Ian Stanley

The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting.

Study Design. Three hundred patients, attending their general practitioners with attacks of acute low back pain, formed the subject population for a study of fear avoidance and other variables in the prediction of chronicity. Follow-up was at 2 and 12 months. Objective. The hypothesis to be tested was that evidence of psychological morbidity, particularly fear-avoidance behavior, would be manifest from the outset of the presenting attack in susceptible subjects. Summary of Background Data. While back pain is an almost universal human experience, only about 5% of sufferers seek medical advice. Most of these respond to conservative treatment. However, approximately 10% of those who experience an acute attack of low back pain go on to become chronic sufferers. Methods. Psychosocial and physiological data (including fear-avoidance measures) were collected from a sample of 300 acute low back pain patients within 1 week of presentation and at 2 months, to try to predict 12 month outcome. Results. Data analysis showed that subjects who had not recovered by 2 months were those who went on to become chronic low back pain patients (7.3%). Using multiple regression analyses, fear-avoidance variables were the most successful in predicting outcome. Using multiple discriminant function analyses, the results suggest that the outcome in terms of the future course of low back pain can be correctly classified in 66% from fear-avoidance variables alone and in 88% of patients from all variables. Conclusions. The results suggest that, at the earliest stage of low back pain, fear of pain should be identified by clinicians and, where this is severe, pain confrontation should arguably form part of the approach to treatment.

Chronic low back pain rehabilitation programs : A study of the optimum duration of treatment and a comparison of group and individual therapy

Study design. Eighty‐four patients with chronic low back pain were treated using cognitive behavioral principles on a pain management program. Outcome data were collected at four points: 10 weeks before treatment, immediately before and immediately after treatment, and 6 months after treatment. In part 1 of the study, patients were assigned randomly to group or individual treatment contexts. In part 2 of the study, patients were assigned randomly to programs of 15, 30, or 60 hours duration. Objectives. To identify the differences in outcome between programs that treated patients as part of a group and those that treated patients individually and the effects of duration of treatment on outcome. Summary of Background Data. Cognitive behavioral programs have been shown to be an effective means of managing chronic low back pain. The literature is concerned with group programs, however, the duration of which vary widely. Method. Psychological and functional variables were measured before and after treatment and at the 6‐month follow‐up visit. Changes in these variables were measured, and comparisons were made between group and individual programs and between 15‐, 30‐, and 60‐hour programs. Results. Data analysis showed a significant, beneficial effect of intervention in terms of the majority of variables; however, these changes were generally independent of whether patients were treated as part of a group or individually and whether patients completed a 15‐, 30‐, or 60‐hour program. Conclusions. Cognitive behavioral rehabilitation programs have been demonstrated to be an effective means of reducing psychological distress, of changing cognition, and of improving the function of patients with chronic low back pain; however, the length of program and whether patients were treated individually or as part of a group did not affect outcome. This finding has clinical and economic implications.

A primary care perspective on prevailing assumptions about persistent medically unexplained physical symptoms.

Objective: To re-examine the widespread assumption that medically unexplained physical symptoms represent discrete syndromes resulting from somatization of mental illness. Method: Primary care patients (N = 223) with medically unexplained symptoms of at least one years duration were recruited to a study of exercise therapy. Data gathered from patients, from their general practitioners, and from medical records were used to examine relationships between self-defined disability, symptoms, mental state, and use of health care. Results: Levels of disability and health care use were both raised, but were only weakly correlated. While most patients were depressed and/or anxious, a minority (14 percent) were neither. Although mental state correlated with disability, health care use was unrelated to either. Among a wide range of recorded symptoms, few correlations were found to support the existence of discrete syndromes. Analysis of agreement between patients and their doctors in assigning symptoms to broadly defined “syndromes” appears to reflect collaboration that is largely expedient. Conclusions: In this sample of primary care patients with persistent unexplained physical symptoms, we found little evidence of discrete somatic syndromes. The level of health care use is no indication of mental state or level of disability, and the findings are equally consistent with depression or anxiety being secondary to disability and its consequences as with them being primary. The observed collaboration between patients and their doctors carries the risk of shaping, reinforcing, and legitimizing dubious syndromes.

Adherence to Group Exercise Physiotherapist-led experimental programmes

Summary One response to the increasing demand for physiotherapy services from primary care is to develop group exercise programmes led by physiotherapists operating in an educational/advisory role. However, since physical symptoms in patients referred from primary care are often mediated by complex and unrecognised psychosocial factors, it is not clear what format of group physiotherapy will engage such patients in a programme of exercise training. This paper reports problems experienced with patient engagement in physiotherapist-led groups undertaking either an aerobic exercise or a stretching and relaxation programme. The programmes formed, respectively, the intervention and control arms of a study investigating the role of exercise in primary care patients with persistent unexplained physical symptoms. We outline ways in which these problems were addressed and review our experience in the light of previous research on patient engagement with exercise.

Detection of depression in primary care : Comparison of two self-administered scales

Two self‐rated questionnaires, SELFCARE (D) and Hospital Anxiety Depression (HAD) Scale, were compared in relation to their efficacy in detecting depression in 72 elderly patients attending general practitioners at a health centre in Liverpool, England. The sensitivity, specificity and overall misclassification rates of both the scales were assessed against a diagnosis arrived at by using a standardized interview schedule, Geriatric Mental State (community version), and a computerized diagnostic scheme, AGECAT. In this preliminary study, SELFCARE (D) was found to be superior to HAD as a screening instrument for depression in the elderly population in primary care.

Wrong Problem, Wrong Treatment Unrecognised inappropriate referral to physiotherapy

A combination of increasing demand from primary care and limitations on the capacity of NHS physiotherapy services to respond is likely to re-open the debate about the appropriateness of referred cases. Musculoskeletal symptoms are the commonest, and an increasing, reason for direct referral from primary care to physiotherapy. However, evidence suggests that in primary care such symptoms often reflect somatisation of patients’ unrecognised mental illness. In a study of primary care patients with persistent physical symptoms due to somatisation of mental illness, we found a substantial minority (45%) who had been referred for one or more courses of physiotherapy. We present case histories from a number of patients who had received physiotherapy to illustrate patterns of somatisation of mental illness. Physiotherapy does not appear to benefit and may harm such patients by reinforcing their somatic orientation and delaying access to more appropriate interventions. The absence of recent published accounts of inappropriate referral from general practice to physiotherapy suggests that the problem of somatisation is either not recognised or not acknowledged by the two professions. We consider approaches to reducing this type of inappropriate demand on physiotherapy services.

Videotaped exercise instruction: A randomised controlled trial in musculoskeletal physiotherapy

Rising demand for physiotherapy services suggests the need for strategies which delegate greater responsibility to patients for their own care. The transfer of self-treatment knowledge and skills by face-to-face instruction or in writing have both practical and theoretical disadvantages when compared with instructional videotapes for use by patients at home. Advice and exercise instruction on videotape has not been formally evaluated in clinical practice. The present study compared the effectiveness of videotape with face-to-face instruction for two common musculoskeletal conditions. Primary care patients referred to physiotherapy were randomly assigned to one of three types of instruction. Two of the groups were provided with instructional videotapes—one featuring the treating physiotherapist, the other an anonymous physiotherapist; the third group was instructed using traditional face-to-face methods. Outcomes were assessed at 4-6 weeks using a range of measures. Patients in the videotape groups were prescribed more exercises and were more skilled in performing them than were the face-to-face group. However, in terms of clinical progress, instruction by videotape was no more effective than face-to-face. Videotaped instruction proved popular and appeared to help motivate patients to continue self-treatment but produced no detectable saving in physiotherapist time in consultation.

Monitored access and self scoring in computer assisted learning for family medicine

Abstract A CAL package for medical students, designed to increase problem-handling skills in family medicine is described. Based upon the responses of established practitioners, the package permits anonymous free text entry and self assessment moderated by internal categorization of responses. Student access and self-scoring are monitored by a parallel teacher program. The choice of programming language and aspects of software design for this project are discussed. The moderated self-scoring process, which is felt to have wider application in CAL, is described in detail. Observation of the package in use and other aspects of evaluation are considered.

An evaluation of Enpharm, a computer assisted learning program for pharmacists

Enpharm is a computer assisted learning program for pharmacists. It is based on case studies which occur in community practice. Pharmacists using the program respond to cases presented by free‐text entry, then compare their input with that of a peer group of 76 community pharmacists.

ENPHARM: self-scoring computer-assisted learning for pharmacists

Abstract Postgraduate continuing education in community pharmacy is entering a new phase in its development, with an increased emphasis on distance learning. With the widespread adoption of computer systems, both in pharmacies and at home, the potential exists for computer-assisted learning (CAL) to make a significant contribution to distance learning by community pharmacists. ENPHARM is a major initiative in the use of CAL for pharmacy postgraduate education. The program provides a self-scoring exercise in responding to case problems which present in community pharmacy practice. The methods used to develop this program, including peer group comparison and free text entry, are described and analysed. The validity of such an approach in the context of postgraduate education for professionals and the methods used for self assessment are discussed critically.