Greater Glasgow & Clyde Back Pain Service - Claire MacKelvie

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Lecture given by Clinical Physiotherapy Specialist, Claire MacKelvie to the West of Scotland Pain Group on Wednesday 30th November 2011. Claire describes the development and function of the back pain …

Lecture given by Clinical Physiotherapy Specialist, Claire MacKelvie to the West of Scotland Pain Group on Wednesday 30th November 2011. Claire describes the development and function of the back pain service.

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  • Thank you for inviting me to present today at this west of sct pain group winter meeting. I have been a huge fan of these meetings and have attended many in past years since their beginnings and I fet honoured when karen henderson apprached me some months ago...... One thing I have realised, through putting this together, is how the back pain service has evolved and all the many things we have achieved . I joined in 2006 and have been involved in some of the developments – but I can say it is a fantastic, forward thinking, team to work in and I am very proud to be part of it.
  • Why there was a need for a service What the service consists of / who / what / where Some stats re numbers / where referral from / pathways How this works in reality – a case study Brief guide to our website on staffnet that you can all access. Patients can access a limited version on www
  • Every year 3-7 million GP consultations are for back pain and it accounts for 80 million lost working days. It accounts for £3.8 billion in lost production and Incapacity benefits of £1.4 billion If you went looking in the 90’s, you would find loads of guidleines including european new zealand, rcgp, ahcpr, kendall, linton, main etc guide to assessing YF’s in acute LBP. Pathway group looked at developing evidence-based pathways in Glasgow as not clear pathways in Glasgow
  • The message is – i’ll risk insulting you, is to subclassify into three groups – acute, nerve root and potential ssp LBP from L1 to buttock / thigh area , less than 6 weeks Nslbp – key message reaassured ++ and return to normal function / RTW etc asap, simple analgesics, avoid bed rest etc etc Nerve root pain – below knee to foot / toes – reassure with caution. Consider onward referral for surgical review if not resolving 3 months. So what we needed really........was superhero service ( like ghost busters?! ? Back busters? ) to establish / monitor and evolve pathways in GG ( then t become GGC)
  • north east Glasgow 2.5 specialists.
  • Evidence evaluated biopsycho
  • When I started 2006 it was 13 specialists - currently 10.7 physios and 0.8 psych staff. Vision was for specialists - resource / gatekeeper to MRI and/or surgery / service development / education role IMPORTANT to say – all musculoskeletal physios have a responsilibility for LBP mgt Managed under RAD but over acute and primary care personally I would be, like many of us, on more than one site - my split is 3 days victoria, 2 days milngavie clinic just now. Some in team across 3 or even covering 4 sites. Tough stuff, but touching base at all sites is aim.
  • delivering this more than 85% of the time according to our stats yearly which is meaty stuff standards – means early assessment of red flags / yellow flags and appropriate advice / info given as per RCGP and other guidlines ( eg kendall / linton )
  • my week breaks down into......mainly clinical - ed rolled in to this time only recently more clearly defined following a MSK staff consultation by GGBPS. reality – specialists not taking the time for development due to clinical pressures working now to protect this now full time specialists have to take a devleopment day - this means more effective use of the time. personally I am looking at our physio led bakc class across GG and C which is a valuable inpu for a certain group who need encouragement others exploring other threads
  • To give you an idea of where referrals into the team are from Large proprtion coming directly now to physio – so need for increase safetly measure hence red flag training / cauda equina guidleines at self re phones / clinics etc / saftely measure sin place by GGCBPS Consultant – may be ortho, A&E, neurosurgeon, neurology occ, pain clinic ( yourslves ) Review for 2 nd opinion by colleague – happening more often now. This is one reason that physios have to be on the ball with red flags now, as we are first line clinicians often now for back pain – hence red flags training given as part of triage to discharge.
  • audit of all musculskeletal physios across scotland and what they were documenting in assessment of LBP. this shows how well Glasgow are doing in terms of assessing LBP. ( well documenting it at least!) Glasgow excellent at red flags and cauda equina and YF’s Glasgow falls down on neuro assessment documentaion and documenting provision of info / back book ( TSO ) but this was addressed with training packages following the result showing postive action on outcomes from audit. multifactorial – hard to draw firm conclusions.
  • Staff should have biggest part of their caseload LBP according to incidence of referral into physio per staff member. If not then de skilling can occur. This specilaists see bit less than half of all LBP in Glasgow
  • Big message - acute not all we are seeing as a service. Somewhat contrived to think we would just see acute, but this has been perception of some in the past. GGCBPS – is aware that all must be skilled in acute and chronic management of LBP My personal caseload is more chronic than acute – as tends to be review of complex patients
  • Are other pathways If ready for independent exercise – will go to community leisure centres – we have links via liva active referral / vitality ( levels of exercise / graded) Others will
  • in line with RCGP guidelines and evidence, many patients discharged to self care. FTA rates - similar to that across other services GP – suspected SSP, or visceral referral, not LBP / hip etc exercise classes – both very different classes – addressing needs of diff groups well. Some ready for community ex, some not quite ready - surgery – 8% for opinion, big rise on data, was much smaller numbers in previous years. ? Why – perhapsdue to redirection of ortho referrals to our service / increase awareness of pathways. No conversion to surgery data – therefore not accurate re who went for sugery Psych – small but significant benefit in my experience – great intervention for small numbers. - shows improved management in physio services – davdi craig, you agree? Always smaller number than anticiapetd – servioce evolving as a result pain clinic – small number – but very signifcant intervention for those who go. Pain ed classes – will now be measured as of sep11 with revamp database
  • I am lucky enough to have been involved with comprehensive workbook ( on staff net website ) and delivery of classes small number but valuable input – individualised graded exposure, management of fears/stress / RTW issues / goal setting and ativity section always lower numbers than anticipated, so service evolving towards other ways of delivering psyh support in GGCBPS – considered very crucial to service and valuble to all MSK physio staff
  • innovative patient education development of services offered in primary care / community, early intervention ( 7% chronic, 3 % to pain clinic most in community) Moseley - Patients can understand pain physiology Understanding pain reduces the threat and fear associated with the pain and enhances the individual’s ability to cope with it more successfully Launched 2006 – one or two per year at 2 sites, so far about 13 or 14 classes. Plan to use data Outcome measures – pain disability, pain stages of change, coping stratgeies as well as VAS. Comprehensive workbook with all presentaitons / ideas / and goal setting sections etc I am lucky enough to have opportunity to deliver classes
  • frost 2006 liked model of our classes – reaching poorer socioeconomic groups with higher incidence co-morbidities personally thread for me – revamping to improve outome measures ( RMDQ / IPAQ / TSK ) and consistency and start gathering data from all centrally
  • The rare - small window ces ( data?) - handful per year. (pathway doc training)
  • Pathway document – big lauch 2006 – remember? Here in ebenzeer. Frost and waddell supporters of service++ , Lit review – red flags, obesity and LBP, Referral templates / questionnaires / patient info leaflets on exit routes
  • We have one! 1 st sept – now psych inputting data into same excel based database Evolving / changing – but updated red flags from lit review e.g. HIV / IVDA / tight band like pain.
  • Why did we bother developing


  • 1. Claire MacKelvie BSc (hons) MCSP Clinical Physiotherapy Specialist WSPG 30/11/11
  • 2. Outline
    • Background
    • The service
    • Some facts and figures
    • http://
    WSPG 30/11/11
  • 3. WSPG 30/11/11
    • Rising Trend of LBP disability ( Waddell, The Back Pain Revolution, 2004 )
    • Guidelines:
    • RCGP 1999 – underpins GGCBPS
    • AHCPR 1994
    • Kendall et al 1997
  • 4. Reminder RCGP guidelines
    • For acute NSLBP – quality subjective, reassurance ++
    • Acute nerve root –reassure with caution. Consider surgical review 3 months
    • Potential SSP – refer on for medical review urgently
    WSPG 30/11/11
  • 5. Pilot of Service
    • Pilot carried out April1999 – March 2000
      • 1281 referrals, 88.5% seen within 2 weeks
      • 95% RTW within 4/52
      • 9.8% had psychosocial issues / distress
    WSPG 30/11/11
  • 6. WSPG 30/11/11 GGBPS Mission Statement “ The GGBPS aims to provide the highest standards of care to the healthcare users of Greater Glasgow. The service is evidence based , and systematically evaluated and developed to ensure this. Patient centred, we will respect the individuality of all patients and their carers. Using a bio psychosocial model of back pain , self-management and the principles of rehabilitation are central to the service approach; the aim is to develop the GGBPS as a centre of excellence for the management of patients with low back pain.” GGBPS Pathway Document Version 2.1 Feb 2010
  • 7. WSPG 30/11/11
      • 11.5 clinical specialist physios, 2.8 Clinical Psychologists
      • Lead clinician
      • 21 sites
      • Pathways to radiology / surgery
  • 8. Standards of GGCBPS
    • possible acute Nerve Root seen within 1 week
    • Acute NSLBP ( buttock and LBP) seen within 2 weeks
    • (Acute - 6 weeks of pain or less)
    WSPG 30/11/11
  • 9. Specialist Role
    • Clinical ( 60%)
    • educational (20%)
    • service development (20%)
    WSPG 30/11/11
  • 10. Referral sources 2010 WSPG 30/11/11
  • 11. National LBP Audit 2009 Glasgow did well compared with national outcomes of documented subjective measures in LBP WSPG 30/11/11
  • 12. Back Pain Numbers Seen in Greater Glasgow Area from 2008-2010 WSPG 30/11/11
  • 13. Glasgow LBP Acute / non acute split 2010 WSPG 30/11/11
  • 14. What exit routes GGCBPS offers
    • Self care
    • MRI / surgical review
    • Physio led back class
    • Psychology led back class (evolved to be offered diff support) refer to workbook
    • Pain Education Classes
    • DEXA ( not exclusive to GGCBPS physios )
    • Community based exercise classes
    WSPG 30/11/11
  • 15. Exit Routes 2010 WSPG 30/11/11
  • 16. Enhanced Back Class
    • psychosocial risk factors
    • LBP< 1 year, not making progress at 6/52
    • joint psychology and physiotherapy
    • a Cognitive Behavioural Approach
    • Statistically significant reduction in anxiety,
    • fear avoidance & disability
    WSPG 30/11/11
  • 17. Pain Education Classes
    • Professor McEwen report
    • Professor Moseley - understand pain
    • 6 weeks, 3 hours, 2 sites.
    • Aims to:
      • Optimise patient understanding & self mgt skills
      • Theory & practical – interactive / individualised
      • Home tasks to promote integration into lifestyle
    WSPG 30/11/11
  • 18. Physio led back classes
    • Graded Activity can reduce Pain Related Fear and improve function and ability ( Klaber Moffett, Spine 2004 and Cochrane Review 2010)
    • All MSK pain patients have increased risk of morbidity, CV and Ca (McBeth, J et al. Rheumatology 2009 and Torrance, N Eur J Pain 2010 )
    • Scottish Government targets / Quality Strategy
    WSPG 30/11/11
  • 19. What else does GGCBPS offer?
    • Training Packages
    • Triage to discharge
    • Yellow flag training / dept tutorials
    • Band 5 core LBP in-service
    • Pain Ed Classes training for referrers
    • Daily resource for staff / IST
    WSPG 30/11/11
    • Clinical support
    • Case studies
    • Critical appraisal papers
    • In-service locally
    • Specialist review for 2 nd opinion / onwards ref
    • Advice on SSP / CES
  • 20. Website
    • http://
    • Pathway Document
    • Lit reviews
    • Referral templates
    • Patient advice resources
    • Calendar of training
    WSPG 30/11/11
  • 21. Database
    • Recently revamped
    • Collated data across GGC
    • Opportunity for audit / research improved
    WSPG 30/11/11
  • 22. Outline
    • Background
    • The service
    • Some facts and figures
    • http://
    WSPG 30/11/11