The brilliant pain scientist Louis Gifford said when a patient arrives to receive care they are interested in learning four things:
- “What is wrong with me?”
- “How long will it take to feel better?”
- “What can I (the patient) do?”
- "What can you (the therapist) do?”
A 2022 qualitative assessment by Subialka et al. supported this well-known saying. A fifth question was also identified, “what is the expected outcome?”1 Additional commentary suggested that many participants attending physical therapy for musculoskeletal conditions struggled to identify “how PT played a role within their overall healthcare.”
This leads me to more questions:
- Is creating patient buy-in to physical therapy necessary?
- Is it possible that working to answer these five questions is the ideal way to create patient buy-in?
- And if so, what is the best starting point?
A Symptom-Modification Approach
Creating patient buy-in is indeed a necessary part of physical therapy! While there is no singular best way, when indicated, my bias is to use manual therapy within a symptom modification approach as a beginning. Greg Lehman’s 2018 JOSPT Viewpoint was invaluable for shaping my thoughts and opinions on the topic of symptom modification.
The Viewpoint describes symptom modification as, “an approach that aims at reducing symptoms and improving function with a variety of clinical approaches. It is born out of the realization that identifying the structural source of the symptoms is generally not possible, and that reducing pain is often a desired outcome of patients and therapists. If symptoms are reduced early in the treatment plan of care, the patient may be able to get back to meaningful functional tasks quicker.”2
A symptom modification approach always starts as an assessment, and if successful, helps share the treatment plan and prognosis. Modifying symptoms can happen with a hands-on or hands-off approach.
Hands-on options may include:
- Mobilization with MovementTM (MWM)
- Shoulder Symptom Modification Procedure
- Manipulations
- Spinal tractions
- Other manual therapy techniques that provide immediate pain relief
Hands-off options may include:
- Modalities
- Specific exercises (ie. isometrics, eccentric, etc.)
- Cognitive functional therapy
- McKenzie exercise
- Activity modification principles
Manual Therapy as a Symptom Modifier
Sometimes a hands-off approach is necessary based on an individual patient presentation that features pain-dominate characteristics (ie. acute injuries, peripheral neurogenic, nociplastic features, etc). However for me, when indicated, hands-on symptom modification is a priority. Individuals whose symptoms can be modified quickly in-session and between sessions with manual therapy may help identify responders to manual therapy and may help make a more accurate prognosis about their recovery timeline.3-4
Symptoms commonly targeted for modification may include limited/painful ROM, pain with functional activity, or pain with force production (ie gripping, etc). Implementing a thorough hands-on assessment using Mobilization with MovementTM procedures during the Objective Exam is my go-to. I want to assess if an instantaneous change is possible. A change that the patient can feel and notice within minutes.
There is something about a hands-on manual therapy examination approach that adds context and confidence to the assessment vs. a hands-off approach. Another Viewpoint I found helpful in shaping my thoughts is titled “Manual Therapy: Always a Passive Treatment?”5
How many times have you heard a patient say, “the doctor did not even look at my painful joint, let alone touch it!!”
The instantaneous change in symptoms may be short-term or long-lasting, but showing someone their pain is malleable is powerful!
The Bottom Line: “Using Manual Therapy for Patient Buy-in”
Using manual therapy early can add hope to a situation and change a mindset about pain when a patient perceives their symptoms can modulate quickly without medicine, without surgery, and without imaging.
If we anchor manual therapy in the correct context as a symptom modifier, and not a fix or permanent solution, the changes made with manual therapy can lead to patient buy-in. Early buy-in can pave a way to the good stuff; to multi-modal approaches like self-care, aerobic/strength training, sleep, lifestyle change, and behavior change to help pain now and overall health long-term.
Using manual therapy to modify symptoms, when it is possible, is a necessity to get early buy-in! Manual therapy as a symptom modifier is a driving force for “Why Manual Therapy”. It may also be the origin of consistently answering the big questions patients want to know.
Thanks for reading!
Jarrod
References:
1. Subialka JA, Smith K, Signorino JA, Young JL, Rhon DI, Rentmeester C. What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment. Musculoskelet Sci Pract. 2022;59:102543. doi:10.1016/j.msksp.2022.102543
2. Lehman GJ. The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice. J Orthop Sports Phys Ther. 2018;48(6):430-435. doi:10.2519/jospt.2018.0608
3. Cook C, Petersen S, Donaldson M, Wilhelm M, Learman K. Does early change predict long-term (6 months) improvements in subjects who receive manual therapy for low back pain?. Physiother Theory Pract. 2017;33(9):716-724. doi:10.1080/09593985.2017.1345025
4. Cook CE, Showalter C, Kabbaz V, O'Halloran B. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?. Man Ther. 2012;17(4):325-329. doi:10.1016/j.math.2012.02.020
5. Rhon DI, Deyle GD. Manual Therapy: Always a Passive Treatment?. J Orthop Sports Phys Ther. 2021;51(10):474-477. doi:10.2519/jospt.2021.10330