Welcome: Measure What Matters
🎯 The Core Challenge
People with chronic pain often don't receive the thorough, systematic assessment that athletes enjoy. Pain, strength, and function aren't always well correlated, making objective testing feel daunting. The solution? Master your serial testing.
📊 What is Serial Testing?
Serial testing is the repeated testing and tracking of objective markers through time. It's familiar territory in sports medicine (think: quadriceps strength tracked across ACL rehabilitation), but becomes more nuanced in chronic pain management.
🎯 The Model
3-factor Venn diagram for choosing and framing tests that patients will value
💎 The Framework
Theory of Consumer Values (TCV) to understand what makes testing meaningful
🔧 The Application
Real clinical examples showing the framework in action with back pain
🎓 Why This Matters
Serial testing isn't just about collecting data—it's about providing a service that people with chronic pain will actually value. When done correctly, your testing battery becomes a powerful tool for:
- Building patient trust and therapeutic alliance
- Challenging unhelpful beliefs through objective evidence
- Creating curiosity and engagement in recovery
- Tracking meaningful progress beyond pain scores
- Educating patients about factors influencing their condition
📚 What You'll Learn
- Theory of Consumer Values (TCV): The 5 factors that make your service valuable (FECSE)
- The 3-Factor Model: What matters to patients, clear messaging, and objective data
- Test Framing Strategies: Validation vs. expectancy violation approaches
- Clinical Application: Real examples with chronic back pain
- Implementation Tips: Making serial testing systematic in your practice
💎 Theory of Consumer Values (TCV)
Understanding What Creates Value
The TCV framework helps us understand what makes our clinical service valuable to patients. This isn't about "selling" your service—it's about providing a service that people will genuinely value, which is especially critical in chronic pain management.
The 5 Components: FECSE
Each letter represents a distinct dimension of value that influences whether patients will engage with and benefit from your serial testing approach.
F - Functional Value
Meeting Needs in Context
Does your testing actually help them in their life? This is about real-world applicability and addressing what matters to the patient's daily function and goals.
Testing that shows a parent can safely lift their child addresses a functional need that matters to their life context.
E - Emotive Value
The Experience of Service
How does it feel to access your service? This encompasses your soft skills, empathy, understanding, therapeutic environment, and the emotional experience of testing.
Conducting tests in a supportive, non-judgmental way that acknowledges patient fears and validates their experience.
C - Conditional Value
Cost-Benefit Analysis
Is it worth the resources required? Even if testing meets a functional demand, patients weigh monetary cost, time investment, and opportunity cost.
Providing home-based proxy tests reduces reliance on expensive clinic visits while maintaining assessment quality.
E - Epistemological Value
Sparking Curiosity
Does your service spark the innate inquiry impulse of learning? Are patients coming back because they're genuinely curious about their progress?
"I wonder what my test will show this week?" - Creating intrinsic motivation through curiosity about objective progress.
🔗 How TCV Connects to Serial Testing
When designing your serial testing battery, you should intentionally consider all five TCV dimensions. Your tests should be:
- Functional: Relevant to patient goals and daily life
- Emotive: Delivered with empathy and in a supportive context
- Conditional: Worth the time and cost investment
- Social: Building trust and collaborative partnership
- Epistemological: Creating curiosity about progress and recovery
💡 The Key Insight
"Understanding TCV isn't about being better at 'selling your service'—it's about providing a service that people will value, which is super important, especially in chronic pain."
- Steven Collins
🎯 The 3-Factor Serial Testing Model
This model breaks down test selection into three distinct but overlapping circles. The serial testing "sweet spot" exists where all three circles meet—tests that simultaneously address patient concerns, communicate clearly, and provide objective data.
SWEETSPOT
🎯 The Integration Principle
If there isn't one test that meets all three domains, having a few tests that each meet more than one domain is a good second option. The goal is comprehensive coverage across all three circles.
Breaking Down Each Circle
Circle 1: What Matters to the Patient
Functional | Emotive | ConditionalTo some degree, testing must be relevant to the goals or concerns of the person seeking care. This isn't optional—it's the foundation of engagement.
What This Targets (TCV)
- Functional: Tests address what matters in their daily life
- Emotive: Demonstrates empathy and understanding
- Conditional: Shows cost-benefit consideration in their journey
Clinical Application
If a parent is concerned about lifting their child, your testing should directly address that concern. Generic strength tests that don't connect to their worry miss this circle entirely.
Give patients proxy tests they can track at home to avoid over-reliance on clinic visits and improve the conditional value (cost-benefit) of your service.
Circle 2: Clear & Coherent Messaging
Social | Epistemological | EmotiveThis circle may not be intuitive, but it's critical. The tests you choose through shared decision-making should not contradict the narratives you believe facilitate recovery.
⚠️ The Contradiction Problem
Telling someone "your back is strong" but then being too afraid of flare-ups to include any direct measures of "back strength" sends contradictory messages. This undermines your social credibility and the patient's understanding.
What This Targets (TCV)
- Social: Maintains your "street cred" and professional credibility
- Epistemological: Sparks curiosity about how results fit the recovery narrative
- Emotive: Creates coherent, trustworthy therapeutic experience
The Two Framing Approaches
1️⃣ Validation of Patient Experience
"Yes, this is your safe limit currently, so we probably shouldn't exceed it often."
Confirming what the patient suspects and setting appropriate protective boundaries.
2️⃣ Expectancy Violation
"What do you think your result will be? ... Actually, you did much better than you expected!"
Getting patients to guess (usually anchoring low), then showing actual results that exceed expectations, directly challenging negative beliefs.
Circle 3: Objective Data / Norms
Functional | EpistemologicalThis is the bread and butter of clinical and performance testing. The ability to choose tests with strong reliability and repeatability, objective tracking capability (ideally with MCIDs), and normative comparisons.
Key Requirements
- Reliability: Test gives consistent results when repeated
- Objective data: Quantifiable metrics that can be tracked over time
- MCIDs: Minimal Clinically Important Differences for meaningful change
- Normative data: Comparisons to reference populations
The Critical Balance
Nailing this circle isn't just about being clinician-centric. You must know how to utilize objective data to facilitate functional and epistemological values so the data means something to patients in their lives.
Data for data's sake doesn't create value. The numbers must connect to patient goals, spark curiosity about recovery, and inform meaningful decisions.
✅ Putting It Together: The Sweetspot
The most powerful serial testing batteries exist at the intersection of all three circles:
- Tests that patients care about because they relate to daily function
- Tests that communicate clearly without contradicting your therapeutic narrative
- Tests that provide reliable, objective data for tracking meaningful change
When you achieve this integration, you create a testing approach that patients genuinely value and engage with throughout their recovery journey.
🎭 Test Framing Strategies
The Power of How You Frame Results
The tests you choose matter, but how you frame and deliver results can be equally powerful. There are two primary framing strategies that serve different therapeutic purposes in chronic pain management.
🛡️ Validation Framing
Confirming Patient Experience
"Yes, this is your safe limit currently, so we probably shouldn't exceed it often."
Purpose
Validates what the patient suspects about their current limitations. This approach confirms their experience and helps establish appropriate protective boundaries.
When to Use
- Early stages when tissue is genuinely irritable
- Building trust by acknowledging patient concerns
- When appropriate caution IS warranted
- Type 1 presentations with real tissue sensitivity
TCV Connection
Emotive Value: Demonstrates empathy and understanding
Social Value: Builds therapeutic alliance through validation
Functional Value: Sets realistic, safe activity boundaries
Patient reports severe pain with any trunk flexion. Testing confirms limited straight leg raise and pain with neurological exam. You validate: "Your nervous system is genuinely sensitized right now. Let's respect that and start gently."
💥 Expectancy Violation
Challenging Negative Beliefs
"What do you think you'll be able to lift? ... Interesting! You actually lifted twice that amount!"
Purpose
Forces patients to confront their negative beliefs by having them predict results (usually anchoring low), then showing them they exceed their expectations. This creates cognitive dissonance that challenges catastrophizing.
When to Use
- When capacity exceeds perceived ability
- Addressing kinesiophobia and fear avoidance
- Type 2b presentations needing graded exposure
- When beliefs don't match objective reality
TCV Connection
Epistemological Value: Sparks curiosity and challenges beliefs
Emotive Value: Creates surprise and positive emotional experience
Functional Value: Expands perceived functional capacity
Patient believes they can only lift 10kg safely. Before testing: "What do you think you'll be able to lift today?" They guess 10kg. They actually lift 30kg pain-free. "Wow! Your back handled three times what you expected. What does that tell you about your spine's resilience?"
🎯 The Strategic Choice
Your choice of framing strategy should align with:
- Current tissue state: Genuine irritability vs. disproportionate fear
- Patient beliefs: Appropriately cautious vs. catastrophizing
- Stage of recovery: Early protection vs. later exposure needs
- Therapeutic goals: Building trust vs. challenging avoidance
⚠️ Critical Consideration
Don't use expectancy violation when tissue is genuinely irritable! This could:
- Cause actual tissue aggravation
- Break therapeutic trust
- Reinforce belief that pushing through is always good (Type 2a risk)
- Create a flare-up that undermines progress
✅ Best Practice: Match Your Framing
For Type 1 Presentations (Real Irritability)
→ Use Validation Framing
"Your concerns are warranted. Let's respect your current limits."
For Type 2a (Endurance Copers)
→ Use Validation Framing to challenge toughness
"I know you want to push through, but your tissue genuinely needs protection."
For Type 2b (Fear Avoidance)
→ Use Expectancy Violation progressively
"Your back is more capable than you think. Let's find out together."
🏥 Clinical Application: Chronic Back Pain Example
The Real-World Integration
Let's see how the 3-Factor Model, TCV framework, and framing strategies come together in a common clinical scenario: chronic low back pain with nerve-related fears.
📋 Case Presentation
Patient Concern
Patient is worried that their back is too fragile to pick up their child and doing so would "damage their nerves". They report significant fear and avoidance of lifting, bending, and loading activities.
Therapeutic Narrative
The clear and coherent message we want to communicate: "Your back is resilient!"
This narrative needs tests that support it—avoiding contradictory messaging that would undermine this core therapeutic goal.
🎯 Applying the 3-Factor Model
Circle 1: What Matters to Patient ✓
- Functional concern: Ability to safely lift their child
- Fear: Worried about "damaging nerves"
- Goal: Return to normal parenting activities
Tests must directly address: Lifting capacity and nerve integrity
Circle 2: Clear & Coherent Messaging ✓
Narrative: "Your back is resilient"
- Must include direct measures of back/lifting strength (not avoid them!)
- Must include objective nerve function tests
- Results should challenge catastrophic beliefs about fragility
Framing strategy: Expectancy violation (if capacity exists) to challenge fears
Circle 3: Objective Data / Norms ✓
Tests chosen must have:
- Reliability and repeatability for serial testing
- Normative data for comparison
- Clear objective metrics to track progress
📊 The Chosen Test Battery
IMTP (Isometric Mid-Thigh Pull)
- Patient Circle: Directly relates to lifting capacity—functional for picking up child
- Messaging Circle: Demonstrates back can handle significant load (resilience!)
- Objective Circle: Excellent reliability, normative data available, trackable force output
Expected Outcome: Often patients produce much more force than they anticipate
SLR (Straight Leg Raise)
- Patient Circle: Addresses nerve-related fears with objective measure
- Messaging Circle: Shows nerve mobility and tolerance to stretch
- Objective Circle: Standardized test, degree measurement, bilateral comparison
Expected Outcome: Often within normal limits despite patient fears
Neurological Exam
(Including dynamometry & reflexes)
- Patient Circle: Directly addresses "damage their nerves" fear
- Messaging Circle: Provides objective evidence of nerve integrity
- Objective Circle: Standardized clinical exam with clear positive/negative findings
Expected Outcome: Typically negative findings, challenging catastrophic beliefs
✅ The Complete Integration
Together, these three tests create a comprehensive serial testing battery that:
- Addresses the patient's specific concerns about lifting and nerve damage
- Supports the "back is resilient" narrative without contradiction
- Provides objective, trackable data with normative comparisons
- Creates opportunities for expectancy violation
- Tracks meaningful progress through serial assessment
🎬 The Testing Session Conversation
Clinician: "Before we test, what do you think you'll be able to lift today? How much force do you think your back can handle?"
Patient: "Maybe 10 kilos? I'm really worried about my back."
Clinician: "Okay, let's see what happens..." [Performs IMTP, patient generates 450N]
Clinician: "Interesting! You just produced force equivalent to lifting about 45 kilograms. That's more than four times what you thought you could do. What does that tell you about your back's capacity?"
Patient: "Wow... I had no idea I could do that without pain."
Clinician: "And your neurological exam is completely normal—reflexes good, strength equal both sides. Your nerves are not damaged. Your back is actually quite resilient. Let's track these numbers over time and you'll see them improve even more."
This is expectancy violation in action—creating cognitive dissonance that challenges catastrophic beliefs while providing objective evidence.
📈 Serial Testing Schedule
With the patient, agree on a rough serial testing schedule (e.g., every 2-4 weeks initially, then monthly). This creates:
- Epistemological value: "I wonder what my tests will show this week?"
- Social value: Collaborative journey with regular checkpoints
- Functional value: Objective tracking of progress toward lifting goals
⚠️ Important Reminder
Don't get stuck on any one data point—focus on the trend. Individual testing sessions are opportunities to educate how chronic pain can fluctuate with allostatic load (sleep, stress, life demands). A worse result one week isn't failure—it's learning about contextual factors.
🔧 Implementation Guide
Making Serial Testing Systematic in Your Practice
Understanding the framework is one thing—implementing it consistently is another. Here are practical strategies for making serial testing a seamless part of your chronic pain management.
Step-by-Step Implementation
Step 1: Initial Assessment - Build Your Battery
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Identify patient concerns
What are they worried about? What can't they do? What do they need to return to?
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Establish your therapeutic narrative
What's the coherent message? (e.g., "Your back is strong," "Movement is safe," "Nerves heal")
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Choose 2-4 tests that hit all three circles
Patient-relevant, message-coherent, objectively measurable
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Explain the testing plan
"We'll track these measures every X weeks to see your progress and learn about your condition"
Use shared decision-making. Ask: "Would it be helpful to track your lifting strength over time?" vs. "I'm going to test your strength." Autonomy increases buy-in (TCV: Emotive & Social value).
Step 2: Baseline Testing - Set the Anchor
For Expectancy Violation:
- Before testing: "What do you think your result will be?"
- Let them guess (they usually anchor low)
- Perform test objectively
- Show actual result: "You did X, which is Y more than you expected"
- Explore: "What does that tell you about your body's capacity?"
For Validation:
- Test objectively
- Confirm their experience: "Yes, this shows your tissue is currently sensitive"
- Frame positively: "And this baseline means we'll be able to track improvement"
- Set safe boundaries: "This is your current safe zone"
Step 3: Schedule Serial Assessments
Early Stage (Weeks 1-6)
Frequency: Every 2 weeks
Why: Rapid changes early, need frequent feedback
Middle Stage (Weeks 6-12)
Frequency: Every 3-4 weeks
Why: Consolidating gains, tracking trends
Late Stage (3+ months)
Frequency: Monthly or longer
Why: Maintaining gains, long-term monitoring
Book the next assessment before they leave. Creates commitment and builds epistemological value ("I'm curious what my tests will show in 2 weeks").
Step 4: Follow-Up Testing - Track the Trend
What to Do at Each Assessment:
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Quick review of previous results
"Last time you lifted 300N, let's see where you are today"
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Repeat tests in standardized way
Consistency matters for reliability
-
Show the trend, not just the number
"You've improved 40% since we started"
-
Educate about fluctuations
If results are worse: "You've had poor sleep and high work stress this week. That's your system envelope being smaller—let's see this as learning, not failure"
Individual sessions aren't pass/fail. They're data points in a longer trend. Use variations to educate about allostatic load and contextual factors affecting pain and function.
✅ Documentation & Tracking
Essential Elements to Record:
- Test name & date
- Objective result (e.g., "IMTP: 380N")
- Patient prediction (if using expectancy violation)
- Pain level during test (0-10 VAS)
- Contextual factors (sleep quality, stress level, recent flare-up, etc.)
- Patient interpretation ("What does this result mean to you?")
Create simple graphs showing progress over time. Visual representation of improvement is powerful for motivation and creates epistemological value.
🎯 Common Challenges & Solutions
"I don't have time for multiple tests"
→ Choose 2 tests that cover all three circles. Quality over quantity. IMTP + neurological exam might be sufficient for many back pain cases.
"Patient doesn't seem engaged with testing"
→ Revisit Circle 1 (What matters to patient). Your tests might not be relevant to their actual concerns. Use shared decision-making to choose tests together.
"Results fluctuate too much week-to-week"
→ This is actually valuable! Use it to educate about allostatic load and contextual factors. Show them the overall trend despite fluctuations.
"Patient gets discouraged when results don't improve"
→ Explore contextual factors (system envelope). Frame stability as success ("You maintained your capacity despite high stress week"). Look for other positive trends.
🎓 The Ultimate Goal
"Sticking roughly to these testing schedules can be an important step in helping the patient learn about the things that impact their function and condition."
Serial testing isn't just about tracking numbers—it's about creating a learning journey where patients develop understanding, build confidence, and make informed decisions about their recovery. When done well, it becomes one of the most valuable aspects of your chronic pain service.