Back Pain: Breen A

Pincus T, Santos R, Breen A, Burton AK, Underwood M, Anonymous00084. · Royal Holloway, University of London, London, UK. · Arthritis Rheum. · Pubmed #18163411 links to  free full text

This publication has no abstract.

van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A, Anonymous00002. · No affiliation provided · Eur Spine J. · Pubmed #16550447 No free full text.

This publication has no abstract.

Harvey E, Burton AK, Moffett JK, Breen A, Anonymous00150. · Department of Health Sciences, Alcuin College, University of York, York, UK. · Man Ther. · Pubmed #12635637 No free full text.

Abstract: Trials of manipulative treatment have been compromised by, amongst other things, different definitions of the therapeutic procedures involved. This paper describes a spinal manipulation package agreed by the UK professional bodies that represent chiropractors, osteopaths and physiotherapists. It was devised for use in the UK Back pain Exercise And Manipulation (UK BEAM) trial--a national study of physical treatments in primary care funded by the Medical Research Council and the National Health Service Research and Development Programme. Although systematic reviews have reported some beneficial effects of spinal manipulation for low-back pain, due to the limited methodological quality of primary studies and difficulties in defining manipulation, important questions have remained unanswered. The UK BEAM trial was designed to answer some of those questions. Early in the design of the trial, it was acknowledged that the spinal manipulation treatment regimes provided by practitioners from the three professions shared more similarities than differences. Because the trial design specifically precluded comparison of the effect between the professions, it was necessary to devise a homogenous package representative of, and acceptable to, all three. The resulting package is 'pragmatic', in that it represents what happens to most people undergoing manipulation, and 'explanatory' in that it excludes discipline-specific variations and other ancillary treatments.

Parsons S, Breen A, Foster NE, Letley L, Pincus T, Vogel S, Underwood M. · Centre for Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry, UK. · Fam Pract. · Pubmed #17602173 links to  free full text

Abstract: BACKGROUND: Chronic pain has large health care costs and a major impact on the health of those affected. Few studies have also considered the severity of pain in different parts of the body across all age groups. OBJECTIVES: To measure the prevalence and troublesomeness of musculoskeletal pain in different body locations and age groups, in a consistent manner, without using location specific health outcome measures. METHODS: A cross-sectional postal survey of 4049 adults registered with 16 MRC General Practice Research Framework practices. Frequency of chronic pain overall and troublesome pain by location and age was calculated. Logistic regression was undertaken to explore the relationship between chronic pain and demographic factors. RESULTS: We received 2504 replies; response rate 60%. The prevalence of chronic pain was 41%. The prevalence of chronic pain rose from 23% in 18-24 year olds reaching a peak of 50% in 55-64 year olds. Troublesome pain over the last 4 weeks was commonest in the lower back (25%), neck (18%), knee (17%) and shoulder (17%). Troublesome wrist, elbow, shoulder, neck and lower back pain were most prevalent in the 45- to 64-year-age groups. Troublesome hip/thigh, knee and ankle/foot pain were most prevalent in those aged 75 or more. CONCLUSIONS: Great efforts have been made to develop and test treatments for low back pain. Our findings suggest that the overall prevalence of troublesome neck, knee and shoulder pain approaches that of troublesome low back pain and that similar efforts may be required to improve the management these pains.

Konstantinou K, Foster N, Rushton A, Baxter D, Wright C, Breen A. · Spinal Physiotherapy Specialist/Research Physiotherapist, Haywood Hospital/ Primary Care Sciences Research Centre, Keele University, UK. · J Manipulative Physiol Ther. · Pubmed #17416271 No free full text.

Abstract: OBJECTIVE: This study investigates the immediate effects of flexion mobilizations with movement techniques (MWMs) on spinal range of movement in individuals with low back pain and also their impact on pain. A preliminary attempt has been made to describe the clinical profiles of subjects who were thought to benefit from MWMs. METHOD: A small-scale explanatory study was conducted using a crossover design, placebo-controlled, with subjects and assessors blinded. After assessment by physiotherapists, 26 subjects with low back pain with pain on lumbar flexion, thought to be appropriate for treatment with MWMs, participated. Subjects received an MWM intervention and a placebo intervention in a randomized order. Lumbar spinal flexion and extension and pain during flexion were recorded immediately before and after each intervention, using double inclinometry and visual analogue scales. RESULTS: Mean spinal range of movement increased significantly with the MWM intervention, as compared with the placebo (true flexion: MWMs 49.2 degrees [SD 16.4], placebo 45.3 degrees [SD 14.1], P = .005; total flexion: MWMs 76.7 degrees [SD 22.4], placebo 69.7 degrees [SD 21.5], P = .005). Mean pain scores did not change. CONCLUSIONS: The MWMs produced statistically significant, but small, immediate spinal mobility increases but no pain reduction when compared with placebo. By introducing clinical judgment into the subject selection process for the trial, 19 (73%) of 26 subjects benefited from MWMs techniques in terms of range of movement and/or pain intensity, whereas 9 (35%) subjects showed such changes with the placebo intervention.

Pincus T, Foster NE, Vogel S, Santos R, Breen A, Underwood M. · Department of Psychology, Royal Holloway University of London, Egham, Surrey, TW20 0EX, UK. · Man Ther. · Pubmed #16914363 No free full text.

Abstract: Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain (LBP) patients in the UK. We investigated the attitudes of these three professional groups to back pain using a recently developed and validated questionnaire, the Attitudes to Back Pain Scale for musculoskeletal practitioners (ABS-mp). A cross-sectional questionnaire survey was sent to 300 of each professional group (n=900). Responses were analysed from 465 practitioners: 132 chiropractors (28%), 159 osteopaths (34%) and 174 physiotherapists (37%). Overall, all three groups endorse a psychosocial approach to treatment, and see re-activation as a primary goal. However, physiotherapists and osteopaths tend to endorse attitudes towards limiting the number of treatment sessions offered to LBP patients more than chiropractors, and chiropractors endorse a more biomedical approach than physiotherapists. When practice setting (NHS versus private practice) was considered (in physiotherapists alone), physiotherapists working for the NHS endorsed limiting the number of treatment sessions more than those working in the private sector and would also less frequently advise their patients to restrict activities and be vigilant. The results may help explain current clinical practice patterns observed in these groups and their uptake of clinical guideline recommendations.

Pincus T, Vogel S, Santos R, Breen A, Foster N, Underwood M. · Department of Psychology, Royal Holloway, University of London, Egham, Surrey, UK. · Clin J Pain. · Pubmed #16691092 No free full text.

Abstract: OBJECTIVES: Little is known about practitioners' beliefs and attitudes to the treatment of low back pain, and whether these influence their clinical decisions, intervention strategies, and patient-centered outcomes. This study aimed to develop, test, and explore the underlying dimensions of a new questionnaire, the Attitudes to Back Pain Scale (ABS), in a specific group of clinicians, practitioners who specialize in musculoskeletal therapy. METHODS: Items for the draft questionnaire were derived from interviews with practitioners (chiropractors, osteopaths, and physiotherapists). The draft questionnaire (52 items) sought to assess practitioners' attitudes concerning role and self-image plus their beliefs about treatment goals and prognosis of low back pain. The questionnaire was sent to a random selection of 300 practitioners from each professional group, and 546 (61%) responded. Split-sample analyses were performed using exploratory and confirmatory factor analysis. RESULTS: Separate exploratory analyses were done for attitudes concerned with personal interaction (34 items) and attitudes about treatment orientation (18 items), producing six domains: limitations on sessions, psychologic, connection to health care system, confidence and concern, reactivation, and biomedical. Confirmatory analyses indicated that the model tested presented a good fit. Validity interviews revealed high agreement of categorization and low levels of difficulty in categorizing the items. CONCLUSIONS: The internal structure of the new questionnaire not only shows excellent psychometric properties and good face validity, but also has the added advantage of being developed with a specific clinical context in mind. Additional evaluation is required to fully describe the psychometric integrity of this instrument.

Breen A, Austin H, Campion-Smith C, Carr E, Mann E. · Institute for Musculoskeletal Research and Clinical Implementation, AECC, 13-15 Parkwood Road, Bournemouth, Dorset BH5 2DF, UK. · Eur J Pain. · Pubmed #16434220 No free full text.

Abstract: BACKGROUND: Biopsychosocial management of non-specific back pain in general practice has been problematical, with frequent inappropriate referral for imaging and secondary care interventions and lack of self-confidence in the ability to provide evidence-based care. AIMS: To examine GP attitudes to managing back pain as a biopsychosocial problem in order to inform future educational strategies that may improve practice. METHODS: Twenty-one GPs from separate practices within the Dorset and Somerset Strategic Health Authority area (UK) participated in telephone interviews leading to the development of vignettes to refine the theoretical framework for subsequent focus group interviews about evidence-based back pain management. Transcripts were analysed thematically. RESULTS: There were 5 main emergent themes. These were generally negative and dominated by concerns about doctor-patient interaction. They included feelings of frustration, mismatches of perceptions in the doctor-patient relationship, problems in relation to time, challenges and discord between stakeholders in the process (for example, over sickness certification) and a lack of resources for education, awareness and local services to refer to. Psychosocial aspects of the actual care process were rarely raised. Participants favoured education that is multidisciplinary, in small group format and involves the participation of patients. CONCLUSIONS: This study illustrates the difficulties that GPs may have in applying the relevant evidence for the successful management of back pain. A desire to avoid conflict in the relationship with patients explained much of the problem of implementing evidence in general practice. This indicates a need for insightful educational strategies that involve active GP participation.

Pincus T, Vogel S, Breen A, Foster N, Underwood M. · Department of Psychology, Royal Holloway, University of London, Egham, Surrey TW20 0EX, UK. · Eur J Pain. · Pubmed #16291300 No free full text.

Abstract: AIMS: (a) To investigate how widespread is the use of long term treatment without improvement amongst clinicians treating individuals with low back pain. (b) To study the beliefs behind the reasons why chiropractors, osteopaths and physiotherapists continue to treat people whose low back pain appears not to be improving. METHODS: A mixed methods study, including a questionnaire survey and qualitative analysis of semi-structured interviews. Questionnaire survey; 354/600 (59%) clinicians equally distributed between chiropractic, osteopathy and physiotherapy professions. Interview study; a purposive sample of fourteen clinicians from each profession identified from the survey responses. Methodological techniques ranged from grounded theory analysis to sorting of categories by both the research team and the subjects themselves. RESULTS: At least 10% of each of the professions reported that they continued to treat patients with low back pain who showed almost no improvement for over three months. There is some indication that this is an underestimate. reasons for continuing unsuccessful management of low back pain were not found to be primarily monetary in nature; rather it appears to have much more to do with the scope of care that extends beyond issues addressed in the current physical therapy guidelines. The interview data showed that clinicians viewed their role as including health education and counselling rather than a 'cure or refer' approach. Additionally, participants raised concerns that discharging patients from their care meant sending them to into a therapeutic void. CONCLUSION: Long-term treatment of patients with low back pain without objective signs of improvement is an established practice in a minority of clinicians studied. This approach contrasts with clinical guidelines that encourage self-management, reassurance, re-activation, and involvement of multidisciplinary teams for patients who do not recover. Some of the rationale provided makes a strong case for ongoing contact. However, the practice is also maintained through poor communication with other professions and mistrust of the healthcare system.

Breen A, Carr E, Mann E, Crossen-White H. · Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic, Bournemouth, UK. imrci@ · J Nurs Manag. · Pubmed #15089958 No free full text.

Abstract: OBJECTIVES: (1) To determine the acceptability of the Royal College of General Practitioner Guidelines to small samples of nurses, General Practitioners and acute back pain patients, (2) to determine what additional roles for nurses in the management of acute back pain in primary care might be acceptable to these samples, (3) to evaluate the responses of General Practitioners, nurses and patients to a suggested service model based on the RCGP Guidelines, (4) to identify opportunities for and barriers to the further development of such models and to obtain the appraisal of the above by an external group of assessors. METHODOLOGY: Using a qualitative design the pilot study included Primary Care (General Practitioners, Practice Nurses and Patients) with the main outcome measures as: appraisal questionnaires (for RCGP Guideline), qualitative content analysis of focus group narratives, and appraisal of process and outcomes by an external panel. RESULTS: Attitudes towards the RCGP guidelines were positive, but professionals and patients alike did not think their recommendations could be implemented with the current service provision in primary care. There was criticism by professionals of the capacity for a nurse-led service within practices. Access to chiropractors, osteopaths and/or specialist physiotherapists in National Health Service primary care was raised as a need by both groups. All members of the Advisory Panel approved the processes for the recruitment of participants, focus group questions and analysis. DISCUSSION: Barriers to implementation of the RCGP Guideline and to a nurse-led acute back pain service in general practice, were illustrated. These mainly relate to grossly inadequate capacity to deal with multidimensional patient needs, allowing progression to chronic pain states and much higher health care costs. There was a strong desire to include a different group of professionals in primary care. We recommend a local needs assessment and consideration of a national strategy for the implementation of the RCGP Guideline in primary care.

Breen A, Breen R. · Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic, Bournemouth, Dorset, United Kingdom. · Clin J Pain. · Pubmed #12840621 No free full text.

Abstract: OBJECTIVES: This study sought to determine what functional and affective outcomes had the most predictive value for overall satisfaction and improvement in patients seeking chiropractic treatment of low back pain. METHOD: Baseline questionnaires were completed by 965 patients seeking chiropractic help for low back pain, with blinded follow-up at 6 weeks. Patients were asked about effects on pain, anxiety, normal activity, work, depression, lifestyle, satisfaction, and overall improvement. Stepwise multiple regression analyses were used to evaluate the contribution of change scores to overall improvement and satisfaction. A 2-stage block regression was conducted to find out what additional factors besides overall improvement predicted patient satisfaction. RESULTS: There were weak to moderate, but highly significant, relationships between the change scores and both improvement and satisfaction. However, most of the variance (57%) in the latter was explained by overall improvement and a very small amount (0.5%) by improvements in activity, leaving nearly 43% unexplained by any of the variables. Pain, work, and ability to control pain together predicted 27% of the variance in overall improvement. No other variables predicted this, leaving 73% of the variance unexplained. DISCUSSION: Pragmatic rather than affective variables played some part in predicting satisfaction through global improvement in these patients. This should help to inform future interpretation of clinical trials of chiropractic treatments for back pain. However, the nature of the "unknown" components needs further investigation. There are initial indications in the literature that information giving, and the reconfiguration of patients' perceptions of the problem, may contribute to patient satisfaction generally. Further work is needed to confirm this and to establish where such interventions can also contribute to overall improvement.

Breen A. · No affiliation provided · BMJ. · Pubmed #9915748 links to  free full text

This publication has no abstract.

Breen A, Vogel S, Pincus T, Foster N, Underwood M, Anonymous00666. · No affiliation provided · J R Soc Med. · Pubmed #16738363 links to  free full text

This publication has no abstract.