Pain affects between a third and half of UK adults and is strongly linked with psychological wellbeing. Persistent pain often leads to increased psychological distress, while psychological distress increases the likelihood of developing or continuing to experience painful musculoskeletal conditions. However, pain care is often fragmented within primary care meaning psychological distress can go under-recognised and untreated.
There was a gap in physiotherapists’ confidence and training that was a barrier to supporting people’s mental health needs.
The Health Innovation Network Academic Science Network was chosen to work on this challenge as part of a Q Lab call out, which enabled us to generate and test innovative ideas to improve psychological care for people with persistent pain.
Working with St George’s Hospital and Kingston Hospital in South London, we identified that the psychological needs of people using physiotherapy services could be better supported and that there was a gap in physiotherapists’ confidence and training that was a barrier to supporting people’s mental health needs.
Psychological issues related to patients’ ongoing pain can have a real impact on their treatment outcomes. They could end up bouncing around the system between physiotherapy, the chronic pain team and their GP. Many patients weren’t really getting the support they needed to understand and manage the impact of pain on their psychological health.
For physiotherapists there can be a lot of fear around starting conversations related to mental health and wellbeing. Supporting psychological wellbeing was identified as a training need with most physios we spoke to saying they didn’t feel competent or confident to address this with their patients. Working with Q enabled us to develop and test an evidence-based training and supervision package for physios that focused on psychologically informed treatment strategies and techniques to start conversations with patients about mental health and provide tools for them to manage their pain.
What did the project involve?
During the initial six month phase of the project we ran focus groups with MSK physios where we combined our findings with evidence-based literature to start developing a training course. With further Q funding we invited the Physiotherapy Pain Association (PPA) and Professor Francis Keefe, Duke University, USA who developed a lot of the research, to join our project. This resulted in the Psychologically Informed Collaborative Conversations (PIC-C) project in January 2020.
The course is very experiential. They had to practise all the tools, techniques and exercises – which many reported as extremely relevant given the circumstances they were working in during the height of the second wave of COVID.
While there were challenges with COVID-19 and some of our colleagues being redeployed to support COVID patients and staff wellbeing, there was also a positive impact in that we moved online and were able to have our patient representatives and USA-based Professor Keefe work with us remotely the whole time. We also developed the training course to be delivered online, which has actually strengthened the scalability and potential reach.
From September to February we piloted the 16-week online course with 38 physiotherapists. Several physios themselves were redeployed to support the COVID wards, however, most were able to secure protected time to complete the course. The course is very experiential. They had to practise all the tools, techniques and exercises – which many reported as extremely relevant given the circumstances they were working in during the height of the second wave of COVID.
The course involved eight weeks of training and eight weeks of supervision so there was a chance to put their skills into practice, come back to facilitators and share their experiences. The supervision element of the course is one of the unique selling points and was highly valued by the physios.
How were patients involved?
We had two patients with lived experience join us as equal project partners, attending all meetings and challenging us from their perspectives as patients. They reviewed and developed a lot of the content, made films and contributed their own stories.
We had two patients with lived experience join us as equal project partners, attending all meetings and challenging us from their perspectives.
We asked patients to keep a journal during the design, content creation and evaluation stages of the project, as a way of capturing their reflections.
Their involvement is integral to PIC-C and we co-produced a Patient Co-Creation Report to showcase how we worked together, available on our on our project webpage.
Results and next steps
Evaluation showed a real shift, with physios reporting a reduction in anxiety and increased confidence, with 100 per cent of respondents stating PIC-C had a positive impact on their confidence in delivering psychologically informed consultations.
A change in practice in using psychologically informed strategies and techniques with patients was shown, as participants progressed through the training. Before the training, 19 per cent of participants stated that they focused on ‘developing a therapeutic alliance’ as a standard part of their practice. Post-PIC-C, this increased to 81 per cent of participants.
We were really pleased to see added workplace benefits as a result of the training. One hundred per cent of physios reported increased resilience and 96 per cent said they had more compassion for others. Given they attended the training during the second peak of the pandemic, we were encouraged to see that, of those who responded, 93 per cent reported that PIC-C has improved their work satisfaction and 50 per cent reported a reduction in work-related fatigue.
PIC-C is now ready for implementation at scale following our webinar launch to 270 delegates in summer. Although we ran the project with physios, psychologically informed care is relevant to all health professionals working with people with pain. We’re currently going through the Personalised Care Institute for accreditation and have future courses planned through the PPA. PIC-C can be commissioned for teams/organisations and we are speaking with higher education representatives who are interested in PIC-C as a standalone module to complement health professionals training.
How did working as part of Q Lab impact on the project?
Working with Q gave us a real opportunity to explore an under-researched area and test our ideas. There’s an expectation that you’d have an output but there’s not an expectation that you’ll get it right. This is really important – it is about the learning journey.
You may be out of your comfort zone at times (think cardboard, sharpies and pipe cleaners!) but ultimately innovation happens when we have time to experiment and get creative.
There’s no way that clinicians on the ground could secure time to explore and test ideas that may not work – so the Q funding meant clinical team members had protected time. Without this funding the project quite simply wouldn’t have gone forward.
If you’re considering working with Q Lab I would say, definitely. Come with a partly formed idea and ideally with your partners on board if you can. Recognise that that first six months goes really quickly. It’s very exploratory and you can’t generally get from concept to delivery in six months. I’d encourage you to be open minded – Q work very differently to how most clinical teams operate and begin given space to explore and think can be a bit it can be a bit of a shock initially. You may be out of your comfort zone at times (think cardboard, sharpies and pipe cleaners!) but ultimately innovation happens when we have time to experiment and get creative.
Get involved with the latest Q Lab project. Find out more on our news page.
Visit the PIC-C page on the Health Innovation Network South London website.
Find out more about World Mental Health Day 2021 on the WHO website.