Hi, I am Your PT and Surgery is OK.

Social media in the PT world has been buzzing recently with the news of Tiger Woods’ 4th spinal surgery and Steve Kerr’s comments on his past back surgery.  As PTs, we often urge our patients to avoid going under the knife–especially for the treatment of persistent pain.  But what happens when the patient comes to you with a strong expectation and belief that surgery will help?  That surgery is the right option and was developed from another healthcare provider that they trust?  Do we adamantly educate the patient against this option?

I have to say that my immediate reaction is to shout from the high hills to run away and don’t ever look back at the option for surgery.  However, we need to look at the patient’s perspective.  It is important to consider if the patient is ready to change their beliefs/behaviors.  This brings me back to a recent blog post by Jessie Podolak where she discusses the different stages of behavior change which I feel can relate to the different stages of belief change.  Are we assessing where the patient stands on their ability to change their beliefs?  If a patient comes in and is ready to hear other options besides surgery, this provides an open window for us to potentially shift their stance when surgery might not be the best first line of treatment (i.e. persistent back pain).  But what happens if the patient is dead-set on having surgery?  Do we even try to change their mind?

Again, my immediate thought is to ram information down the patient’s ears on why surgery may be the worst option for them.  However, I have had to take pause in this mindset.  Will I truly be able to change the patient’s beliefs if I go about communicating in this way?  I think we need to recall Louw and colleague’s work on pre-surgical pain neuroscience education (PNE) (1 year follow-up study here) and (3 year follow-up study here).  The authors found significant healthcare savings and positive beliefs about their experience with surgery with only one 30 minute session of PNE.  This reminds us that although a patient may go on to have spinal surgery, we can still have downhill effects if we intervene before that procedure.  Imagine what could happen if you had more than one 30 minute session with someone who is dedicated to having surgery.

The idea of this pre-surgical interaction reminds me of a comment made on Kory Zimney’s blog post from last month.  John Ware commented on this blog where he brought up a great analogy stemming from Lorimer Moseley that I think we must consider for those that may be set on surgery:

“I also use Moseley’s analogy of “preparing the soil” so that movement takes place in a new, rich and fertile environment where new behaviors can be allowed to grow and flourish. But you still have to tend to the garden, and you’ll have to pull some weeds from time to time. You also may have periods of drought or storms that require you to replant. But, at least you have the soil there for behaviors to grow again. At the very least, you have the knowledge of how to rejuvenate the soil to make it rich and fertile again.”

Those storms may in fact be surgery–dare we say that surgery is OK?  We may not be able to change everyone’s stance on whether their invasive procedure is the right way to go, but we need to plant those seeds in the hopes of growing belief/behavior change.  They may grow in one visit.  They may not.  The patient may go in a direction that we don’t agree with, but we must keep our arms open for them if (and when) they come back to us.  We have to be ready to tend to the garden when the flowers begin to grow.

@ShepDPT

 

To learn more about pain neuroscience education (PNE) and how to use it in your clinic, check out our course today!

8 responses to “Hi, I am Your PT and Surgery is OK.

  1. Great points Mark. We need to make sure we are putting the clients stage of readiness in to account and their expectations. Trying to convince every client that surgery is wrong could set a number of them up for failure when they go through with it.

    Starting with the clients goals is key.

    1. Mark Shepherd says:

      Thanks for reading the post, Bryan. I have reflected on this topic for some time and feel that I have been quick to jump on patients for their beliefs. Rather than understanding their perspective first and then trying to educate appropriately, I blindly started touting why PT was superior. Often times PT is when utilized appropriately, but we have to remember that we are not the only profession that treats patients.

      1. Totally agree. My mom just had a knee replacement. I realized in her mind the only thing to fix her symptoms was a knee replacement. When she scheduled it I just let her know what she would go through and that it would be okay. We tend to be blind to our nocebo treatments because we really want to do good. We can be harmful when we want to “fix” the patient ourselves apart from their beliefs.

  2. Jessie Podolak says:

    Mark,

    Great post! I especially like your comment, “The patient may go in a direction that we don’t agree with, but we must keep our arms open for them if (and when) they come back to us.”.
    As Adriaan and Colleen Louw are famous for saying, “It’s ALWAYS about the patient.”

    As you so eloquently noted, once a pro-surgery decision has been made, whether we agree or not, we have the opportunity to cultivate the soil for a great outcome. If we consider Louw et al.’s recent systematic review on sham surgery, we know that MANY patients feel better just having gone under sedation / anesthesia and having an incision made.

    I’m reminded of a quote from Adriaan years ago: “Once the brain is convinced enough has been done to protect you, it can stop producing pain.” For some people, they may “need” that surgery to convince them that enough has been / will be done, more from a neuroscience point of view than a tissue perspective.

    In a perfect world, we would get our hands on patients before their minds are made up, but once they have crossed that line and committed to surgery, our eye-brow-raising, scoffing, arguing or questioning may very well do more harm than good.

    1. Mark Shepherd says:

      Great quotes and points, Jessie. I used to get really sad about the cases that would end up going on to get surgery who really didn’t need it based on the literature. I would feel like I was failing and going against everything I believed. I think we are quick to jump to Tiger Woods and other celebs who end up having surgery as we usually do not have a clear sense of what was said or done from a rehab perspective. I know that there are probably patients who I had seen who went on to get surgery who then went on to another PT. That PT may have thought: “Why the hell did that PT not stop this person from having this procedure?” We have to remember that the patient may be married to a specific intervention–we can only do our best to guide them to what is best.

  3. John Ware, PT says:

    Thanks for the mention, Mark.

    When I was talking about “drought and storms” though, I was using that analogy in the context of Kory’s reference to changing the “filter” of what patients have in the past perceived as something threatening to their tissues. The presumption is that the patient possessed an idea or belief about the threat value of, say, a degenerative disc, that was inaccurate- that they were placing too much emphasis on pathoanatomy and not considering other potential inputs that might contribute to a recurrence of their pain. For example, has the stress level at work increased? Have they fallen off their regular exercise routine? Has a combination of personal issues made them too busy to maintain the healthier lifestyle that they had resolved to incorporate into their daily life after their original injury? These are the “droughts” and “storms” that I was referring to. They aren’t as easy to “blame” as a degenerative disc, but to the extent they influence the stress system and behavior, they can impact how you feel in your body. “Fertile soil” refers to the knowledge of the multi-dimensionality of the pain experience. However, over time and under various circumstances confidence in that knowledge may wane. Our patients may need to rejuvenate the soil from time to time. A visit with their PT first of all to rule out something serious, but probably more importantly to review the concepts that they learned about pain when they first saw us may be the boost they need.

    We need to remain resolute in our confidence in conservative strategies to manage persistent pain problems. If the patient is intent upon having surgery, we can respect that decision without necessarily endorsing it. We need to find that balance between confidence in what we have to offer and humility in the uncertainty of what works best to treat persistent pain. Certainly patients respect when we tell them, “This is what I do and this is why I think it’s best.” The surgeon will tell tell them the same thing. And that’s the way it should be when there’s a lack certainty about the best course of treatment.

    1. Mark Shepherd says:

      Thanks for the clarification, John. I really love that analogy and is one I bring into the clinic as often as I can. Your last point resonated with me–It is great to lay the options out on the table in a somewhat neutral way. Let the patient make the ultimate decision. The process will enhance self-efficacy and probably will strengthen their beliefs around which ever road they travel. Thanks again for reading.

  4. Aaron Gibson says:

    Hi, Mark! I think many people believe that surgery is the only option for even minor back-related problems. Patients are finding the quickest way possible to relieve the pain. You are right the patient’s perspective is important. But, when it comes to chronic back pain many people would like to choose the easiest way possible (which is not surgery of course). Sometimes it may be possible to talk to a patient to look for option rather than going under the knife. Thanks for educating people.

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