Resources for GPs
The Bury Integrated Pain Service is an evidenced based pain service with a strong physical and psychological multi-disciplinary focus. Patients are initially assessed by a team of experienced specialist pain physiotherapists and specialist pain nurses. They undergo a full bio-psychosocial assessment and physical examination (where appropriate). If investigations are required these can be arranged directly via the integrated MSK service without the need for further appointments.
A treatment plan will then be agreed with the patient, based around their personal goals and evidence-based treatments. This may include referral on for multi-professional assessment from psychological therapists or medical practitioners.
Tier I treatments
Some patients will not require extensive rehabilitation. For these patients advice will be given to general practitioners regarding primary care management and the patient will be provided with appropriate information and referred to community exercise partners or Healthy Minds.
Tier II services
Most pain patients are managed by tier II services, which are outlined below.
Foundation Pain Management Programme (PMP)
The PMP is a multi-disciplinary rehabilitation programme delivered at three locations across the Bury locality in groups of 8-10 patients. It is run by specialist physiotherapists and psychological wellbeing practitioners and aims to teach patients appropriate management strategies, engage them in a graded exercise programme and encourage long-term self-management.
One-to-one pain physiotherapy
Whilst being an effective treatment, group-based rehabilitation is not appropriate for all patients. Some patients may prefer to be seen on a one to one basis. Therefore, our pain physiotherapists offer individual rehabilitation sessions with the same over-riding philosophy as the foundation pain management programme.
One-to-one nurse-led rehabilitation
Patients with non-musculoskeletal pain are treated by our specialist pain nurses, who provide education about the underlying causes of pain, advise patients regarding long-term pain management strategies and how to return to desired activities.
Patients who are having problems sleeping or need support with low mood, anxiety or depression are treated in the Healthy Minds service. This can take a number of forms, such individual therapy, group work, telephone treatment or an online course. Treatments are delivered by various therapists, depending on individual needs.
Cognitive behavioural therapy
Patients who require greater support may be referred for Cognitive behavioural therapy. This is sometimes delivered as a stand-alone intervention or often in combination with physiotherapy. It aims to help patients develop strategies to improve their functioning and well-being and enhance self-management.
Advice and guidance regarding pain medication can be given by one of our non-medical prescribers, liaison psychiatrist or consultant anaesthetists. For patients with neuropathic pain this may involve a trial of medication to enable patients to engage in active rehabilitation. Patients are then followed up with a view to weaning back off the medication long term. For other patients who are already taking significant amounts of analgesia treatment may involve agreeing a plan to safely titrate down their medication.
Patients with complex needs are discussed at the MDT meeting to establish whether they would benefit from escalation to tier III interventions. In such cases tier III clinicians continue to liaise and work with Tier II clinicians to ensure that rehabilitation is integrated. Once appropriate, patients are stepped back down from Tier III to Tier II.
Tier III to Tier II
Higher level psychological approaches
Patients who become extremely depressed due to pain, or who have a more complex combination of mental health complaints and pain may be seen by specialist Psychological Medicine staff. Care will firstly be discussed at the Multi-Disciplinary Team meeting and then a more detailed assessment is performed and the most appropriate support is put in place. Psychological Medicine staff could include mental health nurses, liaison psychiatrists and clinical health psychologists.
Tier III interventions
Radiofrequency denervation is not routinely performed in accordance with NICE guidelines (NICE CG59, 2016). However, certain patients with non-radicular LBP who meet specific criteria and for who all other interventions have proven ineffective may be suitable for radiofrequency denervation. Patients will first undergo medial branch blocks to ensure that the procedure is appropriate. If this procedure results in clinically meaningful improvements in then radiofrequency denervation may be performed.
Patients with acute (less than six months), severe sciatica may be appropriate for epidural injection. In line with NICE guidance (NICE CG59, 2016) repeated epidurals are not offered. Likewise, epidurals are not offered for spinal stenosis/neurogenic claudication.