Rehab Strategies for Patients with Chronic Conditions A Complete, Patient ‐ Centered Approach to Effectively Treat Challenging Patients 1
My Goals 1. Reduce or resolve your fears in working with the chronically ill 2. Encourage you to “raise the bar” on yourself and your patient; use your skills and don’t let YOUR mind limit YOUR outcome 3. Create consistency in your thoughts, attitudes, beliefs and approaches with your patients 4. Educate regarding the impact of the mental state on performance and outcomes in the medically complex patient 5. Improve your confidence in applying manual therapy techniques in the complex medical patient 2
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• • Hypertension • Visual refractive Depressive errors disorder • Hyperlipidemia • • Osteoarthritis • Diabetes Coronary atherosclerosis • Back pain • Fibromyalgia • • Anxiety UTI • Malaise/fatigue • • Obesity • Joint pain Cancer • Respiratory • • Major depressive Parkinsons problems disorder • Alzheimers • Hypothyroid • Bronchitis • Dementia • Asthma • CVA 4
• Heart disease affects ~ 47% of US • 647,000 die (1 in 4 deaths) • Diabetes affects ~ 9.4% os US; 0.55% to 8.6% (type 1 and 2 respectively) and 25.2% of geriatrics • 79,535 die (7th leading cause) and 252,806 die as secondary cause • Anxiety affects ~ 18.1% of US • <40% seek treatment • Parkinson’s affects ~1.2% of US • Cancer risk for the lifetime is ~ 42.05% men and 37.58% women • COPD affects ~ 14.5% of US • Leading cause of death of women in US 5
Classification “the action or process of classifying something according to shared qualities or characteristics” 6
What should we classify? Things that DIRECTLY impact treatment decisions Cognitive Sensory Motor 7
Demonstration Sit<>stand (Strength) 8
Evaluation Accurate classification for treatment • Pertinent history • MI, cancer, COPD, pneumonia, CHF • Surgery (CABG, stent, filters, pacers) • Rehabilitation (Cardiac, pulmonary) • Specific leading questions OUTCOME MEASURES & TREATMENT GOALS directly impacting movement • Exacerbation • Fatigue • Anxiety • Fear avoidance • Shortness of breath 9
• How many exacerbations of your COPD have you had this year? On average how intense were they (1 ‐ 10 scale)? How many times did you to go to the hospital? • Do you feel tired most of the time? What things make you tired? How long does it take to recover? • Are you anxious when you do …..? If so how much? What do you do to decrease your anxiety? • Are you afraid to fall? Are you afraid to walk outside? Are you afraid to become short of breath? • How short of breath do you become when you do …..? How often are you short of breath? How long does it take to recover? 10
• Exacerbations of Chronic Pulmonary Disease Tool (EXACT ‐ Pro) • Beck Anxiety Inventory (BAI) • Fear Avoidance Beliefs Questionnaire (FABQ) • Fear of Falling Avoidance Beliefs Questionnaire (FFABQ) • Fall Efficacy Scale International (FES ‐ I) • Activities ‐ Specific Balance Confidence Scale (ABC Scale) • Modified Medical Research Council (MMRC) Dyspnoea Scale • Shortness of Breath with Daily Activities Questionnaire (SOBDA) • Dyspnea Management Questionnaire (DMQ) • Modified Borg • Patient Specific Functional Scale 11
Exacerbation COPD patients with severe exacerbation are at greater risk for cardiovascular disease … probably due to the high prevalence of arterial hypertension and diabetes mellitus Quality of life (CAT Test) and glucose control are predictors for increased CVD risk Mekov et al. Cardiovascular risk assessment in COPD patients with severe exacerbation. European Respiratory Journal 2016;48: PA1134 12
Fatigue • “Do you feel tired most of the time?” (Yes increases 10 yr mortality 55%) Hardy et al. J Am Geriatric Soc 2008 • Vital Exhaustion Questionnaire (> 9 increases relative risk 2.57 for IHD) Prescott et al. Epidemiology 2003 • Walking Impairment Questionnaire ‐ PAD (Stair climbing < 8 all cause mortality) Jain et al. J Vasc Surg 2012 13
Anxiety CBT reduced anxiety and fatigue, improved social functioning and better health ‐ related quality of life Freedland et al. Cognitive behavior therapy for depression and self ‐ care in heart failure patients: A randomized controlled trial. JAMA Intern Med 2015;175(11):1773 ‐ 1782. CBT demonstrated “a significant 17% reduction” in perception of dyspnea in patients with COPD Livermore et al. Cognitive behavior therapy reduces dyspnea ratings in patients with chronic obstructive pulmonary disease (COPD). Respir Physiol Neurobiol 2015;216:35 ‐ 42. CBT, exercise and anxiolytic use was associated with changes in depression and anxiety Tully et al. A dynamic view of comorbid depression and generalized anxiety disorder symptom change in chronic heart failure: the discreet effects of cognitive behavioral therapy, exercise and psychotropic medication. Disability and Rehabilitation 2015 14
Cognitive Behavioral Therapy • Depression ‐ O’Hea 2009 CHF • Anxiety & depression ‐ Cully 2010 CHF, COPD • Emotion/anxiety ‐ Karbasdehi 2018 CHF • Chronic fatigue, self ‐ efficacy ‐ Tack 2018 Type 1 DM • Psychological distress ‐ Ires 2019 MS & Parkinson’s • Mood, anxiety, sleep, negative feelings ‐ Dobkin 2019 Parkinson’s 15
Cognitive Behavioral Therapy Psychological problems are based in part on: • Faulty or unhelpful ways of thinking • Learned patterns of unhelpful behavior Patients can learn better ways to cope, relieve their own symptoms and become more effective in their lives 16
Cognitive Behavioral Therapy • Can learn to recognize distortions in thinking that create problems • Can learn to reevaluate thoughts in a different light • Gain a better understanding of behavior and motivation of others • Use problem solving skills to cope with difficult situations • Increase confidence in oneself 17
Cognitive Behavioral Therapy Modifies dysfunctional emotions, behaviors and thoughts • Focus on solutions • Encourage the patient to challenge cognition • Change destructive patterns of behavior • Face fears • Learn to relax and calm the body • Prepare for challenges 18
Cognitive Behavioral Therapy • Not motivational, educational or negotiation • Ask “loaded” questions that you know the answers • Use analogies and examples that are generally known and understood 19
Lab Battery vs generator 20
• “Why do you think you need to rest?” We need to establish “baseline thinking” so we can change it • “How long have you been resting?” They will say only a short time, but we know it has been progressively longer and longer so make them acknowledge this • “Is it fair to say you are doing less than… ?” Establish history of progressive weakness to help them recognize rest hasn’t helped • “Is rest really helping you feel stronger?” This helps them begin to understand that rest isn’t helping as much as they think 21
• Did you ever know someone who decided to begin exercising? How did it feel at first? Did it get better over time? How much could they do at first? Over time? Most people know someone who decided one day to begin exercising and they also know how the typically improve with effort “Is it fair to say they “Rested” before they began? Did it help? • Did you ever play a sport? Or an instrument? Did you have a hobby? Could you do it now? If you practiced a little could you do it better? Most people have played a sport or some kind of musical instrument or participated in hobbies and understand practice is crucial in performance “Is it fair to say you have “Rested” from the activity? Has it help? • Did you read about the marathoner who broke the world record? How was he able to run so fast? Many people are aware of current events and this particular event was a “big thing” and can be used to demonstrate the importance or regular training and the benefits “Is it fair to say he “Rested” before he began? Did it help? 22
• Focus on solutions What do you think you can do? What will you do? • Encourage them to face their fears “OK let’s go…” • Increase their confidence How was that? How do you feel? 23
Fear Avoidance Fear avoidance is directly related to physical disability and perception of quality of life Stenzel et al. The impact of illness perception and fear avoidance on disability in COPD. European Respiratory Journal 2014;44(58):p3674 Dyspnea ‐ related fear may be more closely related to critical processes involved in pulmonary rehab and may have predictive value for COPD outcome Janssens et al. Dyspnea perception in COPD: Association between anxiety, dyspnea ‐ related fear and dyspnea in pulmonary rehabilitation. Chest 2011;140(3):618 ‐ 625. 24
Lab Fear of SOB 25
• “How long have you had shortness of breath?” We need to establish “onset related to disease” in order to challenge • “Never before your disease?” They will say “NO” but we will show them they have always had episodes of SOB and that it is completely normal • “Is rest helping you feel stronger?” See previous 26
Mind ‐ Body Connection Thoughts, feelings, beliefs and attitudes can positively or negatively affect our biological and physiological function 27
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