Go to your home, ball.

“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.