Reading Between The Lines

July 13, 2011 by   Print
Filed under Physiotherapy Blog

Two hours before our scheduled 1st appointment I got a message to call this lady as she felt that she was in “too much pain” to attend for assessment.  There was a time in my NHS service days of 20 min appointments and 25 cases/day that I would have been glad of such a reprieve but not now. My initial disgruntlement at the short notice cancellation was compounded by the knowledge that the appointment was only booked the previous day following a consultation (on the same day) with her Orofacial Pain Specialist.  This raised a few alarm bells and I felt compelled to call her both to ascertain the extent of her flare-up, what her thought process was with regards to her expectation of Physiotherapy and to outline our 24 hour cancellation policy.

From there we began an interesting half hour telephone conversation.  By way of background I should add that I work very closely with the Orofacial Pain Specialist who referred her and on that basis knew that there had been some degree of “priming”.

Our conversation went along these lines.

Good afternoon Mrs. Smith I believe you wanted to have a word with me regarding your scheduled appointment this afternoon?

Yes I won’t be able to make it, I am in too much pain

Oh you are calling to cancel the appointment?  The message I had received was that you wanted to discuss whether it would be appropriate for you to proceed with assessment?

Oh no I am in too much pain.  I couldn’t possibly make it.  Can I reschedule next week?

What do you think would be different next week?

Oh it should settle down by then.  I have been prescribed some new medication, which I am hoping will be effective.

Have you had a lot of medication in the past?

Yes I have tried them all. The last doctor didn’t tell me that I had to take the “nerve tablets” for weeks so they did nothing for me when I took them occasionally.  I have had this problem since my husband died six years ago; I have seen three Rheumatologists and two Pain Specialists and none of them can do anything for me.  Have you ever heard of Fibromyalgia? And none of them can do anything for me.  Do you treat patients with this type of problem?  Do you think you can help? What kind of treatment do you do?

Well undoubtedly you have a complex problem, which many skilled practitioners have failed to resolve.  I wouldn’t do you the disservice of flippantly saying on the telephone that I could help you when so many others have obviously failed.  Why do you think treatment hasn’t helped?

Well I have been a bit depressed since my husband died six years ago and I have tried every kind of treatment – Osteopathy, Chiropractic, Massage, Physiotherapy, Hot Stones.  So I have tried everything I could and nothing seems to work.  I also suffer from depression and that doesn’t help.  But the doctor has given me new tablets so maybe that will improve things.  Can I book an appointment to see you tomorrow?

No.

Oh so you don’t want to see me?

No I didn’t say that.  I said we couldn’t schedule an appointment for tomorrow.  Do you feel the severe incapacitating pain that you have today will resolve sufficiently by tomorrow?

I don’t know.

How long do flare-ups usually last?

Oh can be a few days.

Well my suggestion is that you try at least one week with the new medication (Neurontin) that has been prescribed so you can judge the effect of that medication.

Well it’s just another tablet.  I really don’t think it is going to help very much.

But a few minutes ago you suggested that you thought it was going to be a great help

Yeah I suppose so.  Maybe it will.  But I have tried so many I don’t have much confidence anymore.  What do you think?

I  think you need to try the medication for a week and see if it makes much difference to your symptoms.

Do you think it would help?

I am not going to predict if it’s going to help or not.  I think you need to see whether it’s of any benefit and make a judgement.

But the doctor says it would take 6 weeks to work.

Yes indeed there can be a whole series of progressions on the drugs that you are on and it can take a 6 week period to work through.  However, I think you will have a good indication in one week whether things are improving or not. 

If you call me in one week then we can talk about whether you’re ready to commence Physiotherapy, what you’re expectations are and what you’re commitment to the rehabilitation process is?  You tell me that you get great benefit from Chiropractic Manipulation so I would take it as a good indication that physical treatments have some role to play in your management.  However it is clear that they are not the full solution and we need to address other issues, which may involve posture, muscle conditioning, ergonomics, pain management etc, etc.

Why do you not continue with chiropractic if it has been helpful?

Oh you seem to understand my problem so well.  Can I not come and see you tomorrow?

I need to make this absolutely clear that no individual clinician is going to wave a magic wand and solve the symptoms that you have been experiencing.  It is likely going to take multiple specialists in different areas to assist and also a significant change in your strategy of seeking a solution from what you have described so far.  I would do you no favours by seeing you tomorrow, simply adding another opinion to the long list of opinions that you have sought and in all likelihood not living up to your expectations of miraculous improvements.

Oh, yes, I see. So do you not want to treat me? I can’t go on like this.

I don’t want you to feel that I am refusing to treat you.  What I am trying to do is ensure that you are in a good place to respond to treatment.  As we have discussed, you obviously have a complex problem and there is obviously no point in repeating speculative treatments, which have been tried in the past and failed.

I am very willing to try to help you but I think we need to clarify each of our respective roles in order to increase the likelihood of a positive outcome.  So I will put the ball in your court and wait for a phone call from you next week to discuss the plan to move forward.  Talk to you then.

This conversation struck a chord with me as I reflected on the thought processes of both parties and the strategies used in response to the conversation.  I tried to adopt a style, which was challenging but not too confronting whilst at the same time recognising some fundamental belief system changes I felt were required.

The fact that I deferred arranging for a new appointment was partly to address the trial medication issues as discussed above (incidentally, my expectation is that there won’t be a significant change with the medications or the side effects will be to unacceptable) and secondly so that there can be no misconception that scheduling an appointment was purely for the purposes of me seeking financial gain (as I work in a Private Practice setting and hence my desire to be separated from the long list of other money grabbing failed clinicians). So I ask myself these questions:

Will she call in one week?

Is she likely to comply with a treatment regime?

How far can I go with challenging her distorted belief systems?

Is she likely to comply with a long-term management regime?

Is her depression likely to be an insurmountable compounding variable, which ultimately forms a roadblock?

How do you think I handled this situation?

What would you have done differently?

Let us know your thoughts.

 

Enjoy the clinical challenge.

 

 

 

David

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Comments

11 Responses to “Reading Between The Lines”
  1. Mark Brennan says:

    Hi David

    Interesting situation and thanks for posting it up. This area I find a difficult one to address with this type of patient especially when they are face to face in the clinic (in a private practice setting) but maybe the telephone gives us more scope to put challenging questions to them, initially anyway.

    Will she call in one week?
    yes if she is willing to change her beliefs, no if she is still fixed on finding the magic treatment

    Is she likely to comply with a treatment regime?
    I think only if she sees some quick changes which maybe difficult.

    How far can I go with challenging her distorted belief systems?
    given time, I think this going to be fundamental to push it all the way.

    Is she likely to comply with a long-term management regime?
    only if she is fully ready to change and ready for a new approach, as you stated she needs to be ready for a management approach that is different.

    Is her depression likely to be an insurmountable compounding variable, which ultimately forms a roadblock?
    Probably but it will help her to understand things better why this is. Also depends if this is being managed in other ways such as psychology and how much MDT can be incorporated working together.

    How do you think I handled this situation?
    very well and at least to some extent she seemed willing to engage on a different level to her previous expectations.

    What would you have done differently?
    Only thing is to highlight even more that a lot of this is going to be up to her and to be actively involved in her treatment but maybe this will come on the next session.

    Thanks

    Mark

    • Hi Mark, thanks for the feedback.
      I hadn’t really thought too much on the significance of the telephone versus ‘face to face’ and probably in retrospect it is a bit easier to be more challenging via telephone than in person, although that was not my intention.

      The real thing I wanted to avoid was for this lady to present for yet another re-assessment with delusional expectations and undoubtedly major dissatisfaction when an instantaneous cure was not provided. My thinking was at least if she could be convinced that the solution to her problems will not lie in medication alone (although I have no beef with adjunctive pharmacology).

      I think the challenge will be to create an environment whereby behavioural changes and belief systems can be challenged in a not too confronting way, but also by mapping realistic, objective targets. To this end I think picking specific elements of her symptoms, which may be amenable to specific treatments may be a useful access route to deliver other elements of care.

      Interestingly, and in the context of Jay’s comments regarding “willingness /ability to process information” , this lady rang 2 days later to schedule an appointment, rather than discuss with me, as had been planned – and proceeded to engage in a similar lengthy conversation with my secretary regarding treatment management outcomes etc. This would tend to leave me concluding that she is not well positioned to receive information, but that will form the basis of our next conversation which will ensue shortly. I will keep you in the loop.

      What I am really hoping to do is to ascertain the scope of issues, which are driving her pain experience and identify what areas I can help with and what are outside my sphere of influence. As a wise pain psychologist once described a mutual patient ‘I think she is just stuck’.

      I am trying to engineer a situation where a self-perpetuating prophecy will inevitably be fulfilled if the terms of engagement aren’t clearly defined.

      The real challenge I think will be in getting collaborative focused care from all parties involved.

      Many thanks for your insightful comments and contribution.

      David.

  2. ian stevens says:

    David, I like your considered challenging but non threatening approach. I think you made some comment on body in mind (the neuro one not the ‘other one’!) about how as you have gone on in practice and chosen staff etc its these qualities that are the the most important determining factors in success or ‘failure’. I have Benedetti’s book to read on the neuroscience of the Dr patient relationship to read for a talk to a pain group . You might be interested in this and his papers on nocebo etc which I find fascinating.
    Your patient said this……’I have had this problem since my husband died six years ago’…….This is not uncommon in this type of sensitisation process ….I don’t think there can ever be a reproducible ‘way in’ to solve these problems ……..Rather like a few brilliant examples in a very readable book on why working with your hands is good for you (and working in an office makes you mad!) tacit or non conscious clinical experience often informs practice more than is often discussed. The ‘way in’ is to probably to acknowledge suffering , empathic bodily communication (well discussed by Bevis Nathan (touch and emotion in manual therapy)and to be aware of boundries (when people benefit from the man therapy but seem to be then seem to be able to require help from someone else… I had a similar patient in the other week who was like this with ongoing chronic shoulder pain ……she benefited immediately from an injection delivered by a colleague who knew her v difficult personal circumstances and she resonated to his style and care. She came back happy that something had been ‘done’ and without prompting told me about some of her problems ……
    Anyhow some of it will always be a bit of an art with neuroscience as a model to direct care things may be a bit more fluid and less orthopaedically dominated? I was thinking of David Butlters recent post on spirituallity and the nerve root and the references he provided ….noinotes.wordpress.com/2011/07/06/noi-notes-on-spirituality-and-nerve-root-pain/
    I think you have left the door open for her but she is confused,distressed and perhaps wants a little direction .Its a fine line between care which could be paternalistic and medicalising and expecting people who are at a very low ebb to self care with little outside support …….never easy balance!

    ian

    • Hi Ian, thanks for taking the time to reply.
      I see you have explored some of the other BodyInMind sites also!
      Thank you for the recommendation on Bendetti’s book which is definitely now on my ‘to read’ list. As well ashis published work on nocebo.

      I think the point you raised regarding the combination of Art and Neuroscience (and probably a host of other basis sciences) is really at the root of our clinical challenge and possibly at the root of tensions between clinicians and researchers. I like to have my foot in both camps (which I don’t think is a cop out) but with an undoubted bias towards the communication / interactive element.
      I was going to guestimate a ratio here, but on reflection it would be meaningless as in reality I suspect the specific choice of manual techniques is sometimes irrelevant in the overall context. It pains me to say that having trained as a manual therapist twenty years ago…

      I did see David Butler’s article on the NOI Newsletter regarding spirituality, which I thought was an interesting perspective. I think what is even more interesting is that Clinicians are prepared to discuss these issues openly in a forum, all be it perhaps only when exposed to friendly fire, but none the less at least getting it out there. There was a time (in my ignorance) that I would probably have been quite dismissive of such a discussion, probably on the basis of deluding myself of its non-scientific focus!.
      I really think we need to bring these issues out in the open more, because I think there is a trend of hiding behind the evidence or paying lip service to it when treating in a holistic way anyhow.

      Thank you so much for your detailed, considered response and the sharing of resources, which will undoubtedly be of benefit to all the readers.

      David.

  3. Jay says:

    This is obviously a challenging situation for both parties. The difficulty is that the belief system of the patient has been long shaped by the expectation of a ‘cure’ that is deeply embedded in western medicine.

    You are clearly talking to someone who is deeply depressed, unwell and needs help and support to change those beliefs. People with chronic illness often feel dis-empowered and desperate. The response that most resonated with me in regards to this situation is for the practitioner to be clear that “I do not have the answers, but I can apply what I know and work with you with the goal of pain reduction”. Sometimes simply having that emotional support will benefit the patient far more than treatment. Practitioners are often in the best situation to help initially co-ordinate patient care and help the patient build the right team.

    Too many practitioners throw up their hands at this situation and often the patient will feel ‘left’ by the system, that’s why the suicide rate of this group is predicted at around 50%. A tough challenge but something that desperately needs addressing!

    Although I appreciate that your response was well thought through, and with the best intentions. I am unsure if someone who is that depressed is really in a position to understand where you are coming from.

    • A very perceptive observation Jay, as the comprehension impairment you alluded to does appear to have manifested itself – as I have described in response to Ian.

      My intention is to pursue a follow-up conversation, but I will script out my strategy in advance to try and determine if the information I am trying to impart is registering and more importantly if it is influencing actionable steps.

      I must confess I am still torn between whether to try to provide this on the telephone initially, or to leave the discussion for the scheduled appointment – which I know will last longer than the 1 hour normally allotted!

      Although again for reasons outlined in response to Ian, I think a “one-off” assessment that challenges her beliefs or doesn’t establish a sufficient rapport to achieve compliance, is really only going to compound her situation.

      Again, many thanks for your time and thoughtful analysis.
      The jury is still out.

      David.

  4. ian stevens says:

    ‘There was a time (in my ignorance) that I would probably have been quite dismissive of such a discussion, probably on the basis of deluding myself of its non-scientific focus!.’

    Me too …….
    www.jneurosci.org/content/26/46/12014.short
    Have a look at this for example and the abstracts…….I like the title nocebo is the enemy not placebo…….
    www.cortona.ethz.ch/services/archive/2006/teachers/fbenedetti
    More background above………I think the tide is turning academically and the ‘evidence’ regarding complexity and clinical interactions serves clinicians better (for the majority of modern health problems) than the typical courses presented.
    At a personal level its interesting that Lorimers and David Butlers messages in particular are influencing people .Sure the science is interesting but note the delivery – particularly Davids…Calm , considered, reflective , full of humour , comfortable with complexity and a tone of voice which gives a bit of hope!
    I am not saying content does not matter but I am more and more convinced that the above factors are of paramount experience.The downside of working like this and absorbing the emphasis on communication, personal development is that it requires more energy expenditure –we mirror who we engage with bodily(I am fascinated by embodied cognition -see the excellent better movement blog by Todd Hargrove)

    Jay , I fully agree with you especially ‘something needs doing’ …Particularly in primary care its a modern epidemic . Physiotherapists are often in the no mans land where such issues crop up all the time . It is often left to people who are drawn to this type of work or have more empathy to try and help – there is little emphasis in training or basic acknowledgement of the issues…Its a much bigger cultural issue I believe –medialisation of suffering , tick box medicine , rushed appointments and services geared for an acute medical model …
    frontierpsychiatrist.co.uk/interview-with-iain-mcgilchrist/
    Covered by this (unless you have a lot of time on your hands i wouldnt get the book but it is a an amazing achievement!)
    A brief thought by the author …..’It still seems to me a scandal, in view of the fact that over 60% of GP consultations are ultimately psychiatric in nature, that you can’t become a GP unless you have done attachments in obs & gynae, and paediatrics, but you don’t have to know the first thing about psychiatry’….This is an issue that I see daily ……

  5. Jay says:

    Hi David,

    The difficulty is that this process of mental change may take months or years to achieve. One phone conversation or appointment alone, no matter how long probably wont address that.

    As you might have guessed, I am not a clinician, but have seen this interaction through the eyes of a patient. So hopefully an alternative perspective will be of value.

    I understand that this is a very complex problem – How do you manage someone who is going endlessly from one practitioner to another – believing the next one will solve their problem? This behavior is only occurring out of desperation and the lack of a ‘cure’ all this feeds into the depression making it insurmountable.

    From a patient perspective, and in an ideal world – how would I change this?

    1. Practitioner team based approach and communication.
    2. Patient ownership – builds confidence, control and reduces helplessness. By feeling involved any change has a much greater chance of sticking. Incorporate the patient as an equal partner.
    3. Realistic goal setting and milestones in conjunction with the patient.

    Good luck and it is wonderful that you have chosen to discuss this issue as it shows a strong commitment to better patient care.

    NB: I truly don’t wish to offend you but I would like to point out that the photo you have chosen to represent your patient is condescending (Feel free to remove this comment).

    • Hi Jay.

      thanks for the feedback.

      I think the points you make in an “ ideal world” scenario are certainly what clinicians strive for. There are a number of practical impediments to this type of strategy which pose a very real obstacles in practice and undoubtedly hamper the quality of care. Some that spring to mind are…

      1.Multidisciplinary clinics are generally tertiary in nature (last point of contact) and therefore provide services for end of line patients who have exhausted or failed numerous other interventions (at least this is the case in the British Isles)

      2.This system failure perpetuates disability and denies access to specialists who could potentially assist with the clinical management.

      3.The vast majority of patients with musculoskeletal pain present to primary care settings which may be GP, physiotherapist, chiropractor, masseur etc. The challenge is to ensure that these practitioners are aware of the multifactorial nature of pain and more importantly have the specific skills to address the necessary components.

      4.This leads to another challenge of defining professional boundaries and scope of practice. Without laboring the point here this has been a very long-running issue regarding who is responsible for addressing psychosocial issues related to pain and the complex consequences of persistent disability. The short and simple answer to this is that any clinician involved with delivering care has a role to play and the challenge is determining when to involve other members of the care team.

      5.When patients present to primary care providers with a musculoskeletal complaint which turns out to be multifactorial in nature with significant symptoms Psychosocial drivers they may frequently not be prepared to entertain alternative explanations for their.

      In my opinion this is one of the major drivers of “therapy shopping” and it’s often only with this background that a willingness or readiness to change emerges. Undoubtedly, frustration and despair disillusionment are frequently well established at the stage.

      6.And finally a relevant but usually not talked about subject is the system of payment and reimbursement. In environments where care is provided on a pay per session (basis which is frequently the case in this jurisdiction) it certainly places strain on the patient therapist relationship when the rate of change does not meet expectations.
      This source of pressure is less of a feature when third-party payers handle the financial commitments becoming a less tangible block.
      The corollary of this that healthcare provision is seen simply as a business aimed to extract as much remuneration is possible which I think must further exacerbate the sense of disillusionment. We try very hard to detect and respond to this early.

      7.Point taken on my patient image selection. My view was that it represented, despair, frustration and anger rather than being condescending. Just shows the complexity of communication!

      I appreciate your time and valuable contribution to this discussion.

      David

  6. Wendy says:

    I was interested to see the various discussions above – particularly in regards to the benefits of phone vs face to face interaction. Personally I prefer face to face interaction as it provides so much more information than interaction over the phone as you have the benefit of body language. I also think it gives more opportunity to develop rapport which is crucial though I completely understand why an initial phone call was necessary in this instance when faced with a short notice cancellation. It gave you valuable information and offered the opportunity to open doors of communication.

    I think as clinicians we need to be very mindful of our own thought processes, expectations, our own road blocks and barriers when we deal with patients and even more so when faced with complex cases that are so multi-layered. The initial discussions above focused very much on the patient and their ‘compliance’ and ‘commitment’ to therapy which I think is very much part of the model in which we are trained in. Within that approach lies questions such as ‘is the patient going to listen to me/do what I say for treatment to be ‘successful’’. In dealing with people with persistent pain who are depressed, anxious and desperate to find a solution, I don’t think it is that black and white. Whilst there needs to be a baseline commitment on the part of the patient to attend and be prepared to make change I don’t think it is helpful to be black and white about whether you think they will be compliant from the start as an absolute as it is dependent on many different factors. ‘Compliance’ can depend on factors relating to you as well as them. It is a complex dynamic such as whether they gel with you, whether what you offer makes sense to them, whether they feel what you can offer will be helpful or will enable them to make change, and whether in fact what you can offer is what their bodies and minds need in order to heal and then more instrinsic factors such as their beliefs, motivations, prior experiences etc. Some of these factors relate to the therapist as well as the patient. This dynamic is complex and requires constant readjusting and responsiveness for the partnership to be therapeutic. I mention this issue of compliance in detail as I have worked in situations where people with persistent pain have been consistently been discharged from care on the basis of non-compliance and the full onus for the patient’s ‘failure’ in treatment has been placed with the patient and the clinican has not questioned whether they:

    (a) had been able to connect and develop rapport with the patient to engage meaningfully in treatment;
    (b) had the motivation to help the patient (and working with complex cases takes more energy, persistence and patience and can contain far more emotional content than treating someone with a simple ankle sprain);
    (c) had the necessary skills and knowledge to effectively treat the patient (i.e. following a biopsychosocial/Explain pain type approach for persistent pain instead of a mechanistic approach);
    (d) when the problem was beyond their capacity or experience as clinicians and sought help from more senior or experienced clinicians in order to learn.

    I think it is great that you have acknowledged at the outset that you may not have all the answers for this lady as I agree that it is wrong to give false hope, particularly when she has seen so many people before. Hopefully what you can offer her is a greater understanding of her condition and have the necessary skills and approach to be able to move forward. She is clearly suffering, clearly desperate to find a way out of this and I am not surprised that people in her situation continue to hunt for a solution from all sorts of avenues. Yes, she may also be trying to find a ‘miracle cure’ or ‘quick fix’ however again, I think it is important to recognise when you are interpreting the situation. It is a fundamental human drive to be happy and to minimise suffering and it is clear that this lady has been suffering since the death of her husband. The good news is that she connects her pain and the grief process – some patients don’t and this opens the opportunity for discussion if you are comfortable. I think it is also important to recognise that she is the sum total of all her experiences. I am not convinced that labelling her beliefs as ‘distorted’ is all that helpful, particularly given the information above. I think we can overlabel things trying to bring in an ‘evidence based’ approach at the expense of it being helpful for the patient. Certainly you need to explore what her thought processes are and discuss with her whether these are helpful thoughts or unhelpful (training in cognitive behavioural therapy can be very helpful for this) however some people can live quite happily in a world of what we can label ‘distorted thinking and beliefs’ whereas this lady recognises that she is depressed and is at the point of seeking help. Something in her recognises that this isn’t a way to live so there is a willingness at some level to change. How you can tap into this will depend on a myriad of factors relating to you as well as her. As Jay highlighted, realistic goal setting is very important in these circumstances and she needs to be very involved in the whole treatment process as an equal partner. This may feel foreign to her if she has been managed under a completely medicalised/paternalistic model with other health professionals and again may be something that takes time and effort to work through with her.

    Ultimately these people need time, energy, patience and persistence and not all clinicans are keen to work in this way. I have been fortunate to work in both public and private practices where I can assess more complex cases in either 60, sometimes 90 minute appointments. This extra time afforded me the opportunity to take a very thorough history and conduct a thorough examination and discuss a treatment approach as a partnership (note no treatment at the first appointment which was explained prior to them making an appointment). The most common feedback from people has been that no-one else has taken the time to listen to them in this way or to assess them so thoroughly (obviously respecting pain!) and paves the way for a trusting interaction which will serve you well when it comes to challenging unhelpful beliefs etc. Without that rapport, facilitating change becomes very difficult.

    There is some interesting work on the role of Oxytocin in healing which Dr. Kerstin Uvnas Moberg has been investigating (see the Oxytocin Factor as well as her papers). This is not a neurotransmitter that is discussed much in the field of chronic persistent pain however and is commonly only talked about in relation to mother-baby bonding and breastfeeding however it is powerfully involved in modulating the autonomic nervous system and bringing the body back into a state of homeostasis allowing the body to heal. Oxytocin is one of the hormones produced by the body when we connect with people/feel safe/establish rapport. It can also be produced by touch and closeness. Low levels of oxytocin are associated with depression, most widely studies in the postnatal population. It is also associated with inducing deep quality sleep in new mums and may have a role, together with serotonin in modulating sleep in other people. We are still learning about this hormone in the non pregnant population but we know that higher levels are secreted in people who are open/non judgemental/not stressed/able to bond and interestingly this encourages similar responses by those in close contact – hence my commentary above on the role of the clinician in facilitating change by being aware of themselves/their judgements and their thoughts. It is probably underestimated the role that this particular neurotransmitter plays each time we interact with our patients however the message is clear that our manner/ability to establish rapport/ability to remain calm and provide a relaxing environment can facilitate its secretion and provide a good foundation for establishing a beneficial therapeutic partnership.

    Good luck and thanks for posting this! It will be interesting to see how things progress.

    • Wendy, wow – what a fantastic contribution, Thank you so much.
      And I don’t think I disagree with any of the points you raised and I’m certainly grateful for the detail Oxycontin mechanisms which I will certainly explore further.

      I’ve deliberately taken some time before responding to you because some of the issues you raise regarding clinicians perspective on compliance and the dismissal of patients who are non-compliant forced me to reflect on my own practice and consider what I actually meant by referring to “compliance”.
      What I was really trying to convey was that I would be able to develop a sufficient rapport with the patient to at least give her sufficient reason to attend 4 -6 treatments where we could formulate treatment objectives, pursue legitimate targets for manual therapy and exercise (which are my fundamental tools as a physiotherapist) and subsequently address aspects of symptoms which may have musculoskeletal manifestations but ultimately have origins in other mechanisms. So my choice of the phrase “compliance” was in the most general sense of “presenting for treatment”.

      From that point I feel the challenges will be to address the myriad of components you allude to, establish rapport, credibility and hopefully modulate symptoms. I would envisage using cognitive strategies as part of this approach – but these may be “Under the radar initially”.

      The use of the phrase “distorted beliefs” I guess does imply some element of judgment on my behalf (which it wasn’t meant to) but the fundamental view here was at least to establish that I wasn’t going to promise miraculous solutions with my new brand of snake oil and therefore perhaps to moderate expectations of our interaction / consultation.

      As I alluded to in response to Jay I’m particularly interested in this issue of clinicians addressing psychosocial, behavioral and belief perspectives as part of a complex pain pattern. These issues have come sharply into focus in the last decade with the widespread recognition of the multifactorial nature of complex pain but I’ve seen very little discussion on equipping the primary care clinician with skills to address this.

      Having been involved in pain management programs and clinical education for 20 years I have been fortunate to be exposed to the current thinking on pain mechanisms and perhaps have modified my practice – some consciously and some unconsciously over time without taking cognizance of the process. The type of insightful comments posted on this feedback are certainly timely – enforcing reflection and re-evaluation.

      Interestingly, my initial thoughts on this case would be that challenging behavioral components would probably not be too confronting simply on the basis of so much failed intervention based on treating target tissue sensitivity. Many other situations would pose more of a challenge. The clinical challenge I see is the timing of the behavioral interventions which will likely be required and my ability to provide bit-sized, sequential steps to achieve these mutually agreed goals.

      I certainly don’t want to get into a situation of being critical of behavior but not providing a practical alternative strategy- so this would be high on my agenda.

      Returning to the issue of clinicians addressing psychosocial issues I have pursued many of the internationally renowned experts in this field such as Prof. Mike Sullivan, Stephen Linton, Chris Main, Francis Keefe, regarding who is responsible for instituting behavior modification in primary care. Much of this has surfaced since the concept of psychosocial flags has been popularized www.physiodigest.com/197/psychosocial-flags/.
      I think it is undoubtedly now the view that frontline clinicians are duty bound to recognize and act (using cognitive strategies) as part of their clinical practice. We can no longer hide behind blurred professional boundaries as a convenient excuse for not tackling or addressing uncomfortable issues. The challenge is having the skills to do so. Professor Peter O’Sullivan I think has developed a very practical model for musculoskeletal clinicians to integrate these concepts clinical practice which we discussed here www.physiodigest.com/5859/cognitive-functional-therapy/.

      In conclusion I worry that in these days of such emphasis on scientific evidence-based practice the communication skills necessary to deliver effective care are not seen as relevant or scientifically valid. Perhaps it only comes from clinical mileage that we adopt a more holistic perspective?
      David

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