Primary Care Pain Management and Rehabilitation An anthroposophic 1 approach for patients suffering chronic pain unresponsive to previous pain clinic and secondary care interventions 2 David McGavin MRCGP, GPwsI Pain Management & Jan Prior DipClinPsych, CEO Blackthorn Trust, Blackthorn Medical Centre, Maidstone, ME16 9AN Gene Feder MD FRCGP, Professor of Primary Health Care, University of Bristol SUMMARY 105 patients suffering chronic pain unresponsive to previous pain clinic and secondary care interventions and without prospect of clinical improvement were referred for anthroposophic treatments. Of the 60 patients with outcome assessment, physical health improvements were demonstrated in 45% and mental health improvements in 57% of patients completing the SF12v2 quality of life measure. Self-reported changes were recorded in increased levels of confidence (53%), control over life (60%), decreased dependence (32%) and steps in personal development (80%). For those who were motivated to take part there were high levels of satisfaction and reductions in use of medication, OPD, A&E, out of hours and GP attendance. INTRODUCTION Blackthorn Pain Management is an individually tailored programme for patients whose chronic pain is beyond further conventional help. It aims to reduce levels of pain and address secondary limiting factors e.g. insomnia, anxiety, depression, exhaustion. The therapies and sheltered working environment strengthen self-confidence and self-esteem, broaden outlook and experience and encourage greater independence through social interaction and reduction of isolation. Patients can learn that they are their own best resource amid the challenges they face. The programme is particularly suited to patients for whom: The condition has proven difficult to treat Further interventions and medication may be doing more harm than good; Emotional and psychological factors complicate the condition e.g. anxiety, depression, PTSD; There is social isolation, lack of direction & purpose, need for companionship; Rehabilitation, occupation and employment are pressing issues; Relations between doctor and patient have become strained; 1 Anthroposophic medicine was founded in the 1920 s by Rudolf Steiner and Dr Ita Wegman. Anthroposophy means knowledge of the human being. http://www.ivaa.eu/userfiles/file/system_anthroposophic_medicine_print.pdf 2 This report details the interventions and outcomes after 2 years of a 3 year contract first commissioned by West Kent PCT in April 2010. This period was preceded by a 3 year pilot whose data relating to use of NHS services has been included. 1
PRESENTING CLINICAL CONDITIONS All conditions were chronic, present for between 1 and 20 years and usually accompanied by significant co-morbidities. Principal presenting conditions of 105 patients Spine-related 52 Fibromyalgia/CFS 11 Post-trauma/surgical 9 Inflammatory arthritis 6 Osteoarthritis 6 Reflex Sympathetic Dystrophy 5 Whole body 4 IBS 4 Migraine 4 Post Stroke 2 Osteoporosis 1 Burning Mouth Syndrome 1 Co-morbidities included multiple system atrophy, PTSD, depression, chronic anxiety, recurrent infections, psychosis, personality disorder, subarachnoid haemorrhage, bipolar disorder, epilepsy, Lewy Body dementia, Crohn s disease, hemiplegure, haemophilia, diabetes, ischaemic heart disease; METHODS A. One-to-one therapies include art (painting, clay modelling, sculpture & metal glass therapy), biographical counselling, eurythmy (movement therapy), rhythmical massage and the prescription of anthroposophic medicines. Engaging the patient is the first task, as many patients are tired, resigned and see little hope. He/she often needs wrapping up to give a sense of security before the necessary energy and motivation can be realized. The work or friction of the therapies can then be adjusted appropriately according to need. Patients are called upon to apply themselves with gradually increasing activity, to practice specific skills at home and take up opportunities to free up old habits and exercise newly emerging potential. B. Social enterprise in Blackthorn Garden to help one practise social skills and begin to apply oneself to work again. A wide variety of sheltered work opportunities are provided in the bakery, kitchens, vegetarian café, greenhouses, garden, craft & wood workshops and charity shop. Selfconfidence and esteem are re-kindled by working as part of a team. Time-keeping, performing to required standards, taking on new situations encourages trust in oneself and others. New friendships develop. Individuals inspire and teach one another by their own example and effort. C. Coaching toward employment helps build further confidence and enthusiasm to venture toward the world of work through training, volunteering and employment opportunities within and outside Blackthorn. 2
WAITING TIMES & DURATION OF TREATMENT Waiting times are never longer than three weeks. Three clinics are held each week (Tuesday & Saturday am, Wednesday pm). Time of starting is more dependent on the patient s condition and ability to attend than difficulty fitting them in. The programme has kept well within the PCT s overall limits to maximum duration of treatment relating to the costing of the programme. 105 patients referred 1.4.2010 31.3.2012 PCT contract expectation/requirement 9 (9%) assessed once and not taken on 12.5% 36 (34%) discharged within 6 months 3 25 % 24 (44%) discharged within 12 months 25 % 15 (14%) discharged within 18 months 37.5% 21 (20%) still undergoing treatment MEDICATION USE Efforts are made during treatment to reduce the use of conventional medicines. This benefits the rehabilitation process by (i) reducing side effects including drowsiness, tiredness & lack of motivation; (ii) acting as a measure of progress and achievement in overcoming dependence. Cost savings are relatively small. Medications recorded included: analgesics (non-opiate, opiate, NSAID, anti-neuropathic, migraine & rheumatic), anti-depressants, tranquillisers & hypnotics. Their use was recorded at baseline and part of each follow-up consultation and on discharge. 58 patients eligible for assessment from period April 2010 March 2011 Baseline total of medicines Medicines reduced Medicines increased Medicines unchanged 243 100 49 94 Mean total/pt Mean reduction/pt Mean increase/pt Mean unchanged/pt 4.2-1.7 +0.8 1.6 3 This group of patients were not yet eligible for outcome assessment 3
INDIVIDUAL OUTCOMES 105 patients referred between 1 st April 2010 and 31 st March 2012 18 patients in programme for less than 6 months therefore not yet eligible for assessment 87 patients in the programme for 6 months or more 5 not eligible 4 2 SF12 invalid: under 16yrs 9 no response to follow up 10 failed to engage 5 1 died 60 patients SF12v2 assessment (Appendix 1 & 3) & self-report questionnaire (Appendix 2) Physical health SF12v2 Better 27 (45%) Worse 11 (18%) Same 22 (37%) Mental health SF12v2 Better 34 (57%) Worse 8 (13%) Same 17 (30%) Confidence Increased 32 (53%) Decreased 6 (10%) Same 22 (37%) Control Increased 36 (60%) Decreased 7 (12%) Same 17 (28%) Dependence Increased 9 (15%) Decreased 19 (32%) Same 32 (53%) Steps in development Yes 48 (80%) No 11 (18%) No data 1 (2%) New hobbies Yes 27 (45%) No 33 (55%) Satisfaction V. satisfied 33 Satisfied 15 Neutral 3 Unsatisfied 0 V. unsatisfied 1 4 Patients are eligible if they live within West Kent and have been discharged from secondary or pain clinic attendance; 5 Effectiveness of the programme depends on the patient s ability to attend regularly and engage in activities. To allow for common difficulties of ill health affecting motivation and attendance, a period of 3 months and having taken part in at least 7 therapy sessions are considered necessary conditions to determine the patient s capacity and intention to engage. 4
GP, OUT OF HOURS, OPD and A&E ATTENDANCE Use of NHS services could be assessed over the 5 year period which includes the 3 piloted years & 2 years of commissioned programme. Attendance was measured prior to entry (baseline) and annually for 3 years following the patient s discharge. However, account was not taken of the specific reason for each attendance and has therefore included attendances which did not necessarily relate to the patient s chronic pain condition e.g. cataract, diabetes, CHD. There was an apparently sustained reduction of GP, OPD and A&E attendance. 156 total number referred between 1 st April 2007 to 31 st May 2011 27 patients in programme less than 1year 129 patients in programme at least 1 year 7 ineligible 15 did not start 19 failed to engage 6 too ill to engage (2 died) 2 transferred to secondary care 11 moved away 2 inadequate data 67 patients engaged in the programme for at least one year 1 year pre-referral Year 1 Year 2 Year 3 (67 patients) (67 patients) (41 patients) (27 patients) GP attendance 879 (av.13,1) 553 (av.8.3) 348 (av.8.5) 211 (av.7.8) Out of Hours 59 (av.0.9) 26 (av.0.4) 29 (av.0.7) 8 (av.0.3) OPD/A&E 391 (av.5.8) 179 (av.2.6) 126 (av.3.0) 90 (av.3.3) Av.baseline att. Av.att/patient/yr Difference/patient/yr GP attendance 13.1 8.2-4.9 OOH 0.9 0.5-0.4 OPD/A&E 5.8 3.0-2.8 5
HOSPITAL ADMISSIONS: EMERGENCY & PLANNED Admissions were also assessed over the 5 year period. The number of admissions over 3 years prior to referral (baseline) has been compared with the three subsequent years extending beyond each patient s discharge from the programme. However, admissions were not necessarily related to the patients chronic pain conditions but included other reasons e.g. cataract surgery, newly diagnosed cancer, mental health problems. 156 patients referred between April 2007 & May 2011 100 : referral date did not allow full 3yr follow up 56 patients whose referral allowed for 3 year follow up 1 did not attend first interview 3 did not return after first interview 2 too ill to take part 4 failed to engage 40 patients engaged in treatment 7 lost to follow up (2 moved away, I died) 5 incomplete data 28 patients with data 3 years pre- and post-engagement in the programme Admissions Baseline 3 years Absolute difference Difference/pt/yr Emergency 23 17-6 Planned 24 17-7 Total 47 34-13 - 0.15 6
WHAT PATIENTS SAY.. I feel as though I can cope with my illness and not let it take over my life like it did As I am now receiving the help I so long needed it has made me realise I can lead a normal life I feel more confident in dealing with difficult situations at work, no sick leave for over a year! It has given me a light at the end of the tunnel, now able to do housework and cook meals If anything goes wrong I recover quicker. I ve learned a lot about myself I seem to cope with pain in that I have the ability to push myself more Dramatic increase in my well-being and fitness. Self-belief increased what I say I do Overall Blackthorn has helped with mobility, but still need to ask for help I am independent and able to do things for myself more now BT tries to help me where others haven t given more hope for life when I was so depressed I m not going to be pushed around anymore. I now see that if my life is to improve I must act I have more positive thinking in me now.blackthorn has made me feel I m worth something again Starting to go out by myself and making decisions. They have saved my sanity and given me something to aim for Instead of the condition controlling my life, I am learning to have some control of the periods between episodes I feel much more grounded and not everything is a major drama Appendix 1. The SF-12v2 is a validated generic measure developed as a shorter more versatile alternative to the SF-36 Health Survey www.sf-36.org/tools/sf12shtml measuring changes in physical and mental health. The SF12v2 was administered at baseline, 6 months, and 1 year and on discharge from the programme. 7
2. Self-report questionnaire How much has your time at Blackthorn helped you accomplish? 1 Your confidence in yourself Much less than before/less than before/much the same/considerably improved/greatly improved 2 The control you hold over life Much less/than before/less than before/about the same/some improvement/much more control 3 Your dependence on others Very much less/much less/about the same/more than before/much more than before 4 Do you feel you have taken any steps in your own personal development? Yes/no 5 Have you developed any new interests or hobbies? Yes/no 6 How satisfied have you been with your treatment? Very unsatisfied / unsatisfied / not one way or the other / satisfied / very satisfied 3. SFv12v2 assessment Physical Health Mental Health Better Worse Same Better Worse Same 17 (28%) patients at 6 months 8 (47%) 1 (6%) 8 (47%) 12(71%) 1 (6%) 4 (23%) 27 (45%) patients at 12 months 15(56%) 6(22%) 6 (22%) 13(48%) 4 (15%) 10(37%) 6 (10%) patients on leaving the project 2 (33%) 1 (17%) 3 (30%) 4(67%) 0 (0%) 2 (33%) 10 (17%) patients 6-12 months after leaving the project 2 (20%) 3(30%) 5(50%) 5(50%) 3(30%) 2 (20%) 60 patients overall 27(45%) 11(18%) 22(37%) 34(57%) 8(13%) 18(30%) 8
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