Jennifer Walker, PT, DPT
Physical Medicine and Rehabilitation Services
VA Connecticut Healthcare System, West Haven Campus
Healthcare providers have the responsibility to provide patient centered excellence in health care and do no harm to those they work with. In my experience as a practicing Doctor of Physical Therapy, I have learned that the first fifteen minutes of an evaluation with a patient can set the stage for a positive or negative physical therapy (PT) journey. Often phrases such as “is this going to hurt?” or “my pain is a 10/10” are heard in clinic. It can be a challenge to educate a person on “why they hurt” or on the importance of a treatment intervention when some discomfort is caused by it. I have noticed that fear can cause an individual to avoid learning helpful strategies to function and return to an optimal level of independence. It was not until I started working with a dynamic group of health psychologists within an Integrated Pain Clinic (IPC), that I learned how prevalent and powerful pain-related fear was and how much it would impact my practice as a physical therapist.
Patients referred to the IPC are evaluated by a team of providers with a focus on the biopsychosocial model of medicine. Our interdisciplinary team evaluates both the mental and physical state of a person which is imperative to treating and understanding chronic pain. An environment where patients can be vulnerable about the complexities of coping with chronic pain is cultivated when considering a person’s emotional state (i.e. frustration, fear, depression, anxiety) in the context of pain and physical limitations. One challenge I face frequently working with patients coping with chronic pain, is that many have participated in physical therapy services and are not optimistic that further services will provide pain relief. For this cohort of individual’s, I have found that both cognitive behavioral therapy for chronic pain and physical therapy services enables patients to improve their functional movements and better cope with their pain. The effort, progress, and outcomes I have witnessed are remarkable. One patient’s journey is worth sharing.
Two years ago, a gentleman was referred to my outpatient PT clinic with a diagnosis of chronic foot pain. He presented with an overall dismal attitude and low motivation to participate in a PT evaluation and treatment. During his evaluation he expressed his frustration with his medical providers, chronicity of foot pain, and difficulties performing police related duties which impacted his mood and social life. From a physical therapy point of view, I remember feeling somewhat overwhelmed as to which aspect of care to focus on first. He reported he stopped exercising because he feared “doing more damage” to his foot. He had physical therapy services in the past without relief and questioned why he was referred for more. I was able to obtain a partial physical assessment including range of motion, muscle strength, and balance measurements for this gentleman and rule out any red flag causes of his pain, but most of the session was spent listening, providing education, and discussion of goals.
After his evaluation that day I remember immediately contacting one of the health psychology interns, who is now Dr. Alexandra Singer, to review his case and seek advice on treatment planning. After two failed foot surgeries and many sprained ankles this gentleman was now fearful that partaking in social events, performing fully on the job and taking care of his overall health would cause him more pain. While on the phone with Dr. Singer, I learned about motivational interviewing and how to better understand this individual’s perception of pain by providing him with appropriate outcome measures where I was able to learn about his high pain catastrophizing and rumination. I was provided with insight on how best to organize treatment sessions and how to educate effectively after reviewing the outcomes. Dr. Singer and I discussed how to gently introduce the biopsychosocial model to the patient and the overlap of physical therapy and psychology services. Without hesitation and to my surprise on the third visit, he agreed to be enrolled in cognitive behavioral therapy for chronic pain. Dr. Singer and I spoke weekly to ensure overlap with his home exercise program, work schedule, and overall improvement in his health. As a diabetic, he was educated by psychology on weight management and I followed up with instruction on the importance of good foot hygiene. I reinforced breathing techniques and meditation during more aggressive physical therapy treatments which enabled him to work through the discomfort. Pain neuroscience education was introduced to him to better explain how pain is created in the brain and I did so through pictures and metaphors based on his history of injury. Throughout the course of treatment, he became excited and motivated to participate in both therapies. He even expressed his appreciation for the teamwork.
I am thrilled to report that this patient was discharged from PT and health psychology services where he adhered to treatment which resulted in a successful outcome. He is now able to perform better on the job using mindfulness techniques for pacing and workload. He also implemented good shoe support, orthotic compliance, lower extremity stretching and core muscle strengthening. His overall pain and pain catastrophizing scores lowered significantly, and he even left on discharge day with a smile on his face. He left well educated on his pain and “why he hurt” and how staying active would not harm him.
This is just one of many examples of how the opportunity to work so closely with clinical health psychologists has enhanced patient care, my clinical practice, and broadened my understanding of pain and how to strategize my physical therapy treatments. I mentioned earlier how impressive the first fifteen minutes of an interview with the patient needs to be, utilizing motivational interviewing to develop an insight on one’s pain and really listening is monumental to the interview. It is important to remember as a healthcare provider the person in front of you may be dealing with wounds that go deeper than just physical pain, but also include complex emotions that affect a person’s physical pain severity. Working together as a team to address the person holistically, will ensure patient centered excellence in health care, which we all have a responsibility of providing. “Talent wins games, but teamwork and intelligence wins championships.” -Michael Jordan