Clinical problem solving and the kinesiopathological model

Welcome to this fortnights musings over research and articles. If you would like more information on courses we offer at The Knowledge Exchange click HERE. If you are looking for further support or research papers that you can’t get your hands on leave your details HERE.

A few years ago I watched this seminar by Bernard Roth from Stanford University (thanks Raphael Bender!).

The full version can be found HERE. It’s worth the time.

It’s a beautiful talk about asking the right question and problem-solving.

It recently came to mind with the discussions around the kinesiopathological model (Figure 1), and other similar corrective exercise models.

I personally see these models as a noisy distraction from asking the right questions and consequently helping someone problem solve. This is in spite of my own history of adopting these models to make sense of what I was seeing in clinical practice.

They are a bit like Bernard’s ‘gas release’ example when really we should be asking ‘how do we get the cover open?’

In the context of people in pain: do biomechanics, muscle timing patterns, postures, alignment (etc.) have to change for them to be out of pain?

Can we measure ‘dysfunctions’ and if so, can we change them?

If they exist how well are they related to pain?

What if we instead asked, what is it this person could do if this (insert complaint) was not a barrier?

This leaves us withy many ways to help that person get back to what is meaningful to them. It also enables us to be truely person-centred when problem solving.

It doesn’t mean to say prescribing exercises to correct these arbitrary dysfunctions will not work, but they may not be working for the reasons we think they are. This in part is illustrated by the large volume of literature that has found no specific type of exercise to be greater than any other for pain REF REF REF. A few alternative hypothesises that may explain the common findings between various exercise interventions: the person started moving more, fear decreased, the person had an increased trust in their body, sufficient application of load for adaptive changes, other neuro-immune changes that are linked to improved general health, regression to the mean, normal healing times.

These models may also lead to many other unnecessary treatments that lead to increased healthcare expenses and/or over-treatment. These strategies may not be completely harm-free.

The other downside to asking the wrong question and becoming fixated on dysfunction is the sense-making an individual may go through. For example, if the person felt better after our corrective exercise prescription - what happens when they (almost inevitably) feel pain in that area again in the future. Do they then attribute that to the wrong activation pattern? Joints being ill-aligned? Is their posture being bad again? That they need a practitioner to give them the right exercise or intervention to fix them again?

This here is how I think exercise prescription can run the risk of being passively administered and create dependency.

Beliefs are inherently hard to change, and evidence suggests we are not great at it. Perhaps then we need to be more mindful early on about what they may take away from the clinical interaction.

If we help people to ask the right question then we equip them with the skills to start problem solving without always having to depend on a therapist. This in my opinion should be at the heart of healthcare.

Granted, creating problem solving people is a terrible business model for private practice - but there is no shortage of people in pain - retention should not be a metric of healthcare, and thus, I see this as a priority for us to focus on.

What do you think? As a whole are we asking the right questions? Can reframing the questions we ask change our longterm outcomes (disability, healthcare utilisation etc.)?

Thanks again for reading, if you have comments, want more info on any papers mentioned, or want to know more about our mentorship program click HERE

Until next time,

Brendan

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