Cite this article: Bone Joint Res 2023;12(3):199–201.

Aim: Examine how individuals on Teesside, diagnosed with mechanical back pain, socially construct the beliefs they hold about their back problem. The Spinal Assessment Clinic, at Middlesbrough General Hospital, uses a comprehensive and co-ordinated approach when assessing and treating individuals. More information demonstrating how people suffering with mechanical back pain are influenced by their psychosocial and cultural beliefs would enable the team to enhance the process. This research, is an anthropological examination of individual’s thoughts and beliefs as they absorb the information extended to them. This will be valuable in enhancing clinicians, sufferers and academics understanding of back pain. The research is still in the recruitment phase. Method: This is an ethnographic study using a phenomenological framework to interpret the narrative and pictorial accounts given by individuals suffering with mechanical back pain as they proceed through their treatment at Spinal Assessment Clinic. Interviews are informal, the intention being to listen to each individuals life story and explore the way in which the narratives evolve, as they explain the lived experience of their pain. Individuals are being recruited from the Spinal Assessment Clinic. One of the research methods utilised is that of pain imagery, with volunteers providing a drawing, representing their back pain. Results: The drawings demonstrate that physical pain is not always viewed by individuals as a biological problem, it may be externalised or expressed as an emotion. The images are filled with vivid metaphors symbolising each individuals unique interpretation of their pain. Conclusion: Initial results demonstrate there is a gap between the patients’ visualisation in their drawing and the narrative accounts provided

Introduction: The purpose of this research is to use an anthropological approach to examine the narratives of individuals living in Teesside, who have been diagnosed with mechanical back pain at a nurse led Spinal Assessment Clinic. The narratives that people use to construct their back pain must be taken into account if they are to be helped, as their beliefs about their problem will impact upon their expectations and compliance. Method: After their first appointment in the Spinal Assessment Clinic, individuals who were diagnosed with mechanical back pain were invited to join the research. Each individual was interviewed three times as they progressed through the clinic system. The second time was after they had or had not attended the back pain management classes. The last interview was after their final review and they were discharged from the clinic. The interviews were casual with very little input from the researcher. Conclusion: Individuals appear to have a hidden agenda when they attend the clinic and this helps them to decide whether to accept or dismiss their diagnosis. The narrative used by the multidisciplinary team is interpreted according to each persons agenda often leaving individuals with a totally different interpretation to that intended by the multi disciplinary team. People appear to tell clinicians what they think they want to hear, but during their interviews for this research different narratives often emerged. Listening to people’s life stories and examining the narrative they use to explain their back problems can enable the multi disciplinary team to better understand individuals and their problems and assist in their own professional development as well as improving services for patients

There is a desire to reduce the economic burden of low back pain. This in is part because of the 226% increase in invalidity benefits paid out for spinal disorders in the ten years to 1994/5. This paper examines the effect of the change from Invalidity Benefit to Incapacity Benefit in 1995, and considers the utility of these figures as a means of assessing changing patterns of back pain disability. Data were obtained from the DSS on how benefit data were collected and numbers of days of Invalidity/Incapacity Benefits that were paid from 1983/4 to 1998/9. The data suggest that since 1995 that the rate of spinal disability has fallen and has now been stable at 90 million days per year for four years. The headline Incapacity Benefit figures have a very loose relationship with health impact of low back pain. Around 30,000 people per year make the transition to claiming long term Incapacity Benefit from claiming short term Incapacity Benefit. Incapacity Benefit figures are of little utility in assessing changes in low back pain disability. Numbers making the transition to Long Term Incapacity Benefit may be a more useful indicator

Radioprotective gowns are an essential part of operating in orthopaedicse. As we are aware from the evidence, surgeons, and in particular orthopaedic surgeons, are at risk of developing chronic neck and back pain. This is likely a result of the combination of of long operations, heavy equipment, radioprotective gowns and poor ergonomic set up. Women are a minority in orthopaedics. Amongst trainees there has been an improvement with 20–25% of current trainees are women, however at consultant level this percentage is a lot lower at 5–7%. Radioprotective gowns worn by trainees are frequently not well fitted and few surgeons have access to bespoke fitted gowns. A questionnaire given to 32 trainees in the region found a significant burden of back pain in trainees and 57% of surgeons felt their gowns were not appropriately fitted. In this study every woman questioned reported back pain as a result of operating and 87% felt the gowns used exacerbated back pain, this figure was 56% in men. 80% of surgeons felt that surgeons would benefit from bespoke fitted gowns, even those that did not themselves have severe back pain. 45% of trainees felt their pain was moderate to severe. In surgery we have the responsibility to protect ourselves and our colleagues from work based injury and illness. Back pain should not be ignored as a symptom and radioprotective gowns is a good place to start. Overall the majority the gowns exacerbated their back pain during or after procedures, worse in women as described above. We can use this data and do what we can to provide trainees with a range of sizes whilst working in hospitals during their training. Anectodally women sizes were less available in the departments and we can work to improve this and reduce the burden of pain amongst surgeons

Objectives. This paper describes the outcomes obtained from a 12 hour group based multidisciplinary functional restoration programme for patients with persistent low back pain who presented with psychosocial obstacles to recovery. The programme was designed to address modifiable psychosocial obstacles to recovery over a four week period, reduce pain related disability, improve pain self-efficacy and reduce patients' reliance on analgesic medication. Design. A single group retrospective analysis. Participants. Data from 54 participants with non-specific low back pain (Male = 26. Female =28, mean age 43.7yrs) who attended a four week functional restoration programme between September 2012 and June 2013 were analysed. Results. There was a statistically significant improvement between Oswestry Disability Index and Pain Self Efficacy scores before and after the treatment intervention, and at 9 month follow-up (p<0.001). When only scores at the end of the treatment intervention and month 9 were compared there was no significant difference (p=0.184 for ODI, p=0.341 for PSEQ). Patients also self-reported reduced reliance on analgesic medication after the treatment intervention and at 9 month follow-up. Conclusion. The findings indicate that a group based multidisciplinary functional restoration programme for patients with persistent low back pain, which targets modifiable obstacles to recovery, can be effective in reducing disability, improving self-efficacy and reducing reliance on medication in both the short and medium term. This article has also been published online in Wiley Online Library (. wileyonlinelibrary.com. ) DOI: 10.1002/msc.1078 in Musculoskeletal Care Journal (2014) © 2014 John Wiley & Sons, Ltd. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose. Cognitive Muscular Therapy (CMT) is a new treatment for low back pain which integrates psychological techniques for pain management alongside training to improve postural control. Rather than focus on postural alignment or strength, CMT aims to improve the regulation of postural tone (low-level activity which supports the body against gravity). This is achieved by teaching patients an awareness of compensatory paraspinal activation, which can be triggered by overactivity of the abdominal muscles. The aim of this study was to understand whether CMT could reduce symptoms associated with low back pain and improve paraspinal muscle activation. Methods and results. Fifteen patients with chronic low back pain received seven weekly sessions of CMT from a physiotherapist. Clinical data was captured at baseline and two weeks after the intervention using the Roland-Morris questionnaire and the pain catastrophising scale. Activation of the erector spinae muscle during walking was also measured at baseline and after the final intervention session. Change data were analysed using paired t-tests. There was a 75% reduction (p<0.001) in the Roland-Morris score from a mean (SD) of 9.3(2.9) to 2.3(2.6), along with a 78% reduction in pain catastrophising (p<0.002) from 16.6(13) to 3.7(4.8). Activation of the contralateral erector spinae muscles reduced by 30% (p<0.01) during the contralateral swing phase of walking. Conclusion. In this small sample, CMT delivered large clinical improvements and reduced activation of the low back muscles during walking. Larger randomised trials are now required to confirm whether CMT could outperform existing physiotherapy treatments for chronic back pain. Conflict of interest. No conflicts of interest. Source of funding. University of Salford

i Background and purpose Although there are now many trials of the effectiveness of back pain treatments, there are few robust cost effectiveness analyses of these treatments. ii Methods and Results: We analysed the cost-effectiveness of adding to ‘best care’ in general practice for patients consulting with low back pain: spinal manipulation; exercise classes; or manipulation followed by exercise (‘combined treatment’) alongside the UK BEAM trial. We collected health care resource use and health-related quality of life data at baseline, 3 and 12 months from 1334 trial participants. We estimated participant-specific quality-adjusted life-years (QALYs) and costs over the 12 months study period. Over one year mean treatment costs relative to ‘best care’ were: £195 (95% credibility interval £85 to £308) for manipulation; £140 (£3 to £278) for exercise; and £125 (£21 to £228) for combined treatment. All three active treatments increased participants’ average QALYs compared with ‘best care’ alone. For each extra QALY that combined treatment yielded relative to ‘best care’, it cost £3,800; in economic terms it had an ‘incremental cost-effectiveness ratio’ (ICER) of £3,800. Manipulation alone had an ICER of £8,700 relative to combined treatment. If the NHS were prepared to pay at least £10,000 for each extra QALY (lower than previous recommendations in the UK), manipulation alone would probably be the best strategy. If manipulation were not available, exercise would have an ICER of £8,300 relative to ‘best care’. iii Conclusions The UK BEAM spinal manipulation package is a cost-effective addition to ‘best care’ for back pain in general practice

Twelve patients presenting with acute low back pain only and demonstrating intensification of low back pain during passive straight leg raising were investigated with CT or MRI scanning. None of these patients had leg pain. The painful and reduced passive SLR was accompanied by further increase in pain on dorsiflexion of the foot and reduction in pain on knee flexion, findings normally associated with sciatic pain due to acute nerve root compression following disc protrusion. Imaging demonstrated significant central disc prolapses at L4/5 or L3/4 in all patients. In those who showed unilateral restriction of passive straight leg raising, the scans revealed central disc protrusions with a disposition to the affected side. None of these patients had neurological deficits effecting the leg, bladder bowels. The clinical presentation, imaging and anatomy of the spinal canal would clearly implicate the anterior dura as being the source of the pain, being compressed by a central disc protrusion. The nerve supply of the anterior dura as opposed to the posterior dura is substantial. The dura as an origin of acute low back pain has received some but not widespread attention in the medical literature. The clinical outcome of these patients typically mimicked those who present with acute sciatica. The majority improved spontaneously and only a small proportion continued to have significant pain some months after the onset of symptoms. Diagnosis of this clinical syndrome, which has not been fully described before, may give some focal point for an explanation of the pain source to the patient and give some lead to further investigations

Purpose and background. Low back pain burdens individuals, society and services, including Emergency Departments (ED), straining services and prolonging wait times. Despite reported personal influences on deciding to attend ED, the role of third-party advice remains underexplored. Sparse guidance for clinicians and service-users highlights the need for effective back pain management strategies, to alleviate system pressure and optimise patient outcomes. This study explored how advice influences the decision to attend the ED for back pain. Methods and Results. From a subtle realist stance, the design was a secondary analysis of qualitative data, where 47 patients (26M:21F, aged 23–79 years) with back pain were purposively sampled from four EDs (2 Northern and 2 Southern) in England between August and December 2021. Eight patients had previously visited ED for this episode of back pain. As this was during the pandemic, semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed using a reflective thematic analysis. Three themes were identified as crucial in making the decision to attend ED: The Healthcare professional; Trusted others; and the Individual. Healthcare professionals often dictated decisions, leaving participants feeling powerless. Trusted others provided varying support levels, often acting as allies. Individuals grappled with anxieties around their condition and treatment expectations. Conclusion. This study highlights the need for clinicians to provide clarity and guidance to individuals and their Trusted others, seeking advice regarding escalation to visit the ED with back pain. There was evidence that worrying about pain was a significant motivator for attending ED, resulting in malalignment with current practice guidelines. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Study design: Prospective cohort study. Objective: To investigate association between recovery from low back pain (LBP) and body mass index (BMI) in patients with LBP undergoing physiotherapy. Introduction: The relationship between obesity and LBP has long been debated. There are no published studies examining the influence of BMI on recovery from LBP. Methods: One hundred and forty patients with chronic LBP and no neurological deficit underwent a back-specific physiotherapy programme. BMI and recovery parameters such as pain intensity (visual analogue scale scores), and self-experienced impairment and disability scores were measured. The range of motion of the lumber spine was also recorded. These variables were compared pre and post treatment. Statistical analysis was performed using paired t tests, Spearman’s rank correlation coefficients and ANCOVA. Results: Mean age was 38 years (range 18–67) with 62% males and 38% females. The treatment resulted in significant improvements in all the recovery parameters (P < 0.005, paired t test). No significant association was detected between the BMI of subjects and % changes in pain intensity, self-experienced impairment and disability, and range of motion of the lumbar spine. A comparative analysis of the after treatment recovery parameter scores in normal (BMI ≤24.9), overweight (BMI 25–29.9) and obese (BMI ≥ 30) revealed no significant differences in the mean pain intensity and mean self-experienced impairment and disability scores. Conclusion: Although a BMI within normal range is desirable for prevention of many health conditions including LBP, it does not influence the overall recovery from low back pain in patients undergoing physiotherapy treatment

Background. Low back pain can lead to neuroplastic changes in the central nervous system, known as nociplastic pain. As nociplastic pain may be provoked by premorbid sensory profiles, such profiles may be prognostic in the development of nociplastic pain over time. Objectives. To investigate whether four sensory profiles are prognostic in the development of symptoms of nociplastic pain in people with acute low back pain. Methods. A longitudinal type 2 prognostic factor research study was performed in accordance with the PROGRESS framework, using a baseline and a follow-up after 12 weeks, between the Adolescent/Adult Sensory Profile and the Central Sensitisation Inventory. Study participants were consecutively included from primary care physiotherapy practices randomly spread throughout the Netherlands. A multivariable regression analysis was performed to adjust sensory profiles by the level of pain, disability, age, and duration of low back pain. Results. After adjustment Low Registration B=0.41, 95%CI (0.37, 0.99), Sensory Seeking B=0.37, 95%CI (0.24, 0.73), Sensory Sensitive B=0.51, 95%CI (0.50, 1.06), Sensation Avoiding B=0.46, 95%CI (0.43, 0.99) were significantly associated with the development of nociplastic pain symptoms. Conclusion. Sensory profiles in people with acute low back pain predict symptoms of nociplastic pain after 12 weeks. Conflict of interest: No conflict of interest. Sources of funding: No funding obtained

Purpose and background. Understanding patients’ expectations of back pain treatment can help improve their experiences, adherence and outcomes. Patients typically expect a diagnosis and exercise-based physiotherapy, but often undervalue the role of psychological factors. This study explored patients’ expectations of outpatient physiotherapy treatment for back pain in primary care. Methods and Results. The design, a secondary analysis of a qualitative cross-sectional study, involved 25 patients (13M:12F), aged 20–81, referred with low back pain (duration 7 weeks to 9 years). This sample did not include patients with serious spinal pathologies, known psychological disorders, or those unable to communicate without assistance. Face-to-face interviews were undertaken in patients’ homes, which were audio-recorded, transcribed verbatim and analysed using the six stages of thematic analysis outlined by Braun and Clarke. Patients expected a caring clinician and a strong therapeutic relationship, where they felt believed, openly communicated with and valued as an individual. Most patients expected a diagnosis and credible explanation for their pain. There was an almost equal split between those keen to take responsibility for their care and those who felt this was the clinicians’ role. Expectations of passive therapies were slightly higher in this study than existing research. Most patients were realistic about outcomes and expected treatment to reduce their pain, but not cure it. Conclusion. A positive experience mattered most to patients, valuing the relational aspects of their care more than the clinical content provided. Patients saw back pain through a biomedical lens, and most failed to recognise the role of psychosocial factors in their condition or treatment. Conflicts of interest. None. Sources of funding. Funding for primary data: Arthritis Research UK (now Versus Arthritis)

Background. Various studies have highlighted issues regarding the prevalence of back pain due to lead apron use. The health and safety executive guidelines on personal protection equipment state that an employee should be able to carry the weight of a lead apron without injury (HSE, 2017). It has been suggested that wearing a 15 pound lead apron can place pressures of up to 300 pounds per square inch of the intervertebral discs (Khalil, 1993), ‘interventionalist's disc disease’ has been identified as a confirmed entity (Ross et al. 1997). Aim. To evaluate the prevalence of back pain amongst theatre staff and correlate this to lead apron use. Methods. Data collection (November 2018 – February 2019) involved the distribution of questionnaires to staff using lead aprons on a routine basis at Salisbury District Hospital. Results. A total of 59 members of staff responded to the questionnaire. The results showed that 30% staff had a previous history of back pain, of these 61% felt that their back pain had worsened since wearing lead aprons. 46% of staff who did not have any previous history of back pain developed new back pain since wearing lead aprons. A total of 46% of staff feel that their back pain has been exacerbated or caused by lead apron wearing. Conclusion. The study highlights that a significant proportion of staff had new or worsening back pain due to lead apron use. This can lead to time off work and could lead to unsafe practice around ionising radiation. No Conflicts of interest No funding obtained

To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic lower back pain. This prospective cohort study was conducted from 20th March 2017 to 19th March 2019. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months. A total of 600 patients were included in the study. The mean age of patients was 44.2 ± 11.92 years. There were 337 (56.2%) male patients while 263 (43.8%) female patients. Baseline mean vitamin-D levels were 13.32 ± 6.10 ng/mL and increased to 37.18 ± 11.72 post supplementation (P < 0.0001). There was a significant decrease in the pain score after 2nd, 3rd& 6th months (61.7 ± 4.8, 45.2 ± 4.6 & 36.9 ± 7.9, respectively) than 81.2 ± 2.4 before supplementation (P < 0.001). The modified Oswestry disability score also showed significant improvement after 2nd, 3rd & 6th months (35.5, 30.2 & 25.8, respectively) as compared to baseline 46.4 (P < 0.001). About 418 (69.7%) patients attained normal levels after 6 months. Vitamin-D supplementation in chronic lower back pain patients may lead to improvement in pain intensity and functional ability

Background and purpose. Trajectories of change over time can illustrate the course of pain. Back pain trajectories have previously been identified among adults. Understanding different patterns of back pain among adolescents could shed light on how persistent back pain develops. We aimed to identify and compare trajectories of back pain among adolescents in the general population. Methods and results. This prospective cohort study followed 1,336 adolescents (initially aged 11 years) every three months for three years, using self-completion questionnaires. Latent class growth analysis was used to cluster subjects into distinct trajectories of back pain. Six clusters were identified. Most subjects (78%) had very low likelihood of back pain throughout follow-up. The second largest cluster (10%) had relatively low and falling probability of back pain. Two clusters (4% each) showed increasing probability of back pain. One cluster had a peak likelihood of pain around age 13 (2%). The smallest cluster (1%) had very high probability of back pain throughout follow-up. The more painful trajectories had significantly fewer males, higher levels of depression and somatization, and lower life satisfaction at baseline, but differed little in physical activity or BMI. Conclusions. Over a fifth of adolescents had trajectories indicating back pain, but a minority had persistent pain problems. Poorer baseline psychological status and female gender were linked with more frequently experienced pain. Trajectories indicating rising or persistent pain might be illustrating the beginning of a long-term pain problem. Headache, facial pain and stomach pain trajectories were also identified in this sample; findings were similar to back pain

Aims. 1. To develop a decision aid - Decision Support Package (DSP) - that will provide low back pain (LBP) patients, and their treating physiotherapists with information on the treatment options available to the patients. 2. To develop a training package for physiotherapists on how to use the DSP. 3. To encourage and evaluate the informed shared decision making (ISDM) process between patients and physiotherapists during consultation. Method. We developed a DSP informed by existing research and collaboration with physiotherapists, patients and experts in the field of decision aids and LBP. We did six pieces of exploratory work: literature review; 2009 NICE LBP guidelines review; qualitative screening of transcripts of interviews of LBP patients; focus groups (patients); nominal group (physiotherapists), and Delphi study (experts). We collated these data to develop the DSP. We also developed a training package for physiotherapists. Results. We developed a LBP patient resource for use prior to their first consultation and a training package for physiotherapists. The DSP contained information on acupuncture, structured group exercise, manual therapy and cognitive behavioural approach. LBP patients would expect these treatment options to be offered to them at their initial consultation. The training package for physiotherapists was on DSP use and communication skills during consultation. Conclusion. We have developed an evidence and theory informed Decision Support Package and physiotherapists training. We are currently piloting its use in one NHS Trust prior to running a pilot RCT (N=150) to test is effect on improving patient satisfaction with LBP patients' treatment choices. Conflicts of Interest. None. Source of Funding. National Institute for Health Research- Research for Patient Benefit (NIHR-RfPB). This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Previous studies revealed the close relation of anxiety and low back pain. Among people with chronic low back pain, anxiety is the most commonly reported mental disorder. Thus, in the literature, there are several studies considering the anxiety as a risk factor for chronic low back pain. The authors also documented a significant differences between sexes in anxiety and quality of life due to low back pain. US National Institute of Mental Health reports that the lifetime prevalence of an anxiety disorder is 60 % higher in women than in men and that the onset, severity, clinical course, and treatment response of anxiety disorders differ significantly in women. In addition, literature has showed that women may have a worse quality of life when they have low back pain. University students may undergo an undue amount of stress, with negative outcomes in terms of academic resuşts and personal, emotional or health, consequences. Moreover, stress can be experienced at different time periods, not only during university life, but also before, during the transition from undergraduate to professional level, and after, during the transition to the life work. After all these literature knowledge, we designed the study to compare the anxiety and quality of life levels of female and male specifically university students with low back pain aged between 18–26. In this study, 100 female and male university students with low back pain aged between 18–26 were included. The low back pain level were measured by Visual Analogue Scale (VAS) and the disability level due to the pain was measured by Revised Oswestry Low Back Pain Disability Questionnaire (ODI). Beck Anxiety Inventory (BAI) was used to evaluate the anxiety level and also, Short Form 36 survey (SF-36) was used to understand the quality of life for subjects. These questionnaires were asked to participants on online platform via Google Forms between March 2020 and May 2020. SPSS Version 25.0 program was used for statistical analyses. The result of the study showed that there was a statistically significant difference between female and male students on anxiety levels (p<0.05). There were no statistically differences between female and male students on ODI and VAS (p>0.05). In female group, BAI and “Physical function” and “General Health” subgroups of SF-36 have negative correlations (p<0.05). When we correlated BAI and all subgroups of SF-36 in male group, the statistical results were showed that negative correlation with all subgroups (p<0.05) except “Energy and Fatigue” subgroup (p>0.05). We conclude that female university students with low back pain have higher anxiety levels than male students. Future studies can work on young students to cope with the psychological problems for well-being

Purpose and background. Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by physiotherapists to patients with back pain at their initial consultation. Patients and methods. Twenty-five audio-recordings of patients with back pain and physiotherapists in a primary care outpatient department were collected, transcribed, coded and thematically analysed using a Framework approach to identify the content of advice given. Results. The mean duration of consultation was 38 minutes 59 seconds (range 26:21–53:16). Advice was given in 88% (n=22/25) consultations and 96% included additional exercise instruction. Cognitive reassurance was evident, focussing on getting people confident to ‘move your back’ despite pain and encouraging active lifestyle changes. Beyond reassurance and discussion to enhance confidence, the key topics of advice given were: activity promotion; postural changes; practical self-help advice regarding ways to sit; pain-management advice including medication and the use of heat. Gaps were identified in the completeness of the advice given and there was a lack of specificity, especially relating to the frequency of recommended tasks and activities. Conclusion. Advice and reassurance are integral to enabling people to self-manage their back pain. Despite its importance, little is known about the advice offered by clinicians. This novel, observational study identifies the topics of advice given by clinicians in back pain consultations and recognises the need for guidance to be patient-centred and specific. No conflicts of interest. Sources of funding: The data were collected as part of Lisa Roberts's Arthritis Research UK academic fellowship [17830]. Lisa Roberts currently holds an NIHR senior clinical lectureship (round 3)

Purpose and Background. Patients with low back pain are increasing globally. Physical dysfunction and psychosocial factors such as stress, anxiety, and fear of movement, often referred to as yellow flags, play a role in the persistence of low back pain. What is not known is the extent to which yellow flags are screened for and treatment adjusted accordingly by Physiotherapists in India. The aim was to determine the current knowledge and awareness of physiotherapists in India regarding psychosocial factors for managing patients with low back pain. Methods. Semi-structured interviews gathered data from of six physiotherapists, The interviews were conducted online. The data was transcribed and analysed using thematic analysis. Results. The main finding was that the physiotherapists in India had a limited knowledge regarding psychosocial factors for management of low back pain. They were not supportive of adding yellow flag screening into their routine treatments due to lack of t awareness of such screening tools Physical elements of low back pain were focused on during treatment by the therapists and recommended by management. The physiotherapists noted that high daily patient volume left them with limited time to alter treatment protocols. Conclusion. There appears to be limited information and education delivered to the physiotherapists in India regarding psychosocial factors for managing low back pain. The addition of these factors in the education and treatment protocols could address these important factors when managing patients with low back pain in India. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained