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STarT Back – the Biopsychosocial Approach in the Management of Low Back Pain
L A M L A M , P R I S C I L L I A , D M ( P H Y S I O ) , Q M H
L A U S A U Y I N G , J A M I E , S P T , P W H
L E E Y U E N K W A N , W I N N Y , P T I , U C H
L U K F U N G Y I N , S T E P H A N I E , P T I , A H N H
O V E R S E A S C O R P O R A T E S C H O L A R S H I P P R O G R A M ( O C S P )
1 7 M A Y 2 0 1 7
Content • STarT Back Approach • Psychologically informed practice for
high risk group • UK physiotherapy clinics and STarT
Back research team • The way forward
The Biopsychosocial Management of Complex Low Back Pain: A Stratified Care Approach
Clinical attachment
Haywood Hospital visit
Intensive Lectures and workshops
Meeting with research team
Low back pain
Treatment
“Get the right patient to the right person at the right time”
STarT Back : Subgroups for Targeted Treatment
Stratified care approaches More systematic approach to management decision
Significantly decreased disability related to back pain
Hill et al 2011 Hill et al 2008
Sowden et al 2011
• A simple prognostic screening questionnaire
• 9 Questions: Disagree/Agree • Identify modifiable risk factors
(biomedical, psychological, social) for on-going back pain disability
Q Area
1 Referred leg pain
2 Comorbid pain elsewhere
3 Disability (walking)
4 Disability (dressing)
5 Fear of movement
6 Anxiety
7 Catastrophizing
8 Depression/mood
9 Overall impact
High Medium Low
STarT Back Tool Scoring System
Matched Treatment Pathways
Aim: To reduce pain and disability and enable patients to actively self manage LBP
S/E Physical exam
Self management
30 min face to face session
Local exercise venues
HIGH RISK Additional psychological obstacles to recovery
MEDIUM RISK Mainly physical obstacles to recovery
LOW RISK Low risk of chronicity
Advice sheet
Back book
15 min DVD “Get Back Active”
Advice information
Matched Treatment Pathways Aim: To restore function (including work), minimize disability even if pain is unchanged and to support appropriate self-management
45 mins session
6 sessions 3 months
reassurance
Ex to ↑ function
Manual therapy
RTW advice
HIGH RISK Additional psychological obstacles to recovery
MEDIUM RISK Mainly physical obstacles to recovery
LOW RISK Low risk of chronicity
Acupuncture
Matched Treatment Pathways
Aim: To restore function, minimize disability even if pain is unchanged, improve psychological functioning and enable patient to manage ongoing +/- future episodes of back pain
60 mins session 6 sessions 3 months
Cognitive behavioural approach
HIGH RISK Additional psychological obstacles to recovery
MEDIUM RISK Mainly physical obstacles to recovery
LOW RISK Low risk of chronicity
ILLNESS
BIO
Psychologically Informed Practice Main et al 2012
Investigate patient’s specific belief/expectations
As precursor to identifying targets for intervention and obstacles to recovery
Dx & treatment
Attitude & beliefs
Behaviour
Family
Compensation
Emotions
Diagnosing language leading to catastrophising and fear
Sig withdrawal from normal ADL
Expect quick and easy cure
Family emphasizing fear of harm
Loss of enjoyment and mastery
Kendall et al 1997
Work
Rx cost incurred
Poor job satisfaction
Common pain related beliefs
Hurt = Harm Pain is uncontrollable
Passive treatments are the answer
Dr. Kelvin Vowles
Pain Suffering
multiplied
Struggling with pain
Failure
Lost freedom & opportunity
Pain and Suffering
Suffering controlled
Maintained life
direction
Success
Pain
Freedom & opportunity
Understanding typical emotional reaction to pain Linton and Shaw, 2011
Anxiety Fear Anger
Guilt Frustration Depression
• Open avenues for understanding pain
• Patient feel being understood
• Enhance engagement and treatment
Active listening Reflecting
Paraphrasing Clarifying
Summarizing
Communication Skill
• Exchange thoughts, feeling and ideas, verbal and non-verbal
• To build up rapport and trust with patients • To facilitate self-disclosure • To co-produce the agenda
Help resolve ambivalence in the direction of change
Establish successful behavioural change
Baseline 20% off average capacity
Target
Current status
e.g. Hiking x 60’
• Values based • Generated by patient • Important • Realistic • Enhance motivation
Graded exposure / pacing
Building up confidence to cope with pain
Self efficacy • Confidence in
performing a particular behaviour
• Overcoming barriers
Social persuasion
Experience of doing
Mastery experience
Vicarious learning
Hill et al, 2011 (n=851)
At 4 and 12 months post D/C:
• Fear avoidance beliefs • Time off work • Patient satisfaction • QOL
Clinical Attachment Cheadle Hospital Biddulph Primary Care Centre Cobridge Primary Care Centre Bentilee Neighbourhood Centre Rising Brook Clinic Greyfriars Therapy Centre
• Implementation of stratified care (STarT Back) in clinical services
• Recent & ongoing musculoskeletal research
• Presentation of services in HK in relation to implementation challenges & opportunities
Haywood Hospital Visit •Occupational Therapist
•Consultant Rheumatologist
•Physiotherapist
•Clinical Psychologist
•Rehabilitation Consultant Doctor
•Stratified cared alters decision-making for the better •Low risk patients are not over-treated •Medium / high risk patients have a greater chance of treatment and this greatly improves outcome •Training upskill the physiotherapists
Our reflection
MSK ASP
Pilot new service model
Therapists’ perception, knowledge and acceptance
Information material
1) Adoption of STarT Back Approach in Back Pain Management in Hong Kong: From Incubation to Implementation
2) New Stratified Care Model for Back Physiotherapy Adopted from The United Kingdom: A Pilot Study in a Regional Hospital in Hong Kong
IAAHS, AHG HAHO Colleagues