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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