Physiotherapy Theory and Practice

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Applying Psychology to Enhance Physiotherapy

Outcome

Vicki Harding & Amanda CdeC Williams

To cite this article: Vicki Harding & Amanda CdeC Williams (1995) Applying Psychology to
Enhance Physiotherapy Outcome, Physiotherapy Theory and Practice, 11:3, 129-132, DOI:
10.3109/09593989509022410

To link to this article: http://dx.doi.org/10.3109/09593989509022410

Published online: 10 Jul 2009.

Submit your article to this journal

Article views: 3623

View related articles

Citing articles: 9 View citing articles

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=iptp20

Download by: [5.67.215.76] Date: 17 July 2017, At: 22:44

pltvtiothnapy 77mg and Iforlrrt (I995) 11, 129- I12
0 Lawrcnrr Erlhaum Asroriatrr Limitrd 1995

EDIT0R IAL

Applying psychology to enhance physiotherapy

outcome
Physiotherapy is one of the main health pro- to determine their treatment. For instance,
fessions involved in rehabilitation, helping lumbar spondylitis provides a poorer working
patients to take an active part in their return to model for the therapist and the patient than a
function. The role of the physiotherapist is made concept of the patient’s individual complex of
more challenging when patients’ expectations, tightness, weakness, stiffness and spasm, with
and those of their medical carers, are distinctly reference to the postural forces and abnormal
lower than those of the physiotherapist; it is also movement patterns helping to generate or per-
harder when patients construe all their symptoms petuate these signs. Physiotherapists will have
and difficulties as manifestations of significant worked alongside health professionals who as-
pathology. Applying psychological models and sume that they have to resort to coercion or
principles is much more than ‘common sense’, bullying in order to achieve improved function
and can bridge these gaps, making sense of in patients who are unwilling. Patients may as-
patients’ predicaments, and providing pos- sume this too when they believe the physio-
sibilities for change and improved function therapist’s expectations are more than they can
(Harding and Williams, in press). Since we work cope with. The undoubted effectiveness ofphysio-
in the chronic pain field, we will use it in ex- therapy is testimony to physiotherapists’ abilities
amples, but the principles have application to all to teach, to improve patients’ confidence, and to
spheres of physiotherapy rehabilitation. their treatment skills and knowledge. However,
A simple disease model equates severity of some patients require special handling. Problems
pathology with severity of a patient’s symptoms, can arise with very anxious patients, those who
complaints and disability. This problem is com- appear to have little ‘motivation’ for making
pounded if other ‘pathogenic’ factors - emotional changes, plateauing or dropping off in im-
or personality-based are proposed to account
~ provement after discharge from rehabilitation,
for discrepancies between pathology and dis- and seeking further referral. Unshakeable faith
ability (Gamsa, 1994). The patient may be in the power of a machine poses problems when
described as showing ‘functional overlay’, hy- the more chronic patient keeps returning for a
pochondriasis, or even psychogenic pain. Since ‘top-up’, cspecially when it substitutes for chang-
personality traits are by definition unchangeable, ing old, unhelpful habits. Other difficulties can
the advantage of the label is that it lets the arise with patients who continue to attend with
therapist offthe hook it’s the patient’s fault. But
~ an implicit ‘do something!’, yet report every time
whatever we guess about ‘personality’, people’s that therapy, especially any requiring movement
behaviour is variable, not fixed. What matters or exercise, made the pain worse or unbearable.
in the therapeutic setting, therefore, is patients’ Applications of psychology to enhance thera-
behaviour, which in turn is related to their beliefs peutic benefit have been sparse in physiotherapy
and to the therapist’s behaviour. training, and most physiotherapists would have
While rejecting the simple disease model and difficulty defining their skills in understanding
steering clear of personality judgements, physio- and helping more challenging patients, or know-
therapists tend to choose a descriptive diagnosis ing what went wrong when problems continue.
or neuro-biomechanical approach to a problem, Is there a theoretical model physiotherapists
rather than using Latin or Greek diagnostic labels can turn to which will enhance the rehabilitation
130 PHYSIOTHERAPY THEORY AND PRACTICE

model and whose applications are testable? The aging disability is inappropriate if no attempt
cognitive-behavioural (C-B) model within psy- has been made to change reversible disability.
chology is based on a normal rather than a Helping a patient to come to terms with a wheel-
disease model of human behaviour. It addresses chair existence is detrimental to walking re-
the successful and unsuccessful attempts by the habilitation, just as providing disability aids is
person to adapt to various circumstances such as likely, both physically and psychologically, to
illness, major life change, loss of valued activities worsen the disability effects of disuse.
and roles, and repeated failed treatments. A great Physiotherapy treatment has three main aims
deal is known about how humans learn and for behavioural change: initiating and increasing
unlearn habits. This knowledge is applied to desired behaviours, maintaining these be-
the physical, practical and psychological habits haviours, and decreasing and/or stopping un-
associated with chronic conditions, and to their desired behaviours.
accompanying fears, depression and other emo- Learning new skills or re-learning old skills is
tions. The focus is on what can be described, most rapidly brought about by applying learning
defined and measured, both of behaviour and theory. Skinner’s (1959) principles are directly
the circumstances in which it occurs, and of applicable to some aspects of patients’ behaviour,
beliefs. so a behaviour to be encouraged, for example
The major components of the C-B approach walking without aid or increasing knee flexion
can be found in Kanfer and Goldstein (1991), through use and exercise, is reinforced initially
Bellack and Hersen (1985) and Beck (1989). In by frequent praise from the therapist, but then
chronic pain management, the components are by the patient, by a system of reward or ideally
operant learning (Fordyce, 1976; Roberts, 1986), by their own sense of enjoyment or achievement.
the goal-setting approach with its emphasis on If a patient only stops an exercise at the point
systematically paced activity (Fordyce, 1976; Gil, where he or she is in increased pain, and is
Ross and Keefe, 1988), the application of prac- frightened, this makes for an aversive experience
tical coping strategies such as relaxation (Linton rather than a reinforcing one. Patients may need
and Melin, 1983), and cognitive change (Turk, a behaviour such as an exercise explained and/
Meichenbaum and Genest, 1983). The aims of or demonstrated to them first (modelling), and it
the approach are not to find the elusive cause is likely that patients will improve faster and be
for the patient’s problem or a magic cure, nor less anxious in a physiotherapy setting where
even the perfect exercise programme, but to help they observe reinforcement being used with other
the patient cope better with problems. Rather patients.
than using terms like ‘compliance’, the C-B ap- Of course, what the patient achieves with the
proach looks at ‘how to establish new habits in safety of the therapist present and in the hospital
place of unhelpful ones’. One sometimes wishes setting may be much harder at home on his or
patients had been less compliant and passive her own. This needs to be addressed from the very
where certain medical interventions have led beginning (Marlatt and Gordon, 1980). Using the
to poor outcome (Pither and Nicholas, 1991). goal-setting approach links behaviour change and
Patients need to make informed decisions, sharing treatment goals to the patient’s longer-term goals
and eventually shouldering responsibility for by means of pacing, a systematic approach which
problem-solving in their own environment. provides graded exposure for feared activities
A physiotherapist would ideally like to dis- (Kanfer and Goldstein, 1991). Pacing makes ac-
charge every patient pain-free, happy and dan- tivity or behaviours time- or quota-dependent
cing. Lesser but more realistic treatment goals rather than symptom-dependent. Pacing from
relate to the stage the patient is at, and recognise modest baselines is incompatible with over-
that it is unrealistic to use the acute medical model activity/underactivity cycles, the pattern shown
of ‘cure’ for recurrent and chronic problems, by patients who alternately push hard and then
and carry out repeat assessment and treatment. are unable to keep going. Setback plans ran also
Equally, teaching a patient coping skills for man- be incorporated to help patients through difficult
 PHYSIOTHERAPY THEORY AND PRACTICE 131

times, providing realistic strategies that help stop for example, ‘wear and tear’ (thoughts associated
patients feeling ‘I’ve failed’ or ‘It doesn’t work with exercise wearing one out further and rest
after all’. Making links between new behaviours being essential), ‘trapped nerves’ (worrying
and a patient’s beliefs is important for the main- thoughtdimages of raw nerves which require
tenance of treatment change, since in- surgical untrapping) and degenerative joint/disc
compatibility between them will result in fall- disease or ‘arthritis’ (images of crumbling bones
off once patients are away from the therapist’s or joints with dire implications for the future).
reinforcement and influence. It is helpful if Physiotherapists know of the plasticity of the
patients work towards independence from the nervous system, the ability of the body tissues to
start using self-reinforcement, finding re- strengthen and toughen, and how best to enhance
inforcements in their own environments and this. Patients need to know this too. They need
using behaviour cues and reminders. Patients information; they may also require help to chal-
also maintain improvements better when they lenge unhelpful beliefs by looking a t the evidence
attribute those improvements to their own efforts, for and against them. Worry from one or two
not entirely to the will or skill of the physio- falls, an article in the newspaper, etc., is laid
therapist. Self-attribution is taught from the very against other disconfirming evidence, including
beginning. Acceptance of responsibility for their the patient’s own experience.
body and health means acknowledging that 2. Fears and anxious thoughts, such as beliefs
patients’ hard work and the healing capabilities that the patient is unable to manage without the
of their bodies brought about change. Physio- therapist, cannot always be resolved easily by
therapists can be catalysts and guides, but it is reassurance. Reassurance is only reassuring if the
important that they do not take credit for what patient (not just the therapist) feels reassured!
belongs to the patient. Patients need to reassure themselves using good
A number of unhelpful behaviours in chronic quality information and experience (Salkovskis
problems may be adaptive in the acute stage (e.g. and Warwick, 1986).Relief of anxiety by avoiding
limping), but create problems when they continue a feared activity perpetuates avoidance. If a
beyond healing. Stopping or reducing unhelpful patient thinks a pain signals deterioration, he or
behaviours is brought about by removing re- she is likely to avoid things that increase the pain,
inforcements that maintain them, and by teach- even if it brings about improvement, since this
ing and reinforcing competing or incompatible also relieves anxiety. A desired behaviour that is
behaviours. Patients’ responses and states are absent cannot be reinforced, so the cause of the
formulated as behaviours in a value-free way anxiety needs to be tackled.
rather than as wrong. Patients do not do un- 3. Depressed mood is common in chronic
helpful things deliberately, or because they are conditions and can also be present in more acute
neurotic, hysterical or wicked, but because those illness or post-trauma. Patients’ thoughts focus
behaviours have been reinforced. on not feeling like doing anything, that it is
Basic behavioural skills can easily become a not worth doing anything, or even that they
part of mainstream physiotherapy practice. Cog- themselves are not worth it. They tend to focus
nitive skills are less easy to acquire and more on personal failure and difficulties, setting them-
complex cognitive problems need the expertise selves unrealistic and unreasonable targets with
of a clinical psychologist. There are three main which to measure success, construing achieve-
areas, however, that physiotherapists can re- ments as failures or as chance events. Depression
cognise, and by helping patients identify and can be mistaken for ‘poor motivation’, a hy-
challenge their more unhelpful thoughts and be- pothetical construct of little practical use. Factors
liefs, can bring about changes in patients’ feelings that raise mood include aerobic exercise, having
and associated behaviours: a range of worthwhile and pleasurable goals to
work towards, and interrupting the downward
1 . Unhelpful beliefs in physiotherapy are typ- spiral into depression with challenging mean-
ically about pathology and images of the body; ingful thoughts: ‘I’ve coped before, I can do it
132 PHYSIOTHERAPY THEORY AND PRACTICE

again’; ‘The doctor/physiotherapist said I will to these programmes. This is an exciting and
improve; it’s slow and I’m feeling down, but I’m also very satisfying area of work, and the more
further on than last week’. widespread adoption of the approach into physio-
An integrated C-B approach raises some ques- therapy generally should contribute to enhancing
tions about the validity and appropriateness of practice and outcome.
certain treatment approaches. Physiotherapists
need to seriously reconsider: Vicki Harding and Amanda CdeC Williams
INPUT, Pain Management Unit
Aids that undermine confidence in weight- St Thomas’ Hospital, London, UK
bearing and movement.
Reassessment and retreatment when the prob- References
lem is the same as before - it is bolstering the
medical model rather than an active coping Beck AT 1989 Cognitive therapy and the emotion
disorders. Pelican, Harmondsworth
approach. Bellack AS, Hersen M 1985 Dictionary of behavior therapy
Repeated reassurance by the therapist. techniques. Pergamon Press, New York
The power of placebo elements in any treat- Fordyce WE 1976 Behavioral methods for chronic pain
and illness. CV Mosby, St Louis, M O
ment, affected (among other variables) by the Gamsa A 1994 The role of psychological factors in chronic
patient’s and therapist’s expectations. It is only pain. 11. A critical appraisal. Pain 57: 17-29
Gil KM, Ross SL, Keefe FJ 1988 Behavioral treatment of
worth putting your faith in treatment where chronic pain: Four pain management protocols. In:
the literature shows significant benefit over France RD, Krishnan KDD (eds) Chronic pain, pp
placebo. 376-41 3. American Psychiatric Press, Washington, DC
Harding VR, Williams ACdeC (in press) Extending
Providing treatment or modifying behaviour physiotherapy skills using a psychological approach:
based on hunches rather than on evidence. Managing chronic pain in a cognitive-behavioural
Common sense provides contradictory guide- multidisciplinary team. Physiotherapy
Kanfer FH, Goldstein AP 1991 Helping people change: A
lines. textbook of methods, 4th edn. Pergamon Press, New
Oversimple explanations of a problem which York
suggest high risk or encourage expectations of Linton SJ, Melin L 1983 Applied relaxation in the
management of chronic pain. Behavioural Psychology
a technological ‘fix-it’. I I : 337-350
Expecting information alone to change well- Marlatt GA, Gordon JR 1980 Determinants of relapse:
established maladaptive habits, when the Implications for the maintenance of behavior change. In:
Davidson PO, Davidson SM (eds) Behavioral medicine:
patient does not have the required skill in his Changing health lifestyles, pp 4 10-452. Brunner/Mazel,
or her repertoire, or confidence in using it. New York
Pither CE, Nicholas MK 1991 The identification of
iatrogenic factors in the development of chronir pain
Although physiotherapists can utilise basic syndromes: Abnormal treatment behaviour? In: Bond
psychological principles to enhance treatment MR, Charlton JE, Woolf CJ (eds) Proceedings of the
VIth World Congress on Pain, pp 429-434. Elsevier,
effectiveness for patients who do not follow the Amsterdam
usual course of recovery, it can be helpful to Roberts AH 1986 The operant approach to the
discuss management with a clinical psychologist management of pain and excess disability. In: Holzman
AD, Turk DC (eds) Pain management: A handbook of
or refer on to an interdisciplinary C-B pro- treatment approaches, pp 10-30. Pergamon Press, New
gramme. These exist, among others, for patients York
with head injuries, spinal injuries, chronic pain, Salkovskis PM, Warwick H M C 1986 Morbid
preoccupations, health anxiety and reassurance: A
coronary rehabilitation and chronic fatigue, and cognitive-behavioural approach to hypochondriasis.
are becoming more widespread. Behavior Research Therapy 24: 597-602
By learning the cognitive-behavioural ap- Skinner BF 1959 Cumulative record. Appleton-Century-
Crofts, New York
proach and integrating it with their own skills, Turk DC, Meichenbaum D, Genest M 1983 Pain and
physiotherapists are making a major contribution behavioral medicine. Guilford Press, New York