Several different thoughts have crept into to my mind sparked by what I have read and conversations I have had. I would like to share these insights with you.
I remember when I was visiting Bill Hartman Dad a few months ago and we were talking about a specific treatment that is quite controversial in therapy today. He said something that really resonated with me:
“Thus, pain can be viewed as a single perceptual component of the stress response whose prime adaptive purpose is to powerfully motivate the organism to alter behavior in order to aid recovery and survive.”
Notice what I bolded there. Pain is a single component of the stress response. Not the stress response. Not a necessary component of the stress response. Just one possibility.
Why do we place so much importance on pain?
Many proponents of modern pain science (myself included) often use this statement against individuals who are over-biomedically inclined:
“Nociception is neither necessary nor sufficient for a pain experience.”
Agreed, pain is not always the occurring output when nociception is present. That said, pain is only one of several outputs that may occur when a tissue is injured. Just because pain is absent does not mean other outputs are also absent.
Many different outputs can occur when an individual is under threat.
Let me propose a new quote to those who focus solely on pain.
“Pain is neither a necessary nor sufficient output of the stress response.”
Why should we limit ourselves to only treating pain? Why should we limit ourselves to only treating outputs? (Spoiler alert, we can’t treat outputs, change them) I have a better idea.
Today, I start treating a human system under threat.
The Threat Matrix
Dad showed me this great editorial here in which Eric Visser expands upon Melzack’s original pain neuromatrix.
Visser calls this idea the threat matrix. To simplify the idea, threatening inputs from the body and the environment enter the system, are scrutinized by the brain, and then the desired output to combat the threat occurs.
Input –> processing –> output
This framework explains how any output, desirable or undesirable, can occur from a stressful input.
Let’s apply this to an example that we have all been through; a breakup with a significant other.
Your significant other decides to leave you, how do you feel?
The answer depends on the individual. Some folks may feel depressed. Some may feel anger.
Some may even experience pain.
These feeling are all outputs that occur as a result from an input (i.e. the breakup) that disrupts homeostatic balance of the human system. The outputs that occur are the ones that the brain determines best aid the individual in recovery and survival.
Let’s now take this thought to the therapy realm. I sustain tissue damage and nociceptive information travels to the brain to be scrutinized. What output(s) could occur? Let’s think of a few possibilities.
Endocrine alterations in gut/reproductive function
Increased/decreased immune activity
Yada yada yada
All of these could occur, some of these could occur, or none of these could occur. The response to the offending input is going to depend on the individual’s brain scrutinizing the situation.
One could argue that a nociceptive event could lead to someone developing anxiety and poor immune function without ever experiencing pain if that is what the system feels best aids in survival.
Nonspecific Effects my Arse
There are many treatments out there that people deem worthless because research demonstrates minimal effects on pain compared to placebo. If someone gets better with this intervention, we deem that nonspecific effects led to the change in pain.
I call bullpoop…sort of.
Nonspecific effects could be a contributing factor to someone benefitting from a particular treatment, but the problem with most pain research is that often pain level is the only thing that is measured.
If pain is only one possible output of a system under threat, how do we know that a treatment didn’t affect a different output?
Answer: We don’t because it wasn’t measured!
Let’s take a controversial treatment for example: dry needling.
Some say it works wonders for pain, some are vehemently opposed, and research is mostly mixed. What do we do?
Perhaps both camps are wrong. Why? Pain is the only output being discussed.
What if this whole time, dry needling worked because it altered inputs coming in from the immune, autonomic, or [what the hell evahhhh] system, which led to changed output from this system primarily with pain output altered secondarily? And here is the kicker; the intervention only works if these systems respond as well as our pain system under a particular threat.
Well we don’t know that because we didn’t look at it. But looking at multiple systems when an intervention is implemented may give us more explanatory power as to why certain treatments help certain individuals. With this information, treatment could be streamlined and implemented.
Making pain our only concern to treat severely limit our capacity to help individuals. If we think of treating the stress response itself, we open up a huge realm of issues our interventions may affect.
If you take a look at the book “Spark” and the corresponding research, we see how exercise can alter many different outputs.
Why can’t rehab folks be a piece of this puzzle? It does not seem unreasonable to me that we could get referrals for anxiety, depression, or whatever output the stress response creates.
Strategically implemented exercise can help alter the stress response. That possibility makes me so hopeful for our professions.
How can one best assess a system under threat?
If clinicians are to assess if an individual is undergoing a chronic stress response, we need to find a reproducible methodology that gives us this information. We must look at the human system from the input/output standpoint.
There are several outputs that can be measured to assess an individual’s homeostatic state:
Other specific medical tests
These are all great tests that can assess the amount of system stress an individual is undertaking. That said, I feel there is an even simpler method of assessing the stress response:
Our physical examination
Assessing the stress response begins with the subjective examination. This piece of the clinician-patient interaction helps us assess potential offending inputs as well as individual processing.
If we come across red or yellow flags, we can easily refer out to providers who can deal with that piece of the stress response. Here is where a psychologist, surgeon, oncologist, other medical professional can come into play. These individuals can alter the offending inputs or help influence processing that therapists and the like may not be able to touch.
Let’s say we get through our subjective and we screen out that the above professionals do not need to be a part of this person’s care. Let us now proceed to our objective examination.
Assessing movement may be the simplest way to assess an individual’s stress status.
If we are to provide the “ideal” physical examination, we need to perform tests and measures that best differentiate a stressed from nonstressed individual.
To undertake this task, we need to have a few assumptions about what a nonstressed individual looks like. Let’s call this individual the “adaptable human.”
The adaptable human will have desirable multi-system variability. That is, human systems can perform as needed under certain situations without being “stuck” in a particular range. For example, blood pressure should stay lower when at rest and rise when performing physical activity. When blood pressure remains high at rest and with physical activity, that individual possesses system rigidity.
The adaptable human will have desirable multi-system capacity. That is, human systems can tolerate prolonged stressors without faltering. For example, a human can perform longer durations of physical activity with blood pressure remaining in levels that would not threaten one’s life.
The adaptable human will have desirable multi-system power. That is, human systems can tolerate intense stressors without faltering. For example, blood pressure can reach a desired level to allow for a particular physical activity to occur.
Our examinations ought to assess these three qualities: variability, capacity, and power.
Of the three, variability is most fundamental because almost every healthy human system functions in the manner. The movement system is no exception to this rule.
Movement variability, the ability to move in three planes, is the simplest reflection of this concept. A nonstressed system will possess movement variability. A stressed system shall become rigid and lose triplanar mobility.
Think to the last time you were stressed. Did your muscles tense or relax? As muscles tone increases, range of motion decreases. Assessing movement variability is an easy way to assess the general tone an individual has, and I speak more of why this notion is favorable here.
To assess variability, our examination must:
Look at the entire individual’s body
Cannot have bias toward one output (e.g. pain)
Must be reproducible and predictable
First, let’s look at popular rehab systems that I feel would not work in this instance and why.
Maitland: Biased toward altering one output (pain); segmental in nature.
McKenzie: Biased toward altering one output (pain); segmental in nature.
SFMA: Not necessarily biased toward one output, but does not look at entirety of human movement. Only two movement planes are assessed. Cannot see if an individual has variability in the frontal plane.
DNS: Wait? Do they even assess?
I shall let my bias now creep in as I suggest the current best model we have for movement variability is PRI.
There are several reasons why I think PRI is currently the best model to assess threat:
It is not biased toward altering one output, as movement rigidity can occur along with several other outputs besides pain.
The entire human movement system is assessed in three planes.
The protective patterns one undergoes in threat are predictable and similar for all individuals.
When one deviates from these patterns, likely pathology had to be created in order to do so.
If an individual can produce nonpathological triplanar movement throughout his or her body, then movement variability is present. A movement system under threat will not have this capacity. A threatened movement system will become rigid.
Establishing movement variability is our primary way to reduce threat-response outputs.
If undesirable outputs remain once movement variability is established, then we know other interventions must be given to address these areas.
If pain is still present, then previously mentioned assessment systems hold value, as does graded exposure.
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.