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Two clinical scenarios and some rampant speculation

By Noigroup HQ Patient examples 12 Feb 2014

A friend of noi sent us this post with some thoughts to consider…

I’ve always had an unhealthy interest in investigating how things work. Directing that interest towards the practice of Physiotherapy has been a bit like tugging at a loose thread on a woollen jumper. It wasn’t long before all I was left with was a big unraveled mess on the floor. I’ve been in the Physio game for about 20 years and every day it just gets curiouser and curiouser.

Scenario 1

Mrs X arrives for her second treatment of acute, localised low back pain. First treatment had improved her flexion reach significantly and she was very pleased. So far so good. Should be an easy fix from here. One or two more treatments? Problem is I feel really off today. I didn’t sleep a wink because the neighbour’s dog barked all night. I haven’t had lunch yet and I have a headache. As much as I try to convince myself otherwise, I’m just not interested in Mrs X or her back pain right now. This should be interesting. I put on my happy face and ask her how it’s been. “So much better!”, she starts off, but then as she picks up on my slightly less than interested vibe, her expression and her story changes. It takes her only a moment to go from a warm, smiling “So much better!” to a subdued “actually, it’s ok but I still have had a lot of difficulty”. The sudden contrast in self-reported symptoms seems to go unnoticed by the patient. Nothing surprises me nowadays. I know how it works.

I apply the exact same treatment which worked so well last time. She tells me that it feels ‘really irritating’. Last time she told me it felt wonderfully relaxing. But that was two days ago.  I reassure her that this sort of thing can happen sometimes (like when my neighbours head out for the night and forget to give Trickywoo a bone), and it’s not a problem. I begin some mobilisation and after a while comes the rather pointed question “What are you trying to do?”. Trying?! I nearly laugh at how ridiculous the situation is. “Same as last time” I say, “just getting that joint moving nicely for you. Does it feel ok?”, but her tone tells me she’s not happy; and the only reason she’s not happy is because I’m exhausted. When she gets up, her back is tight and sore and she’s not satisfied. Identical treatment, opposite response. I scramble to save the interaction from total loss but the damage is done. She doesn’t book a follow up appointment despite my suggestion to do so.

Scenario 2

Mr Y enters.  New day and I’m ‘in the zone’ as they say.  Rapport is immediate, the channels of communication are open.  The conversation flows, humour is spontaneous. Nice.  Mr Y gets up on the plinth and I start the treatment.  He’s lying face down and I notice that if I slow my breathing, he immediately follows suit.  He seems to be particularly in tune with what I’m doing today.  Having done some study into hypnosis, I’m keen to see what’s possible with a receptive patient.  I ask him to lie supine so I can stretch his hamstring.   I make no mention of hypnosis, and as far as the patient is aware, it’s business as usual. I make a point of not watching him directly as I focus all my attention on my breathing for a few minutes. Soon I notice something unusual in the corner of my eye. His face begins to display very odd grimacing and ‘lip smacking’ movements. His hands do some unusual automatic movements.  I’ve seen this before in a few other patients – first the eyes glaze over, then the facial movements happen. This is always followed by an anxious glance in my direction to see if I noticed. I noticed alright, but I pretend that nothing is amiss.  Absence seizure? Tourette’s syndrome? Tardive Dyskinesia? I don’t think so.  It switches off immediately I stop focusing, as it did with the other cases I have witnessed.  Aside from that there’s no history of weird neurological problems. I end the treatment and he looks at me askance as if to say “what on earth did you just do?” I could offer an explanation, but something tells me it wouldn’t fly. His back pain was easy to fix.

And the rampant speculation part…

Did you twig as to what’s going on with Mrs X? That’s right, Mrs X is not her real name. I made that up. Aside from that, what makes someone change her story in the blink of an eye? Does her pain sensitivity change when she feels I’m not interested? Does her back lock up when she feels like I don’t care? Did my tired expression remind her of the look on her husband’s face when he gets home from work? At our first meeting, she thought I was some sort of whiz and announced to the whole waiting room how wonderful she felt. This most recent meeting had revealed an ungainly fall from grace on my part! Sorry Mrs X.

Most physios would of course have lots of sensible rebuttals and suggestions for me. But I have so much supporting clinical evidence, it’s overwhelming. Whatever small effect a physical treatment might have, it is completely overpowered by the quality of the therapeutic relationship.

Here I’m reminded of Milton Erickson’s words:  ‘Any six months-old baby can look at mother’s face as mother spoons some pablum towards the baby and read in great big headlines on mother’s face “Who on Earth could stand the taste of this stuff?”  And the baby agrees and spits it out’. Looks like I got spat out.  But it’s not like I didn’t deserve it.

Mr Y’s scenario is important.  If treatment outcome is primarily due to interpersonal relationship (as Mrs X’s cases suggests), I need to know how this is mediated. Is it what I say? Is it how I say it? Is it how I move? Is it my confidence? My handling? Or is it something completely separate to all of this? I don’t get an answer to my question, but I do find out that a 100% non-verbal, non-physical communication is not only possible, but possibly powerful. Or he could just be possessed…. let’s keep an open mind here!



  1. Cameron , thought this was great . Really important practically and seldom discussed . Its the elephant in the room !
    The more i am aware of all this the more aware I am of myself and how often I am knackered with a full caseload . I can easily access all i have to offer when its a blue form (orthopaedic simple trauma usually) ..the white ones can be anything (from GP’s or self with medically unexplained syndromes and pain ) .Trouble is most people think they are treating ‘blues forms’ all day and this is seldom the case….

  2. Could maybe someone remind who the quote should be credited to….
    ” The art of medicine is keeping the patient amused while nature takes its course”

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