Motivations and Change: The Coaching Physiotherapist

This blog has emerged from a range of sources and an interest in how physiotherapists can utilise coaching skills into patient care.  It also considers how this can then develop into day to day practice with teams and the wider health-care community.

Debates surrounding the “Hate exercise, Love activity” campaign driven by the CSP, as well as the concept of exercising through pain and around the theoretical proposals of “windows of opportunity” have also made us consider the links between coaching, motivation and the other issues surrounding these discussions.

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This discussion stems from an interest in “self-determination theory” (SDT).  SDT can be traced to humanistic psychology that emphasises an individual’s effort toward self-actualisation, which is the point where the realisation of a persons potential transpires. It is formed via the premise that as long as the basic psychological needs of an individual are met then a natural “growth” will occur.  SDT also relates to how people perceive their locus or control, which is the extent to which an individual views their own behaviour, perceived by internal factors (interests, values and identities), is in relation to external factors such as other people’s demands and regulation through the environment.

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As clinicians who wish to help our patients, we are in a constant flux with respect to helping an individual move towards self-actualisation.  SDT theory argues that as humans we require three basic psychological needs to be met; autonomy, competence and relatedness  and when these needs are satisfied, then self-regulation creates a sense of well-being and engagement toward their goals.

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Autonomy can be described as being in control, competence  is the need to be effective and relatedness  is the need to feel valued and connected with others.  It is also suggested that if self-regulation is not achieved then individuals may develop patterns of behaviour that offer short-term benefit but may not realise their long term goals or achievements.  These patterns of behaviour may manifest through feelings of fear, guilt or through the pursuit of an external reward.

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In physiotherapy we may have to be aware of unwittingly developing these feelings in our patients, such examples may include:


“You must do your exercises to help you, if you don’t, how can you ever expect to get better!”Fear

“It is your responsibility to do these exercises! If you don’t then we cannot help you”Guilt

“If you do these exercises, we can show you have tried, then we can justify asking for a scan, because we have moved through the right process”External Reward


So, how does this relate to many of the discussions around exercise or activity, having a “window of opportunity”, or pushing into pain?

Importantly (Gagne and Deci 2005) & (Spence and Oades 2011) speak of a vital fourth motivation, integrated motivation, where the individual experiences fun and enjoyment from a goal that was extrinsically set.

These concepts, we propose, link to the exercise prescription we offer patients. It suggests that the first three motivations (fear, guilt, external reward) will not lead to the three required; the need for autonomy, competence and relatedness and therefore will not lead to internal motivation.  An integrated approach, i.e. finding what the individual enjoys (internal reward) and make it relatable to their goals, and then motivation led by the individual is far more likely to happen.

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So, asking a patient to stand in a room on their own, repeatedly doing a movement over and over again, experiencing pain based upon the premise that it may help, could be conflicted.  The reason that it could be conflicted is that on the one hand, the movements may build power, strength, endurance, flexibility, however on the other, unless it leads to a feeling of control, effectiveness and connecting to others then the chances of the physiological changes observed in studies having any long term benefit is compromised. Of course, if the exercise can be experienced to offer these three needs, irrespective of the pain experienced, and manifest in a sense of reward, then the result is likely to be more successful.  So, the context, meaning and relevance of the exercise must be acknowledged and accepted, and of course it might be a starting point, so we are not suggesting that individual exercise plans are wrong, far from it, rather what we are saying is that they need to meet the psychological needs as well as physiological aims.

Therefore, when developing an exercise programme, the activity and its environment as well as the motivation and choice for the individual will need to be taken into account in order to meet these psychological needs.  This may improve compliance and become an integrated part of life, rather than be regarded as a treatment.  This is far more likely to create a sense of self-actualisation and reach a person’s full potential.

So perhaps, the “hate exercise, love activity” concept is really just a real world self-determination theory model that allows therapists to be wider and more person-centred in their exercise prescription.  The development of social prescribing parallels this and we may see a shift from gyms, and weights to parks, bikes, and rambling (for some of course), as self-actualisation can absolutely come from the gym and heavy exercise, but in the right group and social context.

The term “window of opportunity” is so often linked to hands-on treatment, and is actually in our opinion, a far wider and deeper concept.  It is when changes in behaviours or beliefs lead to the individual having the support to meet their psychological needs.  It is when a humanistic coaching approach opens up the opportunity for change through the clinician-patient relationship.  The window is never opened unless a humanistic coaching process is initiated, and so irrespective of our treatments and their proposed effects, it must be built upon a coached approach to the care episode.

Developing the environment for change requires taking others perspectives into account, acknowledging their feelings, minimising pressure and offering choice that make sense to the patient within their community.  There is no reason why a short term pain relieving intervention offered in the appropriate context should not help this, however, we must remember that, although these treatment offer pain reduction, it is the appropriate psychological responses surrounding this that offer the chance for change. The short term period of pain relief is described as neuro-modulationand it is suggests that one’s self is separate from our physiological being, and of course that is not the case, so perhaps we offer the opportunity for people to modulate themselves, alter the pain experience, and affect beliefs; we therefore, don’t specifically modulate nervous systems!

Good quality physiotherapy offers autonomy, and as such opens a psychological window that offers this opportunity, and as the “window” remains open the growth towards competence can begin.  With the development of competence (this could be confidence in a movement, increased integration of activity, improved engagement in tasks) the key is to then create the social support that offers the individual fun, enjoyment and the opportunity to feel valued (this could be increased social interaction, returning to work, or perhaps joining a club).

So, in summary we propose that some patients refer to activity as part of their normal life and we can see why, conceptually and psychologically, linking recovery to activity and not a pre-determined view of exercise can build upon SDT theory.  When patients are active, then they are of course exercising, but they are not limited by external goals such as repetitions, time and weight, they are influenced by internal integration such as enjoyment, interaction and fun and this perhaps is why the campaign developed this way.

External limited exercise prescription is a vital approach to recovery for numerous patients but perhaps it should be underpinned by SDT theory which may lead to the development of improved personalised exercise plans and improved outcomes.

Many of these concepts can be applied in our working environments and from coaching managers, athletes and staff we can utilise similar concepts across environments.

Neil will be talking about this and more at PhysioUK19 so if you are going, we hope to see you there!

 

Neil Langridge, NHS Consultant Physiotherapist

Matthew Low, NHS Consultant Physiotherapist

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Exploring “Physiotherapy”

The social identity of our profession is vital, both in respect to how we see ourselves, and also how the public views us.  It sets the expectations of us as a profession and also the sociocultural context of our patient’s expectations of the profession.  Our social identity can drive our own personal and professional strategies that may lead to challenging tensions that exist between how the public may judge us and how we evaluate ourselves and our colleagues, from within and between the healthcare professions.

From the viewpoint of the public, they may assume that our role is to massage sore limbs, prescribe exercises, hand out walking aids, run out on sports fields, and prescribe medications, list for surgery or just helping people recover with advice and guidance.  In whatever way they may perceive us, there will be numerous accurate or inaccurate views.

This short blog looks to consider the word Physiotherapy and its two elements – Physio (nature, natural or physical) and therapy (treatment, counselling, healing).  A real life viewpoint of a patient of Neil’s has made him consider the therapeutic element within the patient narrative. All clinicians are blessed to be invited into a patient’s story, and in so many cases, this can be a very humbling experience. This story was one of those, and it led us to reconsider the name of the profession – Physiotherapy.

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When we describe ourselves as a “Physio” it seems fairly clear to us and it sets an expectation of physicality translating to recovery. We may not describe ourselves so easily as a “therapist” because there are a range of therapists in healthcare and this therefore fails to distinctly identify ourselves, however being “therapeutic” and offering “therapy” is an integral part of person-centred care.  I am sure that there are many of us who have experienced the confusion in how the word ‘physio’ is used as a treatment as opposed to a professional title!

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So, what is the “therapy” we offer? Exercise on its own has physiological benefits; helping people move helps numerous biological, psychological and social system changes.  In the realm of human biology for example, movement behaviour changes, observations can be made with respect to the tone of muscles, the strength of a contraction, the biochemistry within the soft-tissues, or due to alterations of the nervous system, things change. How that change is experienced, perceived, acknowledged and understood contextualises those physiological reactions within the emotional context of the individual, and this is where the “therapy” may happen in the cases that we see. The biopsychosocial model has been unintentionally interpreted as three distinct components and there may be the tendency to treat through the bio lens, an example being how exercise may strengthen the individual to improve their physical capacity and potentially ignoring other psychological and social contexts.  However, there is the recognition that a key component to integrated the biopsychosocial approach is through the provision of a cognitively informed practice to enhance recovery.  Although our language, through its inherent limitations, has to separate this complex and dynamic systems approach, it is very difficult to come to terms with the understanding that these systems cannot really be separated and treated as such, as they are inextricably intertwined.

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As we will all appreciate, every interaction, intervention and communication will, in some way, have an emotional effect on that individual, we are human and fundamentally social beings.  And so, that interaction whether it is the prescription of an exercise designed to help improve the capacity of a tendon for example, using the most up to date isometric technique may be shown to change a range of difficult to pronounce chemicals, or giving advice to move and stay active, or perhaps using hands to help someone, or whatever, the “therapy” is the emotional interaction and understanding that enhances the observable physical changes.  The ‘objective’ changes without the emotional context, become just observations without the translation of a positive lived experience.

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So, as someone who trained many years ago and initially believed the physical treatments produced the physical responses, it is always a humbling experience to put the pen down, sit back, and listen to the story. To hear how the agency of a person is lost and to really appreciate the emotional cost associated with that.  Hearing the impact of how “physical” treatments have failed and in order to make sense of the situation is truly bi-directional within an intersubjective space.  The way in which progress can be made and enhance the biology of recovery in instances such as these, was to offer the “therapy” within the patient story and not from an externally situated and objective physical sense (Physio).

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We would like to thank Neil’s patient for kindly sending this, allowing us to publish it, and being so open in their discussion.

Matthew Low and Neil Langridge

“Hi Neil,

As we discussed, here is the story of my back problems, I hope it isn’t too long winded, but once I got started it was quite therapeutic!

I’m 53 years old and can’t remember a time when I haven’t had to careful with my back. Almost any little thing could trigger painful spasms and more prolonged periods of stiffness and pain. Besides that I kept myself reasonably fit walking my dogs, horse riding when I was able and had a pretty normal life. Just before Christmas 2001 I think, I bent to get something from the oven and “wow” the pain was so bad I couldn’t move, general opinion that followed was a disc issue which took about 6 weeks to improve. After that it made me even more conscious and nervous about everyday movements and actions. New Years Eve several years later and I got a virus which led to Sarcoidosis my particular symptoms being respiratory, bronchitis and constant coughing and vomiting through that. Needless to say I hurt my back badly with that, and after the operation to remove a lump from my lung I had awful pain, not from the operation site but of course from lower back.

Very soon after returning to work in a job I loved and had been in for years the company folded, I was redundant and not exactly a fit candidate for anything! Shortly after that my dog had a bad accident which then meant 6 months of treatments and care at home and vet visits every week. At this point my husband of 20 years decided that a friend of ours would be a much better option for a fun life than that with a sickly woman and her crippled dog. Enter depression , stress and more back pain, and add financial worries into that too, I was in a bad way. So that was my life for the next 10 years, ups and downs, living in total fear of my back going completely and then being rejected by those around me in my work, new relationship, and family. The whole time I tried to hide my feelings as to how bad I really felt, how often is it said those with depression outwardly laugh and joke so you would never know?

 I think probably the worst part was when both my parents died within months of each other, my Dad on Christmas Day 2012, and my Mum Good Friday 2013. Things had been very difficult with them for a few years as my Mum had dementia and I felt so guilty that my back pain prevented me from doing more for them. The day after my Mothers funeral my back was so tight and sore I went for a long walk and tried to forget things and have a good day, but that evening going upstairs something “went” over my right hip and into my lower back, and that was that, pretty much permanent pain that ruled my life.

So then you try everything don’t you? Regular medications didn’t work or made me ill, physiotherapy made it worse! Chiropractic worked to some degree but then ended up making it worse and being treated for free, I had acupuncture with some success, then again it got worse, hydrotherapy which was good but was not affordable after the NHS treatment. Just after my parents deaths I even went to a faith healer who laid hands on my back whilst a white dove of peace, ironically a right vicious individual, flew about crapping on everything, particularly a 7ft black statue with a massive afro and colourful robes. I guess he had some significance, but it was lost on me, no results! The only thing I found helpful was a tens machine which blocked the pain messages from the brain, I also found distraction such as a good play on the radio at work, or a night out with friends would give me something else to think about and the pain eased. Generally though I lived my life in fear and pain, anxious about anything and everything and even about what may happen, I was totally negative and an absolute pain to be around. Thank goodness my GP recommended me to someone who understood what was happening, and you turned everything I’d been told and believed upside down.

You diagnosed PTS going back years, then think phantom limb syndrome whereby my brain was now hardwired to send pain signals when there wasn’t any pain! Sure I still have irritation to my nerve endings which give me grief from time to time, but I am learning to deal with these set backs, not an easy thing to do. I needed to de stress, I took a month off work, anti depressants, and learnt to relax and stop running about. During those 4 weeks I had one day of pain! Taking myself out of the situation broke the cycle of pain = stress = pain. I took up gentle yoga, having never attended an exercise class in my life I was scared to death I wouldn’t even be able to get on the floor. I needn’t of worried everyone had some problem or another and we help and encourage each other. I’ve found it a very positive thing to do as after not moving for so long I found after a week or 2 I was improving and doing more than I ever thought I could.

I know it can be really difficult to realize that actually the very real pain you are feeling is in fact manufactured by your mind, and to many people it just doesn’t make sense, it takes a while to get your head round, but once I did I haven’t looked back and have apparently achieved such a lot in the couple of months I have tried to turn things round. I am naturally a pessimistic and negative person, but I really do believe now that if you can open your mind to the possibility that you have it in yourself to change then anything is possible, and the sense of achievement you get from doing the very things that challenge you is a great feeling!”

Putting the spotlight on ourselves: Governance to improve practice.

Another timely blog by Neil Langridge, Consultant Physiotherapist, discussing the recent Social Media discourse surrounding governance and professionalism.

For clarity, the purpose of this blogpost is threefold:

  1. To assure and reassure patients that there are current governance processes in place.
  2. Add a viewpoint on the context of governance and professionalism
  3. To clarify a position in response to proposed models of reform that should be rejected within the context of unethical behavior without due process.

Over the last 24 hours I have read and watched some interesting opinions on how as a profession we should internally govern practice. As a clinician who has been involved and led investigations where serious incidents have happened, such as operations that should not have occurred, missed cancer diagnoses, HCPC referrals, and inappropriate/unprofessional behaviour etc I have wanted to engage with the discussion with a little more depth.

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There is no doubt that certainly across numerous health sectors certain disasters, injustices, unsafe practices have led to changes in policy, process, safety measures and ultimately improvements in care. The Francis Report is a great example of significant developments in which learning from terrible circumstances have seen changes in policy and practice, the Shipman enquiry also, was a clear example of learning from tragedy, unsafe, and unethical practice.

As a profession I am not suggesting that the recent discussions are in line with this level of circumstance, however what can we learn from these processes to ensure the profession remains able to assure the public is that we remain as vigilant as we can about improvements to care, and/or dealing with unsafe or unethical practice.

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I have experienced serious incidents and learning (as I am sure many readers will have too) for example, having to apologise directly to a patient that we missed an opportunity to diagnose the cancer they had earlier, working with a colleague who through investigation identified further deeper issues in the working environment, making HCPC referrals which I knew could be devastating (but I knew it was the right thing to do). What I had to do in every case was to be sure of the evidence I had to support my reports, if not then my conduct would come into question, I would not being fulfilling my role, and patients and staff would be no safer if I was not vigilant in my assessment of the evidence in front of me.

I made sure I worked with partners such as the Freedom to Speak Up Guardians, engaged in open discussions with staff, but most importantly patients and through these relationships, what I was looking for, was to ensure the patient was listened to, treated fairly, given the information they needed, and offered every opportunity to engage through the process. I also had to also always consider the clinicians’ well-being as these can be incredibly stressful times, and they needed support as well.

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Vital to this is that we always want and must learn from these processes, patients generally say through complaints about services that they don’t want what happened to them to happen to others, and they are 100% correct. It is our ethical duty to learn from incidents and to audit those improvements and therefore the CQC, HCPC, patient advocacy groups, professional bodies etc can quite rightly be assured on behalf of the patient/public that learning, change and progress has been made.

The reason I wanted to write on the back of the SoMe discussions was that if, as a profession, we do not follow these principles and processes, then we ourselves under the pretense of righteous behaviour, will ultimately undermine how clinical governance works, and in doing so, we ourselves will be the unethical clinicians in our approach to improving practice.

Patients want to know we ask the questions, they want to know we apply the principles of due diligence, and they want to know we have the credible processes to provide safe practice, hence the need to work with the processes and governing bodies, not independently of them, to continue to provide improvements in care.

In the private sector if clinicians are ultimately falsely advertising or treating unethically, then we should make the right referral inclusive of trading standards and advertising watchdogs, let them build the case from evidence, and we should still make the appropriate clinical referrals to ensure we have done what we should from an ethical perspective.

My main point being, is that we should be challenging unethical practice but if carried out in a “Name and Shame” model, then the transparency, learning, and safety gets lost under a blanket of personal opinion and bias; and it’s clear from previous changes in clinical culture that working in partnerships, working in evidence, and working within governance models, is how we can remain a trusted clinical profession.

Neil Langridge @neiljlangridge

Consultant NHS Physiotherapist

A Disconnect with Connect Health: A Reasoned View of Bilateral Leg Pain and Cauda Equina Syndrome

This is a timely guest blog post by Consultant Physiotherapists Chris Mercer, Laura Finucane and Sue Greenhalgh.

Last  week, Graeme Wilkes, MD at Connect Health released a “white paper” blog relating to bilateral sciatica and Cauda Equina syndrome (CES). The blog has generated significant discussion and clearly this debate and discussion is to be welcomed if we are to improve the management of this patient group. In the last week, we have all had several contacts from physiotherapists and service leads seeking guidance on how to manage patients with bilateral leg symptoms, but no other manifestations of CES.

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The Cauda Equina – published with permission by Ruth Eaves

This is our response to the paper by Graeme Wilkes which we would consider   a “green paper”- an item to promote further discussion on the topic, which we feel warrants a broader, more nuanced approach to managing these patients. The overriding message of his paper is that patients presenting with bilateral sciatica should be sent for an emergency MRI to rule out CES. We do not advocate that patients with bilateral leg pain with an absence of CES symptoms should be scanned as an emergency. Our reasons for this are outlined below.

Bilateral sciatica has been added to the list of possible symptoms of CES, though the message is not universal or clear, as Graeme points out. There is a lack of clarity from NICE, with the Clinical Knowledge Summary adding it to the list of CES symptoms but no mention of it in the NICE guidance for LBP and sciatica. Graeme’s own mini Twitter survey showed that there is a lack of consistency in approach to managing this patient group, and the GIRFT review did not offer clear guidance.

So what are front line clinicians supposed to think of all this, and how can we move forward in a way that will not overload the system and cause unnecessary anxiety for the patients and staff involved?

We think it might be helpful to look at the terminology and definitions involved, and then discuss the management pathway for these patients.

 

Terminology

The term bilateral sciatica is not a helpful term and perhaps we could refine it more accurately to  “radicular pain” or “radiculopathy”, where we can attach not only pain distribution, but also physical testing to the diagnosis. This would at least help to remove those patients with spinally referred leg pain where there is no neurogenic origin. Whilst the definitions of radicular pain, radiculopathy and spinally referred leg pain are also not entirely consistent, they may help to refine the patient group we should be concerned about.

Once the diagnosis of bilateral neurogenic leg pain is established, we would support a reasoned approach to onward management. Referring all of these patients to ED for same day MRI is likely to have several consequences;

  • There will be an inevitable burden placed on ED and MRI resources, and we would argue that this would be disproportionate and would risk overloading an already overburdened system unnecessarily.
  • Both the patient and the clinician involved will potentially be more anxious about the condition.
  • The rate of negative imaging for “suspected CES” will increase further. We know already that around 90% of people referred for imaging for possible CES have negative scans, and adding bilateral leg pain to the list of indications for emergency scan would further increase this percentage.
  • The effect of this may be to then dilute trust in the referring clinicians, which may have the knock-on effect of decreasing acceptance of future requests for imaging/referrals.

 

Management

Graeme Wilkes rightly acknowledges the excellent work of Nick Todd in the management of CES over many years, and he clearly has been very influential in helping to manage this patient group. His perspective is very much that of a secondary care spinal surgeon as you would expect. The burden and challenge of early identification of patients with CES is predominantly in primary care, and often with the first contact clinician. Given that the patient may present with much more subtle signs and symptoms in the early stages, it is clearly important to be able to explore symptoms in detail in order to identify those patients at risk. We need to identify patients who are in the classification of “suspected” or “incomplete” CES, not those “white flag” patients that Todd talks about who have Complete CES and likely very poor outcomes from surgery.

In order to identify these patients early, we already delve deeper into questions about bladder, bowel, sexual function and saddle sensation changes, as we know there are myriad of reasons for these functions to be disrupted, most of which are not CES. We would suggest a similar approach to bilateral leg symptoms. Rather than a blanket approach of onward referral, we think that careful questioning, examination and safety netting of these patients would be a prudent way forward. The majority of patients with bilateral leg symptoms will not need emergency scanning. Below are categories of patients with bilateral leg symptoms and suggested pathways  which we feel reflect the more nuanced presentation of patients and may offer a reasoned way  forward to managing this group of patients.

 

  • Bilateral leg pain with normal neurology, normal neurodynamic tests and no other CES symptoms- treat as per symptoms and monitor progress. Safety net with CES card or similar.
  • Bilateral leg pain with normal neurology, positive neurodynamic tests and no other CES symptoms- treat as per symptoms. Safety net with CES card or similar- if already had conservative treatment then may refer for scan on a routine basis (but not looking for CES)
  • Bilateral leg pain with abnormal neurology and normal/positive neurodynamic tests and no CES symptoms. Management depends on the degree of neurological deficit- if gross motor weakness or deteriorating neurology, then refer for an urgent scan ( but not same day) and safety net patient re CES.
  • Bilateral leg pain with any other CES symptoms- refer on for emergency scan

 

This suggested subgrouping of bilateral leg pain patients may reflect more truly the range of people seen, and may help clinicians to make an informed and balanced decision on how to manage them. Unfortunately there is very little black and white in the management of CES patients in the early stages- we know that these are a complex group of patients who do need our urgent care when appropriate. We are all committed to that and support any moves to improve the outcomes for the small number of people whose lives are so dramatically affected by CES. We also acknowledge that as first contact clinicians we have a responsibility to manage the potential risks in a balanced and reasoned way, and we feel that the approach outlined above may help to do just that.

Chris Mercer, Laura Finucane and Sue Greenhalgh

 

“Tis the season to be jolly”

A couple of thoughts about this year and the year ahead for MSK Physiotherapists

by Neil Langridge, NHS Consultant Physiotherapist

At this time of year it’s a great time to look back as well as looking forward. To do this personally and professionally I think is a great way to re-set the scene for oneself, and it also to develop goals and aims for the coming year. I like to look back at the previous year, and this year in particular I think has been a shift in the MSK world that really we should be “jolly” about as well as mindful that there is so much work ahead for the profession.

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There have been some real advances in what might be available for the physiotherapists of the future. Advanced practice has really taken off, it’s just the start but there have been some enormous leaps forward. Work developing the “Multi-professional  framework for advanced clinical practice” although published 14 months ago, will certainly begin to influence many opportunities for physiotherapists and AHPs. This is now driving advanced practice models such as the apprenticeship model which was approved in 2018 which will see employers, Universities, and clinicians working together to gain improved care, careers, and clinical practice.

Education

First contact work has gained further credibility with more data, more service transformation and courses being developed in Universities to support this work. It has seen its own framework underpinning it, data tools to help monitor it, cost calculators to help plan for it as well as clinicians coming together to help drive it. Health Education England working with partners in NHS England and the CSP have driven this to the table where STPs (Sustainability and Transformation Partnerships) are discussing it as part of remodelling and CCGs were mandated to provide pilots across England.

These pieces of work were well presented in the fantastic piece of work “AHPs into Actionand this document will help continue to inform how AHPs can continue to re-design and transform. Physiotherapists within the MSK field were used as examples in this document and once again highlights the national profile of what we do and can do.

The NIHR document “Moving forward – physiotherapy for musculoskeletal health and well-being” highlights some of the wonderful research that has led our practice and continues to inform the future.

Whether you agree or disagree with the messages the CSP have been driving many new initiatives in the promotion of the profession and activity. The wonderful campaign video that supported “Rehab matters” was very well put together, and really emphasised the need for rehab to be at the heart of our medical futures and values. The “Love activity, hate exercisecampaign had some controversy but it certainly once again brought home the importance of activity within our communities. PhysioUK 18, was in my opinion, a great success and was sensibly priced to encourage those who had not networked and gained CPD at this event in the past, the opportunity to experience a varied and interesting programme.

At a more local level, the” BigRs” movement continues to create conversation and developments. I have been fortunate enough to attend these, speak at them and also be part of the ongoing strands of work around trying to help develop the profession. I really like this model of critical enquiry, development, and challenge, but it’s done in such a way it encourages those involved via the winning of hearts and minds, building a model around respectful dialogue and leaving emotion and personal conflicts at the door. The “Physio Matters” team and “Connect Health” should be congratulated on their work so far with this and I look forward to the future work from this group.

From a personal and professional point of view, I am aiming to try to see how our MSK team can start to impact on the health and well being of the population we serve. Our main challenges this year are to try to improve our public health outcomes, look to engage with schools, local community groups and just widen the impact of physical exercise and good health models for our communities. This is something I am particularly looking forward to. We also have the challenges of supporting staff in tough environments; we have therefore looked to support staff at MSc levels, build improved local educational opportunities, seeing staff progress into specialist roles.

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I am looking to drive a Band 8a clinical lead in physiotherapy only, not as an Orthopaedic triage specialist, but as someone totally focussed on rehabilitation. I have witnessed these discussions across SoMe and want to act on them within my service. We have a Band 4 sports rehab role near ready to be advertised, this is something I am really keen on, the old style remedial gymnast, leading some of our classes and using skills in class taking and rehabilitation to complement what we do across all the services to de-medicalise where appropriate and where we can. The changes in CCG directives in many surgical options means we as a profession are ideally placed to resolve these lines of practice, it will be a matter of getting houses in order to achieve this.

These initiatives have been massively helped by the information I have received on SoMe and the discussions have prompted my local conversation, driving plans for 2019, so thanks to those I have learnt from.

I am looking forward to seeing the HEE funded FCP e-Learning programme to be completed. This was initially started by just asking SoMe colleagues for help and the interest and comments were staggeringly helpful. I now have an amazing team of contributors and all of the modules have a person-centred approach underpinning them.  The modules will, I think, be a valuable free to access resource. SoMe will be the platform to support its launch.

As in any reflections, there are concerns and worries, as it can’t be all “jolly”, things we wish we had done better, I certainly spend time thinking on this. I know we must continue to move forward and not harp back to historical philosophies.  We cannot ever really rest in developing an evidence-base that makes sense and change practice for the physiotherapists of tomorrow, in so doing, challenging the out-dated practice of today and consequently place our profession in the most professional light possible. I always look back in how I could have managed situations, people, working relationships and patients better and these are always my constant wishes to improve on.

The balance in being brave, critical and balanced in thinking whilst engaging change is a tough one to make, but one I will always strive for. I will continue in 2019, to push my service forward, see staff flourish, improve my own practice, be critical where necessary, and challenge those who I feel hold those processes back with personal, emotional views that inhibit the profession on the multi-professional and national stages. In my opinion being critical is an absolute must for development, offering an alternative view an absolute, but most importantly, do so in a way that commands respect from multiple perspectives through the skill and mastery of facilitating change that as a profession, I believe, we must develop further.

We have a fantastic profession and there are loads to be proud (and jolly) about, however, I don’t see things through rose tinted glasses, and I do know there are HUGE changes to make, but I still see the glass as half-full and I remain happy and positive (most of the time) about the future. In any culture there will be a mix of people and views, and I through 2019, will keep developing my knowledge of these, engage with those who offer different views, and challenge those whose values I just cannot find concordance with, as it is the professional values and behaviours of some that can at times influence the many. As well as being critical of the evidence base, I think the many should also develop and be confident enough to enhance critical enquiry across multiple mediums, sadly I know many who just feel inhibited through fear of reaction in SoMe and how they might be labelled.

So, in conclusion 2018 for Physiotherapy and the MSK arm of the profession has been a really advancing year in my opinion, there are loads to get involved in within the national new models of care, SoMe driven initiatives, evidence-based programmes, and local clinical practice progression, and so perhaps if you take those on they may aid your 2019 goals, like they have mine, good luck therefore with whatever you hope to achieve in 2019.

I wish anyone who is good enough to take the time to read this, my best wishes and kindest regards for the coming year.

Neil.

Reflections of a Dinosaur: Big R’s, the patient narrative and a final thought on myths in the debate on manual therapy.

Slide1

Neil Langridge, Consultant Physiotherapist, gives his personal reflection on the latest Big R’s conference here:

I have just got back into work this week after the Big R’s event over the weekend in Manchester. I was wondering how it would go as I had been asked to provide a keynote talk on the place for manual therapy in contemporary MSK practice. On my panel was Karli Gibson, a very level-headed and forward thinking physiotherapist who I think has a lot to offer the profession, and Adam Meakins, a specialist physiotherapist in the management of shoulder conditions who has built up quite a following within the profession, and has developed many strong arguments regarding the case for change.

The event proposed some really innovative ideas, but most importantly brought together individuals interested in better care for patients, improving the MSK offer to the public and I felt, all in the spirit of working together.

I was fully aware that my presentation and the subsequent discussion was likely to be a bit stormy, the session was moderated by Mark Reid, who I thought did a really good job. I have to firstly tip my hat and really congratulate Jack Chew and his team, which also applies to the Connect team who equally supported the event. I can’t fail to be impressed individually with Jack, who undoubtedly “walks the walk”, he is very forward thinking, very passionate and very gracious in the way he works complex areas of discussion and debate. His work is fairly unique in my opinion within our profession, and more like him would only be a good thing. His team, Rob, Jack, Mark et al likewise, very sensible, but willing to challenge the status quo and build from within, an impressive group.

The Connect team were also very appropriately vocal and led some really interesting workshops which I thoroughly enjoyed, and there were some great discussions on orthopaedic triage, FCP and what advanced practice is. I am gladly linked in with them to develop further strategies concerning excellence, and I know it will be a pleasure to work with them. This felt a lot better than the last meeting where topics such as “eradicate ultrasound!” felt very narrow, so this experience was miles more positive.

The patient stories were really powerful and humbling, Joletta, Adrian, Pete, and Tina all contributed hugely, I think there should be a patient voice on every panel in the future. Martin, a very entertaining, driven, enthusiastic physiotherapist from Kenya gave a great insight into Physiotherapy away from these shores, a great perspective driving presentation.

So, I made my little speech and I addressed a few thoughts that run round SoMe and within the profession and also I learned what the panel’s view were, which was really valuable. So, what did I learn and speak about;

  1. The term “low-value treatment” applied to MT is not seemingly that true. It depends what you define as value and then if you base it purely on economics, surprisingly against usual care it fairs well against exercise and better than usual GP care in many MSK conditions. Societal value tends to suggest that applied hands on to certain patient groups are valuable to those individual personally. So, when individuals speak of high and low value, ask, what do you mean, valuable to whom, and by what measure? Try it, you may find the answer is not as clear as you thought.Value Price
  2. The “Window of opportunity” – I know many are not fans of this term when applied to MT, but it is my opinion it applies to every intervention, whether education, exercise etc. The break in the pattern behaviour, belief, understanding, or a change in the perception and emotional response. We then use this to set the scene differently for the patient. So, when individuals say MT inappropriately uses the “window of opportunity” analogy, then ask do not our other interventions use similar processes?Open windows
  3. MT disempowers patients? I heard the patient stories relaying powerful messages they heard about being “weak, unstable, needing a stronger core, things being in and out”. Its always cringing and saddening on the part of a professional to hear those stories. It’s therefore in the message and the clinician behaviour that disempowers, and of course, you can plainly disempower by just talking to someone, it’s not unique to MT. Of course MT has the potential belief system associated with that as it can lead the patient to believe they need to see someone to fix them; once again, that’s the clinician, not the treatment. The disempowering therapist can lurk under any treatment system.
  4. Adam was asked what he doesn’t agree with regarding MT, all of it, some it etc? I was in total agreement that massage should not be an NHS offer. In terms of well-being if individuals wish for that then I see no problem with them accessing this outside the NHS. Handshake
  5. He didn’t agree with techniques being used even in the clinical context when the patient is lying on the treatment plinth. He did, however, seem concordant with the use of hands-on in the facilitation of movement, which seemed to be in some conflict with the strong message “Manual therapy sucks”.
  6. The panel discussed Harm; Adam stated that MT was “harmful”. I was conflicted with a previous statement that suggested all MT should be in a spa, whilst then saying it was harmful, I was also not sure what is meant by harm in this context. If it is harmful then ensuring it is within a clinical context would be key and moving that out to your local hairdresser (as suggested) might not be such a good idea. I would agree that the language around MT could be harmful to the process and perception of recovery, but the vast majority of MT physically is not, and no evidence was proposed that supported the perception of MT as a treatment method being harmful to patients.
  7. So, MT in the sense of relaxation and well-being – keep it out of the NHS, use as part of ongoing health and well-being if that is something the patient values.MT in the clinical context I propose can be used when patients are fearful, limited by pain and have tried initial education, reassurance, and exercise. Then you can “play with some processing” aiming to give the patient a different emotional perspective towards their condition.
  8. MT will get challenged about – “what are the mechanisms?” Well, the simple answer is we don’t know. My proposal is that there is no single mechanism, and multiple mechanisms will be at play, their effect on a socially constructed individual cannot be just down to the mechanics or basic physiology. The really important point for me is that this (IMO) is the case for all interventions. Some have a greater physiological and anatomical understanding of the effects than others but in Physiotherapy do we really know all the mechanisms at play after exercise, education, reassurance? Two people can say exactly the same reassuring commentary and the receiver of this could react in totally different ways to that advice. Therefore, a “truth” in these interactions is a pretty tough call. We can suggest them, but we don’t really know the interactions of all the possible neurobiological, emotional, physiological mechanisms and that is not unique to MT, so some sense of perspective is needed regarding this argument. So, we base the nature of success on some theoretical proposals and patient-reported outcomes. The same for any Physiotherapy MSK intervention. Maybe it looks a little like the picture below?

Tangled

In the end, I really found the 2 days inspiring. Within the panel, Karli brought pragmatism to the debate which resonated well with me, whilst Adam was considered in his responses and I have said this before, I agree with many of his proposals, but for any argument, for me to be convinced, I need strong positions of belief to be flexible in how they respond to differences of opinion, so we can all see the multiple perspectives rather than the singular one. I feel this was a common theme of how we move forward, gaining the multiple views and then finding common-ground to help in professional growth.

So, many voices were heard, and disagreement will always remain, but that’s Ok and very healthy. I think without individuals who push the questions then the conversations would not be where they are, which is so much better as we move away from strongly held doctrines, philosophies of our practice and consider the future for an evidence-based profession which is grounded in the patient story.

Neil Langridge.  Consultant Physiotherapist.

Managing Complexity In Musculoskeletal Conditions: Reflections From A Physiotherapist

I was fortunate enough to have been invited by Physio First to contribute to their journal ‘In Touch’ and I chose to write about managing complexity with the different types of ‘evidence’ that we deal with in a healthcare setting.

This is an area of interest for me and I still grapple with many areas of clinical practice.  These include balancing the normative and narrative examination, evaluating and weighting the evidence appropriately for the person seeking care in front of me and also reconciling and communicating the reasoning process within a person centred framework.  Clearly, this is work in progress and I hope this reflective piece demonstrates a movement in this direction.

I hope this paper is informative and useful in that it shares some of my deliberations, thoughts and perspectives in clinical care.

Many thanks to Physio First http://www.physiofirst.org.uk/ for giving me the opportunity to share this.

Managing complexity in MSK conditions In Touch Article

Fusion of perspectives

Please feel free to make comments and feedback your thoughts and views below.