Photo credit: F Delventhal

Roughly 2300 years ago, Aristotle came up with his list of logical fallacies in his treatise on logic and argument, The Organon. Fallacies are tricks that your mind is likely to play on you to make you believe that one thing is happening, when in reality, it isn’t. The most famous from his list is The Fallacy of False Cause commonly described as “correlation does not equal causation”. Confirmation bias really makes people susceptible to logical fallacies as they look for any evidence to support their beliefs.

Below I have identified 5 categories of what I call “treatment fallacies”. In my experience, these are the most common tricks that physical therapists fall for when trying to interpret their own effectiveness. Since I have heard that people on the interwebs really like their information provided in list form, here, in no particular order, are my…

Top 5 Treatment Fallacies!!!

1. The Nice Patient Fallacy

In general, people are nice and polite. They really don’t want to hurt anyone’s feelings. When they see their medical providers, they don’t want to insult that perfect stranger by challenging their statements or giving the impression that they think the provider is incompetent. For example, I’ve listened to a new intern give a patient a confusing and rambling explanation only to then see the patient nod and say, “That makes sense.” What??? No it didn’t!!!

Patients want to please their provider, especially if the provider is friendly, warm, and compassionate. If the patient feels like you are honestly trying your best, they will often report subjective improvements, just to be nice. Sometimes the provider will even lead the patient by focusing their comments on any positive report and ignoring anything negative. I have seen patients who told their previous PT that everything was all fixed and great (“My treatment works!”) just to get discharged and not hurt anyone’s feelings. They lied to you.

Of course you don’t solve this by being a jerk, you solve it by encouraging honesty and making the patient know that it’s okay to express concerns. Don’t act hurt or get defensive if the results aren’t perfect (they rarely are anyways). I find that asking questions like, “During what activities are you still reminded that you had a knee injury?” can be helpful.

2. The Imagine If We Didn’t Treat It Fallacy

In this fallacy, the therapist assumes that if the patient never received treatment, their condition would continue to worsen over time. One thing that we know is that all symptoms improve over time, even if just a little bit. Occasional exacerbations will almost always return to their baseline if you just wait a couple weeks. The only kind of patient that a therapist sees is the kind of patient who receives their treatment. As you apply your treatment, you will see improvement with almost every patient and assume, “My treatment works!” No dummy, that’s just time. You are just running a one-provider, uncontrolled, and horribly biased clinical trial. Sucker!

Sometimes therapists unintentionally encourage this by saying things along the lines of, “Imagine how much worse it would be if we didn’t treat it!” For all you know, you may actually be slowing their recovery. Don’t just trust your experience, read the literature.

3. The Impossible to Comply Fallacy

In the Impossible to Comply Fallacy, the physical therapist puts together a home program for the patient that is just ridiculously extensive. For example: 27 different exercises for the rotator cuff to be performed 3x/day plus stretches that require a 2 minute hold in each position. One of two things will happen in this scenario:

1. The patient can’t complete their program and admits it to the therapist. “Aha! Your lack of progress is due to your non-compliance! Why won’t patients do their homework? My treatment works!”

2. The patient can’t complete their program and DOES NOT admit it to the therapist. Now, what do you think goes through the patient’s head? “I told my PT that I did my entire home program, but if I tell them that my symptoms are no better, they’ll know I’m lying…” They tell the PT that they did the program and are now better. “My treatment works!”

Either way, the PT convinces themselves that their treatment is effective. Keep your home program straight forward and simple. Start with just your top 3 or so exercises that should have the biggest effect, making it easier to comply. Think minimal effective dose. As you progress the home program, identify portions that the patient can discontinue to keep the home program streamlined.

4. The Feels Good Fallacy

The Feels Good Fallacy refers to treatments that feel good to receive. There are so many treatments that fall into this category: massage, ultrasound, hot packs, electrical stim, gentle stretching, most manual therapy techniques, a lot of alternative medicine, the list goes on and on. The patient feels good immediately after this kind of treatment (for whatever reason). It is easy to assume that this is having a direct effect on the underlying pathology. Again, “My treatment works!” A lot of these interventions just help people relax and don’t actually make any lasting changes to tissue.

There actually can be some operant conditioning going on here as well. The patient knows that if they report discomfort when they first arrive and tell you that the feel good treatment really made them better, you will provide the feel good treatment again. This can reinforce the pain behavior. If the treatment is passive, it can also encourage an external locus of control, a Victim-Healer relationship between the patient and provider. Hey, I’m all for any relief from pain, even if temporary, but don’t think that anything is really happening to the tissue. If you use these treatments, try to focus on feel good options that the patient can do to themselves.

5. The Hurts Like a Motherfucker Fallacy

We end with my favorite treatment fallacy! This is probably the most common one I see today. It is the complete opposite of the Feels Good Fallacy. Your treatment is unpleasant. It hurts. It hurts bad. One might say it hurts like a motherfucker. Examples? Prolotherapy, surgery, platelet rich plasma (PRP) injections, foam rolling, deep tissue massage, IASTM, scar mobilizations, punching your patient in the face (this is bad for therapeutic alliance in my opinion), and so on. There are three main ways that this can be affecting symptoms without having any effect on tissue:

1. It really FEELS like something significant is happening to the tissue, both to the patient and the provider. This gives the treatment really good face validity (it appears to do what it claims to do) which we know will greatly enhance non-specific effects. Our friend placebo can be responsible for all the effects. “My treatment works!”

2. It gives a new reference for pain – it resets the scale. In other words, it creates so much pain to the region that the patient perceives their previous pain as relatively lower. Think of it this way. Imagine me playing my favorite Megadeth song in the clinic at ‘4’, which is unpleasantly loud for the patient (Weird. Who doesn’t love Megadeth?). I say, “Oh yeah?” and crank that bad boy up to ’10’ for the next two minutes. When I bring it back down to ‘4’, the patient says, “Thanks, that’s better.” I didn’t actually do anything, but who cares? Their ears stopped hurting. “My treatment works!”

3. Like with the Feels Good Fallacy, operant conditioning could be at play here as well. The patient comes in, “My leg hurts.” You tell them that they need your *hurts like a motherfucker* (patent pending) treatment and beat on that area inflicting some real pain. Next time they come in and you ask, “How’s the leg?” they say, “Better!” What they might really be saying is, “I definitely don’t need that again. Please put the tool away. I’ll be good. I won’t complain anymore.” Well, that solved that problem didn’t it? “My treatment works!” See also “I’ll Give You Something to Cry About”.

Be aware…

Now of course these fallacies are not always at play every time a treatment is painful or feels good or whatever. Many surgeries have good science behind them and great track records for effectiveness even though they can hurt like a … well … they can hurt pretty bad. Just be aware of that tricky brain of yours trying to derail your critical thinking skills. As Richard Feynman reminds us:

“The first principle is that you must not fool yourself — and you are the easiest person to fool.”