7 Principles for Effective Patient Engagement

Patient Engagement for Spine

Dr. Jerome Fryer (Chiropractor) cuts to the chase and shares his success in clinical practice and the best ways to engage patients. Beyond the scripting and mundane approach to marketing yourself, pay close attention to a patient’s needs right at the outset. Engaging will ensure compliance and Jerome Fryer shares his 7 principles to his clinical success.

The secret 7 

  1. Pay attention Early.Watch your patient move. Observe with close attention how a patient presents in the waiting room or observe how they get out of the chair and make early observations about the behavior. This lets the patient know you are paying attention. It sets the stage that you are engaged.
  2. Tie in history.Whether the history is fresh, like the observations you’ve identified in getting to the treatment room, or whether it was when the patient felt the injury onset with a particular movement….tie it in to the exam! Even if you are not too sure exactly on the pain trigger, set out a differential, and communicate the anatomical structure(s) that is likely injured.
  3. Touch the patient’s area of complaint.This is a no-brainer but so often I hear that doctors and other therapists do not even touch the area of complaint. Chiropractors, for example, like I am, are doctors who use their hands. SO USE THEM. A patient is asking you to figure out the anatomical problem so investigate the area.
  4. Tell the patient what you are doing.This is another common-sense thing to do but is often not done. If you are checking the ligaments of the knee, say “I am checking the ligaments of your knee”. A patient wants to know what you are doing. Use your voice to communicate.
  5. Ask if this hurts.The best orthopedic tests are the simple ones. That is, “ does this hurt? ” This is especially helpful when investigating posterior to anterior pressure of the spinous processes (and inter-segmental tissues) of the spine. Too often are doctors concerned about what they feel. More important is what the patient feels. This is a direct way to engage and let the patient know you have found a sensitive tissue and you are paying attention.
  6. Treat the Tissue.If you have found something sensitive in the area of chief complaint, treat the area of chief complaint. Even if you do not have a full understanding of the patho-anatomical lesion, do your very best in developing a plan and communicate that plan. You don’t have to be 100% correct but let your patient know what your plan is. Don’t be afraid of failure and be honest.
  7. Share your findings and plan.There is no better way to communicate than to use a dynamic model to help patients clearly see and observe the tissue. I have been using Dynamic Disc Designs Corp. models for 9 years and when a patient can see where and why it hurts, it is the best way to get the patient engaged with the treatment plan. Compliance also goes way up for home care exercises.


Jerome Fryer BSC DC is a practicing chiropractor that is focused on improving outcomes. He has developed dynamic models to help the patient understand clearly not only the cause of their pain but also the strategies to decrease it.

Validation and Invalidation: Your Patients and the “Nocebo Response”

Nocebo Response

No doubt you’ve heard of “the placebo response”. But how about “the nocebo response”? Much research has been done about now an inert pill, when presented with positive conditioning and expectations, can be as effective as the real thing, but not nearly as many studies have been conducted in regards to the nocebo effect, where the mere suggestion of negative association with a pill or procedure brings on negative side effects.

But the word “nocebo” doesn’t just refer to experiences will medications and treatments. Recently, a pair of doctors at the University of Southampton and University of Exeter Medical School in England penned a journal article entitled: “Bad is More Powerful than Good: The Nocebo Response in Medical Consultations”, which profiled how patients could get worse due to “sham interventions” and other interactions that elicit a negative response from them.

In particular, Drs. Maddy Greville-Harris, PhD, and Paul Dieppe, MDb, focused not on nocebo responses that came from negative information about medication side effects (about which some study has been completed) but, rather, the role of negative communication between doctor and patient in generating a nocebo response in a healthcare setting.

The researchers believe that doctor-patient communication and the way it plays out can significantly impact the outcome of a course of therapy. Based on their studies and on previous research, the authors concluded that the nocebo response can happen when the patient responds negatively to the conversation(s) they have with their healthcare provider.

Among the key components in the nocebo response are the concepts of validation and invalidation, the authors opine. Validation refers to the communication of understanding and acceptance while invalidation means the opposite, that is, non-acceptance and non-understanding. This is a bit different than empathy; a doctor can be empathetic and show feelings of warmth and kindness but may not portray acceptance and understanding on an intellectual plane (rather than an emotional one).

It’s important to note that, in this article and others similar to it, it’s often determined that while validation is wonderful and gives the patient confidence to move forward, the damaging effects of invalidation tend to be more powerful than the uplifting effects of validation. In other words, bad is more powerful than good, the authors note, or the power of bad human interactions are stronger than that of good human interactions.

Confused? It’s actually simple. The negative things you say to a patient will do more harm than the positive things will do good. Hence, Greville-Harris and Dieppe conclude that it is better for the medical professional to concentrate on NOT invalidating the patient rather than simply focusing on empathy, understanding, and validation.

In tests conducted to support this dissertation, consultations with patients at a pain management clinic were observed and then the observer’s observations were reported. After that was completed, semi-structured interviews were conducted with the patients (5 women with chronic pain issues) and the four consultants. The interviews were played back in order to discuss validation and invalidation.

In many cases, patients identified feelings of being “dismissed” by their physicians and “disbelieved” due to the comments by their healthcare providers. Many believed that the doctors did not “invest in them” nor did they “show insight into their condition”.

The authors described the scenario:

“Patients described feeling hopeless and angry after invalidating consultations, feeling an increased need to justify their condition or to avoid particular doctors or treatment altogether. Although the sample was small, these findings are in line with previous work. Thus, invalidation during consultations may elicit powerful nocebo responses in patients that have so far not been adequately researched.”

Furthermore, the researchers concluded the physicians think they are validating their patients by being empathetic and compassionate when, in fact, those reactions could be eliciting the wrong response from the patient. Many see such emotional responses as condescending or patronizing and lead the patient to believe that the doctor doesn’t take stock in the severity of their condition. In addition, a doctor who says “there is nothing wrong with you” when the patient is clearly experiencing pain makes the patient feel like their complaints are less than legitimate.

So, the question all medical professionals must ask themselves is if they are validating their patients or simply pacifying them during their conversations AND, more importantly, if their conversations are invalidating. Are you providing “lip service” or having a real, legitimate discussion with your patients? Do they leave your office knowing that you not only care about their condition and are sorry for their pain but also that you understand their concerns and can address them professionally and through proper patient education? Or do they walk away feeling belittle and confused?

Patient education is a huge part of the picture. For spine specialists, tools like Dynamic Disc Designs’ (ddd) many lumbar and cervical models demonstrate a true knowledge of your craft AND offer the chance for the patient to grasp some of that knowledge as well. After a consultation that includes a frank discussion and spine education using the fully-movable, highly-detailed spine models made by ddd, patients are satisfied that their concerns are validated and that you can offer more than a pat on the back and a “I hope you feel better soon”.

By educating patients with Dynamic Disc Design models, you can strive to eliminate the nocebo response, instead providing a consultation that “validates” your patient and prompts them to return to you for treatment.


Source: http://www.amjmed.com/article/S0002-9343(14)00798-0/abstract

Making Sense of Lumbar Ablation

Lumbar Ablation

Lumbar ablation (or radiofrequency ablation) is a commonly used procedure performed by pain specialists. It is a pain-relieving option for many individuals who are dealing with debilitating lower back pain. The electromagnetic waves used in this procedure work to create heat energy, which is then delivered to the nerves that carry pain impulses, destroying the nerves of the medial branches and relieving the pain.

Why use lumbar ablation?

By addressing these pain-carrying nerves, spine interventional pain doctors can provide a patient with a longer stretch of pain relief than that which would be offered by other procedures such as injections or even nerve blocks. Chances are that the patients you’re considering for treatment with radiofrequency ablation have already received treatments that may have included steroid injections, facet join injections, or some sort of sympathetic nerve block. If the patient had only very temporary pain relief from those, you can offer them the possibility of a longer stint without pain by using the lumbar ablation, perhaps as long as a year.

Many types of conditions respond well to radiofrequency ablation. These include spondylosis, chronic spinal pain, post-surgery spine pain, and post-traumatic pain from accidents that include injuries such as whiplash or seat belt-related injuries.

Lumbar ablation involves inserting a thin needle or radiofrequency cannula, guided by live x-ray, near the nerves that are to be addressed. Once the cannula is determined to be in the correct position, electric current passes into the surrounding tissues and the target nerve is destroyed. The procedure is fairly short and generally painless. (Patients can be given a mild sedative if necessary but deep sedation will not be used.)

Of course, that’s the short explanation. While not every patient wants to know all the particulars of the procedure you’ll be performing, many individuals prefer to know what will happen during ablation. Knowledge eases their mind and reduces anxiety or panic. An explanation of the procedure (and its results) by you – their doctor – will help them recognize that this is the right thing for them.

To do this, it’s time to pull out your spine models. Hopefully, you own a well-crafted, fully-movable 3D model such as the ones made by Dynamic Disc Designs (ddd). These unique models are the best available for explaining procedures such as lumbar ablation.

With the use of models like ddd’s popular Medial Branch Model, doctors can begin by demonstrating the patient’s facet pain condition and how it affects the spine, and then can proceed with an explanation of how the ablation will help. With this ultra-detailed model, spine specialists can also talk about neo-innervation and demonstrate the reasons for chronic pain and how the ablation will assist in its relief from the facet joints. The patient can hold this pliable model in their hands and move the parts, allowing them a better understanding of what’s causing their discomfort because they can literally “see” the spine.

Dynamic Disc Designs offers a variety of lumbar models, all highly-detailed yet simple enough for the layperson to understand. Models may be purchased individually or in a bundle, according to the needs of the specialist. (Discounts apply when models are purchased in multiples.)

From chirohub.com:

“This awesome product has passed all of our tests and impressed us across the board.  We feel very confident in awarding the Dynamic Disc Model the Official ChiroHub Seal of Approval.”

Lumbar Herniated Disc Surgery a Must for Some Patients

Lumbar Herniated Disc Surgery

Most patients with herniated discs prefer to travel the non-surgical road when it comes to treatment for their condition. It’s natural to want to avoid “going under the knife”, so to speak. For these patients, most chiropractors and other spine specialists will suggest NSAIDs and rest for at least four to six weeks and, often, that’ll do the trick. But when a regular course of non-surgical treatment doesn’t seem to be getting the job done, surgical intervention may become necessary to relieve pain and set the patient on the road to recovery.

So, when is it time to talk to your patient about surgery? Generally, the problems listed below are a good indication that something more drastic must be considered.

  • Medication has not significantly reduced the symptoms of the herniated disc
  • Physical therapy has not aided in reducing the symptoms
  • The individual is having severe pain that interferes with the tasks that must do daily, including walking and standing as well as tasks related to their specific job or duties
  • Neurological symptoms appear or worsen, including numbness or weakness in the legs

Any or all of these could even occur before the normal course of non-surgical treatment is completed. In other words, if progressive neurological symptoms happen at 3 weeks, then it may be time to recommend surgery for this particular patient.

Surgery. That’s a scary word, especially for individuals who have never spent any time in the hospital. It’s likely your patient will have an adverse reaction to the word when you mention it as an option, but they should know that lumbar herniated disc surgery has an excellent rate of success and is actually quite minimally-invasive. You’ll want to explain that both the microdiscectomy and the endoscopic discectomy are usually performed on an outpatient basis, with patients coming home – in most cases – on the same day as the procedure. You can also talk to your patients about the specifics of the procedure and explain what’s happening now that they have a herniated disc and what will change once the surgery is complete.

Just about everything about their surgery and about the lumbar spine in general can be demonstrated via the use of a detailed spine model like the ones made by Dynamic Disc Designs (ddd). These models were designed with spine specialists in mind, but were also created to help the lay person understand the complicated workings of the spine. Doctors who use ddd models to educate their patients about their conditions and about upcoming procedures create patients who are less frightened and more confident about their doctor’s recommendations. That confidence generates patients that will stay with your practice and recommend you to others.

For more information on the right ddd model(s) for your spine surgery or chiropractic practice, browse the website and watch the videos for a detailed explanation of how each model works.

“The LxH disc model is the most realistic patient education tool I’ve seen in 27 years of practice. When patients see the model, they immediately “get it”. If you treat herniated discs in your practice, this is a must have. I commend Dr. Fryer on his painstaking efforts to produce such a finely crafted and well thought out model.”
–Dean M. Greenwood, DC

Lumbar Extension Exercises Help Your Patients Heal

Lumbar Extension Exercises

There are so many reasons for experiencing back pain. Sometimes it’s a result of the work our patients do, including heavy lifting and repetitive movement that taxes our lower back. Sometimes we merely overdo it in everyday life while, other times, an accident or fall causes our lower back pain.

Whichever the reason, it’s important to find ways to combat the pain, so recommending lumbar extension exercises for back pain is often a wise idea, where appropriate. Such exercises are often a “no-brainer” because they are easy to do at home and require no equipment. The only thing necessary is motivation and the desire to feel better.

Chances are that if you prescribe lumbar extension exercises for your patients, you’ll want to take the time to demonstrate how to do them properly or, at least, provide the patient with illustrations or videos that assist them in doing these in the proper manner so as not to cause further harm. You’ll likely do that in your office or some other space where physical therapy takes place. Hopefully, you’ll supervise the patient and correct anything they may be doing wrong.

Patients need careful instruction from their doctor or physical therapist, so communication is essential. You wouldn’t send them home with the suggestion to “look up lumbar extension exercises on the internet and do some of those”, would you?

But will you take the time to explain to them WHY you’re suggesting these lumbar extension exercises? Truly, it’s not enough just to give your patients or clients an assignment. They should know why you’ve made this suggestion and what kinds of benefits they will reap from doing the exercises daily.

For this kind of spine education, you need the right tools. These tools will demonstrate the workings of the spine and help explain why these exercises will be advantageous to the patient’s recovery. From these tools, your patient will learn how they injured themselves or what’s affected due to their condition, why they hurt, and how their spine will positively respond to the exercises.

The only way to do that accurately is to use a spine model, and the only spine models that are realistic enough to get the job done are those manufactured by Dynamic Disc Designs (ddd). These models are amazingly accurate and they move just like a real spine. So, if you want your client/patient to do prone press-ups or a standing extension, you can show them exactly what will happen to their spine as they do those exercises and why their back pain may cease with the stretching.

There are numerous lumbar models available from ddd and you can browse their website or consult with the company’s expert creator, Dr. Jerome Fryer, to determine which are best for your practice. Because Dr. Fryer designed these models for his patients, who were plagued with various problems, he can easily assist you in choosing the one (or more) that will address the issues and conditions you most often encounter in your practice.

I use the spinal disc model daily to educate my patients. The dynamic nature of this model conveys the importance of proper movement patterns and disc mechanics.”
Dr. Douglas J. Taber, DC,

A Lumbar Injection May Be the Answer for Low Back Pain

Lumbar injection

Anyone suffering low back pain likely prefers a non-surgical way to combat that pain…and a lumbar injection may be the answer for many patients. This is a practice that’s been in use for more than a half-century and one that proves to be helpful for a number of conditions, like sciatica.

Specifically, a lumbar epidural steroid injection (ESI) aims at pain relief and can be quite successful on its own. For many, it seems an easy way to reduce discomfort and, as such, return to normal activities that may have been curtailed due to lower back pain.

Of course, if you’re able to convince a patient that the injections, when paired with a well-crafted rehabilitation program, can provide an even better chance of eliminating lower back pain, you’re certainly headed in the right direction.

While a lumbar injection isn’t necessarily a long-term fix – some patients only achieve relief for a few weeks – it can indeed provide enough relief to allow a patient to begin or continue with stretching and other exercises that will result in more lasting results. It’s important to note that it is preferable not to allow the patient to begin to rely on lumbar epidural steroid injections alone; these should only be a step towards self-motivation and the desire to do what it takes to make oneself well again.

It’s hard to convince someone to take time for exercise and stretching, especially if it’s a patient that works a long day, tends to a family, and has a long list of other responsibilities that occupy their time. But it’s your job as a spine specialist to educate them as to the advantages of giving their lower back a little extra attention, even if just for 10-15 minutes per day.

To accomplish this task, try using the very realistic models offered by Dynamic Disc Designs (ddd). These lumbar models are ideal for demonstrating why the patient’s back hurts, what the lumbar injection did to relieve the pain, and how they can continue to live pain-free by doing a little extra work on their own.

The ddd models look like the real thing! That’s because Dr. Jerome Fryer, the designer of the many models offered by the company, made them after being frustrated with the unrealistic models that were available for patient education. He wanted his patients to “see” the spine, feel how it moves, and understand their role in spine health. As such, models like the Professional LxH lumbar model are the most realistic on the market and spine specialists of all types – chiropractors, osteopaths, surgeons, physiotherapists, massage therapists – are singing their praises, noticing that these models provide such a clear picture of the spine’s workings that patients walk away confident about their diagnosis, their treatment, and their responsibility to themselves as a patient who wants to feel better.

“You can use a poster or a tablet to educate your patients, but they will see an image on a poster or a tablet. If you use a 3d model, they will have a spine in their hands. There is not a minute to lose in a clinic and a ddd model is simply the best way to demonstrate back pain. Quick, visual, concrete, straight to the point.”
– Louis Riendeau, DC

Explaining the Risks and Successes of Lumbar Discectomy Surgery

Lumbar Discectomy Surgery

“You need surgery.”

That’s never a phrase that patients want to hear. Use the word “surgery” and most individuals go into panic mode. And rightfully so. While no responsible doctor recommends surgery without expecting there will be an upside and positive results, any kind of surgery carries a fair number of risks. As doctors, it’s all about letting the patient know that the successes outweigh those scary risks.

A lumbar discectomy, of course, is used to treat a herniated disc. In the case of a microdiscectomy, the surgery can be performed on an outpatient basis, usually with no extended hospital stay at all or perhaps an overnight stay in some cases. Happily, most patients can return to a fairly normal level of activity in no time at all, so – as surgeries go – it’s quite routine.

The success rate in regards to lumbar discectomy surgery is quite high. Around 90 percent of patients report no further discomfort or other issues, though statistics show that somewhere between 5% and 10% may suffer a recurrent disc herniation, either within a few months or many years later. It’s difficult to tell who may be a candidate for recurrence. When multiple disc herniation recurrences happen, the patient may be a candidate for more-complicated spinal fusion surgery.

Of course, risks are present and complications can indeed happen. A dural tear may occur, resulting in a slightly more complicated recovery period. Nerve root damage is a rare complication as is bowel or bladder incontinence due to surgical error. And there’s always the risk of infection. But these are rare.

Nonetheless, when a lumbar discectomy is recommended it is necessary to explain both the positives and negatives of such a surgery. It’s essential for your patient to understand everything about their impending surgery, including the scary stuff, though chances are you’ve learned how to emphasize the positive over the not-so-positive.

Your nervous patient will benefit from the most comprehensive explanation you can provide them about their surgery. So, it’s time to put away the poster and laser pointer and trade these tools for a lumbar model from Dynamic Disc Designs (ddd), an innovative company that offers the best in spine education products. The company’s lumbar models, such as the Professional LxH, easily demonstrate the particulars of disc herniation and are an ideal way to teach a layperson about the spine.

Models manufactured by ddd are fully-dynamic and lifelike, providing spine surgeons with a tool that allows patients to hold and manipulate the spine and, therefore, grasp how it works and what occurs during a herniation. With these models, the doctor can also demonstrate how the discectomy will solve the problem and what is necessary to maintain good disc health.

Those who use ddd’s models will tell you that they are ideal in putting patients’ minds at ease before and after surgery and are the perfect tool for explaining other spine issues as well.

Dynamic Disc Designs offers a variety of both lumbar and cervical models for your surgical spine practice. They may be ordered individually or in bundles at a reduced price. Browse ddd’s website for photos and informative videos.

ChiroHub calls ddd models: “…beautifully designed, accurate, user-friendly, and professional grade.” They add: “The quality is impressive to patients, and the ability to demonstrate and describe flexion and extension loads on a disc herniation makes a huge impact on patient compliance.  Sure, you could go get a Mr. Thrifty skeleton for less, but you’ll find yourself wishing you could actually show what happens to a patient’s disc when they lift improperly.”