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The Four Laws of Quality Care, Law IV

Welcome to the final edition of this four-part series on The Four Laws of Quality Care!

So far, we’ve talked through establishing and maintaining rapport (Law I), approaching the exam to help foster understanding and commitment (Law II), helping people make sense of their problem (Law III), and now: Treatment.

Law IV states: Provide matched interventions, considering the person’s values and perspectives, while keeping in mind contextual effects.

We’ll break this down into roughly 2 categories for simplicity:

  1. Matched interventions

  2. Contextual effects

    1. (Included in this are the patient’s values & preferences)

Provide Matched Interventions...

So what’s meant by matched interventions? All this means is matching the treatments we provide with the relevant data that we have.

There are two main categories that we'll touch on right now:

  1. Matching interventions with impairments & activity limitations/participation restrictions

  2. Matching treatment dosage with symptom irritability

Matching Interventions with Impairments & Activity Limitations

If you’re familiar with the ICF lingo, you’ll know that:

  • Activity limitations and participation restrictions relate to the effects of the person’s problem on their life

  • Impairments are the specific body structural/functional issues that we address directly.

(for a more detailed overview, click here)

A common habit that we tend to fall into is impairment-chasing. We are trained to find impairments, and we’re quite good at it. We can find movement abnormalities, mobility issues, and strength deficits in pretty much anybody.

The problem is that not all impairments are relevant. Many of them may not be contributing to the person’s problem in any way.

Chasing impairments—by treating any & all impairments that we find—can lead to inefficient treatment at best, and can contribute to fear and body-fragility beliefs at worst.

A key to effective and efficient treatment that fosters and body-positive beliefs lies in our ability to match the impairments we find with the person’s activity limitations and participation restrictions (their life).

For example:

Let’s say you’re working with a person who has knee pain on stair descent (activity limitation) that limits their ability to visit their grandkids (participation restriction).

You find the following impairments:

  • Knee extension mobility deficits

  • Knee flexion mobility deficits

  • Knee flexor muscle power deficits

  • Hip abductor muscle power deficits

  • Hip flexor muscle power deficits

Where would you start? What’s the most relevant impairment?

You could probably make an argument for a few of them, but most would agree that addressing the knee flexion mobility deficits is the best place to start (given the limited information provided).

This is because stepping down stairs has certain movement requirements, knee flexion mobility being key among them. If someone doesn’t have the required mobility, the way they move and their strength become much less relevant.

Matching Dosage with Irritability

Irritability is a clinical construct developed by Maitland. He developed it through noticing certain clinical presentations that are likely to be easily exacerbated by testing and treatment.

Irritability is something that's often overlooked but is critically important for predicting the patient’s response to testing and treatment.

There are three main components for assessing irritability (1).

  1. The vigor of activity required to provoke the symptoms

  2. The severity of the symptoms, once provoked

  3. The time it takes for the symptoms to subside once aggravated (persistence)

Some dichotomize irritability as either irritable or non-irritable, while others name it in terms of low, moderate, or high irritability. The importance lies simply in assessing it and keeping it in mind when making treatment decisions.

Determining a patient’s irritability comes through testing and retesting.

It starts by forming an irritability hypothesis, which is initially made after the history, based on what you discover about the three components of irritability listed above.

It’s further refined during and after the physical exam, as well as treatment, based on how the patient responds.

If you continue with this process, your treatment will be much more effective because you will be able to provide the right dosage of intervention(s). This is because the correct therapeutic dosage and symptom irritability are highly related to one another.

A common mistake that I’ve seen in those that I’ve mentored—as well as in myself—is providing the right intervention with the wrong dosage.

You might be spot-on with your intervention(s), but if the symptom irritability is high and your dosage too high, you’ll make the symptoms worse. Similarly, if the symptom irritability is low and your dosage is too low, you won’t make a change.

The main concept to grasp here is that everything is a test. Every question we ask, every test we do, every intervention we provide is further data to prove or disprove our irritability hypothesis.

Being accurately dialed-in to someone’s symptom irritability is a game-changer, which—when combined with selecting the most relevant impairments—will allow you to treat with laser-precision.

...Keeping In Mind Contextual Effects

Contextual effects refer to the non-specific effects that occur from the context in which treatment is delivered.

These are distinct from the specific effects of the treatment itself, which are often differentiated in research by the difference between the placebo and the active group(s) (3).

It is well known that the psychosocial context and the therapeutic ritual around the patient can influence the patient's brain activity and the therapeutic outcome (4).

Most of us are aware of this, and perhaps feel that contextual effects amount to a very small amount of the overall outcomes. But there are studies that show staggeringly large contextual effects. A meta-analysis by Zou et al. of 215 RCTs with over 41k subjects showed that on average, 75% of the overall treatment effects for pain in treatments for knee OA were explained by contextual effects (3).

That’s HUGE!

How is this possible?

In an excellent article by Testa et al., several mechanisms are described, including (4):

  • Conscious expectation and the unconscious classical conditioning

  • Reward-learning

  • Observational and social learning

  • Modulation of anxiety, desire, motivation

  • Memory and prior experience

  • Somatic focus

  • Personality traits

  • Genetics

So what does all this mean for us?

Does nothing that we do really matter? Is it more about showmanship than clinical skill or reasoning?

What this means for us is that contextual effects are happening all the time, whether we’re aware of it or not. Everything from the PT’s and patient's features, the patient-clinician relationship, the characteristics of the treatment, and the overall healthcare setting influence the context and therefore the outcome (4).

The more we’re aware of this, the more we can use it to the benefit of the patient. Not our benefit. The patient’s benefit.

Using contextual effects to the benefit of the patient involves many things that we already do:

  • Being professional

  • Being optimistic during the consultation and regarding the problem

  • Delivering clear diagnosis, prognosis, and explanation of the patient’s problem

  • Requesting and trusting the person’s opinion

  • Encouraging questions

  • Investigating expectations, preferences, and the patient’s previous experiences

  • Showing and telling the patient that a therapy is being applied

  • Personalizing the treatment, taking the patient’s preferences & opinions into account

  • Utilizing therapeutic touch

The difference is that the more we understand the contextual effects of care, the more we can intentionally avoid unnecessary negative contextual effects.

Importantly, this is not a substitute for clinical skill or evidence-based care. Rather, it is a more inclusive understanding of what clinical skill and evidence-based practice really are.

The bottom line is that it all matters:

  • What we do, how we do it

  • What we say, how we say it

  • How we are

This is the blending of the art and the science of healthcare.

As Testa et al. put it, “The difference in clinical success between two different PTs, both practicing with reference to the scientific evidence and application of the clinical guidelines lies in the different level of implementation of the ‘art’ component of the profession (4).”

In Summary:

  • Determine the level of symptom irritability, based on:

    • The vigor of activity required to provoke the symptoms

    • The severity of the symptoms, once provoked

    • The time it takes for the symptoms to subside, once provoked

    • The person's symptom-response to testing & treatment

  • Determine the person’s relevant impairments based on your testing of the movement requirements of their activity limitation

  • Treat the impairment(s) with a dosage/vigor that reflects their level of irritability, in a manner that facilitates safety

  • Retest their activity limitation to see if a change was made. Their response will tell you if you selected the right intervention and the right dosage

Try This:

Focus on ONE of the following for 1+ weeks:

  1. Facilitate an environment characterized by safety, learning, & exploration

  2. Investigate symptom irritability and dose interventions accordingly

  3. Determine the person’s relevant impairments based on your testing of the movement requirements of their activity limitation

Once you feel like you have a handle on your first focus, layer on another one for a few weeks, and finally the third. This will allow you to truly integrate the new information and ways of practicing.

Thank you so much for reading. I’d love to hear from you! Please let me know your thoughts in the comments below, and feel free to share this with friends who you think would enjoy too!




  1. Barakatt, E. T., Romano, P. S., Riddle, D. L., Beckett, L. A., & Kravitz, R. (2009). An exploration of Maitland's concept of pain irritability in patients with low back pain. Journal of Manual & Manipulative Therapy, 17(4), 196-205.

  2. Kelley, M. J., Shaffer, M. A., Kuhn, J. E., Michener, L. A., Seitz, A. L., Uhl, T. L., ... & Wilk, K. (2013). Shoulder pain and mobility deficits: adhesive capsulitis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic Section of the American Physical Therapy Association. Journal of orthopaedic & sports physical therapy, 43(5), A1-A31.

  3. Zou, K., Wong, J., Abdullah, N., Chen, X., Smith, T., Doherty, M., & Zhang, W. (2016). Examination of overall treatment effect and the proportion attributable to contextual effect in osteoarthritis: meta-analysis of randomised controlled trials. Annals of the rheumatic diseases, 75(11), 1964-1970.

  4. Testa, M., & Rossettini, G. (2016). Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Manual therapy, 24, 65-74.

  5. Moseley, G. L. (2007). Reconceptualising pain according to modern pain science. Physical therapy reviews, 12(3), 169-178.

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