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.
“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.