Therapeutic Alliance

Question 1

Treatment Effects

Answer 1

Positive AND/OR Negative effects of your intervention canbe influenced by many things…the primary factors are:

• Specific effect of treatment (neurological physiological, biomechanical, etc.) Includes:
  – Type of treatment and body part addressing
  – Vigor of treatment
• GENERAL Contextual effects of treatment
  – Strong alliance between PT and patient
  – Expectations and/or beliefs of the patient and PT
  – Personal trust of the patient in the PT
  – Positive or negative outlook of PT regarding the patient
• Unexplained variability: “HOW DID THAT HAPPEN!”

Question 2

___ effects influence treatment the most

Answer 2

General

If the patient doesn’t have buy into what the PT is doing outcomes are not good.

The prognosis for patients with low back pain who are seeking conservative treatment is significantly better if they rate their interaction with their treating clinicians higher.

Question 3

5 E’s for Alliance

Answer 3

• Engage the patient
  – Understand the patient’s expectations and concerns
  – Greet in a warm and friendly manner and maintain good eye contact
  – FIND A COMMON discussion point
• Empathize with the patient (avoid being judgmental)
  – Be aware of feelings, values and beliefs
• Educate the patient
  – Assess what the patient understands about their condition
  – Address their key concerns
• Enlist the patient
  – Ask them what THEY think is going on?
  – Seek the patient’s input on the treatment plan
  – What are THEIR GOALS. Negotiate priorities
• End the visit
  – Did you meet their expectations for treatment
  – Are you both on the same page?
  – Restate the plan and express confidence and hope

What is your biggest fear (Important question to ask)

Giving examples of people who are going through the same thing and positive outcomes

Question 4

Patient Education

Answer 4

• Use patient friendly terms when explaining their condition.
• Provide REPUTABLE resources if they want more detail
• Use NON-threatening WORDS: Words that Harm vs. words that heal (part of your assignment)
• AVOID Threatening pictures! (i.e.: google)
• Often, you do not know exactly what the source of symptoms are but you have ruled things out…explain to them what it is NOT. “Ruled out the bad things”
• Allow them to ask questions. Allow them to think about it and come back with questions. (Give a small hand out with bullet points and have them come back with questions)
• Explain what physical therapy has to offer.
• Come to a MUTUAL consensus on plan of care

Question 5

Words that harm:

Answer 5

WOW!
That’s the worst I have ever seen!
This isn’t good!
You should not be doing that!
Terms of different medical condition

Don’t look at photos, makes it worse!

Back pain #1, Neck pain #2

Question 6

Pain Definition

Answer 6

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”

Question 7

Why educate about pain?

Answer 7

Pain MAY lead to fear avoidance and other conditions

Question 8

Catastrophizing

Answer 8

• Negative pain coping style
• “Their condition is beyond their control” and will inevitably result in the worst possible outcome
• Associated with negative contextual factors and “threatening illness information” – pictures and words
• Linked with: Magnification, helplessness and pessimism
• Can measure it: Pain Catastrophizing Scale (Sullivan. 1995)

Question 9

Pain related fear and anxiety

Answer 9

• Pain related fear: Focused on current pain and THE POTENTIAL OF FURTHER INJURY
• Pain/Fear related anxiety: “What will happen in the future?”
• Leads to AVOIDANCE/HYPERVIGILANCE (Seek more causes of fear/pain)
• Assessed by the Fear Avoidance Belief Questionnaire (FABQ): What are patients’ personal beliefs about how physical activity and work will affect their pain

Question 10

Hypervigilance and avoidance

Answer 10

Leads to disuse, depression, and further disability

Question 11

Fear, Anxiety and Hypervigilance

Answer 11

• Chronic/persistent pain
• Depression and other affective disorders
• CENTRAL SENSITIZATION – Actual physiologic changes of how pain is processed in the brain
• PERIPHERAL SENSITIZATION – Actual physiologic changes of peripheral nerves as they become more sensitized to stimulus
• MOTOR ADAPTATION – muscles function differently due to fear/avoidance.
• Altered motor control/coordination during functional tasks
• Increased EMG activation of large muscles and diminished EMG of deep stabilizers
• Altered force production (Fatty infiltration of muscle)
• Diminished endurance of stabilizers

Question 12

Over a one year period if you see a PT over an MD first you spend…

Answer 12

50% less on healthcare

Teach how to move (back pain is normal), don’t do imaging unless they have signs, no medical diagnosis we do impairment based.

Question 13

Foundations of PNE and any form of patient education:

Answer 13

ADDRESS WHAT YOU IDENTIFY – We cannot ignore this!
Cognition – Diminish fear and catastrophic beliefs (“Cognitive Restructuring”)
Behavioral – what are their FUNCTIONAL GOALS

Question 14

Bone Spur

Answer 14

• Natural form of the body laying down bone as a result of stress placed on the body.
• Wolff’s Law!
• Greater bone spurs toward 80s. Back pain is most common when 50 then goes back down to same as 20s.

Question 15

Good words to use:

Answer 15

No red flags
current guidelines
Common
Heal
Speed the process along
95% likelihood of getting better
Calms down