1. Optimizing Outcomes Digging Deeper into the Basic Tenets

2. The Basic Tenets 1. Understanding the science behind the FOTO system 2. Standardizing Patient Instructions 3. Serial Status’ 4. High completion rates 5. Cognitive Behavioral Treatments

3. Validity – who’s job is it? The Researchers’ Job Content Validity Face Validity Structural Validity Construct Validity Measurement error Scaling Scoring Etc… etc … etc... etc…. Our Job Participation Rates Completion Rates Minimize Risk of Bias –What we say and do –What we don’t say and do

4. Minimizing Risk of Bias Step 1: Standardized Introductory Screens Step 2: Suggested Supplemental Instructions

5. Standardized Introduction Intake

6. Standardized Introduction Status

7. Minimizing Risk of Bias “How should I answer this?”

8. Tips to Avoid Interpreting

9. Completely Disagree Unsure Completely Agree 0123456 I should not do physical activities which (might) make my pain worse. I cannot do physical activities which (might) make my pain worse. Example: The FABQ-PA

10. Tips to Avoid Interpreting

13. Proxy Cognition Under age 8 Recorder Hand motor control Language Reading level Reasons to Actively Help the Patient

14. New Proxy/Recorder Process

15. Proxy

16. Recorder

17. Supplemental Instructions There are no wrong answers. We want to know what YOU think. If a question does not seem to apply to you, choose the response closest to the right answer for you…select the “best fit” answer. If you are asked about something you haven’t done recently, estimate how hard it would be if you tried to do it now.

18. Supplemental Instructions Keep in mind that the computer does not know who you are. These are standardized questions. Don’t worry if something doesn’t seem to directly apply to you, just indicate the closest answer. Scenario: Optional surveys with potentially sensitive questions (e.g., psychosocial depression screen) I’m interested in learning more about how your condition may or may not be affecting you either physically and/or emotionally.

19. Supplemental Instructions “The computer is assessing your present physical abilities. In order to find out what you can do, it has to find out what you cannot do. (like math testing in school)” Scenario: 80 year old patient wants to know why they are being asked if they can run. “The computer does not know you. It doesn’t know if you are 18 or 100 years old.”

20. Supplemental Instructions Scenario: Function is limited by medical contraindications Example: post-op rotator cuff repair.

21. Biopsychosocial Model Patients referred to physical therapy 30-50% show clear signs of depressive symptoms (Haggman Phys Ther 2004, Werneke JOSPT 2011) 50% experience elevated fear of physical and/or work activities (Werneke. Spine 2001) Nearly 20% classified at high risk based on psychosocial factors for poor outcomes (Werneke JOSPT 2011)

22. Screening for Psychosocial Factors Psychosocial modules Fear of physical and work activities Hart PTJ 2009 Catastrophizing Sullivan PCS Psychol Assess 1995 Psychosocial distress Depression & somatization Single item screen Hart J Qual Life Res 2010 Dionne’s risk assessment Werneke JOSPT 2011 STarT risk classification Hill et al Arth Rheum 2008 Self Efficacy Anderson et al Pain 1995

23. Biopsychosocial Science Screening for patient’s beliefs, fears, illness perceptions, emotions and behaviors regarding his or her pain experience, & Targeting patients at high psychosocial risk for cognitive behavioral therapy (CBT by physical therapists)

24. Patient’s beliefs & behaviors Cognitive Behavioral Treatment CBT techniques –Meaning response “Therapeutic alliance (TA) –Patient-practitioner interaction Clinician’s communication skills Clinician’s mannerisms –Advanced CBT programs for patients classified as high risk

25. Cognitive Behavioral Technique Meaning responses –TA between patient-practitioner The patient is comfortable approaching you Collaborative relationship Patient has trust & confidence in your ability to function effectively on their behalf Vong et al APMR 2011

26. Cognitive Behavioral Technique Meaning responses –Communication Praise & attention to (+) behavioral change Ask questions that build self-efficacy beliefs Patient centered interviewing & goal setting Positivity & problem framing Zolnierek et al. Med Care 2009

27. Cognitive Behavioral Technique Meaning responses –Clinician’s mannerisms Enthusiastic vs. lukewarm Behavioral and verbal messages Moerman et al. Annals Int Med 2002

28. Meaning Response vs. Placebo Meaning responses –Active ingredients to RX –Encompasses patient management strategies from a psychosocially informed perspective Placebo –RX is inert –no active RX ingredient –RX effect is due to patient expectancy

29. Meaning or Non-Specific Response Meaning response = non-specific factors Linde et al BMC Medicine 2010 –Meta analyses of 37 acupuncture trials with a total of 5754 patients –Reported large meaning response effects which made it difficult to detect small additional specific effects of the actual treatment rendered

30. Meaning or Non-Specific Response Meaning response = non-specific factors Menke M. Do manual therapies help LBP. Spine 2014 –Meta analyses of 336 spinal manipulation studies –Non-specific factors explained: 97% of outcomes for acute LBP –3% of treatment (SMT) 67% of outcomes for chronic LBP –32% of treatment »Exercise with support considered most effective strategy

31. Therapists who are skilled at the enhancement of meaning responses while embracing evidence-based interventions are providers of choice to produce best outcomes Best Patient Outcomes Summary: Literature Review

32. Advanced CBT Programs High Low Medium Lumbar impairment Low

33. Advanced CBT Programs Recommended for physical therapists Two types Formal task-specific activity/exercise approaches Graded exercise (operant) conditioning program Fordyce JC APMR 1973 Graded exposure program Vlaeyen JW Behav Res Ther 2001

34. Advanced CBT Programs Graded exposure (task-specific training) Function-focused program 5 steps –Education –Hierarchy of tasks/activities reported as least to most difficult –Practice (graded exposure) specific activities & tasks –Task-specific strengthening exercises* –Problem solving skills & goal setting * Modified from Vlaeyen JW. Pain 2000

35. Graded Exposure Step1 Education “The Message” Buchbinder R et al. Spine 2001 Burton AK et al Spine 1999 (Back Bk) Sullivan MJ et al. PT Canada Therapy alliance Control not cure Hurt vs. harm Stay activeSpine is strong

36. Graded Exposure Step 2 Develop hierarchy of activities & tasks w patient –FOTO report: lists patient’s difficulties and limitations with performing activities: e.g. no difficulty to extreme difficulty –Fear of Daily Activity Questionnaire (George JOSPT 2009) Open-ended questions for additional activities patient expresses fear or difficulty doing Important to know which functional tasks are most problematic so that task- specific programs can be designed to target these tasks and activities Tenet #1

37. Item Mapping Activity –Usual work, housework, or school activities? –Walking around a room? –Bathing and dressing? Amount of Limitation –Moderate difficulty –Yes, limited a little –No not limited

38. Graded Exposure Step 3 Practice (graded exposure) least to more difficult tasks/activities –Ask patient to perform task-specific activities reported as difficult e.g. lift groceries, push vacuum, mop floor.. Purpose –Allow correction of patient’s misconception of pain –Learn “hurt” vs “harm” principles

39. Graded Exposure Step 3 Task-specific training Philosophical shift in strength training –Instead of prescribing a series of traditional & typical isolated extremity or trunk strengthening exercises, the therapist develops a strength training program utilizing task specific exercises i.e. patient is exposed to tasks rated as fearful or difficult (George JOSPT 2009)

40. Graded Exposure Step 4 “Educate” purpose of exercise is linked to improving ability to perform the task Program consists of breaking functional tasks into multiple key biomechanical components and prescribing exercises for each component part Alexander et al. JAGS 2001 Example difficulty rising from sitting –Components based on impairments and physical performance: forward slide, max trunk flexion in sitting, pelvic elevation in sitting, isometric positions after lift-off from chair etc –Alter difficulty of training: with/w/o hands, alter seat heights etc…

41. Graded Exposure Step 5 Develop problem solving skills –Across a wide variety of work and home tasks –Progress to new tasks rated more difficult –Key educational message: “hurt vs. harm” although your back hurts does your back limit you from doing the task? Crombez et al. Health Psychology 2002