A guest blog by Neil Langridge, Consultant Physiotherapist.
I am looking forward to the up-coming “Reforming MSK Practice” event arranged by Chews Health and Connect Health and I have been invited to speak on “the place for manual therapy in contemporary MSK”. Initially my views were, “it’s been discussed a lot, can I add to this?” and “what I am I letting myself in for?”, as many of the audience will of course be of the view – “don’t reform it, just ditch it”.
So, I decided to think carefully about whether a) should I speak B) if I do, what will my approach be? I also wanted to take into account the conversations regarding “passive therapies” in the context of reasoning and responsibility. So, rather than being reflective I thought I would take a prospective stance and feed some of my thoughts into the debate prior to the event as a means to help me set out how to approach the heart sink topic that is “reforming manual therapy”, and I thought I would share these with anyone interested and potentially coming.
My first consideration (and really what this short blog is about) is to consider the understanding of what a passive therapy is. The term is really used a lot, and is used in numerous cases to describe a range of interventions. It gets linked with the term “low-value” and I thought this was worth exploring also at a later date.
It seems to me that some would suggest that “passive” is about the patient/service user etc as a recipient, is not activated and the responsibility of the “treatment” lies with someone else dispensing it (the clinician). The low value element may be that the costs to deliver the passive treatment do not impact on the costs of the pain and disability to society and the individual, and so provides a negative investment. Others may have different definitions but I will maintain those for now.
I think it is entirely clinically correct, morally appropriate and ethically sound to empower patients within our care to take control, self-manage and be activated towards recovery. This is without doubt a professional responsibility. It also seems good practice to me to hand the responsibility of wellness and recovery to the patient with information and education.
Ok, so now to an alternative view, as I think this concept of passive and active is not as dichotomous as it has been presented, and as with all discussions, this one is possibly a bit murkier, but with a lot more depth than just saying its one or the other.
Let’s start with some simple questions, or maybe not so simple. When and how is the responsibility for the condition, symptom, and injury handed over to the clinician, and if it is, should it be and by how much? When is this handed back? Why would a patient hand the responsibility of their condition over? Well, highly likely you encounter this every day, all the time? There are patients who want to know what they can do for themselves, attend with great self-efficacy and are just ready to be activated with the right advice. There is nothing passive here, and they inherently would resist treatments that do not enhance control. Fantastic, enjoyable interactions, great outcomes, high value (less intervention face to face, and generally good self-efficacy = gets improvement and returns to society in a more positive position so adds a positive element to the “value” argument). The treatment is therefore led by the fact that their natural Behaviour is active, their outlook is active and so the treatment is active (if defined as being patient–led).
If society was like this 100% of the time the whole make up of support, social care, medicine and our culture would be radically different. The reality is we live in a supportive health culture where choices of behaviour are available, in other cultures it’s not so flexible, and the support network is just not there. However, we are in a culture (NHS/Social Care system) where there is a choice of care approaches based on numerous factors within the individual, and from external influences that can lead to behaviour within the patient, that may range from be very willing and active to very unwilling and passive.
As therapists we address a lack of recovery with first-line measures, education, exercise and reassurance being the main-stay of this approach.
I believe that the choices therefore between active and passive can be underpinned more effectively by not simplifying the concept into “is the treatment passive or active?”, but understanding motivations, behaviours of the patient and oneself as a clinician and the subsequent interaction of that therapeutic alliance, let me try to explain.
In many interactions we as therapists try to be therapeutic and start to activate those who have beliefs that are more passive about their treatment but also there are those who need, for a time, to hand over responsibility to others. The responsibility for their condition can be draining, tiring and the need to hand that over, is an ask for help, and when it happens the immediate feeling of well-being is clear, we see this all the time in the caring professions. Just off-loading the problem can be experienced as therapeutic. Now at this point we have to make a clinical call, how ready is the patient to make the changes that are needed to move onto self-recovery? How active is their behaviour? Would a treatment delivered by a clinician to a patient enhance a process of recovery, or negatively affect it?
If we have accepted the responsibility for supporting the patient, how we approach this is a case for clinical reasoning not a simple decision of dichotomy, such as “do a passive therapy or don’t do it”. Understanding barriers to re-engagement will be key, and give far more information than basing a clinical decision on a simple algorithm. The barriers to recovery may not be a case of a lack of motivation, a passive approach, or a resistance to change. It may be case of what I would describe as “condition weariness”. They have been living with pain and disability and all the stresses and pressures that come with that. The ask for help does mean they are not wanting active self-management strategies, but some may need a blend, a time where they are feeling someone else bearing that burden with them and taking a greater responsibility of the condition for a period of time.
Ever heard the term when a patient phones up with an enquiry “who is looking after you?” this perfectly describes a really important supportive responsibility. Ever been stuck with something and someone has said “I will sort that for you”, you know it would be better if they showed you how to do it yourself, but sometimes you just want to hand it over, it doesn’t mean you won’t, with advice, give it a go next time, it just means right there and then, you need the responsibility taken off you, and you relax and the pressure is less.
There are times I believe when we “look after our patients” via what has been described as a “passive”, using hands to support movement, using gentle movements to areas of the MSK system to aid a perceptual change, emotional alteration and facilitate an alternative pain experience to a task or function. This is passive in terms of not “patient led” but it is active in its emotional support if chosen and applied appropriately with the right information, explanation and language.
We share our treatments, we don’t / shouldn’t apply them in silence and look to offer good psychologically informed measures that support the emotional side of the patient presentation. Initiating a time where they experience a reduction in symptoms, whilst being psychologically supported and seeing that their function can be altered can (in my opinion) be empowering as long as the so called “passive” intervention has active emotional support and is a on a pathway towards self-determination and is not over-complicated by mis-interpretation and pretentious, confusing explanations and language.
When we treat a patient and they believe they are receiving it rather than doing it for themselves it hands-over responsibility for a time to the clinician and this “break”, even if short gives possibly a freedom to re-calibrate their thoughts. That’s how I now see hands-on treatments; a break in the process that helps the individual re-frame the recovery experience, to see it differently, to have an alternative view. Some have described this as a “window of opportunity”, some really dislike that term, in essence, it’s a pause in the process, a change in the current behavioural response and this can perhaps means the patient sees the art of the possible enhancing autonomy and confidence.
In my opinion I am not changing anything with my hands really other than the influencing the body and minds’ perceptions, awareness and emotions towards their condition in ways that stimulate a range of sensations that if managed and formulated correctly, can be a positive therapeutic experience.
For me a “passive therapy” is a therapy that is driven by the clinician’s unwillingness to set a goal of autonomy and this subsequently feeds a lack of confidence in the patient. Therefore IMO, it is not the treatment that is passive it is the behaviour of the clinician that lacks activation. In behaving in a passive way and doing so when given the responsibility for the condition, these clinicians act unfairly, unwisely and inappropriately by not developing a strategy of responsibility handover.
Perhaps the wise clinician will know how much responsibility to take, when to take it, how to enhance it and when to hand it back, and this should not be seen as condition specific, but person specific.
Neil Langridge, Consultant Physiotherapist