PURPOSE We aimed to determine the effects of implementing risk-stratified care for low back pain in family practice on physician's clinical behavior, patient outcomes, and costs. METHODSThe IMPaCT Back Study (IMplementation to improve Patient Care through Targeted treatment) prospectively compared separate patient cohorts in a preintervention phase (6 months of usual care) and a postintervention phase (12 months of stratified care) in family practice, involving 64 family physicians and linked physical therapy services. A total of 1,647 adults with low back pain were invited to participate. Stratified care entailed use of a risk stratification tool to classify patients into groups at low, medium, or high risk for persistent disability and provision of risk-matched treatment. The primary outcome was 6-month change in disability as assessed with the Roland-Morris Disability Questionnaire. Process outcomes captured physician behavior change in risk-appropriate referral to physical therapy, diagnostic tests, medication prescriptions, and sickness certifications. A cost-utility analysis estimated incremental quality-adjusted life-years and back-related health care costs. Analysis was by intention to treat. RESULTSThe 922 patients studied (368 in the preintervention phase and 554 in the postintervention phase) had comparable baseline characteristics. At 6 months follow-up, stratified care had a small but significant benefit relative to usual care as seen from a mean difference in Roland-Morris Disability Questionnaire scores of 0.7 (95% CI, 0.1-1.4), with a large, clinically important difference in the high risk group of 2.3 (95% CI, 0.8-3.9). Mean time off work was 50% shorter (4 vs 8 days, P = .03) and the proportion of patients given sickness certifications was 30% lower (9% vs 15%, P = .03) in the postintervention cohort. Health care cost savings were also observed.CONCLUSIONS Stratified care for back pain implemented in family practice leads to significant improvements in patient disability outcomes and a halving in time off work, without increasing health care costs. Wider implementation is recommended. INTRODUCTIONI t has been stated that "most cases of back pain resolve regardless of the course of therapy, and some do not get better no matter what is done. Therein lies the problem for practitioners, patients, and policy makers."1 Health care systems universally face the challenge of providing effective primary care for low back pain within constrained resources, in the face of increased demands for treatment and investigations.2,3 Back pain is now the 6th highest contributor to the global burden of disease. 4 In the United Kingdom, 6% to 9% of adults consult a family physician for back pain each year, 5 accounting for 14% of consultations. 6 More than 60% still report pain and disability a year later, 7,8 and 2% to 7% will develop severe persistent symptoms 9 leading to high levels of reconsultation, work loss, and sickness certification. 10 evidence-based treatments, but the optimal approaches to tar...

Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial Nadine E Foster, senior lecturer in therapies (pain management), 1 Interventions Advice and exercise (n=116), advice and exercise plus true acupuncture (n=117), and advice and exercise plus non-penetrating acupuncture (n=119). Main outcome measures The primary outcome was change in scores on the Western Ontario and McMaster Universities osteoarthritis index pain subscale at six months. Secondary outcomes included function, pain intensity, and unpleasantness of pain at two weeks, six weeks, six months, and 12 months. Results Follow-up rate at six months was 94%. The mean (SD) baseline pain score was 9.2 (3.8). At six months mean reductions in pain were 2.28 (3.8) for advice and exercise, 2.32 (3.6) for advice and exercise plus true acupuncture, and 2.53 (4.2) for advice and exercise plus non-penetrating acupuncture. Mean differences in change scores between advice and exercise alone and each acupuncture group were 0.08 (95% confidence interval −1.0 to 0.9) for advice and exercise plus true acupuncture and 0.25 (−0.8 to 1.3) for advice and exercise plus non-penetrating acupuncture. Similar nonsignificant differences were seen at other follow-up points. Compared with advice and exercise alone there were small, statistically significant improvements in pain intensity and unpleasantness at two and six weeks for true acupuncture and at all follow-up points for nonpenetrating acupuncture. Conclusion The addition of acupuncture to a course of advice and exercise for osteoarthritis of the knee delivered by physiotherapists provided no additional improvement in pain scores. Small benefits in pain intensity and unpleasantness were observed in both acupuncture groups, making it unlikely that this was due to acupuncture needling effects.Trial registration Current Controlled Trials ISRCTN88597683.

Anglia. She has a special research interest in family placement and has published widely on foster-care, attachment and permanence. Bente Moldestad is a clinical social worker and a researcher in 'The Norwegian Longitudinal Study on Out-of-Home Care' in the Child Protection Unit, Uni Research, University of Bergen. She has published a range of articles on parents of children in foster care and kinship care. Dr Ingrid Höjer is Associate Professor in the Department of Social Work, University of Gothenburg. Her main research interest is child welfare, with a focus on foster care, including foster families, sons and daughters of foster carers and parents of children in foster care. She has published widely in these areas. Her recent research is on young people leaving care. Dr Emma Ward is a Senior Research Associate in the Centre for Research on the Child and Family, University of East Anglia. She has worked on a range of projects including studies of prospective adoptive parents, permanence in foster care and parents of children in foster-care. Her current research is on looked after children and offending. Dag Skilbred is a child welfare worker with main interests in interactive competence, parent counselling and inter-agency work, and has published in these areas. He is now working in the project 'Screening of Children within Child Welfare Service-Inter-Agency Work on Assessments and Services' at the Child Protection Unit, Uni Research, University of Bergen. Julie Young is a Senior Research Associate in the Centre for Research on the Child and Family, University of East Anglia. She has been involved in studies of adoption, the influence of post-adoption contact on all parties, the adjustment of birth relatives to the adoption of their children, fostering and child protection. Dr Toril Havik is a specialist in clinical child psychology and Head of Research at the Child Protection Unit, Uni Research, University of Bergen. She leads the research programme 'The Norwegian Longitudinal Study of Out-of-Home Care' and has published widely on varied aspects of foster care.

Objective. Older adults with knee pain report low levels of exercise and physical activity. One explanation for this might be that they believe exercise is unhelpful or even harmful for knee pain. We therefore explored the attitudes and beliefs of older adults in the community about the role of exercise for knee pain using mixed methods. Methods. A survey was mailed to 2,234 older adults registered with 1 general practice within the UK. The survey included 23 attitude statements derived from published exercise recommendations. Semistructured interviews were completed in a purposeful sample of questionnaire responders (n ‫؍‬ 22) and were recorded and analyzed thematically. Results. The questionnaire response rate was 59% (n ‫؍‬ 1,276), and 611 respondents reported knee pain in the past 12 months. There was considerable uncertainty about the benefits of exercise; <50% largely or totally agreed on any attitude statement relating to the benefit of exercise for knee pain. The interviews revealed that attitudes and beliefs about exercise for knee pain are linked to the individuals' perceptions about their knee problems, and that many different barriers and facilitators to exercise and physical activity exist. These barriers and facilitators could be grouped as those relating to the person, the knee problem itself, and social or environmental factors. Barriers and facilitators varied between different individuals and over time. Conclusion. The overall uncertainty within the community about the role of exercise for knee pain highlights the challenges faced by those living with knee pain in completing physical activity, and for health care professionals prescribing exercise for this patient group.

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