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ObjectivesEvaluate the outcomes and explore experiences of patients undergoing a residential combined physical and psychological programme (CPPP) for chronic low back pain.DesignA longitudinal observational cohort design, with a parallel qualitative design using semistructured interviews.SettingResidential, multimodal rehabilitation.Participants136 adults (62 male/74 female) referred to the CPPP, 100 (44 male/56 female) of whom completed the programme, during the term of the study. Ten (2 male/8 female) participated in the qualitative evaluation.InterventionA 3-week residential CPPP.Outcome measuresPrimary outcome measures were the STarT Back screening tool score; pain intensity—11-point Numerical Rating Scale; function—Oswestry Disability Index (ODI); health status/quality of life—EQ-5D-5L EuroQol five-Dimension-five level; anxiety—Generalised Anxiety Disorder-7; depression—Patient Health Questionnaire-9. Secondary outcome measures were the Global Subjective Outcome Scale; National Health Service Friends and Family Test;.ResultsAt discharge, 6 and 12 months follow ups, there were improvements from baseline that were greater than minimum clinically important differences in each of the outcomes (with the sole exception of ODI at discharge). At 12 months, the majority of people considered themselves a lot better (57%) and were extremely likely (86%) to recommend the programme to a friend. The qualitative data showed praise for the residential nature of the intervention and the opportunities for interaction with peers and peer support. There were testimonies of improvements in understanding of pain and how to manage it better. Some participants said they had reduced, or stopped, medication they had been taking to manage their pain.ConclusionsParticipants improved, and maintained long term, beyond minimum clinically important differences on a wide range of outcomes. Participants reported an enhanced ability to self-manage their back pain and support for the residential setting.

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DICKSOK OX PURQATIVEL). 283 republication of Dr. Willan's plates, with the additions of Dr. 13atema~ row in progress, nrust trot be overlooked. Without these, his S) nopols is in some l>lrces not easily unclerstood ; but with thcm, every thing that the pract~cal plrysician calr desi1.e ou the subject of cutaneous di~ensev is placed within his reach. In this order of ciiseabes, the only novelties we have to refer to are, the nroclc of curing impetiginous vingwornl by adhesive plus~er, suggested by Dr. Rcid C l~n n y ;* and the f. ct, nolicetl in our obeervatio~rs un tlre prcvaililtg diseases, that Eczelna rubrunt can be produced by the external application of red precipitate.+ 11) concludi~~g our details on the practice of Metlitins, we have ollly further to mention the observations of Dl.. Volentin on the use of 'the actual cdutery, co~\firn\ed by P~.ofessor Reich's case,+ the important commu~ricalion of MY. Gnitskcll on biliury obstruction, in which hydatide to a great i~n o u n t were discharged ; § the recorninendation uf Dl*. Eichrdt, of Carlrulrc, in favoui. of the external use of oxymuriatic acid, in vencreal diseases ;ll Dr. Baillie's paper on grcen jaundice ;T and a curious paper by the late Dr. Clarke on the eflects of cati~bg oysters on women after child-birth ;** as parti~ularly desorvlng of attention. merly Supe11intendi1,g Physician of his lrnye~~ial Majesty's Squodron in the Mcdway. [From the Edinbu~h hlcdicd culd 8urgicd Jo~irnnl.]T w s hllowing observations, so far es.they relate to tire gea. era1 utility of early blood.lotti~~g and pu~~gativcs, in a fever which, on two occasio~x., prevailed ia the Russian scttiadron in R@08it8y,. p. 51.t Ibicl. 1-01. iv. p. 525. 4 Ihitl ral. iv. p. 345. 9 Ibid. p. 466.

Reviews of oral opioid trials have shown that many side-effects need to be considered when treating patients with non-operable osteoarthritis and soft-tissue problems. European and American guidelines recommend their use with or without paracetamol. The controversy surrounding the use of non-steroidal anti-inflammatory drugs/cyclo-oxygenase-2 inhibitors is limiting physician and patient choices. There is a great need for alternative medication or ways of using current compounds. Moore and McQuay [1], in this issue of Arthritis Research & Therapy, reviewed 34 trials using oral opioids against placebo or a comparator. The review included 5,500 patients; importantly, 4,000 patients contributed to the sideeffect profile. It is this profile that is significant in today's world of public and patient safety. Doctors and patients do need help, and preferably evidence, to make choices when treating all types of musculoskeletal conditions. Moore's review highlights two problems: first, that the trials were of short duration, and second, that the side-effect profiles were a problem, causing patient withdrawals of at least 22%.The European League Against Rheumatism recommends opioid analgesics with or without paracetamol as useful alternatives for patients in whom non-steroidal antiinflammatory drugs (NSAIDs), including cyclo-oxygenase-2 (Cox-2) selective inhibitors, are contra-indicated, ineffective and/or poorly tolerated [2,3].The American Pain Society and the American College of Rheumatology give similar advice for the use of opioids in rheumatoid arthritis (RA) as well as osteoarthritis (OA) [4,5].Trials have shown that opioids are effective in OA and RA and improve sleep and quality of life [6]. If opioids are effective, are they safe? Schug and colleagues [7] showed that they have a good safety record and most have a high therapeutic index. In acute overdose, respiratory failure can occur but there does not seem to be any specific organ toxicity. The side-effects of nausea, vomiting, somnolence and sedation can present problems. It is accepted that patients usually rapidly develop tolerance to these sideeffects. Unfortunately, tolerance does not develop for constipation, so this side-effect needs treatment. In Moore's review, dry mouth was experienced by 25% of patients, which is a significant problem for this age group of 55 years and over. These problems do limit the use of oral opioidsmost patients who require medication for non-cancer pains are over 65 years old and very often constipation is already a problem, especially with the use of concomitant medication for co-morbidities. Constipation as a drug side-effect is rarely acceptable to patients, even in the older age groups, as most people wish to enjoy independence and the best possible quality of life. The withdrawal rate in trials is 22% [1], but this is likely to be an underestimation; in reality, most patients cannot tolerate nausea and somnolence for long even if they are assured that it will wear off given time. Car driving becomes difficult, eve...