Stop focusing on the cliff’s edge

A singular focus is rarely beneficial for ourselves, or our patients in clinical practice – or more generally, in life itself. 
Think of the example you see in action movies… The main character running from a boulder, directly in front of it. Or, away from danger right towards a cliff’s edge as if they can’t see anything else. The whole time you see this from the outside and think, “Just take two steps to the left!’

In a threatening situation it’s understandable that we may become the deer in the headlights. Instead of looking for a safe exit, we hyper-fixate on the problem.

Let’s apply this analogy to clinical practice for our patients – 

If I lift that way, I’m going to hurt my back, so I better not lift.

Only this treatment from my therapist will stop me from getting injured, there’s no point trying anything else.

My knee hurts in the gym, so I can’t get back on the basketball court at all.

Now, what about for ourselves, instead of the patient?

If I have my patient return to play before these specific goal metrics are achieved, they’re going to reinjure. We shouldn’t change their training yet.

I can’t have my patient move that way because they say there is pain. We can’t add that to their rehab.

Instead of being stuck with the tunnel vision of seeing a problem and its consequences, try your best to focus on alternative actions you could be taking – what is to the sides of the boulder? Can you turn away from the cliff, or where is the safer way down?

Now, think of the alternatives in practice – what stimulus can we change for a painful movement? What is the need for metrics if the quality of training meets the demands of match play? How can we adapt movement to build comfort and self-confidence?

I have been reading more about motivational interviewing and communication skills lately to address ambivalence and increase patients’ own motivations. One of the core themes to this is to spark cognitive dissonance in our patients’ views. Cognitive dissonance is the conflict between two or more differing thoughts, beliefs, or actions. This challenges their thoughts toward their presentation or prognosis and helps create effective change. 

Here’s an example in a conversation between a patient (P) and clinician (C) – 

…

P: I can understand that these exercises will help build strength and reduce my knee pain, but the pain right now is too overwhelming to do these, and I don’t think I can get back on the court. (Ambivalence)

C: The process to build your capacity and return to play is daunting. How do you feel about not training to return to play again?

P: Well, I wouldn’t have to face that challenge or deal with the pain in the gym. But my knee pain wouldn’t get any better, would it? And I enjoy playing. That’d be something I miss. (Cognitive dissonance)

C: If we explored some other exercises that are more comfortable and that you enjoy, how would that change your outlook on our exercise program? 

P: Yeah, I think that would make me feel more confident again. I just want to enjoy being in the gym. Changing it up would help me start training more. (Intrinsic motivation and change)

This is a very short and direct example of having your patient experience cognitive dissonance, halting the focus on a singular problem. But you can see that there are simple communication skills to implement – the use of empathy, affirmation of their experience, open-ended questions, and patient autonomy. You may have many more comments back-and-forth between each of the factors highlighted in bold in clinic. 

It can be valuable to focus on a patient’s complaint or painful presentation to be able to understand and explore their situation or understanding. But after that, the continued focus and narrowed view on this one aspect isn’t allowing for the opportunities created from the above. Once we understand what is limiting their activities, begin to explore – 

What would happen if you were to lift and change ‘x’ about your posture/grip/stance?

How can you move to find the most comfortable position when you’re squatting?

Having these deeper conversations that explore the patients’ beliefs, actions, and ambivalence allows you to then address the alternatives. Using your best understanding as the clinician to provide other outcomes for your patient to reflect on, creates internal change. There is always something to help them to challenge their own beliefs and the actions they take.

Naturally, this is easier when you have more familiarity and experience with pain education, exercise prescriptions and regressions or progressions, or manual therapy techniques for symptom modification (these can be developed). But I’d argue that it’s all too common when building these foundational skills that we as clinicians still focus on the cliff’s edge that is the patient’s pain, and don’t use our ability to ask questions and explore different approaches.