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.

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.1230

Pignataro, 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

I enjoyed reading this article as I think it has been quite relevant to many of the patients I have recently treated. In a recent reflection post, I wrote about a patient who became frustrated with the care I was giving and even stated that he was about to walk out of the appointment. I certainly think that he would believe this appointment started as a non-encounter. There was clearly a mismatch between his expectations and my proposed treatment. While reading this article, it was interesting to me that a few of the positive features of patient encounters were actually points of contention for this patient. During our time together, I tried to give him autonomy and the space to talk about his experiences. I tried to take more of a “coach” position and guide him with treatment. This approach backfired as it seemed that the patient felt that I did not have a clear treatment plan. In the future, I think that I need to read the patient better, obtain clear expectations and set the stage early regarding my method of “working together” with the patient so that I do not come across as unconfident or unknowing of where to take the treatment.

On the other hand, I have been working with a patient with chronic (at least 20 years) of mid thoracic pain and felt that I have moved the pt toward autonomy. This has been a gradual process, but I think that it has been achieved through listening to the patient, gently getting more information about her prior treatment experiences and acknowledging her fears. We have been moving slowly in terms of exercise progression and I emphasized early on that I do not want to flare-up her pain and put her out for multiple days. This immediately appeared to be a relief to her and she seemed to leave the initial eval with some hope as she verbally expressed. I have also explained that this is a teamwork approach and that we need to find the treatment that works best for her which involves both of our input. In the MacNeela, Doyle, O’Gorman, Ruane, and McGuire study that was cited within the Holopainen study, the idea that active listening and bedside manner having a large impact is discussed. It explains that having a good connection and listening was important even when pain was not resolved. I think that I have seen this during the time with my patient because since she trusts me to a certain extent she is willing to try exercises or methods that she may have initially been unsure of.

With sources
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
MacNeela, P., Doyle, C., O’Gorman, D., Ruane, N., & McGuire, B. (2015). Experiences of chronic low back pain: A meta-ethnography of qualitative research. Health Psychology Review, 9(1), 63–82. https://doi-org.ezp.slu.edu/10.1080/17437199.2013.840951

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.