Designing and Delivering an Intensive Pain Management Programme

Authors: Diana Dubash Psychology Placement Student, Dr Atika Kabeer, Consultant Anaesthetist, Dr Sarah Sherwood, Health Psychologist, Dr Anna Everatt, Clinical Psychologist, Rebecca Pardoe, Lead Physiotherapist, Paul Rees, Senior Physiotherapist, Lynne Harrison, Lead Nurse, and Sarah Benham, Senior Sister.

The Pain Management team at City Hospital, Birmingham deploy a multi-disciplinary approach to the management of chronic pain. One of their main interventions is a Pain Management Programme (PMP) The PMP is designed to help enhance a patient’s quality of life, by encouraging the return to normal daily activities. This may include a focus on self-care, increasing mobility, a reduction of analgesia and the health care services.  It draws upon the cognitive-behavioural model; aiming to educate patients and consequently produce a behavioural change.

City Hospital’s usual PMP’s have a 10 week duration, with the group attending for 2 and a halfhours per week. During these 10 weeks, they cover a variety of psychological, medical and physical topics in relation to chronic pain. Some of these include the medical reasons for experiencing chronic pain, as well as the impacts of your psychological wellbeing on persistent pain. Sleep hygiene and medication are discussed, and the patients visit the gym with the physiotherapists in order to learn new exercises to manage their pain. This yearthe team at City Hospital have successfully acquired charitable funds in order to run a new intensive pain management programme, in a bid to make the service available to those patients who require an intensive PMP. At present, there are no ongoing iPMP’s in the West Midlands, and residential programmes, located in Bath, Wales, Liverpool and London are inaccessible for many of our patients. Therefore it is hoped that this iPMP will succeed in filling a niche in the market, and will benefit many patients living in the West Midlands area.

There is strong research support for the use of iPMP’s; Angst et al (2009) and Artner et al(2012)found that Intensive Pain Management Programmes have significant improvements in short-term results; pain intensity and functionality, when compared to a standard PMP. Oslund et al(2009)found that ipmp’s are effective when you use a multi-disciplinary approach; by incorporating a variety of strategies, you can improve the overall outcomes of an Intensive Pain Management Programme in comparison to a normal PMP. The age of the patient can affect the clinical effectiveness of iPMP’s. People attending iPMP’s tend to be younger than those attending a normal PMP, and consequently are more likely to be affected by psychological problems. As a result, it is essential that iPMP’s have continued psychological input in order to maintain low levels of emotional distress. (Angst et al., 2009)The average age of a patient attending a PMP falls between 50 and 55 years old, however, the average age of patients attending the iPMP was 43 years old; 50% of patients attending were under 35 years old. This is one of the reasons why there is a stronger psychological emphasis placed on the iPMP than the regular PMP; cognitive therapy was present in almost every session delivered, and it therefore became a core component of the iPMP.

The team who organised and executed this new iPMP included Dr Atika Kabeer, Consultant Anaesthetist, Dr Sarah Sherwood, Health Psychologist, Dr Anna Everatt, Clinical Psychologist, Rebecca Pardoe, Lead Physiotherapist,Paul Rees, Senior Physiotherapist, Lynne Harrison,Lead Nurse, and Sarah Benham, Senior Sister.

The main aims of the iPMP were increasing the number of contact hours, gaining an increase in intensity. Providing vocational rehabilitation for the patients; as returning to work is a key element to an increase in quality of life. And finally gaining a decrease inreliance on the medical model. These aims come in addition those set out by the British Pain Society; improving physical, emotional and social health of chronic pain patients, improving participation in daily activities and pain reduction through behavioural changes. (British Pain Society, 2013)

The team decided to hold the programme every Monday, Wednesday, and Friday from 10am to 3pm (including a 1h lunch, and two 15 minute breaks) The programme was delivered mainly at the Park Inn Hotel, West Bromwich, however three of the Wednesday sessions were held at PortwayLeisure/Lifestyle Centre, ‘a centre of excellence for people with disabilities’ in Oldbury.

Measurements
In order to produce some quantitative data, the patients were asked to complete some measurements. These were divided into two categories; physical and non-physical. Physical measurements included 4 basic exercises set by the physiotherapists; Sit – to- stand, Arm Elevations, Step-Ups, and a timed 10 metre walk. These allow the team to see how mobile patients were prior to attending the programme, and also to see if the patient’s mobility had improved during the programme, and if the techniques being taught were being put to use. The non-physical measurements used by the team came in the form of questionnaires. The GAD-7, and PHQ-9 were used to measure levels of anxiety and depression, respectively. The CPAQ-8 measured patient’s levels of pain acceptance, and the PSEQ measured levels of self-efficacy.

Week 1
Week 1 of the programme was held exclusively at Park Inn. The first day was spent introducing the team members and patients, and setting some ground rules for the programme.Measurements were taken, and the difference between chronic and acute pain was explained. An explanation as to why people can suffer with chronic pain was also given. The next two days were spent looking at accepting your pain, the benefits of exercise and any anxieties surrounding physical movement. Medication management was another important component of this week, and patients showed a great deal of interest in this topic. The patients were introduced to Tai Chi by an external instructor and Mindfulness by one of the psychologists, Dr Anna Everatt. At the end of the week, an ‘expert patient’ came to talk to the patients about her experiences with pain. Estelle Greenwood, a fibromyalgia sufferer, delivered an excellent and informative talk. Sheis a living example of a successful woman and mother who suffers with chronic pain and this was very useful for patients.

Week 2
Week 2 began with an introduction to pacing; perhaps the most commonly used word among professionals working within a chronic pain ward. Patients seemed ambivalent about the idea of pacing at first, but towards the end of the programme, many had begun to put its teachings into practice. There was a heavy psychological focus placed on week 2 of the programme, with talks being delivered regarding barriers to pacing and cognitive distortion, stress management, thoughts and feelings and sleep and relaxation. Grasping the basic components of psychology proved harder for some patients, as they had regimented medical ideation surrounding their pain. However, towards the end of the week, these patients began to show signs of a deeper understanding that chronic pain is not purely a medical issue, and it in fact has a variety of psycho-social stressors.Goal setting was another important element, and patients responded well to the idea of SMARTY goals. SMARTY goals are Simple, Measurable, Achievable, Realistic, Timed, and Yours. With a little encouragement from the team, patients were able to produce individual goals which served as something positive to aim towards after the programme had ended.
Week 3
Week 3 saw the start of the vocational rehabilitation element of the programme. External visitor’soccupational therapists from Wolverhampton; Ian Connell and Kay Millinchip, came in and talked to the group about any obstacles to getting employment and helped work through some individual problems patients had. This topic continued for the whole day. Later on in the week, Rebecca Pardoe, Physiotherapist, delivered a talk on the anatomy, pathology and posture. With the use of diagrams and medical models, she was able to explain a plethora of conditions and why they are caused. Patients were very keen on asking about their own pain, and they made full use of this opportunity. On the Friday, the team held a ‘Friends and Family’ day. Here, patients attended with a family member or friend, and the Psychologists lead the activities on this day. They aimed to highlight the difficulties of living with a chronic pain sufferer to the patients, and the difficulties of living with chronic pain to the carers. Towards the end of the day, Dr Sarah Sherwood took the family members aside, and held a brainstorming activity regarding being a carer for a chronic pain sufferer. Dr Anna Everatt stayed with the patients and led a talk about pain behaviours. The final activity was an ‘expert panel’ where the patients and their family members could ask the team members questions regarding chronic pain. All team members attended this session, and having access to professionals from different backgrounds in one setting proved very helpful for the patients.

 

Week 4
The final week of the programme started with another vocational rehabilitation day. The Occupational Therapists, Ian Connell and Kay Millinchip returned and led the morning session. In the afternoon, the team were joined by three organisations; Remploy, Sandwell College, and the NHS volunteering service. A small ‘market-place’ was set up by Paul Rees, Physiotherapist, which enabled patients to talk to each organisation individually. Many patients found this extremely useful, and have continued to liaise with the organisations in order to make efforts to return to work. The final day was spent recapping the events of the previous weeks, and ensuring an understanding of the key messages of the programme by all patients. Measurements were taken again, and the day drew to an end with a discussion of the future. Telephone reviews were to be held with the patients a few weeks after the end of the iPMP, and the group were set to meet again for the final time for a formal review session. This review will be held in January, and here we can see if the patients were able to self-manage their pain as effectively as they were doing whilst attending the group.

Portway Sessions
Portway LifestyleCentre, Oldbury, is a leisure centre that can offer expert help to clients with specific health problems. The Physiotherapists, Paul Rees and Rebecca Pardoe decided to use the facilities at Portway, as they would be able to introduce the patients to a variety of interventionsto help reduce the fear associated with physical strategies, and to help manage their pain. During the three Wednesday sessions at Portway, the patients were introduced to Hydrotherapy, using the gym equipment effectively, and Tai Chi. Patients were encouraged to try every activity, and many patients attended Hydrotherapy more than once.
Whilst a few patients were conducting some sort of physical activity, the remainder of patients were able to attend either a Medication or Psychology review. During the medication reviews, either Sarah Benham or Lynne Harrison would speak to the patient individually about their current medication. Here the patient could report any side effects, or concerns they had with their current analgesia, and request a change in medication and in a significant number of cases patients began to reduce dependency on certain analgesia(word this differently if you want to)
The psychology reviews gave Dr Sarah Sherwood and Dr Anna Everatt a chance to explore the effects of the group on patients individually. Here patients were able to express their views about the group, and raise any concerns. Patients were asked if they were struggling with anything during the group, and many had external problems that were negatively impacting their performance on the group. Having time away from the rest of the group was very important for some patients, as it gave them the opportunity to explore possible psycho-social stressors negatively impacting their pain, in confidence. Research conducted by Oslund et al(2009) shows that psychological intervention is needed in order to maintain low levels of emotional distress in patients attending a PMP, and during review sessions.

The Results
There was an overall increase in the physical measurements. A 69.2% increase was present in the sit-to-stand, a 76.9% increase in arm elevations, and an 84.6% increase in step-ups. Also, 61.5% of patients had a decrease in the time it took them to walk 10 metres.
The results of the questionnaires before and after the programme were also positive. In regards to the GAD-7 and PHQ-9, there was a 53.8% and 69.2% decrease in anxiety and depression scores, respectively. Self-Efficacy had increased by 84.6%, and Pain Acceptance had a 69.2% increase.

This pilot has proved that the iPMP was successful in improving patient’s immediate functionality and mobility, however, with further research, it will become clearer whether an iPMP has any long-term benefits which outweigh those produced by a normal PMP. Following evaluation of the project, and its success, the plan is to disseminate results to Commissioners in order to secure permanent funding, rather than using charitable funds. Until funding has been decided, members of the Pain Management team will reflect upon ways to incorporate elements from the iPMP into the standard PMP, with the hopes to encourage many more patients to get back into work and facilitate a reduction in their pain medication.

The team thoroughly enjoyed delivering this iPMP, and will welcome another chance to run it in the future. They found that it has not only enhanced their knowledge of more intensive PMP’s, but it has enriched their professional careers and given them an excellent opportunity to develop invaluable skills.

References

Angst, F., Verra, M., Lehmann, S., Brioschi, R. and Aeschlimann, A. (2009). Clinical effectiveness of an interdisciplinary pain management programme compared with standard inpatient rehabilitation in chronic pain: A naturalistic, prospective controlled cohort study. Journal of Rehabilitation Medicine, 41(7), pp.569-575.

Artner, J., Kurz, S., Cakir, B., Reichel, H. and Lattig, F. (2012). Intensive interdisciplinary outpatient pain management program for chronic back pain: a pilot study. Journal of Pain Research, pp.209 – 216.

Guidelines for a Pain Management Programmes for Adults; An evidence based review prepared on behalf of the British Pain Society:The British Pain Society 2013

Oslund, S., Robinson, R., Clark, T., Garofalo, J., Behnk, P., Walter, B. and Walker, K. (2009). Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Baylor University Medical Center Proceedings, 22(3), pp.211 – 214.

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