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The North of England Regional Back Pain Pathway

This pathway aims to provide standardized, evidence-based care for acute and chronic low back pain (LBP) in the North of England region. It includes the use of the STarT Back tool for risk stratification, triage and treatment by spinal specialists, a combined physical and psychological program (CPPP), and the promotion of self-management. Physiotherapists play a key role in providing advanced clinical reasoning, exercise prescription, manual therapy, acupuncture, relaxation techniques, and cognitive behavioral therapy.

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The North of England Regional Back Pain Pathway

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  1. The North of England Regional Back Pain Pathway Nicki Skinner MSc MCSP MMACP Triage and Treat Practitioner 17th March 2016

  2. Background • Acute LBP experienced by 90% of population • Back pain is largest cause of disability in UK (11% of disability burden) Global burden of disease 2010 • Cost to NHS >£2 billion annually (Nice 2008) • Huge management variation nationally and locally • Poor adherence to evidence based guidelines

  3. 1st consultation GP/SelfReferral to Physio Red Flags Local Pathway 2nd consultation GP – STarT Back Triage and Treat Imaging Core Therapies Discharge Pain Clinic Triage and Treat NRB Core Therapies CPPP Surgical Opinion

  4. What’s new? • Evidence based care with emphasis on prevention of chronicity • Standardised managed pathway with consistent message from all healthcare professionals • Integrated pathway with rapid access to appropriate services • Combined physical and psychological programme (CPPP) – Back to Health • Save money!

  5. STarT Back APPROACH • STarT Back tool – 9 item self-reported questionnaire • Physical and psychological constructs • STarT Back stratifies patients according to their risk of persistent disability due to back pain. • Scored as high, medium or low risk • Hill et al (2011) – stratified care is cost effective with targeted care towards med/high risk and avoids over-treatment of low risk

  6. Managed pathway Triage and Treat • Spinal specialists – physiotherapists, nurses • Named clinician responsible for each patient • Working in an extended scope role with responsibility for ordering and interpreting investigations then directing care appropriately • Promote and reinforce self-management • Part of the MDT team

  7. Consistent message • Every clinician has the potential to be a yellow flag. (Darlow et al 2013) • Patient and clinician beliefs affect outcomes “Weakness, instability, trapped nerves, wear and tear, disc bulge, degeneration” versus “Safe, strong, sensitive, active, relaxation, normal” Reassurance, advice and information to promote self-management.

  8. Back to Health (CPPP) • NICE (2009) – programme consisting of around 100 hrs over maximum 8 weeks • Spinal Taskforce (2013) – serious gap in current services and recommendation to commissioners • MDT approach • Change mindsets • Improve self management • Increase exercise and functional ability • Demedicalise • Return to work

  9. Physiotherapy and the future! • Sir Bruce Keogh supporting national roll out • Physiotherapists best placed to lead and deliver services. • Advanced clinical reasoning • Exercise prescription • Manual therapists • Acupuncture • Relaxation • Cognitive behavioural therapy • Team workers

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