In this final part of my 3 part series, I explore the third perspective I chose to discuss in my university assignment. I then finish with a brief discussion and conclusion. Throughout this assignment I wanted to draw upon wider aspects of where the biomedical model has infiltrated physiotherapy, this last part explores one small aspect of the vast social-cultural domain.
Perspective 3: Biomedicine infiltrates the socio-cultural domain as expressed through the physiotherapy clinic.
Historically, the physiotherapy clinic has had to convey a specific type of message that defines physiotherapy’s identity and legitimises the professions position in healthcare (Nicholls, 2017). Continuing the theme within this assignment, the image of the physiotherapy clinic is underpinned by the dominance of biomedicine. The physiotherapy clinic sets the foundation for the conduct that is performed within its four walls.
Returning to Foucault’s writing on power, he argued that biomedical discourse was pervasive, operating at multiple levels of society. Foucault emphasised that power was regarded as something that was produced through people’s practices (i.e., within physiotherapy, objects used such as exercise equipment, or the use of strategies such as acquiring autonomy or legitimacy), and not what is known. Foucault believed that biomedicine shaped the way health professionals, and subsequently patients, understood and experienced the body, illness, and health (Nicholls, 2012).
Foucault described the clinic as a “regime of truth”, as it became a discursive link for doctors to express their understanding of disease, having developed their knowledge of the inside the body through autopsy and anatomical dissection (Long, 1992; Praestegaard et al., 2015). Where research has demonstrated that our language has an impact on patient relationships with pain (Barker et al., 2009, 2014; Cedraschi et al., 1998; Darlow et al., 2013, 2015; Stewart & Loftus, 2018; Wood et al., 2019), and according to Foucault, is a component of the “regime” (Cremonesi et al., 2016), little attention has been given to other aspects of physiotherapy practice that contribute.
Several publications have discussed how the physiotherapy clinic conveys a biomedical “regime of truth.” For example, through the sterile white colour of its walls (Nicholls, 2017), the treatment bed used in treatment rooms (Nicholls, 2012), the biomedical discourse used in the clinic by all staff (Eisenberg, 2012; Praestegaard et al., 2015), the time allocated to see a patient and the associated fee (Mescouto, Olson, Hodges, Costa, et al., 2022), the design and décor of the waiting room, the anatomical posters, models and measurement tools in the treatment room, and the visual appearance of a youthful, athletic, bodily aware clinician (Nicholls & Holmes, 2012; Praestegaard et al., 2015). On this basis, a physiotherapy clinic is the way it is because it upholds the very practices of the person using it (Nicholls, 2012).
Discussion
In this assignment, I have explored biomedicine’s enduring legacy in physiotherapy using an ecological view of curiosity. In many ways, Shankar and Foucault wish for us to be beguiled by curiosity, to use it to take a step back, see the status quo for what it is, deconstruct it and examine the many parts that have played a role in securing an enduring legacy. In this case why physiotherapy maintains a legacy of pain in a biomedical body.
The art of being a physiotherapist is a consolidation of many facets, beyond that of the explicit technical, and observable. Concomitantly, many of the authors who have questioned the biomedical view of the body, and EBP’s specific focus on empirical truths through the scientific method, have published literature that discuss views of the body through cultural, economic, social, aesthetic, and political discourses. Areas of inquiry that physiotherapy fails to appreciate in the experiential world of clinical practice. Insightfully, Nicholls (2017, pg.122) echoes this position in his book, ‘The End of Physiotherapy.’ He writes,
‘I would venture to suggest that you cannot become an expert practitioner unless you quickly realise that treating a patient’s body as a machine is largely inadequate for the real world of practice.’
Conclusion
Outlining a rationale in considering a case for biomedicine’s enduring legacy in the domain of pain and physiotherapy, I have presented three overlapping arguments: 1) The imprisonment of bodies; 2) The influence of EBP in preserving the biomedical domain; and 3) Biomedicine’s infiltration of the socio-cultural expressed through the physiotherapy clinic. Using these arguments, I have aimed to demonstrate our professional blindness to biomedicine’s infiltration within physiotherapy, and the subsequent reification of pain residing in the biomedical body. Furthermore, I have argued how the biomedical zeitgeist subverts the BPSM, and without first scrutinising how biomedicine underpins professional practice, attempting a renaissance will be futile.
Thanks for having a read
TNP / The Curiouser
References
Barker, K. L., Reid, M., & Minns Lowe, C. J. (2009). Divided by a lack of common language? A qualitative study exploring the use of language by health professionals treating back pain. BMC Musculoskeletal Disorders, 10, 123. https://doi.org/10.1186/1471-2474-10-123
Barker, K. L., Reid, M., & Minns Lowe, C. J. (2014). What does the language we use about arthritis mean to people who have osteoarthritis? A qualitative study. Disability and Rehabilitation, 36(5), 367–372. https://doi.org/10.3109/09638288.2013.793409
Barradell, S., Peseta, T., & Barrie, S. (2018). ‘There’s so much to it’: the ways physiotherapy students and recent graduates experience practice. Advances in Health Sciences Education, 23(2), 387–406. https://doi.org/10.1007/s10459-017-9804-z
Bendelow, G. (2013). Chronic pain patients and the biomedical model of pain. Virtual Mentor, 15(5), 455–459. https://doi.org/10.1001/virtualmentor.2013.15.5.msoc1-1305
Benning, T. (2015). Limitations of the biopsychosocial model in psychiatry. Advances in Medical Education and Practice, 347. https://doi.org/10.2147/AMEP.S82937
Bolton, D., & Gillett, G. (2019). Biopsychosocial Conditions of Health and Disease. In The Biopsychosocial Model of Health and Disease (pp. 109–145). Springer International Publishing. https://doi.org/10.1007/978-3-030-11899-0_4
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
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.
Cedraschi, C., Nordin, M., & Nachemson, A. L. (1998). Health care providers should use a common language in relation to low back pain patients. Baillière’s Clinical Rheumatology, 12(1), 1–15.
Cremonesi, L., Irrera, O., Lorenzini, D., & Tazzioli, M. (2016). Foucault and the Making of Subjects. Rowman & Littlefield International. https://books.google.co.nz/books?id=mObaDwAAQBAJ
Daluiso-King, G., & Hebron, C. (2020). Is the biopsychosocial model in musculoskeletal physiotherapy adequate? An evolutionary concept analysis. Physiotherapy Theory and Practice, 00(00), 1–17. https://doi.org/10.1080/09593985.2020.1765440
Darlow, B., 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, 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
Denny, E. (2018). Pain: A sociological Introduction. Polity Press.
Domenech, J., Sánchez-Zuriaga, D., Segura-Ortí, E., Espejo-Tort, B., & Lisón, J. F. (2011). Impact of biomedical and biopsychosocial training sessions on the attitudes, beliefs, and recommendations of health care providers about low back pain: A randomised clinical trial. Pain, 152(11), 2557–2563. https://doi.org/10.1016/j.pain.2011.07.023
Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C., & Wasan, A. D. (2016). The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. Journal of Pain, 17(9), T70–T92. https://doi.org/10.1016/j.jpain.2016.01.001
Eisenberg, N. R. (2012). Post-structural conceptualizations of power relationships in physiotherapy. Physiotherapy Theory and Practice, 28(6), 439–446. https://doi.org/10.3109/09593985.2012.692585
Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460
Eriksen, T. E., Kerry, R., Mumford, S., Lie, S. A. N., & Anjum, R. L. (2013). At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms. Philosophy, Ethics, and Humanities in Medicine : PEHM, 8(1), 11. https://doi.org/10.1186/1747-5341-8-11
Ferreira, M. L., Machado, G., Latimer, J., Maher, C., Ferreira, P. H., & Smeets, R. J. (2010). Factors defining care-seeking in low back pain – A meta-analysis of population based surveys. European Journal of Pain, 14(7), 747.e1-747.e7. https://doi.org/10.1016/j.ejpain.2009.11.005
Foucault, M. (1978). The History of Sexuality: An introduction. Pantheon Books. https://books.google.co.nz/books?id=h8knAAAAYAAJ
Foucault, M., Rabinow, P., & Hurley, R. (1997). Ethics: Subjectivity and Truth. New Press. https://books.google.co.nz/books?id=GfCINAAACAAJ
Fox, N. J. (2012). The Body: Key Themes in Health and Social Care. Polity Press.
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
Ghaemi, N. S. (2009). The rise and fall of the biopsychosocial model. British Journal of Psychiatry, 195(1), 3–4. https://doi.org/10.1192/bjp.bp.109.063859
Gleadhill, C., Bolsewicz, K., Davidson, S. R. E., Kamper, S. J., Tutty, A., Robson, E., Da Silva, P. V., Donald, B., Dooley, K., Manvell, J., Manvell, N., Delbridge, A., & Williams, C. M. (2022). Physiotherapists’ opinions, barriers, and enablers to providing evidence-based care: a mixed-methods study. BMC Health Services Research, 22(1), 1–16. https://doi.org/10.1186/s12913-022-08741-5
Greenhalgh, T., Howick, J., Maskrey, N., Brassey, J., Burch, D., Burton, M., Chang, H., Glasziou, P., Heath, I., Heneghan, C., Kelly, M. P., Lehman, R., Llewelyn, H., McCartney, M., Milne, R., & Spence, D. (2014). Evidence based medicine: A movement in crisis? BMJ (Online), 348(June), 1–7. https://doi.org/10.1136/bmj.g3725
Grossman, P., Jackson, J. L., & Nowotny, H. (2020). Curiosity Studies (P. Zurn & A. Shankar, Eds.). University of Minnesota Press. https://doi.org/10.5749/j.ctvzpv67w
Han, C. S., Hancock, M. J., Sharma, S., Sharma, S., Harris, I. A., Cohen, S. P., Magnussen, J., Maher, C. G., & Traeger, A. C. (2023). Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review. EClinicalMedicine, 59, 101960. https://doi.org/10.1016/j.eclinm.2023.101960
Hancock, M. J., Maher, C. G., Laslett, M., Hay, E., & Koes, B. (2011). Discussion paper: What happened to the bio in the bio-psycho-social model of low back pain? European Spine Journal, 20(12), 2105–2110. https://doi.org/10.1007/s00586-011-1886-3
Holopainen, R., Simpson, P., Piirainen, A., Karppinen, J., Schütze, R., Smith, A., O’Sullivan, P., & Kent, P. (2020). Physiotherapists’ perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: A systematic review and metasynthesis of qualitative studies. In Pain (Vol. 161, Issue 6, pp. 1150–1168). Lippincott Williams and Wilkins. https://doi.org/10.1097/j.pain.0000000000001809
Lee, H., Hubscher, M., Moseley, L. G., Kamper, S. J., Traeger, A. C., Mansell, G., & Mcauley, J. (2015). How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain. https://doi.org/10.1097/j.pain.0000000000000146
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
Lin, I., Wiles, L. K., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G., & O’Sullivan, P. P. B. (2018). Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. British Journal of Sports Medicine, 52(5), 337–343. https://doi.org/10.1136/bjsports-2017-098375
Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G., & O’Sullivan, P. P. B. (2019). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med, bjsports-2018-099878. https://doi.org/10.1136/bjsports-2018-099878
Long, J. C. (1992). Foucault’s clinic. The Journal of Medical Humanities, 13(3), 119–138. https://doi.org/10.1007/BF01127371
Low, M. (2017). A novel clinical framework: The use of dispositions in clinical practice. A person centred approach. Journal of Evaluation in Clinical Practice, 1–9. https://doi.org/10.1111/jep.12713
Maric, F., & Nicholls, D. (2019). The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice. OpenPhysio Journal. https://doi.org/10.14426/art/908
McLaren, N. (2021). The biopsychosocial model: Reality check. Australian and New Zealand Journal of Psychiatry, 55(7), 644–645. https://doi.org/10.1177/0004867420981409
Mescouto, K., Olson, R. E., Hodges, P. W., Costa, N., Patton, M. A., Evans, K., Walsh, K., Lonergan, K., & Setchell, J. (2022). Physiotherapists Both Reproduce and Resist Biomedical Dominance when Working With People With Low Back Pain: A Qualitative Study Towards New Praxis. Qualitative Health Research, 32(6), 902–915. https://doi.org/10.1177/10497323221084358
Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2022). A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disability and Rehabilitation, 44(13), 3270–3284. https://doi.org/10.1080/09638288.2020.1851783
Mota da Silva, T., da Cunha Menezes Costa, L., Garcia, A. N., & Costa, L. O. P. (2015). What do physical therapists think about evidence-based practice? A systematic review. Manual Therapy, 20(3), 388–401. https://doi.org/10.1016/j.math.2014.10.009
Nicholls, D. A. (2012). Foucault and physiotherapy. Physiotherapy Theory and Practice, 28(6), 447–453. https://doi.org/10.3109/09593985.2012.676937
Nicholls, D. A. (2017). The end of physiotherapy. In The End of Physiotherapy. https://doi.org/10.4324/9781315561868
Nicholls, D. A. (2022). How Do You Touch an Impossible Thing? Frontiers in Rehabilitation Sciences, 3(July), 1–11. https://doi.org/10.3389/fresc.2022.934698
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
Nicholls, D. A., & Holmes, D. (2012). Discipline, desire, and transgression in physiotherapy practice. Physiotherapy Theory and Practice, 28(6), 454–465. https://doi.org/10.3109/09593985.2012.676940
Nicholls, D. A., & Larmer, P. (2005). Possible futures for physiotherapy: an exploration of the New Zealand context. NZ Journal of Physiotherapy, 33(2).
Paci, M., Faedda, G., Ugolini, A., & Pellicciari, L. (2021). Barriers to evidence-based practice implementation in physiotherapy: a systematic review and meta-analysis. International Journal for Quality in Health Care, 33(2). https://doi.org/10.1093/intqhc/mzab093
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
Pincus, T., Burton, A. K., Vogel, S., & Field, A. P. (2002). A Systematic Review of Psychological Factors as Predictors of Chronicity/Disability in Prospective Cohorts of Low Back Pain. Spine, 27(5), E109–E120. https://doi.org/10.1097/00007632-200203010-00017
Praestegaard, J., Gard, G., & Glasdam, S. (2015). Physiotherapy as a disciplinary institution in modern society-a Foucauldian perspective on physiotherapy in Danish private practice. Physiotherapy Theory and Practice, 31(1), 17–28. https://doi.org/10.3109/09593985.2014.933917
Quintner, J. L., Cohen, M. L., Buchanan, D., Katz, J. D., & Williamson, O. D. (2008). Pain Medicine and Its Models: Helping or Hindering? Pain Medicine, 9(7), 824–834. https://doi.org/10.1111/j.1526-4637.2007.00391.x
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
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ, 312(7023), 71–72. https://doi.org/10.1136/bmj.312.7023.71
Scurlock-Evans, L., Upton, P., & Upton, D. (2014). Evidence-Based Practice in physiotherapy: a systematic review of barriers, enablers and interventions. Physiotherapy, 100(3), 208–219. https://doi.org/10.1016/j.physio.2014.03.001
Setchell, J., Costa, N., Ferreira, M., Makovey, J., Nielsen, M., & Hodges, P. W. (2017). Individuals’ explanations for their persistent or recurrent low back pain: a cross- sectional survey. BMC Musculoskeletal Disorders, 18(466). https://doi.org/10.1186/s12891-017-1831-7
Setchell, J., Gard, M., Jones, L., & Watson, B. M. (2017). Addressing weight stigma in physiotherapy: Development of a theory-driven approach to (re)thinking weight-related interactions. Physiotherapy Theory and Practice, 33(8), 597–610. https://doi.org/10.1080/09593985.2017.1328718
Shankar, A. (2020). The Campus Is Sick: Capitalist Curiosity and Student Mental Health. In P. Zurn & A. Shankar (Eds.), Curiosity Studies: A New Ecology of Knowledge. University of Minnesota Press.
Simpson, P., Holopainen, R., Schütze, R., O’Sullivan, P., Smith, A., Linton, S. J., Nicholas, M., & Kent, P. (2021). Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review. Physical Therapy, 101(10), 1–12. https://doi.org/10.1093/ptj/pzab188
Sistrom, C. (2006). Inference and Uncertainty in Radiology. Academic Radiology, 13(5), 580–588. https://doi.org/10.1016/j.acra.2006.01.004
Slawson, D., & Shaughnessy, A. F. (2021). Reducing overuse by recognising the unintended harms of good intentions. BMJ Evidence-Based Medicine, 26(2), 46–48. https://doi.org/10.1136/bmjebm-2019-111247
Smart, K. M. (2023). The biopsychosocial model of pain in physiotherapy: past, present and future. Physical Therapy Reviews, 1–10. https://doi.org/10.1080/10833196.2023.2177792
Stewart, M., & Loftus, S. (2018). Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 48(7), 519–522. https://doi.org/10.2519/jospt.2018.0610
Stilwell, P., & Harman, K. (2019). An enactive approach to pain: beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences. https://doi.org/10.1007/s11097-019-09624-7
Tramonti, F., Giorgi, F., & Fanali, A. (2019). General system theory as a framework for biopsychosocial research and practice in mental health. Systems Research and Behavioral Science, 36(3), 332–341. https://doi.org/10.1002/sres.2593
Veras, M., Kairy, D., & Paquet, N. (2016). What is evidence-based physiotherapy? Physiotherapy Canada, 68(2), 95–96. https://doi.org/10.3138/ptc.68.2.GEE
Waddell, G. (1987). A New Clinical Model for the Treatment of Low-Back Pain. Spine, 12(7), 632–644.
Wood, J., Mawae, J., & Elmer, S. (2019). Impact of Clinician Experience and Positive Language on Subject Expectation of Cervical Spine Manipulation Effects.
Zurn, P. (2021). Curiosity and Power: The Politics of Inquiry. University of Minnesota Press. https://books.google.co.nz/books?id=wqAiEAAAQBAJ
The Naked Physio / The curiouser 
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