They Said They Couldn’t… But Then They Did. What’s Your Next Move?”
How Therapists Can Assess the Reliability of Client Reports in Everyday Clinical Practice
In rehabilitation settings—whether in outpatient therapy, work conditioning, or general orthopedic care—clinicians routinely rely on client self-reports to inform assessment and guide treatment. Pain intensity, tolerance for activities, and functional limitations are often reported verbally or through questionnaires. But how reliable are these reports?
This is not an academic question—reliable self-reports help guide safe progression. Unreliable reports, on the other hand, may contribute to under-loading, prolong recovery, or misinform discharge planning. Many therapists intuitively recognize this: during one of my many conversations with experienced clinicians, they often say “I know when something doesn’t add up, but I want better ways to document it.”
In this article, we’ll explore practical, evidence-informed strategies for evaluating the reliability of client reports across all clinical settings—not just during specialized assessments. These strategies can be easily integrated into your daily practice and will improve both clinical reasoning and documentation.
Why Assess Report Reliability?
Clients rarely set out to deceive. But many factors—fear, misunderstanding, pain catastrophizing, unhelpful beliefs, even medication side effects—can affect how they report their symptoms and abilities.
Assessing the reliability of reports is about understanding the whole clinical picture, not judging the client.
The goal is to answer: Can I trust what this person is telling me about their function, or is there a mismatch between report and observable behavior?
Inconsistencies Across Time
It’s not uncommon to see a client’s reported limitations shift from session to session—or even within a single visit. A client with persistent low back pain might tell you “I can’t bend forward”, yet rise from the waiting room chair smoothly, and later, climb onto the recumbent bike with great difficulty, grimacing and guarded. On one day they may tolerate lumbar flexion exercises well; on another, they report severe pain with the same movements.
As I often discuss with my University students learning effort analysis, this variability is rarely deception. More often, it reflects fear, pain catastrophizing, or fluctuations in the client’s pain experience. Their perception of what is safe can change day to day—especially if they’ve been told, or believe, that bending might “damage” their back.
One simple way to track and address this: begin documenting reports consistently over time. Use validated questionnaires (like the Oswestry Disability Index or Roland-Morris Disability Questionnaire) at intervals—not just intake and discharge. Then, compare scores to observed function in each session.
"Client reported severe flexion intolerance today, yet demonstrated full lumbar flexion during seated transitions and recumbent bike setup. ODI scores unchanged from prior session."
Over time, this helps both clinician and client see when fears are limiting movement more than physical capacity—a key step toward graded exposure and recovery.
Mismatch Between Reported Symptoms and Observed Movement
Another common scenario: a client rates their shoulder pain as “9/10” at rest, reporting an inability to lift overhead. Yet when leaving, they casually retrieve a coat from a high wall hook without hesitation or apparent discomfort.
Rather than framing this as “catching” the client, skilled therapists use such moments as opportunities to understand and address underlying fear or unhelpful beliefs. During one of my many conversations with an experienced outpatient PT, they said: “I’ve learned to think of these moments as coaching opportunities—not contradictions.”
One helpful tactic is to build intentional “movement cross-checks” into your session—not to test honesty, but to gradually increase the client’s confidence in safe movement. For example, if a client reports squatting is impossible, observe casual movements (like tying shoes) or gently introduce low-load squats with graded exposure.
When documenting:
"Client reported 9/10 shoulder pain with overhead motion, yet performed overhead reach to retrieve personal items without apparent distress or guarding."
This builds a more complete clinical picture, and gives the therapist a path forward: “You moved really well reaching for your coat. That’s something we can build on today.”
Non-Anatomical or Global Pain Reports
Sometimes a client’s verbal report or pain drawing covers large, diffuse, or non-anatomical areas—an entire limb, or the whole back—without corresponding neurological findings. In many cases, this reflects not exaggeration, but misunderstanding about pain or a lack of body awareness.
During one a conversation with a neuro clinic team, we discussed how clients with persistent pain often struggle to localize their symptoms. A therapist shared: “I used to think a full-body pain drawing was a red flag. Now I see it as a sign this client may need more education on pain processing.”
A simple tactic is to introduce pain drawings or symptom diagrams in regular practice—not just for documentation, but as a starting point for conversation:
"I see you marked your whole leg here. Can you tell me where it feels most intense, or where it changes when you move?"
Over time, comparing updated drawings to function can reveal shifts in both symptom experience and movement confidence.
Unexplained Performance Gaps Between Similar Tasks
At times, clients may decline or self-limit certain tasks—while performing other, biomechanically similar movements without difficulty.
For example, a client with low back pain may refuse to lift an object from table height, citing “too much strain on my back”, but later perform a floor-to-waist lift during another exercise station with good form and no hesitation.
As I often point out when teaching effort analysis in FCEs, this is rarely about willful inconsistency. More often, it reflects specific task-based fear or unhelpful beliefs. The client may have been told certain lifting styles are “dangerous,” or may associate certain postures with prior injury.
A useful approach here is graded education and movement re-integration:
"I noticed you did really well lifting from the floor earlier. That tells us your back can tolerate more than it feels like with this table lift. Let’s explore that together."
And document:
"Client declined table lift citing fear of injury, but demonstrated confident and pain-free floor-to-waist lifting earlier in session."
Such patterns guide not only treatment, but also client education—building both trust and progress.
Final Thought: Building Trust Through Thoughtful Observation
One of the most valuable lessons from advanced effort analysis is not simply learning to detect unreliable reports—but understanding how to respond to them constructively.
As therapists, we must first be aware that unreliable or inconsistent reports do happen—and that left unchecked, they can unintentionally limit a client’s recovery. If we accept all reports at face value without observation, we may inadvertently reinforce fear, avoidance, or unhelpful beliefs.
At the same time, labeling a client as “not trying” or as a “cheater” is both inaccurate and harmful. It offers no pathway for the client to improve—and risks eroding therapeutic trust.
Instead, we should document inconsistencies factually, and use them as opportunities for empowerment and graded progression. For example:
"Today you were able to complete this movement, which is very similar to the one you felt unsure about earlier. That’s great progress. Next session, let’s try them both again and build on this success."
This reframes the conversation: not as an accusation, but as an invitation to explore capacity, rebuild confidence, and foster resilience.
As I often remind therapists I mentor: "Effort analysis isn’t about catching clients out—it’s about helping them discover what they can do."
By thoughtfully observing, documenting, and addressing these patterns, we guide clients not only toward greater function—but toward greater self-efficacy in their own recovery.
