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Emily,
I really enjoyed reading this post and actually relate to it quite a bit after a similar encounter I had with a patient this past week. My patient is a 41 y.o. male who is post-biceps tenodesis and his #1 goal is to get back to weightlifting. Last week, he had his 12 week f/u with his surgeon, who, for the second time, told this patient he should never lift weights again due to the amount of OA in his GH joint. He then proceeds to tell the patient that he’s too young to receive a TSA and should just give up on the idea that weightlifting is going to be possible. Needless to say, I was not happy to hear this and incredibly frustrated that the surgeon would say this. Even if there is some merit to the presence of OA in his GH joint, I feel that with the right amount and type of PT, he will certainly be able to get back to weightlifting at a reasonable amount of weight, especially if we can take the necessary steps to ensure stability in his shoulder.
When reading through your patient experience, I thought of my own patient and the long session we had discussing his presentation and prognosis. Of course, you never want to totally negate what the surgeon is saying. However, I think it is our responsibility to give these patients a positive perspective and outlook on their condition. How much research can we refer to that shows the impact of positive expectations with therapy on patient outcomes. I also think discussing the prevalence of OA is important when managing patients that present with a negative outlook on their condition. I have even pulled up the research showing the % of people over 30 y.o. living with arthritis despite being asymptomatic. This often hits home since most people coming into the clinic aren’t aware how common it is. I think it also makes sense to them when you frame it in the perspective of being a human being walking around on Earth for a certain amount of decades and fighting the effects of gravity. Empowering patients that show up with a negative perspective is in my opinion one of the hardest things to achieve, but I feel that if we can give them some form of reassurance that they have the ability to control their own outcomes and not be defined by their condition, then they can leave clinic feeling hope.Clare,
Great post and reflection! I think you bring up some good points on how difficult it can be to read a patient and understand the kind of therapeutic experience they are looking for. I feel that it can be difficult for us as new grads because some patients may look at us as inexperienced or that we don’t know what we’re doing since we are just out of school. It’s definitely hard to pick up on what a patient is looking for unless they directly verbalize it. One thing I like to incorporate into the subjective examination is asking the patient if they’ve ever been to PT before. This allows me to set expectations even if they say that they have been before and I feel allows me to appear confident and competent as to what the plan will be not just for the remainder of the examination, but also in subsequent visits.
It sounds like you’ve done a great job with the patient experiencing chronic mid-thoracic pain and she’s been able to trust your decision making in order to begin to reap the benefits of therapeutic exercise. I feel that sometimes our patients just need someone to actually listen to them and their needs, since they often don’t experience that with healthcare, especially for patient’s experiencing chronic pain.
As a side note, do you feel that having a discussion on pain and the expectation for some pain is necessary with this patient? Is there a need for us to discuss pain neuroscience with our chronic patients in order to break that cycle of repeated pain that they’ve been dealing with for so many years? I often find myself struggling with this, and when it is the right time to have a conversation on pain neuroscience to ensure that it received well.I really enjoyed reading the article by Halopainen et al. and realize that there’s so much for me to learn as a new clinician in regards to how we manage our patients experiencing chronic nonspecific LBP. I definitely feel grateful having received a DPT education that emphasized the importance of a biopsychosocial model and to have that further promoted here in the VOMPTI residency. However, it’s clear there are still many healthcare providers who deliver care through the lens of a biomedical model, causing many patients to feel unheard and unseen. I can say that I have encountered numerous patients that are coming from a referral source feeling like it was a non-encounter, as described in the article. They often feel like they are being rushed out of the office or that there isn’t a clear explanation for why they’ve been experiencing pain. I feel like this is an area where we as physical therapists can strive and make a huge difference right away in the patients perception of the healthcare system and quality of care they’re receiving. On multiple occasions, I’ve had patients say that no one has let them tell their story to its full extent, or they’ve never had a healthcare provider be thorough in their history taking. Another area I’ve personally found to be beneficial in establishing a therapeutic alliance with my patients is explaining what I’m doing, what I’ve found, and what the patient can expect from future treatments. The article speaks to this in category II: seeking support and category III: empowering connection, and I personally feel like taking the five minutes to explain what I think is contributing to the patients pain and what physical therapy can do for them has made all the difference for why those patients continue to come back. One thing I learned this past course series weekend was that sometimes doing a quick neuro screen can be all the patient needs to understand that they’re symptoms are nothing serious even if you know there is likely no neuropathic symptoms. I was able to put this into action this past week with a patient I am treating with 20+ years of LBP. He mentioned feeling that sometimes while he’s sitting at the dinner table, he’ll experience symptoms into his feet and was clearly concerned about it. I performed a neuro screen and found no positive signs, explaining to him every step of the way what I was looking at and why. He definitely expressed relief afterwards and acknowledged that it put his mind at ease to hear me say there was nothing to be concerned about.
Category IV of the article talks about how we as physical therapists can give our patients the autonomy to take control of their own situation and truly change their behavior for the better. This is definitely an area where I feel I could improve, specifically getting the patient’s family involved with changing their lifestyle habits or discussing psychosocial problems more frequently or taking every aspect of their life into consideration when developing an exercise routine. A technique that we’ve discussed in the course series and one that I’ve heard utilized often to promote autonomy in patients with chronic LBP is motivational interviewing. A position paper by Pignataro and Huddleston discusses the use of motivational interviewing in both PT practice and PT education in order to promote autonomy in our patients and allow them to take control of their own health and wellness. I personally think one of the hardest aspects of our jobs as physical therapists is getting patients to adhere to their home exercise plans or listen to our advice regarding activity modification or lifestyle change. I think this is where motivational interviewing can have a huge impact, with improving patient adherence, the therapeutic alliance, and moving towards autonomy. The article discusses how motivational interviewing addresses a patient’s readiness to change based on the transtheoretical model. Rather than just blatantly telling a patient what they need to do to feel better and ultimately increasing their resistance to change, motivational interviewing utilizes empathy, collaboration in decision making, and individualized goal setting to promote behavioral change. The article goes into further detail about specific motivational interviewing techniques with examples and even a screening tool for determining a patient’s readiness to change. I feel that if we don’t understand how ready a patient is to change, it’ll be impossible to develop a therapeutic alliance that allows us to promote autonomy in our patients. Motivational interviewing is something I will definitely continue to research and hope to use in the future when encountering patients with chronic LBP to improve their autonomy. If anyone has any recommendations or other sources about motivational interviewing, please send them my way!
References:
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.1230Pignataro, R., Huddleston, J. (2014). The Use of Motivational Interviewing In Physical Therapy Education and Practice: Empowering Patients through Effective Self Management. J of PT Educ, 29 (2), 62-71. https://journals.lww.com/jopte/pages/articleviewer.aspx?year=2015&issue=29020&article=00009&type=Fulltext
Hey Clare,
Great post! I definitely agree that it can be difficult to decipher what option (surgery vs conservative) may be best for a patient when the evidence is poor or not entirely supportive of one vs another for shoulder pathology. I think you bring up a great point about patient’s personal experiences impacting their decisions. I’ve experienced much of the same and especially within the older populations, I notice they place all their trust in whatever the surgeon says. This I find to be incredibly difficult because of course a surgeon wants to perform surgery, that’s what they do, but how do we counter what they’re saying without seeming entirely contradictory? I think that’s where better research could play a role or being able to phrase your words carefully so a patient understands the multitude of options they have available.
I agree that some patients can get really caught up in their imaging results to the point where it leads to further pain and disability based on their thoughts and behaviors regarding their condition. Like you said, if the imaging matches their clinical presentation, that can be a great tool to lead to better decision making and decreased healthcare utilization. Have you ever utilized the research about asymptomatic imaging when educating patients about their own imaging results? If so, did you feel like it helped their understanding of how the image doesn’t always equal the presentation?I found this week’s discussion topic to be particularly challenging because when I reflect on my clinical experience with shoulder pathologies, I can think of patients where shoulder surgery seemed to help them tremendously, and others where it didn’t improve anything, or perhaps made them feel worse. I think that’s where this topic can be challenging, as it often seems to depend on many factors for whether surgery is the most appropriate option for a patient, and the reasoning behind that can be complex. The first question I decided to answer is: What are the pros associated with shoulder surgery? We tend to focus on the risks (e.g. infection, post-operative stiffness, subsequent procedures, etc) but there are a number of reasons why someone would have surgery of their shoulder – what are some of them?
When I think of the patient’s I’ve seen that have had shoulder surgery, many have either had a traumatic incident that severely limited their function or they had a chronic condition that increased their pain and disability with no success from conservative management (including PT, CSI, PRP, etc.). When I looked to the literature on this topic, I found a lot of articles that analyzed surgical outcomes vs conservative management for anterior shoulder instability. A systematic review and meta-analysis by Hurley et al. (2020) analyzed arthroscopic bankart repair vs conservative management for first-time traumatic anterior shoulder instability.1 They concluded that arthroscopic bankart repair resulted in a 7x lower recurrence rate and higher rate of return to play than conservative management.1 I thought this article definitely challenged some of my own biases as I’ve often found myself leaning towards conservative management as the best first option. It certainly makes sense that a traumatic anterior shoulder dislocation can put an individual at a higher risk for recurrent dislocations, especially in the overhead athlete. In the instance of traumatic anterior shoulder instability in an overhead athlete, I agree that shoulder surgery is the more indicated option vs conservative management due to the demands of the particular sport and high recurrence rates in athletes (up to 100% in some studies).1
In my opinion, other reasons why someone would opt for surgery of their shoulder include: significantly decreased function due to limited ROM, strength, and increased pain, failed conservative management, and inability to perform sport/vocational activities. Despite conservative management being the usual first line of treatment for shoulder OA, one shoulder surgical procedure that is well supported by the literature, when indicated, is total shoulder arthroplasty.2 I think this brings up another good reason why someone would have shoulder surgery; that is, when they have tried conservative measures with minimal to no improvement in pain and disability.
Another topic I found challenging to answer is the question: Critical appraisal of evidence is essential to quality clinical practice. What are some of the challenges with research trials investigating surgery versus other interventions?
Even before I looked at the literature, the first thing that came to my mind was the ethicality of performing some form of sham surgical procedure without actually performing any sort of surgical repair. Due to the invasiveness of shoulder surgery, I find it difficult to imagine how it could be controlled without ethical issues. Considering this dilemma, I found a lot of research that compared surgical interventions to conservative management was often of a lower level evidence and retrospective in nature with a lack of randomization and control group.2-5 Other limitations I found in studies comparing surgical vs conservative management include: risk of bias (how do you choose who gets surgery?), demographic heterogeneity between subjects (poor internal validity), and a lack of long-term follow-up.2-5 Overall, I feel that there will always inherently be some selection bias when comparing surgical vs conservative management, which poses a challenge to the strength of evidence available. However, I feel we can use the evidence that is available, as well as some of the points I alluded to earlier to effectively determine if surgery is truly the best option for our patients. I would love to hear anyone’s thoughts on the potential ways that the challenges for comparing surgical vs conservative management in research could be addressed.
References:
1. Hurley ET, Manjunath AK, Bloom DA, et al. Arthroscopic Bankart Repair Versus Conservative Management for First-Time Traumatic Anterior Shoulder Instability: A Systematic Review and Meta-analysis. Arthro: J Arthro & Rel Surgery. 2020;36(9):2526-2532. doi:10.1016/j.arthro.2020.04.046
2. Pandya J, Johnson T, Low AK. Shoulder replacement for osteoarthritis: A review of surgical management. Maturitas. 2018;108:71-76. doi:10.1016/j.maturitas.2017.11.013
3. Ramme AJ, Robbins CB, Patel KA, Carpenter JE, Bedi A, Gagnier JJ, Miller B, Surgical Versus Nonsurgical Management of Rotator Cuff Tears: A Matched-Pair Analysis. J of Bon & Join Surg. Accessed October 30, 2022. https://oce-ovid-com.suproxy.idm.oclc.org/article/00004623-201910020-00008/HTML
4. Nazari G, MacDermid JC, Bryant D, Athwal GS. The effectiveness of surgical vs conservative interventions on pain and function in patients with shoulder impingement syndrome. A systematic review and meta-analysis. PLoS ONE. 2019;14(5):1-22. doi:10.1371/journal.pone.0216961
5. Alkhatib N, Abdullah ASA, AlNouri M, Ahmad Alzobi OZ, Alkaramany E, Ishibashi Y. Short- and long-term outcomes in Bankart repair vs. conservative treatment for first-time anterior shoulder dislocation: a systematic review and meta-analysis of randomized controlled trials. J Shoul & Elb Surg. 2022;31(8):1751-1762. doi:10.1016/j.jse.2022.02.032Hey Emily,
I thought this was a really good post, and definitely highlights some difficult aspects of patient care. I think you’re right, sometimes it is important in the beginning to just let the patient talk and get their story out in order to build rapport and get the full picture, as long as the information they are mentioning seems relevant. I think it was definitely important to get the full picture with this patient because of the journey he’s had seeing so many other providers and how that’s impacting his pain experience, not to mention his environmental factors. I’ve definitely had some similar evaluations myself where it can be difficult to get any words in at all because the patient has a lot to say. It can be difficult to know when to budge in without seeming rude or just letting them talk so you can gather more information.
Something I’ve been told when encountering situations like this is that you don’t have to do everything objectively in that first visit. I think that rings true for this particular encounter as well. It was important for you to let the patient get their story out so you could see the whole picture, and you’ll have plenty of time in subsequent visits to gather more objective information. Time management can be super difficult at times and in order to ensure that the entire session isn’t spent talking, I personally find it easier to just move on after they finish a sentence and then refer back to that statement while in the middle of performing an assessment or treatment technique so that they know I was listening and acknowledge their statements. When crunched on time, I’ll usually wait to explain to the patient what I think is going on until after I put together an HEP. This also usually allows me the time to get my next patient started with a warm-up in the meantime so they aren’t waiting for me to finish. It sounds to me like you were able to establish a good rapport with this patient just by simply letting him talk, so hopefully the trust is there which will help with future visits. Let me know how it goes in future visits, I’d be curious to hear what other objective information you’re able to find!Clare,
Awesome post! I enjoyed reading about your patient interaction and reflection on these first few weeks of residency. I think your patient was right, that it’s easy to be hard on ourselves especially when we are so new to this profession and trying to be the best clinician possible. I can relate to sometimes feeling like I am overexplaining or speaking at nauseam to a patient about their presentation. I certainly think every patient is different in that some appreciate this and actually benefit from thorough education. However, I think for some patients they couldn’t care any less so I find it’s sometimes a skill to pick up on those social skills and know when to emphasize more education.
Similarly, after reading the article “I need someone to keep an eye on me” I find myself feeling like I need to be with my patient throughout their treatment sessions, which leaves me with a lot more documentation to do at the end of the day. This is a dilemma I’ve been trying to navigate since day 1 of residency. I think every patient is different and some definitely need more attention than others, but I’ve found myself starting to get more comfortable with leaving the patient to do their exercises alone as rapport is established and I’m confident they are performing them correctly. What kind of strategies have you seen other clinicians use to ensure they are not left with a ton of documentation at the end of the day? Do you think it’s possible to change a patient’s perspective on being left alone during treatment if we set expectations early on?Emily,
Great post! I think your points on understanding patient perceptions day 1 is so important, yet often so difficult to do. Finding that balance between listening intently to the patient in front of us but also ensuring that we don’t forget anything or leave ourselves with a lot more work is definitely one of the hardest parts of this job in my opinion. Although it does leave me with extra work, I often don’t bring my computer into the initial evaluation with me and instead use pen and paper. I personally think this makes the patient feel like I am paying more attention and based on my terrible typing skills, I’m able to make fewer mistakes while writing. Although, this does leave me with having to document all that I wrote down later on, which can definitely be time consuming.
I really like the point you made about reassessing subjective *’s. I think this would definitely help the patient understand that you are listening intently and empathetically into subsequent visits. That’s something I could certainly work on myself, asking specific questions about their subjective symptoms that are most meaningful to the patient in follow-up visits. What specific questions do you find yourself most often asking about? Is it more related to their aggravating factors? Or are you inquiring about changes in irritability (time for pain to come on, go away), goals, etc?AJ,
Thanks for your questions. I think you bring up a great point of the importance on how to redirect effectively. I find this to sometimes be difficult if a patient begins discussing at length their situation to the point where they are providing information that isn’t helpful towards my understanding of their presentation. I certainly don’t want to seem rude by interrupting a patient in the middle of a sentence or appearing frustrated that they are talking so much. It is often these moments where I begin to sense that the patient is bringing up irrelevant information or if they begin repeating themselves that I attempt to step in and redirect the conversation. How I redirect differs depending on the individual in front of me, but I find myself often circling back to information they provided in the beginning of the subjective that could help me paint a better clinical picture of their presentation (e.g. MOI, PMHx, aggs/eases). Specifically, I try to summarize or repeat information they have given me as a way to further my understanding, but to also demonstrate active listening so that the patient understands I value what they are saying to me. I also make a big point to individualize my subjective examination by ending with a question about their specific goals and explaining to the patient my intent to help them reach those goals, which I feel makes a huge difference in their buy-in and feeling like their values and preferences are being considered.Resources read: “On Opening the Clinical Encounter” by Chris Worsfold; “Enhance Placebo, Avoid Nocebo: How contextual factors affect physiotherapy outcomes” by Testa and Rossettini (2016); “What influences Patient-Therapist Interaction in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis” by Keeffe et al. (2016)
I really enjoyed reading the three resources above and they served as another reminder of why I love the profession of physical therapy. One of the many great pieces of advice I received from a mentor while in PT school was the importance of customer service as it relates to our patients. As I’ve transitioned from student to clinician, I’ve gained a much better appreciation of the influence our behavior and language can have on patient outcomes/expectations. The first resource I listed looked at the importance of this from the very beginning, and how the way we open a clinical encounter can set the stage for the reminder of the rehabilitation process. I enjoyed what the author had to say about the influence this can have on a patient and feel there were some specific aspects that I could apply to my own clinical practice. I personally tend to start an initial evaluation with “okay, looks like you’ve been dealing (X) pain, why don’t you tell me a little bit about what’s been going on from your perspective.” This typically gives the patient the opportunity to give me their whole story, however, one major component of this initial clinical encounter the article mentioned that I think I could improve upon is when I interrupt the patient. Certain patients will talk for the entire visit if you let them which you have to be careful with, but I personally think I could do a better job of just letting the patient tell the majority of their story before I interrupt to clarify information or ask follow-up questions.
The other two articles I read dove deeper into the specific factors and characteristics of a physical therapist that, when applied on a more consistent basis, positively or negatively impact a patient’s outcome. The first article discussed the individual therapist factors as well as patient factors that can contribute to a placebo or nocebo response. I think (and hope) there’s a part of all of us who decided to pursue a career in physical therapy that enjoys interacting and socializing with others. This article speaks to that and then some by listing out strategies we can use to improve our patient-therapist encounter that has been shown in the research to promote positive patient outcomes. There’s certainly a lot to say about the power of positive thinking, whether it be in our personal or professional lives, and I think these articles point out our role as a physical therapist in promoting positive thinking for better outcomes. As I read both articles, I reflected back on patient encounters that haven’t gone as well as I’d hope and how I could’ve made the situation better by implementing some of these strategies early on. Specifically, I think setting expectations for both the course of the initial evaluation and for the remainder of the overall rehabilitation is something that I could’ve used to improve how patients respond to the interventions I provide. I also feel that emphasizing the intent for shared-decision making with the entire course of treatment is something that could’ve improved these patient encounters and made the therapy sessions more enjoyable for everyone involved.
As a whole, I realize there is a plethora of emerging evidence that points out the importance of the psychosocial component with patient care and less towards the biomedical aspects. Combining both is obviously the most ideal approach to patient care and my hope is that with time and much more experience, my ability to positively influence patients through my language, actions, knowledge, and behavior will improve.