Reassurance… A guest blog by Ian Stevens

Today I am pleased to give you a fantastic guest blog by Ian Stevens a highly experienced physiotherapist in the beautiful Forth Valley in Scotland who gets us all back down to earth and reminds us what real physiotherapy is all about.

Reassurance

“Thank-you, I have been wanting this reassurance for a number of years now.”

This was the parting statement from a patient I saw last week and I have been reflecting on this heart- felt spontaneous comment since. This particular man was unusual in primary care, especially for a referral for musculoskeletal pain since the condition was the only thing he had to complain of.

He was a man in his early seventies who cycled, had run marathons, hill races in his sixties, had modest aspirations in life, and cared for his extended family. There was little to complain about, he no longer took any medication, he slept well and had lots of plans for the future. I had merely presented information to put his mind at ease and suggest he could indeed expect to a great deal more than his doctor had suggested was possible.

Physically this patient had an obvious valgus deformity of his right knee and I used my physiotherapy skills and knowledge to quickly assess his hip, knee and lumbar spine as the complaint of leg pain could have been related to a nerve root disorder. However, as experience and the philosopher physician Osler suggested

“it is often far more important to know what type of person has a problem, than to know what type of problem that person has.”

The tacit knowledge gained through years of clinical case management and life skill is seldom taken into consideration in education or clinical decision making, but practically is often the most important factor in case management and patient outcomes. I instantly related to this man, his desire for continued movement in the outdoors, his enthusiasm for the hills and trails, and his desire to keep on doing these things.

During the consultation and physical examination I could tell by his body language and tone of voice that he was interested in the process and he asked questions regarding his future prognosis and realistic abilities. We talked about adaptation, the low level of correlation between structural ‘damage’ and pain, and how symptoms are much more related to general health or inappropriate load progression than what appears on an x-ray.

The gap between ‘pain’ and ‘pathology’ is filled with a person and their narrative, something which modern medicine often misses or pays little heed to. We tend to concentrate on the structure of the body and its imperfections rather than the many people who live happily with these imperfections and in some cases thrive and remain happily oblivious.

Reflecting now on my own pain problems and physical complaints I realise as I am now middle aged that the vast majority of them have been entirely due to pushing harder than I was capable of, rushing when multi tasking, not taking enough time for recovery, or often when I was emotionally over loaded. I have learned through my contact with therapists, reading and countless clinical contacts that the only thing that ‘works’ and helps settle a person is to understand them as a person, to provide a realistic framework of recovery or to help them accept a situation that cannot really improve.

Reassurance is a skill I have learned to accept as being the essence of my work, but one that professionally and clinically seems to carry little value. To accept a role as one that only reassures to some is demeaning professionally, as it may imply that as one patient recently said to me…

“you aren’t really doing anything are you”?

My answer very often to this question is “no I am not really ‘doing’ very much at all, my aspiration is to assist you the person presenting clinically in helping yourself”. In order to fulfil this role one could argue that a weekend massage course (or an osteopractic diploma AM) would suffice and probably for many patients this would probably be difficult to argue with. However, I feel that reassurance is an art and it requires a constant checking of ‘the self’ as outcomes and patient satisfactions plummet when the therapist is drained or ill at ease.

Reassurance requires knowledge of physiology, healing times, placebo/nocebo mechanisms and the tendency of modern medicine to make a mountain out of a ‘mole-hill’ by dramatically overcomplicating things. Most of all reassurance is an art of personal engagement and an ‘intuiting’ of what type of person is in front of you and what it is they really want from the consultation.

Sometimes as I have described the outcome can be almost instantaneous, predicated by a moment of connection and collaboration. However, sometimes, (particularly in primary care settings and complex pain presentations) due to complex personal and interpersonal factors reassurance never seems to occur. A person often appears to remain perpetually in the ‘danger zone’ , constantly looking for answers in the wrong places perhaps as their perpetual tension and confusion leads them from one therapist or medical encounter to the next.

The art and practice of reassurance is never formulaic, especially in the ubiquitous ongoing pain problems that present in physiotherapy practices across the land.

Attempting to distil an encounter and measure the process in a linear model such as grading a fracture often will kill the spontaneity and process which negates the “thank-you for the reassurance” comment I sometimes hear when the consultation really works.

 

Ian Stevens Physiotherapist, Forth Valley Scotland

Ian qualified about 20 odd years ago in Physiotherapy from Glasgow, developed an interest in pain physiology/stress biology after a being hypnotised by a week of head spinning common sense via Mick Thacker, Louis Gifford and Dave Butler. This was in the early days of the PPA and all things ‘neuro/pain science’ and applying it to many not so keen Glasweigians was a role I embarked on with some occasional degrees of success. I enjoyed the challenge of persisting pain patients in an upper limb clinic and gradually got to realise that the conundrums and no-mans land of ill defined pain was a ‘mine field’. I went on to do a MA in Medical Humanities in order to help cross this mine field with a wider lens via Swansea University .This was fascinating but a death knell to any career ‘advancement’! I have talked on this interface with the arts and science in Physiotherapy at the British Pain Society in 2014, including a tribute to a former friend, mentor and all round great person Louis Gifford. I try to keep level headed through the outdoors,climbing, kayaking, taking photos , wearing native woollen socks ,playing Irish music but never ever using vibram five fingers or riding unicycles.

17 thoughts on “Reassurance… A guest blog by Ian Stevens

  1. Great article. It has reassured my confidence in the future of how physiotherapy will treat our ever growing population of complex pain patients. I still have colleagues that point the blame of their patients pain on anatomical anomalies and writing goals that do not coincidence with their patients own goals. I’m printing this article and posting it on our bulletin board. Also, I loved the quote by Osler.

  2. Loving this guest blog Adam.. especially “The gap between ‘pain’ and ‘pathology’ is filled with a person and their narrative”
    The last line gave me a huge smile as well, though oddly enough they do feel strangely comfortable wearing round the workshop in the summer (weird)
    Keep shooting out these fab posts & podcasts 🙂 #SharingLater

  3. Thank you for posting this simple but eloquent statement of what years of experience in our chosen field can offer patients on a less scientific but more human aspect.

    Sent from my iPad

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  4. Good morning,

    I have read what I can find of your thoughts in the past and it is always written clearly and without ego. It always makes sense as well. Your article on Musculoskeletal Elf is well worth a read as are your thoughts exchanged with Louis Gifford. I also had an Achilles problem that I just left alone and got on with it and it went away and did not return.
    Thank you for writing this.

    P.S Adam, if you put a Bull-Shit-O-Meter at the top of your Christmas list you can use your time more constructively for yourself by scanning incoming messages.

  5. THANK YOU! Adam and Ian for such a great blog; eloquent, highly applicable to my role in primary care and above all – reassuring!! Yes, we do seem to loose sight of the person within the rushed NHS patient/therapist encounter but having just read this great blog I’m going to calm my approach down, take time to find out a bit more about my patients and focus more on the gap between the patient and the pathology! Thanks! Merian Denning Physio in Primary Care, Wilmslow, Cheshire

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  6. Great Guest Blog Adam,
    In order to heal our patients do need Faith.
    Over the Millennia the connection described in the article has been high jacked by the weird and spiritual, while we have focused on structure. I feel you and your guest blogs are making very neat in-roads towards unpicking the mess that has become medicine to the not very ill (Musculo-Skeletal Medicine) We need to use what the weird and spiritual use without being weird, we need to connect with our fellow humans without calling ourselves Spiritual. We need to be in touch with the Mind, Body, Person without the B*llsh*t.
    Thanks again.
    Rob.

  7. Really , it takes a lot to endure , what we can’t be fully rid of and know the limitations , but I give credit to that hug and T .L.C.! REASSURANCE IS AN INSURANCE I BET , well persevere !

  8. Hi Adam, I liked this article, solely because it is one of the fundamental principles I believe a physical therapist should abide by. Thanks.

    Ok, I wanted to DM you on Twitter, but because I am technologically challenged, I could not figure it out. Hence this email.

    Question: I remember having read your opinion on Anatomical Trains by some Myers. Should I waste my time on it or not ? Read or skip ?

    Thanks for your time. Regards Tanvi

    • Hi

      I would suggest you dont waste your time or money on Anatomy Trains. There is very little clinical usefulness in it, just lots of wild claims about things connecting to other things, and how other things can significantly influencing other things. Its all biologically plausible but scientifically improbable.

      Cheers

      Adam

  9. Thanks for including this piece in your blog Adam and I am heartened by the positive comments ! Last week via your own blog and clicking on twitter I found a link to Neil Maltby;s blog here: https://becomingmorehumanblog.wordpress.com/about-2/
    I thought Neil’s writing and commentary were excellent and its though his approach and the writing of Dr’s such as Iona Heath discussed here I remain slightly optimistic. https://abetternhs.wordpress.com/2012/09/19/iona-heath/ The ‘doing nothing essay’ in particular is excellent!
    I have met a few of the people here –Andy Abakhans, now in NZ and Luke in Australia (another good writer and critical thinker) and they are very much like Neil’s writing -sincere and individualistic and patients can sense this a mile off. Institutions and patients need a good dose of humanism to counter the robotic application of naive policies dreamt up by bean counters , academics (those who have completely forgotten about the coalface) and rolled out by managers.
    It’s amazing how far information dissemination has evolved, from crude acetates and the received wisdom and college tutors to no holds barred critical discussions on the net .
    I think we are in the middle ground and hover between the more certain territory of acute injuries/ortho trauma where most of the traditionally educated and experienced are comfortable (me included ) to the less comfortable but dominant (case number wise) general population are.
    This is why I think its important that we take time to consider Adams excellent forthright opinions but make time to other approaches too. Keith’s writing springs to my mind https://keithpkorner.wordpress.com and I always take my hat off to him in being able to vividly describe his encounters with patients in the community in a way that no RCT report will ever do!
    So perhaps there is a place to learn from the writing of the late great Oliver Sacks in our own rehabilitation world and include more narrative into teaching/reflection ?
    All the best for 2016 and if anyone wants Anatomy Trains for a cheap last minute stocking filler drop me a line!

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