Thursday 14 January 2021

Making Sense of the Cranial Nerves: 3 SHORT FILMS

Cranial nerve testing should be within the skill set of ALL clinicians who treat neck, head and orofacial presentations.

Most clinicians are well versed and confident with neurological testing of the upper and lower limbs as well as upper motor neuron tests. However, when it comes to what is arguably the riskiest of anatomical regions, the head and neck ... there appears to be a strong suggestion that history and education have not prepared physiotherapists well for this.

The harsh reality is that many #Physios report that:

1. They were not taught CN’s at University

2. If they were, they are a little rusty with application and interpretation

3. It’s not something they do very often, and the tests are really hard to recall

Indeed a recent Twitter poll revealed that 53% of respondents suggested that they had not been taught these skills at University. Of those that had, over 50% suggested that they were not comfortable with applying them and interpreting the tests in clinical practice.

This is perhaps a little alarming for a profession which is championing the concepts of FCP and ACP roles within healthcare. There is a mismatch here, and a clear need to improve understanding, education and competencies. But it is not just FCP’s & ACP’s who need these skills. They are easily attainable for any clinician, and can easily be understood and applied from UG level. BUT DON'T FEEL BAD ... I think perhaps the educational system in some places (not all), has let us all down, and
I agree entirely, the CN's are a bit complex and do at first provide a challenge to learn.

The missing links are often context, understanding, working knowledge and the application of clinical reasoning.

That is why I've put together 3 short films in the 'Fireside CPD Sessions' series, to help make sense of the cranial nerves, their functions + when and how we might test them.

An opportunity to get to know the cranial nerves and their functions from a clinical reasoning perspective.

This short film is designed to introduce the cranial nerves and consider the subjective questions (that we often don't ask) that might lead us to test them in the clinical situation.

FILM 3. How to remember the Cranial Nerves: A Function Based Approach - A SHORT FILM This short, tongue in cheek, ‘Fireside CPD’ film, draws upon story telling, and offers an inventive and fun method of recalling the FUNCTIONS of the cranial nerves. Pull up a chair, open a bottle, or make a nice cuppa and enjoy a fun and inventive way to remember the cranial nerves based on FUNCTION.

These films should provide a solid base for all clinicians who wish to familiarise themselves with the cranial nerves, gain a basic understanding of their function, AND develop an easy method for recalling the tests.

ENJOY! For more on the Cranial Nerves, go to: http://alteredhaemodynamics.blogspot.... For a 'Cranial Nerves Country Song' ... go to: Look out for 'Cervical Spine: Risk & Rehabilitation for Clinicians' ONLINE COURSE (2021)

Friday 11 September 2020

Risk Assessment of the Cervical Spine: A visit to the graveyard & directions for the future

That old chestnut the 'vertebral artery test' has been with us in Physiotherapy for nearly 4 decades, and yet still the arguments rage on about its clinical use. 

Confusion is never helpful in a clinical (or any) situation, so I've tried to make sense of the background, the logic and ongoing discussion regarding the use of 'the test that refused to die'.

Inspired by the recent debates within the literature, I've put together 3 SHORT FILMS.

Film I, discusses the history of the development and early use of the test. Film II uses some case studies to test the test, and then Film III, takes to the graveyard of old worn out tests, and attempts to offer some logical directions for the future for ALL clinicians working with neck pain, headache, dizziness and visual disturbances.

The key message, is that risk assessment of the cervical spine is relevant for ALL clinicians and NOT (as previously suggested) just for those who practice manual therapy. 

What we know from medico-legal cases is that delays to diagnosis and appropriate management can occur for a range of reasons. It may focus the mind to know that some medico-legal cases I've worked on, have involved assessment of the cervical spine (without intervention).

Hopefully, these films and the case studies contained within them will help to guide clinicians with their problem solving and clinical reasoning, in the quest for safe and efficient practice.

I. The Vertebral Artery Test - A SHORT FILM (Part I)

A short educational film about the long and tortuous history of the 'vertebral artery test', of interest to any clinician who manages patients with cervical spine issues.

II. The Vertebral Artery Test Part II: Risk assessment of the cervical spine

Part II of III, taking a look at the vertebral artery test from the perspective of NON manual therapists. Putting things into context using 4 case scenarios, with regard to risk assessment of the cervical spine. The video covers the umbrella concept of 'cervical arterial dysfunction'.

III. Cervical Spine Risk Assessment: Directions For The Future 


Part III of the vertebral artery videos, takes us to the graveyard of tired old clinical tests, and moves on to offer some directions for the future for risk assessment of the cervical spine. A consideration of blood pressure, cranial nerve examination and sensorimotor testing is incorporated into the clinical case studies that provide background for the video/vlog.

Find more detail at: Look out for the 'Cervical Spine: Risk & Rehabilitation online resources from Alan Taylor & Roger Kerry ... coming soon.

Author: Alan J Taylor is a writer and critic who tries to think about stuff . He works as a PhysiotherapistUniversity Assistant Professor and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog are his own and are not linked to any organisation or institution.  He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a bicylce through the leafy lanes of Nottinghamshire and Derbyshire. In a World full of conflict and division ... like Bukowski, he 'writes to stay sane'.

Thursday 8 November 2018

Who's harming who?: Was Roger Kerry right ... will Physiotherapy eat itself?

Following directly on from Blog I. The case of the 'sprained ankle': A reflection on the narrative of ‘harm’. 

Blog II: 

Who's harming who?: Was Roger Kerry right ... will Physiotherapy eat itself? ... looks at the implications of the the ongoing discussion around 'harm' for the physiotherapy profession and considers how the profession can and needs to move forward.

When I perused again, Roger Kerry's must read 'Physio will eat itself' I was struck once again by this erudite paragraph ...

The recent lively debate surrounding the current narrative of 'harm' has perhaps made Roger's words echo louder in some quarters. 'Harm' has a range of definitions and thus, may be interpreted in a number of ways. 

The definition below, is one that I am often sent and it is perhaps a helpful starting point.

If we are to maintain our stance as a science based profession then data, the interpretation of data and the public messages we convey are important. When I asked Australian physiotherapists and 'leading authorities on back pain' Chris Maher and James McAuley, for their 'harm' definition and supportive data for the recent Sydney Morning Herald article they seemed unable to supply it. That article not only suggested that ergonomic interventions (which I have no intellectual or other investment in) were harmful, but also 'dangerous'. All of this was suggested without ANY supportive data and was a clear example of the manipulation of language. It seems perhaps, that the article in question may have strayed into murky waters of 'opinion based medicine'. Either way, lets be absolutely transparent ... if ergonomic interventions are ACTUALLY 'harmful ' or 'dangerous', surely there should be an immediate call for them to be risk assessed and controlled? 'Harm' is after all, something we should take VERY seriously and that is precisely why we need data.   

Bold statements require bold data, and leading experts should be able to provide that ... OR expect their statements to be questioned.

Interestingly ... Maher blocked me on Twitter for asking for his harm data. That can of course, be interpreted that any way you wish. 

It is worth reflecting that the opposite of harmed is (some would argue) helped. Imagine for a moment, if someone, a therapist or a representative of the the ergonomics industry, had presented a series of patient narratives to say that (say) ergonomics had 'helped' them. No one would be able to deny those patient narratives, after all, they are what the patient thinks, believes and reports ... But now tell me that there wouldn't be a rush to the science and the RCT data to suggest that despite what those patients' believe, there is no strong scientific support for what they described or said, and that all they had to support their statements were associative argument and belief. Indeed, if that was a company trying to sell a product, then they would quite likely be accused of at best, 'opinion based medicine' or at worst ... snake oil salesmanship.

A sociological perspective
The manipulation of language (Unspeak) is a common psychosociological phenomenon and a tactic commonly used by politicians who wish, by creating fear and silencing opposing views, to push through specific agendas. The uncertainty and misinformation which surrounds 'Brexit' springs to mind, and Donald Trump's demonisation of immigrants as rapists, drug runners and (more recently) cop-killers is a further example. This constant media stream affects the macrocosm of everyone's life, and is perhaps one of the factors which wears down an individuals resistance to language manipulation, when it enters the microcosm of their everyday work in physiotherapy.

So if we get back on track and consider physiotherapy treatments or management options.

If a treatment or advice is not efficacious … say so (use RCT evidence). 

If it is uneconomical or costly … say so (use health economics evidence).

If it is 'harmful'  ... provide definition a measure and some data, any data. 

If it is 'dangerous' ... provide data and a proposed risk assessment strategy, root cause analysis or both. 

Above all ... use plain English, with clear and agreed definitions.

Consider for a moment the commonly used Physiotherapy mantra 'Hurt does not always equal harm'  ... then ponder that, in virtually the same breath, we hear the promotion of the idea that X, Y or Z treatment or advice is 'harmful' to the patient, on the back of associative argument only, or in other words, without any supportive data. 

Take heavy school bags and LBP as another example. Contemporary science has suggested that carrying heavy school bags does not appear to be associated with LBP in school children. So with that knowledge, we can now de-threaten the 'heavy school bag' as non-harmful, and re-assure children and parents that they are less likely to be factor contributing to to their present or future LBP. 

But here is the key question ... is the next stage of this process, to go on to say that any practitioner or therapist or newspaper article that offers a contrary option (to the currently fashionable or in vogue ones), is causing 'harm' to patients? As things stand, it could be suggested perhaps ... that they have not kept up do date with the science, that they are  offering advice which is contrary to current thinking, that they may be instrumental to a delay to appropriate management ... but 'harm' or 'harmers'? That would be more much challenging to effectively demonstrate. 

The recently published LBP study suggesting that pain neuroscience education (PNE) appears to be no more effective than placebo, raises some interesting questions with regard to the time, energy and belief invested into that particular modality. Would the next step be to suggest that PNE was harmful? I personally don't think so. BUT ... that is precisely why we need to be more consistent with our word usage as a profession in EVERY respect, and that means with our patients, with each other and with our press releases and SoMe statements. 

These BLOGS, and my Twitter commentary are NOT a defence of passive treatments, inappropriate or outdated advice or anything else really, who would want to defend those things? It is a request for transparency, scientific consistency and an honest dialogue. The recent BJSM (peer reviewed) editorial entitled, 'Evidence based physiotherapy needs evidence based marketing' ... is a salient example of where that scientific consistency has gone sadly astray. We have publicly challenged the authors of this editorial, to provide the harm data on the specific physiotherapy interventions named, OR withdraw their claim on the basis that it is not supported by their Utopian ideal of ‘rock solid research data’. 

Their lack of tangible and credible response (to date) from the authors to that challenge, has been disappointing to say the least. Once again, the reader can make their own judgement on that. 

Amongst and perhaps despite all of this, there is an increasing awareness of the need for a move toward self management options for MSK conditions. It is apparent that we DO have some qualitative data to support the contention that ideas and beliefs (which may be influenced by practitioners choice of words/descriptions) may lead to confusion and uncertainty (amongst patients), leading to negative impacts on activity participation, health behaviours and self-management decisions in knee osteoarthritis.

It would be hopeful to imagine that the best, the most efficacious treatments and communication methods would eventually make their way to the top of the pile without a war of words and obfuscation. The caveat to that though, is that there will always be innovators, early, late adopters and laggards ... that links directly to the diffusion of innovations. Perhaps this is a source of ongoing frustration amongst innovators and early adopters who wish to push for rapid change, but is that a strong rationale for open ridicule? Is that a sound tactic that will facilitate or hasten change? I suspect that they are also difficult questions to answer with any accuracy.

The real world implications of the narrative of 'harm'
There is an important and logical corollary of the ongoing 'harm' narrative to consider and think carefully through. That is, IF the profession collectively buys into the narrative of harm ... and harm ACTUALLY is taking place, then two things may follow logically from there.

1. If it truly IS the case, that some physiotherapists are somehow, 'harming' patients. Then that is a serious allegation with serious implications for the profession.

Questions are immediately raised.

What is the harm? 
How is this harm taking place? 
Where is the line drawn? 
Who are the harmers? 
... and how should the harm be risk assessed, with a view to harm limitation

Those questions would have massive implications for the governing bodies of Physiotherapy the World over. It would require clear definitions, it would require the collection of accurate data followed by root cause analysis (which has its limitations too), risk assessment and action plans put in place to limit or reduce further risk to patients (if that risk REALLY exists). 

2. If there is TRULY is data to to support the narrative of harm, then it is likely that law suits would follow. 

Law suits often develop from a patient or their relatives interpretation of what they see/hear in the news or on social media. So if a patient were able to claim that they were harmed by the mismanagement of their case AND could evidence that, AND were inclined towards blame, then it is quite feasible that a law suit could follow. If that happened then medico-legal expert witnesses would be called in on either side,  to look at the evidence pertaining to the individual case and the profession. That of course, would require the measures applied to the 'harm', which would be considered with the science around the efficacy (or otherwise) of and risk of treatments. These things happen in other professions and are clearly documented.

So the questions remain ... 

Are some physiotherapy treatments (or how they are delivered) REALLY 'harming' patients?

If so ... how are we capturing that data, and what are we doing to risk assess and prevent future 'harm'?

OK, so "how can we move forward?". I hear you ask. 

Recently I watched a video of how things can be done effectively without the need to demonise, shout down opposing views or appear to leave just one solution to a problem ... if you've not seen it you should. Irish Physiotherapist Kieran O' Sullivan calmly discusses LBP, strategies for recovery and the state of the knowledge (to date) in the area, in a most convincing performance. By re-conceptualising what we consider as 'safe' or 'dangerous' physical activities, Kieran says in 45 minutes, far more than months of convoluted 'discussion' on Twitter has achieved on the topic of evidence and word usage in the last year. He does so in a calm, reassuring and humble tone, exposing his own fallibility ... which to me is far more convincing than any shouting match, and a great example of how things can be done in a more constructive way. There are countless more examples out there too ... of skilled evidence based therapists who are doing the very best to navigate an increasingly hostile environment with care, empathy, positivity, cohesion and a range of solutions to the increasingly complex health problems that we encounter.

We can also take a tip from the discipline of psychology, who appear able to both define and measure harm very  effectively and very scientifically. The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials. There are many more examples in dietetics, medicine, drug trials etc. Physiotherapy needs to step up to the science OR lose the narrative ... until it (harm) can be effectively defined and measured.

From: The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials

I share the obvious frustration of many with the slow pace of change, and I suspect (without a shred of evidence) that this is why the narrative of harm has developed. It is worth reflecting that harm, due to its multiple definitions and interpretations, can range from multiple deaths (war) to taking offence ('I felt harmed by your views') and everything in between. In a world where we are seeing increasing mental health problems often linked to self-harming and suicide, it is clear that we are in very emotive territory. No decent ethical therapist would want to harm or mislead their patients, but as science and knowledge moves on, if they are clinging on to outdated knowledge and ineffective methods (as supported by science, rather than opinion) ... should they be classified, demonised or even mocked as harmers? 

OR ... is there a different way to approach this? Is there a middle ground? 

I truly do not know the answer, but it is a question which we as a profession, should not shy away from as the profession attempts to nurture and develop 'good clinicians'.

There IS common ground fortunately, and it is hopeful that many are agreed that there is a need to change the approach to MSK care. This means being more honest with the level and type of care we can and should currently offer, and the outcomes that may be achieved, as highlighted by (Lewis & O’Sullivan BJSM, 2018). It also means being honest with our interpretation of the science and evidence. Scaremongering claims by researchers, academics, clinicians or social media commentators that one treatment or advice or another is harming patients is, in the absence of evidence (of widespread measurable harm), wilfully misleading to patients, therapists and the general public alike and frankly, amounts to 'fake news'.

For the profession to move forward, it requires a radical change of mind set which aligns with the current challenging health care climate. It is a global challenge that is well recognised and which Physiotherapists the World over can rise to … IF and perhaps only if, collectively the profession can bring itself to end the self-perpetuated, conflicts and phoney, self created divisions which evolve from the unnecessary narrative of 'harm'.

For anyone with even the slightest interest in the sociology of conflict ... this article makes a fascinating read and illustrates that in the tiny microcosm of MSK physiotherapy, we really don't need another war. 

Otherwise, Roger Kerry may well prove to be a prophet ... and that really WOULD be a thing. 

HT this time, goes to colleague and regular sounding board Roger Kerry, for his regular thought provoking musings on the psycho-sociology of the physiotherapy profession.

Author: Alan J Taylor is a writer and critic who tries to think about stuff . He works as a PhysiotherapistUniversity Assistant Professor and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog are his own and are not linked to any organisation or institution.  He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a bicyle through the leafy lanes of Nottinghamshire and Derbyshire. In a World full of conflict and division ... like Bukowski, he 'writes to stay sane'.

Wednesday 4 July 2018

A sudden rush of blood to the head: Why words really do matter in EVERY domain

So ... it seems there has been a proper furore and rush of blood to the heads (sorry ... that was a feeble attempt at a haemodynamics link ) of some folk, over the use/choice of a word in the @thecsp (UK) PR campaign ‘Love Activity, Hate Exercise’. 

The whole affair highlights the incredibly emotive power of words/word choice and how interpretation is entirely dependent on perspective and context. 

Love activity, Hate exercise?

Image: CSP
A similar attempt at influencing opinion was run by the American Heart Association  @american_heart (USA) in 2017, they called it ‘5 Steps to Loving Exercise ... Or At Least Not Hating It’. That blog campaign successfully conveyed the message that not everyone likes #Exercise and gave some practical tips that were designed to help non-exercisers begin to #LoveActivity or even exercise.

As well as promoting movement and physical activity (and exercise), one of the key messages of both campaigns seems to be that #Exercise adherents and promoters (I would place myself into that category) ... may find it challenging to see things from a non-exerciser's perspective ... The suggestion being that anything that helps facilitate a greater understanding of the patients perspective, and helps start a conversation, can only be helpful, surely?

That said, HATE is an incredibly emotive word and I've always encouraged my kids never to use it ... so I see the antipathy to its use. However, I can see the value in backing the #LoveActivity campaign, because if a patient uses the 'hate' word (and they do) as therapists we have to have the empathy and skills to deal with that ... It is a psychosocial phenomenon of our times and something we challenge our students to consider the realities of. 

Seems like Marmite ... you'll either LOVE it, OR H*** it … AND quite frankly, it is entirely your choice.

The ugly divisions that have ensued within the profession (and are still going on) are also a psychosocial phenomenon of our times, and times past. The only thing that has really changed is the platform and the players. There have always been differences of opinions and schools of thought. Social media has simply opened up debate and discussion to all. That is probably a good thing in a profession that is striving to change. However, what is clear is that it becomes very easy to create divisions, factions/tribes and to polarise opinion.

Q. Is that a good thing?
A. Maybe, maybe not. It depends on the context, perspective (and perhaps motive).

In Jeremy Lewis and Peter O’Sullivan’s recent BJSM editorial Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?   
They suggested, “… Evidence informed self-management is the key. To achieve this, the efforts of many institutions, including educational, healthcare, political and professional organisations, health funding bodies and the media, need to be involved.” In essence what they were saying was that there is a need for a cohesive and consistent message from ALL invested and concerned with improving patient care. Those cohesive messages whether they are about assessment/treatment methods/modalities, or exercise/advice interventions, need to be evidence informed, consistent and convincing. Most folks are cognisant with the concept that nothing is written in stone, evidence evolves, and what we seemed quite certain about today, may be proved entirely wrong tomorrow.

Q. So, where does that leave us?  
A. It leaves us all, frantically trying to make sense of an ever shifting environment, conflicting stories, personal opinion, interpersonal/tribal battles and #FakeNews.

Q. OK … so what is the solution?
A. That is the 64 million dollar question!

It is also a question I been battling with for a while. Unfortunately, I can’t pretend to know the answers either … and I expect the answers will differ anyway, depending on a range of factors, not least the psycho-sociological environment from where you view all of this. It is my guess that regardless of your environment most folks will feel elements of uncertainty and confusion, whether they are (Physiotherapy) clinicians, researchers, teachers/academics or indeed patients … and it is worth reminding ourselves (wherever we may fall on that spectrum) that everyone his their own ‘coal face’ and everyone contributes to the landscape highlighted by the BJSM editorial.

Here are a few tips or considerations on how to survive in a constantly changing environment.

1.     Evolve or die: Sounds a bit harsh, I know, BUT it is a fact of life. History reminds us, that emerging research has challenged much of our previously accepted knowledge. In addition, much of what we believe to be true today will become obsolete within a decade or so. It may be helpful to recall that one previous profession linked to ours did eventually get 'wound up' ... they were known as Remedial Gymnasts

2.     Be less dogmatic: 1. Above, dictates that dogmatic thoughts or deeds are unlikely to yield results. No system, method, school of thought works for all of the people all of the time. There are (pretty much) always exceptions to any rule.

3.     Get comfortable in the grey: This is difficult but essential. Most folk prefer black and white answers of absolute certainty. I’m sorry, but 1 & 2 above dictate that you may have chosen the wrong profession if you expect or demand that from Physiotherapy.

4.     Be less divisive and collaborate:  When Lewis & O’Sullivan (BJSM) said “the efforts of many institutions, including educational, healthcare, political and professional organisations, health funding bodies and the media, need to be involved (in change, sic)”… they meant it! Clinicians, and patients, clearly play a vital part and social media opinionists require a sense of social responsibility, if they really want to be effective change makers.

5.     Don’t buy into phoney wars: Physiotherapists have always been caught up in hierarchical factions and been led by colourful gurus, still (unfortunately) are. Why there is a need to create divisions’ remains a mystery, perhaps it is the frailty of humans? Regardless, the created phoney wars, appear to serve no one (except those who create them) and simply retard progress.

6.     Recognise how language can be manipulated: Controversial … not really, just a reality of life in a World of fake news. Unspeak is a language style adopted by commentators who wish to make counter arguments untenable. It is a tactic (weapon) used by those who prefer to perpetuate division or phoney wars. It relies heavily on opinion (not evidence) and emotion. It is created to make any alternative viewpoint seem abhorrent or untenable.

7.     Be … pro-honesty, pro-community, pro-evidence and anti-division (if you really have to be anti-anything): See 6 above and ‘Unspeak’ below.

Q. OK … so what is ‘Unspeak’ and what on earth has it got to do with physiotherapy?

A. Unspeak is a term that was coined by Journalist Steven Poole in 2007 in his book ‘Words Are Weapons’. Unspeak has crept imperceptibly into the narrative of Physiotherapy discussions. It is a tactic to make controversial issues unspeakable and, therefore, unquestionable. 

This VIDEO is an interactive documentary investigating the manipulative power of language. Watch it! Once you have recognised it, you will always be able to spot the tactics in ANY environment.
There are many examples; perhaps the easiest to follow is the pro/anti abortion one. Pro abortion campaigners began to call themselves ‘pro-choice’ … after all everyone wants CHOICE, don’t they?

But … in a clever manipulation of language, the anti-abortion lobby quickly countered their opposition, by referring to themselves as ‘Pro-Life’ … because who on earth would argue that they were ‘Anti-LIFE’?

Q. Yes, and …?
A. Oh sorry. The reason this came up again, is because it has been part of the narrative of physiotherapy for a little while now, to demonise certain elements of physiotherapy practice by referring to them (without evidence) as ‘harmful’ … or ‘low value’. It has been highlighted again by the recent and ongoing 'Hategate' controversy.

Q. So what is the problem with that … ?
A. Well here at last, we get to the point … ‘harm’ is a very emotive word, a little like ‘hate’, in fact the two may be associated or linked e.g. “the deaths and horrific injuries (harm) that occurred in the fight, were associated to the long standing hatred between the two gangs”. An extreme example YES, but one that illustrates that harm can truly be emotive. 

To allocate the ‘harm’ to a harmless modality (name your own example HERE .................…………..) seems somewhat disingenuous to say the least. If a modality has been shown to be ineffective or uneconomical (from a health economics perspective) then say so, that is fine. When I railed against this on SoMe lots of folk misinterpreted my stance, but since the ‘hate controversy’ has blown up, we are back full circle to the harsh reality of word choices.

Q. Can you give me an example?
A. Sure. At my particular ‘coal face’ (UG and PG Physio/Sports Rehab Teaching), we have to try and make sense of all of the incoming information (from researchers, clinicians, policy makers, SoMe commentators etc.) and contextualise and disseminate it for inquisitive minds. With the luxury of both time and resources, we do our best to keep up to date, and appreciate how busy clinicians must find that really challenging. We also know a lot more about how the words we use in a clinical environment with patients can affect them adversely (or not, depending on choice).

At the end of the day, very few people WANT to do harm. So when a physiotherapy or Sports Rehab’ student asks if say, muscle knots or massage are ‘harmful’ because they heard it said on the Internet. We try to add some context and perspective, and use that as an opportunity to develop critical thinking.

Q. Yes, but you know this is not about physical harm, it is about adverse psychological effects. So what is your problem?
A.  OK that’s fine, I see that they do occur (in some cases). So why not refer to them as ‘adverse psychological effects’ or delays to diagnosis/appropriate care? I just feel uncomfortable (in the same way as those who who perfectly understandably, dislike the use of the word 'hate') with the use of the language as a tool for demonisation, particularly in the absence of either a clear definition or any evidence to support the statements that are made.

Q. The term ‘harm’ is used in psychological literature isn’t it?
A. Yes, BUT ‘harm’ in this case is clearly defined as adverse events such as measured deterioration of old symptoms/appearance of new symptoms, suicidal/homicidal behaviour etc. See, Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioural disorders: A review of current practice. The same applies to drug trials, where harm e.g. adverse, physical or psychological events are defined and clearly quantified. Creating an environment where certain treatments or people who administer them, are seen as 'harmers' in the absence of either definition or evidence, is a disingenuous and divisive narrative.

Q. OK … what about the word ‘Hate’ in the CSP #LoveActivity #HateExercise campaign, it has been suggested that this has made exercise “unspeakable”?

A. Yes, I saw that, and  is an interesting turn of events. Because of my interest in the use/misuse of language I have thought about it really hard. I think it is important to look at the context in EVERY situation. First of all what is the intent? If the intent were (for some reason) to demonise exercise, then you could perhaps make that argument. BUT, as I understand it the campaign … it’s not trying to do that. Rather, as I said earlier, the CSP campaign appears to be a well-intentioned strategy to raise the awareness and importance of physiotherapists prescribing physical activity and exercise. Whilst at the same time, like the American Heart Association information, it recognises that a large part of the population are not natural exercisers. The question mark appears to make that explicit, as a number of commentators have suggested. However, those who are opposed ethically, to the word 'hate' (and many are) will always find it difficult to get behind a campaign no matter how well intentioned, that contains that particular word. 

Q. So how do we all move forward from here?
A. Well personally, I'd suggest that it has become abundantly clear that the power of language can unite or divide and perhaps everyone has learnt from that. Going forward, we should all be better equipped to spot the manipulation of language in narratives, wherever we may encounter it. As for the rest, I would hand this back over to the two evolving sages, Lewis & O’Sullivan

They suggested we should:

1. Frame past beliefs against new evidence.

2. When in conflict, learn to evolve with the evidence.

3. Acknowledge the limitations of current surgical and non-surgical interventions for persistent and disabling non-traumatic presentations.

4. Upskill and reframe of practice, language (in all domains, sic) and expectations.

5. Consider aligning current practice with that supporting most chronic healthcare conditions.

6. Better support those members of our societies who seek care.

7. Be more honest with the level and type of care we can and should currently offer, and the outcomes that may be achieved (Lewis & O’Sullivan BJSM, 2018).

To do all of those things, will require a radical change of mind set which aligns with the current challenging health care climate. It is a global challenge that is well recognised and which Physiotherapists the World over can rise to … IF and perhaps only if, they can bring themselves to end the self-perpetuated, unnecessary conflicts.

Q. Alan … doesn’t that sound a little Utopian.
A. Maybe… maybe not.

Footnote: There is no guarantee that this Blog does not contain elements of Unspeak. 

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'. He once rode the Kellogs Tour of Britain and worked as a cycling soigneur.