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
explanations.

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.


CFT WORKSHOP 2019- TELL ME YOUR STORY

TELL ME, I’LL FORGET

SHOW ME, I’LL REMEMBER

INVOLVE ME, I’LL UNDERSTAND

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.

Collaborators

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:

I’M LIKE A DOG WITH A BONE – I KNOW WHAT I WANT, AND I WILL NOT STOP UNTIL I HAVE GOT IT”

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.

TELL ME YOUR STORY.

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!

SELF EFFICACY “AN INDIVIDUALS BELIEF IN THEIR INNATE ABILITY TO ACHIEVE GOALS. HOW WELL ONE IS ABLE TO EXECUTE COURSES OF ACTION REQUIRED TO DEAL WITH PROSPECTIVE SITUATIONS.”

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!

I DONT GIVE A RATS ABOUT PAIN. REALLY I DON’T. WHAT I DO CARE ABOUT IS DISTRESS!

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!

FEAR YOUR PATIENTS PAIN AND WHAT WILL YOUR PATIENT DO? FEAR IT!

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!

@Honest_Physio