Physiotherapy December 1999/vol 85/no 12

694

I READ with interest Joyce Williamscomments in November upon ourconclusion (Hope and Forshaw, 1999)that ‘physical therapy alone is unlikely tobe an effective treatment’ in back painpatients presenting with high levels ofpsychological distress. She suggests that a‘school for bravery ‘approach would bethe solution in the majority of theseindividuals. I agree that an approachwhich includes behavioural modification,which the ‘school for bravery’ as describeddoes, is likely to be the most effective formof management for the patient groupidentified in our paper.

What I hoped that the paper would dois highlight the fact that these patientscannot be physically manipulated backinto health and that the traditional skillsof physiotherapists need to besupplemented by an awareness of thepsychological dimension of a patient’spresentation, and in this I again concurwith Mrs Williams.

However, I also believe that our area ofexpertise can be stretched only so far. It has been stated that current educationin physiotherapy does not equipphysiotherapists with the skills to conducta good psychosocial assessment (Watson,1999) and if this is the case then it couldbe assumed that the ability to managesuch problems is also lacking inphysiotherapists generally. Theinvolvement of professionals such aspsychologists is, I therefore believe,

preferable in the production andimplementation of rehabilitationprogrammes to optimise the effect of such programmes.

In this I disagree with Mrs Williams.She states in her 1989 paper that theinvolvement of psychologists wasunnecessary and unhelpful in her ‘schoolfor bravery’ approach.

In the physiotherapy department inwhich I work we select patients into arehabilitation programme on the basis ofa physical and psychosocial assessment.The programme is run jointly with a clinical psychologist and unlike Mrs Williams’ experience patients havecommented on the positive benefits ofpsychologists’ interventions as have thephysiotherapists.

Certainly, having watched thepsychologists at work, I have come toappreciate their skill and the help theycan offer.

As physiotherapists we can developsuperb skills of physical assessment, andthese plus an awareness of thepsychosocial aspects of the disease processcan enable us to select the optimumtreatment approach for any one patient.We also have an integral part to play inthe rehabilitation of patients across a widespectrum of presentations.

However, we have to be careful inthinking that we can manage everysituation on our own. It has to berecognised that a physiotherapist is not

and should not be a ‘Jack of all trades’,and that in a varied number of situationshelp from other quarters is necessary toproduce optimum treatment effect.

In conclusion, therefore, a treatmentapproach which involves a behaviouralelement is to be recommended forpatients who have a psychosocial elementwhich is involved in sustaining theirproblem, but it may be the province ofmore than just the physiotherapist to beinvolved in their management. Whetheror not the ‘school for bravery’ would be a more effective approach to themanagement of this patient group ascompared to the many multidisciplinaryrehabilitation programmes that existaround the world is open to debate.

Philip Hope MSc MCSPChesterfield

ReferencesHope, P and Forshaw, M (1999).‘Assessment of psychological distress isimportant in patients presenting with lowback pain’, Physiotherapy, 85, 10, 563-570.

Watson, P (1999). ‘Psychosocialassessment – The emergence of a newfashion, or a new tool in physiotherapy formusculoskeletal pain?’ Physiotherapy, 85,10, 530-535.

Williams, J (1989). ‘Illness behaviour andwellness behaviour’, Physiotherapy, 75, 1,2-7.

We Cannot Do Everything – and Should Not Try

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