The subjective assessment has been proven to be more effective in some cases than objective testing. Identifying key patterns- fear avoidance, catastrophization,and past experiences of pain dictate prognosis and pain. I have always been biomedical in my approach but have developed an interest into a psychology and mindset.

1. Community Services Physioline
Darren Finnegan/ Catherine Bowe 14/11/2017
Fitting psychosocial assessment
into subjective questioning.

2. Learning Objectives
 Integration of the biopsychosocial information into the
subjective assessment.
 Development of psychosocial questioning skills to aid
clinician in practice.
 Combination of the biomedical, social and psychological
factors into effective clinical practice.
 Understand and discuss the role of physioline within the
different experience levels of the Physiotherapy cohort;
actively discuss common barriers to the service (patient and
therapist) (Cat B)
 Improve knowledge on how and when to self manage or refer
patients on where appropriate (Cat B)

3. ‘Pain is perceived in response to a
perceived threat’
 Lorimer Moseley, 2007, Physical Therapy reviews, 169-178.

4. Assessment is a Treatment.
Introduction.
EQ5D/ Start back.
Current Templates
PL to PBP
Integration of
the
biopsychosocial
information

5. Structure of
Subjective Ax?

6. Integration of the biopsychosocial information
 Laura
• 48 year old with young children (15 & 12year old), works
as an administrator (PT)
• 5 year history of recurrent back pain flare-ups, usually
settle
• Present episode started 5 weeks ago, gradual onset
• GP prescribed Diclofenac, noted OA in her hands and L
knee, increased BP and type 2 diabetes
• Current pain level 5/10, localised to lumbar spine, no
referred pain
• GP assessed her and reports - O/E: Rather overweight,
posture OK. Reflexes, dermatomes, myotomes and slump,
SLR all NAD
• How would you manage this patient PL vs PBP?

7. Integration of the biopsychosocial information
• 48 year old with young children (15 & 12year old), works as an administrator
(PT)
• 5 year history of recurrent back pain flare-ups, usually settle
• Present episode started 5 weeks ago, gradual onset
• GP prescribed Diclofenac, noted OA in her hands and L knee, increased BP
and type 2 diabetes
• Current pain level 5/10, localised to lumbar spine, no referred pain
• GP assessed her and reports - O/E:Rather overweight, posture OK. Reflexes,
dermatomes, myotomes and slump, SLR all NAD
 Main complaint is sleep difficulties and the lack of improvement over the past
month
 She is thinking about giving up part time work and has stopped her child care role
for her Grandson (2 days/wk)
 Previous Physio last year wasn’t particularly successful. She wants to have some
answers why she has so much pain and feels at a loss to know how to help
herself get better
 How would you manage this patient now?

8. Development of psychosocial questioning skills
 Best predictor of injury is previous
injury.
 = Best predictor of pain is reaction
to previous injury?
 Limbic system- Emotion/Feelings
 Thalamocortical- Cognition/Think
 Palaeospinothalamic- Do/Don't
 Brooks et al, (2002)
 Childhood /Healthcare experiences
 Past experiences of others.
Past Experiences

9. Development of psychosocial questioning skills
 ‘The attempt to control or alter, the form, frequency or
situational sensitivity of internal experiences (thoughts,
feelings, sensations) even when doing so could cause
behavioural harm.’ (Luoma, 2007)
 Avoidance vs Persistence/Confronter
 External vs Internal Experiences.
 Verbal vs Non verbal cues
 Fear Avoidance behaviour
 Therapist behaviour on the phone?
 Task persistence behaviour, despite pain, is as
frequent as avoidance. (Crombez, 2012)
Pain Behaviour

10. Development of psychosocial questioning skills
 ‘A negative cognitive response to pain or anticipated
pain, characterized by a tendency to fixate on the pain
stimulus, magnify its threat & adopt a helpless outlook.’
(Sullivan et al 2001)
 Magnification
 Helplessness
 Rumination
 Different clinicians/professionals/ investigations.
 Tends to focus on the future-
 Language- Anxious, Worried, Afraid
Pain Catastrophizing

11. Development of psychosocial questioning skills
’Fear related protective behaviours are inhibited when the value
of another life goal outweighs the value of pain and is given
priority’ (Vlaeyen et al, 2016)

12. Development of psychosocial questioning skills
 Emotional connection to an injury?
 Chronological Injury Record?
 What is the perfect/best outcome of todays session/
Physio for you?
 Current understanding of what physio does?
 Most frustrating injury ever had?
 Worst pain ever had?
 Longest injury ever had?
 Why is that important to you?
 Language Used.

13. Problem patients? Case examples

14. Combination of the biomedical, social and
psychological factors
 45 year old female- R shoulder pain 18/12 ago- onset following
200+ mile drive.
 Physiotherapy- Failed- x3 sessions.
 CATS- USS- Supraspinatus Tendinopathy diagnosed &
injection- improved for 1/12
 Discharged from the service.
 Re-referred with flare up of her shoulder 2/12 post discharge
from CATS.
 What further subjective information would you request?
 Actions? PBP vs CATS vs self manage?

15. Combination of the biomedical, social and
psychological factors into practice.
 Ryan
• 55 year old man, works full time as a service engineer
• 10 years ago had a similar back problem, but was pain free
in-between episodes
• Present episode started 2 weeks ago, after a heavy lift at
work – he felt it ‘go’
• His GP prescribed Dicolfenac and cocodamol, and gave
him a 2 week sick note which is running out
• Currently pain is 7/10, improving daily, but still severe down
his right leg to back of calf
• GP Exam- O/E: Normal build, moderate lateral shift of his
spine to the left, muscle spasm visible, reflexes OK,
dermatomes affected (dull sensation R side), myotomes
OK, Slump and SLR positive R side (60deg). No red flags
present.

16. Combination of the biomedical, social
and psychological factors into practice.
• 55 year old man, works full time as a service engineer
• 10 years ago had a similar back problem, but was pain
free in-between episodes
• Present episode started 2 weeks ago, after a heavy lift at
work – he felt it ‘go’
• His GP prescribed Dicolfenac and cocodamol, and gave
him a 2 week sick note which is running out
• Currently pain is 7/10, improving daily, but still severe
down his right leg to back of calf
• He is not sure when to return to work as he does a lot of
driving
• Main complaint is throbbing leg pain, particularly at night
but managing during the day.
• Coper

17. Combination of the biomedical, social and
psychological factors into practice.

18. Understand and discuss the role of Physioline
within the different experience levels of the
Physiotherapy cohort;
Improve knowledge on how and when to self
manage or refer patients on where appropriate

19. Purpose of Physioline
 New grads and juniors- what are your thoughts on
the purpose of physioline?
 Seniors- Are your opinions the same as this or do
you think it has a different role that hasn't been
mentioned?
 what do you find the pros of PL is to the patient?
 what do you find the cons of PL to the patient is

20. Understand and discuss the role of physioline
within the different experience levels of the
Physiotherapy cohort;
 What do you find the pros of PL?
 What do you find the cons of PL?

21. Understand and discuss the role of physioline
within the different experience levels of the
Physiotherapy cohort;
 What is the purpose of Physioline?
 Physioline is a 20 min verbal consultation to gather a
detailed subjective assessment. After finishing this
assessment we should have:
• a provisional/ working diagnosis
• a plan for both the therapist(s) and the patient
• appropriate management options (F2F, Self Mx,
GP/A+E, Groups as per appropriate service)

22. Improve knowledge on how and when to
self manage or refer patients on where
appropriate
 Self management is an important part of a physioline
clinic. current KPI 30-35% self management of
patients (service dependant). Relevant for your PRP!!
🙋🏼
 This helps reduce workload in clinics
 Reduction in inappropriate patients needing to be
booked into clinic which allows faster access and
more appointment availability for patients who need to
be seen in clinic sooner.
 What typical examples have you that you would self
manage via physioline and clinical reason why these
would be appropriate?

23. Improve knowledge on how and when to self
manage or refer patients on where appropriate

24. Improve knowledge on how and when to self
manage or refer patients on where appropriate
 helps the patient take control of their symptoms and
condition and can manage on a long term basis by
using a BPS approach to a problem. This relates back
to Darren’s point on expectations and goals and why
this is important
 Self management from Physioline typically includes
more detail about their diagnosis and what this means
for them, advice on RICE, modifying activities,
probable healing times, reassurance, information
booklets and condition specific exercises.
 Give examples of patient that are not appropriate for
self management via PL???

25. Improve knowledge on how and when to self
manage or refer patients on where appropriate
 Ongoing feedback
 (individual and service)
 Future training
 (1:1, supervision and support)
 Self-reflection and self-audit

26. Summary
Physioline Contract Specific
 Low Back pain pathway- South Tees
 South Tees Templates
 WARNING to the clinician in clinic- Fear Avoidance,
Catastrophizing, Past Experiences of pain- May need to
be addressed in clinic.
 Structure of the Physioline Template
 Pain is a perceived threat so use physioline as a chance
to reduce this threat.
 Watch Inside Out!!!

27. References
 Lorimer Moseley, 2007, Physical Therapy reviews, 169-178
 Plisky et al (2006), Star excursion balance testing as a predictor
of lower limb extremity injuries in high school basketball players,
Journal of orthopaedic sports medicine, 36 (12).
 Brooks JC, Nurmikko TJ, Bimson WE, Singh KD, Roberts N.
fMRI of thermal pain: effects of stimulus laterality and
attention. Neuroimage. 2002;15:293–301. [PubMed]
 http;//www.bodyinmind.org