PhysioTools creating PhysioFools? – Is exercise prescription software holding us back?

PhysioTools represents one of my earliest experiences working in MSK Outpatients. I will refer to PhysioTools throughout this blog but you may use other exercise prescription software…they really are all the same though.

The first time I logged into PhysioTools I felt like I had stumbled on the answer to musculoskeletal pain…was this the secret that wasn’t being given out to the general public struggling with chronic pain? All you needed was a log in you’re free! A plethora of exercises all neatly illustrating perfectly how to perform each exercise. A preprepared description of every exercise where all you had to do was plug in the numbers ‘3’ and ’10’ followed by ‘3-5 times a day’. Ahhh simpler times.

Just stop for a second. Imagine if I said to you right now from the moment you read this that I want you to start brushing your teeth for 3 minutes a day, 5 times a day, for the next 4 weeks until I see speak to you again. Would you? Yes? No? Maybe on the most part? What would go in to determining your choice to comply with my advice?

The 2 key words that I always consider when prescribed movement to the people I work with are IMPORTANCE and CONFIDENCE. How important is engaging in exercise based rehab for the person I am due to work with and how confident am I that they will be able to take it and run with it. If you were trying to help someone lose weight and their goal was to feature on ‘My 600lb life’ then I’d probably tell you importance is pretty low on their agenda. If you were trying to help someone with Chronic Low Back Pain get back to working and enjoying their life then importance may be high but the second they recieve the PhysioTools print out with 1)Knee Rolls 2) Trans Abs 3) Pelvic Tilts 4) Knee Hugs 5) Deadbugs followed by I’ll speak to you in 3 weeks then confidence is going to disappear – I’ve seen it and been there.

I like to think of building confidence with individuals like running a bath. It takes the right balance of hot and cold water, combined the right amount of bath soak, floating rubber duck, relaxing music, and chilled out ambience to run the perfect bath. It takes ages to create but then it’s gone in seconds as soon as you pull the plug. That moment you feel you’ve done a great job can all be sabotaged when you press print and pull the plug by delivering non-personalised care.

The perfect Bath…Takes ages to prepare and seconds before it’s gone.

Why do I say this? I can’t tell you how many times I have heard the phrase “I’ve done all the exercises” (Let’s not forget theres over 3000 of them on PhysioTools so they’ve probably not) or “All they did was give me a sheet of paper”. There appears to be a huge disparity between what we feel is evidence based practice and patient expectations. Exercises prescribed through PhysioTools are done so with the best intentions but to me the sheet of paper a patient walks out of the clinic room with symbolises a lack of personalised care.

Imagine you asked me to bake you the best cake I could possibly bake. I might go and shop at Waitrose and get the finest ingredients money can buy. I might find the best possible recipe and dedicate a few hours of my time baking it before finally throwing it in the microwave for 20 minutes on high. If the ingredients are good quality it’s still going to taste like s*** when I give it to you. Your consultation might consist of the best ingredients but the second your patient sees another exercise sheet like the one they have had last time or the one Brian 3 doors down has pinned up on the fridge then your cake is going straight in the bin.

So you’re telling me to prescribe exercises but not give them exercises? What do you want me to do I hear you cry?

Here’s another example. You go to a foreign country and you want to find someone really nice to eat. You find a local who hands you a flyer with the address of a local restaurant they recommend and wish you on your way. Or that same local pulls a piece of scrap paper from his back pocket and scribbles down a barely legible map directing you to their favourite place. Meet personalised care. Meet feeling like someone has listened to you and taken the time to assist you.

But I can’t draw. My stickmen aren’t going to help anyone!

This comes back to my favourite topic in exercise prescription. How many exercises to prescribe? For me I can’t say I have ever given an individual I have been working with in recent times more than 1 to 2 exercises to work on. I can’t even say that I have had to draw that exercise for them on many occasions because the structure of the appointment is built around exposure and behavioural experiements. My appointments used to consistent of subjective, objective, special tests, diagnosis, print. I can’t tell you how much more I started to enjoy my job when the “subjective” became listening. When the “objective” became observing and understanding. When the “treatment” changed from an PA to L4/5 to exposure with control and experimenting with movement.

The content of the subjective assement has taken priority over the conducting of the “assesement”. Subjective assements changed drastically during my career from a framework of PC (presenting condition) HPC (History of present condition) VAS, Aggs, Eases, Diurnal Pattern, Special Questions, PMH (Previous Medical History), DH (Drug History), SH (Social History) to the Peter O’Sullivan inspired “Tell me your story”.

I do not need to preach about the importance of a biopsychosocial model in health care but what emphasis does an individual feel is being placed on their work and home life that is often impacted by musculoskeletal pain when it’s merely a closing remark or ‘any hobbies’ and ‘what do you do for work’ as it is the last question on your subjective assement sheet. I’ll tell you…Not a great deal of emphasis! If the individual you are with chooses to tell you about their work at the beginning of the consult you can sure as hell recognise that work is a signficant factor in their story!

During modern day telephone consultations you may suprise yourself by how much of a conventional subjective assement you are able to ascertain by simply sitting and listening. Yes it may not follow the traditional framework order but when the consultation is not expert driven and less of an interview and more theraputic (remember Physiotherapy) telling your story and directing the conversation can be hugely powerful for the individual to whom you are talking!

This isn’t a blog about communication but yet again and I can’t emphasise this enough – the better you become at communication the greater your theraputic alliance, job satisfaction, and overall enjoyment of being a Physiotherapist will be! (I’ll be sure to do a blog on this in the not too distant future)

If PhysioTools works for you then I wish you the very best…if like me you wanted more from your work than being a human printer then read on.

Treatment in my modern day practice consists of 2 main graded exposure treatment principles. Habituation and Pain Memory Extinction.

The process of habituation

Habituation is the process by which, when faced with a repeated stimulus, the response is less and less intense. It is considered the most primitive form of learning, the body “remembers” and “learns”. Think about diving into an ice cold swimming pool. The initial sharp icey cold water takes your breath but with prolonged exposure habituation occurs.

Pain Memory Extinction relates to expectancy violation. Individuals in clinic will already describe the ‘special test’ in the form of an aggravating factor. Modify, experiment, play with the movement that has been described and violate expectations of pain. There is nothing more powerful than a self reported aggravating factor ceasing to provoke the predicted pain response. How you choose to do this is the skill, with the right amount of controlled exposure and recontextualising pain this is possible, it may take a degree of creativity, it will definitely take trust and theraputic alliance but it is possible. I recommend referring to The Mature Organism Model for more on this.

Recontextualising pain is an art. One which requires effective communication skills to understand your patients beliefs and mindset. Do not challenge beliefs, work with them. Challenging beliefs will only create conflict but working with them to create new beliefs and understanding will help to build rapport and develop self-efficacy.

We live in a world where the vast majoirty of people have a video camera in their pocket yet we insist on continuing to send out generalised self help information. Providing a video on the patients mobile phone with verbal prompts and queing in relation to the movements they have performed in clinic represents personalised care in my eyes.

I recognise that NHS pressures make more frequent contact challening but violating expectations with movement in clinic should be followed up as soon as possible! This is what builds self-efficacy! Recognising you can do something and doing it again straight away! Like when you first try to lose weight, that initial drop on the scales can be powerful when you have a substantial amount of weight to lose! In order to create the dramatic effect and emphasise the messages you provide during a consultation bringing your patient back the following week can be hugely powerful. Confidence increases, the support is there!

I finish all of my consultations emphasising that I am there if they need me. “Contact me on this email address, or give me a call if you need to discuss this before we see each other again, anytime I’m happy to talk and support you.” Dont worry your inbox will not be flooded within days, only on occasion have individuals taken me up on the offer but I like to think that the fact the offer is there helps build rapport and confidence.

My version of PhysioTools following consultation with patient with 3 year history of persistent shoulder pain

The question comes back to what do you percieve the mechanism to be behind the exercises you prescribe? The relationship between strength and pain is loose and fraught with holes. Movement is essential for living, when movement ceases you stop living. When you begin to think outside of structure and diagnosis for the management of persistent musculoskeletal pain that is when you really begin to step inside the biopsychosocial model. When you start to listen and stop waiting for your opportunity to talk then things will change. Listen with curiosity. Speak with honesty. Act with integrity. The greatest problem with communication is we don’t listen to understand. We listen to reply. When we listen with curiosity, we don’t listen with the intent to reply. We listen for what’s behind the words.

My job became easier when I stopped being a slave to PhysioTools. My job became enjoyable. My job did not become a job anymore it became something I looked forward to doing – to helping!

Hopefully if you’ve stuck with this you’ll maybe reflect on your current practice and wonder is there anything else I can do for this individual other than complying to the norm. Stop conducting subjectives and start listening and having conversations. Stop worrying that your objective assement has not included 20 different special tests and you’re not sure of the diagnosis. It goes without saying that screening for red flags and non-MSK causes preceeds all of this but for the management of persistent musculoskeletal pain we can do more!

Finally, I sympathise with you all during COVID-19. Telephone consultations have drastically changed the way we work but even in ight of the current climate seek to understand your patients, not send them a sheet of paper for them to be followed up in 3-4 weeks! Good luck!

Until next time

MattThe Honest Physio

The curtains have ears! – Honest confessions from my career so far

Working in Musculoskeletal outpatients was always the way I envisaged my career ever since embarking on my BSc in Physiotherapy.

After graduating from University the first thing I did was trawl the internet searching from a MSK Physio job that would employ a newly qualified physio without any expirence other than a few 6 week placements making use of a clinical educators Physiotools login credentials!

I felt like I knew everything. I wasn’t super confident or arogant but I knew how to use theraband, I knew 3 sets of 10 and I knew that rolling your knees from side to side would eliminiate chronic back pain…………..

So how did I go from being so sure that I knew how to eradicate someone’s musculoskeletal aches and pains to being a nervous wreck dreading going to work. I would consistently check my colleagues diaries to ensure they had patients at the same time as me so that I wouldn’t be overheard, in the event that I would be the only clinician seeing patients I would take my patients in the room next door and shut the door, I would wish and hope that my patients would not turn up and my heart would sink at the moment the late arrival checked in at the reception desk.

I’ve never been the most confident person in the world but within a matter of weeks of qualifying and working in my first MSK post I started to find myself suffering from anxiety like I’d never felt before. Surely this wasn’t normal. All of my colleagues knew what they were doing. They knew how to diagnose everything. They knew how to treat everyone. I knew nothing. They knew it all. How could I possibly ever be like them – I wasn’t cut out of this.

Friday nights were my escape. Over 48 hours not thinking about my job. Except that never happened. I’d spend the entire weekend thinking about the referrals I’d already skimmed for the following week. TMJ Pain, Chronic cerviogenic headaches, Sciatica for 3 years, neck pain following a car accident. Youtube became my go to – I would watch videos of manual therapy techniques that I would apply the following week. Asking someone for help represented weakness. Why should I be asking someone how to do my job! I watched countless hours of youtube videos on how to perform certain treatments. I had no idea why they would help but atleast that would appease the patient and make them feel like I knew what I was doing!

But that didn’t prepare me for the questions.

“Do I need a scan?” – Yes, no…maybe I don’t know – loads of people have scans they must help!?

“So do I just have to live with this?” Probably yeah your old – I can’t fix you so yes you do

“It’s wear and tear – it will never get better will it, why would exercise fix wear and tear?” Nope probably won’t but my job is to press print on this printer and get you out of here as quick and painlessly as I can

“My never is trapped and it needs freeing can you massage it away?” I think that’s what I’m here for – sure you’ve had raging radicular leg pain for 3 years but what it’s been missing is a 10 minute massage off an inexperienced 20 something year old

I had no idea how to answer my patients questions. What worried me more though was what on earth do my colleagues think of the explanations I am giving. Afterall the only thing separating me from my patients was a pair of curtains! Everyone know’s that curtains block all sound…right? When Wendy is telling me all about how her low back pain is stopping her from being intimate with her husband and she’s worried she will end up in a wheelchair nobody else hear that because the curtains were there…

It’s only now looking back I realise I was suffering from imposter syndrome. What I still don’t know is why? Was it just me? Does everyone feel like this?

As I have devloped in my career the phrase I have found coming out of my mouth more than ever…”I don’t know the answer to that”. 21 year old me would NEVER say that. 21 year old me would explain the acromion was hooked shaped. 21 year old me would explain that the discs are like jam donuts. 21 year old me would rattle off the biggest load of shite that sounded vaguely plausible in order to field the impossible questions I was being faced with.

My favourite game became will the patient DNA my appointment before I give up on them. I feared others reading my notes. I feared peer reviewing my patients with senior clinicans in case my knowledge gaps were exposed for everyone to see. I hated being presented with possible solutions from my colleagues to apply to my patients when really in my head I was screaming “Take this patient off me I don’t have a clue what I’m doing..I know it. The patient knows it. Even you know it! HELP ME!”

I followed the same structure to every appointment – Subjective – Objective – Heres your diagnosis – Let me go and print a sheet off Physiotools and let me book you in for 3 weeks.

The patient would come back 3 weeks later – “How is different…did you do your exercises? Yes.

Now would be the point to press where it hurt because I didn’t have a bloody clue what else to do!!

Patient comes back..How was it..better for 2 days but now it’s back again…Ok I’ll do it again.

Patient comes back..How is it…the same as before. Ok here’s some different exercises. See you in 3 more weeks in the mean time I will ask someone for some advice (reluctantly)

“So what have you tried up to now” – Physiotools. Pushed on it, put some ultrasound on it. Massaged it. Told them to try pilates. I’ve done everything!

“Have a look at X and if that hurts get them to do exercise Y” Ok will do….

When the patient came back and I assessed the SIJ or palpated for hypomobility at L4 I’d still be clueless about what to do next and that would be the start of let’s see who’s going to crack first – you not turning up anymore or me telling you to go and see your GP for pain relief.

So why did it change? Well losing my Physiotools login helped! I can’t stress enough how much I feel that Physiotools holds patients back! Sure for an acute problem providing some simple exercises whilst natural history takes it’s course can be helpful and a print out may be relevant but I maintain that the vast bulk of MSK outpatient caseloads is occupied by persistent musculoskeletal pain. Peristent pain which isn’t likely to get better through a sheet of paper or a quick massage every 3 weeks – peristent pain which I could help with by being me! A thinking feeling person – the exact same as the person sat in front of me!

I started to listen. I stopped talking. I started to show empathy. I started to be a person who would listen and seek to understand what was impacting the person sat infront of me. What mattered to them! Meaningful patient centred goals. Understand where they had been, what made them tick, what concerns they had that I could help address.

I stopped thinking I could diagnose everything. I realised my book of special tests was no longer as special as the title made it seem to be. It was a special waste of £20 that I would never see again because it didn’t help me help people!

I started to realise I was in the business of treating people and not body parts. I sought to understand communication – I started to listen closely to what my colleagues would say and what was succesfull and what wasn’t.

I began to realise that no physio I had ever worked with and will ever work with will help absolutely every patient in their caseload. Infact I started to realise that shit sticks. The words that some would pass on to their patients would stick with them and maybe would get them off their caseload but in the long run encourage chronicity. Since the first time I heard the word iatrogenic (if you don’t know what this means look it up!) I recognised the role we play in a patients journey.

Maybe not everyone feels the way I have. Maybe not everyone can be comofortable with diagnostic uncertainty. But being a good Physiotherapist is not being a good ‘diagnostician’ or a good manual therapist. Being a good physiotherapist is about so much more.

If you ever find yourself in the same position I have been…fearing others overhearing what you’re saying…dreading your next consultation….worrying that you’re not cut out for this…believe me you’re not the only one. Working with people is the most challenging thing you could possibly do and 3 years of undergradute study and even 20+ years of clinical experience won’t prepare you for your next appointment because ever person you meet is totally different. Every person you meet has their own unique set of goals, beliefs, perceptions, values, barriers, enablers that you should try to seek to understand.

Discussing patients over a set of notes will not allow you to understand those things. Closing your mouth – open your ears and being an empathatic person will help you.

Be brave, find a mentor – find someone you aspire to learn from – ask for help – don’t suffer in silence and fear every day of clincial practice. Ask questions – seek to understand – read!

When I abandoned physiotools and opened my ears and shut my mouth the thing I started to hear at the end of more appointments than ever before was ” I feel better already!” – something I never ever heard after trying the manual therapy techniques I discovered from trawling youtube.

People are complicated recognise that. I challenge you next week to try and help someone without following the Physiotools model of care.

Good luck – stay humble, be kind and recognise you’re not the only one who feels like this.

Until next time

MattThe Honest Physio

Guidance, empathic communication and teaching is the main role of a physiotherapist – A blog inspired by Louis Gifford.

This is a guest blog produced by Ian Stevens and was delivered to The British Pain Society presentation on Compassion in Modern Healthcare. Great thanks to Ian for contacting me and sharing this with me.

Louis Gifford was a unique individual whom I am profoundly grateful to have known. Professionally Louis opened up my mind to new ways of thinking about interacting with those with persisting pain problems. Personally, and on many levels, Louis also helped me keep my faith in the human condition as he was consistently generous, kind and enthusiastic in all his communication with me over the years I knew him. Louis, like many of the influential people who have given talks at these meetings, was charismatic, driven and a real iconoclast. He achieved much in his life and died in 2014 of prostate cancer. He spoke with the gentle distinctive burr of a Cornishman and followed in the footsteps of his physiotherapy parents Louis was well known in the emerging physiotherapy pain interest world, but he will be probably unknown to most medical practitioners outside the Falmouth region of Cornwall where he lived and practiced. Despite this his influential and critically wellreceived books have been sold throughout the world. Louis’ idea of compassion involved action and interaction with those he listened and communicated with as patients and the many clinicians he taught when delivering his ground- breaking courses.

Most doctors and physiotherapists are educated in a structurally dominated
pathological model. This is appropriate in some circumstances, particularly where acute injury or end stage pathology is concerned. My education was firmly within this structural model of the body and initially I tended to see all problems through this lens. However, very early on in my career I quickly came to realise the limitations of this model, especially when presented with the typical outpatient caseload of on-going pain or unsuccessful post-operative management. As is often the case in
physiotherapy practice there is a desire to assist patients with the ‘tools’ at your disposal: physical assessments, tissue ‘treatment techniques’, exercise, ergonomic ‘adjustments’ and the like.

When I met Louis and spent a week with him on a teaching programme I realised that I had become fairly stuck and frustrated in my practice. That week of being exposed to information from pain science, stress biology, motivational psychology and seeing how some patients could be transformed by knowledge, education and extended consultation was a revelation. I’m going to talk about Louis’ influence on my career through his immersion in pain biology, his interactions with pain pioneers like Pat Wall, his interest in memory and his interaction with Steven Rose.

A case history

At the micro level of pain management we are all dealing with suffering and often profound frustration. The following case history is that of a patient who had an RTA in 1977. A scan two years later suggested that he needed surgery but had to wait a further two years for the operation. During this long period he explored lots of alternative therapies and was also treated by three or four different physiotherapists. The operation was a fusion of the L4 and 5 vertebrae. In his words:

“After six weeks of aerobic rehabilitation I hit a brick wall and my
symptoms returned, leaving me in a permanent state of chronic pain
for the next 11 years. I underwent lots of treatment and moved to
Spain (from Glasgow) for the better weather. I attended the pain clinic
in Glasgow where every possible drug and treatment was thrown at me from TENS machines to steroids, none of which helped and some made me worse. I was finally deemed suitable to go on the pain management programme, having initially refused by the psychologist, as she believed that my understanding and attitude towards my pain was incorrect. I felt that it was the other way round and that they were trying to make me fit into their rigid understanding of what would work rather than assessing my life to see what would be most effective. The psychologist refused point blank to believe me when I said that I wasn’t feeling any better from the tasks, which she prescribed, and my experience within the programme was similar. All of my passions in life involved music, art and film, and their pacing system required me to minimise practising in these fields to the extent that I was doing so little I was getting depressed. One of the negative aspects of this programme was that I was with a group all of whom were at least 20 years older with a drastically different life outlook. They were extremely negative, but right from the time of my accident I had always felt that it was up to me to take responsibility. I did get some positive things
from it, such as learning mindfulness meditation, and being believed by
the other health professionals. After leaving the programme I felt I was
only marginally better informed about chronic pain. Shortly afterwards
my wife and I had a daughter and I had to become her primary carer.
This took its toll on me and increased my pain.”

A month later he was bedbound with continuous muscle spasm, and once again he had hit a brick wall. It was at this stage he moved into the area where I work. He continues:

“His approach: discussing with me my life and pursuits, and treating me accordingly, was far more encouraging on anything I had had before. I focused on energy and fitness levels, exploring movements and exercise that would feed into my existing attitudes. It took daily commitment and dedication from me as all things do when dealing with chronic pain but it is the first time I have experienced progress as well as increased wellbeing. I was encouraged to do more of the things I loved rather than less, and felt less depressed.”

I am not saying that I helped this patient significantly, but the reason I was able to help him was probably due to my knowledge gained from managing some previous complex cases and the resonance and connection I felt with this particular person. As an aspiring musician myself and talking to a real musician I understood where he was coming from. Primarily, I was able to explain his pain in ways that he understood, and to engender by using active strategies to enable him to get a bit better. It was really only by understanding pain physiology and neuroplasticity at a micro level as well as the whole person, and ignoring most of my initial physically dominated
education that I was actually able to help him.

We can look for explanations of pain and suffering in many different areas and disciplines; philosophy ethics even global politics. At the local level – the ground and clinical level – I sometimes think that simpler approaches can ‘work’ and engender great change in people. When I reflect on places that allow me as a person to develop, it seems to me that these are quieter more serene environments. Patients, particularly those that are distressed, confused or fearful need environments that facilitate or promote change and reduce threat. However most of the pain clinics that I have worked in or have spent time in tend to do the opposite. I have often been asked to interact with patients in sterile environments where a silver tray for instrumental procedures and a stark couch are the items on view in the consultation room. This does not seem to be an appropriate environment for the promotion of relaxation and confidence.

We talk about the micro evidence in pain about neuroplasticity and maladaptive pain processes, but there is also positive neuroplasticity and things can improve as in the story I have just related. In retrospect, the postero-lateral fusion of this patient’s spine was unnecessary and his problems were possibly largely iatrogenic. He was disabled by the interventional structural approach to pain which led to an unintended
negative sequence of events.

I was powerfully influenced by the talk given by John Loeser, former president of IASP, at Launde Abbey in 2013. He described the influential and iconoclastic John Bonica. Bonica was a driven dynamic man who left an indelible mark on Loeser. Bonica worked twenty hours a day. He created the IASP by corralling people into a monastic retreat centre from which they couldn’t ‘escape’ . He started a movement through his own dynamic energy, his forceful attitude and persistent dogged determination. It wasn’t through randomised trials and science that the IASP was formed (although science was very much involved and Melzack and Wall were present at the inaugural meeting).

Physiotherapy, in my experience, is usually a secondary consideration in medicine; often viewed as something to placate patients when nothing else has worked. However many clinicians and patients fail to understand the role that movement has in life and health since, neurophysiologically, much more of the brain is developed to serve movement than to language.

‘Language is only a little thing sitting on top of this huge ocean of movement’, Oliver Sacks suggests. Movement is more than a little bit of exercise. The sensation of pain can be changed through perception and attending to movement and sensory experiences. This bodily attention coupled with cognitive evaluation or re-evaluation is perhaps one of the main roles that physiotherapy could offer in clinical encounters (particularly with the many patients with ongoing undiagnosed musculoskeletal pain). We hear a lot about limitation of time and resources in pain management but often failure of interaction is the biggest single problem.

In order to take a photograph, particularly one that may have some impact, it is sometimes necessary to shift your bodily perspective: at normal height you may miss what you want to feel and you may have to crawl on the ground to look at a different angle. Many writers have described this process better than I can. In this regard I have been influenced by the phenomenological nature writing of Nan Shepherd. Shepherd, a writer who spent her whole life around the Cairngorm mountains, beautifully captured the transformational aspect of the way her bodily processes influenced her thoughts and feelings. Sometimes analogy is appropriate where a shift in perspective is necessary when interacting with individual patients. There is often a necessity to shift one’s vantage point or perspective in order to reach across to another person. I believe this process of guidance, empathic communication and teaching is the main role of a physiotherapist.

Compassion and interaction….

Louis was a driven, interesting and independent thinker. I communicated with him for over 15 years and he has left an indelible memory in me. He spent much of his adult life researching into and communicating about pain. Looking at this picture I think you can see the kindness in his expression and the twinkle in his eye – he was an amusing bloke. Remarkably, he was able teach complex information to people schooled, drilled and brainwashed into thinking that the structure of the body holds all its secrets. As physiotherapists we have to think and to interact and we have been trained to use our hands. Most people are not averse to being touched if it is done in the right way. Scientifically the justification and relevance of touch in medicine may be understood by considering the work of Robert Sapolsky who is one of the world’s foremost stress biology researchers. Sapolsky’s primate research emphasises the powerful interaction that baboons derive from touching. The ones that most regularly have nits picked off their backs have the lowest cortisol profiles. Raised oxytocin levels associated with engagement and bonding are developed through touch, not just through words. Physiotherapy is a structure and movement profession. Sometimes, as Paul Dieppe revealed fixing the structure, such as replacing a joint, doesn’t solve the problem. Some people are made worse by the rehabilitation process itself when this involves forcing the body to do things when it is in a defensive state. Understanding at the micro level why some people report pain, including the understanding of the sensitisation of peripheral tissues really helps in clinical decision-making. Louis explained, though his research and that of Patrick Wall and others on adaptive and maladaptive plasticity in the nervous system, why some people can be helped by massage and manipulation but in others it causes an amplification of pain. If you are schooled in a physical, structural, mechanistic knowledge base you haven’t a clue why that should be happening.

Traditional thinking about movement is structural, but largely through Louis’ pioneering work we are moving out to encompass culture, physiology and wider issues. Emotional suffering is a large and often overlooked aspect of clinical practice. Reasoning philosophically about touch, interaction and bodily processes can help to transform emotion. This is a big under-researched idea in medicine. Louis made sense of many complex presentations. He made me aware of neuroscience and through this enabled me to think about the individual psychosocial factors an broaden the rehab process.

Being the change

I attended a course with Louis Gifford about 15 years ago. The clinic was full of chronic problems: patients who had had ‘failed’ surgery, nerve root blocks etc. I saw great transformations in about three or four days purely through education, explaining neurophysiology and how severe pain had become maladaptive. Some people were completely transformed through simple understanding and movement-based practice. My structural training led me to try and find all sorts of complex physical reasons for apparently structurally based pain. However it is unfortunately still the case that the majority of practice appears to be based on dualistic notions of pain rather than more complex models and fluid constructs such as Melzack’s neuromatrix theory. Understanding the trajectory of Louis’ career is an illuminating journey of challenging existing paradigms, developing new integrated teaching tools and the realisation thatchange is never easy, as in the case history. Like me, and many other young physiotherapists, Louis wanted to get competent at treating physical, musculoskeletal pain and as I did went on traditional orthopaedicbased courses like those that James Cyriax presented (Cyriax was a bone-setting doctor at St. Thomas’s in the post-war years [with his own very aggressive methods of manipulation] that developed very financially successful courses [as well as a very lucrative private practice], which still attract a lot of attention). An Australian physiotherapist called Geoff Maitland, who had attended Cyriax courses in London developed a system of assessment and treatment for physiotherapists in the 1980s that strongly influences physiotherapy musculoskeletal practise even today. Louis went off to Australia to do the ‘Maitland’ course and research but he read a very seminal paper by Patrick Wall written in 1991 about central changes involving sensitization in the spinal cord and brain after peripheral nerve injury, and a lot of strange cases of pain sensitivity suddenly started to make sense. Louis immersed himself in pain biology and memory research, and integrated these with Sapolsky’s stress biology. He tried to integrate all these into a model, to explain persistent distress and dysfunction. Among the literature he produced was a teaching tool called ‘The Mature Organism Model’ whereby tissue injury was ‘sampled’ not only at the periphery but at the spinal cord and multiple different regions in the brain. This processing is influenced not only by cellular processes but also by past experience and the culture a person lives in. Subsequent motor and sympathetic output, the movements that we see and the experiences people tell us about are all part of a complex interconnected ‘sampling’ and ‘processing’ system. Most people manage perfectly well after minor injury with little input from medicine. However, there are, as most clinicians realise small numbers of patients where this is not the case and the pain defence system may become ‘maladaptive’. As time moves on and pain outlives its ‘usefulness’ a person may become increasingly disabled and deconditioned. Treating this type of scenario requires physiological and social knowledge as well as ethical and cultural understanding.

How do I work with this kind of information in practice? I no longer get out my skeleton; I sometimes use my whiteboard to explain about the senses. Sometimes, but admittedly not very often, one can quickly reduce threat. Following on from Louis’s seminal work and the dissemination of knowledge to physiotherapists at national conferences and weekend courses more awareness of pain biology and educational approaches began to grow in physiotherapy practice. The well known Australian educators David Butler and Lorimar Moseley developed the book Explain Pain which combined cartoon drawings with up to date science in order to teach these concepts to patients. Education and interaction, rather than intervention and structural treatments, have helped many people in ongoing pain. An example of how I use some of the information I have learned over the years in practice is in the following brief case history.

A lady came to see me the other day that has really arthritic knees. Her knees were particularly sensitive despite having a few unsuccessful steroid injections. I simply doubled up my consultation time on the next visit and went over her case in longer detail. Within a week the temperature in her knee had reduced. Her knee pain was bound up with her husband’s mental breakdown; he was a butcher who had lost his business, and she had had to take on two or three jobs. I explained that the load on her body and all the central effects were affecting the output of her nervous system, and that she needed to calm that down. She understood that, and used ice packs, and in order to reduce the load on her body stopped one of her jobs and used a crutch temporarily. She was able to reduce her medication.

Louis introduced me to Benedetti and his book The Patient’s Brain: the science behind the doctor-patient relationship. Hope and trust – even if you are deeply suspicious of science – have a neurophysiological basis. The physical distance between people can affect them either positively or negatively as the nervous system projects around the body (the ‘peripersonal space’). People may become more vigilant and the space around their body ‘shrinks’ (through body-mapping as personal space neurons in the CNS have been reported to adapt to changing circumstances).

Traditional tribal people for example feel linked to distant people – whether that is a metaphor or an actual physiological process is speculative. However in our atomized and often-disconnected culture, where connection with others may be cautious and defensive, touch and clinical encounters may in some situations help to counter this. Perhaps this is one reason why in the right context massage and other body therapies are sought in times of distress? However, one thing that is apparent in the
scientific literature is that the nervous system is potentially plastic and adaptable.

I have been helped clinically by the knowledge I have gained through expanding out of ‘structuralism’ into complex physiology, as well as the literature of philosophy and ethics. Benedetti’s work rationalizes and validates what we are trying to do. The room you are working in, the way you approach people and the way you interact have measurable effects. In our science-based world that’s a pretty concrete reason for understanding it, and also for me minimizes the need to work with pseudo-scientific

Louis Gifford was ahead of his time and faced opposition from traditional groups in my own profession, and throughout the mechanistic world of rehabilitation. However Louis persisted; his work and ideas spread and led, particularly in Australia, to dissemination and the research which proved his ideas. He was a great disseminator, he was a great teacher and he modelled effective therapy. Over the years I have become less of a physical therapist and more of a teacher and a ‘therapist’ through reading, reasoning but primarily through my interaction with Louis Gifford.

It was heartening to me to receive a copy of Louis work, which was posthumously edited and published by Phillipa Tindle, Louis wife and partner. This trilogy of 1319 words is a fitting tribute to Louis and I know of no other person from the medical or therapy world that could have completed such a comprehensive piece of work. It is unlike so many books relating to pain and rehabilitation, the books are readable, funny, anecdotal and useful! The books reveal the man who wrote them, sceptical, impressively well read, articulate, personable but most of all a flawed human like the rest of us who is able to see the funny side and admit his mistakes too.

The best paper I have read for many years is Iona Heath’s The art of doing
nothing. Heath characterises the art of doing nothing in medicine as “active, considered, and deliberate. It is an antidote to the pressure to DO and it takes many forms including listening, noticing, and thinking, waiting, witnessing and preventing harm: peach an art in its own right requiring judgment, wisdom and even a sense of beauty”.

It is not an exaggeration to suggest that Louis Gifford did an enormous amount practically and academically but the end result of the action in practice would appear quite simple. He taught me to try to understand more and to be creative in getting this information across to the individual but most importantly to try and keep a sense of humour and perspective along the way.

The desperate patient – causes the desperate clinician- to do desperate things.

If there is any one word I find myself using on a regular basis in both these blog posts and when talking to my fellow clinicians it is the word self-efficacy. 

I think back to my early days working in private practice. A middle age gentlemen, couldn’t have been any older than 55, came in with a recurrence of his medial sided joint line tenderness of his left knee. His name was Paul. I was sat in my clinic room and when I heard the front door of the clinic open I heard a booming scottish accent bellow the words ‘right, which one of your physio’s is going to be zapping my knee today then?’ he said to the receptionist. 

I’d never met Paul before so I grabbed his previous clinic notes from past visits which resembled the entire works of JK Rowlings Harry Potter series.

They read as follows:

14/02/2015 1MHz 1:1 0.8 W/Cm2 and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

16/02/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

18/02/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

24/02/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

01/03/2015 1MHz 1:1 0.8 W/Cm2  and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

I decided to flick the pages back even further. 12/12/2011. 1MHz 1:1 0.8 W/Cm2 and DTF’s to medial joint line. Good response to Rx. R/V and resume Rx.

Ok Let’s go back a bit more I thought! 06/08/2008. Aaahhh Here it was the first admission for left knee pain (lets ignore the rest of his problems for this blog). The notes read:

“Patient presented with left sided knee pain after going for a long walk with his dog 2 days ago. No Locking/No Clicking/No trauma/ No giving way. Positive medial joint line tenderness. Clinical Impression: Medial Meniscus Tear. ?Arthoscopy. Well That escalated quickly.

So up I get and walk through to the clinic reception, notes under arm, and before I even get chance to introduce myself Paul is thundering full steam ahead into the clinic room with a gait cycle resembling that of a wounded animal. Up he pops. Straight onto the plinth. Trousers round his ankles. 

“I’ve not seen you before son.” (just to clarify he is not my dad)

“Hello Paul, my name is Matt. I’m one of the physiotherapists here”. Would you mind telling me a little bit about why you’re here?”.

“Are you taking the piss son. It’s my bloody left knee. It’s knackered lad – now be a good lad and get that machine over there on it!” He barked back.

“Do you think before we do that maybe we could have a little chat about the issue to see how I can help you best?”

By now I could tell I was really saying all the wrong things. The look he had on his face was one of a man who knew his way round this clinic room and had seen his fair share of physios.

“I’ll tell you what – get that machine buzzing and we can chat as we go – how does that sound.” (It sounded bloody tragic but by now I could feel my face burning up and even a bead of sweat rolling down my arm pit)

“Sound’s good” I feebly responded with what felt like a frog stuck in my throat.

I wheeled the machine over looking at it the same way I did a washing machine in my first week of University – completely perplexed. 

I proceeded to analyse the machine with Paul watching over me like a hawk stalking it’s prey. To be fair by now Paul virtually had shares in this ultrasound machine, he should be self treating while I sit in the corner and supervise!

F*** sake how do I work this thing! I wondered in my mind! There it is! The ON switch!!! As the screen lit up it was go time.1MHz 1:1 0.8 W/Cm2 I repeated in my head over and over as I scrolled through the numbers using the dial on the machine. A quick squirt of the lubricating gel on the ultrasound head and we were ready. GAME TIME.

Hold on a second – I haven’t even examined the thing! What am I doing!

The desperate patient – causes the desperate clinician- to do desperate things.

As I put the ultrasound head onto his knee he looked at me like I had just cold called him asking about his mis-sold PPI.

“Wrong one son.”His intimidatingly deep voice boomed.S***

Take 2. I placed it onto his left knee – medial side and off we went!

“So what do you want to talk about- the weather, holidays, TV, Football?” – It was like a new man was on the plinth! His whole demeanour had changed, like a crack addict who had got their latest hit.

“Tell me about your knee, Paul”

“My Knee? It’s shot. Knackered. Bone on Bone. Its grinding together – I should never of gone for that bloody walk! Doctor say’s if I don’t get it seen to now by you good people then it will be a knee replacement next year but they probably won’t do it because I’m too young – so I’ve stopped bloody everything!”

“How was it before the walk?”

“Perfect- I’d never had a problem with it! After that walk it hurt to put weight on it for a couple of days so I came here and your colleague told me about the cartilage being worn away.”

“Ahhhh it’s feeling better already son!” Paul said.

“It’s had a big impact on your life then” I stated.

“Too right – no more taking the dog out, I’ve gained weight, I’m a diabetic now, and I can’t play football with my grandson! But I’ll tell you what, I’m not having one of those metal knees, I’ve seen a video of them things being done – brutal!”

We continued to chat in this way and by now you should be building up the picture. Acute episode of knee pain some years ago after having NO prior knee pain, comes to see his doctor and a physiotherapist. Given some crappy diagnosis and treatment with no reassurance and scare the living crap out of him and destroy his quality of life. And where is his self efficacy now? Well every time that ultrasound probe made contact with his skin I can assure you it was sucking the life out of it. Paul was a victim of the machines!

I glanced over to the ultrasound machine. S*** I never even started the thing!

“Much better now son- cheers for that! Same time next week then?” Paul said as he clocked the time and recognised the treatment should be reaching its conclusion by now.

Like hell was I going to just let him walk out of that room with a bit of lubricant on his knee making him feel better.

I proceeded to assess his knee, 125 degrees of flexion, minimal joint line tenderness, negative meniscal tests. What’s going on I pondered. This guy came into the clinic in agony and was leaving with a nice bit of placebo only to be heading through to reception to book his next treatment for the following week.

“See you next week Matt!” his strong Scottish accent echoing through the waiting area.

When my clinic ended that evening and I was sat writing up my days notes the clinic owner poked her head into my room.

“How did it go with Paul today Matt? Nice and easy, usual treatment?”

That stuck in my head and when Paul came back to see me the following week usual treatment was abandoned. This was my one of first realisations of how I could do more as a physiotherapist to help empower my patients!

Now this blog isn’t about how I treated Paul (although I will do one on request) but instead about how these machines and passive treatments rob our patients of their self efficacy.

But…..I use manual therapy and passive treatments to get a buy in from my patients – I hear clinicians cry. If that’s your response then I suggest you look a little deeper at your so called ‘soft skills’. When you hone your soft skills then the buy in comes naturally, without the need for all of these sham treatments.

A blog from Adam Meakins entitled Abandoning Manual Therapy summarises this perfectly in this one paragraph:

“In my opinion manual therapy is often used to justify the therapist’s existence giving them a feeling of purpose and responsibility, and often used to pander and pamper to patients rather than to genuinely help them.”

And would this even be a blog without some knowledge bombs from my idol, Louis Gifford.

Gifford points out that as a profession, we struggle to give our patients rational answers to simple questions and make clear what we can and cannot do. Think about it, what information do you expect to receive from the doctor when you have a bad cold? Do our patients really expect us to fix them or do they want the answers to these four simple questions…

  1. What is wrong with me?
  2. How long will it take?
  3. What can I (the patient) do for it?
  4. What can you (the healthcare provider) do for it?

By the way, the answer to all 4 of those questions is not an machine with some gel on it just like my good friend Paul now recognises.

As always people.

Stay Honest.






Courses should help us to both confirm and challenge our bias.

This weekend however was all about confirming my own bias. Peter O’Sullivan’s 3 day CFT workshop in London was easily one of the best courses I have attended in my career. I feel that Peter (@PeteOSullivanPT) would modestly prefer that I credit the CFT workshop to his widespread team (see below image) across the globe rather than as an individual accolade. Peter’s distinctive hair (which I can only envy) and charisma spearheads the CFT movement and the fantastic work that the team are doing was clear to see for all of the attendees over the 3 days.


After the 3 days I spent attending the workshop and having accumulated a plethora of knowledge bombs I left with a sense of optimism knowing that the physiotherapy profession is moving forwards and having improved my own self efficacy (more on self efficacy to follow).

The CFT approach was demonstrated on 4 patients to whom Peter was blinded on days 2 and 3 and the effortless execution which Peter demonstrated was inspiring and reflected the attributes of a highly skilled practitioner who has honed his style and communication skills over many years.

To leave this 3 day workshop and feel that you are now a certified CFT practitioner would be naive but to leave with a recognition that you are able to grasp the foundation skills and nurture those skills within clinical practice a fantastic start point.

Peter’s approach was an amalgamation of motivational interviewing and sound clinical reasoning which allowed him to create a strong therapeutic alliance and gain the trust of these patients in front of a packed lecture hall. Peter was able to subtly incorporate key motivational interviewing techniques and violate his patients expectations of pain through the connection he had developed and build their self efficacy through the power of doing. To paraphrase Peter:


Peter listened to his patients, understood and validated their concerns and was careful not to dismiss any beliefs in which they were strongly invested. Peter is a world class clinician who utilities some extremely intelligent techniques. Peter used the patients own words back at them – emotive words, words that had come directly out of the mouth of his patients. We should not make assumptions, but what we can do is use the words our patients use back at them! Not only does this show that you have listened – but it shows the clinician is not making assumptions, the things that “terrify, fear, scared, worried” can then be addressed.


Chesters et al. 2019 found that “physiotherapists prefer open focused questions when addressing the topic of patients’ presenting problems in initial clinical encounters, providing patients with a focus, whilst still allowing them to express themselves in their own words”. What better way to allow your patient to feel in control and able to lead the consultation than with the phrase TELL ME YOUR STORY. Peter continually used the phrase at the start of each consultation without exception. What do you think of when you think of the word story? A narrator. A beginning. A middle. An end. The narrator takes the story where they want. Peter feels that a patient should have the opportunity to be the narrator and that within the first minute of a consultation you will be privy to a key piece of the puzzle. So rather than the traditional “how are you today?” where the patient must confide to the social norms of “fine thanks” sit yourself down ready for story time.

If you haven’t completed a motivational interviewing course yet – do one! (There’s a couple of great resources available in the form of the book “Motivational Interviewing in Health Care: Helping Patients Change Behaviour” aswell as The Physio Matters Podcast – Session 64) oh and I did the artwork for the podcast on a side note 😉

After every patient story Peter utilised a very simple motivational interviewing technique. A summary. Why is a summary useful? Have you ever been in the situation where your friend/partner/ colleague recognises that you’ve completely blanked out everything they’ve just said only for them to then say “what did I just say?”. Is there a sweeter feeling in the world than being able to accurately recount their previous ramblings play by play. Nope. A summary is your perfect opportunity to show that you have listened.

Peter asked permission to provide the summary. Allowed the patient to intervene should the summary be incorrect and provided an account of the patients story, identifying the key points and facts with the whole focus of building therapeutic alliance. And guess what. Nobody interrupted him. Why, because he had listened, and the account he gave back to the patient was a perfect summary, drawing on the key incidents, using the emotive words, and identifying patients goals!


Thankfully in physiotherapy departments the tide is slowly changing it seems and we are educating our patients with evidence based medicine however this often results in clinicians telling patients how common disc bulges are in the asymptomatic population – Yes, this is very important, but how do you think a symptomatic patient feels when they are presented with these facts? They do not sit in this category of having an asymptomatic disc bulge in their eyes – they have a symptomatic one! Peter was able to listen to his patients story, and who doesn’t love a good story! Recognised what was important to them within the story and tailor his assessment and treatment around this. Not once did he violate his patients belief system by sitting them down and lecturing them- he violated his patients expectations of pain through doing– now consider what is a more powerful method for changing someone’s beliefs and expectations, sitting down and having the facts presented in a lecture format or physically having their expectations and beliefs altered through their own doing and actions. All of this without manual therapy, without lecturing, but instead with listening and understanding with one goal in mind – Improve self efficacy.

If you are unfamiliar with the concept of CFT – I suggest that you become familiar with it. Not because CFT is THE way but because it is A WAY. So what is Cognitive Functional Therapy?

CFT is built on 3 pillars:

  1. Making Sense of Pain
  2. Exposure with control
  3. Lifestyle Change

Think about doing 1 of these components in isolation without the other 2? A patient presents with disabling LBP. You can’t talk a patient better. Show them! Give them a new representation of pain and then show them what they can do! The bigger the violation of expectation the greater the effect!

The work of Holopainen et al. 2018 identified the things which our patients do and do not like!

Patient’s DONT like it when:

  1. We don’t listen or interrupt
  2. We don’t consider their expectations
  3. Give unclear or scary information
  4. Don’t involve them in the rehab plan
  5. Blame them
  6. Don’t write things down for them
  7. We are in a rush or don’t follow them up
  8. Over treat unnecessarily!

Can you guess what they do like? Reverse all of these! CFT is built on these things. And this is normal human behaviour! People like to be listened to, understood, involved! We are in the business of treating people. Often my colleagues say I didn’t train as a psychologist! I don’t want to treat like this! I became a physiotherapist because I like the human body and how it works” I’m afraid to say that you’re in the wrong job then. Because in this job we treat human beings – with highly sophisticated and complex minds, get comfortable with being uncomfortable, if you think a sheet of paper with a few exercises on it is physiotherapy then you’re mistaken. That is like going to a restaurant for a meal only for the chef to come out with the raw ingredients and dump them on your plate. Peter described our role as clinicians as being facilitators and coaches. You are there with your patient to help them put together a jigsaw puzzle. Except you don’t have the front cover. You have all of the pieces of the puzzle, and the patient can vaguely remember what that front cover looks like. Our job is to work together to help put the puzzle back together, by working together making sense of what the puzzle should look like we can help our patients put it all back together!

NICE Guidelines for LBP identify the importance of using a risk stratification tool. A fantastic tool yes, but do you think people like to be stigmatised? Put into a box? Do you think a patient likes to be labelled as “yellow flaggy?” Do you think their pen might choose to tick a different box in order to avoid being stigmatised. I certainly do! Yellow flags aren’t really yellow flags, yellow flags are called being human. If pain threatens to stop you from doing the things you love doing and worry about the future then I would assume that to be a normal human response. Do not put your patients in a box of being “yellow flaggy” – identify that they have come to you for some help and support not to be put in a box! So use these tools yes – but do not rely on these tools! Listen to the story, empathise, don’t be a robot, show some emotion, show humour! Be a human being!

The traditional assessment model will certainly become a thing of the past for me. I distinctly remember learning as an undergrad student how to assess the spine, how to assess peripheral joints and how to palpate the spine (although I couldn’t and still can’t feel s***).

Think about this:

Patient “I have pain when I roll over in bed and when I bend down to pick something up”

Clinician: “OK, stand up, touch your toes, arch backwards, walk your hand down to the left, walk it down to the right, lie on your front, lie on your back, lets see how your hips move, lets test your nerves, slump, slouch, stretch, lets see what your hamstrings are doing. OK you can sit back down, I will be back in a minute with an exercise sheet”

Baffling hey?

Patient “I have pain when I roll over in bed and when I bend down to pick something up”

Clinician “OK, let’s take a took at you doing those things”

Which clinician would you like to see if you had a problem? The one who look at your problem or the one who gets you to do a whole host of random tests because they learnt them in a text book and from out of date undergraduate courses!

What is more important than assessment of “joint mobility”? Peter suggests (and I agree!) patient response to stimulus. Assess how sensitised the system is! Pressure response, exposure to cold stimulus, allodynia, pain response to repeated movements! The model of assessment needs to change, and CFT is here to hold your hand and guide you through this change!


How many people in the world are living with pain? I don’t know, look it up.

How many people are living in pain and seeking help? I imagine a fraction of the number above.

What does that tell you? People are resilient, people are able to tolerate a bit of f****** pain!


If you’ve been able to rule out sinister pathology (Maher et al Lancet 2017) then what are you afraid of? Ask yourself this – why are there people living with pain and not seeking intervention but also people living with pain and seeking intervention? The answer is self efficacy- some people feel empowered to manage their own problem without worry and fear. These cognitive factors (worry/fear) fuel pain. Address the cognitive factors, violate expectations, build self efficacy and develop therapeutic alliance! Do you think that rolling around on a spikey ball builds self efficacy. No. Do you think lying on your front and having a back massage for a persistent problem where you get pain with bending builds self efficacy? No. You get where I am going with this right? As Physiotherapists we can empower our patients – we can help build their self efficacy and not fear their pain!

As I write this I’m sat in a coffee shop, headphones in, people watching. As the lady opposite me takes a sip of her drink I’m watching her face. I should probably stop now. But what do you think her face would do when she takes her next sip if whilst she was not looking I replaced her frothy cappuccino with some lemon juice. You’re probably making that face right now thinking about drinking a cup of lemon juice! What does the face tell you? Everything! The face projects emotion. The face projects these cognitive factors! Look on your phone now, look through the emojis! There are faces for every possible emotion you can think of- Happy, sad, confused, scared, worried, the list goes on! So as you watch a patient move where do you think you should be looking? You got it. The emotional projector! Peter doesn’t mean it offensively when he says he does not care about pain. He cares about distress and where is he getting that from? Looking at the thing that will tell you! What emoji can you see on the face of your patient?

Fear and worry are common cognitive factors in those patients who come to see us with pain. If you don’t think your patient is fearful or worried, then I would suggest that you’re not looking hard enough. In November 2018 I attended Ben Cormack’s course when he used the phrase – Find the hook. The hook is the thing which is meaningful to your patient, the reason they are sat infront of you. This is what your appointment should be tailored around. Passive adjuncts in physiotherapy need to become a thing of the past, these machines, tapes, needles (the list goes on!) rob people of their self efficacy- they create dependency! Yes, this is a fantastic business model, but if that’s the reason you work as a physiotherapist then you’re doing it for the wrong reasons. We are in this industry to help people first and foremost, right!?

After watching Peter take an extensive history, complete a thorough assessment of the patients feared and challenging tasks and confront their fears, Peter would involve the patients in a discussion around what he had found and what the patient had experienced. Now to say Peter did not use manual therapy would be narrow minded. Manual therapy is defined by The Orthopaedic Manual Physical Therapy Description of Advanced Specialty Practice manual therapy is defined as “a clinical approach utilizing specific hands-on techniques, including but not limited to manipulation/mobilization, used by the physical therapist to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.”

Did I observe Peter put his hands on a patient? Yes. Did I observe reduced pain with feared activity? Yes. Did I witness relaxation, movement facilitation and improved function. YES. By far the greatest and most simple yet effective manual therapy I have ever seen.

Following each patient consultation Peter gave us the opportunity to work through the clinical reasoning process where he highlighted the key components of the patient story. During the clinical reasoning process and through identifying the key modifiable factors in the patients story it became apparent as to why Peter had tailored the patients treatment in the way he had and gain a greater understanding of how the CFT model worked.

CFT Spider Diagram to identify key modifyable factors in patients story

Now if I refer back to paragraph 1 of this short blog. “This weekend however was all about confirming my own bias”. As I sat in the workshop finding myself becoming enthralled in each slide I could not help but think CFT was already the way I was working without recognising it. It is at this point if you have not already read the works of the late great Louis Gifford I urge you to go and get a copy of his trilogy Aches & Pains. Louis Gifford’s introduced me to the idea of the MOM (Mature Organism Model – as per below). Here are some of my favourite quotes from Louis Gifford:

“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/rehab/ graded recovery/functional recovery process – then its my opinion that your therapist is a complete waste of time” 

“Integrating psychological and social issues into practice is not an easy matter for professions that are linked historically to tissue/injury/pathology-based explanations and treatments for all pains. Overcoming a natural antipathy to integrate ‘other’ issues, concepts and explanations is a major step towards effective practice change.”

“Most of us tend to think of pain as an unpleasant, distressing sensation that originates in traumatized tissues and courses its way along neural pathways to the brain and consciousness. Thus, the amount of pain perceived fits with the amount of damage done and the pain happily recedes in direct relation to the pace of healing.

The problem is that our clinics and departments are full of patients who have ongoing pain with no clear trauma or disease process, or who have suffered trauma but the pain continues on long after a reasonable healing period.” 

Louis Gifford was way ahead of his time. Peter O’Sullivan and his team are still ahead of their time but thankfully the work he and his team do is dragging our profession into the future! Thank you Peter O’Sullivan. Thank you CFT for confirming my bias.

That’s all for now!