Physiotherapy: The Body and the Rhizome (#BTCP)

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.

TNP

Picture created by Craiyon @ craiyon.com

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6 Comments

  1. While I appreciate the attempt to view phenomena, in this case, PT & pain mgmt, “outside the box”, the fundamental issue for the profession seems to be its obsession with that very siloed “box” in order for it to feel safe inside it. PT cannot change if it continues to hide inside its box or refuse to acknowledge that it fears introspection to such an extreme that its orthodoxy has become its prison. To my eyes, it looks like much of the *thinking* in PT has evaporated as a function of so many PTs choosing to abandon this dead-end career path. I used to believe that Nicholls, et al, had real ideas about real change in the profession, but I see little tangible signs of maturity or willingness to let go of the past. Instead, endless professional naval-gazing and self-promotion, incl books, courses, workshops, etc., that never really remain focussed on the larger picture. PT is a fossil. It has remained frozen in the past, and it seems, it has all but resigned itself in preferring nostalgic pride over pursuing relevance in a healthcare world that needs new ideas, better ways of approaching healthcare issues. Sigh.

    Liked by 1 person

    1. Thank you for your response Maddy. Indeed many have responded to Nicholls et al, and accused them of ivory tower syndrome. That it is easy to sit and view from above and proclaim how things need to change and yet not be in the thick of the challenges.
      For example how do you rewrite a profession that is so aligned to complement social and economic systems that if veering away from them would lead to its complete demise sooner rather than later?
      Much is at stake in the world of physio. Ultimately it will be government policy and societal change that will determine its fate I feel.

      Like

      1. Firstly, thanks Paul for another really interesting and thought-provoking blogpost. There are a few physios starting to use Deleuze and Guattari’s work now, but this is as good a summary of the way their work might be applied as I’ve seen. Deleuze’s writings are notoriously difficult, but the way these six characteristics of rhizomes are unpacked and applied is superb.

        I did want to respond specifically to Maddy’s comment, though. I’d agree that there are some areas of PT that seem “stuck” at the moment and there are a lot of people fearful for the profession’s future, but I think that’s equally true of medicine, nursing, OT, and most other established professions. Physio certainly isn’t the exception here.

        I don’t agree, however, that PTs are hiding in a “box”. There are a tonne of new approaches to PT emerging around the world if you’ve got a mind to see them. Look at the work going on around children’s disability and rehab by some of our Canadian PTs, the embodied phenomenology of our amazing Norwegians, PTs challenging historical gender stigma and colonial histories of professional power, new ways to connect PT to environmentalism, people going beyond the ‘body-as-machine’ by learning to use the philosophies of Merleau-Ponty, Foucault, Bourdieu, and, in Paul’s case, Deleuze and Guattari, new thinking on causation, radical new ways to educate PTs in The Netherlands, moves towards embodied cognition, and so on.
        To my mind, a lot of people’s fear comes not from being stuck in a box, but from the new freedom that they don’t know how to handle. It’s the fear of the unknown. I’ve spent most of my academic life trying to ‘diagnose’ physiotherapy — trying to understand how we arrived at this point, facing the problems we now face — and I’ve come to realise that a lot of PTs just want to be told what to do. It’s how they’re often trained to think. But it’s very hard to provide easy fixes when we know so little about how PT got here, and the things that make our work possible. So I’ve tried to explore that in my writing, and at least make a start on understanding PT better, so that we have firmer foundations to build from. Truth be told, I’ve only scratched the surface of what might be possible, and there are decades of work ahead of us before we even get close to knowing what PT “is” and how it might look tomorrow.

        So, I think it’s also a little unfair to suggest “Nicholls, et al. (once) had real ideas about real change in the profession” but, based on your assessment, no longer give you what you need. Perhaps I could point you to the last three chapters of Physiotherapy Otherwise, published only 8 months ago, which suggest a raft of new ways for physiotherapists to practice, even going as far as giving it all away! But if that doesn’t satisfy you, you might look at the 1,000 scholarly blogposts that have been written over the last 8 years on the Critical Physiotherapy Network, or 200+ weekly Digests of inspiration from around the edges of PT practice. You might take a look at the yearly free online course that the CPN runs, or the two edited collections of radical PT ideas from nearly 50 authors from around the world. The three journal special issues, or the dozens of paper written by CPN members and others in the last 3-4 years showing radical new ways to think as a PT.

        Curiously, you suggest, on the one hand, that PTs “fear introspection”, but also critique the “endless professional naval-gazing (sic)”. You suggest PTs prefer “nostalgic pride over pursuing relevance in a healthcare world that needs new ideas, better ways of approaching healthcare issues”. But I would suggest that we are perhaps in the most fertile and creative period in the entire history of the profession, and there are tons of PTs now exploring new territory if you’re open to seeing them.

        Gilles Deleuze — the philosopher Paul cites in his blogpost — once said, “There’s no need to fear or hope, but only to look for new weapons”. I think there are a lot of PTs now taking up this challenge and I’d encourage Maddy and others of like mind to do the same. There’s a fight to be had!

        Liked by 1 person

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