“It’s locked isn’t it? I’m full of muscle knots, right?”. As a manual therapist you see the open goal, the crowd is yelling “shooot, shooot!!”. Modern science is shouting “waaait, hold your horses!!”. What do you answer? Many patients expect us to find something wrong with them.
Ideology vs Economy – Wielding a double-edged sword
For a year now I have consequently chosen to dedramatize. “No, it doesn’t feel that bad at all”, or “your neck is moving perfectly fine”. The reason? Well, according to science I “cannot feel or detect joint dysfunctions” or “detect trigger points”, assuming these things even exist. I’ve done it to strengthen the patient’s self image, kill some myths about biomechanical problems. To be a therapist on the front line of science. To sleep well at night.
Problem is, the last period I haven’t slept all that well. My schedule which used to be relatively full, now looks like a swiss cheese, full of holes. I often find myself in situations with patients where I have to “convince” them to come back next week, I am on the defensive. This is a situation that is quite new to me.
It was all easier before; “This will take three to five times. You have a locked part here in the thorax that needs a few times to loosen up, and these tensions and trigger points usually resolve within a few weeks, given the right attention”. What did I base this assumption on? Well, the model of explanation came from my education, and the prognosis from experience. It was easy to sell the idea; the patient had dysfunctions, my job was to correct them. Like a body mechanic.
Patients want reality. They want to know what is wrong with them, and how long it will take to get well. Putting too much lipstick on the pig (ie the patients problem) might lead to the patient thinking; “If I haven’t got any locked joints, or the trigger points aren’t actually real, why am I even here with this joint-cracking trigger point-pushing person?”.
Getting too lost in ideology, basing my treatment model on too many uncertainties, makes it somewhat harder to present a credible prognosis/plan to the patient, and the patient can sense this doubt from miles away.
The nomadic patient
Pain works as an alarm system, and doesn’t always indicate harm. That’s a neat piece of information, but when is it necessary for the patient and will everybody benefit from this knowledge, in all situations? Are there even times when “agreeing” with the patient about their biomechanical understanding is useful, and the best course of action is to “rehabilitate their misconceptions” further down the road?
If the patient feels lectured or misbelieved, isn’t there a chance that she will move on to the next door clinic instead, serching for the next guy shooting from the hip with his cannon of manipulations? Can I expect my patients to understand all this new stuff and change their beliefs within reasonable time, before I am bankrupt and my competitors are having an early retirement?
The truly lost patient is the one that does not know he is lost. This is the nomadic patient, constantly searching for the new fix. If my role as wizard disappears, chances are that many patients will just continue their search for the next wizard.
The discrepancy between modern science and patient beliefs
It can be tricky to change people’s beliefs and make good business at the same time. One year ago i started to implement the biopsychosocial model for real. It’s been a bumpy ride through unknown waters, without a formal education from school, only multiple sources of scattered information on the internet. Hours of “trial and error” in the clinic, both frustrating and immense fun. Some patients have bought the concept and found the “true meaning of life”, some were quiet and uninterested, some cancelled their next appointment because “I didn’t seem to understand that they just wanted me to crack their neck” or that “I suggested that the problem was only in their head”.
There obviously seem to be discrepancies between what some patients believe and want me to do, and my wish to strengthen their inner locus of control or just act “according to science”.
Looking at the numbers
An obvious trend becomes visible when looking at the statistics from my last six months; the amount of patients who see me only one or two times has increased, along with the amount of patients seeing me five-six times or more. The two-to-five times has decreased.
My experience is that the treatment series for “small problems” (short term pain?) has gotten shorter and more people cancel prematurely. It might be because of elaborate explanations that doesn’t compute with the patient’s needs or expectations, or that the role of locked joints and muscle knots has gotten so trivialized that my role as therapist has suffered the same fate. One far-fetched (?) theory is that some actually bought the story and realized they could manage on their own.
On the other hand, I think I have gotten far better at helping people with long term pain, hence the increase of longer treatment series. These people usually see the logic of “moving one stone at a time” and the biopsychosocial model has made it possible to reach out to and commit people to the project, instead of losing them when all you could offer was the same package of kneading and cracking as everyone else.
Timing and individualizing information
In the middle of adjusting to the paradigm shift within manual therapy, it looks like we therapists also have to strive to find a balance with patient expectations. I think we need to be like the good old psychologist saying “well you’re right, but…” instead of “you’re wrong”.
The patient needs to feel like he’s been taken seriously. His beliefs about what is wrong, or beliefs stemming from other therapists, cannot be brushed away like if it’s meaningless nonsense. I mean, how can we expect our patients to buy into all this new information overnight, when a large part of our own profession seem to be sitting on the fence?
To me, the strict ideological approach doesn’t seem to be “best practice” with every patient, all the time. In the end it’s about “give and take”. If the therapist/patient world views are too far apart, and there is no time for these views to merge, there is a risk of massive cognitive dissonance and even a galvanisation of the patient’s inaccurate beliefs.
On the other hand, gradually explaining to the patient how certain things are either impossible or more or less probable through metaphors and examples, might be a better way out. Changes in behaviours and beliefs should emanate from the individual we are trying to treat, and that might take different amounts of time.
Currently, this type of information might be of more use served in tasty bits and edible amounts, sacrifying some ideology for efficiency. Some day, when a larger part of our profession choose to jump off the fence, we may be able to serve the whole cake in one sitting.
Big thanks to Mikal Solstad Øiaas for valuable input
Originally posted in the Paincloud blog in 2015
