12 minute read
The Physiology, Philosophy and Physics of our Clinical Reality
BY OWEN LEWIS
Reading this magazine, studying with Born to Move, or being in clinic is an exploration into
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the unknown to find the known. Unlike most articles and books I’ve read, workshops attended and courses studied, this article is not attempting to find certainty, truth, answers or fact; instead it aims to ask better questions.
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ncertainty is a clinical reality that can support or undermine our capacity to become expert practitioners. Many of us feel we don’t have sufficient knowledge or need more techniques, and may feel a failure to unravel the complex problem that clients present us with. The result is often a hesitant blinkered approach as we revert back to old habits and protocols rather than allowing our imagination to flourish and expertise to develop. Our clinical reality is the battle with these inner demons of uncertainty.
Here I suggest that this uncertainty is actually a necessary tool in the clinic. Let us look to the dusty world of philosophy, a somewhat unusual place to find a practical guide towards clinical excellence. Such a guide allows researchers and practitioners as a flexible framework to direct a espoke assessments and treatments. It’s time we move away from the conventionally rigid protocols that restrict us to working on symptom rather than the cause.
Our work as practitioners is exceedingly complex and as we progress in our professional lives we can find a deeper level of confusion and become slightly more comfortable with the certainty
of uncertainty. But this does not just happen, it must be part of our continual development as practitioners.
Research is certainly one of those Marmite subjects. Love it or hate it, research can help our practice. However, its power over our work can also damage credibility and confidence.
Gradually some researchers are starting to dovetail their research to enrich and be informed by clinical experience. Case studies are gaining some credibility, it is no longer all about randomised control trials. The result is that research is coming off its lofty perch in the clouds and is being brought down to ground level, and into our clinics and studios.
Unfortunately there is still a tendency for research to be singular, considering one variable often out of context. Research such as ‘A study comparing hip flexion and lower back pain’ is still all to common. This type of research, while interesting, does not reflect our clinical reality. Our clients more often exhibit multiple impairments and persistent pain. Their lower back pain is linked with their lack of hip flexion, associated with their poor ankle dorsiflexion that stems from the fear created by the whiplash of a car accident that manifests in the headaches and chronic tension in their occipitals that was exacerbated by the childhood asthma and lack of motion at their second rib. My treatment must therefore include neural, dural, articular, myofascial, psychological and motor programming components for that individual. Figuring that all out, finding these interrelationships and discovering the best place to intervene was yesterday’s ‘normal’ client. There is clearly no protocol and no research that will ever cover the complexity of the individual client.
The change from the absolute power of research would, I expect, please the medieval patron saint of universities and scholars, Thomas Aquinas. Aquinas challenged the prevailing assumption that “the human mind cannot know any truth unless by light of God”. In the medieval world of Thomas Aquinas it was a universally held view that everything important for us to understand had to come from the single approved source: God. Aquinas realised many of the great philosophers and thinkers that he studied were Pagans, or at least not Christians. He carefully opposed the view of the church realising that one could know things without knowing anything about God. Aquinas was particularly concerned that the Bible, as such a prestigious
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source of information, could swamp observation. He feared that people would be so impressed by these revelations from authority that they would discount their own powers of observation, reflection and experience.
Today, tension between higher authority and personal (dare I say, clinical) experience remains. The modern version of Aquinas’s observations is the refusal of almost any kind of knowledge that doesn’t come with the backing of data, experiments, mathematical modelling and peer-reviewed journal references. The higher-authority may not be God, but it still exists. But before we dismiss research completely, a word of warning from the ‘prince of paradox’ the English philosopher G.K. Chesterton. Chesterton remarked that “the problem with people who lose belief in God [and here we might replace God with ‘higher authority’] is not that they end up believing nothing, but that they will believe in anything.”
I’m sure no one wants a war between researchers and practitioners that, like any war, would “not determine who is right — only who is left” (Bertrand Russell) PIC1. However, it is a war that often exist within each of us. Part of us represent the absolutist: the part that enjoys standing on the granite rock of anatomical truth, with plain unvarnished objective fact at the centre. Counter to that view is the relativist within, that mocks these concrete ideals in favour of situational and individual-specific critical thinking. As we turn to the high priest of relativism, Nietzsche, who explains that “There are no facts, only interpretations”. This concept seems to echo our clinical need to deal with each individual, individually.
Many of us still hold scientific research up as the bastion of certainty and truth. The irony of this is that research is based on uncertainty. Doubt is the bedrock of science. The greatest scientific minds are not certain. Even Darwin who begins The Origin of the Species with a less that certain “It seems to me”. Or
the physicist Richard Feynman who clearly values doubt: “Doubt is clearly a value in science. It is important to doubt and that the doubt is not a fearful thing, but a thing of great value.”
In research, being unsure drives further investigation, develops better hypothesis and improves future research. Research proves and perpetuates this idea, and demonstrates this by one of the most common statements in all of research: “more research is needed.” By this simple statement the researcher is telling us they are still doubtful of the nature of their truth and, critically, are still willing to continue to explore.
I would hope that this spirit of exploration is mirrored in our clinics. Unfortunately, most of our clinical training is significantly different. Initial training often revolves around our ability to follow protocols. Training in certainty may well undermine our confidence and imagination. Protocols are most often the result of the current gold standard of research, randomised control trials (RCTs). Research that better reflects the complexities found in clinic is now showing the limitations of this generalist approach. Protocols are significantly limited to a rigid one-size-fits-all approach. Perhaps we are still unduly affected by the Roman anatomist Galen. Galen influenced medical thinking, both clinical and research, for thousands of years. He produced some brilliant work but also taught a version akin to a medical Gospal of certainty. Galen’s treatments worked, he claimed, “on everyone except those who were going to die anyway.”PIC2
It is gradually becoming an accepted view that protocols don’t or can’t work for everyone. This presents a problem to clinicians who rely on protocols. It forces clinicians to learn how to develop hypotheses, to test and retest and develop ideas all in the time and space available in our clinics and studios. While possible, this is difficult.
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The result of such difficulty is to revert back to habitual patterns of treatment. The irony being
that we are asking our clients to change, while we are failing to do so ourselves.
The point I’m attempting to make here is that doubt is a useful tool. That when coupled with both research and intuition becomes a powerful weapon in positive change.
It is clear that both research and clinical experience is important. Problems arise when we insist exclusively on either one or the other. Perhaps the fad of research-based practice is just as limited as intuition-based practice when compared to a combined approach of allowing intuition to stand on the foundation of research.
To be a great researcher or have clinical excellence we needs similar skills. To be able to develop sound hypothesis, test and re-test, use doubt and being comfortable with uncertainty are all essential skills.
To improve our research and so our clinical skills I suggest we all need to improve our skills of questioning. You might like to consider the following questions when next you get a chance:
How can doubt improve clinical excellence? Are protocols still relevant? How do you develop sound hypothesis in your clinic/studio? Does research reflect clinical reality? What are you most certain of? What are you most uncertain of?
While you improve your flair for metacognition, the skill of thinking about thinking, let us continue to dare to doubt.
What is your current area of interest? Is it the shoulder, hip, ligaments or fascia. Are you finding that this current area of interest has allowed you to notice more and more clients presenting with this problem. But is this true or does your current view create the rose-tinted spectacles that distorts your reality?
Physicists such as Neils Bohr have long known that a quantum of light, or photon, will behave like a particle or a wave depending on how it is measured. This suggests that reality is what you choose it to be. Bohr beautifully explained this when he stated that “A physicist is just an atom’s way of looking at itself.” Bohr like Schrödinger (and his cat) all came to realise that the “observer is the observed” (Krishnamurti). The actual process of assessment can alter the assessment itself. No wonder then that doubt creeps in when we assess our clients. How can I know, with any certainty, what it is that I assess daily in my clinic?
Take this idea further and we encounter the ideas of Descartes. In his explorations Descartes asks us to doubt everything. That in order to be “a real seeker after truth, it is necessary that at least once in your life you doubt,
as far as possible, all things.” His questions doubt our senses, he points out can deceive. An idea confirmed by the simple illusions and fake news stories. Today our reality, with the influx of Zoom into our clinical lives, looks more like the film The Matrix. This film cultivated Descartes' ideas that there is a ‘real’ world as we sense it but actually the characters inhabit a complex computer program. Ideas such as these lead us quickly to climb this strange ivory tower and we begin to doubt reality. All this philosophising calls for a dose of something real. Time to return to earth and get practical and solid.
Stand up. Place your hands on your pelvis, better still your iliac crest. Turn to the right and note how your right foot supinates and your left pronates. Still looking forward? Result, your head has rotated to the left, relative to your torso. This simply describes some of the biomechanics of normal human movement. Information like this can be used in the assessment of your clients. Imagine that a client comes to you complaining of foot pain. You assess the feet and note a difference in the height of one arch compared to that of the other foot. Knowing what you do about the predictable nature of human biomechanics, as outlined above, you change your client’s pelvic position, back to neutral. ‘Hey presto’ their foot position and reported pain has improved. No longer are you at the beck and call of foot pain protocols. Now you are treating the cause and creating long-term changes. In this simple example, the pelvic rotation was causing the poor foot alignment, foot mechanics and the cause of the reported pain. Of course you can reverse this idea and change feet to affect the pelvis for another individual with another pattern. To add a third dynamic, consider how the neck/head position might have driven either the pelvic rotation and/or the foot position. As you delve into this, you’ll find that
the variations are almost endless. This endlessness reflects the complexity and individuality of each of your clients. Fundamental principles, not protocols, will allow you to use this method causal over symptom based treatment. To predict outcomes, use doubt to explore and make longer lasting positive change for each uniquely individual client.
One of the principles of the Born to Move workshops is to empower clinicians to ask better questions. We aim to embrace doubt and so act more like a curious researcher constantly asking why. The consequences of this approach are to search and find causes through a collaborative exploration between client and practitioner. This replaces the hierarchical ‘I know best’ approach that places the practitioner in the impossible position of being expected to know all the answers. This approach is not some kind of final form of miraculous insight or absolute truth. In the place of rote learnt protocols is a principled based, ever changing form of insight and imagination. Together with our clients we at Born to Move are content to explore as our understanding unfolds towards increasing order and complexity.
OWEN LEWIS is a highly experienced and educated clinician. An accomplished teacher of many years he has recently teamed up with James Earls to create Born to Move. Born to Move is a comprehensive set of courses that are not confined to any one doctrine but blends and utilises James and Owen’s varied and extensive understanding of the body in movement. Being taught by Owen is to experience simplicity within the complex. Seeds of knowledge watered by a wealth of clinical relevance.
Clinically Owen has gained a distinguished reputation. Grounded in his extensive anatomical and biomechancial understanding he works alongside his clients. Taking a principle based framework that allows the discovery of individually tailored, effective solutions to problems and empower change.
His diverse interests in art, anatomy, philosophy and movement to ensure his workshops are a pleasurable part of your training.
