Communication Surrounding Pathology in the Orthopedic Setting

Advisor: Dr. Jeff O’Laughlin, PT, DPT, OCS, FAAOMPT

Committee Members:  Dr. J. Quinlon Curtis, PT, DPT, OCS, FAAOMPT      |         Dr. Joshua Torrey, PT, DPT, OCS

Background

There is a growing body of literature surrounding the delivery of musculoskeletal education and care to more accurately match what research has provided.^1-4 The healthcare system is increasingly burdened with the presence and management of numerous neuro-musculoskeletal conditions.¹ However, due to the fact that neuro-musculoskeletal conditions are generally less life-threatening, the healthcare system has not placed an emphasis on the development of policies and programs that address them. The lack of this structure leads to a lack of general population awareness, student/trainee education/ and service delivery changes.¹ An over-reliance on interventional procedures, imaging, and pharmacotherapies to address structure and biology has been considered ineffective, yet this idea has not been translated effectively in practice.^5-6

Despite the growth in the popularity of physical therapy and the ability to receive care through direct access, many individuals still seek physician guidance or internet-based sources prior to seeing a physical therapist.^6-7 Information from the internet is often misleading, as research has highlighted that many health information sources are not backed by research, are not reviewed by qualified individuals, do not adhere to best practice recommendations, and do not explain the limitations of imaging.^8-9 Often times, this leaves patients with a lack of thorough understanding of the condition, unnecessary expenses,¹⁰ or a discouraging (but often normal)¹¹ imaging report, which can lead to a heightened uneasiness.^12-13 Rather than solely focusing on the structural changes that are asymptomatic in many, Physical Therapists should be aware of the multiple systems that could be contributing to dysfunction in order to provide information to patients that allows them to better understand their abilities and enhance movement.¹¹ All of these factors play into forming an efficacious therapeutic alliance helping to promote retention through a plan of care,¹⁴ reframe health beliefs, enhance self-efficacy,¹⁵ and improve clinical outcomes.^16-17

Statement of Need

Patients will enter the healthcare experience with varying past experiences and education levels that lead to varying methods of targeted interventions and education. For patients to appropriately understand and manage musculoskeletal conditions, we, along with other medical professionals need to understand and incorporate current research findings into thought, education, and practice. We need to know how and when to deliver information to mediate prior beliefs about one’s condition that might be associated with fear, anxiety, and beliefs of permanent damage. An inappropriate understanding of one’s condition can be extremely detrimental, affecting the quality of life, movement, and response to medical advice.^7-9 However, an inappropriate clinician interpretation of the patient’s pathological findings and clinical presentation can be even more detrimental, compounding upon the aforementioned factors.

The more that these concepts gain ground for research, the more they are integrated into doctoral and clinical education. Even with excellent mentorship through clinical education experiences, a new clinician might only skim the surface of having enough research and tools on hand to confidently apply and educate patients on their musculoskeletal pain and conditions while also attempting to consciously reframe the patients understanding or prior health beliefs. These are concepts that might come with years of practice, yet are extremely important for long-term and proper condition management. As a 3^rd year student and new clinician, I have found myself desiring to have a better base of research, proper language, and understanding of normative ranges for common complaints seen in the orthopedic setting. For some, it can feel daunting to consider adding layers of complexity to a patient encounter on top of the initial feat of implementing correct clinical procedures. I desire to educate patients in a way that promotes self-efficacy, reduces fear, and even redirects prior beliefs, as I have seen those who I admire do so naturally. Through conversations with my peers, I know that I am not alone in this.

Purpose: This Capstone serves to target multiple areas of communication and education surrounding pathology in the orthopedic setting. These include verbiage and language skills to promote a less fearful understanding of conditions and pathology, a review on indications for imaging, and an updated literature review of common pathology in the spine and shoulder. The primary goal of this material is to 1) stress the importance of implementing these concepts through providing evidence-based information, 2) provide a practical and quick reference to use in the clinic. My hope for others is similar to what I have found for myself; that these materials will help new clinicians with confidence in approaching these conversations with patients.

Products and Deliverables

Clinician/Student Handouts (Handouts Combined)

1. Handout 1:  Verbiage and Message Framing
   1. Resource for clinicians regarding helpful vs harmful verbiage in the orthopedic setting
2. Handout 2:  Imaging Considerations
   1.  Resource for clinicians regarding indications for and consequences of imaging
3. Handout 3: Pathology of the Spine
   1. Resource for clinicians regarding normative pathology in the spine with data for both asymptomatic and symptomatic populations
4. Handout 4: Pathology of the Shoulder
   1. Resource for clinicians regarding normative pathology in the shoulder with data for both asymptomatic and symptomatic populations

Evidence-tables: Normative Information

The evidence tables consist data and a deeper analysis of the information in spine and shoulder handouts (3 and 4). 

1. Pathology of the Spine: Evidence Table
2. Pathology of the Shoulder: Evidence Table

Evaluation

Materials were “delivered” to 12-15, 3rd-year students, and newer clinicians (1-2 years). Delivering my materials to the intended audience and having them fill out a survey for feedback allowed me to see the relevancy of this information. While it was an area that I certainly felt like I needed improvement in, I wanted to also gauge its relevancy for other students and new clinicians. This evaluation utilized the 5-point Likert scale (strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, strongly disagree) to help me better understand the information needs of this audience as I enter the field as a clinician and educator. See or take survey here.

The survey findings are indicated below.

• 100% of individuals selected somewhat agree or strongly agree with the following statements:
  • “I plan on referencing these materials in practice”
  • “I feel that I have new information to put into practice.”
  • “Materials are visually engaging”
  • “I feel that I would benefit from similar handouts for other joints/regions of the body”
  • “The graphs serve to better my interpretation of age-normative findings”
• Verbiage: Prior to reading the handouts, 60% of individuals did not recognize the weight of some of the words in Handout 1, and 80% used some of these words in practice without a second thought. 90% admit to sometimes using anatomical terms with patients by accident.
• Imaging: About 70% of responders feel that they confidently know how to speak with patients about imaging, however, 100% of responders felt that Handout 2 was a good reminder of the indications for imaging and 100% believe that imaging can lead to unnecessary procedures. In regards to the statement: PTs should be able to order imaging: 40% strongly agree, 30% somewhat agree, 20% neither agree nor disagree, and 10% somewhat disagree. One responder mentioned that more information regarding the implications of PTs ordering imaging might be helpful. This statement was more for my curiosity about where individuals stand on this topic, but I do agree that more implications would be beneficial. 
  • Some PTs might contribute to the over-prescription of imaging, while others with proper education/reasoning would be extremely skilled in their discernment of who should receive imaging. Will patients with the proper explanation be okay with putting off imaging if we explain that it’s not necessary–Or will they prefer to see another provider who will give them imaging? These are all great questions that we might not know the answer to until it happens. Perhaps looking at research in military populations or other countries where PTs can image might be beneficial.

• Proficiency of Clinician Knowledge: An average of the findings indicates that reviewers feel that 37% of 3rd-year students, 56% of new clinicians 1-2 years, and 69% of clinicians >2 years are proficient in these topics.
• Likes: Evaluators liked aesthetics, charts, and organization of information and in general felt that the information was easy to follow and understand. Additionally several appreciated the summary statements and highlighted information. 90% of individuals felt that the evidence tables emphasized the quality of the research however 80% feel that evidence tables are wordy and hard to spend time on.
• Improvements:  In general most of the evaluators mentioned that more information and examples of how to approach imaging and pathology conversations with patients might be helpful. One requested more information regarding the implications of PTs ordering imaging, as that is a step that our career might be moving towards. Several had questions/confusion regarding the symptomatic information on Handout 3.

Self Reflection

I am pleased with the results of the evaluation and feel that I have developed an effective resource for clinicians to reference in regard to communication and education about pathology. I agree that more information regarding how to speak with patients about pathology would be helpful. Unfortunately, there is not a lot of research in this area, but perhaps more discussion-based literature might be helpful to provide. As mentioned, several individuals had questions regarding the potential for symptomatic individuals to have greater amounts of certain pathological findings on their imaging and there might be a more clear way to present this information. This section serves to highlight the importance that clinicians should not take either of the extreme points of view: “Pathology never contributes to pain” or “Pathology always = pain”. Rather, we should consider that sometimes pathology might contribute to the patient’s pain, as shown in the symptomatic section, while also considering that a great number of individuals with very similar pathology do not have symptoms. We can use this as an educational point to encourage and empower individuals and counter their negative beliefs associated with their pathology or pain. Lastly, I find the survey results on information proficiency at various levels very interesting. If only 37% of 3rd-year students and 56% of new clinicians are proficient in these topics, a change in education emphasis might be necessary and beneficial, but it is also important to recognize that communication skills are enhanced with time and practice. I am excited to put this information into practice and feel that my materials were beneficial for my own growth and those who reviewed the materials. I look forward to continuing to emphasize the need for these concepts in order to better those around me, future students, and the education levels of the general population. 

Acknowledgments

First of all, I’d like to thank my Capstone advisor and committee members. I have had the opportunity to work with each of them in different ways, and have greatly appreciated their education, teaching, and expertise in orthopedics, therapeutic alliance, and physical therapy in general. Jeff, thank you for your patience and guidance as I narrowed down the focus of my goals for this Capstone. Your mentorship throughout Capstone and throughout my teaching scholar position in your class has built confidence in my abilities as a future clinician. Quinn, thank you for multiple conversations about Capstone direction all while treating my neck and upper back pain at UNC Therapy Services. You have helped shape many goals for where I would like to be as a Physical Therapist and have shown me the importance of effective communication with patients. Josh, thank you for initially mentoring me through my communication with patients as you lead me through the ICE elective. This helped me to see a gap in and a desire to refine my own techniques in addition to helping students and clinicians to do the same.

Next, I would like to thank all of the individuals who helped to evaluate my educational resources. Many of these were students in the 2022 and 2023 cohorts, as well as new clinicians that I know from Texas. Your valuable feedback has given me a sense of direction with further efforts to help students and new clinicians feel more confident in their abilities. This also helps me to better communicate ideas and reach the goal of greater understanding, communication, and therapeutic alliance for myself and those around me.

Lastly, I would like to thank the support of the UNC faculty, my cohort, and my family. These people are my biggest supporters and I would not be where I am today without all of them. They have encouraged me in my journey and have helped me create goals for everything from this capstone to life– to my future as a Physical Therapist!

References

The following references are for the text on this webpage. Other references from handouts and evidence tables are listed within the specific components. 

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