%. Results: Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favouring the EDU+EXE group (mean SD change: -25.4±26.7 vs -6.6±30.7, p50%) raised from 47% to 70%, at 3 and 12 weeks, respectively. In the EXE group this proportion raised from 25% to 34% (Relative risk of 1.87, and 2.04 respectively). At 3 weeks, 41% of the participants in the EXE group achieved a level of response of “no important change” (