Connectivity #3 - Connectivity and physiotherapy

This post is part of a new project for the Critical Physiotherapy Network.  If you want to know more about the project, track back to this post.

Connectivity, as I see it, is about the way people use mediating technologies to engage meaningfully in the world.  Connectivity is about real life, real people's abilities, real problems - the very things that physiotherapists face every day.  In some ways, it's nothing new to physiotherapy, but it carries with it the possibility of a radical revision of our purpose and function as a profession.  Here are some thoughts on how connectivity might enhance and/or challenge our practice.

Physiotherapy has always followed a reductive biomedical model that divides people up into organ systems (cardiovascular, musculoskeletal, neurological, etc.), and we teach our student how to recognise normal bodily function (usually based on 'normal' anatomy and physiology), and then how to diagnose the abnormal (pathology).  This is the basis of all our assessments, most of our treatment and rehabilitation, and almost all of our practice philosophy.  There are many important reasons why we do this, but the approach comes with many problems that are not often acknowledged.  Connectivity not only tackles these problems head on, it also offers positive alternatives that are in line with the way health care is changing.

Biomedicine privileges special knowledge of the body,  and this purposefully puts practitioners in the position of experts and patients as passive recipients of care.  It places a great deal of emphasis on curative and acute health problems (and health professions' ability to diagnose and treat them), and pays much less attention to long term health conditions that require care not cure.  Biomedicine favours reductionism (dividing the body up by systems and regions - orthopaedics and neurology, for example), and organises the entire health care system accordingly.  It emphasises normalisation, where individual variances are evaluated against population norms and people are judged as normal or abnormal, mad or sane, able bodied or disabled, against sometimes arbitrary, shifting definitions, decided upon by the self-same experts who proffer the remedy.  In keeping with Western cultural ideals, biomedicine and the physiotherapy that follows it, valorises autonomy and independence, and views co-dependence and inter-dependence as suspect.  Medicine favours individuals over communities and cultures.

These are just some of the limitations people have identified with biomedicine, and the tensions that accompany them are manifest in any number of shifts taking place in health care that are calling for change.  To take two examples: primary care and collaborative practice.  Primary care is built around principles that put the client/consumer/patient in the centre of the decision-making process.  Expertise is devolved to communities of need and health professionals act in service of communities.  Collaborative practice (a term that I personally prefer to interprofessional/transprofessional/interdisciplinary practice) emphasises democratic decision-making, in which leadership is shared and owned by people who have a vested interest in sharing skills, negotiating priorities and being involved in capacity building.  Both of these approaches are seen as future developments in 21st century health care, but both are being held up by medicine's dogmatic assertion that the 'doctor knows best.'  (The push for Evidence-Based Practice is but one example of the turf war being waged by medicine to reassert it's dominance over democratic decision making in health care).

Connectivity challenges biomedicine and offers one possible future for health care.  If physiotherapists embraced it, it might induce us to change the entire basis of our practice.  For example, we would not assess patients to find out what was wrong with them.  The assessment would be a more open process, less directed by us, and more open to the other person's agendas.  Secondly, patients would cease to be passive recipients of our ministrations, and instead become collaborators - equals.  Their intimate knowledge of their experiences of health and illness would be valued alongside ours.  No-one's knowledge would be superior simply because they held a certificate for it.  Thirdly, we would shift our focus from only looking for the biological cause of the problem (although this might also be necessary), to identifying the need, desire, impetus and barriers to change.  Our view of movement would have to shift from the narrowly biological notion we currently draw on, to embrace something much more vibrant and diverse.  We would become advocates for movement, touch, the body, function and activity in all its forms.  We would seek out barriers people are facing that are preventing them from engaging in those things that give meaning to their lives - the things that cause them suffering, pain and intertia - and our role would be to help people overcome them, to help them liberate themselves to move again.  We would still work with our hands, we would still mobilise and position, exercise and assess.  We would still problem solve and use our inductive reasoning skills, but instead of pursuing a narrow set of biologically determined outcomes, we would look to liberate movement in all its forms to enable people to make meaningful connections for them - sometimes despite what other people think and believe.

Connectivity is about diversity and inclusiveness, connectedness and community, co-dependence and mutuality.  These are very different concepts to those we currently valorise in physiotherapy.  But ask yourself how well medicine born of the 19th and 20th centuries is now operating, and ask what the future holds for a profession that still espouses ideas of universal norms, biological reductionism and control?  Connectivity offers one response to the changing economy of health care that may offer some valuable insights into how the profession might develop in the 21st century.

In the post that follows I will summarise a few of the philosophical drivers of connectivity.

As before, if you have any comments, please either post them below or email me directly (david.nicholls@aut.ac.nz).