The interpretation of experience and its relationship to body movement: A clinical reasoning perspective

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Manual Therapy 11 (2006) 2–10 www.elsevier.com/locate/math

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The interpretation of experience and its relationship to body movement: A clinical reasoning perspective Ian Edwardsa,, Mark Jonesb, Susan Hillierc a

School of Health Sciences, University of South Australia, Australia Graduate Programs in Musculoskeletal and Sports Physiotherapy, School of Health Sciences, University of South Australia, Australia c Biomechanics and Neuroscience, School of Health Sciences, University of South Australia, Australia

b

Received 30 August 2005; accepted 17 October 2005

Abstract In this paper, we present findings from literature which suggests an intrinsic relationship in patients with chronic pain between the development of rigid and limited perspectives based on the interpretation of experience and the development of decreased repertoires of movement patterns. We present a research-based clinical reasoning model for conceptualising the teaching of movement for patients with chronic pain and contend that therapists can intentionally teach movement using fundamentally different reasoning and learning processes. We propose that these different kinds of learning will assist clinicians to translate the findings of diverse and complex pain research to clinical practice and, in particular, the teaching of these patients both new perspectives and movement patterns. r 2005 Elsevier Ltd. All rights reserved. Keywords: Chronic pain; Interpreted experience; Clinical reasoning; Movement; Teaching

1. Introduction The learning of movement and its therapeutic application with patients through teaching is arguably the most central role of physiotherapists. For manual therapists there remains a significant challenge in assisting patients with chronic pain to learn or re-learn various movement patterns. In part this paper focuses, from a clinical reasoning perspective, on how the interpretation of pain and illness experience over time influences the learning or unlearning of movement in these patients. Historically manual therapists have addressed the physical impairments identified as contributing to loss of functional abilities and participation in the various fora (family, social and work) of patients’ lives. Recent literature suggests that manual therapists also understand patients’ interpretations of their illness and/or pain experience in order to address their decision making around activity and participation capabilities Corresponding author. Tel.: +61 883022065.

E-mail address: [email protected] (I. Edwards). 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.10.002

which are, in turn, influenced and informed by these interpretations (e.g. Osborn and Smith, 1998; World Health Organization (WHO), 2001; Main and Watson, 2002; Butler and Moseley, 2003; Waddell, 2004; Jones and Edwards, in press). Clinical reasoning is concerned not only with understanding these patient perspectives but also with understanding the nature of our own thinking and decision making as practitioners. What are the underlying assumptions upon which therapists base their interpretation of diverse data (e.g. patient beliefs and perspectives as well as physical impairments) in order to make diagnostic and treatment decisions? How does the manner in which therapists interpret patient data, even allowing for such diversity of data, influence the way in which they choose and implement management strategies? What are the implications for clinical management (e.g. teaching movement) of being aware of and intentionally varying these reasoning processes? In order to address these questions this paper is structured in three sections. Firstly, we consider the manner in which patients with chronic pain often

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constrain body movements and so diminish their previous repertoire of movements and, by extension, functional abilities. In the physiotherapy literature there has been an emphasis on the identification of so-called ‘chronic pain behaviours’ (e.g. fear avoidance) and the design of remedial strategies to address these more than there has been on an understanding of how these behaviours are the consequence of interpretive and decision making processes by patients (Jones and Edwards, in press). In the second section, we describe a model of clinical reasoning emanating from a qualitative research study (Edwards et al., 2004) which describes how expert therapists reason, even with a particular patient and within one treatment session, using an interplay of fundamentally different clinical reasoning processes. Significantly, in a departure from previous clinical reasoning theory (e.g. Hayes Fleming, 1994; Benner et al., 1996), these reasoning processes are not deployed in a manner where one type of reasoning is employed for interacting with patients and another type for choosing and implementing treatment procedures. In the third section we explore how these fundamentally different reasoning processes both have important roles in the teaching and learning of movement.

2. The interpretation of experience in chronic pain Patients render their experiences sensible to themselves and others through the act of interpretation. Patients’ interpretations of illness, pain and/or disability experiences are formed in relation to the depth and diversity of their ‘interpretive resources’ (White, 1998, p. 1). The term ‘interpretive resources’ refers to a pool of beliefs, values and behaviours which are derived from cultural and social influences as well as patients’ own unique personal circumstances and histories ((Mezirow, 1991; White, 1998; Sim and Smith, 2004). These cultural and social influences constitute a way of understanding experiences (often tacitly rather than consciously) which enables patients to bring the particular events of their lives into some kind of general comparison with the similar experiences of others (e.g. the experience of being off work with low back pain) (White, 1998). From this ‘generalizing’ of experience is a resultant learning to adopt the language and behaviour expected of someone with a chronic condition (Osborn and Smith, 1998). The notion of the ‘sick role’ (Parsons, 1978) and the ‘validating’ of illness or disability through the ‘generalizing’ of experience (i.e. what is deemed legitimate sickness behaviour) is an example of meanings being shaped at a social level. Associated with this patients with chronic pain report a sense of distress in their attempts to find a balance between their own interpretations of their illness experience and what others understand and expect of them (Osborn and

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Smith, 1998; Steen and Haugli, 2000; Gustaffson et al., 2004). In such a scenario, patients’ descriptions of their illness experience tend to become ‘monographic’ (i.e. single theme), flat descriptions of life which for them render events predictable (White, 1998, p. 2). This can be to the point that they often express fixed and limited perspectives on situations such as their condition, ability to work, and their ability to participate in family life and even physiotherapy. Readers may recognize the often stereotypical accounts of symptoms and history during interviews with patients with chronic pain. The perspectives of these patients regarding their pain (expressed in therapy and elsewhere) are ‘less permeable’ in so much as they are less open to change and ‘less dependable’ in that they do not appear to ultimately ‘work’ for the person (Mezirow, 1991; Osborn and Smith, 1998). Illness representation or schema research emanating out of cognitive psychology echoes this notion of narrowing and rigidity of perspectives (Leventhal et al., 1980; Bishop, 1991; Skelton and Croyle, 1991; Turk and Rudy, 1992; Pincus and Morley, 2001). Illness representations or schema are also learned through both social and personal experiences and function as individuals’ implicit theories of illness that they use to interpret and respond to health threats. In schema theory it is not only the person’s existing beliefs and assumptions that make up their mental representation and contribute to determining their coping but also their appraisal of the threat their problem/pain or the situation poses (e.g. seriousness, social desirability, personal responsibility, controllability and changeability) (Bishop, 1991; Salkovskis, 1996). This appraisal in turn shapes how further experiences are interpreted. The interpretation of experience, therefore, is not a fixed ‘cause’ and ‘effect’ system. Rather, it is a changing one. Pincus and Morley (2001) propose that everyone has their own schema for pain, illness and the self that normally have some degree of overlap. As schema evolve over time, in situations such as chronic pain, these schema become ‘enmeshed’. That is, repeated simultaneous activation of aspects from different schema is thought to be a mechanism of learning that results in a blurring of representations such that elements from one schema become incorporated in another. This ‘enmeshment’ of schema is believed to be one explanation for why events leading to activation of one schema with relatively benign consequences can develop into a schema eliciting more significant effects (Pincus and Morley, 2001). While the notion of illness and pain schema are likely already considered by those interested in pain and psychosocial influences, the concept of a self-schema may be less familiar. Selfschema is a complex multifaceted construct that relates to who you are with reference to who you used to be (prior to your perceived change in self) and who you would like to be in the future. It includes an evaluative

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dimension that contributes to an individual’s sense of self-worth. Pain has the ability to disrupt aspects of the self such that repeated failures to function ‘normally’ and the negative emotions that result, can lead to changes in a person’s self-image (Osborn and Smith, 1998; Steen and Haugli, 2000). While Pincus and Morley (2001) focused on mental representations of illness, pain and self, research investigating body schema (or the real-time representation of the body in space, reflecting sensory input with corresponding motor consequences), provides evidence for further influences of pain (e.g. Moseley, 2004; Moseley et al., 2004; Van Damme et al., 2004; Hudson et al., in press). Using different methodologies these two research groups reported significant findings with subjects having difficulty disengaging from chronic pain, experimentally induced acute pain and even from cues signalling impending pain. A number of hypotheses are entertained in the discussions from this research with the prevailing opinion being that information-processing biases reflect a limitation in ‘‘disengagement’’ from the painful, or anticipated painful, body part. This difficulty allocating attentional resources away from pain correlates well with other findings that greater worry about pain is associated with greater hypervigilance, or somatic attention, with potential for amplification of somatosensory input and subsequent validation of patients’ beliefs and fears (Eccleston, 1995; Eccleston et al., 1997; Crombez et al., 1998a, b). Somatic vigilance may also be related to catastrophic cognitions which in turn may be related to the ‘‘meaning’’ individuals attribute to their pain as reflected in their attitudes and beliefs about pain (Moseley, 2004). It is intriguing to consider whether body schema could similarly be affected by chronic pain and disability experiences, and if so, could body schema and the motor system with which it is integrated be enmeshed along with pain, illness and self-schema as proposed by Pincus and Morley (2001)? Clearly this would require further research to establish. However, with contemporary perspectives that sensory, cognitive, emotional and motor ‘systems’ are not separate in the brain (e.g. Melzack, 1996; Ratey, 2002; Moseley, 2003) it appears a reasonable proposition. Next we consider this further and question whether these various schema, and in particular a person’s flexibility of perspectives, or their scope of ‘interpretive resources’ may correlate with the limitations in body (posture and movement) awareness and movement commonly observed in patients with chronic pain. In clinical practice, the interpretations of experience described so far in patients with chronic pain appear to have a parallel with similar expressions of stereotyped and impoverished movement patterns in these patients: movements which could be described as exhibiting a narrower repertoire and of being less ‘rich’ in terms of spontaneity and complexity.

Traditionally manual therapists have approached the problem of impoverished movement patterns in patients with chronic pain through structurally oriented management strategies aimed at, for example, improving posture, flexibility and coordination. Clinical management strategies have tended to be based in recent years on behavioural or neural processing explanations. Fearavoidance has been a prominent behavioural descriptor while other behaviourally related ‘diagnoses’ such as ‘secondary gain’ and ‘abnormal illness behaviour’ have been widely used. More recently, such an approach has been informed by the biopsychosocial model with the use of such strategies as ‘cognitive-behavioural therapy’ (Harding, 1998; Waddell, 2004; Klaber Moffett et al., 2005). This latter method, although offering much to the therapist in what is a difficult area of practice, has been criticized for its emphasis on the changing of behaviour (as expressions of people’s beliefs) with the importance of examining the origins of such beliefs being more a subsidiary strategy (Sharp, 2001). Recent research by Moseley and colleagues with patients who have chronic pain has focussed on ‘interpretive’ rather than ‘behavioural’ activities. They have investigated the effects of specific explanations regarding the neurophysiology of pain to patients with chronic pain and shown positive changes in beliefs and attitudes (Moseley et al., 2004) in pain and movement (Moseley, 2004) and in the way the brain allocates importance to injury or physical self-related cues (Burnett and Moseley, 2005). The pain neuromatrix model’ (Moseley, 2003) describes the brain as an ‘orchestra’ (involving the many ‘players’ and ‘instruments’ of the brain) which plays the pain ‘tune’ as a memoried and stored response to perceived threat. Learning to constructively re-interpret the ‘threat’ which patients perceive leads to beneficial changes in patient experience and function. We encourage readers, as would Moseley (personal communication), to understand ‘threat’ not only in terms of patients’ fears. Experiences such as ‘loss of hope’ and ‘loss of social participation’, ‘helplessness’ and even ‘sense of shame’, have been found to be potential pain perpetuating experiences of those with chronic pain (Salkovskis, 1996; Osborn and Smith, 1998; Gustaffson et al., 2004; Sim and Smith, 2004). For example ‘loss of hope’ has to do with the attribution of meaning. Similarly, ‘loss of social participation’ and ‘sense of shame’ and ‘helplessness’ have socially determined elements. In other words, self-image and a projected future for the ‘self’ may be part of the ‘threat’ influencing the interpretation of pain and movement. The mind-body dynamics discussed in the diverse literature of neuroscience (neuromatrix theory), psychology (schema enmeshment) and sociology (diminished ‘interpretive resources’) together suggest an

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intrinsic relationship between the interpretation of experience and movement. However, an integrated conceptual framework of biomedical and psychosocial thinking is still needed to guide manual therapists’ inquiries, interpretations and decision making in order to implement such findings in clinical practice. We propose that clinical reasoning provides such a conceptual framework.

3. Clinical reasoning and movement: it is not only what therapists see but how they see it Edwards et al. (2004) carried out a qualitative, grounded theory study of the clinical reasoning of expert clinicians in three different fields of physiotherapy: manual/musculoskeletal; neurophysiotherapy; domiciliary care (home based) physiotherapy. Grounded theory is a method often used to generate theory or explanations which are grounded in the data, and regarding a phenomenon about which little is known (Strauss and Corbin, 1994). The aim of this research was to study the clinical reasoning of these therapists in the natural settings of the clinicians’ usual clinical practice. Data were collected through the ‘shadowing’ of these therapists over the course of at least 2 days of clinical practice. All treatments and subsequent interviews were audiotaped and field notes written. The tapes were transcribed and analysed using a grounded theory coding process and a case study method (Edwards et al., 2004). The study’s findings were that, regardless of field, each therapist reasoned in a number of focussed and identifiable areas of reasoning in practice which we term ‘clinical reasoning strategies’. Clinical reasoning strategies cover a broad range of clinical practice responsibilities; including reasoning related to diagnosis, procedure, interaction, teaching, collaboration, prediction and ethics (Table 1). These activities can be viewed through two fundamentally different reasoning processes: hypothetico-deductive reasoning and narrative

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reasoning. These reasoning processes have underlying assumptions parallel to those underlying quantitative and qualitative research paradigms (Fig. 1). The quantitative (experimental) paradigm and corresponding hypothetico-deductive mode of reasoning hold that knowledge is objective, measurable, predictive and generalizable (Denzin and Lincoln, 1994; Higgs and Titchen, 2000) (Fig. 1). Quantitative research generates knowledge through the deductive ‘testing’ of hypotheses. Similarly, hypothetico-deductive (diagnostic) reasoning involves the generation and subsequent testing of hypotheses in a similar deductive (or cause and effect) manner in order to reach a diagnostic or procedural decision (Elstein et al., 1978). Qualitative research often produces knowledge through an inductive generation of hypotheses in areas where less is known about a phenomenon. In broad terms qualitative research approaches (in particular the interpretive paradigm) and narrative reasoning hold that knowledge is socially constructed, context dependent and that there are multiple realities rather than a single truth waiting to be discovered (Fig. 1). Narrative reasoning is based, therefore, on the premise that individuals construct their own unique interpretation of their experiences (e.g. of their pain or disability

quantitative

qualitative

Scientific/ experimental/ positivist

Interpretive

Underlying assumptions about truth/ reality

objective measurable predictable generalizable

context dependent socially constructed multiple realities

Reasoning processes

hypothetico-deductive

Knowledge generation: research paradigm

narrative

Fig. 1. Assumptions underlying research paradigms and reasoning processes.

Table 1 Clinical reasoning strategies Diagnostic reasoning: The formation of a diagnosis related to physical disability and impairment with consideration of associated pain mechanisms, tissue pathology and the broad scope of potential contributing factors. Narrative reasoning: The apprehension and understanding of patients’ illness experiences, ‘‘stories’’, contexts, beliefs and cultures. Reasoning about procedure: The determination and implementation of treatment procedures. Interactive reasoning: The purposeful establishment and ongoing management of therapist–patient rapport. Collaborative reasoning: The nurturing of a consensual approach towards the interpretation of examination findings, the setting of goals and priorities, and the implementation and progression of treatment. Reasoning about teaching: The activity of individualized and context sensitive teaching. Predictive reasoning: The active envisioning of future scenarios with patients including the exploration of their choices and the implications of those choices. Ethical reasoning: The apprehension of ethical and practical dilemmas that impinge on both the conduct of treatment and its desired goals, and the resultant action towards their resolution.

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Knowledge generation: research paradigm

quantitative Scientific/ experimental/ positivist

Interpretive Instrumental learning/ action

Underlying assumptions about truth/ reality

objective measurable predictable generalizable

Reasoning processes

hypothetico-deductive

Action/ learning

qualitative

Instrumental

context dependent socially constructed multiple realities

narrative

Communicative

objective measurable predictive generalizable

Movement

Fig. 3. Assumptions underlying instrumental learning of movement.

Communicative learning/ action

context dependent socially constructed Movement multiple realities

Fig. 2. Assumptions underlying instrumental and communicative learning and action.

experience, including its social consequences). Two people may have very similar impairments in terms of tissue pathology but have very different levels of disability due not only to their particular circumstances but also to their particular interpretation of their pain/ illness experience and the meaning (and implications) they attribute from this interpretation of their problem (s) to their lives. In this clinical reasoning strategies model, physiotherapy management (as Table 1 suggests), includes a scope of knowledge and clinical skills beyond just the selection of an appropriate procedure(s), its application and reassessment. The terms instrumental and communicative (Fig. 2) emphasize the respective implementation of hypothetico-deductive and narrative decision-making processes in various forms of clinical management (from application of specific therapeutic procedures through to education directed at challenging and assisting patients to ‘reinterpret’ unhelpful thoughts and beliefs). Learning is a tangible outcome of skilled clinical reasoning. The clinical actions taken as a result of that reasoning can lead to learning for both patient and therapist. When therapists employ an instrumental action and learning they look through a clinical reasoning ‘lens’ which enables them to see a decision or action with respect to assumptions about knowledge which are objective, measurable, predictive, and generalisable (Fig. 3). This often involves the manipulation or control of observable events be they physical (e.g. joint or muscle function) or interactive (e.g. behaviourally applied graded exposure to perceived threats) (Edwards et al., 2004). In instrumental action and learning, therefore, therapists’ reasoned decisions, actions and subsequent learning are structured in a way where concepts of normality or what is correct underpin generalized interpretations. That is, treatment techniques may be selected and applied with their effects measured and predicted through reassessment often based on population ‘norms’.

Fig. 4. Assumptions underlying communicative learning of movement.

In communicative action and learning different underlying assumptions concerning knowledge are that it is context dependent, socially constructed and there are multiple realities (Fig. 4). Communicative learning is concerned with understanding what others mean when they communicate their perspectives about such things as intention, motivation, experience and values (Mezirow, 1991). Communicative action in a clinical situation may involve therapists firstly understanding these perspectives and then fostering reflection on the adequacy of these perspectives in their patients. An example of how this type of learning and how instrumental and communicative learning and action inform each other is found in the vignette ‘Moira’s headaches’ (taken from Edwards, 2001 and cited in Jones et al., 2002). Vignette: Moira’s headaches Moira (a pseudonym) is a patient (from the study by Edwards, 2001) who presented with a gradual onset and 18-month history of continual facial/TMJ area headaches with associated disabilities in work (nurse practitioner) and family/home care activities. One feature of Moira’s presentation was her ineffective coping style while under pressure (work and demands of a 2-year-old), and resultant learned motor patterns (e.g. continual mandibular clenching in response to stress). Evident in the assessment was not only her lack of awareness of the factors contributing to her symptom provocation (e.g. stress and anger resulting from the work-load and pressure of being a working mother with a 2-year-old son and having difficulty coping with a demanding mother-in-law’s expectations) but the apparent perception of herself as a poor coper and, to a certain extent, her inadequacy as a mother. An avoidance of conflict with her mother-in-law meant her anger was poorly dealt with allowing her teeth clenching

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(and headaches) to persist without insight into these potential contributing factors. An example of instrumental action and learning in this case took place when the therapist, as part of management, was able to demonstrate to the patient an asymmetry, for example, in excursion of temporomandibular movements. Masseter and temporalis were palpated (and shown to Moira on a chart and in front of a mirror) and proprioceptive neuromuscular techniques such as hold–relax were employed to achieve a relaxation/lengthening of these muscles. The TMJ excursion was reassessed and the differences in range and/or symmetry of movement was observed and noted by the therapist together with Moira. In other words, Moira learned (was taught) to perform a manoeuvre where through the selective contraction of muscles and their subsequent relaxation, there was a demonstrable effect on a particular variable (i.e. TMJ excursion) as a part of a larger analysis of the situation. The effect of this was empirically observable and measurable at least in terms of quality of movement. The communicative teaching in this situation, however, was quite different but, nevertheless, took place in conjunction with the instrumental teaching above. This kind of teaching can be achieved through a number of strategies. One simple example which introduces the idea of self-reflection to Moira was where the therapist told a narrative concerning another patient which provided an alternative or new perspective by which Moira could reflect on her own situation: I had a guy, who was a plasterer, and he had terrible headaches, and I said to him, ‘‘What do you notice happening?’’yand he really didn’t notice very much. But he asked the people whom he worked with, and he said, ‘‘Well, how do I look when I’ve got a headache?’’ and they said, ‘‘You smile all the time,’’ and he realized he was clenching his teeth, trying to look like he wasn’t in painybut teeth clenching was really perpetuating the headaches. Here, the intent is to foster insight for Moira with regard to the factors which were potentially contributing to the ongoing production of her headaches. The relationship between behaviours (e.g. chronic teeth clenching), and symptoms (e.g. headaches), were not self-evident to her. In fact, during the day the points at which teeth clenching behaviour were most prevalent may not have even been evident to her. Similarly, the relationship between her interpretations of her situation, her view of herself and her unhelpful and habitual jaw clenching behaviours may have been lost in the understandable focus on her symptoms. This pointed to the need for Moira to, firstly, gain insight through personal reflection and then, possibly with the help of others, such as her physiotherapist, to be able to practise observing such connections. If Moira’s beliefs and

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attitudes were to remain entrenched then a referral to a suitably qualified practitioner (e.g. psychologist) may be appropriate. 4. Instrumental and communicative learning of movement Moira’s story reminds us, as does current pain research of the importance of providing patients with a plausible account of the ‘irrationality’ of chronic pain. Thus, the so-called irrational and recalcitrant behaviour of pain experienced by those with central pain states is externalized from the patient to the problem. No longer is the patient themselves held to be the primary source of irrationality in the situation (Steen and Haugli, 2000). For example, a biomedically focussed form of reasoning has indicated to practitioners and patients alike in the diagnosis of chronic pain that if there were not sufficient ‘hard’ objective signs on examination or through investigation that patients’ pain could not be substantiated (Main and Watson, 2002; Waddell, 2004). The ‘objective’, ‘measurable’, ‘predictable’ and ‘generalisable’ nature of the biomedical model (similar to instrumental forms of reasoning and learning) is an example that a model, which contributes so much to the development of health care, can also have unproductive and even negative effects when applied in the wrong context—in this case with respect to the interpretation of lived experience (Waddell, 2004). There is evidence that manual therapists’ perception, reasoning and management approaches may be constrained in clinical practice by a biomedical (or instrumental) reasoning ‘lens’ (Jorgensen, 2000; Ostelo et al., 2003; Potter et al., 2003; Struber, 2003; Daykin and Richardson, 2004; Frost et al., 2004). A communicative form of reasoning and learning, using a ‘lens’ of reality as ‘context dependent’, ‘socially constructed’ and the notion of ‘multiple realities’ casts a different analytical light on the interpretation of experience. Instead of being caught between the imperative to act out particular social roles (either ‘successfully or unsuccessfully’ (Osborn and Smith, 1998; Steen and Haugli, 2000)) and deal with the resultant guilt imputed to them for pain which cannot be substantiated, patients are enabled to begin to identify the effects of the problem (pain) on their lives rather than viewing themselves and their pain as inextricable identities (White and Epston, 1990; Orchison, 1997). This may not be dissimilar to a process of ‘un-enmeshing’ enmeshed body schema discussed earlier. We now discuss how ‘enmeshment’, as a negative aspect of the relationship between interpretation of experience and body movement, can be further addressed through enlarging repertoires of patient perspectives and movement patterns. Physiotherapists have typically addressed patient movement impairment in an instrumental manner

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characterized by prescribed therapeutic interventions with specific goals. These goals are derived from the empirical measurement of physical impairments which, are in turn, related to evidence gained from population norms (Carpenter, 1996; Struber, 2003). It is important to add, however, that instrumental approaches to movement training (exemplified by the precision required in the teaching and learning of isolation strategies for activation of particular muscle groups) remain important diagnostic and management strategies for manual therapists. In this section, we argue against a simplistic separation of body and mind by proposing that clinical reasoning and the management arising from clinical decisions (such as the teaching and learning of movement) need not be dichotomized to either the physical or non-physical but be applied to both. We contend that therapists can intentionally teach, and patients learn, movement with either instrumental or communicative assumptions or a combination of the two depending on the needs of the particular patient. As therapists we are generally more familiar with instrumental approaches to practice, A communicative approach to teaching and learning of movement is not primarily or exclusively directed at physical impairments but rather is concerned with the exploration of movement as a catalyst for further learning. An example of such an approach to learning movement, known and valued by many manual therapists, is Feldenkrais’ (1972) ‘Awareness through movement’. We do not attempt a full exposition of Feldenkrais’ methods here. Instead we discuss this work as a vehicle for illustrating how movement can be taught and learned using the assumptions underlying communicative learning. On the one hand we make the point that viewed through a communicative ‘lens’ of reasoning and learning, Feldenkrais’ approach need not be considered as ‘alternative’ or outside mainstream thinking in physiotherapy as it is when viewed through an instrumental or biomedical reasoning ‘lens’. On the other hand we propose that movement can be taught and learned using communicative assumptions in a generic manner and not confined to a particular philosophy such as Feldenkrais, notwithstanding its significant contribution to understanding movement. Feldenkrais described a relationship between a person’s self-image (with its educational, cultural and social contributions) and the expression of that selfimage in unhelpful, inefficient and even painful habits and patterns of body movement. His approach to movement is not prescriptive in that it does not seek to retrain movement by addressing specific impairments toward some ideal of ‘normalcy’. Instead it conceptualizes movement as having a social construction in so much as it is, in large part, an expression of a socially and culturally constructed self-image. Our patient,

Moira’s excessive and pain producing TMJ activity (and quite possible other postures and movement patterns) is, through a communicative reasoning ‘lens’, an expression of interpreted experience. A strong theme in the treatment session with Moira in the Edwards (2001) study was Moira’s perception of herself (i.e. selfimage) as a poor coper and as one who did not live up to the perceived expectations of her mother-in-law. In Jones et al. (2002) we used this example to point to the need for therapists to assist patients to reflect on, and identify for themselves, the links between interpretations of experience and a resultant behaviour such as mandibular clenching. In this paper, we go further and suggest (in conjunction with the literature discussed earlier) that interpretations of experience (i.e. the meanings imputed to experience) are embodied in particular movement patterns. Where repertoires of patients’ perspectives may be described as limited, rigid and habitual in their expression so too may their movement patterns. The aim of a communicative approach to learning movement, with someone like Moira, is to enlarge these repertoires, acknowledging their intrinsic relationship, and therefore assist patients to ‘deconstruct’ the habitual, fixed nature of both their perspectives and their movement patterns. Since each person’s self-image is unique, so too, Feldenkrais (1972) argues that increasing awareness of that image or identity through movement exploration reflects one person’s particular or unique set of realities. That is, there is not necessarily one right set of movements or method of addressing impairments for everyone. In this context movement ‘change’ is based on an open exploration of possibilities beyond or around any current stereotypical patterns. Persons with chronic pain may have longstanding histories where they have ‘learned’ not to succeed or, alternatively, ‘un-learned’ how to succeed at various tasks. Feldenkrais uses movement learning lessons that incorporate changes in spatial relations between body parts and also ‘create’ conditions of greater support (e.g. floor positions for exploring postures usually associated with the upright position) in order to dissociate movement from its habitual context (Reese, 2005). In this manner, habits of movement just like habits of thinking may be ‘deconstructed’ and new, even novel (in the sense of being unusual) movements and abilities are explored. Variation of movement (i.e. toward a larger repertoire) is a key to further learning and adapting to the demands of a changing environment (physical and social). In a communicative reasoning and learning approach (as for Feldenkrais) movements are intended to further knowledge and perception (about oneself and the world), and not seen as an end in themselves (Reese, 2005). In Moira’s case learning to identify and address length changes in the mandibular muscles through specific relaxation techniques took place in a largely

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instrumental manner. A communicative learning of movement in her case might also explore combinations of movement which ‘deconstruct’ habits of posture and movement viewed as both ‘interpretation’ and ‘motor response’ to the particular experience of her environment (physical and social). Enlarging movement repertoires in this way, Moira’s learning would not be confined to the learning of technical or functional skills but include the intentional learning of new or alternative interpretations of experience, in part through movement, particularly around meanings that have been attributed to various movements and postures. This may well be a form of learning through movement (as well as cognition) which addresses ‘self-image’ as Feldenkrais stated long ago.

5. Conclusion Communicative action and learning offers clinicians, in conjunction with instrumental learning and action, a way of acknowledging, in clinical practice, the complexity of mind–body relationships described in contemporary accounts of pain such as ‘schema enmeshment’, ‘interpretive resources’ and ‘threat reduction’ in neuromatrix theory. We have focussed in this paper on the interpretation of experience and body movement of patients with chronic pain. However, in order to understand the thinking of these patients, manual therapists must also understand the basis of their own thinking or reasoning. Instrumental and communicative forms of reasoning and learning suggest that in reasoning about and teaching movement is not only what therapists see but how they see it which is important.

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