Ep 274: Psychologically-informed practice in your hip repertoire, with Dr Kate Jochimsen

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[00:00:53] Dr Kate Jochimsen We do have a fairly mature playbook for psychologically-informed practice for chronic low back pain. We have the Yellow Flake screening system, we have, you know, different frameworks, we have very tailored pain neuroscience education. But those tools and that specific culture, that specific context, hasn't been carried over to active patients with hip pain.

[00:01:20] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today.

[00:01:40] The biopsychosocial model of health has been around since the late 1970s. In musculoskeletal rehabilitation, the biopsychosocial model is prominent in clinical practice guidelines for a variety of different conditions, with different approaches advocated for how to provide rehabilitation within the model.

[00:01:57] Today, with Dr Kate Jochimsen as our guide, we're exploring psychologically-informed rehabilitation practice, taking principles that have become prominent in the chronic low back pain field and seeing how they might apply to young, active people with chronic hip pain.

[00:02:12] Dr Kate Jochimsen is an assistant professor in the department of psychiatry at Harvard Medical School, a researcher at the Centre for Health Outcomes and Interdisciplinary Research at Massachusetts General Hospital, and a member of the Physical Therapy Residency Faculty at the Massachusetts General Hospital Institute for Health Professions. Her work bridges the gap between sports medicine and psychology, with a primary focus on chronic pain and hip injuries. Dr Kate Jochimsen, welcome to JOSPT Insights.

[00:02:40] Thanks so much, Claire. It's lovely to be here. Kate, psychologically-informed care has been growing in stature in musculoskeletal practice. What's different about psychologically-informed rehabilitation for active people with hip pain compared to the psychologically-informed rehab for people with chronic musculoskeletal pain that our listeners might think of?

[00:03:00] The core principles of psychologically-informed practice. They're not condition-specific. So whether we're working with someone with low back pain, knee pain, hip pain, really we're trying to understand and address the psychological responses that are naturally occurring when people sustain an injury or are experiencing pain.

[00:03:19] So those responses might include fear or worry, avoidance, maybe they're frustrated, right? Or they're angry, they're lacking confidence, or maybe they're an athlete and they're really going through some identity loss. Any of these factors can influence engagement and rehabilitation, their adherence to any exercise program you get them, and then ultimately their recovery.

[00:03:41] So as clinicians, we then address those factors, right? We want to measure them and address them through education, how we communicate with them, helping to build their confidence and really change their behaviors. That's a lot of what we do in rehab is behavior change. And to do that, we'll use strategies, right?

[00:03:59] Like graded exposure therapy, pain neuroscience education, motivational interviewing. We might also sprinkle in some mind-body interventions like mindfulness, or we might use a psychological skill like cognitive reframing. Where things I think become different when we're talking about patients specifically with hip pain is the context in which those psychological responses occur. So the context that you're treating the patient in changes more than the toolkit itself.

[00:04:29] Two of the patterns that I personally see as a clinician a lot in active patients with hip pain are, one, this group of patients who are really struggling around identity and sport performance. So, you know, the thing that the patient loves, the thing that gives them purpose or community or enjoyment, it's the very thing that they're either avoiding or unable to do because of their pain. The other is sort of this idea of role fulfillment, right?

[00:04:56] So for many young adults or middle-aged adults who have chronic hip pain, and particularly this applies to those middle-aged moms in this patient population, of which there are many, we see and hear a lot of concerns about maintaining family responsibilities, keeping up with their children, and really just being able to do their day-to-day activities in their everyday life.

[00:05:19] I think one common thread between psychologically informed care and hip pain and psychologically informed care and chronic low back pain is that hip pain also has this really powerful structural narrative. So patients are often told, you know, you have impingement, you have a labral tear, your hip bone is shaped abnormally, and those labels can really create strong beliefs that their hip is damaged and therefore vulnerable.

[00:05:44] You know, in low back pain, we've spent a long time learning how to contextualize imaging findings and really reducing our overemphasis on these structural explanations. But in hip pain, we're still catching up. So psychologically informed care for hip pain isn't fundamentally different than, let's say, what you would see in chronic low back pain. The principles are the same and they're universal.

[00:06:10] The challenge that we're currently facing in treating chronic hip pain is really adapting them to the unique stories of the people who are struggling with chronic hip pain and the stories that they're telling themselves about why they're having hip pain and what their capacity can be in the future. I think that's going to resonate a lot, Kate, with our listeners because it's similar to what we hear about, you know, people who've had an ACL injury have a different story and a different experience. People with chronic hip pain have a different story and different experience.

[00:06:39] Someone with chronic shoulder pain or throwing related shoulder pain in an athlete, different story, different experience. So I think that's really going to resonate. And the other thing I love is that there's a smorgasbord of different interventions and approaches that you can choose, which helps you really find what works for you, what resonates for you. But more importantly, what's going to work and resonate for the person you're working with? Yeah, absolutely. I like to think of it as a toolbox, right? We have a large toolbox as clinicians.

[00:07:08] I need to strengthen someone's quad. I have a million different resources in my toolbox as to how I can go about that. The same is true when we're talking about psychological response to pain or injury. I have this patient in front of me. I first need to understand, okay, what is the challenge? What is the barrier that they're facing? And then go to my toolbox and say, okay, what can I try? And the first thing might not land, just like the first exercise might not be a success. That's why our toolbox needs to be deep.

[00:07:35] Picking up on this idea of the toolbox, how do you develop the skill set in that tool or the techniques in that toolbox or the tools to extend the metaphor in the toolbox? I don't know about you, but when I was training, these were not typically things that were integrated into my clinical training. Hopefully, we're getting better at integrating these sorts of techniques into clinical training now. How would you suggest our listeners approach learning about these different tools and using them well?

[00:08:05] Yeah. So this is certainly one of the premier challenges to implementation of psychologically informed care, whether it's in hip pain or any pain or injury that we treat. It's programs, educational programs are getting better at enhancing competencies around identifying psychological barriers to recovery and, you know, teaching students about how to intervene when they see these.

[00:08:30] You know, whether that's starting with motivational interviewing or just like expanding the goal setting we're already doing. People do not leave these programs fully competent and capable of delivering this kind of care. And that is not the fault of the program or the student. It's just where the system is currently. And there are a lot of systematic barriers to implementation as well. In the clinic, do you have the time? Do you have the capacity to go out and get continuing education? So how can people learn? There are a lot of opportunities in terms of continuing education.

[00:09:00] So if you're going to CSM, if you're going to NATA, if you're going to ACSL, like if you're going to a conference, try to seek out lectures where, you know, this is the topic of conversation and ask questions, talk to speakers, build a network of people who have been doing this work to help support you. I can only speak for myself, but I know that I am always more than happy to speak to anyone who's interested in this type of work. I also know there's a lot of really great reading resources out there.

[00:09:28] Not saying that clinicians have a lot of time on their hands to do a deep dive in the literature, but I know JOSBT and other journals as well have done a great job of sort of trying to keep up with the pace at which we are, you know, developing psychologically informed interventions and really getting them out into the hands of the clinicians who can then learn how to deliver them. There are resources available, continuing education, reach out, build a network. The other thing I will say is that tech can really help us fill the gap.

[00:09:58] Right now, I think it can be really challenging for people to learn a whole new skill set when they're already inundated with really busy clinic schedules and little time to even do basic things like notes. So there are a variety of apps that they can recommend to patients. Those range from apps that deliver paid neuroscience education, cognitive behavioral therapy skills, mindfulness apps, relaxation apps.

[00:10:25] You know, there's VR technologies that are integrating all of these things. So I think that we can lean on technology to help backfill as we're, you know, training the next generation to really embrace this model of care.

[00:10:41] Apps and VR are actually really, really useful and have strong utility when we're working with athletes because athletes, their travel schedule, their practice schedule, like you're not always there to be able to help them in their moment of pain, in their moment of worry. I would bet my life that they have their phone with them, right? And they can pull that out and they can open an app or they have a VR headset in their luggage. Thanks for sharing all of those resources and we'll link it.

[00:11:11] People will find links in the show notes. I wanted to talk a little bit about your research work and what got you thinking about applying this psychologically informed approach specifically to the population you work a lot with, active people with hip pain. Where is the research at and what's underpinning it to help us feel confident that this is truly an intervention worth pursuing?

[00:11:34] I will say that my personal journey on this path to studying psychologically informed practice in active patients with hip pain really started with my clinical observations. I'm just a curious person by nature. I was working clinically. And early in my career, I worked with a lot of people recovering from hip arthroscopy. And I just noticed, as many clinicians do, this was not unique to me, that recovery trajectories varied dramatically, right? Like two patients, they had nearly identical imaging.

[00:12:04] They had the same surgery by the same surgeon, the same rehab protocol, oftentimes the same physical therapist. And yet one would thrive and the other would really struggle. And I couldn't explain that variability with any of the measures that we were already collecting. And so really that observation is what led me to pursue my PhD to really understand why some people were recovering well and others were not. So, you know, I've spent over a decade now.

[00:12:34] I don't want to age myself. Building, you know, along with many other amazing researchers and clinicians, this body of evidence really demonstrating that psychological factors do consistently emerge as important predictors of pain and function and quality of life in this patient population. We recently published a large systematic review that included well over 50 articles. And there was evidence to support this claim. So it's not just my research.

[00:13:03] It is not only in chronic hip pain. It is just part of the human experience that how you think about your circumstances, think about your experiences and how you feel about them will impact not only the physical sensations you feel, including pain, but your motivation and the behaviors that you adopt around rehabilitation and activity engagement.

[00:13:28] What surprised me, I suppose, when I got into this field and started digging into the literature was that we do have a fairly mature playbook for psychologically informed practice for chronic low back pain. Like people have done incredible work in this space. We have the yellow flag screening system. We have, you know, different frameworks. We have very tailored pain neuroscience education.

[00:13:54] But those tools and that specific culture, that specific context, really, like we were talking about before, hasn't been carried over to active patients with hip pain. So, you know, the next logical step was for us to set out to build what doesn't exist. So, you know, screening systems, communication guidance for clinicians and tailored rehab interventions to help this specific patient population.

[00:14:19] What's your advice for listeners who are doing a kind of mental audit of their practice and thinking, geez, I wonder if I'm even doing this right? And is there more that I can do to support active people with hip pain? First, I would applaud that. It would be like amazing that you're reflecting and really wanting to help your patients to the best of your ability. So, like, kudos to you. Most clinicians probably undersell themselves.

[00:14:44] You're probably already doing some elements of psychologically informed practice. I think the question that we can reflect on and ask ourselves is, A, am I doing it intentionally? If not, can I start? B, am I measuring its impact, right? If I'm doing it, am I measuring whether or not it's working? And then, like you mentioned, are there opportunities to add other skills to my toolbox that I can then provide to my patients to help them? We do a really good job in rehab of measuring things, right?

[00:15:13] We measure strength, we measure range of motion, we measure performance metrics, and we measure them all very carefully. Yet many of us don't measure psychological response to injury. We do it in research, but we don't very often do it in clinical practice. And so I think that the first step to sort of auditing your program and saying, can I do a better job, is really understanding, I need to know how I can help.

[00:15:37] Right, so I need to screen my patient's psychological response to injury and pain, and I need to do that over time. Because needs are going to change throughout the course of recovery, and I need to understand whether or not any interventions I'm delivering are actually working. Really understanding your patient's beliefs about what's wrong with their hip, right? So checking in with yourself and saying, like, have I checked in with my patient? Like, do I know what their conceptualization of what's happening is?

[00:16:07] And speaking to them a lot, not just about their goals, right? Like, you want to be able to run a 5K. But, like, what are the values underlying those goals? Because the values and sort of the long-term, why is that important to you and what will that add to your life? Those are what's really going to build sustainable motivation for achieving those weekly process goals. Integrate screening.

[00:16:34] Measure psychological responses to injury and pain the same way that you would assess their physical responses. Measure, monitor, and then when they become a problem, treat them, right? Not everyone is going to need psychologically informed care at every stage of rehabilitation. So we need to understand when we can help, who we can help, and how we can help. An ideal sort of program might look like would be it's measured, like we said. It's monitored over time.

[00:17:03] It's collaborative, right? The patient is brought into the conversation. And then it's contextualized and patient-specific. There are nuance here, right? Like, fear is not always bad, for example. Fear early after injury or after surgery, right? Like, right after someone has their ACL reconstructed, a little bit of fear is appropriate, right? It's protective. It's there for a reason. We don't necessarily want to eliminate that fear.

[00:17:30] What we want to do is identify when it becomes persistent and it begins to limit their recovery. Ultimately, what we want our patients to feel is supported and hopeful, feel like they're in control. And I think that the other thing that's important here that the chronic low back pain literature has done well is we need to be able to be honest even when we're uncertain.

[00:17:55] And I think that that is a really hard line to walk, especially if you're a young clinician, because it's much easier to snap into rigidity and certainty. But we don't have that in the chronic hip space. So we need to use language that's reinforcing capacity, that is using language like your tissues are adaptable. You're getting stronger. We're building tissue capacity, right?

[00:18:24] Shifting our language away from sort of the old school mentalities of be careful. You know, you're impinging. You have a labral tear. You're going to develop OA, which is wear and tear. You know, I think ultimately we want to provide our patients reassurance that's tied to a plan, right? Not just tell them like, don't worry, you're going to be fine. And also not just scare them into surgery.

[00:18:49] What are the sorts of conversations between patient and clinician that need to happen alongside of our usual exercise-based approaches that we're typically reaching for to make this psychologically informed practice really successful? I love, Claire, how you said alongside exercise-based approaches, because I think that's really important messaging, is that exercise remains the foundation of rehab.

[00:19:17] Psychologically informed practice complements exercise. It doesn't replace it, right? So when we do it well, it's just going to improve patient engagement and improve their confidence. So it's not a replacement. It's an addition. I think that the four conversations that I always remind myself to have with patients are, one, the meaning conversation. And this is really important in patients with chronic hip pain. And I'll ask it something like, tell me what you understand is happening to your hip.

[00:19:46] Or what do you believe is happening in your hip? Understanding your patient's story is really important because their beliefs are going to shape their behavior. And so if someone believes that their hip is fragile, that their hip is deteriorating over time, every time they feel pain, it's getting worse, that's an important piece of the puzzle. And then they're more likely to avoid loading their hip.

[00:20:13] They're more probably likely to avoid doing their home exercise program, etc. And so part of your job becomes dismantling those beliefs and helping them build a belief system that is supportive for recovery. The second is similar, though different. And that is the pain conversation. So I'll ask it something like, what factors seem to influence your specific symptoms, right? Like on a good day, a low pain day, what do you notice?

[00:20:43] And sometimes I'll give them prompts like, how did you sleep? What did you do socially? How much activity did you get? Et cetera. And then alternatively, what did a high pain day look like for you? The reason I ask that is because it creates an opportunity for us to discuss pain as really multifactorial. It's this experience that is created by a variety of factors. And this provides us with a lot of different levers we can pull to try and reduce your pain.

[00:21:12] So it introduces that concept in a way where it brings the patient into the conversation. It helps them present their story and the factors that are really important to their symptoms. The third conversation is the avoidance conversation. So usually I'll ask this as something like, are there activities that you're no longer doing because of your hip?

[00:21:36] And I ask that because I want to understand where there might be opportunities to integrate things like graded exposure or imaginal exposure, right? Are there things that like, there's maybe a mental block for you in terms of being able to perform that activity? Like, yes, maybe it also provokes your symptoms and we need to build joint capacity.

[00:22:00] But do we also need to build your confidence and your ability to do that activity? And do we need to maybe turn the dial down on your anxiety or fear around that activity? The last conversation is around values and ownership. I will ask something along the lines of, if we're successful here together, what would that look like for you? Or something like, what's currently missing in your life because of your hip pain?

[00:22:30] I really want to understand why those things matter to you. So let's say the answer is playing with my kids or returning to the sport that I value. Those become sort of the foundation for that patient's motivation. On those challenging days, on the days where we're learning something about, oh, that didn't go as planned. And we're having a setback or we're having a pain flare.

[00:22:57] Those are things I can tap into to help the patient maintain motivation. The other thing is really helping the patient take ownership. So always explaining, taking a step back and saying, like, here's the rationale. Like, we're doing this because X, Y, and Z, right? This is their body. This is their rehab. It is important that they understand what we're doing and why. And it's important to build their autonomy throughout the process.

[00:23:26] I also like to do that alongside building their confidence. One thing that all the folks who are trained to deliver the HIPS intervention, I really drill this in hard. And that is that we start every session by asking what went well this week. Because every clinician knows that every patient's going to walk in and you're like, how did it go this week? And the first thing out of their mouth is going to be like, well, I was really bad. And I didn't do my home exercise program like I was supposed to.

[00:23:54] And I, you know, all the things that went wrong, which is fine, right? We can acknowledge the areas we need to improve. But it's really important to highlight what went well. And there's always something. Even if it's that, you showed up today. Let's finish up by talking about measuring. You mentioned at the top of our chat that measuring is really important. What are the tools you like to use and would recommend our listeners consider adding to their toolbox?

[00:24:25] I have my researcher brain that wants a certain set of questionnaires. And then I have my clinician brain that wants a different set of questionnaires. I'm going to answer as a clinician first. In clinical practice right now, I would do one of two things and it would depend on the amount of bandwidth I have. So if I am in a very high volume clinic where we are seeing a lot of patients, they're not just hip patients,

[00:24:51] but I want to implement a psychological screening tool that I can give to everyone at a variety of time points, I'm picking the Ospro. That is because you can give them the Ospro. You can choose which option is best for you. It varies in question length from minimal amount of information to more information.

[00:25:15] But you can actually backwalk those scores to get representative scores of a lot of the psychological constructs that are really important. So things like pain catastrophizing, pain anxiety, kinesophobia. They're just general pain cognition and emotional questions. If I have more time and I wasn't maybe as worried about patient burden, I would probably sprinkle in a few more. And the ones that I would sprinkle in are one, the pain catastrophizing scale.

[00:25:44] This, in every population that I have worked with, has shaken out as one of the primary risk factors for the development of chronic pain and the maintenance of chronic pain. The other that I would be using is a pain self-efficacy questionnaire. And that is because I think that one of the things that we do really well in rehab is we build patients' confidence.

[00:26:09] And I think that this is a really good way of demonstrating that to patients by tracking their self-efficacy over time. My researcher hat would add several more. I think the HIP-RSI, psychological readiness to return to sport, is also a really good one to give.

[00:26:28] We still need additional evidence using that scale in, you know, broader populations and looking at it relative to symptom recurrence and re-injury and things like that. But I think it's a really good tool to use, especially as you're nearing that functional stage of recovery and the return to sport period.

[00:26:53] Kate, you've given us so many practical tips, so many suggestions for conversations, suggestions for how to measure these constructs and measure progress in rehabilitation. It's been wonderful having you share your knowledge, what you've learned from research and also what you've learned from clinical practice and how to bridge those gaps with us today. So, Dr. Kate Jocholmson, thanks for joining me on JOSPT Insights. Thanks so much.

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