Measuring distress in musculoskeletal physiotherapy

IMPARTS SEMINAR

Tuesday 16th 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

Assessed & managed by band 4 – band 8 practitioners from the physiotherapy profession

Musculoskeletal Conditions• Acute• Sub-acute• Chronic presentations

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

Rules of the Society of Trained Masseuses, taken from Barclay, 1948 p 42

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

0

2

4

6

Year 1 Year 2 Year 3 Year 4

Increasing Demand

Demand

Models of commissioning services

• Any Qualified Provider

• Commissioned Services

Physiotherapist development

‘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’

Foster et al. 2011

Entry level

Post qualification level

• Skills and knowledge development are body part driven

• Skills and knowledge development are body part driven

Increasing unmet demand on physiotherapy services

Physiotherapist training

Patient choice & competition

between providers

Models of commissioning

with an emphasis on targets

Historical socio-political roots of physiotherapy

Limited availability of pain

management programmes

‘[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

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)

Hunt et al, 2013Knee

Nielson, M. et al. 2014Physical Therapy

Lamb, S. et al. 2010Lancet

Sullivan et al. 2006Physical 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?

Musculoskeletal PROMEQ-5dVAS

Back pain

Other

PHQ-2GAD-2

High riskSTarT Back Medium risk

Low risk

PHQ-2GAD-2

PHQ-9GAD-7FABQPCSPSEQ

PHQ-9GAD-7FABQPCSPSEQ

Supported self management

Assessing the effect

• MSK monitoring PROM (Hill et al. 2014)

• EQ-5D

• VAS

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.

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).

The Keele MSK-PROM for Monitoring Musculoskeletal Health

Treatment pathways

• STarT Back

• Anxiety

• Depression

• Low risk - supported self management• Medium risk - usual physiotherapy care • High risk - psychologically informed physiotherapy

• Significant – Group physical exercise/ IAPT self-referral

• 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