Musculoskeletal physiotherapist headache clinic

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Initiative Type

Service Improvement

Status

Deliver

Added

10 July 2023

Last updated

23 October 2023

Summary

In May 2021, headaches were the single most common referral to the Sunshine Coast Hospital and Health Service (SCHHS) neurology outpatient department, with most headache referrals listed as category 2.

There were long-standing issues regarding access to neurology services with demand continuing to exceed supply, despite significant investment in Senior Medical Officer (SMO) FTE and clinic availability. The category 2 clinic wait-times were over the recommended timeframe of 90 days. Furthermore, it was believed that a significant number of these headache referrals were being insufficiently and/or inappropriately managed.

This project developed an effective, equitable wait-list prioritisation process, underpinned by rational and efficient clinical decision making that were likely to result in

better patient outcomes and improved service delivery planning.

More than 200 patients were screened at the Musculoskeletal Physiotherapy Screening Clinic (MPSC) of the (SCHHS), with referrals dating back from January 2021.

1st batch of patients screened July 2021
151-discharged (135 category 2 and 16 category 3).

Of these:

54 (35%) - DCx2 – ‘success’ discharged from both MPSC and neurology wait-list
87 (58%) - DCx1 – ‘fail’ discharged from MPSC and returned to neurology wait-list
35 (40%) immediately following initial MPSC screening consult
50 (57%) failed targeted active management
Two (3%) mistakenly, following FTA by two (administrative oversight)
10 (7%) - FTAx2 – ‘success’
One -failed to attend initial screening appointment. Five without engaging in any treatment. Five early on in treatment
Of 104-patients who completed targeted active management, regardless of discharge status, 58 (56%) responded positively to treatment (GROC > 2/5)
The MPSC headache pilot trial had significantly greater than expected initial success, with one in three patients (34%) discharged following targeted active treatment. This represents a significant number of patients who did NOT require a neurology appointment. Refinement of the pathway may push these numbers higher. Owing to the success of the pilot, the MPSC headache clinic has become a permanent feature of neurology outpatients, with recurrent funding afforded.

Key dates

Jun 2022

Jul 2023

Implementation sites

Sunshine Coast University Hospital

Aim

To strive for an effective, equitable wait-list prioritisation process, underpinned by rational and efficient clinical decision making, likely to result in

better patient outcomes and improved service delivery planning.

The proposal was for advanced-scope musculoskeletal physiotherapists to triage the SCHHS neurology patient wait-list, providing assessment and treatment for those headache sufferers deemed appropriate, thereby supporting an opportunity to create efficiencies in the management of resources via innovative utilisation of the health workforce. The aim for such an approach was to directly reduce the neurology category 2, and indirectly the category 3, waitlist times, whilst providing timely and appropriate intervention for patients.

Benefits

targeted active management appears to have valuable role in management of chronic primary headache
56% appropriate primary headache patients were successfully managed
short course of spinal manual therapy and/or specific exercise warranted in all patients with determined spinal component to their headache
poor prognostic indicators
of 87 patients (‘fails’) reinstated onto new wait list, more than 75% had significant emotional health and/or BMI concerns
nigh on impossible to infer from GP referral whether patient may be responder vs non-responder
individual screening of headache cohort by appropriately-skilled clinician needed
high level of manual assessment competency essential

Background

Recurrent headaches are amongst the most disabling disorders in the world, with headache considered the most prevalent pain disorder, affecting 66% of the global population (Global Burden of Disease study, 2016 – Lancet). There is a one year prevalence of 79% for any type of headache (Steiner et al, 2014 – Journal of Headache and Pain). Headache is associated with substantial personal and societal burden, being the third most frequent cause of time off work (sick) in Australia. Pain, disability and psychosocial consequences occur, with depression common. As headache disorders are most prevalent among the working-age population, they have a large economic impact (Patel et al, 2019 - Journal of Headache and Pain).

Headache prevalence shows no sign of abating, with current and projected public health costs being substantial. Early diagnosis and management of headache presents an important opportunity to alter the course of this disabling condition.

Solutions Implemented

International data suggests that early, appropriate treatment of primary headache syndromes can reduce the likelihood of conversion to a chronic headache disorder (with subsequent burden to both the HHS and society at large). A significant proportion of primary headache disorders are known to have bidirectional musculoskeletal contributors, and it was proposed that by directly targeting and treating these, the burden of headaches requiring neurologist input would be reduced. The prevalence of musculoskeletal conditions generally rises with age. Considering the aging population of the Sunshine Coast, the burden will result in an ongoing increase in future demand for musculoskeletal services.

Evaluation and Results

At least one third of chronic primary headache sufferers, who participated in the pilot trial, realised significant improvement.

Outcomes:

Three outcome measures were used:
number of patients discharged from both MPSC and the neurology wait list, following either their initial MPSC consult or a course of treatment within MPSC (physiotherapy and/or psychology and/or an informed dietary journey)
number of patients discharged from MPSC and reinstated on the neurology wait list following either their initial MPSC consult or a course of treatment within MPSC (physiotherapy and/or psychology and/or an informed dietary journey)
each patient will complete a ‘Global rating of change’ (GROC) score Results (up to December 31, 2022)
137- patients were discharged, with 43 still undergoing active treatment.

Of the 137 discharges:

• 47 (34%) were a ‘success’ - discharged from both MPSC and neurology wait-list

• 78 (57%) were a ‘fail’ - discharged from MPSC and returned to neurology wait-list ‘fails’, 31 (40%) were reinstated immediately following the initial MPSC screening consult

• 12 (9%) were removed from both MPSC and the NWL owing to repeated FTA.

Of the 94 patients who completed targeted active management, regardless of discharge status, 51 (53%) responded positively to treatment (GROC > 2/5)

Fails

Of these 78 (57%) patients, with GROC scores ranging from -2/5 to 5/5 (average 0.8/5):

Lessons Learnt

Appropriate patient selection is the key to refining the process, however, it is very difficult to pick a suitable vs unsuitable patient solely from a GP referral.

There is not much that we would do differently.

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