Elsevier

Manual Therapy

Volume 11, Issue 1, February 2006, Pages 2-10
Manual Therapy

Masterclass
The interpretation of experience and its relationship to body movement: A clinical reasoning perspective

https://doi.org/10.1016/j.math.2005.10.002Get rights and content

Abstract

In this paper, we present findings from literature which suggests an intrinsic relationship in patients with chronic pain between the development of rigid and limited perspectives based on the interpretation of experience and the development of decreased repertoires of movement patterns. We present a research-based clinical reasoning model for conceptualising the teaching of movement for patients with chronic pain and contend that therapists can intentionally teach movement using fundamentally different reasoning and learning processes. We propose that these different kinds of learning will assist clinicians to translate the findings of diverse and complex pain research to clinical practice and, in particular, the teaching of these patients both new perspectives and movement patterns.

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)

  • T.J. Sharp

    Chronic pain: a reformulation of the cognitive-behavioural model

    Behaviour Research and Therapy

    (2001)
  • S. Van Damme et al.

    Impaired disengagement from threatening cues of impending pain in a crossmodal paradigm

    European Journal of Pain

    (2004)
  • P. Benner et al.

    Expertise in nursing practice: caring, clinical judgement and ethics

    (1996)
  • G.D. Bishop

    Understanding the understanding of illness: lay disease representations

  • Burnett, Moseley L. Does explaining pain reduce the threat value of spine and pain-related words? A blinded randomised...
  • D. Butler et al.

    Explain pain

    (2003)
  • C. Carpenter

    The evolving culture of physiotherapy. Barbara Edwardson Lectureship

    Physiotherapy Canada

    (1996)
  • A. Daykin et al.

    Physiotherapists’ pain beliefs and their influence on the management of patients with chronic low back pain

    Spine

    (2004)
  • N.K. Denzin et al.

    Introduction

  • Edwards IC. Clinical reasoning in three different fields of physiotherapy—a qualitative case study approach, vols. I...
  • I. Edwards et al.

    Clinical reasoning strategies in physical therapy

    Physical Therapy

    (2004)
  • A.S. Elstein et al.

    Medical problem solving. An analysis of clinical reasoning

    (1978)
  • M. Feldenkrais

    Awareness through movement

    (1972)
  • H. Frost et al.

    Randomised controlled trial of physiotherapy compared with advice for low back pain

    BMJ

    (2004)
  • M. Gustaffson et al.

    From shame to respect; musculoskeletal pain patients’ experience of a rehabilitation programme, a qualitative study

    Journal of Rehabilitation Medicine

    (2004)
  • V. Harding

    Application of the cognitive-behavioural approach

  • Cited by (22)

    • A qualitative grounded theory study of the conceptions of clinical practice in osteopathy - A continuum from technical rationality toprofessional artistry

      2014, Manual Therapy
      Citation Excerpt :

      Such research also facilitates an understanding of how practitioners learn from practice and develop as practitioners (Richardson et al., 2004). For example, the literature suggests that the views and assumptions that manual therapists' hold about different aspects of their clinical work, such as the body (Thornquist, 1991, 2006; Nicholls and Gibson, 2010), movement (Edwards et al., 2006) and their professional role (Thornquist, 2006; Evans, 2007; Lindquist et al., 2010), influences the way in which they practice. Recent research in musculoskeletal physiotherapy indicates that how practitioners conceive clinical practice and view practice knowledge influences the way in which they learn and develop clinical expertise (Petty, 2009; Petty et al., 2011a,b).

    • Functional Movement Training for Recurrent Low Back Pain: Lessons From a Pilot Randomized Controlled Trial

      2009, PM and R
      Citation Excerpt :

      In addition, this study suggests that more functional simulation of daily activity and movement awareness may be of additional benefit to individuals with recurrent LBP. Movement awareness techniques have been advocated for many years [35-37]. Findings from this present study provides limited support of these types of approaches.

    View all citing articles on Scopus
    View full text