communication

Reflections on Knowledge and engagement with the Other

I feel very lucky and privileged to be a Physiotherapist. Physiotherapy, a profession that encompasses many dimensions such as clinical, educational, leadership, consultancy and research but most importantly, as a group of responsible people who engage and supports Others.  It is with this in mind, at this most challenging time, that I reflect on my journey with my profession and how I value others.

I was very fortunate to meet Dr Filip Maric amongst a number of inspiring people including Joost van Wijchen, Laura Rathbone, Els Lamers, Ann Gates and Vincent Bastiaans at HAN University as part of an International week.  It was a wonderful visit that both stimulated and challenged me.  During many conversations, I was struck in particular with Filip’s area of interest of fundamental ethics, particularly from the viewpoint of Emmanuel Levinas and I would like to thank Filip for introducing me to this.

The ever-growing fountains of knowledge:

Physiotherapy, as a profession, has grown in its wealth of knowledge with an ever-expanding research base.  An area of interest of mine is how to consider this wealth of knowledge and apply it, in the best way, for the individual person or group of people.  Most of my focus is usually on individuals due to the nature of my job but I recognise that population health is of the utmost importance.  For the purposes of this post, I would like to focus on the care of individuals.

The field of philosophy examines the assumptions, foundations, and implications of science, as well as the manner in which it progressively explains phenomena and predicts occurrences.  I believe now, perhaps more than ever, that science and the humanities are both of equal importance within the context of growing knowledge and technological advancement.  Kerry, Maddocks and Mumford (2008) made a very clear point on this over a decade ago.

How might we understand knowledge and unpack it?

I often refer to Aristotle who describes knowledge as episteme (knowledge as fact), techne (knowledge as craftsmanship) and phronesis (knowledge as wisdom; to do the right thing at the right time, in the right context).  This can be unpacked further but it is clear that knowledge that is viewed in this way is complex and dynamic phenomenon.

If we look at knowledge as facts, it could be seen from the viewpoint of science.  Science attempts to discern objective, concrete and universal knowledge, often through repeatable and measurable ways through the use of our senses.  For science to be taken seriously, it has to rigorously test hypotheses, often through failure, in order to make advancement.  However, the scientific lens may not unearth all of the areas that Aristotle refers to and it may assume that these universal laws are applicable in every context.  This philosophical bias (Andersen, Anjum and Rocca, 2019) may, for good reason, emphasise carefully controlled studies over other methods to minimise contextual or confounding factors in order to establish a truth without bias but in doing this, possibly risk missing the very elements that may be of importance (Kerry, 2017).

Knowledge that is seen as craftsmanship or wisdom, by its very nature, is inherently value laden and embedded within a social context.  As such, knowledge does not exist in its own vacuum and therefore, is not complete without a way in which it is applied in the real social world.  In Physiotherapy practice, it makes sense to me that the ethical position on how we apply this knowledge is of prime importance.  The judicious use of knowledge requires the application of its multiple sources to be grounded within an ethical framework in which it is delivered.  Tonelli (2010) makes the compelling case that clinical research, pathophysiologic rationale and clinical experience are all required to make sound judgement in a casuistic way for the individual case.  This multi-dimensional perspective of understanding knowledge, amongst many reasons, may be why knowledge translation is challenging.  Added to this, the consequences of certain philosophical biases that are incorporated into practice underscore the ethical nature of Physiotherapy practice, thus calling forth the need for a deeper understanding of human beings embedded within their socio-cultural contexts within the complexities of health care.

To summarise, I believe that knowledge is complex, dynamic and context sensitive.  Therefore, a number of viewpoints or lenses are useful in order to make sense and apply this knowledge.  Knowledge from science and the humanities are both important in order to apply it in the real world.  The application of this knowledge, therefore, must be grounded within an ethical framework that is coherent within its setting.  In this case, within Physiotherapy, I argue for a humanistic framework which leads us to a philosophical perspective of Emmanual Levinas and the fundamental ethics surrounding Others.

Levinas and the Other:

Filip Maric and Dave Nicholls wrote a paper ‘The fundamental violence of Physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for Physiotherapy theory and practice’.  The paper briefly introduces the background of Emmanual Levinas of which I will summarise below.

Levinas was born in 1906 in the Jewish community of Russian-occupied Kovno (now Kaunas, Lithuania).  He went on to study philosophy in Strasbourg where he read classical philosophical works from Plato and Other Greek philosophers through to Descartes, but also modern philosophy.  Subsequently, Levinas studied under the famous phenomenologists Edmund Husserl and Martin Heidegger, who were significantly influential in the development of his future method and thought.  The influential tensions that Levinas experienced during the Second World War alongside Heidegger’s affiliation with the Nazi party strengthened his insight towards an alternative fundamental ethical way of being that contrasted with the phenomenological focus on the self.

Much broader, Levinas felt that much of Western philosophy tended to subvert the ethical relation to the other by placing persons within the unifying system of ontology (the nature of being), hence denying persons their right to be themselves or their otherness.  The inherent tendency of a culture based in a philosophy that seeks to overtake a person’s otherness into the same as themselves is one of power, control, oppression and even tyranny.  Levinas makes a phenomenological claim that an ethical relationship, which is founded upon respect for the other’s radical alterity (or difference), exists prior to the ontological relationship, which is based on knowledge and comprehension of the other.

Put in another way, one’s relation to the other is the foundation of human knowing, not the other way around.

When I encounter someone else, I experience a difference between the other and myself. This initial difference is the first moment in ethics, in the acknowledgement of another who obligates me. The foundational nature of the ethical relationship is one that may be neglected in Western philosophy and its branches. The influential work of Heidegger, for example, treats ethics as secondary to ontology (the nature of being) and epistemology (the nature of knowledge).  Levinas suggests that it is the ethical perspective, in the experience of the other, that should be the norm, and that this creates the standard to which other Western philosophical perspectives are seen relative to.

“Indeed, the objectifying thematization inherent to the Western logos as ontology does not do justice to the way in which the Other exists. The only adequate response to the face is my being devoted to the Other. If I reduce the Other to an interesting topic for my observation or reflection, I am blind to the claim that is constitutive of the Other’s coming to the fore.” (Peperzak, 1997, p. 34)

Simply put, the implicit use of objectification that is dominant in Western philosophical reasoning does not do justice to others.  Rather, in Western philosophy, if we attempt to reduce others to our observations or reflections of ones-self then we are at risk of causing potential harm to others.

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What implications might this have for Physiotherapy?

Although I have not read around a large amount of Levinas’ work that would place me anywhere near as an expert, the reading that I have done has resonated.  Levinas’ work calls forward the need to embrace diversity, cultural and social differences.  It engenders a mind-set change to hesitate and consider others first and foremost.

In clinical practice this elevates communication and interpersonal skills as a priority because it is through our embodied way of understanding others that we seek to appreciate and comprehend through sense-making, on an equal footing, with others.  We, as clinicians may have knowledge of the body, of physiology, of anatomy or whatever, but first and foremost we are people making sense of each other with the acknowledgement that, in our difference, we are both human beings with different sources of knowledge and experiences.  In all cases, my patients are far wiser than I am, in many ways, but certainly in regard to themselves.  This nurtures a sense of epistemic humility, for example, I could have a huge amount of knowledge and understanding around the latest randomised controlled trials, systematic reviews, narrative review and qualitative papers surrounding a condition like low back pain, but unless I am able to engage and understand others and placing themselves first within the clinical encounter, the sense-making process of each other will be lost.  The inter-subjectivity, or sense making process, using body communication, language and insight to the other uplifts the therapeutic encounter.  A genuine curiousness of the other places them truly at the centre of comprehension that comes before all considerations of being or knowledge of the condition that the other person presents with.   Carl Rogers, the American Psychologist, embodies this perspective in his book, ‘On becoming a person’, wonderfully:

“…I find that the more acceptance and liking I feel toward this individual, the more I will be creating a relationship which he can use.  By acceptance I mean a warm regard for him as a person of unconditional self-worth-of value no matter what his condition, his behaviour, or his feelings.  It means a respect and liking for him as a separate person, a willingness for him to possess his own feelings in his own way.  It means an acceptance of and regard for his attitudes of the moment, no matter how negative or positive, no matter how much they may contradict other attitudes he has held in the past.  This acceptance of each fluctuating aspect of this other person makes it for him a relationship of warmth and safety, and the safety of being led and prized as a person seems a highly important element in a helping relationship.” (Rogers, 1961, p. 85)

Levinas and the face to face encounter

Levinas felt that the human face was of fundamental significance in encountering others.  The face is not considered as a physical or aesthetic object.  Rather, the first, usual unreflective encounter with the face, is as the living presence of another person and, therefore, as something experienced socially and ethically.  The face looks towards others, which both at the same time overwhelms and resists the existential experience of the human encounter. If one refuses the existence of the another’s face, it causes an overflowing experience that calls to the other in a fundamentally moral way.

Levinas insists that science, technology and other theoretical systems of knowledge cannot function independently.  Human existence does not form the basis of knowing in and of itself. Rather, ‘‘…it is the epiphany of the Other’s face and speech rupturing the homogeneity of my universe and breaking its totality’’ (Peperzak, 1997, p. 12).

Modern technology, however, has allowed novel forms of interaction that have permitted clinicians to see others at distance.  During the current Covid-19 crisis, the use of video consultations has transformed the usual clinical encounter.  By seeing the other, in their own environment and communicating as if one where with them has been a revelation.  Those, like myself, now find the telephonic clinical encounter distancing, devoid and stale in comparison.  One can truly see that the healthcare encounter has forever been changed as a result.  The new telehealth system of care will bring both excitement and scepticism resulting in both revolution and disruption. Only time will tell how the future landscape of Physiotherapy care will end up.  Either way, how the profession evolves through considered conversation with others both within and outside of Physiotherapy will determine its own future success.  Educational institutes will have to adapt as well, once again, highlighting the importance of person-centred communication and ethical considerations causing us to hesitate on our own traditional practice and hubris.

The recent months have indeed caused me to seriously reflect on the Physiotherapy profession and perhaps, if you have managed to get this far, I hope this blog has created a space for you to reflect.  Once again, I would like to thank everyone that attended the HAN International learning week that triggered my thoughts.  If there was any time to consider others, I think the time is now. Please, continue to be kind to yourself and more importantly, others.

 

References

Kerry R, Maddocks M & Mumford S (2008) Philosophy of science and physiotherapy: An insight into practice. Physiotherapy Theory and Practice. 24:6, 397-407.

Laplane et al (2019) Why science needs Philosophy. PNAS 116 (10) 3948–3952.

Andersen, Anjum and Rocca (2019) Philosophy of Biology: Philosophical bias is the one bias that science cannot avoid. eLife; 8: e44929.

Kerry, R (2017) Expanding our perspectives on research in musculoskeletal science and practice. Musculoskeletal Science and Practice. 32. 10.1016/j.msksp.2017.10.004.

Tonelli, M.R. (2010), The challenge of evidence in clinical medicine. Journal of Evaluation in Clinical Practice. 16: 384-389.

Maric F and Nichollls D (2019) The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice. Open Physio Journal.

Peperzak, A (1997) Beyond – The Philosophy of Emmanuel Levinas. Illinois: Northwestern University Press.

Rogers C (1961) On Becoming a Person: A Therapist’s View of Psychotherapy. Boston: Houghton Mifflin.

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.

Motivation-sign-with-a-beautiful-day

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.

self-growth

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.

Self-Determination-Theory-Visual_1

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.

self-determination-theory

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

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!”

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.

 

 

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.