Hi, I am Amy McDevitt,
and I am going to be
interviewing Paul Minkin
today for our hands-on,
hands-off podcast.
So this is our newer AOMT podcast.
So I'm really excited to
have Paul as a guest.
Paul is a professor at
Hawaii Pacific University in Hawaii.
And we actually had the
pleasure of working
together for almost 13
years at the University of Colorado.
And so Paul has been
publishing in the area of
manual therapy and
orthopedics for many years
and is quite well known in
the AOMT community.
But I'm going to turn it
over to Paul to talk a
little bit more about himself.
And then I want you to just
tell our listeners a little
bit about yourself and what
you like to do and what
some of your interests are.
So I'm going to hand it over to you, Paul.
All right.
Thanks, Amy.
Well, thanks for inviting me.
I'm excited to be here and, you know,
privileged to be a part of AOMT overall,
the organization that's
done so much for my career overall.
So, you know, talk about yourself.
That's always a challenging
question overall, you know,
kind of on a spiritual
journey as of late.
So, you know,
labeling myself as this or
that or that kind of thing
kind of seems shallow and fake.
But, you know, just...
I'm a human being who's
trying to be the best husband, father,
physical therapist,
professor that I can be.
You know, I've been on a long journey.
I've just celebrated 30
years of being a physical therapist.
So I've maintained,
I've stayed clinically
active for those whole 30 years and,
and been in academia for 20 years.
And, uh,
Enjoyed my time at the
University of Colorado and
retired from there with a pension,
which was pretty exciting.
And now I'm teaching at a
new hybrid program in Hawaii,
which is just amazing overall.
Our students are so diverse
and hungry for knowledge
and that type of thing.
So it's been an interesting
transition from brick and
mortar to more of a hybrid
education model.
But I'm loving every minute of it.
And I'm a firm believer in
the approach overall.
Yeah, yeah.
That's great.
And so you've been at Hawaii
Pacific for how long?
Two years?
Two years.
Yeah.
Just celebrated two years,
if you can remember that.
Wow.
Well,
what we decided to talk about today
with you,
and part of this was your choice,
was patient expectations.
I know personally,
you and I have had many
conversations about this,
just because we both
believe that it has such an
incredible influence on what we're doing.
And so
I'm going to kind of back us
up and I would just love to
hear your thoughts on just
explain to the listeners a
little bit about what
patient expectations are, I guess,
from a definitional
standpoint and how they are
really a critical piece in
potentially influencing outcomes.
So I just want to hear a
little bit about what your thoughts are.
Yeah.
So patient expectations are
kind of the beliefs and
anticipated benefits that
patients have regarding the
interaction that they have
with their healthcare provider,
the outcomes,
the quality of care they might receive.
So when patients have
positive expectations,
they're more likely to
engage actively in their therapy.
It can help reduce their pain overall.
They're more likely to be
adherent to their home program.
And it
there's pretty good evidence
that it can improve their
pain and their function in the long run.
So really the patient's
expectations are framed by
a lot of different things overall,
but they're such a powerful
part of the treatment,
especially in physical therapy,
that if we don't pay attention to them,
we're missing a huge part
of the therapeutic alliance
and the care package.
And you were saying just a
moment ago that there's
multiple things that feed
into patient expectation.
So based on your many years
in clinical practice,
what do you think are some
of those elements or
influences that are going
to influence what patients
are actually expecting when
they come to us for
physical therapy or manual therapy care?
Well,
the important thing is to remember
that every patient is a
human being with this
complex milieu of past
experiences and education,
what they believe about
themselves and others,
what they've heard from their family,
their friends and Dr.
Google and that type of thing.
It's also strongly
correlated with their worldview.
Are they optimistic by nature?
Are they pessimistic by nature?
So the interesting thing is
that these expectations
that the patients come in with
which again can come from
many different avenues,
those can be changed by a
positive healthcare interaction,
forming a good therapeutic
alliance with your patient
and that type of thing.
So you never know what's in
the soup of that individual,
what led to those expectations.
It could have been something
they heard or something
they read or something they experienced,
but really exploring that I
think is a key part of what
we do as healthcare providers.
And so with that being said,
what are some of those key
things that you think we
need to do from like the
moment we start interacting
with that patient, that human?
What are some of the first
couple of things that
you're going to do to try
to glean how to meet them
where they're at in terms
of expectations?
Well, the first thing, I mean,
I love Peter O'Sullivan's, you know,
tell me your story,
kind of just listen to the
patient and where they've been.
and the journey they've been
on since this condition came on.
It may be something that
just started two days ago,
or it may be something
they've been dealing with
for decades overall.
So just listening to that
patient and being present for them,
really tuning in and kind
of letting them tell their story.
The research is pretty clear
that in most healthcare interactions,
the patient is interrupted
before they get to complete
their opening statement.
you know, hear what they have to say.
And that helps you start to
understand what their
expectations might be.
You know, if they come in and say, well,
I saw this provider and
they told me this and I saw
this provider and I told
they told me that nothing's been working.
You can kind of really start to hear
You know,
the frustration and being able to
empathize with that individual.
That's, that's really, you know,
where it starts overall.
And then I'll ask them,
what are your expectations
from treatment?
What are your specific goals?
Patient centered?
What, what do you want to be able to do?
What are you not able to do now?
And what do you want to be able to do?
Um, and then asking them what,
what they think is going on.
Maybe they've heard five,
five different stories from
five different providers.
And maybe they have a set
idea of what they think is going on,
or maybe they have no idea
and they're looking to you
for guidance overall.
So really exploring those expectations.
And again,
it's based on their past experiences.
And then, you know, things emerge that are,
you know, in your opinion,
potentially detrimental.
to the improvement of the individual,
that's where you can start
to use some of the
motivational interviewing things and say,
is it okay if I share with
you some information about
back pain or neck pain or
that belief or that type of thing?
Yeah.
I had a conversation with
students similar to what
you're saying just the other day.
And we were talking about,
one of the associated
faculty used this word,
some of our patients have
become medicalized.
They bounced around between
so many providers and
they've heard all these different
kind of stories about why
they are in pain or what
they need to do next,
or you're not going to get
better unless you do this or this.
And so we were talking in
class about just those
challenges of sometimes
trying to undo a lot of
what's been done for
individuals that are kind
of just moving through the system.
And then you see harmful
things on social media on top of it.
So what are
What are some of your
thoughts or strategies?
Like how do you undo the
things that have negatively
influenced patients and
change their expectation
for what they might get out
of care with you?
yeah as you and I know that
that is one of the most
challenging patients to
treat is the one that comes
in and says you know my
chiropractor or my physical
therapist told me my sacrum
is out or my l5 is out and
I need you to put it back
in and they've got six or
they're all six six yeah
Yeah.
And those patients are
really challenging because
they had a previous
experience where maybe it was positive.
Maybe they did see a
physical therapist or a
chiropractor who did a
manipulation and they heard
a pop and all of a sudden
they felt better and they
were back doing what they want to do.
And they're bringing that
expectation into the treatment.
And those are the really
challenging patients, I think, to treat,
especially if they're fixated on
you know,
I'm broken or I'm out of
alignment and I need you to
fix me and make me better.
So, you know,
I really try and engage them
with the current best evidence,
try and hear where they're coming from,
but also encourage an
active approach that, you know,
there's things that I can do,
but the most important part
of this relationship in
your recovery is what you do.
Yep.
And you mentioned Peter O'Sullivan earlier,
and I followed a lot of his work in it.
And he really does a beautiful job,
I think, of dialing into, you know,
in some of the things that
he's published on cognitive
functional therapy,
really having the patient
learn and be active in the process.
So I think that's also really important.
You talked about using best evidence.
So before we talk about best
evidence of what
interventions and what the
plan of care should look
like for the patient,
what is some of the current
best evidence surrounding
patient expectations?
What does that look like right now?
Well,
there's an overwhelming amount of
evidence from both medicine
and in physical therapy that, you know,
if a patient has a positive expectation,
whether that was influenced
by the healthcare provider or not,
that's going to impact their outcomes.
So really, you know,
some of Joel Bialoski's
work where they used manipulation,
let's say, and they said,
you know,
this is a technique that we think
will improve your back pain,
or we think this is a
technique that we don't
know if it will help your back pain,
or this is a technique that
we think may make your back pain worse,
you know,
that framing to the patient
actually impacted the outcome.
So
The evidence is pretty clear
that if a patient has a
positive or a negative expectation,
and that's not modified,
let's say on a negative side,
a negative expectation,
if that's not modified,
their outcomes are not
going to be as good as if you potentially
change those expectations.
And I hate to use the word
manipulate their expectations,
but that's really what we want to do.
We want to sell the evidence
that this treatment will
likely make you better and
kind of reframe the
treatment that you're delivering,
making sure you're very
clear about it and
Uh, you know,
that that's the challenging
part a lot of times,
but you have to kind of
present to the patient, okay,
this is what my exam showed me.
And you need to stay away from saying,
you know,
you're out of alignment or you
have bad posture, all those words that,
that harm kind of thing and say, you know,
this is what I found in my exam.
This is what the current
best evidence says about
treating those findings.
And we published a paper
called the Healthcare Buffet,
where we kind of present to your patient,
well,
evidence shows we could use some
manual therapy, we could do some exercise,
you could do some aerobic conditioning,
those type of things.
We could work on some pain
science education,
we could work on some
relaxation techniques,
and those would probably
all benefit you or any of
those of interest to you.
And that whole
patient-centered care and
shared decision-making,
you actually put the
evidence in front of the patient and say,
what aligns with kind of
your world belief?
What do you think would give
you the best outcome?
And then let them choose,
and then you proceed together as a team.
Yeah.
I like that approach.
I think it makes total sense,
especially on the heels of
kind of all this kind of
contemporary and updated
information that's coming
out about patient-centered
care and why that's so important.
But I think it's hard,
as at least you and I both
educate entry-level students,
I think it's hard for us to
help them see that you have
to kind of lay out the options.
It's not all on you, actually.
It's got to be on the patient, too.
So how do you
You said there's evidence in
certain regions that
positive expectations
anyway might drive outcomes
in terms of like a manual
therapy intervention.
How do you measure that type of a thing?
So for those listeners that
aren't necessarily as familiar with it,
what does expectation research look like?
What are you actually measuring?
Yeah,
we ask the patient their past
experience with certain treatments.
We ask them specifically,
do you think that exercise
will help your condition?
Do you think that
manipulation or manual
therapy will help your condition?
Do you think that stretching
would help your condition?
And we give them kind of a
Likert scale for when not
likely or very likely or
those kind of things.
uh and so we kind of assess
their expectations prior to
treatment and we can look
at whatever treatment they
received in that research
and see if their
expectations correlated
with the outcomes overall
and you know you and I
published a few things and
and um with uh josh cleland
and joel bylosky and mark
bishop we published on neck
pain and back pain and
shoulder pain and uh
There's probably a few that
I'm missing overall,
but it comes in with the
expectation that the
treatment that they're
going to receive will help them.
Their outcomes are better.
And the other thing I wanted
to talk about with you is, you know,
you get these patients in
these studies and they know
that it's a manual therapy study.
Maybe it's a randomized controlled trial.
and the randomization occurs
and we open the envelope and we say,
you're in the exercise
group or you're in the control group,
you can see them,
the ones that have this
really high expectation
that manual therapy is gonna help,
they kind of deflate a little bit.
And there are healthcare
seekers and that kind of
thing that will actually
look for studies where they
can get the treatment that
they really strongly
believe in and that type of thing.
clinical research is really
hard to be able to take a
naive patient and deliver
two different types of
treatment to see which one
is superior because these
patient expectations,
every patient coming in has
some thought or belief about, you know,
what they're going to
receive and what they think
will help them.
And if it doesn't match what
they think will help them,
their outcomes are not
going to be as good.
Yeah.
It's interesting.
I think that's the perfect
example of when we see it
because our hands are tied
and we're forced to be
prescriptive because we're
in a clinical research environment.
But what's amazing is you
get to the clinic and you
actually get to tell the patient,
these are all the options.
Like you were saying,
what did you call it?
A healthcare buffet?
Yeah.
Healthcare buffet.
Like you go to an Asian
restaurant or something and
there's all this stuff that
you can choose from.
Right.
And some, some you like,
some you don't like.
Yeah.
But I like that analogy
because in the clinic it's
just different and the
patients can choose or
prioritize what they what
they want to do if you're
kind of exercising that
that shared decision making model.
So you talked a little bit
about some of the studies
that were done in the past,
and that was I think it was interesting.
I remember when you and I
were kind of looking at
the patient expectation
information from the lumbar
spine and the neck and the shoulder,
all those figures looked
very much the same.
So do you think that's fair
to say that you would
probably see the same
patient expectations in
terms of influencing
outcomes in other regions
like the foot and ankle and
the knee and across
orthopedic conditions?
Yeah,
I think there's very few exceptions
to that.
the studies that have
explored expectations where
if a patient had a positive
expectation for that
treatment and they received
that treatment,
that the outcomes were not
better compared to the alternative.
And we've seen it in other
conditions as well, headaches, migraines,
irritable bowel syndrome,
all kinds of different medical treatments,
that type of thing.
And as I said before,
the interesting thing about
those patient expectations
is you can mold those
the patient can come in and
they can maybe have a
neutral or a negative
expectation about a treatment,
but through a good
therapeutic alliance where
you really connect with that patient,
get to know them as a human being,
know that you're in this as a team,
can share the evidence with them and say,
you know,
the research shows this
intervention would probably help you.
What are your thoughts on that?
You can actually change
their expectations.
And when you do change their expectations,
their outcomes improve.
Yeah, yeah.
So I have a question, it's related,
but on a slightly different topic,
you know,
there's a lot of information
that's come out about
placebo and nocebo and,
and patients might have an expectation.
Oh gosh,
there's that little thumbs up
thing that I didn't mean
for that to happen.
Tell me how placebo effect
and expectations kind of
collide when it comes to
clinical practice,
or even what does some of
the research say about
placebo and expectations?
What does that even mean?
Yeah, so placebo effect, well,
placebo is a supposedly
inactive treatment.
That could be a pill with sugar in it,
or it could be a sham
manipulation or something like that.
The placebo effect is what happens,
you know,
the physiological or
psychological changes in a
patient's condition
resulting from the belief that
that they're receiving an
effective treatment.
So even if that treatment
has no therapeutic value,
so patient expectations are
a part of placebo,
but they're not all of it overall.
So, so you,
you can change a patient's
expectation and improve
potentially the placebo effect.
But you know,
a lot of people get confused
on placebo versus control
and that type of thing.
So a placebo can be a control and,
You have a no treatment
control where patients
don't receive any treatment.
But the state of the art in
medicine is to compare the
active treatment to a
similar treatment that the
patient thinks is going to
benefit them overall, whether
you know,
it actually has some therapeutic
value or not.
And then we know that the
placebo effect is around 30 to 35%.
If patients think that they
are actively receiving a
treatment or doing
something that will make them better,
that we will see improvements in that.
So the bar is really, does the,
treatment that you're
investigating exceed that
bar of 30 to 35% will
improve with the placebo
and to actually show that
it made a significant difference.
So it almost seems like you'd have to have,
if we're getting granular,
you'd have to have your
experimental group, a sham group,
and then a true control
where nothing is happening
in order to maybe sort that out.
Yeah,
because natural history is such a
powerful thing.
Even in patients with chronic pain overall,
there is an ebb and a flow
to it and kind of a natural
history overall.
So you really, you know, it is nice,
like in our study where we
looked at thoracic
manipulation for patients
with cervicogenic headaches.
We had those patients come in.
We did the baseline data.
The ones that got the
control got no treatment for four weeks.
And they stayed the same, right?
Yeah, yeah.
And they'd had headaches, I think, what,
for an average of five years?
Yeah, our average was 10 and a half years.
10 and a half years of headaches.
And so the group that got the control,
which was no treatment,
they just sat idle for four weeks.
But it was a crossover study.
So we wanted to deliver the
thoracic manipulation to
one group while the other
group sat on the sidelines.
And then after four weeks,
they entered the game.
We did the thoracic
manipulation and the
improvements almost exactly
mirrored each other overall.
So that kind of proves that
what we did in the
intervention made a
difference in these
patients who had had
symptoms for 10 years.
And we had that control
group where no treatment
was delivered and they
didn't change at all.
Yeah.
And I'm wondering, you know,
things like that,
it's hard to know how much
natural history for something that's been
occurring in an individual
for 10 years as opposed to
two months is also probably
going to look different.
It just occurred to me, Paul,
that we actually gathered
patient expectation data,
but we never did anything with it.
So maybe this is the impetus
for us to do a secondary
analysis of some of that
data for individuals with
cervicogenic headache.
Yeah, yeah.
So what are some of the
thoughts you have on, like,
I would love for you to share with people,
what's the link?
What is the language that
you would use if someone
has a negative expectation?
So I'm talking about that
patient that comes in and they're like,
my brother, you know, went to PT.
It wasn't helpful.
I'm not even sure if this is going to help,
but I can't get, you know,
an injection until I do six
weeks of physical therapy
or I can't do this or that,
or I don't know.
How do you.
I have my own ideas,
but I want to hear your thoughts.
How do you realign those?
What are the words that you use?
uh well that's challenging
and it's it's um you know
every every patient is
different like in the
situation with the brother
had a bad experience maybe
explore that a little bit
more but uh you know maybe
there was some other
variable in there that that
affected the outcome
overall but you know really
I try and bring it back to
the patient this is your
life this is your
experience this is what the
current best evidence says
this is what my uh
expert clinical judgment
says would probably benefit you overall.
And if you bring that
negative expectation into
this therapeutic relationship,
it will impact your outcomes.
So I'll give them papers.
I'll let them read papers.
I'll send them to websites
that I trust where they can
explore the intervention
that we're talking about,
that maybe we can start to
reshape that expectation
from the brother's bad
experience or whatever.
Yeah.
you know,
bring them around to maybe a more
neutral or more positive
type of an expectation overall.
But, you know, again,
you have to value the
patient's experience,
but you have to bring it back to them.
This is your life.
This is your story.
This is, I think, will help you.
And then, you know, if you can change that,
I think you can bring them
around to that position.
So for some of our listeners
that are maybe a little bit
earlier in their education or training,
Would you say this is
something that you're
constantly and dynamically
doing throughout your interactions?
Or do you believe you kind
of deliver a little bit of
bolus of information in the
beginning in terms of
trying to change expectations?
Yeah, that's a good question.
That really gets into our bias, right?
A lot of us are strongly
opinionated about what we
do and why we do it and
look at social media and
all the manual therapy,
love it or hate it kind of
things overall.
So we do have to present it
in an unbiased fashion and not try to
persuade patients or talk
them into a treatment that
maybe they are not interested in overall.
But it is challenging,
but trying to just present
it in a factual basis and
then really involve the
patient and listen to them.
What are your thoughts on this?
of them will say you know
manipulation is a prime
example cervical
manipulation while my
cousin's sister's brother
got manipulated by a
chiropractor and had a
stroke and crashed into a
ditch and things like that
that's that's probably a
patient that you're not
going to bring around to
letting them letting you do
a cervical manipulation on
them overall so there are some
barriers to expectation,
I would say overall.
But in general,
if you can start to reframe
whatever their expectation is,
if it's on that negative side,
you can bring them around.
But if you can't,
then move on to something else.
Yeah.
And so how are you in the
context of being an entry level educator?
How are you kind of
sprinkling some of this
content in with your students?
How are you helping them to
to understand that this is
another component of how we
need to interact with our patients?
Yeah.
So, you know,
I really emphasize that
therapeutic alliance with
patients and being present
for your patients.
Most of our students,
when they're sitting in
front of a patient,
they've got their heads
going in a thousand different directions.
They've got a checklist in front of them.
They don't even make eye
contact with the patient.
Or they've got their tablet
or their computer up and
they're documenting while
the patient is talking.
And I really try to get them
out of that mode where they
can be with that other human being,
look them in the eye, talk to them.
And I've always told my students,
you've heard me say this,
that your interaction may
outweigh your intervention, right?
I mean,
we've got all these studies that
show that manual therapy
helps maybe a little bit in
the short term.
But if you look that patient in the eye,
get to know them as a human being,
really invest in them as a
healthcare provider,
that will likely have a
better effect on the
outcome of your treatment
than any treatment we can
throw at our patients overall.
Yeah.
And I think it's exciting to see that,
you know,
there's work being done now to really
try to figure out how to
better harness that shared
contextual piece.
It's not all about,
it's interesting because I
think we're starting,
I hope we're starting to
move away from the fact
that we think all of our interventions,
whether it's manual therapy
or exercise or what drive the outcomes,
it's so much bigger than that, including
you know,
our topic here today of expectations,
but also of some of these
shared mechanisms.
So I think it'll be
interesting to see what
more we learn about how
that really needs to be a
big player in the
intervention outside of just, you know,
exercise and manual therapy, for example.
Yeah.
What are some things that are kind of,
I don't know, when you've done lectures,
I know,
in various places and in Europe on
patient expectations,
What are some of the biggest
things that your audience
tends to be curious about?
Or what are some of the
things that maybe continue
to interest you about this topic?
Or what are some things that
surprise you maybe about this topic?
Well,
I think the big thing is just not
paying attention to the
fact that patients have
expectations and that you
can explore those and that
you could potentially
modify those expectations.
I mean,
that was eye-opening to a lot of
people that I give this talk to,
and they say, well,
isn't that deceptive if you tell them,
you know,
this manipulation will make you
feel better?
If you're sharing...
current best evidence and
you can back it up with research, then,
you know, it's not deceptive at all.
You know,
and then harnessing the placebo effect.
I openly embrace the placebo
effect in physical therapy.
I think it's a huge
component of what we do,
whether it's manual therapy or exercise.
And I will tell patients that.
I mean,
the new research out on open label
placebo, where you tell the patient,
I mean,
there's one great study on chronic
low back pain
who these individuals had had pain for,
I think, five years at a minimum.
And they gave them a placebo and they said,
there's no active substance in this pill.
But in research studies,
it has shown that people
who take this pill have an
improvement in their pain
and their function and that
type of thing.
So they're very open about
the fact that this is a placebo.
And they saw significant
improvements in those
individuals and they
tracked them out to five years.
And that was maintained out to five years.
And, you know, at the end of the study,
When they stopped giving them the placebo,
a lot of these patients would say,
where can I get a prescription for that?
Where can I buy that?
And you tell them it's just a sugar pill,
right?
There's nothing in it,
but they want to keep taking it.
And there's something about
that doing something active
for your health.
Maybe when they're taking that pill,
they're thinking, well,
maybe I should walk a
little bit more today or
maybe I should eat a little
bit better today.
or maybe I should get more sleep.
They take a more active role
in their recovery just
because they're doing
something they think has
potential therapeutic value overall.
I tell my patients that.
There may be a placebo effect in this,
but we know that the
placebo effect is very powerful.
It's getting your brain on
board with this plan of
care that we're going to be
doing and that will improve
your outcomes.
Wow.
So you're saying maybe it
boils down to like the
ritual of taking a pill and
maybe something that's
happening in the present
when they're doing that?
Yeah.
I mean,
just the fact that the patient
every day is taking that
pill because that was key
in that placebo study,
that open label placebo.
And they've done it near
irritable bowel syndrome too.
Exact same thing.
where they told the patient,
you have to take this every
day and you have to
document that and that type of thing.
So the ritual of doing
something every day that
may help with their back
pain or their irritable
bowel syndrome and that kind of thing,
I think just shifts their
mindset overall that, hey,
maybe I'm not going to eat
that cheeseburger for lunch.
Maybe I'll get a salad or
maybe I'll go for a walk
instead of sitting on my
phone on social media for
the entire hour overall.
So-
Yeah,
I think that that research is so
interesting.
And I think it's important
for us to think about that component too,
that some of what we're
doing is probably tapping into placebo.
So what do you do?
I love the scenarios of like, you know,
you get a patient that
comes in the clinic and
they're dead set on the fact
that ultrasound is gonna
help their neck pain.
I mean,
I've seen those patients and you have to,
how do you kind of rectify
that disconnect between, you know,
it actually kind of kills
me to plug the machine in
and actually do this,
but yet the patient is
saying that they're
expecting that it's gonna help.
What's your response to that
and how do you manage that?
Yeah, that's interesting.
I remember I was talking to John Childs.
This was like 20 years ago
or so and asked him that exact question.
The patient comes in and said,
last time I hurt my back,
I had ultrasound and it really helped.
And he said, do the ultrasound.
That's their expectation.
And I've tried the contrary where I'll say,
the evidence shows that
ultrasound is not very
beneficial for back pain,
probably won't help you a whole lot.
And then that creates a little bit of
adversarial relationship.
This is my experience.
This helped me.
And you're telling me that
you're not going to do it
because there's not a study
that shows that it helped me.
Right.
Yeah.
So I will embrace those things.
I may share a little bit of
knowledge about the
the benefit of ultrasound.
But, you know,
the other important thing is
while you're doing that ultrasound,
you can be educating the
patient and do some science education,
or you can talk to them
about activity modification
or reinforcing their home
exercise program or the
overall plan of care and
that kind of thing.
So it's not really wasted time.
And who knows, maybe it,
maybe it does help them.
So, you know, I try not to,
poo-poo too much on
patients' positive expectations.
If something in the past helped them,
by all means,
unless it was something
harmful to their health,
drinking too much or using
drugs or things like that, opioids,
that kind of thing,
that's a different discussion overall.
But if it's something that
has no potential harm overall,
then I fully embrace that.
Yeah.
And I think what's also hard
for us to swallow sometimes,
I've had experiences where
patients absolutely 100%
have the expectation that,
that they should have or
move forward with the
surgery that I don't
believe they necessarily
have objective findings to
support the need for that.
But I'm telling you,
it's hard to talk a patient
out of a surgery that
they're convinced that they need to have.
So I believe that's another
avenue where I just, I tread lightly.
I present information and research, but,
um,
you know,
surrounding what some of the
outcomes are with some of
these orthopedic surgeries.
How do you handle that?
Well,
a lot of those situations are driven
by the surgeon,
where it's not just the
patient who absolutely believes it.
The surgeon has told them
they absolutely need this
surgery to get back to function.
And that's where we can present.
Let's take lumbar stenosis, for example,
the main stenosis study
that tracked patients out
10 years who had surgery,
lumbar fusion versus not.
And they looked exactly the
same out to 10 years.
You can present some of that.
information to patients.
Now,
if there's a clear indication for surgery,
you know,
they've got progressive
neurologic deficits or a
spondylolisthesis that's
unstable or something like that,
that's a different story overall.
But that is where I will try to, you know,
counteract what they may
have heard from another provider.
Well,
that provider told you
absolutely need this
surgery to get back to what
you need to do.
I'm telling you from personal experience,
I've seen patients just
like you who have gotten
back without doing that surgery.
So I tell them, give me six weeks,
give me six weeks.
And if you're not where you
want to be in six weeks,
after I've done all the
patient education and maybe
some manipulation of their expectations,
if you're not where you
want to be in six weeks, by all means,
you can, you can go get that surgery.
Yeah.
So,
From the clinical perspective,
because I know you treat
weekly up at Wardenburg at
University of Colorado and
their student health center,
do you capture any patient
expectation material or
through intake paperwork or
anything like that?
Or do you pretty much try to
garner what their
expectations are in that
initial encounter?
Yeah, that's really challenging.
I mean, patients get form fatigue, right?
They have to fill up so much
paperwork at their initial
appointment that we don't
routinely assess for expectations.
But that's part of my
subjective interview that
I'll be asking them about it.
You know,
what kind of treatment have you had?
What do you think is going
on with your back pain?
What do you think will help
with your back pain?
Those type of things.
Yeah.
Do it more informally.
You know,
it would be ideal if we could
have a standardized.
The other thing about the
expectation literature is
there's no one form.
I mean, I did a,
I looked at a systematic
review where there were 19
different patient expectation forms.
I mean, yeah.
Which one do you use?
You know, so, so again,
I tend to do it more informally,
but I do think you can
glean a lot of information
just from asking the patient.
Yeah.
Okay.
Um,
I've kind of two more questions and
then I'm just kind of
eyeing those guitars behind you.
And I don't know,
I might try to twist your
arm to play a little.
All right.
That'll be for another one.
So in terms of, of, um, where's,
what's the future of
expectation research?
Like,
are you kind of privy to what that
next layer is now that we
know that expectations can
influence outcomes, especially with
You know, people with musculoskeletal pain,
is there anything on the horizon for us?
that you're aware of?
Well,
I think the interesting thing will be
pragmatic clinical trials
where you kind of let the
clinician explore
expectations and then maybe
make some suggestions to
the patient and that kind
of thing versus a more
prescriptive kind of
approach where you just
deliver the treatment.
I mean, that's been done to some extent,
but really embracing that placebo effect
And then, you know, potentially exploring,
you know,
the effect of placebo in
physical therapy itself, because,
you know,
we hate to think that some or
much of what we do is
actually placebo effect, but it is.
I mean, going into that placebo effect,
again, that's the, you know,
the patient changes their
thinking or their
psychology or their
physiology based on their
expectations and their
thoughts of what's going on,
if we can change that overall.
And Joel Bialoski has done a
lot of really good work on that front.
But I think just embracing
the whole package,
because we have all these
studies coming out,
let's say on back pain that shows that
there's no one clear exercise, you know,
specific versus global or
local versus global and
those kind of things.
And the key thing that comes
out of those research,
and same thing in manual therapy too,
it doesn't matter the
exercise or the technique,
it's getting the patient doing,
which goes back to that
whole ritual thing that
they're actually doing
something that may improve their health.
Maybe that's the important thing.
It doesn't matter
how the movement system
people are gonna hate this,
but it doesn't matter how
specific our movement
analysis is and our exercise prescription,
which is a whole nother
topic that PTs suck at,
but maybe it's just getting
the patient moving.
Exercise will help you.
What do you like to do?
What can you do at home?
So many times we prescribe
exercises that the patient
either can't do or is not
interested in doing at home.
So just getting, embracing, you know,
what they will actually do.
And that's where
motivational interviewing
can really come in.
how likely are you to do
this exercise program that
we just talked about today
and kind of moving in that direction.
So I'd like to see physical
therapy research start to
embrace all of these things
and to include therapeutic
alliance and the patient expectations,
as well as current best
evidence on exercise and
manual therapy and those
kinds of things and kind of
look at the whole package together.
And then the other thing that John Childs
told me we need to stop
comparing one PT
intervention to another PT intervention.
We need to start comparing
what we do as a profession
from the initial
second that we interact with
that patient until we end
that episode of care,
compare that to what
orthopedic surgeons do or
that kind of thing and give
them the whole package
rather than just breaking
it down and saying, oh wait,
what does this manual technique do?
Or what does this stretch do?
Or what does this exercise do?
Use the whole package and
compare it to other
standards of care for that
condition to prove that our
profession has a better
answer in most situations to
you know, the medical model, if you will.
Yeah, I couldn't agree with you more.
And some of the, you know,
kind of details of what we're missing.
And I know, I mean,
you and I have been working
with a bigger group on a
neck pain clinical practice
guideline revision.
And one of the things that
we've struggled with as a
group is we can't,
no one's reporting dosing.
They're doing menotherapy,
but we don't know what it
is because it's not well-defined.
But I love that idea of
taking more of like a meta view, I guess,
of what we're doing from
beginning to end in, you know,
an episode of care instead
of trying to dial into
these minutial details,
because we don't have
answers for dosing for
exercise or manotherapy.
We're actually doing a, you know,
we're lost.
I think we don't, you know,
we think that manotherapy
holds all this power,
but we know that the
multimodal approach is best,
but we still don't know how
much is the right amount.
So I love that concept of
maybe thinking about, you know,
looking at the forest and
not so much being in the
trees and trying to figure
out how we measure up to
what's happening in other
avenues of health care.
Yeah.
And that's what if you
haven't read any of Julie
Fritz's most recent work,
that she's kind of taken
that 20,000 for you.
You know,
it doesn't matter what you do in a,
you know,
from treatment to treatment, what you do,
it's kind of stepping back.
Is it more of an active approach?
Are you using current best evidence?
Are you educating the
patient and that kind of
thing and looking at the whole package?
Because what we do as
physical therapists is not
manual therapy or exercise
or this kind of thing.
It's a whole package,
which those soft skills are
such a huge part of.
Yeah.
And those are the things
that I think as educators
are the most challenging for us
to figure out it's kind of
that affective domain of learning.
How do we keep scaffolding
that in to the curriculum?
So our students really
appreciate that as a
skillset and not just their
perceived need to develop
psychomotor skills.
Cause I think some of the
other ones are equally,
if not more important.
And I think patient
expectation is a part of that.
Okay, so top,
Top two or three things that
you as we kind of wrap up
our conversation that you
want our listeners to think about,
whether they're educators
or clinicians or students
or residents or fellows in training.
Give me like a top two to
three things that you want
people to walk away remembering.
Well,
I think just acknowledging that the
person sitting in front of
you is a human being that's
bringing a lot of things to
the table that you know nothing about.
So exploring that a little
bit and finding out what they believe,
what they think, what they've heard,
those kind of things.
And then trying to tailor
your treatment approach to
that individual human being
who's sitting in front of you.
I like to say to patients,
the good news is you're in
the right place.
I see this a lot.
There's current best
evidence that shows that we
can make some improvements
in this area overall.
just really involving them in the,
the overall shared decision-making,
that type of thing,
involving your patient in their,
their plan of care overall.
And then, you know,
moving forward with them as a team,
rather than you being the
dictator and saying, you know,
this is what we're going to do.
And today we're going to do
this and that type of thing.
And then again, that,
that therapeutic alliance,
just getting to know who
your patients are before you, you know,
enter that relationship with
them is so powerful.
I mean,
talking to them about their kids or
their dog or things like that.
I mean,
that has such therapeutic value
that we can't really put a finger on,
but just having that,
that interaction with the
human being that's in front of you.
Yeah.
Okay.
Um, what book are you currently reading?
I didn't put that on the list,
so sorry to spring that one on you.
Yeah.
Um,
I am reading this book
called The Holographic
Universe right now that
kind of explores
spirituality and quantum
physics at the same time.
We always hear we're all connected, right?
Everything's connected.
Well, on a physical level,
at the quantum physics level, it's true.
And so it's just interesting
to kind of explore that.
And how did you get there?
How did you find that book?
Was that a recommendation or?
Yeah,
I think it was another book that I
read that was kind of talking about,
you know,
when you get down to that
quantum level overall,
how everything is connected and, you know,
the whole wave particle duality thing,
you know, is it a wave?
Is it a particle?
As soon as you start to observe it,
things change,
which is what happens in
our patients too.
When you pay attention to them, you know,
things change overall.
Yeah.
Well, Paul,
I just want to thank you on
behalf of the AMT
organization and myself for
taking the time to talk to
us a little bit more about
patient expectations.
And I think why we value you
as a member of AMT and as
an educator is you're in all of it.
You're in the educational piece,
you are in clinical practice,
and you're doing research.
And so I think
listening to you, it just, you,
you so eloquently kind of
weave all of this together
because you're doing all
those things concurrently.
And I highly value that, that about you.
So I appreciate, you know,
hearing your insights and
having you share a little
bit more with us about this topic.
All right.
Well, thanks.
It's been a pleasure, Amy.
Okay.
Thank you.