Aims and objectives:
The Back Pain Unit started running pain management programmes for patients with chronic low back pain in 1998.
Evaluation in 2001 confirmed clinical efficacy of the programmes and indicated potential improvements could be made in waiting times, efficiency of the service, meeting patient's needs, and helping patients to make informed choices about pain management. We aimed to implement these improvements, whilst maintaining or enhancing long term clinical outcomes, and applied our experience to preventing patients with low back pain progressing to longstanding disability and distress.
Support for the change:
The Back Pain Unit adopts a multidisciplinary team approach and values equally the contributions of occupational therapists, psychologists, physiotherapists, nurses and medical staff, as well as patients.
Budgetary control supports professional development and enhances team working. The Unit's staff are encouraged to play active roles within their own professional departments and national professional organisations, thereby facilitating dissemination of pain management principles, and benefiting from external views. Formal links have been created with internationally recognised experts in the field.
The Unit adopts a rigorous evidence-based approach, enhanced by direct academic links with the University of Nottingham.
Patient and public influence:
Patient views have been sought through informal feedback and patient satisfaction questionnaires. Attendance rates and reasons for non-attendance have also provided valuable information.
'Introduction Days' now inform patients about pain management prior to assessment within the Unit. This earlier contact with the team enables patients to make an informed decision about entry onto the programme. ' Introduction Days' have reduced non-attendance, which, together with flexible working, has doubled the number of patients assessed per day.
Following difficulties reported by both patients and team members, the original programme format was changed from 2 days a week to 1 day a week for 9 weeks with further sessions after 3 and 9 months to increase opportunities for consolidation of newly acquired skills.
Users who were working or had carer commitments reported access difficulties. This was addressed by introducing a half-day per week programme for selected users, which is currently being evaluated.
Structured questionnaires returned by referring practitioners and feedback from patients led to a streamlined referral process, patient opt-in on the basis of key information, and accessible timetabling of the current Early Intervention Programme.
Impact on the workforce:
Increasing diversity of programmes has added depth to professional activities within the Unit. All members of the workforce contribute to decision-making and programme development through regular team meetings and time-out activities. The Unit is currently developing multidisciplinary pain management programmes for patients with sub acute low back pain. Lessons learnt through new developments stimulate further improvements in the original pain management programmes.
Staff have presented evaluation data from the Unit to their professional organisations, and published in peer review journals.
The Back Pain Unit is currently playing a central role in service development through chairmanship and membership of the Back Pain Service Review Group.
Measuring the results:
Clinical outcomes have been measured using standard questionnaires addressing psychological distress (HADS), disability (RMDQ), quality of life (SF36), cognitive and coping styles (PBQ, CSQ). Service outcomes have been measured using administrative data. Patient satisfaction has been assessed by questionnaire and consultation. Performance has been compared with other organisations following systematic review of published data from controlled clinical trials using comparable outcome measures. Recent outcomes have been compared with data from early programmes.
Primary care physicians and physiotherapists contribute through discussion to each stage of the Early Intervention Programme's development, with feedback of outcomes to all stakeholders.
Improved performance:
Drop out rates during programmes reduced by more than 50% following commencement of 'Introduction Days'.
The number of people assessed in one day has approximately doubled. The number of programmes run per year has increased by 30%. Both were achieved with unchanged resources.
Participants' improvements in cognitive style, psychological distress and disability, are maintained at least 12 months after entering a programme. Clinical improvements are comparable to those observed in active treatment arms of published controlled trials. Improvements in psychological distress are greater than those reported in earlier programmes, whilst other improvements have been maintained.
Formal assessment of feedback shows high patient satisfaction with Back Pain Unit Services. Recent analysis of hospital administration systems indicates that more than 80% of programme 'graduates' are pursuing self management after 3 years without having further consulted within secondary care for their back pain.
The Unit is amongst the first in the UK to introduce multidisciplinary programmes specifically for sub acute back pain, thereby implementing national guidelines.
Reflecting diversity:
The Unit provides individual sessions for patients for whom a group setting is unsuitable, and a half-day programme for people who are working or who have other commitments.
The Unit has changed programme content to accommodate patients with literacy problems.
The Unit benefits from having a number of part-time staff, and encourages flexible working. The Unit prides itself in encouraging the professional development and contribution of staff with diverse needs.
The Unit recognises the distinct needs of patients with early and longstanding chronic low back pain.
Sharing the learning:
Evaluation reports are disseminated to stakeholders within and outside the Trust including referrers and management.
The Unit communicates additionally within the Trust through articles in the Trust staff magazine, by oral presentations to the Orthopaedic Department and by participation in the Orthopaedic and Rheumatology Service Review Groups, Pain Services Buildings Design Group, and other management activities.
The Unit contributes to undergraduate medical student teaching and postgraduate medical and allied health professional training.
The Unit has presented and published evaluation findings to the UK Pain Society, the National Pain Management Conferences and the British Society for Rheumatology.
The Clinical Director currently chairs the organising committee of the 10th National Pain Management Conference to be held in Nottingham in September 2005.
Recent publications: Spine:29;87-93. Pain 2002:97;23-31.
Outstanding features:
The overall success of our pain management programmes and the way that they have continuously developed. This has naturally led to our initiating an extended pilot programme for people with sub acute back pain.
We have also been instrumental in the setting up of a Service Review of back pain services currently underway within the local health community.
