The background

Most physical therapists conduct a highly detailed physical examination and evaluation of every patient who walks into the clinic. We look at range of motion, muscle strength, flexibility, anatomy, gait, balance, biomechanics, coordination, joint mobility, posture, symmetry, innominate rotations, “muscle activation,” “core stability,” “functional movement patterns,” etc.

As students, we are taught to measure every intricacy of human anatomy and movement. We assume that this approach will allow us to best devise a treatment plan to address whatever pain or limitation our patients present with. We are taught “normative” data for all of these metrics and how to tell if our patients aren’t “normal”. Furthermore, we are indirectly, and sometimes even directly, taught that falling outside these “normal” ranges will lead to pain and injury.

The problem

Our hyper-vigilance to anatomy and biomechanics (while important in some cases), creates the tendency to search for everything “wrong” with our patients. In an effort to provide patient education, we highlight limitations, weaknesses, abnormalities, anatomic variances, poor postures, “bad” movement patterns, and everything else under the sun.

The treacherous next step in this misguided approach is when we convey this information to the patient. When reviewing the results of an evaluation, we typically point out every category that our patients are sub-par in.

We then tell them that our fantastic interventions and specialist knowledge are the only things that will save them. We make these patients feel lucky to have found us. We heroically imply that were are there to step in and save our patients from text neck posture, pronated feet, an unstable core, a rotated pelvis, trigger points, fascial adhesions, delayed hip muscle firing, and the sad inability to complete a full depth pistol squat.

Yet, as our understanding of the literature evolves, this style of patient education and teaching does not appear to be relevant.

We have learned that resting posture is not well correlated to pain or injury.

We have learned that foot pronation during gait is not correlated to an increased rate of running related injuries.

We have learned that core stability (whatever that actually is) may not be correlated to back pain and that strengthening the core with focused exercise is no better than any other form of exercise for treating back pain.

We have learned that it is HIGHLY unlikely we can impact the length or structure of the IT band, or other dense connective tissue, with our in-clinic interventions.

We have learned that manipulation doesn’t change joint position (sorry guys, not even with a pelvic innominate rotation that likely doesn’t even exist).

The reason

The current model of patient education inundates patients with negative self-perceptions. Furthermore, this tends to generate a scenario in which the patient is dependent on and “needs” us.

Usually, this approach is genuine and well-meaning, but it is a misguided one. In an effort to help our patients by highlighting their flaws, we are limiting healing and autonomy. Yet, this is the patient education model we have been taught. For many of us, it is all we know.

For many physical therapists, it is more fun to be a healer than it is to be a coach. Most of us have a strong desire to “heal” people. It makes us feel special, justifies what we do, and usually leads to some cookies from pleased patients who were “fixed”.

The implications

This type of approach is almost always well-intended, but the downstream implications can be quite severe. Patient education and treatment interventions must reflect a physical therapy diagnosis that is directly related to a patient’s true limitations and goals. When we begin to rely on anatomical factors that have little to no influence on health status, pain, or injury, we are practicing low-value healthcare.

The concept of low-value care is related to a range of other challenges in clinical practice, including over-diagnosis and over-treatment. These are situations in which people receive a diagnosis or a treatment that will bring them more harm than good. The patient education and management model of highlighting flaws will undoubtedly contribute to downstream healthcare resource utilization and will result in over-medicalization.

When we take a micro-level approach to patient care, instead of a macro-level approach to overall health, we see an even more startling implication. This model has a high likelihood of creating false perceptions about pain and the human body. As a result, the patients we are trying to help end up being harmed by us in the long run.

These nocebos can implant thought viruses that linger for years, or even a lifetime. They quietly cause pain, decrease activity levels, and result in a spiral of iatrogenic health effects that could ruin a patient’s life.

Think about it, how many times have patients told you that they don’t bend forward anymore due to fear of their herniated disc? Or that they avoid squatting and long walks in an effort to protect their degenerating knees? Or that their back hurts because their core is too weak to keep everything in place? Or that they don’t engage in their favorite activities because they may move their neck the wrong way?

The concept of biomechanical fragility is alive, well, and running rampant across our world. We have been key propagators of this false dogmatic propaganda. Low-value care not only hurts insurance companies and patient pocketbooks, but also directly impacts the psychological, social, and physical health of millions of people.

The alternative

Stop telling your patients everything is “wrong” with them! Just stop it!

Challenge yourself to change your focus from what is wrong to what may be right. Challenge yourself to point out the positive factors that will promote recovery. Challenge yourself to empower and coach instead of being a healer who promotes dependence.

Tell your patients that they have a lot of great factors to work with. Assure them that they will get better. Each and every patient will present with something you can use as a motivator. There is never a situation in which you can’t find a positive factor or two to point out.

Stand by your patients and address their issues with them instead of being a healer that “fixes” them. Act as a health and rehab coach who offers expert information rather than a provider of treatments and an applicator of techniques. Empower your patients and improve their self-efficacy. Put their health back in their hands.

References

Barrett E, O’keeffe M, O’sullivan K, Lewis J, Mccreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46.

Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008 Aug;108(8):379–90. PubMed #18723456.

Nielsen RO, Buist I, Parner ET, et al. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2014;48(6):440-7.

Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014;15:416.

Schleip R. Fascial plasticity: a new neurobiological explanation. Journal of Bodywork & Movement Therapies. 2003 Jan;7(1):11–19.

Traeger AC, et al. Wise choices: making physiotherapy care more valuable. J Physiother. (2017).