translating research into practice: improving the ...sydney.edu.au/medicine/rehab/about/research...

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Translating research into practice: Improving the management of pain after spinal cord injury

1. John Walsh Centre for Rehabilitation Research,Kolling Institute for Medical Research, University of Sydney

2. State SCI Service, NSW Agency for Clinical Innovation

A/Professor James Middleton1,2, Dr Janet Long 1, and Lyndall Katte 1

Translating research into practice

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Objectives

› To define Knowledge Translation (KT)

- Phases of KT

- Where implementation fits

› To define Implementation

- factors that contribute to success

- Stages

› To illustrate the stages with the SCI Pain Project

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• Overview of the Knowledge Translation Model

• The SCI Pain Project:

• Exploratory phase

• Developing the intervention

• Planning implementation strategy

• Implementation

• Evaluation

• Dissemination

• Sustainability

• Future plans3

Outline


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The Valley of Death: getting research into practice

Image by Mellor from Nature 453, 840-842 (2008)

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It’s hard

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Effectiveness of professional behaviour change strategies from selected EPOC systematic reviews• 363 randomised trials• Mean absolute improvement in care / change in clinician behaviour

(e.g. prescribing) 3-12%

Defining Knowledge Translation and implementation

› “an ideal and an endeavour”

› Evidence from research put into practice

› Not an automatic process

Implementation

› systematic uptake of research

› Establish as routine practice

› Effectiveness and quality of health services

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Knowledge translation

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Implementation strategies

› Passive

Paper implementation

“not another guideline!”

- Active

Education

In-services

On-line training

Coaching

Multifaceted

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Knowledge translation stages

Basic science research

Efficacy studies

Effectiveness research

Implementationi.Explorationofcontextii.Developinginterventioniii.Implementationstrategyiv.Initialimplementationv.Evaluatinginterventionvi.Evaluatingimplementationvii.Sustainingchange

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Early Stages of the KT continuum

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› Efficacy studies

- Compile evidence for efficacy of intervention in controlled settings

- Laboratory work, animal models

- Randomised controlled trials

› Effectiveness studies

- Assessing evidence

- Compile evidence for intervention in "real world" settings

- Clinical trials

Stages of implementation

Explorationofcontext

Developingintervention

Implementationstrategy

Initialimplementation

EvaluatinginterventionEvaluatingimplementation

Sustainingchange

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Active implementation

› Current practice

› Aims

› Strategies

› Acceptable

› The science

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A collaboration between researchers and clinicians

Reasons why people might not change their behaviour when new processes are implemented

Knowledge

Do I understand what it is saying?

Skills

Do I know how to do this?

Social / professional role and identity

Who are they to tell me what to do?

Beliefs about capabilities

How hard / comfortable is it to do?

Theoretical Domains FrameworkMichie, Johnston, Abraham, et al (2005) Qual Saf Health Care 14:26-33

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Beliefs about consequences

What is the cost/benefit to me or my clients of doing it?

Motivation and goals

How much do I want to do it?

Memory, attention and decision making

Will I remember to do it if it’s not part of my routine?

Environmental context and resources

Are there competing tasks / time constraints / equipment issues?

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Social influences

Are the clinicians I respect doing it too? Is the boss supportive?

Emotion

I messed up first time I did it. It was so humiliating

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How to measure implementation success?

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› Feasibility - does it fit here?

› Acceptability: do people like it?

› Appropriateness: is it OK to do?

› Fidelity: it is being used properly?

› Adoption: are people actually using it?

What factors are associated with success?

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Success 1. Preparing for change

2. Capacity — people

3. Capacity — setting

4. Types of implementation

5. Resources

6. Leverage

7. Enabling features

8. Sustainability

Obstacles • failure to prepare

• insufficient capacity

• resistance to change

“then care quality is at risk, and patient safety can be compromised.”

Braithwaite J, Marks D, Taylor N. (2014)

International Journal for Quality in Health Care. 2014 June 1, 2014;26(3):321-9.

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Resources

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http://epoc.cochrane.org/

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Resources

www.improvement academy.org

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Resources

www.improvement academy.org

Resources

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http://nirn.fpg.unc.edu/

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Resources

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http://implementation.fpg.unc.edu/

Resources

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http://www.behaviourworksaustralia.org/resources/

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http://plus.mcmaster.ca/kt/

Resources



Developingtheintervention




Sustainingchange

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Exploratory Phase – Chronic Pain & SCI Project

› Online Survey- Clinicians- Consumers

› Focus Groups- Clinicians- Consumers

› Interviews

› Social media and print media- Spinal Cord Injuries Australia- ParaQuad NSW- Lifetime Care and Support

Authority

IDENTIFYING THE PROBLEM, UNDERSTANDING WHAT IS NEEDED

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Do you feel adequately resourced to manage patients

with SCI and chronic pain?

Yes 18.87%

No 81.13%

How do people prefer to obtain Healthcare Information?

Resource type:

• Internet 74%

• Book 27%

• Flyers 25%

Healthcare Provider:

• GP 91%

• Spinal Specialist 72%

• Physio 58%

• OT 34%

• Massage Therapist 29%

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Setting Clinical Standards & Planning for Implementation

KNOWLEDGE CREATION

‘Discovery’ research (basic, applied)

Knowledge Synthesis (scoping, evidence mapping, systematic reviews)

Stakeholder Dialogues (harness expertise, offer different perspectives, collectively problem-solve)

mobilize ‘Community of Practice’

Further research

Develop Clinical

Practice GuidelinesNO

IMPLEMENTATION PLANNING Audit Current Practice Identify Evidence-Practice Gaps Determine Health Drivers

IMPLEMENTATION STRATEGY

AGREED STANDARDS OF PRACTICE Ready for Implementation

› Applies collective problem solving to important issues

› Defines the key challenges through consultation with key stakeholders to understand the issues and complexities.

› Synthesises information from publications and further expert consultation into briefing document.

› Convenes stakeholder dialogues to:- connect the relevant information with people who can make

change happen (clinicians, researchers, people with SCI, advocacy organisations, managers, policy-makers, funding agencies)

- Harness expertise, gathering views, experiences and tacit knowledge that key stakeholders bring to the issues at hand

- motivate and inspire dialogue participants by bringing them together to address a common challenge.

› Supporting improvements by preparing dialogue summary

National Trauma Research Institute (NTRI) Forum Model

www.ntriforum.org.au

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› NTRI Forum held 20 August, 2013 (N=19)- Researchers, clinicians, consumer, service

providers, govt funding and advocacy organisations

› Context - current SCI projects in NSW & Canada, national & state-wide pain management initiatives, resources/information to underpin implementation

› Aim to develop a shared understanding of currentstandards, practice, and barriers & facilitators of optimal management of chronic pain in SCI, and

› Consider how this information can inform change strategies to optimise clinical practice.

SCI Pain Stakeholder Dialogue

NTRI Forum Model for KT

Bragge, Piccenna & Gruen, 2012

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› SCI Pain algorithms (Siddall & Middleton, 2006)› National Pain Strategy (co-ordinated interdisciplinary assessment & management)

› NSW ACI Pain Mgt Network reviewed Models of Care- ‘stepped care’ to screening & triage, promote active

engagement & self-management by patient; multi-disciplinary, comprehensive, integrated & system-wide (Conway & Higgins, 2011)

› SCI KMN Canada 3-round Delphi survey to prioritise implementation targets (89 → 12 → 7 practices)

› International SCI Pain Basic Dataset version 2.0 (Widerström-Noga et al, 2013)

› Updated Pain Classification (Bryce et al, 2012)

Pain Forum – Contextual Issues

Treatment Algorithm for Nociceptive SCI Pain

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PAINLocated in a region of normal sensation

Dull, aching painRelated to posture, activity, movement

Somatic tenderness

Vague, poorly localised,cramping, intermittent

pain in thorax, abdomenRelated to visceral function

Antibiotics

Cystoscopy Lithotripsy

Disempaction

Adjust bowel aperients &

routine

Oral baclofenTizanidineDiazepam

NOCICEPTIVE

VISCERALMUSCULOSKELETAL

AcetaminophenNSAIDs

Botulinum toxin (if focal spasm)

Intrathecalbaclofen

ColonoscopyBowel transit

studies

Transanalirrigation

Colostomy

Treat muscle imbalance, exercise Postural reeducation, seatingRetrain transfer techniques

Address wheelchair biomechanicsActivity pacing & modificationEnvironmental modifications

NEUROPATHIC(see Figure 4)

-Nociceptive pain

indirectly related or unrelated to SCI, such as

dysreflexicheadache, pressure areas, migraine

Electric shock, shooting, squeezing, burning pain

Segmental pattern,located at NLI and/or

within 3 dermatomes, or involves cauda equina

Electric shock, shooting, squeezing, burning pain

Located more than 3dermatomes below NLI(but may include them)

BELOW-LEVELNEUROPATHIC

AT-LEVELNEUROPATHIC

OTHERNOCICEPTIVE

- - -

Related to repetitive movement

Local tenderness, pain on stretching,resisted movement

Neck or back painKyphus / scoliosis

Worsens during dayRelieved by lying

Possible trigger pts

POOR POSTURE & MECHANICS

“OVERUSE SYNDROME”

Increased muscle tone

MUSCLE SPASM

-- Fever, frequency, urine leakage, debris,

blood, spasms, ADWCC, urinalysis,

MCS, ultrasound, CT

Constipation, diarrhoea, bloatingWorse after meal,

Improved by evacuationImpacted on AXR

Pounding headache,sweating, flushing, blurred vision, etc

Elevated blood pressure (>20mmHg)

-PSEUDOBOWELOBSTRUCTION

INFECTION,CALCULUS

AUTONOMICDYSREFLEXIA

--

-

Tramadol“Strong” opioids

Located in a region of impaired sensation

Spinal fusion

Signs of instability on examination

Structural changes evident on imaging

FRACTUREDISLOCATION

-Exclude pathology, such as peptic ulcer,

gall stones, etc on ultrasound, CT scan, endoscopy

-

-

Identify and treat cause

Identify and treat cause

BP lowering drugs

Further investigation

-

+++++

++ +++ + +

ALL - ASSESS AND TREAT PSYCHOSOCIAL & ENVIRONMENTAL CONTRIBUTORS - POOR PACING, UNHELPFUL COGNITIONS, MOOD DYSFUNCTION (e.g. CBT, Anxiolytics, Antidepressants)

- --

+ -

Siddall PJ, Middleton JW. Pain following spinal cord injury. In: ISCoS textbook on comprehensive management of spinal cord injuries, Chhabra HS (Ed.). Wolters Kluwer, New Delhi pp825-848 (2015).

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Guideline Summary from KMN Delphi Survey

Final Recommendations identified for implementation

› INTERDISCIPLINARY TREATMENT & ASSESSMENT:

› Treat in an interdisciplinary fashion guided by comprehensive assessment (Source: PVA)

› Full text of relevant recommendations:

- “Because chronic pain related to musculoskeletal disorders is a complex, multidimensional clinical problem, consider the use of an interdisciplinary approach to assessment and treatment planning. Begin treatment with a careful assessment of the following: aetiology, pain intensity, functional capacities, psychosocial distress associated with the condition.” [PVA, p.460]25

- “Treat chronic pain and associated symptomatology in an interdisciplinary fashion and incorporate multiple modalities based on the constellation of symptoms revealed by the comprehensive assessment.”[PVA, p. 461]25

Very strong support for this recommendation. (Grade of Recommendation-A; Clinical/epidemiologic evidence–1; Ergonomic evidence–NA, Panel opinion-Strong)

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Wolfe D, Hsieh J, Kras-Dupuis A, et al. Online Delphi to Identify Targets for Best Practice Implementation and Associated Performance Measures Interdependence 2012. Vancouver, BC; 2012.

› 12 SCI Rehabilitation Facilities with onsite Pain Management Services (Craven et al, 2012)- 75% adequate waiting time, 58% services sufficient

- <30% use standardised assessments or validated tools (eg. VAS, BPI, DN-4, etc)

- 25% follow documented standards of care or CPG!

› Priority to overcome regional disparity

- Best practice indicators include: extent of inter-disciplinary care, collaborativeness of inter-facility & regional chronic pain programs, timeliness of PM care, standardisation of assessment & outcome tools, integration pharmacological & non-pharmacological treatment pathways, and improved patient education.

Canadian Environmental Scan

Craven C, Verrier M, Balioussis C, et al. Rehabilitation environmental scan atlas: Capturing capacity in Canadian SCI Rehabilitation. Vancouver: Rick Hansen Institute, 2012.

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› Care highly variable/adherence to identified standards higher in specialist/inpatient centres compared with outpatient and community-based settings

› Lack of access to tertiary centres with expertise, compounded by geographical and travel issues

› Barriers in primary practice include lack of knowledge, limited time and funding, and shortfalls in workforcevolume/training, especially in rural and remote areas

› Facilitators include fostering ‘hub and spoke’ model of education/ capacity building, CDSM models

› Use of formal, standardised assessment tools and management plans, develop case studies / scenarios as an educational strategy

Pain Forum – Key Issues

The SCI Pain Clinical Standards

1. People with SCI should be screened for pain prior to discharge from the spinal cord injury unit

2. If pain is found, assessment will be done using a SCI-validated tool to establish a baseline record of pain history

3. Standard terminology will be used to describe pain, consistent with the International SCI Pain Basic Data Set and the International Spinal Cord Injury Pain Classification

4a). Red flags are to be ruled out for any new or changing pain and managed accordingly if present

4b). Yellow flags will be ruled out for any pain and when identified, managed accordingly

5. A multidisciplinary approach is used to management.38

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Sustainingchange

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Consumer Resources

Developing The Intervention -Resources

http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain

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Introduction to SCI & Chronic Pain

› Pain is common after SCI

› There are a number of different types of pain that occur after SCI

› Learn how to talk about your pain

› Identify SCI Red flags

Understanding Pain After SCI

› Pain is due to primary trauma, nervous system response and secondary changes to the nervous system

› Introduction to pain gates

› What happens to pain gates after SCI

› Explanation of neuropathic pain mechanisms after SCI

› You can re–train the brain to feel less pain – even after spinal cord injury

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SCI Pain, Physical Activity & Exercise

› It is important to be physically active after spinal cord injury

› Be aware of risks of shoulder overuse

› Physical activity can actually help to reduce the pain

› Use pain management principles; set goals, pace yourself and devise a graded activity program for best results

SCI Pain Nutrition & Lifestyle

› A balanced and nutritious diet can help to

• increase your energy

• reduce your pain

› Aim for a selection of fresh vegetables and fruit, whole-grains and lean protein choices

› Monitor your bowel program if on medication for pain that can cause constipation

› Healthy food choices are easier than you think!

› Links to nutrition resources

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SCI Pain & Medications› Different types of medications are used to treat different types

of pain after SCI

› It is important to match appropriate pain medication with pain type

› It is important to have a plan to review efficacy of medication

› Weigh up the benefit (pain reduction/increased function) against the side effects to help guide future planning

Pain and Thoughts

› Thoughts and feelings can influence the pain experience

› You can re-train the brain to reduce the impact of pain on your life

› Techniques include a combination of:

• Managing your thoughts • De-sensitisation• Distraction• Meditation / Relaxation• Goal setting• Graded activity & pacing • Flare up plan• Sleep strategies

“Everyone has a different way to copewith the pain. I used a lot of meditation early on and desensitisation. Now I have taught myself to play guitar, and when I

play it is like a meditation for me.”

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Developing the Intervention

Clinician Resources

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PAIN MANAGEMENT - PHYSICAL

• Goal Setting• Exercise• Strengthening• Stretching• Fitness/Conditioning• Pacing• Graded Activity Plan• Flare Up Plan• Upper limb preservation

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PAIN MANAGEMENT - PSCYCHOLOGICAL

• Dealing with unhelpful thoughts

• Relaxation / Meditation

• Desensitisation

• Hypnosis

• Dealing with flare ups

• Pacing

• Goal setting

PAIN MANAGEMENT PLAN

• Pain Assessment

• Pain Features and Types

• SCI Specific Red Flags

• Yellow Flags

• Medical Management

• Physical Management

• Psychological Management

• Referrals

• Re-Assessment

• Resources

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Sustainingchange

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Planning the strategy

1. Spinal Rehabilitation units

Patients with a new injury on discharge from the unit going home / into residential care

2. Community Health Centres

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SITES

Clients accessing their community nursing or allied health services

3. Tier 2 pain clinics (Regional outpatient pain services)Clients referred for specialist pain management

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• Estimated clients with a SCI seen per year

• Community Health Centres: <15 per year

• Tier 2 pain clinics: 0-5 per year

• Spinal Rehab units: 30-80 per year

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NUMBERS


• To improve the process of pain assessment and management in clients with spinal cord injury (SCI) through the use of a decision support tool and web-based resources: increasing the number of people with SCI screened for pain and if pain is present, having a comprehensive assessment and management plan documented.

• To determine the acceptability, adoption, appropriateness, feasibility, fidelity and sustainability of the tools and resources.

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Project objectives

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KNOWLEDGE: spinal cord injury chronic pain educational resources

ENVIRONMENTAL CONTEXT AND RESOURCES: access to the website

MEMORY, ATTENTION, DECISION MAKING: checklists, other documents

SKILLS: coaching on the SCI Pain Navigator, gaining experience

Planning for known barriers:

Retrospective audits of files for last 12 months

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Pain Clinic #1 Process map


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Pain clinic audit

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Standard 2 If pain is present,

assessment will be

done using a SCI‐

validated tool, to

establish a baseline and

record of pain history

No Initial Pain intensity scores

only

Interference recorded but

not scored or compared

well over time

0123456789

Jan Mar Apr Sept Nov

Pain intensity

Pain interference

Pain clinic audit

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Standard 4 a) Red flags are to be ruled out for

any new or changing pain and

managed accordingly if present

b) Yellow flags will be ruled out for

any pain and when identified,

managed accordingly

No

Yes

Reliance on GPs to

pick up problems

Not systematic

Difference between

the professions

Clinical Standards SCI Pain Project Y/N Comments

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Spinal rehabilitation ward audit of discharge docs

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Standard 4 a) Red flags are to be ruled out for

any new or changing pain and

managed accordingly if present

b) Yellow flags will be ruled out for

any pain and when identified,

managed accordingly

Yes

Yes

Consistent

Well documented

Appropriate

management initiated


Spinal rehabilitation ward audit of discharge docs

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Standard 3 Standard terminology will be

used when describing pain,

consistent with the

International Spinal Cord

Injury Pain Basic Data Set and

the International Spinal Cord

Injury Pain Classification

Yes

& No

• Correct and consistent

pain classification

• Descriptors often absent

• Sometimes fragmented

pain history, recorded

over lengthy time period

• Intensity and

interference not

consistently reported

and rated

• Location not

consistently specified


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Sustainingchange

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Coaching with case studies

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Bryce TN, Biering-Sørensen F, Finnerup NB, Cardenas DD, Defrin R, Ivan E, Lundeberg T, Norrbrink C, Richards JS, Siddall P,

Stripling T, Treede RD, Waxman SG, Widerström-Noga E, Yezierski RP, Dijkers M. (2012) International Spinal Cord Injury Pain (ISCIP) Classification: Part 2. Initial validation using vignettes. Spinal Cord, 50, 6, pp. 404-12

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Sustainingchange

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Data collection

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Clinicians involved with

education only

Clinicians using

resources

Consumers carers,

advocates

Clients

Survey 1a x x

Survey 1 x

Survey 2a x x

Survey 2 x

Survey 3 x x x

Survey 4 x x x

Interview A x

Interview B x

Observations& reflections

x x x x

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Measuring implementation success

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Accept-ability

Adoption Feasibility Fidelity Appropriate-

ness

Survey 1 x x x

Survey 2, 3 x x x x

Interview A x x x x x

File audit x x x x

Survey 4 x x x x x

Website

Usage

x

Tool Usage x

Interview B x x x x

Prospective audits of files for next 12 months

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Sustainingchange

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Thank you to our sponsors and research partners

Office of Health and Medical Research

NSW Agency for Clinical Innovation (ACI)

National Trauma Research Institute (NTRI)

Lifetime Care and Support Authority (LTCSA)

NSW Health clinicians and managers

ParaQuad NSW, Spinal Cord Injuries Australia

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