Which knowledge? An examination of the knowledge at play in physiotherapy with children

ABSTRACT

This article explores how knowledge is expressed and enacted in the practice of physiotherapy with children. The empirical material was generated through close observation of seven physiotherapy treatment sessions involving 7 children between 6 and 11 years old and 5 physiotherapists. Observations were undertaken by the first author, whose post-session written notes, along with comments and questions, constitute the database of this article. Through processing and analysis of data, we have written and present three experiential anecdotes as basis for further analysis and discussion. The article shows how children take initiative during therapy and display playful knowledge both of their body, moving capacity and of the equipment and tasks introduced. The physiotherapists seem to tend to emphasize physiological knowledge relating to the body, its functions and the “dangers” of pathological movement patterns. As a result, physiotherapists and child clients appear caught in a kind of stagnant co-existence where their connection and contact are at a standstill and there is little exchange of knowledge between them. We argue that, for therapy with children to develop along qualitative and creative lines, physiotherapists need to explicitly recognize children as humans of knowledge and embrace their playful contributions as significant to therapy.

KEYWORDS:

• Children
• knowledge exchange
• physiotherapy practice
• phenomenology

Introduction

“Knowledge does manifest itself in practical actions. And we may “discover” what we know in how we act” (Van Manen, 2007, p. 22)

The interpersonal and interactive nature of physiotherapy requires different types of knowledge: not simply that relating to diagnosis, prognosis, and biomedical understandings of the body but also knowledge of the experiential dimensions of living with impairments and receiving physiotherapy (Shaw and Connelly, 2012). Yet the training of physiotherapists remains rooted in a biomedical context, while physiotherapy research has mainly been conducted within a biomedical paradigm (Nicholls and Gibson, 2010; Wikström-Grotell, Broberg, Ahonen, and Eriksson, 2013). Despite this biomedical emphasis during training, physiotherapists who wish to deliver a high standard of treatment to adult or child clients need to integrate different types of knowledge (Shaw and DeForge, 2012) and different perspectives (Nicholls et al, 2016) in their practice.

The integration of different types of knowledge within the practice of physiotherapy is becoming more urgent in view of the current emphasis on the involvement of clients themselves (whether adults or children) in therapy and health care (Andreassen, 2008). There is now broad consensus to see even very young children as competent expressive individuals with opinions, feelings and knowledge about the situation in which they find themselves (Christensen, 2000; James, 2010; Prout, 2000; Tisdall and Punch, 2012). Children are now recognized as “human beings” rather than “humans in the process of becoming”; they are viewed as valuable, knowing beings in the here and now, rather than as immature beings on the road to becoming mature adults (Qvortrup, 2009). The recognition of children as competent body subjects is of immense importance to their wellbeing, just as it is for adults (Sartain, Clarke, and Heyman, 2000). As a result of this new perspective, therapists now find themselves called upon to view children as possessing important knowledge relevant to their own therapy.

To date, however, there has been little research examining the different types of knowledge that are expressed, exchanged, and negotiated in clinical encounters. The growing fields of “knowledge translation” and “evidence-based practice” tend to dominate research relating to generating, sharing and application of knowledge. Such fields have a largely “top-down” approach to how research findings (primarily from randomized-controlled trials) should be transferred and integrated into practice and how research-based models and programs should be implemented (Greenhalgh, Howick, and Maskrey, 2014). As a result, little is known about the knowledge expressed, shared and put into play during actual practice. However, one study has shown that the ways in which children reveal themselves as competent participants in relation and dialogue with adults are connected with the play of inter-subjectivity in the child–adult relationship (Bae, 2004). This suggests a need for research aimed at gaining a better understanding of children’s “playful and ambivalent” forms of being and acting (Jans, 2004).

This article is an attempt to address this lacuna. The specific aim is to explore how knowledge is expressed, shared and exchanged in the practice of primary health care physiotherapy with children whose medical diagnosis suggests the need for long-term follow-up.

Phenomenological study work: knowing bodies and embodied knowledge

To be seen as competent involves being seen as someone who knows something, someone who is able to know and to create knowledge. However, the way in which “knowledge” (as a word or concept) is understood varies according to one’s perspective (Quay, 2013). The theoretical perspective of this study rests on a phenomenological understanding of knowledge and what it represents.

From a phenomenological perspective, all our knowledge (including scientific knowledge) is seen as related to our own particular point of view; it derives from our experiences of being and acting as the bodies we are in the environment and situations we at any time inhabit (Merleau-Ponty, 2005). As bodily beings, we always try to get a comprehensive grasp of all the situations and activities we participate in; it is as “knowing bodies” that we are able to understand, act or not act in various situations (Merleau-Ponty, 2005). Knowledge and meaning are relational; an embodied view situates meaning and knowledge within a flow of experience that cannot exist apart from a body engaging with its environment (Irwin and Johnson, 2005; Johnson, 2008). In other words, through our bodily senses, the environment enters into the very shape of our thought; we sculpt our thinking, even our most abstract reasoning, out of our embodied interactions with the world (Johnson, 2008).

From a phenomenological point of view, then, being an active knower is the only way to gain or create knowledge. The process and activity of knowing is an on-going, continuous bodily process of being and living (Merleau-Ponty, 2005). In human relationships, whether between young and old, healthy and sick, one subject is affected by the other subject (e.g. the physiotherapist is affected by the child client, and vice versa) and by the situation they share. We live in co-existence with one another, with things and with the world (Leder, 1990; Merleau-Ponty, 2005; Nancy, 2000). Nancy (2000) argues that coexistence does not “happen” to existence; rather coexistence is existence, since “existence is not done alone.” As knowers who are in connection with one another as well as things and the situation, the physiotherapists and the children gain or create knowledge, which is then both personal and relational.

In Leder’s (1990) theoretical discussion of the phenomenon of co-existing subjectivity he focuses on how some ways of interacting and being together allow for co-existing subjectivity: a co-existence that embraces both participants’ subjectivity. In such situations, the individual subject body disappears as we direct ourselves to the task, to whatever we are doing together.

As “being” always involves co-existence, the nature of co-existing is of importance (Nancy, 2008). Nancy argues that contact between two subjects requires what he calls “displacement.” For example, in a situation involving two individuals in contact, neither can take the other’s space, place, or perspective. However, their mutual contact impels both individuals to shift position. In other words, establishing contact and understanding does not imply that one actor must take on the perspective of the other; rather, it means that both parties must be willing to give up their initial position and move toward the other.

Research method

Phenomenology constitutes both the theoretical perspective and the applied methodology for this study. As such, phenomenology has been the guiding philosophy in the production of the empirical material and in the analysis and writing processes.

Phenomenological research connects with the field of qualitative research, which Denzin and Lincoln (2005) describe as a comprehensive research field in which situated activities always locate the researcher in the world at a certain cultural, social, and historical time. Within this broad research field, researchers deploy a wide range of interconnected, interpretive practices directed toward the studied use and collection of a variety of empirical materials. Each of which makes the world visible in different ways (Denzin and Lincoln, 2005). Theory is central to research as all researchers will have a particular worldview or theoretical perspective, which underpins and shapes their project and its findings (Green and Thorogood, 2013).

Van Manen (1990) makes a distinction between method and research methodology. He holds that methodology is the theory behind the method, including the choice of any particular method and the reasons for this choice. Hence, any method is replete with methodological considerations and shaped by particular philosophical or epistemological perspectives. Finlay and Evans (2009) also emphasize as critical to phenomenological research to engage with the fuller methodology. However, there are many ways to do phenomenological research (Finlay, 2011; Van Manen, 2014), and phenomenological researchers draw on different philosophers and theories as their theoretical foundation. This study has been particularly influenced by the philosophical ideas of Merleau-Ponty, Leder, and Nancy, as also by the research and writings of scholars such as van Manen and Finlay. We are fully aware that the phenomenological approach used in this study, can only render a limited picture of the investigated phenomenon; the phenomenon of knowledge shared and put into play in physiotherapy with children.

The empirical material for the research on which this article is based was generated as part of the first author’s doctoral research. The data derive from observations of seven children between 6 and 11 years of age during regular weekly therapy sessions with five physiotherapists. Each session lasted for 60 min. Two of the participating physiotherapists were observed twice with different children. All seven children were interviewed, as were their parents. Six of the children also participated in a 1-year long movement project. Observations and interviews combined with video observations of the weekly sessions in the movement project, constitute the empirical material for the doctoral project (Bjorbaekmo, 2011). The present article is based on observations made during the seven physiotherapy sessions.

Observation (especially close observation) is particularly suited to research focused on interaction and on the expression and exchange of knowledge. Van Manen (2014) describes close observation as an indirect method of collecting experiential material from others, and maintains that it is not a variant of participant observation. In physiotherapy, where much of the thinking and decision making regarding practice occurs at a rapid and pre-reflective or subconscious level (Ajjawi and Higgs, 2007), close observation requires the researcher to assume an attitude and a relationship as close as possible to the situation, while simultaneously retaining a hermeneutic alertness to it (Van Manen, 1990, 2014). A hermeneutic alertness to situations allows the observer to constantly step back and reflect on the meaning of the situations she is observing and in which she, also takes part.

In this study, close observation involved the first author relating to the therapists and the children simply by being with them, without making any attempt to interrupt or actively interfere with what they did in their activities. At the same time, she was always ready to accept invitations to get involved (e.g., on one occasion, a child wanted her to try the skipping rope, and on another a therapist invited her to try out the vibrating balance board). To the close observer this was an attempt to be present as an interested part in the situation.

The first author wrote up her observation notes after each of the seven sessions. Here she sought to capture the lived experience of the observed situations, not simply to report what had been seen, done and said. The attitude of the observer can be likened to that of an author always on the look-out for stories to tell and incidents to remember (Van Manen, 1990). As they report what they have seen, heard, or participated in, close observers attempt to write in such a way that the reader can see the events and situations as vividly as possible. The challenge lies in finding language and a mode of expression geared to the experiential or lived sensibility of the lifeworld (Van Manen, 2007).

Participants

The seven children who participated in the study were aged between 6 and 11 years. They were diagnosed as having cerebral palsy¹ or spina bifida² or else had undergone heart surgery involving multiple and complex corrections in their first year of life.³ Among the five participating physiotherapists, one worked in the public sector (as a municipal physiotherapist) while the other four worked in private clinics. All the children had previously met the observer through their participation in a 1-year research project that included movement groups and interviews. The project, in which the data was collected, was approved by the Regional Committee for Medical Research Ethics, and was carried out according to the Helsinki declaration. Written informed consent was obtained from the physiotherapists, from the children’s parents, and also from those children able to read and write.

The analysis: a process of reading, discussing, writing, and re-writing

The analysis presented here involved a cooperative effort by three researchers from different backgrounds.⁴ While this opened new possibilities for exploring relational aspects of inter-action in physiotherapy encounters with children, it also presented challenges. The process began with each of us reading, and jotting down responses to, the observation notes marked with the first author’s immediate comments and questions. We then met to share our thoughts and reflections. In our discussions, we focused on two questions. First, what are the described situations about? Second, what jumps out as being of special interest or make us stop and wonder? By posing these two questions, we, during this process, developed a sense of how various types of knowledge were expressed or came into play in the interaction between physiotherapist and child. We came to an understanding of how forms of different knowledge were heard, seen and given significance (or not) in these observed encounters. As the authors read and re-read the field notes and discussed our reflections we agreed on focusing on the phenomenon of knowledge.

On the basis of these discussions a number of anecdotes or examples from the seven observations focusing on the phenomenon of knowledge were written. Each observation contained data of several moments or incidents, and the authors next step were to develop and edit the anecdotes with regard to how knowledge was expressed, shared, not shared and or possibly negotiated. While based on real events and situations, these anecdotes or phenomenological examples should not be understood as exact accounts of what was observed. Rather, they represent a distillation of significant events we identify as highlighting noteworthy aspects of the various forms of knowledge at play in the actual encounters.

In writing and editing the anecdotes, our aim was to capture the essence of experiences, rather than simply describe them. This involved systematic analysis of meaning structures embedded in the actual situation, ones that expressed the pre-reflective substrata of the actual experience. Written observations embody meaning in different ways. The deeper meaning embedded in a text is expressed through a relational tension between words, passages and explicit meaning (Van Manen, 2014). Composing anecdotes based on real events involves reflecting on experiences and attempting to recreate them. This process inevitably represents a transcended form of the actual experience (Van Manen, 2014). Our approach assumes that a powerful anecdote describes a single or few incidents concisely, captures the central moment of an experience, includes only the most important details, is short, close quickly after the incident(s) has passed, often has an effective last line which creates a punctum and it often contains several quotes (Van Manen, 2014).

On this basis we believe that the anecdotes presented in the next paragraph provide significant insights into some lived experiences of how children and physiotherapists engage in concrete therapy sessions. Phenomenological researchers do not look for sameness or repetitive patterns in their data, but rather for what is singular. This means, according to Van Manen (2014), in presenting findings only “the right amount of experiential material” should be presented aiming to create a scholarly and reflective phenomenological text. Following this we present three unique moments, moments that gave us insight into the phenomenon of knowledge expressed, shared, and not shared. In phenomenological research evidence is related to the grasping of meaning of the actual phenomenon or event, but “phenomenological evidence is ultimately ambiguous and never complete” (Van Manen, 2014).

In all qualitative research the researcher is understood as co-creator of both the empirical material and the findings (Denzin and Lincoln, 2005; Van Manen, 2014). As a collaborative team working on the data co-created by the first author in her role of observer, we needed to reflect on the role of the observer, the written observational notes, the analytical process and the writing up of our research findings. No matter how carefully and strictly different ethical procedures are followed in research, situations may arise “which make our heads spin and heart ache” (Finlay, 2011). In this study the observer was well aware of being challenged both in her role as observer and in the process of working with the material afterwards. Adopting a critical attitude towards the way she experienced the various encounters, she reflected on her responsibility of care toward the participants, both during the encounters and afterwards (when working with the data). This responsibility of care in relation to every participant (whether the children themselves or the physiotherapists working with them) was seen to involve respect for both parties in these relational situations. As researchers we have striven to show respect both to our participants and to the practice they participated in. This has also involved a commitment to exploring the research topic within the specific context of our study.

Every research encounter brings up context-specific ethical questions. In phenomenological research, material of a personal nature is often involved (Finlay, 2011). In the present study, one ethical question raised was that of how the observer would be seen by the children and therapists in each encounter. Would the observer perhaps be seen and felt as an intruder? This challenged the observer to reflect on the situation she had been part of and her role in it, before, during and after each encounter. To what extent might the observed encounters have been influenced by the presence of the researcher? What sort of difference had the observer’s presence made? On reflection, too, we realized that the physiotherapists may have felt under some obligation to let the researcher to be present, given that the children and their parents already participated in her PhD study. However, each physiotherapist was given time to prepare before each observed session, and all arrangements were agreed with them as well as with the children’s parents. Both physiotherapists and children seemed confident and relaxed about the situation during all seven observed encounters. On this basis we would argue that the observer has succeeded in capturing some essential aspects of how physiotherapists and children relate to one another, and has shed light on the knowledge that is at stake in between them.

Three anecdotes

Anna

I hear limping steps in the corridor. Thinking it may be Anna, I peer out the door of the room where I’m waiting. “Hi,” Anna says with a smile, and then adds, “My birthday was on Wednesday.” “Oh,” I respond, “Happy birthday.”

The physiotherapist enters the room. I sit on a chair placed against the wall just inside the door. Anna walks to the treatment table and sits herself on it. Using her legs, she tries to operate the mechanism that makes the table go up and down. The physiotherapist puts a pillow on the treatment table and looks through some papers. As she reads, she asks Anna to lie down. Anna does so. Approaching the table, the physiotherapist comments that Anna still has her shoes on. She helps Anna remove her long-sleeved sweater, then her shoes and orthotics. “Take off the socks, too,” Anna requests. “It’s so warm.” The physiotherapist removes them. “Oh, lovely,” Anna murmurs with a deep sigh, making small movements with her feet. The physiotherapist sits down on the table next to Anna’s feet and comments on her new pants, belt and sweater. “Birthday presents,” Anna explains. The physiotherapist begins to touch and move Anna’s feet and asks if they should play the “letter game.” Anna agrees. As the physiotherapist moves Anna’s ankles, knees and hips, they choose a letter and then take turns saying a word that begins with that letter. They continue for several minutes as the physiotherapist moves Anna’s ankles into dorsiflexion, flexes and stretches her knees and finally abducts her hips.

Reflections

This anecdote shows how Anna demonstrates knowing about the possibilities offered by the treatment table by changing its height. It reveals her interest in doing so, as well as her competence in using her legs and her body to manipulate this function of the treatment table. It could also be that her main interest is in helping with the treatment preparations. The physiotherapist, busy with preparing, does not appear to take any special interest in what Anna is doing. She does not seem to notice Anna’s efforts to move the table up and down with her legs. Although the physiotherapist comments on Anna’s new clothes as she joins her on the treatment table, she says nothing about Anna’s wish to remove her socks or the pleasure she expresses through her sigh and lively wriggle of her feet. Once again, what Anna expresses does not seem to be noticed by the physiotherapist in that moment. It could be that the physiotherapist is especially conscious of Anna’s new clothes because she is aware of Anna’s recent birthday. On the other hand, her inattentiveness to Anna’s engagement in preparing for therapy and her movements expressing pure joy after her socks are taken off could raise questions about how Anna and her experiences are being seen during therapy.

When the physiotherapist starts to move Anna’s legs and suggests that they play the letter game, she takes the focus away from what she is doing with Anna’s legs. Playing the game focuses Anna’s attention on letters and words, rather than on her movements, on her body and on her legs. Perhaps the physiotherapist’s intention is to distract Anna from focusing on the sensation of tight muscles and stiff joints. Even if that is the case, she does not explicitly interact with the knowledge Anna brings into the room. She seems to be performing the therapy on Anna, rather than encouraging her to play an active role in it.

Susanne

Susanne has just arrived at the clinic and the therapy session is about to start. “To the mill,” the physiotherapist says. “First with and then without.” I don’t understand what he’s talking about, but I don’t ask. I follow them into the gym. Susanne steps onto a treadmill. She and the therapist press some buttons to adjust the settings. Then Susanne starts walking. “Toes straight ahead,” the physiotherapist urges. Very soon, Susanne begins to let herself follow the band backwards. Just before she slips off she takes a step forward again. She keeps doing this: walking, slipping backwards, and then taking a step forward just before falling off the treadmill. Several times during the session the physiotherapist tells Susanne: “Toes straight ahead.” After about 5 min he says, “Now, without.” Susanne steps off the treadmill, takes off her shoes and ankle orthotics, steps back on the treadmill, and repeats the same procedure.

Reflections

This anecdote shows how Susanne explores walking on the treadmill. While the physiotherapist is concerned about her toes pointing straight ahead, Susanne seems to have a slightly different project in mind. Through play, she explores how her body and the treadmill can interact in this inter-active walking. Nothing is said between the therapist and Susanne about what she is doing; she is simply reminded to keep her toes pointing straight ahead. The therapist repeats this instruction without engaging in a dialogue with Susanne about what she is doing. It might be that the physiotherapist avoids interrupting or commenting as a way of accepting and encouraging Susanne’s inter-active walking play. Or it could signal the physiotherapist’s lack of awareness of the importance of children’s explorative play in therapy. Either way, the physiotherapist does not explicitly communicate anything about Susanne’s contribution to her own therapy.

Emma

The treatment session is about to begin. Emma looks at the physiotherapist and declares, “Mom says you decide what we should do.” “But don’t we decide together?” the physiotherapist queries. “You decide,” Emma affirms. Nothing more is said about the topic as we walk into a large square room with windows facing the sea and the city. The room, which has large mirrors on two of its walls, is empty. The physiotherapist brings out several round flat plastic objects and asks Emma to place them on the floor. Then she gets Emma a therapy skateboard. Emma lies on it and rolls between the plastic stones while trying to hold her head and legs up. “Keep your legs up,” the physiotherapist urges. Emma continues moving around quietly until the physiotherapist asks her to stop and brings out a jump rope. “I can’t jump,” Emma protests. “You’re not going to jump,” the physiotherapist assures her. “I’ll show you what to do. Keep lying on the skateboard and hold the rope with both hands. I’ll pull you around.”

“No,” Emma demurs. “It’s dangerous.” “Dangerous?” the physiotherapist queries.

“Yes,” Emma insists. “I can fall off.” “But you couldn’t fall far; it isn’t really dangerous,” the physiotherapist replies soothingly. Emma lifts her arms and holds on to the rope. The physiotherapist begins to pull her around slowly. Gradually she goes faster, until Emma falls off the skateboard. After the skateboard session, the physiotherapist suggests that Emma jump on the trampoline. While she gets the equipment, Emma moves around the room, trying out some dance steps and looking at herself in the mirror. When the physiotherapist has set up the trampoline, she asks Emma to start jumping.

Reflections

Anecdote three shows how Emma is concerned about who decides in therapy. She firmly states that the physiotherapist decides, but the physiotherapist holds that they co-decide. Emma also demonstrates concern about her ability to balance in prone on the skateboard. She is afraid of falling off, which she finally does. However, her fall does not become a topic in her conversation with the physiotherapist. This could be interpreted as a failure on the part of the physiotherapist to register Emma’s insight into her own body capacity. Or it could be seen as bearing out the physiotherapist’s reassuring statement that falling off the skateboard would not be dangerous. Either way, Emma’s embodied concern about her capacity appears to have been overlooked. As the physiotherapist busies herself with getting the trampoline ready, Emma shows an interest in making dance movements in front of the mirror. Perhaps the physiotherapist was too occupied with her own task to see Emma’s impromptu performance. In any case, she did not take any special notice of it.

Knowledge displayed: recognized or ignored

We now explore how these three anecdotes can be understood as knowledge encounters in terms of the phenomenological perspective presented earlier. In their therapy sessions, Anna, Susanne and Emma all engage in movements and activities that do not receive any explicit attention from their therapist. In different ways, each girl takes the initiative, showing through her movements and activity knowledge of her own body, its possibilities and limitations, and also her knowledge of how to handle the equipment used in her physiotherapy. The therapists choose the activities but give the children a modicum of space and time to explore and create different ways of performing them during the sessions; or the children take the initiative to do this on their own.

In all three anecdotes, the knowledge the physiotherapists show and seem to emphasize is physiological knowledge relating to the body and its functions, and the “dangers” posed by pathological movement patterns. They express this knowledge through instructive guidance on how the child should perform the activities (e.g., keeping toes pointing straight ahead). In their responses to the requests or instructions from their physiotherapist, the children “obey” the physiotherapists by conforming to their knowledge base in doing as they are told. At the same time, like for instance Susanne in her playful exploration in walking on the treadmill, they stick to their own agenda and display different knowledge of their body and its abilities. To some extent, the children assert their freedom to explore and play while performing the instructed and requested activities.

Both Anna and Emma also take the opportunity to explore and play with movement between instructed activities; Anna by exploring the mechanism of the treatment table with her legs and Emma by performing her little dance improvisation. In both cases, the children show that they are agents of knowledge and know how to improve themselves.

The way the children initiate their own movement explorations and express their body-movement knowledge might be understood as an illustration of Sheets-Johnstone’s (1999) contention that our sense of agency is rooted in movement, and that self-movement structures our knowledge of the world. In other words, moving is a way of knowing and thinking. Through their movement expressions, these three children display their knowledge and thought processes. A process that according to Johnson (2008) involve the children’s embodied interaction with the environment, the actual physiotherapy encounter, an interaction which sculpt their thinking and their understanding of the situation, of themselves and the physiotherapy they participate in. These self-motivated efforts might also denote their desire to utilize the opportunities during the physiotherapy sessions to engage in movement activities that maintain and stimulate their vitality and sense of agency. This way of being and acting might be seen to express how children as phenomenological bodies make sense and meaning to the situation they inhabit.

As noted earlier, the physiotherapists appear to be focused on facilitating normality in both movement and movement range, and on preventing pathological development in the child’s body and body functioning. Although not articulated verbally, such goals seem implicit in the instructions given on what to do and how. An example in which the physiotherapist goal and intention in therapy is expressed, but not articulated verbally occurs when the physiotherapist invites Anna to play the letter game while she moves Anna’s ankles, knees and hip joints to prevent joint contractures. When the physiotherapist invites Anna to play the letter game while she obviously also has another agenda, is interesting. How can we understand the situation? The therapist’s objective might have been to draw Anna’s attention away from what the physiotherapist possibly understands as something unpleasant or boring. Inviting Anna to join in the letter game might also be seen as a recognition of children’s desire to play, of their playful way of being in the world. Nevertheless, inviting to engage in this game appears as detached from the therapeutic goal, intention and activity at the moment. There is no obvious connection between the therapeutic treatment and their simultaneously play

Even though physiotherapist and child do not engage in the exact same activity, they do co-exist in the encounter. According to Nancy (2008) existence always is co-existence. He further argues that: “Being cannot be anything but being-with-one-another” (Nancy, 2000). Being-with is the sharing of time and space. It is to be at the same time in the-same place. Elaborating further on this he argues: “With” does not indicate the sharing of a common situation any more than the juxtaposition of pure exteriorities does (e.g., a bench with a tree a dog with a passer-by) (Nancy, 2000).

Consequently, even if physiotherapists and children are with one another in the encounters, this is not in itself sufficient for the sharing of a common situation. It is the dis-position of what might be put into play between the child and the physiotherapist that open up for the sharing of a situation (Nancy, 2000). This dis-position in-between people, things and the environment is about the possibility or not of; togetherness (Nancy, 2000). Togetherness is about to be in contact, and to get in contact demands what Nancy names displacement. For example, in the physiotherapy encounter two individuals in contact neither can take the other’s space, place or perspective. However, in order to share a situation both individuals have to shift position, as displacement is essential to achieve contact (Nancy, 2008).

The interactions between physiotherapists and children in the three anecdotes illustrate a lack of sharing, a lack of displacement; resulting in both parties having their own agenda. The contact and interaction between child and physiotherapist becomes detached and vague.

In co-existents, which a physiotherapy encounter represents, Merleau-Ponty (2005) holds language to play “a crucial role in the perception of other people” and in establishing a common ground between them. The possibility of a common ground established through dialogues and interaction in physiotherapy, is to be seen as “shared operations” in which, as in this study, both the child and the physiotherapist are the creators in a kind of dual being. Merleau-Ponty (2005) clarifies that dual being or “co-existents must in all cases be experienced on both sides”. He further maintains that it is vital that the shared world is understandable for those involved. If their dual being is inconceivable for either both or one of them, the communication and interaction will break down. When communication breaks down each one will operate in their own private world “like two players playing on two chessboards a hundred miles apart” (Merleau-Ponty, 2005). Communication and interaction between the physiotherapists and the children in the three anecdotes can, related to this, be understood as not been established and the two parties, even if being in the same place at the same time, operating in their own worlds and having their own private agendas in what they are doing. Although to create a common ground in a situation, like physiotherapy, requires a commitment from both parties and we believe that the physiotherapist has a specific responsibility with regard to facilitate such cooperation.

The nature of the coexistence between the children and physiotherapists in this study is open to question. Related to Leder (1990) and the notion of co-existing-subjectivity, implying a situation where both the physiotherapist and the child have what they are doing together at the center of their attention is far from what can be seen to be the situation in either of the three anecdotes. Maybe, it is unlikely to expect a physiotherapy encounter to be a situation where the participants might experience being subjects in the same activity. However, if a physiotherapy encounter is neither a situation where co-existing-subjectivity is expected nor desirable as such, a more mutual contact than seen in this study, seems important to strive for. In mutual contact physiotherapist and child can’t speak, act, listen or see from where the other is, but they can reach out and meet one another willingly and with interest. Then their knowing and their exchange of knowledge can occur at many levels.

The physiotherapy encounter implies coexistence, and coexistence involves “being exposed” (Nancy, 2000). Regardless of the character of their coexistence, in the physiotherapy encounter therapist and child are exposed to one another. Among other things, this means exposing one’s knowledge and understanding. As we have shown, the children seem to understand the physiotherapist’s knowledge message in the actual situations by following and giving attention to their instructions. At the same time the children expose playful movement explorations in and in-between activities. For their part, the physiotherapists just seem to give the children moments of space to express and expose their playful movement explorations. Explorations that otherwise are given no explicit attention.

Nancy (2000) argues that meaning is the sharing of being and that in being with one another, we always understand meaning. As expressive bodies always related to one another, to every situation we are involved in we are exposed to one another. We see and are visible, and as Merleau-Ponty (2005) points out: “… we are literally what others think of us and what our world is”. Meaning that despite, even if little is said between physiotherapist and child both understand and get a feeling, an impression of how they are seen by the other. By being with one another, being exposed, they get to know how their competence, their skills and their way of being in the situation are seen by the other. Since both parties experience this co-existence, their individual perceptions and views are not independent of each other; they slip into each other and come together. The relationship between one consciousness and another entails being in the same world, communicating with, being with and being in contact with the other (Merleau-Ponty, 2005).

Related to this perspective, no joint venture and creative exchange of knowledge is established between physiotherapist and child, in this study. The interaction and exchange of knowledge between them seem to take place more as if between “healer” and “sufferer.” It is as if their encounters are a form of stagnant coexistence in which a lack of displacement and lack of contact result in the absence of open and collaborative knowledge exchange.

Closing remarks

Inspired from a phenomenological perspective, we have explored how knowledge is expressed, shared and exchanged in the practice of primary health care physiotherapy with children whose medical diagnosis suggests the need for long-term follow-up. On the basis of three anecdotes from close observation of therapy encounters, we argue that the knowledge exchange tends to suffer from a lack of mutual contact and shared situations between physiotherapist and child.

The study reveals how different forms of knowledge are exposed in the encounters and how the knowledge given attention and significance appears to belong exclusively to the physiotherapists’ knowledge base. However, the relationships between the physiotherapist and the individual child seem to involve a tacit acceptance of the other’s knowledge, despite the fact that little or no active exchange of knowledge takes place between them.

The authors suggest that the practice of physiotherapy would be enriched by a readiness on the part of therapists to share the knowledge they rely on in their work with children. Such a readiness implies explicit recognition of children as competent “humans of knowledge,” along with awareness of the physiotherapists’ responsibility to facilitate contact and shared situations in the encounters. How physiotherapists succeed in making contact with children is related to their awareness with the play of inter-subjectivity in the child–adult relationship (Bae, 2004). Professionals always have to attune and adapt to each individual patient, and in physiotherapy with children the physiotherapists have to engage and involve themselves in, children’s “playful and ambivalent” forms of being and acting (Jans, 2004) to better understand how to inter-act and make contact in shared therapy.

The socio-cultural shift in attitude from seeing children as immature to recognizing them as competent body subjects in their own right, involves challenges of importance for how physiotherapists relate to children, and how the therapy is being designed. There is a further need to explore the relational challenges in physiotherapy as such, and also specifically further explore challenges and possibilities in physiotherapy with children.

Declaration of interest

The authors report no declarations of interest.

Acknowledgments

We would like to thank Gro Rugseth for constructive feedback on an earlier draft of this article.

Additional information

Funding

Financial support was from The Norwegian Fund for Post-Graduate training in Physiotherapy through the FYSIOPRIM project.

Notes

¹ The participants diagnosed having cerebral palsy was, according to Gross Motor Function Classification System (GMFCS), functioning between levels I-IV.

² The participants diagnosed having spina bifida had lessons at about level L5 and S1.

³ Among the participants who had undergone heart surgery during their first year of life, children with simple or moderate defects, such as single arterial septal defect, ventricular septal defect, co-arctation of aorta, aortic valve stenosis, and pulmonic stenosis were excluded.

⁴ The observer (and first author) is a physiotherapist specializing in physiotherapy for children. The second author is a physiotherapist specializing in manual therapy. The third author has a background in the philosophy of science. All three have broad experience in research with different methodology.