Functional Restoration Service

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).

Inclusion criteria:

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

Exclusion criteria

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.

Evaluation

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

1. The responder (patient, family member or carer) was treated with dignity and respect;
2. The responder felt involved enough in decision made about them;
3. The responder received timely information about their care and treatment;
4. The location was clean;
5. The responder was treated with kindness and compassion by staff.