What Are We Doing to Address the Unique Needs of Our Patients?

Is it just me, or does it seem like patients are getting more complex by the day? Every week in the clinic, I seem to add a new co-morbidity to my list of “things I wasn’t taught in school.” How does this syndrome differ from that one, and more importantly, how can I help these patients with this diagnosis? Adding to the complexity is the increased incidence of patients who have “failed traditional PT” but continue to be encouraged by their primary care providers. The physicians who refer the patients seem just as baffled as I am and have admitted that some referrals to Integrative Health (IH) PT occur “because we don’t know where else to send them.” As a Physical Therapist in the Integrative Health Department of a hospital-based outpatient clinic, I’ve learned to lean on my colleagues in the acupuncture and chiropractic fields more than ever. In fact, some of our shared patients have learned to schedule a “trifecta” to optimize care - they schedule all three appointments concurrently, on the same day. This has been especially helpful for patients with chronic pain, chronic fatigue syndrome, mild traumatic brain injury, and hypermobility syndromes. Others with greater mobility challenges who don’t fare as well getting on and off the plinth several times in a day benefit from spreading out the sessions throughout the week, but still benefit greatly from the interaction of care. They report back that knowing their providers discuss their care “behind the scenes” is helpful. I also lean on outside mental health providers and dieticians who specialize in neurodivergency, PTSD, and Postural Orthostatic Tachycardia Syndrome. As much as I’d like to have “all the tools,” I’m understanding more and more as I treat patients that this is just not feasible. Collaboration of care is a boon to patients, though I can see how this would be a privilege of urban living, as many of these providers (acupuncture, specialized dieticians) are less likely to be found in rural environments.

As I am steering now towards Pelvic Health, I wanted to dive into complementary approaches to treating pelvic conditions and found some clinical pearls for treating myofascial pain, which commonly occurs in patients who also have diagnoses of endometriosis, vulvodynia, interstitial cystitis, and irritable bowel syndrome, among others (1). According to Marks et al (2022), manipulative therapy, myofascial release, biofeedback and electromagnetic therapy, photobiomodulation, and acupuncture have all been studied and offer alleviation to persistent pain syndromes in the pelvis. Battlefield acupuncture, which follows a standard protocol of placing studs or taped seeds in 5 places on the external meatus of the ear of the patient, has been shown to decrease pain intensity among those with Persistent Pelvic Pain (2). This technique is offered by our physicians in the Integrative Department for Group Medical Visits (GMV) regarding non-specific chronic pain and reading this paper inspires me to suggest a specific GMV for Pelvic Pain. 

I have also found components of Acceptance and Commitment Therapy (ACT) to be quite helpful in the clinic, especially if they are paired with some sort of mindful movement, and most especially if the patient is attending psychotherapy the day before physical therapy. (3) I find that I can build therapeutic alliance faster and get patients to divulge personal goals that assist in attendance and adherence to personal home programs. This speaks to having a psychologically-informed practice, and I do believe this has incredible merit, especially when treating patients with complex co-morbidities and persistent pain. Physical Therapy appointments occasionally require the therapist to incorporate techniques that are components of more formal psychotherapeutic intervention strategies. This is NOT a substitute for psychotherapy, but a creative way to address change behavior. ACT is a type of Cognitive Behavior Therapy that promotes health behavior change across a wide variety of physical and mental health conditions. It is centered around the concept of psychological flexibility, which is the ability to stay in contact with the present moment regardless of unpleasant thoughts, feelings, and bodily sensations, while choosing one‘s behaviors based on the situation and personal values. There are 6 interconnected processes that promote psychological flexibility: cognitive defusion, acceptance, present moment awareness, self-as-context, values, and committed action. While reading about this type of therapy, I realized that many of my PT interventions and the creative way we as PTs encourage adherence fit into this model. If you are curious, I recommend Zhang et al’s paper from 2018 about the topic (4). 

As the needs of our patients are revealed and determined to be related to their health outcomes, our treatment strategies must conform to these needs. Maybe it isn’t that patients are more complex now, rather that we are actually shining light on pieces of their existence that were brushed off in the past - maybe it’s not “just menopause” or “in their head” or “too far too gone.” I hope that our future clinicians are taking this into consideration, and the typical PT didactic curriculum includes more components of whole-person health care than it did in the past. I am curious about others’ experiences in the clinic - are you referring or deferring to social work and mental health to address parts of the patient’s physical health that you are more than capable of addressing? Are you seeing the person in front of you as a whole person - one who may be showing up with a mess of physical, social, emotional, and spiritual needs? And how are you filling your cup to ensure that this extra work isn’t draining too much out of you? 

References:

1. Till, S.R. (2022). Approach to Diagnosis and Management of Chronic Pelvic Pain in Women, Current Urology Reports, 24(1), 1 - 10
2. Marks, S.K. (2022). Clinical Review of Neuromusculoskeletal Complementary and Alternative Approaches for the Treatment of Chronic Pelvic Pain Syndrome. Pain Medicine, 23 (3), 521-538.
3. Vowles K.E., McNeil D.W., Gross R.T., et al. Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behav Ther. 2007;38(4):412-425. doi:10.1016/j.beth.2007.02.001
4. Zhang C.Q., Leeming E., Smith P., Chung P.K., Hagger M.S., Hayes S.C.. Acceptance and Commitment Therapy for Health Behavior Change: A Contextually-Driven Approach. Front Psychol. 2018;8:2350. Published 2018 Jan 11. doi:10.3389/fpsyg.2017.02350

About the Author

Danielle Berres, DPT, RYT, 2025 CAPP Scholarship Recipient

Danielle is an Integrative Physical Therapist at Hennepin Healthcare, the outpatient wing of Minnesota’s largest safety-net hospital. She is an experienced registered yoga teacher (e-RYT) and has certificates in Integrative and Lifestyle Medicine and Professional Yoga Therapy. She has Bachelor’s degrees in Child Psychology and French Studies and her unique experiences offer a fresh perspective to physical therapy and wellness interventions. Her latest goal is pursuing CAPP - but will it be Pelvic or OB? They are both such great learning opportunities!

Follow Danielle on IG: @yogaladyyy