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The Person, the Patient, the Physiotherapist

When is a person a patient? Or for that matter, do we see our patients as people? What really is the role of the physiotherapist today?

By Eoin Kealy Musculoskeletal Physiotherapy student.

These were some of the presenting questions when I commenced my MSc in MSK physiotherapy. Continuing professional development is essential in physiotherapy and completing an MSc programme was a goal I always wanted to achieve – an opportunity to hone my skills, learn how to critically appraise the research; become a critical thinker and most of all, learn how to do the grade V manipulations. With this skill set I could heal the masses in Stuttgart, where I have been living and practicing physiotherapy for the last four years. The Irish physio in Germany, manipulating peoples pain away (once you pop, you can’t stop), ah what delusions!

It was a sobering moment realising that a grade IV mobilisation is often just as good as a manipulation or that the research on manual therapy in general was less of a biomechanical model but more a combination of neurophysiological and biomechanical with a large dash of placebo.

I began to question my own contribution as a physiotherapist. Years of believing that manual therapy was the Holy Grail only for this belief to be taking away with a few honed but graceful words. As the dust settled, I sat their flabbergasted, I turned to find the shocked faces of my colleagues but alas they were not to be found. Nodding in agreement, adding their own evidence while supporting their claims with research. My fellow counterparts seemed to be in on this. Was I asleep for years or walking through the world of physiotherapy with my eyes closed? I saw those youtube videos of chiropractors, osteopaths and manual therapists working wonders. Can the research be true?

We journeyed on, with Clair and Colette at the helm and began to pick apart our profession. To critically analyse our goals, to draw on relevant research (a scary task sometimes in the classroom, best not to mention core strength!), naturally there came a point where we discussed physiotherapeutic models – biomedical model, biopsychosocial model (BPS), patient/ person centred care to mention a few. It was at this point I began to question my own understanding and underlying assumptions as to what constitutes physiotherapy.

I was trained in the BPS model, but did I really adhere to this method, or gloss over the psycho/socio factors while referring back to the reductionist way of the biomedical model, which emphasises mind-body dualism. Cartesian dualism, how simple you are, the mind and body – two different entities a physiotherapists dream. This unfortunately is a dream, the more we explored the MSK more psychological it got. To fully understand patients, we must view them in a holistic was which encompasses all facets of their lives. Is the BPS model the way to achieve this?

It was in the 1950’s the concept of the BPS model was first introduced although not named, Roy Grinker first coined the term. However, in 1977 George Engel cogently argued that medicine with a specific regard to psychiatry should change from a biomedical model to a BPS model (“The Biopsychosocial Model and Its Limitations,” n.d.). Engel held the opinion that the biomedical model was too reductionist and lacked a holistic approach grounded in general systems theory.

The BPS model is thought to be holistic, but does it allow more eclecticism? Grinker identified that the BPS model should pursue eclectic freedom, that is, the ability to ‘individualise treatment to the patient’. In practice this means, being allowed to do whatever one wants to do (Ghaemi, 2009). Does this eclectic freedom allow physiotherapists or healthcare practitioners to choose whether it is the ‘bio’, ‘psycho’ or ‘social’ that is emphasised – one rather than the other? Is there a rationale to choose one over the other? The ensuing result is a paradox: when free to do whatever one chooses, we enact our own dogmas, conscious or unconscious (Ghaemi, 2009). Does this dogmatism lead us to believe that the BPS model is the undeniable truth and therefore becoming what it sought not to be – dogma?

Like many physiotherapist, I found myself daunted by the task the BPS model presented for me (Cassidy et al., 2011). Was I really helping my patients who have psychological problems or socioeconomic difficulties? Did I really listen to what the patients were telling me, or was I quickly redirecting to the comfort zone of muscles, tendons and bones? Surely this is the preserve of psychologists and social workers, I would reassure myself. Physiotherapists are specialists of the musculoskeletal system not the mind.

This lead me to the question; are we equipped to deal with the psychological and social aspects of our patients’ problems? Physiotherapy curriculums  have changed in recent years and inform the learner of the importance of the psychosocial factors and not just the biomedical issues (Ali and Thomson, 2009). However, the challenge is to apply the insights from research to applied practice. It is a question of striking and reaching the correct balance between a person’s psychosocial needs and the biomedical approach in managing their presenting conditions.

A recent study by Sanders (Sanders et al., 2013) has shown that physiotherapists may find it difficult to implement strategies that identify and manage the bio psychosocial components of the person’s presentation. Many referred to the difficulty of dealing with patients’ lay health beliefs. Psychosocial ‘obstacles’ were viewed as potentially inhibiting patients to follow therapeutic advice. In spite of these difficulties physiotherapists acknowledged the importance of constructive dialogue with patients about the full array of biopsychosocial obstacles to recovery, however they did not feel that they had the adequate skill set or training to deal effectively with psychosocial obstacles specifically (Sanders et al., 2013).

In a recent systematic review, it was shown that physiotherapists treating low back pain (LBP) only partially recognised the cognitive, psychological and social factors in LBP, with most discussion focusing on factors such as family, working life and what was perceived as unhelpful patient expectations. Patients with LBP and whose behaviour suggested these factors may be an issue were stigmatised by some physiotherapists as being demanding, attention seeking and poorly motivated. It was noted that physiotherapists questioned the relevance of screening for these factors as they were perceived to extend beyond their scope of practice, with many feeling they lacked the necessary skills to address these issues (Synnott et al., 2015). These studies show us, that although physiotherapists are trained within a BPS framework, their confidence in implementing this method is lacking.

The BPS theoretical model is a sound approach, especially in applied physiotherapy. When treating people much more is treated than the presenting condition. The person must be seen in their entirety. This encompasses the bio, psycho and social aspects of the person. However, is it not true that these aspects can be separated from one another? Are they not uniquely intertwined, interchanging and constantly influencing the others? If we see that the ‘bio’, ‘psycho’ or ‘social’ sides of a person are interdependent – each influencing the other – why then separate them? People accessing physiotherapy may or may not have psychosocial factors that will affect the outcomes of the treatment. However, the treatment alone brings a ‘bio’, ‘psycho’ or ‘social’ aspect for every individual. They will respond to the clinic environment and have many responses to the treatment including biomechanical and psychological. Patients when they feel the physiotherapists hands, will have a physical response from the treatment approach but also a psychological response of that perceived touch (Bjorbækmo and Mengshoel, 2016).

Back to the question when is a person a patient. This is something that resonated for me when I was posed with the question of “why patients and not people?”. Most research and most physiotherapists call the person receiving interventions, a patient. But what does this really mean?

The word ‘patient’ comes from Latin, meaning “one who suffers” and conjures up a sense of passivity. What do we see when we hear patient? Does it conjure an image of someone willing to take part in their healthcare or rather someone who is a receiver of care, passively waiting to be healed. Is it not simpler and more beneficial to see them as people or users rather than patients and treating them as such? Therefore, making them an active participant in their own healthcare. The BPS model has many positive values, in particular seeing people in a holistic view but if we adapt it to a person-centred care model, which seems more all-encompassing to what a person needs, believes or wishes to have.

Person centred practice is a way of thinking and implementing actions based on people using physiotherapy and other healthcare services as equal partners in planning, developing and monitoring their care – making sure their needs are met. In effect prioritising people and their families at the centre of decisions – recognising them as experts – working alongside professionals to get the best outcome (Mudge et al., 2014). The implementation of a person-centred approach in physiotherapy and health service systems does decisively impact on personal factors, for example, patient satisfaction, motivation, adherence to therapy – thus improving health outcomes (Cooper et al., 2008; Scholl et al., 2014; van Dulmen et al., 2015). A systematic review which looked at studies on processes and outcomes of patient centred care showed positive relationships between patient centred care with intermediate and distal outcome measures (Rathert et al., 2013) . Person centred care allows all parties to ‘speak the same language’. Which will in turn provide a stable foundation thereby creating more satisfactory measures and interventions (Cooper et al., 2008; Scholl et al., 2014).

A person in pain not only has anatomical and biomechanical factors but also cognitive and emotional co-relates. They are not just a somebody in pain but a person with a life narrative. In addition, we need apply these understandings so that our applied practice is informed. When a person comes for a physiotherapy treatment these cited factors may have already influenced and possibly atler the person’s perspective. The person’s psychological and social situation has already informed their perception of their condition, but they are also significantly influenced by how the therapists interact with them. Coming to a clinic for a treatment is also an experience, it can be a new social situation for a person and does bring a psychological response. For example, a person coming to your clinic situated in the middle of a town with the presenting problem of chronic low back pain – traveling by public transport. As no seats are available standing is the only option. After 10 minutes their back begins to ache. They begin to think “why did I not take the train or the car”. Quickly dissatisfaction may present already leading to intrusive repetitive thoughts as to their decision to access physiotherapy – influencing their perception of treatment although not yet in the clinic! By trying to view people in the BPS model, are we not underestimating the complexity of a person with all these factors that can impinge and intrude on their thinking and which may in turn negate any chance of a successful treatment outcomes if not addressed? Are humans not more complex than just the biological, psychological and social aspects? Why not view a person in a holistic manner within a person – centred frame work? Avoiding the titles of ‘bio’, ‘psycho’ and ‘social’ does not confine us to one centre area but rather to see the person as they are – viewing them in their entirety – unbiased.

Person-centred care can be a beneficial way of changing how we view people receiving treatment. It incorporates both the biomedical and biopsychosocial factors which may arise when in treatment but also actively supports the person and empowers them in their own healthcare.

By Eoin Kealy, Musculoskeletal Physiotherapy student.

 

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