The End of Physiotherapy

David A. Nicholls

• Publisher: Taylor & Francis
• Year: 2017
• Print ISBN: 9781138673557
• eBook ISBN: 9781317202622
• Edition: 1
• Topic: Social Sciences
• Subtopic: Health Care Delivery
• Index: Social Sciences

Physiotherapy is arriving at a critical point in its history. Since World War I, physiotherapy has been one of the largest allied health professions and the established provider of orthodox physical rehabilitation. But ageing populations of increasingly chronically ill people, a growing scepticism towards biomedicine and the changing economy of healthcare threaten physiotherapy's long-held status. Paradoxically, physiotherapy's affinity for treating the 'body-as-machine' has resulted in an almost complete inability to identify the roots of the profession's present problems, or define possible ways forward. Physiotherapists need to engage in critically informed theoretical discussion about the profession's past, present and future - to explore their practice from economic, philosophical, political and sociological perspectives.

The End of Physiotherapy aims to explain how physiotherapy has arrived at this critical point in its history, and to point to a new future for the profession. The book draws on critical analyses of the historical and social conditions that have made present-day physiotherapy possible. Nicholls examines some of the key discourses that have had a positive impact on the profession in the past, but now threaten to derail it. This book makes it possible for physiotherapists to think otherwise about their profession and their day-to-day practice. It will be essential reading for scholars and students of physiotherapy, interprofessional and community rehabilitation, as well as appealing to those working in medical sociology, the medical humanities, medical history and health care policy.

Part I

1 Introduction

Physiotherapy – or Physical Therapy¹ – is one of the largest and most successful professions allied to medicine. There are more than 250,000 physiotherapists practicing around the world today and there are physiotherapists practicing in almost every country. Physiotherapy is also one of the oldest organised health professions, originating in the late 19^th century and predating most of the other allied health professions, including dietetics, occupational therapy, podiatry, radiography and speech and language therapy. It draws its inspiration from a set of techniques that may be the oldest therapies known to humankind and it has been an important feature in the development of modern ‘Westernised’ medical care. Physiotherapists have partnered with doctors and nurses during some of the most significant human events of the 20^th century. Physiotherapists – or masseurs and masseuses as they were known then – played an important part in the rehabilitation of injured servicemen in both world wars; they developed rehabilitation systems to help people recover from epidemics of influenza, tuberculosis and polio; and they established themselves as the provider of orthodox rehabilitation services under the welfare reforms that dominated much of the last century. Today, you will find physiotherapists working in private practices and large hospitals, community clinics and specialist rehabilitation units. They are educators, practitioners and researchers, and they work in acute and chronic cardiorespiratory care, exercise-based rehabilitation, mental health, acute musculoskeletal injury, neurology, orthopaedics, pain management, sports, women’s health and workplace health, and they work across the entire lifespan from newborn to a person’s last days.

Physiotherapists have been trusted and reliable servants of the state, and have been rewarded with status and privilege. Most developed countries offer protection of title to physiotherapists, codifying their role and purpose in law. With this comes secure access to patients within the public health system. They are trusted by the public and respected by governments for doing work that often involves highly sensitive and intimate contact with people in a manner that rarely causes any suspicion or concern. Physiotherapy carries with it a high level of occupational prestige (Turner 2001), and through its increasingly significant role within higher education, is beginning to provide critical commentary on the nature of its own practice and its future as a health provider. So, while it might be exaggeration to suggest that physiotherapy has been the backbone of the orthodox healthcare system during the 20^th century, it is probably not unreasonable to claim that the profession has at least represented one of its limbs. Alongside medicine and nursing, physiotherapy has provided one of the principal mechanisms for people to restore movement and function, reduce pain and stiffness, return to fitness and regain their health.

How can it be then, that at the very point where physiotherapists should be congratulating themselves on a job well done, a book can be written that predicts the end of physiotherapy? How can it be, given the seeming health of the profession, its appeal to students and its status within the orthodox health system, that someone might suggest that physiotherapy is facing the most significant crisis of its long and distinguished history? How is it even remotely possible that someone could argue that everything that the profession has achieved may be undone in the years to come? These are the questions that this book attempts to address.

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Many physiotherapists may find this book uncomfortable reading: not because it is highbrow or pessimistic (my sincere hope is that it is quite the opposite), but because it deliberately asks question that practitioners would prefer not to ask and it does so in a manner that may be confronting, challenging and provocative. The book may be uncomfortable reading because it challenges physiotherapists to think differently about their profession, and it runs counter to much of the perceived wisdom emanating from teachers, researchers, policy makers and practitioners about the future direction for the physiotherapy. It has been written primarily for practitioners, students, teachers, researchers and those who work to shape the profession’s future, and so the very people it is directed towards are the very people who may find it most challenging. I hope other readers who know something of physiotherapy’s history, or work with practitioners on a daily basis, will gain a new appreciation for some of the profession’s present tensions, however, and that these readers may find something valuable to apply to their own work. Many of the issues tackled in this book are common to other health professions.

The purpose of the book is to provide the first critical overview of the historical and social conditions that have contributed to physiotherapy’s present problems and to open a space for a different future. Let me be clear, after 25 years of practising, teaching and researching physiotherapy practice, I have come to the conclusion that the profession must change. If we continue to practice physiotherapy in the manner that has seemingly worked so well in the past, the profession – as we know it today – will become increasingly obsolete in the future. The evidence is all around – from the encroachment of other professions to the declining legislative protections and difficulties being seen as an essential part of healthcare reforms. Physiotherapists are being shown daily that they need to find new ways to think and new ways to ‘be’. What they are not being shown, however, is how to do it. It seems there is no route map, no path to follow, no new philosophy of practice that we can marshal their forces behind. This is not because there are no new philosophies of practice in healthcare or a lack of new ideas, but that these seem to be a little removed from the ‘essence’ of physiotherapy practice and they are often couched in pseudo-philosophical language that is far too ‘fluffy’ for many practitioners with a traditional physiotherapy training.

Physiotherapy is in a uniquely paradoxical situation in that it cannot easily develop a new future precisely because of its past. No other health profession experiences this paradox in the same way, and so clinicians, educators and researchers cannot easily look to others for help. What is more, if the physiotherapy paradox prevents the profession from seeing itself more clearly, then reform is going to be very hard, not least because it demands that we challenge some of the principles that define the very essence of what physiotherapists do and who they are. This paradox must be confronted, therefore, if the profession is going to begin the process of reform. And so, it is to this that we must turn if we are to begin the process of seeing physiotherapists’ ways of thinking and practicing more clearly.

The physiotherapy paradox

Physiotherapy is, by anyone’s estimation, a strong profession. In most countries, it is well respected by the public and government, it has legal protection of title and access to the public health system, it is considered orthodox and so benefits from years of close association with other well-established professions like medicine and nursing, and its training courses are often some of the most oversubscribed and popular programmes in the university. Physiotherapists have a reputation for being bold, energetic, positive people often with ‘Type-A’ personalities and a pragmatic drive to get things done. But for all these positive traits, physiotherapy can also be seen as quite an exclusive profession that has a very limited biomedical view of the body, movement, function and health, and a rather unsophisticated view of a profession’s role within society. Physiotherapists are rarely asked to think about their own individual or collective culture, or are trained to see themselves as being connected to broader societal questions. Because of physiotherapy’s history, it can also be seen as somewhat elitist – inferring superiority over other similar professions (like masseurs, chiropractors and personal trainers) through its longstanding association with medicine. It is, in many ways, a profession that mirrors dominant white, European culture in that it assumes culture is something others have and that there is an objective ‘truth’ to the biomedical – or more accurately biomechanical – basis to the profession’s practice that does not need to be questioned. It just is.

New Zealand General Practitioner and poet Glenn Colquhoun makes this point very well in the opening quote when he says that ‘The most difficult thing about majorities is not that they cannot see minorities but that they cannot see themselves’ (Colquhoun 2012). Colquhoun was writing about the tensions that persist between New Zealand Europeans and Maˉori, but he might just as easily have been speaking about physiotherapy and other established health professions, where there is a degree of cultural myopia brought on by the profession’s elevated status in society. But some health professions do more than others to examine their status in society, and do much more than physiotherapy has done to understand its elite social status. As Lauren Williams wrote in 2005:

Much has been written from a sociological or political perspective about medicine and, increasingly, nursing. This is not surprising since doctors largely control the health system and nurses comprise approximately two-thirds of the health workforce. By contrast, allied health professions have been largely overlooked in the literature, which reflects their relatively small numbers and less than powerful position within the health system … Perhaps more surprising, is the fact that the allied health professions themselves have not demonstrated a critical perspective … most of the professions align themselves with medical science, largely neglecting to develop a culture that encourages criticism of their own development.

(Williams 2005, p. 350)

Medicine and nursing, but also professions like occupational therapy, and psychology have all developed sophisticated historical and social critiques both from within their professions and without over the last century². In medicine, for example, discrete branches of history, humanities and sociology exist, each with their own publications and special interest groups, all directed at casting a critical eye over the profession. Elliot Freidson, Thomas Osborne, Nikolas Rose, David Armstrong, Mike Saks, Deborah Lupton and hundreds of others have written about medicine; where it comes from; what it does and does not do; its past, present and future and identified more clearly the ideas and principles that are ever changing in the profession (Lupton 2012; Saks 1995; Armstrong 1983; Rose 1994; Osborne 1993; Freidson 1970). The same is true in nursing, occupational therapy, psychology and many of the alternative and complementary professions, despite their significantly reduced resources. So why does physiotherapy lag so far behind in critical self-scrutiny? It clearly cannot be simply because the profession is elite or orthodox or it would surely have followed the example of medicine and the other professions in developing critical approaches to its practice. And it cannot be said to lack resources because there are many other smaller professions who have been far more active in this field. There must be something specific to physiotherapy culture itself that discourages practitioners from examining their own culture. This is the nature of the physiotherapy paradox.

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One of the principal arguments in this book is that physiotherapy’s longstanding approach towards the body underpins its relative ignorance of itself. Physiotherapists are trained to think of the body in terms of its physical form and function at the exclusion of other ways of thinking. The evidence for this is very clear. In recent years, there has been an explosion of interest in the philosophy and sociology of the body, for example, but little of this penetrates the physiotherapy literature. Physiotherapists are rarely exposed to writings on embodiment, or work that distinguishes the biological from the social, gendered or the post-human body. There is little room in physiotherapy curricula for the writings of Nicholas Fox (Fox 2012), Bryan Turner (Turner 2008) or Chris Shilling (Shilling 2012) even though these are completely contemporary and highly relevant to physiotherapy practice. There is little overt engagement with the vast volumes of disability theory (although this is improving); the science of haptics, physical geography; sensuality or spirituality; the ethics of bodily practices or bodies in a cultural context. Compare perhaps the contents of journals like Body & Society (http://bod.sagepub.com/) with any of the mainstream physiotherapy journals and it will be clear that physiotherapy thinking is and has always been focused on the physical functioning on the biomechanical body³.

This is not a negative statement, however. Every profession has to draw its boundaries somewhere, and anyone who knows anything about the history of physiotherapy will know that its biomechanical approach has been a vital component of the profession’s success over the last century. But just as an approach can open doors to make some things possible, it can also deny other things, and what physiotherapy’s approach has done has opened the door to the problems now faced by the profession while restricting its ability to respond.

My contention is that adopting a specifically ‘biomechanical’ view of the body may have been not just desirable but vital to the success of the profession in the past, but it has now become problematic. It may have been necessary, for example, for the founders of the profession to adopt a biomechanical view of the body to prove their legitimacy in the late 19^th century, which, in turn, led to physiotherapy becoming trusted by government and the public. It may also have been necessary for the women who founded the profession to maintain this dispassionate approach to the body during World War I when female masseuses began treating male patients, and after the war as orthodox rehabilitation for returned servicemen became a vital part of their work. Although training men to massage – many of whom were blind – remained hugely problematic, not least because ‘it was still considered unseemly for lay women to teach men anything involving physical contact’ (Barclay 1994, p. 59). The profession’s ability to set aside its he...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgements
• Abbreviations
• Part I
• PART II
• PART III
• Glossary of terms
• Index