Psychologically Informed Care: The value of integrating psychosocial and behavioral factors into a biomedical practice

1. 1
The value of integrating psychosocial and
behavioral factors into a biomedical practice.
Psychologically Informed Care:
Tim Phillips, PT, DPT, MTC

2. Disclosures
Personally- None
Acknowledgment-
Slides bearing this header are adapted from the course:
“The Biopsychosocial Management of Complex Patients with Back
Pain”
by Gail Sowden, Consultant Physiotherapist at University of Keele, UK.
2 © Copyright Spectrum Health 2018 All rights reserved; no part of this publication may be used, reproduced, or stored in a retrieval system in any form or by any
means without the prior written permission of the copyright owner.

3. 3
PAIN EPIDEMIC

4. What are we treating??
4

5. Key Assumptions of the Biomedical Model
1. Pain transmission is directly from the periphery to the
brain
2. Pain is the result of tissue damage
3. The amount of pain is directly proportional to the extent
of the tissue damage / injury / pathology
4. Pain is either physical or it’s “all in your head”
5
Copyright (©2007) University of Keele:
funded by Arthritis Research UK

6. Dartmouth Atlas
INPATIENT FUSION FOR
LUMBAR SPINAL
STENOSIS PER 100,000
MEDICARE ENROLLEES
20111
6

7. CDC Data3
7

8. Other Outcomes
Failure Rates-
• Unable to meet MDC on outcome tools
• SH Rehab = 50%
• 30% of variance in outcomes are due
to psychosocial factors
• $635 billion/year.4
• > cancer, diabetes, and heart
disease.
8

9. Provider Burnout - Resultant Patient Management
I don’t have the energy to leave the
clinic.
I don’t know what to do for you
I can’t break up with you
I wanna be done with you… yesterday
9

10. 10

11. Psychologically Informed Care
Screen for modifiable
psychosocial targets
■ Depression
■ Fear Avoidance-
Kinesiophobia
■ Catastrophizing
■ Anxiety
■ Faulty Beliefs
Pillars-
1. Motivational Interviewing
2. Neuroscience of Pain
3. Behavior Modification
• CBT
• ACT
• Operant Conditioning
• Graded Exposure
11

12. Pain is an Output of the Brain
Expectations about consequences
(damage/pain)
Sensory Input (nociception)
Immune system
Previous experience
Feelings
Cultural Factors
Social / Work environment
Beliefs, knowledge & logic
Sympathetic & Parasympathetic nervous
system
12
The orchestra Plays the
in the brain pain tune
Copyright (©2007) University of Keele:
funded by Arthritis Research UK
Acknowledgement: Prof. Lorimer Mosley’s publications &
“Explain Pain” course www.noigroup.com

13. Pain Severity / Intensity
A key determinant of disability and it can be an obstacle to
resuming normal activity
• Its not just AND not even measuring nociception
• It reflects suffering, perceived threat, perceived
control, distress, fear, context, etc.
• Makes sense since pain is a PRODUCT of all these
& more
13
Copyright (©2007) University of Keele:
funded by Arthritis Research UK

14. Chronic Pain
Central Sensitization
■ Chronic Pain: “useless bombardment of the brain”
■ it serves no function:
■ no longer alerting to danger or tissue damage
■ Like other chronic conditions: managed, not cured
■ asthma
■ diabetes
14
Copyright (©2007) University of Keele:
funded by Arthritis Research UK

15. 15
OUR RESPONSE

16. PIC at Spectrum Health
• Literature review and model
development - 2013.
• Piloted STarT Back Tool in
Primary Care – 2014
• Team of 6 PT’s studied high risk
intervention with STarT Back
researchers- 2015
• High risk intervention & stratified
care in-service: 2015
• 24 clinicians mentored for 1 year
with pain psychologist: 2015 - 2016
• 2nd LBP pilot with paired
interventions for all risk levels:
2015 - 2016
• Long term follow up: determine
healthcare utilization. ~2017
• PIC for all MSK populations:
2017- today.16

17. Keele STarT Back Screening Tool5
17

18. Patient Centered Communication
• What have you been told about
your pain?
• What do you think is going on?
• What are your concerns?
• Do you know why Dr. X sent
you to me?
18

19. 19 “If we don’t know our history.” Love of Gray, https://www.loveofgray.com/stories/2018/3/6/if-we-dont-know-our-history. Accessed
21 Sept. 2018

20. What did I just hear?
Presence of a belief that pain is harmful or potentially severely
disabling
Fear-avoidance behavior (avoiding a movement or activity due
to misplaced anticipation of pain) and reduced activity levels
Tendency to low mood and withdrawal from social interaction
20

21. What did I just hear?
An expectation that passive treatments rather than active
participation will help.
Problems with disability claim, litigation, and/or compensation
Problems at work, poor job satisfaction
Overprotective family or lack of support
21

22. Catastrophizing
You must hear their suffering story…Once..
• Get the story- facts (what happened then)
• Symptoms (how are you feeling now)
• Empathic reflection-
• I received the emotional component of their message
• (OMG, that must have been horrible to go through!!)
22

23. Meet your patient where they are at…
Scaling treatment to:
economic realities, social realities,
health literacy, values & motivation
→ building to partnership
Psychosocial Factors-
• Operant vs. co-morbid?
**may become a barrier at some point
23

24. The language we should use.
Positive/resilient
- Your body adapts to stress,
Your body heals.
- Generalizing- “other patients I've had
with persistent pain” “This is how it
works for humans...”
- De-escalate Anxiety- via presentation
of exam findings-
- no red flags + no myotomal
weakness = everyday impairment.
24 “Wolverine Fictional Character.” Britannica. https://www.britannica.com/topic/Wolverine-fictional-character. Accessed 21 Sept. 2018

25. Standard messaging
25

26. cognitive BEHAVIORAL therapy
“Information is to behavioural change as spaghetti
is to a brick” William Fordyce
■ Training is mostly concerned with changing actual behavior
not necessarily cognitions
26
Copyright (©2007) University of Keele:
funded by Arthritis Research UK

27. Where do we start?
Layers in the cup-
• Reduce all stressors little
• Reduce 1 stressor a lot
• Build a bigger cup
27
OA
Poor sleep
Sedentary
Depression
Social
Isolation
COPD

28. Visit #2 & #3 and beyond…
Explore Barriers-
• Did you understand what to
do?
• Was is important to do?
• How confident were you to
do it?
• Bad Timing? Is a change
needed?
28

29. Work with the smallest increment possible
• You came today..
• Will you give me 2 weeks?
• Swipe card at the gym
• Job Jar
29

30. Recognition….
Psychosocial factors-
• How do they manifest?
Disengagement = lack of motivation?
The more ambiguous the situation, the
more likely the psychosocial factors
are more likely
30

31. Fear Avoidance
Address fear hierarchy-
• all the things that they have
terminated –
• start with the lowest concern,
• break into component parts
• schedule them frequently.
• Exposure is key
Activity Concern
Walking the dog 5
Stairs 6
Walking on uneven
ground
8
Grocery shopping 9
In/out of car 5
31

32. Patient Management- Chronic Pain
• Identify and achieve goals (start with small achievable goals)
• Engage in meaningful, rewarding, and mastery activities
• Engage in / maintain social contact
• Engage in regular exercise
• Restore or maintain good restorative sleep patterns
• Offer encouragement and reinforcement
• Realize mood often improves as a result of doing things
32
Copyright (©2007) University of Keele:
funded by Arthritis Research UK

33. Growing Pains
Problems with synthesis:
• Am I talking or doing PT ?
• YES…
Overshare:
• Lemme tell you about pain.
33
“The Pain Pathway.” Pinterest. https://www.pinterest.com/pin/67272588163124051/. Accessed 21 Sept 2018

34. Am I Supposed to Do This With Every Patient???
Low
Complexity
Moderate
Complexity
High
Complexity
Ultra
complex
20% 50% >70% >90%
***Referral
necessary
PIC skill
set used

35. 35
RESULTS
35
“I don’t always go to physical therapy.” Pinterest. https://www.pinterest.com/pin/2392606029033815/?lp=true/. Accessed 21 Sept 2018

36. Spine C.A.R.E.
COLLABORATIVE AND REHABILITATIVE EFFECT
STarT Back Tool
administered by MA in PCP
office
Intervention n = 67
■ 40% low risk
■ 20% medium risk
■ 40% high risk
Non-intervention n = 164
INJECTIONS ↓ 57%
ED VISITS ↓ 22%
PROCEDURES ↓ 4%
AVG. THERAPY VISITS 4 visits
IMAGING (PCP driven)
*** when therapist requested imaging
↓ 72%
↓ 118%

37. MDC Met? (Failure Rate)- Patient Reported Outcomes
37
After Mentoring
in Pain Science
and PIC:
Avg= 77%
(vs. 50% effective)

38. Clinician Experience
Therapists reported:
Increased comfort with complex
patients due to:
Better recognition of non-
mechanical/complex nature of
symptoms
Decreased fear and frustration in
the treatment of symptoms that
don’t make sense
Less energy expenditure
(and even less expenditure for non-
complex cases!)
Recognized the value of therapeutic
alliance in treatment outcomes and
patient engagement
Improved goal setting with recognition
of barriers and yellow flags
Improved ability to facilitate self-
efficacy and resilience
Tools and emphasis on exploring
patient understanding and expectations
38

39. Patient Experience
“I appreciate so many aspects of this
PT program & design. It was not like
any other. And I have been through
MANY over the years, seeking pain
relief, injury mgt., and healing chronic
issues.
I was listened to, I was heard, I was
given time to discuss my concerns,
my journey, my current state, and
there were "check-ins" to establish
where things were at each point.”
“My care over weeks & months met me
where I was at, at any given point.
Whether excelling, or regressing, but
always with long term and what I am
experiencing as, LASTING results.
Which is impressive, in the least, as a
20+ year sufferer of complex & chronic
pain.”
39

40. 40
Lessons Learned

41. Lessons Learned
Practice change is HARD
• Peer support is necessary
• Interested clinicians
• 1 year +
• Sets and reps
• EMR support
• Clear behaviors to practice
Same interventions…
Different target…
• Explore the emotional content
of exercise and activity
• Fear
• Confidence
• Joy
• Anxiety
41

42. Heal the whole person.
Triple Aim+
• Improving the patient experience of care
(including quality and satisfaction);
• Improving the health of populations;
• Reducing the per capita cost of health care.
• Attaining joy in work
42

43. Questions?
43
“Questions.” Wylio. https://www.wylio.com/credits/flickr/4100755141. Accessed 21 Sept 2018

44. References
1.http://www.dartmouthatlas.org/data/map.aspx?ind=313
2.Bydon M, De la Garza-Ramos R, Macki M, Baker A, Gokaslan AK, Bydon A. Lumbar fusion versus nonoperative management for treatment
of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Spinal Disord Tech. 2014 Jul;27(5):297-
304.
3.https://www.cdc.gov/drugoverdose/maps/rxstate2016.html
4.Gaskin DJ, Richard P. The Economic Costs of Pain in the United States. In: Institute of Medicine (US) Committee on Advancing Pain
Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
Washington (DC): National Academies Press (US); 2011. Appendix C. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92521/
5.Hill, J C., et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised
controlled trial. Lancet. 2011;378.9802:1560-1571.
6.Bodes Pardo G, Lluch Girbés E, Roussel NA, Gallego Izquierdo T, Jiménez Penick V, Pecos Martín D. Pain Neurophysiology Education and
Therapeutic Exercise for Patients With Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial. Arch Phys Med Rehabil. 2018
Feb;99(2):338-347. doi: 10.1016/j.apmr.2017.10.016. Epub 2017 Nov 11. PubMed PMID: 29138049.
7.Malfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N, Cagnie B,Danneels L, Nijs J. Effect of Pain Neuroscience Education
Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial. JAMA Neurol. 2018 Apr 16.
doi: 10.1001/jamaneurol.2018.0492. [Epub ahead of print] PubMed PMID: 29710099.
8.Vibe Fersum K, O'Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-
specific chronic low back pain: a randomized controlled trial. Eur J Pain. 2013 Jul;17(6):916-28. doi: 10.1002/j.1532-2149.2012.00252.x. Epub
2012 Dec 4. PubMed PMID: 23208945; PubMed Central PMCID: PMC3796866
44

46. This administrative case study outlines the process, outcomes, and
lessons learned over the past 5 years as psychological, social and
behavioral factors were screened for and evidence based interventions
were applied to low back pain and chronic pain in the ambulatory setting.
Physical therapists were trained to appreciate these factors as relevant
treatment targets and upskilled with motivational communication,
cognitive behavioral strategies, and a modern understanding of the
neuroscience of pain.
46

47. Describe how to synthesize psychosocial and behavioral knowledge and
techniques with a biomedical approach in an ambulatory setting.
Describe effective modes of dissemination for new assessment and
management strategies in clinical practice.
Articulate how the addition of psychologically informed care can produce
meaningful improvements in patient reported outcomes (PRO’s),
functional testing, and healthcare utilization.
47