Communicating with Patients

Communicating With Patients: What Happens in Practice? Lisa Roberts and Sally J Bucksey PHYS THER. 2007; 87:586-594. Originally published online April 3, 2007 doi: 10.2522/ptj.20060077 The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/87/5/586 Online-Only Material Collections http://ptjournal.apta.org/content/suppl/2007/05/11/ptj.200 60077.DC1.html This article, along with others on similar topics, appears in the following collection(s): Professional-Patient Relations e-Letters To submit an e-Letter on this article, click here or click on "Submit a response" in the right-hand menu under "Responses" in the online version of this article. E-mail alerts Sign up here to receive free e-mail alerts Correction A correction has been published for this article. The correction has been appended to this PDF. The correction is also available online at: http://ptjournal.apta.org/content/87/7/957.2.full.pdf Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 Research Report Communicating With Patients: What Happens in Practice? Lisa Roberts, Sally J Bucksey L Roberts, PhD, MCSP, is Superintendent Physiotherapist, Physiotherapy Department, Southampton University Hospitals NHS Trust, Southampton, Hampshire, United Kingdom, and Senior Lecturer, School of Health Professions and Rehabilitation Sciences, Southampton University, Southampton, Hampshire, United Kingdom. Background and Purpose Communication is the most important aspect of practice that health care professionals have to master. The purpose of this study was to measure the content and prevalence of verbal and nonverbal communications between physical therapists and patients with back pain. Subjects SJ Bucksey, MSc, MCSP, is Physiotherapy Manager, West Dorset Hospitals NHS Trust, Dorchester, Dorset, United Kingdom. She was a student in the School of Health Professions and Rehabilitation Sciences, Southampton University, when this work was completed. Address all correspondence to Mrs Bucksey at: sally.bucksey@wdgh. nhs.uk. Seven physical therapists and 21 patients with back pain participated in this study. [Roberts L, Bucksey SJ. Communicating with patients: what happens in practice? Phys Ther. 2007; 87:586 –594.] Results © 2007 American Physical Therapy Association Methods The first interaction following the initial assessment was recorded with a video camera. The outcome measures were the Medical Communications Behavior System (verbal communication) and frequencies of nonverbal behaviors (affirmative head nodding, smiling, eye gaze, forward leaning, and touch). Semistructured interviews were undertaken with the physical therapists to determine the perceived influence of the video camera. A total of 2,055 verbal statements were made. Physical therapists spent approximately twice as much time talking as patients, with content behaviors (such as taking history and giving advice) comprising 52% of verbal communications. The most prevalent nonverbal behaviors were touch by physical therapists (54%) and eye gaze by patients (84%). Discussion and Conclusion The prevalence and content of communication can be measured with video analysis and validated tools. Communication is an extremely important but underexplored dimension of the patient-therapist relationship, and the methods described here could provide a useful model for further research and reflective practice. Post a Rapid Response or find The Bottom Line: www.ptjournal.org 586 f Physical Therapy Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 May 2007 Communicating With Patients in Practice C ommunication has been described as the most important aspect of practice that health professionals have to master1 and an essential requirement underpinning any successful encounter.2 It has been widely studied within the fields of medicine, nursing, psychology, psychotherapy, and social science, and the complexity of measuring interactions between patients and health care professionals is well recognized. It is important to consider not only what is said but also the manner in which it is conveyed, as communication traditionally incorporates verbal and nonverbal behaviors. Depending on the situation and the words used, verbal communication may be used for the transference of information or instruction as well as for conveying empathy in order to establish a relationship.3 The effectiveness of any verbal message conveyed to another individual relies on his or her ability to listen, hear, and assimilate the message appropriately.4 Nonverbal communication includes all behaviors that convey messages without the use of verbal language.5 Attempts have been made to quantify the relative importance of verbal and nonverbal behaviors, with estimates of the nonverbal component comprising 55% to 97%,6 90%,7 and 93%8 of the message. Despite the variations in these values, nonverbal aspects of communication are consistently thought to be more influential than verbal behaviors. According to Waddell,9 when the nonverbal message conflicts with the verbal message, people probably will not believe what is said. Although the importance of communication in health care interactions is undisputed, its influence on treatment outcomes is less clear. Current data suggest that positive effects occur when people feel empowered and believe that they have been May 2007 “heard”10; therefore, a “good clinical encounter”10 leads to better outcomes. This view has been substantiated by reports of increased patient knowledge,11 improvements in initial beliefs about medications,11 improved adherence to treatment regimens,11–13 greater understanding of information given,12 and enhanced satisfaction.11,12,14 This view is not universal, however, as some researchers have argued that the explanatory models used by health care professionals intersect with the beliefs of patients and create relationships that do not result in predictable, linear outcomes.15 Recently, interest has grown in examining the implications for clinical care of more patient-centered approaches15 across the health care professions. Within the psychotherapy literature, the development of a “strong therapeutic alliance”16 has been widely considered, and it has been stated that the relationship between the client and the psychotherapist, more than any other factor, determines the effectiveness of psychotherapy.17 Similarly, within the field of nursing, the importance of communication has been recognized, in particular, during the initial phase of the nurse-patient relationship, when roles are clarified and rapport and standards are established.18 Within the field of medicine, it has been claimed that 80% of patients’ complaints arise from a breakdown in communication,19 a finding that highlights the importance of this topic. Furthermore, communication assumes a special importance when things go awry; in a study of 227 patients and relatives who were taking legal action through medical negligence solicitors, “explanation and apology” was the most frequently cited action after the incident that might have prevented litigation.20 With regard to physical therapy, the need to give attention to communi- cation has been accelerated by the emergence of patient-centered perspectives.21 When Stenmar and Nordholm22 investigated clinicians’ perceptions of the most important factors in successful treatment in their sample of 187 Swedish physical therapists, they found that the majority perceived the patient-therapist relationship and patients’ resources to be more important to treatment success than the treatment itself. Despite the importance of communication, there is no gold standard instrument for measuring communication, and various methods have been used within the health care fields; qualitative methods have been used to determine health care professionals’ and patients’ opinions of what constitutes an effective interaction,23 and quantitative methods have been used to measure verbal and nonverbal communications with an array of classification schemes. Although these methods have resulted in greater insight into styles of communication, relatively little still is known about the content of health care consultations.24 To date, this work generally has focused on doctor-patient interactions and has been reported less widely in other health care professions. Within the setting of physical therapy, Talvitie3 investigated the interaction between the clinician and the patient by using a form of interaction analysis to record verbal and nonverbal communications. This method involved the use of an observational instrument based on the Didactic Process Analysis in the Helsinki taxonomy, which was originally designed for use in a classroom setting.25 The measure had been adapted (without revalidation) to suit the classification of verbal communication and socioaffective characteristics in the setting of physical therapy. Despite its apparent validity, Talvitie3 considered this measure to be inappropriate for use within Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 Physical Therapy f 587 Communicating With Patients in Practice tion, any clinicians who had specific knowledge of the outcome measures to be used were excluded (n⫽1) to minimize bias attributable to prior knowledge of the communication categories. Figure. Summary of study design. GP⫽general practitioner. the setting of physical therapy because of insensitivity within the coding categories. Therefore, the search continues for an appropriate, validated tool for measuring the communication that takes place during clinical encounters. Only when the content of this communication is known can clinicians establish ways to optimize the relationship, maximize the nonspecific treatment effects (eg, the patient who experiences less pain during a consultation with a warm, empathetic health care professional), and enhance the patient’s experience. Given this context, the purpose of this study was to measure the content and prevalence of the verbal and nonverbal communications that occur between physical therapists and patients with low back pain in an outpatient setting. 588 f Physical Therapy Method Study Design A pragmatic, prospective, observational study was undertaken in an acute care hospital and in a Primary Care Trust in southern England to identify the verbal and nonverbal communications that occur between physical therapists and patients with low back pain during treatment sessions. The study design included mixed methods (quantitative and qualitative), as outlined in the Figure. Participants All physical therapists (n⫽16) working in the participating departments were given an information sheet outlining the study. Clinicians whose caseload did not include patients with low back pain were excluded (n⫽2), ensuring that all participating therapists were currently treating patients with low back pain. In addi- In an outpatient setting, people with low back pain are among the most prevalent consumers of physical therapy. Although it is essential to build rapport and develop a strong patient-therapist relationship, there are additional physical barriers that can present a challenge in this population. First, patients frequently experience discomfort when sitting (eg, to give a history), and the therapist must remain sensitive to this situation. Second, some components of the initial assessment and subsequent treatment may involve palpating the spine (which usually occurs with the patient lying prone). This scenario potentially limits the opportunities for demonstrating nonverbal behaviors, such as eye gaze, thereby increasing the need for skillful verbal communication. Therefore, we decided to limit the patient population to any adult patients referred to the physical therapy departments with a diagnosis of low back pain. The duration of back pain was not specified in the inclusion criteria, and patients were eligible to participate whether or not their symptoms were referred into the lower limb, as these factors were assumed not to influence the communication occurring during the interaction. Patients with signs and symptoms suggesting possible serious spinal pathology were excluded, as were people whose first language was not English, because of the exploratory nature of the study. Of the 13 physical therapists (4 men and 9 women) who agreed to take part in the study, 7 female clinicians (2 employed by an acute care hospital and 5 employed by the Primary Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 May 2007 Communicating With Patients in Practice Care Trust) successfully recruited patients. Their mean number of years of qualification was 9 (range⫽ 0.5–33 years), with 3 clinicians (43%) at the more experienced (senior I) grade, 3 (43%) at the senior II grade, and 1 (14%) at the least experienced (staff) grade. Twenty-one patients reporting low back pain were recruited for the study (12 men [57%] and 9 women [43%]). The mean age of the patients was 48 years (range⫽21–76 years). Data Collection To measure communication, it is necessary to directly observe the interaction taking place between the physical therapist and the patient.26 This interaction can be recorded with either videotapes or audiotapes, although videotape recording has the advantage of being able to record nonverbal communication in addition to verbal utterances. Conversely, recording patients in a state of undress may deter potential participants and could raise ethical issues. For the purposes of this study, recording nonverbal communication was a priority; therefore, with express (written) consent from both parties, the interaction between the physical therapist and the patient was recorded with videotape during the first treatment session following the initial assessment. This session was chosen because it was a less structured encounter than the initial assessment but was still early enough in the patient’s treatment to capture the developing therapeutic relationship. A tripod-mounted Sony camera (model CCD-FX200E/FX270E)* was placed centrally along the side partition of the treatment cubicle to maximize the view of both the patient and the clinician as discreetly as possible. Because of ethical con* Sony Corp, Pipers Way, Thatcham, Berkshire, United Kingdom RG19 4LZ. May 2007 straints, the camera was manually operated by the researcher, who was present in the treatment cubicle (and confined the videotape recording to the head and neck of participants throughout the data collection process). Following the treatment session, a brief, semistructured interview was undertaken with the physical therapist to determine the perceived influence of the presence of the manually operated video camera, in comparison with the therapist’s usual practice. Outcome Measures Verbal communication. In order to explore the interaction between the physical therapist and the patient, a validated outcome measure of verbal communication, the Medical Communications Behavior System (MCBS), was used.27 The MCBS was developed to measure the communication occurring in situations involving multiple health care providers27 and has categories for informational (content), relational (affective), and negative behaviors for both clinicians and patients. These categories were subdivided further into 13 clinician behaviors, 7 patient behaviors, and 3 miscellaneous categories (Tab. 1). In order to maintain the use of the measure in its original form, the term “behavior” was adopted throughout instead of the term “communication.” Psychometrically, the interrater reliability of the MCBS, assessed with the Pearson correlation coefficient, was greater than .70 for all behaviors occurring more frequently than 2% of the time during an observational study of 101 genetic counseling sessions.27 Factor analysis was done and was found to provide some construct validity, supporting the a priori organization of the behaviors into informational, relational, and negative behaviors (but with further subdivisions for informational behaviors).27 In addition, criterion validity has been determined with the Roter Interaction Analysis System.27 Trends in nonverbal communication. The frequencies of the 5 nonverbal behaviors—affirmative head nodding, smiling, eye gaze, forward leaning, and touch— described by Heintzman et al28 were recorded at 40-second intervals for both the physical therapist and the patient. This outcome measure was developed in the field of business and was subsequently used by CarisVerhallen et al6 in the settings of home nursing and care of older people; the interrater reliability of the nonverbal behaviors was calculated, using the Pearson correlation coefficient, to be between .70 and .98. Data Analysis To determine the content and prevalence of the verbal and nonverbal communications that occurred between the physical therapists and the patients, the primary analysis involved classifying the verbal communication by use of the MCBS and measuring the frequencies of nonverbal behaviors at 40-second intervals. The videotapes were analyzed by a trained, independent assistant, who classified the verbal utterances into the categories shown in Table 1. An interrater reliability exercise for coding these categories was done by the researcher and the independent assistant using the Pearson correlation coefficient with 3 pilot therapist-patient dyads. In addition to recording the frequencies of the MCBS categories, we recorded the durations of the treatment sessions in minutes and seconds. Because of variations in the length of the treatment sessions, the proportion of time that the physical therapist and the patient spent talking was determined as a percentage for each category. Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 Physical Therapy f 589 Communicating With Patients in Practice Table 1. Examples of Categories Within the Medical Communications Behavior System27 Category Example Physical therapist content behaviors 1. History and background probes 2. Checks for understanding information 3. Advice and suggestions Interrater Reliability of Verbal and Nonverbal Behaviors During pilot work, good interrater reliability between the researcher and the independent assistant was demonstrated for both verbal communication (r⫽.97) and nonverbal communication (physical therapist r⫽.98, assistant r⫽.86). 4. Restatement 5. Clarification Physical therapist affective behaviors 1. Emotional probes 2. Reassurance and support 3. Reflection of feelings 4. Encouragement and acknowledgment Physical therapist negative behaviors 1. Disapproval 2. Disruptions 3. Jargon Patient content behaviors 1. Content questions 2. Content remarks 3. Checks for understanding Patient affective behaviors 1. Encouragement 2. Emotional expressions Patient negative behaviors 1. Disapproval 2. Disruptions Miscellaneous 1. Social amenities 2. Silence 3. Nonclassifiable Analysis of verbal and nonverbal communications was done with descriptive statistics by use of the Statistical Package for the Social Sciences (SPSS, version 10.0).† As before, an interrater reliability exercise for coding the nonverbal behaviors was done prior to data collection. The verbatim transcripts of the semistructured interviews were analyzed independently by the researcher and the assistant, and a thematic analysis was used to identify emergent themes. † SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. 590 f Physical Therapy Results Duration At the time of the study, follow-up appointments were usually allocated 20-minute slots. From the 21 interactions observed between patients and physical therapists, 312 minutes of videotape were recorded. The mean durations of the treatment sessions were 14 minutes 51 seconds. The minimum duration noted was 8 minutes 26 seconds, and the maximum duration noted was 31 minutes 45 seconds. Verbal Communication During the 21 sessions analyzed, 2,055 statements were recorded and classified by use of the MCBS, with a mean of 98 statements per session. Overall, clinicians made approximately twice as many statements as patients made. Each MCBS category was recorded as a percentage of the total verbal communication (Tab. 2), demonstrating that overall, content behaviors represented the highest proportions of verbal communication carried out by both physical therapists (52%) and patients (26%). A secondary analysis took into account sex (of patients, given that all physical therapists were women), seniority (ie, grade of staff), and patients’ ages. Of these 3 factors, seniority affected the MCBS categories the most, with the more senior staff members (senior I grade) showing a higher proportion of physical therapist affective behavior (20%) than the senior II grade staff members (12%) or the least experienced (staff grade) staff members (12%). The results of analyses of patients’ ages and genders were unremarkable. Nonverbal Communication The nonverbal behaviors, observed at 40-second intervals during the treatment sessions, are summarized in Table 3. Among the 468 time points observed, the highest proportions of nonverbal behavior for the physical therapists were represented by touch (54%) and then by eye gaze (32%), whereas for the patients, the most frequent nonverbal behavior was eye gaze (84%). Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 May 2007 Communicating With Patients in Practice Perceived Influence of the Camera on Communication Although the physical therapists reported that the more times they were videotaped, the easier they found it to relax, the majority considered that they had decreased the amount of “non–physical therapy chat” that occurred, in comparison with their usual practice; this finding resulted in an underrepresentation of this aspect of communication during this study. Perceived Influence of the Camera on Behavior As determined by the thematic analysis, 5 of the 7 physical therapists considered that the presence of the manually operated video camera influenced their behavior. They identified 3 areas of perceived changes in their behavior: the extent of treatment planning beforehand, the selection of treatment techniques, and a reduction in the amount of time during which the patient was in a state of undress. With regard to treatment planning, one clinician remarked: “I think that the thought of the video camera makes you think what you are going to include in the treatment so that you are absolutely clear about what you are going to do in the treatment session before you go in.” Discussion This exploratory study was designed to measure the content and prevalence of the verbal and nonverbal communications that occur between physical therapists and patients with low back pain in an outpatient setting. For the 2,055 verbal statements recorded, the ratio was 2:1 in favor of the physical therapists. This ratio differs from that found in previous research by Ong et al,29 who reported that, in a doctor-patient oncology setting, patients and doctors communicated relatively equally during their consultation. The higher percentage of physical therapist conMay 2007 Table 2. Medical Communications Behavior System Categories as Percentages of Total Communicationa Category Frequency (%) Physical therapist Content behaviors 1,065 (51.8) Affective behaviors 272 (13.2) Negative behaviors 0 (0.0) Patient Content behaviors 541 (26.3) Affective behaviors 43 (2.1) Negative behaviors 13 (0.6) Miscellaneous Total statements 121 (5.9) 2,055 a Frequency of each verbal behavior that occurred during the 21 interactions as a percentage of the total communication. Miscellaneous behaviors included social salutations and nonclassifiable utterances (eg, “ouch”). tent communication in the present study may have been attributable to the fact that, after the initial assessment, the first treatment session usually involved giving advice and information (eg, about posture, ergonomic and lifestyle factors, and other forms of self-management); discussing psychosocial factors; explaining the risks, benefits, and alternatives of any treatments offered; gaining consent for any techniques performed; and evaluating their outcomes. Physical therapists are likely to have longer appointment times than doctors, make fewer referrals to other health care professionals, and spend more time applying treatments; these factors may account for the differences between the studies. Previous research showed that considerable affective behaviors are required for an effective interaction between a physical therapist and a patient.30 In the present study, these behaviors were shown to be less common than content behaviors; a possible explanation is that a considerable amount of advice still was being imparted to the patients during the early sessions. It is possible that affective behaviors become more prevalent in subsequent sessions, when the therapeutic relationship is more established; this issue is worthy of further research. A more likely reason for the underrepresentation of empathic behaviors in the present study, however, was the presence of the video camera, as the therapists reported that this decreased the amount of nonclinical communication that occurred. This potential limitation also was identified in previous studies.31,32 It is not known from the present study what influence the camera was perceived to have on the patients’ communication, as this factor was not measured; this issue is worthy of further research. Further analysis of the data showed that sex (of the patient) made little difference in the categories of verbal communication recorded in the present study. From the pool of 4 male and 9 female physical therapists, only 7 female clinicians successfully recruited patients into the study. Therefore, it was not possible in the present study to explore the content and prevalence of interactions involving male clinicians and to compare them with those in- Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 Physical Therapy f 591 Communicating With Patients in Practice Table 3. 28,a Nonverbal Behaviors a Behavior Description Eye gaze Either the patient or the physical therapist gazes directly at the face of the other party. Affirmative head nodding Head nods are defined as nodding one or more times as a sign of attentiveness in conversation or as reinforcing what has been spoken. Smiling Smiling in this context is an expression of friendliness. Laughing aloud, in response to a joke, is not considered a nonverbal communication and is coded in the verbal part of the observation scheme. Forward leaning Forward leaning is defined as posture that involves bending forward or sitting closer to the patient when it is not necessary to carry out a physical therapy task. This position conveys involvement and a concentrated focus on the interaction partner. Touch Either the physical therapist or the patient has physical contact with the other party. Types of nonverbal behaviors recorded at 40-second intervals. volving female clinicians. This is a topic for further research, as other studies showed that, in general, women (both patients and health care professionals) spoke more during a medical interaction than men33 and that female-female interactions were likely to result in greater frequencies of affective communications.34 The present study also showed that experienced physical therapists demonstrated affective behaviors more readily than their junior colleagues. A possible explanation is that therapists with less experience often lack confidence in their clinical abilities and so tend to focus on treatment techniques rather than on more affective components, such as patients’ feelings. This notion is supported by the qualitative work carried out by Jensen et al,35 and such sentiments are likely to be com592 f Physical Therapy pounded by the presence of the video camera. During the 21 treatment sessions observed, the numbers of nonverbal behaviors recorded at 40-second intervals for patients and physical therapists were 40 and 652, respectively (a ratio of 1:16). CarisVerhallen et al6 and Ambady et al26 considered that viewing sections of an interaction is an adequate indication of the interaction as a whole, and in the present study, 468 time points were sampled. The results showed that the physical therapists demonstrated nonverbal behaviors that facilitated rapport building, such as eye contact and head nodding. This finding is in accordance with the findings of previous research carried out in the health care field,6 which suggested that nurses use mainly eye gaze, head nodding, and smiling to establish a good relationship with their patients. With regard to touch, Gyllensten et al36 suggested that physical therapists use touch to positively influence their relationship with patients. Perhaps not surprisingly, the highest proportion of nonverbal behavior recorded for clinicians in the present study was represented by touch, a result that may have been expected as a consequence of the hands-on contact that occurred during physical therapy treatment sessions. Unfortunately, it was not possible to determine whether therapists used affective, rather than therapeutic, touch to facilitate relationships with their patients because of the lack of sensitivity in the single category “touch” in the outcome measure chosen. Within the nursing literature, the category “touch” has been subdivided into 2 categories: instrumental touch, which is defined as deliberate physical contact necessary to perform a task, and affective or expressive touch, which is relatively spontaneous and not necessary for the completion of a task.6 In future research measuring interactions within the setting of physical therapy, we recommend that touch be subdivided into instrumental touch (eg, executing a manual therapy technique), demonstration (eg, when therapists demonstrate on themselves how to modify an activity or perform an exercise), and affective touch (eg, making tactile contact with a patient to offer reassurance). Any changes in the outcome measure would require revalidation prior to use. The results also indicated that the physical therapists and the patients demonstrated high proportions of eye contact (156 and 36 times, respectively). Therapists learn at an un- Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 May 2007 Communicating With Patients in Practice dergraduate level about the importance of body language, in particular, eye contact, which is reported to promote a favorable treatment outcome.7,37 More specifically, physical therapists’ eye contact has been shown to increase patients’ confidence and demonstrate that the clinician is interested in the patient’s condition.37 During the treatment of patients with low back pain, however, maintaining eye contact and building this confidence may become problematic if the patients spend a significant amount of time lying prone. Further underreporting of nonverbal behaviors in the present study may have arisen because of the presence of the researcher and the video camera and, on a practical level, it was not always possible to observe both the clinician and the patient simultaneously with a single video camera. Although the present study showed that aspects of verbal and nonverbal communications can be measured with video analysis and validated outcome measures, a number of limitations were evident. The background noise within the department, coupled with the divergent positioning of patients and physical therapists, may have resulted in some underreporting of communications. The use of 2 microphones helped to minimize this problem; however, multiple wall-mounted cameras would have been preferable but were not permitted for ethical reasons. Previous studies acknowledged the importance of recording both the verbal and the nonverbal behaviors that occur during an interaction; however, few authors attempted to do so,6 especially within the setting of physical therapy.3 Although the outcome measures chosen for the present study had not been used previously in such a setting, they were able to effectively record the content and prevalence of verbal and nonverMay 2007 bal behaviors that occurred. Despite being able to measure these aspects of communication, however, they were not able to determine sequences or patterns of communication; this is a topic for further research. In addition, the most prevalent category in the MCBS tool lacked sensitivity. In future studies, it would be advantageous to subdivide the verbal content category into “offering advice” (such as when modifying an activity) and “giving instruction” (such as when teaching an exercise), as the balance of power may be perceived differently during these interactions. Any such modifications would need to be validated against the original MCBS. The methods used in the present study for recording the prevalence and content of verbal and nonverbal communications could be applied to further research (eg, mapping of entire care episodes). In the present study, we considered only the first follow-up appointments for patients with low back pain; however, it would be important to consider the initial assessment as well as subsequent treatments to record the content of the interactions as the relationship develops. Once this baseline is established, research can be extended to include issues of culture and patients’ needs and expectations, as their effect on communication is largely unknown. In clinical practice, recording initial assessments (with express consent) can provide valuable information and material for reflection, helping to identify communication skills and strategies and the impact that they appear to have on patients.38 Such reflection is important because communication is a skill and, like all skills, it requires practice to be performed well.39 Conclusion In the present study, we explored an area of physical therapist practice that is universally regarded as ex- tremely important but is underrepresented within the health care literature. It has been shown that it is possible to reliably record the prevalence and content of verbal and nonverbal communications with video analysis and valid tools, such as the MCBS and the positive nonverbal behaviors of Heintzman et al.28 Although the physical therapists in the present study perceived that the presence of the camera (operated by the researcher) influenced their behavior and communication, this influence became less of an issue the more times they were recorded on videotape. The methods described here could be used in future research to further explore the patient-therapist relationship (eg, mapping of entire care episodes, patterns of communication, and issues such as sex and culture). Once the content of a physical therapy encounter is established, the next challenge is to use communication skills that maximally enhance treatment outcomes. As part of this process, video analysis could be used for teaching purposes to provide feedback to clinicians to improve their communication skills, maximize the nonspecific treatment effects, and improve the patient’s experience. Both authors provided concept/idea/ research design and writing. Mrs Bucksey provided data collection and analysis and fund procurement, Dr Roberts provided project management and institutional liaisons. The authors acknowledge Sue High, Department of Social Statistics, Southampton University, for statistical advice; the physical therapy outpatient staff at Stoneham Centre, Southampton City PCT; and financial support from the Arthritis and Rheumatism Campaign and the Chartered Society of Physiotherapy. This work was presented at the 14th International Congress of the World Confederation for Physical Therapy; June 7–12, 2003; Barcelona, Spain. Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 Physical Therapy f 593 Communicating With Patients in Practice Ethical approval for this study was granted by the Southampton and South West Local Research Ethics Committee. This article was received March 9, 2006, and was accepted January 8, 2007. DOI: 10.2522/ptj.20060077 References 1 Wetherall D. Foreword. In: Silverman J, Kurtz S, Draper J, eds. Skills for Communicating With Patients. Oxon, United Kingdom: Radcliffe Medical Press; 1998:vii. 2 Klaber Moffett J, Green A, Jackson D. Words that help, words that harm. In: Gifford L, ed. Topical Issues in Pain 5. Falmouth, United Kingdom: CNS Press; 2006:105. 3 Talvitie U. Socio-affective characteristics and properties of extrinsic feedback in physiotherapy. Physiother Res Int. 2000; 5:173–188. 4 Williams D. Communication Skills in Practice: A Practical Guide for Health Professionals. 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Physical therapy patients’ view of health care professionals. Physiother Theory Pract. 1998;14:211–221. 31 Lomax H, Casey N. Recording social life: reflexivity and video methodology. Sociological Research Online. 1998;3. Available at: http://www.socresonline.org.uk/ socresonline/3/2/1.html. Accessed February 8, 2007. 32 Anderson C, Adamson L. Continuous video recording: a new clinical research tool for studying the nursing care of caner patients. J Adv Nurs. 2001;35:257–267. 33 Roter D, Lipkin MJ, Korsgaard A. Sex differences in patients and physicians’ communication during primary care medical visits. Med Care. 1991;29:1083–1093. 34 Hall JA, Irish JT, Roter DL, et al. Satisfaction, gender, and communication in medical visits. Med Care. 1994;32:1216 –1231. 35 Jensen GM, Shepard KF, Gwyer J, Hack LH. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Phys Ther. 1992;72:712–722. 36 Gyllensten AL, Gard G, Salford E, Ekdahl C. Interaction between patient and physiotherapist: a qualitative study reflecting the physiotherapist’s perspective. Physiother Res Int. 1999;4:89 –109. 37 Larsen KM, Smith CK. Assessment of nonverbal communication in the patientphysician interview. J Fam Pract. 1981;12: 481– 488. 38 Goldingay S. Communication and assessment: the skills of information gathering. In: Gifford L, ed. Topical Issues in Pain 5. Falmouth, United Kingdom: CNS Press; 2006:85. 39 Daykin A. Communication within therapeutic encounters: message received and understood? In: Gifford L, ed. Topical Issues in Pain 5. Falmouth, United Kingdom: CNS Press; 2006:102. Volume 87 Number 5 Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 May 2007 Communicating With Patients: What Happens in Practice? Lisa Roberts and Sally J Bucksey PHYS THER. 2007; 87:586-594. Originally published online April 3, 2007 doi: 10.2522/ptj.20060077 References This article cites 29 articles, 4 of which you can access for free at: http://ptjournal.apta.org/content/87/5/586#BIBL Cited by This article has been cited by 4 HighWire-hosted articles: http://ptjournal.apta.org/content/87/5/586#otherarticles http://ptjournal.apta.org/subscriptions/ Subscription Information Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml Information for Authors http://ptjournal.apta.org/site/misc/ifora.xhtml Downloaded from http://ptjournal.apta.org/ by guest on October 10, 2015 Book, Multimedia, and Software Reviews Of special note are the dedication to the Gulf Coast communities that were affected by Hurricane Katrina and the 10% of annual royalties that have been pledged to the community of Pearlington, Mississippi. This edition of Introduction to Physical Therapy has immediate relevance and application to physical therapists in the United States. It provides a comprehensive introduction and description of the profession and practice of physical therapy. The additions of chapters related to communication and financial issues are welcome and needed. This text is directly relevant to the education of physical therapist and physical therapist assistant students. It provides breadth and suf- ficient depth to introduce students to the profession and practice of physical therapy, is consistent with APTA core documents and the Guide, and complements current texts used in physical therapy education programs that provide the needed depth for preparation of physical therapists and physical therapist assistants. Anyone interested in learning about physical therapy will find in this book an accessible and thorough description of the profession as it exists in the United States today. MJ Gelsomino MJ Gelsomino, PT, DPT, is Assistant Professor of the Physical Therapy Program, Utica College, Utica, NY. [DOI: 10.2522/ptj.2007.87.7.956] Teaching Motor Skills to Children With Cerebral Palsy and Similar Movement Disorders: A Guide for Parents and Professionals Martin S. Bethesda, MD 20817, Woodbine House, 2006, paperback, 237 pp, illus, ISBN: 1-890627-72-0, $19.95. The goal of this book is to provide families of children with cerebral palsy (CP) and similar movement disorders with a clear, easy-to-read guideline for performing home exercise programs. Martin has done an excellent job in accomplishing this goal. The book is easy to read, has plenty of illustrative, referenced photographs, and is organized logically. Chapter 1 begins with a description of CP and developmental delay. It describes, in nontechnical language, the different classifications Correction “Communicating With Patients: What Happens in Practice?” Roberts L, Bucksey SJ. Phys Ther. 2007;87:586–594. Under the heading “Interrater Reliability of Verbal and Nonverbal Behaviors,” the sentence should read: “During pilot work, good interrater reliability between the researcher and the independent assistant was demonstrated for both verbal communication (r=.97) and nonverbal communication (physical therapist r=.98, patient r=.86).” To ensure that all categories of verbal communication were included, the authors were not able carry out separate interrater reliability assessments for the physical therapist and the patient, as this as this would not have incorporated the “Miscellaneous” category. [DOI: 10.2522/ptj.20060077.cx] July 2007 Reviews_7.07.indd 957 Volume 87 Number 7 Physical Therapy ■ 957 6/13/07 3:15:15 PM