Physical Activity

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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“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.