Psychologically Informed physical therapy

Question 1

Consider the common “wheel” that people experience with Pain and suffering:

Answer 1

> pain
struggling with pain
failure
lost freedom and opportunity
suffering multiplies

Question 2

Acceptance of pain wheel”

Answer 2

> pain
maintained life direction
success
freedom and opportunity
suffering reduced

Question 3

A direct quote from the PTJ special issue:

Answer 3

“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.”

Question 4

Take a look at this “traditional” model. How does this square with what your experience with treatment of LBP?

Answer 4

consideration of physical factors = standard practice

consideration of psychosocial factors = mental health practice

Question 5

standard practice =

Answer 5

address physical impairments based on biomedical concepts

primary goal = reduce symptoms

Question 6

PIPT =

Answer 6

incorporate patient beliefs, attitudes, and emotional responses into patient management based on biopsychosocial models

primary goal = secondary prevention of disability

Question 7

mental health practice =

Answer 7

identify and treat mental illness

primary goal = minimize the impact of psychological disorder on well-being and function

Question 8

Stratified Care

Answer 8

“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”

Question 9

What do you think might be some issues around primary care management with Low Back Pain?

Answer 9

-Unnecessary cases of over-treatment (excess diagnostic work-up)

-Many PTs feel ill equipped to deal with psychosocial factors in complex/distressed patients

-$$$

-Frustration

Question 10

Patients are more likely to have a worse outcome if they have:

Answer 10

higher pain intensity
co-morbidity
referred LE pain
poorer physical functioning
higher levels of distress (fear of activity, depression, anxiety, catastrophizing)

Question 11

The Keele Study: Stratified Care Approach to LBP (match care to risk level)

Answer 11

Step One: Identify patient’s level of risk for chronicity/disability

Step Two: Matched Treatment Pathways

Question 12

Step One: Identify patient’s level of risk for chronicity/disability

Answer 12

The STarT Back Screening Tool

Question 13

Step Two: Matched Treatment Pathways

Answer 13

Referrals based on risk level

Limit PT to those who really need it/can benefit the most

Improve treatment efficiency and effectiveness

Secondary prevention

Question 14

Low Risk:

Answer 14

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

Question 15

Moderate Risk:

Answer 15

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

Question 16

Moderate Risk Treatment = 1st session

Answer 16

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)

Question 17

High Risk Treatment:

Answer 17

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

Question 18

High Risk Treatment: 1st session

Answer 18

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

Question 19

Outcomes of Stratified Care and PIPT

Answer 19

Significant cost savings

Improved referral efficiency

Improved clinical outcomes

Very cost-effective

Overall time off from work was reduced by 50%

Question 20

Outcomes of Stratified Care and PIPT

Low Risk Group

Answer 20

reduction in use of NSAIDs + greater satisfaction with care

Question 21

Outcomes of Stratified Care and PIPT

Medium Risk Group

Answer 21

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

Question 22

Outcomes of Stratified Care and PIPT

High Risk Group

Answer 22

More interaction with the PCP and PT, less disability, less back pain, less depression, fewer days off from work

Question 23

What does PIPT include?

Answer 23

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

Question 24

Pain education

Answer 24

(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

Question 25

Skilled Communication

Answer 25

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

Question 26

Identify patient knowledge, beliefs. Identify what they want:

Answer 26

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)

Question 27

Integrating the Bio with Psychosocial in the Assessment

Answer 27

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?

Question 28

Fear avoidance beliefs and behaviors

Answer 28

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?

Question 29

Approach to exercise/ activity

Answer 29

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)?

Question 30

Challenges to PIPT

Answer 30

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.

Question 31

Entry-level education =

Answer 31

(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

Question 32

Opportunities

Answer 32

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.