Physiotherapists Both Reproduce and Resist Biomedical Dominance when Working With People With Low Back Pain: A Qualitative Study Towards New Praxis

Abstract

Despite recommendations to incorporate physical and psychosocial factors when providing care for people with back pain, research suggests that physiotherapists continue to focus on biological aspects. This study investigated how interpersonal and institutional norms influence this continued enactment of the biological aspects of management. We used theoretically-driven analysis, drawing from Foucauldian notions of power, to analyse 28 ethnographic observations of consultations and seven group discussions with physiotherapists. Analysis suggested that physiotherapy training established expectations of what a physiotherapist ‘should’ focus on, and institutional circumstances strongly drew the attention of physiotherapists towards biological aspects. Resistance to these forces was possible when, for example, physiotherapists reflected upon their practice, used silences and pauses during consultations, and actively collaborated with patients. These circumstances facilitated use of non-biomedical management approaches. Findings may assist physiotherapists to rework the enduring normative focus on biomedical aspects of care when providing care for patients with back pain.

Reciprocity in Low Back Pain Care and Its Role in Power Dynamics: A Give-and-Take Approach

“…Although a deeper discussion on therapeutic touch is beyond the scope of this study, our previous work has also observed how this element allowed patients and physical therapists to discuss and attend to nonphysical aspects of LBP. 13 Our finding adds to our previous work and that of Miciak by illustrating how this story-sharing happens in practice and its contribution to balancing power. Hiller et al 14 observed that casual, non-medical conversation during sessions was a key component for relationship building, encouraging active patient participation, and developing trust, supporting our finding that reciprocating the exchange of personal stories is useful for shifting status between parties.…”

“…This approach allowed a shift from biomedical foci toward more “human” interactions, a shift that has been discussed as difficult for physical therapists working with people with LBP. 13 Finding a similar effect, an interview study by Miciak et al 40 indicated that individuals are interested in knowing their physical therapists stories and that it helps with building therapeutic relationships. Further, personal stories seemed to be shared when therapeutic touch was used.…”

“…Previous research strongly suggests that patient–physical therapist interactions in musculoskeletal practices are often physical therapist-led, with physical therapists’ (often biologically focused) plans frequently determining the narrative. 13 , 14 , 42 Such potentially paternalistic practices require physical therapists to reflect on how to better share power, a key aspect in shared decision-making, 43 and foster a deeper ethical awareness of power asymmetries during clinical encounters. 44 Our analysis from the current study suggests that Johnstone’s theory of improvisation 28 may help provide physical therapists with some suggestions on how to shift this pattern by accepting patient offers.…”

“…Within the past 2 decades, the physical therapist profession has increasingly conceptualized and attempted to rework interactions with patients. The shift to patient-centered care increased attention to social elements of the biopsychosocial model 12 and greater attention to emotional 13 and power 11 , 13 factors. This shift can be considered a resistance to biomedical norms, where physical therapists attend to biomedical and psychosocial needs of individuals, moving from a physical therapist–dominant power to a shared power approach.…”

Towards an ethical multiplicity in low back pain care: Practising beyond the biopsychosocial model

“…Furthermore, the term ‘sociopsychobiomedical’ has been advocated (Department of Health, 2019) to decrease the overwhelming focus on biomedical aspects. Our past work suggests that physiotherapy research (Mescouto, Olson, Hodges, & Setchell, 2022), physiotherapy practice (Dillon et al.; Mescouto, Olson, Hodges, Costa, et al., 2022) and multidisciplinary practice (Mescouto, Olson, Costa, et al., 2022) continue to focus on biological and narrow ‘psychological’ aspects of LBP, with little consideration of the multiple other relevant dimensions. Although some have counter‐argued that psychosocial matters have been overemphasised (Hancock et al., 2011; Jull, 2017), the underlying assumption within the biopsychosocial model seems to lie within a biomedical paradigm despite being established to counter it (Mescouto, Olson, Hodges, & Setchell, 2022).…”