Background and aims. The EU-funded Back-UP project aims to develop a cloud computer platform to guide the treatment of low back and neck pain (LBNP) in first contact care and early rehabilitation. In order to identify evidence-based treatment options that can be recommended and are accessible to people with LBNP across Europe, we conducted a systematic review of recently published guidelines. Methods. Electronic databases, including Medline, Embase, CINAHL, PsycINFO, HMIC, Epistemonikos, PEDro, TRIP, NICE, SIGN, WHO, Guidelines International Network (G-I-N) and DynaMed Plus were searched. We searched for guidelines published by European health professional or guideline development organisations since 2013, focusing on the primary care management of adult patients presenting with back or neck pain (including whiplash associated symptoms, radicular pain, and pregnancy-related LBP). The AGREE-II tool was used to assess the quality of guideline development and reporting. Results. Searches generated 3098 unique citations that were screened for eligibility. A total of 189 full-texts were retrieved, and 18 guidelines were included in the review (from the UK, Germany, France, Italy, Denmark, Poland, Belgium, and the Netherlands). Data extraction showed considerable variation in guideline development processes, especially regarding the methods used for identifying, appraising, and synthesising evidence, and for formulating, agreeing, and grading recommendations. Conclusions. Recommendations for the management of LBNP cover a wide range of treatment options, with self-management advice, analgesics, and exercise proposed as core treatments by most guidelines. A narrative synthesis, taking into account consistency, strength, and quality of guideline recommendations, will be presented. No conflicts of interest. Funding: This abstract presents independent research within the Back-UP project, which has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 777090. This document reflects only the views of the authors, and the European Commission is not liable for any use that may be made of its contents. The information in this document is provided “as is”, without warranty of any kind, and accept no liability for loss or damage suffered by any person using this information

Background and purpose. Adherence to clinical guidelines produces greater improvement in disability in patients with low back pain (LBP), but a wide variation in physiotherapists' adherence has been documented repeatedly. The aim of the study was to investigate the adherence to National Clinical Guidelines for LBP among Danish physiotherapists with regard to three key guideline domains: 1) activity, 2) work, and 3) psychosocial risk factors. Additionally to investigate whether adherence differed between physiotherapists working in private clinics and physiotherapists working at public healthcare centres. Methods. A cross-sectional online survey was conducted with 817 Danish physiotherapists. Adherence to the three guideline domains was assessed using two vignettes. The difference in adherence between the groups was assessed using the chi-squared test. Results. Response rate was 29%. The proportions of physiotherapists giving advice that was strictly in line with the guideline domains were 32% (activity), 16% (work) and 82% (psychosocial risk factors) for Vignette 1 and 6% (activity), 53% (work) and 60% (psychosocial risk factors) for Vignette 2. Physiotherapists working at public healthcare centres were more likely to manage patients strictly in line with National Clinical Guidelines for assessing the psychosocial risk factors. Regarding the two other domains, there was no significant difference between the two groups in terms of adherence. Conclusion. Overall, the participating Danish physiotherapists strictly adhered to only one out of three key domains. This confirms the importance of identifying barriers to implementation of the National Clinical Guidelines in physiotherapy care for patients with LBP, including implementation of the inherent bio-psychosocial model. Conflicts of interest: None. Sources of funding: None

Purpose of Study. To investigate current practice of thromboprophylaxis in major UK spinal centres for both trauma and elective surgery, and to asses compliance with NICE guidelines. Methods. A telephonic survey was carried out which comprised of questions relating to current practice of thromboprophylaxis in major spinal units across the UK. Questions probed practice with regard to trauma versus elective surgery, agents used, timing of prophylaxis, length of treatment and whether practice has changed since the introduction of NICE guidelines. Results. Thirty specialised centres were contacted. Twenty eight centres followed NICE recommendations, with 2 centres using their own protocol. Four centres made changes to their existing protocols after the emergence of NICE guidelines. GCS (Graduated compression stockings) were uniformly used by all, with most centres using flowtron boots and/or foot in addition. The practices are differing within centres for elective versus trauma surgery. Of note, in patients with an acute cord injury, 20 centres used combined pre operative prophylaxis whereas 10 centres used only mechanical prophylaxis. Three units (10 %) describe a noticeable rise in complications related to chemoprophylaxis, whilst only one unit has reported a PE death within the last year. Discussion. Our survey assesses compliance to the NICE guidelines by the UK's spinal units. Mechanical prophylaxis appears to be the most common mode of prophylaxis understandably due to predictable safety profile. Use of chemo-prophylaxis varies amongst different surgeons and centres. Rather than a result of evidence based practice, the decision appears to be related to the previous experiences of that unit. Although the NICE guidelines provide a reasonable platform to the practice of thromboprophylaxis, more studies are required to evaluate the risks of thrombosis and bleeding events in spinal surgery

A statement of the purposes of the study and background:. Merely publishing clinical guidelines is insufficient to ensure their implementation in clinical practice. We aimed to clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care. A summary of the methods used and the results:. We conducted semi-structured interviews with 53 purposively-sampled clinicians from south-west England. Participants were: 16 General Practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses. Thematic analysis showed that official guidelines comprised just one of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organisational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology - “non-specific LBP” - unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services and sparse commissioning of guideline-recommended treatments. A conclusion:. The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centred care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended therapies; and commissioning guideline-recommended treatments for NHS patients

Peninsula Spinal Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK. A retrospective audit in 2000 of cases presenting with metastatic cord compression (MSCC) was conducted. In June 2009 we introduced the role of MSCC coordinator. We present the preliminary results from a 6 month comparative audit and discuss whether implementation of the NICE Guidelines have improved the care pathway. Prospective cohort study with retrospective controlled group. Adults with suspected MSCC. Length of time to MR imaging. % referred for surgical opinion. Length of time on bed rest. % undergoing surgery. Retrospective audit 2000. 38 cases confirmed MSCC. 11 did not have MRI and were treated on the basis of clinical symptoms. Average time from admission to MRI 42 hours. 8 patients (21%) referred for surgical opinion. None had surgery. 38 had radiotherapy. Spinal stability documented on 1 patient. 5.5 days average bed rest. Prospective audit 2009. 54 patients referred to co-ordinator as suspected MSCC. 52 had MRI and 2 had CT. Average time from referral to MRI 41 hours. Average time for patients with neurological deficit 7.6 hours. 54 patients (100%) referred for surgical opinion. 12 patients had surgery (22%). 100% patients had spinal stability documented. Average length of time on bed rest 2 days. It is uncertain whether these results are attributed to the introduction of the NICE guidelines or improved awareness of condition. However we feel that NICE guidelines have improved the care pathway of patients with MSCC. Statement of ethics and interests: Study was approved and registered with audit department

Non-dysraphic intradural spinal cord lipomas are very rare lesions and the management remains controversial. We present our experience with five cases, review the literature and propose guidelines for their management. The case notes of the patients were retrospectively reviewed. An extensive literature search was done, and the relevant articles were analyzed. Between January 2004 and April 2009, we operated on five cases of non-dysraphic intradural spinal cord lipomas. The age at presentation ranged from 17 years to 52 years (mean 32.2). Minimum follow up was 6 months and maximum follow up 5 years. All patients underwent decompression with a laminectomy/ laminoplasty and debulking. The dura was primarily closed in one patient. All patients had regular clinical and radiological follow-up with serial MRI scans. Neurological improvement was noted in all patients. There was significant residual tumour on the MRI scan in all patients. Guidelines for management were formulated on the basis of our experience and literature review. The aim of surgery should be adequate decompression with preservation of neural structures. Aggressive debulking should be avoided. Onset of any neurological symptoms/signs, bowel or bladder symptoms or intractable local symptoms should be an indication for surgery

Aim. To assess whether oncologists are adhering to the NICE guidelines on MSCC. Methods and Results. All patients who received radiotherapy for metastatic spinal cord compression from 1. st. June 2009 – 1. st. June 2010 were identified. This information was then compared to the data collected via the MSCC Coordinator. The notes and radiological investigations were reviewed by the spinal consultant. 34 patients received radiotherapy for MSCC, 15 patients were not referred to the spinal team prior to radiotherapy. On reviewing each individual case 2 patients may have potentially benefited from surgical intervention. Conclusion. Many patients are still not referred for spinal opinion. The vast majority of these patients would not have been suitable for surgery, however, a small number may have potentially benefited

Introduction. Most common osteoporotic fracture. 20-30% of patients with OVFs are presented to hospital while 2.2 million remain undiagnosed, as diagnosis is usually opportunistic. 66,000 OVFs occur annually in the UK with increase by 18,000 cases a year until 2025. 20% chance of another OVF in next 12 months and 3 times risk of hip fracture. Acute painful OVFs poorly tolerated by infirm elderly patients, leading to significant morbidity and 8 times increase in age-adjusted mortality. Materials and Methods. Classify fracture severity and patents with ovfs in 12-month period. To assess follow-up status and if kyphoplasty was offered within 6 weeks as per NICE guidelines. To introduce Royal Osteoporosis Society and GIRFT guidelines on management of symptomatic osteoporotic vertebral fractures. Results. Total no. of patients- 62. Initial pain assessment=40. Pain assessed at ≤6 weeks- 21. Duration from decision to operate to kyphoplasty 8.7 weeks. 11% had kyphoplasty of which 50% noted improvement in pain. 11 deaths. Nearly similar findings to NoSH study. Conclusion. To improve pain assessment on admission of patients with acute osteoporotic vertebral fractures. To follow GIRFT guidelines for early assessment and intervention in patients with acute osteoporotic vertebral fractures to improve pain, mobility and early discharge from hospital. Conflicts of interest. None. Sources of funding. None

Introduction. Spine is a common site for haematological malignancies. Multiple myeloma affects the spine in 70% of cases. New guidelines were published in 2015 to help manage spinal haematological malignancies. Despite neural compression or spinal instability, instrumentation of the spine should be avoided. Surgery carries significant risks of wound complications and more importantly delaying the definitive chemotherapy and radiotherapy. Cement augmentation and bracing for pain and prevention of deformity is key to the new strategies. We aimed to evaluate the different treatment modalities adopted in the spine unit at St George's hospital for spinal haematological malignancies. We compared our practice to the current guidelines published in 2015. Methods. Retrospective review of all spinal haematological malignancy patients who were discussed in the spinal MDT and managed through the spine unit at St George's hospital in the period between April 2019 and February 2021. We analysed the demographics of the patients treated in this period and compared the management modalities adopted in the unit to the current British haematological guidelines. Results. 139 patients were included in this study, 61.9% of them were male. 70 cases came through the MSCC pathway. 15 patients had their spinal involvement in the lumbar spine only below the conus. The Bilsky Grades of the other 124 cases were B0: 35.97 % 1a: 4.31%%, 1b: 7.19%, 1c: 3.59%, 2: 5.75% 3: 32.37%. 43 patients (30.9 %) had neurological deficits on presentation. 70 cases were treated conservatively (50.35%), 21 were treated with brace only (15.1%), 25 had BKP (17.98%) and 23 were treated with instrumentation (16.54%). The number of instrumented cases was small and trending down and cement augmentation and bracing were more frequently chosen for these patients. This comes in accordance to the British haematological guidelines. Conclusion. Utilising BJH 2015 guidelines we have reduced our instrumented operative case load. There is a higher percentage of BKP and Bracing in accordance to the algorithm

Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

Purpose and Background. Clinical practice guidelines (CPGs) recommend self-management for low back pain (LBP). Our recent narrative review on self-management needs revealed a consensus with respect to the critical components of self-management interventions. With mobile health advancements, apps offer innovative support for LBP management. This study aims to identify current apps for the self-management of LBP, assessing them for their quality, intervention content, theoretical approaches, and risk management approaches. Methods and Results. We identified 69 apps for LBP self-management from a systematic search in the UK iTunes and Google Play stores. The most recommended interventions are muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), and core stability exercises (n=32, 46.4%). The average MARS (SD) overall score for the included apps was 2.4 (0.44) out of a possible 5 points, with the engagement and information dimension scoring the lowest at 2.1. In terms of theoretical and risk management approaches, no apps offered a theoretical care model and all failed to specify the age group targeted; only one (1.4%) provided a tailored care approach; 18 (26.1%) included intervention progression; and 11 (15.9%) reported management safety checks. Conclusion. This study shows that app developers generally select interventions endorsed by CPGs. However, the application of a biopsychosocial care model is not being considered. Most of them are of low quality, lacking theoretical approaches to care and consideration of associated risks. It is essential to involve clinicians and patients in developing LBP self-management apps to improve the quality and related approach. Conflicts of interest. None. Sources of funding. No funding obtained. This study has been published in JMIR mHealth and uHealth

Purpose and background. Although clinical guidelines recommend that low back pain (LBP) is best managed in primary or community care, in the UK and globally, LBP accounts for around 4% of emergency department (ED) attendances. Organising and delivering healthcare to be safe, effective, and acceptable requires hearing patients’ perspectives; this study therefore aimed to explore patients’ experiences of attending the ED for LBP. Methods and results. This was a multisite qualitative interview study with 47 adults (aged 23–79 years) who, in the past six weeks, had attended one of four UK NHS emergency departments for LBP (all types and durations). Purposive sampling was used to gain variation in the recruiting site, and LBP and demographic characteristics. Data were collected using individual, semi-structured, telephone interviews (median 45mins). Interviews were audio-recorded, transcribed verbatim, and analysed thematically. We identified significant variation in patients’ experiences of ED care for LBP, which we argue reflects contrasting cultures of ED care. We present three cultures, emergency screening only, ‘cynicism and neglect’, and ‘kindness’; these cultures differ in how they navigate the tension between the ED remit and patients’ perceived needs of care. We draw on Bourdieu's notions of field and habitus and professional identity theory to help explain these findings. Conclusion. Our findings suggest unwarranted variation in ED care for LBP. Implications include the need for urgent access to primary and community care and clarity about best practice managing LBP in the ED; best practice guidance and strategies to implement this should be informed by notions of culture and professional identity. No conflicts of interest.  . Sources of funding. Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Purpose and background of the study. Self-management and behaviour change is at the core of back pain management. Despite the high-rate of recurrence and healthcare utilisation, clinical guidelines do not include guidance for clinicians on return consultations. This project aimed to identify primary care clinicians’ reported practices and experiences of delivering self-management advice for people returning with persistent low back pain (LBP), to inform future delivery of self-management care. Methods and Results. In this qualitative study involving 27 primary care clinicians, four focus groups and two semi-structure interviews were conducted online. GPs (n=5) and physiotherapists working in primary care roles (First contact practitioners n=7, community and interface roles n=7, and mixed roles n=8) in England and Scotland shared their experience of delivering self-management advice to people returning with persistent LBP. Video recordings were transcribed verbatim and analysed with reflexive thematic analysis. Clinicians unanimously shared their frustrations identifying the challenges involved in supporting people who return with LBP. Helpful strategies to support self-management in return consultations were identified by clinicians in addition to service and system-level changes vital to optimise care. Patient-factors affecting delivery of care, lack of defined responsibility and challenges in meeting patients’ expectations illustrated the tensions that exist in return consultations. Conclusion. This novel study provides insight into the experiences and practices of the frontline primary care workforce seeing patients return with persistent or recurrent LBP. It identifies the tensions that exist between services, professional roles and between clinicians and patients regarding self-management. Important practice implications have been identified to improve information-sharing, agenda-setting, and exploring expectations. No conflicts of interest.  . Source of funding. Lisa Osborn-Jenkins is funded by University Hospital Southampton NHS Foundation Trust (UHS) Research & Development PhD Fellowship [GRT0723]

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)

Background. Clinical guidelines recommend epidural steroid injection (ESI) for severe sciatica but there is uncertainty of effectiveness. The POiSE study aims to identify factors, routinely collected in clinical practice that predict outcome in patients who have ESI. This presentation describes characteristics and early clinical outcomes of POiSE participants. Methods. Prospective cohort study in 19 NHS spinal services in England, inviting patients with sciatica listed for an ESI. Participant baseline characteristics and 6-week follow-up outcomes are presented. Outcomes include pain intensity (0–10 NRS), disability (Oswestry Disability Index 0–100) and global change in symptoms. Results. Over 24 months, 693 patients were invited to participate and 353 (51%) completed baseline questionnaires. Mean (SD) age 49.0 years (14.4), 60% female, and 46% (n=101) of those in work had certified time-off for sciatica. Mean pain intensity was 7.2 (2.0) and 6.2 (2.7) for leg and back pain respectively and mean disability (ODI) was 46.5 (18). 60% (n=210) had leg pain for >6 months. Average confidence at baseline (0 to 10) that the ESI would help symptoms was 5.7 (2.4). Of 217 patients reaching 6-week follow-up, mean leg and back pain intensity is 5.0 (2.8) and 4.9 (2.9) respectively and ODI 36.6 (20.4), with 57% reporting improvement (completely recovered/much better/better). Follow-up data collection at 6, 12 and 24-weeks post-ESI is ongoing. Conclusion. Interim analysis shows only just over half of patients are reporting improvement at 6 weeks post ESI. The POiSE cohort study will help better identify the patients with sciatica who are most likely to benefit from this treatment. Conflicts of interest. None. Sources of funding. This study is supported by Health Education England and the National Institute for Health and Care Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Purpose and Background. Guidelines recommend biopsychosocial care for chronic, complex musculoskeletal conditions, including non-specific low back pain. The aims were: 1/ to assess how patients with low back pain respond to osteopathic treatment, both before and after an osteopath has completed a Biopsychosocial Pain Management (BPM) course; and 2/ to assess if it is feasible and acceptable for osteopath participants to receive weekly SCED data and use it to guide patient management. Methods and Results. A multiple baseline single case experimental design trial (. clinicaltrials.gov. , on 18/10/2021, ID number NCT05120921) with 11 UK osteopaths was conducted. Patients were randomised to early, middle or late treatment start dates. Statistical analysis assessed the change between baseline, intervention and follow-up periods. Primary outcomes were the Numeric Pain Rating (NPR) and Patient Specific Function Scales (PSFS), measured during the baseline, the 6-week intervention, and during a 12-week follow-up period. At baseline, the osteopaths reported stronger biopsychosocial attitudes to pain, compared to biomedical beliefs (PABS: 34 behavioural scale; 29 biomedical scale). Overall, patient participants showed daily increases in symptoms during the pre-treatment phase (+0.24/day, p<0.001), and daily decreases during treatment (−2.94 over the treatment phase, p<0.001), which continued post-treatment (−3.36 over 12 weeks, p=0.04). Similar improvements were observed for function. Conclusion. Osteopathic care was shown to help patients with persistent low back pain. Patient recruitment was challenging because of the randomisation. With further development, the method shows feasibility as a means of enhancing research activity among practising clinicians. Previous presentations or publications of the work. The protocol was published (. https://doi.org/10.1016/j.ijosm.2023.100660. ) and presented at SBPR in 2022. The results were presented to an osteopathic conference in October 2023. Ethics approval was received from the University College of Osteopathy Research Ethics Committee. Conflicts of interests. Jerry Draper-Rodi receives fees from the sales of the e-learning course on the biopsychosocial management on the UCO CPD platform. Sources of funding. The research was funded by the Osteopathic Foundation

Background. Advice and education are considered vital components of back pain care within national guidelines. However, a recent systematic review only found low grade evidence for a small average effect. They also reported wide heterogeneity in intervention design and delivery. This review aimed to understand why intervention design varied and what limited effectiveness by examining the underlying theoretical foundations of the studies from that review. Method. Population, context, selection criteria, intervention(s), control, outcome measures, how the intervention was hypothesised to produce outcomes and author recommendations based on results of the study were extracted from text records. The extent to which the advice included matched a published international consensus statement on evidence-based advice for back pain was recorded. Whether interventions or settings were complex was determined using the Medical Research Council complex intervention development and evaluation guidance and the extent to which they met complexity reporting criteria was recorded. Results. The review included 26 trials conducted over 25 years. Differences In causal pathways could explain diversity in intervention design but these were not clearly described or evaluated. All studies were complex in terms of intervention and setting. This was rarely considered in intervention and trial design or when discussing the results. Although interventions were frequently described in detail only a few explained the process and justification of the design. Theories of education or behaviour change were rarely applied. Conclusion. These studies have not deepened our understanding of how education improves outcomes. Future RCTs should engage more with theory and other theory-based research methods should to be considered. Conflict of interest: No conflicts of interest. Sources of funding: No funding

Background. Cauda equina syndrome (CES) is a spinal condition requiring emergency spinal surgery once diagnosed. The patient-reported symptoms are often subtle and none have been shown to be sensitive or specific in confirming CES. Magnetic resonance image (MRI) is the diagnostic gold standard, and guidelines recommend MRI access within 24-hours of symptom presentation. Limited sequence MRI scans (sagittal T2 sequences of the whole spine) have been shown to successfully identify patients with scan-positive CES despite reducing the duration of an MRI. The aim of this audit was to examine utilisation of same-day MRI requests by spinal practitioners from a newly operational same-day emergency care spinal unit over the two-year period. Methods and results. Data was routinely collected over the two-year period and retrospectively reviewed. Data extraction occurred for cases of suspected CES with a same-day scan. Data extraction included type of MRI scan (lumbar/ whole spine/ CES protocol); outcome (admission/ discharge); final diagnosis. After clinical examination, only 258 (24% of 1085) suspected CES cases were identified and scanned within 24 hours, 58% (n=149) of which were with CES limited sequence scans. Only 12% (n=30) demonstrated scan- positive CES resulting in surgery within 24-hours. MRI same-day requests increased between 2020 (n=81, 21%) and 2021 (n=177, 26%), although utilisation of limited sequence scans improved (n=39, 48% in 2020; n=109, 62% in 2021). Conclusion. Limited sequence MRI scans are a time- and cost-saving means of providing screening for those with suspected CES. Improved utility was demonstrated over the 2-year period by the spinal practitioners. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

Introduction. Analgesic drugs are often prescribed to patients with low back pain (LBP). Recommendations for non-invasive pharmacological management of LBP from recent clinical practice guidelines were compared with each other and with the best available evidence on drug efficacy. Methods. Guideline recommendations concerning opioids, non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, antidepressants, anticonvulsants and muscle relaxants from national primary care guidelines published within the last 3 years were included in this review. For each pharmacotherapy, the most recent systematic review was included as the best available evidence on drug efficacy and common adverse effects were summarized. Results. Eight recent national clinical practice guidelines were included in this review (from Australia, Belgium, Canada, Denmark, The Netherlands, UK and US). Guidelines are universally moving away from pharmacotherapy due to the limited efficacy and the risk of adverse effects. NSAIDs have replaced paracetamol as the first choice analgesics for LBP in many guidelines. Opioids are considered to be a last resort in all guidelines, but prescriptions of these medications have been increasing over recent years. Only limited evidence exists for the efficacy of antidepressants and anticonvulsants in chronic LBP. Muscle relaxants are one of the analgesics of first choice in the US, but aren't widely available and thus not widely recommended in most other countries. Conclusions. Upcoming guideline updates should shift their focus from pain to function and from pharmacotherapy to non-pharmacologic treatment options. No conflicts of interest. Sources of funding: This review has been supported by a program grant of the Dutch Arthritis Foundation

Background. Osteopathy has been shown to be effective in the management of chronic low back pain. Guidelines recommend biopsychosocial care for chronic, complex musculoskeletal conditions, including non-specific low back pain but there is a lack of evidence comparing standard osteopathic care, which has traditionally been based on dated and disputed biomechanical theories of dysfunction, with more contemporary biopsychosocial approaches. Methods and results. A multiple baseline single case experimental design trial with 11 UK osteopaths and 60 patients is currently assessing effectiveness of osteopathic treatment for patients with non-specific low back pain of more than 12 weeks’ duration. Patients are randomised to early, middle, or late treatment start dates to increase the validity of inferences about the effects of treatment. Osteopaths have participated in one course on the study protocol and processes pre-participation and will take an e-learning course on the biopsychosocial management of patients with low back pain after the first patient recruitment stage. Statistical analysis will assess the degree and rate of change between baseline, intervention and follow-up periods, and whether differences in effect are observed after the osteopaths have completed the biopsychosocial patient management training course. Primary outcomes will be the Numeric Pain Rating and Patient Specific Function Scales, measured daily at baseline and for 6 weeks during the intervention stage, and weekly or fortnightly during a 12-week follow-up period. Conclusion. This experimental design will offer osteopaths in practice the opportunity to engage in research evaluating the effectiveness of osteopathic care and the influence of a training programme to augment biopsychosocial osteopathic care. Study registration: . https://clinicaltrials.gov/ct2/show/NCT05120921. Sources of funding: The Osteopathic Foundation. Conflict of interest: The authors declare no competing interests. Previous publication of work: This protocol is under review with a peer-reviewed journal