Musculoskeletal health and the promotion of exercise as medicine

Description of impact

Research at Bangor University’s North Wales Centre for Primary Care Research has influenced policy on musculoskeletal health and the promotion of exercise as an important treatment principle in three main areas:
•The management of spinal and radicular pain, in particular its primary care management with spinal manipulation and exercise
•Physical activity promotion in primary care for osteoarthritis of the hip or knee
•Encouraging physical activity in sedentary individuals at risk of developing chronic disease.
This impact is evidenced in developments in policy cf NICE and in care pathways promoted by national bodies including the British Pain Society.


Managing pain: Contribution to national and international back pain guidelines
Results from the UK BEAM trial have contributed to both national [5.1] and international [5.2] back pain management guidelines.
The impact of the underpinning research can be seen in policy and in development of care pathways: In 2013, results from the trial of the primary care osteopathy clinic has been used by the National Council for Osteopathic Research as evidence for the effectiveness of osteopathy for the management of back and neck pain [5.3]. In 2014, results from the sciatica network meta-analysis have been used to inform The British Pain Society low back pain pathway [5.4]. NICE is also in the process of updating their clinical guidance on low back pain and sciatica, due out in Sept 2016. We envisage that the Bangor study results will be considered as evidence*.
Physical activity promotion in primary care for osteoarthritis of the hip and knee: publication of ‘The Hip and Knee Book’
The Hip and Knee Book was published by The Stationery Office in 2009 [5.6] and has sold, up to December 2015, in excess of 17,000 copies, 12000 of those in English, 5000 in Welsh (needs amended to be post 2013 sales only, VM has emailed for this). It has been used to complement educational materials provided as part of continuing professional development for general medical practitioners by the Welsh deanery [5.7], and is currently being considered for translation and trialling in Germany.
Encouraging physical activity in sedentary individuals: Contribution to exercise promotion guidelines and government policy
Results from the trial and concurrent economic evaluation have informed NICE guidance on the promotion of physical activity by means of exercise referral schemes [5.8]. They have also contributed to Welsh government policy on physical activity [5.9] including the expansion of the National Exercise Referral Scheme to include other chronic diseases [5.10]. In addition, in three areas in Wales exercise programmes as part of the National Exercise Referral Scheme have been developed specifically for obese patients with osteoarthritis of the hip or knee which we are planning to evaluate further with Public Health Wales.

Description of the underpinning research

The underpinning research for this Impact Case was carried out by Nefyn Williams (NW), Clare Wilkinson (CW) and Ruth Lewis (RL) in the North Wales Centre for Primary Care Research (team absorbed into Bangor University from Cardiff University in 2011). Multidisciplinary collaborators include: Rhiannon Tudor Edwards in the Centre for Health Economics and Medicine Evaluation, Bangor University, and methodologists, health economists, health promotion experts including Ian Russell (Bangor, then Swansea from 20**), Kim Burton (Huddersfield), Ceri Phillips & Deborah FitzGerald (Swansea), Alex Sutton (Leicester), Simon Murphy (Cardiff), Laurence Moore (Glasgow) and Martin Underwood (Warwick).Management of spinal pain with spinal manipulation and exerciseCW was a Principal Investigator in UK BEAM, which was the largest randomised controlled trial of treatments for low back pain in the UK and recruited 1334 patients consulting general practices. This pragmatic trial with factorial design found that relative to best care in general practice, manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months [3.1]. Exercise and spinal manipulation in particular were cost-effective additions to best care [3.2]. In collaboration with Bangor triallist Russell and health economist RTE, NW and CW undertook a pragmatic RCT of spinal manipulation in primary care for patients with neck or back pain from between two and 12 weeks duration. The primary care osteopathy clinic improved short-term physical and longer term psychological outcomes [3.3] and this proved a cost-effective addition to usual general practice care [3.4].Management of radicular pain/ sciatica Previous systematic reviews have not compared the numerous available treatment strategies together. In 2013-14 RL, NW and CW performed a network meta-analysis, which for the first time permitted the comparison of many different strategies in the same review [3.5]. Useful treatments included non-opioid analgesia, epidural steroid injections and disc surgery. The experimental treatment with biological agents acting upon pro-inflammatory factors released by a ruptured intervertebral disc also showed promise, which agreed with the results of a meta-analysis focussing on these biological agents compared with placebo [3.6]. Although there was insufficient evidence to change practice from these reviews, there was sufficient evidence to suggest that a definitive RCT was warranted. Physical activity promotion in primary care for osteoarthritis of the hip or kneeOsteoarthritis management guidelines emphasise the central role of exercise, weight loss and patient education in the management of osteoarthritis. With regard to exercise, the level of physical activity in older adults in the UK is low and reduced further by pain-related fear of movement in many of those with osteoarthritis. We carried out qualitative research to determine patients’ with knee osteoarthritis views on exercise and physical activity [3.7]. Many were lifelong exercisers or had never exercised; some stopped exercising because of fear of damaging their joints; others however, started to exercise in order to manage their condition. To facilitate this process and to address the lack of information for patients concerning the self-management of osteoarthritis we developed an evidence based booklet promoting physical activity for patients with osteoarthritis of the hip or knee [3.8]. A pilot RCT of this “Hip and Knee book” found that the trial methods were feasible in terms of recruitment, randomisation, and follow-up, and resulted in a small relative improvement in illness, exercise, and fear-avoidance beliefs and physical activity level [3.9]. Encouraging physical activity in sedentary individuals at risk of developing chronic disease: The National Exercise Referral Scheme in WalesAlthough it is widely recognised that physical activity and exercise is beneficial for physical and mental health most of the population is sedentary. Exercise referral schemes (ERS) have been developed which encourage GPs to refer sedentary patients with health problems to qualified exercise professionals with access to tailored programmes promoting physical activity. However, a systematic review that we performed found that the effectiveness of these schemes was minimal [3.10]. A RCT was commissioned as part of the roll out of the Welsh Government’s National Exercise Referral Scheme (NERS) across 12 local health board (LHB) areas in Wales. There were 2,160 participants recruited into the study. NERS was found to be effective in increasing physical activity among those referred for Coronary Heart Disease risk factors. Among mental health referrals, NERS did not influence physical activity but was associated with reduced anxiety and depression. Effects were dependent on adherence [3.11]. NERS was also found to be cost effective [3.12]. This was a rare example of a RCT nested within a public health policy initiative. It also included an extensive process evaluation [3.13].

Impact status	Ongoing
Category of impact	Policy and Public Services, Health/Quality of life
Impact level	Benefit