Case study summary
The chronic pain pathway is one of 10 offered by Sheffield Health and Social Care NHS Foundation Trust. It offers adapted Improving Access to Psychological Therapies (IAPT) interventions for persistent pain, including a new Living Well with Back Pain and Sciatica course. The estimated prevalence of chronic pain in the UK population is 43% and it is associated with psychological, social and economic consequences.
Two-thirds of people with a common mental health problem also have a long-term physical health problem, greatly increasing the cost of their care. By integrating Improving Access to Psychological Therapies (IAPT) services with physical health services the NHS can provide better support to this group of people and achieve better outcomes.
Each year more than 12,000 people enter into treatment with the Sheffield IAPT Service for anxiety or depression. Its new Health and Wellbeing Service works within 10 physical health care pathways, including chronic pain. One of the most common types of long-term pain is back pain. Many people with back pain find it difficult to engage in normal activities and can experience symptoms of depression and anxiety. To meet their needs a new Living Well with Back Pain and Sciatica course has been developed which complements the well-established Sheffield IAPT Living Well with Pain course.
Sheffield IAPT is working closely with Physioworks (PWS) and Sheffield Teaching Hospitals NHS Foundation Trust (STHFT) to deliver an integrated pathway. John Firth from STHFT has an enhanced role as a physiotherapist and Psychological Wellbeing Practitioner (PWP). As he is dual-trained he is able to focus on the physical and psychological aspects of treatment. With his IAPT Step 2 experience he has been facilitating the Living Well with Back Pain course at a variety of sites across Sheffield with senior PWP Elizabeth Ruth. The five-week course is offered for groups of up to 20 people. It offers evidence-based interventions for depression and anxiety, with a focus on how these can improve the self-management of long-term back pain.
“We deliver a psychologically-informed physiotherapy input for pain, depression and anxiety,” explains John. “Patients can self-refer or be referred by their GP or physiotherapist. The course enables them to learn new techniques to manage their low mood and anxiety in the context of pain and meet clinicians and other patients who understand how their chronic pain makes them feel.”
Physical and mental health aspects are combined in line with National Institute for Health and Care Excellence (NICE) guidelines to provide a cognitive behavioural therapy-based approach to help people with chronic pain in their recovery. John explains that NICE guidance on managing back pain and sciatica laid out the need to combine physical and mental healthcare for back pain to make it as seamless as possible so people don’t need to have separate referral procedures.
Supported by colleagues from Move More Sheffield, the course is run at sports and leisure centres, IAPT venues and community meeting rooms. “At Graves sports and leisure centre we had one patient who had asthma as well as chronic pain and who used the gym before or after the back pain course, so from that point of view it’s been very successful,” John adds.
Over the five-week course patients:
- are provided with a wealth of information on how to live with low back pain and sciatica,
- learn ways to manage low back pain and reduce some of the effects it can have on different aspects of their lives such as activities, sleep, mood and relationships,
- learn about the link between worry, muscle tension and pain severity, and helpful behaviours such as muscle relaxation and breathing techniques,
- meet and share learning with other people living with persistent low back pain.
Gemma experienced lower back pain and sciatica after suffering a herniated disc. Being absent from work through her injury, and spending long periods at home managing her condition with painkillers, meant Gemma became in her words “down and despondent”.
She heard about the Living Well with Pain course through her manager. “I plucked up the courage to pick up the phone and book myself on,” she said. “It was nice to find something that would help to manage the physical symptoms while looking at emotional support as well.
“The course gets you to think about the different areas of your life – from getting up in the morning to going to bed at night, and even the sleep in between. It puts you back in control. The course focuses on techniques to reduce pain, rather than take it away – to get ideas for how we could better cope with the pain we have.”
Pacing, one of the techniques taught, involves taking regular breaks from time-consuming activities like housework. A session on sleep helps those having difficulty sleeping. Relaxation techniques reduce muscle tension. “It has helped me to understand there is a strong link between physical and mental health. If either is not as good as it should be it can impact on the other,” Gemma says.
John says: “The Five Year Forward View for Mental Health, which sets out priorities for mental health up to 2021, and NICE guidance are big drivers for our physiotherapy service to include mental health in the management of back pain.”
He adds: “IAPT staff have delivered in-service training sessions to physiotherapists. All Physioworks physiotherapists can use an IAPT prescription pad to recommend their patients to core IAPT or Health and Wellbeing IAPT. In turn, training sessions have been provided for IAPT staff on back pain, sciatica and musculoskeletal problems.” The prescription pad has been developed locally for physical health staff to use with their patients to refer to IAPT.
“Combining IAPT health and wellbeing services with physical health services is really important for the future of helping patients to remain active and prevent frailty as they move towards old age,” John says. “We are working with colleagues at National Institute for Health Research ‘Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber’ to ensure robust implementation evaluation.”
Not all services have IAPT-trained physical healthcare staff who can deliver interventions for both physical and mental health. Non-physical health trained IAPT staff aren’t expected to offer exercise prescriptions for physical conditions. This case study, however, demonstrates what other services can potentially develop in their areas through partnership working, appropriate resourcing and innovative staff development.
As he is dual-trained as a physiotherapist and psychological wellbeing practitioner, John Firth is able to focus on the physical and psychological aspects of treatment when delivering the Living Well with Back Pain course.
Service user Gemma experienced lower back pain and sciatica after suffering a herniated disc. She says the chronic pain and low back pain pathway has helped her to understand ‘there is a strong link between physical and mental health’.