"Passion to do the right thing": searching for the 'good' in physiotherapist practice

BACKGROUND

Practitioners' perspectives of what constitutes a 'good' physiotherapist have not been explicitly examined despite their potential implications for the future practice of physiotherapy. Physiotherapists' perceptions may inform professional priorities including education curricula, professional practices, competency profiles, and patient interactions.

PURPOSE

The purpose of this research was to examine physiotherapists' perceptions of what constitutes a 'good' physiotherapist. The context of the study was musculoskeletal practice (MSK).

METHODS

A hermeneutic phenomenological investigation was undertaken. Semi-structured interviews were conducted with twelve experienced MSK physiotherapists to examine their perceptions of what constitutes a 'good' physiotherapist.

FINDINGS

Seven themes were identified. Good physiotherapists were depicted as: 1) oriented to care; 2) integrating knowledge sources; 3) competent; 4) responsive; 5) reflective; 6) communicative; and 7) reasoning. To deepen the understanding of these themes, we discuss the findings in relation to Joan Tronto's ethic of care theory.

CONCLUSIONS

Physiotherapists' perceptions of what constitutes a 'good' physiotherapist highlight practices that may underpin an ethic of care including the pivotal role of person-centered and relational dimensions of practice. The findings call into question the profession's emphasis on a technical rationalist approach to education and clinical practice and invites conversation about future directions that balance technical competence with relational dimensions of practice.

The day program multiple: Noncoherence and ontological politics

Globally, day programs are increasingly proposed in policy as one way to address the support needs of people living at home with dementia and their families. Day programs represent a kind of space that can meet multiple interests and ideologies concerned with sustaining care at home for people living with dementia. In this paper, we draw on findings from an ethnographic study of how day programs work as care in the community for people living with dementia to argue that day programs' ontological status in research as a "simple location" of care contributes to the ambiguous outcomes and limited evidence available for improving their design and delivery. Using one program as an illustrative case, we demonstrate the multiplicity of a day program and the ontological politics through which the potentialities for care emerge. Robert Cooper's proximal analysis of organizing's and Annemarie Mol's work on ontological politics inform this analysis. Of note in this analysis are the different enactments of a day program and their modes of coordination. We show when these enactments hang together well and when they do not and consider the effects of these politics for care. Of particular concern is how some versions of a day program are easily displaced by the interests of administrative versions and managerial logics. We argue for approaches to research and planning that acknowledge the "day program multiple" and precarious nature of care.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

"Learning by osmosis": the transformative social identity journey of physiotherapists developing psychologically-informed practice, a reflexive thematic analysis

BACKGROUND

Despite efforts to support physiotherapists in integrating psychosocial aspects of care to biological ones, clinical practice remains dominated by biomechanistic priorities. To facilitate change, attention and actions need to consider not only the individual level of the therapists but also the cultural and structural levels of the profession. How these multi-layered social dynamics shape practice have not previously been investigated. The Social Identity Approach (SIA) provides a relevant framework to this exploration.

AIM

This study aimed to identify the social identity processes involved in the development of psychologically-informed physiotherapy (PIP) to understand how they may influence practice change.

METHODS

Nine semi-structured interviews were conducted with self-identified psychologically-informed physiotherapists. A Reflexive Thematic Analysis informed by SIA principles enabled to consider meaning as the product of social processes.

FINDINGS

The analysis of participants' experiences in moving from a primarily biomechanistic practice toward the integration of psychosocial aspects of health demonstrated: 1) a transformative "mind-blowing" identity journey; 2) a journey that is not made in isolation; and 3) where leadership matters.

CONCLUSION

Changes in clinical practice involve dynamics at the collective level of the practice environment and of the physiotherapy profession itself, rather than solely at the individual level of clinicians. An understanding of these complex social processes at a managerial level could be important to better support leaders and clinicians in implementing PIP in clinical practice.

The 'responsive' practitioner: physiotherapists' reflections on the 'good' in physiotherapy practice

BACKGROUND

Being 'responsive' is named as an element of ethic of care theories, yet how it is enacted is not clearly described in health professional practice. Being 'responsive' is implied within patient-centered approaches and promoted as important to health care practices, including physiotherapy. However, ways of being a responsive practitioner have not been explicitly examined. Practitioners' perspectives about how a 'good' physiotherapist enacts responsiveness have potential implications for the future practice of physiotherapy. Physiotherapists' perceptions may inform professional priorities including education curricula, professional practices, and patient interactions.

PURPOSE

The purpose of this research was to explore experienced musculoskeletal (MSK) practitioners' perceptions of 'responsiveness' in the practice of a 'good' physiotherapist.

METHODS

A secondary analysis of data arising from a hermeneutic phenomenological study into physiotherapists' perceptions of what constitutes a 'good' physiotherapist was undertaken. The secondary analysis focused on 'responsiveness,' which emerged as a major theme in the original study.

FINDINGS

Six themes were identified related to 'Being responsive' in a 'good' physiotherapist: Being person-centered, Being attentive, Being open, Being a listener, Being validating, and Being positive.

CONCLUSIONS

As a relational way of practicing, being responsive may facilitate person-centered approaches including a relational understanding of autonomy, inviting dialogue, and sharing power and decision-making with patients. Pivotal to the practice of a 'good' physiotherapist, being responsive in the ways underscored by participants suggests researchers, educators, and practitioners consider relational ways of practicing as a balance to the technical aspects of physiotherapy.

How physiotherapists attend to the human aspects of care when working with people with low back pain: a thematic analysis

Pain is a multidimensional experience. Physiotherapy has attempted to enhance earlier biomedical approaches to patient care through approaches like the 'biopsychosocial' model. Nevertheless, physiotherapy continues to focus on biomedical and/or behavioural aspects of care. We critically investigated how physiotherapists attend to human (psychosocial, emotional, existential, and moral) aspects of low back pain care. We co-analysed ethnographic data with researchers, patients, and physiotherapists using concepts of conforming, tinkering and abandoning 'scripts'. Data included observations of 28 physiotherapy interactions between 26 patients and 10 physiotherapists and 7 researcher-clinician dialogues. Analysis suggests when conforming to scripts, clinicians have difficulty recognising and responding to emotions; time pressure limited clinicians focus, and a biological focus often distracted from psychosocial aspects of people's back pain experiences. In contrast, tinkering with or abandoning scripts allowed space to broaden the focus. Drawing from theorists such as Butler (1999) and Gibson et al. (2020) our analysis contributes to health sociology, arguing that 'tinkering' with or 'abandoning' scripts can foster more humanistic, flexible and reflexive approaches to care. Although health sociologists have explored tinkering, abandoning is new; within physiotherapy, it encapsulates being able to respond with agility to non-physical elements of care without constraint from traditional ways of thinking and doing.

Critical physiotherapy: a ten-year retrospective

Critical physiotherapy has been a rapidly expanding field over the last decade and could now justifiably be called a professional sub-discipline. In this paper we define three different but somewhat interconnected critical positions that have emerged over the last decade that share a critique of physiotherapy's historical approach to health and illness, while also diverging in the possibilities for new forms of practice and thinking. These three positions broadly align with three distinctive philosophies: approaches that emphasize lived experience, social theory, and a range of philosophies increasingly referred to as the "posts". In this paper we discuss the origins of these approaches, exploring the ways they critique contemporary physiotherapy thinking and practice. We offer an overview of the key principles of each approach and, for each in turn, suggest readings from key authors. We conclude each section by discussing the limits of these various approaches, but also indicate ways in which they might inform future thinking and practice. We end the paper by arguing that the various approaches that now fall under the rubric of critical physiotherapy represent some of the most exciting and opportune ways we might (re)think the future for the physiotherapy profession and the physical therapies more generally.

From domestication to imperial patronage: Deconstructing the biomedicalisation of occupational therapy

Occupational therapy knowledge emerged in the 19th century as reformist movements responded to the industrialisation of society and capitalist expansion. In the Global North, it was institutionalised by State apparatuses during the First and Second World Wars. Although biomedicine contributed to the rapid expansion and establishment of occupational therapy as a health discipline, its domestication by the biomedical model led to an overly regulated profession that betrays its reformist ideals. Drawing on the work of Deleuze and Guattari, our aim in this article is to deconstruct the biomedicalisation of occupational therapy and demonstrate how resistance to this process is critical for the future of this discipline. The use of arts and crafts in occupational therapy may be conceptualised as a 'nomad science' aesthetically resisting the domination of industrialism and medical reductionism. Through the war efforts, a coalition of progressive nurses, social workers, teachers, artisans and activists metamorphosed into occupational therapists. As it did with nursing, biomedicine proceeded to domesticate occupational therapy through a form of 'imperial' patronage subsequently embodied in the evidence-based movement. 'Occupational' jargon is widely used today and may be viewed as the product of a profession trying to establish itself as an autonomous discipline that imposes its own regime of truth. Given the symbolic violence underlying this patronage, the future of occupational therapy should not mean behaving according to biomedicine's terms. As a discipline, occupational therapy must resist the appropriation of its 'war machine' and craft its own terms through the release of new creative energy.

An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, and Professional Roles

OBJECTIVE

The purpose of this study was to explore physical therapy through the stories of physical therapists who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) to consider how the profession enacts and constructs gender and sexual orientation.

METHODS

Physical therapists with clinical, academic, and professional roles who identify as LGBTQIA+ were recruited from Australia, the United Kingdom, Canada, and the United States. In-depth data were collected via narrative interviews. An iterative group discourse analysis was used to examine key discourses underpinning interview narratives and how these relate to the physical therapy profession.

RESULTS

Twenty-two physical therapists were interviewed. Participants had between 1.5 and 40 years of experience across various clinical areas and settings. Participants identified with varying sexual orientations and gender identities. Analysis identified discourses discussed under the following headings: (1) normativity, which related to hetero-normative assumptions about sexual orientation and cisnormative assumptions about gender identity and the intersectionality among sexual orientation, gender identity, and other forms of marginalization; (2) stress and labor, which explored the stress experienced by physical therapists who are LGBTQIA+ (due to fear of discrimination or actual discrimination) and additional emotional and other types of labor or work done in the workplace to hide aspects of their lives to feel safe, educate colleagues, and be a role model; and (3) professionalism, which related to the heterosexual/cisnormative (and other) "norms" that comprised participants' ideas of presenting as "professional" and positioning physical therapists who are LGBTQIA+ as "unprofessional."

CONCLUSION

Findings suggest that cultural norms may need to be reconceptualized in physical therapy to promote inclusion and belonging of individuals who identify as LGBTQIA+. Approaches to upskill new and existing physical therapists may include elements such as individual and institutional reflexivity, learning and implementing appropriate terminology, displaying indicators of inclusivity, and cultural safety training. These elements may provide the first steps to promote inclusive and culturally safe environments for individuals who identify as LGBTQIA+ within the profession.

IMPACT

This is the first known study to explore the lived experiences of those who identify as LGBTQIA+ in the physical therapy profession. The findings highlight how prevailing normative discourses in Western society are also present in physical therapy and impact those who identify as LGBTQIA+.

Boundary work: the Mensendieck system and physiotherapy education in Norway

The history of physiotherapy can be seen as a history of boundary conflict, as the profession sought to first establish, then maintain, its distinctive professional identity. Traditional approaches to the sociology of the professions support this, seeing professionalization as an ongoing process of enclosure, encroachment, and conflict. Recent work, however, has emphasized the fluidity and collaborative nature of professionalization projects, and placed more emphasis on inter-professional negotiations and disciplinary coexistence. In this paper, we draw on this work to analyze the harmonization of the independent Mensendieck System of medical gymnastics in Norway, and the emerging state-sponsored physiotherapy system. Our contention is that over the course of the middle decades of the 20th century, advocates of the Mensendieck System and providers of orthodox, biomedically informed physiotherapy, came together and found a way to work collaboratively in a shared space without compromising their distinctive professional identities. We argue that this approach both points to ways we might revisit traditional conflict-based analyses of the history of physiotherapy, while also suggesting new ways of imagining how the profession might change in the years to come.

A socio-emotional analysis of technology use by people with intellectual disabilities

BACKGROUND

Access to information and communication technologies (ICTs) is often thought to enhance the lives of people with intellectual disabilities (ID) and is considered an important aspect of digital inclusion. However, inclusion practices often fail to address societal inequalities that lead to and sustain exclusion. The aim of this research was to enhance understandings of the relationships people with ID form with technology by critically analysing the underlying assumptions of inclusion practices.

METHOD

We employed a post-qualitative approach to reanalyse previously collected data from face-to-face interviews with 10 Australian adults with ID who attended a community literacy programme about their technology use in their daily lives. Two of social theorist Sara Ahmed's key concepts were used to analyse these data: (1) 'stickiness' of emotions, where certain (socially dominant) emotions are considered to attach to objects over time (e.g. mobile phone use is normal/good) and (2) 'fit' between people and objects, where there is a sense of comfort when objects are designed for people like you - those outside the 'norm' experience discomfort and a sense of being 'othered' in their interactions with such objects which do not fit them.

RESULTS

Our analysis identified how people with ID often attributed positive feelings to technology even when they had seemingly negative interactions with their devices (e.g. they could not use certain features, caregivers acted as gatekeepers to access). The positive associations were likely the outcome of implicitly held understandings that society highly values technology (Ahmed's stickiness of emotions). Although some participants accessed technology without difficulty, others experienced discomfort due to difficulties using devices that were not designed for them (Ahmed's fit between people and objects). Importantly, some participants had access to technology and the technical skill to use ICTs, but other factors, such as not having many friends, impacted their ability to use their devices in meaningful ways.

CONCLUSION

Our analysis suggests that digital inclusion practices focused on providing access to technology may unintentionally harm in ways that are not immediately apparent when working with people with ID. Harms might include further marginalisation or 'othering' of people with ID. It is important to recognise that well-meaning attempts to encourage use of ICTs may be counterproductive if they lead to experiences of marginalisation. To avoid this, inclusion practices could focus beyond access to devices, and the ability to use them, to include considerations of the multiple socio-emotional effects. What is a good fit is not entirely predeterminable, exploration of the possibilities for what will work well for any individual requires experimentation and creativity, and a careful attention to unintended effects. Beyond this, the development of new technology should consider how to diversify devices that often fail to fit people with disabilities.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

Cheer* in Health Care Practice: What It Excludes and Why It Matters

Clinicians' positive demeanor and "strengths based" focus can include working to create a cheerful atmosphere in health care environments, cheering for improvements in assessment outcomes, and cheering up clients in situations of decline. Drawing from philosopher Karen Barad's theories of inclusions and exclusions, we investigated what comes to matter (and what is excluded from mattering) when there is cheerfulness, cheering, and so forth (cheer*) in the day-to-day practices of a neuromuscular clinic. We worked collaboratively with clinicians, young people with Duchenne muscular dystrophy, and their families to co-examine the clinic in three iterative exploratory method spaces: (a) group "dialogues" with clinicians; (b) consultative interviews with children, families, and clinicians; and (c) transdisciplinary research team analysis sessions. Cheer* made some things matter in the clinic ("normal" physical function, "positive" emotions, test scores, compliance); and excluded others (grief and loss, "non-normative" bodies and lives, alternative practices, embodied knowledge). We discuss implications across health care settings.

Enhancing the human dimensions of children's neuromuscular care: piloting a methodology for fostering team reflexivity

For those with chronic, progressive conditions, high quality clinical care requires attention to the human dimensions of illness-emotional, social, and moral aspects-which co-exist with biophysical dimensions of disease. Reflexivity brings historical, institutional, and socio-cultural influences on clinical activities to the fore, enabling consideration of new possibilities. Continuing education methodologies that encourage reflexivity may improve clinical practice and trainee learning, but are rare. We piloted a dialogical methodology with a children's rehabilitation team to foster reflexivity (patient population: young people with Duchenne's or Becker's muscular dystrophy). The methodology involved three facilitated, interactive dialogues with the clinical team. Each dialogue involved clinicians learning to apply a social theory (Mol's The Logic of Care) to ethnographic fieldnotes of clinical appointments, to make routine practice less familiar and thus open to examination. Discourse analyses that preserve group dynamics were completed to evaluate the extent to which the dialogues spurred reflexive dialogue within the team. Overall, imagining impacts of clinical care on people's lives-emphasized in the social theory applied to fieldnotes-showed promise, shifting how clinicians interpreted routine practices and spurring many plans for change. However, this reflexive orientation was not sustained throughout, particularly when examining entrenched assumptions regarding 'best practices'. Clinicians defended institutional practices by co-constructing the metaphor of balancing logics in care delivery. When invoked, the balance metaphor deflected attention from emotional, social, and moral impacts of clinical care on patients and their families. Emergent findings highlight the value of analysing reflexivity-oriented dialogues using discourse analysis methods.

Individuals' explanations for their persistent or recurrent low back pain: a cross-sectional survey

BACKGROUND

Most people experience low back pain (LBP), and it is often ongoing or recurrent. Contemporary research knowledge indicates individual's pain beliefs have a strong effect on their pain experience and management. This study's primary aim was to determine the discourses (patterns of thinking) underlying people's beliefs about what causes their LBP to persist. The secondary aim was to investigate what they believed was the source of this thinking.

METHODS

We used a primarily qualitative survey design: 130 participants answered questions about what caused their LBP to persist, and where they learned about these causes. We analysed responses about what caused their LBP using discourse analysis (primary aim), and mixed methods involving content analysis and descriptive statistics to analyse responses indicating where participants learnt these beliefs (secondary aim).

RESULTS

We found that individuals discussed persistent LBP as 1) due to the body being like a 'broken machine', 2) permanent/immutable, 3) complex, and 4) very negative. Most participants indicated that they learnt these beliefs from health professionals (116, 89%).

CONCLUSIONS

We concluded that despite continuing attempts to shift pain beliefs to more complex biopsychosocial factors, most people with LBP adhere to the traditional biomedical perspective of anatomical/biomechanical causes. Relatedly, they often see their condition as very negative. Contrary to current "best practice" guidelines for LBP management, a potential consequence of such beliefs is an avoidance of physical activities, which is likely to result in increased morbidity. That health professionals may be the most pervasive source of this thinking is a cause for concern. A small number of people attributed non-physical, unknown or complex causes to their persistent LBP - indicating that other options are possible.

What constitutes back pain flare? A cross sectional survey of individuals with low back pain

BACKGROUND AND PURPOSE

Low back pain (LBP) is a lifelong problem for many. In acute episodes, or as a persistent condition, LBP is fluctuating in nature, with pain and other features of the condition varying in intensity and duration over time. Symptom flares (also known as flare ups) contribute to this variation and can have a great impact on the lives of those who have LBP. An important goal of treatments for, and research on, LBP is arguably to decrease symptom flare in both frequency and severity. However, this goal is problematic with little research, and no consensus, on how to define LBP flare. In particular, patients' understandings of LBP flare have received limited attention in the literature. To appropriately address this issue, we sought to understand how flares are conceptualized by individuals with LBP.

METHODS

We used an inductive, predominantly qualitative methodology, conducting an online survey with 130 individuals who self-reported experiencing LBP. The survey investigated participants' views on LBP flare including its meaning, features and symptoms, and whether 'flare' and 'pain increase' were synonymous. Qualitative analysis of responses involved thematic and content analysis with descriptive statistics used for the quantitative component.

RESULTS

Our data analysis found that participants identified many aspects of a flare to be important. Qualitative analyses highlighted a number of themes including that LBP flare was conceptualized as: (1) an increase in pain and other uncomfortable sensations such as paraesthesia or muscle tension, (2) an increase in the area, quality and/or duration of symptoms, (3) a reduction in physical, cognitive and/or social functioning, and (4) negative psychological and/or emotional factors. Flare was also discussed as a change that was difficult to settle. When participants considered whether 'flare' and 'pain increase' were synonymous, responses were evenly divided between 'no' (47%) and 'yes' (46%) with remaining participants 'unsure'.

CONCLUSIONS

The key finding was that many people with LBP do not consider their condition to be flared simply on the basis of a pain increase. In general, other features were required to also change. Results highlighted that a narrow focus on pain is unlikely to differentiate minor pain events from a flare. These findings are important as they contrast with most commonly used definitions of a flare that focus predominantly on pain increase.

IMPLICATIONS

Our findings have implications for understanding the trajectory of LBP over time. Understandings derived from perspectives of individuals with LBP highlight that defining flare in LBP is complex. In order to provide person-centred care, individual context and experiences should be taken into account. Therefore, understandings of LBP flare require consideration of factors beyond simply an increase in pain. A comprehensive, person-centred understanding of flare that includes a number of features beyond simply an increase in pain intensity is likely to be useful to better identify flares in research settings, assisting endeavours to understand and reduce LBP. Similarly, in clinical settings a nuanced conceptualisation of flare is likely to help health professionals communicate understandings of flare when working with individuals to manage their LBP.