Physiotherapy, have we “Imprisoned” Bodies?

Physiotherapy is one of the caring professions. It lies alongside Medicine, Nursing and other Allied Health Professions. Every single human on the planet is entitled to healthcare, and whilst some populations of the world do not receive adequate healthcare, there are others that are subjected to overdiagnosis and overtreatment (Maher, O’Keeffe, Buchbinder, & Harris, 2019)

The concepts of overdiagnosis and overtreatment are recent examples of the impact of medicalisation on world populations. This makes me ponder on the extent of physiotherapy’s contribution to overdiagnosis and overtreatment. Interestingly, there is sufficient evidence that would suggest it does; for instance the literature on low back pain (LBP) (Maher, O’Keeffe, Buchbinder, & Harris, 2019; Sullivan, 2011). What about aspects of clinical practice such as imaging? Again the evidence base could suggest this is the case (Deyo, Mirza, Turner, & Martin, 2009; Flynn, Smith, & Chou, 2011). Interestingly and more recently, evidence has suggested that in individuals with a history of LBP, baseline MRI findings cannot predict future LBP over a 10-year period (Tonosu et al., 2017).

Physiotherapy, a profession that bases its identity on movement, the movement system, and health is going through a transition of change, and whilst we attempt to reconcile a philosophy underpinned by a biomechanical model to a biopsychosocial model, the turbulence of change is impacting the identity of the profession. Concurrently, and more pressingly, I wonder about the impact the biomechanical/biomedical model has had on the individual living with chronic illness or disease. Take the biomechanical model for instance and the discourse that surrounded the way bodies should be. Postural faults, leg length discrepancies, and misalignments, upper and lower crossed syndromes are reasons for a person’s ongoing pain and disability and yet much of this has been refuted (or is unsubstantiated) (Lederman, 2010). Yet the impact of what clinicians say to people can have a lasting impact (Ben Darlow et al., 2015, 2013).

As I continue to grapple with philosophy, my reading has led me to the works of Michel Foucault. In his final book “The History of Sexuality” (1978) he discusses the concept of ‘biopower’. Foucault refers to biopower as, “literally having power over bodies; it is an explosion of numerous and diverse techniques for achieving the subjugation of bodies and the control of populations”

Foucault explains that the human has become objectified. A science, as something to be understood. We categorize, measure, and compare the body to what is understood to be normal and abnormal and how this impacts the function of society. Humans as a species become something to be studied themselves.

This concept of objectification becomes subjectification. The information that objectification provides gives healthcare professionals “power” over society. The intention is that we treat people on the basis we can rehabilitate to support their recovery, re-enabling them to maintain their contribution to the function of society. In the same instance, we affirm our position as individuals with the “know how” to promote recovery and health. In essence humans become subjects of a system the requires them to maintain the smooth running of a societal machine. This, as I understand, is what Foucault refers to as the subject within the concept of biopower.

It is important to note that Foucault’s interpretation of power was not one of oppression or force. Whilst some may argue that Foucault’s work shared parallels with that of Marxism, Foucault rejected Marxism. Foucault saw biopower as something productive, not oppressive.  He argued that practices of power were based upon discourses, knowledge, power, and truths to carve the way society and state operated. In addition, Foucault argued that rationalisation was not generalised across society, that there were specific rationalisations, suggesting there was more than one way to do something. Foucault would ask, “what justifies doing one thing over the other?”  Consider this again within physiotherapy and the postural structural biomechanical model. Patients are categorised as such as having faulty mechanics or postural faults based upon the premise that body movements and positions fell outside of normal measurements and categories. In the context of physiotherapy, “What justifies biomedical discourse over other means of discourse?”

Is physiotherapy immune from biopower? Historically, the profession has served the state, expanding its autonomy to become a profession that rehabilitates and advises on movement. Underpinned by a biomedical/biomechanical model, physiotherapists rehabilitate injuries through hands-on approaches, mobilising and manipulating in an effort to rebalance asymmetries, postural faults, and misalignments (Lederman, 2010). In addition, physiotherapists provide advice on how best to move, with the intention of minimising the risk of injury. For example, from the 1970s to the 1990s in New Zealand the message, “don’t bend your back like a crane” was synonymous with the physiotherapist Len Ring. Len led the charge on ergonomic spinal care and minimising back injuries in the workplace. His signature message has been left imprinted in a generation and has been shown to influence the younger generation when it comes to spinal care and lifting in the home and workplace (Darlow et al., 2014). Perhaps unsurprisingly, Foucault writes of biopower, ‘Baldly, at first sight and somewhat schematically, we could say that…discipline is exercised in the bodies of individuals’.

A further example of “discipline” is physiotherapy’s migration into living healthy and active lifestyles, the movement ‘exercise is medicine’ is a mechanism to encourage populations to take responsibility for their own health, with the support of objective truth that exercise is therapy for chronic disease (Pedersen & Saltin, 2015). Again I want to stress here that I am not suggesting that we oppress or force people into exercising. However, we are legitimising disciplinary power through academic and institutionalised knowledge. Contrastingly, people living with chronic disease or pain can be made to feel guilty for not following instructions or advice provided by clinicians, who, from one perspective cling on to ideologies that “they know work” or from the other, utilise an increasing and confirmatory evidence base to justify their understanding about bodies. The feeling of imprisonment of bodies or the sense that a person’s ‘life is on hold’ (Bunzli, Watkins, Smith, Schutze, & O’Sullivan, 2013; Ryan & Roberts, 2019) is a significant factor in the reality of living with chronic disease or pain.

This echoes the example Foucault gave of “objectification becomes subjectification.” That to a person living with chronic disease their body is never truly their own as they are caught in the fray between the battle of self and “patient”. That the more that is understood about the body the more people become “imprisoned” by it.

We could think of people who live with chronic disease as ‘subjects’ of knowledge, not the possessors. In their effort to seek resolution and resolve of disease they surrender their bodies to diagnostic imaging, surgical procedures, specialised exercise regimes – the latest craze is to address a “condition” called gluteal amnesia, which is claimed to be a cause of lower back pain (McGill, 2007). These methods become legitimised in the name of expert opinion, are then used to gaze deep into the essence of an individual’s very being, and in return, risk delegitimising the person, estranging them from their own bodies.

I ponder on the impact physiotherapy has (historically and albeit inadvertently) upon the perpetuation of the “imprisonment of bodies.” Is the crisis of chronic disease a crisis of governmentality, much like the argument surrounding the covid-19 epidemic (Suri, 2020)

The question now is…. What do we do about it?

Post Structuralists such as Foucault would argue, that we are not reducible to an identity – that our position and identity is not solely defined by the restoration of impairment to promote function. Instead, post-structuralists would look into our history. Exploring our past can help us to develop alternate practices, opening up other ways of being, open new opportunities and ways to practice and challenge the identities that are currently on offer. Ultimately, Biopower. It doesn’t have an effect on people physically but on possible future actions and possibilities.

Rather than asking, “how should one live?” Perhaps a more apt question is, “how might or could one live?”

Thanks for having a read.

TNP

References

Bunzli, S., Watkins, R., Smith, A., Schutze, R., & O’Sullivan, P. (2013). Lives on Hold A Qualitative Synthesis Exploring the Experience of Chronic Low-back Pain. Clinical Journal of Pain, 29, 907–916.

Darlow, B., Perry, M., Stanley, J., Mathieson, F., Melloh, M., Baxter, G. D., & Dowell, A. (2014). Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. BMJ Open, 4(5), e004725–e004725. https://doi.org/10.1136/bmjopen-2013-004725

Darlow, Ben, Dean, S., Perry, M., Mathieson, F., Baxter, G. D., & Dowell, A. (2015). Easy to Harm, Hard to Heal. Spine, 1. https://doi.org/10.1097/BRS.0000000000000901

Darlow, Ben, Dowell, A., Baxter, G. D., Perry, M., Mathieson, F., Perry, M., & Dean, S. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine, 11(6), 527–534. https://doi.org/10.1370/afm.1518.INTRODUCTION

Deyo, R. a, Mirza, S. K., Turner, J. a, & Martin, B. I. (2009). Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine : JABFM, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102

Flynn, T. W., Smith, B., & Chou, R. (2011). Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good. Journal of Orthopaedic & Sports Physical Therapy. https://doi.org/10.2519/jospt.2011.3618

Lederman, E. (2010). The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain. CPDO Online Journal, 1–14.

Maher, C. G., O’Keeffe, M., Buchbinder, R., & Harris, I. A. (2019). Musculoskeletal healthcare : Have we over ‐ egged the pudding ? International Journal of Rheumatic Diseases, 22(September), 1957–1960. https://doi.org/10.1111/1756-185X.13710

McGill S. (2007). Low back disorders: Evidence-based prevention and rehabilitation. Champaign, IL: Human Kinetics.

Pedersen, B. K., & Saltin, B. (2015). Exercise as medicine – Evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine and Science in Sports, 25. https://doi.org/10.1111/sms.12581

Ryan, C., & Roberts, L. (2019). ‘Life on hold’: The lived experience of radicular symptoms. A qualitative, interpretative inquiry. Musculoskeletal Science and Practice, 39, 51–57. https://doi.org/10.1016/j.msksp.2018.11.005

Sullivan, P. O. (2011). It ’ s time for change with the management of non-specifi c chronic low back pain, 46(4), 1–5. https://doi.org/10.1136/bjsm.2010.081638

Suri, A. W. (2020). The Rejuvenation of the Withering Nation State and Bio-power: The New Dynamics of Human Interaction. Journal of Bioethical Inquiry, 17, 535–538. https://doi.org/10.1007/s11673-020-10021-y

Tonosu, J., Oka, H., Higashikawa, A., Okazaki, H., Tanaka, S., & Matsudaira, K. (2017). The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PLoS ONE, 12(11). https://doi.org/10.1371/journal.pone.0188057