Exercise Prescription in Chronic Pain Patients in Gladstone
Patient adherence to prescribed home exercise programs has been the nemesis of many a physiotherapist since the dawn of time. Physiotherapists work with a vast array of personalities in a wide variety of settings. Whether it’s working in a hospital orthopaedic ward, in a chronic pain clinic, with elite athletes or just your every day private practice patients, issues of compliance always raise their head.
It goes without saying that managing patient adherence in Gladstone has a massive influences on patient outcomes. It seems to be easier working primarily with athletes and Orthopaedic patients, as with these patients a quick wake up call and a few stern words about only getting out what you put in was adequate to set their rehab back on target. Simple. However, the circumstances of working with chronic pain patients present a completely new set of challenges.
Physical activity and exercise prescription form an important part of the accepted clinical guidelines for patients managing CLBP. Getting patients in Gladstone with chronic pain to adhere to these recommendations can often prove difficult which decreases the effectiveness of our intervention. Hence, interventions that can increase patient’s adherence may also enhance treatment outcomes. But how can we achieve this?
Clinically what can be seen that is not being done well
Quite often pain is allowed to become the driving factor and focus in chronic pain patients. These patients are already so responsive to pain, and much of what we do as health professionals in Gladstone, Queensland ends up reinforcing these pain processes. Constantly asking patients to rate their pain, or seeing how their pain reacts to different activities and movements can sensitise their nervous system further, and if patients “go looking” for their pain, by repeatedly performing movements to see if they hurt or constantly assessing if activities are painful, then they become more likely to find pain.
What the research is saying?
The Self Determination Theory (SDT) suggests that we humans have a basic psychological need for “autonomy” – feeling free to engage in a behaviour, “perceived competence” – feeling effective in our actions, and “relatedness” – feeling supported in our interpersonal relationships. When these needs are supported, patient’s participation in treatment will be more autonomous and less controlled.
With our current knowledge of the chronic pain process, we are also aware that these psychological needs are lacking in this patient population. Unfortunately research has found that controlled motivation in the healthcare domain often involves patient engagement due to external pressure, coercion, or feelings of guilt. Like many things in healthcare, this distinction between autonomous and controlled motivation represents a continuum rather than a dichotomy with more autonomously motivated behaviours leading to greater psychological well-being and long term behavioural persistence.
What does this mean for you as the Physiotherapist in Gladstone?
Providing a healthcare environment that promotes autonomy, support and behavioural change via autonomous motivation will lead to better adherence to home based exercise treatments.
Implementation of the Self-determination Theory can be achieved by application of the 5 ‘A’s;
- ASK. This phase largely involve strategies to promote patients sense of relatedness. For example Using open ended questions, paraphrasing and empathising. By asking a patient if they are ready to consider advice regarding activities outside the clinic you can also get a gauge of their readiness to accept advice. For example “There are a number of things you can do that would help… would you like to hear a few suggestion?”.
- ADVISE. Education regarding their condition increases the patients’ sense of competence. Ask the patient to paraphrase this to test their understanding of their condition. Provide the rationale behind you’re advice. For example “Research shows that physical activity, such as walking, is a great way too…”.
- AGREE. Employ SMART Goals ensuring active participation from the patient when setting goals. For example “Earlier you mentioned you find it hard walking for long periods. For this week we could set a target of 15 minutes walking per day, how many days do you think you could achieve that target next week?”. In chronic pain patients it is particularly important to set achievable goals so that patients are able to experience success therefore start low. It is also important to start low so that patients in Gladstone use their goals to drive their activity level and move away from using pain to dictate their activity levels.
- ASSIST. Foster competence and autonomy by helping the patient identify likely obstacles to adherence and develop strategies to overcome these barriers. This should also involve suggesting changing thought processes towards pain. For example from “I can’t walk to the shop, it’s too painful” to “I now know from my healthcare provider that when I get this pain there’s no tissue damage being done, it’s just activity within my nervous system, if I just take my time and remember to breath, relax and rest when I need to, I will be able to walk to the shop”.
- ARRANGE. Provide the patient with a rehabilitation diary to help them keep track of their home based rehabilitation and invite the patient to contact you in the event of difficulties or questions.
Ways of interacting with patients can also include focusing more on how the patient managed to cope with their pain, turning the attention away from the pain itself and instead looking at how they found ways to change their pain or complete their normal tasks. Setting pain tolerance levels for exercises, celebrating successes and having structured goals will all assist with this as well.
Implementing these strategies into practice, not just for chronic pain patients, but for all patients, has made a significant difference to many patients. Greater autonomous motivation results in greater adherence to prescribed exercise programs and lifestyle advice and better overall outcome.