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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Remaining connected: The pragmatic physiotherapist.

Guest Post by Dr Neil Langridge, Consultant Physiotherapist NHS.

Clinical decision-making; we all do it every day. Researchers have tried to define it across and within professions, mentors try to instil it and students grapple with it. Our profession has tried to make it less challenging; sub-grouping, clinical prediction, stratification are just a few of the algorithmic processes designed to make clinical life a little bit easier and safer.

Experience and knowledge, meta-cognition, synthesis, hypothesis testing, recognising patterns, narrative and collaborative processes are just a few examples of the theoretical models that are also designed to help explain our thinking, but often just leave us more confused.

Then of course we remember we are dealing with a patient who has thoughts, feelings, considerations and beliefs that we have to interpret. Algorithms don’t really deal with this very well.  Combine this with our own clinician “yellow-flags”(1), and how these affects our thoughts and behaviour and the subsequent decision, and we have a heady mix of psychological, behavioural, biological and cognitive challenges to deal with.

Trying to formalise this has led to counter suggestions that N=1 and so many of these “groups”, “patterns” and presentations should be individualised and so suggesting we must maintain a bespoke treatment package for patients. I have read that some will then challenge this as they believe this gives therapists the cart Blanche to then do just as the patient wants and they must remain within the evidence base irrespective of what may have worked before. All very reasonable arguments and dependent on your standpoint something to consider when looking ahead at the challenges our profession has in the battle to ensure we remain grounded, ethical, scientific and caring.

I have found these discussions fascinating as with many interactions they can lead to an end of the spectrum debate, opposites being forceful in their views and perhaps the complexity of the clinical decision is the key reason why this provides so much interest. It also sparks debate as it addresses many of our own ethical challenges in treatments to offer and the professionalism behind that call.

The clinical diagnosis in the past has housed numerous methods, words, meanings. Pathological models, tissue-based approaches, neuro-biological, behavioural and cognitive designs are some of the models we choose to summarise our findings. I would propose that the diagnosis has a number of requirements to give it clinical validity. It should be made clear, it should inform the management plan; it should be transferable within the profession and across professions and it should cover the barriers to recovery. So, in essence it could describe the symptoms, it can cover why the condition may not be recovering and what the barriers are and also the particular needs of the patient.  So we have processes and pathways and clinical reasoning within the spectrum. Algorithms/ process therefore can be described as thinking that is somewhat convergent (narrowing to one answer), whilst the clinician with reasoning is possibly more divergent (able to offer multiple perspectives/solutions).

So, our divergent thinker still needs to follow a reasoning approach that will lead to a diagnosis and the multiple factors need to be translated into an end-point that makes sense and is transferable. The initial part of the process starts with a diagnosis of exclusion, no red flags, no signs of a major pathology are assumed and so there is specificity to this and so easily defined. This thinking approach then broadens into whatever model the clinician then follows, and the practitioner describes the area of symptom, barrier (s) to recovery, and then potentially how they link. For example in low back pain, see below;

In this small limited model observations are made, based on the limitations noted, treatment choices are considered, they then should be contextualised within their evidence base, and then it is down to the clinical acumen to make it relevant for the individual. So, this is not about N=1 versus evidence based medicine, it is about the use of clinical acumen and pragmatic decision-making, in essence the clinician would be unwise and unethical to choose a treatment that is not;

1. Based on the physical/cognitive/behavioural limitations to recovery.
2. Based on what the evidence in the literature supports.
3. Based on the clinical agreement of the clinician and patient as collaboration.
4. Based on a bespoke package for that particular patient (not their condition)

This is not the clinician forcing their views, nor the patient demanding their needs. This is about the best use of the available evidence along the spectrum.  The picture below highlights that acumen and skill are about taking the evidence and placing it along the spectrum of reasoning and ensuring a broad method of enquiry is applied.

Placing ourselves at one end of a spectrum of reasoning lowers clinical flexibility and reflexivity, such as;

1. We only do what we have always done.
2. We rigidly follow our interpretation of scientific evidence.
3. We only do what the patient wants.
4. We just follow algorithms.

The interpretation and acumen therefore will be shrouded in the rhetoric of those that that continue to hold views that stop them moving around a spectrum of reasoning – the counter to this is the pragmatic physiotherapist who has the innate ability to consider all evidence sensibly and contextualise it clearly.

So, my thinking for what it is worth is that maintaining a critical view of the evidence and subsequently applying it is not in conflict with providing a bespoke, person-centred plan. It is inherently combined, and allows for the clinician to translate all available evidence into a diagnosis that quite rightly is contextualised, pragmatic, evidence based and individualised and to this end, that’s probably the best we can do for now.

Neil Langridge.  Consultant Physiotherapist.

 

The Pragmatic Therapist: 

Clinical Decision Making from Multi-factorialism to Dispositionalism

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

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

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

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

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

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

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

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

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

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

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

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

Matthew Low.  Consultant Physiotherapist, NHS.

 

Reflections on the “Reasoning, Responsibility & Reform in MSK Practice” Event

Thinking about a disconnect: Big data and person-centred care

Musculoskeletal Physiotherapy commonly experiences many shifts in thinking, beliefs and concepts which over time lead individuals and groups through paradigms that generally conclude with enthusiastic acceptance. Then, as knowledge deepens, widens and expands a retrospective, reflective period occurs as we recognise the frailties, errors, and theoretical contradictions in our thinking that then become challenged or supported by the available evidence base. It is with this in mind that Matt and I have taken the opportunity to reflect on the “Big Rs” event that enabled a discussion surrounding MSK Reasoning, Responsibility and Reform.

We have taken some days to consider our own thoughts on the event as we wanted to complement, support but also challenge some of the conclusions proposed. It is with balance that we support the wave of spirit and verve that was undoubtedly a feature of the day, but as in all new ways of thinking, Challenge, Critique and Consideration (the Big Cs if you like) are just as important in providing a levelness that we believe is vital to a real sustainable dialogue.

It was a pleasure to receive an invitation to attend the event which was co-hosted by Connect Health and Chews Health. I was very pleased to take part and was curious to how the day would pan out, how I would feel about it, and most importantly the next steps to be generated.

I was excited by the nature of discussion surrounding reform in MSK but held some reservations regarding the corporate nature of sponsorship and any conflicts of interest. This discomfort remained, however, the organisers must be commended for bringing individuals together to really start addressing some challenges we have within our profession.

I thought Jack Chew put forward a well-thought out and transformational proposal around the concepts of change, and he certainly has really walked the walk with how he and his team are working towards changing the professional landscape. Connect Health have developed a data-warehouse that is big and compelling when taken at face-value, and again they should be commended for trying to move the profession forward with a number of innovative concepts and investments.

As part of the agenda, data was presented and methods of assessing “quality” and “good practice” were subsequently discussed. A strap line I heard given through the day, “if you can’t measure it you can’t manage it” made me reflect, as this ethos is in some conflict with my own beliefs about what our profession needs to consider as a process of change and evaluation.

In my opinion, the management of a patient does not need a measurement/number to understand it, and therefore manage it, I really believe this. Perhaps when making a case for an intervention based product or service within a tender process, then the numbers will matter the most, and I absolutely understand their need, however when it comes to understanding what good practice looks like just basing it on an outcome/ number to make that conclusion is in my opinion too narrow and naïve.

Any understanding of a good treatment outcome should not be accepting of that fact, to develop a deep understanding we must ask the question of why was it successful? Many treatment interventions in Physiotherapy that are clinician-led have moderate or poor efficacy but our profession has individuals who profess to see amazing outcomes with certain modalities. It is now in our nature to discredit this as poor evidence, however I would propose we look at why the outcome has happened and make the hypothesis that the patient/clinician interaction and communication/expectation (some call it placebo, others name it non-specific treatment effects) is therapeutic in action and should be the underpinning skill in our profession. This treatment effect is a challenge to measure so by the account I heard it can’t be managed. It must, however, in my opinion, be accepted, learnt from, developed and installed as the marker of great practice. The treatment may be dropped as lacking efficacy and this is right, but the clinician’s ability to be therapeutic them should be celebrated, understood and shared.

Understanding or accepting that “treatments” are strongly psychological, emotional and behavioural means that the binary assumption that outcomes from 1000s of patients are due to certain treatments being effective and others not is chronically lacking in interpretation. It is right that we as a profession look at treatments critically where we are unable to provide a sensible rationale, I would advocate and strongly support this notion, but what I think is desperately needed is an improved understanding of the patient-clinician interaction, and how clinicians in everyday practice can begin to use these “soft-skills” (horrible term) as key elements of the successful treatments rather than solely on the traffic light system that was presented to me at the “Big Rs” event.

When there are pockets of good practice, look firstly at the clinician, why are THEY so good, not what treatments they offer. Look at their skills as a human, not as a treatment applicator, look at the way they empathise, listen, communicate, empower, and develop relationships. This is the context of the treatment. Any service (in my opinion) wanting to develop must understand the patient narrative, the lived experience with pain, the culture of the healthcare journey within their own service. This is the baseline from which treatments (in whatever format that is) can then begin to move a patient in a positive direction. The Health Foundation use this type of picture which I think nicely informs how I would like to see the discussion move towards.

Health Foundationhttp://personcentredcare.health.org.uk/person-centred-care/overview-of-person-centred-care/putting-person-centred-care-practice accessed 21/11/2017

I did not hear any of these features until the discussions continued over a few drinks at the end of the evening, and for me, this should be central to delivering the care our patients really respond to. Once this is a central feature to us and we become Physio-behaviourists and well as Physiotherapists, we can then drive out the ineffective interventions that have no mechanical, biological, anatomical sense to them, and we will hopefully allow our MSK teams to grow confidence in direct person-centred care rather than the production of a numbered outcome.

I don’t know what the answer is, I am very happy though to be part of any transformational movement, but I do feel we need further cultural transparency/clarity on our beliefs (and patient beliefs) regarding what makes a great clinician, not a great treatment. This, I believe, will then build improved outcomes, followed by the eradication of poorly evidenced treatments and the further development of an evidence base that accepts that numbers and measures do not always singularly direct treatments, and this finally needs to be inherent from within our students, professional leads, academics and clinical communities.

Neil Langridge

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Matthew Low

Conclusion

Matt and I are very much behind the notion of challenging treatments and approaches that hold no value, and cannot be rationally explained. What we do propose however is that we take a step back and consider the wider conversation before rapidly making judgements on interventions in a binary way. We think that the reform that we should consider must involve the understanding of knowledge and how evidence can be applied, person-centred care being held at the centre of our treatment choices, and the appreciation of social construction and how this leads to therapeutic relationships that ultimately inform outcomes.

We undoubtedly found the event engaging and thought-provoking, and we are enjoying the sense of debate, discussion and movement that it has gathered. What we do propose in support of this is a strategic model of reform that is well thought out with consideration of all factors that could influence the decisions our profession makes surrounding what makes good practice, and how that can be articulated sensibly and clearly to all relevant stakeholders in MSK medicine and rehabilitation.

If the profession is going to reform then this must be inclusive, transparent with declared conflicts of interest, as well as strategic and pragmatic. We look forward to seeing what happens next.

Dr Neil Langridge, Consultant Physiotherapist @neiljlangridge

Mr Matthew Low, Consultant Physiotherapist @MattLowPT

References

Machado G, Maher C, Ferreira P, Pinheiro M, Lin CWC, Day R, MacLachlan A and Ferreira M (2015) Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials. BMJ 350:h1225

Machado G, Maher C, Ferreira P, Day R, Pinheiro M and Ferreira M (2017) Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of Rheumatic Diseases. 76: 1269-1278.

Mathieson S, Maher C, MacLachlan A, Latimer J, Koes B, Hancock M, Harris I, Day R, Billot L, Pik J, Jan S, and Lin C (2017) New England Journal of Medicine 376: 1111-1120.

Carr, W and Kemmis, S (1986) Becoming Critical. Education, knowledge and action research, Lewes: Falmer.

Gabay J and Le May A (2011) Practice-Based Evidence For Healthcare. Clinical Mindlines. Routledge. Oxford.

Kerry R (2017) Expanding our perspectives on research in musculoskeletal science and practice. Musculoskeletal Science and Practice (32) 114-119.

 

 

Motor Control in Musculoskeletal Physiotherapy: A Concept Analysis

A few people have contacted me with regards to my recent poster presentation that I gave at IFOMPT 2016 in Glasgow.  Below is the content of the poster, please feel free to ask questions or post comments in the comment section or via Twitter @MattLowPT.

by Matthew Low, Dr. Nicola J. Petty, Dr. Clair Hebron
University of Brighton, School of Health Sciences, Eastbourne, United Kingdom

Background

The term motor control is used commonly in physiotherapy research and clinical practice however the meaning of the term is unclear. A systematic review of the literature revealed variation in the use of the concept of motor control within and between the specialties of the physiotherapy profession. In addition, the literature identified that motor control is used interchangeably with terms such as neuromotor control and core stability. The ambiguity of the term may cause miscommunication and misunderstanding in physiotherapy education, research and clinical practice.

Purpose

To clarify the concept of motor control and its use in musculoskeletal (MSK) physiotherapy practice.

Method

The evolutionary method of concept analysis was used to investigate the socially constructed concept of motor control. Literature between 2009 to 2014 was selected from CINAHL, AMED and Medline databases to provide contemporary, peer reviewed and relevant data on the concept.

Two hundred and ten abstracts were reviewed from which 50 studies were included in the analysis due to their relevance to physiotherapy practice (figure 1). An inductive process of analysis was used to collect the attributes, antecedent theoretical models, consequences and related terms of the concept of motor control.

Results

Forty-one different attributes of motor control were identified in the literature across the musculoskeletal, neurological and paediatric physiotherapy specialty areas. The highest prevalence of research articles that used the concept of motor control was within the musculoskeletal literature (n=35).

The term motor control was used interchangeably with neuromuscular control, neuromotor control and core stability (table 1).

Four clusters of attributes were interpreted from the literature; movement performance, structural, equilibrium and cognitive/perceptual attributes. The musculoskeletal literature had a greater number of attributes within the movement performance (57%) and equilibrium clusters (23%). The neurological literature had a high number of movement performance attributes (70%) with the paediatric literature having an even spread of movement performance (35%) and equilibrium (25%) attributes but the greatest proportion of cognitive/perceptual attributes (45%). Both the neurological and paediatric speciality areas had no structural cluster of attributes referenced in the literature (see figures 2, 3 and 4).

The MSK literature tended to focus on the balance between movement performance and movement stability with a greater focus on structure whereas the neurological physiotherapy literature tended to focus on the function and purpose of movement. The paediatric physiotherapy literature had a tendency to focus on individuals’ interactions with the environment to provide developmental learning opportunities.

The results reflect the underpinning antecedent theoretical models of motor control in each of the specialty areas. The neurological and paediatric literature were based upon the neurodevelopmental and motor learning theoretical models.

The majority of the MSK literature focused on spinal rehabilitation (n=26/35). Eighteen of the 26 spinal rehabilitation research papers used Panjabi’s spinal stability model as a fundamental theoretical basis for this research. The consequence of this facilitated the development of the surrogate conceptual term ‘core stability’.

Figure 2. A word cloud representation of the attributes of motor control in the Musculoskeletal Physiotherapy literature.

 

Figure 3. A word cloud representation of the attributes of motor control in the Neurological Physiotherapy literature.

 

Figure 4. A word cloud representation of the attributes of motor control in the Paediatric Physiotherapy literature.

Conclusion

Motor control is a broad, vague and ambiguous concept that is open to interpretation. There is inconsistency in its meaning within and between physiotherapy specialities. The use of the concept of motor control is determined by the context in which it is delivered, including its underlying theoretical model and the time in which the research was conducted.

Implications

The lack of clarity of the concept of motor control could be problematic in clinical practice, education and research resulting in an inappropriate application or interpretation of the concept. A recommendation from this research paper is that a Delphi study may be helpful to bring consensus to the concept of motor control within physiotherapy, which in turn, could inform future theoretical model(s) to be developed.

Key-Words: Concept Analysis; Motor Control; Physiotherapy Theory

Funding acknowledgements: Not applicable

Clinical Reasoning in the Management of LBP – A Personal Exploration

I have an interest in clinical reasoning and attended a workshop run by Peter O’Sullivan; it sparked ideas on how multiple classification systems could be used simultaneously to, perhaps, gain further insight into a patient’s complaint. I must declare that Peter and his team have had a huge influence on how I practice and I would like to acknowledge and thank them in this blog. In fact, the clinical reasoning tool I use is based on the cognitive functional therapy approach following the workshop that I attended in 2012. We recognise that lifestyle, physical, psychosocial factors, pain mechanisms and their manifestations as well as beliefs, thoughts and feelings affect the therapeutic encounter. However, how can we bring this together?