If you stop and listen when you are in the clinic today, what phrases do you hear?
Through the various sounds bouncing off the clinic walls, I am sure some phrases will stick out to you.Here are a few that I have heard in my time as a clinician that I feel need to stop.
“Squeeze your Glutes”
This is often times used as a verbal cue.Although the PT may be targeting the gluteal muscles for a good reason, I often visualize the patient ambulating of descending stairs.Even though the gluteal muscles may need to fire, the cue “squeeze” just doesn’t seem to fit into true functioning.When was the last time you truly and consistently “squeezed” your gluteal muscles when ambulating or descending stairs.I am all for engaging the gluteal muscles when needed, but let’s pick a better phrase than “squeeze your glutes.”
“If you feel pain, stop.”
As I reflect on my early career, I used this phrase often.The major issue here is that this only contributes to the ‘hurt equals harm’ mindset.If we are using best practice we should empower patients not to be fearful of pain.This phrase misses the mark.If a patient feels pain, we should investigate further – is it getting worse, how intense is it, etc.?We should not just immediately abort the mission.If someone feels pain with an activity, explore and empower.
“Relax, relax….RELAX!”
This is a pet-peeve of mine and I hear this often when PTs are performing manual techniques or passive movements usually in an attempt to make the patient relax so that they can perform said technique.This verbal phrase is usually followed by the therapist wiggling the arm, almost in the same way we might wiggle the cord to the vacuum cleaner when it gets hung up on something.I don’t know about you, but this motion plus a verbal cue of saying RELAX does everything but allow the patient to relax. If the patient is not allowing you to freely move him/her it is probably more about you than the patient.Make sure your manual non-verbals say “I got you” and let that do the talking.
“They are faking their pain.”
All pain is real.This phrase is usually the one that comes after working with a challenging patient, usually one who is suffering from persistent pain and has been passed around the medical system for some time.They are often lacking trust in any healthcare provider and often feel like no one believes them.If your mindset is that the patient is faking their pain, you have not done your job of digging deeper to see what other factors are going on in the patient’s life.As healthcare providers, we should do all we can to treat with empathy and respect – this phrase does little to support that notion.
Of course there are probably more out there that you hear on a daily basis and my phrases are mostly biased to the outpatient setting.My question to you is what phrases do you want to have stop?
@ShepDPT
––– Comments
Matt
Commented • February 24, 2019
“If you feel pain stop”. So what should we change this to? “If you feel pain, keep going, ignore it”. Actually one of my statements I never want to hear. “No pain, no gain”, I hear that all the time and that is frankly stupid when used in Physical Rehabilitation. Use it all you want for power lifters and body builders but that isn’t the game in PT. It depends on the situation, of course it is appropriate and essential for a patient to stop if they feel pain, especially if it is new or unexpected. Once you suspend the activity, then you have a conversation about the location, intensity, duration, etc. Then make a decision to proceed, modify, or discontinue the activity. I have had techs tell the patient without my permission to “keep going” in orthopedic acute care just post-op. NO!!!! NO!! And NO!!! That is not to say we are afraid of discomfort, that is par for the course but unexpected or severe pain must always be investigated. Most often, you rest, investigate it and proceed. That maximizes safety and the patients sense of control. My statement to stop is to stop telling patients to “straighten up their back” as soon as they get out of the w/c or hospital bed. Whoever says that is putting no thought into their statements. None, you are repeating something your mother told you when you were a kid. That has no place in a professional medical instruction. You will not find that cue in any research based literature, it is nonsense, and detrimental to the patients gait and balance performance especially if they have been immobile for an extended period of time prior to standing. The biggest source of information we utilize for gait and balance is vision so you are telling the patient to alter their visual plane and natural visual focus which diminish les their visual information regarding movement so they can what have a straight spine? I got news for ya, unnaturally standing up straight doesn’t suddenly straighten the spine. That is plain stupid and everyone says it all the time. If your concerned about spinal posture why don’t you speak of posture when they sitting or laying down? The elderly spend far more time laying down and sitting than they do walking or standing yet no one ever talks about posture in those positions. They only care about it when the poor patient stands up... Do you think the gravitational forces acting on the spine only occur in standing? That is a stupid and uninformed thing to say yet go to any hospital in America, any SNF and you will hear PT’s and Nurses shouting it out everytime a poor patient stands up or walks. It’s stupid and detrimental. PLEASE STOP SAYING IT!!!
Mark Shepherd
Commented • April 1, 2018
Thanks for your input, Suhail. While I respect your points, I have to disagree with your first couple of comments. I still stand by my thoughts about the phrase "squeeze your glutes". I think my main frustration here is the word "squeeze". I definitely agree that the cue is straight forward and can be used with the specific tasks you listed, but I much rather use tactile cues matched with a verbal cue of "you should feel your muscle engaging here." I think squeeze gives the patient an all or nothing cue. Now maybe this is the goal and I can get that, but most times if we are trying to try for functioning, we shouldn't be having a maximal voluntary contraction. You mentioned: "As therapists we need to advise patients on what kind of pain is normal and expected." I agree, but would change your verbiage to "we need to advise patients on what types of sensations are to be expected." Your examples highlight the dichotomy of good vs. bad pain - is there such a thing? Who decides on whether pain is good or bad - us? The patient? Isn't pain meant to protect - thus being a good thing? Furthermore, you stated that "In this case I would not want my patient to ignore this phrase because it will lead to further injury" - I also am not sure I 100% follow this as not all pain indicates tissue damage. Check out this article to gain more insight/review on these topics: https://www.tandfonline.com/doi/abs/10.1080/09593985.2016.1194652?journalCode=iptp20
Mark Shepherd
Commented • April 1, 2018
Serena - thanks for reading. I agree here. We shouldn't shame or guilt people into doing something - we are trying to change behavior and it is not that simple. If we want someone to participate in a program we have to investigate their beliefs, expectations, resources, etc. in order to be successful - not just throwing out phrases like this.
Serena Keklik
Commented • April 1, 2018
Dear Mr. Shepherd, Thank you for the great post and I agree with all of the points. I work with the geriatric population in an inpatient setting. I hear the phrase “use it or lose it” very often. I understand that therapists want to motivate patients to comply with exercise program rather than refuse it. I think we should look at the underlying reason for the refusal first. Does this phrase really help to encourage them to participate? Sincerely, Serena Keklik, PT
suhail
Commented • April 1, 2018
Greetings Dr. Shepherd, I like “squeeze the glutes” as a cue because I only use it during specific exercises like squats, bridges, kettlebell swings, or deadlifts. It’s an easy cue to understand and makes the exercise more effective. During functional activity like ambulation and stair descending you want unconscious glute activation which will come from increased tone due to exercises that emphasized glute activation. I think the “if you feel pain stop” is good advice for the patient to follow at home. As therapists we need to advise patients on what kind of pain is normal and expected. For example during stretching the patient may report pain as stretch pain that feels good after. This would be expected pain that is normal. However if the patient has a strain and stretches they will feel a different kind of painful stretching sensation as if the muscle is tearing. In this case I would not want my patient to ignore this phrase because it will lead to further injury. This was a great topic to blog about and I liked your advice on the “Relax” cue. I think every PT can relate to that situation and has probably used that exact cue. A phrase I would like to see stop is “You need to lose weight.” While this can be a contributing factor to the problem, I’ve see too many PTs fall back on this as the cause when they can’t figure out the real issue. Warm Regards, Suhail PT
Tyler Compton PT, DPT
Commented • March 27, 2018
The context that I am thinking of and hear most often is related to your first example. I.e. Clinicians telling patients to keep a neutral spine while performing exercises to protect the spine. I wish I heard more of your second example!
Phil Gainan
Commented • March 23, 2018
Some times the verbage that comes out of our mouth may be the info. that has been passed down from previous generations . Often times it can be even be nonsence; but we have heard it so many times it can feel like it is a fact.
Tereza Strausser
Commented • March 23, 2018
That is really funny, but sadly true. Agree with all these and got a couple more in my head.
Mark Shepherd
Commented • March 23, 2018
I agree that it could potentially send this message, but feel that the context around it will make or break the message. If you are saying that your spine is unstable and using our muscles will make it more stable to protect it can increase threat and fear - pain will be effected by this. If we talk about your nervous system being like an alarm system to protect your body, spine, etc. that can be more healing than harmful. The context changes the message. By and large, though, we have to be cautious with how we frame this phrase. Thanks for your input and reading!
Tyler Compton PT, DPT
Commented • March 23, 2018
I'm interested to hear people's thoughts on "Protect your back/neck." To me this instills the idea that these structures are fragile and easily damaged.
Mark Shepherd
Commented • March 22, 2018
This phrase also only reinforces the boom-bust cycle that many patients often experience and leads them to frustration and ultimately more pain.
Mark Shepherd
Commented • March 22, 2018
"Wear and tear" - this is another good one. The challenging part about this phrase is that it rolls off the tongue so easily. I have been caught mid phrase saying this at times and is something we really need to watch!
Zach Kovacevic
Commented • March 21, 2018
Utilizing "wear and tear" to describe joint pathology can re-inforce fear-mongering and catastrophization often making it difficult to encourage any sort of movement (what we do) into the plan of care.
Sheik Abdul khadir A.M.K
Commented • March 21, 2018
We may have to stop "No pain ,No gain" This implies that more the pain more the benefit.
Jennifer Stone
Commented • March 21, 2018
I think I like the term "support" better. Depending on the patient sometimes I use "motor control" also.
Mark Shepherd
Commented • March 21, 2018
The "stability" word gets to me as well. I often feel like this word is non-threatening when talking PT to PT, but when used in front of a patient, I am not so sure I would go there. We may mean that we are trying to improve the motor control of the spine, but saying the word "stable" or "stability" implies that something is unstable. Not the best imagine to have in one's mind.
Mark Shepherd
Commented • March 21, 2018
Amen.
Rob
Commented • March 21, 2018
“Your [fill in the blank] is out and mobilizing will put it back in”. It’s ingrained in so many of us and always sounds like nails on a chalkboard to me...
Jenn Stone
Commented • March 20, 2018
Anything that references any body part being “out” or “dislocated” (when it isn’t actually). The term “stability” when it comes to the spine can be okay but I have too often heard it used to mean “immobility” and have major issues with that.
Mark Shepherd
Commented • March 20, 2018
Wow, Kelli. Thanks for sharing your story. It is amazing to me how many providers people will see and usually aren't any better for it. Unfortunately, many of these providers are PTs. Many times when we fail, we blame the patient - "they were faking", "they were non-compliant", on and on. I love how you really confronted your pain and looked at the many factors that contribute to the pain experience. You use your experience as ammo to empower your patients - way to go! Thanks for reading.
Kelli
Commented • March 20, 2018
I really like your fourth phrase that needs to stop: "They are faking their pain." A few years ago, entering my last year of my DPT program, I began to have unrelenting back pain. I had countless PT professors and clinical instructors look at me. I have had 10 musculoskeletal diagnoses given to me by numerous clinicians who are colleagues. My pain began to change and is not only in my back, but groin, shoulder, and sometime radiates up into my face. I've had a lot go on in my life over the past few years, many stressful events that have been major triggers of my varying pain types of pain. I'm currently in the process of eliminating those triggers (transitioning out of patient care) in order to help with my pain. Battling chronic pain, depression, and anxiety has made me an entirely new clinician. I understand my patients so much more now than ever before. My personal experience has taught me so much more than anything in my academic or formal clinical education could have taught me. I am more empathetic and more willing to listen to patients. Often times, if a patient comes to an evaluation in extreme pain, I often will spend the majority of the time listening while employing gentle techniques. Many times, people need "manual therapy" just as much for their mind as they do their physical body. I'm such a believer, both personally and professionally in Lorimer Mosely's work on pain science. I wish every PT would read his research and educate their patients more on pain. The brain is a powerful thing and as PTs, we need to exercise the brain (patient education!!) just as much as we need to physically exercise or mobilize the physical body.
Katie
Commented • March 20, 2018
At my job (and I'm sure many others) we are suppose to document a pre and post pain number. I often fail to meet that standard, or will ask pre and post, post treatment. Not best practice for accuracy but I HATE starting a session asking for a number. It alone almost never changes my plan.
Keith Roper
Commented • March 20, 2018
Absolutely! We are asking them to confirm our biases and many do...
gohar
Commented • March 20, 2018
This post is helpful to me. thanks
Mark Shepherd
Commented • March 19, 2018
Great one! How we frame the question can lead to bias and only reaffirm our own biases. Using something like "how are things feeling now" or "has anything changed" are probably better open-ended questions that the patient can answer in their own words. Thanks for reading.
Mark Shepherd
Commented • March 19, 2018
Yep. Starting a PT session with this I think is a slippery slope!
Mark Shepherd
Commented • March 19, 2018
Nice, Tim! These definitely resonate with me. Many of these play into the potential for not building self-efficacy in the patient. Too often I see people with persistent pain come in over contracting their core or even thinking that if they do not actively and consciously contract their core, something "bad" will happen. This takes some time to de-educate to re-educate.
Keith Roper
Commented • March 19, 2018
"Does that feel better?" immediately after an intervention. The pt feels obliged to concur, most of us like to please, but this influences the patient response and makes it less likely they are honest with you. As if pain is always caused by a lesion we can Fix with an intervention...
James E Glinn Sr
Commented • March 19, 2018
How about stopping or minimizing the usage of this question:"What is your pain number today?"
Tim Mondale
Commented • March 19, 2018
How about, you have pain because of "a weak core", "joint stiffness", or "faulty mechanics", as if there is a causal relationship?