You’re Not Fixing Your Patients

Patients and therapists alike often joke about how their therapist fixed them, or they need fixing again. The term is commonplace and seems harmless at the surface. It’s an easy way to characterize the experience of physical therapy. Your knee hurts, you work with a physio, it gets better. Thus, you’re fixed. Makes sense to me. The only problem: that’s not how it works. The culture of “getting fixed” is harmful to both the patients and the profession of Physical Therapy as a whole.

“Fixing” implies that therapy is a passive experience. It leaves out the education, self efficacy, and empowerment that takes place during a physical therapy intervention. And it ignores the central point of therapy: therapists help people fix themselves. We aren’t magic voodoo healers, so let’s stop pretending to be.

Physical Therapy is active medicine

• Most medicine is passive. People walk into a doctor’s office expecting to be fixed. Strep throat? Antibiotics. Fixed. Cavity? Filled. Fixed. Back pain? Cortisone shot. Fixed. The problem with this mindset is that physical therapy isn’t quite that easy. The therapeutic experience is multi-faceted. Patients are often asked to make lifestyle adjustments, do home exercise, and actively participate in their healing. This holistic understanding and subsequent adherence to physical therapy is a key determinant of success in both surgical and non-surgical patients (1).

Involve the patient in their treatment, help them fix themselves

• Make treatment a collaborative effort. Ask the patient what they enjoy, give them a voice. Patient education and involvement in the decision-making process have been shown to be highly correlated with patient satisfaction and outcomes (2). The therapist should set clear expectations at the onset of therapy. Although the patient may not love every aspect of therapy, finding an agreeable treatment plan and having them enjoy part of it will go a long way towards recovery.

• The therapeutic encounter between patients and therapists is complex and reflects the multidimensional nature of patient satisfaction (2). It’s not as simple as just removing the thigh bone, you have to smile while you’re removing it, therapy is a joint venture.
• A good relationship where the patient and therapist can hold eachother accountable increases the probability of success. This is key as home exercise ramps up and patients want to return to full activity. Careful here. The reality is that even if all patients are compliant, up to 1/3 of them will perform their home exercises incorrectly (4). So keep the programs simple, increase volume over time, keep exercise selection low, and be realistic.
• Tapering physical therapy before discharge can assist with self efficacy. Once a week, or even every 2 weeks at the end of treatment may be beneficial for long term self management. Tailored physical therapy has been shown to be superior to a standalone self management program on 3 month return to work rates and lifestyle exercise interventions (3,6).
• Providing educational material about the importance of exercise has been shown to help with patient compliance and independence as well (5). In other words, hammer it home.

We aren’t Voodoo healers.

• When I got into Physical Therapy I never anticipated there would be so much controversy. I had no idea how many therapists were choosing to ignore research in their treatment approach. Therapists making up their own secret manual therapies, patients getting their immune systems re-aligned by chiropractors, even bringing their dogs to chiropractors (its a real thing, I swear). There are just so many misconceptions out there about healing. Bottom line is don’t underestimate the power of placebo in manual therapy (9). If it seems too good to be true, it probably is.

• The worst thing about all of this misinformation is it creates an overwhelming feeling of anxiety for the patient. It removes their control over the situation. Along with therapist’s affect, the ideas of backs being misaligned, pelvis’ slipping in and out, and scary sounding problems contribute to pre-treatment anxiety, a negative factor in treatment outcomes (7).
• It’s important for a patient to understand that most injuries run their course. Even the dreaded slipped disc. Don’t let your patient be that guy still complaining about his “slipped disc” 20 years later. Educate your patients on the normal course for their injury. Instead of telling them you can’t fix their disc, tell them most people with disc herniations on MRI’s are walking around pain-free (10).
• In addition to healing, educate your chronic patients about their pain. The reason as to why symptoms persist past the acute to sub-acute stage and become chronic is unclear, but likely results from complex interactions between structural injury, physical impairments, and psychological and psychosocial factors (8). They need to appreciate the interplay of factors in order to work on their pain.

In closing

Therapy is active medicine. You’re not a handyman. You have skills, not tools. Your patient’s consistency and accountability is crucial to their success. Help them achieve this. Teach them that they’re “fixing” themselves, and not vice versa. Check your ego at the door. Don’t take all the credit. You’re not a voodoo healer. Sometimes people just get better.

 

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References

1. Gambhir RP, Valenti D, Rashid H. Compliance with Physical Therapy is a Key Determinant of Success of Thoracic Outlet Surgical Decompression. J Am Coll Surg. 2015 Sep;221(3):778
   
2. Ali N, May S. A Qualitative Study into Egyptian Patients’ Satisfaction with Physiotherapy Management of Low Back Pain. Physiother Res Int. 2015 Aug 27. [Epub ahead of print]
3. Andersen LN, Juul-Kristensen B, Sorensen TL. Efficacy of Tailored Physical Activity or Chronic Pain Self-Management Programme on return to work for sick-listed citizens: A 3-month randomised controlled trial. Scand J Public Health. 2015 Jun 25. [Epub ahead of print]
4. Faber M, Andersen MH, Sevel C. The majority are not performing home-exercises correctly two weeks after their initial instruction-an assessor-blinded study. PeerJ. 2015 Jul 21;3. eCollection 2015.
5. Van Waart H, Van Harten WH, Buffart LM. Why do patients choose (not) to participate in an exercise trial during adjuvant chemotherapy for breast cancer? Psychooncology. 2015 Aug 17. [Epub ahead of print]
6. Andersen LN, Juul-Kristensen B, Roessler KK. Efficacy of ‘Tailored Physical Activity’ on reducing sickness absence among healthcare workers: A 3-months randomised controlled trial. Man Ther. 2015 May 2. [Epub ahead of print]
7. Healy GM, Finn DP, O’Gorman DA. Pretreatment anxiety and pain acceptance are associated with response to trigger point injection therapy for chronic myofascial pain. Pain Med. 2015 Aug 26. [Epub ahead of print]
8. Campbell L, Kenardy J, Andersen T. Trauma-focused cognitive behaviour therapy and exercise for chronic whiplash: protocol of a randomised, controlled trial. J Physiother. 2015 Aug 26.[Epub ahead of print]
9. Chaibi A, Šaltytė Benth J, Bjørn Russell M. Validation of Placebo in a Manual Therapy Randomized Controlled Trial. Sci Rep. 2015 Jul 6;5:11774.
10. Boden SD. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990. 72(3): 403-408.