Measuring physiotherapy

Why is it that physiotherapists measure things?

Over the last few weeks I’ve talked with some physio colleagues about their work, and been struck by the way they are asking some pretty fundamental questions about physiotherapy.

One conversation revolved around the trend towards active treatment and patient self-management. “Why is it”, this colleague asked, “that some physios are giving up on so-called passive treatments? If we were artists, we wouldn’t give up on painting just because the latest trend was for video installations.”

Is it because physiotherapists have come to believe their job is to ‘fix’ things in a way that artists never do?

There seems to be a lot of hubris and ego tied up in the presumption of fixing things.

And maybe we would serve some people better by setting our sights at responding to their present situation, rather than thinking that our work begins and ends with cure?

After all, fixing things only really works when problems can be fixed. So where does that leave people with longstanding, incurable health problems, that just need someone they trust to work with them, not on them?

Another conversation was about person-centred care.

This colleague is near to completing an amazing PhD that has shown that most of the physios in their study hardly ever use the language and ideas embodied in person-centred care.

The physios in their study were very much about motivation, and patient self-management, and all the language we’re now hearing about things like Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT).

And it was interesting to hear how easily these approaches had been adapted to fit the physio’s ways of thinking and working.

This is perhaps not surprising given that CBT and ACT live at the objective, scientific end of the psychology spectrum, with relational, narrative, or broadly ‘humanistic’ psychology approaches at the other.

One of the things that separates these two poles is the way they engage with the patient’s core beliefs.

Relational humanistic approaches stress the need to reduce the distance between the therapist and patient.

This is done by the therapist building close, interpersonal relationships with the client, and finding ways to reduce their own power and build up their patient’s sense of control.

The objective scientific approach is very different. Here the control lies squarely with the therapist. The goal is to capture the patient’s beliefs in a form that can be measured, compared, shared, and evaluated.

And so lots of tools, models, standardised interventions, assessment grids, symptom checklists, belief algorithms, activity profiles, alternative action formulations, behaviour diaries, anger self-monitoring records, and so on, are used to instrumentalise the approach. (If you’d like to see some of the many examples of these, click here).

Why are we putting these tools between us and the patient? Are the benefits of an objective measure worth the loss of proximity to what people really feel? Are we so uncomfortable with people’s subjectivity that we need these tools as a proxy for scientific respectability and authority?

The third conversation was about our need for practical solutions.

I’ve been writing theoretical pieces about physiotherapy for years now, often holding to Kurt Lewin’s adage that ‘There’s nothing more practical than a good theory’ (Lewin, 1952).

In all that time, I haven’t had a paper accepted in which one of the reviewers hasn’t asked me to expand on the practical implications of my ideas.

The colleague I was talking to – also a writer on physiotherapy – called it the ’tyranny of clinical implications’.

It’s not that there’s anything wrong with the practical usefulness of ideas or clinical implications, per se, only that it feels sometimes that we give ideas no room to breathe before we want to ensnare them and put them to work.

The American writer and art critic Rebecca Solnit once joked that museums love artists the way that taxidermists love deer (Solnit, 2014), because ‘something of that desire to secure, to stabilize, to render certain and definite the open-ended, nebulous, and adventurous work of artists is present in many who work in that confinement sometimes called the art world’ (ibid).

I sometimes think Solnit could have been talking about physiotherapists.

References

Lewin, K. (1952). Field theory in social science: Selected theoretical papers by Kurt Lewin. London: Tavistock.

Solnit, R. (2014). Woolf’s Darkness: Embracing the Inexplicable. The New Yorker. https://www.newyorker.com/books/page-turner/woolfs-darkness-embracing-the-inexplicable.