Note from Zac: This is my first guest post, and to start things up is the one and only Trevor Rappa. Trevor was my intern for the past 9 weeks and he absolutely killed it. Here is his story.
It’s very exciting for me to get to write a guest post for Zac’s blog that I have read so many times and learned so much from. The experience I have had with him over these past 9 weeks has been incredible and I hope to share some of it with all of you that read this.
He challenged me to think critically in every aspect of patient interaction: how I first greet them, which side of them I sit on, the words I use, and how I explain to the patient why I chose the exercises they’ll go home with. All of this was to create a non-threatening environment to help to patient achieve the best results they can.
He also taught me how to educate patients with a TNE approach, incorporate other interventions such as mirror therapy into a PRI based treatment model, and deepened my understanding of the neurologic concepts behind performance.
Therapeutic Neuroscience Education
Perception of threat can lead to a painful experience which will cause a change in behavior. It’s the PT’s role to introduce a salient stimulus to attenuate the perception of threat in order to cause a positive change in experience and behavior (Zac and I came up with that, I really like it).
Pain is not the enemy. Teaching patients that their pain is normal and it doesn’t always mean that they are damaging themselves can be challenging as pain is often the reason patients seek out or are referred to PT. Some of the points we tried to teach patients were
Pain is there to keep you safe, which is good
Pain does not equal tissue injury
No pain, no gain is not what we’re looking for
Discomfort is okay
Knock on the door of pain, don’t try to kick it down
A large part of educating patients is helping them re-conceptualize why they are having pain. Most patients think of pain in terms of a pathoanatomical model (ie tissue abnormality=pain) and this is perpetuated by a lot of members in the medical community. The pathoanatomical language often causes a higher perception of threat and induces greater feelings of being broken, hopeless, and unfixable.
Re-educating the patients that what they are experiencing is normal and teaching them why it is normal helps decrease their perception of threat. We do not want to use language that will make patients more threatened, like telling a 20 year old that they have the spine of an 80 year old (numerous times our patients have been told that by other medical professionals). Getting them out of a mindset that if they move a “faulty tissue” they will make their situation worse is one step in this process.
Regardless of whether the patient is dealing with a more acute injury or one that has become chronic, there are three things we taught each patient that we would do in PT to help decrease some of the sensitivity they may be dealing with. Those three things are movement, space, and blood flow. These three things require the patient to be active in their therapy which gives them control.
Many of the patients with chronic conditions had stopped doing the things they enjoyed. Giving them activities which they can do without perceiving pain, or that can help decrease their pain, shows patients that they do not need to rely on external passive interventions to feel better. Getting patients to believe/understand that they have the control and power to make themselves feel better is one of the most important things a PT can do.
Mirror therapy, sensory discrimination, and PRI
Learning how to use different interventions to help decrease sensitivity and pain was huge for me. We used mirror therapy with different types of patients whether they had chronic pain or were post-surgical. The mirror activities usually started with the patient moving their unaffected limb while watching their affected limb move in the mirror. For example, if you right arm hurts you’d move your left arm while looking at the mirror because it would appear that your right arm is moving. We would progress patients to where they were moving their affected limb behind the mirror while still watching the reflection of their unaffected limb moving in front of the mirror. With the example above, you would still be watching the reflection of your left arm in the mirror making it look like your right arm is moving but would also be moving your right arm behind the mirror. This helped introduce patients to moving a sensitive area without experiencing pain, thus decreasing the threat of movement.
Another intervention I had not used before was sensory discrimination. We used this mostly in our post-surgical or more acute population to help decrease the local sensitivity after an injury and to try de-smudgify (that may or may not be an actual word) their homunculus [note from Zac: Totally is].
Sharp-dull discrimination was used first, then we progressed to two-point discrimination and usually ended with graphesthesia. The progress for patients from not being able to discriminate between sharp-dull to having graphesthesia showed me how powerful the role of the somatosensory homunculus is in the pain experience.
And of course, I learned more PRI from Zac. He challenged me to use more integrated non-manual techniques with patients while also limiting the number of cues I used. This was great because it is very easy for me to over coach these techniques. He also gave me a better understanding of some of the big concepts in PRI, such as neutrality.
Neutrality vs Hypofrontality
Neutral is a huge word in PRI that is often thought of as the end game when in reality it is just the beginning of a PRI treatment. The end goal is to get someone alternating and reciprocal. The idea of neutral always made sense to me as a good goal for performance as “neutral” joint positions is where the greatest force would be able to be produced. Talking to Zac about this he brought up what Bill Hartman Grandpa 🙂 has said: Neutral is a neurologically prefrontal state in which learning can occur, as the prefrontal cortex (PFC) is active during tasks that require attention. However, this is not a state you want an athlete performing in.
An active PFC is good when athletes or patients are in rehab because their cerebellum and basal ganglia are learning new movements that can then be used with less activity from higher cortical areas during performance. The movements used during these activities can become reactive after enough learning, practice, and repetition (those 3 things go hand in hand).
During performance or training we would not want an athlete using the higher cortical areas that elicit attention as this would make them slow and inefficient. Instead, we would want them fast and efficient (ie reactive and reflexive). A transient state of hypofrontality allows an athlete to reach a state of “flow”, which Mihaly Csikszentmihalyi describes in his book Flow, which is where the highest levels of performance occurs. This would allow the lower reactive (cerebellum and basal ganglia) and reflexive (brain stem) centers of the brain to essentially take over making them fast and efficient.
So from a theoretical neurologic stand point you do not want an athlete in a prefrontal state during performance. Good rehab and programming can help them become alternating and reciprocal through graded exposure and relearning of certain movement patterns in a neutral (prefrontal) neurologic state. Once this foundation is there, power and capacity can be added through training (which Zac talks more about here ). This may allow an athlete to stay alternating and reciprocal during transient states of hypofrontality when performing, not “neutral”.
Another concept that stood out to me from talking with Zac is the difference between extensor tone and extension. Extensor tone is necessary for power production during performance but it does not necessarily mean that the athlete is going into a position of extension. When someone is in extension they limit their degrees of freedom for movement and thus their movement variability. Using extensor tone from a neutral position, for lack of a better term, would allow them to display power while maintaining their potential movement variability (be alternating and reciprocal). This idea was something that made things click for me.
I learned a lot from Zac and want to thank him for all his help and time he spent teaching me. Needless to say, this was an amazing clinical internship for me and I cannot recommend enough that other students should try to get Zac as their CI or for patients to get treated by Zac. He is the real.
And now what everyone has been waiting for… Zac quotes
Help for cueing exercises
“Shakin’ like a polaroid picture”
“We don’t want Fat Joe and the lean back”
“Do you remember the three little pigs? I want you to be the big bad wolf and blow their house down”
“Do you have the big 3? Jordan (L abs), Pippen (L adductor), and Rodman (L glute med)?”
“We like a tight right butt and we cannot lie, the other therapists can’t deny”
“I’ll start calling him Buffalo Bill, cause he’s abducting like crazy”
“We don’t want you to have hamstrings like Goldmember”
Zac after getting his wisdom teeth out, he doesn’t remember saying these things
“I have lateral trusion!”
“Check out this IR” and then he self-tested his own HG IR
“I ain’t got time to bleed”
“Nobody makes me bleed my own blood”
“If you ain’t assesin’ you guessin’”
“There’s 45 miles of nerves in the human body if you put them all in a straight line, but don’t try it at home cause you’ll die.”
“…hmm..interesting” in Bill Hartman Grandpa’s voice
“…sure about that?” in grandpa’s voice
“Her teeth told me she had bunions”
“I don’t know why he told us the same diagnosis five times.”
“Breathing is really important. The research has shown if you don’t do it you will die”
“How about this word, variability. How about this word, salience. How about this word, anti-fragile. How about this word, POTS.”
Over the past few weeks I have felt called to write about an often uncovered yet extremely important component of the therapeutic process: Patient interaction.
We had an instance in which I came back into the clinic from my lunch break and my intern was supposed to have a patient evaluation. Instead, she opted to have me take this particular patient. This patient was a lovely 17 year old lady who was being seen for bilateral foot pain. This was her second bout of therapy, and her and her mother was very dissatisfied with their last physical therapy experience just a few months (and 17 visits) prior. She was not a happy camper and wanted a second opinion. After hearing stories from my coworkers, I expected the worst.
We progress through the evaluation, and my student observes nothing but smiles throughout from the patient and her mom. Jokes were cracked, movement was looked at, and edumacation happened. At this point, after a little explain pain and kinetic chain discussion, these women were sold.
We leave the treatment room and I said “that wasn’t so bad yes?” My student replies “that’s because they are in love with you.”
But really, that essentially is what you have to do with the patient interaction. You can have the greatest hands, the greatest exercise plan, and evidence up the wazoo; but if your patient hates your guts you will fail. I heard this from Patrick Ward that 80% of your success with patients depends on if they like you. A recent RCT supports this notion as well. You have to get your patient to fall in love with you and your approach, in a nonsexual manner of course.
While I am neither aware nor sure if possible there exists any evidence regarding the best way to interact with a patient, I am going to run through how I approach the patient experience. I don’t know if my way is the most successful or even the best way, but I generally get good patient satisfaction reviews so deal with it.
Here is what an excellent patient interaction achieves:
If you read The Polyvagal Theory, Stephen Porges discusses neuroception, which is basically how your nervous system responds to situations after evaluating all given sensory input. If your autonomic nervous system perceives someone or something as threatening you will either fight, flight, or freeze. The goal then, is to make the patient feel safe when working with you. This shift allows for decreased sympathetic response and increased prosocial behavior, both necessary and influential when working with pain states.
The patient interaction is also a great way to get the placebo effect. I know the placebo effect often is thought of as deceitful and providing ineffective treatment, but that is far from the truth. All the placebo effect does is maximize the belief and perception that a treatment will work. In fact, the belief that something will work is part of a recent CPR developed for cervical spine manipulation in neck pain. In On Intelligence, perception and behavior are one and the same. So by optimizing one’s perception, we can optimize one’s motor behaviors.
Moreover, I think it is important to have fun with what you do, and make the physical therapy experience a pleasant and rewarding time for all involved. Think of how we are perceived; “PT stands for pain and torture,” or “I hate physical therapy.” Adding humor and performing fun activities can make PT a more fruitful time.
Seeing how my student has been progressing is a good example of this. When she first started out, much of the focus was geared toward getting all the relevant information, making sure she was performing all the tests, manual therapy, and exercises well. One thing that was really lacking was the patient interaction. After stepping in a few times when she struggled, you could see some of her patients just open up and smile during our short stint together. After explaining the above to her, my intern is now asking patients about their life stories, weekend plans, and empathizing with their problems. She is even stealing some of my jokes, which is okay because half of my material is not original.
The first impression is very meaningful and sets the tone for the patient interaction. When I meet a patient for the first time, I will call them by name and have them walk to me. I get several pieces of information from this introduction:
1) Their sitting posture.
2) Their facial expression when you make eye contact.
3) How they get out of the chair.
4) Their gait pattern and speed.
These pieces help me understand how well and willing the patient moves, as well as their general demeanor. Depending on if I see someone hop right up with a huge smile on their face versus someone who is slouched in their seat and slowly trudges over towards me, my interaction with them often changes. With the former, I will be more upbeat, with the latter, I will be mellow. The more you can mirror the patient, the greater bond you can develop.
This small gesture reveals so much about your patient. The firmness and way they shake your hand can tell you a lot about their personality. There are several different handshakes you may experience:
Which you should use depends on how you wish to be perceived. If I see someone who seems to need more guidance, I may use a more dominant type of handshake. If I see someone who needs reassurance, I may use a more submissive handshake. Regardless of how you shake one’s hand, make sure you use firm pressure and warm eye contact.
The subjective examination is very important, but not for the reasons you think. I know my mentors in my residency will kill me, but I personally do not feel the subjective examination really steers me in a particular treatment direction. Rather, I see the following as the subjective exam’s goals:
1) Find out how you may help them.
2) Establish rapport.
3) Understand the patient and their story.
4) Make the patient feel understood.
5) Rule out red flags.
You obviously want to find out what brings them to you, but for me the objective tells me where to go. The subjective examination is more for the patient than you, so let’s talk about how to maximize that interaction.
How you face the patient can make or break your interaction. Remember the goal is to reduce threat perception and make them feel comfortable with you. To maximize this goal, you want to eliminate as many barriers as possible. So you probably do not want to face the patient like this…
And definitely not this
Rather, I like this orientation
Here you are staying close to the patient while simultaneously respecting their privacy because you are not directly facing them.
Now I know what you are saying, “But Zac, you are using a computer, clearly that is going to kill rapport and act as a barrier.” I would agree to some extent, there are two things here that you ought to notice:
1) The computer is not directly in front of the patient, thus is not a barrier.
2) I maintain quite a bit of eye contact while typing.
Now granted some people may still feel uneasy about me typing in front of them, so I will usually ask if I sense that this is problematic. But you can still develop some semblance of intimacy with the patient by playing with 5 different variables.
The 5 Intimacy Variables
In order to develop an intimate experience with the patient, we can add/subtract 5 different ways to create a bond with someone:
2) Eye contact
5) Saying the person’s name
The more of the above variables you utilize when you interact with someone, the more of an intimate encounter you may experience. You want to use neither too many nor too few variables when interacting with someone. Too many will make you seem creepy (and potentially send the wrong message) and too few will make you seem distant. I generally shoot for 2-3 at a time.
So if we take the above setup example, I am keeping a close proximity toward the patient and maintaining eye contact, however I am not directly facing the patient. I may modulate the interaction throughout by saying the patient’s name or providing a light touch of the arm. So here I can utilize my 2-3 variables at a time.
While the objective’s goal is to guide your treatment plan, it can also be a great time to further build rapport. Perhaps the best way to establish that you care is by providing a thorough examination.
How many people have been to a 5 minute physician visits compared to one who may spend up to 30 minutes taking a look at you? Which physician is better liked? The fact of the matter is, people want and expect a thorough examination, so give it to them.
This is where I feel like something such as the SFMA can come in handy. People may have gone to other clinicians who just looked at the affected region, but this clinician is looking at everything, he/she must be different. So when I am performing an assessment, I generally perform something closer to the SFMA top tier and then do my own type of breakouts from that. What can I say, I’m a rebel.
Throughout the examination, I will sprinkle compliments or ask about things like their plans for the rest of the day, anything I can do to further establish rapport.
So you finished the subjective and objective, and you likely have the information that you need to treat. The post-evaluation education is the spot in which you can really win or lose people. David Butler suggests that there four questions that the patient would like answered:
1) What is wrong with me?
2) How long will it take to get better?
3) What can I do to make it better?
4) What can you do to make it better?
I will usually educate the patients to some degree on pain physiology, followed by whatever objective impairments I find that can improve upon one’s complaints. In order to maintain low threat perception, I will rarely break out models or use terms such as “motion x is crushing body part y” or “you have weak area z” or “your spine is unstable,” even if these components may be somewhat true. Reason why comes back to reducing threat perception. Seeing models of bulging discs or using some semblance of the above language tends to just freak people out and moreover is often inaccurate. People just need to know that it is safe to move, when it is safe to move, and move well when they do.
I will finish my education by asking the patient an incredibly important question. Drum roll………………………………
Do you have any questions?
Especially the case with pain neurobiology, if the patient does not understand where you are coming from, they will not be able to fully buy in to your methodology and plan. So make sure any questions the patient has are answered to the best of your ability.
I always finish my interaction with patients with the following phrases
1) “Do you have any questions, comments, concerns, or complaints?”
2) “Is there anything else I can do for you or that I did not cover?”
I ask these questions to again establish an open communication and rapport. I want to make sure that the patient is completely satisfied with the experience that I have provided them. Moreover, finishing the session with the same ending every time they come in provides the patient with some consistency and helps establish your brand; in my case, the Zac Cupples brand.
So there you have it, the above methodology is how I approach a patient interaction. I have based many of these methods on what I have read regarding people interaction, so the below resources might be good to check out. If you can get your social capabilities to a high standard, the rest will take care of itself.
It has been a great and even nostalgic experience thus far. I remember just a couple years ago being in this young lady’s shoes having the same successes, failures, and questions she has now.
I think working with me may have been quite a difference from the scholastic framework that she was accustomed to. This difference is because our common theme for the week was wait for it…………………………………….The Brain.
Most schools, especially in the orthopedic realm, teach about developing physical therapy diagnoses and treating various pathologies. However, we had a couple different cases in which we didn’t necessarily nail down a pathology yet got fantastic results.
The first patient we saw was a lovely middle aged woman who was classic for the biopsychoscial treatment model I espouse. She comes into seeing us with chronic low back pain over the past 3 years, has had several TIAs, been diagnosed with an eating disorder, and generally lives a stressful life. Our comparable sign for the day was flexion which was at 50% range and painful (or DP for you functional movement folks out there).
We discuss what we think is going on and the first words out of my intern’s mouth: Central Sensitization. Music to my ears, I think she will do just fine.
Our next patient was a middle aged man coming to us for medial knee pain that began while playing volleyball. Upon observation, big findings were general hypermobility with a slight limitation in knee extension on the involved side. Our comparable sign for the day was stair negotiation.
This gentleman came in with the same frame of mind as the lady above, what is wrong with me, what structure is making me painful. His complaints were very vague and difficult to reproduce except for stairs. We perform a similar treatment to above–Explain pain, breathing exercises combined with some hip activation–and guess what happens? Knee extension mobility returns to full and decreased symptoms with stairs.
Once we finished with this patient, my intern asked me what I think was wrong. My answer: It could be a thalamus problem.
In both of these cases above, I could not pinpoint an exact “structure at fault” as we both were often taught in school, yet both patients improved. I am inclined to believe that more and more that the structure at fault is and always will be the brain.
If you look at most of the research regarding anatomical correlates and pain, it is not so good. Depending on who you look at, 30-80% of asymptomatic individuals have abnormal MRI findings. Pain and structure do not always go hand in hand, and moreover, we are not very good at determining a structure. The most recent editorial in JOSPT by Paula Ludewig and a friend of mine Becky Lawrence discusses this problem, and it is definitely a step in the right direction.
Since we are not so good at finding and probably treating pathologies, I propose instead that we start treating people; people who are undergoing a pain experience that is compounded by multiple factors. That neck pain that fits a closing pattern may not have hurt if they did not undergo a stressful event a week prior. Even though we are always operating under some degree of uncertainty, the way we approach treatment ought to follow a similar step-by-step process:
Rule out any potential red flags. Make sure they are someone you can help.