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.
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.
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.
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
Matt – The Honest Physio