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Changing the Model of Patient Education: Stop Telling Your Patients Everything is “Wrong” With Them

The background

Most physical therapists conduct a highly detailed physical examination and evaluation of every patient who walks into the clinic. We look at range of motion, muscle strength, flexibility, anatomy, gait, balance, biomechanics, coordination, joint mobility, posture, symmetry, innominate rotations, “muscle activation,” “core stability,” “functional movement patterns,” etc.

As students, we are taught to measure every intricacy of human anatomy and movement. We assume that this approach will allow us to best devise a treatment plan to address whatever pain or limitation our patients present with. We are taught “normative” data for all of these metrics and how to tell if our patients aren’t “normal”. Furthermore, we are indirectly, and sometimes even directly, taught that falling outside these “normal” ranges will lead to pain and injury.

The problem

Our hyper-vigilance to anatomy and biomechanics (while important in some cases), creates the tendency to search for everything “wrong” with our patients. In an effort to provide patient education, we highlight limitations, weaknesses, abnormalities, anatomic variances, poor postures, “bad” movement patterns, and everything else under the sun.

Unfortunately, we too often fail to recognize what is RIGHT with our patients. This is an often neglected, yet critical component of patient education.

The treacherous next step in this misguided approach is when we convey this information to the patient. When reviewing the results of an evaluation, we typically point out every category that our patients are sub-par in.

We then tell them that our fantastic interventions and specialist knowledge are the only things that will save them. We make these patients feel lucky to have found us. We heroically imply that were are there to step in and save our patients from text neck posture, pronated feet, an unstable core, a rotated pelvis, trigger points, fascial adhesions, delayed hip muscle firing, and the sad inability to complete a full depth pistol squat.

Yet, as our understanding of the literature evolves, this style of patient education and teaching does not appear to be relevant.

We have learned that resting posture is not well correlated to pain or injury.

We have learned that foot pronation during gait is not correlated to an increased rate of running related injuries.

We have learned that core stability (whatever that actually is) may not be correlated to back pain and that strengthening the core with focused exercise is no better than any other form of exercise for treating back pain.

We have learned that it is HIGHLY unlikely we can impact the length or structure of the IT band, or other dense connective tissue, with our in-clinic interventions.

We have learned that manipulation doesn’t change joint position (sorry guys, not even with a pelvic innominate rotation that likely doesn’t even exist).

This list could go on and on, but the central focus is that our overly detailed biomechanical reasoning for what we do, why we do it, and why it works falls dramatically short.

The reason

The current model of patient education inundates patients with negative self-perceptions. Furthermore, this tends to generate a scenario in which the patient is dependent on and “needs” us.

Usually, this approach is genuine and well-meaning, but it is a misguided one. In an effort to help our patients by highlighting their flaws, we are limiting healing and autonomy. Yet, this is the patient education model we have been taught. For many of us, it is all we know.

For many physical therapists, it is more fun to be a healer than it is to be a coach. Most of us have a strong desire to “heal” people. It makes us feel special, justifies what we do, and usually leads to some cookies from pleased patients who were “fixed”.

I often find that the average provider also feels the need to justify the doctoral education with a fancy and meticulous examination. We then follow up with a highly structured depiction of pain and dysfunction. This method of patient education does not benefit the patient in the way we would hope.

The implications

This type of approach is almost always well-intended, but the downstream implications can be quite severe. Patient education and treatment interventions must reflect a physical therapy diagnosis that is directly related to a patient’s true limitations and goals. When we begin to rely on anatomical factors that have little to no influence on health status, pain, or injury, we are practicing low-value healthcare.

The concept of low-value care is related to a range of other challenges in clinical practice, including over-diagnosis and over-treatment. These are situations in which people receive a diagnosis or a treatment that will bring them more harm than good. The patient education and management model of highlighting flaws will undoubtedly contribute to downstream healthcare resource utilization and will result in over-medicalization.

A prime example of this can be seen with the opioid epidemic. Pain is an experience governed by the central nervous system, yet it has been widely labeled as a vital sign. The inappropriate over-treatment of pain with ineffective and highly addictive pain medications has wreaked havoc on millions of patients. Our healthcare system has suffered too.

When we take a micro-level approach to patient care, instead of a macro-level approach to overall health, we see an even more startling implication. This model has a high likelihood of creating false perceptions about pain and the human body. As a result, the patients we are trying to help end up being harmed by us in the long run.

These nocebos can implant thought viruses that linger for years, or even a lifetime. They quietly cause pain, decrease activity levels, and result in a spiral of iatrogenic health effects that could ruin a patient’s life.

Think about it, how many times have patients told you that they don’t bend forward anymore due to fear of their herniated disc? Or that they avoid squatting and long walks in an effort to protect their degenerating knees? Or that their back hurts because their core is too weak to keep everything in place? Or that they don’t engage in their favorite activities because they may move their neck the wrong way?

The concept of biomechanical fragility is alive, well, and running rampant across our world. We have been key propagators of this false dogmatic propaganda. Low-value care not only hurts insurance companies and patient pocketbooks, but also directly impacts the psychological, social, and physical health of millions of people.

Check out The Role of Optimism in Patient Outcomes for tips on how to take a more positive approach to patient care.

The alternative

Stop telling your patients everything is “wrong” with them! Just stop it!

Challenge yourself to change your focus from what is wrong to what may be right. Challenge yourself to point out the positive factors that will promote recovery. Challenge yourself to empower and coach instead of being a healer who promotes dependence.

Tell your patients that they have a lot of great factors to work with. Assure them that they will get better. Each and every patient will present with something you can use as a motivator. There is never a situation in which you can’t find a positive factor or two to point out.

  • Tell your young patients that they will experience faster healing rates.
  • If your patients don’t suffer from a disease that slows down healing, tell them that their strength will drive them to recovery.
  • Emphasize the benefit of a good family support system.
  • Enthusiastically relay that it’s awesome that your patient is able to do some cardio – and how much that can help pain and health.
  • Share with your patients that their ROM is really good and that you’re impressed with how well they move.
  • Let your patients know that almost everyone has small rotator cuff tears and that it won’t be an issue for them at all.
  • Tell your patients everyone has disc degeneration and it’s simply a version of “wrinkles on the inside”.
  • Point out that pain is normal and even a good thing in plenty of situations.
  • Inform patients that inflammation is an indicator of a healthy immune system at work.

Stand by your patients and address their issues with them instead of being a healer that “fixes” them. Act as a health and rehab coach who offers expert information rather than a provider of treatments and an applicator of techniques. Empower your patients and improve their self-efficacy. Put their health back in their hands.

References

Barrett E, O’keeffe M, O’sullivan K, Lewis J, Mccreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46.

Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008 Aug;108(8):379–90. PubMed #18723456.

Nielsen RO, Buist I, Parner ET, et al. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2014;48(6):440-7.

Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014;15:416.

Schleip R. Fascial plasticity: a new neurobiological explanation. Journal of Bodywork & Movement Therapies. 2003 Jan;7(1):11–19.

Traeger AC, et al. Wise choices: making physiotherapy care more valuable. J Physiother. (2017).

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About Jarod Hall

Jarod Hall
Jarod Hall is an outpatient orthopedic physical therapist in Fort Worth, TX. He directs Greater Therapy Centers Southwest Fort Worth. He is an adjunct instructor at University of North Texas Health Science Center in orthopedic and musculoskeletal examination and intervention. He runs his blog at www.DrJarodHallDPT.blogspot.com, which he writes on various topics related to orthopedic physical therapy, manual therapy, pain science, and much more.

5 comments

  1. Nicolas Ferrara

    100% yes. We really need to stop thinking of ourselves as healers at this point.

  2. Emma Lam

    Great post! A large part of being a PT is giving our patients ownership, power, and understanding over their own bodies and potentials…and helping them break down any inaccurate thought viruses! Awesome article!! 😀

  3. David Mittwede

    I agree with the root message and how to encourage and empower patients but I believe that studies have been done and patients with sever or chronic pain just want to know what is going on and they want answers to why they are so miserable.

    I think there can be a healthy medium to where you can justify their pain but educate them on expected healing and empower them to give input and help them make decisions about their condition so they don’t feel like a helpless sufferer bumbling from one health care provider to another hurting and just getting pain pills and imaging and talk of surgery.

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