Persistent Low Back Pain (PLBP) is the leading cause of disability worldwide. Disability and costs attributed to PLBP are projected to increase in coming decades (Hartvigsen et al, 2018). Research has now established that for people with PLBP, their cognitions and coping mechanisms play a bigger role in the progression from acute to persistent pain than physical features (Wertli et al, 2014).
Clinical guidance (NICE, 2016) recommends that service users (SUs) who are not responding to routine management or have significant psychosocial obstacles to recovery, should be considered for a combined physical and psychological programme (CPPP). However, there are no clear current guidelines on the best format for a CPPP.
The Back in Action (BiA) programme was introduced to address the needs of these SUs. This service evaluation aims to assess the effectiveness of the BiA 58 hour multi-disciplinary CPPP format on SUs pain related cognitions and function.
the PSEQ increased by 13.87 (CSD=11),
the 5RSTS reduced by 8.26s (CSD=4.1s)
and the 6MW increased by 105.29m (CSD=54m).
Data was sampled from all SUs that completed the intensive component of the BiA programme between January 2015 and December 2018. SUs completed six psychometric self-reported outcome measures at initial assessment, pre and post programme, and three physical outcome measures pre and post programme. Outcome measures included the Tampa Scale of Kinesiophobia (TSK), Pain Self Efficacy Questionnaire (PSEQ), Timed 5 Repetition Sit-To-Stand (5RSTS) and Six Minute Walk (6MW). The mean change was calculated between initial and post programme scores for the TSK and PSEQ, and pre and post programme for the 5RSTS and 6MW.
277 SUs started the intensive intervention with 10 failing to complete the intervention and 19 having incomplete data sets. Therefore analysis was conducted on 248 SUs, mean age 47.8 years (Range 22-78), with 141 females and 107 males. All four outcomes demonstrated a Clinically Significant Difference (CSD) from 2015 to 2018. Mean scores in TSK reduced by 9.66 (CSD=9.2), the PSEQ increased by 13.87 (CSD=11), the 5RSTS reduced by 8.26s (CSD=4.1s) and the 6MW increased by 105.29m (CSD=54m).
The results show the BiA programme produced consistent results over four years, significantly reducing Kinesiophobia, improving self-efficacy and increasing functionality in PLBP SUs.
A weakness of the evaluation was the loss of data from the 10 SUs that dropped out and the number of incomplete data sets, which may have skewed the results. In the future, following up those that failed to complete the programme and capturing missing scores would allow for more accurate results and interpretation.
Cost and savings
The programme has a total yearly budget of £154k that includes the cost of the MDT and community venues.
We haven’t completed analysis on the social return on investment as yet but this is a priority. Long term follow up of patients suggest significantly less healthcare utilisation post intervention.
BiA received an Advancing Healthcare Award in 2016 for prudently advancing practice so there can be confidence in the delivery of prudent healthcare.
Despite the increasing prevalence of PLBP, there are currently no detailed guidelines for the delivery of CPPPs. The format used by BiA delivers consistent clinically meaningful changes in an increasingly complex group of SUs presenting with psychosocial obstacles to recovery. This format could be replicated across other health boards to address a common gap in the spinal pathway with confidence in its outcomes, cost effectiveness and prudency.
Top three learning points
No additional funding was required for this service evaluation.
This work was presented at Physiotherapy UK 2019
Please see the attached Innovations poster below.
For further information about this work please contact Amy Thomas.