Measuring distress in musculoskeletal physiotherapy IMPARTS SEMINAR Tuesday 16 th September 2014
Service Redesign Rational for Service Change Introducing Screening of Psychosocial Factors Different approach to Patient Management
General Practice Trauma & Orthopaedics Rheumatology Pain Clinic Other Musculoskeletal Conditions Acute Sub-acute Chronic presentations Assessed & managed by band 4 band 8 practitioners from the physiotherapy profession
Musculoskeletal conditions & mental & behavioural disorders are major causes of years lived with disability in the UK (Murray et al. 2013) 1990 2010 1. Low back pain 1. Low back pain 2. Major depressive disorders 2. Falls 3. Neck pain 3. Major depressive disorders 4. Other MSK disorders 4. Neck pain 5. Anxiety disorders 5. Other MSK disorders 6. Falls 6. Anxiety disorders 7. COPD 7. COPD 8. Drug use disorders 8. Drug use disorders 9. Migraine 9. Asthma 10. Asthma 10. Migraine 11. Osteoarthritis 11. Osteoarthritis
Guidelines Osteoarthritis CG 177 Low Back Pain CG 88 Rheumatoid Arthritis CG 79
Biomedicine Separation of mind and body Illness / disease located in specific areas Division of body
I. No Massage to be undertaken except under Medical direction (No General Massage for Men to be undertaken. Occasional exceptions may be made at a Doctor s special request for urgent or nursing cases). II. No Advertising permitted in any but strictly professional papers II. No sale of Drugs to Patients allowed Rules of the Society of Trained Masseuses, taken from Barclay, 1948 p 42
6 Increasing Demand 4 2 0 Year 1 Year 2 Year 3 Year 4 Demand
Models of commissioning services Any Qualified Provider Commissioned Services
Physiotherapist development Entry level Skills and knowledge development are body part driven even when students develop knowledge and competence in the assessment and management of psychosocial obstacles to recovery [from MSK disorders] from their training institutions, failure to consolidate this knowledge and these competencies within the clinical environment essentially halts their development Post qualification level Skills and knowledge development are body part driven Foster et al. 2011
Models of commissioning with an emphasis on targets Increasing unmet demand on physiotherapy services Patient choice & competition between providers [Patients] only get the body part they have been referred for looked at - i.e. just the hand, not the whole arm. Then when no improvement is made, they are referred to fix the next part - i.e. shoulder. A more holistic approach is suggested. Reference: Patient with LTC Limited availability of pain management programmes Historical socio-political roots of physiotherapy Physiotherapist training
The incorporation of a bio-psychosocial approach in musculoskeletal physiotherapy Physiotherapists do demonstrate awareness of the importance of psychosocial factors when asked But.. Could not identify which factors were important in affecting outcome (Overmeer et al. 2004)
Nielson, M. et al. 2014 Physical Therapy Hunt et al, 2013 Knee Lamb, S. et al. 2010 Lancet Sullivan et al. 2006 Physical Therapy
Screening for risk of poor outcome in people with musculoskeletal disorders Depression (PhQ9 ) Anxiety (GAD 7) Fear avoidance (FABQ) Pain catastrophizing (PCS) Self efficacy (PSEQ)
What is the primary reason that you are seeking treatment from this service? Back pain PHQ-2 GAD-2 STarT Back Musculoskeletal PROM EQ-5d VAS High risk Medium risk Low risk PHQ-9 GAD-7 FABQ PCS PSEQ Supported self management Other PHQ-2 GAD-2 PHQ-9 GAD-7 FABQ PCS PSEQ
The Keele MSK-PROM for Monitoring Musculoskeletal Health This questionnaire is about the health problem for which you are seeking treatment from this service. Place a tick in one box for each question below to indicate which statement best describes your view today (from never to all the time ). Each column records a different treatment visit. Assessing the effect MSK monitoring PROM (Hill et al. 2014) EQ-5D VAS Q1. Needing help Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 How often do you need help from others because of your symptoms? Never 1 Rarely 2 Sometimes 3 Frequently 4 All the time 5 Q2. Work/daily routine Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 How often have your symptoms interfered with your normal work/daily routine (including social activities, household chores, & hobbies)? Never Rarely Sometimes Frequently All the time Q3. Activities and roles Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 How often are you prevented from doing activities and roles that matter to you? Never 1 Rarely 2 Sometimes 3 Frequently 4 All the time 5 Q4. Severity of worst problem (e.g. sleep, fatigue, driving) Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 What is the one thing you have the most difficulty with? Note it here: How often are you finding this difficult? Never 1 Rarely 2 Sometimes 3 Frequently 4 All the time 5 Q5. Understanding how to deal with symptoms Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 How often do you feel unsure about how to deal with your symptoms? Never 1 Rarely 2 Sometimes 3 Frequently 4 All the time 5 Q6. Overall impact Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Overall, how often do your symptoms bother you? Never 1 Rarely 2 Sometimes 3 Frequently 4 All the time 5 Any and all copyrights in Questions 1-6, their order and layout vest in Keele University (May 2013).
Treatment pathways STarT Back Anxiety Low risk - supported self management Medium risk - usual physiotherapy care High risk - psychologically informed physiotherapy Significant Group physical exercise/ IAPT selfreferral Depression Some depressive symptoms - Group physical exercise/ IAPT self-referral Probable major depression same day letter to GP Suicidal ideation - risk assessment A&E / liaison psychologist support / same day letter to GP
Investing in Staff Exposure to a 2 day motivational interviewing programme and follow up with coaching and feedback focussed on developing patient-centred consultations and facilitating change behaviour in people presenting with musculoskeletal pain Exposure to a one day programme with colleagues from INPUT challenging the more traditional physiotherapeutic care offered to people with musculoskeletal conditions Planned educational sessions with a psychologist to help build capability within the service to deliver psychologically informed physiotherapy.
Psychologically informed physiotherapy Developing physiotherapist skills in: Problem-solving Facilitating patients to increase levels of physical activity Developing self-efficacy Working with patients who are fearful of movement Mindfulness as a strategy for patients Relaxation techniques and education
Evaluation Evaluate patient data for 3 months prior to additional support and education provided by psychology Evaluate patient data for 3 months post psychology education and supported intervention Collect and analyse patient and staff views and experiences of service redesign
Thank you