When we perform a test on a patient, whether it be something physical such as a straight leg raise or tissue palpation, a questionnaire or a blood pressure test, of course we think that we are testing the patient.
Rarely do we ever pause to think that the patient is actually testing the tester- in essence our test performance. What the patient offers back in the test response will be dependent on your handling, looks, words, context, timing, place of testing, previous test experiences, what they feel they need to offer – the list is a long one.
Most tests attempt to assess one specific output system of the body – for example, motor responses, pain, cortisol levels, inflammation etc. but this is impossible – many systems will combine to construct a response to any test.
It can be a bit disheartening and can make you wonder what you are testing sometimes (and why so many hours were put in to “perfecting” a technique). But there is no need to despair or throw all of the tests out. Every test will be a collision* between nervous systems – yours and the patient’s, but they don’t have to be violent and when used with updated clinical reasoning, powered up by modern neurobiology and framed within a biopsychosocial context every test can be a powerful interaction that will provide mountains of information about both the patient and you.
-David Butler
*collision
Noun: Physics. the meeting of particles or of bodies in which each exerts a force upon the other, causing the exchange of energy or momentum
Nice one Dave.
Physio is a ‘pas de deux’, and even though we’re leading, pacing and directing the interaction, we need to be constantly mindful of how our dance partner is moving, feeling and responding.
During a good treatment, the gates of communication are wide open and the therapist is gently but repeatedly guiding the client along the same themes – comfort/health/wellbeing. Most of this communication is ‘energetic’ (I’m not sure what other word should be used here, but it is non-verbal and non-physical). The more ‘pure’ the therapeutic environment, the less likely issues such as codependence and transference/counter-transference will muddy the waters. These are very basic considerations in the therapeutic environment.
EG
http://en.wikipedia.org/wiki/Transference
http://en.wikipedia.org/wiki/Codependency
This thing about interacting nervous systems is so vital to the understanding of Physio, particularly in the treatment of chronic pain. I’m so glad it was mentioned here on the Jam!
If I am too open to someone with chronic pain, there’s a high chance of counter-transference coming into play. That’s no good. I don’t want to be affected by that. Each of us will tend to close down around such people, and I think it happens as an unconscious protective mechanism. If I really open up to such clients, I know from experience that I will burn out. Anyone would. In general, people with severe chronic pain are not pleasant to be around. And yet openness is *absolutely necessary*, otherwise there will be no real change. What to do? Education is great, but not enough in itself.
I tend to think that chronic pain is simple to treat, even though I find it difficult! 🙂 It’s all about the nature of this interaction, the openness of energetic communication and the differential between therapist and client. The therapist cannot “step down” to openly meet the chronic pain client unless he has one very important skill mastered. The skill is the combination of 1) openness and 2) non-reactivity. It’s very easy to fake being open. And it’s very easy to fake being un-reactive.
People who work in the emergency services are interesting. Because of the extreme psychological shocks involved in such work, they can fall into the trap of being very closed off people. They might *appear* open, but if you don’t feel it, then it’s not there. And sometimes there is a fake non-reactivity on top of that. Probably necessary to some degree, but as a therapist, this is a disastrous situation.
EG.
http://www.ncbi.nlm.nih.gov/pubmed/16451324
What ever presents it is “The perceived truth” at that moment 🙂
We could also think about testing as a cooperative investigation. We could ask ourselves, “How do I feel when I am performing a ‘test’, or need to touch a patient? Do I come from an “I test- you test”, position, or from a position of cooperative investigation – “let’s find out”?
I think that the therapist’s behavior, which is also a contribution to treatment, should be the fourth leg of the evidence based treatment triangle- making it a trapezoid!
Our responsibility to our patients is larger than our knowledge and experience, the best evidence available, and the patient’s wishes. It also includes our behavior and our feelings – which we can learn to observe and use as an additional treatment tool.
I agree. The physiotherapist’s personality and the physiotherapist-patient relationship are crucial to the outcome of the evaluation and treatment.
That remember me Michael Balin. He said that in 1957 for de family doctors!
M Balint. The doctor, his patient and the illness. Ed. Churchill Livigstone, 2005
Many thanks for these comments
David