To identify the prevalence and impact of minimizing language used by physiotherapists in consultations with patients reporting low back pain. Minimizing is a cognitive distortion, characterized by reframing events to reduce their significance, that can be used to underplay health symptoms, soften criticism, minimize distance between speakers, or indicate tentativeness in requests or questions.
Design: 80 observed primary care consultations between physiotherapists and people with back pain were analyzed, 42 initial consultations and 38 follow-up treatment sessions.
Setting: A musculoskeletal physiotherapy service at a primary care setting in Southern England.
Participants: Patients over 18 years, reporting back pain, with or without referred leg pain (and no: ‘red flags’; spine surgery; other more troublesome musculoskeletal disorder; or severe psychiatric/psychological condition). Quotas were used to purposively sample the physiotherapists and include all staff grades (experience: 6 months―15 years post-training).
The consultations were audio-recorded, transcribed verbatim and analysed by a linguist and clinician to identify the prevalence of minimizing phrases and the recipients’ response.
The patients’ mean age was 48 years (range 20―81 years) and median back pain duration, 28 weeks (range 7 weeks―9 years). The mean duration of initial consultations was 38 minutes:46 seconds, (range 26:21―53:16) and for follow-up sessions was 20 minutes:06 seconds (range 03:36―34:29).
In total, 14 words/phrases were identified in the initial consultations in the longitudinal study that were used in a minimizing context. The five most-prevalent words/phrases used by physiotherapists were: ‘just’ (mean use n=54.4 per interaction); ‘bit’ (n=16.5); ‘sort of’ (n=13.2); ‘little’ (n=11.4) and ‘kind of’ (n=11.4). Meanwhile, the five most-prevalent words/phrases used by patients were: ‘just’ (mean n=23.5); ‘sort of’ (n=14.4); ‘bit’ (n=9.0); ‘little’ (n=4.8) and ‘quite’ (n=4.6). There was evidence where minimizing was used for mirroring, (previously identified as an empathic gesture), e.g. Physiotherapist (while palpating): How’s that?”; Patient: “…..a bit tender”; Physiotherapist: “…..Just a bit tender when I’m pressing it, yeah?” Conversely, in-depth analysis showed that the minimizing phrase was often followed with an escalation by the patient e.g. Physiotherapist: “Were you woken up just once or twice?”; Patient: “…..But I still have problems moving in bed..… I can’t lie on my side..… I’m finding that very difficult”, negatively impacting the therapeutic alliance.
The practice of minimizing is more-frequently used by physiotherapists than patients, and can positively or negatively influence the therapeutic alliance, such as mirroring for empathy or escalating symptom reports. This novel finding has not been reported in physiotherapy interactions to date and is worthy of further research.
Further developing communication skills remains a priority for every physiotherapist to optimize patients’ outcomes and experience. Directly observing clinical practice minimizes recall and social desirability bias and provides learning opportunities for clinicians to explore their conscious/unconscious use of minimizing language and its impact on the therapeutic alliance, with greater awareness of escalations in patients’ responses.
Back pain
Therapeutic alliance
