Managing patient expectations

The general population assumes that the location of the pain IS the location of the problem. But most manual therapists know that, often times, the painful region is not the site of dysfunction. The painful area is usually the area that could not adapt well to dysfunction elsewhere. It is the victim but not the criminal. When the patient paying for treatment comes into the clinic expecting treatment at an area that is not the cause of symptoms, the therapist must negotiate a solution. If not, the patient will be upset and lose faith in the therapist and this may even create a negative placebo effect. The therapist must still find and treat the actual problem, but he must do so strategically.

Solving this problem begins with taking a thorough history. As the patient describes symptoms, the therapist will ask: when they occur, are they related to any other activities, what lessens them, what treatments have worked or failed for these symptoms, what diagnostic testing was done, etc. The more questions that the therapist asks and the more he listens to what the patient has to say, the more the patient will come to trust that the therapist cares and truly knows how to do his job. The therapist should not interrupt the patient unless that patient continually wanders off the subject. But the therapist will direct the patient with open ended questions to find the important facts that the patient may not think are important.

Questions regarding what has worked and what has NOT worked in the past are one key to educating the patient during this process. For example: a patient complains of low back pain and lumbar muscular tightness that is worsened by walking but massage and joint manipulation treatments to the spine gave her only short term relief. The therapist knows that the lumbar spine and muscles could be involved but now knows that several treatments to the muscles and joints were not affective. He has not done his own assessment yet but he can gather more information and help to make the patient more receptive to his future treatment by what he says. He would like to know specifics about those treatments and those specifics will help him educate. Example: How many massages did you have? What areas did they treat? So they spent a lot of time working into the muscles but it did not change things? In this last question, the therapist is not only confirming what he has been told but he is also planting a seed of doubt in the patient’s mind. The patient might now consider that there is more to the problem then the lumbar muscles.The therapists will ask questions about the joint treatment. Example: Were joints adjusted above or below the problem?, Was the pelvis evaluated? The therapist knows that dysfunction at the pelvis can cause the same lumbar symptoms and are often worsened by walking. He wants the door open for evaluating and treating the area so he leaves those questions in the mind of the patient. It is wrong for the therapist to assume or say that he knows the problem before the physical evaluation but it is important to open the patient’s mind to the possibility that the real problem could have been missed in the past by looking in one region. If a treatment did seem to help but not resolve the problem, the therapist can help open the patient’s mind by saying: ‘it sounds like treating this area helped but there must be more to it. It sounds like several things are adding up to cause this problem’.

Even if the patient has not had failed treatment, there are still ways to help open the mind of the patient. If the patient has had any exposure to Traditional Chinese Medicine, they know that it is common to be treated with acupuncture far away from the area in question.  They have accepted that the mind and body are connected in very intricate ways but they likely still have a mental block that keeps them from seeing Physiotherapy, like TCM, should be performed to treat the body as a whole of interconnected parts…not just single part.

When the physical exam begins it is important to acknowledge where the symptoms are and touch that area. This lets the patient know that you are listening to her. Verbal confirmation helps build trust. Example: ‘yes this is tight, yes this is sensitive’. At this point, the therapist knows that he still needs to fully examine the patient but that the patient does not know what that is or why it is needed. The therapist must explain this briefly to keep the confidence that he has built. Example: ‘past treatment probably failed because no one found the biggest problem causing your symptoms, I would like to do a more extensive examination to find it’,or ‘it is very common for other parts of the body to be involved with these types of symptoms, I need to be thorough when examining you to find all of the problems’.

Even with the best communication skills, the patient may still be quite close minded. This can be frustrating for the therapist who knows human anatomy, kinesiology, neurology and various treatments and approaches that he has seen work. The patient might agree that the PT knows more about these things but still believe that he knows more about HIS symptoms and HIS body.  The therapist can use analogies that fit things that the patient already knows.  Here are just a few examples: 1. the business man: ‘if a business owner has 10 workers and 5 workers do any work, which will complain? Those who have to do twice as much work! Should the owner correct them or the 5 lazy workers? If all the workers do their own work, things will run smoothly and there won’t be complaining. The body is the same way. If we find the parts that aren’t working, then the overworked parts should stop complaining’ 2. the mother: ‘if you aren’t watching the 4 toddlers on the floor and one started screaming and crying do you wonder if another toddler caused the child to scream by hitting or taking a toy away? That is the way that I think when looking at the body. It is very common for one part of the body to feel pain because another part of the body caused the aggravation’. 3. the mechanic: ‘if the car battery dies and then you replace it but that battery dies too, do you think the problem may be somewhere else? The alternator must recharge the battery and if it doesn’t, the battery will die. The battery dying was a symptom of the problem but the alternator was the problem. The body is very similar.’

These types of analogies may bring out some of the pride that the patient has in their work which gives the therapist a chance to tie the picture together.  The business owner could say: I don’t let people like that work for me’. The PT can agree and say: ‘I wouldn’t either. And I don’t like seeing parts of the body that don’t do their jobs. I can’t fire them, but I can make them start doing their job.’  The mechanic might say: ‘it might not be the alternator but the wiring or both’. The PT can agree and say: ‘You know more about engines but I know about the human body and it is complex. I have a big list of things to look for when someone has your symptoms’. In both cases, the patient has told the therapist that he can problem solve and it opened the door for the therapist to explain that he thinks the same way but applies it to the human body.

In the end, the biggest thing to build patient confidence and lead that patient to return for another appointment is to improve symptoms. That opens the door for you to treat whatever problems you find. But building trust and changing the patient’s assumptions from the beginning of that first visit(and throughout each session) may determine success or failure.

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