Physiotherapy, as an allied
health-care profession, has emerged from medical practice and, although it
cannot be considered apart from it, in recent years has found its own unique
space within the biomedical sciences.
Its situation is manifold since,
on the one hand, physiotherapy finds itself still under the domain of medicine
in Hospitals and Health Care Clinics that are led by rehabilitation physicians,
traumatologists, orthopedists, etc., where the physiotherapist’s task focuses mainly on the
application of the treatment as prescribed by the physician. On the other, it has
developed as an independent clinical practice in which the physiotherapist represents
the entry-level health care practitioner, being thus required to assess,
diagnose, plan and implement treatment physiotherapeutically as well as to evaluate
the patient for referral to other health care professionals.
Added to this situation is the
fact that physiotherapy is no longer a clinically centered profession alone, for
it has also included research within its field of action. With this increasing
focus on research and its ever-growing scope, physiotherapy is gradually becoming
an independent science and as such is trying to follow the scientific method in
the same way as its parent science does. Since the 1990s, medicine, instead of
following the traditional model based on expert opinion, intuition or habit, it
has turned to evidence-based medicine and clinical decision-making based on
evidence.[1]
This is changing the way we deal with patient diagnosis and is finally breaching
the gap between clinical practice and research.[2]
Physiotherapy also is following this new paradigm and, in this sense, is trying
to become an evidence-based physiotherapy (The creation of PEDro[3]
and the data from WebPT[4]
are an example of this pursuit).
This situation although
promising and indubitably positive, presents some problems with respect to
physiotherapy science.
Firstly, physiotherapy is
leaping forward on the wings of new medical models, without neither defining
nor establishing a coherent scientific model for itself as a science. The very
definition of physiotherapy is not available. What we find are vague, imprecise
and ever-changing descriptions of its scope and legal definitions. Whether
described by the WCPT[5],
APTA[6]
or any other physiotherapy association, it does not explain the domain in
scientific terms. I recently read in Scott’s Foundations of Physical Therapy[7]
that a definition of the term was impossible and that what we had to do as
physiotherapists was to find a definition of our own. Each physiotherapist, depending
on his/her own practice, country and situation, should have to come up with a
satisfactory definition (having then, as many definitions as there are
physiotherapists that may be willing to generate one). This situation of not
being able to define the term physiotherapy
itself shows how precarious physiotherapy is with respect to its scientific desires. In this sense, it
needs the infusion of epistemological thinking and systematicity in order to
establish its foundations and build its future developments in a stable manner.
Perhaps this very lack of a consistent model is part of what makes it so
versatile and flexible when acquiring and using any therapy that may benefit a
patient, no matter what paradigm it may follow (biomedical, holistic, etc.) But
I think that even at the risk of losing some flexibility, physiotherapy would
benefit enormously from a solid foundation. Setting its boundaries will give it
the tools to progress and experiment more coherently. Physiotherapy needs to
formulate fundamental questions, and create definitions of its own terms, as
well as specify the ones used from medicine.
Is there a science of
physiotherapy as such or is it just a well-intended project? Which are the
theoretical and observational statements of physiotherapy? Can we construct a
clear definition of physiotherapy? What are the specific differences of
physiotherapy? What are its main concepts and how are they defined in
physiotherapy (for instance: disease,
disorder, dysfunction, etc.)? What
are the signs and symptoms specific to physiotherapy and which ones have we merely
integrated from medicine? Is it coherent to be following the evidence-based
model at the same time that we are following alternative therapies such as
acupuncture, osteopathy, etc.? Is it enough the evidence of practice and its
success, or do we need to perform Randomized Control Trials (RTCs) as well with
these holistic approaches regardless of theoretical inconsistencies? These are
some of the questions that arise when thinking physiotherapy as a system.
I think that before advancing
further on other issues, it is paramount that we address first these
theoretical problems, before entering into any other matters concerning
physiotherapy practice.
The objective of this blog is to
venture in the fascinating task of constructing the science of physiotherapy, to dare to think scientifically trying to
answer these questions and to formulate new ones that may clarify and establish
its boundaries, helping us to develop towards directions that now we cannot
even imagine.
[1]
Zawadowicz,
Maria, "Scientific Method in Medicine: Bringing Unity to Research and
Clinical Decision-Making." (2009). First-Year Writing Contest.
http://publications.lakeforest.edu/firstyear_writing_contest/7
[3] Physiotherapy
Evidence Database.
[4] Physical Therapy
Software.
[5] World
Confederacy of Physical Therapy.
[7] Scott, Ron. Foundations of Physical Therapy: A 21st
Century-Focused View. McGraw-Hill. New York. 2002. p.p.3-5.
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