New ways of helping patients to manage pain

The effects of pain, chronic or acute, reach far. They can stretch deep into physical, psychological and social wellbeing, and can also be difficult to assess, treat and manage. Many are affected: the British Pain Society (BPS) says that up to 10 million Britons suffer pain daily, often with significant impact on quality of life and an individual’s ability to work. The economic burden is high, too: it costs the NHS £4 billion a year to treat pain in adolescents alone, according to the BPS, while the cost to the Exchequer of back pain is estimated at £5 billion a year.

But none of this is news to physios. For many, relieving patients’ pain is their core business; many more are involved in other ways – developing practice, shaping policy, undertaking research.

Tools and techniques for treating pain have advanced considerably over the last 30 years. Practice has evolved, along with physios’ skills and knowledge, to the extent that many practitioners are working way beyond what was traditionally their role.

Sarah Wilson is chair of a Physiotherapy Pain Association (PPA) working group that has been involved in a project to scope the role of physios in pain management. This is a significant piece of work, the first stage of which has been to describe the values, behaviours, knowledge and skills used by physios in treating people with pain. The next stage will be to develop descriptors of competence that can be used in staff appraisals.

‘Pain management is quite a different specialism for physios,’ says Ms Wilson. ‘There’s often a heavy use of behaviour techniques, for example. And as we started to move away from those core physio techniques and modalities, we said, wait a minute, how do we know people are capable of doing this? What makes for a good pain-management physio?’

As she points out, the breadth of ‘pain’ is huge, from acute to chronic and right through the lifespan. ‘We’re talking about an enormous number of patients with very different and complex needs,’ she says. The ultimate aim, then, of the PPA project is to protect both patient and clinician by ensuring that physios are practising within their professional and personal competence.

A draft framework document produced by the PPA working group went out to consultation in April and a final version will be launched at Physiotherapy UK this month. The consultation drew comments from near and far – UK clinicians as well as feedback from Sweden, Germany, Canada, Australia and the United States, among others. ‘That was interesting because it highlighted the difference in the way physios worldwide work with pain,’ Ms Wilson says. ‘Some brought up things we hadn’t thought about – litigation, for example.’

Wilson is keen to stress that pulling together a complete competence framework is still some way off. ‘A lot of physios are saying this is fine but we want you to define what competence is. Really we’re at the stage before that. This is the underpinning piece of work from which we will then develop the competence framework.’

That said, the first stage is ambitious in its scope in that it tries to capture the range of work undertaken by physios who manage pain, in a wide variety of settings.

That work includes

• requesting investigations

• prescribing

• administering injections

• planning, monitoring, modifying and carrying out treatments

• supporting patients in coming to terms with their pain

• conducting complex assessments, including questions about deliberate self-harm.

The PPA document draws on the CSP’s physiotherapy framework, which defines the behaviours, skills and knowledge required for contemporary physiotherapy practice. Ms Wilson says: ‘That really broke down the core components of physiotherapy and so we said, okay, what’s different about pain-management physio and how do we capture that using a framework? We’ve taken a very complex area and tried to distil it down to get at what’s at the heart of it.’

The PPA framework describes the behaviours, skills and knowledge for physios at four different levels: entry-level graduate, experienced graduate, advanced and expert. It outlines the knowledge and understanding expected for each level in a number of different domains, such as understanding of acute and chronic pain and its management, communication and promoting teamwork.

Pain management

Ian Taylor, head of physiotherapy for the adult learning disability service at Kent Community Health NHS trust, embodies expertise in each of those domains. He also illustrates the scope of pain-management work undertaken by physios.

Mr Taylor has a long-standing interest in undiagnosed pain in people with learning disabilities, which, because of communication issues, can often manifest itself in a person’s behaviour. In partnership with a consultant nurse in chronic pain, he devised a training package for carers to help them identify when a client is in pain.

‘The problem we’ve got is that clients with learning disabilities are communicating they’re in pain but what we, as carers, are not doing is picking up those clues,’ says Mr Taylor. He cites as an example an older woman who, when carers tried to help get her up in the morning, used to hit out. ‘People said she had challenging behaviour. What she actually had was quite severely arthritic hips but nobody had picked it up. She couldn’t say: “My hips are sore, don’t move me,” so she was striking out instead.’

Thinking differently

The training is designed to make carers think differently. ‘The whole package is basically about how someone might present when they’re in pain and different strategies to then manage that pain,’ says Mr Taylor. Called I hurt, help me, the package helps build a pain profile for the individual. It is drawing interest from across the UK and he hopes it will be rolled out beyond Kent.

On the other side of the country, George Oliver and Graeme Paul-Taylor also exemplify physios’ innovative approach to pain management – albeit in a markedly different way from elsewhere.

The physiotherapy service at Cardiff and Vale University health board has won funding from the Healthcare Foundation’s Shine programme to trial a group approach to patients’ low back pain.

Mr Oliver, the heath board’s clinical lead physio, says the idea is to ‘change the nature of the conversation’ and to make sure psychological and social aspects of patients’ back-pain experiences are fully included within their management.

Developed in partnership with the psychology service, the idea is to switch patients’ first point of contact from a one-to-one setting to a fast-tracked group intervention. Patients are invited to attend the group. They are not obliged to do so but those who do can then choose between individual physiotherapy or self-management. A stratification tool will be used to ensure that those who opt for the former see the most appropriate person for their needs. Mr Oliver says: ‘We looked to try and change the front end of that traditional assessment framework, and how the patient is then managed and supported within the physiotherapy service.’

Mr Paul-Taylor, physio lead for the project, says it aims to empower patients and help them reframe their problem. ‘We think it would be helpful to move people away from a very biomedical, physical way of thinking about their back pain and ensure that their conversations with physios include all those biopsychosocial elements.’

All key stakeholders, including service users, were consulted about the new approach and the physios involved have been given extensive further training in back-pain management. ‘The new part is working in a group intervention,’ says Mr Paul-Taylor. ‘That’s the bit that’s creating excitement – as well as a bit of anticipation. But I think it will go really well.’

A mid-term review will assess progress at six sites across the health board, with a final report in October next year. fl

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