Psychosocial Status Assessment by PT's

[Michael McMurray]

Physiotherapists’ assessment of patients’ psychosocial status: Are we
standing on thin ice? A qualitative descriptive study. Manual Therapy 20 (2015) pp 328-334

To celebrate Mark Jones coming to Richmond i thought one of his recent articles would warrant a discussion board post.

What are your thoughts about this article? How do you think the increased awareness on pain education impacts the points of this article? What do you think the role is of the PT in recognizing and addressing psychosocial issues?

[Kyle Feldman]

I am very confused how this article is 2015 when none of the new graduates are DPT’s
This must have been conducted many years ago or is it because it is in australia?

It also seems to me that the psychosocial skills of a PT are learned in con ed or past experience. I would have liked to have had a better background of each therapist to know where they have learned and studied

It is frustrating when people assume every works comp patient has psychosocial issues which is why they are workers comp. I have worked with a lot of these patients and when you treat them as a normal patient and just listen to them they end up doing so much better. This article looked like the therapists lumped these patients into that psychosocial category
In our clinic every workers comp patients gets an FABQ. After this study I am wondering if every patient should get some sort of form

I feel that this article supports the need for pain neuroscience education courses. I think identify the issue is the first issue and those courses really help therapists do this.
I know as a new grad I did not put psychosocial factors high on my list (I was trying to make the diagnosis my priority) But with experience this is almost more important it seems like.

I agree with some of the PTs in this article that we are not a clinical psychologist and if the symptoms are severe we should refer out. However I disagree 100% that we should do nothing once we refer. I would say <5% of all patients that walk in the door would benefit from a referral. The rest would benefit from our screening and understanding in conjunction with the PT care.

[Aaron Hartstein]

I was a bit surprised by this article at first- it was shocking to read some of the comments (especially from the more experienced therapists) and learn how little they understood psychosocial issues and their impact. It did make me reflect back on my first year of practice though and I can honestly say, I wasn’t far off from them.

I learned about “yellow flags” in school which essentially meant listening for these in the subjective. I did learn about the FABQ but I feel like I never truly understood what it meant scientifically to have psychosocial factors influencing recovery. I think for many young PTs, high FABQ scores could be interpreted as the patient was exaggerating, or they had other intent for financial gain, etc. I can sadly say I had this view initially (and I even had some education on this in school)! I think for me, despite being educated in school, there was no carryover on clinicals and in my early clinical practice to apply this material and learn it in a clinical role. My first job was in a very low income, low education area and everyone had 10/10 pain and nothing seemed to fit a clinical pattern. I would listen to the PTs around me joke about these patients and it began to shape a view in my mind that was not accurate about psychosocial factors. This patient would walk in the door and I was immediately frustrated and did not give them the benefit of the doubt- I already knew they weren’t going to get better because they “didn’t want to try”. I think had I been surrounded by good mentors who further educated me how to recognize fear avoidance and psychosocial factors impacting recovery in the clinical setting (not just in a lecture) and how to manage it, I would have been much more successful treating these patients.

I think what differed about the education I received in school and the education I received in VOMPTI was the emphasis on therapeutic neuroscience education. This definitely changed the way I viewed these patients and in turn, made me much more successful with them. In grad school, I was taught about high FABQ, graded exposure, graded exercise, etc. but I did not have an understanding about WHY people had these views. I did not know any of the science behind it- the changes in the brain, etc. I think because of this, I had more of the mindset that these patients had alternative motives, etc. When I finally learned about TNE, I didn’t look at all these patients with frustration. Instead, I was able to be empathetic. I was able to explain to them why they were so frustrated as well and I was able to make progress.

I definitely agree that education in this area needs to be better. And it needs to be comprehensive. If you only receive part of the picture, you’re free to draw your own conclusions about the rest. And if you are not influenced by good PTs/mentors early on, this can be very detrimental.

[Aaron Hartstein]

I think this was actually a really cool article because recognizing biopsychosocial behaviors in our patients and providing pain education is such a hot topic that’s getting more and more attention. I think this is a huge area we can grow in as a profession. Pain is the number one reason people come to physical therapy, so if we can do whatever it takes to positively change someone’s pain experience, whether through exercise, manual therapy, or education, that’s a win for our profession. Therefore I think addressing psychosocial issues with our patient’s best interest in mind, then that is something we most definitely have a role in.

What stood out to me the most was “the most consistent barrier highlighted was participants’ lack of formal education in PS theory and assessment.” So I thought it would be a good idea to send this paper to one of my professors in grad school with that sentenced highlighted to see what his thoughts are since he is an educator in our profession. Fortunately for me, I think my PT program did a good job at exposing us to this issue. I think it helped that one of my professors did a lot of pain science research. It also helped that one of my clinical instructors encouraged me to read “Explain Pain” by David Butler while I was on one of my internships. So luckily, I can’t say I didn’t learn this in school. However, one of the biggest things I struggle with is addressing psychosocial issues with formal measures when it’s not just chronic low back pain. It’s easy to use the FABQ with these patients to help gauge their mental state, however, we currently don’t have a questionnaire that can be used for other chief complaints like shoulder, knee, hip, etc. I also don’t think patients have to have chronic complaints to be included in this group.

I really do think if we can improve our capability of addressing the psychosocial aspect negatively affecting our patient’s pain experience, then we have the potential to really improve our patient’s outcomes and satisfaction of care.

[Aaron Hartstein]

This article brings up an important view of our ability to assess PS factors. Ultimately, we know we are treating the entire person and this includes the PS factors, but how often do we feel comfortable and confident in tackling this. Like the article mentions, some PTs feel most comfortable to screen or go with a “gut feeling” or refer if need be. I have to say that the hardest part of working this past year is understanding TNE and effectively and confidently using it in practice. Our owner has her Masters in Counseling so she is always giving us “tips and tricks” on communicating with patients about pain and how to have a good evaluation process that supports building a relationship with your patient. From the book, an interesting article (Hoffer Gittel 2000) compared the efficiency and outcomes of nine hospitals with respect to joint replacement surgery. Some invested heavily for training in “relational competence” versus investing in highly qualified surgeons/physicians. The study found significant differences, in that the hospitals trained for “relational competence” had a 31% reduction in length of hospital stay, 22% increase in quality perceived, 7% increase in post op freedom from pain, and 5% increase in post op mobility. This went to show me that I can work and work on mastering a technique, but it may not produce the benefits as significantly if I have not addressed the patient’s PS factors.

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