What Messages Do Patients Remember? Relationships Among Patients' Perceptions of Physical Therapists' Messages, Patient Characteristics, Satisfaction, and Outcome

Discussion

This study sought to examine whether patient characteristics such as pain catastrophizing and depressive mood are related to perceptions of “satisfaction with physical examination,” “back pain is benign message,” and “stay active message.” Furthermore, the aim was to investigate whether variations in perceptions of this biopsychosocial message constitute a risk factor or is a mediator for treatment outcome and treatment satisfaction. The aim was also to study if physical therapists' treatment orientations influence patient perceptions of the biopsychosocial message. The study showed that a vast majority of the participants (87%) perceived the message and only a small minority (13%) did not. It also showed that baseline levels of catastrophizing and depression were significantly correlated with whether the patient was “not perceiving the biopsychosocial message,” and “not perceiving the biopsychosocial message” also was significantly related to treatment satisfaction and disability at 6-month follow-up. The results also indicate that participants who were less satisfied with their treatment results after 6 months had not perceived the message that back pain is benign, that they should stay as active as possible, and that they should progressively increase their activity level. They also were less satisfied with the physical examination their physical therapist conducted, even when controlled for pretreatment pain intensity. Furthermore, participants who did not perceive this biopsychosocial message were at risk of higher disability 6 months after the start of treatment. “Not perceiving the biopsychosocial message” was not a mediator for treatment outcome and treatment satisfaction. The results also showed that the physical therapists' treatment orientation was not related to whether the participants perceived the biopsychosocial message. There are several possible explanations for these results, and they can be explained from a patient's perspective or from a therapist's perspective.

First, when we look at the fact that pain catastrophizing and depression were correlated to perceiving the message from a patient's perspective, we have to remember that patients with a high level of catastrophizing tend to have fear and avoidance beliefs, cognitions in terms of harm, and negative emotions such as fear of injury.³³ They often display distress, and taken together, this often leads to their own model of a serious disease.^33–35 The message of back pain being benign and to stay active may not be in concordance with their own view of their back problems. Moreover, these patients often display selective attention, with their main interest being attention to pain and pain-related information.³⁶ Distress, maladaptive cognitions and beliefs, negative emotions, and selective attention combined may simply lead to them not “hearing” the message that is contradictory to their own beliefs.

Another explanation would be the influence of recall bias. We attempted to minimize the influence of recall bias by providing the alternative “do not remember” as opposed to just “yes” and “no.” There is, however, no way of knowing the extent of it. We have no reason to assume that recall bias in this study was disproportional to other studies.

From a therapist's perspective, we cannot rule out that a number of participants with high catastrophizing and low mood may not have been given the message that back pain is benign and to stay active. As mentioned previously, these patients often are distressed and have a behavioral coping strategy aimed at eliciting emotional or tangible support from others (ie, health care providers). This strategy positively reinforces pain and illness behaviors and undermines successful adaptation to pain.³⁷ The physical therapists might have reacted defensively on this coping strategy by not conveying the message and thereby reinforcing the patient's own model of a serious disease. Yet, the fact that physical therapists' treatment orientation did not differ between the participants perceiving the biopsychosocial message and those not perceiving the message indicates that patient characteristics might be more important for perceiving the message than physical therapist characteristics.

Patients with high catastrophizing and those with a lower mood were to a greater extent not satisfied with the physical examination performed by the physical therapists. This finding also can be understood from both a patient's and a physical therapist's point of view. From a patient's view, one can assume that the explanation of the back pain given by the physical therapist after the examination was not in line with what they expected to hear. Moreover, a message that back pain is benign and to stay active is controversial when the patient's beliefs and cognitions are oriented toward a more serious back problem. The explanation and message were not what they expected, and a natural conclusion for the patients would be that the physical therapist did not examine them properly. A less plausible explanation would be that the physical therapists performed a different physical examination on patients with high catastrophizing than on other patients. There is no reason to believe this is the case.

The fact that not perceiving the biopsychosocial message is an independent risk factor for lesser function 6 months after treatment start may not be so surprising. Because these patients did not perceive the biopsychosocial message, the patients' own maladaptive beliefs and cognitions were not challenged. It is likely that they persisted in the coping strategy of avoiding activity, leading to greater disability.

The effect on treatment satisfaction can be twofold. First, a recent review on treatment satisfaction with physical therapy³⁸ showed that aspects of communication that patients value in physical therapy are the ability to provide a helpful explanation about the patient's condition, the ability to give prognostic information, and the ability to explain the patient's role in the treatment process. However, when the information and explanation patients receive are contradictory to the patients' own beliefs, it is not surprisingly that this results in lower treatment satisfaction. Second, the review showed, unexpectedly, that the actual treatment outcome was infrequently and inconsistently a determinant of satisfaction with physical therapy care. It is believed that patient satisfaction with physical therapy care is determined more by interactions with the therapist and the process of care than by the outcome of treatment.³⁸ There is evidence that the relationship between overall patient satisfaction with care and satisfaction with clinical outcome is weak.³⁸ In our study, patients with high catastrophizing either received a message from the physical therapist that was opposite to their beliefs, or the physical therapist chose not to convey the message, thereby reinforcing the patients' maladaptive coping. Either way will probably not enhance patient satisfaction.

The fact that only a small minority of participants (13%) did not perceive the message should be seen as positive. This percentage is in line with the percentage of patients who end up in chronicity and is probably yet another marker for that. Yet, this is an important minority who should be recognized in clinical practice.

To our knowledge, no earlier studies have investigated the relationship among patient characteristics, perception of information, and treatment outcome. Although the correlations are rather low, the results of this study seem to contribute with another piece of the puzzle, explaining how patient characteristics influence the course of events during care, leading to treatment outcome. The clinical implication of the results of this study is that physical therapists cannot rely on the assumption that patients with high catastrophizing levels or lower mood hear or remember a biopsychosocial message or information when it is conveyed to them. Interpretation of a message or information is dependent on existing beliefs, cognitions, and emotional state. To make sure the message is heard and interpreted in the way it is meant, the message or information should be very clear and unmistakable. After this, the therapist should ask the patient to repeat the message in his or her own words. This approach would give an indication of whether the message was perceived and in which way it was interpreted by the patient. Misinterpretation of a message contradictory to one's beliefs is probably not uncommon.

The strength of this study is the large number of patients, which makes the results robust. However, there are some limitations as well. One weakness of this study is that we do not have any data on actual practice behavior and, therefore, do not know which message or care was given. As mentioned earlier, it might be that therapists changed their behavior or care according to how they perceived the characteristics of the patient in front of them.

In summary, this study shows the physical therapists' treatment orientation was not related to whether the patients perceived the biopsychosocial message. Yet, maladaptive cognitions and negative emotions such as patients' baseline levels of catastrophizing and mood are related to patients' perceptions of the message delivered by their physical therapists. The study also shows that the way information is perceived by patients influences treatment outcome and treatment satisfaction, and not perceiving the message is an independent risk factor for greater disability and lower treatment satisfaction at 6 months into treatment, even when investigators have controlled for pretreatment pain intensity. Physical therapists are advised to check that patients with higher levels of catastrophizing or lower mood perceive and interpret a biopsychosocial message in the way it is intended.