Multidisciplinary Treatment of Low Back Pain in Plymouth UK Charles - - PowerPoint PPT Presentation

Multidisciplinary Treatment of Low Back Pain in Plymouth UK

►Charles Peers BSc (Hons) BSc (Ost) NHS

Osteopath

Western Locality

►Plymouth ►South Hams ►West Devon ►SE Cornwall

Aims of Plymouth Back Pain Pilot

►Adopt and test CSAG Guidelines ►Monitor outcomes via rigorous audit ►Monitor cost ►Demonstrate cost effectiveness/ Clinical

Excellence

►Produce publishable data

Conflicting Evidence/ Management of Clinical Complexity

► ? Pathology ► ?Disc/Nerve Root ► ? “Simple” Mechanical

Back Pain

Manipulation Exercise Acupuncture MRI Referral Epidural Acupuncture MRI CBT Exercise

Biopsychosocial model of low back disability

► Bio

• simple
• nerve root pain
• Pathological

► Psycho

• attitudes and beliefs about low back pain
• fear avoidance beliefs about activity and work
• personal responsibility for pain and rehabilitation
• psychological distress and depressive symptoms
• illness behaviour

► Social

• Family

► attitudes and beliefs about the problem ► reinforcement of disability behaviour

• work

► physical demands of job ► job satisfaction ► other health problems causing time off work ► non-health problems causing time off work or job loss

Audit Criteria

► Patient waiting times ► Diagnostic Triage Category ► Modality Used; Manipulation/Caudal

Epidural/Acupuncture/Exercise

► Treatment duration ► Outcome; ordinate pain scale, Oswestry/ Bournemouth ► Imaging ► Subsequent secondary care ► Patient/GP Satisfaction ► Work Status ► Costs

Risk Factors for Chronicity

• Previous history LBP
• Total work loss (due to LBP) in last 12 months
• Radiating leg pain
• Reduced SLR
• Signs of root involvement
• Reduced trunk muscle strength
• Poor physical fitness
• Heavy smoking
• Self- rated poor health
• Psychological distress
• Depressive symptoms
• Disproportionate illness behaviour
• Low job satisfaction
• Personal problems
• Medico-leqal proceedings

Advanced Practise: Accurate Prognosis

►Stratification of patients at Triage ►Awareness of prognosis in development of

treatment plan via multidisciplinary team

►Prognostic Indicators for Outcome ►Use of Start Back ►Linton Halldern ►See also Harms et al.

Multidisciplinary Team

►Integrated Model ►CHOICE

Back Pain - Primary Care Management Consider diagnosis Investigations as per protocols Suspected diagnosis Inflammatory back pain Non specific back pain Nerve Root Pain - leg pain (radiculopathy) Serious pathology Red Flags – Cauda equina syndrome or 2 week wait referrals Refer to rheumatology Up to 3 months duration Refer ABPS or physio More than 3 months duration Refer SABPS

• r physio

Up to 3 months duration Refer ABPS or physio Scoliosis More than 3 months duration Consider LSAS Resolving Continue treatment and discharge Not resolving Not resolving MRI/ consider referral for neurosurgical spinal MDT

• r pain clinic

Refer sub acute back pain service Consider MRI / referral for neurosurgical spinal MDT or referral pain clinic Referral for spinal surgery Resolving Continue treatment and discharge A&E Refer RDE Not resolving Not resolving Referral for pain clinic 2 week wait Consider physio / SABPS

Sentinel

►Community Interest Company (“CIC”) ►Provider Umbrella ►Formed by GP shareholders from 41 out of

42 Plymouth practices

►Referral Management Stratification see

Pathway.

Clinical Commissioning Group “CCG”

►Commissions service from Provider Umbrella ►?AQP Any qualified Provider ►“New Devon CCG” ►Savings expected £17.5 million 2012/13 ►Thrust of service data to demonstrate cost

savings and compliance with evidence base/ NICE.

Patient satisfaction survey

GP satisfaction: Acute service 2005/6

10 20 30 40 50 60 70 80 90 100

Very satisfied Satisfied Adequate Not satisfied Very dissatisfied

Subsequent treatment after SAS

20 40 60 80 100 120 140 160 180 Neur Pain DerrifOrthoRheuOther Oste ChiroAcup No fu Series 1 Series 2

Number of patients

Neurosurgery Pain Clinic Derriford Hospital Orthopaedics Rheumatology Other Osteopathy Chiropractic Acupuncture No Further Treatment

Subsequent treatment after Sub-acute service

Commissioning Competencies

►Stimulates the market, market entry of non

traditional workforce

►Prioritise investment, uses resources in a

planned and sustainable manner, monitors performance and outcomes

►Promote improvement and innovation,

applying best practice locally

Benefits

►Demonstrable financial efficiency/savings ►NICE conformity ►Achieves low waiting times ►Promotes Care close to home ► Self management via patient’s increased

independence

►Use of recognised outcome measures

Reading List?

► Low Back Pain: What determines functional outcome at six

months? An Observational Study. Harms M.C. Peers C.E. Chase D. BMC Musculoskeletal Disorders. 2010 13; 11: 236

► A Rapid Access Treatment Facility for Acute LBP Based in

the Primary Care Setting. Journal of Orthopaedic Medicine. Gurry, B. Hopkins, M. Peers, C. Anderson, S. Watts, M. 2004 Vol 26

► Five Years of the Acute Low Back Pain Service for

• Plymouth. Journal of Orthopaedic Medicine 2006 Gurry, B.

Vol 28, 26-29