Assignment 2

Satnos, Kirsten Gail A.

Assignment 2: Patient Education (25 points, including 5 points that are assigned to
grammar, spelling, and formatting; 3-4 pages)

Given a patient with chronic low back pain, prepare a patient education session,
using the Pain Neuroscience approach.

Patient Case: Cindi is a 62 year-old woman with chronic low back pain for the past 2 years; pain
at rest is 3/10 and with activity is 7/10. She is now experiencing pain in the right shoulder, as
well, rated at 3/10, indicating central sensitization. She lives alone in a 2 level house; her
daughter lives close by and is supportive. Her PMH includes diabetes, depression and knee OA.
Her goals are to be able to go on walks with her friends and be able to play with her 2
grandchildren.

If you are unfamiliar with central sensitization, please review the following resources:
http://www.instituteforchronicpain.org/understanding-chronic-pain/what-is-chronic-pain/central-
sensitization

1. How would you explain chronic pain to this patient? Provide two (2) examples of
appropriate analogies you could use to explain chronic pain to benefit the patient.
Explain how you would use the analogies.

Informing and educating patient Cindi will be based on her needs and readiness to learn.
Things to consider in learning would be: (1) her age, patient is already in her 60s, therefore we
may consider educating with discussion and variety of brochures and reference materials to
understand more about chronic pain, (2) her other comorbidities, her depression, we should
take into consideration of patient’s emotional capabilities because sometimes is becomes a
barrier in learning and (3) her environment, the patient lives alone in her house, therefore in
teaching the patient, let’s get her involved in her plan of care and other needs.

On Initial assessment of the patient, we both identify her impairments and functional
disabilities. After having all these findings we will now educate the patient about her condition
in relation to what she is experiencing at the moment. We will explain to her the medical
background on how chronic pain developed in relation to her past medical history and the
relationship of chronic pain to the central sensitization she developed in her shoulder. We will
explain that in this condition, her nervous system is constantly in a state of heightened
reactivity, leading to a lower pain threshold; because of this the patient will be experiencing
increased sensitivity to pain or even to touch being perceived as pain and increased anxiety. We
need to educate her that with her condition, there are various factors that we consider with her
chronic back pain and shoulder pain. Factors of her age, diabetes, depression and
osteoarthritis. With her age, osteoporosis and arthritis are considered in relation to her chronic
back pain. With her right shoulder pain, we may consider her diabetes. Diabetes affects the
nervous system and circulation and many articles suggest the correlation between diabetes and
frozen shoulder. And lastly with her increased sensitivity with pain, patient’s mental condition is
put in consideration, as patient was noted to have depression. Studies have shown that anxiety
is related to lower pain threshold.
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Satnos, Kirsten Gail A.

References:

Institute for Chronic Pain Website. http://www.instituteforchronicpain.org/understanding-

chronic-pain/what-is-chronic-pain/central-sensitization. Accessed June 01, 2019

Plack, M and Driscoll, M: Teaching and Learning Physical Therapy from Classroom to Clinic (2nd
Edition), Slack Incorpotated, 2017.

2. Choose a behavioral change model, explain what it is, and explain how you would use it
to communicate with the patient about changing pain behavior.

Transtheoretical Model (Stages of Change)

The transtheoretical Model is a model of intentional change that focuses on the decision making
of the patient. This model explains that patient’s change in behavior happens continuously
through a cycle or process. It demonstrates that patients transition through six different stages
of change, which are: (1) Precontemplation, (2) Contemplation, (3) Planning or Preparation, (4)
Action, (5) Maintenance and (6) Termination.

On assessment, we can already identify what stage of change the patient is in. In the case
scenario above, patient already planned for her goals for the therapy, she is in the preparation
stage. At this stage, the patient already have an understanding of her condition, what we need
to do is discuss with the patient the procedure and plan of care we need to do in order to help
her achieve her goals for the coming sessions and with our case her goal is to be able to walk
with her friends and play with her grandchildren outside her house. We educate the patient to
help her understand the process she need to take in order to achieve these goals. And during
session, at the action stage, we continue to provide feedback and reinforcement as an effective
tool for encouraging positive behaviors and provide support. At the maintenance stage, we
continuously affirm and reevaluate if patient is maintaining the change and if we have achieved
her goals, if not, we need to reassess and modify as needed.

References:

T Baranowski, K Cullen, T Nicklas et al. Are Current Health Behavioral Change Models Helpful in
Guiding Prevention of Weight Gain Efforts? Obes Res. 2003; 11:23S-43S.

Plack, M and Driscoll, M: Teaching and Learning Physical Therapy from Classroom to Clinic (2nd
Edition), Slack Incorpotated, 2017.

3. Choose three (3) Motivational Interviewing (MI) strategies and explain how you would
use them to facilitate behavioral change.

The following Motivational Interviewing (MI) Strategies are used to successfully facilitate
behavioral change:

a) Asking Permission
Assignment 2
Satnos, Kirsten Gail A.

Asking Permission most often converse respect to our patients as comparison to having
discussion, giving lectures or asking them directly to change. Patients most often times
responsive in discussing change when asked.

b) Open-Ended Questions
With open-ended questions, we encourage our patients to a more reflective conversation flow
and build empathy with our patients and would not give a feeling of being cornered for an
interrogation. This motivational interviewing strategy reassures and encourages the patient to
tell more of their stories. And the therapists’ role is to respond with a summary or reflective
statement.

c) Statements Supporting Self-Efficacy

In this strategy, therapists provide statements that will facilitate and support self-efficacy or
self-confidence. It is done through recognition of patient’s strengths, giving support and
positive feedbacks on the changes they have achieved, and it can be done through scaling
techniques. For instance, we follow-up our patient by asking how where they able to the
change in behavior, followed by asking them how do they feel about their change. This for me
is very crucial, since most of the patients have little self-confidence and sometimes a little
hesitant to change.

References:

J Hettema, J Steele and W Miller. Motivational Interviewing. Annu Rev Clin Psychol. 2005. 1:91-
111. doi: 10.1146/annurev.clinpsy.1.102803.143833.

Plack, M and Driscoll, M: Teaching and Learning Physical Therapy from Classroom to Clinic (2nd
Edition), Slack Incorpotated, 2017.

d) List two (2) appropriate patient resources that are evidence-based (such as the website
above) and that you can share with the patient. Briefly explain why they are useful.
Examples of poor resources are WebMD, Google, and the like.

M Galan-Martin, F Montero-Cuadrado, E Lluch-Girbes et al. Pain Neuroscience

Education and Physical Exercise for Patients with Chronic Spinal Pain in Primary
Healthcare: A Randomized Trial Protocol. BMC Musculoskeletal Disorders. 2019.
20:505. Doi: 10.1186/s12891-019-2889-1.

L Mosley. Combined Physiotherapy and Education is Efficacious for Chronic Low

Back Pain. Australian Journal of Physiotherapy. 2002. 48:297-302.

Many of the treatments practiced for chronic pain used in clinics are mainly passive
(pharmaceutical and invasive) and shows poor outcome. In this two article, it provides us an in
depth information about two treatments currently applied in the public health system that
shows promising outcomes, combination of physiotherapy (manual therapy and exercise
training) and pain neuroscience education. Incorporating education programs in therapy shows
clinical positive effects. Education that emphasizes on the cognitive-behavioral or
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Satnos, Kirsten Gail A.

neurophysiological aspects reported to help in reducing disability, normalization of pain

cognitions and increase patient’s self-efficacy. In addition, these resources discusses that
combining physiotherapy treatment that consists of manual therapy, specific exercise training,
active coping strategies and neurophysiology education are essential in treating chronic pain.
They are seen effective in producing functional and symptomatic improvements in patients with
chronic pain. With supporting evidence, it also mentioned that the intervention demonstrates
sustainability, the effect is long-term thus patient subsequently seek fewer health care visits.
Therefore, with this promising approach, we may discuss this treatment programs we may want
to do to help our patient achieve its goals. In addition, as mentioned in both article, we also
need to take in consideration the following non-treatment factors that will contribute to the
therapeutic effects, such as patient expectation, health provider expectation, patient-provider
rapport, therapist enthusiasm and perceived level of expertise.