KEYNOTE LECTURE

The Pursuit of Excellence in the Face of Constant Change Ruth Grunt Key W d Professha\ relevance. paradigm delineation, outcome mea- sures.

Summary Paradigms or patterns of practice which function well in a tran- quil period m a y cease to do so if the world around the profes- SlORal activity changes. A first step in the pursuit of excellence patticuhrtf in changing times. is to krmw who we are, to agree on collective and individual paradigms. Much physiotherapy regeerch cmthues to focus upon improvement in impairments, ram than health dated quality of lie outcomes in evaluating efficacy d physco(herapy interventions.

‘The Great Debate’ Amid considerable controversy, in February 1993, the New South Wales branch of the Australian Physiotherapy Association staged ‘The Great Debate’. The debate’s theme was ‘Physiotherapy will be obsolescent by the year 2010’. The debate was chaired by a well known current affairs spokeswoman on Australian national television. The chair of the adjudication panel was the wife of a former Prime Minister of Australia, Mr Gough Whitlam. Like her hus- band, she is a woman of considerable stature both mentally and physically.

Happily, the team for the negative was success- ful. As its first speaker, I put its case which went something like this: Physiotherapy embod- ies change and change negates obsolescence.

To effect change, physiotherapists must be responsive to the situation that requires change, thus acting as an antidote to obsolescence. Clear professional growth in Australia in response to threat and change was argued, and fitted well within concepts described by Elliott Friedson, the dominant writer of the last decade on the subject of professional power. He described strong professions as strengthening their profes- sional autonomy and, importantly, maintaining a professional cohesiveness in the face of threat (kiedeon, 1987). Focusing upon responsiveness to some specific threats, which are not delineat- ed here, evidence of professional growth was cited with the following examples:

Establishment of physiotherapists as first- contact practitioners not requiring medical rafenal for patient treatment, achieved with the maintenance of close collegial links with the medical profdon.

0 Gaining the right for physiotherapists to order X-rays of the musculoskeletal system; such ordering attracting a rebate through private health insurance. .Becoming the first profession of any world- wide, which uses manipulative techniques in treatment, to formalise a protocol for pre-manip- dative testing of the cervical spine.

Maintaining professional unity and cohesive- ness in the retention of a single national associa- tion to represent the profession.

Establishing a strong voluntary commitment to continuing education. It has been estimated that a higher proportion of Australian physio- therapists attend physiotherapy conferences than in the home of mandatory continuing edu- cation, the United States of America. The Australian Journal of Physiotherapy was used as a litmus test of change, of growth or obsolescence. Its considerable growth, the num- ber of research studies and the one-year waiting l ist to get a paper published were cited. Professor Jules Rothstein, editor of Physical Therapy, while on an Australian tour in 1992, stated that more papers were being published by Australian physiotherapists per head of professional population than by his own countrymen and women despite the fact that the maxim ‘publish or perish’ was strongly held in the USA. Finally, in my revisitation of the presentation at The Great Debate, I included arguments supporting the continuing relevance of physio- therapy as evidenced by continuing and changing demand: ~Continuing and growing demand for physio- therapists worldwide as predicted in Time mag- azine, January 4, 1993, in which an American study was cited. This study found that among the people who will be most in demand in the next decade a re physiotherapists. From Australia’s workforce in the year 2001 (DEET, 1991) a growth of 47.3% in employment in phys- iotherapy in Australia for the decade 1991 to 2001 is expected. In 1986, the US Bureau of Labour Statistics estimated that physical thera- py would have to double its numbers to fill the vacancies anticipated by 1995. A major shortage still exists in tha t country (Barnes, 1992). Walker (1994, p 5091, has stated the situation in the United Kingdom: ‘Demand for physiotherapy

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services continues to rise, especially in view of developments in community care and GP fund- holding. It is projected that NHS physiotherapy staff in post within the UK as a whole could increase by a further 10% from 1993 to 1998 - this will require yet higher student intakes.’

0 Increasing community awareness of the impor- tance of a healthy lifestyle. This is evidenced by strong community support for:

Physiotherapy health promotion programmes targeting primary school children. Strong support for physiotherapy fitness pro- grammes for the over-60s. Strong support for prevention and interven- tion programmes in industry and in sport.

Responsiveness to change in the face of threat, change and growth in research and publication, maintenance of a strong relevance of physio therapy to community needs - these I argued would most surely negate the obsolescence of physiotherapy.

Fine words helped to win the debate on that day but challenges for our profession remain.

The Pursuit of Excellence and Paradigm Delineation Myers (1992) in writing of the Canadian Physio- therapy Association gaining momentum in its stride towards 2001, quotes Secretam ‘Excellence in our society is less a product of conflict and hostility than of collaboration - the combined efforts of a committed team. Simply put, the difference between whether an organisation is mediocre or superb is determined by whether all its individual members are mediocre or superb.’ Secretan continues: ‘The more we decentralise the more we become dependent on the competence and human-relations skills of the individual.’

Decentralisation (regionalisation) is a part of the health reforms which have taken place or are taking place in most Western countries. Our col- leagues, our new graduates are moving out well beyond the traditional locations in well-estab- lished physiotherapy departments where senior staff were their exemplars from whom values, attitudes and behaviours were absorbed.

In one sense this may be no bad thing, particu- larly if these potential mentors are themselves unable to adapt to change because of rigidity of attitude or crystallisation of beliefs, or unsup- portive of clinical research or reluctant to imple- ment research resulta in clinical practice. On the other hand, those menbring experiences may be

crucial to the professional development and mat- uration of young individuals.

Richardson (1993) in an excellent and thought- provoking paper argued that in the current cli- mate of health care there is a need for a strong defence of physiotherapy professional attributes, abilities and aspirations. She encouraged us, as did Tym-Lennb (1989, 1991) before her, to artic- ulate paradigms for physiotherapy. Tornebohm (1986) suggests that paradigms (or patterns of practice) which function well in a tranquil period of normal activity may cease to do so if the world around the activity changes. Furthermore, he identified that there may be faulty paradigms which do not allow individuals to develop and expand ideas, and to incorporate new knowledge.

The word paradigm in its etymological sense means pattern, prototype or typical example (Tyni-Lend, 1989). To be a physiotherapist implies that one has paradigms specific to that profession.

Profession-specific paradigms or patterns are acquired through the formative years of under- graduate education, amended and developed through subsequent clinical practice and subsequent formal and informal continuing pro- fessional education. All the inputs assoc- iated with those experiences taken together, form for the individual physiotherapist a picture of the world of professional activities and a frame of reference for distinguishing tha t world from the paradigms of other disciplines. There are individual professional paradigms and as Kuhn (1970) who first used this concept described, there are professional community paradigms. These incorporate the thinking, the values, the scientific theories, the problem- solving approaches and the methods and tools venerated in physiotherapy practice as a whole.

Kuhn and Tornebohm both saw the acquisition of identifiable aspects of a profession’s para- digms as a sign of maturity in the development of a science because the paradigms focus and direct activities of fact gathering in such a way that they can be used and built upon systemati- cally. As Richardson stated ‘The idea of a para- digm of physiotherapy is an appropriate stance to explore, since it closely relates to a continuing argument within the profession as to whether physiotherapy is an art or a science.’ I would contend that physiotherapy is both, and para- digms by their very definition, allow for both the art of clinical practice and the development of theory underlying such art through clinical reasoning and research, to develop the science of physiotherapy.

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The following quotation is apposite: ‘Physical therapy today is in the midst of a crisis of identity; it is indeed a profession in search of an identi ty.... This, of all times in our history, is a time for strong identification. We must ask ourselves if in our attempt to develop in multiple directions we have assumed a cloak of unidentifiability.’ Does that sound like todays challenge? Yet it WBB written two decades ago and preceded enormous growth and develop- ment in physiotherapy in tbe United States.

That was Professor Helen lrlielop presenting the tenth Mary Maanillan lecture in 1975 entitled: The not 80 impossible dream’, perhaps one of the moat frecluently quoted papers from Physical Thempy. She presented at that time the concept of pathokinesiologv as the distinguishing clinical science of physiotherapy, intending that this would pmvide physiotherapy with a much-need- ed identifying paradigm (although she did not use that term). Hielop grounded her concept fairly and squarely on social and cultural needs. She considered that pathokineeiology (or movement dysfunc- tion) should not be considered outside both a socio-cultural and 8 scientific framework ~purtilo, 1986). While you and I may rarely use the term patho- kinesiology we would, I believe, all agree that the primary paradigm of physiothempy is the maintenance and restoration of function. We seek to return our clients to their optimal func- tional activity and e h c e for them, and with them, an appreciation of health and a healthy lifestyle.

While thie might be a unifping professional paradigm in the mould of Kuhn, Tornebohm sees paradigms as personal acquisitions of individuals. Thus different professional paradigma may well be found - for example, by cardiotwpiratory physiotherapists as compared to neurological or manipulative physiothera- piete.

Undergraduate education and training will set the scene for the development of professional vduea, beliefs, attitudw and begiMing practi- tioner competence. Poetgraduate practice and education (both formal apd continuing educa- tion) will result in physidherapista perceiving and responding by weighting different experi- en-, and meking out different experiences on their way to establiohing their career path, be it rn a clinician in a particular area of phyeio- therapy practice, as a manager, academic or xwmrch tbsraplrt. Richud#nr etatea that ifphysiotherapista do not

put their paradigms to systematic study others may do so, to the detriment of the profession. Thus it might be argued that a firat step in the pursuit of excellence, most particularly in chang- ing times, is to know who we are - that is, agree our collective and individual paradigms. The next steps are to put these to systematic study.

Physiotherapy as Art, Science and Placebo In reflecting upon physiotherapy as art, science and placebo it will become clear that not one of us can be exempted in the pursuit of excellence. Using as a simplistic measure the number of continuing education courses advertised in physiotherapy journals and professional newsletters around the world, the art of physio- therapy as gauged by the enhancement of the ‘hands on’ skills is very much alive (Grant, 1994). Clinical practice specialties abound and physiotherapists describe themselves by the area of clinical practice in which they work. There are even paradigms of practice with experts’ names attached to them, for example, a Cyriax trained physiotherapist or a physio- therapist who uses the Bobath approach; or a geographical attachment, the Norwegian or Australian approach in manual therapy for example. If these or other labels describe us, then we will have certain values, beliefs, aspira- tions, clinical ekills and theories. We need to guard against the uncritical accep- tance of any concept in our pursuit of excellence. Uncritical acceptance ‘eventually coerces per- sons using the concept to point solely to the authority of the person who introduced it [in order1 to validate that the concept is real‘. By no meam can a concept validated by authoritative declaration alone, pass scientific scrutiny (Purtilo, 1986). It is all too easy for us to continue to use time- honoured approaches in the management of patients to restore function simply because the patient improves, apparently as a consequence. Perhaps the oldest dilemma of clinical practice, be it physiotherapy or medicine, is whether to ‘accept attractive rhetoric [or a philosophy] as the basis for treatment or to wait patiently for science to capture the truth through empirical data and theory’ W e b s et al, 1986). We still have relatively few theories in physiotherapy which can be used to generate hypotheses or propositions about relationships. Yet theories of treatment provide the basis for growth and mat- uration of ideas and concepts. Thus it would be very tempting and apparently justifiable for the clinicians among us to say we

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will continue to treat our patients in this or that way, until the researchers or scientists in the profession demonstrate that we should do other- wise, or that we were right all along. Ah, but the clinicians cannot be let off the hook so easily. Indeed in the pursuit of excellence, most partic- ularly in time of change, clinicians would be derelict in their duty if they espoused those views. Clinicians have led the way in the devel- opment of the theories upon which physiothera- py knowledge is based. It is the clinicians who must continue to make such a contribution now. Indeed the researchers and scientists in the profession need clinicians to guide, to prioritise their endeavours.

It is instructive at this point to define and to consider the definition of theory. Tammivaara and Shepard (1990) stated that: ‘Theory is a word encompassing two concepts: contemplation and observation. (The Greek thea, meaning “a viewing“ is also the root for theater.)’ Through contemplation and observation, theories or ideas about how things relate are developed.

Observation and contemplation, the ability to notice things that easily escape attention, describe these with ‘clarity and rigour’ (Rose, 1986) and delineate relationships between them, are the hallmarks of many of those physio- therapists who have made a major contribution to our knowledge base in physiotherapy.

Theory as described in this way develops through the additive effects of experience. That is, by reflecting on the experience (the contem- plation component) it is possible to note patterns that can be developed into systematic ideas about phenomena.

All the time in clinical practice we are testing theories, yet how often do clinicians consider their practice in this light?

Let me delineate another couple of steps in the pursuit of excellence. When a treatment does not work as expected, a physiotherapist who is aware of the power and usefulness of both theory and clinical reasoning might - after ruling out more immediate causes - ask whether the conditions under which the treat- ment is supposed to work (namely the theory or even philosophy underlying it) have been met. To elaborate further, when as clinicians we are surprised by a clinical problem that does not respond in a way in which we expected, i t may be t h a t we have been selectively attentive. That is, we have noted only the positive cues in the patient’s subjective and physical examination which fit the particular syndrome we have diagnosed.

Unless we recognise such selective attention and retrace the steps in our clinical reasoning to meet the needs of the patient more effectively, we are indeed in trouble. Schon (1988) proposed that unrecognised selective attention suggests that a practitioner may have ‘over-learned’ what she or he knows, tending as a consequence to become narrow, rigid and prone to burnout. Is this not an apt illustration of a faulty paradigm at work? In our pursuit of excellence, selective attention of this kind must be identified and re-examined through observation and contem- plation.

The cynic, some would say realist, would argue that it does not matter - selective attention or not, we find our patients improve.

For clinicians, for educators and indeed for managers, it is instructive to consider for a few moments the natural history of some disorders that we treat, and particularly to consider the issue of the placebo response.

Let me take the natural history of low back pain by way of illustration of the first point. Anderson et a1 (1983) and Frymoyer (1988) have described low back pain as a generally self-limiting condition. Their epidemiological studies indicated a recovery rate of 70% within three weeks and 90% within six to 12 weeks. Thus it may not matter what is done by way of examination and treatment, and even reflective practice, let alone selective attention, since our treatment approach is reinforced because patients improve.

Second is the issue of the placebo effect. The placebo effect will be considered ‘generically’ but the relevance to physiotherapy will be abundantly clear.

The placebo effect has been studied extensively. Gallimore and Turner (1977) after reviewing 1,500 articles and books on the subject conclud- ed that the characteristics of the physician (or indeed of the physiotherapist), rather than of the patient, are crucial in producing the placebo response. There is much evidence that a thera- pist who shows concern and support, is friendly and reassuring, and conveys expertise and trust- worthiness may evoke a strong placebo response (Shapiro, 1960; Libeman, 1962; Ben-Zira, 1976; Gielen, 1989; Wall, 1992). This information comes as no surprise to us, and the pain diminution or relief which accompanies the therapist-patient relationship is in actuality an important aspect of physiotherapy, and needs to be seen for what it is - communication and the creation of a therapeutic environment which may, on occasion, mimic the physiological

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responses expected by the application of the actualtreatment. A classic example suffices to illustrate the strength of the placebo response. Hashish et al (1986) in a double blind study measured swelling, trismus, pain and serum C reactive protein (an index of inflammation) before and after treating patients following the removal of wisdom teeth. There were 150 patients assigned to five groups - a control group with no treat- ment and four ultrasound groups. Three of these patient groups were treated with different dosages of therapeutic pulsed ultrasound (0.1, 0.5 and 1.5 watts/cm*) and the fourth group received mock ultrasound.

Wishing to determine the effective dose, the researchers found that the ultrasound machine was effective whether the machine was turned on or not, provided that the patient and the therapist believed it was emitting sound. The importance of the research however was that while all treatment groups improved as com- pared to the control group, the mock ultrasound produced better results on all four measures than the group treated with 1.5 wattslcm’ ultra- sound dosage. That is, factors deemed to be local expressions of tissue damage were significantly changed as a result of the placebo treatment.

Endorphin release has been shown to be a placebo reaction and may help in explaining these results. However, placebo mediated endor- phin release is by no means the only physiologi- cally induced placebo effect. Among those recorded in the literature are improvements in the shape of electrocardiograms, depression of cholesterol levels, control of diabetes and changes in gastric acidity (Gielen, 1989; Wall, 1992). What are the ramifications of such findings? Namely, that improvement in our patients aRer treatment cannot ips0 fact0 be taken as evidence of the accuracy of the theory upon which it is based, nor indeed of the efficacy of the specific technique used. This is thought-provoking, and reminds us again of the remarkably strong and indistinguishable links between psyche and soma.

For an informed discussion of the placebo effect (and here I draw heavily on Wall (19921, it is instructive to consider some of the myths surrounding the placebo response. Each of these has been refuted. First, that placebo res- ponders have nothing wrong with them in the first place ‘but suffer a somatic hallucination’. Second, that there is a fxed fraction (one-third) of the population who respond to placebos. This myth has arisen through the misreading

and misquoting of the classic work by Beecher in 1955. Wall (1992) in scanning a large series of double-blind studies showed that the fraction of placebo responses could vary from 0% to loook, depending upon the circumstances of the trial. Third, that placebo responders suf- fer some personality defect - neurotic, introvert, extrovert, suggestible - which explains the response. Fourth, that giving a placebo is the same thing as doing nothing. Wall has emphasised that the placebo response is a quite separate phenomenon from spontaneous improvement in a condition.

What are the mechanisms upon which the hypotheses of the placebo effect are based? Wall (1992) has identified three. The first is that the effect is produced as a result of a decrease in anxiety on the part of the patient. This seems very reasonable but a t this time lacks valida- tion. The second hypothesis is that the expecta- tion leads t o a ‘cognitive readjustment of appropriate behaviour’. White et al (1985) in their book on the subject provided considerable evidence that the placebo responder to a particu- lar technique or drug can be identified by simply asking him or her what is expected. This applies as much to the therapist (or the doctor or the nurse) as it does to the patient.

The third hypothesis is that the placebo effect is a classical conditioned Pavlovian response. The work by Voudouris et al (1989, 1990) supports this last hypothesis. In the first stage of the experiments by these workers, the tolerance thresholds of normal subjects to iontophoretic pain stimulation were established. The subjects’ responses were then compared with and without the application of a placebo cream. In one group of subjects the placebo cream was applied and subjects were informed that it was a powerful analgesic. As expected, some subjects showed placebo responses.

In another p u p the cream was applied and the intensity of the iontophoretic pain stimulation reduced, unbeknown to the subjects. These sub- jects who had experienced an apparently truly analgesic effect of the cream, subsequently became strong placebo responders to the original pain stimulus and the cream.

These results have relevance for research involving placebos, particularly for within-sub- ject cross-over designs. The results suggest that subjects who receive a placebo before the admin- istration of a particular treatment may well not be equivalent to subjects receiving the placebo after the treatment. Voudouris et al (1990) also suggested tha t their findings may help t o explain the worsening of symptoms sometimes

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observed in chronic pain patients, when a vari- ety of short-term palliative treatments are tried and then discontinued.

Thus we have a potent 'cocktail' for the profes- sion. On the one hand there is an urgent need to establish the efficacy of our treatments know- ing that for all treatments, placebo responses are considerable. As Wall put it, the placebo response is 'a tiresome and expensive artefact which prolongs and complicates the true effect of a therapy'. Such placebo responses do not of course apply to physiotherapy alone, but they are not so easily controlled as might a t first appear.

On the other hand, we may usefully take heed of Voudouris et a2 (1990) who stated: 'Until the underlying mechanisms of the placebo response are better understood, our potential for max- imising the effectiveness of all therapies will remain under-utilised.' That is, the placebo response is there to be harnessed.

Physiotherapists as Health Promoters I suggested earlier that we would all agree that the primary paradigm of physiotherapy is the maintenance and restoration of function. I suggested too, that we seek to gain or retain for our clients their optimal functional activity, and in so doing enhance an appreciation of health and a healthy lifestyle on the part of our clients. Was this simply rhetoric?

Most physiotherapy is still based on a trad- itional interventionist model wherein the physiotherapist provides services to a patient to effect recovery or enhance rehabilitation. In gen- eral, physiotherapy of this kind has been in such high demand that there has been less time available to devote to the important areas of health promotion and health education. However, physiotherapists are uniquely quali- fied bioscientists (as well as clinicians) with an exclusive understanding of human movement ('homey, 1986). All physiotherapists have the knowledge and ability to inform the community of the ways in which 20th century (and indeed 21st century) lifestyles can be modified and enhanced, to prevent many common disorders particularly of the musculoskeletal system.

Our society will always have need for the skills offered by physiotherapists - particularly an ageing society, particularly a society where those who are able to make such choices are retiring early and/or placing emphasis on self- development and balanced living for quality of life; and where living longer means that chronic diseaees are becoming more prominent.

Yes, we are uniquely qualified and society will always have need of the skills we, as physiother- apists have to offer. But will it be we who deliver those skills or will i t be other professionals? How will these skills be delivered? Indeed will they be delivered at all?

Sackley (1994) stated: 'The move towards more efficient management of the NHS has forced physiotherapists working within the Health Service to consider objective measures of the outcomes of their treatment. The effects and efficiency of physiotherapy are being quest- ioned, before the service is purchased.'

Both she and Jette (1993) agree that the out- come measures chosen may not be the most appropriate to demonstrate any positive effect of physiotherapy. Jette while acknowledging that clinical researchers have many reliable and valid health related quality of life (HRQL) mea- sures available for physiotherapy outcomes research, states that the ideal HRQL instru- ment for use in physiotherapy clinical practice has not yet been developed.

Although there is a burgeoning interest in the systematic study Of quality of life as a health related outcome, it is a relatively new phenome- non. 'Against the ethical and economic concerns raised by an ageing population, the concomitant rise in chronic diseases, and escalating health care costs, many authors emphaeise the paucity of evidence of the known effectiveness of many health care practices.' (Physiotherapy is no exception.) Jette (1993) continued 'Although most physiotherapists would agree that the ulti- mate goal of providing physiotherapy services to people with chronic disease is the improvement of functional status and ultimately the overall quality of life, most physiotherapy research focuses on improvements in impairments (such as range of motion, muscle strength, aerobic capacity) in evaluating the efficacy of care. Although patient-level functional outcomes are part of physiotherapy rhetoric, they have yet to become a major criterion for evaluating the impact of physiotherapy interventions.

'The examination of the outcomes of health inter- ventions is not new. The examination of the effi- cacy of health care services through randomised clinical trials has long been the standard for evaluating the outcomes of health care research. The unique contribution of the health outcomes movement, however, is to focus attention of reeearchers, clinicians, and policymakere alike on HRQL outcomes of importance to patients. It is virtually impossible with existing knowledge to determine the effects that most physical ther- apy services have on patient-level outcomes,

much less whether the effect is preferable to the outcome that might have resulted from the application of other services or no services.

‘Against this backdrop, it has become imperative for physical therapy professionals to begin con- ducting outcome research using broad measures that reflect the functional and quality of life out- comes we espouse. Measures of HRQL are need- ed in clinical research and in clinical practice to determine compensation, predict prognosis, plan placement, estimate care requirements, choose different types of specific care, and indicate changes in patient status in response to deliv- ered care’. I know that in the United Kingdom this challenge is being grasped, but much remains to be done.

This presentation has ranged far and wide. The pursuit of evidence that physiotherapy interven- tion is effective, is indistinguishable from the pursuit of excellence in physiotherapy in times of constant change and challenge.

British physiotherapists can look back on an illustrious past, 100 years of growth and devel- opment in physiotherapy. Challenge and change were part of the very fabric of that history, the warp and woof of it. The challenges that the pro- fession in the United Kingdom faces in its m- ond century, and indeed we all face as we move towards the third millenium, are certainly dif- ferent from those of o w prof-sional forebears, but they are not greater, nor are they other than opportunities in disguise.

A u f b u r a n d A d d r w s ~ ~ ~ n c e Ruth G m t BPT M-, is dean of the Faculty of Health and Biomedical Sciences, University of South Australia, Adelaide 50oo.

This paper was a keynote address to the Centenary Congress of the Chartered Society of Physiotherapy in Birmingham in september 1994.

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