Using Metaphors & Analogies to Improve Patient Education in Physiotherapy

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    If there’s one thing that is the bedrock in our care of patients as physiotherapists it is patient education. We educate our patients about a lot of things. Here’s just a short list:

    • patient’s condition
    • our assessment findings
    • treatment plan
    • anatomy and physiology
    • specific treatments and their rationale
    • referral to another healthcare provider
    • diagnostic report findings and significance

    That’s a lot of patient education. And if done well, good patient education can help improve patient satisfaction and patient outcomes.
    We’re often trying to explain complex topics to our patients in a way that makes sense to them and their understanding of their bodies. For example, think about trying to explain pain science to patients. It’s such a complex topic with words like dorsal horn glangion, neocortex, central sensitization, etc. It’s no wonder that it can be a challenge.
    And I think we can all agree that we’ve heard the common complaint from patients of not feeling heard or not quite understanding their condition or treatment program.

    The Power of Language

    Patients can also come in with their own metaphors and analogies that have already biased their understanding and potential recovery. They talk about “my pinched disc”, “my neck is out”, etc. If we don’t engage in powerfully accurate language, we may find ourselves struggling to progress and empower our patients.
    Patient communication is complex and involves both listening and talking on the part of both the patient and the physiotherapist.

    How Do I Know if What I’m Saying is Connecting?

    Often times we think our patients understand what we’re saying only to find out a little later in the session that it didn’t at all. Our patients don’t like to look stupid and will hold back asking for clarification. Patients may also apply their understanding of certain medical terminology even though our intention and understanding could be quite different.
    There are 5 things that you can do to help the communication cycle with your patients:
    1. Be explicit with your invitation for questions and dialogue. Be upfront with them that it’s ok for them to ask for clarification. Let them know how important it is for their recovery that they understand the rationale and plan. Also let them know that sometime you can use unfamiliar words and concepts out of habit and that their questions helps to reframe this content.
    2. Ask the patient to repeat back their understanding of what they just heard. This can especially helpful with assessing any potential distorted beliefs around diagnoses, MRI findings, etc.
    3. Watch for the non-verbals. Although our patients will typically give verbal agreement with what we are saying, their non-verbals can paint a different picture.
    4. Give the patient the opportunity for clarification. This is along the same veins as #1, but is related to a specific conversation topic. For example, if you’ve just finished providing an explanation around the anatomy and diagnosis of shoulder impingement, you can then ask if they have any questions or anything seem a little muddy?
    5. Take more time. Time is always at a premium in clinical practice, but nothing can substitute for quality time. It’s important to slow down so a patient doesn’t feel like they’re imposing on you if they ask a question.

    Metaphors, Analogies and other Literary Devices

    Language is powerful and our ability to use it well can make the difference in the success of our treatment with our patients. But communicating well is hard. Thankfully literary devices such as metaphors, analogies, similes and word pictures can help us.I had to do a little research to freshen up on the differences between these different devices just so I didn’t get it wrong.
    Here’s a quick refresher from this blog:

    • analogies: are comparisons that helps you see the relationship between two items
    • similes: compare two items using ‘like’ or ‘as’
    • metaphor: compare two items by saying something is something else

    Having an arsenal of relevant and appropriate literary devices can help make things easier for you when you’re in the middle of a busy day. In fact, a quick search revealed a study in 2010 in the Journal of Palliative Medicine evaluating the impact of oncologists communicating with seriously ill patients using metaphors and analogies (Can Metaphors and Analogies Improve Communication with Seriously Ill Patients?). This cross-sectional observational study with 94 patients made the conclusion that metaphors and analogies may be associated with better patient perceptions of communication.

    “It’s a peculiar atrophy of the imagination at a time when our scientific imagination knows no bounds. I think our right brains are churning, wanting to label and make colorful and to connect, but the imagined constraints of science and data have introduced a peculiar self-consciousness.” — Abraham Verghese

    Speaker and physician storyteller Abraham Verghese talks about the need for better, more effective medical metaphors. He has a great Ted Talk called “A Linguistic Prescription for Ailing Communication” that you can check out here.
    I want to put the caveat out there that simply adding metaphors and analogies to your patient interaction won’t necessarily improve patient communication. Great patient interaction and communication requires empathy, sensitivity and time.
    If you’ve been in practice for any amount of time, you’ll have different metaphors and analogies that you’re using with your patients.
    Getting a better repertoire of metaphors and analogies can make a world of difference in connecting patients and helping them understand a complex topic and improve their compliance and recovery. I know that I amaze myself with how easy it is to fall flat in a half-baked analogy that I had to think of on the spot because a patient wasn’t connecting with my explanation.

    Metaphors are All Around Us

    As I’ve been working on this article, I’ve been asking colleagues and reflecting on my own use of language. And it’s amazing to uncover how often we use metaphors.
    A very common metaphor that we use as physiotherapists is “Exercise is Medicine”. And there’s a lot of analogies that we build off this single powerful metaphor. We can talk to our patients about how just like other medicines we need to think of dosing when it comes to our exercise. We can talk about how just like other medications we need to take our medicine regularly. Patients understand medicine and the concepts around adherence, consistency and dosing. By using this metaphor we can help patients understand the value of these traits when it comes to aerobic and corrective exercise.
    An analogy that I often use with patients when educating on movement system impairments is that of our bodies being like cars. We tend to wear out the parts that we use too much. I then give the example of tires versus backseat seat belts (never used unless you have kids!). I go onto explain how important it is for them to move through their hips and not always through the lower lumbar spine.

    Pain Science Metaphors

    I’ve found that one of the areas that is the most challenging to help patients understand is that of pain and pain science.
    I know one of my go-to metaphors when educating wound-up pain sensitive patients is that of a volume dial. I’ll explain that their pain is the dial of a stereo and right now it’s getting cranked up to high and everything is too loud. I talk about the need to turn down the dial and get things back to a comfortable listening volume.
    Two books that I’ve found helpful would be Explain Pain by Butler and Moseley (no surprise there!) and Therapeutic Neuroscience Education by Louw and Puentedura. And they use a smattering of powerful word pictures and metaphors in their books to help with explaining pain.
    David Butler & Lorimer Moseley in Explain Pain evoke powerful word pictures with their use of different metaphors and analogies such as:

    • Your sensory system is an alarm system
    • Your brain is like an orchestra (orchestra can play many tunes, but with pain the same tune is played over and over.)
    • Inflammatory soup (The pain sensitizing chemicals released by damaged nerves )

    Metaphors and analogies can range from the simple to the complex and really depend on the concept being conveyed. For example, Low & Puentedura share a more complex metaphor regarding central sensitization and the role of the descending pain inhibitory mechanisms of the body.
    They use the analogy of an organization with the CEO (the brain) at the top and numerous vice presidents (different regions of the body) reporting to the CEO on a regular basis for analysis. If there’s the problem the CEO may ask for more frequent reports and for reports to bypass the VP level. As with persistent pain, these reports occur more frequently and the CEO becomes more paranoid about what’s going on resulting in increased analysis. The brain gets more pain inputs and will become more aware of the painful body part. Since the CEO is a bit neurotic it can start snooping around to adjacent divisions to see if there are problems there. This can be experienced by patients as pain in related areas even without the presence of injury.
    An example is always a great way to see the difference. Let’s say we’re taking with a patient about the importance of their thoughts and how it can increase their pain. Which do you think will have more impact?
    “Your thinking can make your pain worse so it’s important to watch what you think. Negative, stress-provoking thoughts can increase your pain.”
    “Sometimes we can get thought viruses-negative thinking about our condition. It’s so important to keep our nervous system healthy especially when we’re in pain. That’s why we need to kill thought viruses when they enter our mind so it can’t make our nerves sick.”

    Neuroscience Nuggets

    David Butler, a couple of years back, shared on NOIJam (a blog by the Neuro-Orthopaedic Institute) some neuroscience nuggets with the goal of sharing metaphors relating to pain and neuroscience. I thought this was great and wanted to share a few of them here:
    Your Muscles Are Dry
    This is a powerful metaphor. I mean who wants dried out muscles? David Butler explains the meaning behind this metaphor:
    This is all about ischaemic nociception. Simply, sit for a long time or hold your head in one position, you will force fluid out of tissues and pH will drop. Acidosis in tissues is a noxious by-product of ischaemia, lactic acid and inflammation. Nociception occurs via acid sensing ion channels. There is quite a gang of these ASIC channels right though the nervous system but here we are referring to them in the peripheral tissues. They are quite sensitive, reactive to a pH of less than 7.
    This quick, powerful metaphor can help get people moving and get them thinking of wetting/lubricating their muscles with movement.
    Keep Your Nerve Juice Loose
    This metaphor of equating axoplasm to juice helps patients understand importance of movement to keep axoplasm flowing. As David Butler explains:
    This nerve juice is quite thick – at least five time thicker than water, and it has to flow both ways within the longest cells in our bodies…This nerve juice also has some very interesting properties; it’s thixotropic, which means that it is thicker when it doesn’t move, but when shaken and stirred it will flow more easily.
    To see the list of neuroscience suggets from David Butler, visit here.

    Where Can I Find Better Metaphors

    I’d love to have you share different metaphors and analogies that you use in practice (or have come across).
    I’ve posted a question on the ignite forums here where you can share yours.

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