I am yet again pleased to give you another guest blog on The Sports Physio. This time by Jack Chew who will need little introduction to most of you due to his 'notoriety' within the physiotherapy social media world. He is the voice, and some say brains, behind the excellent Physio Matters Podcasts found here, which if you haven't subscribed to yet you are missing out on some great interviews with some fantastic guests delivering some awesome advice, wisdom and education all for free. Episode 7 for some reason is a clear stand out session for me… Anyway, Jack isn't just the 'Prince of Podcasts' he is also a practicing clinical physio offering a consultancy and second opinion service, his details can be found here

Jack has written about a subject that is very close to my heart and that I have written about before, critical thinking. Jack highlights some of the pro's and con's of one of critical thinking key features, the constant asking 'so what'…

So without further ado, its over to Jack…

I’ve an affliction called ‘So-What-Syndrome’.

The often professionally crippling, yet always psychologically liberating, condition that I call ‘So-What-Syndrome’ (SWS) is easily diagnosed. The most obvious symptom is a near-compulsive urge to ask ‘so what?’ when presented with information of any kind, by anyone, through any medium.

On reflection, I can see my affliction with SWS has been a long one. As a child, I ‘got away with it’, since an inquisitive nature was encouraged, and as a teenager being anything other than apathetic and moody was enough of a novelty to avoid conflict with most in authority. But with age, and a vague degree of maturity, it became increasingly difficult to keep my rather literally and metaphorically large mouth shut.

Fortunately for me, but unfortunately for my A-level biology teachers, I also studied English Language, media and marketing at college and was therefore encouraged to question everything and become comfortable with a lack of answers. Once I somehow made it to Physio school, my compulsive need to ask, suggest or imply ‘so what’ was defining me. Many around me would sit quietly knowing that if I was conscious enough to be concentrating, I was bound to ask the question. But as I met more clinicians and more critical thinkers, I slowly realised… I was not alone! Was ‘so-what-syndrome’ contagious? Was there a section of the Physio school allocation for those showing tell tale signs and symptoms?

For the reasons I will come to in a little while, I believe that having SWS has helped me in my career, but as for whether it helped or hindered my time at University, is debatable… Helpful self-directed questions such as: ‘So what’ if Simon’s right elbow doesn't fully extend’ became rather less productive ones such as ‘So what’ if I don’t learn my normal vital sign and arterial blood gas values’.

Complacency was a symptom that very nearly crippled me and from what I’ve experienced since meeting other SWS sufferers, it is this often hidden symptom that can be most damaging.

So before we do what the evidence based movement is famous for doing and ‘get carried away on a theme’ [2] [3], allow me to attempt to contextualise SWS and it’s place within a clinical reasoning framework.

• Asking yourself or others ‘so what’ does not, and should not, lead to an absolute disregard of that variable.
• ‘So what if Simon’s right elbow doesn't fully extend’ for example, helped me to understand that pain is much more complex than the biomedical model had long suggested. But it still mattered to my mate who was a county level, right handed fast bowler whose action was being scrutinised [4].
• Having SWS tendencies does not mean that you have the right to be blatantly inflammatory when debating a topic. As aforementioned, the questioning and challenging of long held beliefs and opinions are basic critical thinking principles, so don’t sound like a broken record.

Although this irritatingly autobiographical and borderline narcissistic account might seem like an unusual way for a Physio to present quite basic critical thinking; it is the only way I can think to present it honestly. Critical thinking is incredibly personal and therefore cannot be taught with facts and figures.

We often expect our students, colleagues, patients and peers to ask themselves ‘so what’ simply because we have come to think differently about a certain clinical entity. Our endeavor to improve our ability to provoke changes in people must go further than paying lip service to than the age-old job application favorite of ‘advanced communication skills’. When are we going to make basic education and empowerment skills a priority across the board?

I’ve frequently heard much smarter people than me use the quote: ‘before learning comes unlearning’. To be honest, my experience working with patients in pain and clinicians with sticky beliefs makes me question why both can’t be simultaneous, but if I run with it for the sake of simplicity, I’d suggest that we can’t productively learn OR unlearn with a ‘one track mind’. If your only position against a treatment modality or assessment technique is ‘there’s no evidence’ or ‘it’s too passive’ or ‘my patients won’t like it’ or ‘don’t forget the bio’. Then I would argue that your understanding of contemporary, evidence informed practice is as flawed as those who are completely resistant to change. [5] [6].

Throughout my life, SWS has been both a help and a hindrance at times and my ability to find the correct balance and delivery of my opinions is far from polished, as you can probably tell! But when it comes to clinical practice and my somewhat unique exposure to experts in my field, I certainly find more positives than negatives when evaluating my SWS. That said, a number of clinicians have turned the tables on me a few times with questions such as: ‘So what if we don’t agree that ‘Physio Matters’? ‘So what if we sell one mechanism of effect when it might be another?’ [16] and of course debate then ensues. And it’s these debates that occasionally provoke another SWS symptom; frustration.

Frustration that a vast number of clinicians seem so willing to accept opinion as fact, despite our industry being relatively young and rapidly progressing. But more concerning for me is that a vast number of clinicians seem so keen to latch onto a palpation finding, a movement dysfunction or a combination of both in order to diagnose and treat in a manner which suits their complacency and/or wallet, even if it’s at the expense of long term patient outcomes.

So in case you’re wondering how so-what-syndrome presents in clinical and non-clinical situations, here are a few examples that I made a note of as they cropped up in two of my working days in March 2015. References are links to nuggets of reading/listening/watching that sprung to mind at th
e time and helped with my decision-making.

And yes, they are worded as if I’m talking to myself…

Clinical:

• So what if you observe pes planus at rest and dynamic 'over-pronation' when running? [7] [8].

• So what if your patient is from a socio-economically deprived area? [9]

• So what if you don't feel that you're being 'specific' when you're using manual therapy? [10] [11]

• So what if your patient is fearful of movement? [12] [13]

• So what if the patient's left scapula is winging when they raise their arm… without load… in a warm clinic room… whilst being watched? [14] [15]

• So what if your colleagues get results with modalities that lack evidence backing or the basic support of biological plausibility? [16]

• So what if someone sits slouched throughout their subjective? [17] [18]

'Less’-clinical:

• So what if you're constantly doubting the mechanism of effect of your own previous success and ‘ruing the ones that got away’? (Aside: Apologies to the solicitor who saw me in Kent in Feb 2010. I now suspect that it was in fact a frozen shoulder and the injection that I discouraged may well have helped).

• So what if you encounter conflict with your peers as you try to find your 'style' in applying evidence informed practice? [19]

• So what if you've been on the latest 'new-age' movement and education course and can expertly ‘talk the talk’ through a case study? [20]

And I think, most importantly of all, especially considering the location of these ramblings:

• So what if you prefer to read and listen to blogs and podcasts over systematic reviews and RCTs?

I'm not for a minute saying that you needn't read the geeky stuff, but I absolutely disagree with the blog-bashing that often comes from the higher echelons of academia.

Forgive my soapbox moment here, but next time your blog-quoting is stifled by Mr A Snob et al (2005) [21], I encourage you to ask them whether, according to their own logic, they would mind removing the discussion sections from their often dry, formal and clinically-distant papers. That usually gets them flapping…

The discussion section of any paper is a glorified blog, often with similar levels of bias. Don’t be petulant and ignore the data, but please, lose the guilt and read a variety!

And finally, as a follow on to my last point:

So what if you want to be entertained?

In this age of scrutinised efficiency and CPD budget cuts, the vast majority of clinicians that are reading, listening, watching and tweeting are doing so in their own time in order to better serve their patients and therefore society. Now of course we should immerse ourselves into statistical analysis, philosophy, sociology and everything in-between at times, but the process of education needn't be boring!

This is an incredibly exciting time to be a physiotherapist or any professional working in the musculoskeletal field. So forgive yourselves for craving something different from your CPD but most importantly; get comfortable asking yourself, your colleagues, your managers, your commissioners, your governing bodies: SO WHAT?!

Because it's not just me… is it?!

Jack Chew BSc SWS MCSP CWLS

References:

[2] Deydre et al (2005) The Use of Ultrasound Imaging of the Abdominal Drawing-in Maneuver in Subjects With Low Back Pain – http://www.jospt.org/doi/abs/10.2519/jospt.2005.35.6.346#.VRVr-0LVvFI

[3] Adam Meakins (2014) – All aboard the bandwagon. https://thesportsphysio.wordpress.com/2014/08/02/all-aboard-the-latest-bandwagon/#comments

[4] Mike Stewart (2015) – Keep your balance. http://knowpain.co.uk/keep-your-balance/

[5] Kerry et al (2014) Causation and evidence-based practice: an ontological review. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2012.01908.x/abstract

[6] Matt Low (2015) – Clinical Reasoning in the management of LBP – A personal exploration. https://mattlowpt.wordpress.com/2015/02/14/clinical-reasoning-in-the-management-of-lbp-a-personal-exploration/

[7] Neal et al (2015) – Static foot posture as a risk factor for lower limb overuse injury: A systematic review and meta-analysis. http://www.researchgate.net/profile/Bradley_Neal/publication/271327404_Static_foot_pronation_as_a_risk_factor_for_lower_limb_overuse_injury_a_systematic_review_and_meta-analysis/links/54c54e8f0cf256ed5a9a973a.pdf

[8] Griffiths, IB (2012) – Overpronation – accurate or Parachronistic terminology? http://content.yudu.com/A1w1fo/32DY10-13/resources/index.htm?referrerUrl=http%3A%2F%2Fwww.sportspodiatryinfo.co.uk%2Fblog%2F

[9] Lowe et al (2014) – Does deprivation influence treatment outcome

in physiotherapy? http://www.maneyonline.com/doi/abs/10.1179/1743288X13Y.0000000132

[10] Bereznick et al (2002) – The frictional properties at the thoracic skin-fascia interface: implications in spine manipulation. http://www.sciencedirect.com/science/article/pii/S0021929002000143

[11] Kim Ross (2008) – Scientifically Scrutinizing Spinal Manipulative Therapy. http://www.canadianchiropractor.ca/research/scientifically-scrutinizing-spinal-manipulative-therapy-979

[12] Doury-Panchout et al (2014) – The influence of kinesiophobia on recovery of joint function following total knee arthroplasty. http://europepmc.org/abstract/med/25392087

[13] Vincent et al (2014) – Kinesiophobia and Fear Avoidance Beliefs in Overweight Older Adults with Chronic Low Back Pain, Relationship to Walking Endurance. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647684/

[14] Ratcliffe et al (2014) – Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review http://bjsm.bmj.com/content/48/16/1251.short< /a>

[15] JS Lewis (2011) – Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? http://www.maneyonline.com/doi/abs/10.1179/1743288X11Y.0000000027

[16] Jack Chew (2014) – Jack’s Ironic Toothache http://knowpain.co.uk/jacks-ironic-toothache/

[17] O’Sullivan et al (2013) – The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review http://www.tandfonline.com/doi/abs/10.1080/00140139.2012.676674#.VRWD5ULVvFI

[18] Karim Kham with Kieran O’Sullivan (2015) – BJSM Podcast: Practical tips for treatment of LBP. http://www.pain-ed.com/blog/2015/02/27/podcast-by-dr-kieran-osullivan-with-bjsm/

[19] Tim Noakes (2010) Ted-X: Challenging beliefs. https://www.youtube.com/watch?v=4lzs5wpLkeA

[20] Emanuel Brunner (2015) What clinicians say they advise for low back pain is not what they actually do in clinical practice. http://www.pain-ed.com/blog/2015/02/14/what-clinicians-say-they-advise-for-low-back-pain-is-not-what-they-actually-do-in-clinical-practice/

[21] Snob A et al (2005) Why blogs are the scourge of the musculoskeletal industry. (Come on, you know that’s not for real! … yet).