The early stages of low back pain: a pilot study of patient diaries as a source of data.

BACKGROUND: Low back pain accounts for a significant proportion of a GP's workload, but care of the condition is widely regarded as unsatisfactory. Recent recommendations to improve primary care management include more appropriate explanatory models and early access to physical therapy. OBJECTIVES: This study explored the feasibility and utility of patient diaries as a source of qualitative data on patients' experience of low back pain presenting in primary care. METHOD: Within a larger study of physiotherapist-led management of low back pain presenting in general practice, a random sample of patients was invited to keep a record of their illness experience over 7 days using a diary. Patients' written accounts were then subject to qualitative thematic analysis. RESULTS: Diary respondents did not differ from the wider group of patients presenting with back pain. Patients recounted diverse experience of disability, pain and emotional reactions. The specific themes which emerged from our analysis support the relevance to patients of a biopsychosocial paradigm in the management of low back pain. CONCLUSIONS: Diaries are a feasible and valid source of qualitative data in patients with new episodes of low back pain. In addition, they may provide the clinician with useful information and their completion may offer direct benefits to patients.

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.

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.

Management of joint and soft tissue injuries in three general practices: value of on-site physiotherapy.

A prospective study was undertaken to determine the potential benefits in patient management and cost effectiveness of physiotherapists employed by general practitioners compared with direct hospital access and access via consultants. The study involved 401 patients from three rural general practices in south Cheshire and north Staffordshire and took place over six months. On-site physiotherapy in general practice premises resulted in higher referral rates to the physiotherapist compared with the practice using direct hospital access or the practice with access via consultants. Both on site and direct access physiotherapy were associated with fewer prescriptions and lower overall prescribing costs per patient than access to physiotherapy via consultants. There was less time lost from work and normal duties for patients attending the practice with on site physiotherapy compared with those attending the practice which required referral via hospital consultants. Access to physiotherapy via hospital specialists resulted in considerably longer delays than on site physiotherapy and greatly increased the financial costs for the patient. Physiotherapy in general practice premises is a cost effective way of dealing with joint and soft tissue complaints. Direct access to the physiotherapy department within hospitals results in longer delays but provides a satisfactory service. There is little to recommend the utilization of hospital consultants as a means of access to physiotherapy.

What do medical students seek to learn from general practice? A study of personal learning objectives.

With the aim of stimulating learning which is more self directed, fourth year medical students in Liverpool are encouraged to set personal learning objectives for the general practice attachment. On average, a student defines seven objectives for the three week attachment. A classification of objectives derived from the 1989 cohort of students is presented and the objectives could be seen as focusing on the practice population and its health problems, the role of the general practitioner, the work of general practice, the management of general practice, general practice as a career, and general learning. The validity and reliability of the classification are considered. Along with the advantages of this approach in motivating students to learn, the findings are considered in relation to impending changes in undergraduate medical education and the future role of general practice teaching by departments and by practice based colleagues.

Advanced training in general practice in the UK for overseas postgraduates.

The strengths of general practice in the UK as a training environment for overseas doctors intending to implement the World Health Organization strategy 'Health for All by the Year 2000' in primary care are identified. A course of advanced training for teachers and administrators of primary care is described and evaluated in terms of participants' academic achievements and wider issues, including influence upon the development of primary care in their countries of origin.

Continuing education: a survey among general practitioners.

A survey of perceptions of continuing education--content, methods and current provision--was undertaken among all established general practitioners in one health region of the UK using a postal questionnaire. Interviews were conducted with a small random sample of respondents and with a larger sample of non-respondents to the questionnaire. Data from the questionnaire and interviews demonstrated overall a wide diversity of content and methods of continuing education perceived as appropriate, with duration of experience and involvement in undergraduate teaching or postgraduate training as significant determinants. The findings are used to review, critically, current provision of continuing education for general practice and to suggest ways in which future provision might reflect the range of educational need perceived by doctors.

A system of affective learning behaviours for medical education.

Two basic questions are raised about the relationship between emotion and learning, the affective domain of education: how can objectives be defined without specifying 'desirable' attitudes?; and how, as part of learning, do we revised existing attitudes? A model of the affective domain is described which links, in the setting of the consultation, the emotion and learning behaviours of the doctor. The model depicts a system in which emotion and behaviour are interdependent, and existing values can be amended. From the model the attributes of sensitivity and flexibility are defined in terms of the doctor's capacity to modify behaviour and control the impact of emotion. The present unsatisfactory position of affective learning in medical education and training is reviewed; and its importance to general practice re-emphasized. Use of the model to define objectives in this domain is proposed.

Comparative rating of consultation performance: a preliminary study and proposal for collaborative research.

Factors governing the appropriateness, reliability and validity of rating scales in the measurement of professional performance are reviewed. The origin and preliminary testing among undergraduated and general practitioners of a brief consultation rating schedule is described.Statistical criteria are proposed for the analysis of ratings, by groups, in the comparison of consultation performance. Using these criteria the capacity of the 10 rating schedule items to discriminate between two contrasting consultations was examined. Each of the items was used at some time by students or doctors to express significant preference for the same consultation; and on this basis all the items are considered to merit inclusion. One item showed highly significant intra- and inter-observer reliability.The schedule is reproduced in full, together with a data-collection document and significance chart, with the aim of encouraging groups of doctors to test the validity of the items in the comparison of other pairs of consultations. It is proposed that future versions of the schedule should reflect the experience of such groups in testing existing items and in defining additional items which satisfy the proposed criteria.

A method of assessment during vocational training: report of a pilot study.

Problems arising from the present rate of failure of vocational trainees in the MRCGP examination are outlined; and the role of formative assessment during training in reducing this rate is considered. A study is described in which trainees in a number of centres were assessed by a method designed to measure specified cognitive abilities and areas of knowledge. The method, based on written papers, provides each candidate with a profile of performance and generates comparative standards. Reliability of marking, the distribution of candidate-scores within and between areas of assessment and techniques for monitoring the effectiveness of questions are reported. Use of the method by College as an educational service to trainees is considered, along with its potential as a Part I MRCGP examination.

Randomised double blind controlled clinical trial of intranasal budesonide in treatment of hay fever.

The effectiveness of budesonide, a new non-halogenated glucocorticoid administered by nasal inhaler, was evaluated in a double blind comparison with placebo in patients presenting with hay fever. Patients were supplied with antihistamine tablets and eye drops for use when they considered that their symptoms were inadequately controlled by their inhaler. Patients recorded the severity of their symptoms in a daily diary card and visited their general practitioner for assessment weekly for four weeks. All nasal symptoms of hay fever were appreciably reduced in the group taking budesonide and, although their eye symptoms were more severe than in the group taking placebo, they did not use appreciably more eye drops than the latter. The placebo group used appreciably more antihistamine tablets than those in the budesonide group. No patients were withdrawn from the budesonide group because of treatment failure or unacceptable side effects. The results suggest that budesonide is an acceptable and effective treatment for the nasal symptoms of hay fever.

Data-linked groups: a method for continuing professional education.

The relationship is reviewed between standards of performance and the objectives of continuing education. The difficulties of providing continuing medical education which has objectives derived from appropriate standards are illustrated by reference to general practice. A method is described in which a number of small groups of general practitioners attend separate but simultaneous evening meetings linked to a coordinating centre by a viewdata system. In this way the same problems from general practice are presented to each group. Participants respond first as individuals then contribute to group discussion, led by a tutor, from which a consensus approach to each problem emerges. This is transmitted and received along with those from other groups, at the coordinating centre. All responses to a problem are combined there and made available to the groups on viewdata later in the evening. The validity of the exercise is discussed in relation to the type of problem used, the group-consensus and the combining of responses from a number of groups. The method appears to be attractive to general practitioners, relevant to their work and capable of providing continuing education based on appropriate standards of performance. Its possible application to continuing education in other disciplines is referred to.

The assessment of cognitive abilities in clinical medicine.

A study to test the hypotheses that discrete cognitive abilities necessary to clinical practice can be identified and their achievement reliably assessed by methods applicable to a large number of students is described. Eight supposedly discrete cognitive abilities related to clinical consultation were defined and the performance of medical students in them tested by short-answer question papers. In addition, knowledge of specific definitions and of therapeutics was examined. The study, conducted over one academic year, involved 222 medical students--102 in the penultimate, and 120 in the final year of their undergraduate course. Marking strictly to a previously agreed schedule was undertaken independently by three examiners; and students' performance in relation to each ability (and area of knowledge) determined. The findings showed intra- and inter-marker reliability to be highly satisfactory; and student performance in any one ability to be independent of that in any other. This suggests that the cognitive abilities chosen are indeed discrete. The importance of cognitive abilities is discussed in relation to education and training in clinical medicine.