TY - JOUR
AU - PhD, Marco Campello, PT,
AB - Abstract This study assesses the feasibility of training U.S. Navy Physical Therapy staff members (PT staff) aboard a U.S. Navy Aircraft Carrier in psychologically informed physical therapy (PiPT). Training was conducted prior to deployment over 3 d and included background information, skills development, and application in the form of role playing and case studies. During deployment, nine phone conferences were conducted to reinforce training, assess skills, and discuss implementation. PiPT knowledge was assessed by a written test and role-playing skills. The adoption of the training was determined by analysis of clinical notes and verbal responses of the PT staff during phone conferences. There were two PT staff members on the carrier. Both received passing knowledge test scores and demonstrated role-playing proficiency. Clinical note assessment and discussions during conference calls also indicated successful implementation. The feasibility of training Navy PT staff to implement PiPT was demonstrated. PT staff successfully translated training into practice. This is significant, since PiPT has the potential to limit attrition due to musculoskeletal injuries in Navy personnel. Factors believed to be associated with the success of the training include adoption of the PiPT model by PT staff and reinforcement of changes in clinical practice during deployment. INTRODUCTION Musculoskeletal injuries (MSIs) pose a significant problem for active duty service members (ADSMs) and are the main reasons for separation and long-term disability.1–4 In a recent study by the current investigators, the rate of conversion from first career limited duty assignments to the Navy’s fitness for duty assessment or physical evaluation boards was 15 % for MSI-related cases.5 Only 28% of those referred to physical evaluation boards return to full duty.6 The implications of this problem are both financial- and safety-related, in terms of the loss of trained ADSM and a potentially compromised existing workforce. Studies of MSI disability in civilian populations have shed light on this problem. It is well established that disability from MSI involves interplay of biological, psychological, and social factors.7 Though numerous risk factors for disability have been identified, psychological factors are among the strongest predictors of MSI outcomes.8–12 Recent studies have corroborated these findings in military populations.13 The fear-avoidance model provides an explanation for the association between psychological factors and functional outcomes.14 In this conceptualization, if an injury is perceived as threatening, catastrophizing (imaging the worst) ensues, leading to fear and avoidance behavior. Avoidance behavior results in lack of activity leading to more pain and ultimately disability. If the pain perception can be reconceptualized, catastrophizing will cease, movement will commence, and recovery will result.14 The psychological factors described in the fear-avoidance model have been labeled “yellow flags” and are known risk factors for disability. Yellow flags are maladaptive thoughts than can be successfully modified with cognitive-behavioral therapy (CBT).12,15–17 CBT is rooted in the work of psychologist Aaron Beck, who observed that automatic thoughts or responses to stimuli result in affective states that may interfere with adaptive behaviors and proposed techniques to alter these thoughts.18 CBT helps the patient develop adaptive pain coping strategies through the use of techniques such as acceptance, distraction, relaxation, imagery, cognitive restructuring, and goal setting.19 CBT for pain management administered by a mental health professional in conjunction with physical therapy (PT) is shown to be superior to PT alone in reducing disability in patients with subacute and chronic MSI.20–22 This may be in part because standard PT is based on a biomedical model that emphasizes remediating the affected body part during treatment. In contrast, the biopsychosocial model emphasizes patient-centered care and focuses on the cognitive, emotional, and behavioral responses to pain that are associated with outcomes. A combined treatment approach is recommended by back pain guidelines for patients beyond the acute phase of injury.23,24 In a previous study, the present authors conducted a randomized controlled trial with ADSM at risk for disability from back pain in which we trained a multidisciplinary team of health care providers including physicians, physical therapists, and a psychologist in a combined approach.22 We reinforced the training by providing weekly teleconferences to discuss cases and answer questions. Our study found that, following treatment, the intervention group had lower perceived disability and fear-avoidance beliefs than the control group who received usual care. Recently, it has been proposed that physical therapists can be trained to identify yellow flags using CBT principles as part of routine clinical practice.25–27 This approach has been described as “psychologically informed physical therapy” (PiPT).28 If proven successful PiPT is an important advancement in broadening patient access to the benefits of CBT. Patients often see physical therapists early in care when there is an opportunity to modify maladaptive beliefs before the fear-avoidance cycle is reinforced. Additionally, patients who may benefit from CBT are sometimes unwilling to see a psychologist for fear of stigma, cost or time constraints.28 Studies that have evaluated PiPT training have shown mixed results.25,29,30 Some physical therapists may not be receptive to the biopsychosocial paradigm and some who are, have stated they are not comfortable implementing elements of this approach.31–33 Overmeer et al29 developed an 8-d training course for physical therapists in PiPT that included addressing the biopsychosocial model, yellow flags, behavioral principles, communication, modifying fear of movement, and role playing.29 They found that while attitudes and knowledge of the physical therapists shifted in the expected direction, their behavior did not. As a result, the training did not improve outcomes in patients overall.29 The authors point out that a one-time training is insufficient for changing behaviors, even if attitudes are altered. Ongoing education and reinforcement that includes specific ways to address yellow flags is needed. Successful implementation of PiPT in the Navy has the potential to reduce attrition and improve recovery time. However, PiPT has not been tested in ADSM. The military is a unique culture which may limit generalizability from civilian studies. For example, due to the demands of military duty, ADSM may be frequently exposed to working with pain and may not be able to avoid heavy work when injured. Also, seminal studies conducted by Henry Beecher during World War II suggest that injury itself has a different meaning for ADSM than for civilians such that ADSM have a higher tolerance for pain.34 Training Navy PT staff to conduct PiPT is an important first step in understanding how this approach can be applied in the U.S. Navy and other military organizations. U.S. Navy aircraft carriers provide an optimal environment in which to study this problem. Guidelines and studies done in the military clearly support early intervention as an effective approach to reducing risk of disability and poor work outcomes.22,35 ADSM aboard a carrier have easy access to early care.36 In addition, ADSM aboard a carrier do not have to leave their command for therapy, making treatment compliance likely. Also, the lack of communication between carriers allows us to rule out any contamination of training effect on PT staff aboard another carrier that may be used as a control group. Therefore, we developed a PiPT training course for U.S. Navy PT staff aboard a carrier.37 This study is part of a larger quasi-experimental pilot study supported by the Office of the Assistant Secretary of Defense for Health Affairs through the CDMRP, Award No. W81XWH-14-2-0146 to test the effectiveness of PiPT for ADSM with MSI aboard a carrier (in process). In order to ensure the internal validity of the intervention during the trial, it was necessary to demonstrate that PiPT training among the participating clinicians in the intervention arm was possible before assessing patient outcomes. Our experience can help other military clinicians, who are considering implementing PiPT, to determine the utility of this approach in their setting and inform future patient outcome studies. The purpose of this study is to assess the feasibility of training Navy PT staff to implement PiPT during a deployment. Methods This paper reports on the PiPT training process, transfer of knowledge, and the translation of knowledge into practice in a military setting. Two carriers were available for the study during the study period. We selected one carrier to serve as the intervention arm for the larger pilot study. PiPT training was given to the PT staff of the intervention carrier only. Trainees The usual complement of PT staff on a carrier includes a physical therapist and a PT technician. Both staff members on the carrier served as trainees. Both had traditional professional training and backgrounds and neither were known to have had previous experience in CBT or PiPT. Training of the Physical Therapist and PT Technician Training of the PT staff was conducted by a psychologist and a physical therapist from the research team. Training took place in person 2 wk prior to deployment. The carrier psychologist was present during the training to provide feedback, assure buy-in, and see that referrals to psychology when appropriate would proceed smoothly. Training took place over a 3-d period. The first session included basic concepts of PiPT such as models of pain and disability, understanding the complexity of pain, evidence-based predictors of disability and delayed recovery, models of care and principles of cognitive behavioral pain management. The second and third sessions were focused on skill development. This included identification of yellow flags through screening tools, demonstration of PiPT patient education and related behaviors, interviewing techniques, and how to develop a plan of care to modify psychological risk factors. The syllabus used for the training is shown in Table I. Emphasis was given to providing reassurance, improving patient coping skills and modifying pain behaviors. The PT staff was given visual tools to enhance patient education. The trainers utilized an interactive format that included role playing and case studies portraying specific characteristics of patients in a military setting (Table II). Role playing focused on developing skills required to educate patients at risk of delayed recovery and to implement a plan of care based on the principles of PiPT. Trainees were also coached in how to document yellow flags, if present, in their clinical notes and to indicate how the flags would be addressed in their plan of care. Table I. Training Syllabus Day  Main Topic  Goals  Skills  Assessment  1  Basic concepts of PiPT  Understand the biopsychosocial model of pain and disability Understand the concept of PiPT  Demonstrate understanding by utilizing examples from the rehabilitation setting  Knowledge test  2  Identifying yellow flags and other risk factors associated with delayed recovery.  Learn how to use study assessment tools to identify patients at risk Learn how to use the clinical interview to identify patients at risk Learn how to develop a plan of care based on the presence of psychological risk factors and their modification  Demonstrate how to identify obstacles to recovery Demonstrate how to assess the need for a psychological evaluation Demonstrate communication skills necessary to elicit risk factors for delayed recovery during the clinical evaluation Demonstrate how to develop a psychologically informed plan of care  Role playing and case studies  2  Addressing yellow flags to prevent delayed recovery Educating the patient at risk  Learn how to communicate with and educate patients at risk of delayed recovery Learn how to implement a plan of care based on the principles of PiPT.  Demonstrate patient education skills Demonstrate communication skills  Role playing and case studies  3  PT documentation Feedback and review  Standardize evaluation and progress notes to ensure high-quality data  Demonstrate use of key phrases associated with the implementation of a plan of care based on PiPT Demonstrate how to document changes in attitudes, beliefs, and behaviors through observation and communication during treatment Demonstrate how to document changes in yellow flags and standardize questionnaires at the end of treatment  Role playing and clinical note analysis  Day  Main Topic  Goals  Skills  Assessment  1  Basic concepts of PiPT  Understand the biopsychosocial model of pain and disability Understand the concept of PiPT  Demonstrate understanding by utilizing examples from the rehabilitation setting  Knowledge test  2  Identifying yellow flags and other risk factors associated with delayed recovery.  Learn how to use study assessment tools to identify patients at risk Learn how to use the clinical interview to identify patients at risk Learn how to develop a plan of care based on the presence of psychological risk factors and their modification  Demonstrate how to identify obstacles to recovery Demonstrate how to assess the need for a psychological evaluation Demonstrate communication skills necessary to elicit risk factors for delayed recovery during the clinical evaluation Demonstrate how to develop a psychologically informed plan of care  Role playing and case studies  2  Addressing yellow flags to prevent delayed recovery Educating the patient at risk  Learn how to communicate with and educate patients at risk of delayed recovery Learn how to implement a plan of care based on the principles of PiPT.  Demonstrate patient education skills Demonstrate communication skills  Role playing and case studies  3  PT documentation Feedback and review  Standardize evaluation and progress notes to ensure high-quality data  Demonstrate use of key phrases associated with the implementation of a plan of care based on PiPT Demonstrate how to document changes in attitudes, beliefs, and behaviors through observation and communication during treatment Demonstrate how to document changes in yellow flags and standardize questionnaires at the end of treatment  Role playing and clinical note analysis  Table I. Training Syllabus Day  Main Topic  Goals  Skills  Assessment  1  Basic concepts of PiPT  Understand the biopsychosocial model of pain and disability Understand the concept of PiPT  Demonstrate understanding by utilizing examples from the rehabilitation setting  Knowledge test  2  Identifying yellow flags and other risk factors associated with delayed recovery.  Learn how to use study assessment tools to identify patients at risk Learn how to use the clinical interview to identify patients at risk Learn how to develop a plan of care based on the presence of psychological risk factors and their modification  Demonstrate how to identify obstacles to recovery Demonstrate how to assess the need for a psychological evaluation Demonstrate communication skills necessary to elicit risk factors for delayed recovery during the clinical evaluation Demonstrate how to develop a psychologically informed plan of care  Role playing and case studies  2  Addressing yellow flags to prevent delayed recovery Educating the patient at risk  Learn how to communicate with and educate patients at risk of delayed recovery Learn how to implement a plan of care based on the principles of PiPT.  Demonstrate patient education skills Demonstrate communication skills  Role playing and case studies  3  PT documentation Feedback and review  Standardize evaluation and progress notes to ensure high-quality data  Demonstrate use of key phrases associated with the implementation of a plan of care based on PiPT Demonstrate how to document changes in attitudes, beliefs, and behaviors through observation and communication during treatment Demonstrate how to document changes in yellow flags and standardize questionnaires at the end of treatment  Role playing and clinical note analysis  Day  Main Topic  Goals  Skills  Assessment  1  Basic concepts of PiPT  Understand the biopsychosocial model of pain and disability Understand the concept of PiPT  Demonstrate understanding by utilizing examples from the rehabilitation setting  Knowledge test  2  Identifying yellow flags and other risk factors associated with delayed recovery.  Learn how to use study assessment tools to identify patients at risk Learn how to use the clinical interview to identify patients at risk Learn how to develop a plan of care based on the presence of psychological risk factors and their modification  Demonstrate how to identify obstacles to recovery Demonstrate how to assess the need for a psychological evaluation Demonstrate communication skills necessary to elicit risk factors for delayed recovery during the clinical evaluation Demonstrate how to develop a psychologically informed plan of care  Role playing and case studies  2  Addressing yellow flags to prevent delayed recovery Educating the patient at risk  Learn how to communicate with and educate patients at risk of delayed recovery Learn how to implement a plan of care based on the principles of PiPT.  Demonstrate patient education skills Demonstrate communication skills  Role playing and case studies  3  PT documentation Feedback and review  Standardize evaluation and progress notes to ensure high-quality data  Demonstrate use of key phrases associated with the implementation of a plan of care based on PiPT Demonstrate how to document changes in attitudes, beliefs, and behaviors through observation and communication during treatment Demonstrate how to document changes in yellow flags and standardize questionnaires at the end of treatment  Role playing and clinical note analysis  Table II. Case Study Example Frank G is a 20-yr-old male machinist mate third class (MM3). He is married with a 3-mo-old son. He does not smoke and maintains a normal body mass index. This is his first deployment. A couple of days ago, while lifting a heavy container overhead, as part of his usual duties, he hurt his right shoulder. At first it was a little sore, and he was able to continue working with no interruption of his usual duties. Today, however, when he woke up he could barely move his shoulder and is in excruciating pain. He tried to stretch it out, but it made the pain worse. He presents at medical with decreased range of motion on the right shoulder and reports pain at an 8 out of 10 level. Frank completes the intake questionnaire. When evaluated he appears extremely agitated and fearful about his shoulder pain. Frank reports poor sleep quality following his injury and feels that he will be unable to complete work tasks with his current pain level. When questioned, he explains that about 4 yr ago he had a football injury in the right shoulder that healed pretty well, but his doctor at that time warned him to be careful on that side. He had to stop playing football. He began to work out daily and get into excellent shape to enter the Navy. Job description: MM3 – mainly repairs and other services to the ship. Assigned to the tender of repair ships. Discussion points: Cognitive reassurance/ education – explaining the nature of the injury, developing effective communication skills, modifying maladaptive beliefs, setting realistic expectations. Yellow flags: fear, catastrophizing, bothersomeness  Frank G is a 20-yr-old male machinist mate third class (MM3). He is married with a 3-mo-old son. He does not smoke and maintains a normal body mass index. This is his first deployment. A couple of days ago, while lifting a heavy container overhead, as part of his usual duties, he hurt his right shoulder. At first it was a little sore, and he was able to continue working with no interruption of his usual duties. Today, however, when he woke up he could barely move his shoulder and is in excruciating pain. He tried to stretch it out, but it made the pain worse. He presents at medical with decreased range of motion on the right shoulder and reports pain at an 8 out of 10 level. Frank completes the intake questionnaire. When evaluated he appears extremely agitated and fearful about his shoulder pain. Frank reports poor sleep quality following his injury and feels that he will be unable to complete work tasks with his current pain level. When questioned, he explains that about 4 yr ago he had a football injury in the right shoulder that healed pretty well, but his doctor at that time warned him to be careful on that side. He had to stop playing football. He began to work out daily and get into excellent shape to enter the Navy. Job description: MM3 – mainly repairs and other services to the ship. Assigned to the tender of repair ships. Discussion points: Cognitive reassurance/ education – explaining the nature of the injury, developing effective communication skills, modifying maladaptive beliefs, setting realistic expectations. Yellow flags: fear, catastrophizing, bothersomeness  Table II. Case Study Example Frank G is a 20-yr-old male machinist mate third class (MM3). He is married with a 3-mo-old son. He does not smoke and maintains a normal body mass index. This is his first deployment. A couple of days ago, while lifting a heavy container overhead, as part of his usual duties, he hurt his right shoulder. At first it was a little sore, and he was able to continue working with no interruption of his usual duties. Today, however, when he woke up he could barely move his shoulder and is in excruciating pain. He tried to stretch it out, but it made the pain worse. He presents at medical with decreased range of motion on the right shoulder and reports pain at an 8 out of 10 level. Frank completes the intake questionnaire. When evaluated he appears extremely agitated and fearful about his shoulder pain. Frank reports poor sleep quality following his injury and feels that he will be unable to complete work tasks with his current pain level. When questioned, he explains that about 4 yr ago he had a football injury in the right shoulder that healed pretty well, but his doctor at that time warned him to be careful on that side. He had to stop playing football. He began to work out daily and get into excellent shape to enter the Navy. Job description: MM3 – mainly repairs and other services to the ship. Assigned to the tender of repair ships. Discussion points: Cognitive reassurance/ education – explaining the nature of the injury, developing effective communication skills, modifying maladaptive beliefs, setting realistic expectations. Yellow flags: fear, catastrophizing, bothersomeness  Frank G is a 20-yr-old male machinist mate third class (MM3). He is married with a 3-mo-old son. He does not smoke and maintains a normal body mass index. This is his first deployment. A couple of days ago, while lifting a heavy container overhead, as part of his usual duties, he hurt his right shoulder. At first it was a little sore, and he was able to continue working with no interruption of his usual duties. Today, however, when he woke up he could barely move his shoulder and is in excruciating pain. He tried to stretch it out, but it made the pain worse. He presents at medical with decreased range of motion on the right shoulder and reports pain at an 8 out of 10 level. Frank completes the intake questionnaire. When evaluated he appears extremely agitated and fearful about his shoulder pain. Frank reports poor sleep quality following his injury and feels that he will be unable to complete work tasks with his current pain level. When questioned, he explains that about 4 yr ago he had a football injury in the right shoulder that healed pretty well, but his doctor at that time warned him to be careful on that side. He had to stop playing football. He began to work out daily and get into excellent shape to enter the Navy. Job description: MM3 – mainly repairs and other services to the ship. Assigned to the tender of repair ships. Discussion points: Cognitive reassurance/ education – explaining the nature of the injury, developing effective communication skills, modifying maladaptive beliefs, setting realistic expectations. Yellow flags: fear, catastrophizing, bothersomeness  Reinforcement of Training During the Deployment Trainees were given a detailed manual following the training to support compliance. Two methods were used to ensure compliance with the training during deployment. First, teleconferences of 1 h duration were conducted to allow the PT staff to discuss complicated cases and engage in problem-solving with the investigators. Questions and concerns were addressed and successes were also discussed and reinforced. A second tool used to reinforce PiPT skills was the periodic audit of de-identified clinical notes. During training, the PT staff were taught how to indicate whether or not yellow flags were present for each patient and if so, how to address each flag during the therapy session. These sections of the notes were assessed by the investigators for thoroughness of documentation and appropriateness of the PT staffs’ responses. During deployment, two independent investigators randomly sampled the PT staffs’ clinical notes on a bimonthly basis using pre-established criteria. Deficiencies in implementation detected through this process were addressed with the PT staff during teleconferences. Evaluation of the Training Feasibility of implementation of PiPT on board a carrier was guided by recommendations from Yates et al38 for assessing the treatment quality of clinical trials. Criteria for feasibility were as follows: Knowledge of main PiPT concepts: assessed by a knowledge test given at the end of the training for which a passing score was 85% (Table III). Demonstration of PiPT skills: demonstrated by the ability to use eight case studies and three role-playing scenarios to screen for yellow flags and delineate interventions following the training. A scored of pass or fail was given. A two person inter-rater agreement of 100% was required to obtain a passing score. Demonstration of PiPT application: assessed by analysis of clinical notes during the deployment. Demonstration of PiPT acceptance: demonstrated by verbal responses of PT staff during phone conferences. Table III. Knowledge Test All Questions Are to be Answered Either True or False  1. PiPT should be used only for high risk patients.  2. Studies have shown that patients who are at high risk for disability tend not to benefit from medically based PT.  3. PiPT is based on principles of CBT for pain.  4. In the biopsychosocial model, the patient is a passive participant in treatment.  5. The neuromatrix theory emphasizes the importance of psychological factors in the progression of pain and disability.  6. Black, orange, and yellow flags are all categories of psychological factors.  7. All patients with yellow flags should be referred immediately to a psychologist.  8. Expectations of outcome can be modified by the health care provider.  9. A behavioral approach to PT can improve the patient’s self-efficacy.  10. Health care providers with a biomedical perspective are more likely to follow guidelines for musculoskeletal injuries than those with a biopsychosocial perspective.  11. Fear of movement always indicates a poor prognosis.  12. The most important concepts to keep in mind when using a psychologically informed approach are self-care and self-blame.  13. Telling patients what to expect is an important part of patient education.  14. Positive Waddell signs mean a patient is faking.  15. Pink flags are associated with negative expectations.  16. Health care providers can cause yellow flags by focusing only on the medical aspects of an injury.  17. Studies have shown that it is easy to keep your own attitudes and opinions from influencing the patient.  18.Yellow flags improve with time on their own and do not need to be addressed.  19. Patients who think something is seriously wrong with them are more open to positive information than those who are not worried about their health.  20. Diagnostic tests should be used as much as possible to detect any and all pathology before treatment.  21. Pain is the most important thing to consider when designing your plan of care.  22. Physical activity should always be avoided when a patient is in pain.  23. PT can be successful even if pain is not resolved.  24. Pain is directly related to the amount of tissue damage.  25. Learning to cope with stress promotes recovery from back pain.  All Questions Are to be Answered Either True or False  1. PiPT should be used only for high risk patients.  2. Studies have shown that patients who are at high risk for disability tend not to benefit from medically based PT.  3. PiPT is based on principles of CBT for pain.  4. In the biopsychosocial model, the patient is a passive participant in treatment.  5. The neuromatrix theory emphasizes the importance of psychological factors in the progression of pain and disability.  6. Black, orange, and yellow flags are all categories of psychological factors.  7. All patients with yellow flags should be referred immediately to a psychologist.  8. Expectations of outcome can be modified by the health care provider.  9. A behavioral approach to PT can improve the patient’s self-efficacy.  10. Health care providers with a biomedical perspective are more likely to follow guidelines for musculoskeletal injuries than those with a biopsychosocial perspective.  11. Fear of movement always indicates a poor prognosis.  12. The most important concepts to keep in mind when using a psychologically informed approach are self-care and self-blame.  13. Telling patients what to expect is an important part of patient education.  14. Positive Waddell signs mean a patient is faking.  15. Pink flags are associated with negative expectations.  16. Health care providers can cause yellow flags by focusing only on the medical aspects of an injury.  17. Studies have shown that it is easy to keep your own attitudes and opinions from influencing the patient.  18.Yellow flags improve with time on their own and do not need to be addressed.  19. Patients who think something is seriously wrong with them are more open to positive information than those who are not worried about their health.  20. Diagnostic tests should be used as much as possible to detect any and all pathology before treatment.  21. Pain is the most important thing to consider when designing your plan of care.  22. Physical activity should always be avoided when a patient is in pain.  23. PT can be successful even if pain is not resolved.  24. Pain is directly related to the amount of tissue damage.  25. Learning to cope with stress promotes recovery from back pain.  Table III. Knowledge Test All Questions Are to be Answered Either True or False  1. PiPT should be used only for high risk patients.  2. Studies have shown that patients who are at high risk for disability tend not to benefit from medically based PT.  3. PiPT is based on principles of CBT for pain.  4. In the biopsychosocial model, the patient is a passive participant in treatment.  5. The neuromatrix theory emphasizes the importance of psychological factors in the progression of pain and disability.  6. Black, orange, and yellow flags are all categories of psychological factors.  7. All patients with yellow flags should be referred immediately to a psychologist.  8. Expectations of outcome can be modified by the health care provider.  9. A behavioral approach to PT can improve the patient’s self-efficacy.  10. Health care providers with a biomedical perspective are more likely to follow guidelines for musculoskeletal injuries than those with a biopsychosocial perspective.  11. Fear of movement always indicates a poor prognosis.  12. The most important concepts to keep in mind when using a psychologically informed approach are self-care and self-blame.  13. Telling patients what to expect is an important part of patient education.  14. Positive Waddell signs mean a patient is faking.  15. Pink flags are associated with negative expectations.  16. Health care providers can cause yellow flags by focusing only on the medical aspects of an injury.  17. Studies have shown that it is easy to keep your own attitudes and opinions from influencing the patient.  18.Yellow flags improve with time on their own and do not need to be addressed.  19. Patients who think something is seriously wrong with them are more open to positive information than those who are not worried about their health.  20. Diagnostic tests should be used as much as possible to detect any and all pathology before treatment.  21. Pain is the most important thing to consider when designing your plan of care.  22. Physical activity should always be avoided when a patient is in pain.  23. PT can be successful even if pain is not resolved.  24. Pain is directly related to the amount of tissue damage.  25. Learning to cope with stress promotes recovery from back pain.  All Questions Are to be Answered Either True or False  1. PiPT should be used only for high risk patients.  2. Studies have shown that patients who are at high risk for disability tend not to benefit from medically based PT.  3. PiPT is based on principles of CBT for pain.  4. In the biopsychosocial model, the patient is a passive participant in treatment.  5. The neuromatrix theory emphasizes the importance of psychological factors in the progression of pain and disability.  6. Black, orange, and yellow flags are all categories of psychological factors.  7. All patients with yellow flags should be referred immediately to a psychologist.  8. Expectations of outcome can be modified by the health care provider.  9. A behavioral approach to PT can improve the patient’s self-efficacy.  10. Health care providers with a biomedical perspective are more likely to follow guidelines for musculoskeletal injuries than those with a biopsychosocial perspective.  11. Fear of movement always indicates a poor prognosis.  12. The most important concepts to keep in mind when using a psychologically informed approach are self-care and self-blame.  13. Telling patients what to expect is an important part of patient education.  14. Positive Waddell signs mean a patient is faking.  15. Pink flags are associated with negative expectations.  16. Health care providers can cause yellow flags by focusing only on the medical aspects of an injury.  17. Studies have shown that it is easy to keep your own attitudes and opinions from influencing the patient.  18.Yellow flags improve with time on their own and do not need to be addressed.  19. Patients who think something is seriously wrong with them are more open to positive information than those who are not worried about their health.  20. Diagnostic tests should be used as much as possible to detect any and all pathology before treatment.  21. Pain is the most important thing to consider when designing your plan of care.  22. Physical activity should always be avoided when a patient is in pain.  23. PT can be successful even if pain is not resolved.  24. Pain is directly related to the amount of tissue damage.  25. Learning to cope with stress promotes recovery from back pain.  RESULTS Training and reinforcement during deployment was conducted over a 9-mo period. At the end of the training, both the physical therapist and the PT technician received passing knowledge scores (100 and 85%, respectively). Both PT staff members demonstrated their capacity to score the screening tools, screen patients during role playing, and outline PiPT interventions to modify yellow flags. Both passed this assessment with 100% agreement of the trainers. During implementation, 19 clinical notes were independently evaluated. Evaluators looked for the documentation of the presence or absence of yellow flags in clinical notes demonstrated by information such as: “increased stress levels and fear of re-injury,” “fears not being able to work again,” or “no flags.” They also looked for a plan to address yellow flags when present shown by phrases such as, “patient education in pain coping techniques.” Functional goals such as: “improve quality of sleep,” “return to lifting activities,” “return to regular exercise program,” and “return to full duty” were also reviewed in the treatment plan section. If any of this information was missing, it was addressed during the next teleconference and corrected in future notes. This was done until no missing information was detected, such that all notes were complete at the end of the deployment. Both PT staff members participated in all nine teleconferences. These calls took place only when the ship was able to establish ship-to-shore communications. The PT staff presented challenging cases during these meetings to demonstrate how they managed the cases and to get feedback from the investigators. These discussions indicated that they were applying PiPT skills consistently and proficiently throughout the deployment. During the teleconferences and in separate email correspondence after deployment, the research staff received unsolicited feedback from the PT staff. Some of their comments were “Education is probably the most important thing we do in the clinic…,” “It is important for patients to understand why they feel what they do, what it means, and what it doesn’t mean…” “We get better buy-in and see good clinical progress as a result [of PiPT]” “Patients responded well to graded activity in order to restore confidence in movement and to overcome the pain memory and subsequent fear-avoidance behavior.” DISCUSSION PiPT is an emerging approach to managing patients with MSI, a significant cause of disability and attrition in the Navy. This study demonstrated that PT staff aboard a U.S. Navy carrier can be successfully trained to practice PiPT. This was demonstrated in several ways. During the training, both PT staff members were actively engaged and open to learning about the treatment strategies. They were able to easily identify patients in their practice who could benefit from PiPT. Both PT staff members obtained passing scores on the PiPT knowledge test following training, indicating a high level of information retention. In addition, both trainees demonstrated their capacity to score the screening tools, screen patients, and outline PiPT interventions to modify yellow flags during role playing. During deployment, both PT staff members participated in all nine teleconferences demonstrating their commitment to improving their practice of PiPT. Through their discussion of challenging patients, their buy-in of PiPT was clear. As the study progressed, they became skilled at identifying and responding to yellow flags as demonstrated in their problem-solving skills and their clinical note documentation. Previous studies that have sought to demonstrate the effectiveness of PiPT on patient outcomes have shown mixed results. A common explanation for this in the literature is the inadequacy of training or acceptance on the part of the PT.31,33 Therefore, one important finding of our research lays in the identification of facilitators of training uptake. Both a paradigm shift and change in clinical practice are necessary. Central to the success of the PiPT training was the PT staff members’ desire and ability to shift their treatment paradigm from a traditional biomedical approach to a biopsychosocial approach. This has been cited as a difficulty in previous studies on implementing PiPT.31,33,39 We believe that the PT staff successfully made this transition based on their high level of performance during our monthly conversations and their feedback at the end of the study. We attribute our success to several things. Firstly, our training took place in a small, intimate setting allowing for a relaxed and open atmosphere. We encouraged questions and comments throughout the training and tried to make it as interactive as possible. The use of case studies that reflected actual ADSM experiences after MSI made the case studies highly relevant to the PT staff which further facilitated participation. Also, the staff had 2 wk before deployment to practice PiPT on shore. We were able to give specific recommendations for addressing yellow flags during that time. In addition, PiPT skills were reinforced on an ongoing basis during deployment through teleconference participation. We also provided visual materials to the PT staff to be used as tools, which made it easier and faster for them to educate patients so as to reduce yellow flags during treatment. Once the PT staff learned the benefits of PiPT, they realized the importance of the training and had confidence in the biopsychosocial approach. As the PT staff became more proficient in providing PiPT, they stated that it became an effortless and permanent part of their patient care for all patients. Our findings indicate that PiPT training changed clinical practice in a number of ways. Clinical notes and conference calls demonstrated that the PT staff routinely evaluated yellow flags through questionnaires and clinical interviews, addressed yellow flags through education and the use of visual aids, and used a functional approach to PT that emphasized physical goals over pain relief. In addition, they discussed cases with each other to ensure seamless patient transfer and learned how to detect patients who required immediate referral to the psychologist. Changes in documentation notes included describing yellow flags and how they were addressed in treatment. One advantage we had was that the PT staff we worked with had the latitude to increase the time of the initial evaluation to include patient education. While the time it takes to address yellow flags decreases as PT staff members become more comfortable with the approach, there is no doubt that adding this aspect to treatment takes more time than usual PT sessions allow. Taking additional time to evaluate the patient may not be possible in other settings, and potentially limits the generalizability of these findings. However, given the importance that yellow flags have in determining treatment outcomes, it may behoove PT staff to use some of their evaluation time on this issue. This would require the support of supervisors and management to be successful and it is important that results like those reported here are disseminated to promote this cause. It is also worth mentioning that the active goal-oriented approach to PT, which is guideline-based and was emphasized during the training, reinforces the messages of PiPT. Once patients see that they are able to function, even with pain, yellow flag beliefs such as “pain equals damage,” “I will never get well,” and “movement is bad for me,” are challenged. Patients develop improved outcome expectancies and increased self-efficacy to manage their own pain. This type of PT requires no additional session time. Our training also emphasized the importance of an interdisciplinary approach to care. The on-board psychologist was included in the training to learn the PiPT approach, give us feedback, and facilitate timely and appropriate referral to her services. All patients were screened for clinical levels of depression, anxiety, and PTSD prior to treatment. Those that exceeded the cut-off were offered a referral for psychological support. This permitted inter-professional discussion about patients and allowed for coordinated care which is key to a biopsychosocial approach to treatment. One potential drawback to PiPT is that increased referrals to other specialties may be taxing on other health care providers within a specific health care facility and this must be considered before PiPT is implemented. This study demonstrated feasibility in a unique study environment. Of note is that PiPT training required only 3 d of the U.S. Navy PT staff member’s time and nine follow-up teleconferences between the study investigators and the ship’s PT staff to support and reinforce maintenance of PiPT study protocols. One limitation of this study is that the carrier PT staff consisted of only two members and therefore our sample size of trainees is small. This is the standard PT staff assignment aboard carriers. We were also limited by the realities of deployment schedules and therefore, could only train one carrier staff. However, our objective was to determine the feasibility of the training and sample size was not a priority. We note that neither of the study PT staff members had prior exposure to the PiPT concept nor is there reason to believe that their professional training or Navy experience was substantially different from other Armed Forces PT staff. The ease of implementation with the study PT staff suggests that other PT staff in the Armed Forces could be trained as successfully in a similar manner. We believe the course syllabus and training material used in this study can be easily modified for other health care settings. For example, shore-based PT staff that treat large numbers of ADSM can also be trained in PiPT. It is not yet known if this would generate results similar to the present findings. We plan to test this in future large-scale studies. CONCLUSIONS This study demonstrated the feasibility of implementing PiPT on a U.S. Navy aircraft carrier. All four criteria for feasibility outlined by the investigators were met. This is significant, since PiPT has the potential to modify maladaptive beliefs associated with disability and attrition in U.S. Navy personnel. Successful training requires both a change in treatment paradigm and clinical practice. The use of actual case examples and reinforcement during deployment contributed to the success of the training. It is not known how this training will impact patient beliefs and functional outcomes. Currently, the investigators are assessing this question in a quasi-experimental study with a concurrent, non-equivalent control group.37 Successful outcomes would support the implementation of this approach throughout the Navy and further the long-term goal of sustaining injured ADSM at full duty status, ensuring a healthy and combat-ready force. Acknowledgements The authors thank Elizabeth Plowman, PT, DPT, OCSLT, MSC, USN, Nicholas Azzaro HM2(FMF/EXW/IDW/SW), and Tahney C. Johnston, Psy.D LT/MSC/USN for their contribution to this study. Presentations Presented as a poster at the 2016 Military Health System Research Symposium, Kissimmee, FL (Abstract number: MHSRS-16-0092). Funding This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs, through the Peer Reviewed Orthopaedic Research Program under Award No. W81XWH-14-2-0146. Opinions, W81XWH-14-2-0146. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense. Human Subjects Statement Research data derived from an approved Naval Medical Center, Portsmouth, Virginia Institutional Review Board (Institutional Animal Care and Use Committee) protocol number NMCP2014.0058. References 1 Cohen SP, Nguyen C, Kapoor SG, et al.  : Back pain during war: an analysis of factors affecting outcome. Arch Intern Med  2009; 169( 20): 1916– 23. 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TI - Feasibility of Training Physical Therapists to Implement a Psychologically Informed Physical Therapy Program for Deployed U.S. Sailors and Marines with Musculoskeletal Injuries
JF - Military Medicine
DO - 10.1093/milmed/usx229
DA - 2018-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/feasibility-of-training-physical-therapists-to-implement-a-zxlYVOdc3C
SP - 503
EP - 509
VL - 183
IS - suppl_1
DP - DeepDyve
ER -