1/25/2016 TARGETED TREATMENT. Targeted Treatment: Communication

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1 Targeted Treatment: Communication Jason Beneciuk, PT, PhD, MPH Research Assistant Professor University of Florida Brooks Rehabilitation PHHP Research Collaboration Psychologically Informed Physical Therapy Practice: Pragmatic Application for Low Back Pain Jason Beneciuk, PT, PhD Research Assistant Professor, University of Florida; Brooks Rehabilitation PHHP Research Collaboration Carol M. Greco, PhD Assistant Professor of Psychiatry Licensed Psychologist University of Pittsburgh School of Medicine Steven George, PT, PhD Associate Professor DPT Program Director, University of Florida; Brooks Rehabilitation PHHP Research Collaboration Learning Module TARGETED TREATMENT 1

2 Risk Stratified Care 1) Identification 2) Targeted Treatment Elevated psychological factors; with or without physical factors Physical & psychological factors; psychological factors not elevated Few physical & psychological factors Psychological informed physical therapy Physical therapy to address symptoms and function (primarily targeting physical characteristics) Advice, education & self-management Patients are risk-stratified based on prognostic profile STarT Risk: Targeted Treatment High Risk Psychological informed physical therapy: Assessment and management of pain related psychological risk factors Adopting cognitive-behavioral principles to address unhelpful beliefs and behaviors TARGETED TREATMENT: HIGH RISK 1. Communication 2. Pain coping skills 3. Activity based 4. Physical impairment based 2

3 TARGETED TREATMENT: HIGH RISK 1. Communication 2. Pain coping skills 3. Activity based 4. Physical impairment based Psychological Informed Practice Important that patient agrees with approach Outcomes aligned with patient expectations (patient-centered) Communication between clinician & patient is crucial 3

4 Example 1 Based on responses to one of the questionnaires you have completed you are at high risk for chronic pain; therefore we are going to address psychological aspects of your pain in physical therapy. Example 2 Based on some of the initial information you have provided, I am thinking it would be beneficial if we also address how you think and deal with your pain; in addition to other physical therapy treatment does this sound like a reasonable approach? Communication with Patients Common Errors Not exploring patient beliefs Not referring to patient beliefs during explanation of condition Not verifying patient understands explanations provided Main et al. Best Pract Res Clin Rheumatol

5 Communication with Patients Enhanced Communication Shared Decision Making Family Patients Caregivers Clinicians Expected Outcomes Treatment Decisions Effective Communication Skills Active listening Motivational interviewing Goal-setting Effective Communication Skills Active listening Motivational interviewing Goal-setting 5

6 Active Listening Non-verbal Direct eye contact Facial expression (eg, reflect empathy) Verbal Discussion-based (avoid temptation to lecture) Clarification (accurate perception of patient concerns) Summarization (paraphrasing what patient has described) Effective Communication Skills Active listening Motivational interviewing Goal-setting Motivational Interviewing Guides patient to explore and resolve mixed feelings about changing Approach to help patient realize potential misperceptions between current behaviors, goals and values Miller & Rollnick (1991, 2002) 6

7 Motivational Interviewing Collaborative and respectful approach to enhance patient motivation toward behavioral change efforts Strategies: Support self-efficacy Open-ended questioning Reflective listening (clinician provided summary) Affirmation (acknowledge patient effort to change) Miller & Rollnick (2002) Facilitation of Self-Disclosure Explore patient concerns about problem Patient is asked to elaborate on response Example: STarT Back Tool items Important we are not critiquing patient responses; only asking to elaborate*** STarT Back Tool Thinking about the last 2 weeks tick your response to the following questions: Disagree Agree My back pain has spread down my leg(s) at some time in the last 2 weeks 2 I have had pain in the shoulder or neck at some time in the last 2 weeks 3 I have only walked short distances because of my back pain 4 In the last 2 weeks, I have dressed more slowly than usual because of back pain 5 It s not really safe for a person with a condition like mine to be physically active 6 Worrying thoughts have been going through my mind a lot of the time 7 I feel that my back pain is terrible and it s never going to get any better 8 In general I have not enjoyed all the things I used to enjoy 9 Overall, how bothersome has your back pain been in the last 2 weeks? Not at all Slightly Moderately Very much Extremely Total score (all 9): Sub Score (Q5-9): Have patient elaborate on why they agree with this statement Keele University 01/08/07 Funded by Arthritis Research UK 7

8 Effective Communication Skills Active listening Motivational interviewing Goal-setting Goal Setting Collaborative process between clinician and patient Are goals aligned with patient expectations? Goals should be: Realistic Specific Measureable Direct link between communication and education 8

9 Activation Philosophy unambiguously educating the patient in a way such that the patient views his or her pain as a common condition, rather than as a serious disease that needs careful protection. Vlaeyan & Linton, Pain, 2000 Activation Philosophy Reassurance no permanent damage the spine is strong even when painful Encourage patient to resume normal activities (if appropriate) Encourage active role in recovery Emphasize positive attitude & adaptive coping styles beneciuk@phhp.ufl.edu THANK YOU Brooks-PHHP Research Collaboration 9