The End of Physiotherapy, 1st Edition
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For Tom and Ali
Contents
Acknowledgements xi
Abbreviations xii
PART I 1
1 Introduction 3
The physiotherapy paradox 5
The new economy of healthcare 9
Design and structure of the book 14
Notes 17
References 17
2 Physical therapies before 1894 19
Introduction 19
Ancient physical therapies 20
Physical medicine from the Renaissance 21
A particularly partial history 25
Industrial bodies 27
Women and the physical therapies 30
Closing words 36
Notes 37
References 38
3 The quest for legitimacy (1894–1914) 42
Introduction 42
The Massage Scandals 42
The birth of the STM 46
Courting medical patronage 49
The creation of an examination system 50
viii Contents
The registration of members 52
Closing words 55
Notes 56
References 56
4 The pursuit of orthodoxy (1914–1973) 58
Introduction 58
Serving the State 59
A noble cause 61
Practice innovations and sexual tensions 66
Specialisation, differentiation and polio 70
Welfare State and the creation of a profession 74
Physiotherapy’s white heat of technology 78
Notes 81
References 82
5 Physiotherapy under neoliberalism (1973–present) 84
Introduction 84
Healthcare reforms since 1973 86
Physiotherapy since 1973 92
Specialisation and new doctors 92
Clinical practice since 1973 97
Closing words 107
Notes 108
References 109
PART II 119
6 The body 121
Introduction 121
The biomechanical body hiding in physiotherapy 122
The body in Western culture 123
Maintaining the body-as-machine 126
The elusive body 131
New bodies in physiotherapy 133
Bodies in pain 134
Fat bodies 136
Cyborg bodies 137
Closing words 138
Notes 140
References 140
Contents ix
7 Posture and movement 144
Introduction 144
A brief history of posture and movement 147
Defining physiotherapy’s approach to posture and
movement 155
Posture, movement and physiotherapy 157
Closing words 164
Notes 164
References 165
8 Function and rehabilitation 169
Introduction 169
What are function and rehabilitation? 172
Physiotherapy and the history of rehabilitation 176
The classification of function and disability 183
Function, rehabilitation and physiotherapy 188
Closing words 193
Notes 195
References 196
PART III 203
9 Implications for education, practice, regulation and research 205
Introduction 205
Education 206
Practice 215
Regulation 220
Research 227
Closing words 231
Notes 232
References 233
10 The end of physiotherapy 243
Introduction 243
The changing economy of healthcare 245
The new health workforce 247
Changing boundaries 249
Technological fantasies 252
Emerging opportunities for an ‘otherwise’
profession 254
x Contents
Moving beyond the present 256
Possibilities for radical change 259
Closing words 262
References 265
Epilogue: Methodology 269
Introduction 269
Key influences 270
A focus on ruptures, discontinuities and contingent
history 272
A concern with what discourses do, not what people
say they do 273
Power as productive 273
Postmodern, poststructural research 274
Not prescribing an answer 275
Closing words 276
Notes 276
References 276
Glossary of terms 280
Index 282
Acknowledgements
The End of Physiotherapy has been years in the making. For more years than I care
to remember, I have been arguing for the profession to break out of its self-
imposed shackles and reach its full potential. Along the way, I have been fortunate
to have had the advice and support of countless colleagues and students who have
shown admirable patience and kindness in sharing their thoughts and ideas,
comments and supportive criticisms. I am particularly indebted here to Martin
Chadwick, Erik Dombroski, Dave Holmes, Peter Larmer, Jo Fadyl, Filip Maric,
Debbie Payne, Amélie Perron, Trudy Rudge, Todd and Caroline Stretton, Rachel
Vickery and my friends and co-conspirators in the In Sickness and In Health
community. Many thanks go to Richard Horwood, Gwyn Owen, Jenny Setchell
and Kate Waterworth, who offered valuable comments, critique and suggestions
on various parts of the book. And to my colleagues and friends in the Critical
Physiotherapy Network, especially those on the CPN Executive, who prove every
day that there is a growing and passionate community of practitioners looking for
some new ways to think about our profession. Thanks go to the superb team at
Routledge who have supported this book from the outset, especially Emily Briggs
and Carolina Antunes. Most especially, I would like to acknowledge and thank
Barbara Gibson, whose critique, inspirations, exemplary scholarship, friendship
and influence is woven into every line of this book. And finally, to my family, who
have walked every step of the way with me. To Sue, my constant companion
and partner in everything, this book is ours. To my mother, Irene, and the memory
of my father, Michael, and, of course, to Tom and Ali. You are precious beyond
measure.
Abbreviations
APA Australian Physiotherapy Association
APTA American Physical Therapy Association
CPA Canadian Physiotherapy Association
CSP Chartered Society of Physiotherapy
ISTM Incorporated Society of Trained Masseuses
STM Society of Trained Masseuses
WCPT World Confederation for Physical Therapy
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 19th century and predating most of the other
allied health professions, including dietetics, occupational therapy, podiatry, radio-
graphy 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 20th 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 protec-
tion 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
4 Part I
system during the 20th century, it is probably not unreasonable to claim that the
profession has at least represented one of its limbs. Alongside medicine and nurs-
ing, 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.
•
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 philoso-
phies of practice in healthcare or a lack of new ideas, but that these seem to be a
Chapter 1: Introduction 5
little removed from the ‘essence’ of physiotherapy practice and they are often
couched in pseudo-philosophical language that is far too ‘fluffy’ for many practi-
tioners 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 physiother-
apy 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 biomedi-
cal 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 them-
selves as being connected to broader societal questions. Because of physiothera-
py’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 profes-
sion 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 speak-
ing 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
6 Part I
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 psy-
chology 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 pro-
fession (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 cul-
ture itself that discourages practitioners from examining their own culture. This is
the nature of the physiotherapy paradox.
•
One of the principal arguments in this book is that physiotherapy’s longstanding
approach towards the body underpins its relative ignorance of itself. Physiothera-
pists 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.
Chapter 1: Introduction 7
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 the-
ory (although this is improving); the science of haptics, physical geography; sensu-
ality or spirituality; the ethics of bodily practices or bodies in a cultural context.
Compare perhaps the contents of journals like Body & Society (http://bod.sage-
pub.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 func-
tioning 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 compo-
nent 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 19th 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 heteronor-
mative social attitudes, however, may have subsequently placed the profession in
an enviable position when the welfare reforms of the 1930s and 1940s established
physiotherapy as the orthodox provider of rehabilitation services. Security of state
protection led to the professionalisation and regulation of physiotherapy around
some quite restrictive definitions of its scope, but the move towards university-
based education in the latter part of the 20th century created opportunities for crit-
ical analysis of these restrictions. Still, physiotherapists sought to perfect its view
of the body-as-machine through clinical trials and evidence-based practice. The
profession’s research capacity has grown, but only really in the area of the clinical
sciences that most physiotherapists believe to be the cornerstone of its practice.
And why would they think otherwise? Throughout this entire period, physiother-
apy has flourished. Its purpose clear, its distinguishing characteristics obvious, its
status the envy of other similar allied and complementary professions.
At no point in its history has the profession been seriously challenged to think
otherwise. From its inception in the 1890s in England to the present day – a point
8 Part I
I will return to in much more depth later – physiotherapy has been on a course of
incremental growth and so has never seen the need to challenge its long history of
success. Clearly, there have been threats to the profession’s dominance from the
horizontal and vertical encroachment of other professions, but nothing to make
physiotherapy seriously question its identity or the theoretical and philosophical
basis of its knowledge. Indeed, if you asked physiotherapists to define the theoret-
ical and philosophical basis of the profession, they would be hard pressed to tell
you. This lack of insight leads to the paradoxical situation where physiotherapists
generally believe that their professional identity is opaque and vague and that the
public does not understand what they do, while all along their professional identity,
knowledge base and beliefs about what is real could not be more straightforward.
Rather than physiotherapy having an opaque and vague notion of itself, the
argument I set down here is that physiotherapy is, in fact, quite straightforward.
The problem is that physiotherapists have no training in how to ‘read’ it, and so it
can appear more complicated and confusing than it actually is. This is the true
nature of the physiotherapy paradox: the fundamental principles that underpin
physiotherapy prevent its practitioners from viewing health in other ways that
might, in turn, help the profession to see itself more clearly. Where other professions
require their practitioners to have a more rounded appreciation for the complexities
of health and illness, disability and disorder, physiotherapists typically concentrate
only on the body-to-hand and work with the physical form and function of the
person in front of them. To explain this with reference to two other allied health
professions, one only has to look at nursing and occupational therapy to see how
their approach to health is so very different.
Both nursing and occupational therapy have what are lazily called ‘holistic’
approaches to the health. Both are concerned not only with the physical body, but
also the broader personal, cultural, environmental, spiritual and social dimensions
of what it is to be human. One only has to look at two of the commonly used mod-
els of occupational performance and science to see this. The Canadian Model of
Occupational Performance and Engagement (CMOP-e) and the Model of Human
Occupation (MOHO) (Townsend & Polataiko 2007; Kielhofner 2008), each looks
to emphasise different dimensions of human occupation but neither only considers
the person’s physical performance as their sole interest. Similarly, the nursing pro-
fession has spent years debating the true nature of nursing (Dahlke & Stahlke Wall
2016). Drawing on critical theory, philosophy and sociology, it is implicit in nurs-
ing that there is a diversity of approaches to practice, all underpinned by a robust
engagement in science. These skills of critical analysis are necessary for nursing
and occupational therapy practitioners if they are to understand the complexities
of the patients they serve, but they are also easily applied back to the profession itself
and critical self-analysis has been a longstanding hallmark of these professions.
No such breadth and depth of scholarship exists in physiotherapy. There are a
mere handful of tentative models of physiotherapy practice, and these are rarely
debated (Trede 2006). Helen Hislop’s call for a pathokinesiological model of practice
in 1975 (Hislop 1975), and Cheryl Cott et al’s 1995 Movement Continuum Theory
of Physical Therapy (Cott et al 1995) remain unchallenged, as does Catharina
