Critical Reflections on the Physiotherapy Profession in Canada

A rethinking of scope of practice, patient access, accountability and payment is coming to bear on healthcare systems around the world … We must be ready to meet these changes and effect a positive outcome for our patients and our profession.

Michel Landry, President, Canadian Physiotherapy Association (2007–2009)¹

Physiotherapists are faced with a number of unprecedented opportunities and challenges that require new ways of thinking about and practising physiotherapy. Significant among these is legislation recently tabled in Ontario that will enable physiotherapists to order tests such as x-rays and to diagnose patient conditions that are within the profession's scope of practice. This expansion of scope follows closely on the heels of progressive changes to physiotherapy (PT) in Canada and other countries, including the move to entry-level master's and doctoral training programmes, increasing privatization of PT services, licensure of alternative practitioners, and health workforce reform. Because of the current global economic crisis, federal budgets are being tightened; in Canada, this has implications for transfer payments to provinces and for alterations to the funding of PT services. Collectively, these changes signal profound shifts that are underway for PT as our profession continues to evolve in response to social, political, and economic influences. In order to respond, we argue, it is crucial for PT to engage in rigorous critical reflection on the theoretical basis of physiotherapy practice. As we outline below, critical reflection will assist us in further developing the foundations of PT, opening up new opportunities for growth and change in PT practice, research, and education.

Critical theoretical reflection^2–4 is a tradition in the social sciences of explicitly examining ideas and concepts that are dominant, given, or taken for granted in social institutions and practices, in order to reflect on how “things could be otherwise.”^5(p.158) Thus, we use the term “critical” in a manner that may be less familiar to some physiotherapists. While there is arguably a strong tradition of reflection and visioning in PT, very little of this work has translated into the kind of robust theoretical analysis that has been extensively reported in other health professions.^6–12 Others have written about the lack of an established theoretical framework in PT.^13–18 Although our practice is underpinned by theoretical knowledge, we have largely borrowed our conceptual groundings from elsewhere in the biomedical, physical, and social sciences¹³ or concentrated on “middle range theories” that are specific to different areas of practice.^19(p.25) These contributions are important, but what is missing is the work of addressing, unpacking, and (re)imagining larger ideas about the practice of physiotherapy. In effect, scarce attention has been paid to the conceptual assumptions that underpin PT or to their implications for the future of the profession. We suggest that engaging in critical theoretical reflection will help the profession take advantage of the rapidly changing cultural, economic, political, and social environments of health care; open doors to new roles and diverse professional identities; and assist us in addressing the changing needs and preferences of an expanding clientele.

Importantly, there is already preliminary work in PT that begins to situate practical and empirical questions within more robust theoretical frameworks. For example, changing philosophical perspectives on the PT management of children with physical disabilities has resulted in a practice shift toward offering early powered mobility.¹⁸ In another example, Nicholls and Gibson have recently written about a theory of embodiment that integrates the self, body, and society beyond the “body as machine” model that is prevalent in PT, in order to offer new ways for physiotherapists to understand and to respond holistically to their patients' experiences of illness.²⁰ In a third example, Nixon is using a critical public-health ethics lens to evaluate the intersections of disability and HIV/AIDS across Canada and southern Africa, enabling an approach to PT that takes into account dominant political forces such as economic globalization.²¹

There are numerous other opportunities to explore diverse ways of thinking and practising in PT. For instance, the relationships between different areas of PT practice and the International Classification of Functioning, Disability and Health (ICF)²² could be critically explored, expanded, and critiqued. Other conceptual work with the ICF could include its applicability to patients' real-life experiences of disablement; the relationship to other models, such as Determinants of Health²³; and the relationships between participation and inclusion. Our intent is not to denounce current dominant ideas as “bad,” or to suggest that they be discarded, but to highlight the fact that the dominant understandings embedded in PT and other health practices constitute just one way of approaching physical therapy practice, and that critical reflection opens up potentially fruitful avenues for exploration and growth.

Somewhat paradoxically, the lack of a central organizing concept in PT limits our ability to think broadly about future directions. Physiotherapy is a diverse profession, with multiple approaches, methods, and ways of knowing. Other health professions, however, arguably enjoy a clearer sense of identity, purpose, and even branding by virtue of their well-defined organizing concepts—for example, “occupation” in occupational therapy, “care” in nursing, and “healing” in medicine. Physiotherapists have long commented on the lack of an overarching theoretical concept in PT,^13,15,24,25 and some have attempted to articulate foundational principles.^26–28 Most significant among these has been the Movement Continuum Theory,¹⁴ which appeared in the pages of this journal in 1995 and showed tremendous promise, but which was not sufficiently taken up and, as a result, has remained underdeveloped.

To enhance the theoretical development of PT, we can learn from advancements in other health professions. Medicine and nursing, for example, offer theory courses in their professional programmes, have journals devoted to the development and application of theory, and provide spaces in existing journals that welcome and encourage theoretical engagement. For example, Nursing Inquiry encourages submissions related to “philosophical inquiries that investigate the assumptions underpinning clinical practice and raise questions such as ‘Why do we engage in particular practices?’”²⁹ We suggest that the time is ripe for PT to develop and rigorously engage in similar practices of theoretical reflection, development, and application.

Our hope is to stimulate wider discussion and debate among our PT colleagues and to inspire others to engage in theoretical reflection across physiotherapy practice, education, and research. We anticipate that the issues raised here may manifest differently in different contexts, and that there are aspects that we have not considered. To that end, we welcome criticism, debate, and ongoing dialogue.