Placebo Treatment

[Eric Magrum]

How can you change you daily practice to maximize your placebo, and minimize your nocebo effects?

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[Erik Kreil]

I love this article for the way it parallels a common thread in the book I’m reading, “How Emotions are Made” by Lisa Feldman Barrett. Dr. Barrett describes how we as humans are the architects of our own realities; we interpret what’s happening around us and create meaning for them. Dr. Benz and Dr. Flynn’s article here does a great job describing a clinician’s role in helping guide how a patient is interpreting their experience in our ability to give it meaning, shaping a patient’s response. This may mean that we limit the use of catastrophizing phrases, or maybe we don’t create an “event” precipitating a manipulation technique, in Aaron’s example.

Our bodies respond to the predictions our brain uses to help us function – and survive – in this world, and that includes the regulation of our sympathetic and parasympathetic nervous outputs. If our brain predicts failure or potential harm, it’s no wonder that our bodies will respond with resistance to change. This really emphasizes the importance of clinicians’ first impressions and handling skills, and is exemplified on a grander scale when patients’ outlooks are observed to influence the success of their surgeries.

Connecting the dots between a Physical Therapist’s desire to do good and a patient’s desire to be helped tells us how to implement this back-door approach to generate the most positive outcome for the patient. The verbiage “to be helped” is interesting, because what a person defines as being helpful is innately original to that person. To be most effective in our treatment, communication, and care, our approach has to be patient-centered to that person in front of us at that moment.

[Jon Lester]

Erik – I really like how you put the last part of your comment. “What a person defines as being helpful is innately original to that person”. This is a great way to define how the way that we word our questions/descriptions/assessment is vitally important to how a certain patient will respond. Each person that we work with is completely unique and our words will impact them based on how they interpret them. This can be applied to the concept of increasing the placebo effect to improve patient outcomes. The way that we articulate our descriptions can curve a patient’s expectation from positive to negative or negative to positive (or anything in between).

During the last year or so at SU, I was a part of a research project that looked into the effects of various factors (dress, verbiage, gender matching/mismatching) on the subject’s subjective and objective outcomes. We found that there wasn’t a large difference in the outcomes objectively, however there was a difference in the subject’s perception of their objective improvement. The patient’s that were matched to specific criteria expected to get better and some had perceptions that they actually did improve, despite the numbers not showing that they did.

For reference our findings supported that two controllable factors improved patient’s expectation of a positive result: 1) giving the subject a detailed explanation of the intervention and 2) dressing professionally. As you can imagine, these two factors could potentially lead a patient to believe that we are more competent as a healthcare provider and potentially be more effective in our interventions – an example of utilizing the placebo effect to our advantage.

This goes to show that our words, how we dress, and our overall interactions with our patient’s can affect their expectation of our treatments. Whether we choose to be as detailed or dress as professionally as the methods in our study described, it is clear that our brief interactions with patients had an impact on their perception of treatment. This potentially could enhance the effects of placebo on their outcomes long term.

[Cameron Holshouser]

Very interesting comments.

I think we all use the placebo factor in patient care. In my opinion there are two types of placebo: intentional and unintentional. Unintentional placebo would consist of what Jon was talking about, dressing professionally, body language, eye contact, appearing invested, listening to patients, mannerisms and overall appearance. One older study looked at how physician physical factors influenced willingness to comply with exercise recommendations. They found that patients with higher education and higher income levels could be positively influenced by a physician being of appropriate weight, a regular exerciser, and non-smoker. While female patients could be positively influenced by physicians being well groomed, well dressed, accessible, and good listeners. https://www.ncbi.nlm.nih.gov/pubmed/8673568

Intentional placebo, I would consider to be using placebo knowingly for your benefit. The JOSPT article “Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation” does a great job exemplifying placebo. This article mostly focuses on specific words, but words are very powerful. The article opens with this quote, “words are, of course, the most powerful drug used by mankind.” This is so true. It is sometimes tough for me explaining imaging findings to patients, when they have already seen the results explained by the doctor. These patients hear “disc bulge, instability, bone on bone, etc”.… rather than “bump/swelling, needs more strength and control, and narrowing/tightness – respectively. I try to use placebo words with patient education but sometimes I still struggle with changing my clinical dialect. Some words may not sound harmful to us as PT’s but that same word may be taken differently by the patient.

https://www.jospt.org/doi/pdf/10.2519/jospt.2018.0610?code=jospt-site

[jeffpeckins]

Erik, in reference to your comment about making a manipulation an event – I think this is the perfect example of being able to use a treatment and frame it in whichever light you choose, taking into account patient-preference. For example, if a patient states previous pain-relief following going to a chiropractor and enjoys having manipulations done, then I would choose to make it a grand event (with exercise following the manipulation of course). However if a patient expresses no strong feelings towards manipulation, but I think it could help them, I may minimize the event and try and work it into other joint mobilization techniques. If a patient expresses fear with manipulation, then I will probably find another technique to utilize. I believe that the important part is determining the patient’s thoughts and beliefs about manipulation (or any treatment) and then altering your approach with its use.

Jon, I’m curious as to how detailed an explanation the research study gave patients about the intervention. Did it use layman’s terms or was it technical? Did the study allow for patients to ask further questions? I ask because sometimes I have trouble finding the line between educating patients and over-educating them. Were the explanations more about how to perform the intervention, or was it about why the intervention would be helpful to them?

I think this article is an important reminder of the importance of every word we say and every non-verbal gesture that we make in our interactions with patients. I think that as a profession, we are so pain-oriented, but I believe this may backfire on us. In my doc system, I can’t submit a note unless I give a numeric pain rating of before and after treatment. If I am constantly asking a chronic pain patient about their pain with every exercise or manual technique I perform, I am reinforcing the idea that it is likely that movement will increase their pain and further damage their body. This is unintentionally providing a nocebo to an already likely anxious and impressionable individual. Chronic pain is oftentimes present in the absence of physiological damage, so framing my interventions in non-threatening ways should hopefully help decrease their fear of pain with movement.

[Caseylburruss]

I enjoy this article as well. I think a huge part of how we as clinicians can “improve the lives” of our patients is by being present and practicing with intention and mindfulness of the patient in front of you. This idea of mindfulness has been a mantra of mine since I read Dr. Langer’s book and is a concept that I think is applicable to not only our daily interactions with people but with patients volitional seeking our help as physical therapists. In Dr. Langer’s book she shares her results from a study that shares the profound impact of mindfulness. In this study, two different groups of symphony musicians were asked to play a piece of music for the same audience. These musicians were selected for this study because they had expressed boredom within their jobs due to the monotonous nature of symphony performances. Musicians in one of the groups, labeled the “mindful” group, were each asked to apply subtle personal changes to their parts; a slight deviation from the written piece to “make it their own”. The control group was asked to simply replicate a previous performance they enjoyed playing, without any variations, deemed as a mindless activity. The audience, which listened to both groups of musicians, overwhelmingly preferred the “mindful” group’s performance over the control group. People could consciously feel the “mindful” group’s efforts or their applied mindfulness, while playing. The result was not only more satisfying for the audience, but for the musicians as well. This study also shows how mindlessness can occur even when performing skillful tasks and its ability to mask the brilliance of their work as musicians.

What I love about this study is that it sheds light to what it can mean to show attention to detail and how the power of intention can affect those around you. I feel that our effort towards treating patients shouldn’t be any different. I also think it shows the potential for even the most talented and knowledgeable _____PT_____ (insert any profession here) can have unfavorable outcomes based on their inability to impart mindfulness. I feel as though not only are we doing a disservice to our patients but also to ourselves when we don’t take advantage of the placebo effect that we as clinicians can have. Ok, sentimental post over!

[Matt Fung]

I really enjoyed how this article highlighted the impact of the words we choose when we interact with and educate our patients. During my clinical rotations I remember one of my patients coming in and telling me that her doctor informed her that “her rotator cuff was hanging on by a thread.” Now this is an extreme example, but we can only imagine the effect of her doctor’s words had on her mental makeup and her outlook on rehab. Not only that now she was scared that her arm was going to fall off if she tried to use it promoting fear avoidant behavior.

Jon – The point you made “there wasn’t a large difference in the outcomes objectively, however there was a difference in the subject’s perception of their objective improvement” should not be overlooked. Patients are often times coming to us in a time of need and we need to appropriately address their physical concerns as well as creating a positive environment where they expect to feel better. If patients feel that they are improving and feeling better they will be more inclined to reach their goals.

[Eric Magrum]

Great job guys – some really well thought out discussion here.
Cameron stole some thunder posting the link; we discussed a bit in class last weekend.
So here is the “Sticks and Stones…” editorial.

Please have a read and post a specific patient/clinical example of where this thinking discussed in the editorial, helped/or hurt a specific patient experience.

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[Jon Lester]

In response to Eric’s post – I really like how this article paints a picture of how our words can affect our patient’s perception of their condition. I initially read the article when it was first posted and, since then, have been more mindful of my words with certain patients. I noticed that my tendency when greeting a patient in the waiting room was to say “Hey ___, how is your ___ feeling today?”. By doing this I might have made them over-analyze their symptoms and maybe put it in their head that they should be thinking about their body part all day. Since reading the article, I have been making an attempt to be more vague in my initial greeting, but still get a subjective report that I want. The major change I’ve made is just starting with “Hey __ how have you been since our last visit?”. This minor change might make a small difference in their mindset at that moment and for the rest of the session.
A specific example of this that I have is an older gentleman with LBP who I have been seeing for a couple weeks. I introduced myself on Monday with “How’s your back feeling today?” and his response was “Well now that you mention it, it’s kind of aching. I hadn’t thought about it much today”. That session, the patient had a little more pain with functional activities that weren’t painful during previous sessions. Today, I saw him again and avoided discussing pain at all, unless he prompted it. He was able to go through the whole session with no pain. Now granted, this is an N of 1 and I might have been hyper-analyzing it, but I think this gave me more insight on how even my wording during “hello’s” can make a positive or negative effect on the patient’s session.

In response to Dhinu’s post – I hate to say it, but I think that I fail to take advantage of the professional dress factor that could influence the placebo effect. My clinic is very laid back in a sense, with certain PTs wearing sweats and a t-shirt to work everyday, while others wear polos, and others wear button downs. I try to put myself right in the middle, with a loosely (sometimes un-) tucked polo and pants. In my mind, this wouldn’t affect how professional I would view someone, but that’s coming from my point of view. Some might find this completely unprofessional and might feel that I am not competent as a PT. I might try to change this up this week and see if I notice any changes. It’s never easy to admit that your dress is not up to par..but that was the first factor to stand out to me.

In response to AJ’s post – I think that the biggest factor of patient interaction that I can see I am going to have a hard time with is the amount of time that we have with patients. At my clinic, we are given a full hour to evaluate a patient, which is plenty of time to discuss POC and improve the shared decision making process with new patients. However, PTs can occasionally be triple booked in an hour slot for followups. Granted, they are scheduled every 15 minutes throughout an hour (not all at once). This gives us only a short period of time to talk with them and incorporate active listening because we have other patients in the building that we need to work with. I can 100% understand how this affects their perception of care and potentially their outcomes. Luckily, I am treating mostly on the hour right now, but once my schedule gets more rigorous, I will need to develop more refined interpersonal skills in order to ensure that my patient interactions are optimal in the time that I can give each patient. I’m curious if the more experienced members in the chat have any advice on how to best do this?

[jeffpeckins]

One example that comes to mind happened last year while I was a student. I was evaluating a patient with cervical pain who had an MRI done (35ish yo female with no neurological symptoms). In an attempt to get an idea of her interpretation of what her physician told her about the MRI, I asked her what the MRI showed. She listed off about 10 things wrong with her saying things like “slipped disc, degeneration, head too far forward, etc.” Like the article stated, since she was in a lot of pain, she was hyper-focused on the negatives and her interpretation of the findings were “colored by her psychological state”. Before I knew it she was crying and she became very upset.

With the help of my CI, we were able to calm her down a bit. We emphasized that these findings are normal and typical for any person her age, regardless of if pain is present or not. It took several sessions to really get this education through to her, but eventually she demonstrated less fear about her condition and we were able to help her get better. We used the teach-back method often with her after pain education, so that we had an idea of what concepts about her pain were clear and what were not. It also helped us understand which aspects of our education she most connected with.

I liked this article because it pointed out that patients who are in a lot of pain are vulnerable to harmful language and “seek information that supports (their) vulnerabilities.” When I read the educational handout that Ben received, I did not think it was scary or that the language used was threatening. However I wasn’t reading it through the eyes of someone who has been in pain for years, and also has a family member that has been diagnosed with “failed back surgery syndrome.” Thinking about the language I use through my patients’ POV will help me be more conscientious of what words I am choosing to say.

[Cameron Holshouser]

When I have a differential diagnosis case, most of the time I am trying to identify the tissue at fault and/or movement pattern that might be leading to their chief complaint. During the subjective and objective examination, I am clustering information to fit a certain tissue/category. When I finally (hopefully) get to my conclusion of what is going on, I then realize that I cannot simply tell the patient what I am thinking is the root of their problem because I am worried about creating more fear/harm.

For example, I recently evaluated a young female who presented with mid/low back pain. After my evaluation, I reached a decision that her symptoms were most consistent with clinical lumbar instability, similar to low back pain with movement coordination impairments. Somewhat happy with my examination, I then realized that I cannot tell my patient that I think she has clinical instability of her lumbar spine, for obvious reasons. I ended up saying something along the lines of: based on my exam, there are some areas that are a little tight/stiff (T/S) which is causing increased stress/demand/movement in other areas of your body (hypermobile/painful lumbar segment). I was pretty vague and found myself talking too much trying to explain myself, which I think confused the patient. I think the main reason I did this was because I did not know what to say. This article is nice because it gives alternative words such as for this case, using words like “needs more strength and control” instead of “instability.” Sometimes I find myself over explaining things to patients. I don’t know if it is because I am trying to reassure myself of my findings or to sound knowledgeable to patients, I’m not sure. But does it really matter anyway? The only thing the patient wants to know is if you can help their problem so that they can get back to what they were doing previously. So, I feel like less is sometimes more – at least for patient explanation, maybe not for documentation.. Patient education is definitely an area that I need to work on.

Jeff, great points. I definitely feel like talking to patients who already know their imaging findings can be the most difficult. I like your point of keeping the patient’s point of view in mind.

[Erik Kreil]

About 6 months ago, a young mother walked into my office reporting “debilitating” low back pain. She moved with purpose, cautiously, and with poor isolation of muscle and joint movements. What was most astonishing was that she reported her back pain became much worse 2 weeks ago that she attributed to sleeping later than usual that day; off-hand, she mentions that was also the day her doctor interpreted her MRI, explaining that a spondylolisthesis is an unstable segment that her entire spine is resting on.

I quickly jumped into the rehabilitative framework of cognitive behavior therapy, attempting to change the way she’s thinking about her low back pain. This proved unsuccessful, however, since I failed to parallel with the patient. Her catastrophic idea of what is happening in her body was so far opposite what I was explaining to her that it simply didn’t resonate, and she likely didn’t believe I was taking her pain as seriously as I needed to.

In a way, I often feel like a safari guide as patients embark on the path to rehabilitation. Patients are usually aware of what they might encounter or how to prepare, but most have never done this before. Newer pain research is supporting that pain is an output from the brain rather than an input from the tissue, so if a patient perceives the presence of potential harm or danger they might walk the path of rehab with greater hesitancy or fear.

The young mother taught me a lot about successful management strategies for catastrophized pain. Jeff, I love your approach to use the teach-back method, really seeing what resonates with your patient. I began giving my patient a word bank to choose from, such as “pain-pain,” “bothersome,” or “annoying,” hoping to develop within her a deeper sense of what she’s experiencing. I framed her reality with context, citing research that shows we can’t hang our hat on form dictating function. These strategies took my map of the “safari” and overlaid it with hers, leading us on a smoother course to a positive outcome.

[Matt Fung]

“.. in a world of online information.. we are only ever one click away from either confirming our darkest fears or igniting a previously unconsidered concern.” This quote is more applicable than ever with the internet at our fingertips. I agree that patients that come in with imaging results or pre conceptualized beliefs about their pain based on what they found on the internet are the toughest cases. This reminded me of a patient that I had during my second clinical – he was in his late 30’s coming in with chronic radicular symptoms. My CI had been working with him prior, with minimal symptom improvement. This gentleman was convinced he had sciatica and was taking all sorts of medications to help ease his pain. Every session he would come in and we would spend the first 15 mins discussing his findings on the internet regarding his pain. He wanted to know the exact mechanism of what could be potentially causing his pain, instead of allowing us to assess and treat his own unique presentation. In the end we attempted to have the pain science talk with him and discuss new findings in research as Erik mentioned, but he seemed to not take kindly to the thought that pain could be in fact an output from his brain and not input from his tissues and did not return for follow up visits.

I believe that everyone has made great point about being vague and framing diagnostic tests findings with words that are not threatening as the paper mentioned. Cam I too have find myself over explaining findings and talking myself into circles until patients are looking at me with a blank confused look. I believe that it is important for us to keep in mind that everyone has their own thoughts and beliefs and we need to be sure that we tailor our words to each unique case.

[Caseylburruss]

Last week, I had an initial evaluation with a patient referred for low back pain with sciatica. This man had a history of LBP but currently was experiencing new and more severe symptoms unlike his previous episodes. During the subjective interview, the man was expressing his own theories and worries of what was going on. He was throwing out terms like bulging disc and stenosis. This man was obviously distraught and worried he had really done a number on his back and wasn’t going to be able to go on vacation, cook (his hobby), etc.

After completing my objective evaluation and testing, the first thing I said to him was something along the lines of “Based on my evaluation, you should feel confident that you do not have a bulging disc and there are no abnormal neurological findings.” And if I remember correctly, I hadn’t even gotten to my PT diagnosis before he let out the biggest sigh of relief. I then went on to explain my PT diagnosis using words that were very non-threatening with little medical weight behind them, things like: “your hips are a little stiff”, “your tissues are a little irritated”, etc. It was a profound moment for me to see how delivering my diagnosis and my patient education could give such visible peace of mind…. and hopefully in the long run better patient outcomes (fingers crossed!)

And as much as I would like to take full credit for this myself, I can not. Luckily, this was during mentoring time and with some guidance the importance of prioritizing the relief of this patients fear was definitely eye-opening for me. Self-reflecting on this afterwards, I don’t think I would have weighed as heavily on the way I explained my findings to this man. I probably would have used more medical terminology, assured this patient through more complex explanations, and may have “eaten my own words” for lack of a better phrase.

Since, I’m making a conscious effort to talk to patients knowing that we have both the capability of inflicting fear with too much terminology but also the ability to relieve patient’s anxiety. So when I get those questions like “What do you think is wrong with me/it(insert any descriptive here)?” “Why do I have increased pain when I do X,Y,and Z?” I mean these are the questions we get every day. I try to respond in a way that doesn’t impart fear but peace of mind, or at the least spin the the impairments that are less medical like “the tissues are just irritated, your knee can’t tolerate the load you are putting on them when you work 8 hours a day quite yet” instead of saying “you probably have some degenerative changes under your knee cap and your quadriceps are still really weak and when you are going down stairs….. blah blah blah” I respond in way that doesn’t invoke more worry or anxiety.

And I think Cameron brings up a good point. Does it really matter how well we can explain to them in physical therapy terms and jargon whats wrong with them if all they care about is if we can help them? And I would argue it probably does not. However for me the difficulty lies on being tactful when explaining dysfunction and impairments, because its definitely easier said then done! However, I think this article and these discussions highlight that working with patients requires good verbal communication and the awareness of its impact. I see it as another “tool” or “art” form we have at our disposal to improve our clinical skills and improve patient outcomes.

[Dhinu Jayaseelan]

Interesting discussion on an important topic. Here’s an additional article that may be relevant. It goes into the neurobiology of placebo a bit, and provides a number of decent representations of the interplay of various factors and treatment outcome.

I like the examples you’re providing of when ‘words went wrong’ – it’s important we reflect on bad or negative experiences and identify how we don’t bias outcomes negatively based on our delivery.

Are there factors listed in this article that you are not, but could be, taking advantage of?

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[AJ Lievre]

Wow, you guys are really doing a nice job. Let me add to the theme of the discussion. Check out this article and reflect on what you feel you do well and/or what you need to work on in regards to patient interaction. Are there things about the dynamic of your work environment that helps or hinders this interaction?

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[jeffpeckins]

In response to Dhinu’s post, something I need to improve on is “delivering clear diagnosis, prognosis and explanation of the patient’s problem”. I struggle with this and for several reasons. Sometimes I am not exactly sure what the diagnosis is. AJ and I talk a lot about committing to a diagnosis, so that is something I try to do, but there are times when I am not really sure what is going on. Other times I am confident in my diagnosis, but talking to the patient in terms they can understand is difficult. In an attempt to simplify things and use less technical/scary language, I sometimes find myself over-talking and confusing my patients, something that has been mentioned several times on this thread (I’m glad I’m not the only one!). Another aspect that I need to be more mindful of is taking into account patient’s expectations and previous experiences. I do a good job of finding out and talking about this to patients in the initial evaluation, however it is something that needs to be discussed and tweaked throughout the patient’s time in PT. Their opinions may change, or I may think their opinions have changed when they actually have not. Lastly, something I have never considered is how much older patients and/or LBP patients care about the healthcare setting and organizational aspects of the PT experience. This isn’t something we can change a lot as residents, but it is something to be mindful of.

[jeffpeckins]

In response to AJ’s post, I am very lucky that I work in an environment where I always have one-on-one patient interaction. I never have to worry about balancing multiple patients at once, or worry about patients feeling like they don’t get enough time with me. It is really helpful because the work environment makes it easy for me to develop rapport with patients and to make sure I have addressed all of their questions and concerns. I am sure that I will eventually work in private-practice environments where I will need to learn better time-management skills and balance treating multiple patients at once, all while ensuring they feel like they have adequate attention.

Similar to my response on Dinhu’s article, I can improve in my patient education, and I hope that as I develop more confidence in my skills and knowledge, I will do a better job with this. In the meantime, I will need to make a conscious effort that I am explaining what is going on with the patient, what my treatment approach will be, and why I believe the interventions will help the patient. All while taking the patient’s expectations and opinions into account.

I also should make a bigger effort to show patients that I am being flexible with them and their time with me. For instance, with two patients this week, in order to fit them into my schedule, I put their appt time 15 min earlier than I usually have to work in the morning. I didn’t say anything to them because I didn’t think it mattered. However this article states that patients appreciate flexibility and making them feel like they’re a priority. So in the future, when I make sacrifices or am flexible with patient’s appointment times, I should try and casually make them aware of this, as it may enhance the patient-therapist interaction.

[Matt Fung]

In response to the article that Dhinu had posted, I agree with Jeff in that fact that I have much room for improvement when it comes to delivering a clear diagnosis, prognosis, and explanation to the patient. As I mentioned before I often find myself over-explaining and neglecting to use patient friendly words at times, which leads to increased confusion on the patients behalf. Additionally, I find myself using negative information such as the on mentioned in this article, “this procedure could lead to a slight increase in pain” as a means to prepare the patient for the movement. After reading this article I will be more cautious of the phrases I use as it can significantly influence the outcome of the procedure. Another factor that this article mentioned was taking into account patients expectations and previous experiences. I have been making a conservative effort during my initial evaluations to explain to the patient what to expect on day 1 and subsequent visits. I typically say something along the lines of, “you might leave a little more sore today than you came in because we are going to be attempting to reproduce your pain.” I realized that I needed to address this after a few of my patients came in during first follow ups telling me they left in more pain after the initial evaluation. Lastly, one point that I believe Jon mentioned in a previous post and was brought up again in this article was that professional dress, whether it be a laboratory coat, or tailored clothing had a positive placebo effect. At my clinic we are required to wear shirt and tie, which is new to me compared to my clinical affiliations where I typically just wore a polo shirt. There have been a few instances where patients have commented on the professional dress of the clinical staff and believed that it was a positive addition to their rehab experience.

[Erik Kreil]

I really appreciate how Dhinu and AJ’s articles compliment each other. I found it so interesting that major determinants of satisfaction for male patients are the therapist and overall outcome, whereas female patients were more satisfied with organization and communication. It really goes to show that clinicians can begin to predict successful forms of framing their approach to the patient, within reason.

When Dhinu’s article discusses phrases that may generate nocebo effects, such as “this test could lead to a slight increase in pain,” it makes me reflect on some ways I’ve grown to prefer to phrase the situation with my patients, like “this will help us map what you can do.” I’ve found that generally framing it as a positive experience – the why of it – is more helpful than talking about the negative aspects. As I read these articles, I’m realizing that patients are gathering as much information as the Therapist in the evaluation. They are almost comparable to an audience member of a play; constantly drawing information from the characters’ garb, their demeanor, and intentions.

At the end of it all, everything boils down to knowing the person in front of you. Dhinu’s article explains that placebo is the meeting point between active biologic change and psychosocial context. The question then is, how do we access that biologic change within the context of this individual? Jeff, I think your difficulty committing to a diagnosis can be mediated through AJ’s article. Where confidence and expertise may be a growing portion on the overall scale of things, maybe you can create balance by increasing other components proven to help, such as empathy and active listening.

[jeffpeckins]

Erik,

I love your phrase: “this will help us map what you can do.” That is a much better way of phrasing it and it allows a negative experience for the patient (pain, inability for patient to do something) into a positive experience where they believe that their discomfort helped you figure out how to appropriately treat them.

Also, I believe you are right. As a new clinician I/we aren’t going to know everything and have all the answers the patient is looking for. However we can control the other factors (patient rapport, timeliness, humor, etc) which will also help patients get better faster.

[Cameron Holshouser]

Placebo factors – Dhinu’s Article

Things I need to work on:
– I tend to ask about pain way too much. For some patients such as those with chronic pain, asking about pain constantly doesn’t help your differential and it also has a nocebo effect. Mike and I have talked about this during residency time. Using phrases such as “does that change anything” rather than asking “was there any pain” during an exam should help avoid the nocebo effect and take the focus off pain.
– I struggle with making a clear prognosis during an initial evaluation. I tend to avoid telling a patient a prognosis because I am just not sure what their prognosis is due to lack of experience. When I do give a prognosis, I have been trying to use statements that “under promise and over deliver” vs the opposite – similar to restaurants giving estimate wait times. But I feel there is a fine line with this because you also do not want to tell the patient too long of a prognosis that they don’t come back.
– Tailoring plan of care to meet age and gender perceptions (based on the article) such as males want to see outcomes, females want organization and communication, while older adults like to know about access to services and effective communication.
– I also have tried to use more positive verbal instructions, especially with manual techniques this week. I have tried to use something like “most people say this feels good” vs “let me know if this is too painful.” I think this has helped patient buy-in.

Work Environment – AJ’s Article
– I think there are common themes with all patient – therapist interaction articles. The big thing that I take away from this article, is it makes me consider what the patient is going through from their perspective. Imagine yourself, sitting in the waiting room with some type of injury. You are in a vulnerable state. You’re missing out on things you’d rather be doing (working making money, playing sports, etc). You are relying on a PT to get you better. How would you want to be treated? If we can be empathetic, answer their questions about what’s going on, explain what you can do to fix it, explain the process behind it, and be flexible this should lead to favorable outcomes.

Side note: PT’s at our facility are now required to wear royal blue polos every day due to change in company…I wonder if our patient perceptions will change since most of the articles support clothing that is either lab coat, tailored clothing, tie, or other professional clothing.

[Caseylburruss]

I found it interesting in this article that it talks about how “the phases of the course of the musculoskeletal disorder can influence the outcomes of care” in terms of patient satisfaction. The article points out that acute patients look for expertise, reputation, level of training and professional behavior compared to chronic patients whom organization of care is the most important. I don’t think until recently I have taken this into account as much as maybe I should. This article does not expand much on this, which is a bummer but, I wonder why that is?

Is it because those who have chronic pain have been bounced around between so many providers they are confused and exhausted of not truly understanding their musculoskeletal disorder? Is it because they have been given a laundry list of medical diagnosis, threatening terms like “bone on bone”, and had every imaging and test done under the sun with little explanation of the results?

I have noticed that most chronic patients are extremely good at laying out their extensive medical history of what this doctor said, the exact date of this imaging/test, the x-rays showed this, etc. But do they even understand what all of that means? These patients have sought so many people for help however they still have NO IDEA what is going on with them in a way they can comprehend or contextually understand. I think this is where we as one of the many health care providers these patients are seeking can be more mindful. Although they may know what their test results are and what the doctor said but do they truly understand what that means for them in a context that is meaningful. That being said, I want to start asking patients “what do you think is going on?” and “What does that mean to you?”. Because what I’ve seen is that you can learn a lot about what this persons expectations, their current prognostic outlook and preferences are by asking this question. Which in this article, clearly shows can make a difference in the therapeutic outcome.

Maybe these patients need more education on what they’ve been told or the lack of what has been said. Maybe using verbal communication that is less medically driven but functionally meaningful to reach their patient specific goals and or address their unique participation restrictions so they can gain some sense of control is where I can improve with my chronic patients. I’d like to get better at taking these black and white diagnosis and impairments that have been assigned to them by their doctors and personalize it to them. Their “bone on bone” doesn’t mean we can’t make progress, get pain relief, or get you back to doing X,Y,and Z. Showing empathy, giving encouragement and recognizing patients opinions is huge.

I can relate to Cameron, in regards of struggling with clear prognosis, I often dread that question of when do you think I will get back to ________, or those patients requesting a timeline. I have been using the phrase “Rome wasn’t built in a day” phrase a lot, whether that is effective or not is still up for debate but it seems to be working for me. I try and use my active listening skills here and say something like “So you said this has been going on for ______ weeks/months/years, so its not going to be an overnight transformation,” then give them functional skills of what needs to happen first before whatever it is they are trying to get back to. I tend to put my foot in my mouth a lot so I try and switch this conversation of the progression I like to see to return to running, throwing, etc. I would love for more tips on how to approach prognostic questions as well!

[Caseylburruss]

Sorry its me again!

After reading the systematic review I realized that 11/12 identified codes within the 4 themes were based on good verbal and patient interactive skills. Not only does this data not surprise me it makes me re-evaluate how much of my own patient communication I can improve on. I sought out this residency knowing I wanted to enhance my skills regarding my technical ability and skills (under theme 2). Which I am happy to see my investment is going towards good use and will help me improve my patient interactions. However, what I didn’t understand is how much I have to learn and the vast growth I can gain in my verbal communication skills.

After a recent mentoring time with a highly irritable and hypersensitive patient with chronic low back and hip pain I have never been so appreciative of these themes. This patient was struggling in many areas of her life. Her medical history form was extensive however very suggestive of someone was dealing with a hypersensitive system, from GI issues, sleep disturbances, depression, and muscle aches and pains. Upon our patient interview, patient reported her hesitancy of coming to physical therapy due to her skepticism of what could be done to help her. Based on her state of hypersensitive state I was so nervous how to proceed with my objective portion of my evaluation. I was weighing in my head what tests can I do, based on what I have gotten in terms of signs and symptoms. My little student driven brain was, where can I categorize her low back and hip pain?Dysfunction, Derangement, etc. This was my first mistake. I completely lost my ability to focus on the more interpersonal and communication skills needed with this patient. I was not able to step away from my own selfish desire to make sure I could get a PT diagnosis and have something to write in my objective evaluation form then using this time with a patient who was obviously struggling and who has had many medical professionals write her off as another chronic pain, depressed, and hypersensitive patient. I was missing the fact she was telling me what she struggles with, the daily difficulties she has and her obvious demeanor of complete frustration and hopelessness. With the direction of Eric, I started to understand that my drive to get objective data out of this patient was not where my attention and energy should have been directed towards. This patient needed education, personalized care, time to have her view point heard, and needed a health care provider confident that we were going to be able to help her towards patient specific realistic goals. I learned quickly how the communication skills, being able to clearly explain her impairments, and giving her nuggets of information to hold onto throughout the session to boost patient compliance and buy-in. It was a mentally draining experience but I am confident we reached her in a way many other health care providers hadn’t. The verdict of her return is still TBD but I am hopeful!

[Eric Magrum]

Test post –

[Erik Kreil]

I’ve recently had an influx of student athletes on my caseload, and I’ve found a common trend line that younger folks have a really hard time expressing their symptoms. A big part of what we’ve been talking about is how perception influences a patient’s interpretation of their pain experience. The more I think about it the more I connect the dots to what we’ve been discussing here that perception is largely based on experience. So it’s no wonder these younger kids have a hard time describing the true spectrum of their experience – it’s all still very binary for them (e.g pain or no pain). They have no developed concept of what pain is or what’s even possible for their human body. It’s likely that they parallel their body unit not as an active organism capable of healing itself, rather more likely to something that’s obvious like a car engine. In their world, medical diagnoses are given to you; you have a cold, or you get the flu.

It’s been interesting trying to mold their conceptual understanding of their bodies, rehabilitation, and what they’re really capable of. We have a huge opportunity to guide human beings to a better experience of life and potentially start nipping future MRI and surgery seekers in the bud.

[Caseylburruss]

Erik you are so right! Young kids are pretty lousy at expressing themselves when it comes to explaining their pain or describing their symptoms. I’ve also found it just as difficult sometimes to get certain student athletes to buy-in to get them to understand why they should, need and want to be there. Because face it, most of the time they are there because their parents are making them. If this is the case, which sometimes its not, I have a hard time convincing myself whatever we do in therapy will translate over into their day to day life if they don’t understand how this has any correlation to playing soccer, going up to make a lay-up, or whatever the case may be. I think more than ever this is where we can set ourselves apart from other healthcare providers by providing that patient-centered intervention guided by function. I have been trying to correlate my therex and other interventions with things they can relate to whether it be side stepping with a basketball in their hand, SL balance on foam while kicking a soccer ball against the wall, or breaking their tasks into parts so they can at least see how it relates to what they want to do. I’ve found that to be really helpful for me to take away some of the medical jargon I tend to want to throw at people and get them to talk to me about what is hard for them to do in their sport. I have also been trying to give them specific tasks that I want them to be able to do when they come back, making it very goal oriented. For example, “I want you to be able to rock out 15 of these SLR at the beginning of next visit.” Kids like to win so I try and use that to my advantage a lot of the time when it comes to getting them to do their exercises. I think sometimes I take on a personal goal to get them to care more than they actually do and maybe that’s a waste of effort on my part but hey, you live and you learn. Anyone else have any good suggestions or thoughts on this?

[jeffpeckins]

I agree that kids have a difficult time expressing themselves. Not only are many only able to differentiate pain vs no pain, many of them have no idea what causes their pain. A lot of times I will ask about their aggs and eases, and they have no idea what to say. At this point, I try to give them examples, and many times that helps them. But still many will not know how to answer, because they don’t think like that. So I have found that if I can tell I’m not getting anywhere drilling them with questions about their pain, its much easier and more specific to try and act out their sport or activity they participate in.

I also agree with Casey that making their exercises as sport-specific as possible helps bring in context to their pain. I believe that most athletes are motivated to participate in PT, however making the connection between their deficits and pain, and their ability to perform well is very important. I find that I oftentimes have to be very open with what I am doing and why I am doing it, and how it will help them either have decreased pain, or improved performance.

[Cameron Holshouser]

We tend to see a decent amount of younger kids at our clinic (high school and college). I agree with your point Erik, it can be very challenging when communicating about pain with this population. I have found that it tends to be even harder for younger patients, especially if the parent is in the room answering the majority of the questions. But this is interesting. The older population can generally tell you very specific details about their pain such as location, description, time of day, etc. However, when I ask younger patients about their symptoms, they typically give me a blank stare and don’t know how to put into words what they are feeling. What I have been doing recently, is starting to ask less about pain and rely more on my objective exam. I have been asking less subjective questions and starting my objective exam earlier to get an idea of their movement quality which can tell you a lot more than what they are telling you. As the objective testing goes along, I will ask follow-up questions related to their primary complaint. This has helped me some, but I have also run into a problem of the young patient not telling me everything, and I find out something different from the parent. Still working on this, any tips would be helpful.

[Matt Fung]

You all make great points about the challenges of communicating with the younger patient. That population struggles to describe their symptoms and express their goals. Cam I agree that it becomes more challenging when you have the parent in the room who wants to tell you their story at well. It becomes important for us to balance the communication between patient, parent, and PT. I too try and keep our sessions as interactive as possible, geared towards their interest, to keep their attention and not let them get bored. I have also found that less is more with patients in this younger population. I try not to over explain or complicate tasks as that only results in the blank stare back in confusion.

One the same topic of communication, I am currently treating a patient who only speaks Italian. Fortunately for the evaluation the patient came with their significant other who was able to translate for us, but each subsequent visit has been just the patient and I. It has been a little struggle attempting to teach and educate this patient about her symptoms and our interventions. I have found that our best line of communication is through demonstration to this point. I recently started using the google translate app to assist our communication, but I was wondering if anyone had any suggestions or more experiences treating patients who’s primary language is not English?

[Laura Thornton]

Here’s one of the features in PT In Motion this month to go along with the discussion of treating young athletes:

http://www.apta.org/PTinMotion/2018/11/Feature/SmallAdults/#

Have a read and share any discussion points you think might be relevant when communicating with this younger population.

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[Erik Kreil]

Laura,

The article is extremely serendipitous! It makes some great points that actually bring us full circle to the original talking points of this forum. The same truth for any patient is that we have to enter their world. When we exclusively speak our personal language, the meaning bypasses the patient and the intent is lost. As the article remarks, kids are not small adults and their world/ language is in constant evolution as they attempt to make sense of it all.

I love how the folks in the article utilize video recordings of the patients’ movements to get their point across. I can see how that’s a fantastic bridge between languages, and Matt maybe this is the bridge between you and your Italian patient. For kids, it could be really helpful to withhold your professional interpretation and ask guided questions to see how the patient chooses to describe the recorded movement. Now the treating PT can parallel the patient, enter their world, and begin to mold an accurate interpretation from within.

[jeffpeckins]

One thing the article emphasizes that I agree with is the importance of parent participation in the child’s physical therapy. There have been times when I am very impressed with athlete’s parents, because they are able to pick up on their child’s biomechanics and are very in-tune with their child’s pain. They may not know exactly what is going on, but they definitely know when their child is moving differently. When they participate in my PT sessions, they will begin to notice the biomechanic aspect of things I point out to them, and they can do a great job of reminding their child of these things when they are doing their HEP or participating in their sport. As the article mentions, filming the athlete’s movement helps a lot with this. I think kids can be motivated, but they have a difficult time seeing the end-goal or end-result, which makes HEP adherence difficult. Having their parents on board really helps with this. I think making their exercises sports-specific is helpful, but ultimately its tough to hold a young kid accountable for their rehab.

[Author]

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