This project was designed to allow patients with low back pain faster access to physiotherapy and to implement the NICE guideline NG59 for low back pain and sciatica in over 16s: assessment and management.
Patients were given the opportunity to attend an education and advice session, including a set of exercises within 2 weeks of their referral to physiotherapy instead of waiting on the waiting list.
Patients carried out the exercise program at home for 4 weeks after which time they contacted the physiotherapy department. A physiotherapist would then decide on the most suitable course of action either; one to one assessment and treatment, gym sessions with a technical instructor or discharge to continue to self-manage. It was intended that seeing patients early and using risk stratification tools would help identify those who required early and more intensive support. It would provide those who needed less support with information to help them to self-manage their low back pain.
Aims and objectives
There were a number of aims for the service in order to provide a better treatment pathway and outcome for patients with low back pain with or without sciatica.
- Provide in-depth education about low back pain to reduce the risk factors for chronicity.
- Empower patients to self-manage in the short and long term.
- To facilitate patients to remain in or return to work and continue normal activities.
- To provide a more timely initial management of their condition.
- To make use of risk stratification to identify patients who may need more intensive or prompt support to reduce the risk of a poor outcome.
- To assist in managing the waiting list more effectively to reduce waiting times, without having a negative effect on patient experience and outcomes.
Reasons for implementing your project
The number of referrals to the physiotherapy department was exceeding the number of new patient appointments each month. Therefore, the waiting list was growing resulting in a wait of 12 weeks for an appointment. This placed the patients at an increased risk of their problem becoming chronic and their needing longer episodes of treatment in the physiotherapy department.
Referrals for back pain were the most common and it was felt this group of patients had some specific needs that were not being addressed well through the current pathway. Many patients referred with low back pain had seen their GP multiple times and had not been given the appropriate advice on how to self-manage. They had developed fear avoidant strategies and were stopping doing their normal activities including working. Due to the short appointment times for physiotherapy patients, these yellow flags were often difficult to address and negatively affected the patients’ rehabilitation. We wanted to implement a service that would enhance the patients care whilst addressing our waiting list, which would benefit all our service users.
Additionally, it was difficult to ascertain from the referrals which patient’s problems were acute or who was at risk of a poor outcome and might need more urgent and intensive support. We needed to create a system which would allow these patients to be identified so they could be seen more urgently.
How did you implement the project
Initially the numbers of patient referrals for back pain per week were analysed to ascertain whether a group approach was feasible. We established there were 15 to 20 per week and of these between 10 and 15 contacted the physiotherapy department to make an appointment. We felt that 10 patients could be supported in a group setting and it was decided to move forward with the plan.
A presentation was created to provide advice and information on how to manage their back pain. Attention was paid to addressing yellow flags by devoting a large part of the talk to explaining pain and the nature of back pain and sciatica itself. There was also an emphasis on ways in which to go about their normal activities or to return to them. A set of exercises was devised that would be suitable for people with a range of abilities and categories of back pain. As there was limited information on referrals and patients would not be screened individually it was important to screen for red flags. In addition to this any factors that would affect their ability to exercise needed to be ascertained.
An assessment form was designed for the patient to complete prior to the session including the following:
- Basic details of their current condition and past medical history.
- Red flag screening questions.
- The STarT Back risk assessment tool.
- Patient Specific Functional Scale (PSFS) in order that the intervention could be audited. This is where patient feedback was captured, together with a satisfaction survey.
There were no financial implications in setting up the program as existing staff were able to run it, utilising space in the physiotherapy department. The band 7 took overall responsibility for the program as this was a static post which provided continuity. A band 3 technical instructor provided administrative support and to lead the exercises and a rotational band 5 provided extra help to patients to complete the pre-assessment forms and to supervise the exercises. Having 3 people to supervise the exercises would allow then to be tailored and adapted to the individual’s needs.
An email box was set up to receive patient emails and the Band 7 had a dedicated time to receive phone calls to review patients’ progress. Admin staff were educated about the benefits of the program over waiting 12 weeks for a one to one appointment. This enabled them to encourage patients choose the program and ensure the sessions were filled. A database was created in order that the outcomes of the program could be reviewed after 6 months and on an ongoing basis.
At the 6 month review there was a high level of satisfaction from patients who attended the session.
- 69% of patients felt that their attendance enhanced the management of their back pain.
- 65% had been fully compliant and 35% partially compliant with the exercises.
- Patients felt empowered to exercise and move more with less fear. Many had been able to return to some of their normal activities or work.
- PSFS scores had increased by 5 points on average. 40% of patients contacted the department after the 4 weeks.
- 96% of these patients required further assessment and treatment.
- Some required a brief intervention such as more tailored exercises and reassurance and others a more comprehensive treatment program including manual therapy.
- Patients who required further treatment had waited less time from referral to one to one physiotherapy than if they had stayed on the waiting list. Acute appointments were offered immediately after the session to a number of patients.
- Those who scored highly on the StarT back tool and had low scores on the PSFS.
- Patients who had been on sick leave since their acute onset of pain.
- Patients who were unable to care for young children. This patient group had more timely access to comprehensive support than if they had remained on the waiting list. 60% of patients did not contact the department for a telephone or email review for the following reasons.
- 53% had found the exercises and advice had enabled them to self-manage or their pain had resolved.
- 15% had sought private treatment as they wanted individual treatment sooner.
- 23% felt they would not benefit from further physiotherapy wanted to self-manage or returned to their GP.
The waiting list for first appointments for all conditions fell to 8 weeks after 6 months.
Key learning points
Prior to establishing the program, the effect of education and advice in reassuring and giving confidence to patients in order to help them self-manage had been underestimated. We learnt that many patients were keen to self-manage with the right advice and exercises rather than having a number of appointments.
Consequently, those patients who have not attended the session and are at low risk are given more advice and less intensive support to encourage self-reliance. The initial exercise program was comprised of 6 exercises. Feedback from patients was that this number was difficult to complete due either to a lack of exercise tolerance, lack of time or increased pain for a significant period after the exercises.
Often patients picked the exercises they found easier or performed them incorrectly as it was hard for them to remember the techniques despite having written instructions. The number of exercises was reduced to 3 and as a result there was greater compliance with completing them. Patients also tended to perform them more effectively and the improvement in PFSF scores continued as before the change. Initially there was some negative feedback from a small number of patients who had not known they were attending a group and they had not understood that this did not replace their individual physiotherapy.
As a result, the administration staff attended the sessions to gain a better understanding and were able to clearly explain this to patients when making the appointment. In addition, they were given an in-depth explanation at the beginning of the session about the aims of the program, with reassurance they would still have individual treatment if that was required.