Welcome back to the Healing Pain Podcast with Dr. Mark Bishop, PT, PhD
So many factors can cause and modify pain, not only physical but mental and emotional as well. Taking the psychological aspects of it, Dr. Mark Bishop tackles how expectations and biases influence the outcome for patients who have chronic pain. Dr. Bishop is a physical therapist with 30 years of experience managing musculoskeletal disorders. Learn how patient expectations are related to rehabilitation outcomes and how provider biases influence those expectations. Likewise, find out the ethical implications for applying expectation into clinical practice Dr. Bishop goes in-depth with the topic.
As always, it’s great to be here with you where we talk about pain care and the latest pain science. We are talking about expectation, bias, and how they influence the outcome for patients who have chronic pain. If you’ve been following along with this podcast, you know that pain is highly modifiable by psychological factors. One of those psychological factors includes expectation. We’re going to be speaking with Dr. Mark Bishop all about expectation and bias in pain medicine. He is a physical therapist with 30 years of experience in managing musculoskeletal disorders. He is on the faculty at the University of Florida in the Department of Physical Therapy where he teaches professional and graduate programs, in addition to working in research.
His research has focused on the mechanisms of efficacy for conservative interventions for pain, particularly Manual Therapy and he has been recognized with multiple research awards. He is a Catherine Worthingham Fellow of the American Physical Therapy Association. He was recently recognized by the APTA for advocacy work-related to the promotion of physical therapist as non-pharmacologic alternatives to opioid therapy for chronic pain. In this episode, you will learn about patient expectations, how they are related to rehabilitation outcomes, how provider biases influence these expectations and the ethical implications of applying expectation into clinical practice. If you’re new to the show, welcome to our tribe. Make sure you sign up for the mailing list so I can send you a new episode each and every week. Let’s get started with Dr. Mark Bishop.
How Expectations Shape Pain with Dr. Mark Bishop, PT, PhD
Mark, welcome to the podcast. It’s great to have you.
Thanks, Joe. I’m really happy to be with you.
You have a great new topic that we’re going to dive into about expectation and bias in the world of physical therapy and pain care. It’s something we haven’t explored yet. I’m interested to piece through some of the great research you have on it. I like to ask a lot of people come on the podcast to tell us about where you are now, what you’re researching, what you’re working on and what your journey has been to land where you are.
I work at the University of Florida. I’m on the faculty in the PT Department. I have affiliations with the Center for Pain Research and Behavioral Health. UF has a pretty vibrant pain research community through the Pain Research and Intervention Center of Excellence. Our current focus is thinking about the plasticity of pain and how we can use plasticity to help pain management. It’s my opinion that people think about plasticity as a way to make pain worse. If we’re able to successfully modify someone’s pain experience, then we’re also looking at a positive form of plasticity. We’re thinking of different ways we can make your nervous system more plastic so responses can be bigger, particularly in those people with chronic pain where potentially plasticity has left their nervous system less responsive. They have less variability and less flexibility to adapt. Can we find ways to improve that?
The journey here took a long time. I trained in Australia and was a sports guy. That’s all I was ever going to do. In fact, I remember telling Dianne Jewell when we finished neuroscience, that was the last time I was ever going to think about the brain because I was a Manual Therapy sports guy and that’s all I was going to do. I had the great opportunity to go to Canada and work in pro sports there and learned from some Manual Therapy people in Canada. I then came to the US where at that time there weren’t a lot of sports physiotherapy. That was the domain of athletic training. The first job that I got here in the US they said, “We have a spine management program.” I wasn’t that confident in thinking about managing spinal pain.
There was a cohort of us who like every nerdy physio would go to the library on a Sunday when the new issue of Spine came out. We’d read Spine and that started this interest in learning more. It was right around the time in ’94, I can’t remember what that acronym stands for, now it’s the Quality of Research Group. They put out the first guidelines for back pain that I’d ever read and that also got us thinking about how we could more systematically think about managing spine pain and pain in general, which eventually then led to me taking classes at night and finally getting a PhD. I started that journey looking at pain but then about halfway through, it transitions to thinking about pain and movements, which then led to working with folks who had Parkinsonism. We did a lot of neuroscience there. Last time I saw Dianne Jewell was at a conference a couple of years ago and she though it was pretty ironic that almost everything I do is related to how you think and what’s going on in your nervous system and all that type of stuff.
Once I finish that PhD work, I transitioned back into pain thinking particularly about manual therapy, which is one of my first loves and why that is so effective. Can we be more effective? How do we help that 20% of people or so who don’t respond? That led to the way we’re thinking now. There’s one more anecdote here that the thing that I’ve been fortunate about here at UF is the great collaborations with clinical psychology, who have influenced our thinking about aspects of care, aspects of interventions that potentially we weren’t thinking about. We were just looking at what happened when I push on a joint or move a muscle. We were focused very peripherally and the psychologists were the ones who said, “Did you ever ask the person what they were thinking?” We started asking people what they’re thinking and that’s led to the way we think about this now.
It’s interesting that you have come full circle. You started out as a Manual Therapist and went into the neuroscience and now you’ve married the two, which I think is great. We probably need to see more of that in physiotherapy and pain care in general. When did you start researching about expectation? How did that come about specifically?
One of our psychologist collaborators in early 2000s developed something called the Patient-Centered Outcome Questionnaire. They were looking at outcomes for just chronic pain management in general. There were several questions, one was, “How much change would you need to think treatment to be successful? What do you expect to happen?” That got us thinking a little bit about what we’re doing in the Manual Therapy research. A name some people might recognize, Joel Bialosky was working with Steve George. For his dissertation, he did a couple of studies looking at, “Can I manipulate your expectations by the way I talked to you? If those things are manipulated, how does that affect the immediate outcome?” That led to Joel’s early paper with me and Josh Cleland talking about expectations as an overlooked part. Joel’s dissertation then went on to examine that more closely and laid the foundation for our group to begin to focus on this aspect of care, which quite frankly is commonly thought about and lots of other types of care. We just hadn’t thought about it much in Manual Therapy and in the physiotherapy management of pain. That’s how it started just about everything we do has an emphasis or certainly a large component that revolves around what you’re thinking and what I’m thinking as we provide the care.
What do you expect is going to happen? It’s such a powerful question. Maybe we explained to some of what the treatment is going to entail, how many sessions, what it might feel like. What you expect is going to happen is a big one. This is an eye-opener. I hope a lot of people start to include that in their intake.
We have some other papers where it turns out that the six-month outcome of treatment is predicted most strongly by asking that question on day one, “Do you expect to be recovered in six months?” That was a stronger predictor and what treatment we did for you, your other characteristics. That’s an example of a predicted expectation. What the person thinks is going to happen influenced how they perceived the results, independent of what we measured, independent of what we did. In the end, my opinion would be is that your recoveries are your opinion. Are you feeling better? It doesn’t matter if I measure something different. You’re the one who is living with whatever it is. That’s another thing I found a little bit almost shocking right at the start. In 30 years of practicing these techniques and I’m quite good at this particular technique. It turned out that what you thought at the start before we even did anything was the most important part of that management.
Through my mind, this is going to all the different techniques I’ve studied, continuing education courses, things I’m still studying. I wonder always if the power lies in the patient and not necessarily in us. More importantly, how we help to facilitate people through the process that they’re going through. Let’s first start with the basic. What is an expectation? Can you define that for us?
I would say simply an expectation is a thought or something about what is about to happen. In the medical literature, there are many different types of expectations. I read a paper, there were about 64 expectations that someone comes to a treatment, but those have been nicely summarized by Thompson and Sunol into four broad categories that seemed to work, at least for my simple mind. That’s normative expectations and that might be what I expect when I show up at your office. I expect somewhere to sit. I expect to be, able to find parking, I will do some forms, these procedural things that I expect to happen while I’m there. Then there are my ideal expectations and I conceptualize those as my hopes. What do I hope? In the best possible world, what is going to happen?
There’s a third set, which are the predicted ones. These are what do I think is actually going to happen, which is different from my hope? I have this ideal picture of what I would like to happen. What do I think is actually going to happen to me as a result of this? Then the fourth one, which is a little bit nebulous but I think a great place for physios is this unformed expectation. These things, you don’t know what to expect. Through our interaction, I have the opportunity to help shape or guide those a little bit. That touches on what you’re talking about before. Are there things that you and I can work on that you’re unaware of or you don’t know? You have questions that can help guide your recovery.
Mark wrote a great paper. It’s called Individual Expectation: An Overlooked, but Pertinent Factor in Achievement of Individuals Experiencing Musculoskeletal Pain. It came out in 2010 in Physical Therapy Journal. It’s a great resource for a physio or someone else who’s interested in expectation. You can read that. It’s a tremendous resource. When we start to think about expectations as far as how it works, let’s say in the nervous system, in the brain, in our body, what are the physiological mechanisms that are happening?
There are several different ways that expectations work. If I can give a plug, there are some good papers on this very topic by Fabrizio Benedetti who is an MD. He and his collaborators have done extensive work on how this fits together. Primarily expectations that I have fed into the placebo mechanism. One of the things that I would just like to touch on is when some people hear placebo, they’re thinking about a passive thing or negative thing. Certainly, the brain imaging and a lot of the neurophysiological studies show that when the placebo mechanism is activated, the same areas of the brain are engaged. You’ve got the engagement with opioid pathways and a couple of other pathways that are working. You have actually profound physiological changes in response to this overall mechanism. That’s not just for pain. There are some great studies of folks with movement disorders. You can condition hormonal responses.
Another Benedetti paper, a great one looks at you can actually condition someone to release growth hormone through a placebo mechanism. That is a pretty profound physiological impact. It’s got a branding problem. It’s still seen as a very passive, nothing, and it’s anything but. It’s a tremendously active neurological process. You could reconceptualize it as your own endogenous capacity to change your physiology. If I told you that I was about to do a treatment and we’re actually going to enhance the active cortical mechanisms that engage your endogenous pain relief, that might be better than saying to you this technique uses your expectations to cause a placebo effect. I think it’s part of that whole physiological cascade. That also includes things like learning, beliefs, a whole lot of other cognitive issues as well as the physiological changes.
I was just at World Congress for the International Association for the Study of Pain. There were a couple of placebo lectures that I sat in on. To your point, we need a newly branded name for it. With placebo, you think I’m going to give you this little sugar pill and you’re going to go away. There’s so much more to what placebo is and we can use it to help people in their treatment. Along those lines as we start to balloon and expand that conversation a little bit and this ties into expectation as well, what are the ethical implications for understanding what expectation is, how it works and then communicating with your patient?
My opinion would be that if I know a way to engage you actively in your own recovery, then I should probably use that to enhance your ability to get back to whatever you’re doing. The fact that every intervention that is provided probably includes an element of this mechanism means to me that we’re already doing this. Ethically, if I can enhance that to make things better than that is a good thing. The conversation begins to change when people are thinking about paying for care versus best care. It’s a slightly different conversation. The ethics to my mind have revolved around, “Can I charge you for something that essentially you’re doing yourself?”
Once again, if that allows your recovery and I know that a lot of medication, efficacy, some of the movement disorder management, a lot of these surgical interventions, if that mechanism is a large part of recovery and all those things, I think ethically we’re okay. I still need to engage with you. I still need to do something. I suppose I could talk to you on the phone, but I don’t know if that would engage the effect as much as if you and I embark on the journey together and I’m guiding you and helping you through that process. That is still an active intervention by me. I think ethically we’re okay with that if we can reconceptualize it away from a passive nothing. As soon as we get away from it being a passive nothing and recognize that it’s a profound mechanism, then I think that will change the conversation a little bit.
I’ve been practicing since ’96. When I first started practicing, a postoperative ACL repair probably was a rehab of about seven months. Then shortly after I started practicing, they came out with these accelerated protocols which are five months, four months. Patients would come in actually thrilled because the physician would tell them, “We’re going to put you on an accelerated protocol and you’re going to get better faster than patients we’ve had in the past.” Not everyone always was able to go step-by-step on that accelerated protocol, but a lot of people did. I wonder if that’s a version of expectation in motion in the communication between the physician or the physio or perhaps the entire team.
It’s probably a powerful example of it, particularly that instruction coming from someone who may be viewed as an expert or an authority in that for them to say, “Yes, you’re on this new protocol that will cause you to return early out then I’m expecting to return earlier. I may be willing to do or accept things a little bit differently than if you said, “Slow down, this is going to take you two years.” I would say that anytime we’re engaging with the person, we’re modifying or molding their predicted expectation.
It’s interesting because a lot of practitioners are very cautious about giving chronic pain patients a time frame of when they’re going to start to feel better or when the pain’s going to subside, alleviate or go away. There are so many different terms that people use. It’s interesting to think is there a place to talk about the time frame with people that might help them in a way? Of course, based on evidence because we still have to practice in the way that it’s evidence-based.
That’s a very important thing to emphasize that in all these conversations it’s important that you’re not misrepresenting and not overly confident and that type of thing. Someone with chronic pain, maybe the conversation wouldn’t be that your pain will go away but say, “We can get you back to activity or what is it you want to do? We can get you back to your social interactions and your goals.” It gives them some time frame. That is perfectly adequate. We probably can’t say, “Your pain will go away,” but say, “We will teach you some ways to deal with it when it gets bad,” but you should be back to doing things in whatever time frame you and the patient agree on.
As a practitioner, how do we start to notice our own biases in the way that we’re communicating the type of treatment techniques that we’re adopting and using in the clinic? It’s such an important question right at this moment in the pain science world, where there are certain techniques and treatment interventions that are extremely popular and there are others that have a huge evidence base that people are ignoring.
Quite frankly, the only way I became aware is when people like Joel were doing the work. If I was providing interventions in the study, I had to fill out this thing saying, “Which intervention do I prefer to do? Which one do I expect to help this person? Which one do I not expect to help this person?” It became very obvious to me that my bias was towards manipulation. Manipulation and exercise, those were my biases. Until you begin to actively think about that type of stuff, you may not be aware of those. I think if I’m really honest about it, I have a bias towards mobilization in the cervical spine, manipulation in the thoracic and lumbar spine. I think I could even break it down more of those.
My recent work has indicated that my belief in my ability to help you, my self-efficacy, actually impacts our alliance. I don’t know if you’ve heard that term, the therapeutic alliance thing. If you perceive me to be well-trained and competent, your confidence and expectations in me rise. The way I get self-efficacy is through doing things over and over and getting confident, having some successes and those types of things. Me having a bias towards Manual Therapy and having used that for 30 years, I’m very confident in my capacity to change something in you. In our interactions, I’m not saying, “I’m awesome. I’ve got the hands that will heal you.” There’s something in the way we interact that builds confidence. Your confidence in me to help you out. That bias is actually useful in building the alliance.
I want to switch gears for just a moment because I spent some time at World Congress. There were fantastic presentations. Every presenter there is top of the class. Some are basic science researchers, some are psychologists, some are physicians. Taking the perspective from advocating for the physical therapy profession, I noticed that physical therapy was extremely underrepresented at the conference. It’s a week-long conference that goes from 8:00 in the morning to 7:00 at night. I would say probably less than 3% of the conference were PTs or physios. We had decent representation during the poster session, but the actual lectures I found to be a little disappointing as far as physical therapy goes. As a researcher yourself, what recommendations do you have for our profession to be more visible?
I’d say probably the most visible physio I think of immediately from the US is Kathleen Sluka. She gave a plenary up there and certainly, Steve George is pretty involved in ISP. There are certain parts of ISP that are heavily dominated by physiotherapists. There’s a special interest group, pain, mind and movement, almost all physiotherapists. Certainly, people are involved in those special interest groups. I think that the challenge, if I use the term parochial that’s not using that in a negative way, but we talk to each other a lot. There are a couple of people like Kathleen and Steve who have focused on getting involved in pain management in general rather than pain management by physiotherapy and physiotherapists particularly.
There are some newcomers that are rising up through the ISP ranks and the American Pain Society ranks. People like Meryl Alappattu for example who does chronic pelvic pain and she’s quite involved with the pelvic pain research through International Pelvic Pain Society, which is part of ISP. We’ll begin to see more physios at that level as we’re starting to do a lot of work as a profession in the rehabilitation and particularly the non-pharmacological rehabilitation with the whole crises around medication. Quite frankly, failure to manage chronic pain and I’m talking about us as a healthcare system. I think physical therapists and physiotherapists are ideally situated to take the lead and the ownership of that because it’s stuff that we do, and we do well.
I’m hopeful that we will begin to see more rehabilitation people rather than neuroscientists and pharmacologists as the only people who were talking about how we manage pain. There is an international person I respect a lot from Belgium who’s doing a lot of the stuff with chronic pain and plasticity. These are all physical therapists and physiotherapists who are at the forefront of a lot of these. I think we will see more from those people as we move ahead.
To peel the onion layer back one more, within our country, within the United States of America, it’s a big country with lots of money, lots of resources. What do we have to do at the university level to see physiotherapy in the pain research by physiotherapists expands?
A couple of different things. The APTA made a strong move last year in my opinion when they adopted the ISP pain curriculum for physical therapists or endorsed it rather. Hopefully, that may provide a resource for programs who are looking to incorporate a little bit more about pain science. A couple of those papers about how much of medical curricular and physio-curricular actually devoted to pain. It’s a little shocking to know that it’s on a couple of hours out of three years. As programs begin to think more about that, they have this resource so that’s good. The APTA has also put together a couple of work groups to develop public-facing information as well as clinician facing information. I want to learn or improve my ability to manage pain. Here are some resources and some training.
As a profession, we need to incorporate a lot more collaborators from psychology potentially to be a bit more comprehensive in our own studies so we can think about things like sleep, mental health, and some of these least traditional domains that physiotherapists manage. I’m not a psychologist, I can’t do Cognitive Behavioral Therapy, but I can identify someone who’s going to benefit from that probably better than I am. I can apply some principles to my treatment and I can incorporate some of those things in my studies.
I think we’re beginning to get some momentum to improve our ability to do this. People have recognized that we have been under training potentially, and being able to thread some of these things through a couple of different courses is going to be useful. One more point related to that, the other thing is if we can be clear whether we’re studying pain the symptom versus maybe chronic pain, the disease, nervous system disorder, I think that will help. At least I know I have spent some time confusing those and I’m thinking about those separately as given our studies a lot more clarity.
That never entered my mind until you just said it probably. That’s a good point to clarify for both patients and practitioners. Mark, it’s been great chatting with you. Thanks for joining us on the podcast. Can you tell everyone where you work, how they can find you so they can learn more about the great research you’re doing?
I want to thank Mark for being on the podcast. He’s a great physical therapist, educator and researcher. Make you sure this episode to your friends and family on Facebook, Twitter, LinkedIn or wherever your favorite social medial handle is. If you are new to the podcast, you can sign up for the newsletter. Thank you all for being here and we’ll see you on our next episode.
- Dr. Mark Bishop
- Individual Expectation: An Overlooked, but Pertinent Factor in Achievement of Individuals Experiencing Musculoskeletal Pain
- Kathleen Sluka
- Meryl Alappattu
- @PhysioBish on Twitter
About Dr. Mark Bishop, PT, PhD
Mark Bishop is a physical therapist with 30 years of experience managing musculoskeletal disorders. Currently, he is faculty at the University of Florida in the Department of Physical Therapy where he teaches in professional and graduate programs in addition to working in research. This research has focused on the mechanisms of efficacy for conservative interventions for pain, particularly manual therapy, and has been recognized with multiple research awards. He is a Catherine Worthingham Fellow of the APTA and was recently also recognized by the APTA for advocacy work related to promotion of physical therapists as non-pharmacological alternatives to opioid therapy for pain.
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