Physiotherapy and professional clinical guidance in an out-patient clinic for people with multiple sclerosis : body and movement in sense making and professional development

Abstract

Enkeltkonsultasjoner hos fysioterapeut og klinisk veiledning av kommunefysioterapeuter foregår i enkelte MS-poliklinikker. Målet for studien var å utvikle kunnskapsbasen for denne tjenesten med utgangspunkt i brukerperspektiv samt teorigrunnlaget for nevrologisk fysioterapi. Studien inkluderer en spørreundersøkelse blant 72 personer med multippel sklerose (PmMS), kvalitativt forskningsintervju supplert med observasjon av 12 PmMS og 9 kommunefysioterapeuter. Resultatene viste høy tilfredshet med fysioterapi uavhengig av funksjonsnivå, alder og kjønn, og ca. 60 % av pasientene rapporterte bedring i gange og reise/sette seg samt signifikant lavere anstrengelse i disse aktivitetene etter konsultasjonen. Deltakelse gjennom kropp og bevegelse gav PmMS utvidet innsikt i egne bevegelsesproblemer. Bedringene i bevegelse forstås som forbigående endringer i pasientens mulighet for interaksjon med omgivelsene, styrking av pasientens følelse av eierskap og kontroll over egen bevegelse. Opplevelse av endring, utfylt med poliklinikkfysioterapeutens forklaringer relatert til funksjonelle aktiviteter, gav pasientene utvidet innsikt i egne muligheter og begrensninger. Veiledning i egentrening gjennom “hands-on” supplert med forklaringer var vesentlig, og relevansen ble forsterket ved implementering av øvelser som pasienten i løpet av konsultasjonen hadde erfart førte til bedring. Kommunefysioterapeutenes deltakelse i bevegelsesanalyse av en kjent pasient hvor poliklinikkfysioterapeuten brukte tilpassede håndteringsteknikker i utforsking av endring, styrket formidling av aktive elementer i praktisk kunnskap, spesielt ferdigheter i klinisk resonnering. Endringer i bevegelseskvalitet som fremkom gav utvidet innsikt for kommunefysioterapeutene i forhold til den aktuelle pasienten samt kunnskap av relevans for lignende pasienter. Tidligere erfaring i nevrologisk fysioterapi synes vesentlig for kommunefysioterapeutenes muligheter for implementering av råd. Komplementære læringsarenaer, styrking av kommunefysioterapeutenes perspektiver i veiledning og struktur for gjensidig informasjonsutveksling anbefales. Kroppsfenomenologi åpner for å se fysioterapeutens håndtering av pasienten og den fysiske interaksjonen mellom dem som en form for kommunikasjon på linje med verbale og non-verbale uttrykk. Den fenomenologiske tvetydigheten til kroppen, skaper rom for integrering av relevant nevro- og muskelbiologi, bevegelsesvitenskap og teori om praktisk kunnskap. Førstepersons perspektivet på kroppen bidrar til utvidelse av det teoretiske fundament i nevrologisk fysioterapi. Denne avhandlingen løfter frem betydningen av kropp og bevegelse i utvikling av innsikt hos PmMS og i profesjonell veiledning, samt autentisk praksis som læringsarena i nevrologisk fysioterapi.

Multiple sclerosis (MS) leads to a variety of symptoms that cause difficulties in a person’s activities of daily living (ADL); movement disturbances are one of the major problems. Out-patient (OP) clinics in hospitals offer regular single sessions of physiotherapy (oPT) complemented by optional professional clinical guidance of community physiotherapists (cPTs). Limited knowledge exists regarding physiotherapy in these settings.

The overall aim of this study was to derive new knowledge regarding physiotherapy in OP clinics and to explore the theoretical framework for neurological physiotherapy.

A survey of 72 people with MS (PwMS) and qualitative research interviews and observations were performed with 12 PwMS and 9 cPTs.

The results showed strong patient satisfaction with the physiotherapy regarding both interpersonal and clinical skills independent of ambulatory status, gender, or age. Approximately 60 % of the patients reported short-term improvement in standing up/sitting down and walking and a significantly lower perception of exertion during these activities after the consultation. Participation through body and movement played an essential role in the inter-subjective process between the oPT and PwMS. Expressions and perceptions of movement, and physical interaction (handling) appeared to be significant for deepening the communication process; allowing for pre-reflective information to be exchanged and integrated into the reflective considerations which deepened the PwMS’s insights regarding their own movement problems.

Improvements in performance of movement is understood as short term changes in embodied intentionality, enhancement of the patient’s sense of ownership and sense of agency; hence, an improved ability to engage in ADL. Perceptions of change in movement appeared as a strong element in PwMS’s sense-making process regarding their own movement problems. These perceived changes, contextualised in the oPT’s explanations that interlinked the changes with basic elements in balance and walking or other relevant ADL, deepened the PwMS’s insights regarding their own limitations and possibilities. PwMS reported that guidance in tailored self-assisted exercises is vital. The relevance of the exercise seemed to be augmented through implementation of movements which they during the session had experienced improvement from performing. Hands-on guidance supplemented by verbal instruction appeared to enable the patient to actively perform exercises that explore new and more optimal movement strategies, but independent replication may be difficult.

Participation in authentic movement analysis of a familiar patient with whom hands-on facilitation techniques were used appeared to augment the development of active elements in practice knowledge and, particularly, in the cPTs’ clinical reasoning skills. Changes in quality of movement that evolved during explorative treatment in clinical guidance sessions deepened the cPTs’ sense making in the particular situation and general aspects of relevance for physiotherapy to similar patients. Observing how improvement or decline in quality of movement was obtained in authentic clinical settings reinforced reflections in practice and on practice and provided access to vital context-bound elements in practice knowledge, which are only available through first-hand experience of the particular actions.

Professional guidance through observation and discussion seemed insufficient with regards to the development of handling skills. Previous practice knowledge regarding neurological physiotherapy may determine what the cPTs gain from the guidance session as concerns implementation of the advice in subsequent treatment. Complementary ways of learning involving supervision of the cPTs’ actions may be necessary. A strengthening of the cPTs’ perspectives as a basis for professional guidance and as a structure for mutual collaboration is recommended.

The present thesis emphasises the significance of perceptions of body and movement in sense making for PwMS to gain a deepened insight regarding their own movement problems and opportunities regarding ADL and also in professional development of cPTs. Furthermore, clinical settings as arenas for professional guidance are highlighted; providing access to other aspects of professional competency than words alone. These findings should be considered when information “packages” and physiotherapy services to PwMS and continued professional development programs are established. Moreover, an exploration of phenomenology of the body as an overall foundation for neurological physiotherapy, providing a first-person conception of the body, is presented. These conceptions allow for an understanding of the physical interaction between the physiotherapist and the patient as a form of communication similar to verbal and non-verbal elements (gesticulations, etc.) and allows for a possible expanded comprehension of physical handling and inter-subjectivity in physiotherapy. The phenomenological ambiguousness of the body, simultaneously being and having a body or simultaneously a body-as-subject and a body-as-object, creates a space for integrating relevant neurobiological, muscular, and movement sciences and the possibility of complementing this theory with practice knowledge. This incipient extension of the theoretical foundation for neurological physiotherapy requires further development.