The ESCAPE-pain programme is an evidence based group rehabilitation programme for osteoarthritis incorporating educational pain management and coping strategies with an individualised physical exercise regime for each participant to support their physical and mental approach to their pain.

Osteoarthritis affects over 8.75 million people in the UK and is a major source of disability with a large socio-economic burden. 

In this blog our Senior Improvement Lead, Laura Rogers shares the myths and learnings gained from rolling out the ESCAPE-pain project in the East Midlands. 

ESCAPE-pain was a national AHSN Network project delivered by AHSNs across the country. 

The impact of chronic pain in the East Midlands

Hip and knee osteoarthritis are an enormous problem for adults in the East Midlands. According to data from Public Health England, in the East Midlands, 18.6% of the general population suffer from hip osteoarthritis and 11% from knee osteoarthritis. That is almost one in five suffering from moderate to severe knee pain from osteoarthritis every day. The impact is not just pain, people struggle to work, to play with their grandchildren, to keep active and most importantly to keep good mental health. The negative impact of osteoarthritis on our society is significant and is not simply felt in the older demographic but many working people in their 50’s.

The case of need for the ESCAPE-pain programme

Why bother with ESCAPE-pain? Surely existing physiotherapy services adequately cover the treatment of osteoarthritis. Do patients really need a 6 week programme? These are questions raised when we discuss the management of osteoarthritis in the community. Here we look at the evidence, the myths and the learning gained from rolling this programme out.

ESCAPE-pain delivered over 6 weeks (12 sessions) enables patients to be listened to and treated holistically covering health coaching, diet, behavioural interviewing, and physical activity. Participants have the opportunity to have open and honest discussions around complex barriers and behaviours that may impede completing physical activity. Delivering the course over 6 weeks has shown to be an effective model for establishing sustainable changes in behaviour[1]. Not only is it effective over the long term, but can be delivered by qualified fitness instructors as well as physiotherapists, occupational therapists and assistant practitioners in community centres, leisure centres, acute, community and mental health NHS trusts, prisons, leisure centres, and football clubs.

Current NHS physiotherapy provision has dwindled with the proliferation of Any Qualified Provider (AQP) contracts commissioned to provide two rapid acute interventions for minor musculoskeletal conditions. Unfortunately, this is not meeting the needs of chronic osteoarthritis and people often do not feel empowered or supported to make significant lifestyle changes resulting in people returning to their GP, A&E or orthopaedic surgeon looking for a solution. Joint replacements will only be offered when joint deterioration reaches a clinical threshold, leaving many people suffering. The economic impact of this is significant with costs spread across the health and social care system.

East Midlands Impact

A significant number of eligible sites (outpatient physiotherapy departments, leisure centres, local community settings) across the East Midlands are now delivering an ESCAPE-pain programme.

How the programme adapted during COVID-19

Whilst the COVID-19 pandemic brought face-to-face classes to a halt, we have actively promoted a virtual model delivering online classes. The programme in the East Midlands has not only seen uptake from existing providers but despite the pandemic, it has not stopped new sites from starting classes. 

Derbyshire Community Health Services NHS Foundation Trust began to deliver the programme virtually in 2020, all training was delivered virtually which would normally happen face to face. Despite coming onboard during the pandemic, it is already seeing the positive impacts of the programme.

Clinical and project sustainability 

Research[2] demonstrates the long-term impact of the ESCAPE-pain course showing it to substantially improve the health, wellbeing and independence of many people while reducing health care costs. 

In terms of project sustainability – both the virtual and face to face ESCAPE-pain programmes will continue to be delivered, trained physiotherapists, occupational therapists, health practitioners and fitness instructors we have in the region.

It is now seen as ‘usual business’ for hip and knee osteoarthritis which continue to generate a significant proportion of referrals into physiotherapy departments.

Learning and reflections

Without a doubt, the robust evidence base, and well organised national programme management was pivotal in the success of this project. However, it also demanded challenging conversations to share the compelling story and to overcome the mindset shift to offer a different model of care. Whilst the costs were marginally increased initially, the long term quality impacts on participants mental and physical health have been well documented ensuring that a sustainable cost-effective solution is available. There is more work to be done to share and adopt this approach more widely with commissioners and ICS boards to follow the approach already adopted with chronic back pain.

Empowering people to understand and take control of their chronic condition and to see the positive lasting effects is incredibly rewarding, and to be able to flex this programme during COVID to offer virtual support to often isolated participants has been invaluable.

More information

A recent partnership between Health Innovation Network (HIN) and Orthopaedic Research (ORUK) has given the project a confirmed sustainable future to continue so many more can benefit across the country.

Find out more about the East Midlands ESCAPE-pain programme on our project web page. 

Author 

Laura Rogers, Senior Innovation Lead 

1. When delivering exercise rehabilitation programmes for osteoarthritis (OA)/chronic joint pain, it is crucial to provide sufficient exercise to stimulate improvement in pain and function. A systematic review with meta-analyses highlighted a positive dose-response between the number of supervised exercise sessions and improvements in pain and disability - for every additional 10 exercise sessions the pain relief effect size increased by more than 0.2 (Juhl et al 2014). Also, a Cochrane Review showed that interventions comprised of at least 12 exercise sessions produce much larger improvements in pain (p=0.03) and physical function (p=0.02) than interventions that have fewer than 12 sessions (Fransen et al 2015).

2. Thirty months after completing ESCAPE-pain, participants had sustained improvements in physical function (Hurley et al 2012), lower community-based health care costs, medication costs, and total health and social care costs compared to usual primary care, as well as a very high probability (80–100%) of being more cost effective (Hurley et al 2012).