Your Psychological Biases Are Stealing Your Money

This post is in response to “3 Psychological Biases and Your Money,” by Joseph Reinke, CFA, CEO of FitBUX. If you are in the physical therapy profession, then you may be interested in FitPT, the FitBUX physical therapy community. You can follow @FitBUXofficial and @FitPTofficial on Twitter.

In the 1960s, Walter Mischel and his colleagues conducted one of the most famous experiments in the history of psychology. The researchers examined self-control, and they created the “marshmallow test” to study willpower in kindergartners. The test consists of offering a child the choice between one treat immediately or two treats if they wait for 15 minutes. Oh, and if the child wishes to wait in order to receive two treats, then they wait alone while a treat sits on the table. If you spend much time with small children, then you can imagine the agony involved with this task. Here is a hilarious video of some kids attempting the marshmallow test.

As a graduate student, I commiserate with these children. It’s easy to spend money, and it’s much harder to set aside money in order to have more later. Every time I receive a financial aid disbursement, I need to remind myself that some extra cash does not mean that I can afford a new phone. We students need to constantly “override” our brains in order make prudent financial decisions.

Joseph Reinke, CFA, and CEO of FitBUX recently discussed three psychological biases that are important for paying off debt. Even if you’re still in school — or perhaps especially if you’re still in school — it is crucial to attend to these biases and note how they influence your financial decisions.

1. Self-control bias

The self-control bias simply means that it’s typical for us to want to consume now instead of saving for later. When we have money in the bank from loans, it might feel like we can spend that money on whatever we want because we’ll be able to get a “good” job to pay off loans later. There’s no guarantee, however, that we will be able to afford our student loan payments after graduation. Indeed, many law students are facing the grim reality of earning “a degree they can’t use, bought with a debt they can’t repay.”

Just like the children who couldn’t wait 15 minutes in order to get a second marshmallow, we students face a challenge of self-control. We have the opportunity to accept loan disbursements for living expenses, but many of us don’t fully grasp the cost of our loans. Sure, a trip to the mall might seem trivial compared to the cost of tuition. But every time I calculate my estimated monthly loan payment, I’m a bit more motivated to get a few more wears out of a grungy T-shirt.

2. Framing bias

But what if it feels like no one else wears grungy T-shirts? It is tough to make wise financial decisions when debt is socially acceptable, but it’s our responsibility to determine what is and is not affordable for us. This is where we must decide on our priorities. For $80, would you rather (1) be a student member of the APTA for two years or (2) buy a Kindle this year and a nice pair of shoes next year? Only you can make this decision.

Social context is powerful. In the 1950s, Solomon Asch conducted experiments on conformity in college students. His experiments consisted of groups of eight students, and seven of them were confederates (i.e., actors). The task of experiment was simply to say which line on the right matched the line on the left (see Figure).

Figure. Card used for Asch conformity experiments. Participants are asked which line on the right matches the height of the line on the left. (By Fred the Oyster, GFDL,

The obvious correct answer is C. Asch found that in a control group where the actors provided the correct answer, the study participants were incorrect less than 1% of the time. When the actors all provided the same wrong answer (i.e., when all actors answered A or all answered B), participants conformed to the group’s answer 36.8% of the time. These results are fascinating, and participants reported different reasons for conforming. Many participants expressed that they knew that they were answering incorrectly, but were afraid of drawing attention by standing out.

As a student, are you willing to make tough financial decisions, even if it means standing out from the group?

3. Inertia and Default Bias

Inertia is partly responsible for the status quo bias — which is a preference for “business as usual” regardless of any evidence of its superiority. This can have harmful financial consequences when the status quo actually neglects saving for retirement, medical emergencies, or major life changes.

As students, we must be cautious when accepting our first job offer, because the quality of our benefits involves much more than salary. The tendency to accept the default offer could rob us of valuable benefits, including 401(k) matching, health insurance, continuing education reimbursement, and PTO. What is more, you may want to consider negotiating instead of accepting the offer. By the way, this excellent piece from Ben Fung (@DrBenFung) provides some tips for negotiating your salary.

Make the most of your education by overriding these biases. Don’t let these biases steal your money. 

I believe that the future of the physical therapy profession is bright, but our financial future won’t magically flourish. We have work to do. Sometimes it means being brave enough to resist conformity, and sometimes it means waiting the extra 15 minutes for that marshmallow.

For more guidance with handling your student loans, check out FitBUX and FitPT.

Pain Catastrophizing Sabotages Joint Replacements

Pain catastrophizing” is a relatively new term. In short, it’s a negative cognitive style. Laura Frey-Law & Steve George write that pain catastrophizing “at the extreme includes feelings and beliefs that the pain experienced is beyond the control of the individual and will inevitably result in the worst possible outcome” (in Sluka, 2016).

The instrument most commonly used for pain catastrophizing is the Pain Catastrophizing Scale (PCS). The PCS is free to use. Here is the manual from Michael Sullivan, and here is a printable version of the PCS.

Several studies suggest that the PCS consists of three dimensions:

  • magnification (“I worry that something serious may happen”),
  • rumination (“I can’t stop thinking about how much it hurts”), and
  • helplessness/pessimism (“It’s awful and I feel that it overwhelms me”).

There is strong evidence that pain catastrophizing is associated with greater pain and poorer function in patients with osteoarthritis, shoulder pain, and fibromyalgia. What is more, studies of low back pain and fibromyalgia found that catastrophizing predicts later pain, even though pain does not predict later pain catastrophizing. This suggests that catastrophizing isn’t just associated with pain — it may cause pain.

This appears true even after joint replacements. A recent systematic review examined pain catastrophizing in six studies of patients undergoing total knee replacements. Five of the six studies identified pain catastrophizing as a significant predictor of pain persisting 3 months or more after surgery, with one of the studies finding that pain catastrophizing predicted pain two years later. What is more, Riddle et al. (2010) found that patients undergoing total knee replacements with a preoperative PCS score of 16 or more were six times more likely to have a poor outcome. The authors defined a poor outcome as failing to achieve the minimal clinically important difference of 4 points on the WOMAC six months later.

So, if pain catastrophizing causes pain, then can we reduce the risk of pain by reducing pain catastrophizing?

There is preliminary evidence that we can. One cohort study examined the effects of a pain coping skills training compared to usual care after knee arthroplasty. The pain coping skills group focused on developing strategies for patients to cope with pain, including relaxation training, distraction, activity-rest cycling, and pleasant activity scheduling. Psychologists provided the pain coping skills sessions, half of which were within one month prior to surgery. Just two months after surgery, patients in the pain coping skills group reported greater reductions in pain severity, catastrophizing, and disability compared to the usual care group.

Psychologists may not be the only ones who can solve the problem of catastrophizing. Riddle et al. (2012) published a protocol of a randomized trial examining the effects of a pain coping program delivered by physical therapists. The researchers are tracking outcomes of patients who score high on the PCS and undergoing total knee arthroplasty. The study is interdisciplinary in nature; physical therapists in this study are receiving training from clinical psychologists, and nurses are providing arthritis education to participants. This study may provide a repeatable method for physical therapists, nurses, and clinical psychologists to cooperate and to maximize the benefit from knee replacements. The study is called the Knee Arthroplasty Pain Coping Skills Training (KASTPain) trial, and you can keep up with it here.

I won’t be surprised if Riddle and company find results similar to studies of cognitive-behavioral-based physical therapy after spinal surgery. There is evidence that physical therapy can assist in breaking the cycle of fear and disability, so perhaps we will see the same for pain catastrophizing.

Nonetheless, even though pain catastrophizing may sabotage joint replacements, we can at least identify those at risk for poor recovery.

The Time for Mindfulness is Now

How do you act when you’re angry? What about when you’re sad, frightened, or disgusted?

Do you yell at whomever is bugging you? Do you just shut down and run away? Or do you break down and cry?

Do you even know when your emotions are getting the best of you?

For those of us in the healthcare industry, we bring our emotions into every interaction with our coworkers, patients, and clients. Our feelings influence our service, for better and for worse. Sometimes it’s hard to look at someone in the eyes and set aside our differences in order to succeed with the task at hand. Animosity or outside stressors pose a problem for professional relationships and for the therapeutic alliance. I don’t think the answer to this problem is stoicism, though, because the attempt to suppress emotions could backfire.

The answer to this problem is mindfulness. We need to be aware of our thoughts, feelings, and attitudes. Only through awareness of our emotions can we let those fleeting states pass, and only through letting emotions pass can we truly attend to the present.

I’m no paragon of mindfulness. It’s not easy. But since the election on Tuesday, I feel a call to find balance so that I can be a successful student and an empathetic physical therapist. Let’s be honest — regardless of whether we’re ecstatic or outraged with the results of the election, we’re all struggling with balance in our lives right now.

Succeeding at mindfulness is tough, but practicing is easy. I found a simple three-minute breathing space practice that is accessible to anyone with just an extra three minutes. Dr. Zindel Segal writes that the three steps are as follows:

  1. Attend to what is. The first step invites attending broadly to one’s experience, noting it, but without the need to change what is being observed.
  2. Focus on the breath. The second step narrows the field of attention to a single, pointed focus on the breath in the body.
  3. Attend to the body. The third step widens attention again to include the body as a whole and any sensations that are present.

That’s it. You don’t need to be in a fancy pose. You don’t even need to close your eyes. You can do this while you’re walking, standing in line, or taking a shower. Just set an alarm for three minutes and start attending.

I’d like to add a tip for focusing on the breath. For me, I like to count the breaths, starting with 1 on the first inhalation, then 2 on the first exhalation. After 5, I count back down to 1 and repeat back and forth. I find that I get distracted less when counting up and down between 1 and 5, instead of just counting upwards.

I plan to set aside three minutes after parking my car in the morning, right before heading into the clinic. When could you set aside three minutes?

Breaking the Cycle of Fear and Disability

Spinal surgery is on the rise. The annual number of laminectomy and spinal fusion surgeries increased from 1998 to 2008 by 11% and 137% (!) respectively, even though the benefit of spinal surgery for some patients is questionable at best.

Three randomized controlled trials (RCTs) found no evidence for the superiority of lumbar fusion at 11-year follow-up. Compared to the general population, people who have had lumbar spine surgery continue to have poorer physical and mental health, and as much as 40% of individuals after lumbar spine surgery have persistent pain and disability (Atlas et al., 2005; Jansson et al., 2009).

Despite advancements in medical technology, surgery is not more effective than physical therapy for lumbar spinal stenosis (Delitto et al., 2015). But it would be remiss of us in the physical therapy profession to pat ourselves on the backs and declare victory. We need to ask ourselves why physical therapy is at least as good as surgery, if not better, at treating low back pain.

In light of evidence that low back pain is “a multidimensional disorder,” our approach in treating low back pain should be multidimensional, too. Peter O’Sullivan et al. (2016) recently published a strong plea for our health care system to embrace a “cultural shift”:

There is growing evidence that the management of low back pain needs a paradigm shift. This perspective considers low back pain (after screening for red flags) as a protective mechanism that emerges in response to perceived threats from multiple domains in the individual context. In this context, negative societal beliefs and fear about the meaning of low back pain can escalate pain and lead to unhelpful behavioral responses, leaving patients distressed and disabled. (p. 935)

The above argument is consistent with the fear-avoidance model of pain (see Figure; Leeuw et al., 2007), which argues that pain in combination with pain-related fear can lead to avoidance, disability, and even more pain. This cycle repeats indefinitely until the person confronts their pain-related fear. After confronting fear, the person can increase their activity, increase their fitness, and reduce their risk of future disability. They break the cycle.

Fear-Avoidance Model
Figure. The Fear-Avoidance Model, from Physiopedia. See Leeuw et al. (2007).

It shouldn’t be surprising that multidimensional approaches such as classification-based cognitive functional therapy (CB-CFT) yield better outcomes than traditional physical interventions (Vibe Fersum et al., 2013). Evidence for psychologically-informed physical therapy practice is puzzling, but newer approaches such as CB-CFT and the STarT Back stratification are promising.

Kristin Archer et al. (2016) are among the latest to find superior outcomes in patients receiving multidimensional rehabilitation, this time in patients receiving spinal surgery for chronic low back pain. Eighty-six patients were assigned to one of two educational treatments after undergoing laminectomy with or without arthrodesis for a chronic degenerative lumbar condition. Both treatments consisted of six sessions of 30 minutes in length, except for a 60-minute initial session. For both groups, the first session was completed in person, with the remaining five sessions delivered over the phone.

The control group focused on postoperative recovery and included discussion about proper biomechanics after surgery, the benefits of exercise, sleep hygiene, stress reduction, and strategies for preventing future injury. The second treatment, called Changing Behavior through Physical Therapy (CBPT), is a cognitive-behavioral-based approach that focuses on both decreasing fear of movement and increasing self-efficacy in order to reduce pain and disability. Sessions in the CBPT program “focused on empirically supported behavioral self-management, problem solving, cognitive restructuring, and relaxation training” (p. 80). You can read more about the CBPT intervention in Archer et al. (2013).

Six months after surgery, the CBPT group demonstrated several benefits compared to the control group. Those receiving CBPT scored lower on the Brief Pain Inventory and on the Oswestry Disability Index, and CBPT even showed improvement on performance-based tests such as the 5-Chair Stand and TUG tests. For the CBPT group, the changes were greater than the minimal clinically important difference for all measures, with effect sizes ranging from .41 to .79.

To me, this study is another drop in the bucket of evidence supporting biopsychosocial approaches to low back pain. What is more, the authors show a potential mechanism suggesting why a multidimensional approach to pain could outperform surgery alone — by decreasing the fear of movement. Indeed, those receiving cognitive-behavioral-based physical therapy education showed a reduction in movement-related fear and an increase in pain self-efficacy compared to the control group.

It’s time for us as a society to ask whether we should treat the multidimensional condition of low back pain with something as spectacularly unidimensional as surgery alone. But we can’t stop there. Are we really succeeding in promoting multidimensional approaches in physical therapy? Are we really using patient-centered care that values the uniqueness of every person?

As Archer, O’Sullivan, and others show us, we must move our profession toward the biopsychosocial model — not just in theory, but also in practice.

Only then can we break the cycle.

“Whether you believe you can do a thing or not, you are right.”

Henry Ford once said, “Whether you believe you can do a thing or not, you are right.”

His words are powerful. I imagine that he was talking the need for relentless confidence as an entrepreneur, even though we can apply his quote to the physical therapy profession, too. And I don’t just mean for what we do as professionals, but for what our patients can do in therapy. If our clients truly believe that they will improve, then indeed they will (at least on average, compared to those who don’t believe that they will improve.)

I’m not sure that any topic is hotter than patient expectations in the physical therapy profession. I’ve seen debates on Twitter about taping, cupping, and ultrasound, with a strong push back from others who want physical therapists to forget about less effective modalities and focus on exercise. On the other hand, in a presentation at the AAOMPT 2016 conference, Mark Shepherd and Tim Flynn drew attention to a recent study that suggests that the language we use about our interventions can drive progress, even for clockwise ultrasound (Louw et al., 2016). (Rather than argue for widespread use of ultrasound, Shepherd and Flynn addressed the power of our language and our relationships with patients.)

Both sides of the debate make important points. I don’t yet have the credentials or experience to offer any addition to the debate about expectations regarding the type of treatment, but I’d like to discuss some research about expectations in a different context of physical therapy. A new theory of motor learning emphasizes the power of positive expectation in motor learning, and it’s called the OPTIMAL theory.

OPTIMAL is acronym for “Optimizing Performance through Intrinsic Motivation and Attention for Learning,” and it was proposed by Gabriele Wulf and Rebecca Lewthwaite in a 2016 paper in Psychonomic Bulletin & Review. Whereas discussions about expectations often end up arguing about whether we should focus on exercise only or whether we should include other approaches like manual therapy, dry needling, kinesiotape, electrical stimulation, or thermal modalities.

We are probably more likely to agree that exercise and motor learning are important in physical therapy. Wulf, Lewthwaite, and other scientists have conducted several studies about expectations in motor learning, and I think that physical therapists should know about these studies. Research in this field focuses on learning a variety of skills, ranging from putting in golf to bowling in cricket, and many other studies examine the effects of expectations on balance training.

For example, Lewthwaite & Wulf (2010) examined the role of positive feedback on balance training, and assigned participants to one of three groups. One group received positive feedback, even though it may have been false positive feedback. This group was told their performance on a balance task was better than average, no matter whether their performance related to average performance. The second group was told that their performance was worse than average, again regardless of actual performance, and the third group received no normative feedback.

In a delayed retention test, those in the “better” group showed more effective learning than those who were told that their performance was “worse” than average. What is more, the control group performed similarly to the “worse” group. Aside from ethical concerns about honesty, that sounds to me like we should heap unconditional praise on people, and that staying silent is just as ineffective as telling them that they’re doing a lousy job. Wulf & Lewthwaite also mention that research supports incremental theory over entity theory suggests that we should ensure that we praise performance instead of a trait. In other words, we should say something like, “Those kicks were very good,” instead of something like, “You are a great soccer player.”

Even tricking the brain can lead to better performance. One study of putting assigned participants to practicing putting in different iterations of the Ebbinghaus illusion (Witt, Linkenauger, & Proffitt, 2012; see Figure). Half of participants practiced putting into a hole that appeared small because of the illusion, while the other half practiced into a hole that appeared large. The group that believed that the hole was large performed better on a retention test, which may challenge us to find ways to modify the environment of our clinics in order to encourage confidence.

The Ebbinghaus illusion.
Figure. The Ebbinghaus illusion. The orange circles are the same size.

Another putting study showed that those who practice putting into a target with a 14 cm diameter performed better than those who practiced on a 7 cm diameter. Though it may seem logical to practice in with challenging parameters, the authors suggest that we are better off practicing in an environment that is easier at first in order to build confidence.

Wulf & Lewthwaite argue that these positive expectations promote greater focus on the task goal and decreased self-focus during a task. Expectations are only one part of the OPTIMAL Theory, and I encourage those interested to read their paper to find out more.

After reading the paper myself, I might not be a better golfer, but I do have a better idea of what I would look for in a golf coach.

And of what I would look for in a physical therapist.

The STarT Back Screening Tool is Changing Physical Therapy

Forecasting is tough work. Whether one is a meteorologist or a stock broker, it takes guts to make a prediction. The same applies to making predictions in the physical therapy profession.

The beauty of a prediction is that it is testable. We can look at a set of data, make a reasonable guess about what will happen, and see what actually happens. All too often, health professionals avoid gathering enough data to even make a prediction. If you’re a therapist, then perhaps you’re tempted to get started on treatment because you’re afraid of irritating your patient with a lengthy evaluation. Perhaps you doubt whether standardized outcome measures really make a difference. Perhaps you’re just so overwhelmed by the sea of available measures that you won’t even test the water.

But if you treat low back pain, then one short, simple measure demands your attention. It’s called the STarT Back Screening Tool, and it’s changing the physical therapy profession.

The STarT Back Tool (abbreviated from Subgroups for Targeted Treatment Back Screening Tool) consists of nine items. Here is a printable version. It includes items about several aspects of low back pain: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter five items comprise a psychosocial subscale. Scores range from 0-9, and a score falls within one of three subgroups based on “risk” for poor prognosis. Low risk scores range from 0 to 3. If someone scores 4 or 5 on the psychosocial subscale, then they are classified as high risk. All other scores are classified as medium risk. 

The goal of the STarT Back Tool was to aid decision-making in primary care. Those considered high risk for poor prognosis may be identified and referred to other services — particularly psychological services — while those considered low risk wouldn’t receive the same treatment. This type of stratified care lends itself well to empirical research, because patients could be randomized into either standard care or stratified care after classification into their respective risk-based subgroups.

The group at Keele University that designed the Tool conducted exactly this experiment. Hill et al. (2011) found that those receiving stratified care showed a greater reduction of disability compared to standard care at 4 months and 12 months (with Cohen’s d of 0.32 and 0.19, respectively, and p < .01 for both time points). What is more, those receiving stratified care achieved a greater mean increase in generic health benefit and greater cost savings compared to the standard care group at 12 months.

There were several differences between the stratified care model and the standard care model. The main distinguishing feature of the stratified care group was high risk patients received psychologically-informed physical therapy, for which the physiotherapists received nine days of training. Also, those in the low risk group received only one visit in the stratified care group, consisting primarily of education and encouragement to exercise and to return to work.

Using the STarT Back Tool in primary care is one thing, but what about in an outpatient physical therapy setting?

At the University of Florida, Jason Beneciuk and Steve George (2015) conducted a study similar to that of Hill et al. (2011), but with a twist. Whereas the Keele University group provided extensive training of therapists, Beneciuk & George provided only 8 hours of training and did not randomly assign treatment based on score on the STarT Back Tool. Instead, Beneciuk & George randomized physical therapists into either a group receiving no training or a group receiving the 8-hour training about psychologically-informed physical therapy and pain neuroscience. The training discussed activity-based interventions such as graded activity/exposure and educational-based interventions that incorporate explanation of basic pain neuroscience.

Beneciuk & George found that those receiving stratified care showed greater improvements compared to standard care at 4 weeks for both pain and disability (with Cohen’s d of 0.4 and 0.76, respectively, and p <= 0.01 for both). What really makes these between-group differences fascinating is that the researchers didn’t actually control the type of interventions. Instead, they merely provided education to physical therapists and let the PTs be PTs.

Based on the data, though, we can’t rule out the possibility that educating PTs about pain neuroscience and psychology could lead to greater therapeutic alliance. Whether or not this study is a victory for psychologically-informed physical therapy, it certainly appears to be a victory both for increased training for PTs and for increased screening using the STarT Back Tool.

What is more, The STarT Back Tool is more predictive of chronic low back pain than are physiologic measures, demonstrates acceptable reliability and validity in several languages, and is mentioned in the clinical practice guidelines for low back pain by the Orthopaedic Section of the APTA. A recent preliminary evaluation even shows promise for modifying the STarT Back Tool to assess other pain conditions.

In an outpatient orthopaedic setting, I’m much more comfortable with predicting prognosis after learning about the STarT Back Tool. Still, it takes hard work to know when to modify your treatment and when to refer your patient.  

But maybe forecasting is a little less tough after all.

The Curious Case of Psychologically-Informed Physical Therapy

I love psychology, but physical therapy has a psychology problem.

I’ve already written about how the physical therapy profession should be more willing to embrace psychological research. There are some good explanations of why PTs are slow to adapt their practices to the biopsychosocial model. Many psychological interventions are poorly described, poorly implemented, and even poorly supported by evidence. Still, there is evidence to suggest that the psychosocial aspect of pain is more important than muscle physiology in predicting chronic pain. To me, ignoring the psychological element of physical therapy is just plain backwards. To others, we talk too much amount psychology.

The pendulum swings far and swings often with this topic in physical therapy. This isn’t surprising, considering the inconsistent research findings and the philosophical extremes about the role of psychology in physical therapy. One recent publication from Mary O’Keeffe et al. (2016) highlights the inconsistencies in this research, and the paper leaves me wondering where the pendulum will swing next. (By the way, Dr. O’Keeffe is on Twitter.)

O’Keeffe et al. completed a systematic review and meta-analysis comparing physical interventions, behavioral/psychological interventions, and interventions that combine physical and psychological strategies. The authors reviewed 24 randomized controlled trials that investigated differences in treatment effects for nonspecific chronic spinal pain. The “physical” interventions included TENS, ultrasound, stretching, exercise, motor control exercise, manipulation, and massage, while “psychological” interventions included breath therapy, relaxation therapy, and cognitive-behavioral therapy.

Most trials in the review compared physical interventions to combined approaches, with most studies finding no significant differences between groups. Only four of the studies found significant differences in both pain and disability, favoring combined approaches (Friedrich et al., 1998; Friedrich et al., 2005; Kankaanpaa et al., 1999; Sahin et al., 2011). The authors’ meta-analysis yielded statistically significant differences for both pain and disability between groups at short-term and a statistically significant difference for long-term follow-up in disability.

O’Keeffe et al. conclude that combining physical and psychological treatments appear to offer “only a small additional benefit” (p. 12). The authors recommend that physical therapists consider the time and resources necessary to provide combined interventions in order to choose the most cost-effective option.

If there really is a strong psychosocial component of nonspecific chronic pain, then this paper is puzzling. Why aren’t psychological treatments more effective than purely physical ones? As far as explanations for the lack of differences between groups, O’Keeffe et al. offer four possible reasons:

  1. Both physical and psychological treatments may involve a shared mechanism. For example, perhaps both exercise and cognitive-behavioral therapy lead to decreased fear of movement and improved self-efficacy, which thereby lead to reduced pain and disability.
  2. “Nonspecific factors” such as therapeutic alliance, patients’ expectations, and patients’ treatment preferences may drive progress in therapy, regardless of the type of intervention.
  3. The RCTs might not have been appropriately designed. O’Keeffe et al. note that even some “combined” approaches did not even discuss with patients the importance of sleep and life stress.
  4. The RCTs may not have tailored treatments to the needs of patients.

All four of these reasons are not only plausible, but also supported by evidence. The fourth reason deserves particular attention, in my opinion. O’Keeffe et al. refer to a large RCT that categorized patients with low back pain into different “risk” profiles (Hill et al., 2011).  Hill et al. found that some patients may be more likely to benefit from psychological intervention if they are in the “high risk” category, which is characterized by psychosocial elements of pain (e.g., pain catastrophizing, fear of movement).

This presents an interesting direction for psychologically-informed physical therapy practice. If there is a meaningful way to predict which patients will benefit from a psychological intervention, then PTs who are uncomfortable with psychological techniques could effectively screen “high risk” patients and refer them to the appropriate professionals who are comfortable with those techniques. What is more, PTs who prefer to incorporate psychological treatments in their practice could identify patients who are most likely to benefit from those treatments.

Recent research about this type of stratified care is promising. In an upcoming post, I’ll spend more time on how the STarT Back Screening Tool is a compelling way for physical therapists to stratify care.


Going to St. Louis for AAOMPT 2016? Find me!


In one week, I will be flying to St. Louis, MO, to attend the national conference of the American Academy of Orthopaedic Manual Physical Therapy (AAOMPT). If you’re going to AAOMPT, then find me! I’m giving a platform presentation at a Research 5×5 on Saturday, October 29th at 10:15 am. The platform is about a study group — “Ortho Club” — that my DPT classmates and I created to prepare for our first clinical internship at the University of Florida.

If you’re going to AAOMPT, then I also encourage you to look for my fellow students who won scholarships from AAOMPT sSIG for their one-minute videos answering the question, “What does orthopaedic manual physical therapy mean to you?”

Check out our videos here.

My fellow AAOMPT sSIG scholarship winners include:

  • Daniel Crusoe and Rachel Selina (University of Michigan-Flint)
  • Eric Fridline (University of Michigan-Flint)
  • Rachael Lewin, George Tate, and Richard Eatinger (Bellarmine University)
  • Jessica Holloway (Northern Illinois University)
  • Joel Fundaun (Regis University)

I am looking forward to AAOMPT 2016, and I hope to see you there!

What are your goals?

“I’m going to walk out of here without a walker, without a crutch, without a cane — without any of that.”

A patient told me this during his evaluation in inpatient rehab. It was three days after his total hip replacement. Considering that he was still struggling to walk with a walker, I remember appreciating his optimism even though I may have doubted his prediction. It was the first week of my internship, so I had the opportunity to work with him until his discharge. I was excited to see how well he would progress, not just because I cared about his improvement in therapy, but also because I was curious about whether he would meet his ambitious goal.

He was right. I was wrong. “I told you I wouldn’t need any of that stuff,” he told me right before his discharge.

The day my patient was discharged, I learned an important lesson about the power of setting goals. I felt that merely the act of telling me his goal made it more likely that he would achieve it. If he had not told me his goal, then I probably would have set different goals for him, like being able to walk with a cane instead of a walker. He had a higher goal in mind, and I simply wouldn’t have known about it if I hadn’t asked him.

There is a temptation in physical therapy to set goals for patients without including patients in the process. On one hand, there is actually some evidence that assigning goals to people (i.e., instead of allowing participation in goal setting) might not necessarily lead to worse performance, so long as the goals are important enough to the person trying to meet them (Locke & Latham, 2002Latham, Winters, & Locke, 1994).

There are are several risks to assigning goals to patients without their participation, however. One problem is that the goals of the physical therapist aren’t always important to the patient. How many people really care about hip circumduction or thoracic kyphosis? If we can educate people to explain why they should care, then that’s one way to improve performance, but we still might be missing the forest for the trees. We still might miss the patient’s higher objective. 

I first heard about the idea of a higher objective from an episode of the Healthcare DisruPTion podcast, in which Jerry Durham and Andrew Rothschild interview Matt Watkinson — author of The Ten Principles Behind Great Customer Experiences.  Durham, Rothschild, and Watkinson talk about many ways that physical therapists can improve the customer experience for our patients. One of the biggest mistakes that we make in healthcare is that we overlook what’s actually important to our customers. People want to be in less pain, to play a better round of golf, or to walk out of the clinic without their walker. As Theodore Levitt said, “People don’t want to buy a quarter-inch drill, they want a quarter-inch hole in the wall.”

In her book Grit: The Power of Passion and Perseverance, Angela Duckworth talks about how our goals should fit within a hierarchy. Our top-level goal should be an ultimate purpose, whether it is related to our health, family, or career. Dr. Duckworth writes that we should have several mid-level goals to support to top-level goal, and several low-level goals to support our mid-level goals. As physical therapists, we might know how to write low-level or even mid-level goals for our patients, but only our patients can write their top-level goals — their higher objectives.

Since we can’t telepathically know our patients’ top-level goals, then what good is a patient evaluation without asking about goals?

If I hadn’t asked about my patient’s goals, then I would have been satisfied with the goal “to ambulate 500 feet with least restrictive assistive device.” I would have missed the point, though. He didn’t want any of that.

“A Middle Way”: Psychologically Informed Physical Therapy Practice

One day in PT school, one of my professors gave a strong case for why anatomical factors are less predictive of persistent pain than are psychological factors. My classmates were a bit speechless. I couldn’t blame them. We just spent several months — and an unbelievable amount of tuition money — learning anatomy under our assumption that pain in a certain anatomical location is related to injury to a certain anatomical location. That day in class, it felt like the air was let out of the room.

But I was thrilled.

After class, I asked my professor a few questions about psychology in physical therapy. I wondered whether cognitive-behavioral therapy was within our scope of practice as physical therapists. I questioned whether physical therapists are open to psychological interventions. I asked what psychological treatments look like in a physical therapy setting. He answered my questions graciously, and told me that he had something that would probably interest me.

He brought me to his office and showed me a special issue of the Physical Therapy Journal on “Psychologically Informed Practice.”  I was still thrilled, with my excitement getting increasingly geekier. I read every paper in the issue, word for word.

That day altered the course of my training as a student. As I’ve said before, my background is in psychology. Over the course of several years, though, I drifted away from the field of clinical psychology and toward the field of physical therapy. I thought that I had moved to other side of the planet as far as health professions are concerned. Finding out about an approach to physical therapy that embraces psychology tied my two primary academic interests together.

In that special issue of PTJ, Chris Main and Steven George elaborate on the definition of psychologically informed practice (PIP). They write,

Psychologically informed practice is offered as a “middle way” between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness.

The authors describe standard practice as having the primary goal of reducing symptoms, with the core philosophy of addressing physical impairments based on biomedical concepts. On the other end of the spectrum, mental health practice carries the primary goal of minimizing the impact of psychological disorder on quality of life, with the core philosophy of identifying and treating mental illness. Main & George suggest that the primary goal of psychologically informed practice is secondary prevention of disability, with the core philosophy of incorporating patients beliefs and emotions into patient management based on a biopsychosocial approach.

In simpler terms, standard practice cares about physical problems in order to reduce physical symptoms. Psychologically informed practice cares about physical problems and the psychosocial parts of their problem, and PIP aims to reduce the impact of a condition or injury even if the symptoms remain. A logical extension of this approach is that PIP may involve a physical therapist providing something like cognitive-behavioral therapy in order to manage factors that contribute to the pain experience.

For many physical therapists, awareness of the psychosocial component of pain is nothing new. In my experience, though, many PTs have never heard the term “psychologically informed practice,” and they have no intention to learn how to use psychological interventions. (Unless they say that exercise is a psychological intervention, which appears partially true for some people, but probably not true for serious mental illness.)

Thus, there is likely a wide range of responses to PIP. I’m particularly interested in those who are either students or fresh PTs. Do you feel confident in providing something like cognitive behavioral therapy? If not, then would you want to learn how to do it? From the many conversations I’ve had about PIP, it seems that the longer a PT has been practicing, the less willing they are to provide PIP.

I have no interest in trying to convince someone to take a specific view about PIP. Rather, I’m interested in working together to find out (1) whether PIP is actually more effective than standard care and (2) how to use PIP in a specific, repeatable way.

So far, the answers to these questions are complicated. Every year, though, the research literature sheds more light on PIP. In an upcoming post, I’ll focus on a study published last year by two of my PT school professors: Jason Beneciuk & Steven George.