Table 1 Session content for the “Toolkit for Optimal Recovery” (TOR)

1

Discuss treatment rationale and goals

Review and correct misconceptions about recovery trajectory after orthopedic injury

Normalize pain after an injury. Move patients away from the mind-body dichotomy by discussing how all pain sensations originate in the brain. Discuss the difference between “hurt” versus “harm”

Learn how the sympathetic nervous system influences symptoms; learn about the disability spiral and how it can lead to slower recovery and chronic pain after orthopedic injury. Learn physical, emotional, and cognitive factors that can speed or slow recovery after orthopedic injury

Provide education about the parasympathetic nervous system and relaxation; demonstrate relaxation strategies (diaphragmatic breathing, body scan)

Set goals for skills practice: practice relaxation strategies daily

2

Practice diaphragmatic breathing

Review previous material and homework; problem-solve barriers to practice

Provide education about the biopsychosocial model and mind-body links

Conduct mindfulness exercise on pain sensations. Assist patients in identifying what thoughts, feelings, and behaviors are triggered by the pain sensations and normalize this experience. Provide education about mindfulness techniques for observing thoughts-feelings-behaviors non-judgmentally.

Learn decision tree for unhelpful thoughts: adaptive thinking for thoughts that are not true (e.g., “Pain means that I am getting worse”); acceptance, validation/compassion, and letting go for thoughts previously reframed who keep coming back, or for thoughts that are true but not helpful (It is harder to walk right now).

Set goals for skills practice: practice diaphragmatic breathing, body scan or mindfulness on pain daily, complete at least one decision tree exercise, complete at least three reframing exercises

3

Practice diaphragmatic breathing

Review previous material and homework; problem-solve barriers to practice

Learn problem solving skills; assist patients in identifying a problem related to injury and applying problem solving skills

Learn acceptance strategies; assist patients in identifying when to use reframing vs. problem solving vs. acceptance

Provide rational for activity pacing; assist patients in setting activity goals consistent with their values; assist patients in applying acceptance, reframing or problem-solving skills to achieve activity pacing goals

Set goals for skills practice: practice diaphragmatic breathing, body scan or mindfulness daily, complete at least one decision tree exercise, including options for problem solving, acceptance, and reframing; follow activity pacing protocol

4

Practice diaphragmatic breathing

Review previous material and homework; problem-solve barriers to practice

Review all skills; assist patients in identifying which skills are being used, how helpful they are, and how they can be implemented in the future

Interactive quiz to identify improvements patients have made, skills that are being used, skills the patients would like to continue to work on and a plan for continued coping