Jonathan

June 2021 Online, part 3

This is the third part of my thoughts about the online cognitive functional therapy course with Professor Peter O’Sullivan in June 2021. Overall it was a great success.

Here are the links to:

Cognitive Functional Therapy Course, June 2021 Online, part 1

Cognitive Functional Therapy Course, June 2021 Online, part 2

Exposure

Exposure to mechanical stresses needs to be done carefully and the assessment should tell you what kind of pain the person has and how easily, or not, it is aggravated.

“Baby steps are needed for big steps to be achieved.”

We learn by mirroring and can use our own bodies to illustrate, making it easier for the patient to copy what we are aiming for.

It’s critical to develop a sense of safety around the exposure challenge as they’ll be very anxious when you get them to do the things they fear and have been avoiding.

I think of the extension pattern, where the person keeps their core tight and holds the lumbar spine in lordosis, as Self-Imposed Functional Fusion or SIFF. I’m slightly tongue in cheek here but it’s the commonest pattern and I wonder if Self-Imposed Spinal Stenosis and Self-Imposed Nerve Root Compression contribute to symptoms in these presentations. They’re not the whole story but I think they may sometimes be enough to get the symptom bucket to spill over into pain.

Get the patient to increase their pain so you can contrast it later with the improvement they get with CFT approach, allowing them to learn.

Giving Up Early

Watching Peter with one of his patients in particular, I was struck by how far he went in finding out what the patient wanted. The lesson for me was that once you’ve sorted out the presenting problem for the patient, don’t just say “Great” and discharge them. Find out what else there is, lurking in the background. They may be able to bend over and lift objects but have trouble in the car. Once you address that you may find they have some, slightly smaller, problem sleeping. It’s worth chasing all the symptoms and “disabilities” before you can say you’ve done a good job.

Day 3

Patient Stories and Treatment.

If you challenge the patient too hard, you challenge the person and not just their beliefs. This will likely result in a poor outcome.

Challenge at the correct time and at the appropriate level. Before that you can roll with the resistance/beliefs (just noting them) until you have a good enough relationship to start the harder work. [Remember not to be right. At least not to say so].

Nobody listened, nobody believed, nobody understood. That’s what my ex-colleague Patrick said years ago – this is what patients think if you really ask them. So be different. Listening is an effortful and active process.

Constantly check what the person is thinking, because they could go off on a cognitive tangent you are unaware of which may hold them back.

A key is re-engaging with valued activities. It has to be valuable to the patient, not an exercise without functional meaning for them. Like knee rolling, pelvic tilting and pretty much any back exercise we use…

I have attended the cognitive functional therapy course twice in person in London, but this year was different due to the limitations on travel from the pandemic.

However, the online format for the cognitive functional therapy course works very well indeed. We miss the social interaction, the meeting new people and enthusing about new ideas and treatment, but this is a good substitute and could remain part of the repertoire.

Becoming a mirror is the key to getting your patients to see themselves.

To see the other parts of this reflection series, please use these links

Cognitive Functional Therapy Online Course June 2021 Part 1

Cognitive Functional Therapy Online Course June 2021 Part 3

Reflections

If you’ve done any study of motivational interviewing (MI), you will know this. And MI is the most useful skill you can acquire, way more useful than manipulation, mobilisations, kinetic this or that, core stability, Pilates etc. etc. Because everyone has a psychology and that’s what drives their behaviour and their coping with pain and disability.

MI divides reflections into simple and complex. Both are important and we saw Peter doing examples of each.

• Simple “You fell over and hurt your wrist..”, in response to someone describing the incident. It’s a kind of repetition, just letting the person know you are paying attention.
• Complex, where you interpret what the person has been saying and suggest things about the situation they may not have explicitly expressed. Peter does it by this kind of example “What I’m hearing is that after your MRI you were told a bunch of things and since then you’ve been very worried your discs are black, they have squashed down and have the consistency of cheese”.
• If you do a complex reflection, there is a risk you’ll get it wrong. It’s vital to check this with the patient and correct the details.

When someone suggests they want their life back, ask them what “life back looks like” so you get a clear idea of their goal, which will vary hugely and often encompasses activities which will surprise you and which you wouldn’t otherwise be aware of.

If people adopt an unhelpful coping style or behaviour, you can ask “How successful has x been for you?” to get them to reflect and perhaps become more open to a new approach.

By these kinds of open questions you open up the agenda for the patients to tell you what they need and want.

If you let them, our patients will tell us how we can help fix them. All we have to do is listen.

Reflections June 2021, Part One

To see parts 2 and 3 here are the links:

Cognitive Functional Therapy Online Course June 2021 part 2

Cognitive Functional Therapy Online Course June 2021 part 3

BigMan and I (yes, we both paid) settled down at 0800 on the Saturday morning to listen to Peter O’Sullivan on the cognitive functional therapy course.

He was zooming us from Perth, Australia in the first of four five-hour periods in which we learned more about helping people change, about really listening and understanding what’s going on. I put it on the 55-inch TV and it worked really well.

BigMan is bored of me trotting out one of my sayings – “You can’t convince anybody of anything. You can only help them convince themselves.” Since we’re both physiotherapists, we are automatically oriented towards telling rather than listening. This means it’s hard to change, to convince ourselves to change and really listen.

So here’s a list of the things I took from this course, some are brief and some I will discuss in more depth. Thoughts in square brackets [blah blah] are my personal reflections.

• Typically the therapeutic process takes 12 weeks [i.e. don’t expect it to take less time cos it probably won’t].

• [The process is finished when it’s finished, not when the 5 sessions are done and the person needs to be discharged, either due to NHS restrictions or insurance company instructions.]

• Many negative patient beliefs are based on encounters with health care personnel. [For example, us.]

• Pain behaviours arise early in life and may relate to parental styles of coping with pain. Asking about the family can be really illuminating.

• If a person is not conditioned to an activity, repeated attempts to achieve that activity may worsen pain. [What does conditioned for an activity really, really mean in terms of tendons, bursae, muscles, nerves..?]

• Flip the story away from damage towards movement, sleep, happiness and activity.

• Time, communication, access to the therapist and support are the primary elements. [It’s no use leaving your patient with the impression they can’t contact you at any time]

• [Never discharge your patients. This doesn’t mean you don’t stop seeing them. Discharge is something routine to us but can feel like abandonment to the patients. And abandonment is a very powerful force on the negative side]

• [Explicitly recognise the reality of a patient’s pain. It’s not enough to “express” it implicitly. You have to say it out loud.]

• Take care to check out discrepancies in the patient’s story. Problems may lurk there.

• “I’m interested in the things you’re concerned about” is a great way to express your intent. It tells them that their agenda is in the driving seat and you’re not just filling in a form.

• “How do you FEEL about that?” is a great question and not often asked by physiotherapists. But it is the key point. What have they interpreted from what’s been going on and how do they feel about what they have deduced is their problem.

• If a patient improves very quickly, be careful. They may worsen very quickly too.

The online version of the cognitive functional therapy course was working well. We’d already learned a lot about how to refine our approaches. Parts Two and Three related more to the patient management that Peter moved on to.

How Much Do Patients Need to Know?

James looked at me in a way that conveyed “That thing that you’re thinking, it’s just not right” and I knew a teaching point was coming.

James Lavers is a great teacher of video techniques for personal or brand marketing, and his courses are worth attending for the action they will inspire in you.

I was in London, on the south bank of the Thames close to Tower Bridge, a postcard backdrop to the course during our coffee breaks.

He had asked me something like “What do you want your viewers to do?” and I had answered with “I want them to understand….”

That’s where he stopped me. Then he said something that has always remained with me and informed my physiotherapy practice as well as other parts of my life.

He said “Your patients don’t need to know your expert shit.”

I don’t think I understood the implication of that at the time. I took it as something I should not do, that is to explain things I didn’t need to explain. And that this would make my videos or video courses better.

I’ve been reflecting on that sentence ever since. And repeated it to many people, with proper attribution to James, who most of them do not know.

The real relevance has slowly struck me ever since, and was strongly reinforced when I next visited London.

CFT at the Royal Free

Along with my colleague Neil Davey, I attended Professor Peter O’Sullivan’s last course on Cognitive Functional Therapy at the Royal Free Hospital. The course is always inspiring for the clarity of thought and the practical demonstrations.

The practical demonstrations are amazing! Peter interviews a patient he has never seen before, in front of 300 physios and other health professionals, and shows us how we can help a person change. And they change right in front of us. And the change persists.

Now Peter is a person who has always worn his learning lightly, you never feel any superiority from him although he is clearly more able than pretty much all of us.

This time, however, a new thought struck me as I was walking back to Crouch End with Neil. Peter had seen four patients over a day and at no time had he done any “physio explaining” about pain neuroscience or disc structures or cognitive influences on pain. That seemed new.

He never showed his expertise openly to the patient but guided them towards finding their own ways to change. By showing them that their feared movements or postures did not result in a catastrophic outcome, he made them rethink their views of their body and how it could be safely used.

Do Patients NEED To Understand Anything? Or Do We Need Them To?

Now Neil and I have somewhat different views on this. I’m more of the view that a patient never needs to understand anything about their back or other pains, although I take that position more to limit over-delivery of our technical knowledge than I mean it literally. I think – just show them that the movement or activity is safe and that’ll do it.

Neil is not so sure. He probably has a point.

I’m starting to read the literature around pain education and reassurance, both of which I’m very sceptical about at this moment. But that might change….

Wearing our learning lightly means we don’t let our egos get in the way in showing the patient how knowledgeable we are about this or that subject. It’s just not needed.

In spinal surgery and neurosurgery clinics stenosis is a common presenting symptom. A person over 60 years old complains of leg pain, typically worse in walking and standing and better sitting or bending forward.

In physiotherapy consultations many patients complain of troublesome leg symptoms, and it is unclear whether there may be nerve root involvement.

Leg Pain

Severe leg pain occurs in two main age groups, the 30s and 40s with nerve root compression from disc prolapses and the 60s+ with nerve root compression from stenotic changes affecting the exit canals.

There may be another group however. People may hold themselves in a state of pseudo-nerve compression or joint discomfort due to the way we typically react to back pain and leg pain.

Overdoing the Lordosis

We adopt repeated patterns of posture to reduce our back and leg pain. One of the commonest is the active maintenance of a lumbar arch or lordosis for long periods and in most functional postures. And we carefully avoid flexing our back when we bend over, when we think we are at most risk of back injury.

An increased lumbar lordosis reduces the space available in the lateral nerve root canals and compresses the facet joints. Keeping the lumbar spine in end-range extension could increase the pressure on any nerve root or other sensitive structures in that area.

Functional Stenosis

This is a functional stenosis, the symptoms maintained by continually contracting the spinal erector muscles, keeping the lordosis as much as possible and using a lumbar roll in a chair or a car.

Clinical observation indicates that encouraging a patient to relax their lumbar muscles and to flex forward can improve their symptoms. Backache from maintaining the lumbar extensor muscles in contraction can ease and then the leg symptoms also ease. With routine practice of lumbar flexion in a relaxed manner, the tightness or compression may be reduced enough to lessen leg symptoms.

A continuing focus on a structural tissue interpretation of symptoms and on MRI findings may be leading us to ignore this simpler and more functional issue. Holding the lumbar spine actively in extension could give nerve root-like symptoms and facet joint pain, referring pain to the buttocks, thigh, calf or foot.

Fear Avoidance

Fear underlies the maintenance of lumbar extension. Fear of increasing the pain or aggravating whatever we think is going on anatomically. The McKenzie technique’s ideas on lumbar flexion causing posterior displacement of the disc and thereby worsening symptoms is relevant. Physiotherapists have taken this idea that keeping a lumbar lordosis at all times is vital and that lumbar flexion will worsen symptoms.

Our backs love flexion. Repeated lumbar flexion is good for our discs and our spine, increasing blood flow and relaxing the extensor muscles that are often in perpetual contraction. Encouraging people to perform lumbar flexion is an exercise in reducing the anxiety around doing something they feel would be harmful, or have been told not to do.

There is little evidence that keeping our back straight and bending our knees when we lift is necessary or reduces stress or risk to the lumbar spine. It may do the opposite.

Getting Out of the Way

We could get our of our own way. Our bodies know what to do when sitting, lifting, walking or lying, we just have to relax and let them get on with it. And our job as physios may be to facilitate this change and strip away the layers of protective beliefs and behaviours that many of us build up around our spines.

Many back and leg pain problems appear to be functional syndromes. They are maintained by the actions and behaviours of the person and not related to any particular anatomical abnormality. We should be able to help these people and avoid the ‘there’s x or y wrong with your back’ ideas that excessive concentration on anatomical features leads to. It’s not technical but it takes skill to do it.