Hi, this is the second part of the module on transformative care, and this part is about implementing transformative care. The case of Mona Lisa. Now Madame Lisa, as they say in Italy, is a 37 year old mother and wife from a wealthy family just outside of Florence, Italy. She was asked to sit still while a local artist Mr. Leonardo Da Vinci painted her portrait to celebrate the birth of their second son Andrea. She developed pain after sitting still for hours at a time while the artist took his sweet time painting her picture. So with any case, you need to really start with a decision tree. What are the decisions that need to be made in terms of a particular patient, and their level of complexity based on a variety of factors. So let me go through an example of a decision tree that I use with my patients in terms of both prevention of chronic pain. And managing, their pain condition. The decision tree goes through a variety of decisions, and I've got them listed here as number one, two, three, and four. But the first thing we need to do is collect the data that, and information that we need in order to develop, and make good decisions. First, so the first one is the history and examination testing. Let's, let's see what we found with Mona Lisa. Well, she complained of headaches and jaw pain, the daily constant, often severe, eight on a ten point scale. Neck and back pain is daily constant often severe. And other symptoms including dizziness, nausea, and stomach pain. The onset was three months ago while posing for the artist. But she did have a history of shoulder and back pain after falling from a horse drawn carriage. She's tried a variety of herbs, including rose, lavender, sage, bay, as well as blood letting and massage, but nothing seems to help for her. So, she is restricted. She's sleeping poorly. She drinks about four to six cups of coffee per day. She is not active per day during the day either. She's not emotionally coping very well with a problem. She tries to keep a smile on her face but feels tense and irritable. And she's becoming anxious and depressed. She's also becoming disabled for, because of the problem. She has difficulty in balancing relationships with her mother and her home responsibilities. She also feels demons have inhabited her. What else would explain the pain from her point of view. She blames her husband and his artist friend, and she needs more help at home since the pain has really come on. She is not able to do her household responsibilities. So her examination findings were very consistent with most patients with persistent pain. She has tenderness in a lot of different muscles she has trigger points in the shoulder, neck, back, and jaw. The imaging that we did, did no, showed that there was no degenerative changes or arthritis in the joints or radiographs. The range of motion was limited, about 20%, which is characteristic of patients with myofascial pain. And the range of motion limitation both in the jaw, neck and shoulders. There seemed to be no sign of neural entrapment. No sensory deficits or numbness. And her dysfunction she had no noise or deviation in range of motion of either the neck nor the jaw. So she's a very straightforward case. So the first decision we want to make, number one, is what is the problem list. So we've done a history. Got into some of the details. The problem list basically from it, it includes three things. One is the chief complaints. The diagnosis, the physical problem that's causing the pain. And the contributing factors which are those factors that predispose, initiate, perpetuate the condition but in some way complicate the management. They are the risk factors, the protective factors in, in these cases. So and you can divide the factors into the seven realms. Of course in the body, it's the physical characteristics, such as past trauma, posture, weight, range of motion. In the mind, the dominant thought process or attitudes. Or emotional problems, such as prolonged negative emotions, depression, anxiety, anger. Or lifestyle factors, such as regular behaviors, habits and actions that she does, like diet, sleeping or feeling rushed. Spiritual aspects, the loss of hope and faith currently as well as into the future, a lack of direction and purpose. And the social or societal issues, that include those problems in the patient's social environment. The relationships social support, abuse, stress, conflict, all of these play a role. And maybe environmental conditions too, such as safety issues, pollutants, lighting air that may contribute to the pain. So in, in Mona Lisa's point of view, it's her chief complaints we described. Her physical diagnosis was myofascial pain and migraine headaches. She had no disk problems or arthritis in her neck or back. And the contributing factors were a long list of different factors loss of range of motion, no exercise, poor posture. Unrealistic expectations poor compliance poor follow through, depression, anxiety, some anger with the artist and, and her family, her husband. Behavioral issues including poor sleep, shoulder and back tensing due to the pain of lifting the children a lot, clenching her teeth. Social factors such as family stress, conflict with her husband. Spiritual factors. She sort of has a sense of loss of hope and purpose. The pain's going on now. She doesn't really know to do. She has high expectations but has not been able to meet them. And then environmental factors. There's a number of safety issues at home. So these are the factors you want to change and, and train the patient on changing in the context of the problem. So let's go to number two. Now that we have the problem list, we understand the full complexity of the case, what we need to do is really decide is it a simple case. Or is it a complex case? Now, if we, it's a simple case, we decide, do we really need to treat this or just provide training on self management? And if we do treat, a single clinician's typically adequate to provide integrative care, both training biomedical care as well as any complimentary care. But if it's a complex case. Then we go to the right side, and then we decide, is this too complex? Really that the patient is better off waiting to treat until other factors are controlled. And if that's the case, then we do treat, if we do decide to treat, we go with a team of clinicians, and I'll go through each of these decisions. But in every patient, all patients, they do get training in self-care regardless whether they're simple and complex. So let's go through what are the criteria for deciding simple versus complex? Well, we believe just from our experience, that there's a variety of factors. Here's six of them here that would help determine if the patient was complex. If they have multiple physical problems, and diagnoses going on. Number two, if it's persistent pain, it's longer than six months in duration. If they have significant emotional problems, such as anxiety, depression, and anger. Is there frequent use of health care or pain medications? Is there daily repetitive muscle strain habits? And if there's significant lifestyle disturbances like sleep activity. Activity level is decreased, or eating habits. So if, in either case, we still need to provide the self care. And let me go through what the self care training is. What we recommend with every patient is they go through an exercise program, as we've discussed multiple times in the past, including stretching, conditioning, meditation or relaxation exercise, and maintaining a relaxed, balanced posture. We also want them to stop tensing habits. Whether it's clenching the teeth, tensing the shoulders or back, we want them to relax the muscles. We want to reduce any repetitive muscle strain, such as phone bracing, or carrying a bag on the shoulder, lifting at the waist, using a computer with the head forward. And the shoulders and arms tense. And in addition, we want them to provi, provi, provide some self-management counter-stimulation like heat or ice while they do their stretching exercises. And then if they feel, they need to add some anti-inflammatory medications, such as ibuprofen, they can be very helpful as we've discussed. So the next decision then, once self care is provided, is really to decide if it is a simple patient, we want to decide do we treat or only provide self care. Well, this decision number three is really about determining whether anything more than self care is needed. In some cases, self care is going to be the primary treatment and that's all that's needed, if it's relatively simple using these three criteria. So, the pain is severe enough to affect functioning or quality of life that we do treat. If there is evidence of any progression or persistence of the problem it's better to treat it as an early intervention. Or number three, the patient has desired treatment also. So let's go to decision number four. So say it is complex patient, then we need to decide. Are there some situations where even if we treat the patient now, we're going to be unsuccessful because there's too many other factors going on in the patient's life. In this case, we do work with a team of clinicians. But we first have to decide whether we need to defer treatment for a while and address other issues. The criteria for this. Is that we decide to defer or refer treatment if there's one, a primary chemical dependency problem. If they're only interested in opioid medications, we, we wait on that and address that particular issue first. If there's a primary psychiatric disorder, if they are primarily depressed and the pain is a secondary issue, their biggest concern is their depression, we need to address that first. If there's significant litigation, if the patients are really interested more in settling the case. And some having some type of financial remuneration. That's easy to decide on, by just telling the patient, if you, do get care, and you get better, you're going to get less, of a settlement. So it's important to just wait until the settlement is done, and then we would proceed with care. And I can estimate how much the care would cost. And then we need, if the patient is overwhelmed with other concerns, if they're a single mother, they're working full-time and they're going to school at night. They just don't have time to really get better, to improve and do the things they need to really enhance their health and wellness and reduce the pain. And lastly as a patient is passive, they're unmotivated and they really do not accept the responsibility. They want to be a passive patient, lay back, get care, and improve. So all of these really should cause you to think, is treatment really indicated now because the prognosis is so poor or should we, can we proceed with care? So if we proceed with care and treatment, we really need to make sure that we understand that whole complexity of care. So if it was a more complex problem list, a lot more things going on with the patient, obviously you're going to have a more complex care plan. So. How you want to make the changes are based on the first, second and third order change. And first order change, where we reinforce a lot of things they're already doing, we prescribe primarily self-care, for an acute self-limiting problem. And this can be provided by a health educator in an office very, very easily, and it reinforces a lot of the change that they're already doing. Now the second order change is they really have a lot of issues that are going on but they are not at a point where they really, it's so complex that they need multiple clinicians involved. So we still want to achieve a second order change and re, reflect more of an integrative care with a simple multi-level problem. And a single clinician's quite successful perhaps. Adding an health educator or the clinician themself providing the self-care or self-management training. But the more complex problem is enlightenment, and that's well, in those cases we need a third, third-order change. And a trans, transformative care program is really what's needed in those cases. And these are for complex problem with many life issues. And an interdisciplinary team is the best care for that patient. And then, we want to make sure that we use a health educator. Now, in some cases a physical therapist, it's a health psychologist. Nurse practitioners or other health professionals provide the role of a health educator. But there is a model provided by medicare for a diabetic health educator. And this could be very easy applied to chronic pain also. It's typically a certified health professional such as a nurse, physician assistant, exercise therapist, etc. We administer bio-behavioral assessments. They're scored by the health educator. Sometimes we even do genomic assessment, assessments to define a problem list. We need to inform and then train the patient, and this is what the health educator does, about the personalized lifestyle management they need to do. And finally we need to educate them on the disease process, and all the aspects of care. Takes a fair amount of time, to do this, but it's, very satisfying, from the patient and the provider's point of view. And the rest of the team members to have a health educator involved. So why do we involve a healthcare interdisciplinary team with those complex patients? Well, the example of, interdisciplinary teams is that you have three to four clinicians at work with each patient to deal with different aspects of their problem. Whether it's a physician or dentist, health psychologist, social worker, physical therapist, health educator. Each person can be involved in different aspects of the problem. We try to involve one interdisciplinary environment, same clinic, appointment book, same chart, evaluation form, same building system so there's a communication that goes back and forth between the clinicians. And each clinician has to reflect a consistent paradigm. That of self-care, self-responsibility that, that 80% of the problem is really under the patient's control and they need to take responsibility and make the changes needed. They, we need to provide training and treatment and use a human systems approach. So finally, the take-home message. With this particular part, is really that we need to transform our care process to achieve a transformative care model for the patients. And, and an interdisciplinary team is often the best way to do that. It helps us understand and manage the whole patient. It allows us to work on multiple aspects of the problem simultaneously. It improves compliance and outcomes. It saves time. It's much more economical, and ultimately it's a lot more enjoyable for both the clinicians that working in the team, as well as for the patient. So you all have a chance to work together. So thank you very much. [SOUND]
