Audio file
File
K. Mescouto1, R. Olson2, P.W. Hodges1, N. Costa1, M.A. Patton1, K. Evans3, K. Walsh4, J. Setchell1
1The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia, 2The University of Queensland, School of Social Sciences, Brisbane, Australia, 3Healthia Ltd, Brisbane, Australia, 4Metro South Health Persistent Pain Management Service, Brisbane, Australia
Background: Despite recommendations to include psychosocial factors when providing care for people with low back pain (LBP), research suggests biological aspects remain the focus of physiotherapy practice with little attention to broader aspects of care. There has been little exploration (philosophical or applied) of how this dominance of biological aspects is enacted in clinical practice, nor how resistance to this biological dominance could be practiced.
Purpose: This study had two aims:
1) to investigate how power plays out in the enactment of biological and ‘human’ (e.g., psychological, social, interpersonal, cultural) aspects of care in the management of people with LBP in private practice settings, and
2) to co-develop recommendations to enhance these human aspects of care where needed.
1) to investigate how power plays out in the enactment of biological and ‘human’ (e.g., psychological, social, interpersonal, cultural) aspects of care in the management of people with LBP in private practice settings, and
2) to co-develop recommendations to enhance these human aspects of care where needed.
Methods: In this qualitative study we apply a Foucauldian philosophical lens to understand how power is involved in the biological and human aspects of LBP care. Foucault conceptualises power as dispersed (not just top-down) and visible within multiple aspects of clinical care. The research team thematically analysed data from 30 ethnographic observations of physiotherapy consultations (26 patient participants), and 7 collaborative discussions with 10 physiotherapist participants. An advisory panel of 5 people with lived experience of LBP provided patient input into all study components.
Results: Analysis produced two overarching themes.
Theme: 1) biological focus: our collaborative analysis traced how power reinforced the preference for biological over human aspects of care in physiotherapy management of people with LBP. The focus on biological aspects was enacted when patients and physiotherapists were drawn towards familiar norms of biological approaches of physiotherapy practice, when such approaches appeared to be tied to physiotherapists’ professional identity, and when institutional circumstances contributed to reinforcing the biological focus of interactions.
Theme: 2) human aspects of care: these aspects received less attention in consultations, with physiotherapists often missing important cues from patients regarding aspects beyond the biological. However, there were times where resistance against the dominance of biological foci was observed, with physiotherapists attending to patients’ emotions and other non-biological concerns. For example, some participating physiotherapists attended to the human aspects of care when they adopted a slower pace, provided silent moments, and created more flexible consultations. Further, during the study’s 7 discussions with clinicians physiotherapists challenged their biological assumptions that usually frame how they work.
Theme: 1) biological focus: our collaborative analysis traced how power reinforced the preference for biological over human aspects of care in physiotherapy management of people with LBP. The focus on biological aspects was enacted when patients and physiotherapists were drawn towards familiar norms of biological approaches of physiotherapy practice, when such approaches appeared to be tied to physiotherapists’ professional identity, and when institutional circumstances contributed to reinforcing the biological focus of interactions.
Theme: 2) human aspects of care: these aspects received less attention in consultations, with physiotherapists often missing important cues from patients regarding aspects beyond the biological. However, there were times where resistance against the dominance of biological foci was observed, with physiotherapists attending to patients’ emotions and other non-biological concerns. For example, some participating physiotherapists attended to the human aspects of care when they adopted a slower pace, provided silent moments, and created more flexible consultations. Further, during the study’s 7 discussions with clinicians physiotherapists challenged their biological assumptions that usually frame how they work.
Conclusion(s): Although in the present study there were signs of some shifts towards broader ‘human’ aspects of LBP in physiotherapy practice, the focus on biological aspects still dominated as a normative practice. Physiotherapists could resist the strong draw of this institutionalised habit when used strategies that challenged their practices and usual ways of working, but this required ongoing negotiation and re-negotiation of power that allowed more collaborative and reflexive practices to enhance the human aspects of LBP care.
Implications: Physiotherapists may be able to resist the biomedical dominance by adopting practical recommendations for clinical change that include: using collaborative communication to invite patients’ suggestions, attending to power differences and patients’ and physiotherapists’ emotions, and creating time to address human aspects of care.
Funding, acknowledgements: This work was supported by National Health and Medical Research Council of Australia Fellowships [JS: APP1157199 and PH: APP1102905]
Keywords: low back pain, power dynamics, qualitative research
Topic: Pain & pain management
Did this work require ethics approval? Yes
Institution: The University of Queensland
Committee: The University of Queensland Human Ethics Committee A
Ethics number: 2019000231
All authors, affiliations and abstracts have been published as submitted.
