Author: Carl Davies
Before I became a Physio I completed a degree in Health, Exercise, and Behaviour Change. I focused almost entirely on human psychology and spent my placements with Clinical Psychologists working with people with Obesity, Complex/Chronic Pain, CFS.
When studying Physiotherapy, I was lucky to be part of an excellent course and cohort at Salford University. The course was structured to push students to think about person-centred, evidence-based care, and pushed self-management and exercise over passive treatments. It still (as all courses then did) taught mobilisations, massage and electrotherapy, but they encouraged their use as adjuncts to treatment rather than the overall solution. Whilst they didn’t say it, and the course didn’t contain any behavioural change and psychology, they alluded to personal activation being an important factor in treatment outcomes.
I graduated, quickly moved to MSK, before specialising in complex pain and stress-related disorders. I saw that the system was going to be slow to recognise the importance of psychology, personal connectivity and behaviour change and went on to study stress biochemistry before moving into system leadership and culture change within healthcare organisations.
Fast forward 10 years, the evidence-base is growing and ‘Physio culture’ is changing. Anyone who really understands how cultures or society changes knows that it isn’t quick. In fact, it’s frustratingly slow. According to the theory of the ‘Diffusion of Innovation’, the innovators will drive the early shift in paradigm. This will lay the foundation for a proliferation in evidence as the early adopters try and help shape the future direction. This evidence will be absorbed and the stage of the early majority sees us hit a tipping point, dragging on board the late adopters and eventually the laggards.
However, when it comes to changing cultural behaviour, it is not uncommon to see a period of conflict (think gun laws, slavery etc). It’s usually when sections within the early adopters/majority take it upon themselves to ‘demand’ change and the resistance from late adopters and laggards pushes back. There is no doubt, this form of aggressive lobbying can be very effective and is necessary when those behaviours are harmful (but usually influences changes to policy in order to push through the change). Whether it is necessary in a discussion around Physiotherapy treatment choices is a very different question, and is not the point of this blog.
Many of the people who have not quite ‘changed’ are certainly on their own journey towards change, and quite often the argument for defining having ‘changed’, the reason ‘to’ change, and exactly ‘what’ should change is far more grey than many believe.
The demand to move away from passive treatments to self-management is one such example. Physiotherapy seems as though it is in some form of ‘civil war’ at the moment, and I don’t think we are actually getting anywhere in the discussion. From a clinical perspective I see myself much more aligned to people who recognise the complexity of personality and individual behaviour. However, the argument seems to have been split into a dichotomy, with anybody commenting being lumped into one ‘side’ or another:
- Passive Treatments Do Harm (anybody who does them is a rubbish physio)
- Passive Treatments Don’t Do Harm (so therefore they are fine to use)
It is vital we recognise that it is far more nuanced than that and like most subjects it’s not black and white, but very very grey. I find the above ‘dualistic’ perspective infuriating and overly simplistic. However, I do not want to get drawn in to that debate because it’s polarising and unhelpful. Rather, we should consider shifting the conversation to two different issues:
- The personal activation of the patient
- The intention of the clinician
Patient Activation Measures are now reasonably well established. However, I still rarely see them adopted in clinical services. Instead, many physios simply make their own judgement as to whether that patient is “ready to take charge of their own health” and if they aren’t “that’s their issue, not mine”. Before we can truly understand what approach is most suitable for the patient, we should first ‘understand the patient’. Patients are individuals, with a lifetime of different experiences, belief systems and personal & social circumstances that determine how they behave and how active they are in the management of their own conditions. The biopsychosocial model (that so many of those demanding change seem to reference) does not include any component that says “you must be willing to take care of your own health or you don’t get treatment”. That’s why we still treat patients who smoke, are obese, or partake in other high-risk behaviours. Instead, the biopsychosocial model encourages all clinicians to recognise that psychological and social factors may actually inhibit an individual’s appetite to engage with more active treatments. If a patient needs the helping hand of passive treatment on their journey to acceptance of the need to partake and be active in the management of their condition, we should provide it. That’s how to achieve the best outcomes, but how we do that is the critical factor….
The intention of the clinician when delivering passive treatments is critical to this discussion. Let’s imagine I am going to take 3-6 sessions to get a patient activated to manage their own condition. During the first few sessions I provide some passive treatments (understanding that the patient finds that an important part of treatment so will help with making them feel listened to and understood), but during those sessions I take the time to understand their beliefs, deconstruct them and then re-educate them whilst offering a robust self-management plan. This is applying a behavioural change model (unfreeze, change, refreeze) to help shift a patient from one belief system to another. That is a very different approach to a clinician who is possibly (or definitely in some cases) wanting the patient to be dependent on them for treatment, and makes no attempt to engage the patient in their own care. Providing a passive treatment with the intention of allowing the patient to believe that said passive treatment was responsible for their improvement is wrong, there should be no argument about that. However, my personal experience is that the number of physiotherapists adopting this approach is very small. It gets even more complex when you start to explore the drivers behind the behaviour and why those ‘frustrating individuals’ won’t just simply engage “for their own benefit”.
To exclude ‘passive treatments’ altogether and ban them as ‘harmful’ without appreciating the nuance is throwing the baby out with the bath water. I remember numerous cases where a patient presented in my clinic having had “all that lifestyle, physio stuff and it didn’t work” and they commonly said “I know what works for me”. It was clear they had come for something and if they didn’t get it they wouldn’t be back. Pushing these patients to accept best practice when they are not in the psychological state to do that ‘is’ dangerous and ‘harmful’. In an example where they will only stay with you mentally (which you need for true behaviour change – to get them to see need for, and want to, change) if you ‘offer’ something passive you have 2 choices:
- Flat out refuse to give them what they need and say, “I’m sorry, I can’t offer you that treatment”. Bearing in mind that this patient will then likely go and seek somebody who ‘will’ give them that treatment. Which will ultimately perpetuate their problems.
- Bend your old rules to their needs in order to achieve the ‘overall aim’ of getting them to be more active in the management of their own condition.
Much of the narrative appears to be driven by Physio’s who have no experience in complex pain clinics. Many say “I see complex pain all the time” in their MSK OPD clinics, but they aren’t complex pain patients. They are patients with ‘complex MSK conditions’. I’m talking about the kind that have deep underlying psychosocial drivers for their pain. The type that after you build that rapport with, and gain their trust, you are able to truly understand these psychosocial reasons that underpin their complaint. It wasn’t uncommon for patients to disclose to me, for the first time, a history of sexual abuse. I could then help them get the support they needed from my psychologist colleagues – but doing that only works through trust. I wouldn’t ever get there if I hadn’t kept them ‘in the room’. Building trust with patients is more than saying “trust me, I know all the evidence and the evidence says…..”. We cannot employ the BPS model, if we choose to ignore the PS simply because it makes applying the best biomedical intervention difficult.
In summary, the conversation should not be “are passive treatments harmful?” but “can passive treatments be harmful if clinicians use them to encourage dependency?”. I expect the reason that we aren’t having that discussion is because it was answered a long time ago and Physiotherapists are overwhelmingly in support of that. So now the ‘purists’ are demanding a complete ban instead. It’s complicated still further because humans often work within complex systems, and complex systems are usually built around the culture. The culture shapes individuals at different rates and levels and it’s why we are so diverse. That diversity means that every patient you see is on a different journey towards acceptance from a psychosocial perspective (regardless of their underlying biomedical condition). It is our role to help those patients on their journey, by whatever means necessary, to achieve the resulting outcome of active ‘self-management’. The quicker twitter Physio’s start having a conversation about how we use our skills to help ‘change behaviours’, rather than which ‘treatments’ we choose, the better for all of us. Which is why this all comes down to behaviour change theory and leadership within systems……