Self-Management of Pain: Your Physical Therapist as a Guide

Too many medical approaches in today’s society are dependent on others (therapists, doctors, etc) and include passive treatments (medications, injections, etc.).  It can be empowering to take control of your own health and seek active forms of treatment for conditions such as low back pain, arthritis, or even every day sprains and strains.  Self-management allows you to develop a sense of control over your problem and offer you tools to use for a lifetime.  However, many are unsure where to start.

Therapeutic Alliance and Self-Management of Pain

In order to optimize self-management for any painful condition, a meaningful working relationship, or therapeutic alliance, in which the patient and provider work together, should be established.  This begins by developing a patient-preferred approach to treatment.  If you prefer to exercise aerobically then you should not be forced to perform lumbar stabilization exercises for your back pain.  If you enjoy strength training in the gym you should not be prescribed aerobic exercise for your knee pain.  Exercise you enjoy is medicine for the body and mind.  Both forms of exercise have been shown to be beneficial for managing back pain.  Let’s choose together what you prefer.

Developing a positive therapeutic alliance with your physical therapist also allows for the careful monitoring of progress over time.  There are going to ups and downs along the way.  Your physical therapist can help pick you up during challenging times.  Your physical therapist can also progress your plan appropriately when things are going well.  A physical therapist can work as a coach offering constructive feedback and encouragement.   They can help you make periodic adjustments to your self-management program.  With this approach, you are in control of your own health and your therapist acts only as a guide.

The interaction between you and your health care provider has been shown to be one of the strongest predictors of patient satisfaction with physical therapy care, and a key contributor to a successful outcome.  Research shows the amount and quality of the interaction between a patient and their physical therapist has a profound impact for those with persistent back pain.  Taking advantage of these positive interactions will magnify the effects of any exercise program or lifestyle modification. Having the same therapist, will potentially enhance the therapeutic alliance, guide you towards your preferred self-management strategies, and help you achieve the best possible long-term outcome.

What Self-Management Looks Like

Your physical therapist will first seek to understand your beliefs about pain and your condition.  Many people hold negative beliefs which are unhelpful to recovery or they are simply untrue.  For example, many people continue to believe that a herniated disc will never heal.  Your physical therapist will redirect you towards what you can control and strategies to improve self-efficacy.

Often a large amount of active participation over a long time is needed to change unhelpful beliefs and poor lifestyle habits.  Your physical therapist will guide you towards forms of physical activity you prefer and which are appropriate.  It is also important that you fully understand the time it takes for the body to heal itself.  The body’s natural healing mechanisms can be enhanced with the appropriate dose of physical activity.  Start too slow and your recovery will be delayed.  Start too fast and “flare-ups” will kill your motivation. Your physical therapist will help you find the best starting point and teach you how to progress.

Exacerbations of pain are going to occur.  You are going to have “flare-ups” of your back pain, neck pain, or shoulder pain.  This needs to be accepted and expected.  You want to develop resilience for these set ups.  There are always strategies available to help you through these challenging times.  Thinking the worst is never helpful in these situations.  Remaining optimistic is the first step.  Next, identify what is under your control to get you back on track.  This is where your physical therapist can help you focus your efforts.

Closing Thoughts                         

People with persistent painful conditions don’t always need more medical treatment.  They need a coach or guide to show them how to manage on their own with active forms of treatment.  Physical therapists can fill this role.  Developing a positive working relationship, or therapeutic alliance, with your physical therapist will get you set on the right track.  The rest is up to you.

Direct Access Physical Therapy: Q & A

Many healthcare consumers are unaware of the fact that they are free to access the services of a physical therapist without a physician referral. Every state allows for evaluation and some form of treatment without a physician referral. This has been the case in the state of New Jersey for almost 15 years, yet most of the patients that we work with in our Barnegat and Manahawkin physical therapy clinics are unaware of this. Most continue to believe that they must first visit another health care provider before seeking the services of a physical therapist. When we educate people about direct access we are greeted with a bit of surprise and many questions. Below are a few of the common questions we receive about Direct Access.

Direct Access saves time, saves money, and improves outcomes.

What are some of the advantages of accessing the services of a physical therapist first?

Directly accessing the services of a physical therapist saves time and money. Consumers are able to avoid wait times to see physicians and avoid delays in treatment while further testing might be pursued. Often these tests are not necessary and can potentially slow or negatively impact recovery (MRI for Low Back Pain>). A 2014 systematic review concluded that direct access controls health care costs and promotes high quality healthcare1. Compared to accessing physical therapy through a physician referral, those who directly accessed services were more satisfied with care, were prescribed fewer medications, underwent fewer diagnostic tests, and achieved better overall outcomes in fewer physical therapy treatment sessions. We have observed similar findings at both our Barnegat and Manahawkin physical therapy clinics. Patients who access our care directly achieve better overall outcomes in 20% fewer treatment sessions.

Are physical therapists qualified to deliver direct access services independent of physician referral?

Yes. Physical therapists are licensed healthcare professional who hold doctoral degrees. Physical therapists undergo extensive training in differential diagnosis and medical screening. This entails distinguishing non-serious musculoskeletal problems (low back pain, rotator cuff problems, meniscus tears, arthritis, etc) from more sinister potentially life threatening conditions (cardiac disorders, cancer, etc). Physical therapists at BSR Physical Therapy have also undergone more extensive residency, fellowship, and board certification training which focus further on these diagnostic skills. Physical therapists are not trained to make or confirm serious diagnoses but we are able to recognize when patients do not belong in our clinics and need an appropriate medical referral. We routinely refer patients to other medical specialists based on our physical exam or when the patient is not progressing towards their goals. Physical therapist’s clinical examination skills are on par with or better than most other healthcare professionals (Evidence here). How many other healthcare providers are going to spend one full hour actively listening to their patients in order to elicit all their concerns and then perform a comprehensive physical examination?

Will insurance companies cover direct access physical therapy services provided without a physician referral?

More and more health insurance companies are now covering physical therapy services without a physician referral. This is because of emerging research evidence showing cost savings with this approach2. At our clinics our front office professionals verify all health insurance benefits before starting treatment. In the majority of instances (>75% of cases) we are finding that a physician referral is not necessary to access and cover physical therapy care.

Approximately 10% to 20% of our patients access physical therapy care directly and this number is on the rise. Healthcare consumers are saving time, money, and achieving superior outcomes with greater convenience when directly accessing physical therapy. Health insurance companies are now recognizing these advantages as well. As health care reform continues to evolve, the health care consumer is becoming a more active participant in their own care. Direct access to physical therapy is here to stay and growing.

References:

  1. Ojha H a, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14-30.
  2. Pendergast J, Kliethermes S a, Freburger JK, Duffy P a. A Comparison of Health Care Use for Physician-Referred and Self-Referred Episodes of Outpatient Physical Therapy. Health Serv Res. September 2011:1-22.