allowed to be actively involved in the decision-making process and establishes agreed-upon expectations and goals. It’s important to discuss with patients alternative treatment options that are available to them and the likely outcome of the therapy you are providing. This in turn will create realistic patient expectations, formulate achievable treatment goals and improve patient satisfaction. See Box 3 for tips on how to prevent miscommunication.

HOW TO DEAL WITH PATIENTS IN CHRONIC PAIN

Often patients with chronic spinal pain are likely to develop signs of clinical depression and this can lead to difficulties with anger management. When we are experiencing pain or injury, it is easy to change the way we communicate. You can appreciate how quickly a patient will become tired, short tempered and irritable as their symptoms persist. In these situations the patient’s perception of pain can alter, a large number of psychological barriers can then arise towards an outside therapist trying to be proactive and assist their recovery. If a therapist encounters a patient in this situation, try to imagine a protective psychological barrier to keep a clear professional boundary – otherwise patients can quickly place unnecessary expectations and burdens on the therapist, which can be difficult to cope with. One example of this is the

development of ‘yellow flags’ which are psychosocial indicators suggesting an increased risk of progression to long- term distress, disability and pain. These can relate to the patient’s attitudes and beliefs, emotions, behaviours, family, and workplace. The behaviour of health professionals can also have a major influence. The presence of yellow flags may highlight the need to address specific psychosocial factors as part of a multimodal management approach. Key features of psychosocial yellow

flags are: n The belief that pain is harmful or severely disabling

n Fear-avoidance behaviour (avoiding activity because of fear of pain) n Low mood and social withdrawal

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BOX 3: BE AWARE OF COMMON PITFALLS IN OUR COMMUNICATION WITH PATIENTS

n Not listening intently n Think before you speak; try to understand your patient’s issues n Keep spontaneous rather than to a formula n Avoid being over-tired or stressed (a therapist who is tired from a heavy case-load will be quick to respond and could react in a more confrontational manner)

n Do not talk in medical jargon or overuse abbreviations; tailor your language to meet your patient’s understanding

n Do not pre-judge your patient or jump quickly to a diagnosis; develop empathy towards your patients and show respect

n Limit the amount of information, so your patient will recall the salient points after their appointment n Actively include patients in the discussion of their treatment options and management of their condition.

n Expectation that passive treatment rather than active participation will help (3).

In this scenario, cognitive behavioural therapy (CBT) should be considered as this is a psychotherapeutic approach to pain that can address maladaptive and dysfunctional behaviours. Turner and Clancy (4) have demonstrated the usefulness of CBT in the management of chronic low back pain. It’s often observed in everyday practice that there can even be a physical barrier to tolerating a manual technique for patients with chronic pain, anger management difficulties or willingness for their complaint to improve. Experience how mental attitudes can affect treatment effectiveness by trying out the practical challenge on openness to treatment (Box 4). The description of the case study

BOX 4: PRACTICAL CHALLENGE – OPENNESS TO TREATMENT

Ask a colleague to lie face down on a treatment plinth, gently place their arm behind their back, then find a common tender point in their upper trapezius muscle you have selected to ease using a trigger point release technique. 1) Ask them to close their eyes and focus on a mental image of ‘anger, frustration, stress and anxiety’ while the therapist applies a constant contact pressure in an attempt to release the muscular trigger point over a 1-minute period.

2) Now repeat the technique on their other side, but this time ask them to close their eyes and focus on the opposite mental image of “being calm, relaxed, open and responsive to treatment”.

This is a great way to demonstrate how a psychological state of mindfulness can affect the patient’s openness to receive a therapeutic technique for pain relief, and you will be amazed how such a different neuromuscular response can be achieved.

(Box 5) clearly shows the importance of a good therapist–patient partnership and how the observance of non-verbal signs led to a diagnosis and a positive treatment outcome in a case of chronic pain.

KEY POINT

Building trust through clear communication is key to a successful therapist–patient relationship; once this trust is broken, a therapist will no longer be able to provide effective patient care, regardless of how good you are as a clinician.

SUMMARY Effective communication with patients will immediately improve your practice, helping you respond better to the individual needs of your patient and their treatment expectations. Advanced communication is a complex skill that needs to be acquired (the key factors are summarised in Fig. 1). The process of reflective listening allows the therapist to fully understand what the patient says and respond in a dynamic way, resulting in a successful therapist–patient relationship. Skilled

sportEX dynamics 2013;36(April):22-26