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Copyright Patient Success Systems, LLC 2021 1
Thoracic Case Thoracic Case Thoracic Case Thoracic Case
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.
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
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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
• Anatomy/Physiology
• Pathoanatomy
• Biomechanics
• Kinesiology/Kinetics
• Clinical reasoning process
• Diagnostic Paradigm
• SenMoCORTM
• Others
• Anatomy/Physiology
• Psychology theories
• Social Brian/Neurobiology
• Theory of Mind
• Mirror neuron system
• Interpersonal neurobiology
• Diagnostic Paradigm
• DSM
• Mobilization to improve local physiology
• Dry needling
• Observation – Instruction-Education to enhance learning
• Empathy – Communication to create a successful relationship
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“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
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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
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 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
Relationship Centered
• 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
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
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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
Relationship Centered
• 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
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 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
Relationship Centered
• 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
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
• 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.
• 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
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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
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
• 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
Perceived Problem Questions
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.”
• 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.”
• 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”
• 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”