What you will learn - IAOM-US

1/28/2021

Copyright Patient Success Systems, LLC 2021 1

Thoracic Case Thoracic Case Thoracic Case Thoracic Case

StudyStudyStudyStudy

A Biopsychosocial

Perspective

John M. Woolf, MS, PT, ATC, COMT

www.patientsuccesssystems.com

[email protected]

What you What you What you What you

will learnwill learnwill learnwill learn

• An evidence-based perspective of the biopsychosocial aspects of a case study.

• A framework upon which to build a therapeutic alliance with your patients.

• Build a foundation from which to enhance communication and relationship skills for a better experience and better outcomes.

Facilitator

©2013 Clinicient, Inc.

John Woolf is the former owner of ProActive Physical Therapy in Tucson, Arizona. He also serves as a Member of the Clinical Advisory Group at Clinicient, Inc. He is the former co-director of the International Academy of Orthopedic Medicine-US and was Director of Sports Medicine for The University of Arizona, where he coordinated rehabilitation and medical coverage for Division I athletes.

He belongs to the American Physical Therapy Association and the National Athletic Trainers’ Association and has lectured in the University of Arizona’s Sports Medicine Fellowship Program and continues to lecture nationally on how to implement a model of Relationship Centered CareTM into health care organizations. A graduate of the Northern Arizona University College of Physical Therapy, John has a masters degree in Exercise and Sports Science from the University of Arizona and pursuing a PhD in Performance Psychology.

[email protected]

@JuanLoboPT or www.patientsuccesssystems.com

JOHN WOOLF, PT, MS, ATC, COMT, PhD(student)

CEO, Patient Success Systems – Training and Consulting

Today’s Approach

• Excerpts from Patient Success Systems courses

• Strategic Communications as a Clinical Tool

• The Science and Application of Patient Engagement for Better Outcomes

• Reflection on recent evidence

• Opinions based on experience

• A Biopsychosocial Application of each case in the series

1 2

3 4

1/28/2021


Background Story

• How can we demonstrate better outcomes?”

Outcomes Research

Patient Treatment Outcome

Patient Beliefs and

motivations

Technique

Placebo

Patient Provider Alliance

Environment

PT Beliefs

Biopsychosocial

Biomedical

Diagnosis – “The Slide”

Sizer, P., Personal Communication

Knowledge and Skills for a Complete Clinician

Structural Dx & Rx

• Anatomy/Physiology

• Pathoanatomy

• Biomechanics

• Inflammatory process

• Clinical reasoning process

• Diagnostic Paradigm

• Selective Tissue Tension

Functional Dx & Tx BioPsychoSocial Dx & Tx


• Pathoanatomy

• Biomechanics

• Kinesiology/Kinetics

• Clinical reasoning process


• SenMoCORTM

• Others


• Psychology theories

• Social Brian/Neurobiology

• Theory of Mind

• Mirror neuron system

• Interpersonal neurobiology


• DSM

• Mobilization to improve local physiology

• Dry needling

• Observation – Instruction-Education to enhance learning

• Empathy – Communication to create a successful relationship

5 6

7 8

1/28/2021


“Psychologically

Informed”

Main, C. J., & George, S. Z. (2011). Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research. Physical Therapy, 91(5), 820–824. doi:10.2522/ptj.20110060

Why be

Psychologically

informed?

• Clinical outcomes

• Organizational outcomes

• Professional satisfaction

A “Complete Clinician”

BioPsychoSocialHow do we “do” this?

BioPsychoSocialBioPsychoSocialBioPsychoSocialBioPsychoSocial• Physical explanation of the

symptom

• Anatomical/Chemical

• FunctionalBio

PsychoSocial

• Explanation related to the mind or brain

• Emotions

• Beliefs

• Behaviors

• Environmental factors

• Relationship

• Culture

9 10

11 12

1/28/2021


The Confusion

Beach, M. C., & Inui, T. (2006). Relationship-centered Care. A Constructive Reframing. Journal of

General Internal Medicine, 21(S1), S3–S8. doi:10.1111/j.1525-1497.2006.00302.x

Clinician Knowledge

Patient Centered

• Each patient is a unique individual

• Psychosocial, emotional, and lifestyle issues are integral to medical care

• Patients differ in their values, preferences, and expectations for care

• Patients’ perspective, culture, and personality are relevant to the process of care

Relationship Centered

• Each relationship is unique and is a product of the work of each participant

• The manner in which a clinician participates in an encounter fundamentally affects the course, direction, and outcomes of care both episodically and longitudinally



Clinician Approach Philosophy and Attitudes

Patient Centered

• Value partnership with patients

• View patients as experts

• Acknowledge that patients deserve respect

• View the provider-patient relationship as a therapeutic vehicle


• Value the achievement of mutual respect and unconditional positive regard

• Acknowledge that affective engagement, rather than affective neutrality or detached concern, can further the therapeutic bond and its efficacy

• Acknowledge that clinicians and patients are both active human participants (not just role occupants) who co-construct their relationships

• Acknowledge that relationships are reciprocal and involve mutual tasks, duties, and responsibilities



13 14

15 16

1/28/2021


Clinician Behaviors

Patient Centered

• Show respect to patients

• Find out about patient’s values, expectations, preferences, and background

• Tailor approach to the patient based on knowledge of patient

• Help patient get story across, listen well (nonjudgmentally)

• Respond to patient’s emotions, show empathy

• Seek common ground as a point of departure for formulating therapeutic plans


• Attend to/monitor one’s own behavior as an influence on the other(s)

• Be aware of and acknowledge own feelings and biases (emotional self-awareness)

• Acknowledge the importance of relationships to the therapeutic process and outcome for both partners

• Acknowledge need to take both participants’ values, attitudes, and personality into account

• Acknowledge areas of agreement and disagreement on values, expectations, etc.

• Monitor the state of the relationship

• Acknowledge the importance of the relationship to one’s own well-being



Clinician OutcomesPatient Centered

• Patient feels honored, respected, attended to, etc.

• Patient likes and is satisfied with provider

• Patient has lower anxiety

• Patient has trust in provider

• Patient adheres to treatment

• Patient remembers information, advice

• Patient is more actively engaged


• Mutual attunement and harmony

• Informed decision making

• Added depth and vitality to interactions

• Clinician becomes a source of social and emotional support for the patient

• Patient becomes a source of professional reward/gratification for the clinician

• Protection against professional burnout

• Greater agreement on treatment plans



Patient-Centered Care

Patient Provider

© 2020 Patient Success Systems, LLC

Patient-Centered Care

Patient Provider


17 18

19 20

1/28/2021


Relationship-Centered CareTM

Me You


Relationship-Centered

Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2012). The

Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Physical

Therapy, 93(4), 470–478. doi:10.2522/ptj.20120137

Relationships


21 22

23 24

1/28/2021


Identity

External

EnvironmentInternal

Experience


Major Schools of

Psychology

• Structuralism

• introspective methods to identify the basic elements of experience by asking subjects to describe their experience while performing a mental task

• Functionalism

• Examination of why animals (human and other) behave viewed from an evolutionary perspective. Precursor to evolutionary psychology

• Psychodynamic Theory

• Examination of the role of the unconscious in human experience and behavior. Very difficult to study

• Behaviorism

• An attempt to completely bypass the study of the mind because its not possible. Study behavior to eliminate the “black box”. Stimulus-Response Model; operant conditioning and principles of learning

• Cognitive

• The study of thoughts as mental processing that includes perception, judgement, and memory. Cognitive neuroscience.

• Social-Cultural Psychology

• study of social and cultural influences on thinking and behavior. An individual’s relationship with oneself and with others and their environments.

Working Model of PsychoSocial


Internal Maps of RealityPeople respond to their internal map of reality, not to reality itself.

• Internal maps are formed through our language and sensory representation systems as a result of our individual life experiences

• The map is not the territory. Our mental models of reality, rather than reality itself, determines how we respond to the world and act

• Successful providers are able to understand their own “maps” and their patients’ maps


25 26

27 28

1/28/2021


Identity

External

Environment

Internal ExperienceWorldview

History

Tribe

Beliefs

Values

Identity

Mission

Thoughts - Judgements

Emotions

Behaviors


Basic Unit - Dyad


External

Internal Experiences

Internal

Experiences

Patient Provider

Basic Unit - Dyad


Do we see this situation the same way?

How close are we to agreeing upon what we both see?

Are we in agreement about where we are going?

Are we in agreement about how to get there?

Patient Provider

Internal Experience

Worldview

History

Tribe

Beliefs

Values

Identity

Mission


Emotions

Behaviors

Internal Experience

Worldview

History

Tribe

Beliefs

Values

Identity

Mission


Emotions

Behaviors

The Goal

29 30

31 32

1/28/2021


A Successful Outcome


Accurate

Assessment

A diagnosis:Structural

Functional

A Treatment

Plan

Diagnosis specific

Patient Specific

Provider Specific

The “proper dose” of

intervention

Successful

Execution of the Plan

Ongoing productive

engagement

Completed

Treatment Plan

A measurable result

How do we frame the GOAL?

• Improved Self-Reported Outcomes

• Improved Objective Clinically Measured Outcomes

• Patient Satisfaction

• Document: “Goals achieved”

• A Completed Plan of Care• Patient’s goals were met

• A mutual agreement that the plan is not working


WE have to get to here AND we want to get here…

• An ongoing relationship with the patient• They return with future needs• Promote you to referral sources• Promote you to friends and family

Regardless of the Clinical Outcome


33 34

35 36

1/28/2021


What Tools do we Have?

Bio

• Our Hands

• Equipment

• Tools

PsychoSocial

• Empathy

• Communication

• Connection

• Inspiration


Relationship

Resources: Basic Psychological Needs

• Competence• Challenges that match patient ability• Opportunity for patients to demonstrate capabilities• Aligning patient rehab goals with salient non-therapy activities• Positively worded feedback verifying patient progress• Educating about the rehab process• Realistic expectation

• Autonomy• Ownership over rehab process• Provision of choices and options• Provision of meaningful rationales

• Relatedness• Development of caring relationships• A sense of connection with fellow patients


Hall, M. S., Podlog, L., Newton, M., Galli, N., Fritz, J., Butner, J., … Hammer, C. (2020). Patient and practitioner perspectives of psychological need

support in physical therapy. Physiotherapy Theory and Practice, 1–16. doi:10.1080/09593985.2020.1780654

Reframe

37 38

39 40

1/28/2021


BIOPSYCHOSOCIAL APPROACH

• Reframe Goals as a Destination “From Here to There”

• Provides a mental construct that the engagement is a Process or a “journey”.

• Reflect on WHO you are in this Process

• A technician providing procedures and techniques

• More than “Doing stuff”

• Consider the frame of being a GUIDE

• You are guiding someone to a destination

• To succeed at getting to the destination, you must work together.

• Establish a Therapeutic Alliance

• Agreement on the Destination and the Plan to get there


Person has problem

I want to go there (away

from here), but I don’t

know how!

• A symptom that he or she does or does

not understand

• Anxiety and uncertainty

• A “map” to navigate the “territory”

• Will it get her to where she wants to go?


A Patient Starts Here and Wants to Go There



know how!


They Meet You




know how!

Can you help me?

41 42

43 44

1/28/2021


You Agree To Try




know how!

Can you help me?

Yes, I can try

There Begins a Process of Engagement




know how!

Can you help me?

Yes, I can try

Getting here

requires clarity

on all the factors

of this place and

some idea of will

be necessary to

get there

A Deep Understanding of Multiple Variables


To begin this process I

need to feel safe

I need to know if I can trust

you to lead me.

I need an ongoing feeling

Competent, a sense of

Autonomy, and that I

Belong here.

Getting here

requires clarity

on all the factors

of this place and

some idea of will

be necessary to

get there

Past Story

To help you get there I need to know some things.

• All the factors that lead to you being HERE

• Where EXACTLY do you want to go? And why you

want to get there?

• What you are willing to do to get what you want?

The Journey Forward Begins


Starting here

requires clarity

on all the factors

of this place and

some idea of

what contributed

Getting here

requires clarity

on all the factors

of this place and

some idea of will

be necessary to

get there

Past Story

A Therapeutic Alliance• Agreement on Goals

• Agreement on the Tasks to

Achieve the Goals

• Unconditional Positive regard

Co-creating a “map” to

the destination

45 46

47 48

1/28/2021


Reconciling Maps


Getting here

requires clarity

on all the factors

of this place and

some idea of will

be necessary to

get there

Past Story

My Map

My Map

10 Skills

1. Motivational Language - Solution Language2. State Management3. Calibration4. Rapport5. Pacing6. Active-Listening Skills: Open Questions, Backtracking,

Summarizing7. Healing Map Interview - Perceived Problem8. Healing Map Interview – Goals, Pathway, Barriers,

Resources9. Readiness to Change Measure - Resolving Non-compliance

10.Measuring Therapeutic Alliance


Case Discussion

Goal: Completed Plan of Care

• Co-create a plan of care

• Must integrate the patient's reality into the plan

49 50

51 52

1/28/2021


Skill #7

Healing Map Interview

“Build a Map of your patient so that you can use his/her map to help them navigate the Territory”



• 5 Step Process to create a “well formed outcome”

• Creates a structure to “see” the “whole picture” with the intent of establishing a therapeutic alliance

• Uses previous skills (motivational language) to build a map

• At the end you will have a “map” to guide the patient to an agreed upon destination


Patient’s Healing MapTM

Pathway

to Goals

Perceived

Problem

Barriers

Resources

Goals




USE ALL PREVIOUS Relationship SKILLS!

Rapport

Open questions

Pacing

Backtracking

Summarizing

53 54

55 56

1/28/2021


The case:• In a systematic approach, we have

gained essential information

• We have a sense of who this person is: The “surface” level of her experience

• 29 yo male warehouse worker. Able to work

• 1 year history of continuous thoracic pain

• Former bodybuilder, golfer, cyclist, martial arts, but has had to stop because they increase his pain.

• Has received multiple forms of treatment with temporary success

The case: • Dx: Two pain generators

• IDD

• Costotransverse articulation – Ribs at segments T7-8 and T8-9

• Plan of Care

• Education –

• Chronicity of pain

• Thoracic and Rib mobilizations

• Dosing return to activity

Perceived Problem Questions

• What is your understanding of what is going on with you?

• What has Dr. ____________ told you about your condition, treatment, prognosis, and progress?

• Does that make sense to you? What questions do you have?

• What do you think is the cause of your pain?

• What do you think is contributing to this condition?

• What does it mean that you have this problem?

• What are you expecting from our treatment?

• At this point, how confident are you that the treatment will be successful and you will get better?



• What is your understanding of what is going on with you? • “Something is out, but my chiropractor could not get it to stay in”

• “I’m afraid its not going to get better”

• What do you think is the cause of your pain?• “My back is out of alignment”

• What do you think is contributing to this condition?• “I don’t know, I have not been doing except working

• What does it mean that you have this problem?• “but I can’t do a lot of things the other guys do and I don’t think I’ll bet promoted if I’m so

limited.”

• What are you expecting from our treatment? • “I want to get back to playing golf”

• At this point, how confident are you that the treatment will be successful and you will get better?

• “Not very. This has been going on a long time”© 2020 Patient Success Systems, LLC

57 58

59 60

1/28/2021


Skill #8Healing Map Interview

Goals

Pathway to Goals

Barriers

Resources


Questions: Goals

• What would you like to accomplish in therapy?

• What would you like to accomplish today?

• How would you like things to be different when we are done working together?

• Stated in the positive. • Example: “So if your pain was gone, what would you be experiencing instead?” …ease, function, strength, etc.

• What will having this outcome do for you?

• (Or) What’s important about this?• (Ensure goal is in patient’s control, specific, realistic and attainable)

• When do you want it? (time-oriented)

Advanced technique:

• Imagine stepping into the future and having your outcome fully…What will you see, hear, and feel when you have this outcome?


Questions: Goals

• What would you like to accomplish in therapy? • “Get back to playing golf and working without pain”

• How would you like things to be different when we are done working together?

• “Hummm…less pain, I consider myself a pretty tough guy, but I am really tired with this pain.”

• When do you want it? (time-oriented)

• “I don’t care as long as it works”.

• What would you like to accomplish today?• “Hum...I really want to know if this is going to be more of the same”

Advanced technique:

• Imagine stepping into the future and having your outcome fully…What will you see, hear, and feel when you have this outcome?


Questions: Pathway

• What do you think will be required to Reach your goals?• “I’m not sure how to keep something in place. I will do what it takes.”

• How long do you think it will take to get better?• “It has been so long, I don’t really know.”

• How much time can you dedicate to doing things at home?• “A fair amount, I really, really want to get back to being active.”

• How many times per week can you be here for treatment?• “I am still working, and my co-pay is pretty high. I think I can make it 1-2 times

per week”


61 62

63 64

1/28/2021


Questions: Potential Barriers

• What might get in the way of you reaching your goals?

• “I have an ‘alignment’ issue”

• Can you picture yourself in the future having reached your goal?

• “Yes, I don’t know how to keep it in place”

• What might get in the way of you getting to your appointments?

• “Work schedule and copay”


Hall, M. S., Podlog, L., Newton, M., Galli, N., Fritz, J., Butner, J., … Hammer, C. (2020). Patient and practitioner perspectives of psychological need

support in physical therapy. Physiotherapy Theory and Practice, 1–16. doi:10.1080/09593985.2020.1780654

External Environment

Internal Experience

• External: Environmental

• Work

• Internal:

• Stress – Anxiety

• Resourceful around a ‘construct’ of the diagnosis: alignment.

Additional conversation

YOU: “It sounds like you want this thing back in place and to stay there”

Patient: “Yes, can you do that?”

YOU: “I think I can get you feeling better, and it might require a slightly

different approach, would you be willing to try?

Patient: “Yes, as long as it works!”


BioPsychoSocial Awareness

• He is active and generally good health

• He has had a series of injuries and has attributed the limited success to adjustments based on alignment

• He currently holds a belief


• A belief is something that we hold to be true even if the facts do not support it.

• To maintain a belief we must

• Omit and/or distort facts

• Changing beliefs is very difficultto do


Help Us Address Patient Beliefs • 3 Primary Areas of Pain Beliefs

1. Causal attributions

2. Treatment expectations

3. Expectations of a cure

• “Without explicitly asking patients about their beliefs and expectations to realize a shared understanding of the pain problem, PT’s are at risk of talking and acting at cross-purposes.”


Daykin, A. R., & Richardson, B. (2004). Physiotherapists’ Pain Beliefs and Their Influence on the Management of

Patients With Chronic Low Back Pain. Spine, 29(7), 783–795. doi:10.1097/01.brs.0000115135.19082.97

65 66

67 68

1/28/2021


Biopsychosocial concerns:

• That you both align on the diagnosis.

• How can you achieve this alignment?


Questions: Resources

• YOU: “You have had this pain for a while. You have had some success with manipulation, but it has not lasted.

• Patient: “Yes, it always feels good when I get that pop, and it lasts for a while, but does not stay. I try to pop in my self, but it does not work as well.”

• YOU: “Tell me what you understand about what happens with the pop.”

• Patient: “Well, I assume that is when the joint goes back in.”

• YOU: “Good, it helps me to understand how you see the issue. The pop is commonly understood by people to be a realignment, and there is another explanation that I think will help in our treatment.”

• YOU: “I think when we explore that other explanation, we are going to make some headway on getting this better in a way that lasts. Would you be open to that”

• Patient: “Hummm. Yea, I guess. I don’t think I understand it.”


Biopsychosocial “intervention”

• Listening to what’s important (value criteria)• Being active

• A lasting result

• Empathy • I understand what is important to you and I understand

how you see it.

• Education• Must reconcile the “new diagnosis”.

• An effective story that “Expands His Map” DON’T ATTEMPT TO DESTROY HIS MAP

• Compliance• Not likely an issue

• Strategies• Getting aligned on the diagnosis AND the treatment plan

• Setting realistic expectations© 2020 Patient Success Systems, LLC

• “I understand that it is important for you to stay active so that you can keep working and get back to golfing, biking and other stuff”

• “You have been dealing with thing for a long time, and you have had some manipulation that has created some results, but they did not last.”

• “It is tiring dealing with this ongoing pain without any lasting solution.”


Listen to Value Criteria

69 70

71 72

1/28/2021


• “I understand that it is important for you to stay active so that you can keep working and get back to golfing, biking and other stuff”

• “You have been dealing with thing for a long time, and you have had some manipulation that has created some results, but they did not last.”

• “It is tiring dealing with this ongoing pain without any lasting solution.”

• “Hear you, it takes a lot.”


What makes these or any

statements

“empathetic”?

Empathy Education

• Be a GREAT Educator!

• Explain pain as it relates to thepathology – RESPECT HIS CURRENT MAP

• Explain why manipulation has beenhelpful AND why it has not lasted.

• Use a skeleton and demonstrate thearticulation of the ribs to the spine andhow the “chemistry” or “sensitized issue” has not been able to “clear thechemistry” or “adapt”.

• “I will manipulate with the intent to“clear the chemical irritation” or to “get that tissue to adapt”

• Speak at the level of your

patient

• Use metaphors and

analogies to help

communicate concepts © 2020 Patient Success Systems, LLC

Compliance

• Not likely an issue, but we could lose him if he does not see results soon enough.

• We need time to change the physiology and he has a previous experience of stuff not working well.


Strategies

• Continuous check-ins at the begging and end of each session.

• “Are we going in the right direction?”

• “hang in there, I mentioned that ittakes time to change that tissue (the disc, the costo-vertebral articulation, and the nervous system’s sensitivity”


73 74

75 76

1/28/2021


Your SkillsEmpathy

Listening for Values Criteria

Reframing and summarizing

Collaboration


Relationship-CenteredAligning Maps

Pathway

to Goals

Perceived

Problem

Barriers

Resources

Goals

Pathway

to Goals

Perceived

Problem

Barriers

Resources

Goals


Healing Map Summary

• Every patient has a map

• Master clinicians can elicit a patient’s map and either use it as is or help the patient expand her map

• Knowing your patient’s map will allow you to make the best therapeutic intervention for that person

• Foundation to relationship-centered care, allowing patient to take ownership


Our Goal

• To align our maps toward a common destination

• Therapeutic Alliance

• To understands the patient and their situation and recognize the impact on their capacity to heal.

• Internal and external factors

• To approach the patient encounter as a “complete clinician”

• To ensure both patient and provider stay engaged with the treatment plan

• To complete a plan of care


77 78

79 80

1/28/2021


Case Result

• Better after first visit: Why?

• Mechanical Chemical Efficacy?

• Psychoneuropharmacologic?

• Ritual?

• Relationship?

• 12 total visits over 6 weeks

• Brilliant Result that was based upon the correct diagnosis and applied in a relationship-centered manner!

Thank you

81 82

Documents

What you will learn - IAOM-US