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David,
I appreciate your honesty in your reflection on needing to have utilized more of a behavioral aspect compared to exercise, as I am finding I do this as well. As important as exercise is to our treatment and our profession, I find I am sometimes hesitant to address the behavioral aspect or don’t recognize the need for it soon enough. I also agree with your statement on where the challenge is knowing when and how much to integrate CBT into the treatment. I think there is a level of difficulty or challenge in gauging how receptive the patient may be to that method of treatment, and subsequently implementing it at the appropriate time for this reason. We may recognize the need for it, but the patient may not feel ready or willing to implement the strategies into their daily life. We can always educate and “plant the seed”, but it really is up to the patient to put into practice the recommendations we provide. I think as long as we spend the appropriate amount of time educating the patient and conveying the possible value of our different treatments, building that therapeutic alliance, like you said, outcomes can be better for this population.
Thank you for your thoughts!
I have had the chance to work with a couple of patients who sustained whiplash, and fortunately, majority of them have been on the positive end of the spectrum with their recovery. Some recovered quicker than others, and I do believe the psychological, or lack of involvement/impact in this domain, had a positive part to play in their successful outcomes. The ones that recovered well also had active lifestyles, or physically active jobs, that required and/or encouraged them to return to movement and activity sooner than later, which would support the statement of promoting returning to regular activity compared to immobilization treatments. They all had varying presentations and symptoms, however, the ones that did have slightly more psychosocial or emotional involvement did take longer to recover compared to those that didn’t.
I have noticed they are a challenging population to treat, and after reading the articles posted, I believe our core method of treating this population should remain the same – to treat the whole person. I don’t think we can abandon an approach directed towards physical impairments, because there are likely going to be some physical impairments present that we need to address. No one person is the same, and not all whiplash disorders present the same way. Therefore, I believe it is more imperative to implement evidence-based practice and the concept of “treating the whole person” with this population just as much as it is important to do with chronic low back pain patients. Just like in chronic low back pain, in WAD there is some level of physical impairment as well as other layers of possible central hyperexcitability, emotional distress from the event, and high pain levels. We have to evaluate how much of each area is involved between physical impairments, social-emotional, and psychological needs. This may be requiring a referral to another provide to build a more team-based approach or can be managed within the clinic alone. I believe finding the best balance in treating these varying areas comes from what is most impactful on the patient’s life at that moment in time we are seeing them and adjusting each visit accordingly. Initially, it may be more social-emotional and may transition to more physical impairments as the emotion of the event calms and more local impairments are able to be addressed. I think this method would challenge us to constantly keep an open mind with each visit, and to analyze how the patient is presenting during that specific visit, allowing for an ebb and flow between addressing different domains along the course of their care.David,
I loved reading your reflections, and I too was amazed by the article “Evaluation is Treatment” article. Just yesterday I was challenged to practice this with an evaluation I had involving very heavy topics and more emotional pain than physical pain. I had to suspended my plans of getting all the information and tests I needed, and just needed to be present with them and simply listen. There will be other visits to get the remaining information I need, but in that moment, they just needed to tell their story. I also agree with your comments on avoiding phrasing or words that can be harmful and negative. It’s amazing to me that we can do so much to help our patients by just performing active listening, reframing ideas around pain, and using words of encouragement and healing; neither of which even involve touching the patient!
Sarah
Hello All!
The two resources I found compelling were, “What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis” by O’Keefe et al and “Evaluation is treatment for low back pain” by Louw et al. I continue to be reminded that the brain and body are so complex, and there are so many parts and pieces that go into treating the patient. I have always been intrigued by the topic and concept of pain science, and I believe these two articles amplify how much goes into the perception of pain, and that it is not just about level of possible tissue damage. It’s much deeper, therefore our treatment should be much deeper than treating tissues.
Regarding the article by O’Keeffe et al about influencing patient-therapist interactions, the four themes discussed addressed not just therapist skill and knowledge, but therapist communication and active listening, level of empathy and compassion, and thoughtfulness with making treatment individualized to the patient. While I try to demonstrate and implement all of those characteristics daily, this article challenges me to continue to practice being present with my patients and to not be distracted by the documentation I may need to complete or other tasks that need to be done that day. The article also addressed the theme of environmental and organizational aspects regarding scheduling availability and flexibility. This reminded me that patient care is also very much so a team approach involving therapist, technicians, and patient care coordinators. This reinforces that good communication between team members is also essential in quality patient care.
The article by Louw et al researching how the evaluation alone impacts perception of pain levels was truly astonishing to me. Several recent evaluations come to mind where I feel I could’ve leveraged this concept better with patients who had high irritability/severity levels during initial evaluation, and where the phrase “do less better” is on repeat in my thoughts. More of a deeper subjective evaluation and less of a physical examination potentially could’ve changed their level of pain by the end of the session. To have objective data demonstrating improved pain levels after executing the concepts of active listening, hearing the patient’s story, asking more thought provoking questions to understand the patient better, is amazing to me. This encourages me to dive deeper with my questioning and explore more of the answer’s patients give me, even if that means taking a few more minutes away from objective examination time. We are given 1 hour of one-on-one time with each patient for initial evaluations, and this challenges me to optimize each minute I have with them.
Considering all of those aspects, treating tissues is only a small portion of treating the patient. This only reiterates that we don’t just treat an injury, but we treat the whole person.Thank you for your time,
SarahDavid,
In my experience that I have had so far, patients that have a medical background can be some of the most challenging patients to treat because of their level of knowledge of the human body as well, which can sometimes be helpful or a hindrance. I commend you for addressing her MRI results and something I have found helpful when getting the response like you did with, “well this is where my pain is,” is that I acknowledge that while many are asymptomatic and normal imaging findings, they can sometimes be cause symptoms and that the tests we will do in the examination will provide more clarity on the current episode. I also note we will provide the tools they needs to manage their symptoms independently. I also appreciate that you encouraged her to return to the gym where she found relief, most likely physically AND mentally. I encourage you to continue to have that listening ear and calming presence with her, because like you had mentioned, her stress of being a nursing student, during Covid times no less, is mostly likely very taxing – mentally, physically and emotionally. I love to incorporate diaphragmatic breathing with patients that demonstrate high levels of anxiety. When paired with exercises, as a mindfulness practice, or as an exercise alone, I have found some patients are open to this and are willing to try it. This may be a beneficial tool for her while on clinical rotations when stress and anxiety begin to run high. Keep up the good work David!