Traditionally in health care, patients have been told what to do when they come in for therapy. If we want to build better therapeutic alliances and maximize our positive effects, we need to consider our patients’ expectations and preferences.
A lot of what we do makes patients feel better due to patient education, assurance, general effects of exercises and placebo effects. So we have to maximize the potential of our treatment's specific and non-specific effects by giving options to patients as often as possible.
Studies have shown that manipulation, McKenzie, stabilization, strengthening or graded activity all have small effect size improvements for low back pain. And when compared to each other, there is not a significant difference between each of these treatments. This reinforces that patient preference for a treatment approach should be highly considered.
Any type of treatment (be it a specific type of manual therapy, therapeutic exercise, or modalities such as cold/heat) has the potential to be effective for all patients, but in reality not every treatment will work for all your patients. This is where the patient’s expectations and collaborating with the patients come into play. Perhaps you have encountered a patient who prefers a non-thrust mobilization over a high velocity low amplitude (HVLA) mobilization. Even if you are the world’s expert on HVLA techniques, this particular patient would receive greater benefit from a non-thrust mobilization.
"It is the patient who ultimately must make informed choices about the care he or she will receive.”2
A few examples from my clinical experience:
1) After an evaluation, I used to assume that the patient would return for his or her return visit; however, I now explain my findings and present treatment options. I then allow the patient to choose to make a return appointment.
2) When I am giving a home program, I will ask if the patient believes the exercises will be beneficial and feasible in terms of positioning and timing. Most of the time, he/she will agree with the program. Other times, modifications are made to accommodate the patient.
3) Before performing manual therapy, I will present the patient with options and ask if he/she has any preference between them or even an active exercise. If the patient has no preference, I pick the technique I am most comfortable with.
4) If patients are completing their HEP with improvement of symptoms, I would ask what the patient find to be most helpful and least helpful to their condition. Then I will reason why and discontinue that particular exercise if it makes sense and reinforce with more exercises similar to the ones that are benefiting the patient.
“Collaboration with patients is part of the clinical reasoning process of an expert”3
During my residency, we are taught the importance of presenting our evaluation findings to the patients, providing options for treatment, and letting them make the decision. They take ownership by selecting their own intervention, which results in better adherence to the home program. Recently, one of my patients came in with a shoulder pain after dislocation with subsequent relocation, and presented with very limited shoulder range of motion. I made the mistake of giving the patient supine home exercises. She returned 2 weeks later with minimal improvement due to lack of compliance with exercise. It was not the patient’s fault as her preference was doing exercises in sitting or standing, as she does have a full time day job and would like to do the exercises throughout the day. I could have avoided this pitfall by asking during the evaluation if she had any positional preferences and coming up with practical exercises to do.
"Collaborative reasoning is the nurturing of a consensual approach toward the interpretation of examination findings, the setting of goals and priorities, and the implementation and progression of intervention" 1
In PT school, I did not realize the importance of patient collaboration. Continual self-reflecting and learning will be crucial to grow as a professional. Ask patients what they think and get them involved!
1. Edwards, et al., Clinical Reasoning in Physical Therapy. April 2004. Journal of Physical Therapy. 312-330.
2. Putting patients first:Patient-Centered Collaborative Care. http://fhs.mcmaster.ca/surgery/documents/CollaborativeCareBackgrounderRevised.pdf
3. Wainwright, et al. Novice and Experienced Physical Therapist Clinicians: A Comparison of How Reflection Is Used to Inform the Clinical Decision-Making Process Journal of Physical Therapy. January 2010. 75-88.