Working with complex persistent pain

Purpose

To describe the role of an Advanced Physiotherapy Practitioner (APP) working within a multidisciplinary team with people with complex persistent pain in acute hospital, outpatient and community settings.

To describe relevant physiotherapy skills required in these settings

To describe the clinical outcomes of the service

£777,000 of savings
Shown in the service within one year
70% of patients
Reported improvement within one domain of quality of life

Approach

A two year pilot of a multidisciplinary team (Complex Pain Team - CPT) comprising an Advanced Physiotherapy Practitioner (APP), Clinical Psychologists, a Clinical Nurse Specialist (CNS) and Pain Consultants was set up with the aim of improving care for inpatients with complex pain. The APP role was envisaged to mimic that of established outpatient pain physiotherapists, providing pain assessments and introducing self-management with additional support from the multidisciplinary team to manage additional complexity. During the first year, the APP collated information that describes the role and unique skills of the APP as well as clinical outcomes of the CPT in order to describe the role and its impact on clinical and service outcomes. This was achieved by recording key physiotherapy skills used in practice, particularly where this deviated from typical outpatient work. In addition, the job description, case notes and discussions within the CPT was collated. Economic and questionnaire outcomes on quality of life were also recorded.

Outcomes

The APP's interventions were aligned with traditional pain physiotherapy skills i.e. assessment, activity management, health promotion and pain education within the context of their comorbid conditions. Of note, the APP adopted a first contact practitioner role in A & E. The APP completed initial triage for referrals, including completing assessments, and optimising analgesia (supported by the CNS). Treatment emphasis was on brief pain management intervention and either signposting to relevant local services or follow up in outpatient services. The APP was involved in planning and delivering pain education to health care professionals throughout the organisation, leading on supporting physiotherapists and other AHPs in their specific work areas. The APP alongside CPT colleagues delivered training to primary care staff (including GPs), held joint appointments with community physiotherapists, and conducted domiciliary sessions. They participated in multi-sector meetings with social, mental health, ambulance and primary health care services offering insight into the impact of pain across the health economy and, implementing care plans.

Cost and savings

Questionnaires showed that 70% of patients reported a significant improvement within one domain of quality of life. Overall, the service showed a £777,000 saving within one year.

Implications

This reflection provides evidence of the role of a specialist pain physiotherapist working to deliver care across traditional boundaries as part of a truly integrated UK inpatient-community-outpatient service for people experiencing persistent pain. The role provides opportunities for strategic leadership, models integrated care, requires a willingness to step out of silos and was facilitated by advanced practice skills in independent prescribing, procedure listing and imaging.

This service improvement example supports the traditional practice of completing post registration roles that rotate across sectors. It exemplifies the benefits of advanced practice in conferring confidence and trust in physiotherapists to deliver outcomes in complex systems working with health and social care professionals.

Top three learning points

  • The APP role is well placed to provide leadership in pain management across professional groups and to develop pain management skills in others outside the speciality.
  • Working in an unknown area with complex and ever changing challenges requires a unique perspective and ability to sit with and work around uncertainty.
  • The role has added value that has been recognised across the organisation and with patients allowing this to be scaled up and offered to more patients.

Fund acknowledgements

The Complex Inpatient Pain Team (CPT) is jointly funded by UCLH Charity and Camden CCG.

Additional notes

Presented at Physiotherapy UK 2017. 

Author's email address: jackie.walumbe@nhs.net