In part 1 of this series, I explored the enduring legacy of biomedicine and its obscured view of the body, and how this view reduces the human and the body to objectifiable matter. To understand the enduring legacy deeply, I proposed using a state of ecological curiosity to explore three perspectives that perpetuate the legacy of biomedicine in physiotherapy practice. Part 2 of this 3 part series, I look more closely at 2 of these 3 perspectives.
Perspective 1: The imprisonment of bodies: Institutional and clinical knowledge fixes pain in the biomedical body
Institutional education of physiotherapy practice has historically concentrated training around the biological and physical sciences, retaining a fidelity to a mechanistic view of the body (Nicholls, 2017). This view of the ‘body-as-machine’ is an inherent part of physiotherapy practice and has been argued to be largely inadequate for explaining multi-dimensional components that comprise the emergence of pain and the gestalt human (Quintner et al., 2008). Adopting the dualism of subjective and objective, physiotherapy attempts to link the subjective experience with the objective biological view of the body, and because the biological view of the body is the dominant discourse in physiotherapy, the subjective becomes overshadowed by the objective. The tension between the objective and subjective body is eloquently outlined through the work of Michel Foucault.
In his final book “The History of Sexuality” (1978) Michel Foucault discusses the concept of ‘biopower.’ He 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, 1978; p.140). Foucault emphasized that through the use of discipline, power can be exercised, and the human becomes objectified. Physiotherapists categorise, measure, and compare the body to that of what is understood to be normal and abnormal and how this impacts the function of society (Nicholls, 2017). The information that objectification provides gives physiotherapists “power” through society. This suggests we treat people on the basis that we can support their recovery, re-enabling them to maintain their contribution to 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.
It is important to note that Foucault saw power as productive, not oppressive, suggesting there was more than one way to do something. In this regard, Foucault would ask, “What justifies doing one thing over the other?” Considering physiotherapy and its engagement with biomedical discourse, an adaptation of Foucault’s question could be, “What justifies biomedical discourse over other means of discourse?” In the current climate of physiotherapy practice this is an astute question. Take physiotherapy’s migration into living healthy and active lifestyles. The movement proclaiming ‘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 and chronic pain (Pedersen & Saltin, 2015). However, this legitimises a “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, whom, from one perspective cling on to ideologies that “they know work”, or from the other, utilise an ever 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 et al., 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 the way 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. This is represented by the increasing issues of ‘too much medicine’ (Lewis et al., 2020; Slawson & Shaughnessy, 2021).
The extension of biomedicine beyond that of the body, and how it arises in other areas of clinical life is central to the physiotherapist’s professional identity. Unbeknownst to the physiotherapist or perhaps regarded as inherent, subliminal to their awareness, there is much about the ontological foundations of biomedicine that continue to go unquestioned. Having explored examples of where biomedicine infiltrates physiotherapy practice through power, I now turn towards a critical appraisal of biomedicine’s influence in physiotherapy research practices.
Perspective 2: The influence of biomedicine in physiotherapy research
Physiotherapy is regarded as an evidence-based profession with many proponents outlining the benefits of evidence-based practice (EBP) (Scurlock-Evans et al., 2014; Veras et al., 2016). Defined by Sackett et al., (1996) as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ EBP has rapidly become the centrepiece to empirically grounded science (Greenhalgh et al., 2014). This is demonstrated through the development of clinical practice guidelines, where new and appropriately scrutinised evidence aids to inform, support, and encourage physiotherapists to adopt best practice (Lin et al., 2018, 2019). However, what has since followed is a “strict adherence” to the evidence or a covert adoption of a positivist paradigm in clinical practice (Van Trijffel, 2019; Walsh 2011).
An example of the dominance of biomedicine in physiotherapy research literature is the persisting debate of specificity related to the presence of patho-anatomical structures as a cause of back pain. Advances in technological imaging methods such as x-rays, magnetic resonance imaging (MRI) and computed tomography (CT) scanning can identify pathology in the body which are presumed to correlate with symptoms of back pain. However, diagnostic imaging can fall into the trap of inductive inference leading to the premise that what is observed on imaging is a cause of disease (Eriksen et al., 2013; Sistrom, 2006). This position has been brought into question through the popular paper by Brinjikji et al., (2015) which revealed patho-anatomical features in spines of individuals who reported no pain. Indeed, when considering low back pain of a chronic nature, causal mechanisms are said to be “enigmatic” (Eriksen et al., 2013).
The enigmatic argument of causation is a continuing debate within musculoskeletal practice. Recently, Han et al., (2023) published a systematic review of 62 studies on the diagnostic accuracy of clinical testing for specific structures (disc, facet joint and sacro-iliac joint) as sources of low back pain. Applying these findings critically, physiotherapists could propose that specific classification models (McKenzie diagnosis and therapy) and cluster testing (sacro-iliac joint) common within physiotherapy practice can identify specific patho-anatomical structures involved in the genesis of pain. Whilst this review provides opportunities for contemporary healthcare to reduce the increasing problem of overdiagnosis and overtreatment (Lewis et al., 2020), these examples demonstrate where contemporary physiotherapy practices continue to perpetuate the legacy of pain residing in a biomedical body.
EBP has resulted in multiple challenges for physiotherapists. Research studies have outlined issues in EBP implementation including research interpretation, failure to adopt clinical practice guidelines, dearth of access and time, lack of interest, and research findings omitting an appreciation for contextual factors (Mota da Silva et al., 2015; Paci et al., 2021; Scurlock-Evans et al., 2014) that have been consistently shown to play a role in development and perseverance of persistent pain states (Gleadhill et al., 2022).Furthermore, academic physiotherapy circles have argued how this approach to practice is problematic. Several authors have commented on the enduring institutional knowledge within physiotherapy (Daluiso-King & Hebron, 2020; Domenech et al., 2011; Gardner et al., 2017; Nicholls & Larmer, 2005; Setchell, Gard, et al., 2017; Stilwell & Harman, 2019), which perpetuate the mechanistic and simplistic view of the body, health and illness, and the resultant impact on healthcare delivery (Nicholls and Gibson, 2010). Moreover, Nicholls & Gibson, (2010, p. 500) further state the quandary of adopting the biomedical model (to raise physiotherapy status), noting “We may have inadvertently reduced the subtle complexities of health and illness to a narrow set of biological principles.” It stands to reason, despite attempts to broaden clinical physiotherapy practice through EBP, that physiotherapists are confined to a biomedical model in day-to-day clinical practice (Mescouto, Olson, Hodges, Costa, et al., 2022; Nicholls, 2017). It is at this juncture that I shift my attention to the socio-cultural domain and how biomedicine is expressed through the physiotherapy clinic.
We’ll return to the final perspective in part 3.
Thanks for having a read
TNP / The Curiouser
The Naked Physio / The curiouser 
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