Beyond methods: The promise of qualitative inquiry for physical therapy

Physical therapy offers the promise of alleviating pain and dysfunction, improving quality of life, and enabling social participation. The aims of physical therapy encompass ‘physical, psychological, emotional, and social wellbeing’.1 As our profession continues to mature and expand, we are increasing extending our reach not only into new areas of practice but into new forms of knowledge and knowledge creation - new ways of investigating what we do and how myriad physical, social, cultural and political forces intersect to mediate health and wellbeing.2 New questions and anxieties arise as we expand from impairment-focused interventions to the complexity of enabling social roles and participation.3 These exciting new directions offer unprecedented opportunities and challenges that require innovative research approaches. Qualitative research has a key role to play in this expanding knowledge base and its potential has been largely untapped in physical therapy.4 For the profession to thrive, an increasingly sophisticated body of theoretically-grounded qualitative research is essential. This special issue is dedicated to outlining the incredible diversity in qualitative research in addressing the intersecting forces that affect client wellbeing and physical therapy practice.

Qualitative research is on the rise in physical therapy, which has raised its profile but also generated concerns and misunderstandings about its uses. More and more researchers are recognizing the value of including ‘a qualitative piece’ to complement a clinical trial or other quantitative study. In this issue, McPherson et al’s paper5 outlines a number of ways that qualitative approaches can be used in conjunction with quantitative research. These kinds of combined studies have increased the acceptance of qualitative health research over the last two decades and contributed to an expanded knowledge base. At the same time, however, there is a growing concern that qualitative research is becoming significantly diluted and misunderstood.⁶6,7 Smith et al8 in this issue critically examine ‘mixed methods’ research and warn that qualitative research is being relegated to the role of servant to ‘science-based research’. These concerns arise alongside a misunderstanding of the depth and breadth of contributions offered by qualitative research and, in part, can be attributed to the rising demand for standardized forms of knowledge wherein the gold standard of evidence remains the randomized controlled trial.9 The rise of descriptive and mixed method studies exposes a new problem that is not unique to physical therapy – the lack of exposure to the philosophical underpinnings of qualitative research, and more broadly the contributions of theory (whether or not applied to an empirical study) to physical therapy knowledge.10,11 A recent issues of Physiotherapy Theory and Practice on Philosophy and Physiotherapy, guest edited by David Nicholls and myself explores these ideas further.12

The potential of qualitative research in physical therapy, and the health sciences more broadly, inheres in its ability the illuminate the unseen and/or unexamined social, political and cultural forces that impact on health, function, and participation.13 To do this effectively, physical therapy research needs to be increasingly transdisciplinary - drawing from theory, knowledge and methods in the social sciences and humanities. These days, the majority of physical therapists likely have some awareness of the kinds of research problems qualitative inquiry addresses, and there are myriad texts to assist the novice (see for example, Carpenter and Suto14). Nevertheless, with some exceptions,15^–17 historically physiotherapists were relatively slow to take up qualitative research, or at least in making explicit links to physical therapy practices. Introductory texts most often highlight the function of qualitative inquiry in describing individuals’ experiences and perceptions, and underscore the importance of ‘giving voice’ to clients. But qualitative inquiry has so much more to offer beyond this function.

Qualitative research at its best can help to address some of the most tenacious issues in health and rehabilitation. These include, for example, examinations of how power relations affect care practices, how we conceive of and measure complex phenomena like disability and quality of life, issues of globalization, the commodification of health, more fully exploring clients’ moral experiences, understanding illness and disablement trajectories, and reimagining the transformational possibilities of physical therapy. A ‘second generation’ of qualitative research is needed that goes beyond surface descriptions to tackle these and other complex areas of inquiry. I join with occupational therapy colleagues in calling for ‘studies that overall are more pointedly critical, more theoretically sophisticated, more methodologically productive, and more politically relevant’.18 For physical therapy to thrive, it requires a more diverse knowledge base that reflects multiple ways of understanding and investigating the world around us. This is not limited to describing client’s experiences and perspectives, or in fleshing out quantitative results, although I am not by any means discounting the importance of these studies. In addition to this work, we need research that investigates and provides new theoretical insights into the intersections amongst health, body, behaviours, beliefs, practices and socio-cultural contexts. These kinds of studies are beginning to emerge in the profession (see for example,19^–26). It should also be noted that those of us working in the field today owe a great deal to pioneering qualitative researchers such as Katherine Shepard,15 Gail Jensen,16 Christine Carpenter,17 and Cheryl Cott,27 who led the way in demonstrating the tremendous potential of qualitative research in physical therapy and have mentored a generation of researchers in the field.

This special issue aims to accomplish two objectives. The first is to help inform novice researchers on the diversity of theoretical and methodological approaches in qualitative research. The second objective is to highlight how these approaches can be employed to address a wide range of questions in physical therapy. In the spirit of supporting transdisciplinary inquiry, we have included papers from both physiotherapists and colleagues from other disciplines, each of whom is conducting leading-edge research programs that inform physical therapy practice and scholarship. Some of the papers are introductory and others are more advanced. Together they provide a rich overview of qualitative inquiry, its promise in addressing enduring practice issues, and how it differs from quantitative research in fundamental ways beyond ‘methods’.

Three complimentary papers in the collection discuss phenomenology and its various forms and applications to physical therapy. Shaw and Connelly’s paper28 provides an overview of five phenomenological traditions and how each can inform physical therapy research. Drawing primarily from the Husserlian tradition and examples of physical therapy research, Greenfield and Jensen29 explore how phenomenology can illuminate the lived experience of individuals with newly acquired disabilities and the implications for client centred physical therapy care. Finally, Papadimitriou, provides a detailed demonstration of phenomenological data analysis and interpretation.30 In doing so she elegantly opens up the black box of qualitative analysis to illuminate the relationships between theory, reflexivity, and interpretation.

While phenomenology and it various forms are gaining wider acceptance in physical therapy research, postmodern approaches are only beginning to emerge. Nicholls’ paper31 draws on a study examining an unconventional clinic aimed at treating breathing pattern disorders to highlight the potential of postmodern research to re-imagine and reform some of the unexamined but deeply ingrained assumptions in physical therapy practice. Similarly, the intersection between bioethics and physical therapy represents another exciting area for qualitative research beyond the study of clinical ‘dilemmas’. In their paper, Hunt and Carnevale32 demonstrate how a carefully theorized conception of moral experience can be used to illuminate aspects of disability experience that may be missed by other approaches.

Research that seeks to understand the perspectives of children is especially lacking in rehabilitation. Wiart33 outlines how interpretive approaches can be used to better understand child and family values and ultimately improve family centred care. Her work is consistent with the new social studies of childhood in highlighting that children must be considered as individuals in their own right and thus their perspectives should not be represented through adult proxies.34

Specific methodological approaches and debates are addressed in three papers by Smith et al.,8 McPherson et al.5 and Levack.35 I have noted the contributions of the former two papers above. Levack’s paper builds on an emerging methodology in qualitative research, qualitative metasynthesis, and its contribution to the physical therapy knowledge base. Levack provides a helpful introduction through a detailed example that involved synthesizing qualitative research of the experiences of recovery from traumatic brain injury.

To conclude, my hope is that this special issue strikes the right balance between introducing qualitative research to the uninitiated and advancing the field. I think it is fitting to end with a quotation from Gail Jensen who, in 1989, encouraged physical therapists to diversify their research approaches:

Physical therapy as a field of study contains phenomena, events, problems, people, and processes that provide rich resources for different types of inquiry. A broad array of quantitative and qualitative research methods will enable us to understand the complexity and richness of both the clinical and educational environments in physical therapy and contribute to the development of a theoretical knowledge base.16

These words are just as true today. Many advancements have been made, but the tremendous potential of qualitative research to inform physical therapy research, practice and theory has yet to be fully realized.

I would like to thank Christine Carpenter for her help in developing the issue. I also owe a great debt to the reviewers for their thoughtful comments that contributed to the quality of the papers. Finally my thanks to the editorial team at PTR for all their assistance: David Baxter, Suzanne McDonough, Esme Loukota, Brigid Ryan, and Saoirse Milotte.