It’s been a while since I reviewed a paper, and this paper caught my eye. Amanda C. de C. Williams is one of my favorite researcher girlfriends. Because her research captures the social and anthropological aspects of pain. She has been researching and teaching for a very long time.
This study is an observational study in which physical therapists watch videos of people with chronic low back pain performing movements. Although the movement is quite decontextualized (i.e. not integrated with activities of daily life), it is the type of movement that people may find difficult. These are reaching forward with arms horizontal while standing (forward reach), bending towards the toes while standing (forward bend), rising from a sitting position (standing to standing), and sitting from standing ( from standing to sitting). The video shows 10 people with back pain, all chosen from her large set of 16 people performing each movement twice. The selection was based on representing the widest possible variation in gender, age range, and people affected by pain. movement. Most were her less than 30 seconds.
Sixteen physiotherapists were included, who worked full-time or part-time in senior roles with people experiencing chronic pain. The average time since graduation for these clinicians was approximately 21 years (range 10-33 years).
Each physiotherapist watched eight videos extracted from a series of recordings and was asked, “How would you describe that movement?” “Describe it as alert and slow.” Further questions were asked, such as “Is this true?” Questions such as “When did you notice something unusual or unusual in your movements?” and “Did you notice a flow in your movements?” and “What is one piece of advice you would give patients to help them with this movement?”
The analysis followed a framework analysis method in line with thematic analysis, but using existing theory (e.g. deductive rather than inductive analysis where themes are developed de novo from the data themselves) and and completed independently by another researcher. Inductive analysis of “flow”. When we compared the two forms of analysis, we found them to be very similar despite their different approaches to thematic analysis.
What did they find? This is interesting because we rely on physical therapist observations to understand movement patterns when considering clinical reasoning and ultimately treatment. Guards are identified, usually qualified by noting the presence of a guard in some part of the movement or part of the body. The level of agreement was not high. Oops.
However, guarding is different from “hardness,” “slowness,” and “powerfulness.” Hardness is thought of as being “hard” or “wooden”, while guard was thought of more in terms of emotion. The brace was not really specified except for putting weight through the hand (putting the hand on the thigh) when sitting or standing.
Guarding was described as “cautious,” “defensive,” “fearful,” and “avoidant,” a feeling of reluctance to move, and participants described this as “thoracic,” or “avoiding,” the feeling of not being able to move at the time. I associated it with the body part I was looking for. “I want to move my lumbar spine” Interestingly, participants did not comment on their anxiety about this exercise…
The flow between physical therapists was also less consistent, but interestingly, therapists commented on limited information about the person in context, and were more likely to comment on the person and their beliefs and feelings than on guard observations. It seemed like there was a lot of curiosity. Flowing movements have been described as “nice,” “intuitive,” and “confident,” and are said to express confidence in the movement, even if the actual movement itself is unique. It seemed like that.
In their discussion, these authors found that although there was less agreement among physical therapists on the specifics of guard and flow, when asked to elaborate on their analysis, they found that when observing and describing tension and anxiety, reported being more consistent.
Why is this study important? What does it add?
One characteristic of the movements of people in pain is hesitation or “fluid” movement, or lack of flow. The study’s explanation is that these experienced therapists, although inconsistent with each other, perceived fluid movement based on the tempo of the movement, likely representing what has been described as: This suggests that there is a possibility that Csikszentmihalyi. It’s neither overly controlled nor uncontrolled. It looks effortless, allows you to move freely between positions, and there are no sudden changes in speed between parts of the movement or body parts.
The advice given by these physical therapists was also consistent with Csikszentmihalyi’s idea of “just manageable” (“just right” tasks), which involves stopping or changing movements just before alertness or hesitation occurs.
The authors then discuss what they believe is important from this research. Importantly, the nature of the movements appeared to reflect both emotional and “biological” limits, and these physical therapists were able to identify them, albeit less consistently. is.
Guard is a term often used in the rehabilitation of painful movements. Flow – Not much. There is some good evidence that movements associated with real-world activities, rather than movement fragments taken out of context, are more varied, more precise (when precision is important), and more fluid ( See Wulf, G., & Lewthwaite, R. (2016). Optimizing performance through intrinsic motivation and attention to learning: An optimal theory of motor learning. Psychology Bulletin & Review, twenty three(5), 1382-1414. ). Also, people try harder when it’s important to them. Therefore, they are more likely to walk briskly to catch a bus than when asked to “show me how to walk,” and their gait patterns may be more varied.
I am always working on understanding the real world and understanding what people need and want in their lives. If movement therapists (a very broad church!) could more consistently observe and interpret an individual’s movement practices in their daily lives, we would be able to understand very little of what that person actually wants and needs. There will be fewer dissimilar exercise interventions. to do. Getting healthy is a worthy goal, but you may not have the confidence to lift your mountain bike into the bike carrier in the back of your car, carry your wriggling child to bed, or vacuum the entire house. may not be available. At the end of a day when they were busy in the garden. As with almost everything else in chronic pain management, the effect size of exercise is small in both pain intensity and disability. And I think there’s an overemphasis on exercise compared to what you need or want to do that day.
Looking at studies like this, I think people’s trust in therapist movement analysis should be tempered a little by knowing the following: 1. The level of agreement between these experienced therapists was very lowIn less experienced clinicians, this value may be lower. 2. Movement taken out of context bears little resemblance to the real world. Contextualized movements that we need to make. 3. Fluidity of flow or movement can be a useful structure. This is because the clinicians seemed to be more influenced by their curious exploration of the person than by the supposed physical movement deficiencies. On the other hand, exploring defenses seemed to elicit more attention to biomechanics. 4. Last sentence of the abstract Really resonates: “Pain-related motor behaviors are better understood in terms of their specific functions rather than lumped together without reference to function.”
There are a lot of methodological questions. For example, what was the ethnic background of each of the people in the video? Was it painful to record? Why wasn’t real world activity used? Why did he have two methods for data analysis (this is partially explained)? But for now, this study piqued my curiosity, so I decided to share it.
Williams, ACC, Buono, R., Gold, N., Olgbard, T., and Bianchi-Bertose, N. (2023). Guard and flow of movement in people with chronic pain: A qualitative study of physical therapist observations. Euro J Pain. https://doi.org/10.1002/ejp.2195