Listening is therapy: Patient interviewing from a pain science perspective

Abstract

The interview of a patient attending physical therapy is the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A thorough, skilled interview drives the objective tests and measures chosen, as well as provides context for the interpretation of those tests and measures, during the physical examination. Information from the interview powerfully influences the treatment modalities chosen by the physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy sessions. Traditional physical therapy focuses heavily on biomedical information to educate people about their pain, and this predominant model focusing on anatomy, biomechanics, and pathoanatomy permeates the interview and physical examination. Although this model may have a significant effect on people with acute, sub-acute or postoperative pain, this type of examination may not only gather insufficient information regarding the pain experience and suffering, but negatively impact a patient's pain experience. In recent years, physical therapy treatment for pain has increasingly focused on pain science education, with increasing evidence of pain science education positively affecting pain, disability, pain catastrophization, movement limitations, and overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it is time for the examination, both subjective and objective, to embrace a biopsychosocial approach beyond the realm of only a biomedical approach. A patient interview is far more than "just" collecting information. It also is a critical component to establishing an alliance with a patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in pain. This article highlights the interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanism assessment.

Risk Factors for the Elevation of Psychosocial Barriers in the Recovery of Lumbar Pathology

“…This reveals the importance of preventing and reducing the frequency of patients who transition from acute to chronic stages [5,7]. A biomedical, pathoanatomical model negatively influence the patient's overall status and those dealing with chronic low back pain [8,9]. A recent systematic review demonstrates that a multidisciplinary biopsychosocial rehabilitation approach is an effective treatment strategy for low back pain [10].…”

“…Most patients will not have a meaningful pathoanatomical diagnosis as imaging findings may be considered abnormal despite being asymptomatic, and the likelihood of abnormalities increase with age [12]. Trends demonstrate earlier medi-doi: 10.7243/2055-2386- [6][7][8][9] cal imaging led to greater probability towards surgery and healthcare spending [1]. Structural change on imaging in an asymptomatic population continues to support the notion that other factors such as emotion, behavior, cognitive beliefs may contribute to patient's pain perception.…”

First, do “nothing”… and listen

“…While the latter aligns with common practice and meets the expectations of athletes and clinicians alike,1 it presents a temptation to rush into a specific treatment path that is difficult to resist. Even pain science education (‘explain pain’) as a recognised treatment of common musculoskeletal disorders might still underestimate the initial interaction between the practitioner and the patient 2. It seems that listening, or the opportunity to discuss problems, might be as important as specifically targeted education 2…”

Teaching patients about pain: It works, but what should we call it?

“…The second article by Diener, Kargela, and Louw (2016) addresses the importance of listening in the patient interview. All clinical encounters start with the patient interview, and it is here where therapeutic alliance most likely begins.…”

“…With the increasing interest in subgrouping of patients, knowledge of pain mechanisms and recognition of psychosocial risk factors, there is a need to determine which patients are most appropriate for a pain neuroscience education approach. Diener, Kargela, and Louw (2016) take on the task of developing an interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanisms' assessment.…”