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The Art and Science of Physiotherapy

Updated: Jul 18, 2023

My condolences to you "Pure Scientists". I used to be one too.


The scene: 2010, Nottingham UK. The NeuroOrthopedicInstitute International Conference


The Players: Michel Coppieters, master researcher. Me, science-minded clinician.


Time: Afternoon plenary session (which began with a surprise blaring of Paperback Writer and a series of beach balls launched to the crowd (see video...)


Action:

Dr. Coppieters is presenting his research on the mobility of the median nerve during upper limb neurodynamic movements. He describes the roll of exercise prescription for these patients, and advises the audience that

"these exercises only work if you really explain to the patient what they do and get their buy-in."

The moment the presentation ends and the call goes out for questions from the crowd, my hand shoots up.

"Dr. Coppieters, that statement you made is the exact opposite of science. If something works, it just works. It doesn't require the subject to believe that it works."

Now if you've ever been to a plenary session at a major conference, in a room full of hundreds of clinicians, you'll know that the questions from the audience tend to be very cordial and polite. When there is a hint of criticism in the questioners tone of voice, or in the actual question itself, there is a palpable mood change in the room. Heads turn. It gets a bit quiet.

My greatest memory of such an awkward moment during question time is from 2004, when I watched as Nikolai Bogduck stood up and told the presenter that he was wrong, there are not 7 ligaments in the cervical spine. "There are only four!" he spat, red in the face. I love awkward moments. Good learning experiences generally come from them. (That's a story for another day)


So my comment to Dr. Coppieters didn't go over so well. I was coming from the framework of pure science: When you fail to 'blind' someone, you may get inaccurate results.


True enough in a study, but I couldn't see at the time that a teaching moment with a patient is very different.


Dr. Coppieters was telling us the research shows that doing the exercises called "flossing" and "tensioning" was effective.


But the exercises are quite unusual. They are a very different type of exercise than stretching and strengthening. It can be hard to convince a patient of the effectiveness of an unusual, novel exercise. The issue wasn't that the patient had to believe in them. They just need to understand the point of them so that they would be motivated to do them. Ensuring compliance was what he meant. And what does that require? A good strong therapeutic relationship. (And that of course, my dear friends, is where the Art of Physiotherapy comes in)


I was a bit of an educated fool at that time. I've come a long way. I now understand the beautiful balance between the Science and the Art of Physiotherapy. Connecting with your patient in terms that they understand and are motivated by - that's the sweet spot:

You start with the science, and you mix it up on a palette and paint it on to your patient's canvas in a unique portrait - something just for them.

How exciting. What an energizing profession we are in!


Here's a painting by Sophia Wang, artist and Physical Therapist. Dr. Wang believes that the practice of Physical Therapy is "Art based in Evidence."



Here are some ideas on how to motivate your patients:

 


1. If what you're asking of the patient seems to them to be overwhelming, here's a few practical tips based on the book Switch, by Chip & Dan Heath:


"Shrink the change."

Here's how to shrink the change into something they can manage: If they are exercise-naive, and what they need is to exercise 3 times per week for 6 weeks, then give them a 10 session challenge. Tell them that you want them to exercise 10 times, then see you again. Then, after you show them their exercises on the first day, give them credit for that day!


Here's how I do it: I print off for them a pie chart like this one, and tell them to scribble in 1 pie each day that they do their exercises. Then I scribble in one of them to show them that they're already 10% on their way. Shrink the change, and they will better envision themselves achieving the mini goal you help them set. Then move on to the next goal from there.


 

2. Give them an emotional message, not just a data dump. Instead of saying "the research tells us that exercising reduces your risk of developing disabling arthritis" (yawn... boring), how about telling them:

I see you, one year from now, playing with your grandkids again, and not hurting.

We are motivated more by emotion than reason. We all know this to be true (and the academics have proven it too): So find out what matters to your patient, and give them a message that will resonate with them.


3. Stop prescribing vague home exercise programs. Lack of clarity on exactly what your patient needs to do, how often, and for how long is a major barrier to motivation.

"To spark movement in a new direction, you need to provide crystal-clear guidance."(from the book Switch)

I tell my patients that I prescribe exercise like a doctor prescribes medicine: with a very specific dose in mind. If they overdose, they might be in trouble. If they underdose it might be ineffective. And when I am uncertain of how many repetitions is the exact right dose for them, I make my best estimate, and then I very convincingly advise them to do that exact number. Vagueness is a motivation killer. Whether 20 is the exact right number isn't the point. They need to believe that it is.


4. Measure progress. In a meaningful way. And make sure you choose to measure something that will change quickly.

"When you engineer early successes, what you're really doing is engineering hope. Hope is precious to a change effort." (from the book Switch)

Think of a frozen shoulder. Do you still take goniometry measurements as part of your assessment? I do. And here's why. Frozen shoulder can be a terribly long process. You might end up working with your patient for months and months. In order for them to keep at it and not get discouraged, they need to KNOW that something is getting better, and they often won't notice much pain relief as their shoulder starts to move more. So measure it!


If they start with 65* of active shoulder abduction, then go ahead and measure it again in 2 weeks. Let's say it's now 72*. That's very little real change (they certainly won't notice it themselves). But 6 degrees of improvement out of 65 is significant. Here's what you can then say to them:

It's still fairly early, but you've already made a 10% improvement in that range of motion. Keep up the good work!
 

I've spent a career collecting information from other disciplines to help me understand and coach my patients towards an enjoyably long healthspan. I hope you find some motivation in these thoughts.


Jeff Begg

 


*Dr. Sophia "Sofa" Wang is a board certified specialist in Orthopedic Physical Therapy (OCS) and a Clinical Specialist Spine Fellow of the Kaiser Permanente Southern California Spine Fellowship at Panorama City. She received a Biology B.S. from Emory University and a Doctorate in Physical Therapy (DPT) from the University of Southern California, and completed an orthopedic residency at Glendale Adventist. She shares her passion for the human movement system as a certified Movement Links Specialist and as a course content writer for Medbridge continuing education for Movement System Impairment (MSI) Syndromes. She advocates for physical therapy as an art based in evidence, through an acceptance and appreciation of the variability of approaches in our profession.

If you are an artist and clinician, and would like to feature some of your art here, send us a message at admin@physiotherapyguild.ca.

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