I’m very proud to have contributed to this month’s International Federation of Societies for Surgery of the Hand (IFSSH) eZINE. As an advocate for all surgeons and therapists to incorporate mental health awareness and support in conjunction with their usual treatment, it is an honour that this topic is being broadcast across the world. It’s a bit heavy, but a shortened version is below!
Mindfulness, Health Coaching and Hand Therapy
Psychosocial risk factors correlate highly with patient reported pain and functional outcome following hand surgery. Despite this, hand therapists and hand surgeons are not trained to support patients with psychosocial challenges. With a greater awareness of the mental health needs in today’s population, it is essential to develop our skills to support patients with complex needs.
Identifying people who would benefit from an enhanced approach
There are some risk factors that suggest a person may benefit from a more supportive approach instead of standard treatment alone. These signs include:
- Multiple pain sites
- Pain for more than one year
- Anxiety and/or depression
- High functional disability
- A lack of confidence in performing activities (low self-efficacy)
It is reasonable to assume a significant proportion of people attending a hand clinic will have some of the above factors and are at risk of a reduced self-reported functional outcome. 25% of the UK adult population experience a mental health problem each year and 10-14% of UK adults have a moderate to severely disabling chronic pain condition. An awareness of these factors can allow for a psychologically enhanced approach with the view of achieving a better outcome for the individual.
Health Coaching is used increasingly in primary care to support people with chronic conditions to develop healthy behaviours to improve their prognosis. Health coaching acknowledges the challenges people face in introducing new behaviours and empowers them to make changes that are practical for them. With greater awareness that many people present with challenging health and social circumstances, health coaching can be a valuable skill for hand surgeons and hand therapists.
Health coaching offers an entirely different way of interacting with patients with complex needs. It emphasizes the need to develop a recovery plan that is realistic and achievable and to not expect strict adherence to a generic programme. Crucially, this plan is developed by the individual with support from the clinician. It is essential the rehabilitation plan has meaning for the person. This is achieved through functional goal setting, a health coaching skill any clinician can implement. Functional goal attainment becomes the focus of therapy sessions, not improvement in impairment such as range of motion and strength.
Functional goal setting is a transformational process for many people. Fear and avoidance of functional tasks is necessary, and actively encouraged, in the acute phase of recovery to protect the injured limb. However, when pain persists, many people still believe it is damaging to participate in painful activity. This leads to reduced independence with a negative impact on mood that perpetuates the fear-avoidance cycle. The simple act of asking someone what activities they would like to perform better can provide a shift in thinking. It is no longer dangerous to function in the presence of pain. It is healthy and necessary.
Grading the goals with a tool such as the Patient Specific Functional Scale can also be a revelation. Tasks that previously seemed overwhelming, can feel more achievable when measured in increments. The clinician can reassure the patient that small increases in discomfort are to be expected when a new activity is introduced. Further reassurance can be provided by helping them develop a plan to manage the pain if it becomes distressing. Motivation is provided by reviewing the goals at each appointment and celebrating small improvements. This builds the essential skill of confidence in performing a task in the presence of pain (self-efficacy). Self-efficacy has been shown to be one of the most important factors in achieving a good functional outcome when recovering from a musculoskeletal condition.
A Word of Caution
A well-meaning clinician may spot fear-avoidance behaviour in someone and wish to help them overcome this. A typical impulse is to tell them they are fine and it is safe to return to normal tasks. This can help some but can have a negative impact on more vulnerable patients. This statement can be too generic, unachievable and dismissive of their very real pain. It can lower their mood and motivation even further. If time is short, it is more helpful to ask if there is one thing they would like to do better. Ask them what a first step towards achieving this could be, reassure them a slight increase in discomfort is normal and help them formulate a plan if they become too uncomfortable.
Health coaching recognises that a therapy programme is far more effective if it is meaningful to the person. A time-pressured clinician may expect everyone to adhere to a generic programme, however there are many people who are not capable of this. With a little awareness and flexibility, we can engage more people through an individualised health coaching approach.
Mindfulness-Based Cognitive Therapy
Health coaching can be helpful however even this can be too challenging for a more vulnerable people. Their difficulties are overwhelming them and a psychological approach is indicated.
Although some hand clinics have access to a specialist psychologist, it is becoming increasingly important that all clinicians have the skills to deal with mental health problems. It has been shown that physiotherapists who have received basic training in cognitive behavioural therapy (CBT) can help people with psychosocial risk factors overcome low back pain better than standard treatment alone. Psychologically enhanced care has not yet been widely adopted by the hand surgery and therapy community but it has the promise of being an essential skill.
CBT helps people notice and change problematic thoughts or behaviours so they can feel better. In acute care, it can be difficult to convince someone that changing their thoughts and behaviour will improve their condition when there has been tissue damage. Another approach may be warranted. Evidence has emerged that mindfulness based interventions (MBI) are equivalent to CBT in helping patients to manage low back pain. MBI acknowledges and accepts challenges are present. It can provide a viable way forward for a distressed person who has experienced an injury, received all appropriate treatment, and is no longer progressing.
MBI sits under the umbrella of Acceptance and Commitment Therapy. Accepting difficulty without striving for change reduces the physical and mental stress response and thus can reduce suffering. A person learns to accept thoughts, feelings and sensations around pain and disability and to shift their focus to their present moment experience without judgement or striving for it to be different than it is. With practice, this reduces their distress and enables them to gain a calmer and more balanced perspective on their health. From this point, they can begin to engage in meaningful activities that give them a sense of pleasure and accomplishment. This can result in an improvement in mood and function and a reduction in pain and anxiety facilitating a greater sense of wellbeing.
Teaching mindfulness in a clinical environment requires training. It is not intuitive for hand surgeons and therapists to help someone accept their condition. We are trained to fix them, especially in acute care. It can be difficult for someone to engage with accepting their current state and this needs to be approached with sensitivity and skill. The first step in learning how to incorporate mindfulness into clinical practice is to complete an 8-week mindfulness course for yourself. Only by learning and practising these techniques will you be able to support patients through the transition from fixing their difficulties to accepting them.
I am now able to offer patients hand therapy, health coaching and one to one 8-week mindfulness-based cognitive therapy courses depending on what they need. There are still some people I’m not able to help, but I can certainly support a greater number than I could with just my hand therapy skills. Whether someone needs an exercise programme, health coaching to achieve functional goals or to learn MBCT to accept difficulty, I hope I’m helping more people to live a more fulfilling life. It has certainly made my job more rewarding.