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 Manipulation Exercise ► ?Disc/Nerve Root Acupuncture ► ? “Simple” Mechanical Back Pain CBT MRI Exercise Referral Epidural Acupuncture MRI

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 Serious pathology Red Flags – Inflammatory Nerve Root Pain - leg pain Non specific back pain Cauda equina Scoliosis back pain (radiculopathy) syndrome or 2 week wait referrals Up to 3 More than 3 Up to 3 More than 3 months months months months 2 Refer to duration A&E Refer duration duration duration week rheumatology RDE Refer SABPS Refer ABPS or Consider wait Refer ABPS or or physio physio LSAS physio Resolving Resolving Consider Continue Not Not Continue Not physio / treatment and resolving resolving treatment and resolving SABPS discharge discharge Refer sub MRI/ consider referral for acute back neurosurgical spinal MDT pain service or pain clinic Consider MRI / referral for Referral Referral Not neurosurgical for pain for spinal resolving spinal MDT or clinic surgery referral pain clinic

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 2005/6 100 90 80 70 60 50 40 30 20 10 0 satisfied Satisfied Adequate satisfied dissatisfied Very Not Very

Subsequent treatment after Subsequent treatment after SAS Sub-acute service 180 160 140 120 Number of patients 100 80 60 40 20 0 No Further Treatment Neurosurgery Neur Pain DerrifOrthoRheuOther Oste ChiroAcup No fu Pain Clinic Orthopaedics Rheumatology Other Osteopathy Chiropractic Acupuncture Hospital Derriford Series 1 Series 2

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