June 2021 Online, part 3
This is the third part of my thoughts about the online cognitive functional therapy course with Professor Peter O’Sullivan in June 2021. Overall it was a great success.
Here are the links to:
Cognitive Functional Therapy Course, June 2021 Online, part 1
Cognitive Functional Therapy Course, June 2021 Online, part 2
Exposure
Exposure to mechanical stresses needs to be done carefully and the assessment should tell you what kind of pain the person has and how easily, or not, it is aggravated.
“Baby steps are needed for big steps to be achieved.”
We learn by mirroring and can use our own bodies to illustrate, making it easier for the patient to copy what we are aiming for.
It’s critical to develop a sense of safety around the exposure challenge as they’ll be very anxious when you get them to do the things they fear and have been avoiding.
I think of the extension pattern, where the person keeps their core tight and holds the lumbar spine in lordosis, as Self-Imposed Functional Fusion or SIFF. I’m slightly tongue in cheek here but it’s the commonest pattern and I wonder if Self-Imposed Spinal Stenosis and Self-Imposed Nerve Root Compression contribute to symptoms in these presentations. They’re not the whole story but I think they may sometimes be enough to get the symptom bucket to spill over into pain.
Get the patient to increase their pain so you can contrast it later with the improvement they get with CFT approach, allowing them to learn.
Giving Up Early
Watching Peter with one of his patients in particular, I was struck by how far he went in finding out what the patient wanted. The lesson for me was that once you’ve sorted out the presenting problem for the patient, don’t just say “Great” and discharge them. Find out what else there is, lurking in the background. They may be able to bend over and lift objects but have trouble in the car. Once you address that you may find they have some, slightly smaller, problem sleeping. It’s worth chasing all the symptoms and “disabilities” before you can say you’ve done a good job.
Day 3
Patient Stories and Treatment.
If you challenge the patient too hard, you challenge the person and not just their beliefs. This will likely result in a poor outcome.
Challenge at the correct time and at the appropriate level. Before that you can roll with the resistance/beliefs (just noting them) until you have a good enough relationship to start the harder work. [Remember not to be right. At least not to say so].
Nobody listened, nobody believed, nobody understood. That’s what my ex-colleague Patrick said years ago – this is what patients think if you really ask them. So be different. Listening is an effortful and active process.
Constantly check what the person is thinking, because they could go off on a cognitive tangent you are unaware of which may hold them back.
A key is re-engaging with valued activities. It has to be valuable to the patient, not an exercise without functional meaning for them. Like knee rolling, pelvic tilting and pretty much any back exercise we use…
I have attended the cognitive functional therapy course twice in person in London, but this year was different due to the limitations on travel from the pandemic.
However, the online format for the cognitive functional therapy course works very well indeed. We miss the social interaction, the meeting new people and enthusing about new ideas and treatment, but this is a good substitute and could remain part of the repertoire.