Translation, cross-cultural adaptation and psychometric properties of the Back Beliefs Questionnaire in Modern Standard Arabic.

Purpose To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) into modern standard Arabic and examine its validity, acceptability and reliability in Arabic-speaking patients with low back pain (LBP). Method The BBQ was forward, back-translated and reviewed by an expert committee. Seventeen bilingual patients completed Arabic and English BBQs. LBP patients (n = 199) completed the Arabic BBQ. Sixty-four repeated it a week later, and 151 completed the Arabic Fear-avoidance Beliefs Questionnaire (FABQ). Results The expert committee followed advice from the developers to maintain Arabic equivalence of "back trouble(s)". Patients found the questionnaire comprehensible and acceptable. Agreement between the English and Arabic versions of the BBQ was acceptable, ICC = 0.65 (0.25-0.86). Most item-by-item agreement ranged from fair to moderate (K = 0.12-0.54). Mean (SD) of BBQ, FABQ total, work and physical activity subscales were 25.31(6.13), 44.76(19.49), 21.17(10.10) and 13.95(6.65). The BBQ correlated with the FABQ at r = -0.33, work subscale r = -0.29 and physical activity r = -0.30 (all p < 0.01). Cronbach's α = 0.73 indicated high internal consistency. Test-retest reliability was high, ICC = 0.80 (0.68-0.87). Item-by-item agreement ranged from fair to acceptable (K = 0.31-0.66). Conclusions The Arabic BBQ has good comprehensibility and acceptability, acceptable agreement with the English BBQ, high internal consistency and test-retest reliability. We recommend its use with Arabic-speaking LBP patient to determine their beliefs and attitudes about their back pain, as they have been shown to be important predictors of persistent LBP disability. Implications for Rehabilitation There are limited valid and reliable outcome measures for back pain in Arabic. The Back Beliefs Questionnaire (BBQ) is a tool that measures attitudes and beliefs about back pain. We recommend the use of our valid and reliable, translated and cross-culturally adapted tool with Arabic-speaking patients. The tool can measure attitudes and beliefs concerning the future consequences of LBP, with regards to recovery and return to work in this sample. Findings will improve back pain management options aimed at reducing back pain disability though challenging and modifying beliefs in the Middle East or with migrant populations in the West.

A DELPHI STUDY OF RISK FACTORS FOR ACHILLES TENDINOPATHY- OPINIONS OF WORLD TENDON EXPERTS.

BACKGROUND AND PURPOSE: Achilles tendinopathy can be a debilitating chronic condition for both active and inactive individuals. The identification of risk facors is important both in preventing but also treating tendinopathy, many factors have been proposed but there is a lack of primary epidemiological data. The purpose of this study was to develop a statement of expert consensus on risk factors for Achilles tendinopathy in active and sedentary patient populations to inform a primary epidemiological study. STUDY DESIGN: Delphi study. METHODS AND MEASURES: An online Delphi study was completed inviting participation from world tendon experts. The consensus was developed using three rounds of the Delphi technique. The first round developed a complete list of potential risk factors, the second round refined this list but also separated the factors into two population groups - active/athletic and inactive/sedentary. The third round ranked this list in order of perceived importance. RESULTS: Forty-four experts were invited to participate, 16 participated in the first round (response rate 40%) and two dropped out in the second round (resulting in a response rate of 35%). A total of 27 intrinsic and eight extrinsic risk factors were identified during round one. During round two only 12 intrinsic and five extrinsic risk factors were identified as important in active/athletic tendinopathy while 14 intrinsic and three extrinsic factors were identified as important for inactive/sedentary tendinopathy. CONCLUSIONS: Risk factors for Achilles tendinopathy were identified based on expert consensus, and these factors provide a basis for primary epidemiological studies. Plantarflexor strength was identified as the primary modifiable factor in the active/athletic group while systemic factors were identified as important in the inactive/sedentary group, many of the potential factors suggested for either group were non-modifiable. Non-modifiable factors include: previous tendinopathy, previous injury, advancing age, sex, steroid exposure, and antibiotic treatment. LEVEL OF EVIDENCE: Level V.

The Automatic Detection of Chronic Pain-Related Expression: Requirements, Challenges and the Multimodal EmoPain Dataset.

Pain-related emotions are a major barrier to effective self rehabilitation in chronic pain. Automated coaching systems capable of detecting these emotions are a potential solution. This paper lays the foundation for the development of such systems by making three contributions. First, through literature reviews, an overview of how pain is expressed in chronic pain and the motivation for detecting it in physical rehabilitation is provided. Second, a fully labelled multimodal dataset (named 'EmoPain') containing high resolution multiple-view face videos, head mounted and room audio signals, full body 3D motion capture and electromyographic signals from back muscles is supplied. Natural unconstrained pain related facial expressions and body movement behaviours were elicited from people with chronic pain carrying out physical exercises. Both instructed and non-instructed exercises were considered to reflect traditional scenarios of physiotherapist directed therapy and home-based self-directed therapy. Two sets of labels were assigned: level of pain from facial expressions annotated by eight raters and the occurrence of six pain-related body behaviours segmented by four experts. Third, through exploratory experiments grounded in the data, the factors and challenges in the automated recognition of such expressions and behaviour are described, the paper concludes by discussing potential avenues in the context of these findings also highlighting differences for the two exercise scenarios addressed.

Recommendations to facilitate the ideal fit note: are they achievable in practice?

BACKGROUND: Although the UK fit note has been broadly welcomed as a tool to facilitate return to work, difficulties and uncertainties have resulted in wide variation in its use. Agreement on what constitutes the 'ideal' fit note from the perspective of all stakeholders is needed to inform best practice. A recent Delphi study conducted by the authors reached consensus on 67 recommendations for best practice in fit note use for employed patients. However, such recommendations are not necessarily followed in practice. The purpose of this study was therefore to investigate the perceived achievability of implementing these Delphi recommendations with a further reference panel of stakeholders. METHODS: Potential participants were identified by the research team and study steering group. These included representatives of employers, government departments, trades unions, patient organisations, general and medical practitioners and occupational health organisations who were believed to have the knowledge and experience to comment on the recommendations. The consensus Delphi statements were presented to the participants on-line. Participants were invited to comment on whether the recommendations were achievable, and what might hinder or facilitate their use in practice. Free text comments were combined with comments made in the Delphi study that referred to issues of feasibility or practicality. These were synthesised and analysed thematically. RESULTS: Twelve individuals representing a range of stakeholder groups participated. Many of the recommendations were considered achievable, such as improved format and use of the electronic fit note, completion of all fields, better application and revision of guidance and education in fit note use. However a number of obstacles to implementation were identified. These included: legislation governing the fit note and GP contracts; the costs and complexity of IT systems and software; the limitations of the GP consultation; unclear roles and responsibilities for the funding and delivery of education, guidance and training for all stakeholders, and the evaluation of practice. CONCLUSIONS: This study demonstrated that although many recommendations for the ideal fit note are considered achievable, there are considerable financial, legal, organisational and professional obstacles to be overcome in order for the recommendations to be implemented successfully.

WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY?

UNLABELLED: Achilles Tendinopathy is a complex problem, with the most common conservative treatment being eccentric exercises. Despite multiple studies assessing this treatment regime little is known about the mechanism of effect. This lack of understanding may be hindering therapeutic care and preventing optimal rehabilitation. Of the mechanisms proposed, most relate to tendon adaptation and fail to consider other possibilities. The current consensus is that tendon adaptation does not occur within timeframes associated with clinical improvements, therefore the clinical benefits must occur through another unidentified pathway. This clinical commentary critically reviews each of the proposed theories and highlights that muscle alterations are observed prior to onset of Achilles Tendinopathy and during the disease. Evidence shows that the observed muscle alterations change with treatment and that these adaptations have the ability to reduce tendon load and thereby improve tendon health. The purpose of this clinical commentary is to review previous theories regarding the mechanisms by which eccentric exercise might affect Achilles tendinopathy and offers a novel mechanism by which the plantarflexor muscles may shield the Achilles tendon. LEVEL OF EVIDENCE: 5.

Cross-cultural translation, adaptation, and psychometric testing of the Roland-Morris disability questionnaire into modern standard Arabic.

STUDY DESIGN: Cross-cultural translation, adaptation, and psychometric testing. OBJECTIVE: To cross-culturally translate and adapt the Roland-Morris Disability Questionnaire (RMDQ) into Modern Standard Arabic and examine its validity with Arabic-speaking patients with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The English RMDQ is valid, reliable, and commonly used to assess LBP disability in clinical practice and research. There is no valid and reliable version of the RMDQ in Modern Standard Arabic. METHODS: The RMDQ was forward translated and back translated. An expert committee of musculoskeletal physiotherapists reviewed the translation. Eight patients with LBP evaluated item-by-item comprehensibility. Ten patients piloted the RMDQ for overall comprehensibility and acceptability. Seventeen bilingual patients tested the agreement of the Arabic and English RMDQs. Two-hundred one patients completed the RMDQ and the visual analogue scale. Sixty-four patients were followed-up for test-retest reliability. RESULTS: Translation of most items was uncontroversial. The expert committee found the Arabic RMDQ clinically and culturally appropriate. They reviewed item 11, addressing bending and kneeling, because this has a clinical significance and cultural/religious implication regarding prayer positions. All patients reported that it was easy to understand and complete. The Arabic RMDQ had high overall agreement with the English RMDQ for the global score (intraclass correlation coefficient [ICC] = 0.925; 0.811-0.972). Kappa statistics showed good item-by-item agreement (none ≤0.30). Mean (SD) RMDQ and visual analog scale scores of 201 patients were 10.53 (4.80) and 5.11 (2.28), respectively. The RMDQ had a low correlation against pain intensity (r = 0.259; P < 0.01). A Cronbach α of 0.729 showed high internal consistency. Test-retest reliability of the Arabic RMDQ was good (ICC = 0.900; 95% confidence interval, 0.753-0.951). Kappa statistics were high for 18 items and fair for 6. CONCLUSION: The Arabic version of the RMDQ has good comprehensibility and acceptability, high internal consistency and reliability, low correlation against pain intensity, and good agreement with the English RMDQ. We recommend its use with Arabic-speaking patients with LBP. LEVEL OF EVIDENCE: 3.

Implementation fidelity of self-administered transcutaneous electrical nerve stimulation (TENS) in patients with chronic back pain: an observational study.

OBJECTIVES: The efficacy of transcutaneous electrical nerve stimulation (TENS) for pain relief has not been reliably established. Inconclusive findings could be due to inadequate TENS delivery and inappropriate outcome assessment. Electronic monitoring devices were used to determine patient compliance with a TENS intervention and outcome assessment protocol, to record pain scores before, during, and after TENS, and measure electrical output settings. METHODS: Patients with chronic back pain consented to use TENS daily for 2 weeks and to report pain scores before, during, and after 1-hour treatments. A ≥ 30% reduction in pain scores was used to classify participants as TENS responders. Electronic monitoring devices "TLOG" and "TSCORE" recorded time and duration of TENS use, electrical settings, and pain scores. RESULTS: Forty-two patients consented to participate. One of 35 (3%) patients adhered completely to the TENS use and pain score reporting protocol. Fourteen of 33 (42%) were TENS responders according to electronic pain score data. Analgesia onset occurred within 30 to 60 minutes for 13/14 (93%) responders. It was not possible to correlate TENS amplitude, frequency, or pulse width measurements with therapeutic response. DISCUSSION: Findings from TENS research studies depend on the timing of outcome assessment; pain should be recorded during stimulation. TENS device sophistication might be an issue and parameter restriction should be considered. Careful protocol design is required to improve adherence and monitoring is necessary to evaluate the validity of findings. This observational study provides objective evidence to support concerns about poor implementation fidelity in TENS research.

Communicating with employers: experiences of occupational therapists treating people with musculoskeletal conditions.

PURPOSE: Many employed people with musculoskeletal conditions rely on healthcare practitioners, including occupational therapists, for work-related advice and support. Good communication between healthcare practitioners and employers is considered vital in facilitating work retention and return to work. The purpose of this study was to explore the experiences of occupational therapists in communicating with patients' employers. METHODS: Qualitative data were collected from the responses of occupational therapists to ten statements/open questions in a questionnaire survey of UK occupational therapists. Data were copied verbatim into word documents and analysed thematically. RESULTS: A total of 649 comments were made by 143 respondents. Five themes were identified that were associated with communicating with employers: patient-dependent; employer-dependent; therapist-dependent; extrinsic factors; methods of communication. CONCLUSION: This study has identified that communication between occupational therapists and employers is influenced by a number of factors, including those which are outside the therapists' control. These need to be acknowledged and addressed by therapists, their professional organisation, employers, commissioners, therapy service managers, educators and employees in order to support return-to-work and work retention of people with musculoskeletal conditions.

Validation of two novel electronic devices to time-link transcutaneous electrical nerve stimulation and pain report in patients with chronic back pain.

OBJECTIVES: The analgesic effectiveness of transcutaneous electrical nerve stimulation (TENS) is uncertain. Negative findings, interpreted as ineffectiveness, might be due to poor methodological quality. Monitoring is necessary to differentiate between ineffectiveness and low implementation fidelity. Electronic data-logging devices, "TLOG" and "TSCORE," were developed to monitor and time-link TENS and pain report. TLOG records the time and duration of TENS use and output parameters; TSCORE records time-stamped pain scores. The purpose was to determine the accuracy, reliability, and acceptability of the devices. METHODS: Forty-two outpatients with chronic back pain consented to use TENS daily for 2 weeks. Treatment times and durations were recorded in paper diaries and compared with TLOG data. Using TSCORE, patients reported pain before, during, and after TENS. Pain scores, reported using TSCORE or paper numerical rating scale at the beginning and end of 2 study visits, were compared using Bland-Altman methodology. RESULTS: The mean (SD) difference between paper and TSCORE pain scores was -0.05 (0.81). Limits of agreement (mean difference ± 1.96 SD) were -1.65 to 1.55. Test-retest reliabilities of paper and TSCORE were comparable: Paper mean (SD) difference was -0.33 (0.66), limits of agreement were -1.62 to 0.96; TSCORE mean (SD) difference was -0.10 (0.31), limits were -0.7 to 0.5. TLOG recorded TENS use accurately and worked reliably for 2 weeks in 84% of cases. An overall 79% of participants preferred TSCORE to paper numerical rating scale. DISCUSSION: TLOG and TSCORE are accurate, reliable, and acceptable devices for monitoring TENS implementation fidelity and pain outcome, with potential for improving TENS research methodology and clinical application.

Individual work support for employed patients with low back pain: a randomized controlled pilot trial.

OBJECTIVE: To investigate the feasibility and effectiveness of individual work support for employed patients with low back pain. DESIGN: Pilot randomized controlled trial of a 16-week vocational intervention with six-month follow-up. SETTING: Community/outpatient. PARTICIPANTS: Fifty-one employed participants concerned about their ability to work due to low back pain. Outcome data was obtained for 38 participants at six-month follow-up. INTERVENTIONS: The intervention group received up to eight individually targeted vocational sessions in conjunction with group rehabilitation for low back pain. The control group received group rehabilitation. OUTCOME MEASURES: The feasibility of the intervention was assessed by the recruitment rate, drop-out and loss to follow-up of the participants and the content and delivery of the intervention as recorded by the researcher. The primary outcome measure was perceived work ability. RESULTS: Seventy-three participants were referred to the study over six months. Eighty-seven individual work support sessions were delivered. Thirty-one participants (61% of those retained in the study) attended more than half of the group rehabilitation sessions. The intervention was influenced by the uptake of group rehabilitation, the willingness of the participants to involve their workplace and of their workplace to involve the research therapist. The effect of the intervention on work ability was equivocal. CONCLUSIONS: Although it was possible to recruit participants and to deliver the intervention, considerable methodological problems were identified. However, even if these were addressed, the impact of such interventions is likely to be limited unless there is an integrated approach between healthcare, employers and employees. Further research is required to evaluate work-focused interventions with this client group.

Structural characterization and oligomerization of the TssL protein, a component shared by bacterial type VI and type IVb secretion systems.

The Type VI secretion system (T6SS) is a macromolecular system distributed in Gram-negative bacteria, responsible for the secretion of effector proteins into target cells. The T6SS has a broad versatility as it can target both eukaryotic and prokaryotic cells. It is therefore involved in host pathogenesis or killing neighboring bacterial cells to colonize a new niche. At the architecture level, the T6SS core apparatus is composed of 13 proteins, which assemble in two subcomplexes. One of these subcomplexes, composed of subunits that share structural similarities with bacteriophage tail and baseplate components, is anchored to the cell envelope by the membrane subcomplex. This latter is constituted of at least three proteins, TssL, TssM, and TssJ. The crystal structure of the TssJ outer membrane lipoprotein and its interaction with the inner membrane TssM protein have been recently reported. TssL and TssM share sequence homology and characteristics with two components of the Type IVb secretion system (T4bSS), IcmH/DotU and IcmF, respectively. In this study, we report the crystal structure of the cytoplasmic domain of the TssL inner membrane protein from the enteroaggregative Escherichia coli Sci-1 T6SS. It folds as a hook-like structure composed of two three-helix bundles. Two TssL molecules associate to form a functional complex. Although the TssL trans-membrane segment is the main determinant of self-interaction, contacts between the cytoplasmic domains are required for TssL function. Based on sequence homology and secondary structure prediction, we propose that the TssL structure is the prototype for the members of the TssL and IcmH/DotU families.

The cost effectiveness of NHS physiotherapy support for occupational health (OH) services.

BACKGROUND: Musculoskeletal pain is detrimental to quality of life (QOL) and disruptive to activities of daily living. It also places a major economic burden on healthcare systems and wider society. In 2006, the Welsh Assembly Government (WAG) established a three tiered self-referral Occupational Health Physiotherapy Pilot Project (OHPPP) comprising: 1.) telephone advice and triage, 2.) face-to-face physiotherapy assessment and treatment if required, and 3.) workplace assessment and a return-to-work facilitation package as appropriate. This study aimed to evaluate the feasibility and cost-effectiveness of the pilot service. METHODS: A pragmatic cohort study was undertaken, with all OHPPP service users between September 2008 and February 2009 being invited to participate. Participants were assessed on clinical status, yellow flags, sickness absence and work performance at baseline, after treatment and at 3 month follow up. Cost-effectiveness was evaluated from both top-down and bottom-up perspectives and cost per Quality Adjusted Life Year (cost/QALY) was calculated. The cost-effectiveness analysis assessed the increase in service cost that would be necessary before the cost-effectiveness of the service was compromised. RESULTS: A total of 515 patients completed questionnaires at baseline. Of these, 486 were referred for face to face assessment with a physiotherapist and were included in the analysis for the current study. 264 (54.3%) and 199 (40.9%) were retained at end of treatment and 3 month follow up respectively. An improvement was observed at follow up in all the clinical outcomes assessed, as well as a reduction in healthcare resource usage and sickness absence, and improvement in self-reported work performance. Multivariate regression indicated that baseline and current physical health were associated with work-related outcomes at follow up. The costs of the service were £194-£360 per service user depending on the method used, and the health gains contributed to a cost/QALY of £1386-£7760, which would represent value for money according to current UK thresholds. Sensitivity analyses demonstrated that the service would remain cost effective until the service costs were increased to 160% per user. CONCLUSIONS: This pragmatic evaluation of the OHPPP indicated that it was likely to be feasible in terms of service usage and could potentially be cost effective in terms of QALYs. Further, the study confirmed that improving physical health status for musculoskeletal pain patients is important in reducing problems with work capacity and related costs. This study suggests that this type of service could be potentially be useful in reducing the burden of pain and should be further investigated, ideally via randomised controlled trials assessing effectiveness and cost-effectiveness.

Early identification and management of psychological risk factors ("yellow flags") in patients with low back pain: a reappraisal.

Originally the term "yellow flags" was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability.

Beliefs about back pain: results of a population survey of working age adults.

BACKGROUND: Beliefs about low back pain (LBP) have been widely studied. Research supports the importance of attitudes and beliefs in the development of disability. However, public opinions about LBP have been the subject of few studies to date and more research into public attitudes has been advocated to inform future public health initiatives. OBJECTIVES: To investigate public attitudes and beliefs about LBP, and the association of these with demographic variables. In addition, to determine whether certain group differences in demographic characteristics were useful in predicting individuals with negative attitudes about LBP. METHODS: A stratified sample of 3400 households were invited to participate in the Jersey Annual Social Survey. One thousand five hundred and seventy-four (46.3%) responded and 1132 (71.9%) were identified as being of working age. Complete responses to the Back Beliefs Questionnaire were provided by 1023 (65.0%). RESULTS: Respondents were grouped according to pain report: no current pain, current pain not LBP, and current LBP. Significant differences existed between subgroups for most demographic characteristics. Moreover, beliefs about LBP differed significantly between the 3 groups [F (2,1019)=17.72, P<0.001]. Further analyses were carried out for the subgroups separately. For the Current LBP group, beliefs differed significantly by educational level [F(2,186)=14.65, P<0.001], perceived general health [F (2,187)=4.42, P<0.05], acceptability of work absence [F (2,189)=10.69, P<0.001], LBP impact on activity [F (2,186)=6.38, P<0.01], and previous LBP absence [t (185)=4.84, P<0.001]. Multiple regression using these characteristics produced an adjusted R of 0.25 [F (4,181)=16.33, P<0.001] for the prediction of back beliefs. DISCUSSION: Implications for public health initiatives and future research are discussed.

Investigating decisions to absent from work with low back pain: a study combining patient and GP factors.

BACKGROUND: Determinants of who is and who is not sick-listed following an initial consultation for LBP have received little attention. Both patient and practitioner factors are suggested to be predictive but the interaction has not been investigated. AIMS: To investigate patient and GP factors which determine sickness certification for low back pain. METHODS: Thirty-four General Practitioners recruited 126 patients into the study. Patients completed questionnaires including work status; LBP history; pain; disability, mood and beliefs about back pain. RESULTS: No differences between sick-listed and non-sick-listed groups were observed for age; back beliefs; anxiety; depression or fear-avoidance beliefs about physical activity. Those sick-listed demonstrated greater pain intensity (p=0.009); perceived disability (p=0.040); and fear-avoidance beliefs about work (p<0.000). Regression analyses for GP factors only; patient factors only; and combined GP and patient factors were performed. The ability of the models to correctly classify subjects ranged from 69% for GP variables only; 75% for patient variables only and 82% for the combined model. DISCUSSION: Whether a sickness certificate is issued following an initial consultation for LBP was best explained by combining GP and patient factors. The implications for this in managing absence from work are discussed.

Low back pain patients' experiences of work modifications; a qualitative study.

BACKGROUND: Research indicates that work modifications can reduce sickness absence and work disability due to low back pain. However, there are few studies that have described modified work from the perspective of patients. A greater understanding of their experiences may inform future workplace management of employees with this condition. METHODS: Individual semi-structured interviews were conducted with twenty-five employed patients who had been referred for back pain rehabilitation. All had expressed concern about their ability to work due to low back pain. Data was analysed thematically. RESULTS: Many participants had made their own work modifications, which were guided by the extent of control they had over their hours and duties, colleague support, and their own beliefs and attitudes about working with back pain. A minority of the participants had received advice or support with work modifications through occupational health. Access to these services was limited and usually followed lengthy sickness absence. Implementation largely rested with the manager and over-cautious approaches were common. CONCLUSIONS: There was little evidence of compliance with occupational health guidance on modified work. There appears to be insufficient expertise among managers and occupational health in modifying work for employees with low back pain and little indication of joint planning. On the whole, workers make their own modifications, or arrange them informally with their manager and colleagues, but remain concerned about working with back pain. More effective and appropriate application of modifications may increase employees' confidence in their ability to work.

Staying at work with back pain: patients' experiences of work-related help received from GPs and other clinicians. A qualitative study.

BACKGROUND: Low back pain commonly affects work ability, but little is known about the work-related help and advice that patients receive from GPs and other clinicians. The purpose of this study was to explore the experiences of employed people with back pain and their perceptions of how GPs and other clinicians have addressed their work difficulties. METHODS: A qualitative approach with thematic analysis was used. Individual interviews were carried out with twenty-five employed patients who had been referred for back pain rehabilitation. All had expressed concern about their ability to work due to low back pain. RESULTS: The perception of the participants was that GPs and other clinicians had provided little or no work-focused guidance and support and rarely communicated with employers. Sickness certification was the main method that GPs used to manage participants' work problems. Few had received assistance with temporary modifications and many participants had remained in work despite the advice they had received. There was little expectation of what GPs and other clinicians could offer to address work issues. CONCLUSIONS: These findings question the ability of GPs and other clinicians to provide work-focused support and advice to patients with low back pain. Future research is recommended to explore how the workplace problems of patients can be best addressed by health professionals.

What concerns workers with low back pain? Findings of a qualitative study of patients referred for rehabilitation.

INTRODUCTION: Health and workplace strategies to address work loss and sickness absence due to low back pain are urgently required. A better understanding of the experiences of those struggling to stay at work with back pain may help clinicians and employers with their treatment and management approaches. METHODS: A qualitative approach using thematic analysis was used. Individual semi-structured interviews were conducted with a convenience sample of 25 low back pain patients who had been referred for multidisciplinary back pain rehabilitation. All were in employment and concerned about their ability to work due to low back pain. Initial codes were identified and refined through constant comparison of the transcribed interview scripts as data collection proceeded. Themes were finally identified and analysed by repeated study of the scripts and discussion with the research team. FINDINGS: Five main themes were identified: justifying back pain at work; concern about future ability to retain work; coping with flare-ups; reluctance to use medication; concern about sickness records. CONCLUSIONS: In this study, workers with low back pain remained uncertain of how best to manage their condition in the workplace despite previous healthcare interventions and they were also concerned about the impact back pain might have on their job security and future work capacity. They were concerned about how back pain was viewed by their employers and co-workers and felt the need to justify their condition with a medical diagnosis and evidence. Clinicians and employers may need to address these issues in order to enable people to continue to work more confidently with back pain.