I issued this clinical challenge recently on facebook:
“With your next couple of patients, keep track of how many of your statements and requests to them are actually demands. They may be polite demands, but demands nonetheless. These will be statements like, “tell me about your back pain” or “show me bending forward” or “Do 10 reps of this exercise next” or even “I want you to do…” etc.
The next part of the challenge was to try to not make any demands (even polite demands) in your next interaction. To do this we must take a different approach that is inviting or advising instead of demanding.
Why is this an important exercise to try?
Much is made of the value of self-efficacy and for good reason. It is the concept that a person feels that they are the ones who are driving their outcomes. I feel that it is similar to, or a combination of two other strong prognostic indicators: locus of control and recovery expectations. When it comes to issues with painful movement, we want people to feel that they got better, did so of their own accord, and were responsible for the outcome themselves. To make this clear, think about the converse of this: the person feels better, but feels that they were not in charge of the process and someone else was responsible for the outcome. “I had do what the physical therapist told me and they got me better.” Interestingly, you can read any number of marketing guides that tell you to encourage that very type of statement. That’s a big problem, but that’s for another post.
So, back to the challenge. When we make demands it assumes that we are in a position to demand something. We are taking a role in which we have power over someone else that allows us to tell them what to do. Again, we often do this very politely and with the best intentions in mind. But, if the goal is a patient operating with a high degree of self-efficacy you can see the problem here. It puts them in a subservient role and is not consistent with our goal of a self-efficacious positive outcome. Patients often come in assuming this role on their own and seek out someone to tell them what to do and be responsible for their well being. We’ll address that in the next challenge.
Habits are hard to break and I still catch myself in this all the time. So, I offer some suggestions as you try this.
- Asking is better than demanding. Instead of saying “tell me about your back pain” you could try saying “what brings you in today?” or “What can I help you with?” or “I understand that you’re having some problems with your back.”
- Making statements is different than making demands. Saying that “I understand that you are having some problems” is a true statement about what you understand and makes no demands. Others that I often use are “I’m curious what it looks like when you pick something up from the floor. Could you show me?”
- Getting permission is getting informed consent. This might be the difference between “I’m going to do some tests on you” and “I’d like to do some test. Is that OK?” or “That sounds like something I should take a look at. Is it OK if I roll up your sleeve and take a look?”
These may sound over the top careful, and honestly most patients probably don’t feel bullied or pressured. That is not the point of this exercise (although those are definitely not ok). The point here is that we want self-efficacy. We want our patients in that role and in order for that to happen we can’t steal it from them by assuming a role of power. The first step is that we assume they are self-efficacious and treat them accordingly. Next we can even steer them in that direction. That will be the next challenge.
This is a presentation that I gave on the Rethinking Physiotherapy facebook page in October 2017. It ended up being a pretty nice overview of edge work and my thoughts on context architecture. Also, there are a couple of courses coming up in March 2018 for anyone interested in the weekend workshop.
As I’ve mentioned before, I like to use stories that relate to people’s personal experiences to help them grasp some of the concepts of pain. The following is story that I use a lot.
You’ve been outside working in the cold, maybe pulling weeds in the garden on a crisp morning, or maybe shoveling snow from the driveway. Maybe you do polar bear swimming competitions? Anyway, you get what I mean. You’ve been working outside in the cold and have developed “cold hands.” It’s the kind of cold hands where they got so cold that they kind of almost stopped feeling cold. Then something strange happens. You come inside to wash the dirt off of your hands and suddenly the water coming out of your perfectly normal water faucet feels like molten hot lava!
This is the process of sensitization in action. We have this very cool ability (pun intended), almost a superpower really, where we adapt the sensitivity of our sensations. We don’t even have to think about it. It just happens! When you’ve been out in the cold you adapt the set point to better match the steady input. In other words, you don’t notice the cold as being so cold once you “get used to it.” But, since the set point has been effectively lowered, warm now feels hot and hot feels like molten lava. The purpose is that we have some protective mechanisms in place to keep us safe and to be most concerned with and attentive to changes. So, once we’ve been in one input, like cold, for a while, we adapt to it so that we can better notice changes from that point.
Why is this important? Well, this action of sensitization happens with lots of things besides just temperature. It happens with smell, like when you enter a new room that smells a little funny and after you “get used to it” you don’t smell it so much any more. Or light, like when you come outside into the bright sun after being in a dark room it is blinding until you “get used to it.” And notice that our reactions to most of these inputs while we are sensitized is that of discomfort or distress of some sort. The hot lava water is painful and we withdraw our hands from the water. The blinding light when coming out of the dark is uncomfortable making us squint and shade our eyes. The nasty smell makes us grimace and maybe even cover our nose. The same process of sensitization happens with mechanical sensations for movement and position. We “get used to” a certain manner or degree of movement and position any large deviation from this elicits protective behavior and may be painful. And just like with the hot water example, we may change our set point in a way that “normal” movement now feels abnormal, just like the normal hot water feels like molten hot lava.
When we have sensitized cold hands and the water feels hot, what do we do? We turn the water colder until it feels like a normal amount of hot and gradually turn up the heat as our hands “get used it” and change the set point back to normal. Or we just wait in our nice warm house for a bit and let the hands warm back up more slowly but still “get used to it.”
This is what I tell my patients with painful movement: “You’re sensitized to movement right now and just like with your cold hands, you’ll need to find a way to let yourself get used to normal movement again. So, maybe we find a less straining, easier version of this movement and then gradually make it harder until it feels normal again.” This is probably the kindest and easiest way to do it. Of course you could choose to just keep your hands under the water that feels like lava (do the normal movement in the painful sensitized way) until that feels normal if you want. That might even be a faster way to do it. It just depends on if you want to feel that way for a bit and if you can tolerate it. But, I usually opt for turning the water down and gradually turning it up myself.
Here’s one last twist. Many of the common sensitized movement problems we think persist because the movement is avoided. There is no “getting used to it” process allowed. It’s taking the “rest till it gets better” approach. This may be appropriate in some cases, like an acutely inflamed strain may benefit from a small amount of inactivity. But, other than these limited circumstances, avoidance would be like having the cold hands, coming inside occasionally to put them under hot water to check if it feels normal yet, then going back outside into the cold to wait some more. Come in from the cold and find some ways to turn the water down to allow yourself to desensitize.
At this point, we have elicited a measurable prediction and ran behavioral experiments to refute it. The next step is to build confidence in the results. This step is both simple and very difficult. It’s simple because we are essentially going to repeat the experiments, altering them based on the continual updating of the prediction. It’s difficult because momentum is a powerful thing. A single refutation is rarely enough to alter the course in a lasting way. We’ve typically thought of this stage as a gradual progression, and rightfully so. It usually takes a graded form. But, there are suggestions that it doesn’t need to be. It can jump around instead of strictly climbing a hierarchy. In the Craske review on maximizing exposure based care, they mention letting the patient decide what is important to them to deal with next and letting that guide the order of progression as opposed to some strict hierarchy.
An example of what this stage may look like:
Initial prediction: Bending forward OR lifting more than 20 lbs will damage the back.
Behavioral experiment: Demonstration of the patient getting into trunk flexion in other positions, like quadruped, leading to squatting position that raises into a forward bent position, followed by forward bending. They repeat many repetitions that day and over the next few days, continuing to strengthen confidence that the finding was not by chance.
New prediction: Bending forward AND lift 20 lbs will damage the back
Behavioral experiment: Demonstration of the patient carrying 50# in an upright position (confront with strength). Patient demonstrating the ability to squat 100 lbs through a partial range (confront with strength). Patient starts off seated holding 20 lbs and sets it on the floor. They are then shown how the back is being subjected to the same forces during this maneuver. They then lift 20 lbs. from a chair. They repeat many repetitions that day and over the next few days, continuing to strengthen confidence that the finding was not by chance.
Some important things to note here.
First is that the prediction is not staying static. It gets updated based on the new information. We have a role here in continuing to elicit the changes in the predictions in a measurable way.
Next, the repeating of the process allows a building of confidence in the trustworthiness of the results.
Also, it is likely that there will be occasional times that the result is not good. The more confidence and experience that is gained with achieving the refutation result, the less likely they will trust this negative result!
Repeat the process in varying contexts. This builds confidence that the result is not bound to one particular set of circumstances.
What is very cool is that we can teach this process of “predict -> test -> repeat” as a skill to our patients. We can help them use their creativity to come up with ways to test and progress on their own.
In my last post I submitted that the first step to simplifying the interaction was to elicit a specific prediction.
The measurable prediction from that example ended up being: “If the shoulder is damaged, there will be pain and weakness that won’t improve above 90 degrees of shoulder flexion.” Performing the first step well and getting good measureable predictions makes the next step so much more simple.
The next step is to set up an experiment that attempts to refute this prediction.
This step even has a name: behavioral experiments. I have long been enamored with behavioral experiments because it seemed consistent with what we do in therapy. But, as I mentioned in the first post, adding the concept of Expectancy Violation significantly improved the clarity with which we can engage targets of interventions. It is, in my view, a significant step ahead of targeting beliefs.
I have also long argued that our role as therapists is not that of one who makes the change for the patient. We don’t take pain away or heal pain. Instead, we set up the scenario in which the patient comes to their own conclusions and makes their own changes. We are context architects. We don’t perform the experiment. We set up the lab for the patient to run their own experiments. We are Alfred, not Batman.
So, at this stage the name of the game is to set up experiments for the patient to run. Here’s the thing. We WANT and are TRYING FOR a refutation of the prediction. So, we set up the experiment with this in mind and with skill.
Can they show themselves several position in which the shoulder is strong and therefore opposes the narrative of the weak and damaged/fragile shoulder? Can they show the capacity to improve their strength in the position of concern, more specifically refuting the prediction?
Can we disconfirm with a different way of doing the same thing, a novel movement?
Can they get the shoulder above 90 degrees using a different approach? Maybe they can get there if the hand is planted and stationary and the body moves away from the hand (closed chain shoulder flexion). Perhaps they can simply get their arm above 90 passively, refuting the specifics of the prediction of the shoulder being above 90 in any form (and gets us to a now more specific prediction about the way in which the shoulder must get to 90)
Can we use various physiologic mechanisms like conditioned pain modulation and exercise induced hypoalgesia?
If they perform a series of isometrics in a comfortable position (or even hunting for pain, as Erik Meira puts it), does the manner in which they can subsequently raise their arm change? Can we use desensitization?
If they repeatedly move up to and away from the position at which the protective behavior first becomes noticeable, does the behavior change? Do they gain motion or otherwise improve?
These are but a few of the many possible experimental methods in our laboratory arsenal by which the individual may test their predictions.
Some things that are important to include in this step.
Again the prediction needs to be specific about the outcome of the experiment. Just like in published research we don’t want any post hoc data mining to be able to squirrel around a negative finding that makes it seem positive. We need a clear demarcation of what meets and what refutes the prediction.
It may be helpful to track confidence in the prediction. “How sure are you that this bad outcome will occur if we do this?” They can rank this on a scale of 0-10. Then repeat the question after the experiment. This may help you gauge the success of the refutation. If the experiment was clearly negative (it didn’t bring about the bad outcome) but doesn’t change the confidence rating of the original prediction then something is askew and you may need to alter the manner in which the experiment is taking place or, more likely, the specifics of the prediction. Also, this re-assessment gives the individual a chance to verbalize explicitly and therefore acknowledge a change in their narrative.
Try to come up with or build toward experiments that can be repeated and run by the individual on their own. More on this in the next post.
Remember that the individual will update the prediction after the experiment is complete and so eliciting the prediction step is repeated. The shift in the prediction may be subtle or it may be large. Either way, confidence in the result will need to be built. That’s the next post.