When living with pain are we without a body? A body that has made us who we are, when it goes wrong should we not be allowed to suffer? When we are without a body is it not a foreign experience to not be able-bodied? We possess a physical body and we possess an ability to perceive our reality. As a whole, our body continually reconciles the external world around us with our inner world of thoughts, emotions, and sensations. I appreciate I have inferred a dualism. Yet as one, we are embodied, we become the self. We experience our world through our engagement with it. Be it the touch of a caring hand, the sound of a musical score, the dance with a loved one, the smell of a flower. It is through our body that we interact with our environment.
When pain descends upon its recipient, as a result of ill health or injury, it presents as sensation in the physical body. The body is not just a collection of physical and physiological parts or processes, despite this being the dominant viewpoint of the scientific, biomedical model. Renaissance and Enlightenment scholars such as Francis Bacon, Renee Descartes, Isaac Newton, and John Locke were proponents of the mechanistic body, a machine operating under natural laws (Ball, 2014; Denney, 2018). The mechanistic body continues to be a dominant paradigm in our present healthcare system and in society (Mehta, 2011; Nicholls & Gibson, 2010; Setchell et al., 2018).
Yet, bodies are the subject of culture, gender, race, sexuality, power, communication, identity and many other aspects of our lives (Fraser & Greco, 2005). Therefore, why would pain solely be a product of physical damage? The perpetuating debate that often accompanies this question is also dualistic, the relationship between pain and suffering. The argument that pain, according to medical interpretation becomes a technical matter. The body is reduced to its component parts; that sources of pain can be specific (DePalma et al., 2011) and the uniquely human experience of suffering becomes distinct from the painful body (Illich, 1976; O’Mahony, 2019). The primacy of the biomedical body, a biological determinism (Fox, 2012) to combat pain, suppresses the social dimension and dwarfs any regard that pain is socially mediated(Han, 2021). Suffering is no longer permitted to be a social construct, it becomes a private matter, the individual is psychologised, stigmatized (Cohen et al., 2011; Holloway et al., 2007; Slade et al., 2009; Synnott et al., 2015), suffering becomes a “result of personal failure” (Han, 2021).
Suffering is deemd an emotional construct, invisible in the body, conveyed in language and behaviour. Seen as a deviance, to some, to suffer is an option(Moseley & Butler, 2015). It is not an inevitable outcome like pain, but to have pain is to suffer. In his book, Medical Nemesis, Ivan Illich (1976) denounces the impact medicalization has upon the killing of pain. He writes:
‘This experience, as distinct from the painful sensation, implies a uniquely human performance called suffering. Medical civilization, however, tends to turn pain into a technical matter and thereby deprives suffering of its inherent personal meaning. People unlearn the acceptance of suffering as an inevitable part of their conscious coping with reality…’
Illich wishes to show that suffering is an important part of the human experience, making it meaningful, that to suffer is “to be” a body in pain rather than “to have” a body in pain as inferred by Cartesian dualism. Perhaps it is fortuitous that Illich’s position on “too much medicine” is being revisited (Deyo et al., 2009; Godlee, 2015; Lewis et al., 2020).
Interestingly, the body, as viewed by Cartesian biomedicine, is conceptualized through structure and function, disease and pathology, it considers “what the body is?” and what can go wrong. The abnormal (or disease) versus the normal. Once “abnormal” through the lens of biomedicine, there is no normal. The body is what is (Denney, 2018; Fox, 2012; Mehta, 2011). It is aroborescent.
20th-century philosophers have written about medicine and the body, with contrasting views to that of the Cartesian biomedical model. One such philosopher is Giles Deleuze. His interest in the body was not of “what a body is” but “what a body does”. To emphasize this point I would like to share a thought experiment of my most recent reading using the concept of the rhizome as discussed by Deleuze & Guattari, (1987) in their publication, ‘A Thousand Plateaus: Capitalism and Schizophrenia.’
To begin, I shall elaborate on the term rhizome.
The rhizome in the study of plants or Botany is situated in the plant root system. It is the term given to part of the plant stem that lies beneath the surface, in the soil, giving off roots and shoots from its nodes. The rhizome tends to move horizontally in the ground but is capable of producing roots in many different directions. The uniqueness of the rhizome is that it has the ability to sprout in many different directions if it is faced with an impasse. It can even give rise to new plants if it is separated from the main plant.
Deleuze and Guattari (1987, pp. 3 – 25) proposed the rhizome as a way to challenge conventional and hierarchical forms of knowledge. In this form, knowledge would be “arborescent” taking the form of a tree to portray how it is assimilated. The roots resembling the foundations, and branches, categories and sub-categories. Despite the very literal argument that the tree has many branches (bifurcations), the branches have cultivated from a single root. In the case of physiotherapy – biomedicalism.
Interestingly, we can think of physiotherapy training in a way that is “arborescent.” Foundational knowledge of the biomedical body is taught at university, passing on a fixed way of viewing the body, thinking about the body, and treating the body. Categories (or specialties i.e. musculoskeletal) and sub-categories (or sub-specialties i.e. low back pain) are gradually developed after graduation narrowing the clinician’s field of view, all cultivated from the biomedical roots, only ever viewed through the biomedical tree. This arborescent thought is fixed, only ever viewing the tree (body) in one way.
In contrast, the rhizome, whilst also a type of root, has no end or beginning. It is able to grow from multiple segments shooting off in multiple and unpredictable directions. The rhizome is always changing, creative, continuously moving, making new connections, curiously thinking about new ways to move and directions to head in.
In regards to its conceptual thought, the rhizome has six principle characteristics:
1 and 2 – Connection and heterogenity
The rhizome has the flexibility and curiosity to connect and must be, to anything other including science, art, health, politics, economics etc. It is an endless establishing of connections in thought and movement itself. The arborescent tree is fixed, heading in one direction off a single root.
Deleuze and Guattari (p.7) also refer to the “semiotic” ability of the rhizome linking gestures, cognitions, language that create meaning. Arguing against the homogeneity of language they write “There is no mother tongue, only a power takeover be a dominant language within a political multiplicity” (p.7). There is a perpetuating debate about the semiotics of traditional physiotherapy contributing to the increasing pain and disability rates worldwide (Bialosky et al., 2017; Darlow, 2016; Darlow et al., 2013; Gardner et al., 2017; Lederman, 2010; Nijs et al., 2013; Nolan et al., 2017; Oostendorp, 2018; Sharma et al., 2020)
3 – Multiplicity
We could propose that the tree system, with all its categories and sub-categories, is a multiplicity. This is a reasonable proposition but the tree is binary, it is foundational and categorical, it is fixed following a structure, a single path. Recall that the branches arise off the trunk, which arises from the roots.
Rhizomes grow in diverse directions, they proliferate and move. They themselves do not follow an authority figure of ideas of origin something that Deleuze and Guattari call “subjectification”. Recall the example I gave of physiotherapy education, subjectification enables arborescent thought to “overcode” and turn multiplicities into multiple replicas of itself.
This is not to say that the biomedical body should become redundant (despite the evidence refuting biomechanical reasoning). Multiplicities propose there are many ways of “seeing, feeling, doing or being a particular thing” (Setchell et al., 2018, p. 2).
Physiotherapy then can view the body as multiple not just through the lens of the biomedical. The rhizome within physiotherapy suggests a plurality of the profession not just an allegiance to the biomedical body. This again does not mean we abandon movement or health, we view these terms through a lens of multiplicity with the intention of becoming a pluralistic profession not a subjectified one.
It is here we must understand the importance of curiosity. The rhizome is curiosity, constantly thinking, exploring, creating. It is not teleological. When we reach the limits of our curiosity we become content to fall back on the stock of knowledge and mental habits from our training, biases, and previous experiences, rather than adding to or revising it. We step off the curiosity rhizome because there is little else that we have to fall back on. Thus, we exploit the known rather than explore the unknown. This is because the profession possesses an arborescent system of the dualistic biomedical body.
4 – asignifying rupture
There is professional unrest in physiotherapy, we have discovered new branches throughout its 100-year legacy, all from the arborescent thought of biomedicalism. There are many that have broken away from the arborescent thought, leaving altogether – the average longevity of physiotherapists is less than 7 years in New Zealand (https://pnz.org.nz/workforce).
The rhizome however can be ruptured but will grow again. Deleuze and Guattari (1987) refer to the terms deterritorialisation, reterritorialisation, and lines of flight to describe the changing operation of the rhizome. Is it possible for physiotherapy to deterritorialize from the biomedical body and reterritorializing through a line of flight to other tree systems of thought? By remaining on the “curiosity rhizome” we deterritorialize and reterritorialize as a perpetuating process. It is here I become stuck. Perhaps my lack of understanding of Deleuze and Guattari is what makes me inflexible. Am I so bound by the need for identity that by embracing the “curiosity rhizome” I become lost in endless chaos, desperate to find an arborescent system? I believe the concept of the assemblage can assist in easing my anxiety. This will be for another blog.
5 and 6 – cartography and decalcomania
Cartography is the study and practice of making maps and decalcomania is the process of tracing. These principles oppose one another according to Deleuze and Guattari. The process of tracing aligns with the tree system: “a deep structure is more like a base sequence that can be broken down into immediate constituents, while the unity (of the arborescent thought) of the product passes onto another…” (1987, p. 12). Much can be said of the tracings of physiotherapy from the undergraduate program to the weekend course. Interestingly, a recent publication discusses the issue of tracings in physiotherapy and the impact on practice standards (Peterson et al., 2022).
Deleuze and Guattari (1987) express that “the rhizome is altogether different, a map and not a tracing. Make a map, not a tracing… what distinguishes the map from the tracing is that it is entirely oriented toward an experimentation in contact with the real” (p.12). We could potentially see the similarities in this statement with the contextual effects of pain. That to experiment with the map understanding “what the body does” rather than ruminating on the tracing, succumbing to “what the body is.”
Another consideration we could draw from Deleuze and Guattari (1987) is the contrast between the map and the tracing: “The map has to do with performance, whereas the tracing has to do with alleged “competence” (p.12). Take the example of MRI scans. Could the MRI be an example of the tracing of the map of a body, the scan, however, is not the body. We can certainly tell a lot about a body from the MRI scan, yet this supports and perpetuates the arborescent thought. We only need to look at the scientific research to show that the MRI is not a map of the body it is merely a tracing (Brinjikji et al., 2015; Jacobs et al., 2020; Karel et al., 2015; Nakashima et al., 2015)
The map then is to understand the body in its entirety, how it engages with the real. Many clinicians have said that imaging does not replace a good subjective history and physical examination, and to quote Deleuze and Guattari (1987, p.12), “the tracing should always be put back on the map.” Interestingly, I wonder how this relates to the qualitative research into patient preference for MRI that leads to legitimization and recognition of their experienced pain (Myburgh et al., 2022; Petersen et al., 2016). The challenge however is reconciling the tracing with the arborescent thought of the singular biomedical body.
I mentioned earlier that this blog was a thought experiment. I wanted to capture a variation of how we might see the body and why we might see it in this way. My opening line asked if when living with pain, are without a body, and the beginning of the blog discussed the dualistic argument of pain and suffering and the apparent choices we have. I have proposed the body and the rhizome as a way to consider how we might see the body and how we might practice physiotherapy differently. Not necessarily moving away from arborescent thought of biomedicalism, but opening rhizomatic ways of thinking that are curious towards a pluralistic way of understanding the body, physiotherapy, health, and movement.
Thanks for having a read.
Picture created by Craiyon @ craiyon.com
Ball, P. (2014). Curiosity: How Science Became Interested in Everything. University of Chicago Press.
Bialosky, J. E., Bishop, M. D., & Penza, C. W. (2017). Placebo Mechanisms of Manual Therapy: A Sheep in Wolf’s Clothing? Journal of Orthopaedic & Sports Physical Therapy, 47(5), 301–304. https://doi.org/10.2519/jospt.2017.0604
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American Journal Of Neuroradiology, 36(4). https://doi.org/10.3174/ajnr.A4173
Cohen, M., Quintner, J., Buchanan, D., Nielsen, M., & Guy, L. (2011). Stigmatization of patients with chronic pain: The extinction of empathy. Pain Medicine, 12(11), 1637–1643. https://doi.org/10.1111/j.1526-4637.2011.01264.x
Darlow, B. (2016). Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine, 20, 53–61. https://doi.org/10.1016/j.ijosm.2016.01.005
Darlow, B., 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
Deleuze, G., & Guattari, F. (1987). A Thousand Plateaus: Capitalism and Schizophrenia. University of Minnesota Press.
Denney, E. (2018). Pain: A sociological Introduction. Polity Press.
DePalma, M. J., Ketchum, J. M., & Saullo, T. (2011). What Is the Source of Chronic Low Back Pain and Does Age Play a Role? Pain Medicine, 12(2), 224–233. https://doi.org/10.1111/j.1526-4637.2010.01045.x
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
Fox, N. J. (2012). The Body: Key Themes in Health and Social Care. Polity Press.
Fraser, M., & Greco, M. (2005). The Body: A Reader (M. Fraser & M. Greco, Eds.). Routledge.
Gardner, T., Refshauge, K., Smith, L., McAuley, J., H?bscher, M., & Goodall, S. (2017). Physiotherapists beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy, 63, 132–143. https://doi.org/10.1016/j.jphys.2017.05.017
Godlee, F. (2015). Too much medicine. BMJ, 350(mar05 12), h1217–h1217. https://doi.org/10.1136/bmj.h1217
Han, B.-C. (2021). The Palliative Society. Polity Press.
Holloway, I., Sofaer-Bennett, B., & Walker, J. (2007). The stigmatisation of people with chronic back pain. Disability and Rehabilitation, 29(18), 1456–1464. https://doi.org/10.1080/09638280601107260
Illich, I. (1976). Medical Nemesis: The Expropriation of Health. Pantheon Books.
Jacobs, J. C., Jarvik, J. G., Chou, R., Boothroyd, D., Lo, J., Nevedal, A., & Barnett, P. G. (2020). Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine. Journal of General Internal Medicine, 35(12), 3605–3612. https://doi.org/10.1007/s11606-020-06181-7
Karel, Y. H. J. M., Verkerk, K., Endenburg, S., Metselaar, S., & Verhagen, A. P. (2015). Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. European Journal of Internal Medicine, 26(8), 585–595. https://doi.org/10.1016/j.ejim.2015.06.018
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.
Lewis, J. S., Cook, C. E., Hoffmann, T. C., & O’Sullivan, P. (2020). The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. Journal of Orthopaedic & Sports Physical Therapy, 50(1), 1–4. https://doi.org/10.2519/jospt.2020.0601
Mehta, N. (2011). Mind-body dualism: A critique from a health perspective. Mens Sana Monographs, 9(1), 202–209. https://doi.org/10.4103/0973-1229.77436
Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of Pain, 16(9), 807–813. https://doi.org/10.1016/j.jpain.2015.05.005
Myburgh, C., Larsen, T. B., & Kjaer, P. (2022). ‘When the picture does not really tell the story’– A qualitative exploration of the MRI report of findings as a means for generating shared diagnostic meaning during the management of patients suffering from persistent spinal pain. Patient Education and Counseling, 105(1), 221–227. https://doi.org/10.1016/j.pec.2021.04.031
Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine, 40(6), 392–398. https://doi.org/10.1097/BRS.0000000000000775
Nicholls, D. A., & Gibson, B. E. (2010). The body and physiotherapy. Physiotherapy Theory and Practice, 26(8), 497–509. https://doi.org/10.3109/09593981003710316
Nijs, J., Roussel, N., van Wilgen, Paul. C., Koke, A., & Smeets, R. (2013). Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual Therapy, 18(2), 96–102. https://doi.org/10.1016/j.math.2012.11.001
Nolan, D., O ’sullivan, K., Stephenson, J., Sullivan, P. O. ’, Lucock, M., Nolan, D., Sullivan, O. ’, Stephenson, K., & O ’sullivan E F, P. (2017). What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskeletal Science and Practice. https://doi.org/10.1016/
O’Mahony, S. (2019). Medical nemesis 40 years on: The enduring legacy of ivan illich. Routledge Handbook of the Medical Humanities, 114–122. https://doi.org/10.4324/9781351241779-10
Oostendorp, R. A. B. (2018). Credibility of manual therapy is at stake ‘Where do we go from here?’ Journal of Manual and Manipulative Therapy. https://doi.org/10.1080/10669817.2018.1472948
Petersen, L., Birkelund, R., Ammentorp, J., & Christensen, B. S. (2016). “AN MRI REVEALS THE TRUTH ABOUT MY BACK”: A QUALITATIVE STUDY ABOUT PATIENTS’ EXPECTATIONS AND ATTITUDES TOWARD THE VALUE OF MRI IN THE ASSESSMENT OF BACK PAIN. European Journal for Person Centered Healthcare, 4(3).
Peterson, S., Shepherd, M., Farrell, J., & Rhon, D. I. (2022). The Blind Men, the Elephant, and the Continuing Education Course: Why Higher Standards Are Needed in Physical Therapist Professional Development. Journal of Orthopaedic & Sports Physical Therapy, 1–14. https://doi.org/10.2519/jospt.2022.11377
Setchell, J., Nicholls, D. A., & Gibson, B. E. (2018). Objecting: Multiplicity and the practice of physiotherapy. Health (United Kingdom), 22(2), 165–184. https://doi.org/10.1177/1363459316688519
Sharma, S., Traeger, A. C., Reed, B., Hamilton, M., O’Connor, D. A., Hoffmann, T. C., Bonner, C., Buchbinder, R., & Maher, C. G. (2020). Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open, 10(8), e037820. https://doi.org/10.1136/bmjopen-2020-037820
Slade, S. C., Molloy, E., & Keating, J. L. (2009). Stigma experienced by people with nonspecific chronic low back pain: A qualitative study. Pain Medicine, 10(1), 143–154. https://doi.org/10.1111/j.1526-4637.2008.00540.x
Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016