If you want to learn more about Cognitive Functional Therapy, you can sign up to Kieran O'Sullivan's course here: Click here

TELL ME, I’LL FORGET

SHOW ME, I’LL REMEMBER

INVOLVE ME, I’LL UNDERSTAND

Courses should help us to both confirm and challenge our bias.

This weekend however was all about confirming my own bias. Peter O’Sullivan’s 3 day CFT workshop in London was easily one of the best courses I have attended in my career. I feel that Peter (@PeteOSullivanPT) would modestly prefer that I credit the CFT workshop to his widespread team (see below image) across the globe rather than as an individual accolade. Peter’s distinctive hair (which I can only envy) and charisma spearheads the CFT movement and the fantastic work that the team are doing was clear to see for all of the attendees over the 3 days.

After the 3 days I spent attending the workshop and having accumulated a plethora of knowledge bombs I left with a sense of optimism knowing that the physiotherapy profession is moving forwards and having improved my own self efficacy (more on self efficacy to follow).

The CFT approach was demonstrated on 4 patients to whom Peter was blinded on days 2 and 3 and the effortless execution which Peter demonstrated was inspiring and reflected the attributes of a highly skilled practitioner who has honed his style and communication skills over many years.

To leave this 3 day workshop and feel that you are now a certified CFT practitioner would be naive but to leave with a recognition that you are able to grasp the foundation skills and nurture those skills within clinical practice a fantastic start point.

Peter’s approach was an amalgamation of motivational interviewing and sound clinical reasoning which allowed him to create a strong therapeutic alliance and gain the trust of these patients in front of a packed lecture hall. Peter was able to subtly incorporate key motivational interviewing techniques and violate his patients expectations of pain through the connection he had developed and build their self efficacy through the power of doing. To paraphrase Peter:

“I’M LIKE A DOG WITH A BONE – I KNOW WHAT I WANT, AND I WILL NOT STOP UNTIL I HAVE GOT IT”

Peter listened to his patients, understood and validated their concerns and was careful not to dismiss any beliefs in which they were strongly invested. Peter is a world class clinician who utilities some extremely intelligent techniques. Peter used the patients own words back at them – emotive words, words that had come directly out of the mouth of his patients. We should not make assumptions, but what we can do is use the words our patients use back at them! Not only does this show that you have listened – but it shows the clinician is not making assumptions, the things that “terrify, fear, scared, worried” can then be addressed.

TELL ME YOUR STORY.

Chesters et al. 2019 found that “physiotherapists prefer open focused questions when addressing the topic of patients’ presenting problems in initial clinical encounters, providing patients with a focus, whilst still allowing them to express themselves in their own words”. What better way to allow your patient to feel in control and able to lead the consultation than with the phrase TELL ME YOUR STORY. Peter continually used the phrase at the start of each consultation without exception. What do you think of when you think of the word story? A narrator. A beginning. A middle. An end. The narrator takes the story where they want. Peter feels that a patient should have the opportunity to be the narrator and that within the first minute of a consultation you will be privy to a key piece of the puzzle. So rather than the traditional “how are you today?” where the patient must confide to the social norms of “fine thanks” sit yourself down ready for story time.

If you haven’t completed a motivational interviewing course yet – do one! (There’s a couple of great resources available in the form of the book “Motivational Interviewing in Health Care: Helping Patients Change Behaviour” aswell as The Physio Matters Podcast – Session 64) oh and I did the artwork for the podcast on a side note ;)

After every patient story Peter utilised a very simple motivational interviewing technique. A summary. Why is a summary useful? Have you ever been in the situation where your friend/partner/ colleague recognises that you’ve completely blanked out everything they’ve just said only for them to then say “what did I just say?”. Is there a sweeter feeling in the world than being able to accurately recount their previous ramblings play by play. Nope. A summary is your perfect opportunity to show that you have listened.

Peter asked permission to provide the summary. Allowed the patient to intervene should the summary be incorrect and provided an account of the patients story, identifying the key points and facts with the whole focus of building therapeutic alliance. And guess what. Nobody interrupted him. Why, because he had listened, and the account he gave back to the patient was a perfect summary, drawing on the key incidents, using the emotive words, and identifying patients goals!

SELF EFFICACY “AN INDIVIDUALS BELIEF IN THEIR INNATE ABILITY TO ACHIEVE GOALS. HOW WELL ONE IS ABLE TO EXECUTE COURSES OF ACTION REQUIRED TO DEAL WITH PROSPECTIVE SITUATIONS.”

Thankfully in physiotherapy departments the tide is slowly changing it seems and we are educating our patients with evidence based medicine however this often results in clinicians telling patients how common disc bulges are in the asymptomatic population – Yes, this is very important, but how do you think a symptomatic patient feels when they are presented with these facts? They do not sit in this category of having an asymptomatic disc bulge in their eyes – they have a symptomatic one! Peter was able to listen to his patients story, and who doesn’t love a good story! Recognised what was important to them within the story and tailor his assessment and treatment around this. Not once did he violate his patients belief system by sitting them down and lecturing them- he violated his patients expectations of pain through doing– now consider what is a more powerful method for changing someone’s beliefs and expectations, sitting down and having the facts presented in a lecture format or physically having their expectations and beliefs altered through their own doing and actions. All of this without manual therapy, without lecturing, but instead with listening and understanding with one goal in mind – Improve self efficacy.

If you are unfamiliar with the concept of CFT – I suggest that you become familiar with it. Not because CFT is THE way but because it is A WAY. So what is Cognitive Functional Therapy?

CFT is built on 3 pillars:

1. Making Sense of Pain
2. Exposure with control
3. Lifestyle Change

Think about doing 1 of these components in isolation without the other 2? A patient presents with disabling LBP. You can’t talk a patient better. Show them! Give them a new representation of pain and then show them what they can do! The bigger the violation of expectation the greater the effect!

The work of Holopainen et al. 2018 identified the things which our patients do and do not like!

Patient’s DONT like it when:

1. We don’t listen or interrupt
2. We don’t consider their expectations
3. Give unclear or scary information
4. Don’t involve them in the rehab plan
5. Blame them
6. Don’t write things down for them
7. We are in a rush or don’t follow them up
8. Over treat unnecessarily!

Can you guess what they do like? Reverse all of these! CFT is built on these things. And this is normal human behaviour! People like to be listened to, understood, involved! We are in the business of treating people. Often my colleagues say I didn’t train as a psychologist! I don’t want to treat like this! I became a physiotherapist because I like the human body and how it works” I’m afraid to say that you’re in the wrong job then. Because in this job we treat human beings – with highly sophisticated and complex minds, get comfortable with being uncomfortable, if you think a sheet of paper with a few exercises on it is physiotherapy then you’re mistaken. That is like going to a restaurant for a meal only for the chef to come out with the raw ingredients and dump them on your plate. Peter described our role as clinicians as being facilitators and coaches. You are there with your patient to help them put together a jigsaw puzzle. Except you don’t have the front cover. You have all of the pieces of the puzzle, and the patient can vaguely remember what that front cover looks like. Our job is to work together to help put the puzzle back together, by working together making sense of what the puzzle should look like we can help our patients put it all back together!

NICE Guidelines for LBP identify the importance of using a risk stratification tool. A fantastic tool yes, but do you think people like to be stigmatised? Put into a box? Do you think a patient likes to be labelled as “yellow flaggy?” Do you think their pen might choose to tick a different box in order to avoid being stigmatised. I certainly do! Yellow flags aren’t really yellow flags, yellow flags are called being human. If pain threatens to stop you from doing the things you love doing and worry about the future then I would assume that to be a normal human response. Do not put your patients in a box of being “yellow flaggy” – identify that they have come to you for some help and support not to be put in a box! So use these tools yes – but do not rely on these tools! Listen to the story, empathise, don’t be a robot, show some emotion, show humour! Be a human being!

The traditional assessment model will certainly become a thing of the past for me. I distinctly remember learning as an undergrad student how to assess the spine, how to assess peripheral joints and how to palpate the spine (although I couldn’t and still can’t feel s***).

Think about this:

Patient “I have pain when I roll over in bed and when I bend down to pick something up”

Clinician: “OK, stand up, touch your toes, arch backwards, walk your hand down to the left, walk it down to the right, lie on your front, lie on your back, lets see how your hips move, lets test your nerves, slump, slouch, stretch, lets see what your hamstrings are doing. OK you can sit back down, I will be back in a minute with an exercise sheet”

Baffling hey?

Patient “I have pain when I roll over in bed and when I bend down to pick something up”

Clinician “OK, let’s take a took at you doing those things”

Which clinician would you like to see if you had a problem? The one who look at yourproblem or the one who gets you to do a whole host of random tests because they learnt them in a text book and from out of date undergraduate courses!

What is more important than assessment of “joint mobility”? Peter suggests (and I agree!) patient response to stimulus. Assess how sensitised the system is! Pressure response, exposure to cold stimulus, allodynia, pain response to repeated movements! The model of assessment needs to change, and CFT is here to hold your hand and guide you through this change!

I DONT GIVE A RATS ABOUT PAIN. REALLY I DON’T. WHAT I DO CARE ABOUT IS DISTRESS!

How many people in the world are living with pain? I don’t know, look it up.

How many people are living in pain and seeking help? I imagine a fraction of the number above.

What does that tell you? People are resilient, people are able to tolerate a bit of f****** pain!

FEAR YOUR PATIENTS PAIN AND WHAT WILL YOUR PATIENT DO? FEAR IT!

If you’ve been able to rule out sinister pathology (Maher et al Lancet 2017) then what are you afraid of? Ask yourself this – why are there people living with pain and not seeking intervention but also people living with pain and seeking intervention? The answer is self efficacy- some people feel empowered to manage their own problem without worry and fear. These cognitive factors (worry/fear) fuel pain. Address the cognitive factors, violate expectations, build self efficacy and develop therapeutic alliance! Do you think that rolling around on a spikey ball builds self efficacy. No. Do you think lying on your front and having a back massage for a persistent problem where you get pain with bending builds self efficacy? No. You get where I am going with this right? As Physiotherapists we can empower our patients – we can help build their self efficacy and not fear their pain!

As I write this I’m sat in a coffee shop, headphones in, people watching. As the lady opposite me takes a sip of her drink I’m watching her face. I should probably stop now. But what do you think her face would do when she takes her next sip if whilst she was not looking I replaced her frothy cappuccino with some lemon juice. You’re probably making that face right now thinking about drinking a cup of lemon juice! What does the face tell you? Everything! The face projects emotion. The face projects these cognitive factors! Look on your phone now, look through the emojis! There are faces for every possible emotion you can think of- Happy, sad, confused, scared, worried, the list goes on! So as you watch a patient move where do you think you should be looking? You got it. The emotional projector! Peter doesn’t mean it offensively when he says he does not care about pain. He cares about distress and where is he getting that from? Looking at the thing that will tell you! What emoji can you see on the face of your patient?

Fear and worry are common cognitive factors in those patients who come to see us with pain. If you don’t think your patient is fearful or worried, then I would suggest that you’re not looking hard enough. In November 2018 I attended Ben Cormack’s course when he used the phrase – Find the hook. The hook is the thing which is meaningful to your patient, the reason they are sat infront of you. This is what your appointment should be tailored around. Passive adjuncts in physiotherapy need to become a thing of the past, these machines, tapes, needles (the list goes on!) rob people of their self efficacy- they create dependency! Yes, this is a fantastic business model, but if that’s the reason you work as a physiotherapist then you’re doing it for the wrong reasons. We are in this industry to help people first and foremost, right!?

After watching Peter take an extensive history, complete a thorough assessment of the patients feared and challenging tasks and confront their fears, Peter would involve the patients in a discussion around what he had found and what the patient had experienced. Now to say Peter did not use manual therapy would be narrow minded. Manual therapy is defined by The Orthopaedic Manual Physical Therapy Description of Advanced Specialty Practice manual therapy is defined as “a clinical approach utilizing specific hands-on techniques, including but not limited to manipulation/mobilization, used by the physical therapist to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.”

Did I observe Peter put his hands on a patient? Yes. Did I observe reduced pain with feared activity? Yes. Did I witness relaxation, movement facilitation and improved function. YES. By far the greatest and most simple yet effective manual therapy I have ever seen.

Following each patient consultation Peter gave us the opportunity to work through the clinical reasoning process where he highlighted the key components of the patient story. During the clinical reasoning process and through identifying the key modifiable factors in the patients story it became apparent as to why Peter had tailored the patients treatment in the way he had and gain a greater understanding of how the CFT model worked.

Now if I refer back to paragraph 1 of this short blog. “This weekend however was all about confirming my own bias”. As I sat in the workshop finding myself becoming enthralled in each slide I could not help but think CFT was already the way I was working without recognising it. It is at this point if you have not already read the works of the late great Louis Gifford I urge you to go and get a copy of his trilogy Aches & Pains. Louis Gifford’s introduced me to the idea of the MOM (Mature Organism Model – as per below). Here are some of my favourite quotes from Louis Gifford:

“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/rehab/ graded recovery/functional recovery process – then its my opinion that your therapist is a complete waste of time” 

“Integrating psychological and social issues into practice is not an easy matter for professions that are linked historically to tissue/injury/pathology-based explanations and treatments for all pains. Overcoming a natural antipathy to integrate ‘other’ issues, concepts and explanations is a major step towards effective practice change.”

“Most of us tend to think of pain as an unpleasant, distressing sensation that originates in traumatized tissues and courses its way along neural pathways to the brain and consciousness. Thus, the amount of pain perceived fits with the amount of damage done and the pain happily recedes in direct relation to the pace of healing.

The problem is that our clinics and departments are full of patients who have ongoing pain with no clear trauma or disease process, or who have suffered trauma but the pain continues on long after a reasonable healing period.” 

Louis Gifford was way ahead of his time. Peter O’Sullivan and his team are still ahead of their time but thankfully the work he and his team do is dragging our profession into the future! Thank you Peter O’Sullivan. Thank you CFT for confirming my bias.

That’s all for now!

@Honest_Physio

@Honest_Physio is a Physiotherapist based n the UK combining his passion for art and the biopsychosocial model through social media. @Honest_Physio is a Persistent Pain Specialist working within the NHS. He is strongly influenced by the works of the late Louis Gifford and you can find him on Instagram and Twitter @Honest_Physio and through his blogs over at www.thehonestphysio.com

If you want to learn more about Cognitive Functional Therapy, you can sign up to Kieran O'Sullivan's course here: Click here