To achieve better outcomes, become a master of change.


Our profession understandably has a weighty focus on outcomes, but frequently fails to recognise that in order to achieve them, we must first make change possible.

However, change is a tricky thing, because our brains find safety and economy in what is familiar. It takes real time skill to navigate this in order to unlock the potential for change.

We are given very little training on the science of change.

Most of our clinical challenges are actually rooted in difficulties in facilitating change, but our discussions are still stuck on outcomes.

This leads to a linear thinking fairy tale where we can follow a clearly marked path (skippety skip) helpfully provided in a nice tidy research paper, from initial presenting condition to desirable outcome. And we all live happily every after. The End.

Except that it doesn’t work that way does it?

It is so seductive, so reassuring. And so disillusioning when the desired outcomes are not achieved.

The thing is, humans are not linear. Humans are galaxies.

And natural human movement is a constellation made up of an individual’s context, history, anatomy, neurology, emotions, beliefs and more.

So when it comes to eliciting change, we need a more nuanced and sophisticated model to work from.

Since 2002, I have been teaching based on a model of dynamical systems theory, also known as dynamic systems theory (DST). I used to name it explicitly on the courses but physiotherapists would get freaked out, so I learned to address it with fewer scary words.

An early paper by Thelen & Ulrich, 1991, states that dynamic systems theory addresses the process of change, rather than developmental outcomes. I love that in dynamic systems terms, “there is no end point of development”.

It also recognises that behaviours, movements and thinking arise from the fluctuating interplay of multiple subsystems.

Hard to measure in an RCT, don’t you think? But way more reflective of the real human experience.

So, for almost three decades I have cast a wide and immersive net through a wide range of evidence bases to assimilate the research in fields including biomechanics, neurology, social learning theory, psychology, trauma and emotion, rehabilitation and behavioural science. It creates a web that can reflect an individual, while still providing a structure for choices based on evidence.

Where’s the evidence?

If we look at the great elephant, low back pain, acknowledging the human constellation explains why many studies show a bit of effectiveness for various interventions (pick your favourite) over some domains but no satisfying reproducible consistency.

The closest we see to a more realistic representation is cognitive functional therapy, which attempts to address some of these tensions, but despite the glow of the RESTORE study, various systematic reviews range from contradictory to tepid (Devonshire et al 2023; Takahiro et al 2022). This in no way undermines the concept but rather reflects the genuine challenge of bringing forth more relevant ways to acknowledge, address and measure real human beings, and this early step is to be applauded.

And in the meantime, I shall continue to equip clinicians with a well established framework that allows them to make informed, individualised clinically reasoned choices, knowing that they are probably closer to being evidence based than they ever have been before, despite it not being wrapped up in one grand unified RCT. And teach them to love the science and art of change.

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