Operating outside the physical domain

[AJ Lievre]

At this point in the residency program and course series, we have hopefully emphasized that musculoskeletal pain is a complex experience that cannot be reduced to biological factors. However, being aware of this and knowing what to do about it can be two very different things. Many therapists are aware of the BPS components of the pain experience but do not know how to address the psych and social factors. So rather than learn how to address them, they ignore them. Here are several qualitative articles that discuss therapists’ experiences in implementing the BPSM into care or how they make decisions when a pathoanatomical diagnosis cannot be made. Read one or more articles and see what resonates with you.

Consider these questions as a guide:
1. Do you hear yourself in some of these experiences?
2. What struggles do you have addressing psychological or social factors?
3. How do you plan to do to improve your weaknesses?
4. Were you reminded of a patient experience after reading one of these articles?

Cowell, I., O’Sullivan, P., O’Sullivan, K., Poyton, R., McGregor, A., & Murtagh, G. (2018). Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Musculoskeletal Science & Practice, 38, 113–119. https://doi.org/10.1016/j.msksp.2018.10.006

Josephson, I., Hedberg, B., & Bülow, P. (2013). Problem-solving in physiotherapy—Physiotherapists’ talk about encounters with patients with non-specific low back pain. Disability and Rehabilitation, 35(8), 668–677. https://doi.org/10.3109/09638288.2012.705221

Slade, S. C., Molloy, E., & Keating, J. L. (2012). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558–569. https://doi.org/10.1177/0269215511420179

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016

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[ebusch19]

Another great discussion topic. Essays loading…

All of the articles had similar emerging themes that I relate to when looking back on my patient experiences in the residency and with clinicals. We were lucky in school to be introduced to the biopsychosocial model and begin to discuss ways of addressing psychological and social factors and put it to practice in class. However, similar to what was mentioned in the articles, I can feel overwhelmed at times and lack confidence when it comes to translating what I have learned into the clinic with patients. I remember after CSM going to the lecture with Adriaan Louw and learning about how to apply the different metaphors with patients based on their pain presentation and in my head at the time it made so much sense, but it’s not that simple. He mentioned in his lecture that you need to assess the patient’s readiness to learn about PNE before being able to address their different factors. I agree and have learned that the hard way in clinic where I tried to have the discussion too soon with the patient and she straight up told me “you must think I’m crazy” and then not too long after that she ended up going back to her doctor and cancelling the rest of her appointments. Being able to assess when to have those discussions with the patient is hard and is something I am improving on in clinic. At my last terminal experience in school, we had the cup analogy poster on the wall, so patients often looked at it when they came in the room and kind of laugh after reading it. They would often make a comment about it which made it easier to go directly into the conversation about psychological and social factors. I have the cup analogy picture on my computer and need to start pulling it up more often and would like to have it up on the walls as well to start to get the patients thinking more about it.

What also stood out to me was lack of confidence when being uncertain about the patient’s diagnosis. This is something I struggle with especially when the patient is looking for an answer and I can’t give it to them. This makes it difficult with the initial evaluation since you’re trying to establish that baseline rapport with your patient and get buy-in. I think this is when communication is huge and making sure you and the patient are coming to an agreement with plan of care and making it goal oriented. Often though with higher complexity patients, the evaluations take longer leaving less time at the end of the visit to have that discussion with the patient. This is something I want to improve on and find ways to incorporate some of the discussion throughout the evaluation and not just leave it for the end. Another point brought up in the articles is the need to see improvements within session. This is something I also struggle with. I have a patient I am working with now who has more of a stenotic presentation along with bilateral hip pain, and previous surgeries for his knee. After working with him during mentoring, instead of taking a test/reassess approach where nothing changes, we have focused more on movement and making his exercises more tailored to his goals. We also talked about expectations with treatment, what his expectations were and what ours were and what I want to know from him with symptom response with the exercises. Not going to lie, initially I was not always looking forward to his visits since I felt like I did not have a clear direction of what I wanted to work on with him, but since I have changed my approach, I have established more rapport with him and look forward to our sessions now.

This is a topic I’m really interested in and looking forward to reading everyone’s responses. Also, really looking forward to the Adriaan Louw presentation coming up.

[iwhitney]

Of the articles listed, I chose to read the Cowell et al. (2018) article, which used qualitative interviews with physiotherapists to help determine their perceptions towards managing chronic non-specific low back pain (CNSLBP). I thought the authors did a great job at finding so many common themes between physiotherapists on their perceptions, and those of which definitely ring true for me when I think of my own management of patients with CNSLBP. Specifically, I definitely agree that it can be a huge challenge to address the psychological factors that are contributing to this patient population’s pain, especially if there isn’t any current interprofessional management occurring. Reflecting on my own practice, I feel that something I have a bad tendency of doing is quickly moving on when a patient tells me that they are seeing a psychiatrist or psychologist for their mental health. From a BPS model perspective, I should be asking the patient about their experience with that provider, or even better, reaching out to that provider to help determine ways that I can help address coping or management strategies through treatment, if the patient is okay with that. I feel this would also help me gain the trust of my patient and they would be able to see how much I truly care, that I’m willing to take the time to reach out to another one of their providers to improve the quality of their care.

Another theme from the Cowell et al. article that rang true for me is avoiding reliance on passive treatment. We know from other literature we’ve discussed that manual therapy can most definitely play a role in pain modulation for the CNSLBP population. Similar to the physiotherapists interviewed in that article, I often find myself using manual therapy as a way to “break the ice” and provide an avenue for increased rapport. I use manual therapy as an opportunity to simultaneously perform pain neuroscience education or discuss the biopsychosocial impact on LBP as this is usually a time when both the patient and I are comfortable enough to discuss it. However, I think I could do a better job of setting expectations early and specifically making it clear that the progression of the treatment provided will move from hands on to functional independence exercise prescription. Similarly, I appreciate the discussion on promoting self-management with this patient population. This is certainly a challenging component for me, that is, communicating with this patient population in a way that promotes the comprehension and actual implementation of self management when they have been dealing with pain for more than a decade.

Just in this short time I’ve been a practicing clinician, I’ve seen a common theme that with those patients whom I am able to carefully and gradually introduce snippets of PNE or BPS management while simultaneously building a rapport via humor, a general interest in their life, or something we have in common, they often are far more accepting of the notion that they need to put in the work outside of PT in order to improve their pain long term. In other situations where I haven’t been as successful, patients stop coming to clinic or they simply brush me off by agreeing and moving on to another conversation topic. I think it’s clear that this patient population requires patience, compassion, and a mutual understanding of expectations in order to truly make an impact on their pain and disability. I plan to address my weaknesses by incorporating more motivational interviewing skills, searching for any sort of common ground with my patients to build upon the therapeutic relationship, and advocating for these patients in every way possible, including through the communication with their other healthcare providers with the patient’s approval/consent. I would love to hear anyone’s experience with addressing psychological factors with this patient population or working with mental health professionals to utilize coping strategies during PT treatment.

Resource:
Cowell I, O’Sullivan P, O’Sullivan K, Poyton R, McGregor A, Murtagh G. Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Muscul Sci and Pract. 2018;38:113-119. doi:10.1016/j.msksp.2018.10.006

[cmocarroll]

“Maybe they’ve had a lot of manual
therapy but they have not had my manual
therapy.”

This quote from the Slade (2011) article made me laugh and I’ve most definitely never thought that when treating patients. I was honestly surprised by the articles I chose to read. The PT’s that were interviewed came off as lacking empathy and being quite pessimistic. Some of the responses seemed very judgmental especially in stigmatizing patient’s with chronic low back pain. Some of the quotes in these articles states that these patients are selfish, only think about themselves or are simply attention seeking. So maybe this is the type of attitude you develop as a seasoned PT and have seen large amounts of this type of patient?

In my short few months as a licensed PT, I don’t think I’ve ever thought of patients in this way – especially patients with chronic pain. I always try to empathize with them and realize that their pain experience is real no matter how outrageous or exaggerated it may seem. I figure that most of these patients have been let down by the healthcare system, are frustrated and typically very unclear about what is going on with their symptoms.

In regard to parts of the articles that did resonate with me, I think that I do find it difficult to give patients a specific diagnosis when there is no clear pattern. Like the Slade article mentioned I tend to move more toward explaining impairments and addressing the patient’s questions that way. I wonder if these is enough for some of my patients and typically ask “Does that make sense?” to try and gauge their understanding. Unlike some of the clinicians quoted in the article, I typically do not give into the imaging and use that as buy-in for the pt.

I think that I was provided decent education regarding addressing psychological and social factors. Part of the difficulty for me is figuring out timing and when is best to bridge that gap with the patient. I do my best to simply listen if the situation does not resonate with me and agree with them or validate their feelings. I think I struggle sometimes with giving people concrete ideas/strategies to address their social or pyschological factors but in those instances sometimes even just listening to their concerns seems to be enough. I think a lot of times we become sounding boards for our patients and in my mind that is therapeutic and an important part of care. I try not to skip over or ignore patient’s comments that include social or pyschological factors because it does relate to our care. We are a niche of the healthcare world that gets increased time with patients and I think that lends to creating good relationships with our patients and supporting them in any way we can – whether physically, emotionally or mentally. Of course there is a limit to this and at some point there are issues that are out of our scope of practice, but I think it’s a mistake to say that we don’t have any role in address social/pyschological factors.

Articles reviewed:
Slade, S. C., Molloy, E., & Keating, J. L. (2012). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558–569. https://doi.org/10.1177/0269215511420179

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016

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