The End of Physiotherapy and Re-imaging a New Professional Identity with Dave Nicholls, PhD

Welcome back to the Healing Pain Podcast with Dave Nicholls, PhD

Physiotherapy’s future lies in embracing a kaleidoscope of perspectives, transcending boundaries, and redefining healing itself. For today’s episode, we’re joined by Dr. Dave Nicholls, author of “The End of Physiotherapy” and “Physiotherapy Otherwise”. Dr. Nicholls is here to challenge conventional perspectives and explore the future of the vital healthcare discipline: Physiotherapy. He reveals the hidden potential in embracing a broader scope that includes social justice, psychology, and even phenomenology. He also uncovers why he advocates for a pluralistic approach, where various perspectives coexist to create a more diverse and effective healing landscape. Throughout the episode, Dr. Nicholls demonstrates that it’s time for physiotherapists to bridge the gap between the physical and the psychological, ultimately reshaping the narrative of healthcare itself. Join us in this episode as we challenge the status quo and pave the way for a new era of healing.

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The End of Physiotherapy and Re-imaging a New Professional Identity with Dave Nicholls, PhD

Each week, we explore the dynamic world of physical therapy and neuroscience, as well as uncover the opportunities that ignite change and the incredible possibilities of reshaping the future of pain care. In this episode, we’re embarking on a captivating journey that peels back the layers of the physical therapy profession revealing its evolution, its trials, and its triumphs. From the trenches of World War I to the forefront of modern healthcare, physiotherapy, also known as physical therapy, has stood as a pillar of rehabilitation and wellness.

However, now we stand at the crossroads of an aging society, a global burden of chronic pain, and shifting paradigms that threaten the very existence of the profession. Along with this, the days of viewing the body as a mere machine are giving way to a vibrant mosaic of novel theories, groundbreaking, whole-person therapeutic approaches, and revolutionary technologies.

Joining us to discuss this evolution is none other than Dr. Dave Nicholls, a visionary in the field. Dr. Nichols is a Professor of Critical Physiotherapy at Auckland University of Technology and is not only a respected researcher, writer, and lecturer, but also a torchbearer for critical thinking within physiotherapy. His groundbreaking works, including The End of Physiotherapy and Physiotherapy Otherwise challenge the status quo and provide a fresh perspective that reframes our understanding of the profession.

We’re privileged to tap into his wealth of knowledge as we delve into the history, economics, philosophy, and societal shifts that have sculpted physiotherapy’s past. We’ll also gaze into the future and reimagine the vibrant future that physiotherapy is destined for. If you’re a physiotherapist hungry for insight, a healthcare enthusiast eager for change, or simply curious about the forces shaping our well-being, this episode is a must-read.

Dave, it’s great to have you on the show.

Joe, thank you for having me. Thanks for the invite.

I’ve been looking forward to speaking with you about a lot of the work that you have and some of the publications that you have both in text as well as some peer review. Also, your overall perspective, opinion, and forethought of where we are as physiotherapists or physical therapists and potentially where we could go.

What are the benefits and the challenges? What role do we play in healthcare and how is that changing, or should it even change? These are many of the things that we will cover. The first book that you wrote is called The End of Physiotherapy. It sounds like we’re all going to be out of jobs and people won’t have access to care, but that’s not necessarily what it’s about. It’s about change.

The title of the book is a very weak pun on the idea of the end. It means both the time period and the end of a period of time. I’ll come to that shortly, but also the end, meaning the purpose. What’s the end? The phrase, “The ends justify the means,” it’s what’s the point of physiotherapy. What’s it trying to do? What’s its end purpose?

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The End of Physiotherapy (Routledge Advances in Health and Social Policy)

The temporal aspect of it probably is the most important for me because much of the work that I’ve done tries to see physiotherapy as a project and not as something impermeable. It’s not something that’s always been there or will last forever but a specific project during a particular period of time. Also, that’s particularly important in our world because physical therapies have been done throughout humanity since the dawn of time. They may be our earliest medical interventions, but physiotherapy or physical therapy as a profession has only existed for about 100 or 130 years.

For a vast period of time, before this modern period, people didn’t have a profession to lean on. A lot of the historical work that I’ve done has been to try and find out how people receive physical therapy and how the physical therapies were practiced. Historically, that’s quite difficult to do because of the physical things where there’s not a lot of documentary evidence and a lot of stuff written down about those works.

The history prior to the birth of the profession is interesting. It becomes salient now because we’re facing so many challenges and pressures in the profession. The things that the people in our profession never faced before, the atomization of the body, and the way that the body now has become a place where a million experts can offer their advice, whether trained, untrained, regulated, or unregulated.

The body has become a massive marketplace for expertise and new knowledge. We’ve got what’s called the unbundling of goodness and expertise. Also, the idea that the professions have always claimed to be ethically good but have been shown many times not to be good in the states currently with the opioid epidemic, as one example. The professions have claimed to hold expertise that is special to themselves and require people to go through regulated training, yet now pretty much everything in a physical therapy curriculum is on YouTube and can be done by a robot or AI better than we can often more consistently.

Also, the Digital Revolution is changing the way that we are thinking about knowledge and expertise. For those reasons plus many others, this project of many years to try and establish an orthodox and legitimate profession that encloses physical therapies and delivers them in a specific way does feel to me that it’s coming to the end of that period.

I’m interested in what follows because, to me, physical therapies are things that we will always need. People will always want a careful and thoughtful touch. People will always want to move in a good way. People will always want to find ways of being therapeutic without sitting behind an Instagram feed. What that looks like after the end of a professional project is one of the things that we need to start thinking about now as a profession.

As you were saying that, I’m thinking about, “How do our peers relate to this idea of the end of an era almost?” It’s the end of an era of what we all viewed as traditional physical therapy. I know there are some people that are very scared. They have a lot of anxiety around the idea that the way we have done things traditionally will radically change.

There is perhaps a smaller group, those at the curve of the innovation that are excited and saying, “Thank, God because the way we’ve been doing things is old, antiquated, and broken.” The question is how do we start to get people excited about the idea of the end of an era and the start of something fresh and new?

That’s a fantastic question, Joe. To me, that’s the interesting thing here. The reason for doing a lot of this research and writing is to find that excitement and not be nihilistic and depressed about the decline of physical therapies. The second book that I wrote, Physiotherapy Otherwise, goes through the sociology of the professions and explains from a social logical point of view why physiotherapy is facing the problems it’s facing.

It’s quite clear that in a sense physiotherapy is a colonialist project. It’s an attempt to try and take something that was in the public domain for thousands of years and colonizes it as a middle-class prestige project so that a few people could get financial and prestige benefit from being called a physical therapist.

Otherwise, using physical therapy services in some way, probably.

Also, closing them in such a way that would say you can’t have this or you can’t train in this unless you’ve gone through this very narrow funnel that we’ve approved and regulated. What we’ve seen with COVID is that when services like that are suddenly removed, people have to find other ways to get their mental health and physical health support. Also, to get their pain and chronic lung disease care and to get their post-amputee rehab.

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What we’ve seen with COVID is that when services are dramatically removed, people have to find other ways to get their mental and physical health support and pain care.

 

They cannot access the services they have before and they find 1,000 new ways. Every time somebody finds 1,000 new ways, they realize that physical therapy is just one way to approach this problem 1,000 ways. My grandparents, when they were younger, had only had two choices if they were sick. One was to go to the local doctor and the other one was to go to the hospital.

In the hospital, there was a very narrow group of practitioners they would see. The market was tiny. Now, the market’s exploded and the possibilities are endless. That causes anxiety for a lot of our colleagues because, in an unconscious way, they think, “Whilst we’re protected by state regulations, sponsorship, patronage from the medical profession, and things like that, we’ve got a market. We’ve got these people that we’ve got privileged access to. We like that and we don’t want to give that up.”

The problem is not seeing the possibilities of breaking free of that enclosure and what that might make possible. A lot of the work that I’ve been doing in the last couple of years has been trying to anticipate that it happens and think what it would be that people will be still drawn to physical therapies. It’s because if they have existed for thousands of years, there must be something about them that all civilizations have been drawn to as a therapeutic aid.

One of the things that is an interesting project of work is to try and imagine or try to find what physical therapies are but not only in a humanistic sense because quite clearly, physical therapies don’t only exist in the human world. For instance, if we take something therapeutic touch, we think that when we put our hands on people, there’s a therapeutic effect that happens in some way.

Is that because we’re consciously trying to be therapeutic? That can’t be true because there are many times when you might touch somebody or put your hands on somebody unintentionally and they perceive it to be therapeutic and you have no be no reason to think that you were doing that. It can’t be an intentional act. Is it a human thing? We know that’s not true because if a dog puts its chin on your knee and looks at you with its doleful eyes, that unconditional love can be very therapeutic for people, and so can a walk in the woods.

If therapeutic touch, which is one of the foundation stones of physical therapies, isn’t necessarily only intentional and it isn’t necessarily only human and exists outside of the human sphere, then what do we include in that domain? What do we bracket into that space? There’s an article I wrote called How Do You Touch an Impossible Thing?

In the opening paragraph, I asked this question, “If a leaf falls from a tree and lands on the soil in autumn or in the fall, when that leaf decays, rots, and puts its minerals back into the soil, is that an act of therapeutic touch?” It’s because that kind of leaf helping the soil to regenerate is a helping act. It’s not conscious. It’s not intentional, but we know that therapeutic touch doesn’t have to be. It’s not a human thing, but we know that doesn’t have to be either.

There’s another example that I used in my own mind to try and think through where the limits are. My background is as a respiratory physiotherapist. I would use manual hyperinflation sometimes with a patient lying on the side to open up a segment of the collapsed lung to try and improve their gas exchange. I’d be using the physical properties of that air to push open a segment of the lung, and I would see that as a therapeutic act.

Is that the same then as what the air molecules do as they pass underneath an airplane wing? It’s the same physical properties under the airplane that I’m using in the lungs. Aren’t they both therapeutic acts? When you start thinking about what physical therapies might look like in the future, it’s not enough to contain them to, “What are physical therapies like in an organized physiotherapy profession constrained in its traditional ways, doing the traditional things and working on humans?” With all of the things that are going on in the world, there’s a possibility here for a radically different idea of what physical therapies could be. That’s the kind of place where we could be going.

There’s a possibility for enormous excitement about physical therapy because the skills that you and I have and we were trained with are not going to go out of fashion. They’re not like manufacturing, journalism, news media, tourism, travel, commerce, banking, and things that have been decimated in the last many years by economic reform. Those things are still going to be there many years from now, but I don’t think they’re going to be contained within a professional entity like they used to be.

As you say that, the first thing that comes to my mind because we have so much of it in the US although I don’t have another country that I’ve lived or worked in to necessarily compare it to, but we have a lot of regulation in healthcare in the US. As you talk, when I hear these topics, it makes me first think of, 1) Licensure and 2) Scope of practice. The scope of practice is one that we’re all acutely aware of now because information is moving so fast.

All the health professionals in some way are accessing very similar information in the program. If you’re not accessing that information, you can certainly find it for free, as you mentioned, on YouTube, Instagram, and LinkedIn. I’m there. You’re there. We are all sharing information on these topics. Is it that we should encourage deregulation or is it that regulation can stay the way it is but there are ways to apply or evolve the skills and principles that you know about to other aspects of health, living, humanity, etc.?

There were two levels to that question. One is a philosophical one, and that’s about the nature of Regulation itself. My background has been in sociology and philosophy as well as physiotherapy. My interests are in poststructural and postmodern philosophy. The basic tenet of that is to be skeptical of all meta-narratives. In other words, you’ll have somebody online who will say, “Massages are terrible. The answer to physical therapies is X or kinesio-type or something.” They’ll tell you one thing is bad because they’re trying to sell you the model of something else.

Postmodernism, in a sense, is a skepticism to all of those people who will say they have the answer to anything. That’s for religion, science, and all those grand narrative like biomedicine that have said, “This is how the world looks.” It’s not to replace one bad notion of the world with another bad one. It’s to try and stop us from perpetuating this idea that there is a framework around which all things have to reside.

From a philosophical point of view, I’m opposed to the idea of regulation in the sense of every time you put a box around something, you’re excluding some other things and you want to be asking, “Why this and why not that?” One of my favorite philosophers is the French philosopher Gilles Deleuze. Although his work is impenetrability complex at times, he has this very simple moral framework that says that anything that opens up the possibility for difference and inclusion is good and anything that closes it off is bad.

I use that all the time in my work as an academic and a lecturer. I have courses at the university I teach where I’ve taken away as many rules about the font and the size of the text, what the word count is, and what the referencing style should be. All that stuff is ridiculous. You take it away and, gradually, as you take those rules away, you force these health professionals who are all post-graduates on my course to think about the fundamental issues that you’re asking and not to be sidetracked by the size of the margins on the page and whether the comma is in the right place on the Harvard referencing system.

Take all that stuff away so you can focus on what matters. To some extent, that’s what I’m trying to do with thinking about physical therapy. What I’m trying to do is peel away the outer layers that get in the way of us understanding what physical therapies are. Going back to philosophy, one of the great phenomenologists of the 19th century, Edmund Husserl, phenomenology has become the quest at the moment in chronic pain studies with enactivism. Also, some of the psychologically informed physical therapies are pushed toward existential human subjectivity.

Human experience has been fundamental and understanding pain, but one of the earliest phenomenologists, Edmund Husserl, said, “You can never know the essence of the thing itself. All you can know is the surface layers.” If you think the classic example is of an apple and you have this shiny red apple, what’s the essence of this apple?

If the apple weren’t red and was green, would it still be an apple? You’d say, “Yes, it’s still an apple.” What if it weren’t shiny? It’s still an apple. There are some things about that apple that are the surface layers of appearance that are all we experience. That’s the phenomenon. We never get to the noumena, the thing itself because it’s coated with these layers of meaning that we put on it.

Physical therapies are the same thing. They’re like the shiny red apple. Does it need to be red? No. It could be green. Does he need to be shiny? No. It can be dull. If we keep peeling away, the layers of the unnecessary bits of physical therapy, the phenomenological project is to try to get to the core of what physical therapy is. Now to me, that idea is about intensities. There are things lying at the heart of movement, exercise, and touch. All of those modalities have been caught in the physical therapies, which are the things that have been sustained in the public’s imagination and people’s minds for centuries.

I don’t think we know yet what those things are because we’ve always been happy with the surface-level operational guidelines, rules, and regulations. I’m underpinned by a philosophical idea that not only am I opposed to regulation in the sense of thinking what it leaves out as well. Also, what it includes but also if we keep allowing for that kind of regulation philosophically, we’ll never get to the heart of what the physical therapies are and what makes them tick.

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If we keep allowing for that kind of regulation philosophically, we’ll never actually get to the heart of what the physical therapies are and make them tick and if we don’t get to that, then ultimately, we will fail to be out.

 

However, if we don’t get to that, then ultimately, we won’t be able to practice them in any meaningful way in the future and we’ll be replaced by people who are easier to train and employ than we are. It’s because everything will default to a systematic regulated instrumental way of doing things that’s easy to manage but loses the intensities and essences at the heart of what the thing is.

Deregulation is not something that just physical therapy is facing. If you look at the world of any health profession, nowadays, there are all sorts of different technologies, avenues, and ways you can access information that might be provided by a licensed health professional, whether that be a cardiologist, for example, or a mental health provider. That information is being cracked wide open and shared globally due to technology and social media.

There’s another interesting challenge that’s emerging from this space as well because of the rapid way that the mundane and routine aspects of our work are now being so openly disseminated. Also, it’s being driven by neoliberal economics which is that we need to find ways to save money in the health system because it’s so expensive. Let’s take all of the routine work and give it to people who are with healthcare assistance or cheaper to train and employ than we are or better still, a robot or an AI engine that can do the work of that processing and that administration.

We need to find ways to save money in the health system because it's so expensive. Click To Tweet

We are falling willfully into doing this and at the same, time pushing at the other end for specialization and advanced practice and expertise. However, I don’t think people have thought this through because if you take the example of someone who’s a neonatal cardiologist. They’ve taken twenty years of training to get to this level of specialization. They’ve also gone through thousands of hours of general surgery, of openings and closings, routine checks on blood volume, and goodness knows what else, and now, they’re a specialist.

If you and I had a baby and they were born with a massive hole in the heart, we would want that person to be the one that operates on our child and not some random orthopedic surgeon who’s never opened a chest before. You want the specialist. However, if the journey to becoming that specialist is the fantasy of most established physical therapists they’ll follow that model of gradually becoming the top of the pyramid.

What if the bottom five layers of the pyramid are now no longer done by you? They’re done by somebody who’s a technician or a machine. That’s been a very important part of getting to be a neonatal cardiologist. Those thousands of hours of opening and closing and measuring blood volumes. If that’s what goes away, there’s going to be a hollowing act of the whole base of any professional project.

It’s hard to imagine how a person would become an initial cardiologist in the future. How do they skip that ten-year middle step and still become somebody we would want to operate on our chart? Whilst in physical therapy, we’re pushing for higher and higher entry requirements and higher and higher levels of specialization and remuneration. There’s an enormous hole in those bottom layers, and that work is being given away.

One of the things that’s most common about that kind of work, those bottom layers of the pyramid as well is that exactly where governments want health professionals to be working because that’s the population of complex co-morbid multi-pathology and impoverished people in poor communities. Also, people with poor access to healthcare and all kinds of long-tail complex health problems.

In chronic pain, you see this all the time but what our model of professional practice is becoming is some elite top-of-the-pyramid specialist who only sees those people who have the choices to pick off the tree and not the enormous ways of the population underneath who need our help and benefit from us, but are unmanageable in terms of their size. However, if we give that up, then our profession ceases to be a profession for the whole population and we become essentially a profession for those people who can afford us which cycles back to the beginning of this conversation.

Our model of professional practice is becoming some kind of elite top of the pyramid specialist, who only sees those people who are the choices to pick off the tree, not the enormous ways of the population underneath, who need our help… Click To Tweet

This is why I’ve been so interested in historically what happened before the physical therapy profession existed. In the states, for instance, two of the most common narratives about the way that the physical therapy profession began are that it began in World War I because of the number of injuries that the soldiers received and the necessity to have physical rehab. It then gained a massive boost with infantile paralysis and the polio epidemics in the ‘20s and ‘30s in the States, but neither of those two makes sense because there have been plenty of wars.

In the course of human history, there have been lots of wars, and at no time before World War I did anybody say, “We need a physical therapy profession.” I’ve just finished an article for the Journal of Physiotherapy and Practice, which is about us. The question is, “Is physiotherapy a luxury?” It’s because you find very little evidence of formal physical therapy offered to people in the population prior to 1900 in any country.

I looked at some data from the Napoleonic Wars with the sailors in the British Navy during the Napoleonic Wars. If you think about what life on a Napoleonic wooden battleship would have been like during the Napoleonic Wars, it was treacherous. They were often nine months at sea. They were constantly ill or injured. The injuries that are reported are traumatic brain injuries, amputations, dislocations, and massive soft tissue injuries. They had often had a surgeon on board.

They have massive problems with scurvy, syphilis, and all kinds of other things and yet there is not a single account in the literature of anybody on board any ship doing any physical therapy. You have a traumatic dislocation of your shoulder in a battle and you are expected to make do of yourself now. If you can’t provide physical therapy on what is essentially a floating gymnasium for nine months for the people who are essential to the good running of that naval ship, when are you going to provide physical therapies?

My point in the article is to say that we have been very dependent on the state to sponsor, support, regulate, and control physical therapies for 100-odd years. That time period is coming to an end. When that period ends and we fall into an open marketplace for physical therapies, will the physical therapies look like they did in the 18th century during the Napoleonic Wars which is you only get the physical therapies if you’ve got enough time and money to afford it? Is that the model that we’re looking at?

Now, that seems to me to be a very bleak model of the future of physical therapies. The book I was talking about, Physiotherapy Otherwise is trying to make the argument that rather than face that kind of nihilistic bleak future, why don’t we be proactive now and start doing what people in the food culture movement have done, which is give our therapy away. It’s like Jamie Oliver and Gordon Ramsay do with all their recipes. Give them away so people can learn to be physical therapists in their own right.

Stop trying to protect the profession and contain ourselves and enclose ourselves and continue this colonial project of enclosing this territory of physical therapies. Blow the doors off and start giving those therapies to people so that they are equipped in their communities to manage themselves, their bodies, their health, and their movement. That feels to me to be a much more positive response to what’s coming rather than having the devil take the hindmost.

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Stop trying to protect the profession and contain ourselves and enclose ourselves and continue this colonial project of enclosing this territory of physical therapies, below the doors off, and starting giving those therapies to people.

 

I take that as a social justice stance because as you’re telling the story and painting a potential picture of the future only the wealthiest or those with resources will be able to access one-on-one care from a physiotherapist. Also, when you have a lot of resources, you typically but not always, don’t necessarily have multiple complex conditions. At least in the United States, when you’re looking at people from you know challenged groups or lower socioeconomic groups, they typically have multiple comorbidities and they have limited resources.

Also, at times based on history and as you’re talking about colonialism have policies in place that prevented people from having access to resources. There’s a social justice aspect to this because the question we should ask ourselves is do we want to live in societies where people may be disabled and not have access to the knowledge, wisdom, and care that we all have as licensed health professionals but it’s very foreign to some people.

You’re right. In the book, The End of Physiotherapy, one of the main arguments in the book is that when our profession adopted this idea of the body as a machine or of treating bodies like machines, it’s a very important thing to establish our legitimacy to touch people. A time when there was a lot of paranoia around touch, sexuality, and prostitution, and those kinds of things are very important things to do.

However, when you choose to take such a particular approach to bodies, you deliberately don’t choose a bunch of other approaches and we’re starting to learn that now that for 100 years, we haven’t thought about human subjectivity and human lived experience. The kind of existential experience like being in pain. Some of the most interesting research that’s coming out now is in the chronic pain space where people are starting to ask, “If pain is no longer in the tissues and if we if we’re saying that you can’t find pain in the disc or it’s in the synaptic cleft or something like that. If it’s not in the biology of the body, where is it now? Where is it gone to? Where can we say pain resides?”

Philosophers have been asking that question. Nietzsche was asking that question in 1890 and Kierkegaard before that. The question is about where pain is and what pain functions are. Also, why we exist in pain at all is an age-old philosophical question that physical therapists are just now turning their attention to. They are exploring literature that was never even suggested would be relevant to us because we needed to learn about the Krebs cycle and the oxygen dissociation curve, motor neurons, and things like that. That’s what we were told we had to think about that.

That stuff’s interesting but the other aspect of health that we’ve never thought about is how when you take an idea of the body as a machine and you’re supposed to depersonalize the person, you deliberately pay no attention to the social conditions that exist for a person regardless of their agency and their choice. The things that people are born into and have to live with regardless of their choice, for instance.

If you’re born into a situation where your family is poor, they can’t live in the center of town with good access to all of the healthcare services on the doorstep. They live way out probably where the housing is a bit cheaper, and it may be that it’s probably near a major road network or it’s on polluted land. It’s not a very pleasant place to live. The schools aren’t that great and because nobody wants to go out and teach out there particularly.

The kid grows up with that with less than optimal schooling. They don’t graduate with a very good job so they don’t earn a good salary. They then go off and try to find a place to live and they have to live on the outskirts of town where it’s a long way from the services and so the cycle perpetuates. There are no magic wands here and everybody would love to be better off but we’ve never asked those questions in physiotherapy.

We’ve never seen that by taking a body-as-machine approach to people, we’ve blindly ignored the social conditions that shape what a person’s health might be. Many years ago when I started doing my respiratory work, I did a Master’s degree in Birmingham. It was in Research Methodology and it was in a radical left-wing campus. At the time in Birmingham, in the UK, there were a lot of there’s a lot of race riots and a lot of anger, particularly from the West Indian community and the Pakistani community about police brutality and things like that.

There were a lot of awful practices by the police in the health system too. This department taught a very different kind of research methodology. It was also a Black feminist methodology and it was disability activism and things like that. One of the first books I read was by Simon Williams. It was about chronic respiratory disease and he was a sociologist. He talked about what people with lung disease have to go through in their social worlds to make do when they can’t hold down a job because they’re so breathless because of and they don’t go outside because of the stigma of coughing all the time and spitting stuff out. They think of themselves as increasingly dirty or people accuse them because they smoke of doing it to themselves. They lack empathy and all this stuff.

I thought to myself at the time, in my training as a physio, nobody ever told me this stuff, and yet every day in my work, that’s exactly what I saw. I was in an industrial part of the Midlands. I was with coal miners and people with chronic lung disease all the time. This was exactly what I was seeing and yet, it didn’t feature in my physio curriculum at all.

I suppose that started me off thinking, “It’s not so much a question of social justice.” We come into health professions because we want to care for people and help people. I’m interested in those people who I can help the most and who may need me the most. It’s not so much about social justice. It’s trying to be recognized that certain members of the population are disproportionately disadvantaged in terms of their health, but conditions that are not of their choosing like misogyny, racism, ability stigma, and ageism. There are so many kinds of stereotypes about the way that we think about people that reside in our heads and are as much a project for the profession as making the person have greater elbow extension at the end of a treatment session.

Do you think things like psychologically informed physiotherapy are a way that physiotherapists are responding in this area where they’re saying, “We know a whole lot about the body? We also know a bit about behavior, the brain, and psychology. Now, we’re starting to be queued into social determinants of health whether it’s great treatment packages or models or therapies.” They’re starting to respond in those ways, but they’re still within the confines of 1) The clinical context, and 2) Still within the confines of regulation, the scope of practice, and things like that.

It’s interesting to me, especially in the United States where we hold ourselves in high regard as being innovators and creating things and developing new things. When you look at our profession, we still have not seen the era of innovation happen. It’s happened in other areas of medicine, but we still haven’t quite seen that happen in physiotherapy.

I agree. On the one hand, psychologically-informed physical therapies are doing something but with my sociological hat on, I would also say it’s quite telling how much the people in these approaches like cognitive functional therapies and acceptance and commitment therapy, for instance, behaviorism, and the cognitive approaches are holding very much onto a biomechanistic and biological basis for their beliefs. The brain is still the governing organism here.

The reasons for that are pretty obvious. If we think about the biopsychosocial model as three spheres in the Venn diagram, it has to encompass everything about human subjectivity and the individual’s lived experience. The phenomenological existential experience as well as the psychological. Now, generally, most psychology sits towards the biological end because it follows the principles of biological sciences, reductivism, objectivity, RCTs, clinical trials, and that quantitative approach to seeing the mind mechanistically. Cognition and behaviorism do that very much.

That’s at the top end near the biological sphere but at the bottom end of that sphere, a long way away from there, you also have the whole phenomenological existential fear which completely rejects a biological basis to illness. A biological basis to illness says that illness resides within the body. It’s pathology that through a process of specific etiology, you can find the biological cause of the problem.

Existentialism and phenomenology say, “The reality of something like pain is entirely in the person’s sense of their being and is entirely a psychic construct.” It’s not a biological thing at all. Even if it was biological, you have no way of knowing because the only way you ever approached the world is subjectively through your lived experience, through your senses, and by turning your attention to some things that are meaningful to you at that moment.

Whilst the psychologically informed physical therapies are bleeding out of the biological domain, they are only doing it very slightly. They’re still keeping a placental connection back to biology which is one of the reasons why. I’m in the process in the Physical Therapy Journal of having a conversation with Peter Stilwell and Sabrina Coninx about enactivism.

My argument in response to them is that I’m against the idea of holism. I don’t think we should be aiming to be biased like a social or holistic. What we should be trying to do as a profession is to be pluralistic. I could see, for instance, that you could have a physical therapist who embraces the biological sphere totally and it dominates their treatment approach. They can be as objective and as dispassionate and as focused on the pathology in front of them as they like, but you could also in the next room have a physiotherapist who was a total existentialist. Who said that your pain experience is entirely in your lived experience? I want to know about your lived experience of this pain. I want to build up a kind of subjective relationship with you.

Maybe we shouldn’t be aiming to be socially or be holistic. What we should be trying to do as a profession is to be pluralistic. Click To Tweet

The therapeutic experience is going to be in the interchange. It is not going to be what I do to you. It’s going to be what we do together. There’s going to be an expressive aspect to this. There is going to be an exploratory and iterative process. Therapy sessions are going to be longer. They’re going to be much more discursive. I’m not going to do objective tests and measures. I don’t care about your anatomy. I care about you.

In the next room, you could have somebody who’s a physical therapist who’s totally in a social space, the social domain who’s taking that practice out into the community. Who is working with communities in need and who’s using their power and their prestige to change things about access to open spaces for safe walking and exercising, better facilities for exercise, and therapy? Also, community involvement in therapeutic programs, gardening, outdoor walking, and things in the community.

They are changing the way that the community experiences pollution, fresh air, clean spaces, and safety such that they can become healthier through that kind of physical therapy interaction. Each one of those three therapists grounds their practice on a fundamentally different understanding of the nature of illness as opposed to that Venn diagram, which tries to chuck them all together and say, “You can be all those things at the same time.” I don’t think you can.

The cycle of a psychologically informed physical therapist is doing a service in as much as they’re trying to break the edges of the biological, but there are spaces on the Venn diagram, there’s uncharted territory on that Venn diagram that physical therapies would be blown away by if they could go off and explore those things and they could feel justified in doing that. To feel justified in doing that, we can’t have the kind of regulations we have now that say, “You can’t do it that way.” We have to free those therapists up to become existentialists and sociology or whoever they want to be.

The big positive that I see is training lends itself well to becoming this kind of flexible practitioner that you’re talking about. It’s a great benefit and I believe that many health professionals don’t have that within their program. They’re very focused on the brain. Once practitioners start to practice, they start to awaken to, “There’s a body below this brain that has to be healthy as well.”

I want to unpack this a little bit with you. We still primarily have a body-based profession. We’re using body-based treatments. Let’s say exercise and manual therapy. These are the two main body-based treatments that we’re using. People are comfortable with that. They see through an impairment lens which has problems right there. We have said, “Let’s add something onto that,” because it’s more than impairment happening here.

It’s because pain is not necessarily from the tissue. It’s encoded in the nervous system. Therefore, we need to treat the brain. We develop pain education and psychologically-informed care, but it’s still somewhat through a biomedical lens because you’re targeting an organ or maybe an organ system. You also have phenomenology which technically should be this multidisciplinary approach to living and probably treating people except that people see phenomenology as something that fits into psychology only.

This is where we’re heading in the literature because psychologists have taken on phenomenology. When you look at the root of phenomenology, it’s experience, and a lot of that you experience sensation in your body. Not just what you experience in your mind but also in your body. The separation of mind and body is feudal in many ways. How do we start to encourage our colleagues to think about the body and human experience from a phenomenological perspective without thinking, “I have to be a psychologist to understand and put this into practice?”

Those people who are quiet and conflate psychology with phenomenology are misunderstanding the two fields. They’ve not read enough or understand enough about them. There are aspects of phenomenology that relate to psychology but there are massive aspects of psychology that take off in a completely different track. Particularly, cognitive and behavioral sociology is nothing like phenomenology.

That’s not in terms of its application. That’s in terms of its fundamental beliefs about the reality of life. You’re operating on a very superficial level if you equate the two. That’s like saying anatomy is pretty much the same as Catholicism. They’re not at all the same. We’ve got to do a lot more work to understand what these fundamental principles are. For those people who are interested in phenomenology, there’s a ton of phenomenological work in healthcare.

In fact, there’s a ton of phenomenological work in physiotherapy if they look at the Norwegian Psychomotor Group, which has been running a Master’s degree using phenomenology as its basis. Some of the research that’s come out of that group of people is astonishing. It’s very much applied to the physical therapy/physiotherapy world, but they come up with opposition even in their departments and their own units in Norway from biomechanists who say, “This is taking physiotherapy in the wrong direction.”

They feel like it’s taking physiotherapy in the direction of providing mental health care, which in some way, I’m like, “We do improve people’s mental well-being so why should we not feel comfortable negotiating in that space?”

I’d make three distinctions here because they evolved and developed in three tracks around the same time. At the end of the 19th century, late 1800s, or early 1900s, you have the consolidation of phenomenology as a method. This is the work of Edmund Husserl, Martin Heidegger, and people like that who are interested in the nature of being. It’s Heidegger called Dasein or being-in-the-world. It’s a philosophical question about the nature of being for all things, not just humans, but for everything.

Also, the human experience of intentionality and being turned towards the thing in the world. It has nothing to do with mental health. It has nothing at all to do with mental pathology or illness. At the same time, you have the birth of psychoanalysis particularly in the work of Freud in the early 1900s, who tries to develop a model of the psyche, which then forms the basis of the psychoanalytic training and psychotherapeutic work.

At the same time, you get the birth of what is essentially cognitive psychology. Cognitive psychology and the vast majority of psychology take the very reductive biomedical route to understand the psyche. Whereas psychoanalysis takes the psychic route about the unconscious, the id, the superego, and the ego, which doesn’t have a basis. Freud wasn’t particularly interested in the biological basis of where the id or the superego existed. He was interested in how those things work to create things like paranoid schizophrenia, neuroses, panic, and those kind of things.

There’s an element of mental health in psychoanalytic theory, a massive part of it, but it doesn’t take a biological view. Let’s say you have these forms of psychotherapy, which don’t appear to have anything to do with Biology. Gestalt therapy, for instance, or psychodynamic therapy. Whereas, if you were to think about the pathology, the biological kind of understanding of mental illness as something in the brain, that’s very much along that cognitive behaviorist neuroscience view, which is where our physiotherapists have mostly gone into, and for good reason, I would say.

It’s because if physiotherapists took the phenomenological route and said, “We’re fully into phenomenology,” then you think about the implications of that. You can scrap all the anatomy, biomechanics, pathology and physiology, and kinesiology in the curriculum because you’re now a phenomenologist. It doesn’t mean anything. It doesn’t exist. The entire physio curriculum is gone. We probably lose our connection with Western biomedicine and that patronage, which is a 100-year project to sustain.

If we don’t have the support of the doctors, we’re probably not going to get many patient referrals. That’s a bit risky. I can fully understand why people in the chronic pain sphere are looking to expand, but they’re also keeping hold on to daddy who’s providing them with all the support that they need and not wanting to let go. In that sense, we’re quite immature as a profession.

It ought to be possible that physical therapists can be phenomenologists but the scope of the profession and the tolerance within the profession for seeing it in a much more pluralistic way or a much more diverse way, what I call having 1,000 physiotherapists in the book Physiotherapy Otherwise. At the end of the book, I talk about, “We need 1,000 therapies and we need vernacular physiotherapy,” our therapists fit into their communities and make sense.

A person in Christopher in New York is going to function very differently from somebody working in Mumbai in India because their context is different. That kind of plurality is the direction I would like to see the profession going in. Also, a little bit more bravery and courage because the times there are changing. We are never going to go back to the Golden Age after World War II when everything looked rosy and our parents, our mommy, and daddy with there to support us.

We could happily do knitting our own way. It’s never going to come back. To me, the biggest project is to think about what comes next and I don’t think that’s going to be more containment, control, or constraint. It’s freeing the professional because the stuff we do is magic, but it’s been held back for too long.

I wrote a model paper on pain and the underlying or the underpinning theory in that paper is something called salutogenesis. It doesn’t show up in the physiotherapy literature too much at all. I use it as the underlying theory because, in essence, it’s a sociological model. People say, “How do you use this? What are you going to do with them?” I say, “It needs to be applied in a broad way, and then maybe you can niche down into things, but the application of that is specific to the clinician you are and then the population that you’re working with.” I wrote it through the context of chronic pain so I have niched it down a little bit there. It’s interesting to see if as a profession, we have the ability to broaden our thinking out to the community, the nation, etc., and how that will impact the next generation.

I’d go further. I’m interested in breathing problems. Breathing is a lot like pain. They’re both subjective experiences that can only be understood by the person who’s experiencing them. They’re both phenomenal in the sense that they transcend many aspects of people’s lives. For some time now, I’ve been questioning why it is, I was taught about alveoli and not about the Amazon basin. Why I was taught about ventilators, but not about air conditioning units? Why I was taught about Western concepts of gas exchange, but not Maori concepts of heart and breathe as a birth of life and the connection to the spirit world?

There are so many ways in which breathing impacts people and oxygen and air. There’s an exercise I do with the students when I’m teaching this stuff. Let’s say there’s an oxygen molecule in the room in front of you, let’s say a couple of feet away, when does that oxygen molecule become part of me? Is it out there in the air? Is it in my truck here? Is it in my alveoli? Is it in the mitochondria? Sixty percent of my body mass is oxygen. There’s more oxygen making up my body mass than carbon so there’s quite a lot of oxygen that makes up me Dave Nicholls.

However, I don’t when I acquired that body mass or that solidity as an entity. When it comes to breathing, I’m exchanging breathing with people all the time. Am I them and they are me? Am I connected to that tree? Where do I begin and end? This stuff starts to get quite messy. If we think of chronic pain as only a human experience and limit our physical therapies to that, it feels to me like we’re missing something.

Particularly, now that we’re so concerned about things like air and pain. The two of them are very fundamental things that people are experiencing. We ought to have something to say there. We need to start thinking about a broader field for our work. Also, allowing and giving ourselves permission to get into some of the stuff because some of the things that we’ve been practicing for many years could have a profound effect on more than just people in chronic pain and more than people with chronic lung disease. There are bigger things to be done now.

I’m hopeful that conversations like this can help people stretch their minds a little bit and think, “Maybe some of the fundamental foundational things that I learned as a physiotherapist in school can be applied in a different way that no one’s even thought about yet.” You mentioned touch-with-the-leaf example. It is brilliant, but how do you take that and deliver it to your known community so that it improves their health?

What I’m working on at the moment, that’s my latest work. Hopefully, that’s going to be a book that comes out in the next couple of years to try and work through some of that stuff because I don’t know that there’s something there. I know that there is. I’m not quite sure what it looks like here. If there were 1,000 of us doing this kind of work, we’d get there faster.

There are people out there who have started to do this work. They’re not so visible yet but I’m slowly coming across people like yourself who are thinking differently and therefore acting differently and it’ll change how or what physiotherapy is and how it’s delivered. We look forward to your third, but I want to make sure we point people to your first two big books. The first one is The End of Physiotherapy. The second one is ca

HPP 316 | Physiotherapy
Physiotherapy Otherwise

lled Physiotherapy Otherwise. People can find those books online. Amazon is a good place and other retailers. However, in the meantime, as we wait for your third book, how can people learn more about you?

I would say this about the two books. The second book Physiotherapy Otherwise is free to download as a PDF or an eBook. If you go to my site on the AUT site, you can download a free copy of the book if you want to and if you want the paper version, you can get it through Amazon print-on-demand. It should cost you $20 or so. The first book is incredibly expensive because Routledge put a premium on it. If you have access to an academic library, that’s probably the best way to get it.

The best places to find me are through a site that I write regularly on called ParaDoxa and that’s on Substack. It’s ParaDoxa.Substack.com. I’m writing there every week. You can sign up for free. There’s no cost to that. I’m trying to write some of this stuff there to a broad health audience and push the boundaries of post-healthcare thinking.

I’m also writing a lot all the time and you can find the stuff that I write on the AUT website at AUT.AC.nz. I’m here in New Zealand. You can always email me. If you’ve got any more interest in this stuff, get in touch. I love hearing from people who’ve heard this and think there might be something for them in there. It’s a pleasure to talk. It’s been lovely.

You’re welcome, Dave. It’s been a pleasure. As you mentioned, your second book called Physiotherapy Otherwise is free to download. Please let us know about the new things that you do so you can come back on the show and we can share the information. In the meantime, I asked all our listeners to share this episode with their friends and colleagues, especially, if you’re in physiotherapy, but other health professionals will be interested in some of the perspectives that we shared here as well. Thanks for joining us and we’ll see you next episode.

 

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About Dave Nicholls

HPP 316 | PhysiotherapyDave Nicholls is a Professor of Critical Physiotherapy in the School of Clinical Sciences at AUT University in Auckland, New Zealand. He is a physiotherapist, lecturer, researcher and writer, with a passion for critical thinking in and around the physical therapies. Dave is the founder of the Critical Physiotherapy Network (CPN), an organisation that promotes the use of cultural studies, education, history, philosophy, sociology, and a range of other disciplines in the study of the profession’s past, present and future. He is also co-founder of the International Physiotherapy History Association (IPHA) Executive, and founding Executive member of the Environmental Physiotherapy Association (EPA).

David’s own research work focuses on the philosophy, sociology, and critical history of physiotherapy, and considers how physiotherapy might need to adapt to the changing economy of health care in the 21st century. He has published numerous peer-reviewed articles and book chapters, many as first author. His first book – The End of Physiotherapy (Routledge, 2017) – was the first book-length critical history of the profession. A second sole-authored book – Physiotherapy Otherwise – was published in early 2022 as a free pdf/eBook (available from https://ojs.aut.ac.nz/tuwhera-open-monographs/catalog/book/8).

He was co-editor on the first collection of critical physiotherapy writings – Manipulating Practices (Cappelen Damm, 2018) – and was the lead editor for the follow-up – Mobilising Knowledge (Routledge, 2020). He is also very active on social media, writing weekly on contemporary critical physiotherapy issues. In early 2023 he established a new site specialising in post-critical healthcare (paradoxa.substack.com). He has taught in physiotherapy programmes in the UK and New Zealand for over 30 years and has presented his work around the world.

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