September 25, 2021 at 8:36 pm #8995AJ LievreModerator
During our first weekend together we discussed the importance of the subjective interview from not only the perspective of gathering valuable information from the patient but a chance to develop a rapport and enhance expectations. Much of our success with patients comes from how we do things and less about what we do.
Below is a list of several resources that address more of the art of physical therapy. Find a couple of resources that interest you and consider posting about… what you learned, what you might attempt to utilize during your patient encounters, what you might try and change about your current practice patterns, a patient encounter you were reminded of where knowing more about this could have changed the outcomes.
If you need access to any of these resources let me know, I’d be happy to share. Some of these resources are in the resident module 1.
September 28, 2021 at 11:00 am #9002Sarah FrunziParticipant
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,
September 30, 2021 at 9:46 am #9004David BrownModerator
I really enjoyed reading your response to the articles because much of what you say I can directly relate to. I think it’s amazing how far pain goes beyond tissue damage, especially if it is pain ongoing for several months or years and it has an impact on ADLs. The idea of neurotags and brain smudging of the homunculus are concepts I can barely wrap my head around. If you have free time look at videos/articles showing functional MRIs of the brain and the parts of the brain that light up in response to pain in both acute and persistent pain patients. It’s incredible! And it shows how involved other parts of the brain are, including our emotional drivers with persistent pain. I think this underlines what you talk about next with demonstrating empathy, compassion, and active listening because these traits can have a huge impact on the emotional aspect that can often drive the sensations of pain. I’m with you in that it can be difficult to not think about what’s ahead on your schedule whether it’s a high complexity patient you are worried about or simply just catching up on charting. I’m glad these articles have heightened your awareness of the effects of how we carry ourselves and how we communicate with our patients can have meaningful impacts. Especially with some of the patients you mentioned with high irritability/severity where the more we try and do with them the greater likelihood we could just make them worse. The second article you spoke on I also read and it really stood out to me in how I am going to go about patient management in the future. Thanks for the great post!
September 29, 2021 at 9:04 am #9003David BrownModerator
I think this a great first topic to delve into as a resident as the subjective examination is something I so often overlook in terms of how I go about asking my questions and how I engage with the patient. I find myself going into the exam with the obvious intention of being kind and respectful, but mainly focused on getting the information I need to properly diagnose and treat the patient. I never really thought about how I form my questions and carry myself and the impact that can potentially have on the therapeutic relationship.
I thought the article, “On Opening the Clinical Encounter” to be very eye opening to me because I have never put a lot of thought into how I open my dialogue with patients. I make a point to initiate the conversation with an open ended question along the lines of “How are you? Let’s talk about what’s going on!?”. By doing this I feel that I am not closing down the conversation to whatever body part was circled on the body chart but instead allowing them to take the reins and tell their story. I found that in this article many of the opening lines did not resonate with me; I found many of them to be presumptuous or just plain awkward. I liked how the author spoke to this by mentioning that Dr. John Launer believes asking questions pertaining to the “patient’s problem” assumes that there is a problem when there may not be or maybe there are several problems. By allowing the patient to tell their story I think you are empowering them to decide the impact that it has on their life and if they deem it as a problem. Moreover, using words like “problem” and talking about pain in the opening words could be harmful to the patient. I read an article during PT school called “Words That Harm, Words That Heal” that went into how impactful word choices can be and how that can impact the patient’s outlook on their own situation (especially so with persistent pain patients) and how they perceive you as a therapist; first impressions are important! After reading this article, I intend to go into my evals with a greater intention of my word choices especially in my opening words.
The importance of choosing opening words carefully and being mindful of how you navigate the subjective exam is further reiterated by the article, “Evaluation is Treatment for Low Back Pain”. I have always appreciated the importance of building a strong therapeutic alliance and how that journey begins on day 1, but never in my life did I think that the initial evaluation, without any treatment, would have such a positive effect on patient outcomes. The fact that just the subjective exam alone had a positive effect on LBP and leg pain, FABQ, PCS, and lumbar flexion AROM is incredible. Although many of these measures lacked statistical significance or exceeded the MDIC, this still shows just talking with the patient can have a beneficial effect on their outcomes. The researchers spoke about how moving forward, if we can analyze and harness the elements that drive this progress, we can maximize outcomes for our patients. This especially had an impact for me because I have worked with many patients with persistent pain in conjunction with yellow flags such as fear avoidance behaviors, preservation, and anxiety. These types of situations challenge me because I know manual techniques and simple exercises will potentially only have limited effects.
Equipped with the knowledge of how to properly initiate and engage with my patients upon their entry to the subjective exam, coupled with the understanding that building a strong therapeutic relationship throughout the visit can have lasting effects on their outcomes influences how I go about these early interactions. This also helps to educate me on the clinical management of persistent pain patients and informs me that simply building good rapport with these patients can have immediate and lasting impacts on their outcomes.
September 30, 2021 at 10:30 am #9005Sarah FrunziParticipant
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!
October 19, 2021 at 8:58 pm #9018MauzyjmParticipant
Hey Everyone! Sorry, I’m a bit late…life is a bit crazy right now and balance is…difficult.
However, I am extremely glad that this weekend series has placed such an importance on the subjective exam from all aspects of biopsychosocial driven care, as I have fortunately been taught in school, and definitely come to find out in practice, that a first patient interaction definitely sets the tone for the plan of care and, sometimes, make or break a case.
In regard to that, I felt Wodsford’s “On Opening A Clinical Encounter” and the Chester et al article referenced was interesting. Like Dave, I read Chester questions and I was like “Pretty much all of these questions are really awkward…Idk if I’d use any of them as an opening line”. They seemingly came off oddly worded, abrupt, or(to me) could give a patient the impression the PT didn’t really note any of the potential intake forms or referrals they were given. However, it does re-enforce that patients favor open ended questions that allow them to share their experience/perspective with minimal to no interruption. My experience being primarily rooted in pediatric sports med, I find many of my kids come into the evals nervous/anxious/don’t want to be in PT and almost all have never been to formal PT before. So, I tend to break the ice focusing my first 2-3 minutes on LEARNING ABOUT THEM. Where do they go to school, what sports/hobbies do they have, brothers/sisters, pets, fun facts, yada yada. 1) It puts them at ease, 2) You can gather a great deal of contextual data, living situation/support system information, and learn about the patient’s general personality even prior to them talking about the injury, MOI, or SINSS 3) It shows you care about them as humans versus the body part they are here for. Then, sort of like the winning question “Do you want to tell me your story?” I usually will usually say something along the lines of “I’ve read your intake forms/docs referral/etc, but, when you’re ready, I want to hear about exactly what happened and what’s going on from your perspective/view…” and then, like O’Sullivan, I SHUT UP until there’s an awkward silence:) By doing that, they usually tell you so much of the info need to know and helps your funneling questions be much more direct and efficient. Some kids/parents need a little guidance or encouragement if they don’t talk, but I’ve found that they can give you quite a bit of info with 3-5 minutes of uninterrupted talking :) So, tbh, this kind of just further pushed me to keep doing what I’m doing. I will admit I am someone that usually writes quite a bit while the subjective is being given; so, I do admit that I could be better about solely listening and maybe reflectively responding to better help me summarize the situation, help it stick in my head, and reassure the patient I’m fully present.
I think Dave and Sarah have covered O’Keefe and Louw articles really well (kudos, you two!). So, I’m going in a slightly different direction for the second and clinical case reflection aspect of my response and do so with the Rossettini article. Nerding out a little, I actually found the approach this article took to be quite fascinating. Noting the ubiquitous quality of pain and macro level concerns of the PT-patient interaction and session as well as the micro neurobiology/physiology of parts of the brain/pathways/chemicals are influenced by these interactions…just so cool. While this article has quite a number of takeaways/clinical pearls, I think the BIGGEST one that I could pull was outcomes of MSK Tx were heavily due to patient’s perspective of expectation toward PT, TX history, and baseline pain severity and that our behavior, beliefs, verbal suggestions, and therapeutic touch influence the patient’s perspective. So, we need to be fully aware of who our patient is, what experiences they’ve had, and utilize their goals/experiences/and perceptions in a way that guides our treatment to empower them in a personable and empathetic way…and provide ethically sound evidence based education starting at eval that benefits them vs placebo/nocebo your way to gain the outcomes you want. Clinically, I had a patient that came in with 2-3 years of persistent pain for a condition that shouldn’t have that persistence…further exacerbated by out of clinic contextual factors within her sport, internal pressure to perform, and self-doubt. So, as I’ve approached her care, I’ve made sure that my behavior meets her where she is, reflecting my beliefs and rationale behind my treatments to both her and her mother each session, and provide reassurance so I knew that I would establish the most beneficial and empowering setting I could. Her GAD-7 scores were also slightly concerning, so plug for referring to mental health professionals to further enhance the patient’s ability to handle and perceive out of clinic contextual factors too.
Hopefully that wasn’t too long. Apologies, not quite sure how these work quite yet haha :) Have a great night!
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