MasterclassThe interpretation of experience and its relationship to body movement: A clinical reasoning perspective
Introduction
The learning of movement and its therapeutic application with patients through teaching is arguably the most central role of physiotherapists. For manual therapists there remains a significant challenge in assisting patients with chronic pain to learn or re-learn various movement patterns. In part this paper focuses, from a clinical reasoning perspective, on how the interpretation of pain and illness experience over time influences the learning or unlearning of movement in these patients. Historically manual therapists have addressed the physical impairments identified as contributing to loss of functional abilities and participation in the various fora (family, social and work) of patients’ lives. Recent literature suggests that manual therapists also understand patients’ interpretations of their illness and/or pain experience in order to address their decision making around activity and participation capabilities which are, in turn, influenced and informed by these interpretations (e.g. Osborn and Smith, 1998; World Health Organization (WHO), 2001; Main and Watson, 2002; Butler and Moseley, 2003; Waddell, 2004; Jones and Edwards, in press).
Clinical reasoning is concerned not only with understanding these patient perspectives but also with understanding the nature of our own thinking and decision making as practitioners. What are the underlying assumptions upon which therapists base their interpretation of diverse data (e.g. patient beliefs and perspectives as well as physical impairments) in order to make diagnostic and treatment decisions? How does the manner in which therapists interpret patient data, even allowing for such diversity of data, influence the way in which they choose and implement management strategies? What are the implications for clinical management (e.g. teaching movement) of being aware of and intentionally varying these reasoning processes?
In order to address these questions this paper is structured in three sections. Firstly, we consider the manner in which patients with chronic pain often constrain body movements and so diminish their previous repertoire of movements and, by extension, functional abilities. In the physiotherapy literature there has been an emphasis on the identification of so-called ‘chronic pain behaviours’ (e.g. fear avoidance) and the design of remedial strategies to address these more than there has been on an understanding of how these behaviours are the consequence of interpretive and decision making processes by patients (Jones and Edwards, in press). In the second section, we describe a model of clinical reasoning emanating from a qualitative research study (Edwards et al., 2004) which describes how expert therapists reason, even with a particular patient and within one treatment session, using an interplay of fundamentally different clinical reasoning processes. Significantly, in a departure from previous clinical reasoning theory (e.g. Hayes Fleming, 1994; Benner et al., 1996), these reasoning processes are not deployed in a manner where one type of reasoning is employed for interacting with patients and another type for choosing and implementing treatment procedures. In the third section we explore how these fundamentally different reasoning processes both have important roles in the teaching and learning of movement.
Section snippets
The interpretation of experience in chronic pain
Patients render their experiences sensible to themselves and others through the act of interpretation. Patients’ interpretations of illness, pain and/or disability experiences are formed in relation to the depth and diversity of their ‘interpretive resources’ (White, 1998, p. 1). The term ‘interpretive resources’ refers to a pool of beliefs, values and behaviours which are derived from cultural and social influences as well as patients’ own unique personal circumstances and histories ((Mezirow,
Clinical reasoning and movement: it is not only what therapists see but how they see it
Edwards et al. (2004) carried out a qualitative, grounded theory study of the clinical reasoning of expert clinicians in three different fields of physiotherapy: manual/musculoskeletal; neurophysiotherapy; domiciliary care (home based) physiotherapy. Grounded theory is a method often used to generate theory or explanations which are grounded in the data, and regarding a phenomenon about which little is known (Strauss and Corbin, 1994). The aim of this research was to study the clinical
Instrumental and communicative learning of movement
Moira's story reminds us, as does current pain research of the importance of providing patients with a plausible account of the ‘irrationality’ of chronic pain. Thus, the so-called irrational and recalcitrant behaviour of pain experienced by those with central pain states is externalized from the patient to the problem. No longer is the patient themselves held to be the primary source of irrationality in the situation (Steen and Haugli, 2000). For example, a biomedically focussed form of
Conclusion
Communicative action and learning offers clinicians, in conjunction with instrumental learning and action, a way of acknowledging, in clinical practice, the complexity of mind–body relationships described in contemporary accounts of pain such as ‘schema enmeshment’, ‘interpretive resources’ and ‘threat reduction’ in neuromatrix theory. We have focussed in this paper on the interpretation of experience and body movement of patients with chronic pain. However, in order to understand the thinking
Acknowledgements
The authors would like to thank Lorimer Moseley and Nicole Christensen for their helpful comments in the preparation of this paper.
References (53)
- et al.
When somatic information threatens, catastrophic thinking enhances attentional interference
Pain
(1998) - et al.
Attentional disruption is enhanced by the threat of pain
Behaviour Research and Therapy
(1998) Chronic pain and distraction: an experimental investigation into the role of sustained and shifting attention in the processing of chronic persistent pain
Behaviour Research and Therapy
(1995)- et al.
Attention and somatic awareness in chronic pain
Pain
(1997) - et al.
Conceptual models for implementing biopsychosocial theory
Manual Therapy
(2002) Gate control theory. On the evolution of pain concepts
Pain Forum
(1996)A pain neuromatrix approach to patients with chronic pain
Manual Therapy
(2003)Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain
European Journal of Pain
(2004)- et al.
Health care provider's attitudes and beliefs towards chronic low back pain: the development of a questionnaire
Manual Therapy
(2003) - et al.
The difficult patient in private practice physiotherapy: a qualitative study
Australian Journal of Physiotherapy
(2003)
Chronic pain: a reformulation of the cognitive-behavioural model
Behaviour Research and Therapy
Impaired disengagement from threatening cues of impending pain in a crossmodal paradigm
European Journal of Pain
Expertise in nursing practice: caring, clinical judgement and ethics
Understanding the understanding of illness: lay disease representations
Explain pain
The evolving culture of physiotherapy. Barbara Edwardson Lectureship
Physiotherapy Canada
Physiotherapists’ pain beliefs and their influence on the management of patients with chronic low back pain
Spine
Introduction
Clinical reasoning strategies in physical therapy
Physical Therapy
Medical problem solving. An analysis of clinical reasoning
Awareness through movement
Randomised controlled trial of physiotherapy compared with advice for low back pain
BMJ
From shame to respect; musculoskeletal pain patients’ experience of a rehabilitation programme, a qualitative study
Journal of Rehabilitation Medicine
Application of the cognitive-behavioural approach
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