Patient Centered Approach

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					                A PARADIGM SHIFT
                   The Patient Centered Approach




                Broaden your perspective for treatment




Presented by Rory Koch-Callaghan
Overview – Maximize patient outcomes
•   Introduction
     • Be open minded
     • Biopsychosocial vs biomedical approach
     • Let go of the ego, admit when we are wrong
•   Paradigms for treatment
•   Evidence vs Science based medicine
•   Multi-disciplinary approach – how do they fit in?
•   What is the patient centered approach
•   Patient Spectrum – Where are they on the spectrum, where do the percentages lie?
•   Where do our patients fit in?
               ELEPHANT IN THE ROOM (1)

    Be open minded, Let go of the ego
“The human understanding, once it has adopted an opinion, collects any
instances that confirm it, and though the contrary instances may be more
numerous and weighty, it either does not notice them or else rejects them, in
order that this opinion will remain unshaken”
         Francis Bacon Novum Organum (1620)


“The more we learn and understand,
the more we realize how much
we really don’t know”


“Never speak in certainties, when life is never certain”
                         ELEPHANT IN THE ROOM (2)

    Be able To ADMIT When we are wrong
    The big guys can…
•    Peter O”Sullivan “ Chronic Low back Pain”
      •   “rethinking the management of non-specific chronic low back pain” (In Touch, issue 2, 2011)
      •   “Maintained by the current belief that NS-CLBP is fundamentally a patho-anatomical disorder, and should be
          treated within a biomedical model”
      •   “the challenge for new physiotherapists is to up-skill and adapt to this new paradigm, both in the way we
          interpret clinical information and how we manage NS-CLBP disorders, in order to incorporate the broader
          person centred behavioural approach (Foster & Delitto 2011, O’sullivan 2011)
      •   “It is likely that this PCA will not be limited to LBP, but will provide a framework for the management of other
          chronic pain disorders”


•    Gary T Allsion “The Core”
      •   Stability vs mobility
      •   Admitted in 2011 that he assisted in starting the isolated muscle training movement or “core training” 10 yrs
          ago, but rebuts and admits that isolated muscle training alone is taking us in the wrong direction. It needs to
          be (G Allison, APA conference 2011)
BIO-PSYCHO-SOCIAL APPROACH
Biomedical perspective                         Bio-psycho-social perspective
Intuituve, extermely successful for many       Relatively new in comparison. Research
diseases, entrenched, based on the             shows the more bio-psycho-social you
premise that ilness is strictly a biological   can be, the better the outcomes for your
process that can be cured                      patients
Involves search for a cause                    Recognises multiple causes from biological,
                                               psychological and soiciological domains
Focus on disease process                       Focus on disease and illness
Strong focus on anatomical and                 Strongly acknowledges the interactions
biomechanical principles                       between brain and body
More disease focus                             More health focus
Patient management often passive               Patient management more active, including
                                               self management
Curative monotherapies attempted (surgery,     Therapies interdisciplinary
manipulation, injection)
May fail to recongise preventative medicine    Includes psychosocial contributing factors as
(NOI conference 2012 Adelaide)                 precursors to injury/disease
REFLECT – Your Current understanding

•What/Who has shaped your current beliefs and understandings
     •   Curtin or notre dame
     •   Other backgrounds – sport science, psychology etc.
     •   Exerpeiences – life, work
     •   Mentors, friends, family
     •   As a new grad – lack of experiences???


     •   THINK
           • What are some conditions you are confident of fixing? (ankles, knees, acute LBP)
           • What if someone challenged your concept/understanding of treatment/management? Would you
             be open to it? Or are you certain that they way you were taught was 100% the best way
                  • Eg. PILATES – – isolated muscle training alone may be effective, but is not ideal
EVIDENCE BASED PRACTICE
•   Evidence vs Science based medicine
     • Although physiotherapy sets it self apart from other disciplines by being evidence
       based with our treatment modalities. We must be careful to no ignore clinical
       experience and practical antecdotal evidence.
     • www.sciencebasedmedicine.org


     • The parachute scenario
          • Are we certain that parachutes save lives?
          • Put your hand up if you would take part in the RCT.
WOMEN WALKS AFTER 20YRS IN WHEELCHAIR


•   <iframe width="420" height="315" src="http://www.youtube.com/embed/NcVDpXtEkaw"
    frameborder="0" allowfullscreen></iframe>
LETS START WITH A BIT OF ANATOMY TO GET ON
          THE SAME WAVELENGTH
•   The Virtual Body - The wiring
     •   CNS – The brain “power house” and spinal cord “central wire”
     •   PNS – the Peripheral wires from the central wire
     •   ANS – The communicating wires with the PNS/CNS and visceral organs, arteris/veins/heart – pipes for nourishment.

•   The Avitar - The Exo-skeleton (wouldn’t exist without the wiring) – radiculopathy etc
     •   Muscles, tendons
     •   bones, joints
     •   skin

• Sensory organs – The worldy connector
     •   Connect the virtual body and the avitar with the external environment

• Nutrition and nourishment (energy IN)
     •   We are what we eat
     •   Our sensory organs and our digestive system connect external nutrients with our bodies internal daily needs, and removes the
         waste.
     •   An absence of these can effect the function of both the virtual body and the avitar.
PAIN CABINET IN THE BRAIN

•   The brain – Did you know that there is a pain cabinet in the brain is 500X more potent
    than any synthetic drug made.
     • How do we harness this?




•   REMEMBER Pain is an output of the brains perception (NOT AN INPUT)…..
     • If we can positively influence patients perceptions of the pain (using language,
       education etc.), NEUTRALIZE negative beliefs we can effectively harness the
       strongest pain killers known to man.
                 PARADIGMS FOR TREATMENT
                       Rx Paradigm                                    Examples
                                                                      Education, understanding
Neuro                 Cognitive
                                                                      Thoughts, beliefs
                      Psycho
                                                                      Movement and lifestyle
                      Behavioural                                     habits etc.
                                                                      Muscles, bones, ligaments
Biological            Biological             Patho-anatomical         etc
                                                                      Auto-immune, endocrine,
                                                                      CNS, ANS,
                                                                      Para/sympathetic, genes
                                             Systemic/Visceral        etc.
                                                                      Job requirements
Environmental         Contextual             Function - work, ADL's
                                                                      Sport specific
                                             Sport
                                                                      Family, $$$, work
                      Social

        Example – feel free to change paradigms. My simplistic proposal.
                           Where do we (physio’s) sit???

                    Patient Centered Approach vs Physio

                                             Pain                                               new grad senior
                                    Patient
           Paradigm                 centered Acute   Chronic   Physio -   Physio -   Physio -   Physio - Physio -
           dominance                Approach pain    Pain      CBT        CFT        CSP        New grad 20yrs

Neuro      Cognitive                         5%      15%       Education education

           Psycho                                    10%
           Behaviour                                           movement movement
           al                                        15%       habits   habits
                      Patho-
Biological Biological anatomical             80%     10%                  movement
                      Systemic/Vi
                      sceral                         30%
Environme             Function -
ntal       Contextual work, ADL's            10%     10%                  function

                       Sport                 5%      5%                   rowing

           Social                                    5%


        Percentages are just an example, of where treatment focus might need to be
• WHO else do we need to get involved to
  assist this patient?

                     OR

• Can you solve the worlds problems single
  handedly?
      Multiple Disciplines – Where do they Sit?
                                                             Talking
                                                        Therapies/neuro-    Miscell     Patho-anatomical            Holistic
                                  Movement                    psych         aneou
                                  therapies                                   s
                                                                                                          Docto
                                                                                                          r-        Doctor
                                                                                                          nutriti   - Pain
                                                      Psych - Psych - Hypno           Doctor Pharm Sports onal      speciali Naturo
                                 Pilates Gym   Yoga   clincial Pain tist    Reiki     - GP acist doctor med         st       path
Cognitive
Psycho
Behavioura
l


Biological Patho-anatomical



             Systemic/Visceral                               meds                                          meds Meds           meds

           Function - work,
Contextual ADL's                                             pacing
             Sport

             Social
Patient Spectrum – It’s a Contnuum
  •   Consider….
  •   When your patient walks through the door, where on this spectrum are they?
  •   Where does the treatment focus need to be?
  •   Do other disciplines need to be involved to enhance outcomes?


ACUTE pain                                                            Chronic Pain
-Structural drivers                                                   -Normal healing
-Normal heaing                                                        timeframes passed
processes current                                                     -Psycho-social drivers
-Pain more local in                                                   dominate
the “avitar”                                                          -Pain more in the
                                                                      “wiring”
 Patient – EXAMPLES
 To optimise patient outcomes, who else should we involve?
 Fit the blocks in place…


                                Acute    Chronic    Acute      Chronic     Post
                                ankle    Ankle      Low back   Low back Surgical              Cancer -   Multiple
                                pain     Pain       pain       pain        knee      Stroke   visceral   Scelrosis
                                                    unsure     poor
                                                    about      understand pain,
Neuro     Cognitive                      Fear, pain cause      ing         surgery   ???      ??         ???
                                                               Fearful,
                                         depresse              catastophis fear
          Psycho                fear     d          fear       e           avoidance
                                         can kick
          Social                         footy kids            Avoid
                                                               change      change
          Behaviou                                             movement    movemen
          ral                            don’t run             s           t
                                ligaement                      might be
Biological Biological Patho-A   laxity    Unstable             driver      fixed
                                                               loss of
                  Systemic/              Chronic               homeostas
                  Visceral               synovitis             is
                  Function -                                   Loss of
Environm Contextu work,                                        function    loss of
ental    al       ADL's                  Can't                 ADLs        function


                      Sport     Cant play wont                 Cant play   return
LISTEN
•   Doctors interrupted in a mean time of 18secs
•   Patients who are not interrupted usually talk for only 60-150seconds!!
•   We can absorb 450-500 words per minute, but can talk only 100-150 words per minute.
•   So we can predict what they are going to say if listening actively.
•   Look at the patient – Guage non-verbal cues
•   Listen with empathy
•   Reinforce what they are telling you


               •    THEN, Ask the right questions to get the answers you need
                                 •    Start broad and focus in!
LANGUAGE
  • “ if you cannot communicate, it doesn’t matter what you know”


  • Tracking Chronic Pain Patients – how did they end up there?
      • Told I would never be able to work again
      • Told I had a degenerative spine at 20yrs, what will it be like when im 40?


  • Be careful of the language we use (P O’Sullivan 2011, D Butler NOI 2012)
      • Eg. Instabiity might be the wrong word – from past papers- should be “adverse
        lumbar movement behaviours” – instability can often promote fears of
        movement and catastrophysing.
   HOW WOULD YOU EXPLAIN
DISCOGENIC LBP to someone who
comes in and tells you their disc is out?
              YOUR Treatment TOOL BELT

Move IT

Massage It

Needle It

Mobilise IT

Teach IT

Inject IT

Medicate IT
              What Tools do you have?
Tools in your Belt – Physical Modalities
                    Joint
     Soft Tissue    mobilisations   Pain            Movement     Practitioner       Other

     Massage        Mulligans       Hot/cold        Pilates      Motivation         Ultrasound
                    Mckenzie                                                        Short wave
     Heat           method          Education       Yoga         Listening skills   diathermy
                    Alexander
     Stretch        technique       Meds            Feldnkrais   Education          Laser
     PNF Hold Relax
     tehnique       Manipulation    Movement        Tai Chi      Lagnuage used

     Acupuncture    Mobilisation    Refer on        Gym          Problem solving
     Gratson
     technique      PPIVMS          Elcetrotherapies Hydro

     Dry needling   PAVIMS

     Etc etc        Etc etc         Etc etc         Etc etc      Etc etc            etc

                     What works best….??? No one knows… why?
                     Do you need to invest in some new tools??
• Know your limitations


• Be aware of what is in other peoples tool belts
  and know when to refer on, admit your unsure,
  know when further opinion is needed.


• Harness everyone else’s tool belts to enhance
  the patients overall outcome!
TAKE HOME POINTS
•   Spectrum Continuum – where does your patient sit in this continuum when they present to
    you
•   Get Others involved - Multidisciplinary approach when needed
•   Consider the bio-psycho-social on top of the biomedical model we were taught to enhance
    patient outcomes, prevent the vicious cycle of chronic pain and disability.
•   Be open to new paradigms for treatment. Add some tools to the belt, but know when a
    paradigm of treatment is beyond your current expertise.
•   Hopefully I have planted the seed to think about things a little differently, It might not make
    sense now, but with time the picture will broaden. Someone did it for me.

				
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posted:6/26/2012
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