Ep 171: Mind-body connections in people with hip pain - how clinicians can help, with Dr Kate Jochimsen

[00:00:00] Professor Laura Mamosley is running three face-to-face courses in North America in 2024.

[00:00:06] He's visiting Vancouver, San Francisco and New York City in late September and early

[00:00:12] October this year.

[00:00:14] The two day courses are designed to help you embed the latest in paint science in education

[00:00:18] in your clinical practice.

[00:00:21] Check out the show notes to see Professor Mamosley's program in each of these three iconic Canadian

[00:00:27] and US destinations.

[00:00:29] Yes, you heard correctly the latest in paint science in education in person with Professor

[00:00:35] Laura Mamosley September and October 2024.

[00:00:44] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality

[00:00:49] research to quality practice.

[00:00:52] I'm Clara Don, the editor-in-chief of the Journal of Orthopedic and Sports Physical Therapy.

[00:00:57] It's great to have you listening today.

[00:01:02] Today I'm handing over the JOSPT Insights reins to some of the world's leading clinician

[00:01:07] researchers in the field of hip morphology and hip pain.

[00:01:11] A JOSPT we're really proud to work with the Yahir collaborative to advance research

[00:01:17] and clinical practice for young people with hip pain.

[00:01:20] Over the coming months, you're going to hear more about what's new in the research

[00:01:23] and understanding of hip pain, including how it develops and how to best treat it,

[00:01:29] or geared towards helping you best help the patients and athletes you work with.

[00:01:34] Dr Joshua Heary, sports physiotherapist and research fellow at Latrobe University in

[00:01:39] Melbourne has the hosting duties today.

[00:01:42] A guest on the podcast today is Dr. Kate Yochemsen, athletic trainer and PhD researcher.

[00:01:49] Kate is currently leading NIH funded research to develop mind-body interventions for chronic

[00:01:54] hip pain as a member of the Faculty of Psychology at Massachusetts General Hospital, which is

[00:01:59] part of Harvard University.

[00:02:01] So welcome to the JOSPT Insights podcast, Kate.

[00:02:06] Hi, Josh, it's Father DeBigger.

[00:02:08] We're now in the last decade that there's been this growing recognition or focus on the

[00:02:13] importance of biological health factors in patients with pain.

[00:02:18] So what I thought it would start with is helping us to understand what we actually mean when

[00:02:23] we're talking about biological health factors in some of the pain.

[00:02:27] Yeah, absolutely.

[00:02:28] I'm really glad that we're having this conversation because I think it's a really important

[00:02:32] one to have.

[00:02:33] Most of us may include it, but we're trained primarily in a biomedical model of rehabilitation,

[00:02:40] which emphasizes the biologic aspect of injury, including morphology, motion, strength,

[00:02:45] movement, the things that are really in our real house.

[00:02:48] However, we now know that in addition to these, it's really critical for us to be more

[00:02:53] comprehensive and that includes evaluating and treating our patients' psychological response

[00:02:57] to injury.

[00:02:58] And we're talking about psychological factors, especially in the context of rehabilitation,

[00:03:03] but we're referring to as our patients' beliefs and attitudes, so their thoughts and preferences

[00:03:09] as well as their emotional responses to their injury or pain.

[00:03:13] So these can include pain anxiety or pain-related worry, hypervigilance and fear, pain catastrophizing,

[00:03:20] which is what we think of when we see worst-case scenario thinking, patients that ruminate

[00:03:24] about their pain or feelings of healthlessness, self-efficacy or a patient's confidence in

[00:03:30] their ability to cope with their pain or maybe engage in rehabilitation or physical activity

[00:03:35] and activity avoidance.

[00:03:37] So when patients aren't participating in life events and activities that they find really

[00:03:41] valuable.

[00:03:42] These psychological factors, especially the pain anxiety and pain catastrophizing, are

[00:03:47] associated with the development of product, pain, fallen, orthopedic injury, and that's

[00:03:50] over and beyond biomedical measures of injury severity.

[00:03:54] So this is true broadly, not only for patients with hyper-related pain, so it's really critical

[00:03:59] I think as clinicians for us to appreciate that pain is not just biological, it's also

[00:04:04] cognitive and emotional.

[00:04:06] And thankfully, we know that pain-related thoughts and feelings are in fact modifiable, and

[00:04:11] so that gives us a window of opportunity to help patients understand and then reframe

[00:04:15] their pain.

[00:04:17] When we see our patients with hyper-related pain, are there any psychological factors that

[00:04:24] we should be identifying or thinking about when we're planning out treatment program?

[00:04:31] I think that integrating psychological health screening into clinical practice is really

[00:04:35] important because without screening it's really hard for us to understand if or when our

[00:04:40] patients' injury-related thoughts and feelings are impacting their pain perception and recovery.

[00:04:45] So the psychological outcome measures that are often used are the pain catastrophizing

[00:04:49] scale, the Tampa scale for kinestophobia, and the pain self-opathy questionnaire.

[00:04:54] Personally, those are the ones I use, there are others of course in literature.

[00:04:58] I am always cautious about using cut-off scores to make treatment decisions.

[00:05:02] However, I'm also a clinician and a researcher and so I understand that we need a realistic

[00:05:07] way to guide clinical practice and clinical trials.

[00:05:11] And so in our group, we do use thresholds from literature to identify patients who might

[00:05:15] benefit from psychological skills or mind-body interventions but we try to use the most conservative

[00:05:21] option which allows us to cast a wider net so we don't miss anyone who you know might really

[00:05:27] need some additional support.

[00:05:30] Some other considerations for screening?

[00:05:32] One, I think it's really important to be transparent about the rationale for including

[00:05:36] psychological screening tools with our patients.

[00:05:39] This transparency also starts to break down the stigma around mental health if we're

[00:05:44] honest with our patients about what we're screening and why, and it facilitates open communication.

[00:05:49] I like to give us psychological patient-friendly outcomes along side functional and pain-related

[00:05:54] measures because it really gives us a comprehensive understanding of how our patients are presenting.

[00:06:00] Not only does that allow us to craft a rehab plan that aligns your patient beliefs and

[00:06:05] goals but it also demonstrates to the patients that we care about their overall well-being

[00:06:10] and not just maybe their hip joint pain.

[00:06:14] And then the last thing that I'll touch on in terms of screening for psychological factors

[00:06:18] is that it's really important to do it at the baseline evaluation and it's really important

[00:06:24] to do it over time so that you can track changes and treatment response.

[00:06:29] As always, it's important to keep an eye out for any red flag so persistent and truest

[00:06:33] thoughts or toxic suicide, also hope for other mental health symptoms that are unrelated

[00:06:39] to the patient's presenting problem.

[00:06:41] So if their struggles with mental health are not related to their hip joint pain or injury

[00:06:47] or I guess more broadly in Lescao's Heldovery tab whatever their presenting problem is then

[00:06:53] make sure you're referring to mental health professional.

[00:06:57] When someone has had their symptoms for a long period of time so what we often do is

[00:07:01] point and keep paying.

[00:07:02] We often believe that when you see a symptoms that is directly related to their psychological

[00:07:07] health factors that they may have we know much in that space and you elaborate on the research

[00:07:13] in that area.

[00:07:14] A long duration of symptoms has been linked to inferior outcomes for patients with

[00:07:19] hip related pain, specifically hip arthrophic outcomes.

[00:07:22] However, we don't see a consistent relationship with psychological factors at least the way

[00:07:28] that we've been measuring them in the studies that have been out.

[00:07:32] In all of our work, we haven't found a relationship between longer duration of symptoms and let's

[00:07:38] say higher tink pastoralizing.

[00:07:40] However, I don't think we have enough data yet to conclusively say one way or another whether

[00:07:45] not psychological factors are related with duration of symptoms.

[00:07:49] And so that actually probably brought you really nicely way into my next question is if

[00:07:54] we've screwed our patient for these psychological health factors and identified that some

[00:07:58] of them may be present.

[00:07:59] So we need to consider how these may impact on the outcomes that we may achieve with

[00:08:04] our rehabilitation program and is there evidence for maybe these patients, the ones that

[00:08:10] have inferior outcomes when they undergo a rehab program?

[00:08:14] Yeah, absolutely.

[00:08:15] There's a very quickly growing body of research that is really supporting the importance of

[00:08:21] psychological factors, including the ones that we've talked about here, tink pastoralizing,

[00:08:26] chemesophobia and pain self-apocacy, and others like anxiety and depression in pain and

[00:08:31] functional recovery for patients with hip related pain.

[00:08:34] In fact, there's even work that has demonstrated that psychological factors are some of the

[00:08:40] best predictors of who goes on to develop chronic pain following hip arthroscopy.

[00:08:45] There have been three systematic reviews on this topic, all of which explicitly recommend

[00:08:50] consideration of psychological factors in the assessment and treatment of hip related

[00:08:54] pain.

[00:08:55] And as you know, the 2023 clinical practice guidelines for non-art for the kidney joint

[00:09:00] pain came out recently.

[00:09:02] And they do also recommend screening for psychological factors with level C evidence, which I think

[00:09:07] is a sign of progress being made.

[00:09:10] They don't necessarily provide any recommendations for the treatment of maladaptive psychological

[00:09:15] responses to hip pain, which I think highlights that even when we're identifying that there's

[00:09:20] this need, the psychological aspect of rehab is currently under-adjusted.

[00:09:25] So what can we do as rehabilitation providers and what's medicine conditions to help our

[00:09:31] patients if they do have psychological health factors that may be a heap of data pain,

[00:09:37] but also their potential to respond to our treatment programs or rehabilitation program?

[00:09:42] Yeah, I think that's really a dollar question.

[00:09:45] Right?

[00:09:46] And in an ideal world, we would have psychological skills and my body interventions that are tailored

[00:09:52] to the specific needs of this unique patient population, and also tailored so they rehab clinicians

[00:09:57] providing them.

[00:09:58] Unfortunately, that doesn't exist yet, but we're working on it.

[00:10:02] For now, I think there are three things that I would highlight.

[00:10:05] The first step is adopting a psychologically-encormed practice, which has been around for decades,

[00:10:12] and it incorporates patient's beliefs, attitudes, and emotional responses into rehab.

[00:10:17] And so it's really this clinical perspective of understanding our patients' emotional

[00:10:21] journey through their pain and injury.

[00:10:24] And so in order to do that screening really has to be step one.

[00:10:28] Once we know who we can help, we can then teach patients' psychological and mind-body skills

[00:10:33] in rehabilitation.

[00:10:35] Examples of those types of interventions might include behavioral activation techniques like

[00:10:39] goal setting and activity pacing, education and cognitive techniques like pain neuroscience

[00:10:44] education, graded exposure therapy, and simplified cognitive restructuring, and then mindfulness

[00:10:51] and relaxation techniques like diaphragmatic breathing, progressive muscle relaxation,

[00:10:55] and self-compassion or positive self-talk.

[00:10:59] It's also important for us in the clinic to really teach patients when to use these skills

[00:11:04] for maximal benefit.

[00:11:05] It's not enough to just teach the skill, but we have to teach them how to integrate

[00:11:08] it into their life and integrate it into their rehabilitation sessions.

[00:11:13] So, for example, they might use self-compassion when they don't need a rehab goal, or maybe

[00:11:18] they tap into some diaphragmatic breathing when they notice they start to get some muscle

[00:11:21] tension or pain anxiety.

[00:11:25] These skills can help patients cope with their injury and build resilience, which is beneficial

[00:11:29] in two ways.

[00:11:30] One, it allows them to fully participate in their rehab when they're there with you, whether

[00:11:34] that's strengthening or movement retraining, whatever it may be, it can facilitate stronger

[00:11:39] engagement with that.

[00:11:41] And two, it can help them actually re-engage in activities that they find meaningful in

[00:11:45] their life.

[00:11:46] The next thing I want to mention is that technology is your friend.

[00:11:49] In the first step, I mentioned interventions that you would deliver directly to your patient.

[00:11:54] However, that's not always accessible for people, but there are a variety of out-based

[00:11:58] infertual reality psychological skills programs that you can offer to your patients

[00:12:03] and they require no clinical training.

[00:12:06] Most of those programs include similar components, so pain education, mindfulness, distraction,

[00:12:11] which is a really effective pain relief tool.

[00:12:14] There are also a lot of benefits to tech-enhanced interventions, including they have very low

[00:12:19] levels of stigma.

[00:12:20] You can take them anywhere.

[00:12:21] They're transportable so that they can be done on the patient's phone or a portable

[00:12:25] headset in the clinic, on the road if they're traveling or at home.

[00:12:30] They're asynchronous so they're available to the patient at any time.

[00:12:34] And most of the modules, especially those for pain self-management are very time efficient

[00:12:39] on average sessions last anywhere between like six to ten minutes.

[00:12:43] So it's something that can be accessible even to people who have really, really busy

[00:12:46] lives.

[00:12:48] The last thing I would suggest is really the importance of being both conscious and cautious

[00:12:54] of the language that we use to try and shift away from pathogenic descriptions of pain.

[00:13:00] We recently did focus groups with physical therapists, and they told us that one of the biggest

[00:13:05] barriers to success in rehab for their patients with hip-related pain is that their patients

[00:13:10] have a pathogenic or biomedical view of their pain.

[00:13:14] Sometimes just clinicians I think we can unintentionally reinforce these beliefs, especially

[00:13:19] in the way we talk about hip-related pain.

[00:13:22] So I think in stunner focusing on things that instill a disability mindset, we can instead

[00:13:27] focus on things that patients can change and actually empower our patients to increase

[00:13:31] their confidence and their bodies to recover.

[00:13:34] So for example, a hip-related pain example specifically, and judging focusing on the

[00:13:39] path of anatomy is saying like you have a labral tear and that's why your hip hurts.

[00:13:44] You might say something like together we can film the blank, strengthen your hip, optimize

[00:13:49] the way you're loaded your joint and improve your sleep, increase your physical activity,

[00:13:52] whatever your treatment goals are.

[00:13:54] And hopefully this will help you return to the activities that you value.

[00:13:58] So not only is that approach true, we know that there's a really high prevalence of these

[00:14:02] morphologies in labral tears and asymptomatic people, but it's also empowering to patients

[00:14:07] and helps things see their bodies in a capability mindset instead of a disability mindset.

[00:14:14] And then if we're able to do this, we can actually show patients how they're improving

[00:14:19] over time and that will help to build their confidence.

[00:14:21] Great.

[00:14:22] Thanks, Kate.

[00:14:23] That's some really clear and easy techniques that we can obviously use in our patient.

[00:14:29] So I would like to thank you for joining me on the Javasp.T Insights podcast, sharing with

[00:14:35] us your expertise and knowledge about psychological health factors in patient with hip-related

[00:14:41] pain is really a better privilege to listen to you today.

[00:14:44] Thanks, Josh.

[00:14:45] It's been great.