To follow, or not follow, the script? That is the question (Act 2) — physios’ attention to the human aspects of care for people with low back pain
Lauren FinestonePhysios should ‘tinker with’ or ‘throw away the script’ if they want to respond in a more person-centred way to patients with low back pain.
In Act 1 of this article we looked at a study that illustrated the importance of physios recognising, acknowledging and respond to patients' emotions when they care for people with low back pain.
In this article we cover another 2 themes from that study: how time pressures and focusing only on the biological aspects of care limit physios’ ability to provide the best care to their patients.
Actual or perceived time pressure can challenge physiotherapists ability to address the human aspects of care. That’s when they conform to scripts.
[[you’ve got half an hour, and you’re so focused on the clinical reasoning and getting to the bottom of what could be going on, it’s hard to think about the psychosocial stuff.’]]
The study suggests that there are more opportunities to address human aspects of care when physiotherapists deviate from, or abandon, time-related scripts.
When physios stick to the script
During their fifth consultation, Christine asks Richard how he is.
Richard: ‘Feeling better but I have ongoing right buttock pain’.
The observer noted: ‘Christine sounded really rushed trying to check if the previous exercises and advice were working for Richard. She then rushed through more questions before swiftly moving to the next ‘act’ in the script — the physical examination.
The study found that due to pressure to treat patients within the allotted time, physiotherapists may focus on what they believe is important, rather than what the patient's main concern is.
Here, Christine focused on Richard’s neck despite exploring his main concern — his back —and without giving him the option of saying what he’d like her to focus on.
When physios ‘tinker’ with scripts
Carol Physio initially follows the script with a brief, fast-paced interview and physical assessment, then quickly moves into treatment. But she shifts the pace during treatment. She uses a soothing voice and allows moments of silence, enabling Alice to share more personal information.
Carol: ‘How’s your husband doing?
Alice: ‘His recent PET scan results showed 3 tumours and the doctor was pretty blunt when he told us’.
The study found that when physiotherapists ‘tinkered’ with the script by slowing down the pace of the consultation and creating a safe space for patients to open up about personal issues — while still providing hands-on treatment and focusing on exercises — this allowed Alice to attend to the human aspects of care by showing empathy and being a listening ear.
When physios abandon scripts
In one example the physiotherapist, Rob, abandoned the usual time constraints and spent 50 minutes with Alan instead of the scheduled 30 minutes. This allowed for more time for him to listen to Alan, explore aspects of his life that may be contributing to stress and discuss the relationship between this stress and pain.
The conversation also allowed Alan to self-reflect, and Rob suggested ways to help him increase his confidence and be more comfortable with his back in social situations:
Alan: ‘It’s probably me. Slack. Lazy. Stupid.’
Rob: You’re a bit hard on yourself. We need to build you up so that you have confidence in yourself to lift that case of beer.’
Focus on the bio
When physios conform to scripts
The research found that physiotherapy mostly focuses on physical problems and patients usually agree with this approach. This makes it hard for physiotherapists to use different methods of treatment.
This can result in missed opportunities to understand important patient details, incorporating their concerns and experiences and glean insights into the emotional, social and other contextual factors relevant to the patient's health which and may have led to a different treatment focus.
In Linda’s third clinic visit, she was seen by a third physiotherapist, Claire. Clair began by asking about exercises and what Linda would like to get out of the session.
Linda: ‘I’ve not had a diagnosis and I’d like to know what it is. Also, I’d like to know that I won’t have this for a long time. I want to know that I will get rid of it.’
Claire tries to explain to Linda that her back pain is caused by irritation in her L4/5/S1 region and sacroiliac joints, and that movement will help to settle it down. Linda is not convinced and tries to explain that her pain is at night and that she is tired, but Claire doesn’t respond to this and continues to insist that more movement is better.
Linda also mentions that she was stressed because an ambulance was called for her daughter the night before, but Claire doesn’t discuss this. Her focus on biological concerns misses important emotional, social and contextual factors that may be contributing to Linda's health issues.
When physios ‘tinker’ with scripts
Sometimes, the physiotherapist would consider emotional and social factors, but mainly only in addition to the main focus on physical problems and treatment.
The consultation with carol and Eva began following the typical script, discussing Eva’s pain location and possible physical causes. But the scene changed when Carol began treatment and started soft tissue massage on Eva’s leg.
Eva: (Laughing): ‘I’ve been 1 week without exercise. I know it’s good for me but I know I won’t do it’.
Carol (gently): ‘Stretching would be good especially after shifts. But not when you come home, you are probably too tired. After a good night’s sleep you can try.’
More soft tissue massage on Eva’s leg.
Rather than moving to the next question, Carol’s focus changed. She responded to Eva’s emotionally-laden concerns about being asked to do exercises. She didn’t abandon the biological focus (exercise), but offered a solution to accommodate Carol’s context (acknowledging how difficult it can be to exercise after work).
When physios abandon scripts
It was rare for physios to abandon the bio-focused script. But there were some examples: during Pilates classes, physiotherapists prioritised social aspects of care and created a relaxed, social environment where patients and therapists shared personal information and laughed together.
The observer noted that the patients seemed to enjoy this approach and one patient even stated ‘laughter is the best medicine’.
The takeaway messages
Scripts are embodied in the everyday work of physiotherapists, unconsciously reinforcing approaches to care and making it difficult (but possible) to move beyond them.
Changing or throwing away the traditional physio scripts could potentially change the ending of the physio engagement. It could improve the care delivered to patients and support them to live a flourishing and meaningful life.
M. Dillon, R. Olson, K. Mescouto, N. Costa & J. Setchell (2023): How physiotherapists attend to the human aspects of care when working with people with low back pain: a thematic analysis, Health Sociology Review.
Published 09 February, 2023