Single-Arm Observational Service Evaluation: Efficacy of a Single Advanced Physiotherapy Practitioner Intervention for Patients with Chronic Musculoskeletal Pain.

Purpose

Musculoskeletal (MSK) conditions account for a significant portion of General Practitioner (GP) consultations and are therefore a burden on our health service and especially primary care as these conditions are largely managed within primary and community care. Patients with chronic MSK conditions consult with their GP five times more often than those without and as the age of the population increased this burden is expected to add increased pressure to primary care.

First Contact Physiotherapists (FCP) work at an advanced level of practice as first contacts within primary care and provide a possible solution for these patients. The proliferation of these roles over the last few years has been supported in the literature through studies reporting on the impact of FCP services and satisfaction surveys. NHS documents such as the Long Term Plan also promote an increase in FCP roles and organisations such as the Chartered Society of Physiotherapy and the Royal College of General Practitioners have endorsed FCP. Patients find this role to be an acceptable alternative to accessing their GP for specific conditions which supports these roles from the patients’ perspective.

Despite this support there has been very little evidence to demonstrate the efficacy of FCP services on patient outcomes. This service evaluation therefore aimed to determine the efficacy of FCP interventions on patient outcomes.

An FCP consultation may comprise of an assessment, diagnosis, advice and exercise prescription and as these interventions have been demonstrated in the literature to improve pain self-efficacy (SE) it was decided to assess the outcome of FCP services on the pain self-efficacy of patients with chronic MSK pain.

Mean Pain SE at baseline was 36.56; mean score at follow-up was 41.6.
The mean difference score was 5.04 therefore this result did not reach a minimally important difference.

Fourteen patients had improved PSEQ scores
at follow-up (36%).

Approach

This single arm observational service evaluation was carried out using the Pain Self-Efficacy Questionnaire (PSEQ) before and after a single brief (20 minute) FCP intervention. A convenience group of 39 patients with chronic MSK pain who met pre-determined inclusion and exclusion criteria were evaluated.

The inclusion criteria was as follows: age 18 or over, attending their first FCP appointment, the FCP appointment was their first contact with a primary care clinician about their condition, their main symptom was of an MSK nature, their main symptom or condition was of a chronic nature, they had not sought advice from another health professional at follow-up. This inclusion criteria intended to limit the confounding variables which may have occurred if the patient had discussed or sought treatment for their condition from another health professional before seeing the FCP or between their initial appointment and their follow-up. It also intended to ensure any impact demonstrated would be due to the FCP intervention rather than the condition improving with time which is one reason why a chronic pain subgroup was selected. This was important to demonstrate the impact of the FCP intervention however this did result in a small sample.

In total 25 patients completed the evaluation, 13 were not contactable to follow up, 1 withdrew due to personal reasons. PSEQ was administered by the FCP. Pre-PSEQ was performed pre-consultation in person, post-PSEQ was conducted within 2 weeks of the consultation follow up in person or by telephone. Descriptive analysis was used to analyse the data.

Considering the terms outlined above, the broad research design was a prospective, single-arm, observational service evaluation for a cohort of patients with chronic MSK pain accessing a single brief intervention by an FCP in primary care.

Ethics: The Health Research Authority decision tool was used to identify if ethics approval was required and discussed with the NHS Trust Research and Development Lead. As this was a service evaluation no further ethics approval was required.

Outcomes

Mean Pain SE at baseline was 36.56; mean score at follow-up was 41.6. The mean difference score was 5.04. Chiarotto et al. (2016) suggest 5.5 points to be the minimal important difference for the 10-item PSEQ therefore this result did not reach a minimally important difference.

The standard deviation was calculated using the t-distribution equation of n-1 to account for a sample of less than 30. Standard deviation of difference scores was 13.94 and variance was 194.37. Fourteen patients had improved PSEQ scores at follow-up (36%). Nine patients had reduced PSEQ scores (23%) and two remained unchanged (5%). Higher PSEQ scores indicate stronger self-efficacy beliefs.

Using a 0.05 level of significance and a 95% CI in a two-tailed paired t-test the p-value was 0.083233 (CI -10.79489, 0.71489), this indicates a non-statistically significant result.

In conclusion there was no statistically significant effect on pain-SE for patients with chronic MSK pain when accessing a single-brief FCP intervention. However, this study was a small sample of 39 patients and highlights the need for further study in this area especially as there is limited evidence on patient reported outcomes from FCP interventions.

Implications

These results demonstrate the importance of further research to understand the outcome for patients when using advanced practice physiotherapy services as first point of contact in primary care.

Reassurance, advice, education and guided self-management are potentially important elements of single intervention APP appointments. Patients report that quick access to a specialist assessment helps them understand their problem and may potentially help manage catastrophisation however this study did not find an effect on pain self-efficacy or pain intensity, but this study does guide further research in this area.

Top three learning points

  1. There was a positive trend towards improvements in both pain intensity and pain self-efficacy with a brief first contact intervention. This demonstrates the strength and quality of these services.
  2. Improvements in self-efficacy are important for many behavioural changes and therefore advanced practice first contact physiotherapist interventions may have an impact on other change behaviours such as exercise, smoking cessation and weight loss.
  3. Although the results were not clinically significant this may be largely due to the low numbers of complete dataset which was impacted by the short length of time available for MSc research study data collection and by the number of appointments but despite this it appears that pain intensity can be impacted with exercise and advice alone in a single intervention.

 

Fund acknowledgements

A non-funded service evaluation performed within Gloucestershire Health and Care NHS Foundation Trust as part of an MSc in Pain Management dissertation Cardiff University.

Additional notes

This work was presented at Physiotherapy UK 2019

Please see the attached Innovations poster below. 

 

For further information about this work please contact Hannah Morley.