To provide group based, interdisciplinary, combined physical and psychological treatment (CPPP) service to patients with persistent non-specific back pain, to help restore function and quality of life.
The service’s aim is to train patients to become experts at understanding their persistent low back pain, to manage flare-ups in pain effectively, to set goals to improve function, to reduce reliance on analgesic medication, and to engage in healthy behaviours
The service uses a cognitive behavioural approach, as recommended in the National Back Pain and Radicular Pain Pathway (Pathfinder) (2017) and NICE Guidelines (2016) as an effective way to manage persistent non-specific back pain and disability.
Approach to service design
The service was set up as a CQUIN project in 2011, as at that time there was no provision of CPPP within the Trust, despite it being a specialist orthopaedic hospital. The clinical team met with commissioners, GP’s, spinal surgeons, physiotherapists, orthopaedic physicians, & Advanced Practice Physiotherapists when developing the service.
The services provides group-based (12 person maximum) interdisciplinary treatment - led by a physiotherapist, orthopaedic physician and pain counsellor - using a biopsychosocial approach, underpinned by cognitive behavioural principles.
NICE guidelines at the time recommended behavioural programmes of up to 100 hours, but this was deemed as too expensive by commissioners, so the clinical leads established a 12 hour model which commissioners agreed to fund. Each programme meets twice weekly, for three hours of contact time per week, and continues over a period of four weeks. In service evaluations, this shorter intervention has demonstrated clinically effectiveness (Rogers et al, 2014).
The classes use education, physical exercise and relaxation & mindfulness approaches to empower patients to self-manage persistent symptoms and return to normal activities of daily living, including work, where possible. Patients are likewise helped to reduce their reliance and use of pain medication. 1:1 physiotherapy-led combined physical and psychological treatment is also provided as needed, either to prepare patients for a group programme, or as stand-alone intervention.
Classes are physiotherapist led, supported by an orthopaedic physician and pain counsellor with physiotherapy assistant and administrative support. Expert patients –recruited from preceding programme participants – also provide education to programme participants. Staff accessed a mixture of both internal and external training courses to develop the skillset needed to deliver the programme.
The service also provides health resources to support behavioural change through the use of a dedicated website. Patients are directed to and encouraged to use this website as part of their treatment intervention and are directed towards local authority exercise facilities at the end of each programme to help maintain behavioural change.
The service covers the whole Birmingham population, and was initially provided out of a secondary care centre (a spinal centre) but is now offered through primary care settings utilising a ‘hub and spoke’ model of delivery.
Inclusion/exclusion criteria and referral routes
The programme is designed for patients with persistent low back pain who are struggling to return to normal activities of daily living and are at risk of becoming chronically disabled. Inclusion and exclusion criteria were developed following a review of contemporary back pain guidelines and the views of the multidisciplinary team (Rogers et al, 2014).
1. Adults with persistent non-specific back pain of greater than 12 weeks duration
2. a. At work, either paid or voluntary but struggling to maintain responsibilities
b. Off work, but job remains open
c. Not employed but actively seeking to improve function and quality of life
3. Not responded to routine primary care management such as GP advice, medication, exercises
4. Patient appearing motivated to help themselves to get better
5. Modifiable psychosocial factors impacting on their ability to recover
1. Serious spinal pathology such as tumours, infection, cauda equina signs
2. Significant motor radiculopathy and signs of nerve root compromise requiring surgery
3. Widespread multi-joint pain
4. No other open episodes of care for the same condition
5. Rheumatological conditions
6. Previous attendance on a pain management programme
7. Communication barriers which would prevent ability to follow cognitive component of program
8. Other medical problems which would prevent involvement in physical exercise program such as unstable cardiac conditions, significant respiratory problems, poorly managed diabetes
Referrals are received from secondary care spinal clinics, physiotherapy department and GP referral from primary care. Self-referrals can be made with agreement from GP.
The service receives approximately 40 referrals per month. Staff making referrals are asked to provide a short synopsis of the patients back pain history and any recent investigations or treatments.
Prospective patients have a 40 minute assessment from a physiotherapist prior to being offered a programme. The assessment consists of a standard physical assessment, plus more in-depth clinical assessment of modifiable psychosocial factors.
A series of service evaluations and audits has been conducted by the programme’s clinical leads, in collaboration with colleagues in the academic community.
CQUIN evaluation (Rogers 2013)
A summary of data gathered from the first five programmes run though the service was produced for the service’s commissioners. Clinical leads and commissioners agreed to gather patient-derived data pre- and immediately post-programme on:
- Disability scores, as measured by:
- Oswestry Disability Index. As discussed in Rogers et al (2014), the ODI is one of the most commonly used back disability measures, and has been extensively tested, shown to have good psychometric properties, and proven to be applicable in a variety of settings (Fairbank and Pynsent 2000).
- Patients’ Pain Self Efficacy Scores, as measured by PSEQ. The literature considers low self-efficacy to be an important maintenance factor for patients with persistent spinal pain (Main and Spanswick 2000), and there is a strong association between high PSEQ scores (>=40) and the maintenance of functional gains (Adams and Williams 2003)
- Self-reported changes in pain medication use.
Short term post-treatment evaluation (Rogers et al. 2014)
A retrospective analysis of the first 85 patients referred to the programme - between September 2012 and June 2013 - again examined ODI and PSEQ scores for participants, alongside self-reported changes in medication use.
Data on these outcome measures were collected pre- and immediately post-programme, and again at 9 months post-programme, to assess the longer term impact of the programme.
The evaluation acknowledged that the literature has established improvements in back disability and a range of other physical and psychological measures in addition to ODI and PSEQ scores. However, given this literature was largely based in primary or occupational health settings, the clinical leads elected not to collect data against these measures.
Of the 85 patients referred to the programme during the course of the evaluation, 70 completed the programme. Full data sets (pre- and post-programme) were collected for 54 of these patients. 21 datasets were collected by mail at the 9 month post-programme stage.
Long term post-treatment evaluation (Rogers et al, 2017)
A later service evaluation randomly sampled from all patients to have completed the programme as of December 2015 (373 patients, with outcome measures collected for 272), and approached 120 patients for longer term follow up.
ODI and PSEQ scores were collected for a total of 40 patients for long term follow-up, following a median period of 27 months post-treatment (interquartile range = 1 – 38 months).
The authors acknowledged the low response rates of this study, potentially affecting the validity of collected data. However, analyses of responders and non-responders showed no statistically significant differences in gender, and no clinically significant differences in age.
Medication audit (Smith et al., 2018a)
A clinical audit was conducted with all patients passing through the programme between October 2016 and May 2017. Complete (pre- and post-programme) datasets were provided by 47 programme participants.
The purpose of the audit was to identify the pain medication used by patients and their associated costs; compare medication use with recommendations from the literature; and evaluate patients’ reduction in medication use and any associated cost savings.
This evaluation followed acknowledgement from the service’s clinical leads that data concerning medication use collected through the above evaluations (see, for example, Rogers et al. 2014) were not robust enough for full discussion.
Patient satisfaction scores are routinely collected for the service as part of the Trust’s routine monitoring and evaluation processes. In addition to simple demographic data (age and gender), this captures data on:
- The NHS Friends and Family Test;
- An open field question on what was good about the patient’s care, and what could be improved;
- Ranked score questions on whether
- The responder (patient, family member or carer) was treated with dignity and respect;
- The responder felt involved enough in decision made about them;
- The responder received timely information about their care and treatment;
- The location was clean;
- The responder was treated with kindness and compassion by staff.
The CQUIN evaluation demonstrated improvements in disability scores.
- Pre- and post-programme ODI scores reduced from a mean of 43 to 29 (n=45; (100=completely disabled, 0=no disability).
- The mean pre-programme walking distance in metres for the 6 minute walk tests for programme participants was 242 meters. The mean post-programme score was 303 meters (n=45)
Improvements in patients’ self-efficacy were also found. Pre- and post-programme self-efficacy scores, as measured by Pain Self Efficacy Questionnaire, increased from 26 to 41 (n=45). For the PSEQ, the literature has established that scores of <=40 are associated with respondents being able to maintain functional improvements post-treatment.
87% of a small sample (n=54) of patients reported reducing their use of pain medication following the programme. Of these patients 97% (n=47) reported being confident in being able to continue to self-manage with less or no analgesic medication. Outcomes from the more thorough and robust medication audit are presented below.
The evaluation’s authors – the clinical leads of the programme – noted an expectation that post-treatment follow-ups would demonstrate further improvements to patients’ scores. Outcomes from longer term evaluations that included post- are presented below.
Short term post-treatment evaluation
The evaluation found statistically significant improvements in both ODI and PSEQ scores collected pre- and post-programme; and again between the pre-programme baseline scores and those collected at 9 months post programme. No statistically significant differences were found when only those scores collected immediately post-programme (4 weeks) and 9 months were compared.
This suggests improvements made during the course of the programme were sustained at the nine month follow up, but no further improvements were made following the end of the programme’s group aspect.
73% of patients reported less medication use post-programme compared to their pre-programme baseline. 63% were still taking less or no medication compared to the pre-programme baseline at month 9. Small sample sizes meant medication use data were not tested for statistical significance. Outcomes from the more thorough and robust medication audit are presented below.
Long term post-treatment evaluation
The evaluation demonstrated that the CPPP programme resulted in clinically significantly significant improvements in pain self-efficacy and back disability scores, which were maintained in the long term/.
Statistically significant improvements in PSEQ immediately post-programmed programme compared with the pre-programme baseline assessment. Statistical analysis found these improvements were maintained at patients’ long-term follow up. Significant differences were also found in patients’ long term follow up scores when compared only with pre-treatment scores. 21% of patients had a PSEQ score of >=40 at initial assessment; 71% at 4 weeks (immediately post-treatment) and 65% at long term follow up.
The evaluation found significant improvements in ODI scores immediately post-treatment compared with the pre-treatment baseline assessment; and between long-term follow up scores compared with pre-treatment scores. ODI scores immediately post-treatment were significantly better than at long-term follow up.
This finding suggested to the authors that patients may struggle in maintaining behavioural change once they had left the structured programme, prompting them to consider adjustments to the CPPP service to maintain gains in the long term – such as improved web resources and signposting to community amenities at the completion of the programme.
67% (n=30) of respondents reported reductions in their pain medication usage following their programme. None reported increased use.
The audit found that this translated to a total cost saving of £3728.64/year for the 30 patients – or £124.29/year/head for each patient reporting a reduction in medication use.
The audit also noted a disparity between the recommendations of the medical literature and the use of pain medication by patients, and concluded that CPPP can be used to reduce or stop inappropriate pain medication use.
In a poster presentation of the audit (Smith et al., 2018b), the authors recommended further follow up study to investigate whether cost savings are maintained in the long term; and that further evaluations should test associations between cost savings and improvements in patient symptoms.
Cost and savings
Attendance on the programme costs <£500 per patient. There were no set-up costs as primary care site host the service for free
The medication audit and other evaluations have demonstrated savings on medication use – see above.
As the programme promotes health behaviour change, there are likely to be some long-term healthcare benefits which are difficult to accurately measure.
Low intensity interdisciplinary CPPP can provide significant health benefits for patients with non-specific low back pain, as recommended by NICE Guidelines for low back pain (2016) and the National Back Pain and Radicular Pain Pathway (Pathfinder) (appendix 6 and 7)
Physiotherapists should take a lead on implementing the National Back Pain and Radicular Pain Pathway, and within this, establish multi-disciplinary CPPP for patients with persistent non-specific low back pain
Comprehensive training in using this biopsychosocial approach to treatment, underpinned by cognitive behavioural principles should be provided at both undergraduate and post-graduate level.
CPPP could be made more widely available for a range of pain related conditions, and explored with cohorts of patients with a range of conditions and/or multimorbidities.
The service is enrolled within the United Kingdom Spine Societies Board, National Back Pain Pathway, Clinical Network. The group meets annually, aiming to promote the Pathfinder project and knowledge share.
Top three learning points
Brief CPPP appears to be effective at reducing back disability and pain self-efficacy, with improvements maintained in the longer term. A CPPP can be used to help patients reduce or stop their pain medication
Physiotherapists can play a key role in redesigning musculoskeletal services to improve health outcomes for patients.
Engaging with commissioners and stakeholders is an essential component of this approach.
This work was unfunded.
Adams JH and Williams AC (2003) J Occup Rehabil 13:91–106.
Fairbank JCT, Pynsent PB (2000). The Oswestry Disability Index. Spine 25: 2940–53.
Main CJ, Spanswick CC (2000). Pain management. Aninterdisciplinary approach. London: Harcourt Publishers Limited.
NICE (2016) - https://www.nice.org.uk/guidance/ng59
Rogers (2013) CQUIN Report – Functional Restoration Q4. Unpublished; supplied by clinical lead.
Rogers et al (2014) https://www.ncbi.nlm.nih.gov/pubmed/25052505
Rogers et al (2017) https://doi.org/10.1002/msc.1235
Smith et al. (2018a) - https://journals.sagepub.com/doi/abs/10.1177/2049463718762348?journalCode=bjpb (abstract #38)
Smith et al. (2018b) – Helping patients to reduce pain medication on a combined physical and psychological treatment programme; a clinical audit (poster presentation). Unpublished; supplied by clinical lead.