Guarding and flow: an observational study

It’s been a while since I reviewed a paper but this one caught my eye! Amanda C. de C. Williams is one of my favourite researchers because her work captures social and anthropological aspects of pain – and she’s been researching and teaching for a very long time.

This study is an observational study of physiotherapists watching videos of people with chronic low back pain doing movements. The movements are pretty decontextualised (ie they’re not integrated with everyday life activities) but they are the kinds of movement that people can find difficult. They were: reaching forward with arms horizontal in standing position (reach forward), bending down towards the toes in standing position (forward-bend), standing from sitting stand), and sitting from standing (stand-to-sit). The videos were of 10 people with low back pain, and were chosen from a larger set of 16 people all performing each movement twice: choice was based on showing both sexes, a range of ages, and as wide as possible variation in pain-affected movement. Most lasted less than 30 s.

Sixteen physiotherapists were included, and these were working in senior positions in full or part-time work with people experiencing chronic pain. The average time since graduation of these clinicians was about 21 years (10 – 33 years range).

Each physio watched eight videos drawn from the set of recordings, and were asked “How would you describe the movement”, with further probes such as “Would you describe it as guarded, slow?” etc, and “when do you notice the movement being different/abnormal?”, “did the movement have flow?” and “what single piece of advice would you like to give the patient to help with this movement?”

The analysis followed framework analysis method, which is aligned to thematic analysis but with the use of existing theory (eg deductive analysis rather than inductive where the themes are developed de novo from the data itself), carried out by one researcher, while another independently completed an inductive analysis on ‘flow’. The two forms of analysis were compared and found to be very similar despite the different approach to thematic analysis.

What did they find? Well, this is intriguing because we rely on physiotherapist’s observations to understand movement patterns when considering clinical reasoning and ultimately therapy. Guarding was identified but typically qualified by noting its presence in part of a movement, or a body part. Agreement was not high. Ooops.

Guarding was, however, different from ‘stiffness’, ‘slowness’, and ‘bracing’ – stiffness considered to be ‘rigid’ or ‘wooden’, while guarding was considered more in terms of emotion. Bracing wasn’t really identified except for taking weight through the hands (hands on thighs) when moving from/to sitting and standing.

Guarding was described as ‘cautious’, ‘protective’, ‘fearful’ and ‘avoidant’ – a sense of reluctance to move, and participants related this to the part of the body moving at the time such as ‘thoracic spine’ or ‘didn’t want to move the lumbar spine’. Interestingly, participants anxiety about the movement weren’t commented on…

Flow was also not very consistent between the physiotherapists, but what was interesting was that therapists commented on the limited information about the person in context, there seemed to be more curiosity about the person and their beliefs and feelings than in the observations of guarding. Flowing movement was described as ‘lovely’ or ‘intuitive’ or ‘confident’ and seemed to be described as expressing confidence in the movement, even if the actual movements themselves were idiosyncratic.

In the discussion, these authors report that while there wasn’t a great deal of agreement between physiotherapists on the specifics of guarding and flow, once they were asked to elaborate on their analysis they were more consistent when observing and describing tension or apprehension.

Why would this study matter? What does it add?

One of the characteristics of movement in people who are feeling sore is a quality of hesitation or a lack of ‘fluid’ movement – flow. The descriptions from this study suggest that while these therapists, who were highly experienced, weren’t consistent between one another, they did pick up on flowing movement based on movement tempo, and perhaps might represent something described as by Csikszentmihalyi. Not over-controlled, nor un-controlled. Looking effortless, moving freely between positions, no sudden changes in speed between parts of the movement or parts of the body.

The advice these physiotherapists gave also aligned with Csikszentmihalyi’s idea of ‘just-manageable’ (the ‘just-right’ challenge), stopping or altering the movement right at the point just before the guarding or hesitancy occurred.

The authors then discuss what they believe matters from this study. What matters is that movement qualities appear to reflect both emotions and ‘bio’ limitations, and these physiotherapists were able to identify them, albeit not very consistently.

Guarding is a term used often in pain movement rehabilitation. Flow – not quite so much. There’s some good evidence that movements related to a real world activity rather than a decontextualised fragment of a movement are more variable, more accurate (when accuracy is important) and more flowing (see Wulf, G., & Lewthwaite, R. (2016). Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychonomic bulletin & review, 23(5), 1382-1414.). People also try harder when it matters to them – so they’re more likely to walk briskly to catch a bus than when being asked to ‘show me how you walk’ and their gait pattern is likely more variable.

I’m always about understanding the real world and what it is that people need and want to do in their own life context. If movement therapists (a very broad church!) could be more consistent in the way they observe and interpret movement practice in a person’s own daily life, we’d likely have fewer exercise interventions that bear little resemblance to what a person actually wants and needs to do. Getting fitter, while a worthwhile goal, may not help a person feel confident to lift their mountain bike onto the bike carrier on the back of their car, or to carry their wriggling child into bed, or even to manage vacuum cleaning the whole house at the end of the day when they’ve been busy in the garden. The effect sizes of exercise, like almost everything else in chronic pain management, are small on both pain intensity and disability – and I think exercise is over-emphasised by comparison with the other things a person needs and wants to do in their day.

I look at a study like this, and I wonder if the faith that people place in the movement analyses of therapists should be tempered a little with knowing that: 1. The level of agreement between these experienced therapists was quite low, it’s likely to be lower in less experience clinicians. 2. Decontextualised movements don’t look a lot like real world contextually-embedded movements that we need to do. 3. Flow or movement fluidity could be a useful construct to investigate because it seemed to influence these clinicians towards exploring, with curiosity, more about the person than their assumed body movement deficits, while searching for guarding seemed to elicit more focus on biomechanics. 4. The final sentence of the abstract really resonates: “Movement behaviours associated with pain are better understood in terms of their particular function than aggregated without reference to function.”

I have a bunch of methodological questions – like what were the ethnic backgrounds of each of the people in the video? were they sore at the time of the recording? why weren’t real world activities used? why were there two methods to data analysis (this is partly explained)? But for now, this study piqued my curiosity, so I shared it!

Update from one of the authors (Prof Amanda C de C Williams) re the questions I’ve posed: (NB my interpretation, not word for word).

The ethnic/cultural backgrounds of participants were mainly white – and this is an acknowledged limitation of this study. The research team were more diverse however.

All participants reported pain of moderate intensity at least – 5/10, and some found the movements quite demanding.

The reason decontextualised movements were used relates to the equipment available at the time of this study. The monitoring equipment was not wireless, so people were trailing cords and in a shielded environment. A more recent study being carried out is far less intrusive, uses real world activities and people aren’t encumbered with wires and things.

At the time, the purpose was to train machine learning, so standard movements were used – now that this has been achieved, real world and complexity can be added.

Finally, two different forms of analysis were undertaken because this team was not in the one location, and one of the team members was being trained. While it could be considered a weakness in the study, having two forms of analysis converge on similar themes suggests consistency (it would be called triangulation if there was another person in the mix!!).

Williams, A. C. C., Buono, R., Gold, N., Olugbade, T., & Bianchi-Berthouze, N. (2023). Guarding and flow in the movements of people with chronic pain: A qualitative study of physiotherapists’ observations. Eur J Pain. https://doi.org/10.1002/ejp.2195