Back to All

REP 9 - What are the Questions to Which Physiotherapy Is, and Will Continue To Be, The Answer?

Dave Walton

What is the question to which physiotherapy is the answer?

That was a rather thought-provoking question posed to me by a very clever PT academic and historian named Dave Nicholls from Auckland University of Technology in New Zealand. Dave had reached out following a recent editorial I published in Physiotherapy Canada describing some initial musings from 2017’s Physio Moves Canada project. People say that if you’re the smartest person in the room, then you’re in the wrong room, and I can say with confidence that when I’m speaking with Dave I am in the right room. This question has formed the basis for a bit of an ongoing biweekly chinwag that we continue to have, and I have now borrowed and adapted it for this #30Reps post. The addition of the ‘and will continue to be’ piece is something that I find particularly compelling, and in many ways has been the stimulus for much of my work since the conclusion of Physio Moves Canada.
 

The initial question of what are the social, cultural and contextual problems to which physiotherapy is meant to be the answer is itself interesting, the answer to which can probably be traced back to our very roots. Having emerged as a recognized professional discipline that could touch people around the First World War, one of the earlier ‘questions’ to be answered was how to get soldiers ready for action again thereby preventing attrition. The other primary focus at the time would have been in managing post-polio syndrome, during which the specialized ‘Massage and Remedial Gymnastics’ providers would have used exercise, some manual therapies and physical modalities to optimize function and address issues of disuse and pain. Through the economic boom of the 1920’s this new breed of healthcare provider would have switched focus from remobilizing soldiers (though they would be refocusing there in another 10-15 years) to helping people get back to work sooner. These were times of prosperity and neither employees nor their employers would have wanted to miss that gravy train.
 

So, one could say that physiotherapy had its roots in war and capitalism, though I suspect that was not the motivation for most readers to join the profession. To take a different spin, physiotherapists have traditionally focused on helping their patients and clients to live their best lives through optimizing mobility, managing pain, and generally helping people feel like free and autonomous humans that can pursue their own personal goals. As I traveled across Canada last year one of the things I consistently heard was how this concept of mobility and autonomy was a critical component of many Canadians’ identities. In many ways, helping people recover from mobility problems could also be described in terms of facilitating the patient’s journey towards self-actualization, emotional well-being, and in some cases, even survival. So perhaps that’s the first answer to this question of ‘to what is physiotherapy the solution?’ At risk of being overly-romantic, in a time of what appears to be increasing global turbulence (environment, politics, and economy), perhaps being a profession aimed at optimizing well-being and satisfaction with one’s sense of their current and projected selves is a very noble calling.
 

If we start to prognosticate towards the future then, will these answers continue to be addressing important questions? Recent surveys would lead us to believe that millennials (and whatever the next generation is being called) are looking at the world through very different lenses. If these newer citizens are favouring health and wellness to prevent dysfunction or disease, where is the fit for physiotherapy as a profession traditionally focused on regaining function after an injury, illness or surgery? I feel like the answer to this is going to be dynamic and rapidly evolving. If I take my academic field as a researcher of pain and distress after motor vehicle trauma as an example, that is a field of practice that has changed dramatically over the past 10-15 years in Canada. Where funding for post-trauma rehab was once plentiful enough to keep entire clinics afloat with just that focus, insurers have progressively tightened the purse-strings and now the field is attempting to answer a different question, being ‘what is the most we can do with the lowest funding available?’ And that may be poised to change again – if (or perhaps when) autonomous vehicles become a ubiquitous presence on Canadian roads, assuming they function up to the standards being promised, motor vehicle collisions should dramatically reduce if not be eliminated altogether. So, as someone who has dedicated the prior 10 years to better understanding the outcomes, processes, and predictors of recovery after motor vehicle trauma, is my practice becoming a response to a question that fewer people will be asking?
 

That is just one very simple example of a much larger question. As society shifts towards new ways of thinking about ‘normal’: normal work, normal transportation, normal living arrangements, normal child-bearing age, normal retirement age, normal life span, normal healthcare, all things poised to change with advancements in technology and reductions in traditional funding, we return once again to a fundamental consideration: To what question(s) will physiotherapy continue to be the answer? It seems that now more than ever the profession needs strong leadership that is visionary yet realistic, big-picture thinking but with focused goals and objectives. As the profession changes so too should our leadership, and so should the rest of the membership question tradition while respecting its lessons. History has often borne out the concept of the artist, scientist, or thinker who disrupted the norm and proposed ideas that were dismissed as too radical at the time, only to become widely adopted and embraced decades (or more) later. Physiotherapy as a profession is an interesting case for this in that as a regulated health provider the threshold for ‘too radical’ is not terribly high. Yet it appears we need to find a way to innovate and ensure we are responding to the needs of a new society while operating within tight professional boundaries. I think I can say with confidence that we will not continue to survive by simply finding new ways to perform old functions.
 

As CPA and its branch leaders are also working to find a clear path through an unclear future, it seems that now more than ever the professional community is needed to band together, engage with its leaders, and work collaboratively to develop shared solutions to address challenges both known and yet-to-be-known. While as a profession we have traditionally rallied behind a banner of evidence-based practice, arguably some degree of protectionism and (relative) conservatism regarding our professional scope, it seems that the qualities that are becoming increasingly necessary are creativity, reflexivity, abstraction, tolerance of uncertainty, and courage to live and work towards the fringes of tradition. My personal sense is that our leaders, advocates, regulators, academics, educators, clinicians, and clients will need to engage in what could be difficult conversations towards finding shared values and goals.
 

I would love to hear from you, the membership, about your visions for what an activity- and mobility-based profession could look like in the future. Do those remain important foci? Are there new roles or functions you would like to see become part of the professional identity of physiotherapy? Are there old roles or functions you’d be willing to let go of in the interest of renewal and evolution? What qualities do you expect to be critical for physiotherapy clinicians, academics, and leaders to ensure a viable and thriving profession into a rapidly changing future?
 

Collectively, to what questions will physiotherapy continue to be the answer?

 

30REPS is brought to you by:

 

Comments

 

I love the title "Physical Therapy”. The word physiotherapy is derived from two words Physical and Therapy: 

Physical – from the Latin word “physica” - of things relating to  nature; and things that are characterized or produced by the forces and operations of physics. 

Therapy was originally from the Greek word, “therapeuein” that means to provide medical treatment intended to relieve or heal a disorder.   

Physiotherapy thus, is a (medical) treatment of _disease_, injury, or deformity of an individual.  This status quo should be maintained, as well as the treatment of our clients through different physical agents such as massage (vibration and IASTM included), electrical modalities, heat & cold treatment, and exercise rather than by drugs or surgery.  We are not treating patients through biochemical (except with wound healing using physiotherapy modalities) nor psycho-spiritual means, which other wellness “health care professionals” (quote, unquote) are doing. 

I love physiotherapy in that we get support and respect from the medical doctors.  They untiringly refer to us to provide a conservative approach, more than any other health care professionals.  We want to maintain this status quo by providing a more medical approach as opposed to wellness and satisfaction-based approach. Wellness is a misused term these days whereas satisfaction is applied to customer service (we provide partnership with our patients by doing the work together with them; treatment satisfaction cannot be guaranteed).

What is already in our practice, but not practiced, due to the issues mostly on limited insurance coverage more than lack of public education are maintenance and prevention of diseases or injury.  Yet, we still have to maintain that what we provide is within the limits of the scope of our practice.  We have to maintain applying the principles of physics to explain the biomechanics and treat the body (animals included for animal rehab PT’s) and how various physical energies (except, biochemical and spiritual energies) affect it.  It is totally fine if we PT’s have different approaches to help our patients, as long as the concepts we use in the way we help them heal is standard and we share common values, including putting patient first in developing our goals.  One PT can be very good in educating and empowering a client versus applying manual therapy -  one can only do so many in her treatment sessions.  Meanwhile, I can apply manual therapy without the need of further educating the same client.  But as we see them more often, we have to ask, what’s next (what more can I do to help this patient knowing more about him / her)?

Our times have changed but the human body has not.  Basic theories are right and it only needs us to further explore and prove them.  _Attention and time_ are required to get to know better our patients and advocate on their behalf, and provide evidence we are trying to prevent disease and deformity.  How can we make this happen if we only do documentation and less 1:1 with our patients?  Being "Hands-on” is what we are known for. Let us not lose our identity by losing our touch.

 

The author continues to seek answers from an audience when the answer is embedded in the difficult conversation, not the monologue.  Given that the profession refuses to hold itself to critical account and take responsibility for its own leadership challenges, high rate of attrition from the profession, and limited effectiveness of its interventions, few comments ever make it to see light of day unless they offer positive press.  Change is not possible if the profession is not willing to accept the fact that it is not living up to its duty to serve society.   

Start with addressing the limitations and assumptions in naming a therapy "physical" therapy.  Only the most dogmatic of approaches would artificially separate dimensions of health and then expect that the interventions that sprang forth from such a narrowed perspective would prove effective.  The curriculum needs a huge overhaul to include psychosocial health and move away from biomechanical, pathophysiological traditions that contribute to an increasing irrelevance in the current health care discourse. 

To the censors of the comment boards--if you cannot allow dissent and criticism, then you are the problem.

'doesn't sound coming from my tribe but that's ok.

Physiotherapy would not change its title nor would do an overhaul.  Period.  Unless Ling would get up from his grave.

We can be quite versatile - we can be kin, OT, massage, nurse, osteopathy, chiro, Resp. Therapy, Obgyn, etc.  Jealous much?  

Some would prey on new PT grads, mandate or encourage that they use aides instead, so as not to touch clients.  It is a sabotage scheme, and it could work for a lot of people with agenda. But change is going to happen and we would win this battle.  More and more PT's are waking up.  

Btw, _physiotherapy works_.  You may apply your advice in your practice.  We have enough in our plate, thank you.  Just so you know that there is due diligence of referring out if it's outside the scope of your practice.

I was very intrigued by the posing of your question.  The reverse direction approach got me thinking, and I would like to comment on just that- thinking!  I have been a physiotherapist for 40 years, have worked in a number of different settings with different types of clients.  I am currently the caretaker of a self-contained private practice for the past 20.  What I have known about the human being (in a human body) since this career path rose up in front of me as a possibility, is that thinking and moving are indeed related.  I do not know where or how this thought came to me back then, but came to me it did, in the eleventh grade of high school, and I have wrestled with it ever since.  It affected me initially to the extent that I was not sure if psychology or physio was my path.  I chose physio and now here I am, working mainly with children of various needs, to see, for starters, that they are completely different than adults- yet, they become one, how can that be?

Over the years of working more and more with children, I had to completely adjust my approach which had previously been mostly with adult populations.  I realized that attention was something, as tangible and mold-able as the limbs that were there in front of me to work with.  If I could get the attention, then the therapy was 'tricked' into place, and voila, my job became so much easier (and also more effective).  Therapy became finding ways to 'grab' the attention, then mold it to the therapeutic task that I had to carry out.

Attention is all about thinking.  When one observes a child engaged in a free play activity, one can see the motor planning moments as problem solving proceeds.  One sees thinking in action when one can observe this.  To put thinking with the body opens up a whole new world of possibility. 

Can physiotherapy own up to this tremendous, awe-inspiring reality and be the world that it wants to create, to open itself up to the relationship of thinking to moving so that, through the mutual interaction of both, health is indeed possible?  To keep moving moving along, this is the next urgent step.

Leave a Reply

Your email address will not be published. Required fields are marked *