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.

 

 

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“Passive” therapies: Responsibility; when, who and how?

A guest blog by Neil Langridge, Consultant Physiotherapist.  @neiljlangridge

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”.

Ditch it now logo

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.

Medium-ResponsibilityStartsWithMe-MAIN-1204x372

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.

passivesplash

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).

PExp1

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.

PExp2

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?

old rehab photo

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.

Lastly;

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

Knowledge Translation: Is There A Disconnect Between The Interpretation of Clinical Research and Clinical Practice in the 10/10 Connect Health Guidelines?

I too had the pleasure of receiving an invitation to the amusingly titled ‘Big R’s’ and enjoyed excellent company and conversation. Jack Chew and colleagues are to be commended for hosting the event with Connect Health with a proposition to “Reason” with “Responsibility” and the idea of “Reforming” musculoskeletal practice. Connect Health should also be congratulated for putting forwards their values, strategic goals and aspirations in such an open environment.   It is in the spirit of the three ‘R’s that I would like to focus on a common theme throughout the evening that has been touched upon by Neil earlier with respect to knowledge translation.

Connect Health, put forward, as part of their “10/10 MSK Guidelines” (http://www.connecthealth.co.uk/wp-content/uploads/2017/11/Connect-Health-10-out-of-10-Infographic.pdf) for improving efficiency, reducing clinical variation and improving clinical outcomes, a traffic light system that stipulates the appropriate treatment interventions according to each presenting condition. The justification for the traffic light system is emboldened by a speech bubble that reads:

“If you read one article per day, you’d be 20 years behind, so we needed to close this gap and help our clinicians have evidence at (sic) finger tips”.

This suggests that the traffic light system provides a solution to knowledge translation between ‘evidence’ and practice.

Traffic Light Connect Health

I would like to attempt to unpack some of the challenges surrounding knowledge translation and the use of a traffic light system. The traffic light system appears to convey a linear and non-value laden indicator of efficacy. They categorise ‘evidence’ into red (ineffective treatment indicating that clinicians should not do this intervention), amber (uncertain, consider after other treatment interventions) and green (effective, do this treatment) lights. At first glance, this may seem a reasonable, simple and effective method. Let’s take a closer look, first of all, what is knowledge?

Aristotle described three main aspects to the concept of knowledge. They are episteme, techne and phronesis:

  1. Episteme means, “to know” in Greek. It represents knowledge as ‘facts’ and Plato contrasted this with ‘doxa’which meant common belief or opinion. For example, a therapist may need ‘to know’ many areas of human biology in order to understand how exercise can be utilised as an intervention to treat back pain or to prevent cardiovascular disease.
  2. Techne translated from Greek means craftsmanship or skill. It draws from knowledge but is situated in the skill of its delivery. For example, a therapist may be knowledgeable in the theory of motivational interviewing but struggles with the skill of its delivery.   Techne also includes tacit(understood or implied without being stated) knowledge. Tacit knowledge is embodied, sub-conscious and embedded to personal experience and is the type of knowledge that is very difficult to record or write down. For example, emotional intelligence, communication skills, leadership skills and clinical intuition are commonly cited in healthcare research and practice but are very difficult to conceive or teach.
  3. Phronesis means practical wisdom. It relates to the ethical deliberation of values with reference to practice. It is related to praxis in that it refers to an action that embodies a commitment to human well being, the search for truth and respect for others. It requires that a person make a wise and prudent practical judgement about how to act in this situation (Carr and Kemmis, 1986: 190).

These aspects of knowledge described by Aristotle form an individual’s knowledge. Now, referencing back to the traffic light system. Immediately, you can see that the traffic light system delivers one of the aspects of knowledge, namely episteme, but provides little or no reference to techne or phronesis. Its creator(s) must have made this synthesis of ‘evidence’ with some value judgement as to what good evidence is and is not, but it is not clear how this judgement has been made. One assumes that this judgement was based on an evidence-based hierarchy but it does beg the following questions. Who created the judgements? To whom does their purpose serve, the patient, a population, the therapist(s), the organisation or all of them, and in what way? Does it achieve those aims and at what cost? What values are being accounted for (clinical outcome, financial, quality of life of patients, therapist understanding)? What judgements are made in order to delineate an amber intervention as opposed to a green or red intervention? For example, Pharmacology treatment is cited within the low back pain +/- radiculopathy traffic light system as a “green light”. This is despite pharmacological studies evaluating paracetamol being ineffective for spinal pain and osteoarthritis (Machedo et al, 2015) (http://www.bmj.com/content/350/bmj.h1225), NSAID’s not showing clinically important difference against placebo for spinal pain (Machedo et al, 2017) (http://ard.bmj.com/content/76/7/1269) and Pregabalin not being effective for moderate to severe sciatica (Machieeson et al, 2017) (http://www.nejm.org/doi/full/10.1056/NEJMoa1614292?rss=searchAndBrowse#t=article) amongst other examples. Clearly, the context may be of utmost importance here such as the stage of the disorder, presentation, co-morbidities, and presence of barriers to recovery, previous response to treatment amongst a dearth of other relevant information. The question remains, is the underlying context revealed using the traffic light system?

Creating a hierarchy of evidence is in itself is fraught with problems and challenges. Further discussion of these challenges are beyond the scope of this blog and the literature is extensive but I would encourage readers to watch Trish Greenhalgh speaking about ‘Real verses Rubbish EBM’ here (https://www.youtube.com/watch?v=qYvdhA697jI) and work from Roger Kerry (http://www.mskscienceandpractice.com/article/S2468-7812(17)30153-4/fulltext) as well as work from the CauseHealth team (https://causehealthblog.wordpress.com) (https://philpapers.org/archive/ANJD.pdf) (http://ubplj.org/index.php/ejpch/article/viewFile/1129/1129) and also the Alliance for Useful Evidence (http://www.alliance4usefulevidence.org/assets/What-Counts-as-Good-Evidence-WEB.pdf).

Knowledge does not exist in isolation but exists within a social context. An exchange of knowledge occurs through shared cultural understanding, practices and assumptions and not by a mere exchange of factual information. The traffic light system appears to specify an absolute system of context-free judgements on clinical practice regardless of individual and environmental factors. For example, the abandonment of the use of therapeutic ultrasound was posited as a “good place to start” when reforming MSK practice. However, experts in electrotherapy such as Professor Tim Watson are likely to hold exception to such rules as the evidence demonstrates efficacy if sufficient treatment dose, within the context of an appropriate tissue injury and healing stage, has been provided (https://www.youtube.com/watch?v=hpMFI7UPwMo). Interestingly enough, this is the same as many other treatment interventions in Physiotherapy, including, dare I say it, exercise! A more appropriate suggestion might be that therapeutic ultrasound should not be justified in areas of practice where environmental and practical elements prohibit its efficacy, e.g. using therapeutic ultrasound in a sub-acute muscle tear once every two weeks. As a potential consequence of using a broad brush-stroke approach of describing all therapeutic ultrasound as lacking in sufficient evidence, and therefore abandon its use, is very likely to polarise the MSK community rather than bring it together in a reform of practice, particularly bereft of context. (P.S I would like to declare that I do not use therapeutic ultrasound in my practice, as I do not see the appropriate caseload or work in an environment that would constitute its effective delivery).

Perhaps polarising views could be a way to draw people into a debate or discussion and perhaps this could be the right thing to do? But, I can’t help but think that this approach might be rather disengaging and autocratic, using evidence as a proverbial stick to beat you over the head with. It might be seen that organisations could try to ‘kitemark’ what is good evidence and drag the MSK community of practice “up with it”. However, I can not avoid the feeling that a close relationship exists between knowledge and power with evidence being described as “what powerful people say it is” and, that in its pursuit, could lead onto stifling significant change in practice rather than foster and grow it (http://www.ruru.ac.uk/newsevents.html).   Indeed, creating policies without broader considerations could be seen as using rhetoric to achieve the goals of an organisation with an undertone of efficiency making, cost-cutting, money saving and the handcuffing of professional autonomy.

Gabbay and Le May (2011) describe ‘clinical mindlines’ that go far beyond guidelines as “internalised, collectively reinforced and often tacit guidelines that are informed by clinicians’ training, by their own and others clinical experience, by their interactions with their role sets, by their role sets, by their reading, by the way that they have learnt to handle the conflicting demands, by their understanding of local circumstances and systems and by a host of other systems” (Gabay and Le May, 2011 p 44). One could look at the social media explosion surrounding the big R’s event as well as Physiotherapy continued professional development over the last five years and see it in a way that builds clinical mindlines, but perhaps with some unforeseen consequences. Less experienced therapists that seek knowledge through social media may experience a gold mine, full of forward thinking and verbose well-meaning healthcare professionals. What in actual fact, they might receive is ‘doxa’ or common opinion without much critical thinking surrounding such information. All the more reason for open discussion, deliberation and debate!

The vision of providing a system that values reducing clinical variation is both compelling but also concerning. Allowing clinical reflexivity and context-dependent, autonomous decision-making should be rewarded and at the same time ensuring effective clinical reasoned interventions. Is this process one in which is embodied with a traffic light system of intervention that appears to rewards technicians and not skilled practitioners?

Knowledge translation is a complex, dynamic and reflexive process and might best be viewed like this:

Process of transferring knowledge into action

Dr Vicky Ward, Dr Simon Smith, Dr Samantha Carruthers, Dr Susan Hamer, Professor Allan House (2010) Accessed 19/11/2017 18:52 http://medhealth.leeds.ac.uk/info/662/kt_framework/774/project_report_and_publications

This is quite a contrast to the traffic light system and is food for thought in comparison. However, the traffic light system is a start, especially for newly qualified therapists using it as a heuristic for guiding clinical practice. Clearly, this blog asks more questions than it does answer any, but I have tried to put forward some suggestions that might be helpful.

  1. Providing an open and transparent process for judging clinical guidance.
  2. Acknowledge one’s own clinical practice, research assumptions, values, judgements and beliefs as our ‘facts’ are always value-laden.
  3. Provide a framework for understanding and signpost where the gaps of our knowledge are and promote reflective practice.
  4. Be open regarding our aspirations for the future, which may provide opportunities to use evidence in a more informed and reflexive way.
  5. Encourage clinical mindlines by discussion, debate and use the application of multiple sources of ‘evidence’ at the same time as acknowledging the limitations of the methods from which they came.

I would also like to add Roger Kerry’s key messages from his recent paper ‘Expanding our perspectives on research in musculoskeletal science and practice’ in the Musculoskeletal Science and Practice journal as they are very relevant (http://www.mskscienceandpractice.com/article/S2468-7812(17)30153-4/pdf).

  1. Clinical practice should be based on best evidence, and an era of “clinical freedom” should not be returned to.
  2. As scientific research exponentially grows within musculoskeletal medicine, it is timely to re-examine what constitutes the best evidence for clinical decision making and health policy.
  3. Traditional scientific principles on which much existing research is based are dated and limited by real-world complexity, and a crisis period in both research and practice is now evident.
  4. A research vision for the future is focused on knowledge generation which is truly person-centred and embraces real-world complexity, rather than controlling for it.
  5. The research future should incorporate greater alliances between all stakeholders and expand its context and theories.
  6. Clinicians, researchers, and the people we work with to improve their health should continue to reconceptualise the idea of best evidence for clinical decision-making and health policy.

“Love activity, Hate exercise?” Campaign

As the “Love activity, Hate exercise?” campaign from the CSP starts, Stephanie Mansell, Consultant Physiotherapist at the Royal Free Hosptial brings her considered and thoughtful perspectives on this guest blog.

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The “Love activity, Hate exercise?” campaign from the Chartered Society of Physiotherapy (CSP) launches on the 6thJuly. This campaign encompasses and supersedes several previous campaigns including “older people day” and “workout at work day”. The CSP report that significant resource and market research was employed in developing the campaign, with engagement from physical activity experts and members of the public. Data were collected from more than 10 focus groups, via face-to-face, online and phone consultations from across the UK. At its heart, the campaign is a public health initiative, based upon harnessing the collective power of the physiotherapy profession to affect health behaviour change of the population. As a CSP member, I observe how this is in keeping with the CSP’s mission “to transform the health and well-being of individuals and communities by empowering our members and exerting our influence” and vision to“transform lives, maximise independence and empower populations.” 

The “Love activity, Hate exercise?” campaign aims to empower physiotherapists to have conversations with their patients to enable health behaviour change, specifically around physical activity. Certainly, if members engage it would seem it should be feasible to achieve this. And herein lies a potential hurdle to the campaign’s success. There appears to be significant reticence from some clinicians about the “Love activity, Hate exercise?” campaign, especially regarding the strap-line, whilst there is a sense of apathy from others with only 2,000 members signed up. And so I find myself inspired to find a forum to raise some of the points I simply can’t raise in a 140 character limit.

So before we go any further I asked myself: “what’s the difference between exercise and physical activity?” Captain Google revealed a few top definitions:

Exercise:

Activity requiring physical effort, carried out to sustain or improve health and fitness” Oxford Dictionary (https://en.oxforddictionaries.com/definition/exercise)

“Exercise is physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise is used to improve health, maintain fitness and is important as a means of physical rehabilitation.” Medical Dictionary (https://medical-dictionary.thefreedictionary.com/exercise)

Physical Activity:

“Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure.” World Health Organisation (http://www.who.int/dietphysicalactivity/pa/en/)

“Any form of physical exerciseCollins Dictionary (https://www.collinsdictionary.com/dictionary/english/physical-activity)

“Physical activity includes everyday activity such as walking and cycling to get from A to B, work-related activity, housework, DIY and gardening. It also includes recreational activities such as working out in a gym, dancing, or playing active games, as well as organised and competitive sport.” NICE (https://www.nice.org.uk/guidance/ph44/chapter/recommendations#Box-1-Physical-activity-definition-and-current-UK-recommendations)

Based on the above definitions one could argue exercise and physical activity are not all that different.

So why the “Love activity, Hate exercise?” strapline?

I’m sure all physiotherapists will have used exercise or physical activity in a treatment plan, after all, that is our bread and butter. I’m sure therefore that you’ll all have seen the shutters go down and patients glaze over at the mention of the word “exercise”. In a recent PhysioTalk Twitter chat clinicians and patients gave a whole host of reasons for this. Every patient will have their own reason for disengaging with this terminology. Personally, I suspect it’s partly because “exercise” has become a medicalised term, but mostly for psychosocial reasons. The “Hate exercise?” aspect of the strapline was born from the focus groups with the aims of engaging members of the public, demonstrating empathy and generating debate and discussion. The strapline certainly seems to be generating debate already.

Physical activity guidelines currently recommend adults should participate in 150mins of moderate, or 75mins of vigorous activity a week, with 2 days of strength training(1). There are also guidelines for children and over 65s. (I love the infographics, by the way, they’re so accessible(2)). Where adults are already achieving these targets, they will only see greater physical fitness gains when they increase their activity levels to 300mins a week(3). The health benefits of physical activity are clear: reduced cardiovascular disease, enhanced mood, reduced chance of diabetes, reduced chances of developing breast and bowel cancer, reduced chance of premature death, lower risk of osteoarthritis, lower risk of hip fractures, lower risk of falls and reduced chance of dementia(3). And these are just the benefits where there is evidence to back these powerful claims. I’m sure you can all name further benefits to physical activity, perhaps some less health-related and more psychosocial. Despite these known benefits, adherence to physical activity level guidelines in UK adults is very poor, with high levels of sedentary behavior and as little as 50% of adults meeting the physical activity guidelines(4). Working as a respiratory physiotherapist I estimate at least 50% of my caseload are people with obesity. What we do know is where people are very sedentary, even small increases in physical activity levels will be beneficial(5)and certainly my cohort of patients are prime examples of such patients. It is in the highly sedentary group of patients in particular, the CSP hope the “Love activity, Hate exercise?” campaign can have the biggest impact.

CMO_infographic

The concept suggested by the CSP of the “power of a conversation” is not new. Very Brief Advice (VBA) has been utilised within smoking cessation public health campaigns for many years. VBA involves very simple clinician training and is easy to implement. It involves an AAA approach:

 

Ask: Are you smoking? Would you like to quit smoking?

Advice: Stopping smoking is the single biggest change you can make to improve your health. The best way to quit is with a combination of medication and support.

ActRefer the patient to smoking cessation services

 

The numbers need to treat for VBA is estimated at 40(6). So as a respiratory physiotherapist I have to employ VBA for smoking cessation 40 times before that results in a successful quit attempt. To give you some context the number needed to treat for cervical cancer screening programmes to prevent a death over 10 years is 1140.  So a number needed to treat of 40 is pretty powerful and increases my job satisfaction knowing the short time I take in the appointment with my patients makes a difference.

Whilst those figures may seem moderately impressive, the impact of similar VBA on physical activity levels are even greater. Public Health England report one in four people would be more physically active on the advice of a healthcare professional(7). Additionally, a systematic review and meta-analysis reported a number needed to treat of 12 for VBA for physical activity(8).

I’ve adapted the NICE(9)recommendations for VBA for physical activity to fit the AAA approach (because it’s easier to remember then!):

 

  • Ask: Identify patients who are physically inactive
  • Advice: Advice patients on the physical activity guidelines and emphasise the health benefits.
    • Tailor advise to patients motivations and goals, current activity levels, circumstances, preferences and barriers to being physically active and health status
  • Act: Provide personalised information about local opportunities.
    • Consider providing written information on goal setting. Document the outcome of the consultation. Follow up at the next opportunity, this could involve reviewing progress towards goals

 

There are 57,000 CSP members. So imagine the impact we could have on the activity levels and subsequent health of the nation if we all engaged in the “Love activity, Hate exercise?” campaign. Whichever area of physiotherapy you are working in the physical activity message is of relevance to you and your patients. If one in four people would increase their physical activity levels as a result of your advice, and numbers needed to treat for VBA for physical activity are 12, then we could very quickly start to see the impact of a more active nation. Think of the benefits a sustained change could have. And then think of the benefit that could have on our highly strained and stretched NHS and health services. And then think of the extra job satisfaction you’ll gain from taking a few minutes of your time with your patient to make use of VBA for physical activity. I’d like you, however, to consider how much more powerful the impact could be if other therapists, AHPs, nursing and healthcare professionals joined in too. Certainly, physiotherapists are experts in “exercise” and so we’re best placed to pave the way for other healthcare professional to join in our wake. I do however make a plea to the CSP to work with other professional bodies to generate a greater impact of this (and other!) campaigns and resources. There are very few physiotherapists working in silo physiotherapy departments these days, with most working in integrated therapy departments or as part of wider MDTs. So to truly reap the benefits of the “Love activity, Hate Exercise?” campaign I would implore you to share the message and the resources with your team members,

We live in a world where the complexity of our patients is ever growing. We’re living in the 4thindustrial revolution and an associated changing social structure. Many of our patients have challenging health behaviours and struggle to engage in their care. In order to instigate health behaviour change we need to move beyond a biomedical approach to treatment and towards a biopsychosocial model of care. In fact, the biopsychosocial model of care is not new, having been proposed by Engel in 1977(10). The biopsychosocial model of care should be particularly appealing to physiotherapists, as it allows and encourages holistic assessment and collaborative treatment plans, whilst ensuring the patient is the focus of attention. You will all be aware from your clinical experience how psychology and society impact on the precipitating health behaviours of our patients, as well as their concordance with treatment plans. It is imperative therefore that physiotherapists arm themselves with techniques to empower patients to make sustained health behaviour changes, or else many of our other treatment techniques will become ineffective or academic.

Motivational Interviewing is a simple technique which uses a guiding approach to establish patients’ strengths and aspirations, evoke their motivation for change and promote autonomous decision making(11). Motivational interviewing is based on the principles that; how we speak to patients is as important as what we say, feeling listened to is an important part of instigating change and that behaviour change is intrinsic and patients won’t make those changes simply because we’ve told them to.  If the patients have found the solutions themselves, then the behavioural change is far more likely to result in long-term and sustained change. There is an evidence base for the impact of motivational interviewing on health behaviour change in a number of different clinical scenarios(12). Implementing motivational interviewing can seem like it might cause a time pressure in a busy clinic. But I would argue that in the long run the time benefits are in its favour. Try following the RULE acronym the next time you start a conversation about physical activity levels with a patient(13):

 

Resist the urge to be didactic in your interaction

Understand it’s the patient’s reasons for change (not yours!) that will elicit behaviour change

Listening is important; the patient will find their own solutions

Empower the patient to realise they have the power to change their behaviour (try not to think of He-man or She-Ra  chanting “I have the power!”)

 

In summary; the CSP’s “Love activity, Hate exercise?” is an evidence-based and worthy campaign. If all CSP members engaged we would potentially make a huge difference. We could make a bigger difference if we engaged other MDT members and healthcare professionals. A biopsychosocial model to care is more effective than a biomedical model one and motivational interviewing can be a useful tool in this approach.

Stephanie Mansell, Consultant Physiotherapist, Royal Free London NHS Foundation Trust, July 2018

 

References

  1. Department of Health and Social Care. UK physical activity guidelines In: Department of Health and Social Care, editor. https://www.gov.uk/government/publications/uk-physical-activity-guidelines2011.
  2. Department of Health and Social Care. https://www.gov.uk/government/publications/start-active-stay-active-infographics-on-physical-activity.Accessed
  3. O’Donovan G, Blazevich AJ, Boreham C, Cooper AR, Crank H, Ekelund U, et al. The ABC of Physical Activity for Health: a consensus statement from the British Association of Sport and Exercise Sciences. Journal of sports sciences. 2010;28(6):573-91.
  4. British Heart Foundation. Physical Inactivity Report 2017. In: British Heart Foundation, editor. https://www.bhf.org.uk/publications/statistics/physical-inactivity-report-20172017.
  5. 2018 Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Scientific Report. In: Services DoHaH, editor. Washington, DC: U.S. 2018.
  6. Van Schayck OCP, Williams S, Barchilon V, Baxter N, Jawad M, Katsaounou PA, et al. Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG. npj Primary Care Respiratory Medicine. 2017;27(1):38.
  7. Public Health England Guidance: Health matters: getting every adult active every day. In: England PH, editor. https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day/health-matters-getting-every-adult-active-every-day2016.
  8. Orrow G, Kinmonth A-L, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ. 2012;344.
  9. National Institute for Health and Care Excellence. Physical activity: brief advice for adults in primary care Public health guideline [PH44]. In: NICE, editor. Manchester2013.
  10. Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-36.
  11. Abraham C, Michie S. A taxonomy of behavior change techniques used in interventions. Health psychology. 2008;27(3):379.
  12. Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305-12.
  13. Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques – facilitating behaviour change in the general practice setting. Aust Fam Physician. 2012;41(9):660-7.

The Pragmatic Therapist: Clinical Decision Making from Multi-factorialism to Dispositionalism

In Neil’s commentary, he keenly evaluates the clinical decision making from gathering evidence from a wider perspective and applies it to the particular case.  He also delves into the clinical acumen required for sense-making for both the therapist and the patient.  I would like to discuss multi-factorial reasoning and move towards thinking about dispositions.  In writing my paper the most difficult task was conveying the difference between a multifactorial causal approach and a dispositional causal approach

There is a growing sense of recognising the multi-dimensional nature of clinical encounters where the utility of a whole person approach far surpasses unidimensional approaches (O’Sullivan et al, 2016).  A significant challenge to a whole person approach, despite it being grounded in common sense and resulting in improved clinical outcomes, is that when seeing a person who presents with a clinical problem, once all the evidence is gathered, by whatever means, how do we make sense of it and what do we do about it?  One way to develop a multi-factorial model of explanation, quite simply, is to consider a number of categories and start to fill in these areas with data.  An example might be using a biopsychosocial approach, whereby biomedical, psychological and social profiles are developed with the information gathered by the history and physical examination.  Each of these areas aim to move away from biomedical reductionism (Engel, 1977) but in its place lies biomedical, psychological and social reductionism.  But we have to start somewhere, do we not?

Jones, Edwards and Gifford (2002) present a classic paper applying the biopsychosocial theory to clinical practice.  They refer to Gifford’s mature organism model and to Jones’ hypothesis categories, as well as to the interpretive and insightful understanding of Edwards, to provide a great person centred approach.  This culminates in an excellent reasoning model providing epistemic (knowledge based) and therapeutic value.  The paper pays attention to both the empirico/analytical approach, such as the generation of hypothesis categories, and also to an interpretive methodology such as the way in which the categories relate to each other.

Using a multi-factorial method certainly has its advantages and appears to embrace a holistic approach.  By that I mean, identifying all the potential factors that are present to the complaint and addressing them, in turn or together, to create a critical change in the condition resulting in a positive or desirable effect (figure 1).  However, how many times do we think we have addressed this and yet no change has happened?  How disappointed are the people in our care when they have worked hard with the management plan with no change?  We might have thought that the causal mechanisms of the disorder would have been ameliorated, according to the model we agree with and find most compelling!

ML Multifactorial

Figure 1: An example of using a multi-factorial treatment and management approach

Van Ravenzwaaij et al (2010) described a number of explanatory models from the literature that may shed light on symptoms that we have no clear explanation for.  These include physical explanations (immune system sensitisation theory, endocrine dysregulation theory, autonomic nervous system dysfunction theory and abnormal proprioception theory), psychological explanations (somatosensory amplification theory, sensitivity theory) and hybrid explanations (sensitisation theory, signal filter theory and an illness behaviour model).   Surely, by using a multi-factorial model it would not matter what causal mechanism(s) could explain the condition, treatment or the management.  But by addressing all the identifiable factors would have had some effect on at least some of those proposed theories….surely!

Perhaps we should examine the underlying metaphysical theory (ontological) explanation as it might be more favourable to consider that certain powers may interrupt, counteract or simply overpower (overdispose) others so that no effect takes place.  Erikson et al (2013)in their perceptive paper examine beneath the surface of the complexity that we face every day and is certainly worth a read (maybe a few!).  This dispositional perspective examines the causal components at a deeper level.  Please consider this paragraph:

To move from monocausality to multifactorial causation does not in itself guarantee that we take the complexity seriously. If our methods are designed to treat each factor separately, the phenomenon as a whole is lost even if we include many factors and add them up. Complexity is a core idea of dispositionalism, and this is particularly clear in causation. All actual effects will be multifactorial. The flammability of a match is not alone sufficient for it to light when struck. It will also require the presence of oxygen and reasonably arid conditions. Given that all such factors contribute, and all such may be hypersensitive in relation to what they manifest, then the medical uniqueness of each patient starts to look a credible possibility. Understanding causal interaction is not only about taking into account all the factors involved and how they compose. It is also a question of magnitude or degree. On dispositionalism causes and effects come in degrees. They are not a matter of “all or nothing”.

Multi-factorial thinking is not enough!  In my paper, I attempt to describe how a dispositional approach might be a step forwards with the use of the vector model (figure 2).  The vector model describes how causation may work and be a significant contributor to clinical reasoning.  Further work in progress!

ML Vector model

Figure 2: The Vector Model (Anjum and Mumford – Getting Causes From Powers)

One of the key advantages of a dispositional approach verses a multi-factorial approach is the attention to context sensitivity and non-linearity.  For example, exercise has been shown to be beneficial for chronic musculoskeletal conditions, including exercising into pain compared to pain free exercises, certainly in the short term.  However, the adherence and compliance of exercising into pain may be a barrier to the treatment effect.  This is demonstrated, to an extent, by the relatively high attrition rates identified within studies and also the exclusion of widespread pain disorders such as fibromyalgia.  A multi-factorial approach will use exercise as a treatment but the context of when and how it is applied may not be taken into account, including the potential for exercise to have a deleterious effect.   The presence of causal factors that dispose an individual towards having reduced descending noxious inhibitory control mechanisms (e.g. poor sleep, chronic stress, anxiety and depression) have variable outcomes to exercise including making symptoms worse therefore reducing adherence to an evidence based treatment.  A dispositional account recognises the individual context and may focus treatment towards the factors that are reducing the inhibitory control mechanisms prior to exercise prescription.  Later, a graded exercise programme may be more successful, both in terms of adherence and treatment effect.  This is just one example of a well-intended treatment modality resulting in a non-desirable or negative outcome using a multifactorial approach.  Emergent phenomena, such as the manifestation of persistent pain, do not follow linear paths bereft of context and a dispositional approach may prove fruitful.

If you have the time, please have a read of the papers and give some comments below.

Matthew Low.  Consultant Physiotherapist, NHS

The Big R’s – Part Deux Reasoning and Responsibility Statements

Recently, Neil and I were invited to be panel members for the second #TheBigRs meeting.  We were both asked to give a 5 minute presentation or statement on one word.  With that word, we needed to make our views clear on our perspectives surrounding it in the context of MSK Physiotherapy practice.  Other panel members shared their perspectives and it was all filmed and can be viewed here and here.  A website has been created that provides more information and a forum for discussion.

This blog shares both Neil and my statements that we gave at the meeting.  Please feel free to comment on what you feel, the direction of future travel should be.

reasoning2

The following is my statement on ‘Reasoning’:

Thank you to Chew’s Health and Connect Health for organising the three R’s events.  I think they should be applauded in their strides to try to bring together a growing movement of Physiotherapists in order to help us travel forwards in a worthwhile direction.

All of us sitting here today are leaders in one sense or another, be that in clinical practice with our patients, or in our organisations in the workplace or in our social environments.  As such, our responsibility and our reasoning are deeply intertwined so I shall try to stay within the realm of reasoning as much as possible.  I will draw from Alex Broadbent’s work, a philosopher of Medicine, to frame this talk. I would like to discuss reasoning in terms of how we view the world, secondly how we reason using our knowledge, thirdly how we reason with our morals and lastly how we reason our professional disagreements.

A place to begin is to look at how we view physiotherapy, its practice and through what lens we see it…and there is no getting away from a perspective of realism.  There will always have to be the fact of the matter.  One area of realism is how we view evidence and use it to make therapeutic decisions.  The hierarchy of evidence-based medicine is a very good comparative hierarchy of internal validity where the methods higher up have better internal validity than the ones below.  This is fine, but in so doing makes the issue of external validity much more challenging especially when making causal inferences.  What is clear is that by using the hierarchy of evidence-based medicine to create a map of therapeutic decision-making is not as straightforward as it seems, and it certainly does not tell you the terrain.  I am not saying that randomised controlled trials should not be done, not at all, they should be and are extremely useful but we should stay critical of all methodological short comings and what they really tell us.  I think that we may have to look at evidence in a more pluristic way, using multiple methods and methodologies to critically analyse the area in question and keep in mind the people that we treat are at the very centre of all our reasoning first and foremost.

The next area is how we reason with respect to knowledge, I believe this should be done in a style and manner of humility.  By that I mean to have the willingness to reconsider one’s belief in the face of disagreement and to recognise that knowledge changes with time.  It also means that we take each other’s differing views seriously.  (This includes my perspective on evidence-based medicine by the way!) This also crosses into the style and manner of our communication that I believe should be inclusive, but not in such an overtly apologetic way that no issues are discussed.  In order to be inclusive, communication styles need to be conducted in the context of the social environment and the people present.  If the size and scale of the social environment is so large, that we are unable to communicate recognising body language and tone, for example in social media, then it makes sense to use a more conservative approach.  I am not talking about policing but I am talking about inclusivity.

Next is how we reason morally.  Because we are all part of one humanity, we therefore derive our moral worth from that humanity.  Therefore, all individuals have equal moral worth and whose views and perspectives should be equally valid and therefore should be listened to, heard and taken genuinely. But equally, held to account if our standards of professionalism slip.

Lastly, reasoning surrounding professional disagreements.  This is possibly the most challenging area, particularly with respect to social media.  Perhaps, attempting to start with cases or areas of discussion where there is agreement in the first instance, and seek to identify, in as specific a way as possible, the values or facts that we might disagree.  This may still not lead to agreement, but it improves the chances, and in so doing, maximizes the areas where we can identify common ground.  This is in stark contrast to using a principled approach, which typically dramatizes our differences and polarises our discussions.

We are all passionate individuals and we are stronger together than we are in smaller groups – let’s see if we can take this rewarding profession forwards by listening to each other, providing space for reflection and by standing on the shoulders of those that have come before us.

Matthew Low, NHS Consultant Physiotherapist

responsibility1

The following is Neil Langridge’s statement on ‘Responsibility’:

Responsibility can mean so many things to so many people and of course this is a personal view and perspective. I feel in this context of discussing our profession we have a number of different ideals to consider; Responsibility is something that can come with a sense of pressure, with social expectation, a sense of maturity and wider view of the world around us whilst considering our culture, society , work and family values and our influence upon these. In considering these values I have narrowed this into our natural conversation in terms of our similarities due to our professional status together and hope this offers some suggestions for discussion. Firstly;

  1. Responsibility to and for the patient – to listen, to be empathetic, to be evidence-based, to be safe in our practice, to empower, support and give confidence to others who have lost theirs through illness, injury, pain and distress. This responsibility in essence is perhaps our driving force when we think about the patient and therapist interaction.

 

  1. In considering this role we must also give responsibility to the patient. Empowerment is about taking support away at the right time so the patient can be responsible for themselves which inherently is central to the rehabilitation process, and the therapeutic relationship balance that leads to the patient regaining what they lost. To do this we have a shared responsibility as part of placebo, as the process of the patient handing this over to the therapist is therapeutic. The art to this handovers’ success is the context of their barriers to recovery being altered to a positive responsibility, rather than negative one.

 

  1. We have a responsibility to challenge and change and share. I think here is where I have really seen a major shift in how we as a profession now really are able to internally be critical .Economically as well as therapeutically we must be responsible for how we act and behave, and we must be change efficient and not risk averse. We should continue to be responsible in how we consider best care under the evidence base, it is a professional responsibility to challenge where this is plainly wrong, poorly evidenced or interpreted.

 

  1. Responsibility to and for the profession is vital –working externally with colleagues, building respectful working relationships with other professions is a key change model but as much as we also have a responsibility to challenge and change, but to also have a responsibility take people with us. We have a responsibility to harness where we can to make the biggest effect, public health is a great example of where we have professional, moral and ethical responsibility to address health and wellness – we must impact here as well as other elements of MSK health. We talk of eradicating certain treatment options, and this is a key responsibility: but lets get the focus appropriately balanced. Let’s take Ultrasound for LBP as an example (should not be used) however – consider the numbers we are taking responsibility for here? The number in the population, the number with MSK pain, the number who then seek GP help, the number referred on (5.6 per weighted 1000), the number in physio with LBP who then receive Ultrasound – we are talking tiny numbers – its important but we surely should be focussing our responsibility to address the public health issues. Addressing non-communicable disease has to be the responsibility of the profession surely that’s more important. Smoking kills 6 million people in the world every year, 1.5 billion adults over 20 are obese and physical inactivity is one of the leading risk factors for global mortality. Fitter people mean a more productive society – let’s think big instead of small.

 

  1. Lastly, we have a professional responsibility to ourselves and the professional relationships we build, and this is always a tricky one. In the end how we present ourselves professionally in any arena or any format as a physiotherapist comes with it a level of professional responsibility. How people wish to interpret that can come with a flexible approach. People are free to express opinions and offer views but they are responsible for those actions and consequences of them when providing that opinion as part of a wider profession. If you are speaking for yourself, the you are only responsible for yourself, if anyone speaks for “we” as in the profession, then we are responsible in the impact positive or negative the words may have – this is not about towing a line, or not meeting things head-on, far from it, it’s about doing so in a way that creates the biggest positive impact we can – taking someone with you and creating a change (IMO) starts with respect and understanding on both sides and that for me is the hallmark of a responsible professional.

Neil Langridge, NHS Consultant Physiotherapist.

What can Plato’s Allegory of the Cave tell us about knowledge translation?

The allegory of the cave is a famous passage in the history of philosophy. It is a short excerpt from the beginning of Plato’s book, The Republic (1). There are a number of different interpretations of the allegory, but the one that I would like to present is within the context of education, specifically knowledge translation and the content, style and manner of its delivery. I would like to conclude with relating this to how we, as health care professionals, present knowledge within a professional dialogue.

Plato’s Cave

Imagine a group of prisoners who have been chained since they were children in an underground cave. Their hands, feet, and necks are chained so that they are unable to move. All they can see in front of them, for their entire lives, is the back wall of the cave.

Plato's Cave

Some way off, behind and higher up, a fire is burning, and between the fire and the prisoners above them runs a road, in front of which a curtain wall has been built, like a screen at puppet shows between the operators and their audience, above which they show their puppets”(1)

The-Allegory-of-the-Cave-by-Plato

So, there are people who are passing by the walkway, carrying objects made of stone, behind a curtain-wall, and they make sounds to go along with the objects. These objects are projected onto the back wall of the cave for the prisoners to see. The prisoners talk and discuss these projections and come up with names for them; they are interpreting the view of the world, as it is intelligible to them. It is almost as though the prisoners are watching a puppet show for their entire lives. This is what the prisoners think is real because this is all they have ever experienced; reality for them is an interpretive existence viewing the world as a type of puppet show on the wall of a cave, created by shadows of objects and figures. In a way, this is not dissimilar to our understanding of evidence-based practice, we have a version of truth interpreted through the views of others and we, as clinicians, have to make sense of it and also interpret it ourselves, for others.

Research evidence is still testimony of evidence in that we must trust the rigor, process and presentation of it. We may not have completed and interpreted the research ourselves and therefore careful scrutiny through peer review and individual critical analysis is of utmost importance. The prisoners also co-construct the world between them, sharing a dialogue surrounding the images cast in front of them. As physiotherapists, we also share dialogue surrounding professional practice, or own values and preferences as well as what we think “works” for patients from many different perspectives. Back to the story:

One of the prisoners has help and breaks free from his chains. Then he is forced to turn around and look at the fire. The light of the fire hurts his eyes and makes him immediately want to turn back around and

“retreat to the things which he could see properly, which he would think really clearer than the things being shown him.”(2)

In other words, the prisoner initially finds the light (representing the truth, an alternative truth or reality) very challenging to see and so does not want to pursue it. It would be easier to look away back into the shadows.

However, after his eyes adjust to the firelight, reluctantly and with great difficulty he is forced to progress out of the cave and into the sunlight, which is a painful process. This represents a journey of greater understanding and the challenges that come with it. We have all found the journey of gaining knowledge, interpreting it and applying it a challenge in one way or another in our personal and professional lives. The story continues:

So the prisoner progressed past the realm of the firelight, and now into the realm of sunlight. The first thing he would find easiest to look at is the shadows, and then reflections of men and objects in the water, and then finally the prisoner is able to look at the sun itself which he realises is the source of the reflections. For me, this represents the way in which knowledge can be delivered may be best understood within the context of previous experience including socially acceptable constructs. This allows connections to be made between our prior views of the world and the formation of new information or knowledge that we have perceived and interpreted. When these connections relate to prior experience or conceptualised within familiar paradigms, they become easier to digest, absorb and interpret successfully. Simply being told new information in an abstract way or delivered in a style and manner that is out of keeping of social norms may not be a successful strategy.

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Copied from @michael_rowe twitter feed 28th March 2018

Back to the escapee: When the prisoner finally looks at the sun he sees the world and everything surrounding him and begins to feel sorry for his fellow prisoner’s who are still stuck in the cave. So, he goes back into the cave and tries to tell his fellow prisoners the truth outside. But the prisoners think that he is dangerous because the information that he tells them is so abstract and opposed to what they know. The prisoners choose not to be free because they are comfortable in their own world of ignorance, and they are hostile to people who want to give them an alternative view of the world. My interpretation is that there is a natural tendency to resist certain forms of knowledge, particularly if the subject area has been around for a while. Ignorance is bliss! The prisoner that escaped from the cave questioned all his beliefs as he experienced a change in his view of the world rather than just being told an alternative. Being a passive observer, as the prisoners who wish to stay in the cave, would generally prefer to keep things as they are. This says something to me about the experience of knowledge translation; the impact will depend on a number of variables that effect an individual’s perception.

According to Plato, education is seeing things differently. Therefore, as our conception of truth changes, so will our engagement with education. He believed that we all have the capacity to learn but not everyone has the desire to learn; desire and resistance are important in education because we have to be willing to learn alternative paradigms even though it may be hard to accept at times. Creating the desire to learn through the style and manner of motivational interviewing (3) makes even more sense here, particularly with regards to the ‘righting reflex’. The ‘righting reflex’ is the natural tendency that well-intended people have to fix what seems wrong or incorrect and to set them on to the ‘proper’ course. This often results in telling people what to do in a very directive manner that frequently ends up putting people off or stifling change rather than steering people on an alternative path.

The people who were carrying the objects across the walkway, which projected shadows on the wall, represent the authority of today. Within the physiotherapy profession, they may be our union leaders, educators, researchers, course providers, cultural influencers, social media icons as well as clinical and professional leads; they influence the opinions of people and help determine the beliefs and attitudes of people within our professional society. The person who helped the prisoner out of the cave could be seen as a teacher. Socrates compares his work as a teacher like that of a midwife. A midwife does not give birth for a person, however a midwife has seen a lot of people give birth and coached a lot of people through it, similarly, a teacher does not get an education for the student, but can guide students towards it. Similarly, professional dialogue appears best suited towards guiding people towards alternative “truths” or perspectives. The style and manner of its delivery is clearly important and it appears to have the greatest effect if it is surrounded by within and between each other’s experiences that create connections with other previous understanding. Using a direct style and manner that is out of keeping with professional dialogue is unlikely to facilitate learning or behavioural change, in fact, it is more likely to make people resist it. Much like, if the escaped prisoner returned to the other prisoners brandishing a torch lit by the flame and put it close to them to see an alternative perspective. This would likely cause the imprisoned prisoners flinch and close their eyes from the light, therefore representing stifling learning and behavioural change. An alternative method would be to introduce the light and demonstrate how it changed the shape and position of the shadows while talking them through the process allowing the prisoners to change the perspective through cognitive and perceptive dissonance, therefore representing a challenge in the experience with brand new alternatives presented. Then the attention could be drawn to the firelight and then to the outside and show alternative possibilities.

I hope this blog highlights how we might communicate with each other and helps to reflect on not only what we say, but perhaps more importantly, how we say it! More specifically, the experience of knowledge translation can be transformative if the learner has a direct personal experience. The least effective means of communication of knowledge may be about giving information in a style and manner that is outside of social norms. This is most likely to be polarising, rather than inviting people along with you. A level above this might be information giving that is lacking context or information provided in a style and manner that is hierarchical or top-down. The greatest impact may be that which directly engages with its audience in a way that relates to their previous experiences with the learners making connections themselves during a sense-making process.

References:

  1. Plato: The Republic 514b
  2. Plato: The Republic 515e
  3. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: helping people change. New York, NY, Guilford Press.

Matthew Low, Consultant Physiotherapist NHS.