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I really like this week’s discussion topic and do find it challenging explaining findings to patients with LBP and answering some of the questions they ask as demonstrated in Peter O’Sullivan’s videos. One topic I find easier to discuss with patient’s is on posture, more so static posture with sitting. I can think back to a lot of patients I have worked with, not just patients with LBP, that come in and say they think part of their pain is due to their posture. Fortunately, in school we were introduced and were provided evidence that there is no perfect posture. During my first clinical, my CI also shared some research articles with me on this topic. So many patients are surprised when I tell them that there is no perfect posture, and they don’t need to sit upright constantly throughout the day. I also like Peter’s way of using a clenched fist to describe this to patients.
One topic that Peter brought up that I still struggle with though is posture or form with lifting. I remember being mind blown in school when we were presented research that stated that lifting form does not matter with LBP. At the time I felt like that went against everything I had learned previously. I had two internships at gyms where form was everything which shaped my thoughts with how people in general should lift, especially with workers lifting heavier objects as part of their daily job. Even at the military clinic, one of my CIs also harped on this. I still struggle with this in clinic, knowing when to take a step back and not be so strict on form. If you know Adam Meakins, you know he is not afraid to express his thoughts on form and how it doesn’t matter. Then there is Aaron Horschig or “Squat University” on the opposite end of the spectrum. I don’t want to get too off topic, but it’s conflicting with the research, what I hear from other professionals and from my previous experiences. I can definitely see from Peter’s perspective of the patient who constantly feels like they need to contract their core with every movement and the example of the clenched fist. I had a patient who was 2 months post lumbar surgery and told me she needs to protect her back and was literally keeping her back straight 24/7 to the point she was starting to develop neck pain. She even told me she has to “plank” to brush her teeth and actually did plank to prevent bending over in her back. We were even performing the slump test and she asked me if she needed to keep her core activated. With this patient, with simple movements like that, it makes more sense to educate her that it’s okay to relax her muscles and move, and to not constantly have to contract her core. However, I admit it’s still difficult for me to accept that form does not matter when it comes to lifting.
I know I probably took this a different route than expected but would be curious to hear what others thoughts are on this, if you had similar challenges, and how you go about this with patients.
Great post Ian!
I’m also very grateful they introduced us to the biopsychosocial model and emphasized that in our courses. It’s sad how patients don’t feel seen or understood by their main providers, and even being “tossed” around to different providers with different explanations. I was just talking to my aunt who has fibromyalgia and without even bringing this up she told me how frustrated she was because she works with a team of medical professionals who do not communicate with each other and each of them have provided her a different explanation and option for treatment. She saw a new PT recently and told me she was very pleased with the visit because she finally felt heard.Motivational interviewing is something I want to improve on as well. I know there are some videos of Peter O’Sullivan doing live motivational interviewing with patients. I also found this article that one of the patients from a live interview wrote talking about their experience (http://www.pain-ed.com/blog/2017/03/07/cognitive-functional-therapy-with-peter-osullivan-a-patients-perspective/). I agree that it’s important to be able to assess the patient’s readiness to change and be able to adjust our education/treatment based on that. I will have to read the article that both you and AJ attached!
For this discussion post, I answered the first two questions below.
1. What can you improve upon to help increase patients’ (with persistent LB pain) confidence, self-efficacy, or autonomy?
The article attached really highlighted ways to improve as providers to increase the patient’s confidence, self-efficacy and autonomy. Since AJ has been mentoring me, he has really helped point out ways to improve my verbiage and how I approach communicating with the patient to work on this. For example, one thing that came to mind was when we were doing a progress note with one of my patients with low back pain and I wanted to talk to him about plans moving forward, whether he felt good to decrease frequency or follow-up in a few weeks, etc. I started off the conversation saying how I felt he was progressing well and then went straight in to asking what he wanted to do. I could tell it kind of threw him off and that was not the best way to approach that. In the article, it talks about letting the patient make the decision to continue and not the provider to improve their autonomy, and prevent the patient from thinking that you are abandoning them. After that session, AJ talked to me about it and suggested starting off the conversation with “what are your thoughts about moving forward…” and then giving them the options to make the decisions themselves. I have been approaching it that way since and I can see the difference that it makes with the patients.
In regard to improving patient confidence and self-efficacy, the article mentions the importance of a thorough examination and having the treatments being patient centered and allowing the patient to be in control of it. I think another important part of it, which the article also discusses, is building the therapeutic alliance with the patient to gain their trust in you. Part of that is being an active listener which the article by O’Keeffe et al. mentioned as well. I think taking that time to listen to the patient’s story and what explanations other providers have given to the patient is so important. The article mentions how patients get frustrated when they keep getting “thrown around” to different providers with each one telling them something different and not listening to their whole story. Taking that time to listen to the patient, but also summarize back what you heard from them shows the patient that you are listening and are hearing their story. This is one of my goals for the first part of mentoring is to improve on summarizing back what the patient told me. I think once you have that connection, then that helps builds trust in the treatment plan and the patient can focus more on their treatment rather than worrying about whether they trust you as a provider and what you’re educating them about or the interventions you do with them.
2. Explain a patient experience where you believe the patient would describe it as a non-encounter. What went wrong, and what could you do differently?
I kind of touched on this in the patient reflection post last week with my patient who came in with persistent low back pain for the past 20 years. I thought at the time that I was doing the right thing by educating her on pain science and had her fill out the tampa scale of kinesiophobia outcome measure to assess her fear avoidance. Looking back, I should have taken the time to ask her more questions about her beliefs. When she told me that I probably think she is psychotic for the answers she put for the outcome score, I should have asked her more about why she thinks that way. In a sense, she might have not felt heard by me and did not have the confidence/trust to continue working with me, thinking that there is something more serious going on so she wanted to schedule another appointment with her doctor. Going back to the conversation during the course, following up with questions about the patients beliefs and why they feel that way can possibly get them to come to realization themselves that maybe what they believe doesn’t make that much sense once they say it out loud. Then maybe this can open up doors to them asking more about their pain and wanting to learn more about it, putting the control back in their hands and giving the patient more autonomy.
Holopainen, R., Piirainen, A., Heinonen, A., Karppinen, J., & O’Sullivan, P. (2018). From “Non-encounters” to autonomic agency.Conceptions of patients with low back pain about their encounters in the health care system. Musculoskeletal Care, 16(2), 269–277. https://doi.org/10.1002/msc.1230
O’Keeffe M, Cullinane P, Hurley J, Leahy I, Bunzli S, O’Sullivan PB, O’Sullivan K. What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Phys Ther. 2016 May;96(5):609-22. doi: 10.2522/ptj.20150240. Epub 2015 Oct 1. PMID: 26427530.Hi Ian,
Great post! I also found the discussion post to be challenging. I have only worked with a few patients post surgery and did not get to follow through with them long-term since I was not the primary person working with them at my clinical. I also agree with your reasons for why someone would opt for surgery and also think age plays a big part in that too.
I’ve always thought about the studies that looked at sham surgeries and the ethicality behind that too, especially with all the increased risks involved with surgery in general. I think it’s interesting that you brought up that you were seeing mostly lower level evidence and retrospective studies that compared surgical intervention vs conservative. The research articles that I looked at that AJ attached also mentioned there was a lack of higher level of evidence compared to studies for the knee and linked that to the increased number of RTC surgeries over the years and less of an increase with knee surgeries. It’s interesting that there are a lot more studies for the knee and not the shoulder.
For potential ways for addressing some of the challenges with the doing surgical vs conservative management is challenging. When I was looking at the research, I saw a lot of retrospective studies as well, along with systematic reviews and meta-analyses. I think offering surgical intervention at the end if the conservative treatment did fail has can be used to help reduce bias with choosing who gets what intervention. But that does pose a challenge with long-term follow-ups if conservative management does fail and the participant wants to get the surgery in the end. I think these challenges are a great thing to think about!
The questions that I picked to answer are below:
– Sometimes we forget that as part of a healthcare ‘team’ we actually work together with other professions – not competitively against them. What are some of your biases against surgery? Let’s be honest and put out your biases, then, come up with a few specific phrases you could use in patient interactions to recommend surgical consults without your biases coming through.When thinking about my biases against surgery, I realized that I don’t have very strong opinions or biases for shoulder surgeries compared to surgeries for the low back or for the knee. In school we talked a lot about evidence for knee surgeries that questioned their effectiveness when compared to physical therapy or sham surgeries. There is even more evidence coming out now for treating ACL injuries conservatively rather than performing surgery. Jain et al. mentioned in their discussion that there are a lot more RCTs for knee surgeries that looked at their effectiveness compared to shoulder surgeries and related that back to why there was more of an increase in shoulder surgeries compared to knee surgeries over the past several years1. Similarly with surgeries for the low back, and also from prior experience with patients I worked with where the surgery did not help their pain or it ended up coming back a year later. I think from my previous knowledge of research (or lack thereof) and lack of experience working with a lot of post op shoulder surgery patients, I don’t have a very strong bias against pts having surgery for their shoulder.
At this point, starting off as a new clinician, it’s hard for me to say/lack the confidence to know whether a surgery would be beneficial for the patient or not. In regards to the first part of the question, I agree that we often do forget that we are part of a healthcare team working with the patients doctors, and even more so maybe for newer clinicians or PTs working in private practice clinics where they don’t have the direct contact/communication with their doctors. Conservative treatment for at least 4-6 weeks is always a good option and I have seen a lot of doctors doing that now before determining if surgery might be an option. I know patients also want to avoid surgery the best they can so having that conversation with them if they are not doing well with conservative management is hard, and I do not have much experience with that. Two phrases that I came up with to recommend surgical consult are below:
– After working with someone for 4-6 weeks and not seeing improvements: I recommend scheduling an appointment with your doctor for a surgical consult to see if there is another option to address the pain that you’re experiencing and to help improve your function so that you can get back to doing…
– For someone at initial evaluation or earlier on: Let’s work together for 4-6 weeks to improve your strength, ROM, etc. and then consider a surgical consult if we are not seeing improvements in (pain, what they are limited with, etc.) by then. Either way, if surgery is recommended, working on improving your strength prior to has shown to help improve outcomes afterwards.– What role should diagnostic imaging have in surgical management of shoulder pathology? There are a lot of times where we see abnormality of imaging in asymptomatic individuals – when does imaging become relevant?
It depends? I think for patients with more traumatic injuries, or for patients who are younger, imaging may be more relevant earlier on for surgical management if they are presenting with significant loss in function, ROM, strength, swelling, neural symptoms, etc. For older patients or less traumatic injuries, who do not present with any red flags, I think working conservatively for at least 4-6 weeks should be done first before considering further imaging if they are not progressing well. This question made me think about a patient I recently evaluated who is in his 60s and came in for R shoulder pain. He had a prior RTC repair several years ago and the patient really wanted new imaging of his shoulder. They did another MRI which found a complete tear and retraction of his supraspinatus tendon and his infraspinatus tendon, among other findings that were chronic. His doctor referred him to PT anyways and mentioned that he won’t do surgery since the tendon has retracted and due to the chronicity of the injury. The imaging helped me make sense of his pain and impairments with strength in ROM, but overall, we have been able to make improvements so far with ROM over the past 2 weeks and would have been able to do that without the imaging. I think sometimes it’s hard to avoid imaging when the patients feel like they need to have it done to be reassured/know what’s going on which leads to seeing abnormal findings that may or may not be contributing to their pain, and then potentially leading to surgery that may or may not be needed.
Interested to hear what others have to say!
References:
1. NB, Jain, Peterson E, Ayers GD, Song A, Kuhn JE. US Geographical Variation in Rates of Shoulder and Knee Arthroscopy and Association With Orthopedist Density. JAMA Network Open. 2019;2(12):e1917315. doi:10.1001/jamanetworkopen.2019.17315Hi Ian, I really like your post and thank you for sharing your experience. Patient advocacy is definitely a great skill to have and is so important in our profession. I think the fact that you reached out and talked to the doctor as a new grad is awesome. It’s so hard to know earlier on what path that patient was going to go down with the different injections. Despite what the patient had to go through, which is really unfortunate, it was a good learning experience to have. I had an experience with patient advocacy previously when I was working at the hospital in the acute care setting. My CI and I were working with a patient who was in the garage walking in front of the car when her husband accidentally pressed on the gas pedal and pinned her up against the wall. The hospital was trying to discharge her home after a few days when she was definitely not ready to be discharged and her home environment did not seem very safe. It was a very difficult situation and my CI and I had to talk to her case manager, her nurse and doctor, and explain in our notes why she was not safe to be discharged home. They ended up discharging her home anyways which was really frustrating. I’ve also seen other PTs in the clinic now advocating for their patients, and reaching out to the doctors to have that discussion with them. This is something I would like to improve on as well. I think as a new grad, at least for me, the idea of talking to a doctor with several more years of experience about what I think is going on with the patient makes me feel a little intimidated. Confidence is key and we are the ones working one on one with the patients to identify their primary impairments and potential sources for their pain. That’s great that you reached out to the doctor, and I’m glad your message was well received. I hope the injection in his lumbar spine helped with his pain. You’ll have to keep us updated on how he does!
Hi Ian, thanks for the response! I’ve also thought about just writing things down on paper but I’m not sure what’s better my typing abilities or writing. I definitely should give that another try though and see what I think works best. I do like to write down my objective findings which is easier for me so maybe sticking to the paper will be better so I don’t have to switch back and forth.
In regards to the questions, I think it’s usually a bit of both, asking about an activity/something that they did previously that aggravated their pain to see if that changed and determine if that is something we need to assess/focus on for the session. I am trying to get in the habit of asking more about changes in irritability which can be a good indicator of how the patient is progressing. That is definitely another good subjective * to ask about.
Hi Clare, I really enjoyed reading your response to the discussion. I definitely agree with a lot of what you mentioned with active listening while documenting, the concern with overlapping treatments, and with fascial expressions. For documenting, I’m going to try just typing most things into one box so I’m not having to click around and then just typing keywords so that I’m able to have more eye contact with the patient and not looking down at my computer so much. AJ also talked to me about summarizing what the patient said during the subjective and saying it back to them at the end to confirm whether you heard them correctly or if you missed anything. This is one of my goals for the first quarter that I think will definitely help with improving on active listening during the first encounter.
I’m also concerned with the overlapping treatments, I won’t be able to have my eyes on the patient at all times especially when I’ll have to hand them off to the PTA for part of the treatment. This makes the time that we do have with our patient so much more important to continue to build on the therapeutic alliance with them. It will definitely be a test for sure once our schedules start to build up more.
Hi Clare, I haven’t tried that method yet but I like that approach starting off with the location of symptoms. I think that’s a great way of starting, and maybe getting hands on to confirm location of symptoms before getting the whole story. That probably stands out to the people who have seen multiple doctors who never actually do that and just sit and talk with them for 5 minutes before referring them to someone else. I will definitely try that during my next evaluation.
I also agree that the opener can be situational. I think asking the pt first what brought them in or where they are having symptoms first, you can definitely get more of a read of the patient and then adjust or ask questions as needed.
I remember talking about openers for evaluations during the course and having that stick out to me. This is something I have always thought about, wondering if I was starting off the conversation on the right foot. I feel like my go to now is “what brought you into the clinic” to try to keep it open ended and not close any doors to pertinent information or other areas of pain the patient may be experiencing based on the referral. In the article “On Opening the Clinical Encounter” by Chris Worsfold, he references John Launer’s book about trained mentors and coaches starting off the conversation with “what are you hoping to get out of our conversation today?”. This made me think back to one of my patients who I did the subjective and then asked him what his goals were. He straight up told me he had to do physical therapy in order to get MRI imaging and that’s why he was there. I think if I would have asked him that question from the start it could have changed our conversation. For example, asking him more about his thoughts on what he thought is contributing to his pain and providing education on the benefits that physical therapy could provide him to improve patient “buy-in”. Fortunately, I was able to spend more time with him during the second session to do that. I also like the use of “tell me your story” that Peter O’Sullivan uses and then sitting back and listening without typing. I think that’s something I struggle with sometimes since I’m worried that I’m not going to remember everything they said, especially if I don’t have time to type before the next patient and I have a busier day. This is something I want to improve on. I do feel like when I’m trying to type, I might miss something the patient says or verbiage that the patient uses that can be used as an educational opportunity. For example, during mentoring last week, I had an eval for a guy with R low back pain. He had gone to the ER for his back pain initially and had a whole bunch of tests done and was still really concerned about his back. I was focusing so hard on listening and trying to write down notes (and a little nervous cause mentoring) and didn’t pick up on some of the things he was saying which would have been a good educational opportunity. I saw him again this past week and he straight up asked us if he had a disease that was causing his back pain. For me this emphasizes the importance of just putting the computer down for a second and giving the patient your undivided attention to listen for those things and being able to address them and educate the patient.
This also relates to the four themes that were identified that patients and physical therapists perceived to influence patient-therapist interactions in the article by O’Keefe et al. The first two themes listed were “physical therapist and interpersonal communication skills” and “physical therapist practical skills” which involved listening and patient education. This really emphasizes the importance of the first session to build that connection and trust with the patient. AJ and I talked after the mentoring session last week about how the patient with R low back pain is likely hesitant to move because of his pain and the second session only confirmed his fears when he asked if he had a disease. Providing the patient the education day one could have given him the reassurance that he was likely looking for that he did not have a disease or something more serious going on, and that it’s okay to keep moving.
Lastly, Elizabeth Crepeau in her article from 2016 also speaks to this discussing the two important aspects of attention that are important for building a therapeutic alliance: “listening” and the “clinical gaze”. Can’t emphasize the importance of listening enough, not just during the evaluations but during the treatments as well. During the mentoring session this past week, AJ and I talked about asking about the subjective asterisks at the start of the treatment to assess for any changes or things that could be addressed in the current session. Sometimes it’s the little things that patients say that they don’t expect you to remember and I feel like that says a lot to the patient when they noticed that you remembered and were listening. And then use that information that they are giving you to make the session patient centered. Overall, these are all great articles and provided great insights on how to build the therapeutic alliance with the patient. Becoming a better listener is definitely one of my goals for the residency and as a clinician.
References:
1.Worsfold C. On opening the clinical encounter. Published March 13, 2019. Accessed October 13, 2022. https://www.chrisworsfold.com/on-opening-the-clinical-encounter/
2.O’Keeffe M, Cullinane P, Hurley J, et al. What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Physical Therapy. 2016;96(5):609-622. doi:10.2522/ptj.20150240
3.Crepeau EB. “I need someone to keep an eye on me:” the power of attention in patient-practitioner interactions. Disability and Rehabilitation. 2016;38(24):2419-2427. doi:10.3109/09638288.2015.1129443