I read this article recently and there is good information in the article. I won’t say that I agree with all of the points made in the paper, but there is always room for individual differences in the management of patients.
To start, there has been a shift, over time, towards engaging the patient more into his/her own care. This is not anything new, as Robin McKenzie has been speaking of this at least for the past 40 years. This is a newer concept being taught as a whole though. Previously, Physical Therapists (PT’s) worked heavily on a biomechanical model. This means that we believed that humans were more like cars than the complex organisms that we are coming to realize. If a human is like a car, then some simple maintenance like tun-ups, tire alignments and replacing bad parts is the easy fix. As we now know, humans are not cars. It takes a lot more than “putting things back in place” or trying to fix one structure in order to improve the human experience.
“self-efficacy is people’s beliefs in their ability to influence events that affect their lives…unless people believe they can produce desired outcomes by their actions, they have little incentive to undertake activities in the face of difficulties”
Self-efficacy is a topic that Ben Cormack about during his CEU. This comment makes sense. If a patient doesn’t believe that they can produced desired changes, then why come to PT?
The quickest answer is: 1. They expect the PT to produce the change, 2. their physician told them to try physical therapy, 3. A person that they know, like, and trust told them to try PT.
On day one, I really have two main purposes during the session: create a connection (a portion of the therapeutic alliance) and empower the patient.
Creating a connection is to get the patient to know, like and trust me as a clinician or a person. What I’ve found in my career is that it is much easier to empower the patient when they are inclined to come into the clinic and aren’t coming to see me out of obligation.
Creating that connection takes effort. It is a conscious goal and not one that I will just allow to chance. When the patient comes into the clinic, I already have demographics (personal information regarding diagnosis, physician referral, insurance type, age, residence). The diagnosis and physician referral don’t tend to help me much…unless the referral source has already started to prep the patient to trust me. For instance, for the past 4 years in one setting and the previous 5 years in another setting, I worked closely with physician groups and they would send appropriate patients to me for assessment and treatment. These physicians already prepare the patient for the experience by telling the patient that “if he can’t help you, he won’t waste your time” and “to listen to what he has to say because he is able to prevent surgery in many cases”. These patient’s come into the clinic already trusting me and have high expectations for their experience with me. The physicians made my job much easier because the first part is done.
For those that haven’t been primed by their physician to trust me, I start with the demographic sheet. Where does the patient live? I chose to practice in Joliet because that’s my hood. It’s where I grew up and I know the streets, the alleys, the businesses, the politics and the schools. If a patient lives in Joliet, I will figure out the connection. It’s like the game “6 degrees of Kevin Bacon”. Although it’s a city of near 200K, for those of us that are from the city, we always “know somebody”.
If the patient is not from joliet, how old is the patient? Since I would primarily see Medicare-aged patients, this was frequent. Over 70 year-old males had a higher rate of serving in the military. I will ask if he served in the military. Many times the answers are yes. I have a pretty good working knowledge of the Vietnam War and WWII, so I will always ask which branch, where was basic training, which bases was he stationed at, any time overseas, what did he do after he came home from the service, etc, etc. These patient’s are very easy for me to connect with also. If the patient is of this age group and didn’t serve, there is typically a story that goes along with that experience. Their story opens up more opportunities for me to find that connection.
Big picture: one has to communicate with patients and ask questions in order to create the connection in order to get the patient to know, like and trust me.
While working on creating the connection, I am also trying to figure out what that particular patient is looking for by coming to PT. This is the empowerment of PT.
This is huge! I speak to many community groups. One word that I hear frequently regarding patient’s previous experiences is “waste”. PT is a waste of time. It’s a waste of money. It’s a waste of effort. The reason for this is that the patient doesn’t have an understanding of how the interventions that are prescribed have an impact on his/her life. This is MY JOB! I need to ensure that the patient understands the why’s behind the exercise and how to manipulate or change the exercise as the patient progresses or experiences a flare-up. For many patient’s I teach pain modulation for the first couple of days. This means that through a discovery process we learn ways to reduce the patient’s pain experience. This could be through movement, hot showers, relaxation techniques etc. This varies patient to patient and there is no one-size fit’s all approach to reducing symptoms.
I’ll add one additional comment to the above. Even when patient’s have the tools to reduce symptoms, sometimes other priorities take precedence. For instance, just recently I had a patient who had months of back pain. We had his pain abolished except for when he would sit slouched for hours. He came in on a Monday after a holiday and had a flare-up of back pain. I asked him what he did over the weekend and he simply stated “watched a lot of movies with my kids”. I asked him if he understood why he had pain and if he had any regrets. He didn’t and he said that he was happy that he was able to watch the movies with his kids. As long as the patient is happy, satisfied with the knowledge and progress gained in PT and are living the life that they want to live; then who am I to say that the exercises must be done in a prescriptive manner. Patients are individuals and can make autonomous choices as long as they have all of the information needed in order to make an educated decision.
“Most people who experience LBP will have recurrent episodes with pain that comes and goes…up to 20% of those seeking care for LBP have persistent LBP that they need to manage more or less continuously”
I think that this stat is underused. The fact that 1 in 5 patients will go on to have chronic back pain doesn’t get talked about enough, even in the PT profession. In school, many moons ago, we learned that back pain was self-limiting and will typically get better on its own over the course of 6 weeks. What a disservice to us young professionals! PT school did not set us up to be successful with patients experiencing back pain. We didn’t learn how to connect with patients, empower patients, educate patients in a favorable manner. Do you understand what I mean when I say a favorable manner? So many of my patients come into the clinic with the report that the surgeon said “This is the worst spine I have ever seen”, “you have degenerative disc/joint diseases”, “you have a disc herniation”. None of these actually help the patient to understand their symptoms.
We have to do a better job of empowering the patient to care for themselves, because as I say in the clinic frequently: “I can’t go home with you…no matter how much my wife would like to have one less person to care for”
“…people are more disabled from LBP when they perceive their condition as frightening and out of their control and have low pain self-efficacy”
There are some home-run statements in this article. Most of us in the PT field have general knowledge of back pain. Understand that not all PT’s take the initiative to learn more than they learned in school, which as I stated above was not great for taking care of this population. Those of us that have the knowledge must be able to communicate that knowledge to the patient…otherwise that knowledge is a waste. There is always a passer and receiver, even in healthcare. If I am passing on information to the patient, but the patient is unable to receive that information, then I must come up with a better way of passing the information. For instance, when I throw a baseball to my 3 year-old, it is a much different throw than when I would throw the ball to second from behind the plate. The receiver has to be in a position, with the requisite skills, to receive the information. The passer, or teacher, has to understand the receiver’s skill level and adjust accordingly.
If we can reduce fear and give the patient control over the symptoms, then we can greatly affect the patient’s quality of life. The information may or may not turn off the pain, as in some patients this is an unrealistic goal, but we can help to give them their life back. Don’t get me wrong, in a large group of patients with back pain, we can teach them to turn off their pain complaints, while giving them their life back.
“let patient’s value-based goals direct care…can open the communication about people’s motivation for change and can reveal what facilitates and hinders reaching these goals”
I see thousands of patient visits per year. During the initial evaluation, I always ask if the patient has had physical therapy experiences in the past. If yes, there has to be follow-up questions:
- how’d it go?
- What types of treatments were you given?
- do you feel that it was worth it?
- did you establish goals to work towards?
- What would you need to see in order to say you’ve improved?
These questions are asked in order to better understand the patient’s previous experience, learn what went well and what didn’t go so well and to help me live up to the patient’s expectations.
This is also my way of interviewing the patient in order to determine if I am the best PT for that patient. For instance, if the patient answers questions 2 and 4 with similar answers that I would be providing in my clinic, will that patient answer questions 1 and 3 any differently than they did after their previous experience? If I can’t say that I would do anything different or better than their previous experience, then I don’t feel that I would be worth coming to for PT.
Obviously, if the patient answers these questions in a manner that I can bring more to the table than the patient already received, then I will always take the opportunity to work with this patient. I still need these answers in order to understand how I can bring value to the patient sitting in front of me.
Although many patients may come to PT with the same goals: to reduce pain or increase function, the back story of the patient is very important in order to understand HOW best to work with the patient in front of me to reach those goals.
“make shared decisions…aims at balancing the patient’s right to autonomy with the clinicians’ responibility to protect patient’s safety and ensure best-evidence care…shared decision making is part of patient-centered care and a way to increase engagement, patient satisfaction, and adherence.”
Theoretically, I could’ve stopped that quote after make shared decisions. When working with patients, we are working with people. Not only that, but after the person leaves our office, the person still has to be able to live with their symptoms or lack of ability. We need to understand the patient’s priorities and not usurp the patient’s priorities with our own.
For instance, during a session I will find a movement, posture, position that will reduce the patient’s symptoms in a majority of cases of patients that present with pain. During the session, I will ask the patient if they see the relationship between the movement, posture, position and his/her symptoms. If the patient says no, then I will ask the patient to perform a movement that provokes the symptoms and makes the patient worse. From there, I will ask the patient to perform the movement, posture, position that reduced the symptom. I will continue this type of session until either the patient understand the relationship between the pain reductive movement, posture, position technique and their bettering of symptoms.
Once the patient understands that a relationship exists, then the questions become more personal for the patient: do you think that you could create something like this at home? If the answer is yes, then I ask the frequency question. For some pain complaints, performing the exercise multiple times per day could be very beneficial. I then ask the patient if they could perform the exercise 4-6 times per day. If the answer is yes…case closed. We will come back to the topic on the next session. If the answer is no, then the patient has to give me the reasons why the movement, posture, position can’t be performed so frequently. It then becomes our job as a team to figure out how to overcome the barrier to performing the exercise.
“Define readiness to change”
I’ve been a PT for almost 15 years and still there are so many new graduates that have never heard of this scale. Again, I was blessed in my career and at the time I didn’t realize it. I had the honor of learning from Annie O’Connor, Thomas Lotus, Bill Curtis, Jane Borghammer, Melissa Koski, Katie Rittenhouse, Ella, Joel, John. Every month we met for a study group. In this study group, as a group, we would treat patients that weren’t improving with PT. The meeting was 2 hours long and when there wasn’t a patient to fit into both hours, we would do a journal club for the other half of the meeting. I learned so much from these great minds during the meeting and especially during the following 1-2 hours at the Blue Iquana. As a young PT, I was impressionable and I am just lucky that I ended up in a crowd of who’s who within the PT field just absorbing their teachings. For me, the readiness to change scale was something I learned before ever graduating from PT school, but I didn’t learn it from school. I have this group of dedicated rockstars to thank for that.
Below are the stages within the scale. One of the questions that I like to ask patients is what I learned from Annie:
On a scale of 0-10, how ready are you to make the change to reach your goals?”
Whatever the number the patient gives doesn’t matter as much as how they answer the question following that. For the scenario’s sake, let’s say that the patient isn’t very motivated and answered 3.
The next question is; “why didn’t you say 2?”
The patient then has to reverse thinking from the negatives and barriers that are keeping the patient from accomplishing the goals to a positive framework and what he/she has already done to reach the goal.
These answers give the PT, namely myself, something to build from during the sessions. I can always refer back to the positives decisions and actions that preceded any negative behaviors that the patient may fall into.
These are the stages:
“precontemplation (unawareness or denial with no intention of changing behaviors”
As a healthcare professional, we hate it when patients are in this stage because there’s little that we can do aside from educate to get to the next step.
Story time: my dad had a health scare in 2007. I was just finishing up PT school and had some baseline knowledge, but no where near the breadth of critical reasoning that I have today. He said to me, “what would you say if your patient came to you and was coughing up blood?” You have to know my dad. He was always asking me hypothetical questions. He read a lot and he would typically test his logic vs his college educated son. It reminds me of another saying that he would tell me many times, “we buy you books and send you to school AND THIS IS WHAT WE GET?!”
After some discussion of symptoms, I answered him that I would tell my patient to go to the ER since I was suspicious of a sinister pathology.
My dad told me, “Welp, I guess you better get your keys.”
I was recently visiting my uncle, and this conversation came up. My dad and his brother worked together for 30+ years. He then told me that my dad was walking around coughing up blood for 2-3 months before he went to the ER.
That’s the difference between precontemplation and contemplation.
“Contemplation (ambivalent about possibilities to change)”
There is a cost to change. There is effort, time, and possibly other consequences.
Sticking with the example above of my dad, we went to the ER and they did an X ray and found a spot on his lung, which was fairly large. It was the size of a softball.
Because of this, he was rushed for a PET scan, which is a test that is used to detect cancer. His PET scan came back positive for “something”, but they weren’t ready to call it cancer until it was biopsied.
My dad didn’t miss work for nothing. Now he was forced to deal with the reality that he may never work again. He ended up retiring at this point, which changed his personal identity. For over 3 decades, my dad was a laborer. He identified with being a laborer. Aside from reading the paper or watching the news, this was all he knew.
“Preparation (action planning, start changing behaviour)”
Following the biopsy, my dad learned that the mass in the lungs was not cancer, but instead it was diagnosed as blastomycosis. This was not before he had the entire mass resected from the left lung and was told that he wouldn’t be able to be as active as he was before because he would get short of breath.
He had no time to prepare for retirement. He had no hobbies, no interests outside reading the paper and watching the news.
I would go visit him and he was in the recliner and never left the recliner.
For those that know my dad well, have heard him say this phrase: “get busy living or get busy dying”.
It wasn’t long after this that my dad took action.
“Action (changing behaviours, using self-management strategies but not adopted as a new habit)”
He started volunteering at a horse stable. When my dad was younger, he had a passion for horses.
That passion has returned. He spends hours per day working with horses. This involves feeding, grooming, exercising, and sometimes breaking (training) horses. He wakes up early to leave the house to make sure that they have food and water. He comes home for lunch and goes back out to feed and water in the afternoon.
He drives to the different cabinet shops in the area to shovel out the shavings from the dumpster. This saves the owner of the stable a lot of money from buying shavings from the local farmer’s store. Since then, he has his own horse and cares for my brother’s horses. The horses are like big dogs. I take the kids out there to visit the horses at least yearly and when he goes out to the pasture, it’s like watching the dog wisperer. He screams “Hey Rockstar” (his horse’s name) and its a stampede of horses coming to greet him.
He’s been doing this since about 2009. This is the maintenance portion of the action. Maintenance is making a habit.
For patients that come into the clinic, we have to find a way of going from contemplation to habit and we have a short period of time to do it. Many insurances have visit limits below 10. If we see the patient 1x/week or once every other week, we have a longer period of time to take them through these stages to create healthy habits, but if we burn through the visits within a month, then we may never get to the maintenance phase.
It may be a good business strategy in that we can create lifelong patients because the patient will continue to come back to PT for recurrences. The flip side of the coin is that the patient perceives that PT didn’t help because the patient goals weren’t accomplished and the patient figures “why bother” when told that he/she should give PT a try in the future.
“Patients perceive LBP as unpredictable and uncontrollable and difficult to make sense of, which hampers their ability to deal with it in an expedient way”
As PT’s, we can greatly affect the way that a patient perceives their symptoms, if they are ready to receive the information. Also, the PT has to be able to deliver the information in a manner that the patient is able to receive.
For instance, a high percentage of patients with acute back pain and a smaller percentage, think less than half, of patients with chronic low back pain will come to the clinic with a directional preference. With this type of presentation, the patient will obtain significant relief with one movement, posture, or position. Allowing the patient to figure this out for themselves, through trial and error, gives the patient power and control over the symptoms. The symptoms are no longer seen as uncontrollable or unpredictable. I firmly believe that allowing the patient to come to the conclusion regarding the movement, posture, or position enables the patient to play a large role in the decision-making process. Of course, I could simply tell the patient what to do and why to do it, but when a patient observes the cause and effect relationship for him/herself, the instructions are much simpler. A typical conversation with this patient could go like this:
Me: when we see symptom reduction like you just experienced, this is considered a good prognosis. You should do this exercise every 3 hours for 10-15 repetitions. You should continue to do the exercise as long as it is helping, but should stop if it is making it worse.
Usually though, the conversation goes like this:
Me: What happened when you did that exercise?
Patient: the pain is much better, almost gone?
Me: what do you think that you should do next?
Patient: Hmmm, I don’t know some strengthening exercise?
Me: if some worked the first time to get rid of most of the problem, why not try it again?
I much prefer to use this type of Socratic teaching when assessing and treating patients. It forces the patient to have an active role in the session. The second conversation will play out to where the patient is asking the questions regarding frequency and duration and “what if”, instead of me regurgitating the information to the patient and hoping for some personal value to the patient without context.
“Supervised exercises can be used as a tool to practice problem-solving skills…exercises then become behavioural experiments that help patients reframe their beliefs and emotions related to activity.”
Dominoes vs chess. These are the two examples that immediately come to mind when describing this sentence above, to students that I worked with over the years. We have two options: we can be paternalistic in our treatment approach (dominoes) or we can be team oriented in our approach (chess).
For those choosing the authoritarian approach, the sessions within the plan of care will have this appearance:
- exercises issued from a pre-selected list that are not to be changed regardless of patient response
- “no pain, no gain” without explanation of what this means to the specific patient
- “it’s going to take time” without explanation of what this means to the specific patient
- Hot packs/cold packs issued without an explanation of how it may help the patient
- hands on techniques performed with the explanation of the PT fixing a Knot, joint out of place, or any other narrative from 20 years ago.
- the comparison to dominoes: because I gave you this exercise or did this technique to you with my hands, then you must respond in a specific way. In other words, because I knocked over the first domino, then the rest of them must fall in a specific order.
For those choosing a team-oriented approach:
- There is no preselected exercise. The exercises performed are chosen based on the patient’s preference and response.
- pain with exercises is assessed and explained as either an appropriate or inappropriate response. For instance, someone that has a contractile disorder will have pain when the contractile tissue is stressed, but excessive pain complaints may lead to a flare-up/inflammatory response. A patient with a directional preference should not experience more pain following the directional based movement.
- Patients are educated regarding how much time it should take to demonstrate improvement. If improvement is not seen as this timeline is approaching, then the patient should be reassessed in order to ensure proper classification at the initial visits.
- Hot pack/cold packs may be used, but sparingly. The patient is educated regarding the proposed mechanism so the patient can understand that this can be done at home.
- Hands on techniques may be used, with explanation regarding the neurophysical response and not a biomechanical explanation.
- the comparison to chess: every intervention performed with the patient has a response. The PT’s next intervention should be based on that specific response, either positive or negative. Nothing is set in stone and the treatments are based on the patient’s response.
“Graded exposure…opportunity to provide a positive expeirence and increase the patient’s beliefs in their ability to move and be active…should not be directed by pain as this would reinforce withdrawal from activity”
Graded exposure is not necessarily progressive overload, but progressive overload could be considered graded exposure.
Let’s break that down. Graded exposure is about providing a positive experience performing an activity, which increases the patients confidence and ability to be more active. Sometimes graded exposure is performing the same activity over and over in order to demonstrate to the patient that the activity is safe. The goal IS NOT to “increase muscle strength”. The goal is psychologically based. It is to improve the patients perception/confidence of their abilities.
Progressive overload is based on strength, power and hypertrophy. The basis of this is to perform more volume of an exercise weekly. The end-goal of progressive overload is physiological change, not psychological change.
Another way that this could be stated is that physical activity could be considered graded exposure, but not exercise.
Exercise is considered both physical activity and exercise. Exercise is structured movement that is progressed in one fashion or another. Physical activity is the accumulation of movement performed throughout the day.
Graded exposure could be accomplished through physical activity with the end goal being to produce a psychosocial and possibly a physiological change, but progressive overload is accomplished through exercise with the end goal being a physiological and possibly a psychosocial response.
“LBP invariably involves episodes of flare-ups and situations with increased pain…patients need a toolbox for managing pain and related fears or other emotions”
First, we have to educate patients about the nature of back pain. This is where rote memorization of statistics can be valuable. “80% of people will experience back pain at some point in his/her life”. “About a quarter of people with back pain will have to manage back symptoms over the course of their life”. “Roughly 64% of patients with back pain can perform an exercise to greatly reduce or shut off the pain and for those that can do this, we may be able to cut the recurrence rate of flare-ups by performing the exercise twice per day”.
This is robotic knowledge. This serves to educate the patient that back pain is very common. Many people experience pain that lingers for a while. Many patients can reduce the symptoms by performing some exercises and we can cut down on the chance that the pain will return if they do the exercises that reduced the pain in the first place.
I’ve conversed with many potential patients in the community and a common complaint that I hear is multifold: “I go to the clinic to do exercises that I could do at home. They give me all of the exercises to do at home and none of the exercises actually help”.
If we reduce the number of exercises that a patient performs, and limit these exercises to those that actually have an effect on the patient’s chief complaint, then we can start to overcome these complaints. The effect on the complaint is typically a pain complaint, but it may be an ability complaint. Either way, the exercise, movement, or position has to effect one of these two complaints AND the patient has to understand: 1. why they are doing the exercise, movement, position, 2. how the treatment will help their condition, 3. how often the exercise has to be done, 4. when can they stop doing the intervention 5. what should the patient do when the symptoms return.
“Re-assessment and reflection are necessary to evaluate treatment outcomes and for clinician’s ongoing learning precess…”
A common phrase uttered in the PT clinic is: “these things take time”.
As a PT, we have to be more descriptive than this.
How much time is needed in order for the patient to see a change in symptoms? Does the patient have to go through 1 visit or 15 visits in order to see a change? If the patient is not seeing a change in symptoms after how many visits, is it prudent to change course? Does the patient need to come into the clinic 3 times per week, or can there be the same benefit from once per week or even every other week.
For instance, I recently took a new position at a local teaching hospital and because of that I was working on finding new homes for patients. One patient went to schedule with the larger “A” corporations and was told that she would be seen twice per week, even though I was only seeing her once per week. She asked why the second day was needed, as this would make her leave work early and have to take PTO time. She was told that it is just how they schedule patients.
“I just don’t understand and I don’t think that I ever will”.
We need to have better answers for the patient than those that the professional has traditionally given.
“First, clinicians need training in communication skills, behavioural change techniques, and in working with patient-centered care as this is often not a part of their basic training”
How to communicate is not taught in any schooling required to become a Physical Therapist. We all have life experience, but in those years on Earth, some of us have experiences that may loan themselves to communicating with patients better than others. For those that listen to my ***podcast***, you know that I grew up with an alcoholic father. As much as my dad is my hero, I grew up in a bar. I learned at a young age how to talk to adults. I learned how to talk to veterans. I learned how to interact with people. This experience greatly helps me in my line of work today.
Communication skills can be taught. I recommend for all of my students to take an improv class, because the conversations that take place in the clinic may go towards topics that are sensitive and uncomfortable. Having many experiences with these types of conversations, in a closed environment, will make it easier to have these conversations in real-time.
Also, I recommend students to learn about microexperessions so that the student can not only have verbal interactions, but is able to see if the patient is accepting of the conversation. Understanding how to “read the room” helps guide conversations and steers the conversation towards topics that the patient can relate and avoids topics that the patient is not receiving.
“Then, need for a practical clinical set-up that allows for self-management support including having sufficient time for dialogue…”
This is tough. Ideally, I could spend an hour talking to the patient and learning about their symptoms and goals. Though ideal, it’s u realistic. There are financial implications to having 60 minute appointments…when a patient cancels.
One cancel of a 60 minute visit affects the clinic more negatively financially than a 45 minute visit. In an ideal world, we would have as long as we need with each patient, some being 90-120 minutes and others being only 15 minutes. Unfortunately, it is really hard for the business to operate in a sporadic schedule like this.
This is key. I take students typically year-round and one interaction with a student stands out:
This student programmed 14 different interventions into a 45 minute session. I asked the student to go back and look at previous notes for my patients and see how many interventions are performed on average. She found that in 45 minutes I typically perform 4-5 interventions.
We discussed this and I asked her to have a conversation with the patient on the next visit about how the patient perceived the session and how he felt after the visit. The student’s first question was, “How would I bill for conversation?” I just don’t understand. The conversation is billable based on the CPT code that we are assessing. In this case, we were assessing the response to exercise, because this response dictated how we directed the remainder of the visit.
We can’t allow ourselves to be restricted in our sessions by “billable units”, but we also have to know CPT codes well enough to be able to bill appropriately for our interventions. Assessment and management fits into the CPT code description.
This student wanted to show me how many exercises she could perform in a session. This was her way of demonstrating knowledge. I get it. Students want to demonstrate knowledge, but this wasn’t the way to go about it. Personal trainers, this isn’t meant to cast light on personal trainers, can demonstrate a lot of exercises and can give rationale why they are giving one exercise over another. Physical Therapy is not personal training. Our job goes beyond just “making the patient stronger” or “giving exercises”. Our job is directed at correcting the patient’s complaints, if they are amendable to PT, and working on return to function that was lost.
There is a difference between rehabilitation and habilitation, but unfortunately none of my students even heard of the term habilitation.
Self-management is an end-goal of PT. When a patient is able to self-manage, this reduces the patient’s need to be a patient.
Mark Miller, an instructor for MDT, had a conversation with me in an elevator after a course and recounted a story that occurred between him and Robin Mckenzie:
Mark: I was getting patient’s better and discharging patients. It felt great to help the patient get over their back pain.
Robin: did any of these patients come back to you for back pain in the future?
Mark: of course, they were happy with how we corrected the problem the first time.
Robin: Then did you really correct the problem?
This is the self-management aspect of back pain that we are also responsible for. Back pain, may or may not, get better over the course of time. Meaning that back pain, may or may not, improve without seeking PT. How can we serve the patient?
We can communicate with the patient how to reduce risk factors for future occurrences. This is a start. We can discuss mechanisms of injury and how this may be avoided in the future. We can educate and reinforce good back health behaviors.
“…core elements of self-management interventions across trials that included problem-solving skills, decision making, resource utilization, a focus on the patient-clinician relationship, goal setting, and activity planning”
There is a ton to unpack here:
problem solving skills:
- not all pain requires medical attention. We need to teach self-management skills that allow the patient to understand the difference between day-to-day pains and a pain that requires medical attention. We can’t make the patient afraid to move in the presence of pain. Although this sounds absurd, letting the patient believe that they need to see a physical therapist when he/she experiences pain also implies that the patient isn’t able to self-manage. During the last visit of a patient’s plan of care, I will typically reassure them that they are doing well (obviously this is with a patient that improved from PT), that I am always here for them if they have any issues in the future, but that they have been equipped with strategies to reduce symptoms should they recur and that he/she should try to self-manage prior to calling the office.
- Decision-making: let’s start by being good at the basics. A) does this patient belong in my clinic. This means, “is there a good reason why this patient should see someone other than me before initiating treatment?” For instance: does the patient have abnormally high blood pressure, is the patient tachycardic, is the blood oxygen level too low, does the patient have an active untreated infection, is there something in the patients presentation that was missed like a positive HINTs exam? All of these are reasons that the patient should be seen by someone else before they are treated in my clinic. B) if the patient does belong in my clinic, is this something that I think I could help? C) If this patient does belong in my clinic AND this is something that I think I can help, how long do I expect it to take to see progress? D) If the allotted time has passed that I thought I would either see progress or completely resolve the complaints, then I start all the way back at “A” and start over.
- Resource utilization: As Physical Therapists, we can’t be so arrogant to believe that because we say it to the patient that it must happen. Let’s take for instance a patient with Low Back Pain. In this scenario, the patient works at a desk for 8 hours per day and has a 1-hour commute to and from work. This means that 10 hrs of a 24 hour day outside of the home and for the most part, out of the patient’s control. Let’s now say that the patient has complete abolition of symptoms with flexion rotation in supine. Do we get to tell the patient that this is the exercise that they must do AND THEN get upset with the patient for not doing the exercise during the workday? I don’t believe so. If the patient responds to flexion rotation in supine, does the patient also respond to flexion rotation in sitting? If so, now this patient has a tool that he/she can fit into the workday instead of trying to find both time and a location to perform the exercise while at work. We have to work with the patient in order to assist them to accomplish his/her goals. Let’s take another for instance: a patient has a $40 copay or 50% coinsurance, but can’t afford it. Do we tell this patient that he/she has to come to therapy 2 times per week? Do we use fear tactics to get this patient to buy something he/she can’t afford? Do we work with the patient to shorten the visit if they have a 50% coinsurance so that they are only doing in the clinic what absolutely needs to be done and having the patient do the rest at home? Do we decrease the frequency and increase the duration in order to spread the financial burden over a longer period of time? There are a lot of options that we could take with a patient that has a larger financial burden than he/she can absorb, but we have to think outside of the box in order to work with the patient in problem solving.
- focus on the patient/client relationship: This is controversial for some to hear, but I don’t personally believe that we get to be the person that we want to be when we are working with patients. We have to be the person that the patient needs us to be in order to reach his/her goals. A long time ago, I was called a “chameleon” by a colleague. She used this term in a negative fashion because she thought I was “fake”. I give the patient as much of “me” as the patient needs/wants, but no more. Those that are close to me, within my small circle, get 100% of me. I am paid to help people reach their goals. If there is any part of “me” that may impede the patient/customer believing that they are getting their money’s worth, then I minimize that portion of me. For instance, just recently I had a retired army veteran as a patient. Those that know me, know that I have extension army history in my past. I could talk to this person without a problem and this person opened up to me in a way that wouldn’t have happened if I didn’t search and find that connection early in the relationship. I take all of my experiences in life: both good and bad, and use those experiences in order to create the connection with the patient. Even before that, I try to put myself into the best position in order to use those experiences. For instance, I was recently offered two jobs. One job was in Streeterville in Chicago and the other job was in Tinley Park. I spent a lot of time shadowing both clinics and in the end, I chose the job in Tinley Park. It has a lot of perks for sure, but I watched the interactions and conversations that took place with patients during my shadowing experiences. I much more connect with the patients in Tinley Park than I do with the patients in Streeterville. This was a personal decision and I felt that I would be able to create that Therapeutic Alliance much easier in Tinley Park than in that part of Chicago.
- Goal setting: This actually requires a conversation, but I choose to have this conversation over multiple visits. On the first day, when asking a patient his/her goal, the answer is typically to get rid of the complaint that brought the patient to the clinic. In most cases, it is a pain complaint, but for some people it may be a dizziness, balance issue, function in the case of neurological dysfunctions, etc. I don’t usually press for additional goals on the first session because 1) time constraints and 2) we just met and I don’t want to come across as demanding. Over the course of time as we build the patient/therapist relationship, I will start asking more about goals. I will typically ask the questions like this: is there anything that you are having trouble doing at home or outside of the clinic? If the patient answers yes, then it is an easy transition to ask, “Is this something that you would like to recover/improve?”. If the patient answers “no, there are no other problems”, then I ask them the next question: “If before the injury/pain complaint you would’ve been considered 100% for you, how would you rate yourself currently?” Anything less than 100% forces me to ask, “why don’t you think you are 100%?” Again, I go back and ask if this is something that the patient wants to recover/improve. If the patient says that he/she is 100%, then the discussion starts to drift towards discharge planning. I also find it important for us as the clinician to have discharge planning conversations with the patient, because sometimes the patient’s don’t know how to initiate these conversations. I want my patients to be able to have an open and honest conversation with me and if I am avoiding the topic of discharge for patients that are doing well, the patient may start to feel like a $ or a number instead of a person that I have been developing a relationship with the previous days/weeks.
- activity planning: I like to have a short sit down with the patient at the beginning of each session to touch base, make sure that we are moving towards his/her goals and to ensure that the patient’s expectations are being met. From here, I will discuss what the plan is for the current session and make sure that the patient understands and is in agreement that these are activities that make sense for that particular patient. After the movement, hands on portion of the session is over (usually about 30-35 minutes), I have a quick conversation with the patient regarding what I expect from them for the next few days/week until they return to PT and if the patient believes that he/she can accomplish that before returning to PT.
“interventions of shorter duration (<6 weeks) tended to be more effective than longer lasting interventions”
I had a mentor that used to say, “we want to date the patient, not marry them”. When he said this, he was specifically speaking to timelines of treatment. There’s some research to counter this concept, but that too is different. This particular segment is speaking to the treatment of patients at a relatively consistent frequency for a long period of time. No joke, I’ve seen plans of care that are 2-3 times per week for 4 months. That’s scary! Treating one patient with one issue for that long, in my opinion, leads to a dependence on the caregiver from the patient. How can we justify treating a patient for this length of time at such a consistent frequency. Now…I have no problem with treating a patient for 4 months, nor do I have a problem with treating a patient for 2-3 times per week (in certain cases), but to do both at the same time seems more of a business based plan of care than a patient centered plan of care.
What do I mean when I say that I’m okay with 4 months of treatment? 8-12 sessions spread out over four months. It would come out to 1 visit every 10 days-ish.
Some cases also require heavy scheduling up front and a reduction on the back end, like with a new neurological condition or BPPV.
This will require a paradigm shift in our profession as a whole, but I think that some institutions are better set up for this than others. For instance, those that are in a value based system or capitated system, are already incentivized to have fewer sessions and shorter duration times for patients. This is not a bad thing! What is bad is rationing care from those that need it. This is not what I am saying. I am saying that most patients don’t need to be treated multiple times per week or even weekly in order to see improvements. Unfortunately, in a fee-for-service environment, there is no other way aside from multiple visits and billing multiple units per session for a business to make money. We are seeing some hospitals and larger medical groups go the route of HMO’s. Larger groups that have their own HMO, which I have been a part of in the past, and hires its own PT to manage the patient needs is set up for success in the future of healthcare. We are now seeing hospital systems start and manage their own HMO’s.
“people self-manage most of the time…enable them to do it well”
This was the quote that really hits home. Most patients will come into PT on average twice per week. This means that the patient is in the clinic for anywhere from 1 hour per week up to 3 hours per week. Understanding that there are 168ish hours per week, the patient is in the clinic for 1-2% of the entire week. This means that the patient has to “self-manage” the other 98-99% of the week.
I’ve come across many PT’s that finish their sessions with the proverbial HUM job. For those that aren’t in the know, this stands for Hot Pack, Ultrasound, Massage. Add in some IFC and that describes how some people still practice to date. This does a major disservice to the patient. These treatments are no more likely to get a patient back to their goals than time. If we are no better than time, should the patient waste theirs in our presence?
We need to teach, but not just teach. We need to treat actively, but not just treat actively. We must empower the patient to leave our clinic with more tools than he/she walked into the clinic. We need to motivate the patient to go home and take those tools and apply them to life’s situations.
If we can not do this, are we any better than time?
“Help patients develop self-efficacy…provide and reinforce positive experiences”
Sometimes this works, but other times patients need a good, swift, kick in the ass. Not all patients are going to respond to positive reinforcement. Some patients will respond to tough love. Understanding when to apply a specific strategy is the art within the science.
For instance, patients will thank me for helping them, but the response is almost always the same; “you did the work…I was just a cheerleader”. This is the positive reinforcement. Letting the patient be the hero of their own story and the PT is simply the guide in the story. The PT should be more like Obi Wan and less like Luke.
Other patients will require more work on the PT’s part than simply giving education. Every good story has an Obi Wan, but sometimes it looks like Mickey to Rocky.
“Let patient value-based goals guide management…focus on patient valued goals and shared decision making rather than on pain and dysfunction”
We have a tool for this. It’s called the “patient specific functional scale”. This is designed to take the patients goals and incorporate them into the episode of care.
There are going to be some patients that we can abolish the pain complaints and return to their prior level of function within a few sessions. For these patients, I think that it’s safe for us to focus on the patient’s pain complaint, as that may be the only obstacle to returning the patient back to function.
For those patients that we can’t affect the pain complaint though, we as a profession need to transition to something that we may be able to affect. We have to stop telling the patient that “it takes time” for their pain to go away, unless we are also prepared to give the patient the specific time period that the patient should be willing to wait. We have to stop tricking the patients with sorcery, such as electrical stimulation, and give the patient insight as to how the pain reduction actually happens. This way, the patient is not surprised when the patient returns by the time that he/she returns home from the session.
We have to focus on things that we may be able to change: hope, lifestyle, function, movement.
Kongsted A, Ris, I, Kjaer P, Hartvigsen J. Masterclass: Self-Managmeent at the core of back pain care: 10 key points for clinicians. Brazilian Journal of Physical Therapy.2021;1-11.