Tuesday, June 16, 2009

Bridging the Research-Practice Divide: Using General-Semantics in Physical Therapy Practice

By Bruce I. Kodish (Copyright 1998)
A version of this paper was published in
Physical Therapy Forum, Oct. 21, 1994

How can physical therapy clinicians enhance their effectiveness in providing ever better treatment for their patients? How can they best improve and evaluate their clinical reasoning and problem-solving?

Many time-honored methods of treatment, such as universal flexion or abdominal strengthening exercises for back pain patients, have been brought into question by some. These methods may still form the basis for others' treatment approaches. Practitioners treating these patients debate and fail to agree on "Where is the pain coming from?" Techniques and theories such as myofascial release and cranio-sacral therapy generate controversy among enthusiastic supporters and less sanguine skeptics.

Meanwhile, in our offices we have to decide: What do these disputes mean for me as I work with patients? How can I know how to sufficiently sort out the various claims people make for what they do? What claims can I make for what I do?

We can do formal scientific research. Practically, this requires time, money, and skills that many clinicians lack, so for many this does not appear as a practical option. An option for everyone remains to keep up with research in our field and as a research consumer to learn how to evaluate research that might affect our practices.

What, then, can we conclude? Does this exhaust the alternatives for a scientifically based practice?

It might appear so to some. Take the example of a well-known physical therapy writer for whom empiricism seems a `dirty' word:
"Effective treatment forsakes empiricism as a primary guide" (Wolf, 380).
Does it make sense to summarily dismiss personal empirical observations? Do they have no use at all? While recognizing the limitations of what we can claim from our individual experiences, anecdotal observations, etc., it may serve us better to explore how we can make use of our individual experience in a critical way. We can do this by considering every physical therapist as in some sense involved in the scientific enterprise.

In his book, A Theory of Personality: The Psychology of Personal Constructs, psychologist George Kelly formulated the notion that each human can be viewed in the role of scientist:
"Might not the individual [human], each in his [or her] own personal way, assume more of the stature of a scientist, ever seeking to predict and control the course of events with which he [or she] is involved?" (5).
In this view, each of us as a 'scientist' does 'research' of a sort by seeking to improve our personal knowledge of the world. We do this to make sense of and anticipate events in order to solve problems that we face. We may do this with varying degrees of success but, as humans, do it we must.

The system of general-semantics provides a method for applying this view of humans as scientists to our everyday lives. Formulated by Alfred Korzybski in his book Science and Sanity (1933), the use of general-semantics principles can supply a way to improve every physical therapist's clinical reasoning and problem-solving skills, develop more as a "reflective practitioner" (Shepard and Jensen) and thus help bridge the research-practice divide. In what follows I will provide a brief definition of general-semantics and then discuss applications of some general-semantics formulations to physical therapy clinical reasoning and problem-solving.

The System of General-Semantics

According to Mark A. Jones in his article "Clinical Reasoning in Manual Therapy":
"The clinical reasoning process is influenced by the therapist's knowledge base, cognitive skills (eg, data analysis and synthesis), and metacognitive skills (i.e., awareness and monitoring of thinking processes)" (880).
General-semantics constitutes a theory of metacognition, a working theory of how humans construct their perceptions, beliefs, theories, etc. Metacognition, thinking about thinking, has traditionally been considered part of the branch of philosophy called epistemology, the theory of knowledge.

Over the years many philosophers such as Plato and Descartes have speculated and theorized about how we know what we know. These theorists lacked much empirical knowledge of the human nervous system, psychology and other relevant areas of knowledge such as how scientists and mathematicians actually behave in order to gain knowledge. As a result their views were often riddled with untenable assumptions such as that of a `mind' separate from a `body'. Among other things, what distinguished Korzybski from these theorists was his effort to bring to bear studies in neuroscience, behavioral/social science, natural science, mathematics, linguistics and other fields to develop a scientific and thus up-to-date and open-ended, applied epistemology.

This may seem esoteric to physical therapists interested in what they should do with their patients tomorrow in the clinic. I suggest that what we do in the clinic with our patients very much relates to basic assumptions we make about what and how we know. As an applied epistemology, general-semantics provides a framework and tools for consciously examining such assumptions. Having defined the field of general-semantics, I will now discuss some of its framework and tools and their relationship to physical therapy practice.

Science As A Method
In general-semantics, we accept that the processes used by scientists to understand events have some use for the rest of us in our everyday living.

Based on the work of general-semanticist Wendell Johnson, one view of scientific method involves the following steps:

1) uncovering assumptions and their implications,

2) asking answerable questions about them,

3) making observations to answer these questions,

4) accurately reporting these observations,

5) revising our assumptions as necessary, etc., in a continuing process (Kodish and Kodish 20-21).

Physical therapy clinicians need not do formal scientific research in order to begin applying these steps to their work with patients. Each step can be turned into questions that can guide you and your patients' explorations.

Johnson honed down his analysis even further by noting that
"the scientific method reduces essentially to three questions...`What do you mean?'...`How do you know?' [and] `What then?'..."(Johnson 37). "I have discovered," he says, "that these three are about the most liberating questions you can imagine" (40).
What Do You Mean?
In beginning to apply a scientific attitude to our practices, we can start with the question of `meaning'. Often people ask "what is the meaning of that word, statement, act, etc.?" with an implication that a static `meaning' resides in the word, statement or act. In general-semantics, we prefer instead to ask "What do you `mean'?", "What do I `mean'?", etc. Thus we assume that `meanings' are in each of us as we interpret and respond to words and other events. We call each individual's `meaning'-related responses to words and other symbols and events their semantic or evaluational reactions.

Of course, the `meanings' we give to the words we use are not entirely idiosyncratic. If they were we wouldn't be able to communicate with language as we do. We learn language in a community and share some similarity of `meanings' with others. Thus our words in a sense `carry' a socio-historical `baggage'. However it appears all-too-easy for human beings, including health professionals, to overgeneralize this commonality of `meanings' and to overlook each individual's contribution to the `meanings' he or she makes.

We also tend to assume that those `meanings' are equivalent to our own understandings. This can lead to miscommunication and problems as we overlook people's inevitably idiosyncratic semantic reactions to what we say and do.

An article in the PT Bulletin on medical miscommunications reported on
"The doctor who prescribed eardrops with the directions 'apply 10 drops r.ear'...his patient reported having placed the drops in his rear" (2).
If we're aware of the idiosyncratic nature of the `meanings' people make to what we say and the `meanings' we make to what is said to us, we will more likely take the time necessary to check "How do you understand this?" and "What do you mean?" when giving exercise instructions, discussing symptoms, interpreting prescriptions and medical records, getting histories, etc.

In asking these questions, we elicit other words that can be misinterpreted, misunderstood. This seems inevitable. When we define words and statements with other words and statements at relatively high levels of abstraction, we are using "intensional" definitions. More broadly we can talk about an intensional orientation which involves orienting ourselves primarily by means of such verbal definitions. Such an intensional orientation is exemplified by the patient who comes to the clinic complaining of back pain. You ask him what specifically bothers him. The patient replies, "It hurts." You ask, "Where does it hurt?" The patient replies, "It hurts all over." You ask him to point to where specifically he feels `it'. He replies "Oh it's terrible, doc, it hurts all over." You think, "Oy!"

If a therapist is to get anywhere with this kind of patient, it will be necessary to get him down to specifics. Failure to be able to do so may indicate a lack of sincerity on the patient's part, neurosis, lack of intelligence or difficulties in expressing himself, among other possiblities.

At any rate, with this or any other patient, our role as clinical 'scientists' will involve helping the patient as well as ourselves to get as "extensional" as possible in the `meanings' we make. Getting extensional in our definitions (similar to operational definitions) involves defining our words and statements at lower levels of abstraction through specific factual examples and descriptive statements or by referring to non-verbal experiences.

In general-semantics, we go beyond definitions to talk about an extensional orientation, equivalent to a scientific attitude. This involves orienting ourselves primarily to `facts', realizing that, as general-semantics teacher Stuart Mayper said,
"No 'facts' are simple" (Kodish and Kodish 92).
Thus, with an extensional orientation, we focus on descriptions, specifics and observables as primary, without rejecting the need at times for intensional approaches, definitions, etc.

Another aspect of remaining aware of semantic reactions, the `meanings' people make, is remembering that people respond to non-verbal as well as verbal stimuli. Thus, as clinicians we do well to gain awareness of the non-verbal aspects of our communicating. Such factors as distance, timing and rhythm, dress, tone of voice, etc., may influence our patients in important ways whether we know it or not.

We will also do well to remain aware that what we communicate will surely have an impact on the patient beyond words. People's semantic reactions occur on both verbal and non-verbal levels.

Norman Cousins, in his book Head First: the Biology of Hope, points out that many patients' symptoms seem to worsen immediately after a diagnosis of serious illness. Depression, anger and various negative emotions in response to such a diagnosis commonly occur. Such responses may, according to recent findings in the field of psychoneuroimmunology, actually impair the organism's abilities to recover from illness and injury.

How diagnoses are presented to patients, as well as their subsequent interactions with health care practitioners, may influence such semantic reactions in more or less positive ways. Since serious negative emotional reactions do not result directly from the diagnosis itself but from the `meanings' the patient gives to the diagnosis (Ellis and Abrahms 14), we have a way of positively intervening to help patients mobilize their healing resources to "defy the verdict" (Cousins 239).

I'm not suggesting that physical therapists become professional psychotherapists. I am suggesting that we do have a legitimate role in counseling our patients since what we say and do may have psychotherapeutic (or anti-psychotherapeutic) effects.

Whether we recognize it or not, patients' semantic reactions in relation to their illnesses, injuries, etc., will inevitably affect what we do with them. We can learn to become more aware of these semantic reactions in our patients, to help them to deal rationally and positively with their problems as we work with them and, if our communication and counseling skills don't suffice, to refer them to psychotherapy professionals.

For example, people with back or neck pain are often given a diagnosis of "arthritis." When someone like this comes to me for physical therapy, I make an effort to find out how they interpret the diagnosis. I often find a sense of dreadful inevitability unwarranted by many people's subsequent recoveries. Many such people resign themselves to pain and immobility after getting told "you'll have to live with it."

Among other things, I point out to such patients that many people have indications of "wear and tear" on their x-rays but no back pain. A large part of treatment may involve disputing with words and deeds the negative suggestions that patients have received, internalized and continue to propagandize themselves with as part of their semantic reactions.

In their book Brief Psychotherapy in Medical and Health Practice, Albert Ellis, Ph.D. and Eliot Abrahms, M.D. address all health professionals when they write,
"As a health professional, you will inevitably be called upon to do some psychotherapy" (4). Interestingly enough they later note, "As a professional person who would help some of your patients psychotherapeutically, you would do well to acquire some knowledge of general semantics and to use some of its principles" (134).
How Do You Know?
Extensionally specifying our `meanings' and those of our patients brings us closer to answering Johnson's next question, "How do you know"? Seeking answers to this question gets us to look for evidence to support or refute our statements and those of others. In a more general way, we can also answer this question by studying the process by which we gain knowledge of the world. In general-semantics, we call this the process of abstracting. Understanding this process will help us move even further toward becoming more extensional.

In the process of abstracting, your nervous system constructs your experiences as you interact with your environment. Abstracting provides your sole means of gathering and representing information. Abstracting includes your perceptions as well as how you represent these perceptual experiences in words and other symbols.

The process of abstracting occurs at different levels. According to the best current scientific knowledge, we and everything else are made up of very tiny processes or events, a buzz of activity on the sub-microscopic level. We can call this level I, the process or event level.

Aspects of some of these events impact on our nervous systems, resulting in a chain of electro-chemical events which eventually result in our non-verbal experience, `perceptions', `observations', `feelings', etc. We can call this non-verbal level, level II.Usually we think of level II as the level of `concrete' experience, objects, etc. In general-semantics we realize that even so-called `concrete' experience results from a process of abstracting, where some characteristics from the event level are omitted and others are selected by our nervous systems.

From the non-verbal level we abstract again to the first verbal level, level III, where we label, describe, etc., in words. At this level we can make more or less `factual' statements. We can think of levels II and III as relatively lower orders of abstracting from the event.

From III we can abstract again to another verbal level, level IV, making statements about our descriptions and thus inferring and generalizing. To do this we relate, and go beyond, the factual statements of level III, and summarize, categorize and predict.

Indeed, the process of abstracting can continue to higher levels as we arrive at conclusions from our inferences, generalize about our generalizations, etc. The "etc." indicates that the process can theoretically go on indefinitely, as we continue at higher orders of abstracting to make statements about statements, develop hypotheses, theories, etc.

As we go from the so-called lower order abstractions of non-verbal experience and description to the so-called higher orders of generalization, etc., we move further away from particulars, specifics, `facts'.

Each level of abstracting represents or maps the previous level. So non-verbal perception maps the event level. Our labels and descriptions map our perceptions. Our inferences and generalizations map our descriptions, etc.

We do well, according to general-semanticists, to distinguish as clearly as possible among these different levels of abstraction and to avoid identifying or confusing them. For example, we can confuse our perceptions with events, our descriptions with non-verbal facts and our higher-level inferences and generalizations with descriptions.

In terms of the map analogy, we can mistake our maps for the territories they represent and assume that our maps say all about the territories. Such confusion occurred in the case of a man I know, who, in his seventies, developed an intermittent pain in his hip when walking which, although not severe, concerned him enough to make an appointment with an orthopedist. The physician had x-rays taken, examined them and told the man at their first meeting "You have terrible pain! I'll schedule surgery immediately." At that time the man experienced very little pain and thus decided not to continue with this doctor. The orthopedist, inferring that the man might have pain, went on to incorrectly identify his inference with the man's experience instead of asking the man directly.

A scientific, extensional attitude necessarily involves taking the higher order abstractions that we've developed and empirically checking them against lower order observations, descriptions, etc.

Often with patients with spinal pain and other orthopedic problems, the exact underlying pathology remains unknown. Symptoms don't necessarily have a one-to-one relationship to x-ray findings, etc. Distinguishing between the higher order abstractions of theories, diagnoses, and explanations, and the lower order abstractions of our and our patients' observations and descriptions allows us to work effectively with our patients even when the exact causes remain speculative.

The different levels of mapping or abstracting, our perceptual observations, how we label or describe what we observe, and the inferences, generalizations and assumptions we make, don't exist in water-tight compartments. Our basic assumptions, which involve fairly high orders of abstraction, may be embedded in the structure of our language, how we label or describe things. Our language can influence and may distort what and how we perceive things and how we respond to them.

For example, we may tend to forget that the existence of a classification or diagnostic label such as degenerative disc disease represents a generalization at a fairly high order of abstraction. Any individual so classified will have unique characteristics that may not be included under the label. Yet people may respond primarily in terms of the label and underemphasize the uniqueness.

This occurred with a patient of mine who resented my examining him because the doctor had already provided the diagnosis which `should' have told me what to do. The patient was assuming that all patients with that diagnosis `are' exactly the same. General-semanticists have developed a number of methods for becoming aware of such assumptions and for changing the structure of our language to nudge our evaluating in a more extensional direction. I will now discuss some of these methods.

Recognizing the uniqueness of every individual we deal with, we practice indexing by applying an index number to a category word. So we can index the diagnosis of "degenerative disc disease" and say patient1 with this disorder is necessarily different from patient2 with this disorder. We can also use indexing to specify terms that represent processes along a continuum. Some patients talk as if they either have back pain or they don't, and thus may expect complete (and sometimes immediate) relief. They, and we, may find it helpful to index their pain with 0 indicating no pain and 10 indicating the maximum they can imagine. Thinking in terms of a continuum with degrees of pain may help them to have more realistic expectations and to see small changes. Thus they can notice feeling better sooner, as together we work toward degrees of improvement rather than wait for instant magical results.

Another extensional method is called dating. With dating we put a date on the terms and statements that we make. We live not in a static, timeless world but in a dynamic, process world of change. The use of dating reminds us of the individuality of things, people and events over time and of the necessity of reevaluating from moment to moment. An extensionally oriented physical therapist will treat his/her patients in a similar manner as George Bernard Shaw's tailor: "The only man who behaves sensibly is my tailor; he takes my measure anew each time he sees me, whilst all the rest go on with their old measurements and expect them to fit me" (qtd. in Kenneth G. Johnson 13).

We make use of the term et cetera (etc.) which comes from the Latin for "and other things." Explicit use of etc. encourages a non-allness attitude towards our theories, observations, etc. To behave extensionally you can look for and enumerate examples when you speak and write. After you've done this you still haven't said it all. When you hear yourself or others saying things like "The only way to treat this problem...", you can usefully ask yourself: what have I left out?, what else?, what else?, etc.

You may have noticed my use of single quotes throughout this paper. As I previously noted, language `meanings' that we share give words a socio-historical baggage. These inherited implications of our words and language structure may represent unquestioned assumptions about our subject; e.g., that `meanings' reside in words apart from the people using them. We put quotes around a word or phrase as a reminder to stay alert when using it in order to avoid getting led astray by possible false implications. For example, if we insist on using the terms `mind' and `body', `physical' and `mental', the use of quotes can aid us in not treating these words as if they correspond to separate entities that exist in the non-verbal world.

We can also use hyphens to connect terms that suggest such a separation of what exists in the world as a unified process. For instance, a `physical' therapist cannot work with just the `physical' since human beings function as unified psycho-physical organisms.

These and other extensional techniques are further discussed in the book Drive Yourself Sane written by my wife, Susan Presby Kodish, and myself. They may seem deceptively simple. However, when used they can foster an awareness of your evaluative processes that can help you function more extensionally in your work with patients as well as your personal life.

What Then?
The third question in Wendell Johnson's trilogy, "What then?", leads to what he calls "disciplined generalization" (W. Johnson 37). As he notes,
"It is a way of asking what difference does all this make, what are the implications. If what you say is true is true, what else must be true--or false--what goes with what, what had best be done about it" (Johnson 38)?
Disciplined generalization constitutes an important principle of general-semantics. Awareness of the abstracting process encourages us to ask, "What then?" after we've made observations of a patient, and thus theorize and develop higher order abstractions. Again asking "What then?" when we've thus theorized, we can bring ourselves back to the lower orders of observation and description to check our new or revised theories. If a patient comes to us with back pain, we can hypothesize that they have a musculoskeletal problem that is treatable by us. Asking ourselves "What then?", we can expect that we'll find certain things in the history and examination. We also can expect that if we see or don't see other things, the patient may have a problem beyond our expertise.

For example, a person with a musculoskeletal problem treatable by us will likely have some changes in their symptoms related to positions and movements. If the person we see has constant and unremitting pain unrelated to positions and movements perhaps they need medical-surgical help, not physical therapy at this point.

Asking "What then?" also can help us to evaluate therapeutic claims. For example, proponents of cranio-sacral therapy claim that they can palpate movements in the cranial bones of adults. What then? We can expect that such movements could be observed anatomically. Yet anatomists tell us that these bones fuse by the time we reach adulthood and therefore don't move. Perhaps cranio-sacral therapists have discovered something new and useful. Perhaps anatomists need to revise their views. Or perhaps what the cranio-sacral therapists feel can be explained some other way. What then? Without closing the discussion, skepticism surely seems indicated.

An important part of a scientific attitude involves a "what then?" point of view, e.g., developing assumptions, theories, etc., and also accepting their tentativeness. This requires a willingness to test them and have them disproved. Part of this tentativeness includes looking for alternative explanations. Consider the possibility that what you believe as true could turn out false. What else might explain what you observe? What other explanations could make sense of what cranio-sacral therapists observe? What else might explain the results they get? What then?

George Kelly, not a general semanticist but working along similar lines, proposed an important assumption of the scientific attitude that seems basic to the applied epistemology of general-semantics I'm suggesting for clinical practice:
"We assume that all of our present interpretations of the universe are subject to revision or replacement" (15).
How would our practices differ if we considered the claims, theories, and models we use, our maps, with the tentativeness that this implies?

Not every physical therapist is in a position to do formal scientific research. By accepting an overly restricted view of the scientific method, we may close off the possibility of developing a scientific attitude in our work with patients. The system of general-semantics provides a way to develop more of a scientific attitude, an extensional orientation, in our professional activities. It provides a language and a set of tools for becoming more reflective about what we do; for bridging the research-practice divide.

How you talk to yourself, your patients and colleagues can make a tremendous difference in your effectiveness. By asking yourself and others the questions "What do you mean?", "How do you know?", and "What then?" and by applying the principles and methods I have discussed, you can begin to enhance your practice in new and surprising ways, et cetera.

Works Cited
Ellis, Albert and Eliot Abrahms. Brief Psychotherapy in Medical and Health Practice. New York: Springer Publishing Company, 1978.

Johnson, Kenneth G. General Semantics: An Outline Survey. San Francisco: International Society for General Semantics, 1972.

Johnson, Wendell with Dorothy Moeller. Living With Change: The Semantics of Coping. New York: Harper & Row, Publishers, 1972.

Jones, Mark A. "Clinical Reasoning in Manual Therapy." Physical Therapy 72 (1992): 875-884.

Kelly, George A. A Theory of Personality: The Psychology of Personal Constructs. New York: W.W. Norton & Company, Inc., 1963.

Kodish, Susan Presby and Bruce I. Kodish. Drive Yourself Sane! Using the Uncommon Sense of General-Semantics. Englewood, NJ: Institute of General Semantics, 1993.

Korzybski, Alfred. Science and Sanity: An Introduction to Non-Aristotelian Systems and General Semantics. Lakeville, CT (now Englewood, NJ): The International Non-Aristotelian Library Publishing Company, 1933 (Fourth Edition 1958).

PT Bulletin. July 22, 1987: 2.

Shepard, Katherine F. and Gail M. Jensen. "Physical Therapist Curricula for the 1990s: Educating the Reflective Practitioner." Physical Therapy 72 (1992): 566-582.

Wolf, Steven L. "Summation: Indentification of Principles Underlying Clinical Decisions." Clinical Decision Making In Physical Therapy. Ed. Steven L. Wolf. Philadelphia: F. A. Davis, 1985. 379-384.

Thursday, May 14, 2009

"Back Pain: Where Do We Stand?"

The cover story on Back Pain for the April 2009 edition of Advance For Directors In Rehabilitation refers to a number of rehabilitation professionals, including myself, who treat people with back pain. The following quote from the article, by the Advance Editor Jon Bassett, gives a nice introduction to me and my present work in physical therapy:
In nearly 30 years of clinical practice, Bruce Kodish, PT, PhD, has spanned the range of patient populations, from the halls of a Johns Hopkins University outpatient clinic to home-bound patients in the gritty neighborhoods of New York City. Now in part-time practice in Pasadena, Calif., Dr. Kodish treats a small group of patients with persistent pain problems using a movement-based perspective gleaned from his extensive experience in two well-established schools of thought—the McKenzie Method and the Alexander technique.

"Posture and movement are always connected with each other," says Dr. Kodish, author of Back Pain Solutions (Extensional Publishing). "If I had no methods other than postural training and patient education, I'd still be able to make a difference for a large percentage of patients."

Modern patient trials are starting to quantify the potential of movement-based education. A study in the August 2008 issue of the British Medical Journal found that one-to-one lessons from Alexander Technique practitioners were superior to massage therapy and physician-directed exercise prescription in improving disability and pain scores among patients with recurrent back pain. Six Alexander Technique visits were as effective as 24 visits, and results held up at a year post-trial.

Leading Alexander Technique researcher Ronald Dennis, EdD, defines the method as a nonexercise approach to improving body mechanics. "I see the Alexander Technique in Dennis' terms, as cognitive-kinesthetic education," explains Dr. Kodish. "It applies conscious thought and sensory perception to improve posture and performance.

Yet with so many trademarked approaches with flashy names and fierce disciples, how do cliinicians make the right choice for each case? Rather than pigeonholing patients, Dr. Kodish views the approaches he uses on a continuum of posture-movement therapy and education. "Therapeutic and educational methods overlap, and should draw from an up-to-date, research-oriented knowledge base," he says. "I'm relying on this framework to formulate the best overall treatment plan."