Empathy: 2 sides of a coin? Written by Hugo Stam

Empathy: 2 sides of a coin?

A colleague in our practice recently asked me to assess one of her patients diagnosed with bilateral tennis elbow, a few days later we discussed my findings. My colleague reported that in her opinion the patient’s condition was subacute/chronic, and basically stable enough for both active and passive interventions. However, she felt she had been struggling during treatment to find the right mixture and dosage of treatment ingredients, the course of treatment was marked by several symptom flare-ups, interfering with her attempts to progress the intensity of treatment. Now, after a series of 9 treatment sessions, she felt there was no real sign of improvement, she was facing an ongoing status quo situation, with an anticipated poor outcome of treatment. In particular, she found it difficult to deal with the regular response of the patient during reassessment of „being worse“ as a result of treatment.

Now, how do you react to such a response? To what extent does it influence your reasoning, your communication and your behaviour? Of course, there is always the possibility that some aspect of treatment caused physical overload on some structure, this hypothesis usually makes us reflect on treatment components and it’s measures of intensity (grade, starting position, duration of application etc), in order to be able to decide on options for regression of techniques or intensity of loading during active type movements. You may find yourself in doubt about the dominant pain mechanism: more peripherally dominant and now, as a result of your treatment, stirred up, or more centrally dominant, driven to a large extent by psychosocial factors like anticipation, memory (e.g. from previous physiotherapy treatments), cognitions and in particular, fear of movement and or activity.

To what extent and in what way do you now show understanding and empathy for the patient’s complaints: perhaps by way of facial expression of concern, as if sharing his pain, or by reacting to the cues of being worse with a regression of some treatment parameter (a more gentle grade, doing less active movement or leaving out some movement component altogether). In situations where patients have developed fear for movement (sometimes for both active and passive movement) and or activity, and they attribute their pain increase to structural overload and tissue damage, it is tempting to directly relate this to your previous treatment, and modify your treatment parameter according to „present pain“. A driving element here is not only your estimation of severity and irritability of the patient’s disorder, but also your positive personal commitment to understand what the patient is enduring. To what extent is empathy actually linked in to your clinical reasoning?

I picked up this line of thinking in a recent article by Oostendorp and Samwel. These authors argue that for the development of physiotherapy we cannot just rely on the clinical side, we need to underpin our clinical approaches with sufficient science. This a plea for brick wall application, core of the Maitland Concept, so basically nothing new. However, Oostendorp and Samwel argue that in cases like the one outlined above, it is imperative that management is based upon pertinent current scientific evidence, comprising factors like:
A thorough knowledge and understanding of pain physiology.
Recognising the patient’s (pain) cognitions, beliefs and understandings, so that these can be targeted specifically in terms of neuroscience education (explain pain).
Recent literature is showing that apparently this is not only an issue on the side of the patient. Health practitioners, including physiotherapists, themselves too were shown to have pain cognitions related to (pain) avoidance behaviour, in a similar way as we see it in many patients. This could mean that in such a case the view of the physiotherapist, with a treatment model very much guided by pain, aligns with the patient’s understanding of his problem. This process of alignment of perspectives is called cognitive consonance. Treatment will then be largely pain guided, and therefore inconsistent in terms of components and dosage, depending on how severe or irritable the symptoms on a particular day are. The patient will become aware that the physiotherapist goes along the ups and downs of the severity-irritability slopes of his pain curves. In particular the backing off on „bad days“ may even confirm to the patient that avoidance of what he considers harmful activity or movement, is an appropriate measure. The result will be a mutual reinforcement of treatment behaviour of the physiotherapist on the one hand and the distinct fear and avoidance dominated behaviour of the patient on the other hand, which leads to a downward spiral termed iatrogenic symbiosis. Doesn’t this to some extent sound familiar to all of us: after a certain period of treatment, you feel trapped in a situation where patients paradoxically seemed hooked on what you are doing (my physio understands me, only he/she knows what my back needs…), even though objectively from your side, there seems almost no progression of function.
We particularly need to rethink the factor empathy and the way we deal with fear avoidant type patients: rather than having a short term focus on symptom fluctuation as a basis for treatment (let pain be our guide…), the physiotherapist should act in accordance with long term functional treatment aims (let function be our guide…).

This may all sound very logical, yet daily clinical practice shows it is very difficult to apply, with many confounding factors involved. Don't’ underestimate how such situations can have a negative impact on both the patient (physiotherapy doesn’t work for my problem….) and the physiotherapist (this is a difficult patient, manual therapy doesn’t seem to help in these sort of conditions, it’s all a bit frustrating…). And in the end, you may even start to dislike certain syndromes like tennis elbow, that still lack sufficient theoretical explanation for our clinical understanding. In that sense, I completely agree with Oostendorp and Samwel; clinical reasoning in many clinical situations, without a sufficient scientific fundamental framework, is like a blind flight. No wonder in the end that my colleague might say: I hate treating tennis elbow….
Oostendorp, R. & Samwel, H., 2015. Physiotherapie in der Praxis: Ohne Theorie geht es nicht. Manuelle Therapie, 19(05), pp.229–235.

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