Enhancing Patient Autonomy

[AJ Lievre]

Following our discussion this weekend on chronic nonspecific LBP, it is clear that patients often feel a lack of control over their situation and are often not confident that their condition will improve. Read the article below to help with the discussion. Consider other resources as well and share what you found.
For this discussion board consider the following prompts to get started with an initial post. Feel free to have some latitude with this post based on what you want to discuss.
1. What can you improve upon to help increase patients’ (with persistent LB pain) confidence, self-efficacy, or autonomy?
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?
3. Explain a patient encounter where you felt like you moved the patient toward autonomy. What strategies do you feel worked for that patient and may work again?

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

[Sarah Frunzi]

Non-specific and persistent low back pain, as well as pain science, have always been topics that have caught my attention and interest early on in my PT career. Thankfully, the curriculum of my doctoral program included an entire course on pain science and went into great detail in our musculoskeletal courses on persistent non-specific low back pain. I feel very fortunate to have this incorporated into the foundation of my practice patterns due to the prevalence of this population of patients. Even with this foundation, I have so much to learn with understanding and treating this group. Areas I can continue to improve on to help with patient’s confidence is by continuing to improve my own confidence, as I recognize that my patients need to see me as confident and capable in being able to treat their condition. Some ways I try to build self-efficacy and autonomy with my patients is through patient education and decision making with HEP, treatment, and visits frequency. With most of my initial evaluations, I try to ask the Patient Specific Functional Scale to get an idea of what activities the patient desires to return to. I put a lot of weight into this, and it subsequently guides my selection of many exercises to teach the patient; therefore, they see a meaningful and functional connection to their treatment. With this comes the patient education on the importance of the ‘why’ behind why I choose specific manual therapy techniques or exercises during their visit. This will also elicit the patient to have confidence in me by demonstrating I have heard their goals and desires and am educating them on how to do these exercises at home to build confidence in themselves. Though patient dependent, I will also sometimes incorporate having the patient select exercises for that day based on ones we have already done to have them be part of the visit process, showing they have autonomy and active participation in their care. To build on ways I incorporate autonomy, I try to advise my patients on scheduling appointments ahead of time for days/times they prefer so they are seen at the most convenient time in their schedule. This, I believe, promotes therapeutic alliance, especially in a time where making medical appointments is particularly tough due to Covid; recently, I have had numerous patients endorse they are waiting upwards of 3+ months to be seen by other providers. Just like in the article by O’Keefe on what influences patient-therapist interactions, the mix of interpersonal, clinical, and organization factors all play a role in patient encounters and experiences, subsequently influencing results1 (O’Keefe, M., What Influences Patient-Therapist Interactions). Confidence, self-efficacy, and autonomy are all areas we can leverage with our patients to promote independence in an area of their lives they have felt such lack of control, many of which have felt for decades.
In the hustle and bustle of a busy outpatient clinic, there have been occasions where I would say there have been non-encounters with patients when I haven’t been as present mentally or physically. As a newer PT, I am still learning the best ways to manage my time and the flow of patient care to optimize the time I have with my patients without feeling overwhelmed or feeling like I am “going through the motions” of the day. As I learn how to do this better and grow in my knowledge as a clinician, this is not as frequent, and keeping the intention of being present in the forefront of my mind is a gentle reminder. There have also been times where I have had encouraging encounters with patients. Just yesterday, I had a patient come in for a follow up visit where he shared he almost went to the ER earlier due to 8/10 low back pain that was fairly debilitating throughout the day at work. He is a patient that has been pulled in different directions regarding his care for LBP (with a prior fusion) and has been handed off by several providers. In that visit, I was able to listen to him, provide some gentle manual therapy to calm symptoms, and educate him on ways to manage his symptoms at home. Because of the rapport I have with this patient, the perfect opportunity presented itself yesterday to sprinkle in some pain science education with him. By the end of the visit, his pain was down to a 2/10 and he left with strategies to manage his symptoms further independently. I believe this was incredibly important to him since he has been going to many providers without improvement and feeling hopeless as a result. With Physical Therapy, we are in the awesome position of being able to guide patients in their recovery with the end goal of equipping them with the tools and knowledge to manage their symptoms confidently on their own.

References:
1. O’Keefe, M. et al, “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

[David Brown]

I think this is an interesting topic that speaks to the core of not just our profession but all health professions involved in the care team for a patient with low back pain. Because persistent low back pain can linger for years following tissue damage, it can be very difficult to identify a source of the pain that then can be treated. Despite being trained in pain management and neuroscience, myself (and I’m sure many other clinicians) and the patient desperately want to identify something tangible, like tight muscles or nerves or a hypomobile spinal segment, that when improved, will help resolve their symptoms. I think this is a significant factor fueling these “non-encounter” situations that Holopainen et al spoke about in their research. When a patient has been dealing with these symptoms for many years, and are given different information regarding different diagnoses from different providers, this can easily lead to confusion, anger, loss of the therapeutic relationship, and ultimately a sense that the patient is in the middle of a tug of war between all the information they are being given and advice that they should follow.
For me, a prime example of a patient that I believe was a “non-encounter” was a patient I worked with during PT school when I was volunteering at a pro-bono clinic. The 62 year old patient had been experiencing low back pain with radicular sx for several decades and had numerous comorbidities including high blood pressure, diabetes, and obesity. She had been bounced around to numerous providers to little avail. She had seen a physician, two different PTs, and had been through pain management before her insurance ran out of visits for the year. Despite being told different information about what was driving her symptoms, she still believed wholeheartedly that she could be “fixed” by physical therapy without any input on her part. This thinking was partially entrenched because of a MRI printout of her back showing multiple disc bulges that she brings with her everywhere she goes in her purse. As a student, this was immediately intimidating to me, and with guidance from one of my faculty professors, we decided to try to educate the patient on pain neuroscience and try to convey that there was no longer anything healing in her low back and that instead the brain’s homunculus had been smudged. The patient immediately shut down to this and would not entertain the idea that there was nothing to “fix” in her low back. The patient became defensive and reacted saying that we thought her pain was purely in her head and that she was making everything up. This was an almost impossible conviction to break through and the patient was essentially ignoring our educational pieces. I showed her the video “Understanding Pain in Less Than 5 Minutes, and What to Do About It!” as well as tested her for left right discrimination (she was postive for this), but no matter what I said, she would just say we were wrong. Needless to say, the patient never came back, and I felt terrible and felt as though I had failed her.
I think this case speaks to a bigger problem in the healthcare system and our ability to properly deal with patients with persistent pain. The article does a good job of showing how many health care professionals lean on their scientific background and try to come up with a biomedical explanation instead of just listening to the patient’s story. I think if my patient had been better listened to and pain education was begun sooner, she maybe wouldn’t have had MRI imaging, and she would never have had the idea that there was still a tissue disruption in her low back. Instead, she was given multiple different nerve and pain medications from pain management, and recommended surgery from a physician but was also told she was too overweight to undergo surgery. Had all the health care providers involved in her case been on the same page with each other and collaboratively educated the patient managing expectations highlighting function rather than focusing on her low back pain only maybe her outcome would have been different. I think if PTs and all other healthcare professionals prescribe and encourage non-specific exercises for patients with persistent low back pain and begin this line of rhetoric and education at the very beginning, health care costs, back surgeries, and most importantly, patient outcomes and quality of life will ultimately improve.

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