Musculoskeletal physiotherapist headache clinic

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.

Outcomes

• 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.

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.

Discussion

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.