Planting Seeds of HOPE

…to Improve Physical Therapy Outcomes

A patient that I worked with recently was afraid to move. She was actually terrified to move to phrase it better. She came to physical therapy with low back pain and over the course of our hour together, expressed to me these beliefs and emotions: 

• Fear about reinjuring her back
• Fear that bending, walking, and lifting would make her back worse
• Fear that she would no longer be able to be active
• A belief that ANY movement could be harmful to her back
• A belief that the “degeneration” and “disc injury” that she had been educated on meant that she should not bend/walk/lift at ALL

These BELIEFS were driving her BEHAVIOR:

• She had stopped walking outside of her home
• She was no longer lifting or bending forward if she could avoid it
• She was almost completely sedentary, beyond self-care (bathing/grooming/house chores) and sitting for work
• She was not playing with her children
• She was very guarded and hesitant in all movement throughout our examination

“Your beliefs become your thoughts, 
Your thoughts become your words, 
Your words become your actions, 
Your actions become your habits, 
Your habits become your values, 
Your values become your destiny.”

― Gandhi* (*Many people have been credited with the following quote: Ghandi, Buddha, Margaret Thatcher, etc... regardless, I think the wisdom it contains is very useful!)

How you want to “BE” Starts with your BELIEFS and impacts your BEHAVIORS

It is safe to say that as physical therapists, we have all had the experience of working with patients who have been told many activities that they “can no longer do” because of an injury. Maybe we have even been on the receiving end of that information as a patient- and have clawed our way back into the realm of positivity and growth mindset!

Many forward thinking clinicians are acknowledging the power of words to not only “heal” but to “harm” via a contradictory influence of what may be termed either a “placebo” effect (positive effects from a therapeutic alliance) or the “nocebo” effect (the harm that words and treatments can cause)¹ .

I truly believe that physical therapists and other healthcare professionals have a strong desire to help patients improve their health. However, they may not always communicate in the best ways to promote this or may not be aware of how impactful their words can be on patient beliefs…and behaviors!

This concept of the power of our language and the importance of our ability to effectively communicate and connect with others, is a central tenant of the Level Up Initiative, for which I am eternally grateful to be a part of.

It got me thinking…What if instead of communicating fear, harm, and danger, we made an intentional effort to communicate hope, strength, and possibility?!

There is data to support the idea that patient EXPECTATIONS can directly influence the OUTCOMES that we consistently look for as markers of “success” in physical therapy (and healthcare) treatments (see examples with citations below):

Low Back Pain:

• Patients that had high expectations for improvement had a greater chance (58%) of reporting better outcomes after four visits of physical therapy³

Neck Pain ^{2, 4}

• Patients who had positive and neutral expectations for treatment had REDUCED PAIN⁴
• Patients who had neutral or negative expectations for treatment had INCREASED CORTISOL!⁴
• Patients who had unsure expectations for complete pain relief had reduced odds of successful treatment²
• Patients who definitely expected to be able to do more exercise increased the odds of success of treatment²

Imagine for a minute an alternative way to communicate with patients:

• Delivering a POSITIVE message first: (Focus on what is “Right” vs. what is “Wrong”)
• EMPOWERING patients to move in healthy ways!
• Modeling POSITIVE EXPECTATIONS for our patients
• Communicating REALISTIC (evidence-based) risks/possible limitations of physical therapy treatment or limited effectiveness of “passive” treatment options
• Avoiding over reliance on patho-anatomic models (especially when these do not align with a patient’s clinical exam findings)
• Education regarding the patient’s role in treatment! Need to be an active player both in developing goals and in taking action, for example performing exercises! (but beliefs about movement may need to be addressed before behavior change can occur).

These are all things that are addressed, practiced, and investigated throughout the Level Up Mentorship and are part of what sets it apart from other educational opportunities.

This is why The Level Up Initiative is more than a mentorship.

Now armed with this knowledge, my request to healthcare providers is as follows: Let us plant seeds of hope. Let us communicate that movement is not inherently dangerous. Let us emphasize positive outcomes from physical therapy (and other) treatments. Let us improve the health and quality of life of our patients. 

Written by Leda McDaniel 

References:

1. Bedell SE, Graboys TB, Bedell E, Lown B. Words That Harm, Words That Heal. Arch Intern Med.2004;164(13):1365–1368.

2. Bishop MD, Mintken P, Bialosky JE, Cleland JA. Patient Expectations of Benefit From Interventions for Neck Pain and Resulting Influence on Outcomes. J Orthop Sports Phys Ther. 2013;43(7):457-465.
3. Eklund A, De Carvalho D, Pagé I, et al. Expectations influence treatment outcomes in patients with low back pain. A secondary analysis of data from a randomized clinical trial. Eur J Pain. May 2019:ejp.1407.
4. Malfliet A, Lluch Girbés E, Pecos‐Martin D, Gallego‐Izquierdo T, Valera‐Calero A. The Influence of Treatment Expectations on Clinical Outcomes and Cortisol Levels in Patients With Chronic Neck Pain: An Experimental Study. Pain Pract. 2019;19(4):370-381.
5. Tara Brach Podcast: How Hope Can Heal and Free Us: Part 1