Welcome back to the Healing Pain Podcast with Dr. Rose M. Pignataro, PT, PhD, DPT
Thanks for joining me for this special episode of the show masterclass where we’re discussing the impact of motivational interviewing on chronic pain. In this episode, I’m joined by Dr. Rose Pignataro, who is a doctor of physical therapy and an expert on how to use motivational interviewing specifically in physical therapy, chronic pain and non-communicable disease. In this masterclass, Rose will discuss what motivational interviewing is, how motivational interviewing can be used alongside other treatments such as exercise, pain neuroscience education, CBT or ACT, and how to bill and code for this intervention in clinical practice.
Finally, she’ll go through a case study of a woman with diabetic peripheral neuropathy who is ambivalent to start and exercise or change her nutrition patterns. Make sure you hang on for that case study toward the end of this episode. Dr. Pignataro has joined the Integrative Pain Science Institute as a faculty and educator. You can check out her latest course, which is Motivational Interviewing for Chronic Pain. You can find it on the website at IntegrativePainScienceInstitute.com. Scroll over to courses. Go through our course list and you’ll find it there. Without further ado, enjoy this masterclass with Dr. Rose Pignataro.
Watch the episode here:
MasterClass: Motivational Interviewing For Chronic Pain With Dr. Rose M. Pignataro, PT, PhD, DPT
A big welcome to everyone from around the world. We have lots of people in the chat thread talking to us from across the United States, Canada, Europe and even some people from Asia. Always a special hello to our friends on the other side of the world in Australia who don’t get to join us live typically. Always know that we’re thinking about you, have you in our thoughts, and always welcome you into our global community. This is a masterclass on motivational interviewing specifically for chronic pain and chronic health. It’s intended for practitioners. If you’re not a practitioner, you’re more than welcome to read. Realize that this is intended for professionals. Before making any changes to your lifestyle or medical choices, make sure to consult with your physician or another licensed health professional.
I’m excited to share with you information on motivational interviewing for chronic pain. One of the reasons why I love motivational interviewing is because it enhances every single thing that you do as a licensed professional. No matter what type of professional you are and no matter what type of interventions you’re already using, it can bolster that in essence. Rose is going to talk a lot about that. I’m going to give you a quick rundown of what’s going to happen here. I’m going to introduce Rose. I am going to go through a quick Q&A with Rose to give us some background and context of what we’re going to talk about. Rose is going to go through a case study. Without further ado, let me introduce to you my good friend and colleague, Dr. Rose Pignataro.
She is a Doctor of Physical Therapy with more than 30 years of direct patient care experience, including the treatment of chronic pain and associated conditions. In addition to her clinical background, she has earned a PhD in Public Health with a strong focus on social and behavioral theory, health promotion and wellness. She’s also a certified health education specialist and certified in wound management. She’s an Associate Professor and Assistant Chair of Physical Therapy at Emory & Henry College in Marion, Virginia. Rose is leading the Motivational Interviewing Course For Chronic Pain here at the Integrative Pain Science Institute.
It is a course that’s worth 7.5 CE/CEU hours. The institute is an approved provider for Physical Therapists Continue Education Units for OTs and health coaches. The institute is an approved provider by the American Psychological Association. If your mental health provider, that covers you there. The course is priced at $299, which is an excellent value for what you’re getting here with regards to working with Rose. I’ve seen the back end of the course. The information is amazing. Before we go on to that case study, let’s go into a quick Q&A with Rose. The easiest place to start is how do you define what motivational interviewing is?
The best way to describe it is that it’s a style of communication that’s very patient-centered. It allows the provider to gain further insights into the patient’s perspectives about why they’re seeing us, what they expect to gain from the consultation with us or from continued treatment with us. Also, when we’re talking about any type of behavioral change, it’s very empowering for the patient because it recognizes them as a collaborative partner in their own care, which is something that we don’t always see when we use a more traditional model of healthcare, where we’re acting as the expert and prescribing what the patient should be doing. With motivational interviewing, there’s this bi-directional dialogue where we’re asking the patient questions about their intentions, what they see to be, some of the issues that they could address through their own behavioral changes or by taking ownership of the health condition, what they see as some of the barriers to change, and what they think are the best strategies to address those barriers.
It’s the difference between us educating a patient versus the professional promoting effective behavior change. All health professionals are excellent at patient education. What you’re talking about is enhancing that communication with some of these MI skills.
I would agree with that. It is a form of communication that’s used for patient education. There’s a difference between instructing the patient and where I’m using a more prescriptive approach, which is sometimes appropriate and using motivational interviewing, which is more collaborative. You’re having more of a conversation with the patient as opposed to me telling somebody what I think might be best for them. It allows us to tailor our approach because what’s best for me may not be best for you. It recognizes that.
As professionals, we study so many things in school. We’re constantly learning new things and get our education courses. We always think we know what’s best for the patient. We have the answers. What’s the challenge with approaching a patient in that way?
Sometimes we do know what’s best. You go to school for a long time. You continue reading journal articles and taking courses like the ones that are offered through the IPSI. In many cases, we are the experts. That’s why patients come to see us. The danger in me always being the expert is that I could prescribe or instruct a patient in a certain set of behavioral changes or exercises or something like that. The patient doesn’t necessarily have the capacity to perform or to adhere to those recommendations They don’t know about that unless I provide space for the patient to talk about that.
How does motivational interviewing help a physical therapist effectively treat pain specifically? Is it zeroing in on pain? How does MI enhance our ability to treat pain as professionals?
We recognize that pain is a multifactorial experience for the patient. There are physical and neurological aspects of pain but there are also psychological aspects of pain. It infects the whole person. I can do certain tasks like pain provocation tests and certain objective measures but that doesn’t necessarily capture the full picture. As healthcare professionals, we’ve been encouraged to use the ICF model of disablement where we’re looking at not only the physiological factors but the contextual factors. Unless I ask very directed questions on the patient, I don’t necessarily know what type of support are they receiving from their significant other or from their family. What are their pain perceptions? Do they think that they’ve done something that has caused this pain for themselves? Do they have more of an extrinsic point of view where they think that the pain is coming from a lack of proper treatment from the healthcare professionals, for instance?
Using motivational interviewing helps us gain insight and awareness of what this patient thinks and what’s causing the pain. If the pain is coming from a mechanical problem in the spine but the patient has some type of belief that the pain is coming from the lack of proper pain medications, then we’re not going to be able to come to a central agreement unless we start to talk about what the differences are in our perspectives. Each one of us gets to explain why we think the way we think.
For clarification, the ICF stands for?
The International Classification of Functioning model through the World Health Organization.
It’s a pretty good model for a biopsychosocial approach to treating people. That’s become the mainstay for most professionals and it continues to grow.
That biopsychosocial approach is a better term that you use, Joe. The ICF model goes along with that medical perspective. The biopsychosocial model tends to integrate more of mind and body connection.
This always comes up with every professional, specifically PTs, because we have a lot on our plate in clinical practice. As a physical therapist, how can I start to weave MI into practice? Do I have to have a lot of time for this? Mental health professionals have their counseling all day long. As physical therapists, we counsel as well but we’re starting to expand this and realize that there’s a lot of counseling that has to happen with regard to exercise, nutrition, promoting sleep and all the various things that all of us are talking about as professionals. As PTs, do I have to have an hour to do this? What does this look like? If you can talk to that a little bit.
Although I spend most of my time in academics, I still treat patients. When I’m in the clinic, I have the same productivity standards as other people. I’m not getting extra time to treat patients with motivational interviewing. I use it when I’m going to do any form of patient education. It depends on what your intention is. Certainly, if I’m having a health coaching session, I’m not doing physical therapy. I’m using full 45 minutes to use motivational interviewing to get to the crux of the behavior that the patient needs to address. During a PT session, I’m using more of a brief form of motivational interviewing the same as I would do patient education. I’m teaching somebody a home exercise program. Instead of using that traditional form of instruction, I’m using MI.
You can use a brief form of motivational interviewing where your main intention is to change the patient’s perceptions regarding the usefulness of their behavior as it stands. It encourages them to see their behavior in a different light so that it’s more intentional towards recovery. You can do that in as little as 5 to 7 minutes. Typically, I’m doing that while I’m doing something else. I’m instructing somebody in a home exercise program or I’m doing manual therapy. We have a chance to have a conversation. It’s being much more intentional in your communications. It doesn’t add time to the overall episode.
These skills are informing. It’s the through-line with your communication when you’re working with your patient or client.
It’s being more intentional in choosing the topic of discussion and asking open-ended questions that solicit input from the patient so that you’re able to identify what’s the next best step in the overall plan of care. My treatment sessions are not any longer than the other therapist. In fact, maybe it’s a little bit of bias on my part. I’m more efficient because motivational interviewing has been shown in the evidence to enhance adherence. Instead of showing somebody their home exercise program seven times, I’m showing them once or twice, getting enough feedback where we’re promoting adherence so I don’t have to keep repeating the same thing over and over again.
With your communication style and using these tools that you learned through MI, you’re able to make this concise, which is important, even with mental health professionals. I have some colleagues that work in primary care and behavioral health. They only have 15 or 20 minutes with the patient. It’s not just PTs. It’s everyone across the healthcare spectrum. Primary care physicians are good perspectives. Getting back to those kinds of brief, what you’re saying is sometimes 1 or 2 questions can be the pivot point that starts to move the session on someone’s behavior in the right direction.
Even during an initial assessment, one of the best questions that I can think of asking the patient is what do you think is the best way to address the issues that we identified? That will tell you whether or not you’re on the same page. What’s the reason that you came to see me? What is it that you hope to gain from our interactions with one another?
I come across MI years ago. I love it because it blends well with everything. Can you talk more specifically about some of the research? What has MI shown to enhance specifically?
It originated with two psychologists, Miller and Rollnick. They originally designed it to work with people who had addiction issues and to help those people recognize their own role in addressing the addiction. It recognizes our self-determination as adults. I can’t force another adult to do their home exercise program. I can’t force another adult to modify their activities. I can encourage that and certainly use my own skills as a resource for that patient. It’s expanded from that initial using an addiction science to any type of health behavior. When we look across the American population and the high prevalence of non-communicable chronic diseases like hypertension, diabetes, cardiac disease, chronic pain, what we want to do is look at the things that can be changed. What are the modifiable factors? When you look across the board at modifiable factors that are common to these types of chronic diseases, some of the big ones that stand out are diet and nutrition, exercise and lack of physical activity. It’s more of a sedentary lifestyle. When we look at people with chronic pain, very often, they’ve been disempowered as a function of their impairment or disability. This helps them take ownership and control over that, rather than continuing to be dependent on the health care practitioner.
Does MI blend with pain neuroscience education?
Yes. One of the first things we want to figure out with pain neuroscience is what are the patient’s pain beliefs? What does this person think caused their pain? What do they think is the best approach for treating the pain? We can talk from there. Motivational interviewing allows us to explain our rationale behind some of the recommendations that we might make. Find out from the patient whether or not these recommendations seem feasible. A big one would be fear-avoidance behaviors. The literature supports the fact that motivational interviewing is very effective in addressing some of those fear-avoidance behaviors that stop people with chronic pain from being able to enjoy an active life.
Those fear-avoidance behaviors are important for pain but fear-avoidance comes up in a lot of other types of conditions and areas as well like anxiety, depression, even certain food and changing dietary patterns. People have lots of preconceived notions about food and how do we start to overcome that. There are lots of different applications. A big one that comes in all the time with everything new is how do I bill for this? There are always productivity demands that are placed on us as professionals. With that productivity, people are looking at how many patients are you seeing? What are you billing? How can you bill for MI?
It’s the same way that we bill for traditional forms of patient education. The CPT code for patient education is 98960. That can be used for motivational interviewing. If you’re running a session where you’re educating somebody in different forms of therapeutic exercise, then you use that billing code like 97110 for therapeutic exercise. I’m doing therapeutic exercises combined with motivational interviewing.
Ultimately, within that fifteen minutes of a time code, TherEx, it’s not like the person’s exercising for fifteen minutes and you’re just sitting there as a professional. You’re educating them and guiding them. In the context of MI, you’re helping to sustain and motivate that behavior for the long term. It’s so interesting because as professionals, we’re naturally good at creating these therapeutic bonds and being chatty with patients. This is saying, “How do we zone in on what’s important here, which is the behavior change?”
You’re hoping for a lasting change of behavior so that when the person finishes that episode of care, they are autonomous in managing the condition. The other thing is that we face a lot of restrictions that are secondary to payment. Maybe you think that the patient needs 24 visits but you only get ten. By being more efficient in the way that you were guiding the patient’s care and promoting adherence, you’re getting more out of the sessions that you are allocated to with the patient.
Do you use MI skills when you’re implementing manual therapy techniques?
Yes. It helps the patient to know why you’re doing what you’re doing, also what the end goal is. It encourages the patient to give feedback. We often hear the term passive treatment is I have hands on the patient. It’s not a passive treatment if the patient knows why we’re doing it. The fact that this is a temporary step to make them more active, I want to make them rely on joint mobilization, soft tissue mobilization or anything like that. It’s a means to the end. If I can do these manual techniques to help you be more physically active, that’s the goal. The goal is not to see how good my hands are and how good my manual skills are.
From a PT perspective, we can overlay with manual therapy codes, therapeutic exercise, neuromuscular re-education or therapeutic activity.
Neuromuscular re-education is a big one if you’re doing lifting techniques, body mechanics, gait and balance training.
Anything self-care related. There are behavioral health codes that any practitioner can use and access whether you’re a PT or any other type of practitioner. It’s 96158 and 96159. 96158 is a 30-minute code. 96159 is a fifteen-minute code. Those are codes for adaptive behavioral therapy. It is up to the insurance company. In the country we live in, there are hundreds and thousands of insurance companies. Many companies will reimburse 96158 and 96159 for adaptive behavioral therapy. That includes PTs, OTs and people out of the mental health realm. We’re going to start to wrap up the Q&A here. I want to start to turn toward the case study that Rose is going to chat about. Without further ado, let’s turn that over to Rose and she’ll go through that case study.
Before we go through the case study, there was a good question. Someone asked whether or not motivational interviewing can be used during the examination. Yes, I start using it from the very first encounter with the patient. Often in the initial encounter, we’re explaining to people what we’re doing, what we can offer them as a healthcare practitioner and why we’re doing what we’re doing. I’m also making the patient an active participant. What do they think is causing the pain? What might they think is the best way of going about this? It can be integrated into the examination. Very often, that is what happens from a chronic pain perspective. If we’re thinking that weakness has contributed to the person’s chronic pain, that’s where you start talking about that.
Once I learned MI, I even changed my intake paperwork to ask questions that are more in line with good behavioral principles.
We do that with the wound care intake as well. One of the questions or the intake form is what do you think causes the wound and how long do you think it will take to heal?
When you ask them about what caused this wound and what’s the path you think you should take the healing, what are some of the responses you get toward that?
Sometimes, the patient doesn’t know what caused the wound. My practice is usually around chronic wounds. That tells me that I have a harder job, especially if somebody has a neuropathic foot that’s been caused by diabetes and that person doesn’t see diabetes as a contributing factor. It’s hard to get that buy-in from them. As part of their treatment, I’m going to recommend better dietary control and better blood glucose regulation. If the person doesn’t think that that’s a contributing factor, I’m not going to get the adherence that I would like to see.
I want to turn to the case study. We want to make sure to squeeze that in here. Let’s begin with the case study.
I want to make it clear for HIPAA purposes, for patient privacy, I’ve conglomerated a couple of different patients so that I’m not violating anybody’s confidentiality. The case that I’ve discussed with Joe, because I am a wound management specialist, very often, I’m seeing people with chronic pain that’s related to diabetic neuropathy. In the case that I’m going to discuss, we had a patient come to us with very painful diabetic peripheral neuropathy that had affected both her hands and feet. It’s good that we were able to get the referral as a preventative measure. I’m sure it doesn’t feel pleasant to the patient but I would much rather see somebody with painful diabetic neuropathy than somebody who has lost their protective sensation. Once the pain goes away, then the patient becomes much more vulnerable to injury and not being aware of that injury because of the lack of sensory input.
This particular patient came to see us with pain in the hands and feet. I was already behind the eight-ball because the referral for physical therapy said, “For pain management using electrical stimulation.” The healthcare practitioner that had referred the patient for physical therapy already placed an expectation in the patient’s mind that involved a passive form of treatment here. The patient is coming to see us and they’re expecting to get a TENS unit, which I did think would be helpful. Based on science, the most helpful thing for diabetic peripheral neuropathy is blood glucose regulation. One of my first questions to the patient was, what did she think had caused the pain? She said it was because the provider had taken her off of her pain medication.
She thought that the best way to treat this would be to go back on the pain medication. Certainly, we could see why that would be somebody’s perception. At the very least, if we weren’t going to put her back on the opioid medication, then we needed to provide some other form of treatment like the electric stim. She also didn’t think that the electrical stimulation would be effective. She’s coming to see me reluctantly to prove that physical therapy can’t help. With that knowledge, she’s then going back to the doctor and saying, “I tried this and it didn’t work.” Knowing that that’s where she was starting out, I was able to use motivational interviewing to see whether or not she thought that there were other contributing factors. We talked about the fact that it’s called diabetic peripheral neuropathy.
Through the name, you think that the person’s diabetes has contributed to the problem. What could we do together to address diabetes and not just the pain? The first thing was that the patient was not testing her blood glucose level on a regular basis. She didn’t think that that mattered. Theoretically, it may not matter. There are people that do have good blood glucose regulation and still have neuropathic pain, but this person had a hemoglobin A1c that was close to nine. We know that there’s not good blood glucose regulation. I was able to use MI to teach the patient about what her lab results meant so that she could track her lab results and see how her behavior may or may not contribute to the levels that we were seeing with the hemoglobin A1c.
I also explained that hemoglobin A1c was not a snapshot. It was more like a panoramic view of what happens with your glucose levels over a three-month period. The first thing was that I had to encourage her to check her blood glucose levels at home. Through MI, we reached a compromise. She had originally been instructed that she needed to check her blood glucose levels 4 or 5 times a day. That’s not going to happen with somebody who’s never done it before. It felt very overwhelming to her. We negotiated at midpoint. What if she checked her blood glucose level once as a starting point. I use motivational interviewing to ask the patient, given her schedule, when would it be the easiest for her to take her blood glucose? She said in the morning when she woke up. We use that as a starting point.
Through motivational interviewing, I found out that she was never taught how to use the glucometer well and that she feared pricking her finger. We were able to use modeling, which is a component of social cognitive theory so that I did the finger stick on myself and then the patient did her own. We did that a couple of times in our sessions with one another until she felt capable of doing that at home. Once she was starting to use her blood glucose log and seeing that whatever she had eaten the day before had an impact on her morning readings, she was more willing to talk a little bit more about glycaemic management and diet. I did a little bit of that with her but we also have to remember our scope of practice and the fact that we’re part of an interprofessional care team. Who else can we collaborate with?
We worked together with a dietitian who also uses motivational interviewing. That worked well. She helped the patient create a food plan that went along with the patient’s food preferences, which she knew about by using motivational interviewing. The patient gradually started to see a better window for her blood glucose regulation. It took quite a while before the blood glucose regulation had an impact on the patient’s pain level. That’s the other thing that we needed to keep in mind. This is not a quick fix. In the interim, we did start using electrical stimulation. She went home with a TENS unit and was able to place the TENS unit on the spinal segments to the hands and feet, and get some relief that way. She did become less reliant on pain medication and a little bit more reliant on electrical stimulation. Ultimately, she was able to recognize the value of glycaemic management through her diet and also by adding exercise.
The important component of adherence was that her exercise preference and my exercise preference were not the same. We know what the textbook recommendations are. I’m aiming for 150 minutes a week of aerobic activity consistent with the American College of Sports Medicine recommendations but that’s not feasible. Somebody who’s never exercised before is not going to do that. She also didn’t like to walk because walking increased the pain in her feet, which was understandable. We were finally able to come to a compromise where she was on the new step, which is like a seated stair climbing machine. She didn’t have one of those at home so then we had to transition to something that she could do at home. She picked the walking video. That was one of the steps that we took with MI. I asked the patient, “What do you think would work well at home?” She said she didn’t know. I asked her to search for some. She was an Amazon Prime member. She went on Amazon and looked at some of the exercise videos until she found one that suited what she felt were her capabilities. My goal is to get the patient to be more active. I didn’t have a preference for how that happened.
Are you still seeing this patient? Was she discharged at a certain point?
She’s been discharged but every once in a while, she’ll have a periodic wellness visit with us to go over her glucose log and to talk about any types of barriers that might have come up. That is a step in motivational interviewing. We arrange for follow-up with the patient. First of all, she’s done amazing. You want to affirm how well the patient is doing. People like to be recognized for overcoming challenges. She’s overcome a ton of challenges. She’s down something like 50 pounds. Being able to affirm how well she’s doing helps to continue adherence and to make sure that the patient feels heard and recognized.
There had been some bumps in the road along the way. She did get a blister on her foot at one point that needed to be addressed. It didn’t turn into a wound. That was one of the barriers. The other thing is that she moved. She was out of her circle in terms of social support and the types of foods that might be available at the local grocery store. We talked about the best ways to overcome that. The interesting thing about motivational interviewing is that it helps address people’s self-efficacy. That’s confidence in your own ability to change. Because she became so confident in her ability to change her diet and her exercise habits, she’s tackling her tobacco use as well. Once you gain confidence in one area, it spreads over. It carries over to other areas of behavior.
Fifty pounds is a huge success.
We initially started with a 10% weight loss goal. Once the 10% was achieved, her self-efficacy increased. She continued setting incremental 10% goals.
What I heard from this case study was that you had a patient come in who had probably lower health literacy with regard to what was the cause of their diabetic peripheral neuropathy. They were somewhat ambivalent about the condition itself and knowing what types of changes to make. What you achieve through using good MI skills was taking that HbA1c. Instead of looking at it as a snapshot in time, it’s helping her realize that it’s panoramic. For those who have taken my nutrition course, HbA1c is a long-term look at glucose regulation over time. For people with significant diabetic problems, oftentimes, it’s one of the most important aspects of it. Through that, you’ve helped her monitor her glucose as she starts to become more aware of her blood glucose on a daily basis.
She was more likely to make changes to her diet, which you help coordinate into professional care with regard to a dietitian. However, many of us do not work in those types of environments so we might have to do that ourselves, which is fine. With that, there was a decrease in pain that came later on but that’s normal. A lot of times, what we find is we change the behaviors first and then the pain comes later. She was less reliant on pain medications. She was more likely to exercise. The most important part of that is you’re able to help her figure out her exercise preference. Once someone figures out the type of exercise that they prefer, they’re more likely to continue with that long-term.
One of the things I want to mention is we have to be careful about the words that we choose to tell somebody about what caused their pain. This person was told that she had nerve damage. She did but once you hear the word damage, you assume that it’s permanent. That was part of it as well. If I’m telling you that something’s permanent, then that takes away the patient’s empowerment in a way. If it’s permanent, what can I do to change it? It took a while to explain that. Even if it were permanent, it could be progressive. At the very least, you’re stopping it from getting worse. The best-case scenario is that it will get better. Nerves heal at a slow rate. If it was going to get better, we’d have to be patient with it. It would get better over a longer period of time. She understood that and it did get better.
It’s looking at the patient’s beliefs around their conditions, specifically if it’s related to nerve pain. People come to us and they think, “You have the knowledge and the skills. You’re going to fix this for me.” What I like about MI is it’s a compassionate caring way to turn it back to them and say, “Everything you need resides in you. Everything that you need to heal yourself and start to reverse the pain and the chronic condition that you’re dealing with, whether that’s a specific chronic condition, a non-communicable disease or a mental health condition, all that resides in you. I’m going to walk side by side. I’m going to help facilitate this for you and together we can do this.”
It’s very empowering. It puts the patient back in the driver’s seat. You have to think about it too. When you’re working with somebody who has chronic pain or a chronic condition, that person has likely tried to change their behavior before and they’ve been unsuccessful. With this person, she had been overweight for most of her adult life and had tried unsuccessfully before to lose weight. That affects people’s confidence in themselves as well. I’ve tried this before and it’s not been effective. What makes this time different? It’s incumbent on us to show the person that they are capable. That’s usually done gradually with progressive goal setting and small incremental achievements.
I want to turn to the Q&A. Let’s go first with Scott.
Scott, can you go ahead and tell us?
I’m a chiropractor. I deal mainly with people coming in hurting. How can motivational interviewing help us steer the ship a little bit more away from people’s immediate pain concerns? For instance, something like low back pain is not something that we’re going to magically make go away with some miraculous adjustment, putting your bone back into place or any of this stuff. How do we help them with that to be able to see it in a broader context?
Often it comes down to what’s the patient’s perspective. It may not be reasonable or realistic to completely get rid of someone’s pain. What’s an acceptable level of pain relief for them? Can you use MI to steer them away from using the pain itself as an outcome and maybe using their functional level or ADL as an outcome, their Activities of Daily Living? Aside from pain relief, what is this person hoping to achieve by coming to see you?
The whole thing of getting stuck on the pain practitioner and the patient is tough.
It is very tough. The other thing is if it’s not feasible to get rid of the pain completely, where can this person function? You have a chronically painful condition. You come in to see one of us. Your pain is at a 7 over 10. We can understand why that person’s unable to function. It’s helping someone understand that it may not be realistic to get rid of the pain completely. If we’re not able to do that, what’s the best possible outcome that they can imagine? If that person says 4 over 10, we probably can work together to get to that point.
There’s another one from Judy.
There’s a question here as well. Mark said, “It seems like MI can be used without being built-in and of itself if it’s simply used briefly to enhance the more primary method that you’re using with a client.” I would agree with that, but it can be build in and of itself. When I’m doing diabetes education, it gets built in and of itself as diabetes education. I’m not doing any type of manual therapy. I’m not doing any kind of therapeutic exercise with a patient. There are times when it does get build by itself as its own intervention. Judy, can you go ahead?
I’m a physical therapist who works exclusively with chronic pain patients. I wondered about what kinds of questions I can ask to help. Sometimes, I have patients who exercise excessively. They were 100 miles a week and biking. They go to the gym. They’re going at max heart rates. They’re not seeing that exercise. It’s an accepted form of self-care. Why would you ask me to cut back on that or even to try and clear that plate? It’s a healthy thing for a lot of reasons. I work with a team. I have a psychologist and a nurse. There’s a whole team of us looking at all these aspects. It’s a hard one because it’s viewed as a healthy thing to do but they’re not seeing it as contributing to their pain. They’ll tell me, “I don’t feel that it makes a difference. I think it makes me feel better.” That’s a hard place for me to work with people.
It’d be a hard place for any of us to help people. MI is not like this magic wand. It’s this negotiation that occurs between the practitioner and the patient. First of all, what do they think is causing the pain? If they’re not seeing the exercise as a contributing factor, would they be willing to maybe give it a try? Would this patient be willing to cut back on their exercise and see on a trial basis, whether or not it had an impact on their pain? Without the exercise, what do they think they can do on their own that might give them greater pain relief? It allows us to explain the rationale behind it. If I tell somebody to stop exercising and they think that’s what’s making them better, I have to be able to explain why I think it’s contributing to their pain.
The hard part for me also is because a part of the model that I work in is clearing the slate. It’s trying to start from a baseline where there’s room for them to do mind-body practices, where they slow down enough to be able to feel themselves again. My job on this team is to cut them back enough that there’s that kind of space. I’ll try to give them something that is an alternative movement or an alternative way to move their bodies. The argument is, “It’s ridiculously slow. It’s not going to help me. I’m going to be in more pain.” I hear what you’re saying. It’s a negotiation. It’s what I’m getting from this and try the most incremental approach that works that I can do.
It’s about us recognizing the patients’ perspectives too. From your perspective, can you see why the patient would think that exercise would be beneficial? That is what we give people all the time, that exercise is good for your health and now I’m telling you not to exercise. It’s contradictory. Would they be willing to cut back and see where that takes them, and acknowledge the fact that we could be wrong? Maybe they cut back and it’s not better but at least we’ve ruled something out.
We’re talking about taking a healthy behavior that all of us are looking to promote typically that can be challenging. In this case, what Judy is talking about is the patient has already adopted exercise as part of their lifestyle, except rather looking to reduce that healthy behavior. Sometimes, healthy behavior cannot be healthy. If you look at the studies on sleep, if you sleep too much, the reverse effect happens. It becomes paradoxical. The same thing happens with exercise. I’m curious. With this particular case, knowing that this person does value exercise and it’s part of their life, can we help use MI skills to help them become curious about other types of exercise? Not just the high intensity but realized there’s also a place for lower intensity exercise or moderately intensive exercise.
That’s where Judy was going when she was talking about mind-body and bodily awareness. A lot of times, people that do high-intensity exercises or maybe endurance athletes, people that are used to performing at a very high level, part of their pattern is ignoring signals from their body. They push through the pain. We’re trying to get them to be more aware and more responsive to those signals by picking an alternate activity. Judy, did you mention yoga?
I didn’t mention it but we also have a person on our team who teaches that. I love the way you framed it, Joe and Rose. I’m just getting a different frame is what it is. To be able to acknowledge the value of the exercise, also trying to find why they value it in their lives, how it fits in their lives but considering an alternative. An alternative is nice, just emphasizing the alternative part. Also, the monitoring of the glucose, taking a while to kick in to see a difference, being able to support them through a time where they might not see it but they have to have a little confidence that we’re going to try it and try to find or acknowledge and affirm highlight even the small notices and awarenesses. That would be very helpful.
Even getting used to paying attention to signals from the body or connecting with your body in a different way. People with chronic pain are used to connecting with their body in terms of negative feedback, “I have pain. I’m aware of the pain but I’m not aware of all of the other positive things that come from bodily movement or bodily awareness.” That’s where the mindfulness practices and the yoga come together to help people connect with their body in a more positive way.
I want to answer a question from Rachel. Her question is, “As a massage therapist practicing outside of a healthcare insurance environment with a questionable scope of practice to make suggestions about the outside activity. How is MI useful in session or ongoing for treatment?” I want to make a point to everyone that motivational interviewing has been around for quite a while. It’s been employed by licensed health professionals. It’s been studied by fitness professionals. It’s even been delivered by peers. People with no health care training at all or any fitness training have been delivering those types of formats. MI is crucial for anyone where you’re looking for behavior change. Once you learn good MI skills, you use them in your personal relationships. You use them in communicating with anyone you’re talking to. Those skills come in handy in many different places.
It makes you a better listener. That’s true for me. Part of MI is using what’s called reflective listening. Not only listening to the person in preparation for you to generate a response but genuinely listening so that you are interested in what that person has to say and how they view the world and then asking follow-up questions that reinforce that.
Rose, can you give us an overview of the course? It’s called Motivational Interviewing for Chronic Pain. It’s 7.5 hours CE/CEU.
For me, motivational interviewing is not only about the technique but the underlying social and behavioral theories. It’s something that we call motivational assessment. Part of MI is understanding where the patient is coming from. How do certain theories contribute to the decisions that we make about our own personal behaviors? I mentioned self-efficacy. That’s a component of a lot of behavioral theories. Also, what forms our intention? How do other people’s attitudes and our own attitudes affect our intention to perform a certain behavior or intention to adhere? That’s part of the course as well. Doing motivational assessment, looking at readiness to change. What do we do if we have a patient that’s very resistant to change? What do we do when we have somebody that’s already engaged in change and maybe just needs some encouragement or some redirection to make their behavioral more effective or lasting?
Also, how does motivational interviewing fit in with some of the chronic pain models? How does it complement some of the other interventions that we might be using like the mindfulness practices? What are some of the psychological perspectives that come into play like the fear-avoidance behaviors? Also, things that I haven’t typically considered because I’m coming at things from a very structured physical perspective. Even things like adverse childhood events. Everybody has baggage. What types of baggage is the patient bringing to you in their healthcare encounter? How do we help them unpack that to see how it has an impact on their physical health?
You can find the course on the homepage of the Integrative Pain Science Institute. Go to courses and scroll down. You’ll see it there. Week one is the foundation of motivational interviewing. It’s the how and why am I improving pain outcomes. Week two is motivation interviewing for health behavior change. That’s looking at cultivating collaborative and patient-centered communication. Week three is the spirit of MI, inspiring and sustaining a commitment to change in behavior and a change in pain. Finally, week four is tailoring MI specific techniques, creating personalized action plans to successfully manage pain. With all my courses, it’s the same as Rose’s course. Once you purchase the course, it’s yours. You can go through it at your own pace. You have it for as long as you need to have it. The course is $299.
It’s an excellent course. I’ve seen the content on the backend. It’s very concise. It provides you with everything you need to get started. I’ve known Rose for a while. Between her clinical education, her PhD around this topic, and her background teaching professionals how to use this already, it’s a win-win for everyone, whether you’re a physical medicine professional or a mental health professional. We’re going to wrap up. If you’re following along with the show, please do follow along. You can listen to it as well. Any closing comments or suggestions you want to make, Rose?
I have enjoyed working with you, Joe. I hope that everybody will enjoy bringing a different perspective to chronic pain management. It complements the other courses that you have through IPSI as well.
Motivation interviewing is great. If you’re working on changes in exercise, changes in nutrition, if you’ve taken my ACT course, there’s a significant amount of similarities or I should say complementary aspects of ACT and MI, especially with regard to value-based care. If you’re in the ACT course or the mindfulness course, you’re going to find it once you learn MI that it enhances everything. Not only your patient communication and your skills but it enhances all the other techniques that you’ve had for your entire career. Rose and I both thank you. We look forward to seeing you in the course. If you have any questions, you can reach out to us at the institute. You can send us an email at Support@IntegrativePainScienceInstitute. I want to thank all of you for joining us. Have fun with your friends, family and loved ones. I want to thank Rose for her incredible knowledge and sharing of information here. I learned so much. I know you’re going to learn a ton when you join that Motivation Interviewing for Chronic Pain course. We’ll see you soon. Take care.
Thank you, Joe. Thank you, everyone.
- Motivational Interviewing for Chronic Pain
- Dr. Rose Pignataro
- International Classification of Functioning
About Dr. Rose M. Pignataro
Rose M. Pignataro, PT, PhD, DPT is a doctor of physical therapy with more than 30 years of direct patient care experience, including the treatment of chronic pain and associated conditions. In addition to her clinical background, Dr. Pignataro has a PhD in public health, with a strong focus on social and behavioral theory, health promotion and wellness. She is a certified health education specialist (CHES) and certified wound management specialist (CWS). Rose is an Associate Professor and Assistant Chair of Physical Therapy at Emory & Henry College in Marion, Virginia.
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