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Motivations and Change: The Coaching Physiotherapist

This blog has emerged from a range of sources and an interest in how physiotherapists can utilise coaching skills into patient care.  It also considers how this can then develop into day to day practice with teams and the wider health-care community.

Debates surrounding the “Hate exercise, Love activity” campaign driven by the CSP, as well as the concept of exercising through pain and around the theoretical proposals of “windows of opportunity” have also made us consider the links between coaching, motivation and the other issues surrounding these discussions.

Motivation-sign-with-a-beautiful-day

This discussion stems from an interest in “self-determination theory” (SDT).  SDT can be traced to humanistic psychology that emphasises an individual’s effort toward self-actualisation, which is the point where the realisation of a persons potential transpires. It is formed via the premise that as long as the basic psychological needs of an individual are met then a natural “growth” will occur.  SDT also relates to how people perceive their locus or control, which is the extent to which an individual views their own behaviour, perceived by internal factors (interests, values and identities), is in relation to external factors such as other people’s demands and regulation through the environment.

self-growth

As clinicians who wish to help our patients, we are in a constant flux with respect to helping an individual move towards self-actualisation.  SDT theory argues that as humans we require three basic psychological needs to be met; autonomy, competence and relatedness  and when these needs are satisfied, then self-regulation creates a sense of well-being and engagement toward their goals.

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Autonomy can be described as being in control, competence  is the need to be effective and relatedness  is the need to feel valued and connected with others.  It is also suggested that if self-regulation is not achieved then individuals may develop patterns of behaviour that offer short-term benefit but may not realise their long term goals or achievements.  These patterns of behaviour may manifest through feelings of fear, guilt or through the pursuit of an external reward.

self-determination-theory

In physiotherapy we may have to be aware of unwittingly developing these feelings in our patients, such examples may include:


“You must do your exercises to help you, if you don’t, how can you ever expect to get better!”Fear

“It is your responsibility to do these exercises! If you don’t then we cannot help you”Guilt

“If you do these exercises, we can show you have tried, then we can justify asking for a scan, because we have moved through the right process”External Reward


So, how does this relate to many of the discussions around exercise or activity, having a “window of opportunity”, or pushing into pain?

Importantly (Gagne and Deci 2005) & (Spence and Oades 2011) speak of a vital fourth motivation, integrated motivation, where the individual experiences fun and enjoyment from a goal that was extrinsically set.

These concepts, we propose, link to the exercise prescription we offer patients. It suggests that the first three motivations (fear, guilt, external reward) will not lead to the three required; the need for autonomy, competence and relatedness and therefore will not lead to internal motivation.  An integrated approach, i.e. finding what the individual enjoys (internal reward) and make it relatable to their goals, and then motivation led by the individual is far more likely to happen.

Screenshot 2019-08-31 at 22.19.40

So, asking a patient to stand in a room on their own, repeatedly doing a movement over and over again, experiencing pain based upon the premise that it may help, could be conflicted.  The reason that it could be conflicted is that on the one hand, the movements may build power, strength, endurance, flexibility, however on the other, unless it leads to a feeling of control, effectiveness and connecting to others then the chances of the physiological changes observed in studies having any long term benefit is compromised. Of course, if the exercise can be experienced to offer these three needs, irrespective of the pain experienced, and manifest in a sense of reward, then the result is likely to be more successful.  So, the context, meaning and relevance of the exercise must be acknowledged and accepted, and of course it might be a starting point, so we are not suggesting that individual exercise plans are wrong, far from it, rather what we are saying is that they need to meet the psychological needs as well as physiological aims.

Therefore, when developing an exercise programme, the activity and its environment as well as the motivation and choice for the individual will need to be taken into account in order to meet these psychological needs.  This may improve compliance and become an integrated part of life, rather than be regarded as a treatment.  This is far more likely to create a sense of self-actualisation and reach a person’s full potential.

So perhaps, the “hate exercise, love activity” concept is really just a real world self-determination theory model that allows therapists to be wider and more person-centred in their exercise prescription.  The development of social prescribing parallels this and we may see a shift from gyms, and weights to parks, bikes, and rambling (for some of course), as self-actualisation can absolutely come from the gym and heavy exercise, but in the right group and social context.

The term “window of opportunity” is so often linked to hands-on treatment, and is actually in our opinion, a far wider and deeper concept.  It is when changes in behaviours or beliefs lead to the individual having the support to meet their psychological needs.  It is when a humanistic coaching approach opens up the opportunity for change through the clinician-patient relationship.  The window is never opened unless a humanistic coaching process is initiated, and so irrespective of our treatments and their proposed effects, it must be built upon a coached approach to the care episode.

Developing the environment for change requires taking others perspectives into account, acknowledging their feelings, minimising pressure and offering choice that make sense to the patient within their community.  There is no reason why a short term pain relieving intervention offered in the appropriate context should not help this, however, we must remember that, although these treatment offer pain reduction, it is the appropriate psychological responses surrounding this that offer the chance for change. The short term period of pain relief is described as neuro-modulationand it is suggests that one’s self is separate from our physiological being, and of course that is not the case, so perhaps we offer the opportunity for people to modulate themselves, alter the pain experience, and affect beliefs; we therefore, don’t specifically modulate nervous systems!

Good quality physiotherapy offers autonomy, and as such opens a psychological window that offers this opportunity, and as the “window” remains open the growth towards competence can begin.  With the development of competence (this could be confidence in a movement, increased integration of activity, improved engagement in tasks) the key is to then create the social support that offers the individual fun, enjoyment and the opportunity to feel valued (this could be increased social interaction, returning to work, or perhaps joining a club).

So, in summary we propose that some patients refer to activity as part of their normal life and we can see why, conceptually and psychologically, linking recovery to activity and not a pre-determined view of exercise can build upon SDT theory.  When patients are active, then they are of course exercising, but they are not limited by external goals such as repetitions, time and weight, they are influenced by internal integration such as enjoyment, interaction and fun and this perhaps is why the campaign developed this way.

External limited exercise prescription is a vital approach to recovery for numerous patients but perhaps it should be underpinned by SDT theory which may lead to the development of improved personalised exercise plans and improved outcomes.

Many of these concepts can be applied in our working environments and from coaching managers, athletes and staff we can utilise similar concepts across environments.

Neil will be talking about this and more at PhysioUK19 so if you are going, we hope to see you there!

 

Neil Langridge, NHS Consultant Physiotherapist

Matthew Low, NHS Consultant Physiotherapist

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Reflections of a Dinosaur: Big R’s, the patient narrative and a final thought on myths in the debate on manual therapy.

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Neil Langridge, Consultant Physiotherapist, gives his personal reflection on the latest Big R’s conference here:

I have just got back into work this week after the Big R’s event over the weekend in Manchester. I was wondering how it would go as I had been asked to provide a keynote talk on the place for manual therapy in contemporary MSK practice. On my panel was Karli Gibson, a very level-headed and forward thinking physiotherapist who I think has a lot to offer the profession, and Adam Meakins, a specialist physiotherapist in the management of shoulder conditions who has built up quite a following within the profession, and has developed many strong arguments regarding the case for change.

The event proposed some really innovative ideas, but most importantly brought together individuals interested in better care for patients, improving the MSK offer to the public and I felt, all in the spirit of working together.

I was fully aware that my presentation and the subsequent discussion was likely to be a bit stormy, the session was moderated by Mark Reid, who I thought did a really good job. I have to firstly tip my hat and really congratulate Jack Chew and his team, which also applies to the Connect team who equally supported the event. I can’t fail to be impressed individually with Jack, who undoubtedly “walks the walk”, he is very forward thinking, very passionate and very gracious in the way he works complex areas of discussion and debate. His work is fairly unique in my opinion within our profession, and more like him would only be a good thing. His team, Rob, Jack, Mark et al likewise, very sensible, but willing to challenge the status quo and build from within, an impressive group.

The Connect team were also very appropriately vocal and led some really interesting workshops which I thoroughly enjoyed, and there were some great discussions on orthopaedic triage, FCP and what advanced practice is. I am gladly linked in with them to develop further strategies concerning excellence, and I know it will be a pleasure to work with them. This felt a lot better than the last meeting where topics such as “eradicate ultrasound!” felt very narrow, so this experience was miles more positive.

The patient stories were really powerful and humbling, Joletta, Adrian, Pete, and Tina all contributed hugely, I think there should be a patient voice on every panel in the future. Martin, a very entertaining, driven, enthusiastic physiotherapist from Kenya gave a great insight into Physiotherapy away from these shores, a great perspective driving presentation.

So, I made my little speech and I addressed a few thoughts that run round SoMe and within the profession and also I learned what the panel’s view were, which was really valuable. So, what did I learn and speak about;

  1. The term “low-value treatment” applied to MT is not seemingly that true. It depends what you define as value and then if you base it purely on economics, surprisingly against usual care it fairs well against exercise and better than usual GP care in many MSK conditions. Societal value tends to suggest that applied hands on to certain patient groups are valuable to those individual personally. So, when individuals speak of high and low value, ask, what do you mean, valuable to whom, and by what measure? Try it, you may find the answer is not as clear as you thought.Value Price
  2. The “Window of opportunity” – I know many are not fans of this term when applied to MT, but it is my opinion it applies to every intervention, whether education, exercise etc. The break in the pattern behaviour, belief, understanding, or a change in the perception and emotional response. We then use this to set the scene differently for the patient. So, when individuals say MT inappropriately uses the “window of opportunity” analogy, then ask do not our other interventions use similar processes?Open windows
  3. MT disempowers patients? I heard the patient stories relaying powerful messages they heard about being “weak, unstable, needing a stronger core, things being in and out”. Its always cringing and saddening on the part of a professional to hear those stories. It’s therefore in the message and the clinician behaviour that disempowers, and of course, you can plainly disempower by just talking to someone, it’s not unique to MT. Of course MT has the potential belief system associated with that as it can lead the patient to believe they need to see someone to fix them; once again, that’s the clinician, not the treatment. The disempowering therapist can lurk under any treatment system.
  4. Adam was asked what he doesn’t agree with regarding MT, all of it, some it etc? I was in total agreement that massage should not be an NHS offer. In terms of well-being if individuals wish for that then I see no problem with them accessing this outside the NHS. Handshake
  5. He didn’t agree with techniques being used even in the clinical context when the patient is lying on the treatment plinth. He did, however, seem concordant with the use of hands-on in the facilitation of movement, which seemed to be in some conflict with the strong message “Manual therapy sucks”.
  6. The panel discussed Harm; Adam stated that MT was “harmful”. I was conflicted with a previous statement that suggested all MT should be in a spa, whilst then saying it was harmful, I was also not sure what is meant by harm in this context. If it is harmful then ensuring it is within a clinical context would be key and moving that out to your local hairdresser (as suggested) might not be such a good idea. I would agree that the language around MT could be harmful to the process and perception of recovery, but the vast majority of MT physically is not, and no evidence was proposed that supported the perception of MT as a treatment method being harmful to patients.
  7. So, MT in the sense of relaxation and well-being – keep it out of the NHS, use as part of ongoing health and well-being if that is something the patient values.MT in the clinical context I propose can be used when patients are fearful, limited by pain and have tried initial education, reassurance, and exercise. Then you can “play with some processing” aiming to give the patient a different emotional perspective towards their condition.
  8. MT will get challenged about – “what are the mechanisms?” Well, the simple answer is we don’t know. My proposal is that there is no single mechanism, and multiple mechanisms will be at play, their effect on a socially constructed individual cannot be just down to the mechanics or basic physiology. The really important point for me is that this (IMO) is the case for all interventions. Some have a greater physiological and anatomical understanding of the effects than others but in Physiotherapy do we really know all the mechanisms at play after exercise, education, reassurance? Two people can say exactly the same reassuring commentary and the receiver of this could react in totally different ways to that advice. Therefore, a “truth” in these interactions is a pretty tough call. We can suggest them, but we don’t really know the interactions of all the possible neurobiological, emotional, physiological mechanisms and that is not unique to MT, so some sense of perspective is needed regarding this argument. So, we base the nature of success on some theoretical proposals and patient-reported outcomes. The same for any Physiotherapy MSK intervention. Maybe it looks a little like the picture below?

Tangled

In the end, I really found the 2 days inspiring. Within the panel, Karli brought pragmatism to the debate which resonated well with me, whilst Adam was considered in his responses and I have said this before, I agree with many of his proposals, but for any argument, for me to be convinced, I need strong positions of belief to be flexible in how they respond to differences of opinion, so we can all see the multiple perspectives rather than the singular one. I feel this was a common theme of how we move forward, gaining the multiple views and then finding common-ground to help in professional growth.

So, many voices were heard, and disagreement will always remain, but that’s Ok and very healthy. I think without individuals who push the questions then the conversations would not be where they are, which is so much better as we move away from strongly held doctrines, philosophies of our practice and consider the future for an evidence-based profession which is grounded in the patient story.

Neil Langridge.  Consultant Physiotherapist.

“Passive” therapies: Responsibility; when, who and how?

A guest blog by Neil Langridge, Consultant Physiotherapist.  @neiljlangridge

I am looking forward to the up-coming “Reforming MSK Practice” event arranged by Chews Health and Connect Health and I have been invited to speak on “the place for manual therapy in contemporary MSK”. Initially my views were, “it’s been discussed a lot, can I add to this?” and “what I am I letting myself in for?”, as many of the audience will of course be of the view – “don’t reform it, just ditch it”.

Ditch it now logo

So, I decided to think carefully about whether a) should I speak B) if I do, what will my approach be? I also wanted to take into account the conversations regarding “passive therapies” in the context of reasoning and responsibility.  So, rather than being reflective I thought I would take a prospective stance and feed some of my thoughts into the debate prior to the event as a means to help me set out how to approach the heart sink topic that is “reforming manual therapy”, and I thought I would share these with anyone interested and potentially coming.

My first consideration (and really what this short blog is about) is to consider the understanding of what a passive therapy is. The term is really used a lot, and is used in numerous cases to describe a range of interventions. It gets linked with the term “low-value” and I thought this was worth exploring also at a later date.

It seems to me that some would suggest that “passive” is about the patient/service user etc as a recipient, is not activated and the responsibility of the “treatment” lies with someone else dispensing it (the clinician). The low value element may be that the costs to deliver the passive treatment do not impact on the costs of the pain and disability to society and the individual, and so provides a negative investment. Others may have different definitions but I will maintain those for now.

I think it is entirely clinically correct, morally appropriate and ethically sound to empower patients within our care to take control, self-manage and be activated towards recovery. This is without doubt a professional responsibility. It also seems good practice to me to hand the responsibility of wellness and recovery to the patient with information and education.

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Ok, so now to an alternative view, as I think this concept of passive and active is not as dichotomous as it has been presented, and as with all discussions, this one is  possibly a bit murkier, but with a lot more depth than just saying its one or the other.

passivesplash

Let’s start with some simple questions, or maybe not so simple. When and how is the responsibility for the condition, symptom, and injury handed over to the clinician, and if it is, should it be and by how much? When is this handed back? Why would a patient hand the responsibility of their condition over? Well, highly likely you encounter this every day, all the time? There are patients who want to know what they can do for themselves, attend with great self-efficacy and are just ready to be activated with the right advice. There is nothing passive here, and they inherently would resist treatments that do not enhance control. Fantastic, enjoyable interactions, great outcomes, high value (less intervention face to face, and generally good self-efficacy = gets improvement and returns to society in a more positive position so adds a positive element to the “value” argument). The treatment is therefore led by the fact that their natural Behaviour is active, their outlook is active and so the treatment is active (if defined as being patient–led).

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If society was like this 100% of the time the whole make up of support, social care, medicine and our culture would be radically different.  The reality is we live in a supportive health culture where choices of behaviour are available, in other cultures it’s not so flexible, and the support network is just not there. However, we are in a culture (NHS/Social Care system) where there is a choice of care approaches based on numerous factors within the individual, and from external influences that can lead to behaviour within the patient, that may range from be very willing and active to very unwilling and passive.

As therapists we address a lack of recovery with first-line measures, education, exercise and reassurance being the main-stay of this approach.

PExp2

I believe that the choices therefore between active and passive can be underpinned more effectively by not simplifying the concept into “is the treatment passive or active?”, but understanding motivations, behaviours of the patient and oneself as a clinician and the subsequent interaction of that therapeutic alliance, let me try to explain.

In many interactions we as therapists try to be therapeutic and start to activate those who have beliefs that are more passive about their treatment but also there are those who need, for a time, to hand over responsibility to others. The responsibility for their condition can be draining, tiring and the need to hand that over, is an ask for help, and when it happens the immediate feeling of well-being is clear, we see this all the time in the caring professions.  Just off-loading the problem can be experienced as therapeutic. Now at this point we have to make a clinical call, how ready is the patient to make the changes that are needed to move onto self-recovery? How active is their behaviour? Would a treatment delivered by a clinician to a patient enhance a process of recovery, or negatively affect it?

old rehab photo

If we have accepted the responsibility for supporting the patient, how we approach this is a case for clinical reasoning not a simple decision of dichotomy, such as “do a passive therapy or don’t do it”. Understanding barriers to re-engagement will be key, and give far more information than basing a clinical decision on a simple algorithm. The barriers to recovery may not be a case of a lack of motivation, a passive approach, or a resistance to change. It may be case of what I would describe as “condition weariness”. They have been living with pain and disability and all the stresses and pressures that come with that. The ask for help does mean they are not wanting active self-management strategies, but some may need a blend, a time where they are feeling someone else bearing that burden with them and taking a greater responsibility of the condition for a period of time.

Ever heard the term when a patient phones up with an enquiry “who is looking after you?” this perfectly describes a really important supportive responsibility. Ever been stuck with something and someone has said “I will sort that for you”, you know it would be better if they showed you how to do it yourself, but sometimes you just want to hand it over, it doesn’t mean you won’t, with advice, give it a go next time, it just means right there and then, you need the responsibility taken off you, and you relax and the pressure is less.

There are times I believe when we “look after our patients” via what has been described as a “passive”, using hands to support movement, using gentle movements to areas of the MSK system to aid a perceptual change, emotional alteration and facilitate an alternative pain experience to a task or function. This is passive in terms of not “patient led” but it is active in its emotional support if chosen and applied appropriately with the right information, explanation and language.

We share our treatments, we don’t / shouldn’t apply them in silence and look to offer good psychologically informed measures that support the emotional side of the patient presentation. Initiating a time where they experience a reduction in symptoms, whilst being psychologically supported and seeing that their function can be altered can (in my opinion) be empowering as long as the so called “passive” intervention has active emotional support and is a on a pathway towards self-determination and is not over-complicated by mis-interpretation and pretentious, confusing explanations and language.

When we treat a patient and they believe they are receiving it rather than doing it for themselves it hands-over responsibility for a time to the clinician and this “break”, even if short gives possibly a freedom to re-calibrate their thoughts. That’s how I now see hands-on treatments; a break in the process that helps the individual re-frame the recovery experience, to see it differently, to have an alternative view. Some have described this as a “window of opportunity”, some really dislike that term, in essence, it’s a pause in the process, a change in the current behavioural response and this can perhaps means the patient sees the art of the possible enhancing autonomy and confidence.

In my opinion I am not changing anything with my hands really other than the influencing the body and minds’ perceptions, awareness and emotions towards their condition in ways that stimulate a range of sensations that if managed and formulated correctly, can be a positive therapeutic experience.

Lastly;

For me a “passive therapy” is a therapy that is driven by the clinician’s unwillingness to set a goal of autonomy and this subsequently feeds a lack of confidence in the patient. Therefore IMO, it is not the treatment that is passive it is the behaviour of the clinician that lacks activation. In behaving in a passive way and doing so when given the responsibility for the condition, these clinicians act unfairly, unwisely and inappropriately by not developing a strategy of responsibility handover.

Perhaps the wise clinician will know how much responsibility to take, when to take it, how to enhance it and when to hand it back, and this should not be seen as condition specific, but person specific.

Neil Langridge, Consultant Physiotherapist

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

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.

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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