What’s next for Physiotherapy: Euthanizing the status quo?

 

I recently carried the torch for the PhysioCPDRevolution by presenting some of my own musings and readings about what might be a direction for physiotherapy. Below is a slightly adapted version of the transcript I presented. The presentation was recorded on Facebook Live (here).

The PhysioCPDRevolution was also a year old and so I felt it was respectful to thank people for attending over the last year and in particular to my guest speakers Kirsten Glasgow and Filip Maric for their contributions.

I want to take us on a bit of an ontological journey with a bit of behavior mixed in. For those of us that aren’t familiar with the word ontology it essentially means the nature of being. So, it’s what we consider to be reality or real.  The following notes are primarily based upon my musing and readings within a musculoskeletal, pain science and life science realm. I appreciate what I intend to deliver may be somewhat out there, but I stress and empathise at the same time the importance of knowing this stuff. 

So, the title is what’s next for physiotherapy: euthanising the status quo. I pondered on this and sought counsel because I felt uncomfortable. I felt uncomfortable about upsetting the established order, that I was being too anarchistic,  but sometimes we need to introduce a touch of anarchy to create a a little chaos. And so I feel comfortable that the title is somewhat controversial, however in whatever way you interpret it, the status quo does conserve some stability within the profession, but in order to evolve there needs to be some chaos and complexity so to stir or shake things up. 

I should start by clarifying what I mean about status quo. Status quo means stasis. I might use a metaphor of a stagnant pond, If the flow of fresh water (ideas) reduces then too much of one thing accumulates and all other life dies, fresh water needs to flow through the pond to stir things up creating a complex and chaotic movement of molecules and so breathes new life into the pond. In the context of my blog I refer to status quo as adopting a single paradigm in particular the biomedical/biomechanical model.

However I am fully aware that there are different paradigms out there that people embrace.  An unfortunate observation is that we have a growing problem of new physiotherapy graduates coming out of physio school and leaving the profession within the first year because the “real world” is nothing like what they expected from what they were didactically taught at university.

So, I want to discuss things generally around change but also highlight a few aspects within physiotherapy. 

How important is change/adaptation? What I mean is, change is, well inevitable. Change is the natural order of things. It was Wayne Dyer who said, Change the way you look at things and things you look at change. 

Is there an argument for demonstrating that our current treatment methods have done very little to stem the increase in chronic disease? If something’s not working should we change it? As societies needs change so must our approaches. 

Let’s take something like back pain. Our current methods of treating back pain is still fundamentally based around addressing structure. Some might label this specific back pain as discogenic or myofascial or facet joint or neurogenic. So, We label pain presentations as being specifically to do with something or other, but back pain remains elusive. So, we might say it’s non-specific so it’s none of the above.

BUT!

On the other hand, we acknowledge pain is a multidimensional experience with multifactorial contributors from a variety of domains. So how can it ever be more specific than body part or body region pain? The issue may lie in our desire to reduce it down to something specific because it is easier to think categorically.  However, the world of pain is more complex, there are far more factors that are involved than structure alone in a pain experience, and so having a linear reasoning process is often not sufficient. Once we recognise that it doesn’t shut the only remaining door, it opens up a whole number of other doors that we can learn about that might contribute to someone’s pain experience. It helps to perhaps not clear the fog but maybe understand it better.

 

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For example we are familiar with the contribution of physiological processes such as the hypothalamic – Pituitary-Adrenal gland axis which is important in stress physiology, vaso-vagal responses, circadian rhythms etc, which set off system cascades. There are also psychological factors and sociological factors at play that have an effect on our physiology, something simply would be pro (and anti)-inflammatory cascades that occur from our interactions in varying social context and cognitive perspectives.

Interestingly, another question that arises from this is are we using a reasoning process or a formulation of real time factors? A reasoning process leads us down a body as machine path. A reasoning process is dogmatically coupled to body as machine.

In terms of physiotherapy’s current approaches such as passive treatments* (and perhaps even exercise), admittedly conversations and application about these approaches continue to revolve around the tissue or disease state with a vague and varying argument around pain control, windows of opportunity, symptom modification, facilitation of recovery and neurophysiological effects, but there’s varying levels of utility between individuals regarding these treatments/approaches, and these approaches fail to capture the broader perspectives of why, how and what influences a person’s behavior or implicit physiology. So, whilst the reasoning behind these treatments may confirm a particular set of biases (primarily in the clinician) another school of thought might suggest that they create dependency and we are pandering to the needs of patients.

But let’s consider a clinical engagement with people from a behavioural/physiological perspective. Essentially, we want to facilitate health behavior change whether that’s to reassure, provide counsel, discuss concerns and worries or place our hands on people. It’s all communication. We all have varying levels of responses/expectations based upon our previous experiences and interactions. From the client’s perspective that might be manual therapy, exercise, words, social situations. And where one school of thought might consider the consequences (increase in dependency of client) of said response to the stimuli (manual therapy), there are many potential variables that might increase or decrease a specific behavior be that dependency or facilitating independence and health behavior change. So, can we truly facilitate that through linear causal reasoning processes?

There’s that popular saying different strokes for different folks. So, in essence we should consider being less like batman using our utility (placebo) belt at whatever cost and think and formulate more like Batman’s rationale Butler – Alfred.

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Of course this asks us to embrace uncertainty and when an identity (often part of one’s schema) is rationally and logically threatened by the same mechanism (scientific inquiry) that one believed held the ground fast and firm underfoot… to whom, when and where does one turn? We turn to each other in our networks for support, guidance and empathy.

We all know that humans are not motor cars that the body as machine metaphor restricts our perspective of what or whom we are working with. 

Let’s look at another example – We claim to be the specialists in movement. Yet many of our methods of movement assessment have been refuted. We continue to make assumptions in our practice that correlation is causation. As such that too has been refuted by much research. So, you might be asking what now?

If we are truly the experts in movement then thinking beyond the biomedical/biomechanical is what is required. Models and frameworks have been proposed identifying that movement should be considered from a quantum level (molecules and cells) through too community activities, how movement sustains life, sparks curiosity and creativity, housing and connectivity with others.

Acknowledging the many factors that can affect movement at one end of a continuum to the other. This might include cognitive factors (such as catastrophising or fear avoidance), Emotional and psychological factors (such as anxiety or depression), Physical factors (such as protective behaviours), Lifestyle factors (sedentary behaviour), Environmental factors (worksites, climate change), Socioeconomic factors (financial, cultural, demographics, standards of living)

Humans have an ability to make choices based upon movement and social learning. And so, where a behavioural response might occur with an applied treatment (or stimulus) approach (stimulus – behavioural response) social learning theory implies that humans make decisions based upon our thoughts and experiences with said stimuli resulting in their behavior. This can allow us to make choices and decisions on whether we feel something works, thus provides a formulation and mould of our lived experiences. 

Understanding social learning facilitates a broader perspective of why people react, interact and present the way they do. This brings me briefly onto some of the issues around self-management approaches. Self-management has been referred to as a thing that has been imposed onto consumers or clients by so called experts. Essentially, making the client a passive recipient. Whilst self-management might be seen as a means to reduce healthcare costs it also expects the client to be fully responsible for their own health. Self-management is often delivered in a clinical setting and so there is minimal opportunity for expansion into social and occupational contexts.  What’s the solution? To facilitate flexible persistence, provide ways for people to be self-managing, provide access to resources, provide emotional support, affirmations, educate family members and work colleagues, remove stigmatization and facilitate connectivity.

We all have the ability to anticipate or have expectations based upon previous lived experience. Clinicians and patients. In a clinical setting a clinicians anticipatory mechanism is likely that of lived (clinical) experience + research, to that of the patient that is likely lived experience. And so, in our interactions with patients we hope to have a merging between the clinician and patient of those experiences (Yes patients although may not be aware of it use formulation too). 

Yet the use of evidence to primarily drive the clinician’s argument  does not necessarily account for the clients. And so, when we talk about providing windows of opportunity to evoke change we must consider through our formulation which of the biases (clinical PM vs clients PM) holds preference and how this affects the outcome.

There are many forms of communication found in and between living systems. The fancy term for this is biosemiotics. So, thinking broadly about communication that might be verbal, body language or movement and TOUCH. It is also cellular communication, physiology, growth, behavior and more and so from this we might broaden our thinking into how behavior and communication are interdependent. Louis Gifford’s Mature Organism Model is a wonderful example of this.

If we wanted to get really clever we might refer to this as a predictability model and consider why and how the inferences from interoception (sense of our physiological state within the body), exteroception (sense of stimuli outside the body), proprioception (movement awareness) and cognitions (thoughts) supports our ability to interact and react to our world view, or the interaction or communication of various systems drives our behavior and reasoning. Think Alfred!

So, will we euthanize the status quo? It’s unlikely that we will. Some dinosaurs do need to become extinct but it is likely that as the profession moves forward there will be a place for the dry needlers and the manual therapists but more so at the tail end of the profession. It will serve a purpose but likely a small one, even in dynamic systems, steady states are subject to entropy. The status quo would crumble and collapse without adaptation as society will demand it and so will the profession.

Think of it like that of a rattle snake. Manual therapy and Dry needling etc is at the tale end. It has it’s use (rattles) to evoke some kind of change. Most people faced with a rattle snake will back off, but some don’t, some keep coming back for more and more (crazy Australians usually). Eventually those parts of the tail are shed. 

Change happens over time innovation becomes conservatism and so perhaps the natural way will be that human nature will eventually nurture itself into a direction to benefit humanity. Consider liberal physios vs pureist physios. Liberal physios will nurture the profession, provide evangelistic ways for it to evolve and pureists will either have to evolve too or die off. We are seeing this in manual therapy where it is being viewed more from a neurophysiological perspective rather than a mechanical perspective. Eventually, I suspect clinicians will see that there are many other effects that occur simultaneously (think back to the predictability models) and so the narrative that accompanies the application will change (if not already). Anarchy certainly can and will create change but ultimately the profession itself will adapt because of the bigger demands of society.

Thanks to you all for taking a read, I’d love to hear what other people have to say

I want to thank a few people for helping me with this talk. I want to say thanks to the Deluded Gents and particularly Mark Hollis.  Thanks also to Blaise Doran and Dave Nicholls for their support, encouragement but most of all inspiration. 

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*Passive treatment refers to the patient being a passive recipient of care.