Musculoskeletal (MSK) related pain has a major impact on individuals and society. It is the second most common reason for GP visits and accounts for about 25% of all GP consultations in the UK. It is estimated that 9.3 million working days are lost in the UK to MSK problems, with knee, hip and back pain the most commonly reported.
NICE Guidance: CG177 for the care and management of osteoarthritis (OA) highlights the need for a patient-centered holistic approach to the management of OA to improve access to information, increase physical activity and promote weight loss through education and self-management.
The Health Innovation Network, the Academic Health Science Network for South London has developed a physiotherapy-led service – a joint pain advisor to provide easier access to better care for people with OA of the knee and hip, supporting them with education, information and exercise to manage their condition. The service was evaluated for its feasibility, effectiveness, acceptability.
Aims and objectives
The aim of the project was to evaluate whether an Allied Health Professional (AHP)-led primary care intervention delivering person-centered, holistic, practical lifestyle coaching was a feasible, more effective way to manage patients knee and/or hip pain.
Reasons for implementing your project
In older people chronic knee and hip pain, usually labelled osteoarthritis (OA), is very prevalent and impairs mobility, function and quality of life. The majority of people with OA are managed in the community by their GP, with only a very small minority having joint replacement surgery. GPs have limited time and expertise to support patients presenting with uncomplicated OA.
Poor patient health beliefs, behaviours and lifestyles such as being overweight, inactive combined with fear-avoidance behaviours all contribute to risk factors for developing and exacerbating joint pain. Enabling GPs to implement NICE guidance on managing OA such as effective lifestyle coaching would require additional training and more frequent, longer consultations. AHPs in contrast spend a large proportion of their work persuading people to make lifestyle changes and take up physical activities physical activity to reduce joint pain.
The Health Innovation Network developed a model of care using physiotherapists to deliver a series of face to face consultations with people experiencing knee and/or hip OA. People aged over 45 with a diagnosis of OA or experiencing knee and/or hip pain for more than three months were invited to participate in a study to see if management led joint pain advisor would be an effective and sustainable way to manage uncomplicated MSK pain. Clients attended an initial 30 minute baseline assessment where they were screened for red flags and discussed lifestyle, challenges and personal goals contributing to a jointly developed personalised care plan.
They received tailored advice and support based on NICE guidance CG177 for the Management of OA and invited to attend a review at 3 weeks, 6/8 weeks and six months.
Following the six month review clients were encouraged to return for an annual review with their GP as per NICE guidance recommendations (Recommendation 1.7.2).
How did you implement the project
Two physiotherapists experienced in managing MSK with lifestyle advice, coaching and support were recruited to the Joint Pain Advisor role working across six primary care surgeries in South London.
Participants were invited to a series of four 30-minute appointments: initial (baseline) assessment; follow up at 3, 6-8 weeks and a final review at six months.
At the initial assessment, the Joint Pain Advisor established relationships with participants to assess pain, function, quality of life, physical activity, waist circumference and body mass.
Advisors taught simple self-management strategies and used behaviour change techniques (motivational interviewing, goal setting, action/coping planning) to alter participants’ lifestyles.
At review meetings the advisor reassessed clinical outcomes, fed back progress and reinforced health messages. Feasibility and effectiveness of the service was evaluated using quantitative and qualitative methods.
A total of 498 people used the service across six primary care practices over an 18 month period. The mean age of participants was 65 years (range 40-93 years), mean weight 87 kg (range 49-157 kg), 82% had knee pain, 18% hip pain and many presented with both. 59% referrals came from a GP and 40% accessed the service after receiving a letter inviting them to book an appointment. 63% returned for 3-week review, 50% returned for 6-week review, and 12% returned for 6-month review.
Low return at 6 months was explained by participants reporting they had received sufficient information during the initial assessment and did not need any further support. A minority experienced difficulties getting a review appointment due to the popularity of the service or not receiving letters due to administrative errors.
Patients reported improvements in pain, physical function, quality of life, number of days walking for 20 minutes or more and sit-to-stands performed in 30 seconds. Also reductions in body weight, BMI and waist circumference.
The study showed overall an 18% reduction in pain, a 2kg reduction in weight and a physical activity increase of 2 days a week.
Total healthcare cost was £2,424 lower 12 months post assessment (£39.10 per patient) compared with 12 months prior to assessment - with 21% fewer GP consultations for hip or knee pain and a reduction in referrals to MSK physiotherapy and imaging.
Satisfaction with the service:
100% respondents were satisfied with the service, reporting they felt listened to and received clear, practical advice including a care plan. Before the service, participants reported not knowing the strong association between between pain and being overweight and inactive, nor had they received any advice or support that enabled them to modify their beliefs and behaviours that would reduce their pain and disability.
Our findings show that the joint pain advisor service facilitated easier access to better care, provided clinical benefits and reduced healthcare utilization. The service created a more efficient pathway, providing faster access to support and eliminating fewer consultations and onward referrals / investigations for the participants involved.
Key learning points
- Pressures on primary care services including lack of time and appropriate training means GPs frequently struggle to manage joint pain.
- AHPs are well placed to provide effective, efficient and better care for people with uncomplicated knee and hip pain.
- People want know more about their condition and to be more involved in their care, responding well to tailored support and advice
- Changing beliefs and behaviour requires coaching from practitioners with sufficient knowledge, expertise and time to provide effective, practical information, advice and on-going support. When delivered effectively people can adopt lifestyles that improve clinical outcomes.
- Our findings show people may not want or need regular review if they experience improvements in pain management following targeted advice and support. It may be better that people have the option to self-refer to services when most appropriate to their needs.
- AHP-led primary care for people with uncomplicated knee or hip pain can reduce the cost of care and free up GP time, whilst at the same time providing better clinical results and increased patient satisfaction.