1 Musculoskeletal Disability

Musculoskeletal (MSK) disability has an enormous effect on the quality of life of millions of people worldwide. In the UK alone:

  • One in four, or around 9.6 million UK adults, many of working age, are affected by MSK disability.

  • 30% of GP consultations in England are MSK related (Department of Health 2006).

  • 10.8 million working days are lost per year due to MSK conditions. A large number of co-morbidities, including diabetes, depression and obesity are associated with MSK conditions (Arthritis Research UK 2013).

  • In 2013, more than 25% of all surgical interventions in the National Health Service are MSK related and this is set to rise over the following 10 years (Arthritis Research UK 2013).

  • In 2012, £4.76 billion of National Health Service spending each year is on MSK conditions (Department of Health 2012)

I work as a Physiotherapist in the UK, helping people with MSK disability. Patients are often referred to me because they have not improved with previous treatment. I receive requests from diverse other healthcare professionals such as Orthopaedic Surgeons, Rheumatologists, General Practitioners, Geriatricians, Neurologists, Psychologists as well as other Physiotherapists and Occupational Therapists. MSK conditions can be treated in a number of ways, using diverse treatment approaches, in varying sequences and concentrating on different aspects of a presentation. Some conditions may improve by focussing on lifestyle factors, others by addressing physical or psychological factors.

Even these categories of influencing factors may be misnomers, due to the inter-relations among them. Exercise, for example, may be described as a physical intervention, but has clear psychological effects and requires confidence and motivation to perform. Exercise also exists within a social situation, environment and circumstance. Physiotherapists are privileged in that they, within an accepted social context, have permission to touch, hold and physically assist people through movement in both assessment and treatment. This is a tacit form of communication as well as a method of therapeutic interaction and may assist with the re-education of movement, perhaps by building confidence or trust in one’s body through physical reassurance. It is for these reasons that Physiotherapists and other Physical Therapists commonly see people with MSK conditions.

The field of MSK has always interested me; like a detective, who would try to investigate and scrutinise all the evidence to catch the criminal, an MSK practitioner needs to unpack the complexity of a person and their symptoms to get to the heart of the matter. When first learning about being an MSK practitioner, it seemed to me that if you knew all of the research data, or had all the knowledge of the pathology, the rest would just fit into place. Very quickly, however, I found out that this is not the case. There are many skills and types of knowledge—particularly about people—that are required. It is not all about knowing the numbers.

The majority of the patients I see present with their main symptom being pain. Pain has been described by some in practice and research in an objective and impersonal way, such as on a scale between 0 and 10. This may suit quantitative research designs but in no way shape or form does this describe how pain affects a person. Every person has individual hopes, thoughts, feelings, aspirations, abilities, relationships and biographies. The idea of trying to assign a numeric value to these very individual and personal aspects of life seems to me to be both counter intuitive and destructive. In fact, it is an unreasonable expectation that one could examine each aspect independently without regard to the whole person—they play a role not only in a person’s life, but in relation to how they experience their pain. I always focus on a person’s pain experience.

A person’s pain experience usually has a significant impact on what a person can or cannot do. They lose their agency, which is a person’s ability to participate in the everyday things that they want to do, such as the normal activities of daily living, but also in things that are meaningful to them, such as family activities, sporting activities and so on.

The patients I tend to see also suffer with persistent pain. By that I mean that the pain has lasted longer than would normally be expected—it has not resolved within an expected time frame. Most patients attend their appointments with me without providing a specific history of injury or trauma, and I can see that their symptoms have gradually worsened over a period of time, often without a clear reason. Some of the problems with pain are that it manifests in a very individual and personal way, it affects relationships, and it changes depending on the situation and circumstances of the environment that a person lives in. Pain is inherently context dependent. By that I mean, amongst a number of things, that a person’s history and current situation can change the experience of pain. For instance, if a person is running away from a potentially life threatening situation, they may not feel their ankle break when they twist it, but after experiencing something like that, they might at another time feel severe pain when gently rolling their ankle as they walk over uneven ground.

The non-specific nature of persistent pain presents a number of challenges, particularly if one assumes a biomedical perspective. A biomedical viewpoint is a traditional and very successful form of medicine that assumes a linear interaction between cause(s) and effect(s). An example of this would be identifying a bacterium that causes a disease (such as tuberculosis) and treating it by using antibiotics (medications that affect a bacterium’s cell wall or change its genetic makeup) that then eradicates the bacterium and consequently the disease, and thus the symptoms are cured. In MSK conditions, however, the cause(s) are usually multi-dimensional and are inter-connected with other causes, which interact in ways that are not predictable. For example, in low back pain, a person may suffer with severe symptoms of pain and disability and the tests (such as x-ray, magnetic resonance imaging and blood tests) are unable to identify a specific cause and the diagnosis is therefore typically labelled as non-specific low back pain.

The research literature suggests that the majority of cases of low back pain in primary care are non-specific (Koes et al. 2006). There are people who present with specific causes of back pain, sometimes serious, but their symptoms are usually very atypical in that they affect a person’s systemic health, leading to weight loss, malaise, fever, or night pain with sweats, none of which are in keeping with an MSK disorder. These presentations are rare and the medical literature suggests that they constitute 1–2% of cases (Koes et al. 2006). Therefore, in addition to the challenges presented by non-specific back pain, such as a lack of an easily identifiable causal relationship to focus on treatment, even those with specific diagnoses present with the challenge of having a distinct and personal symptom profile.

In order to make sound and clinically reasonable decisions for the treatment of MSK disorders, a practitioner needs to take these challenges into account. Therefore, a coherent strategy based upon the judicious collection of pertinent information and evidence that is centred on the patient is of paramount importance. Understanding the clinically relevant and biographical context is needed to begin to unpack the clinical picture and the only valid source for this evidence comes from the clinicians and patients themselves. However, many healthcare scientists and practitioners may not trust the information provided about a condition or treatment from a clinician or patient as it may present a number of confounding factors, including bias, based on personal experience or anecdotal information. Such untrustworthy information may cloud judgement and lead an optimal therapeutic strategy astray. To overcome this, a movement of evidence based medicine (EBM), or evidence based healthcare (EBHC), came about in the early 1990’s.

2 Evidence Based Healthcare: The Heart Is in the Right Place, But…

EBM is explicitly cautious about justifications for treatments that are not grounded in ‘trustworthy evidence’. The EBM and EBHC framework states that degrees of trustworthiness can be described in a hierarchy of evidence, in which research evidence generated by controlled trials is valued higher than the evidence generated by uncontrolled trials. In short, the EBHC movement acknowledges “the role of all empirical observations”, however, “it contends that controlled clinical observations provide more trustworthy evidence than do uncontrolled observations, biological experiments, or individual clinician’s experiences” (Djulbegovic and Guyatt 2017).

This is due to the three main principles that EBM is based upon, according to Djulbegovic and Guyatt (2017). Firstly, “not all evidence is created equal, and… the practice of medicine should be based on the best available evidence.” Essentially, those observations drawn from any uncontrolled methodology such as clinical expertise are ranked as the lowest form of evidence, due to risk of bias, and randomised controlled trials (RCT) are ranked as the highest form of evidence.

Secondly, EBM represents “the philosophical view that the pursuit of truth is best accomplished by evaluating the totality of the evidence, and not selecting evidence that favours a particular claim.” Consider that co-morbidities are usually excluded from high quality research trials and therefore are not reflective of the reality of clinical practice. That is, for a study population, a treatment may seem to have been ‘effective’ for a particular condition, but in practice, for the same treatment the presence of co-morbidities may cause harm. Paradoxically, it is the judgement of the clinician that is required to evaluate and synthesise the totality of the available evidence within the context of the individual patient and their environment, including taking into account various co-morbidities that exist in the clinical setting. Yet it is this clinical judgement that is felt to be untrustworthy in the first place.

Efforts are made to reconcile the paradox in the third and last principle: “Evidence is, however, necessary but not sufficient for effective decision making, which has to address the consequences of importance to the decision maker within the given environment and context. Thus, the third epistemological principle of EBM is that clinical decision making requires consideration of patients’ values and preferences.” But, this appears to ‘bolt on’ patient preferences to the end of the aforementioned principles and then offer no insight on how to gather the complexity of evidence together in a person centred way.

One of the natures of ‘truth’ that the EBM/EBHC movement implicitly suggests, is that statistics, given the ‘objective’ status of statistical methods, have a higher ‘truth’ value than other sources of evidence, such as subjective or inter-subjective accounts (e.g. through the sharing of language, experience and understanding) (Øberg et al. 2015). The analyses of studies are often communicated to patients in an absolute or deterministic way, usually in the form of data such as the statistical significance of a finding, the size of a treatment effect, the confidence interval, or the probability of outcome. This assumes a specific philosophical view of what causality is, namely a Humean view of causality (see Anjum, Chap. 2, and Anjum and Rocca, Chap. 4, this book). On the one hand, the clinician may feel confident that the information is ‘factually correct’, but on the other hand the clinician is assuming that the information that they are providing to the patient recognises all eventualities and all contexts. However, in reality they are giving information based on a ‘closed world’ where many factors have been controlled for: a world distinctly separate from that of the open, complex and context sensitive world that the patient actually exists within.

I am not suggesting that epidemiological data or carefully controlled RCT’s are not helpful, in fact they can be seen as the best available way to understand an average treatment effect on an average person from a clinical trial. This could act as a baseline measure of how effective a treatment may be, but RCT’s need to be seen in full light of the limitations that they have, rather than being put up on a pedestal where they are interpreted as the facts of the matter that determine clinical decision making.

3 Therapeutic Alliance: A Dispositional View

EBM/EBHC has been described as a map that creates guidelines for treatment or intervention. As has been shown above, however, EBM/EBHC may serve as a map but it does not describe the terrain. The treatment effects of a person who has such individuality, with a complex, sensitive and biographically inscribed biology, simply cannot be reduced to a sequence of recurring events that are seen to occur time and time again. In other words, the Humean view of causality will not do. A dispositional view of causality, however, has the ability to change the perspective of both the clinician and the patient, moving them toward a much clearer perspective that embraces such complexity.

To recap from Part I of this book, causes are dispositions or ‘powers’ that may tend toward an effect rather than necessitate one. They can operate amongst other dispositions and may lie unmanifested but still be present—they may, for example, still be acting in a way that creates a stable situation, but in such a way that no observable effect is seen. In addition, they interact in non-linear ways and depending on context. This, in my mind, makes absolute sense and accounts for the apparent discrepancies of observed events, but also forms a distinctive and clinically relevant framework for helping people (Low 2017).

Rather than assessing a person, establishing a diagnosis and then looking to the research evidence to inform us how to treat a patient with their preferences, our attention should be particularly drawn towards the person’s story. A person’s story is a phenomenological account that far supersedes that of a descriptive and categorical diagnosis with regards to how to frame and personalise a treatment or management approach. A categorical diagnosis may provide clinical options for treatment but they are often shaped within broad guidelines. An example of this would be ‘education, exercise and weight loss’ for the management of hip osteoarthritis. A person’s story establishes a unique biography that sets up the clinical context by opening a window of insight into a person’s biology. For example, a person’s challenging childhood may shed light on their behaviour towards comfort eating and the complex relationships they may have towards those who may be able to support them. What then lies beneath the statistical data is a person who has hopes, fears, relationship and lifestyle considerations, as well as a rich number of historical events that have influenced them.

The understanding of a person’s story can elicit copious amounts of causal elements that are essential, not only for the clinician but for the patient, in understanding and coming to terms with their pain experience. These causal elements, or dispositions, can be inferred through the creation of a co-constructed narrative. Both the patient and the clinician bring their understanding together within a space where they each attempt to make sense of the situation. This sense-making is inter-subjective; the clinician is interpreting and coming to terms with what the patient is explaining, demonstrating and exploring while in exactly the same way, the patient is trying to make sense of the clinician’s thoughts, feelings and perspectives. I believe that recognising that this sense-making process, that is bi-directional between therapist and patient, is essential to building a strong, therapeutic alliance. There is emerging research evidence to support the idea that having a strong therapeutic alliance improves pain outcomes in patients with persistent pain. Factors such as trust, open communication, using a whole person approach, tailoring an individualised plan and the ability to work through challenges in the patient-clinician relationship have all been identified as enhancing this alliance (Kinney et al. 2018; Bunzli et al. 2016).

Often, in graduate and postgraduate training, a clinician is asked to divide a clinical consultation into subjective and objective phenomena. The ‘subjective’ information is the information that the patient gives to the clinician, including their story and the ‘objective’ information is the clinician’s observations, measurements and judgements. This way of understanding ‘subjective’ and ‘objective’ phenomena undermines the patient as it assumes that the clinician’s observations and judgement are objective whilst the thoughts, beliefs and perspectives of the patient are ‘subjective’ and therefore questionable. It is therefore paradoxical that clinicians who claim that they are ‘evidence based’ appear to pay only lip service to the idea that ‘patient preferences’ are on an equal footing with clinical research and clinician judgement when making clinical decisions.

Indeed, a careful physical examination that takes into account the context of the story is essential in gaining trust with the patient. The sensitivity, order and coherence of the physical examination unveil more than positive or negative tests that fulfil diagnostic criteria. The examination may reveal the distress, the inability to cope and painful memories of living with pain. This clinical information that provides clinical context is essential in formulating a person centred management plan. One way to bring this together is by using a mind map where a person’s story, physical examination findings, clinical investigations and judgements of the clinician form this co-constructed narrative. This bringing together of the normative and the narrative (Launer 2018) seems to me to be far more humanising than the division of a person into constituent parts: biological, psychological and social elements that are further separated into subjective and objective data findings.

I use a mind map, where all the relevant information from the patient is collected, honoured and placed in a timeline. This allows the patient to make sense of all the available information in one place. The patient has explicit permission to give feedback and change any aspect of the mind map if they feel that it does not capture their reality and the situation. The mind map is personal to the patient, so it is important that the patient has the autonomy to change the mind map to reflect their experience. Following the co-construction of the mind map, a vector model can be made, conveying the complexity of interaction between causal elements (see Price, Chap. 7, this book). It is the use of the vector model that allows a patient to see that the variability and context-dependent nature of their pain experience could be better understood (Low 2017, 2018). Causal elements may be non-linear, interactive, contextual and time sensitive. Understanding this can help a patient look beyond the false understanding of their pain being caused by single elements that stack up or aggregate. Assumptions that causal relationships are linear can, for example, result in surprise when pain is experienced even when patients purposely choose not to do activities or tasks felt to increase their pain.

Instead of using statistical data to determine the prognosis and management of a patient, a dispositional view allows and even encourages the context sensitive use of propensities that have been carefully considered in light of the individuality of the patient. Instead of only describing the probability based upon a research population, the individuality of the patient is also considered within the context of how that person relates to the research population.

The use of terms such as ‘propensity’ or ‘tendency’ avoids the deterministic qualities, like inevitability, that can come with MSK diagnoses such as osteoarthritis (OA). Although the incidence of OA increases as we get older, it manifests with a significant amount of variation in different people with different experiences. Socially, it is believed that the presence of osteoarthritis always causes pain and disability, but this is not the case. People believe that a diagnosis of osteoarthritis will mean that their joint will erode, crumble or fall apart (Barker et al. 2009) leading to unnecessary fear, anxiety and loss of activity and agency. This self-fulfilling cycle perpetuates or leads to more pain and disability. However, osteoarthritis is a complex process that is affected by multiple systems including the immune, endocrine, and neuromusculoskeletal systems. Amongst these systems, the experience of pain is modulated by multiple social, psychological and biographical factors, some of which can be tempered, altered and positively changed. Reductions in pain and improvement in function is possible and the manifestation of pain and progressive disability is most certainly not inevitable. Using a mind map and vector model of a person’s individual situation can make a difference and turn the tide.

The phrase, “treat the person, not the scan”, commonly used in medicine, cannot be stated enough as one person may have significant OA changes seen via imaging and present with joint stiffness but no pain, whereas another person with very mild OA changes may present with disabling and distressing pain. This is true across an entire spectrum of MSK diagnoses, including the most commonly found conditions such as low back pain, fibromyalgia and neck pain. Often, MSK diagnoses do not exist in isolation. Mind-body dualism, what the philosopher René Descartes is known for, underpins biomedicine and is reflected within the objectivity of EBM/EBHC in the way that distinct quantitative physical and psychological measurements are used to draw causal inferences without considering the interaction and non-linearity of causal elements that exist within a complex situation such as the lived experience of a person. A dispositional perspective, in contrast, can ground a non-judgemental viewpoint of a person’s lived experience through the use of a mind map and a vector model of powers. Aspects of the clinical picture can be displayed to convey the complex nature of a situation but still allow space to develop a management strategy that a person can understand, accept and initiate.

4 Bringing the Totality of Evidence Together

When implementing a person centred clinical reasoning perspective, how should one proceed? There are many different perspectives on this; my personal approach is to centre the process on the patient. Their story, viewpoint, narrative and situation are central and of the utmost importance as they provide the vital context of the therapeutic encounter. The evidence drawn from clinical research is then applied within the context of the patient, and with sound judgement the clinician then evaluates the applicability of the research to the patient, at this time. Then, both the patient and the clinician bring together the narrative and normative information alongside the clinical research in order to create a truly shared perspective on treatment and management using the mind map and vector model.

All interventions in healthcare aim to improve a patient’s healthcare need, situation or circumstance and they carry a form of risk that may delay progress or adversely affect the outcome. In MSK disorders, the most common risk to a patient in a physical therapy clinic is the potential to worsen a patient’s pain experience. Therefore, careful discussions of the potential risks and benefits of any future action should be made prior to the implementation of treatment. The use of the mind map and vector model makes this process easier and better understood, allowing treatment recommendations to be made in a coherent fashion. The added benefit of doing this allows the clinician to provide options if symptoms adversely change and offer potential reasons why this may happen. For example, a patient with persistent non-specific back pain may present with fear of bending their back, as they may believe that their symptoms are indicative of the spine being damaged. The reason for the patient’s fear may relate to their previous experience of bending to lift an object in the past, for example, or by well-meaning family, friends or healthcare practitioners telling the patient that the pain when bending is harming their spine. The treatment option that may be the most appropriate for this situation is a graded exposure form of treatment whereby the patient starts to understand how their fears relate to their pain and are encouraged to participate in the activities that they fear in a graduated way. It is important to understand why the patient is fearful and this can be explored narratively and by performing behavioural experiments or safe versions of the feared activity. This creates an opportunity to understand the cause and relationship of fear to the current situation and is made explicit by using the mind map. The mind map can help explain a vicious cycle of fear, avoidance of activity and deconditioning that is perpetuating and maintaining the pain experience. The treatment option of graded exposure may increase the patient’s symptoms, so a strategy of the patient being comfortable with the treatment and having options of what to do if their symptoms increase is therefore important.

The details of this are highly context dependent and cannot be demonstrated through statistical data, nor can the clinical adjustments and variations that allow a patient to stay in control of their symptoms. Self-efficacy or the sense of a person’s ability to feel in control of their circumstances or situation is, amongst a number of factors, important for health outcomes (Holden 1992; Keedy et al. 2014). Using the mind map and vector model are useful tools to convey the totality of evidence in describing the patient’s story, their context, the clinical research evidence, the social situation, the risks and benefits of treatment options as well as opportunities to tailor a personalised management plan for the patient.

I have previously written on related cases, of a person with medically unexplained neck, thoracic and shoulder pain (Low 2017), and of a person with persistent and recurrent low back pain (Low 2018), which more fully explain this approach. The former describes a little more of a philosophical account whereas the latter describes a clinical account in greater detail.

In summary, understanding the clinical research that is epitomised traditionally through statistical data does not help the clinical encounter. If anything, there is a greater risk of alienating and depersonalising the lived experience of the patient. Respecting the patient, rather than the statistics, at the centre of the evidence brings with it key aspects of a therapeutic alliance, characterised by connectedness (Babatunde et al. 2017). This connectedness, established through the creation of a co-constructed shared narrative, improves the therapeutic alliance, adherence to treatment from the patient (Babatunde et al. 2017) and personal job satisfaction for the clinician. Although biomedicine has brought about huge successes in the eradication of diseases in the past, it no longer is appropriate for the devastating impact of MSK related disorders. This may be because of biomedicine’s focus on a cure of a disease based upon the implicit belief of monocausality (single cause, single effect), linear causal relationships found amongst statistical frequencies and the lack of acknowledgement of context. In fact, the maintenance of biomedical causal beliefs in regards to pain has been found to be a barrier in the recovery of patients with low back pain (Bunzli et al. 2016). This may be because these patients are still looking for ‘the’ cure or the scan that will identify ‘the’ cause which will lead to the correct treatment and cure. This often feeds a self-fulfilling cycle of negative emotion, despondency, frustration and anger that also adds to the pain experience.

The mutual understanding and respect of the patient creates the cornerstone of positive change and the opportunity for restoring wellbeing. The patient’s context, not the statistical average, guideline or diagnostic classification, is the key to improving the challenges that patients with MSK conditions have. As clinicians we are, after all, here to help people through the difficult challenges of life and, in my mind at least, there is no better purpose in life than to help others. I mentioned earlier that being a physical therapist is like being a detective, but it is really much more than that. Physical therapists are coaches, mentors, and care providers, but most importantly, they are relatable humans who can provide the structure and therapeutic environment for people to recover, heal and grow. Getting to the heart of the matter is more than statistical observations and analysis of average treatment effect sizes; it is the embodiment of human understanding, genuine curiousness, purposeful support and thoughtful guidance towards the emancipatory experience of agency and the fulfilment of our patient’s goals. It is our patient’s stories that ought to be honoured, respected and understood as the centrepiece for clinical decision making, with population data, clinical research, policy and guidelines used to support, rather than to dictate person centred care.