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Implementing Expressive Writing in Outpatient Physical Therapy Clinics: Connecting Theoret...
Fall 2022 - Featured Articles - Perspectives

Implementing Expressive Writing in Outpatient Physical Therapy Clinics: Connecting Theoretical Foundations With Practical Strategies

Implementing Expressive Writing in Outpatient Physical Therapy Clinics: Connecting Theoretical Foundations With Practical Strategies

By Eric Thomas Wanner, PT, DPT; Jennifer Lynne Bird, PhD; and Claudia Jayne Brahler, PhD

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Over the past several years, healthcare professionals have increased implementation of expressive writing as an outlet for feelings, anxieties, and frustrations to help patients manage the stress of an illness or injury. Writing professor Tom Romano describes expressive writing as “where we start when we pour forth first words, seeking to make meaning from fragmented, chaotic inner speech. Expressive writing is writing closest to our speaking voice, the seedbed from which all other writing grows.”1(p189) The process of expressive writing helps writers meaningfully construct experiences and make sense of life. As Romano elaborates, when writers compose expressively without pressure, they remember more and know what they think about the importance of ideas, information, and experience.2(p138) And, as writer Allison Fallon states, “where we get unstuck in our writing, we get unstuck in our lives.”3(p34)

Once used only by high school and college English teachers in classrooms, expressive writing provides a pathway for emotional and physical healing, thus benefitting patients in various healthcare settings such as physical therapy clinics. In healthcare, expressive writing helps patients uncover emotions, fears, frustrations, and dimensions of their recovery. Expressive writing illuminates the human element of patient rehabilitation through an interdisciplinary design, which dovetails writing theory with physical therapy practice. Expressive writing helps clinicians identify challenges patients may face when trying to adhere to a physical therapy treatment program. Recognizing and addressing potential barriers can enhance patient success in adhering to treatment. Given the effectiveness of expressive writing in patient care, we argue that expressive writing can be used as part of best practice to help physical therapists formulate, apply, and gauge patients’ emotional responses to treatment. This article provides a theoretical foundation of expressive writing, describes the use of expressive writing in medical settings, and provides practical suggestions for how physical therapists can use expressive writing as an adjunct to a treatment plan for a patient.

The Theory of Narrative and the Practice of Expressive Writing

Psychologist James Pennebaker explains that writing related to health needs to “explore both the objective experience (ie, what happened) and your feelings about it. Really let go and write about your very deepest emotions.”4(pp40-41) Thus, expressive writing is a type of narrative writing that involves sharing a story while simultaneously expressing emotions about it. Before discussing the existing evidence demonstrating the value of expressive writing in improving both physical and emotional health, we review the theoretical research foundation of narratives and present an in-depth description of the practice of expressive writing.

Theoretical Foundations

Narrative inquiry, a qualitative interpretive research field introduced into the academic community by Clandinin and Connelly, focuses on stories lived and told.5(p20) Specifically, Clandinin and Connelly define narrative as the study of how people make meaning of experience by telling stories about themselves that both reexamine past experiences and create future purpose.6(p24) Clandinin and Connelly tell narrative inquirers to find narrative threads, also known as intersections or patterns of stories.7(p78) For example, in a classroom, a teacher might use narrative inquiry when asking students to share their feedback of a lesson by each speaking individually to the teacher or writing individual responses. An insightful teacher looks for patterns in the narratives to determine changes needed during future lessons. As English teacher Gruwell discovered with her high school students, known as The Freedom Writers, teenagers used writing in their journals to create a classroom community, strong identities, and an outlet for expression.8(p275) The relationship between a teacher and students in some ways resembles the relationship between a physical therapist and patients. In a similar manner that student narratives provide teachers with insights, listening to or reading a patient’s narrative can provide a clinician with insights into the daily experiences of a patient’s suffering from injury or disease, the pattern of activities that cause pain, the emotions involved in that experience, and the patient’s goals, expectations, and fears. A patient’s recollection and interpretation of experiences can lead the physical therapist to a more accurate assessment of the patient’s symptoms within the context of personal and environmental factors. This approach can theoretically lead to a more successful patient specific treatment intervention.

Patient Narratives

Patient narratives broaden the perspectives of healthcare providers regarding patients’ conditions within the context of personal and environmental factors. Notwithstanding their busy schedules seeing patients in a clinic, physical therapists benefit from learning their patients’ narratives. Some patients may have environmental factors preventing them from healing. For example, if patients don’t have access to a gym to do their advanced home program, they might not be able to keep up with the program if that’s not factored into the treatment plan. Or if patients aren’t motivated to do their home program, and write about their lack of motivation, the physical therapist can try to find ways to motivate them, such as explaining the benefits of reducing their pain with movement. Physical therapist Bezner believes a primary focus on a patient’s disease or injury limits the ability of a physical therapist to act holistically.9(p1442) Acting holistically means looking at other factors that could be contributing to the patient’s symptoms, such as anxiety, stress, or diet, and then working with other specialists to provide the patient the best opportunity for a full and quick recovery. Bezner and colleagues share that efficient and effective support for patient behavior change revolves around patient-provider communication and by using holistic methods such as health coaching.10 According to Linda Smith and her colleagues from Duke Integrative Medicine, health coaching builds motivation for behavior change.11(p69) Caldwell and colleagues elaborate on how the health coaching process offers control and self-efficacy for patients by breaking down seemingly unmanageable goals into smaller, manageable, measurable, and attainable goals.12(p56) Both health coaching and narrative medicine encourage patients to reflect on their personal narratives.

Rita Charon, a medical doctor and literary scholar, developed the discipline of narrative medicine. She is the executive director of Columbia Narrative Medicine at Columbia University, where she teaches medical students and residents the skills of narrative writing as part of standard practice to explore the human dimensions of suffering and care. Charon defines narrative medicine as using narrative skills, such as following the narrative thread of a patient’s story, to interpret the story and take action.13(p2) Psychologist Jerome Bruner shares, “there may be something more than the subtlety of narrative structure that keeps us from making the leap from intuition to explicit understanding, something more than narrative is murky, hard to pin down.”14(p5) People may implicitly possess intuition about the narratives they tell themselves; to make the leap, writing provides a method for explicitly processing words to enhance understanding. Romano explains narrative thinking, such as in Bruner’s work, provides a foundation for multigenre writing.15(p18) This form of expressive writing, which arises from experience, imagination, narrative, and perhaps is even presented in the form of a poem, is “implicitly emphatic.”16(p184) Romano clarifies, “expressive writing ought to be the rule for multigenre writers.17(p138)

While Romano discusses the use of a creative form of expressive writing used by teachers with their students, the theoretical foundation of transforming narratives from a person’s thoughts into words on a page also applies to the medical field, as elaborated with the following examples from medicine. Whether a student in an English class writes a life narrative in the form of a poem, or a patient in a physical therapy clinic writes a pain narrative of symptoms, expressive writing builds a bridge for communication. Physical therapy professors Greenfield and Jensen, with their colleagues Delany, Mostrom, Knab, and Jampel, explain that narrative enables clinicians to reflect on a case from multiple perspectives and can connect the subjective human experience to objective measures of practice.18(p925) Goldberg, a nurse, argues why sharing stories provides the reminder that a patient is a person and increases the likelihood the patient will receive patient-centered care.19(p119) She advises patients, especially ones who have chronic pain or illness, to construct a narrative so providers understand the impact of pain or illness on quality of life.20(p168) A written document of symptoms helps the provider see pain from a patient’s perspective and helps the patient remember to share important information.

Patient-Centered Care and Finding Voice in Narratives

Linton and Shaw state that because patients show differences in their beliefs about pain and regulating emotions, clinicians should consider a patient-centered approach to care accounting for individual differences.21(p709) One aim of patient-centered care acknowledges the constantly changing circumstances of both patients and clinicians by incorporating shared decision-making, which customizes care to fit the preferences of each patient.22 Sociologist Brown believes when people recognize and own their emotions, they can find a way through the pain.23(p67) Brown encourages people to talk through their stories if they can find someone they trust who is willing to listen, but believes writing is more powerful.24(pp86-87) She describes writing as “slowing the winds and calming the seas” of the thoughts in one’s head.25(pp262-263) Brown believes writing possesses power because the writer can write about experiences while building the courage to talk to someone.26(pp82-83) She advises each narrator to find someone who earned their trust and the right to hear their story.27(p47) When hearing a story, the listener needs to practice what Brown calls “story stewardship,” also known as honoring the story.28(pp264-265) A physical therapist should demonstrate this willingness to earn a patient’s trust by listening to or reading a patient’s narrative. Greenfield and Jensen encourage physical therapists to listen to patients use their own voices to tell their whole story; this helps clinicians see the patient as a person with a life story and more than the patient’s diagnosis.29(p1192) While a patient often chooses to share a story with a physical therapist using their speaking voice, we argue that using a writing voice may serve as another option for communication between patient and physical therapist. Writing professor Romano defines voice as the writer’s style, or presence on the page, in a piece of writing; similar to a speaking voice, a writing voice describes how each writer uses personality to uniquely put together words.30(pp5-6) Romano elaborates why expressive writing is the most personal writing because it is “an individual voice deliberately working to create meaning.”31(p23) English teachers understand their students’ voices through expressive writing; this means physical therapists can use similar writing methods to understand their patients’ voices.

Journaling Compared to Expressive Writing

English teachers often use the terms ‘journaling’ and ‘expressive writing’ interchangeably, although differences exist. A journal refers to the notebook writers keep As Germer explains, keeping a journal is a self-compassion exercise because the writer describes personal experiences in a private moment of contemplation.32(p242) When journaling, writers choose to focus on a specific topic, such as in the following examples.

Neff suggests keeping a gratitude journal of things that cause the writer to feel joy.33(pp278-279) Carroll recommends using bullet points to organize tasks, events, and notes.34(p5-6) Descriptive writing about topics such as a nature scene that inspires a grateful feeling or a daily task list to inspire productivity serve as good journaling; however, for journaling to transition into expressive writing, the writing needs to become a narrative. Romano explains that narrative thinking expresses learning and discovery through story.35(p11) He describes expressive writing as personal, exploratory, and focused on meaning as the writer thinks on the page and recreates experiences through words.36(pp137-138) Expressive writing works best when the writer does not overthink. Several writers and writing teachers concur on this writing process. Goldberg encourages writers to capture first thoughts not obstructed by social politeness or the internal censor.37(pp8-9) She explains writers accomplish contacting first thoughts by not thinking, keeping the hand moving across the page of a notebook, and figuring out what should be said during the act of writing instead of stopping to reflect.38(pp3-4) Goldberg also advises writers to use a computer if they choose, although pressing keys uses different parts of the brain than handwriting and can result in different ideas.39(p1) No matter which format writers choose, Goldberg tells writers to accept their minds without judging their thoughts.40(p21) Writers need to accept themselves because, to use Goldberg’s metaphor, “writing is an immediate mirror: it reports back to you. You can’t fool anyone, especially yourself.”41(p218) Lamott tells writers to start by getting something on paper, because anything works for a first draft and writers say what they have to say more accurately when they write first then edit later.42(p25) Additionally, Heard advises writers to write what they really think and tell the truth to themselves in writing.43(p29) Finally, Fallon shares that her favorite part of the expressive writing process exists in the transformation of the words on the page, because writers have the power to expose the truth in their lives.44(p106)

Writers have the option of telling their stories only to themselves without sharing the writing with anyone. Cameron describes how writers find precise words to tell their stories when they are honest with themselves.45(p140) Writers may choose to share writing with a trusted audience, such as a friend, teacher, or medical professional, if they need additional help or support. Tindle, a medical doctor, believes envisioning positive outcomes influences behavior. She wanted to know the script inside the heads of the one percent of people who achieved ideal cardiac health, so she talked to her patients.46(p24) If a writer chooses to share, the reader also knows the thoughts inside the writer’s head, especially if the writer forgets to share information during a conversation. If a patient chooses to share writing with a physical therapist, it could encourage discussion that illuminates the pain source and gives the physical therapist more awareness of the patient’s symptoms before and after therapy sessions. The patient may report a low pain level during a physical therapy session but experience high pain levels outside of physical therapy. We argue that writing provides another method of medical practitioners’ learning a patient’s thoughts.

Research On Using Writing in Medical Settings

The following research studies illustrate the healing benefits of expressive writing. Psychologist Pennebaker and colleagues performed the initial study researching the healing benefits of expressive writing; the study illustrated that college students who wrote about traumatic events for 15 minutes a day on 4 consecutive days had fewer visits to the campus health center than the control group 6 months after the research study, thus indicating the potential for writing to have both emotional and physical benefits for the writer.47 Pennebaker conducted another research study where college student volunteers agreed to have their blood drawn before writing, after writing, and six weeks after writing to measure T-lymphocytes and other immune markers in the blood; the results showed people who wrote about their deepest thoughts and feelings surrounding traumatic experiences evidenced heightened immune function compared with a control group who wrote about superficial topics.48(pp36-37) Pennebaker and Evans summarize that since the first study, at least 300 studies about the benefits of expressive writing have been published, and the scope of benefits has grown exponentially.49(p9) Pennebaker and Chung report later studies expanded the scope of writing topics and the amount of time spent writing.50(p15) Evans describes the growing amount of research that indicates the heart rate lowers and people fight infections easier when using writing to release their worries.51(p1) Writing helps patients with their physical and emotional healing process, but patients should use writing in conjunction with physical therapy exercises or other medical treatment, not instead of it.

While the early research studies focused on writing about traumatic events, subsequent studies illustrate writing about positive events can also result in fewer health center visits.52 Prospective writing, a type of expressive writing that imagines the future instead of recounting the past, can lead to post-traumatic growth.53 Enayati reports extreme stress can become self-fulfilling, and writing can help switch the focus of a narrative to post-traumatic growth.54(pp72-74) David discusses applying words to emotions helps with stress, anxiety, and loss.55(pp92-93) Connor explains writers who used words that demonstrated insight and reflection, such as “understand,” “realize,” or “know” experienced the greatest benefit.56(p69) Handler interprets this understanding as the writer starting to accept the events of the story.57(p225) Research illustrates writing helps chronic worriers with anxiety, because the writer transfers thoughts from the mind to the page.58 Psychologist Pipher discusses how the calming act of writing can help eliminate anxiety.59(p79) Zimmermann advises seeking professional help if feelings of depression emerge during writing.60(p18) Just like writing cannot take the place of a patient doing physical therapy exercises, writing cannot take the place of a conversation with an empathetic therapist.

A meta-analysis of the expressive writing paradigm and its potential health benefits revealed that expressive writing has great potential as a therapeutic tool in diverse clinical settings and can serve as an adjunct to traditional therapies and standard treatment.61 Smyth and colleagues conducted research and discovered healthy students asked to form a narrative with their writing reported less restriction due to illness than students who wrote in a fragmented format.62 Pennebaker and Smyth discuss that good narratives organize overwhelming events, and writing allows the author to create a resolution of an event.63(p152) However, Sandberg and Grant caution that journaling immediately after an event can backfire for some people if the event is too raw to process, so it helps to let some time pass before writing and constructing a story that leads to insight.64(p63) Writers always have the option of starting writing and then stopping if the expressive writing process becomes too emotionally painful, or too physically painful (if the writer sits in an uncomfortable chair).

Although nearly 300 studies report the benefits of expressive writing on patient healing, none to date link the value of expressive writing to patient outcomes on standardized physical therapy metrics used to assess patient progress, and none specifically report on the value of expressive writing for physical therapy patients. While the purpose of this perspective article is not to provide a detailed accounting of original research conducted by the authors, we have unpublished data that documents that patients who used positive words in expressive writing activities during physical therapy treatment showed statistically significant greater improvement on existing outcome measurement surveys including the DASH (Disabilities of the Arm, Shoulder, and Hand);65 LEFS (Lower Extremity Functional Scale);66 NDI (Neck Disability Index);67 or Modified Oswestry (for back pain).68 (ET Wanner, JL Bird, CJ Brahler, unpublished data). Our study demonstrated a trend that subjects who clearly articulated their goals in writing and demonstrated a positive outlook when identifying obstacles that could prevent them from achieving their goals experienced greater healing.69 We plan to complete more research to confirm the early findings that illustrate the potential benefits for physical therapy patients.

Discovering that a positive attitude makes a difference in healing aligned our study with existing literature. Seligman, who pioneered the field of positive psychology, argues that optimists take action to have healthier lifestyles, have more support with stronger social networks, and cope better with the stress that causes biological changes in the body, such as in a person’s immune system.70(pp205-207) Research by Younger and colleagues assessed subjects’ amount of positive expectations prior to starting physical therapy by having subjects fill out the Stanford Expectation of Treatment Scale (SETS).71 The SETS assessed patients’ degree of positive expectations prior to physical therapy, which demonstrated favorable results for those with higher expectations, (the more gains they objectively made); there was a statistically significant difference between the negative and positive expectations groups as far as recovery gains.72 In the next section, we discuss how writing can help patients visualize a positive outcome for healing.

How to Use Expressive Writing in Outpatient Physical Therapy Clinics

This section presents a rationale for physical therapists using expressive writing with their patients followed by examples from patients, and a list of ideas for implementing writing in an outpatient physical therapy clinic. (Table 1, Table 2) With the strategic use of expressive writing, physical therapists can obtain additional information about each patient, hold patients accountable for reaching their treatment goals, tailor each intervention specific to the patient, and help patients identify other factors that may be hindering versus helping their recovery. Due to the busy pace of working with patients at physical therapy clinics, physical therapists may feel they do not have time to read writing from patients. Physical therapists who do not want to use expressive writing in their clinics can still use other forms of writing. Suzuki describes an activity called body writing, where writers focus on how they feel physically to stay grounded in the moment.73(p240) If a patient completes a chart that tracks symptoms or pain levels, the physical therapist may use the information to learn more about the patient’s concerns. Even though this is not expressive writing, it still serves as a visual to help patients remember questions to ask the physical therapist. If physical therapists want to encourage patients to use expressive writing, the writing needs to tell a narrative. Mindfulness expert Cameron explains to writers one way to start getting words on paper is through free-form, stream-of-consciousness writing that lets thoughts flow, while another method is by using prompts or thought-starters to begin with a specific idea.74(p46)

Table 1: Pros and Cons of Writing at Home vs. in Clinic

Writing From: Clinic Home
Pros Physical therapist is there for immediate feedback.

 

Higher chance of patient completing writing assignment.

Patient can complete this assignment on their own time.

 

Patient may feel more relaxed when writing.

 

Patients might think about more things that are contributing to their symptoms.

Cons Patient may feel rushed.

 

Physical therapist might not have much time to go over writing immediately.

 

Patient might feel more vulnerable immediately sharing with physical therapist.

Patients might not be as compliant with writing.

 

We prefer using writing prompts with physical therapy patients to give patients a place to start writing and provide physical therapists with information about a patient’s current life story. One example we designed asks patients to respond to a writing prompt about goals (see example after the conclusion). Milkman believes obstacles require tailored solutions and people need tailored goals that acknowledge and match strengths and weaknesses.75(pp200-201) Patients may use expressive writing to set personal goals and describe feelings about the recovery process. Writing goals will give the patient something to strive for during the recovery process and may increase the patient’s motivation. Harding discusses the significant decrease in stress and inflammatory markers noted in people with high eudaimonic well-being, a term she uses to describe striving for meaningful purpose and pursuing goal-directed behavior.76(pp74-75) Duckworth argues for most people, purpose is a powerful source of motivation.77(p148)

Physical therapists can use information from the writing to learn the patient’s narrative and adjust the treatment plan as needed. Understanding physical and mental changes will be crucial in providing each patient with optimal care during the recovery process. Encouraging patients to also narrate their symptoms, feelings, and goals may lead to greater outcomes. It will make patients and their treating physical therapist more aware of symptoms throughout the day and present a clearer pattern of what makes them better or worse. Trespicio tells writers not to overthink prompts, start writing to see what surfaces, then reread the writing to discover patterns.78(p176-177)

Table 2: Practical Suggestions for Physical Therapists and Patients

Variety of Expressive Writing strategies:

Have patients:
•  Use the survey presented in this article’s appendix
•  Write about whatever is on their mind during most pain and least pain
•  Write goals they have for physical therapy
•  Write about obstacles that may prevent them from achieving their goals
•  Write on how to overcome those obstacles to achieve goals
•  Periodically share their writing with the physical therapist
Have treating physical therapist:
•  Adjust treatment based upon patient writing
•  Take the time to go over patient’s writing

It may be easy for a person to see patterns in life experiences, but difficult to see a pattern of behavior that leads to pain. Therefore, the physical therapist can read the writing and notice patterns the patient may miss. The physical therapist might also see a pattern in the patient’s writing related to more of a psychological problem and want to refer the patient to a psychiatrist or psychologist as well. This referral could be a missing link in getting some patients back to their prior level of function or mental health. Psychiatrist Boardman describes positive activities as emotional armor because positive everyday experiences strengthen resistance to everyday challenges, promote recovery when challenges occur, and become a source of vitality.79(p65) Consequently, patients may benefit by focusing on moments of success in their writing to celebrate progress with their physical therapist.

Dalebout, a writer, explains prompts are tools that can be used repeatedly because the writer is different during each writing session.80(pp25-26) By having a patient fill out short answer prompts (see Appendix) it allows the patient to write freely yet with guidance that encourages setting goals, identifying barriers, and taking accountability. By filling out the short answer prompts it makes the patient more aware of other factors influencing recovery. The patient could then be asked to simply monitor the goals set in the survey and write down in a journal when feeling the best versus worst throughout the day along with activities completed at that time. This type of expressive writing will let the patient see a potential trend on the recovery. The patient can bring the journal when seeing the physical therapist so the physical therapist can see what may be helping or hindering the patient. Sometimes the treatment intervention could be perfect but what the patient is doing outside of therapy could be making symptoms worse. Short answer prompts can be used to see how often the patient is completing the required exercises for the home program, as well as potential obstacles that interfere with the completion of the exercises. Having this information will apprise physical therapists if the intervention needs to be modified for better outcomes or if the lack of adherence is related to psychosocial issues.

The potential for more immediate adjustments in the physical therapy sessions or outside of therapy could lead to a quicker recovery for the patient. Accountability is not just for the physical therapist but also for the patient and could capture the important component of incorporating narrative into the rehabilitation process. Using writing to track progress will also encourage self-accountability for the patient since the patient does not have to rely on memory to share moments of success or concern with the physical therapist.

Conclusion

We recommend that physical therapists have patients use expressive writing and adapt our ideas expressed herein to best fit the needs of their patients. Physical therapists can use expressive writing with patients regardless of an individual patient’s diagnosis as an adjunct to the patient’s current rehabilitation program. Expressive writing begins as a blank page the patient can fill out to increase self-awareness and accountability with the added potential to experience improved emotional and physical health. Patients only need a piece of paper and a writing utensil to begin writing. Notebooks work best because they allow the writer to keep all the writing in one place and track progress over time. Physical therapists should start telling patients to write freely about whatever comes to mind related to their pain outside of their physical therapy sessions. The beauty of writing exists in its adaptability to best fit the needs of each individual patient, physical therapist, and clinic. The field of using writing as an adjunct to healing constantly evolves, meaning opportunities exist for more research. Physical therapists can use writing as a resource to help patients write the next chapter in their healing stories.

Examples of Patient Writing

The first example we offer here is of a patient writing in response to a short answer prompt. The writing prompts were designed by the authors of this article. The patient gave permission for her writing to be included. The patient was a 33-year-old woman completing outpatient physical therapy and diagnosed by an orthopedic surgeon as having increased cervical lordosis. The treating physical therapist was a student trained by one of the authors of this article.

Short Answer Writing Prompt: What potential obstacles do you anticipate that might prevent you from meeting your long-term goals (at four weeks of PT)?

Patient Response: Non-compliance with exercises due to my crazy schedule, a sick pet, poor posture, and lifestyle changes.

Short Answer Writing Prompt: What are some actions you plan to take so you could prevent/overcome obstacles that might hinder your progress?

Patient Response: Attempt to schedule exercises like appointments are scheduled.

Short Answer Writing Prompt: How often did you do your home exercises?

Patient Response: Not daily. I admit to not being consistent. Sometimes I feel I need more of certain exercises but I am not the expert so I don’t say anything.

Short Answer Writing Prompt: Please write anything that helped you most in Physical Therapy.

Patient Response: The manipulations of my neck, spine, shoulders, ribs have helped the most.

Analysis of writing: The physical therapist noticed from the writing that the patient did not always ask about exercises during the physical therapy session. An adjustment was made to the treatment plan to focus more on the manipulations/mobilizations that helped the patient. The physical therapist also discussed the patient’s schedule to help the patient find time for more specific exercises. Even though the patient did not write lengthy responses, the writing is still expressive writing because the patient is both describing events that happened and emotions about them (using phrases such as “my crazy schedule” and “sometimes I feel I need”).

The second example is of a patient freewriting, which is writing whatever comes to mind without responding to a prompt. This patient, one of the authors of the article, wrote a reaction to experiencing neck pain and shared it with the treating physical therapist.

Patient Response: After cardio (3-mile hike) and second set of exercises for the day, sat on couch, looked down at phone while feeling stressed about work. Looking down + Emotional stress = perfect storm for neck pain. At least I know this now. Until this goes away my neck can be my guide to making decisions in life. Neck hurts = don’t do something!! Have to keep my sense of humor about this.

Analysis of writing: The writing gave the physical therapist insight into the patient’s lifestyle, as well as the information that the patient’s neck hurt worse when looking down. This writing is a lengthier response and shows expressive writing with a stronger use of voice in the description of events and emotions related to the events (“feeling stressed about work” and “my neck can be my guide”).

Analysis of writing: The writing gave the physical therapist insight into the patient’s lifestyle, as well as the information that the patient’s neck hurt worse when looking down. This writing is a lengthier response and shows expressive writing with a stronger use of voice in the description of events and emotions related to the events (“feeling stressed about work” and “my neck can be my guide”).

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Appendix

Sample Short Answer Prompts from the Wanner Bird Healing Survey for Pain Recovery81

This survey, designed by the authors of this article for physical therapy patients, contains both written subjective questions (short-answer writing prompts) and numerical subjective questions.

Week One

  • What would you like to return to doing in two weeks that you have difficulty with now?
  • How likely do you feel that you will be able to meet your short-term goals?

Not at all likely      1        2       3       4       5       Extremely likely

  • What would you like to return to doing in four weeks that you have difficulty with now? Give specific examples of things that you would like to do again by the conclusion of physical therapy.
  • How likely do you feel that you will be able to meet your long-term goals?

Not at all likely      1        2       3       4       5       Extremely likely

  • Please indicate the degree that the following potential obstacles could hinder your progress.

Current stress level in your life

A large amount      1        2       3       4       5       A small amount

Amount of time to complete exercises at home

A small amount      1        2       3       4       5       A large amount

Motivation to complete exercises

A small amount      1        2       3       4       5       A large amount

  • In looking at your responses to the previous question, how can you make the situation better? (Make time for home exercises by putting them into your agenda, spend more time in less stressful situations, do exercises with friends or a family member, etc.)
  • Are there any other obstacles that could hinder your progress? Please explain.

Week Two

  • How close are you to reaching your short-term goals?

Not close     1        2       3       4       5       Achieved goals

  • Have your goals changed since the beginning of the physical therapy? Why or why not?
  • How likely do you feel that you will be able to meet your long-term goals?

Not at all likely      1        2       3       4       5       Extremely likely

  • What potential obstacles do you anticipate that might prevent you from meeting your long-term goals (at four weeks of physical therapy)?
  • What are some actions you plan to take so you could prevent/overcome obstacles that might hinder your progress?

Week Four

  • Did you feel you accomplished your goals for physical therapy? Why or why not?
  • How happy are you with your progress since day one?

 

Not at all happy     1        2       3       4       5       Extremely happy

  • How pleased were you with the treatment sessions by the physical therapist? (scale 1-5)

Not at all pleased  1        2       3       4       5       Extremely pleased

  • How often did you do your home exercises?
  • How likely are you to continue with your home exercises after physical therapy? (scale 1-5)

Not at all likely      1        2       3       4       5       Extremely likely

  • Please write anything that helped you most in Physical Therapy.

 


Eric Thomas Wanner, PT, DPT

Eric Thomas Wanner, PT, DPT is a Board Certified Orthopedic Clinical Specialist from the American Board of Physical Therapy Specialists and is the Physical Therapy Director of Palm Beach Sports Medicine and Orthopedic Center in West Palm Beach, Florida. He received his BS in Exercise Science from The Ohio State University in Columbus, Ohio and his DPT from the University of Dayton in Dayton, Ohio. He enjoys thinking outside of the box for the physical therapy profession and finding new ways to enhance patients’ recoveries and lifestyles.

 

Jennifer Lynne Bird, PhD

Jennifer Lynne Bird, PhD is a National Board Certified Health and Wellness Coach and an English teacher at Rosarian Academy in West Palm Beach, Florida. She received her BSEd in English Education, MEd in Education, and PhD all from Miami University in Oxford, Ohio, and her health coach certification from Duke University Integrative Medicine in Durham, North Carolina. She loves teaching writing to help people heal from life’s fragile moments.

 

Claudia Jayne Brahler, PhD

Claudia Jayne Brahler, PhD is an Associate Professor in the School of Education and Health Sciences: Department of Physical Therapy at the University of Dayton in Dayton, Ohio. She received her BS in Education from Montana State University in Bozeman, Montana, and both her MS in Exercise Science and her PhD from Washington State University in Pullman, Washington. She enjoys research that connects science, education, and health.

 

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