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

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

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

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

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

ML Multifactorial

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

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

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

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

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

ML Vector model

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

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

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

Matthew Low.  Consultant Physiotherapist, NHS

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

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

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

reasoning2

The following is my statement on ‘Reasoning’:

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

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

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

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

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

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

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

Matthew Low, NHS Consultant Physiotherapist

responsibility1

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

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

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

 

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

 

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

 

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

 

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

Neil Langridge, NHS Consultant Physiotherapist.

The Professional Dialogue: A constructive antidote to a combative climate.

 

Guest Post by Dr Neil Langridge, Consultant Physiotherapist NHS.

I recently had the privilege of attending and presenting at a conference overseas, meeting numerous Physiotherapists from multinational backgrounds. They were keen to collaborate, learn, develop and discuss. They were fantastic in their ability to listen, debate, and be critical in a professional way that made knowledge translation and critical review a pleasure rather than a trial. On my return it made me consider the UK Physiotherapy professions’ approach to building on knowledge, and how especially through social media we conduct discussions which inherently are on an international stage. It made me really consider how these are subsequently digested and the impressions our words, and approaches to professional development are viewed.

We work in an ever-evolving profession. Whether you are a new graduate or near retirement, the process of change is continuous. Over time this has happened at different speeds and has been influenced by “movements”, beliefs, individuals, social need, politics,… this list can go on. National development of new models of care has led the profession into different ways of working across many disciplines with a view of supporting patients and colleagues to deliver new and better ways of managing numerous and diverse patient populations.

The responsibility of the profession is to be ready to help, support and hold an offer that allows other professions to realise that offer with us and utilise the skill sets we have. In engaging with other professional groups, national bodies and internationally we as a profession have to ensure the offer is credible and we are seen as credible partners. There are many ways to present as credible colleagues, and one way is how we critically evaluate our practice and subsequently translate that into new ways of working. As part of the panel discussing responsibility at the up-coming 3Rs event I felt it pertinent to consider my views on this subject and I thought I would share one element, which is professional communication with anyone that is interested.

What has really alerted me of late around this in trying to gauge a sense of where we are as a profession, and how we possibly are seen externally and internally is the responses within Social Media inclusive of discussions, blogs and statements. I have always been comfortable in countering arguments, putting myself into situations where I am likely to be confronted by strong opinions and beliefs, and therefore I have always supported anyone’s right to offer an opinion and to stand by it if it is not illegal, immoral or unethical.

What I have come to realise is that some professional discussions seem to be led by emotion when it comes to challenging outdated practice or beliefs. These emotions seem to be led at times by anger, antagonism, and the under-mining of others, overall the context is very confrontational. I believe passionately that we have a responsibility to challenge internally and be critical of what we do and this freedom of speech is critical to the change process.

But, how does freedom of speech interlink with professional dialogue? They are not separate, but should be viewed as a contextual choice dependent on the social situation. This should be tacit without the need for explicit rules and as such should be a natural evolutionas a professional in practice. This is a question that seems to come up regularly, and is generally answered with a retorts such as; you choose to take offence and swearing in professional discussions is positive practice. It seems if you are thought of as being “outdated” then that means others have a right to “call people out” and we should all welcome that because that is the right thing to do for our profession. So let’s consider that in the context of a wider world view. Medical colleagues, national bodies, international groups and professional colleagues, all would wish for best practice, critical thinking and the progression of healthcare for patients, and they would wish to discuss this, learn from each other and share knowledge. How do you think they would wish to do that? Are we offering the right environment, the best external view of our profession and the atmosphere that encourages discussion?

Argument NL blog

I believe we need to seriously consider the inter-relationships of professional dialogue and behavior and the rights to expression. Perhaps it is worth reflecting on the virtual professional learning communities you are involved in? One of these is Twitter, and as such it is worth considering what the value of this is to you as a clinician. These types of professional learning communities have been described as;

“A group of people sharing and interrogating their practice in an on-going reflective, collaborative, inclusive, learning orientated, growth-promoting way”.

I believe that Social media provides this really well, however are the discussions you see or are involved in “growth-promoting and learning orientated”? What I also believe is that as well as having a professional responsibility to critically drive change from within the profession, we also have a responsibility to not be so aggressive in that mission of practice evaluation that it actually stifles behavioral change and in fact implodes on itself because it is led by emotion rather the cognitive empowerment of the profession.

It is easy to create an emotional response, be angry, confrontational, be threatening; making people think requires more than that; it requires clarity, reasoning, giving individuals the freedom themselves to consider their positioning in a non-threatened way and most importantly, their freedom of professional dialogue. Angry responses limits others and so does not encourage change, in my opinion those that angrily, aggressively sound the horn create an uncompromising environment that can only, ultimately limit some of the change behaviors that those that shout are championing for. It seems to me ironic that some of those pushing for change do so in a manner that actually drives the opposite.

work-together NL

Through communication we construct our own social realities and these then shape how we communicate, this can make a circle and this can become a vicious circle, bouncing around the same arguments, with the same outcomes and no effective change occurring. So, let’s consider a change?

Tannen (1998) speaks of “argument culture” expressing concern that confrontational communication can be counter-productive and self-perpetuating. It limits deep engagement and “Stimulates ritualised opposition that reinforces antagonism, this preventing the collective exploration of underlying complexities. These exchanges tend to escalate, polarising participants…in other words, the argument cultures impedes dialogic conversations, and creates the perfect stage for the performance of entrenched monologues”. The diagram I have put together below I hope gives my blog some pictorial interpretation. If you were a patient listening to your clinician who were about to assess you discuss their profession, where in the diagram below would you expect/hope those clinicians to sit?

Screen Shot 2018-04-08 at 20.15.33

In the end using direct opposition tactics to achieve change may work for social movements, but in professional practice, identity and development I would propose that confrontational attitudes, attacking approaches and undermining manners only provide opposition and not a vehicle for change. I am an advocate for change, development, critical review and challenge but not at the expense of our professional courtesy. The professional arguments we have need to be built on credible dialogue, a willingness to explore and debate and provide a context that encourages the communication, not suppresses it. With this in mind I believe it is always worth considering the next interaction, the next discussion, the next blog etc and be analytical and critical in a way that encourages professional dialogue and always considers how our external/international colleagues may view the work of the profession, the future may rest on the words we all write, and emotional responses we control.

1 Stoll et al (2006) Professional Learning Communities: A review of the literature. Journal of Educational Change. 7 (4) 221-15.

2 Tannen D (1998): The argument culture. Changing the way we argue and debate, London: Virago Press.

3 Kerry R (2017) “Physio will eat itself” https://rogerkerry.wordpress.com/2017/04/24/physio-will-eat-itself/

 Dr Neil Langridge, Consultant Physiotherapist NHS.

 

The Problem of Pain 14th and 15th of April 2018

Dr Mick Thacker

PhD MSc Grad Dip Phys Grad Dip MNMSD FCSP

 *Only Course in 2018*

Mick Thacker Photo

 

Day 1

Session 1 – The Problem of Pain

This session will look at the “folk” perspective of pain as indicative of an unwanted but necessary experience. It will also address pain as a clinical challenge and as a threat to our professional confidence and knowledge base. It will comprise a series of problem statements that the rest of the course will address.

Session 2- Models of Pain

This session assesses and critiques the traditional and existing models of pain and nociception. Including the Pain Gate Theory, Pain Neuromatrix Theory and Homeostatic Emotion models. It will also include an introduction to the Hard Problem, Free Energy Principle and Predictive Processing as a model of Pain.

Session 3 – Top Down before Bottom Up

This session assess the potential for cognitive penetrability on nociception and the emergence of pain. It will focus on how the higher centres are involved in the construction of the perception of nociception and the emergence or not of a pain experience. It will include discussion on

  • Higher Centre Predictive Modeling
  • Mature Organism Model Updated
  • Embodied Cognition and Pain

Session 4 – Somatosensory Error Signalling

This session will concentrate on the nociceptive system from the periphery upwards and propose a re-evaluation of nociception as a source of error rather then as a pure transmission of somatosensory information.

 

Sessions 3&4 combined introduce the challenge to clinicians that physical testing is never a true reflection of tissue states and the day will close with a discussion of the clinical challenge faced, in light of the topics discussed throughout the day.

 

Day 2

Session 5 – Precision Weighting

This session will focus on alterations in sensitivity and processing decisions throughout the neuraxis. It will deal directly with central and peripheral sensitization, nociceptive modulation and the analgesic experience.

Session 6 – Clinical Reasoning

Several models of reasoning will be discussed and ultimately I will demonstrate that at present no model is able to fully integrate the ideas from day 1. I will present a new model of reasoning that integrates predictive processing as a theory into clinical decision-making and management.

Session 7 – Thoughts on Management

This session will consider how we should manage pain based on the content of the previous sessions. It will directly deal with constructs such as hands on/off, physiotherapy as pseudo-psychology. Mindfulness and other emerging treatments will also be discussed.

Session 8 – General Discussion and Summary/Feedback

This session will be an open discussion allowing questions, criticism and banter!

 

Location

Lecture Theatre in the Education Centre of the Royal Bournemouth Hospital

 Price: £220 Student Prices (valid ID required) £150

Refreshments provided. Parking available

Contact:

Owen Mc Caughan

Owen.mccaughan@rbch.nhs.uk

01202 704456

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.

Embed shared decision making Health Foundation

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.

Traffic Light Connect Health

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

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

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

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

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

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

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

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

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

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

Process of transferring knowledge into action

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

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

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

 

 

What does the future hold for special interest groups?

I am a proud member of a few special interest groups, namely the Musculoskeletal Association of Chartered Physiotherapists (MACP) and the Extended Scope Practitioners (ESP) network and was a member of the Society of Orthopaedic Medicine many years ago. There are a number of special interest groups that one could join as a physiotherapist. I am sure that this is the case for other allied health professionals as well. This begs the question of what role special interest groups have, especially in the context of an ever-changing clinical, social, political and educational environment. In the spirit of critical thinking, it is worth exploring multiple alternative and counter perspectives to gain greater insight.

Critical Thinking.001

Therefore, there are arguably no better professionals to provide a viewpoint than Dr Clair Hebron and Dr Neil Langridge as they together have a wealth of clinical, academic, educational and research experience. Please enjoy reading their collaborative work on the topic:

 Making it work: What does the future hold for special interest groups?

 Organisations in health-care may inform and create the structure by which we work. This is enabled   by the provision of strategies, authority, work processes, communication and cooperation. An alternative view to this may suggest that organisational structure stifles practice and development due to bureaucracy limited by rules and procedures. How we view the organisations that we work within, and how they in turn support clinical practice plays a role in how the profession develops, yet any individual that is part of an organisation and wishes to see development needs to perhaps understand the culture of that organisational group and decide whether it is one of innovation and change, or is change resistant.

Within Physiotherapy there are a number of relevant stakeholder groups that when integrated lead to a structure by which practice can be conducted safely such as the Health Care Professions Council and the Chartered Society of Physiotherapy. These groups are further linked to professional practice by local organisational cultures such as NHS Trusts, private health-care, professional sport and academia, and with the support of research evidence this leads to the development of practice as well as the individuals themselves. The NHS and health-care in general is in permanent re-organisation, re-engineering and design, and it is well documented that change resistance leads to a lack of strategy and vision, yet it seems the key in dealing with change apathy/resistance is to assume that change becomes routine, and to survive an organisation has to assume that this is the default position.

Musculoskeletal physiotherapy has seen a huge expansion of research and underpinning knowledge that provides an ever growing supportive framework from which practice can be grounded, and also developed. Musculoskeletal physiotherapists have developed skills and knowledge that define themselves separately from other elements of the profession, and similar to other areas of the profession is in a constant state of evolution. The core of musculoskeletal practice involving assessment and treatment remains constant; however the extension of practice has also been a feature of flexible, responsive change. The advancement of practice has therefore led clinicians to be members of numerous special interest groups (SIGs) and this multi-membership could be argued to be unhelpful when evaluating and leading further advances in scope. SIGs sit within musculoskeletal physiotherapy and attract similar minded individuals to create organisational structures by which exchanging of knowledge, values and beliefs leads to a validation of one’s own approach to patient care. These interactions and clinical exchanges create sub-cultures that in essence have similar goals, mainly improvement in musculoskeletal healthcare, yet also defining them differently to other similar musculoskeletal special interest groups by description linked to history and previous leaders in that particular field. Commonly, this is an individual, such as Cyriax, Mailtand, Kaltenborn and McKenzie, who by clinical evaluation, research and teaching created separate musculoskeletal sub-cultures and approaches, dominated by their experience, knowledge and beliefs. This has led to the expansion of SIGs that are all musculoskeletal in origin but hold different paradigms in method. There are a number of SIGs all with separate identities involved in musculoskeletal physiotherapy healthcare all having separate committees, constitutions, aims, goals and agendas, with the primary goal being to serve the practice of members in each particular group.

A SIGs success however is not just in its history, it is in its future and without expansion and direct relationships with stakeholders, such as patients, GPs, commissioners, students, social care, and the voluntary sector, it could be argued that these groups will have no direct influence on a national scale. Are we at a point where the general public and all relevant stakeholders have no idea what the point of so many SIGs are, or perhaps don’t feel it impacts on them and really what actually is required is a joined up approach and a single community of musculoskeletal practice, that is led by collaborative evidence rather than historical beliefs and concepts. Should professional groups begin to move towards something far more inclusive and representative and be brave enough to deconstruct some of the rigid barriers, to provide a substantial musculoskeletal group that really can influence, lead, develop, improve and support clinicians in providing integrated musculoskeletal health-care?

Is it time for special interest groups to redefine what they are in existence for, and to begin to expand and collaborate together with a vision and a strategy that looks ahead at what a substantial group could do to support the ever-changing face of health-care need? Collaboration leads to greater knowledge, far more constructive research support, strength of voice and ultimately an organisation that has a culture of change rather than individual groups that support the membership but perhaps could do so much more in advancing the evidence base and being a “go to” organisation for all national and international musculoskeletal issues. Perhaps it really is time to consider a community of practice group which is described as group of people who share a craft and/or a profession. The group can evolve naturally because of the members’ common interest in a particular domain or area, or it can be created specifically with the goal of gaining knowledge related to their field. Disbanding boundaries, opening up memberships, creating a sub-culture of openness about practice enveloped in best evidence and moving away from the bureaucracy of the number of musculoskeletal groups is a provocative notion, and challenges individuals who wish to remain specifically “linked” to certain described methods of practice, however, do patients, GPs and commissioner’s for example understand all the specific groups in physiotherapy? If the answer is no, then perhaps it is up to us all to make it clear, understandable, accessible and valuable. To do this well is it time to provide one musculoskeletal group/community of practice that really does represent all and delivers real value to our national organisations and patients and can therefore be the way in which musculoskeletal physiotherapy leads the way in a multi-disciplinary musculoskeletal community.

“Progress is impossible without change, and those who cannot change their minds cannot change anything.”  -George Bernard Shaw

Dr Neil Langridge, DClinP, MSc, MMACP, MCSP, BSc (Hons) Consultant Physiotherapist, Musculoskeletal services, Southern Health NHS Foundation Trust, neil.langridge@southernhealth.nhs.uk

Dr Clair Hebron, PhD, MSc, MMACP, MCSP, BSc(hons).Senior Lecturer Physiotherapy Physiotherapist at the Leaf: http://www.leaftherapy.co.uk Course Leader MSc Neuromusculoskeletal Physiotherapy and MSc Professional Health and Social Care Practice. University of Brighton

I would like this post to create an opportunity for discussion and debate.

What is the future of special interest groups? Is there need for a change in thinking that represents a larger group of professionals to one common goal, one which is the wellbeing of the people we are trying to help?

Please feel free to leave comments and contact myself (@MattLowPT), Clair (@c_hebron) and Neil (@neiljlangridge) on twitter for further debate as much as the platform can allow and once again, thank you for reading.

The Importance of Language

Apologies for not blogging for so long but I am back with a few more perspectives on physiotherapy. Following my first blog on concepts and the importance of their clarity, I thought that I would reflect on the meaning and perception of words from both the clinicians’ and patients’ viewpoints, specifically the words used to convey information to patients with low back pain (LBP).

Did you know that it may take just 39 milliseconds to form a first impression of somebody? (Bar, Neta and Linz, 2006) A bad first impression may take some time to change and communication affects every clinical encounter (Roberts et al, 2013)– definitely worth pondering! (more…)