Education

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!”

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

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

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

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The Cauda Equina – published with permission by Ruth Eaves

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

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

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

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

 

Terminology

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

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

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

 

Management

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

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

 

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

 

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

Chris Mercer, Laura Finucane and Sue Greenhalgh

 

“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.

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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.

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.