As clinicians we have been bombarded with research outlining the important role of psychosocial issues in clinical outcomes.  I have often wondered why these models have been applied to low back pain and whiplash but don’t seem to feature on the radar of many other chronic conditions we  see routinely.  Maybe it’s a case of chronic conditions such as osteoarthritis, ankylosing spondylitis, degenerative joint disease etc having more defined pathology and are therefore being a more acceptable diagnosis to patients thereby deflecting them from further questioning or seeking more treatment.

Regardless there is a vast array of measurement tools available for quantifying

psychosocial components. These include:

McGill Pain Questionnaire

SF36 Health status Questionnaire

Oswestry LBP Disability Questionnaire

Fear / Avoidance Index

Pain Catastrophization Index

Visual Analog Sacale

to name a few.

Taken in conjunction with the now widely accepted concept of Flags;

Red

Yellow

Black

Blue

Orange

we have a huge battery of questionnaires and a framework which can be used to elucidate individual characteristics and tendencies.  I have spent several years enquiring about the merits of these scales in primary care and arguing that specific questions interspersed within a subjective examination yield more direct information than a “profile questionnaire” yielding information about individual tendencies. For example “when are you planning on returning to work?” will yield some specific answers ranging from “never” to “when you get me better” to “when they say their sorry” etc…. Such responses present the clinician with an opportunity to challenge beliefs, identify obstacles or alter a management plan. Several authors of these tools acknowledge the basis of this argument but cite the lack of “research validity” for the approach I’ve outlined. I’ll let you be the judge of that!!!

One of the big challenges in an acute presentation is whether to initiate these type of investigating tools as part of a routine assessment protocol or whether to try to identify high risk patients relatively early in the intervention and alter management strategies accordingly.  On the face of it this might seem like an obvious management plan but there are some very real practical limitations to implementing it.

Firstly – if every acute patient is going to be screened using psychosocial profiling from day one then there are large numbers of patients who are going to be asked a lot of questions which they may perceive as being highly irrelevant to their primary (musculoskeletal) problem and the reason they consulted Physiotherapy.

I think this is particularly significant in the Private Care Sector where we deal with patients who are unlikely tolerate some of the enquiring questions contained in the questionnaires and the  perception of the type of treatment to be administered .  Remember again we are talking about an acute setting here not a chronic pain management setting where the patient mindset is in a different place.

Secondly, the challenge if we wait for recognition signs of slow response to treatment or unpredictable features which emerge as part of one-to-one contacts, three or four sessions into care, is how do we change our management strategy and sell it to a patient in a credible way?  By “selling to the patient” I mean providing a credible explanation for their symptoms, which may be contradictory to what was initially stated, based on the physical findings alone on initial assessment.  This is a major major issue, which is never discussed in formal literature but as clinicians, one which we must find practical strategies to address if we are to be in a position to deliver care.

So the issue of therapist credibility surfaces in two respects: Firstly,in that the explanatory mechanism of a patient’s symptoms may need to change as the therapist gets more information from increased patient contact time and behavioural observation.

Secondly, how do we start to change our rating scale factors to shift the hypothesised mechanism of symptoms from being nociceptive to more predominantly psychosocial?  Of course as in all things in life this is never a clear cut classification as there will be degrees of pain mechanisms in all presentations which may alter and vary as time goes by – ie they are dynamic.

We have discussed pain mechanisms in previous posts. So how do we rise to this challenge of changing our clinical hypothesis to facilitate a different management strategy and delivering that message effectively to our patients in order to achieve compliance?  This again is another un-talked about subject.  The therapist can feel assured in the knowledge that they are following International best practise guidelines to deliver a message which appears entirely credible to the therapist but does not appear so to the patient.  This is a classic situation of “blame the patient” for not listening to the message.  The challenge for the clinician therefore is to recognise early signs, which require a change in the hypothesis of symptom mechanisms. It also means careful consideration of the type of clinical discussions which occur in the early phases of a patient /therapist interaction. (and I don’t mean being “wishey washy/vague” when reporting clinical findings – just systematic and analytical).

Below is a checklist of strategies which maybe helpful in the clinic.

1 Be familiar with the content of international guidelines on management of acute LBP.

2. Develop an opinion o these guidlines (ie agree, disagree or select elements)

3 Evaluate the type of patient you are dealing with (ie tense, easygoing, enquiring, intimidated, hopeless, unrealistic, naive, diligent, self directed, victim etc…)

4 On the basis of your evaluation above be selective about the type of words used to describe symptoms.(ie  pain v’s symptoms, problems v’s disabilities etc).

5. Avoid the pitfall of” information overload” in patients who won’t / can’t process this.

6. Avoid , at all costs, the pitfall of” information overload” in patients who will mal-process / distort the information presented.

7 Be guarded about contradicting professional opinions which are contrary to your own (even if you think they are off-the-wall”). Careful dissection of inappropriate advice needs supportive analysis, not dismissal, and is the difference between alienating a patient and keeping them on board to deliver care.

8.Identify predictable /familiar elements of pain patterns which responses can be mapped.

9. Identify clinical /subjective response characteristics which are improving from treatment – even if the overall patient perception is of “no change”.

10 Eliminate / reduce “Nociceptive” pain mechanisms ie clinical signs of pain, stiffness, muscle spasm, loss of movement before concluding an alternative symptom mechanism (psychosocial). Blaming all symptoms on stress, tension, strained relationships, smoking, excessive weight is a sure-fire way to lose credibility.

I think there are a few more points to add to this list but that should suffice for some mental marination.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 2 comments | Add to del.icio.us
Post tags: chronic disease, clinical examination, detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, pain questionnaires, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, persistent ongoing symptoms, physiotherapy, Previous response to treatment, primary care, prognosis, psychosocial flags, subjective questioning, targeted therapy, therapist credibility, Type of interventions prescribed, whiplash

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Equally important is the identification of patterns of symptoms, which do not appear directly related to mechanical factors which are potentially intractable and unresponsive to physiotherapy.  The delicate balance to be struck here is whether to pursue legitimate treatments which have some realistic possibility of producing significant improvement, countered against the potential for giving the patient false hope with the consequent negative impact of yet another failed intervention.

What factors constitute significant improvement?

Now there’s a topic for another day!!

Factors determining information delivery:

Previous response to treatment

Type of interventions prescribed.

Patient expectations

Patient confidence in care providers

Patient attitude towards collaboration between the care providers (hostile, enthusiastic, detached, despondant)

Patient attitude to the level of disability associated with their condition.

At the other end of the spectrum are patients who present with  acute symptoms  in “high risk” areas – where know there is a strong propensity for chronicity (whiplash and acute low back pain). There is a delicate balance to be struck between trivialising modest physical findings and associating them with a short response time.  This of course fatally damages the therapist’s credibility if the symptoms have not resolved within the predicted short response time.  Alternatively, stating protracted recovery times or extended periods of disability may well become a self fulfilling prophecy.

In this situation the way to manage all acute presentations is to have structured milestones and goals in order to assess the rate of progress.  If this format is applied then patients who are responding at a slower rate can be recognised early and the therapist can equate the level of progression observed over time with the sequence of stages required to achieve full return to function.  This is not the same as telling a patient it may take a year to get better but they are unlikely to see improvement in a given specific functional deficit if they still have symptoms or discomfort when challenged at a lower level.  Therefore, equating functional tolerance with symptom characteristics is an important yardstick for both therapist and patient to monitor.

Enjoy the clinical challenge.
David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, persistent ongoing symptoms, physiotherapy, Previous response to treatment, prognosis, targeted therapy, Type of interventions prescribed, whiplash

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