I was listening to a podcast today where the host was talking about successful entrepreneurs.
Since we’re all entrepreneurs I couldn’t help but notice how the information applied to us as therapists.
While the host wasn’t directing the information at healthcare professionals, the main point he was talking about was being good coaches. His biggest point was that being a good entrepreneur meant being a good coach and communicator.
This is especially true in our profession.
The way we communicate and “coach” our patients can have a profound effect on the results we get with them. Both in a negative and a positive way.
The words we use can have both a positive and negative effect, which sometimes can last for years, depending on how it’s delivered.
As we have been preaching about the evidence-informed practice and implementation of the BPS framework for some time, we felt it important (and it was also requested) to look at how the words we use affect patient outcomes.
Fortunately, Darlow et al. has done a number of papers on this so we can draw from some of the research that has been done!
For now, we’ll look at how not only our beliefs and communication but also our patient’s beliefs can affect outcomes.
Patient Beliefs About Their Back
When we look at the BPS framework of pain it can sometimes be difficult to separate what the differences are between psychological and social influencers that could be causing a patient’s pain.
This first paper(1) lays it out quite nicely and shows that psychological influencers include; fear-avoidance beliefs, catastrophization, self-efficacy beliefs, depression, emotional stress, and outcome expectations. Now, this can certainly be a lot to take in if it were someone’s first visit to come and see you, so don’t think you have to get it all figured out on the first visit.
When they looked at much of the data collected in this paper, they further broke down the information into five main themes.
- The vulnerability of the back
- Special nature of back pain
- Prognosis of back pain
- Activity and back pain
- Influences upon beliefs
Vulnerability Of The Back
Not surprisingly most of the people in this study(1) equated their back issues to physical injury, damage, or dysfunction.
While most were not sure what exactly was damaged they also believed it was possible to hurt their back without being aware they were causing any damage, they also believed that an increase in pain meant more damage, while a decrease in pain equaled recovery.
The interesting part is that while most participants didn’t understand what caused the pain or “injury”, they also came to the conclusion that somehow their back was vulnerable, or designed poorly due to a variety of factors that included genetics, previous injury, or misuse.
There was also a belief where activities that included bending, twisting, and sitting were dangerous things that could cause further injury or pain. In reality, how many times a day do we do these things which are quite safe activities!?
In addition to all these beliefs, many of the patients tended to catastrophize about the possible explanations about the cause.
The Special Nature Of Back Pain
This is another area that brought about some surprising results (at least for me).
People believed that pain was a function of the back and in order to protect itself, it was forcing the person to stop any activity. There were even beliefs associated with the back being its own entity that could achieve its own goals which a person had absolutely no control over.
While this hindered simple things like walking, it also became a threat to people’s financial security as they did not think they would be able to work at their secular jobs.
An interesting consideration was that back pain was difficult to understand without personal experience, however, it was acknowledged that their psychological well-being was affected making people feel old, depressed, and irritable even to the point of impacting their relationships with other people.
The Prognosis Of Back Pain
While the previous sections demonstrated getting a prognosis was important to patients there are some things that proved worrisome for patients.
Some things that stood out were the back’s ability to heal, timeframes, and the quality of healing. This was influenced due to thoughts of vulnerability, not sure if the back could heal, and also because of seeing how back pain affected those with chronic back pain. Most thought due to the type of injury they had, or because of not doing the right things their own back was not going to heal.
The paper(1) concentrated on those three topics, but in just looking at the beliefs around that, is it any wonder people end up developing chronic pain when their belief systems are basically telling them there’s no way they can get better?
Client, Clinician, and Community
To continue on the topic of back pain and beliefs Darlow(2) looked at three different entities that influence our beliefs about back pain, the client, clinician, and community.
We know that psychological factors play a role in all pain but do we really understand why? Because if we did, we could more positively change patient’s beliefs and decrease things like catastrophization, for better outcomes.
As mentioned earlier there are different themes which influence how a patient perceives their back pain. Things like genetics, previous injury, and worries about movement reinjuring the area and are seen as dangerous. So a person can weigh out the risk vs. benefit of not only engaging in activity, but also seeking out care.
As pointed out in this paper (2) almost half of those experiencing back pain don’t seek out care, but for those who do, they see more than one healthcare professional. The things that do cause people to seek care are things like high levels of disability, pain, and maladaptive beliefs like catastrophization.
Now, this is where we can play either a positive role…or sadly, a negative one.
This is because the beliefs of the therapist can influence the beliefs of the patient. Remember, those who are seeking care are typically experiencing disability, pain, catastrophization, so they want more information from a trusted source…YOU!
If we are providing a strictly biomechanical explanation, this can seem threatening as most of those explanations involve things like muscle strain, discs out, hip rotated, the rib is out, etc. In turn when these kinds of explanations are given, if the person feels pain in the area weeks, months, or years down the road, they equate the pain to that biomechanical explanation they were previously given. I’m sure we’ve all seen this in practice when someone comes in and automatically equates the pain they’re experiencing to that “same old injury” that has been going on for years.
Since we know it is likely they are seeking care from multiple professionals, if they are getting different explanations, this can result in not only frustration but increased uncertainty about their capacity to get better.
Interestingly, while very well-meaning professionals give instructions on proper lifting or moving techniques, this can be understood as a need to protect the back creating hyper-vigilance about movement.
However (as we have preached so many times on this blog) providing reassurance, validating a patient, showing that movement is safe, can empower a person not only now, but in the future.
When they looked at community in the study (2) some things that stood out were how messages stemming from places like schools, workplaces, media, and the internet had an influence on people’s beliefs. These actually influenced the amount of support given by friends, family members, and even colleagues. As it turns out, a spouse’s beliefs about pain can actually influence the amount of support or care they give to their significant other.
Now, if your beliefs about pain can actually influence the amount of care you give to someone you love, imagine how this is influenced in the workplace!?
In my past life (before becoming an RMT) I was an industrial first aid attendant in a sawmill, I would see this first hand (although I didn’t understand it at the time). When people were injured at work (keep in mind this was a very bravado-filled environment) people were called wimps (and a host of other names I dare not repeat on this blog), or it was commonly believed they were just trying to get an insurance claim.
If a person is facing this in the workplace, and say their spouse isn’t overly supportive, combined with bills piling up due to the added stress of not working, imagine how this influences not only a person’s beliefs around pain but also the amount of pain they’re in.
The spouse can also have a directly negative effect by emphasizing what the injured person can and cannot do. They can become overbearing in trying to do too much for the person, or by doing too little, again, this comes down to their beliefs.
Part of the issue is that so many of these beliefs don’t match what the current evidence says.(2)
A great example of how this can be changed is the pain revolution cycle tour put on by noigroup. Every year they do a cycling tour to different communities in Australia where opioid usage is high. They visit these communities and put on education events about pain and have seen significant reductions in opioid usage through their education and changing people’s beliefs.
So, imagine what we could do with each of our patients by just providing a little education!?
We’ve heard so many times practitioners saying things like “I don’t need research, my work speaks for itself, I get results”. One small part of the issue with statements like this is that many times a practitioner has been practicing for years and hasn’t updated themselves, or their beliefs, so are still saying things that are way out of date. While they are very well-meaning (and yes probably have some good results) they are still instilling beliefs like “my pelvis is rotated, rib is out, bad back due to genetics etc. etc.” which as we have seen is actually harmful to a person. We have a golden opportunity to provide education to patients that will change this narrative and alter their belief system in a very helpful way. (2) If we can confidently sit in front of someone and provide reassurance that they aren’t broken and concentrate more on education that will be interpreted positively by not only the patient, but their significant others will bring about far more lasting benefit. However, the only way we can gain the confidence to do this, is by reading current research and staying on top of new information and resources like the ones we’ve cited here. Because really, while you owe this to your patients, you also owe it to yourselves.
If you’d like to learn more about how to incorporate these kinds of things in your practice, we have an upcoming course on the low back, hips, and pelvis we are offering via zoom in February where we will be discussing many of these strategies as well as therapeutic exercise that you can check out by clicking HERE
- Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm, hard to heal: patient views about the back. Spine. 2015 Jun 1;40(11):842-50.
- Darlow B. Beliefs about back pain: the confluence of client, clinician and community. International Journal of Osteopathic Medicine. 2016 Jun 1;20:53-61.