STarT Back – the Biopsychosocial Approach in the Management of Low Back Pain

L A M L A M , P R I S C I L L I A , D M ( P H Y S I O ) , Q M H

L A U S A U Y I N G , J A M I E , S P T , P W H

L E E Y U E N K W A N , W I N N Y , P T I , U C H

L U K F U N G Y I N , S T E P H A N I E , P T I , A H N H

O V E R S E A S C O R P O R A T E S C H O L A R S H I P P R O G R A M ( O C S P )

1 7 M A Y 2 0 1 7

Content • STarT Back Approach • Psychologically informed practice for

high risk group • UK physiotherapy clinics and STarT

Back research team • The way forward

The Biopsychosocial Management of Complex Low Back Pain: A Stratified Care Approach

Clinical attachment

Haywood Hospital visit

Intensive Lectures and workshops

Meeting with research team

Low back pain

Treatment

“Get the right patient to the right person at the right time”

STarT Back : Subgroups for Targeted Treatment

Stratified care approaches More systematic approach to management decision

Significantly decreased disability related to back pain

Hill et al 2011 Hill et al 2008

Sowden et al 2011

• A simple prognostic screening questionnaire

• 9 Questions: Disagree/Agree • Identify modifiable risk factors

(biomedical, psychological, social) for on-going back pain disability

Q Area

1 Referred leg pain

2 Comorbid pain elsewhere

3 Disability (walking)

4 Disability (dressing)

5 Fear of movement

6 Anxiety

7 Catastrophizing

8 Depression/mood

9 Overall impact

High Medium Low

STarT Back Tool Scoring System

Matched Treatment Pathways

Aim: To reduce pain and disability and enable patients to actively self manage LBP

S/E Physical exam

Self management

30 min face to face session

Local exercise venues

HIGH RISK Additional psychological obstacles to recovery

MEDIUM RISK Mainly physical obstacles to recovery

LOW RISK Low risk of chronicity

Advice sheet

Back book

15 min DVD “Get Back Active”

Advice information

Matched Treatment Pathways Aim: To restore function (including work), minimize disability even if pain is unchanged and to support appropriate self-management

45 mins session

6 sessions 3 months

reassurance

Ex to ↑ function

Manual therapy

RTW advice

HIGH RISK Additional psychological obstacles to recovery

MEDIUM RISK Mainly physical obstacles to recovery

LOW RISK Low risk of chronicity

Acupuncture

Matched Treatment Pathways

Aim: To restore function, minimize disability even if pain is unchanged, improve psychological functioning and enable patient to manage ongoing +/- future episodes of back pain

60 mins session 6 sessions 3 months

Cognitive behavioural approach

HIGH RISK Additional psychological obstacles to recovery

MEDIUM RISK Mainly physical obstacles to recovery

LOW RISK Low risk of chronicity

ILLNESS

BIO

Psychologically Informed Practice Main et al 2012

Investigate patient’s specific belief/expectations

As precursor to identifying targets for intervention and obstacles to recovery

Dx & treatment

Attitude & beliefs

Behaviour

Family

Compensation

Emotions

Diagnosing language leading to catastrophising and fear

Sig withdrawal from normal ADL

Expect quick and easy cure

Family emphasizing fear of harm

Loss of enjoyment and mastery

Kendall et al 1997

Work

Rx cost incurred

Poor job satisfaction

Common pain related beliefs

Hurt = Harm Pain is uncontrollable

Passive treatments are the answer

Dr. Kelvin Vowles

Pain Suffering

multiplied

Struggling with pain

Failure

Lost freedom & opportunity

Pain and Suffering

Suffering controlled

Maintained life

direction

Success

Pain

Freedom & opportunity

Understanding typical emotional reaction to pain Linton and Shaw, 2011

Anxiety Fear Anger

Guilt Frustration Depression

• Open avenues for understanding pain

• Patient feel being understood

• Enhance engagement and treatment

Active listening Reflecting

Paraphrasing Clarifying

Summarizing

Communication Skill

• Exchange thoughts, feeling and ideas, verbal and non-verbal

• To build up rapport and trust with patients • To facilitate self-disclosure • To co-produce the agenda

Help resolve ambivalence in the direction of change

Establish successful behavioural change

Baseline 20% off average capacity

Target

Current status

e.g. Hiking x 60’

• Values based • Generated by patient • Important • Realistic • Enhance motivation

Graded exposure / pacing

Building up confidence to cope with pain

Self efficacy • Confidence in

performing a particular behaviour

• Overcoming barriers

Social persuasion

Experience of doing

Mastery experience

Vicarious learning

Hill et al, 2011 (n=851)

At 4 and 12 months post D/C:

• Fear avoidance beliefs • Time off work • Patient satisfaction • QOL

Clinical Attachment Cheadle Hospital Biddulph Primary Care Centre Cobridge Primary Care Centre Bentilee Neighbourhood Centre Rising Brook Clinic Greyfriars Therapy Centre

• Implementation of stratified care (STarT Back) in clinical services

• Recent & ongoing musculoskeletal research

• Presentation of services in HK in relation to implementation challenges & opportunities

Haywood Hospital Visit •Occupational Therapist

•Consultant Rheumatologist

•Physiotherapist

•Clinical Psychologist

•Rehabilitation Consultant Doctor

•Stratified cared alters decision-making for the better •Low risk patients are not over-treated •Medium / high risk patients have a greater chance of treatment and this greatly improves outcome •Training upskill the physiotherapists

Our reflection

MSK ASP

Pilot new service model

Therapists’ perception, knowledge and acceptance

Information material

1) Adoption of STarT Back Approach in Back Pain Management in Hong Kong: From Incubation to Implementation

2) New Stratified Care Model for Back Physiotherapy Adopted from The United Kingdom: A Pilot Study in a Regional Hospital in Hong Kong

IAAHS, AHG HAHO Colleagues