Consistent success in the rehab world isn't as simple as just having a the coolest new technique to get patients better. Nor is it your musculoskeletal Dx skills. A patient’s recovery is often multifactorial and may, at times, matter very little on your clinical skills set. As information in psychology and pain sciences grows, we have learned that we are treating the whole patient, with all their issues, not solely the injury. We aren't just working on a pathoanatomical diagnosis but on many other socioeconomic, psychological and social components, and addressing these ‘other components’ are paramount in the patient’s (and ours) success.
Even small alterations of our normal patterns and habits can be dramatically stressful because you have taken that person out of their comfort zone. And that’s what's occurring in all of our patients to some level or another. Many can have a hard time adjusting to this. For instance, increased stress from an injury that has changed their normal routines may lead to fear of what others think about the them and their injury and how they may be accepted by their peers (their are MANY more examples of how pain leads to fear). Additionally, that increased stress can lead to a higher fear avoidance with even simple ADLs and their desire to participate in PT, leading to a lack of overall compliance. This in turn leads to decreased outcomes and that will perpetuate the pain even further. This may even lead to high levels of depression. Serious issues that may be hidden behind the curtain, yet issues that we can make a huge difference in. We don't need to be counselors to handle all these situations, but we do need to have a prepared game plan...
I hope we can see the importance of addressing the whole patient. But how do we combat this as PT (many of us without formal counseling training)? How do we help the patient feel comfortable and accepted about their pain and limitations? How do we make them feel actively engaged in their care?
We help them harness their willpower...
In 1992, psychologist entered one of the busiest orthopedic hospitals in Scotland to examine how one could boost someone’s willpower, especially those resistance to change. The patients were all geriatric, earned less than $10,00 a year and didn’t have more than a high school degree. And they all had a recent THA or TKA. They were all in “life’s final chapter” and most had no desire to “pick up a new book”. And with the pain involved with the surgeries it is not unusual for these people to skip rehab and demonstrate overall poor compliance leading to suboptimal results.
The scientist conducting the experiment gave each patient a booklet after their surgeries that detailed their POC along with, in the back, 13 additional pages-one for each week- with blank spaces and instructions: “My goals for this week are __________ ? Write down exactly what you are going to do. For example, if you are going to go for a walk this week, write down where and when you are going to walk. She asked patients to fill in each of those pages with specific plans. Then she compared the recoveries of those who wrote out goals with those of patients who had received the same booklets, but didn’t write anything.
It seems absurd to think that giving people a few pieces of blank paper might make a difference in how quickly they recover from surgery. But when the researcher visited the patients three months later, she found a striking difference between the two groups. The patients who had written plans in their booklets had started walking almost twice as fast as the ones who had not. They had started getting in and out of their chairs, unassisted, almost three times as fast.”
So why was this successful? The psychologists noticed one common factor being filled in (with specific, detailed plans) of their recovery: They focused on how the patient would handle a specific moment of anticipated pain. The patients detailed every obstacle they might face towards their goal and came up with a solution ahead of time.
Put it another way, the pt’s plans were built around tackling “crisis points”. When they knew their plan and thus the temptation to quit would be the strongest, the patients, intuitively, were telling themselves how they were going to make it over the hump!
What a powerful strategy and something so easy we can benefit from! Implement this one drill into your care to improve their willpower and thus recovery. Have a note card ready to hand them to let them write their goal. Have them work on it while they are receiving their modalities at the end. Have them carry it with them in the pocket as a motivator. Have a “successful goal” board they can attach it to upon completion. Give minor assistance if needed to direct a applicable goal for them or strategies to resolve “crisis points”. Continue to repeat this every week, checking on it at the start of care. You won't have to ask them if they did their HEP in the beginning anymore, rather did they stick to their goal. To stick to their goal they will inherently stick to the HEP-as a primary goal itself or as carryover to overall new willpower they have designed for another goal important to them. [The same way someone who starts to exercise picks up additional healthy habits like healthy eating and smoking less].
The patients who do not write out plans are at a significant disadvantage because they never thought ahead about how to deal with their pain. Even if they were motivated to walk their resolve can be abandoned when confronted with initial pain.
I’m just starting this “self-will power drill” in the outpatient realm and can’t wait to see how it goes! In addition, this will definitely help build rapport with patients as they can see that your truly concerned for their well being and an easy way to encourage and direct them.
This idea and several others come from an excellent book ‘The Power of Habit’ by Charles Duhigg. Its a most read.
