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.