A Treatment Plan Just for You, What Does that Mean?
In the field of rehabilitation (for things like back pain, knee pain, shoulder pain and neck pain) recommendations that come from guidelines, reviews, or consensus statements, research does not give an insight into individuals, but a larger population as a whole. When a study is conducted, results are often given a numerical value (like a pain rating out of ten or a survey score), and then pooled to be analysed. Any conclusions made about a particular treatment approach have to be considered with this information in mind. In most groups of patients who are studied in research, there is some variability in response. Data from research is used to maximize the probability of a successful outcome. Individualized treatment can also help to maximize the likelihood of successful outcomes. Below, we will describe things to consider when individualizing treatment plans.
IF EVIDENCE IS NOT INDIVIDUALISED, HOW DO WE CREATE A PLAN THAT IS?
1. Consider Evidence-Based Prognostic Factors
There has been a trend recently in research, to identify if there are easily identifiable factors that might tell us who has a higher likelihood of success from a particular treatment. An example of this type of study comes in the form of the clinical prediction rules study conducted by Flynn et al., (2002) and published in the journal Spine. This study examined the characteristics in common amongst individuals who respond well to spinal manipulation for low back pain. Care informed by a study like this can help individualise care. Unfortunately, studies like the one mentioned above are not that common, and not available for all kinds of pain. There has also been a call to validate some of the conclusions made by these studies using randomised control trials.
2. Consider Patient Beliefs
While an evidence based approach can help to maximise the probability of a successful outcome, there are often additional things we can do to improve odds of success. A patient may have strong beliefs, such as “Doing a deadlift is the worst exercise a person can do for low back pain”. While there is evidence that some people’s back pain improves while participating in a deadlift program (Berglund et al., 2015), it would not be wise to ask someone who believes a deadlift is bad for their back to perform one for low back pain. Still, at some point in a treatment plan, a deadlift type of exercise may be helpful for recovery (i.e., when there is less pain and improved lumbar extensor muscle endurance). When considering a treatment plan for back pain, or any other type of injury, a patient’s beliefs shape an individualised strategy.
3. Consider Patient Expectations
It is often important to ask about expectations at the outset of an interaction. This can help a practitioner to either craft a treatment plan that fits a patient’s expectation, or to explain why the interaction does not fit expectations. As a chiropractor, patients often expect that I will perform an adjustment and that they will hear a popping sound. While that approach is valuable under certain circumstances, it may not be necessary in all cases. A conversation where a patient has a chance to ask questions about the clinical reasoning may help to reshape their expectations for care.
4. Consider Patient Preferences
Because I am a chiropractor, many people, when they first walk into my office will say, “I don’t want to be cracked.” I am happy to oblige. I will often explain that an adjustment may be a very efficient way to treat a problem, but it is probably not the only way. Most of us have exercises that we like more than other exercises. I like to run, but many people like to swim. While back pain, neck pain, and knee pain are often treated with some form of graded physical activity, it is important to listen to patient preferences and make recommendations for the activity a patient is most likely to perform.
5. Make Shared Decisions
The greatest path to individualization is to involve a patient in the decision-making process when creating a treatment plan. This last recommendation incorporates all that has been mentioned above. This principle is essential to the patient-centered model of care. When making an assessment of needs and creating a treatment plan, I do what I can to be transparent about my reasoning and provide information as frequently as possible. Patients should be making informed decisions about their care. When that is the case, success is more probable.
Patient-centred care is individualised care, and vice versa. Individualized though difficult to translate directly from research, can still benefit from peer-reviewed research to inform decision making. The process is collaborative and adaptable to many different situations.
If you feel that you could benefit from the type of care described above for back pain, neck pain, knee pain, shoulder pain or any other kind of pain, Please contact us at [email protected]
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Written by Dr Ben Matheson, Inovo Medical and posted on 08/11/2017.
Berglund, L., Aasa, B., Hellqvist, J., Michaelson, P., & Aasa, U. (2015). Which patients with low back pain benefit from deadlift training?. The Journal of Strength & Conditioning Research, 29(7), 1803-1811.
Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., … & Allison, S. (2002). A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine, 27(24), 2835-2843.
Mathieu Bélanger, MD, CCFP, CPSO Recognized Specialist (Chronic Pain), is the founder and President of Inovo Medical. Dr. Bélanger began his academic career by earning an undergraduate degree in kinesiology (i.e., the science of body mechanics) before enrolling in medicine at the University of Montréal. He is particularly interested in pain related to sports injuries and musculo-skeletal disorders. This interest led him to travel extensively for various types of training on pain treatment given by leading experts. Since then, his objective has been to play an active role in the development and delivery of the most sophisticated and effective treatments for chronic pain.