By Anthony J. Lombardi
By Anthony J. Lombardi
What do the following things have in common?: the colour of your walls; your waiting room furniture; what the patient hears while waiting in your office; the way you shake your patients’ hands; how often your patients come in for treatment; how you explain things to patients; the magazines in your waiting room; the topic of conversation during treatment; the sensory environment; and almost every other aspect, of your treatment room.
These things, and countless others, influence an untapped reservoir of healing capacity referred to as the meaning response – it can easily be accessed by our patients on every visit; therefore, we need to become aware of it.
I began practising 11 years ago and, since then, I have averaged about 600 new patients per year. Many chiropractors do what I do clinically, and are successful, but was I doing something different unrelated to clinical practice that I could make sure I kept doing to ensure success for both the patients who came to see me and my practice overall? Then I started reading research by Moerman (2002), Walach and Jonas (2004), Newman (2009), and others that exemplified how therapists use this something called the meaning response to harness healing capabilities within their patients during treatments. I began to study articles on meaning response and I realized I was already doing a lot of this – so, I wondered how I could maximize my results along these lines. I would like to share with you how I have been able to successfully improve my clinical results by incorporating simple additions to everyday practice.
“The only important thing is the meaning that it has for you.” – W. Somerset Maugham
Meaning response is the brain’s perception of the surrounding environment, which elicits a physiological response that decreases sympathetic tone. Basically, it’s when a patient walks into the doctor’s office, and instead of feeling nervous, they feel relaxed! This gives the therapist an advantage because the sympathetic nervous system, which is active during pain and times of anxiety, becomes submissive when actual relaxation occurs in the mind and body. For example, when a patient with post-traumatic stress disorder walks into my clinic and is greeted by Nitro, our nine-pound toy poodle therapy dog, a physiological transformation takes place within the patient’s body. Dr. David Neuman, MD, who studies the meaning response, says, “A neurohumoral reaction takes place in response to the patients’ surroundings when they perceive and infuse meaning in activities around them that impact their brain.”
This neurohumoral reaction sees the release of endorphins flood pleasure centres in the brain. This causes a relaxation reflex in the arteries of the central and peripheral circulatory systems, which provide oxygen-rich blood to neuromusculoskeletal tissues. Because this is a reflexive response, the patient subconsciously breaks the psychological and physiological cycle of pain – and this makes the body more receptive to the treatment they are about to receive.
The following list was presented by Walach and Jonas in their paper, “Placebo research: The evidence base for harnessing self-healing capacities”: safety, expectation and understanding; familiarity; and simplicity. These methods have been demonstrated in the medical literature as effective for enhancing healing responses to treament:
“The desire for safety stands against every great and noble enterprise.” – Tacitus
Walach and Jonas feel that safety, in the presence of aid or the expression of care and concern, is the most fundamental element necessary for a positive meaning response. I try to incorporate these elements through a variety of mandatory office protocols. I make it a point for my staff to contact every new patient the day after their first visit to my office. We provide a phone call asking the patient how they are doing, and reassuring them that having post-treatment soreness is not uncommon. Then we ask them if they have any questions for us. In addition, I often personally call patients at home in the evenings if earlier that day they presented with an acute injury. Patients appreciate these follow-up calls because it makes them feel special. Their busy chiropractor’s office is taking time out of their day to call them because they are concerned about their health. This promotes a feeling of safety, security and confidence in their decision to choose your clinic.
Expectation and Understanding
“The improvement of understanding is for two ends: first, our own increase of knowledge; secondly, to enable us to deliver that knowledge to others.” – John Locke
Newman (2009) recommends that we provide experience-oriented interventions that allow patients to expect a resolution to the problem, as they understand it. Basically, if our patients can see tangible changes in their condition, and if you can explain those changes in terms they understand, they will get better faster.
For example, using a functional assessment approach that demonstrates muscle weakness or imbalance is something that lets patients see, feel, compare, and understand the difference in their own way. They are likely unable to interpret an EMG or an X-ray but they can sure tell if the gluteus maximus on the left is weaker than the one on the right. Then using an intervention to restore the muscle strength is a tangible result that provides a positive meaning response to the patient, validating their presence in your office and offering hope for the future.
“The familiar is by far the most beautiful.” – Marty Rubin
In the past five years, hospitals and clinics in the United States that focus on treating heart disease have made it a priority to create a positive non-clinical surrounding called a milieu, which is the French word for environment. Applying therapies in a therapeutic setting where the milieu mirrors a comfortable space, as opposed to in a traditional clinical setting, will elevate the meaning response (Walach 2004). I make an effort to do this from the moment patients walk in my door. The reception area is furnished with comfortable couches, lounge chairs and contemporary seating, which gives them the feel of their own living room as opposed to a doctor’s office. I make sure that no clocks are present so that they can focus on relaxing as they watch a flat-screen TV play educational videos of my staff and me demonstrating all of the treatments offered at the clinic.
This reduces their anxiety about acupuncture, manipulation and massage therapy. In addition to all this, our therapy dog, Nitro, greets patients in the reception area during their visit.
“If you can’t explain it simply, you don’t know it well enough.” – Albert Einstein
Philips is a company that makes automated external defibrillators (AEDs). In their promotional video they demonstrate how easy their product is to use by simply reading the directions to five-year-olds, who attach the leads to mannequins correctly – every time.
At times, we are so wrapped up in our technical backgrounds that we do not learn to deliver explanations in terms others can understand. Making things simple is not always easy, but the better you can explain things to your patients, the better they will respond to your treatments (Jonas 2004).
Chiropractors should get into the habit of explaining concepts such as degenerative arthritis, rotator cuff tears and disc bulges in a way that breaks down these concepts to a level that an eighth-grade student would understand. If a patient has a better idea regarding how the treatment works, they will have a greater neurohumoral response to the intervention (Walach, 2004).
THE THREE SENSES OF MEANING RESPONSE
“Touch has a memory.” – John Keats
This is, by far, the area where we as clinicians have the greatest opportunity to have positive meaning responses in our patients. What the patient sees, hears or feels can trigger neurohumoral reactions within the body that translate into windows of therapeutic opportunity.
In my clinic, I take the opportunity to stimulate the patients’ visual field by giving them pleasant things to look at, such as the colours on the walls, the contemporary furniture and even mother nature: several windows overlooking a treed forest relax the patient as the occasional deer glides past. Because 90 per cent of what our brain perceives is interpreted via the visual field, it is important that we prime the patient’s parasympathetic nervous system by giving them pleasant and relaxing things to look at. Once in the treatment room, simply dimming the lights while the patient is undergoing treatment can enhance clinical results. Miwa (2006) published that providing a dimly lit treatment setting was shown to encourage patients to feel safe and relaxed, and that under these circumstances patients developed more trust toward their treatment provider.
Hearing and Touch
It is important to provide patients with pleasant sounds on their visits to your office. During every visit, I ensure the patient’s favourite music playing in the background. I have an iPod dock in every treatment room. I find that music has positive effects on pain management. According to Siedliecki (2006) in the Journal of Advanced Nursing, listening to music during a treatment can reduce chronic pain from a range of painful conditions, including osteoarthritis, disc problems and rheumatoid arthritis, by up to 21 per cent.
The first thing I do when I greet a patient is smile and shake their hand. In 2012, the Journal of Cognitive Neuroscience published a study on the handshake and found out how important it really is. The study was led by Beckman Institute researcher Florin Dolcos and Department of Psychology postdoctoral research associate Sanda Dolcos. They found that a handshake preceding social interaction enhanced the positive impact of approach and diminished the negative impact of avoidance behaviour on the evaluation of social interaction. Dolcos et al (2012) explained that shaking hands not only increases the positive effect toward a favourable interaction, but it also diminishes the impact of a negative impression.
Patient perceptions can facilitate hope, expectation, positive feelings, relief of anxiety and anticipation of improvement. This is done via physiologic processes that produce healthy neurohumoral responses that can actually accelerate healing. As chiropractors we should embrace and adopt the suggestions from the literature that is beginning to clarify the value of the meaning response in clinical practice.
Dr. Anthony Lombardi is a private consultant to athletes in the NFL, CFL and NHL, and founder of Hamilton Back Clinic, a multidisciplinary clinic. He teaches his fundamental EXSTORE Assessment System and practice building workshops to various health professionals. For more information, visit www.exstore.ca.