Happy Monday Folks! Take a read of this weeks Blog of The Week, based on helping patients help themselves. As always, let us know how you feel on the topic! From the brilliant minds over at evidenceinmotion.com
The patient-provider alliance is a term that is thrown around quite often in patient care related discussions. It’s a term that highlights the collaborative care model of bringing the patient to the forefront of the treatment decision making process in order to optimise individual patient outcomes and self-efficacy. As many are well aware, the history of healthcare practice shows us that this was not always the way. The provider was often viewed as the expert and the patient seemingly brought nothing more to the table than their injury or illness. This method of direction may work for highly motivated patients in particular, but history has shown that those who suffer from chronic pain have been left in the dust and this has resulted in the billion-dollar issue we face today. This idea of expert driven care for chronic pain continues to plague the healthcare community and physical therapists are no exception. This often leads to unnecessary intervention which ranges from surgery to spinal manipulation. While obviously two different ends of the risk spectrum, I have been taught by mentors and observed first hand that both can equally perpetuate maladaptive coping strategies and low self-efficacy in patients suffering from chronic pain. In the grand scheme of assisting patients in managing their chronic pain, less is often more.
As a new graduate assisting in the management of chronic pain, the idea of being able to “fix” everyone that walked through my doors with manual techniques and my knowledge of exercise, quickly faded. In helping my patients suffering from chronic pain, I still struggle with this idea and I beat myself up weekly wondering if I did all that I could to help my patients. When in actuality I probably did too much. This has unfortunately progressed into periods of mental fatigue, frustration (on both ends) and thoughts of giving up and moving on. The word chronic in healthcare almost seems to have become synonymous with helplessness. Our desire to help end the suffering often leads to fruitless attempts at temporary solutions and poor explanations for why people hurt as well as risky options for masking the pain which are ultimately detrimental to restoring self-efficacy.
Research has shown us that understanding the importance of collaborative care and imparting “self-management education” can be helpful in better understanding perceptions of how chronic disease truly effects the lives of our patients as well as achieving more meaningful outcomes. Published in JAMA in 2002 Bodenheimer et al. cited the work of Corbin and Strauss which described 3 sets of tasks faced by people with chronic conditions: “(1) medical management of the condition such as taking medication, changing diet, or self-monitoring blood sugar; (2) creating and maintaining new meaningful life roles regarding jobs, family and friends; and (3) coping with the anger, fear, frustration, and sadness of having a chronic condition.” As physical therapists I believe that we play a huge role in facilitating tasks 2 and 3 but need to understand that creating meaningful life goals and effective coping strategies is literally, for the manual therapists out there, out of our hands.
The key to effective self-management strategies as described by Bodenheimer et al. include traditional education including injury specific information and technical skill, complimented with education on problem solving skills to help patients make decisions, take appropriate actions, and alter these actions as they encounter changes in circumstances or disease. As PTs we often look to the big picture when we generate goals for our patients. Lofty goals are great to have but can be detrimental to the patient in chronic pain, in terms of self-efficacy, if the patient is unable to successfully achieve them. If we ask our patients to walk for 30 minutes a day and they give up at 15 minutes, the likely hood of continuing on the exercise plan is low. If the patient and provider collaboratively agree that exercise is beneficial and set short term action plans (ie. 8-10 minutes per day) the patient is likely to succeed and may later propose a revised action plan to walk more. The important aspect of creating the short term action plan requires the plan be developed by the patient and motivational interviewing will play a key role in extracting this information. When a patient tells us, “I just can’t make it to 30 minutes.” Instead of “well how about 15 minutes”, we say something like “what do you feel would be more achievable time?”, allowing the patient to propose a solution and become more accountable. In a busy clinic environment, we are often propelled to quickly give our patients the answers and this does little if anything for establishing an environment for behaviour change. Similar direction of care is applied when we impart passive treatment interventions.
In summary, we need to be cognisant about stepping out of the driver’s seat and allowing our patients to steer the bus towards their goal destinations which is facilitated by skills of motivational interviewing. It is less about what we can do for our patients and more about extracting self-directed achievable and meaningful goals. Having just completed my manual therapy certification, the greatest skill development I have taken away is not necessarily in how well I can manipulate but in understanding when and with who and why these techniques are appropriate. Keeping self-efficacy and self-management strategies in mind, the matter is often literally out of our hands and a less is more approach can be more effective.