Lets Get it Started

[AJ Lievre]

Check this article out from this months publication of Spine.
Talk about your strategies when setting goals for patients as well as talking to patients about their goals.
Anything that you take away from this article that may alter you approach?

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[Kyle Feldman]

I love the concept of this pilot.
However, the methods could use work. They selected people from an AD, so they may have chronic pain but they are not chronic pain patients which I feel is a HUGE difference. The people who cannot manage are the ones that come to PT. It would have been even better to use this with actual patients.

On the topic of goal setting. I do agree that having the patients make the goals and putting then in their language is key. You need to get them to want to do it. If your alliance is not there, the patient will not be bought in.

I like the concept and hope they do a great job with the study.

[Justin Bittner]

There are several older articles looking at the effect patient centered goals have on outcomes. These studies were primarily done with neuro patients post CVA. Patient centered goals were defined as goals directly related to the patient’s values, expectations and expressed needs. Patients that were involved in goal setting demonstrated improved teamwork, motivation, and compliance. Ultimately leading to better outcomes. I think this emphasizes what Kyle mentioned about building an alliance with the patient to improve overall buy in.

Although these neuro studies are older and not orthopedic in nature, I think together they can potentially lead us to the observation that patients with chronic conditions may benefit greater from a more in depth goal setting process during their evaluation.

Thoughts?

[August Winter]

Although it is a completely different population for a lot of reasons, I think you bring up a good point Justin because there are some strong parallels between individuals with chronic pain conditions and those post CVA. First I think the goals themselves are often not too dissimilar, with both a patient with chronic LBP and one post CVA wanting to do something as simple as walk for 10 minutes without needing to stop. I also think the need for more individual goals to foster motivation and teamwork are paramount for both groups.

For goal setting I have used the PSFS in the past but have found that patients find it a bit clumsy to use. One thing I found helped the patient come up with several relevant personal goals was to discuss during the evaluation and then have the patient take the PSFS home as homework so they could think within their own environment what sort of things were most important. As for this article, I really like the idea of asking patients what they want to focus on, and then providing them the best evidence based options (sounds like EBP to me!). I think going forward I will work on trying to always explicitly ask questions about preferred interventions as they relate to their goals.

[Erik Lineberry]

Having patients reflect on their daily activities during initial evaluation instead of going straight into pain/symptom provocation questions (ex. NPRS, what hurts, etc.) has helped the patient and me start PT with a functional goal in mind instead of starting with a negative connotation to the patient’s condition. This makes PT more personal and positive for the patient and improves patient’s motivation. 50% or more of the patients I see list just the word “pain” as their goal for PT on their intake form and I think this is a bad place to start. I like to point this out to the patient and have them think about what activities their pain symptoms make more challenging than usual throughout the day. Usually the patient will come to the conclusion on their own that having a goal of “returning to running” is better than “no pain”. Not that we don’t want both, but the former is usually something that is more important to the patient and can be used as a motivator moving forward. I am still working on this, I still catch myself leading a patient into an answer and having them unintentionally focus on pain over function.

[Michael McMurray]

I think you all bring up some great points. Goal setting should be in-depth and personal to what a patient would like to get back to doing in their everyday life and not their life revolved around their injury/pain. August, I like the idea of the having a patient consider their goals in their own environment in order to identify problems they may not bring up in the clinic or during an evaluation. With goal setting, I think it is important to be an active listener and put goals in their own words. When patients have difficulty discussing goals, I have found that asking them about what kinds of activities they have avoided or have not done because of their injury/pain can open up dialog about goals that the patient may not have even considered.

[Scott Resetar]

Great posts by everyone.

Justin and August – I agree with your assessment of goal setting with CVA patients vs chronic pain patients. There are many similarities between these populations. They both tend to do better when the understand more about their conditions, and when they come to accept them. Sometimes post CVA patients do a lot better when they just come to grips with who they are now. They are a new person, with new strengths and weaknesses that they must learn in order to cope and become functional again. This is also true with many chronic pain patients. I like to ask something like “If you continued to have your pain, but could do everything you want to do in your daily life, would that be acceptable to you?” If they answer yes, they have a path forward. If they answer no, then a deeper conversation regarding the psychology of pain is warranted, with possible referral to the appropriate mental health professional if they do not make progress.

Overall, I loved this study and will strive to use a similar framework with my patients and make them as involved in their goal setting as is feasible.

[AJ Lievre]

Nice discussion everyone. Glad you found the article helpful.
Scott, one thing you brought up is asking the patient if they are doing everything they want to do in their daily life. This may be interpreted by the patient in a different way than you anticipate. Often times folks with chronic pain do enough in their life to get by, avoid activities that they feel drive their pain up and have come to accept that situation. This allows them to do “what they want” without a problem or pain. Rusty Smith put it perfectly when he related this to the patient “shrinking their world”. What you may want to consider is asking the patient, “if you did not have pain what would you like to do” or “before you had pain, what did you like to do”? This may open a new dialogue and potentially provide the patient with goals they thought not possible before.

[Justin Bittner]

Thanks AJ, glad I read that. That will be helpful for me because I feel like I ask every patient “do you feel your pain is limiting you at all throughout your daily life”. I will definitely be more cognizant of this when communicating with future patients.

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