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'.

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