As medical providers, we have a responsibility to help our patients. I am now entering ‘mid-career’ as a physical therapist and not only have been witness to the many “advances” in our profession, but also humbled by simplicity as I step back and reflect upon what I’ve learned each passing year- By simplicity, I mean the ‘care‘ in healthcare. While a myriad of treatment options continue to emerge, one thing that remains underappreciated is how we deliver this information. Unknowingly, the how may make people worse in these 5 ways:
Imaging, specifically MRI (Magnetic Resonance Imaging) is sometimes a necessary part of an examination; however, it is no surprise it comes with a hefty price tag and results do not always match the clinical presentation.
Consider these studies:
LUMBAR SPINE: Imaging findings of spine degeneration are present in high proportions of people without any symptoms and increase with age.1
KNEE: Incidental meniscal findings on MR of the knee are common in the general population and increase with increasing age.2
SHOULDER: Rotator cuff tears seen on MRI are present equally in both symptomatic and asymptomatic shoulders.3
CERVICAL SPINE: Nakashima4 found that amongst 1211 people, disc bulging was frequently observed with MR in asymptomatic subjects, including people in their 20s.
I am not suggesting we abandon MR’s. Conducting a thorough physical evaluation and using imaging to support a working hypothesis, rather than the reverse, may eliminate the possibility of scaring the patient with incidental findings. We also need to be much better at our choice of words and language when interpreting results to patients. Can you imagine being told that “your spine is crumbling”? Or, “I am surprised you are not in more pain with how bad your knee looks on MR”! Providing patients with an understandable and optimistic MRI summary facilitates optimal coping strategies and allows for better health outcomes.6
Choice Of Words
I love this blog entry entitled “The Importance of Language” by Matt Low’s (@mattlowpt) Blog: Perspectives on Physiotherapy. Matt references Barker et al9 and explores the connotations of words often used by medical providers. For instance, biomedical terms, including non-specific low back pain, arthritis, instability were seen as problematic, as well as other terms we commonly use, including “coping”, “managing back pain”, even “activity”. Poor use of words can lead to misunderstanding, fear, and uncertainty.
Neil Maltby (@neil_maltby) puts this theme into a contextual format in his blog entry “Powerful Words” from my favorite blog, Becoming More Human, and is also worthy of your time to read.
Fear Avoidance Behavior
Nonverbal and verbal fear-avoidance behavior can translate from therapist to patient.5 Body language or choice of words that may suggest you are nervous or unsure about your patient performing a particular exercise or activity may impact their performance or own belief about their abilities. Having confidence during any interaction with patients goes a long way. I do believe this comes with experience, but I also believe for less experienced physical therapists, being prepared for the assorted questions from patients, using confident body language and eye contact, may go a long way until the time is put in to use past experiences. For me this took several years.
Using Fear Appeal to Motivate
Fear appeal is a strategy to motivate people by arousing fear. In medicine, this has been used to change behavior through the threat of harm. For example, “you are going to get diabetes if you don’t change your diet”. Though still widely used, fear appeals have produced mixed results and there is no consensus on how fear can be used effectively to produce long term behavior change.7 Further, threatening information only sparks behavior change when self-efficacy is high.7 In the absence of strong levels of self-efficacy, raising fear levels can lead to maladaptive responses such as shutting down, feeling overwhelmed or denial.7
This is relevant in the physical therapy clinic, particularly when counseling individuals on injury prevention, disease progression, or chronic pain management. How do we convince a patient to adhere to an exercise program? Do we tell them they will only get worse? Do we tell them their condition will continue to decline if they don’t do their home program? Do we have evidence to support our claims? Is this even a threat, and if not, could it be perceived as a threat by certain individuals?
Many times I hear physical therapists complain their patient did not get better because “they didn’t care”, “they didn’t do their exercises”, “they stopped coming to appointments.” Researchers in behavior science recognize that the best questions to ask are: “Why do people change?” and “What can we do to help?” rather than focus on the reasons why people don’t change.8 Motivational interviewing is one approach that is an evidence based, client-centered, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence, and it offers more than simply well intentioned advice or scare tactics.8 Non-compliancy may be a result of the therapist failing the patient and not the reverse!
Non-compliancy may be a result of the therapist failing the patient and not the reverse!
Dependence (or, CO-DEPENDENCE!)
Physical therapists have an identity crisis and all the certifications, specialties, etc. can be overwhelming and confusing to patients. In a competitive market there are therapists who identify themselves as manual therapists, dry needling practitioners, movement experts, etc. in attempts to gain patients, market to a particular type of patient and sometimes promote themselves. In all fairness, I do hold a couple certifications myself, but at times, even I have to look up one’s credentials following “DPT” because I have not heard of it. Amidst the confusion, the patient continues to “shop” and may feel that if one can’t help than another must. Precious time is wasted and sets up a stage for catastrophyzing with each ‘failed’ experience.
We know that higher self-efficacy correlates to improved outcomes. We must collectively promote self-efficacy and provide the tools necessary so that the patient is empowered to take control of their own unique circumstance. If we are making people believe that they need us, we create a co-dependent relationship, not good for either party. Respect the resilience of the body, and intervene as little as possible!
- Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. AJNR Am J Neuroradiol. 2015 Apr;36(4):811–6.
- Englund M, Guermazi, Gale D, Hunter DJ, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008 Sep 11;359(11):1108-15.
- Gill TK, Shanahan EM, Allison D, Alcorn D, Hill CL. Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Int Rheum Dis. 2014 Nov:17(8):863-71.
- Nakashima H, Yukawa Y et al. Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine. 2015 Mar;40(6):392-398.
- Lakke S, Soer R, Krijen W, et al. Influence of physical therapists’ kinesiophobic beliefs on lifting capacity in healthy adults. Physical Therapy. 2015;95(9):1224-1233.
- Bossen JK, Hageman MG, King JD, Ring DC. Does rewording MRI reports improve patient understanding and emotional response to a clinical report? Clin Orthop Relat Res. 2013;471:3637-3644.
- Peters, G. J. Y., Ruiter, R. A. C, & Kok, G. Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory. Health Psychology Review, 2014;7 (S1): S8-S31. doi:17437199.2012.703527
- Butterworth SW. Influencing patient adherence to treatment guidelines. J Manage Care Pharm. 2008 Jul; 14(6B):21-4.
- Barker K, Reid M, Minns Lowe J. Divided By A Common Language? A Qualitative Study Exploring The use Of Language By Health Professionals Treating Back Pain. BMC Musculoskeletal Disorders 123, 2009;(10):1-10.