The Tales We Tell Our Clients

A new client came to me a few weeks ago with pain in her left shoulder, which she had been suffering from for a number of years. I asked her if she had ever seen another healthcare provider about her condition and she said yes, a physiotherapist a couple of years ago. “He told me I have a twisted tendon” she said, “and that in a few years time it’s going to shorten my leg. I already have a pain in my hip”.

Just in case you are wondering, it is anatomically impossible to ‘twist’ a tendon in day to day life, or even from moderate injury – with strong attachments to bone at either end, each muscle-tendon unit lies pretty much as nature intended unless something drastic (and probably extremely painful) happens. Tendons can get torn yes, and some of them (like the latissumus dorsi muscles in the back) twist naturally on their way to their insertion point, but to twist a tendon that it not meant to be twisted, without the need for major surgery? Not gonna happen. As for it shortening her leg… it is a pointless and dangerous exercise to try and predict what will happen to our clients months or years down the line. The body is a marvellously adaptive organism, and even if one part does malfunction, break down or is even removed completely, it doesn’t mean the rest of us falls down like the blocks in a game of Jenga. I was once told by a personal trainer that unless I corrected the slight (completely normal, by the way) curvature in my upper torso, I would end up with a hunchback. Six years later I’m not even close to becoming Quasimodo, but if I had taken his words to heart they might have seriously changed the way I moved and perceived my body, and that could have had negative consequences.

It’s unfortunate, but many manual therapists either don’t care about the stories they tell their clients, believe the stories themselves, or else feel they need to ‘dumb down’ their explanations so that the poor, uneducated client can understand what it is the therapist feels is wrong with them. Of course there is a case for putting things in plain English where possible – no client wants to feel that they have to take a crash course in musculoskeletal anatomy just to understand what their therapist is saying – but it needs to be accurate English. Talking about twisted tendons, tangled muscle fibres or slipped discs is not only anatomical make believe, it serves to give the impression that the body is fragile, and could fall apart at any moment.

In a recent talk on pain and biomechanics on MedBridge, an online educational resource for manual therapists, physiotherapist Greg Lehman put it well:

“People get these false beliefs about their body, and that’s the big problem. I know a lot of the biomechanical explanations will help sell the treatment at the time – I’m realigning your ribs, I’m shifting your ribs back into place, now you’re gonna move better and that’s gonna affect the whole body – and it can work in the short term, and probably for a lot of people it works in the long term. But with some people, they hear “oh my ribs are shifted, and I have a ring shift in my T10 and that’s causing my SI joint to move funny and now that’s stuck…” and now there’s this cascade of pessimism, and now we’re catastophizing, and suddenly the body doesn’t become this robust, beautiful and remarkably adapting thing, but it’s this stack of unstable blocks where everything has to be functioning perfectly, and if it’s not functioning perfectly it needs to be ‘fixed’ by someone or by themselves. And that’s the problem, that leads to a lot of people having persistent pain because they view their body as weak and needing correction rather than something that’s self correcting and amazingly adaptable.”

The tales we tell our clients matter. Studies have shown that catastrophizing, along with depression, can result in increased pain in patients post surgery. Learned helplessness (a sense that a person has no control over their situation, even if they do), can play a major role in depression, and if the story we tell is one of a malfunctioning body dependent on an outside source for support, that takes away any sense of ownership and control. Feeling like some part of our body could go ‘out’ (or misalign, or slip or tangle or twist) without any warning could – with a certain type of client – create anxiety, a fear of movement and the possibility of blowing any pain or injury out of proportion, all of which can worsen exactly the problems we’re trying to ‘fix’.

Stories are powerful. Often, a client will remember the colourful description or metaphor, rather than the less meaningful specifics (I don’t remember anything else from that rather lengthly postural assessment and muscle testing examination, but ‘hunchback’ has stood the test of time). As trusted healthcare providers, it is our responsibility to recognise that the words we say have the ability to form part of someone’s internal dialogue for years to come, and to use that power wisely.

So how to ensure our stories end happily ever after? As therapists, it is to ensure that we choose the words we say to our clients carefully. With any client that makes it through our door, so much more is working well in their body at that moment then is going wrong. We need to acknowledge their strengths, congratulate them on their progress, and pin the recognition for any achievements firmly on themselves, rather than on us. We should be honest when we don’t know something, and conscious of when an analogy might inadvertently harm, rather than help. Most of all, we should recognise the sensitivity, adaptability and innate intelligence that is inherent within every living being. The clients we see have not broken down, and they do not need to be fixed.

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