Thursday, February 27, 2020

Does what we “say” to our patients impact how our patients move and recover?

Image from Canva

The answer may seem obvious. Yes! What we say does have an impact.  But let us take a closer look at how this plays out clinically.  As part of our clinical education, we learn what to say or what not to say.  I remember learning how to perform a posture exam; with a few mutterings and inflections like “oh,” “wow,” “hmm,” and occasionally “uh.”  I realized for the sake of learning, I was just rattling off impairments left and right.  Never was there not a “forward head posture with a kyphotic thoracic spine with rounded shoulders and bilateral abducted, downwardly and medially rotated scapula, etc.”  As one can see, the list of predicted impairments goes on and on. Plenty of information for us to dictate to our mentors, write down and test, making for a lengthy yet thorough examination.  At some point, a patient might ask “Are you going to explain what that means,” “Is it bad?” or just have a worried expression on their face.  Of course, we would say “all will be explained at the end of the examination.” 

Enter the DIMs vs SIMs conundrum we just created for the patient.  Here’s a brief explanation of DIMs and SIMs from Butler and Mosely’s Explain Pain: Supercharged.1 DIM stands for “Danger in Me.”  This simply put is your brain’s way of concluding that there is sufficient evidence of danger to create pain.  Conversely, when we find enough evidence to indicate that things are safe, we will not protect using pain, and all is well.  This is called “Safety in Me.”  DIMs and SIMs in short.  As people, we look for the evidence in the things we hear, see, smell, touch, taste, do, and say; our thoughts, beliefs, places we go, people in our lives, and things happening in our bodies.  

Explain Pain, Supercharged

Returning to our clinical example, we can see how we have added to our patient’s interpretation of DIMs / SIMs just by doing our work. The practice of doing our postural assessment and only highlighting what is not ideal can lead to the patient creating DIMs about their condition.  Instead of calling out “excess lumbar lordosis and anterior pelvic tilt”, we may make the following alternative statements:
-       “Your shoulders stack really nicely above your pelvis.  We may benefit from working on the balance of muscles around your pelvis and hips.”
-       “This alignment can be changed with some training.”

In this way, the patient knows they have to do some work but it is not negative.

Communication about alignment

The question for the clinician then becomes, do you ever think about how you do your work and how it is perceived by your patient?

Therapeutic alliance is best defined as the relationship between the provider and patient.8  A warm, friendly, and reassuring interaction has been shown to improve outcomes instead of an impersonal or uncertain interaction.2  The two main factors to create a therapeutic alliance are the patient’s ability to forge a bond and the clinician’s ability to present themselves as caring and sensitive in the treatment encounter.5  Remembering our patient example, it is imperative to think about the words we use to explain and cue our patients to put them at ease with our process of examination and intervention. Some phrases that I utilize are,
- “Yes I have seen this before and this is fixable”
- “you are saveable”
- “help me understand.”

These interactions are especially important when we are trying create a relationship that educates, inspires and empowers them to change how they move.  

Now that we have established it is important what the patient thinks of us, does it then matter what the clinician thinks?

Let’s examine this question.  According to Cook et al 2013, therapeutic equipoise is simply defined as the clinicians expectations and treatment approach preferences.3  So now we have to consider not only the thoughts and perceptions of our patients, but also that of ourselves.4  Because of this, clinicians will favor different treatment approaches and provide interventions enthusiastically and with the expectation of certain success; thus impacting our clinical outcomes.6  To come back to our patient example, it comes down to what we say, how we say it, and also how much we believe in it.  All of these variables will have an effect on our interventions and outcomes.  The next time you’re in clinic and you try that movement correction to externally rotate and elevate the scapula during shoulder elevation and it does not change their symptoms, stick with it and do not lose that enthusiasm; if you keep trying and explain your rationale for what you are attempting to do for your patient, they might surprise you and “move without making it hurt.”  Teaching and learning new movements can be tough for both clinician and patient.  With some practice in how we work and how our patients perceive our words and cues, we can create the right formula to link the movements.

Choosing our words and cues wisely is important because health care professionals have an influence on what patients take from our encounters.  Darlow et al, in his study in 2013, explored the formation and impact of attitudes and beliefs among people experiencing low back pain. Participants in the study were often given messages by their that the spine needed to be protected.  The explanatory model that insufficient muscle strength results in a more fragile spine can be impactful.  Example statements by participants were: “Basically, all I’ve been told to do by my physios is to work on my core,” or “I’ve been tested by various different physios and Pilates, and apparently my core is ridiculously weak.”

Image from Canva

 Conversely, other clinicians in the study provided education about the importance of movement with positivity and with reassurance.  The impact of this message became quite powerful for a participant with a 6-year history of episodic back pain.  “I feel that I should keep moving and keep doing things as much as possible…I mean going to bed definitely doesn’t help it.  So, I’ll keep active.”  Another participant reported: “Lots of reassurance from the [doctor]…made me feel like, “don’t panic, this is OK, you’ll be fine.  It’s not the start of something thing awful.”7

Bottom line: what we say and how we say it can have a profound effect on our patient’s confidence and anxiety levels.  It’s not always easy, though. Sometimes the right words or cues are hard to find.  We may not get the desired outcome the first or fifth time when learning a new approach.  Learning, changing and growing is difficult, especially during our busy work schedules. Stay present and think about your communication to your patients because the more you practice, the easier it gets to help those movements link!

Ernie Linares is a board-certified Clinical Specialist (OCS) in Orthopaedic Physical Therapy and a Fellow of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT). He is also a Movement Links and Dynamic Neuromuscular Stabilization (DNS) certified practitioner. He currently works as a clinical specialist at the Kaiser Permanente Woodland Hills facility and as Guest Lecturer in the Physical Therapy Department at California State University, Northridge. Ernie also serves on the American Board of Physical Therapy Residency and Fellowship Education as an Accreditation Services Committee Member.

1.    Moseley, G. L., & Butler, D. S. (2017). Explain pain supercharged. The clinician’s handbook. Painos. Australia: Noigroup publication. Liite1(1), 1.
2.    Di Blasi, Z., Harkness, E., Ernst, E., Georgiou, A., & Kleijnen, J. (2001). Influence of context effects on health outcomes: a systematic review. The Lancet357(9258), 757-762.
3.    Cook, C., Learman, K., Showalter, C., Kabbaz, V., & O'Halloran, B. (2013). Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial. Manual therapy18(3), 191-198.
4.    Cook, C., & Sheets, C. (2011). Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials. Journal of Manual & Manipulative Therapy19(1), 55-57.
5.    Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy93(4), 470-478.
6.    Witt, C. M., Martins, F., Willich, S. N., & Sch├╝tzler, L. (2012). Can I help you? Physicians' expectations as predictor for treatment outcome. European Journal of Pain16(10), 1455-1466.
7.    Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine11(6), 527-534.
8.    Kegerreis, S. (2010). Mechanisms and Management Of Pain For The Physical Therapist. journal of Orthopaedic & Sports Physical40(10), 668-669.