Effects of an e-learning programme on osteopaths’ back pain attitudes: a mixed methods feasibility study

A thesis submitted to the University of Bedfordshire, in partial fulfilment of the requirements for the degree of Doctor of Philosophy.i. Background Guidelines recommend the biopsychosocial (BPS) model for managing non-specific low back pain (NSLBP) but the best method for teaching this model is unclear. Printed material and face-to-face learning have limited effects on practitioners’ attitudes to back pain. An alternative way is needed and e-learning is a promising option. E-learning is becoming an important part of teaching, but little guidance is available to the osteopathic profession. ii. Purpose This study had four aims. First to assess the feasibility of running a main trial to test the effectiveness of an e-learning programme on the BPS model for NSLBP on experienced practitioners’ attitudes to back pain; secondly, to assess the acceptability of the e-learning programme and the use of the internet as a mode of CPD; thirdly to provide an effect size estimate; and finally to explore the participants’ views on the e-learning programme and its possible impact on their reported behaviour. iii. Methods First a scoping review of the BPS factors and assessment methods for NSLBP was conducted. It informed the content of an e-learning programme that was designed and developed, and informed by a behaviour change model and an e-learning developmental model. An explanatory mixed methods feasibility study was conducted: first, a pilot Randomised Controlled Trial (RCT) assessed experienced osteopaths’ attitudes before and after the intervention, using the Pain Attitudes and Beliefs Scale (PABS) and the Attitudes to Back Pain Scale for musculoskeletal practitioners (ABS-mp); then semi-structured interviews explored participants’ views on the e-learning programme and its possible impact on their reported practice behaviours. ii iv. Results 45 osteopaths, each with at least 15 years of experience consented to, and took part in, the study. The two trial arms were: a 6-week e-learning programme (intervention group) and a waiting-list group (control group). 9 participants were interviewed for the qualitative strand. The feasibility of conducting a main trial was good, the intervention was well accepted and the adherence to the intervention was good. An effect size estimate was calculated to inform sample size for a main trial. In the qualitative strand, participants’ views on the BPS model fell in with the themes of being Not structural enough, being Part of existing practice and being Transformative. v. Conclusion(s) This study provided new knowledge that had not been reported before in several areas:  how an e-learning programme for experienced manual practitioners should be developed,  a new intervention was reported (e-learning programme), including its design and acceptability,  osteopaths’ views on using the internet as a form of CPD,  information on the challenges faced in implementing a BPS approach

Exploring professional circus artists’ experience of performance-related injury and management

AIMS: Circus is a physically demanding profession, but injury and help-seeking rates tend to be low. This qualitative interview study explored the perceptions and beliefs about injury and help-seeking of circus artists. METHODS: Ten professional circus artists (5 males, 5 females; mean age 33 yrs, range 27-42) were enrolled. Individual, semi-structured interviews were conducted until data saturation of themes was reached. Data were analysed thematically. FINDINGS: Four themes were identified: 1) the injured artist; 2) professionalism; 3) circus life; and 4) artists' experience of healthcare. Most participants described the circus as central to their lives, and injuries had wide-ranging psychosocial consequences. Injury adversely affected participants' mood and threatened their identity. Situational and personal factors (e.g., the belief that pain was normal) pushed participants to use adaptive strategies to perform when injured. Continuous touring and financial constraints affected help-seeking. Easy access to healthcare was rare and participants often self-managed injuries. Experiences of healthcare varied, and participants desired flexible and accessible approaches to prevention and injury management. A modified version of the integrated model of psychological response to injury and rehabilitation process and the concept of identity provided a framework to understand participants. CONCLUSION: Injuries had extensive negative consequences. Work schedules, financial factors, employer support, the artist's perception of the importance of the show, and the relationship between circus and identity influenced injury management and help-seeking. Injury prevention and management strategies could be optimised by developing centres of expertise, online resources, and better regulations of the profession

Applying an osteopathic intervention to improve mild to moderate mental health symptoms: a mixed-methods feasibility study protocol

Introduction: Mental health services are stretched in the UK and are in need of support. One approach that could improve mental health symptoms is osteopathy. Research suggests that osteopathy influences psychophysiological factors, which could lead to improvements in mental health. The first objective of this protocol is to investigate the feasibility and acceptability of four osteopathic interventions. A secondary aim is to evaluate the interventions’ effectiveness for improving psychophysiological and mental health outcomes. Methods and analysis: This study will be an explanatory mixed-methods design. Participants will be 30 adults who have mild to moderate mental health symptoms and not experiencing any issues with pain. The feasibility and acceptability of the interventions will be the primary outcomes. Secondary outcomes will be physiological measures including heart rate variability, interoceptive accuracy and blood pressure. Psychological outcomes, collected preintervention and postintervention, will also be measured by five standardised questionnaires, which include: (1) the Depression, Anxiety and Stress Scale (DASS); (2) the International Positive and Negative Affect Schedule-Short-Form; (3) Acceptance and Action Questionnaire-II; (4) the Self as Context Scale and (5) and the Multidimensional Assessment of Interoceptive Awareness Version 2. Participants will be randomised to one of four intervention groups and receive a single intervention treatment session. These intervention groups are: (1) high-velocity and articulation techniques, (2) soft-tissue massage, (3) craniosacral techniques, and (4) a combination of these three approaches. Mixed design two (preintervention and postintervention) by the four interventions analysis of covariance models will be used to analyse the quantitative data for each quantitative measure. Participants will also be interviewed about their experiences of the study and interventions and a thematic analysis will be used to analyse this qualitative data. This will aid the assessment of the feasibility and acceptability of the study design. Ethics and dissemination: The protocol for this feasibility study has received ethical approval from the Department of Psychology Ethics Committee at Swansea University, ethical review reference number: 2022-5603-4810. Feasibility results from this protocol will be published in a peer review journal and presented at both national and international conferences. Discussion: This study will assess the feasibility and acceptability of conducting osteopathic interventions for improving mental health outcomes. The results from this will help to inform the development of a future randomised controlled trial. The study will also produce original data which could provide preliminary evidence of whether osteopathic approaches are of benefit to individual’s mental health in the form of effect sizes, even if they are pain-free. Trial registration number: NCT05674071

Blinding and Sham Control Methods in Trials of Physical, Psychological, and Self-Management Interventions for Pain (Article I): a Systematic Review and Description of Methods

Blinding is challenging in randomised controlled trials (RCTs) of physical, psychological, and self-management therapies (PPS) for pain, mainly due to their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently employed sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham controlled RCTs of PPS treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment, to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (e.g., duration and frequency of treatments) than others (e.g., physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations

The effectiveness and safety of conservative interventions for positional plagiocephaly and congenital muscular torticollis ::a synthesis of systematic reviews and guidance

Aim To investigate for congenital muscular torticollis (CMT) and positional plagiocephaly (PP) the effectiveness and safety of manual therapy, repositioning and helmet therapy (PP only) using a systematic review of systematic reviews and national guidelines. Methods We searched four major relevant databases: PubMed, Embase, Cochrane and MANTIS for research studies published between the period 1999–2019. Inclusion criteria were systematic reviews that analysed results from multiple studies and guidelines that used evidence and expert opinion to recommend treatment and care approaches. Three reviewers independently selected articles by title, abstract and full paper review, and extracted data. Selected studies were described by two authors and assessed for quality. Where possible meta-analysed data for change in outcomes (range of movement and head shape) were extracted and qualitative conclusions were assessed. Results We found 10 systematic reviews for PP and 4 for CMT. One national guideline was found for each PP and CMT. For PP, manual therapy was found to be more effective than repositioning including tummy time (moderate to high evidence) but not better than helmet therapy (low evidence). Helmet therapy was better than usual care or repositioning (low evidence); and repositioning better than usual care (moderate to high evidence). The results for CMT showed that manual therapy in the form of practitioner-led stretching had moderate favourable evidence for increased range of movement. Advice, guidance and parental support was recommended in all the guidance to reassure parents of the favourable trajectory and nature of these conditions over time. Conclusions Distinguishing between superiority of treatments was difficult due to the lack of standardised measurement systems, the variety of outcomes and limited high quality studies. More well powered effectiveness and efficacy studies are needed. However overall, advice and guidance on repositioning (including tummy-time) and practitioner-led stretching were low risk, potentially helpful and inexpensive interventions for parents to consider

Comparison of common interventions for the treatment of infantile colic ::a systematic review of reviews and guidelines

Objective To conduct a systematic review of systematic reviews and national guidelines to assess the effectiveness of four treatment approaches (manual therapy, probiotics, proton pump inhibitors and simethicone) on colic symptoms including infant crying time, sleep distress and adverse events. Methods We searched PubMed, Embase, Cochrane and Mantis for studies published between 2009 and 2019. Inclusion criteria were systematic reviews and guidelines that used evidence and expert panel opinion. Three reviewers independently selected articles by title, abstract and full paper review. Data were extracted by one reviewer and checked by a second. Selected studies were assessed for quality using modified standardised checklists by two authors. Meta- analysed data for our outcomes of interest were extracted and narrative conclusions were assessed. results Thirty- two studies were selected. High- level evidence showed that probiotics were most effective for reducing crying time in breastfed infants (range −25 min to −65 min over 24 hours). Manual therapies had moderate to low- quality evidence showing reduced crying time (range −33 min to −76 min per 24 hours). Simethicone had moderate to low evidence showing no benefit or negative effect. One meta- analysis did not support the use of proton pump inhibitors for reducing crying time and fussing. Three national guidelines unanimously recommended the use of education, parental reassurance, advice and guidance and clinical evaluation of mother and baby. Consensus on other advice and treatments did not exist. Conclusions The strongest evidence for the treatment of colic was probiotics for breastfed infants, followed by weaker but favourable evidence for manual therapy indicated by crying time. Both forms of treatment carried a low risk of serious adverse events. The guidance reviewed did not reflect these findings

Refining the biopsychosocial model for musculoskeletal practice by introducing religion and spirituality dimensions into the clinical scenario

Addressing religion and spirituality (R/S) dimensions may be uncomfortable for patients and practitioners because they refer to intimate beliefs about existence, vary across the globe and cultures, and are not routinely shared in the modern therapeutic scenario. Often, R/S dimensions are overlooked in musculoskeletal (MSK) practice despite associations with attitudes and behaviour that directly affect quality of life and health outcomes. Inclusion of basic R/S dimensions in the therapeutic alliance may optimise care and establish these dimensions as interactors within the biopsychosocial model. The purpose of this commentary was to provide practitioners with definitions of R/S that are useful for managing care of MSK patients, describe how attitudes towards R/S may be linked to health status, and indicate how R/S dimensions could be discussed in simple ways in a modern therapeutic scenario. Finally, suggestions are provided for MSK practitioners and researchers to address R/S dimensions in Western evidence-oriented healthcare. Highlights Cultural competencies in healthcare include religion/spirituality dimensions. Religion/spirituality dimensions are overlooked in Western manual care. Religion/spirituality within the biopsychosocial model may be clinically relevant. Explicit inclusion of religion/spirituality may optimise the therapeutic alliance. Keywords: Biopsychosocial, Manual therapy, Musculoskeletal care, Religion, Spiritualit

The importance of rigour in the reporting of evidence for osteopathic care in Covid-19 papers

The value of incorporating research evidence into clinical practice is in part, to help acknowledge, accept and manage uncertainties. The urgency related to the Covid-19 pandemic has changed usual publication process and information sharing. The rapid knowledge exchange between theory, research and clinical recommendation has occurred with the hope of preventing Covid-19 related mortality and reducing morbidity. However, expediting knowledge transfer should not occur at the expense of accuracy and cautious interpretation of the research evidence. Such carelessness only serves to inundate the public and health professionals with false or misleading information. Such inaccuracies, especially when relating to potential therapeutic strategies for Covid-19 are likely to have severe negative consequence on people's health. There is therefore a need to avoid speculation and favour scientific rigour and intellectual honesty in claims made about evidence on benefits of manual treatment for Covid-19 patients. This letter to the editor questions overstatements found in Marin et al.'s published narrative review and focuses on three avoidable types of errors: misinterpretation, cherry picking and lack of methodological rigour