Psychologically Informed physical therapy Flashcards
Consider the common “wheel” that people experience with Pain and suffering:
> pain
struggling with pain
failure
lost freedom and opportunity
suffering multiplies
Acceptance of pain wheel”
> pain
maintained life direction
success
freedom and opportunity
suffering reduced
A direct quote from the PTJ special issue:
“We have long paid lip service to the influence of psychosocial factors on clinical outcomes, but the time has come to YELL about the importance of these factors
This special issue is deliberate in laying out evidence to support adopting a broader approach for practice that includes a cognitive-behavioral framework, using low back pain as the example.”
Take a look at this “traditional” model. How does this square with what your experience with treatment of LBP?
consideration of physical factors = standard practice
consideration of psychosocial factors = mental health practice
standard practice =
address physical impairments based on biomedical concepts
primary goal = reduce symptoms
PIPT =
incorporate patient beliefs, attitudes, and emotional responses into patient management based on biopsychosocial models
primary goal = secondary prevention of disability
mental health practice =
identify and treat mental illness
primary goal = minimize the impact of psychological disorder on well-being and function
Stratified Care
“Most cases of back pain resolve regardless of the course of therapy, and some do not get better no matter what is done.
Therein lies the problem for practitioners, patients, and policy makers”
What do you think might be some issues around primary care management with Low Back Pain?
-Unnecessary cases of over-treatment (excess diagnostic work-up)
-Many PTs feel ill equipped to deal with psychosocial factors in complex/distressed patients
-$$$
-Frustration
Patients are more likely to have a worse outcome if they have:
higher pain intensity
co-morbidity
referred LE pain
poorer physical functioning
higher levels of distress (fear of activity, depression, anxiety, catastrophizing)
The Keele Study: Stratified Care Approach to LBP (match care to risk level)
Step One: Identify patient’s level of risk for chronicity/disability
Step Two: Matched Treatment Pathways
Step One: Identify patient’s level of risk for chronicity/disability
The STarT Back Screening Tool
Step Two: Matched Treatment Pathways
Referrals based on risk level
Limit PT to those who really need it/can benefit the most
Improve treatment efficiency and effectiveness
Secondary prevention
Low Risk:
Patients allocated to the ‘low risk-group’ are reassured that further treatment is unlikely to be beneficial or necessary and encouraged not to seek further treatment
They are, however, advised that if their symptoms deteriorate they should re-visit their PCP
Moderate Risk:
All medium-risk patients are recommended for referral to ongoing physical therapy treatment with physical therapists who have undergone training in the matched treatment approach
Individualized physical therapy sessions focus on restoring function and targeting physical characteristics (disabling back pain, referred leg pain and co-morbid pain)
Guidance that patients should receive up to 6 sessions over a 3-month period
Moderate Risk Treatment = 1st session
The first session includes an assessment for making a differential diagnosis particularly for patients with referred leg pain/radiculopathy
The main focus of treatment is to reduce back-related disability
A tailored management plan is negotiated using evidence-based treatments, including advice and explanation, reassurance, education, exercise, manual therapy (potential referral to evidence based treatment such as yoga and acupuncture)
High Risk Treatment:
patients are recommended for referral to ongoing physical therapy treatment with physical therapists who have undergone more intensive training in PIPT (~9-10 days)
Individualized 45-minute therapy sessions focused on restoring function using combined physical and psychological approaches and targeting physical and psychological obstacles to recovery
Guidance that patients should receive up to 6 sessions over a 3-month period
High Risk Treatment: 1st session
assessment for making a differential diagnosis particularly for patients with referred leg pain/radiculopathy and biopsychosocial assessment to explore patient concerns, adopting cognitive behavioral principles to address unhelpful beliefs and behaviors
Therapists use ‘stem & leaf’ questions to identify unhelpful beliefs and behaviors
Therapists use ‘stem & leaf’ questions to identify unhelpful beliefs and behaviors
A specific focus on the prognostic psychological indicators identified by the STarT Back Tool such as low mood, anxiety, pain-related fear and catastrophizing
Outcomes of Stratified Care and PIPT
Significant cost savings
Improved referral efficiency
Improved clinical outcomes
Very cost-effective
Overall time off from work was reduced by 50%
Outcomes of Stratified Care and PIPT
Low Risk Group
reduction in use of NSAIDs + greater satisfaction with care
Outcomes of Stratified Care and PIPT
Medium Risk Group
More people accessing PT, reduction in use of medication, reduced requests for time off from work due to illness, improvement in fear avoidance beliefs, fewer days lost from work
Outcomes of Stratified Care and PIPT
High Risk Group
More interaction with the PCP and PT, less disability, less back pain, less depression, fewer days off from work
What does PIPT include?
Pain education
Skilled Communication
Identify patient knowledge, beliefs. Identify what they want
Graded Activity
Focus on Function
Pacing
Reinforcement
Management of Fear Avoiding Behaviors
Discussion re: overtreatment, “answer” seeking
Pain education
(Explain Pain, Hurt ≠ Harm, Pain is an output of the brain, pain is a combination of biological, psychological, and social factors, what else?)
pain is no in their head
Skilled Communication
Build rapport
develop trust
Compassion, active listening, validation, empathy
Avoid judgement, don’t second guess or assume that you know what the symptoms or the intensity of pain ‘really are’)
Acknowledge and reinforce any positive coping strategies that the patient is already using
Identify patient knowledge, beliefs. Identify what they want:
Gently challenge the aspects of knowledge/knowledge gaps that may be unhelpful (no criticizing)
Example: Expressed need to have a diagnosis
Alternative to consider: an Explanation (be selective)
Integrating the Bio with Psychosocial in the Assessment
Rapport building
Pts understanding of why in clinic today – how they got there, what referred for
Expectations from appointment
Have you got any particular questions that you would like answering today?
What are you hoping for from your appointment today?
Fear avoidance beliefs and behaviors
If an activity is causing an increase in your symptoms do you stop that activity or carry on? Why?
Do you believe that you are structurally sound? Is pain a sign that you are causing yourself harm or damage? Do you think that pain is always a sign that you are causing yourself harm / damage?
Approach to exercise/ activity
What have you been told in the past about activity / exercise?
What effect do you think exercise / activity will have on your pain?
Do you regulate your activities according to your pain / how you feel / according to a plan? When you have a good day do you try to do as much as you can in order to make up for lost time (explain)?
Challenges to PIPT
Entry-level education
Current physical therapist practice
Patients’ expectations of low back pain and physical therapy
Uncertainty about the key psychosocial factors and how to assess or manage them
Reimbursement systems and service priorities.
Entry-level education =
(who self-selects into the profession?
“Early learning often focuses on musculoskeletal problems…”
“the majority of time and attention often is spent on the biomedical assessment and treatment of musculoskeletal problems….” …reinforced in clinical experience
Opportunities
Changing the focus and priorities of entry-level training in pain
Emphasis on the limitations of the biomedical model also should be a standard part of entry-level education
Current Physical Therapist Practice: More evidence from clinical trials and implementation studies.
Enhanced role of physical therapists in educating patients and the public.
Changes to the reimbursement system and service priorities.