Category Archives: Evidence/ research

How Can You Improve Patient Interactions?

153570089_bb99d7108c_mHave you ever been a patient (for any provider, not just PT) and had a really great or a really bad experience?  What was the key to that experience for you?  For me, it was the interaction with the provider.  I’ve contemplated switching providers because of an interaction where I felt like a number, that my concerns were minimized and derided, and that his time was much more valuable than mine.

I received the most recent PTJ yesterday.  A few articles grabbed my attention, including “What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis” (O’Keeffee M, Cullinane P, Hurley J, et al; Phys Ther 2016; 96: 609-622).  It reminds me a lot of the PTJ article by Hush and colleagues from 2011 entitled “Patient Satisfaction with Musculoskeletal Physical Therapy Care: a Systematic Review” which is one I have my students read.

The authors identified four themes in their review: PT interpersonal and communication skills (active listening, empathy, friendliness, encouragement, confidence but not overconfidence, and non-verbal communication), PT practice skills (patient education – a big one for patients, and PT expertise and training), individualized patient centered care (individualized, and taking patient opinion and preference into consideration) and organization and environmental factors (time, flexibility).

The results aren’t all that surprising, but they bear repeating to ourselves as providers; I would argue while both articles examine this in light of musculoskeletal PT, it very likely applies across all specialties and settings. Do positive interactions enhance adherence and give better outcomes?  No evidence on this yet, but it would make sense especially for self-efficacy. I think I do pretty well in my interactions, but I think I’ll focus on my listening and patient education.  What can you work on to improve patient satisfaction and possibly their adherence and outcomes?

Photo credit: X-Factor by Pierre Metivier.

Research on Attire for Physical Therapists


I’ve seen some recent discussion on Twitter about attire for PT’s (including #NoPolo before and after CSM), and my employer is facing a possible change in requirements (we are allowed to be business casual or scrubs, with jeans on Fridays, but are now opening up a TCU within a hospital where the staff will be required to wear black scrubs).  I thought I would pull up whatever research is out there for attire for physical therapists and briefly summarize each (there isn’t much!).

  • 1999 masters thesis by Angell, Glaspie, and Winters – Physical Therapist Characteristics and Practices That Affect Patient Willingness to Comply With Home Exercise Programs.  “The results of this study demonstrate physical therapist personality traits and clinical practices were perceived by patients to be more influential than appearance and role modeling behaviors.”  Interesting conclusion and I would agree that it is more influential. Appearance, specifically professional dress and casual attire, did not reach a level of significance (the majority of respondents said it made no difference), but that is not to say that it might not matter.  Table 3 appears to show a preference for professional>casual>lab coat, and professional attire and lab coat make gains with the older subjects when the subjects are separated into two age categories.
  • Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient preference, perceived practicality, and confidence associated with physical therapist attire: a preliminary study. PTJ ‐ PAL. 2011; 2‐8. I don’t have access to this paper, but their paper is included in Dr. Ingram’s NSC 2013 presentation What You Wear to Work: Appropriate Attire and Professional Image for Our Doctoring Profession.  The most preferred attire by patients was scrubs, though OP’s and college educated patients preferred collared polo and khakis.
  • Finally Mercer E, MacKay-Lyons M, Conway N, Flynn J, Mercer C. Perceptions of outpatients regarding the attire of physiotherapists. Physiother Can. 2008;60:349-357. In ranking photographs of professionalism and preference of attire for a male model, for professionalism it was lab coat>tailored dress>scrubs>jeans, and for preference of attire it was tailored dress>scrubs>lab coat>jeans.  For appropriateness of attire, it was tailored dress>scrubs>lab coat>jeans.  Interestingly “in comparison to their younger counterparts, more respondents aged 56 years and above perceived scrubs on the male model as appropriate.” (note – appropriate, not preferred or professional).  Also, “In contrast to the findings from medical literature, which indicate the lab coat as both most professional and most preferred, respondents in the present study unambiguously preferred tailored dress, despite regarding the lab coat as most professional.”  Also, “Extent of exposure to this therapeutic interaction appears to influence patients’ perceptions of the appropriateness of attire.  The study found that perceived appropriateness of lab coat and scrubs decreased and perceived appropriateness of jeans increased with increasing number of physiotherapy visits.”

So where does that leave us?  First of all, you obviously have to follow the employer requirements.  If you are in a hospital, you have no choice – scrubs are the standard, likely color-coded nowadays.  Some of the large corporate OP clinics have a standard polo/ khaki combo.  But if you are in a TCU/SNF or smaller OP clinic and there is just general guidance, what should you wear?  I have chosen to wear professional attire (khakis and a button-down shirt) for two reasons – for the patient, and for me.

I would agree with Angell et al that it is more the characteristics of the therapist, not the clothing, that makes a difference for (at least) the HEP, but probably even from the moment we first meet. Still, I think that clothing does play a part in the interactions, for me and for them.The literature hints at patients preferring professional clothing (Angell), or certain segment of the population preferring it (Ingram), or they consider it to be more professional and preferred (Mercer).   I also believe in dressing the part so to speak, and I think that is what Roush hints at.  I know that I felt different Monday-Thursday than on a casual Friday when I used to wear jeans.  Am I a better practitioner M-Th in professional attire than on casual Friday or M-F if I wear scrubs?  Absolutely not!  For me, I take my profession and my job more seriously than I do if I wear scrubs or jeans, and I feel more engaged.

I leave you with this from Mercer that I found interesting – “professionalism is a multifaceted construct that, in the health care field, encompasses the traits of competence; engagement (e.g., communication skills and empathy); reliability; dignity toward patients, peers, and self; placing the patient above self; and concern for quality of care.  In more practical terms, it is ‘an image that promotes a successful relationship with the patient,’ such that the patient feels confident in the capabilities of the health care provider.  Although professionalism is the single most important trait that can be enhanced by dressing appropriately, professional attire is only one means of achieving a successful relationship.”  Personality traits and interactions play a significant role in the PT-patient relationship, and I want to use professional attire to help me maximize the interaction, for them and for me.

Picture is from Otis Historical Archives

Articles of interest – initiating change in the clinic, BESTest in subacute stroke

I’m catching up on journals (part of a New Years resolution to reduce/ eliminate the collection I have) and came across two good articles, so I thought I would share briefly.

The first is “Use of the Theoretical Domains Framework to Develop and Intervention to Improve Physical Therapist Management of the Risk of Falls After Discharge” in the November 2014 issue of PTJ.  If you have input into programs at your facility, or you have initiated a program but then had limited change in therapist behaviors, you may want to read this.  I found it interesting as I’m currently reading through “Better” (see previous posts).

The second is “Reliability and Validity of the Balance Evaluation Systems Test (BESTest) in People with Subacute Stroke” in the same issue of PTJ.  If you see patients with subacute stroke (or Parkinsons) and you haven’t checked out this test, you can read more about it here.

Speaking of EDGE task forces (Neuro recommendations)

In the previous post I mentioned the GeriEDGE task force.  In the same October 2013 issue of PTJ, there is an article Outcome Measures for Individuals with Stroke: Process and Recommendations From the American Physical Therapy Association Neurology Section Task Force.  I like how they broke it down into the ICF model (body structure/ function, activity, participation) and then made recommendations for patient acuity, practice setting, and educational exposure.  I will be sure to consult these recommendations when I evaluate a patient with a CVA either in the SNF/TCU setting or in the OP clinic.

Of note, the Neuro section also has posted these and other recommendation summaries on their website:

Limitations of balance tests

I’m working on catching up on issues of journals.  Being a part of a balance outcomes task force for work made the October 2013 PTJ article Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults catch my eye.

The authors purpose was to “(1) to conduct item-level content analysis of balance measures for community-dwelling elderly people based on task and environmental factors and (2) to develop profiles of individual measures summarizing their task and environment representation.”  Using a taxonomy of tasks, they assessed a series of common balance tests with  “7 criteria related to task and environment: (1) task role, (2) environmental variation, (3) object interaction, (4) obstacle negotiation, (5) external forces, (6) dual-tasking, and (7) moving people or objects in the environment” (these 7 criteria led to 12 task roles).  They found current tests focused on single task assessments in a static situation, and that they lacked items examining “postural control demands in daily-life situations involving dynamic changing environments, person-environment interactions, and multitasking.”

The radar plots of each test and the percentage of items in the test that addressed these 12 task roles was a good reminder that one test cannot measure or address all areas of balance.  The most broad was the mini-BEST and the Fullerton Advanced Balance Scale, but as the authors note there are issues with ceiling effects for the mini-BEST and the FAB “has been found to have very few items to assess community-dwelling elderly people with above-average balance ability.”  Creating a test large enough to test all areas of balance would be good, but as they point out it creates a burden for the clinician (they gave the BESTest as an example, which has “twenty seven tasks that evaluate the following six functions of balance.  1) BioMechanical Constraints, 2) Stability Limits Verticality, 3) Transitions/ Anticipatory, 4) Reactive, 5) Sensory Orientation, 6) Stability in Gait”).

So where does that leave us?  First, no test is broad enough to test all areas, so PT’s will need to select several (based upon history of falls and examination findings).  Second, we need to pick tests with good psychometric properties (a good place to find test properties is at Rehabilitation Measures Database.  I look forward to seeing what the GeriEDGE balance task force comes out with – unfortunately I missed their presentation at CSM this year.  Hopefully the authors of this study are developing a balance test that helps address the deficiencies they noted in our current balance test options.



Shared Decision-Making – a way to improve satisfaction, adherence, and outcomes?


Every PT has experienced it. The patient who isn’t improving between sessions (or even losing the gains made during your previous session). “Are you doing the exercises I gave you?” “Oh, no. I forgot where I put the sheet” (or insert any other reason you have heard). Or your patient calls and cancels multiple times in a row, or just doesn’t show up at all.

I’m reading through older journals, trying to clean out my office and learn at the same time. There is an article in the October 2013 issue of PTJ about shared decision making (SDM) which I found interesting, especially after some great CSM programming in Las Vegas this past February. SDM is “a model that reduces the unbalanced power between health professionals and patients… and has 5 characteristics:

  • at least 2 participants have to be involved
  • both parties have to take steps to participate in the process of treatment decision making
  • Information sharing is a prerequisite to shared decision making
  • Deliberation has to take place by discussing the treatment preference of both parties
  • A treatment decision has to be made and both participants have to agree upon the decision.”

SDM has been shown to improve “patient satisfaction, treatment adherence, and health outcomes.” In this study they observed the interaction between PT’s and patients in Belgium (in an outpatient self-employed setting). Interestingly, rarely was shared decision making applied or attempted by the therapists. You can read more about the study here, but there are 12 items in the instrument looking at SDM and I found them interesting and challenging in my own practice. You can read about the OPTION instrument and the items here. How often do we do these items even to a baseline skill level? Can we use the items from the OPTION instrument in improving our relationship with our patient, and thus improve the patient’s “satisfaction, treatment adherence, and health outcomes”?

An exercise app for older adults

I love how the use of technology in the clinic and in everyday life can help patients.  I came across Motivating and assisting physical exercise in independently living older adults: a pilot study on Pubmed (no direct access to the study at the moment), but I found it interesting so I went to the app store and downloaded it (Active Lifestyle by Torino University).  Unfortunately it crashed on me twice when I tried it out tonight, but the concept and adherence rates intrigued me and I hope it continues to develop.  I’ll try it again at some future point when they fix the bug (maybe it is an IOS 7 issue?).  I’ll be curious to see a larger sample size in a future study, especially including a larger group of those who are or have a history of being more sedentary.