A phenomenological and critical examination of knowledge expressed and exchanged in physiotherapy with children

Background

In physiotherapy, as within other health professional fields, the integration of different types of knowledge in practice is urgent in view of the current emphasis on the involvement of clients themselves. Importantly to this study is the current broad consensus to see even young children as competent individuals with opinions, feelings and knowledge about the different situation in which they find themselves. Consequently, the interpersonal and interactive nature of physiotherapy cannot be limited to knowledge about diagnosis, prognosis, and biomedical understandings of the body. It requires the physiotherapists to include knowledge about living with impairments and receiving physiotherapy [1]. Which implies the importance of balancing therapies with a focus on ‘fixing’ children with therapies designed to enhance functioning that safeguards and promotes children’s health and well-being in a broader perspective [2].

However, the growing fields of ‘knowledge translation’ and ‘evidence-based practice’ tend to dominate research in physiotherapy, which also traditionally has been conducted within a biomedical paradigm [3]. These fields largely have a ‘top-down’ approach to how research findings should be transferred and integrated into practice. In order to deliver treatment of good quality, physiotherapists are called upon to integrate different epistemological or paradigmatic understandings in their practice [4]. How physiotherapists do therapy and what kind of knowledge they rely on and apply has hardly been examined, especially where physiotherapy with children is concerned. This study attempted to address this void.

The purpose has; been to examine 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.

Methods: A methodology; based on a phenomenological perspective and research approach has been applied. A perspective that recognises that all humans possess knowledge, whatever their age and ability to function might be. As humans, we are always in a continuous reciprocal relationship with the world, others, things and the actual circumstances we are in at that particular time. Another key aspect of this perspective is the belief that at any point in time, everyone, regardless of gender, body shape and size, age and functional abilities or disabilities, is always seeking the fullest possible grasp of their situation, including the task they are engaged in and the relationships it involves [5,6]. Of this follows, viewing individuals as capable of taking an active role in their therapy and considering them as ‘humans of knowledge,’ capable of providing unique perspectives, conveying specific knowledge content and communicating that knowledge in comprehensible ways. How children and physiotherapists manifest their competence in relationships with one another, in therapy, is determined by their inter-subjectivity, their co-existence at the moment [7]. As already mentioned, physiotherapy is understood as an interactive and interpersonal practice. Thus, how physiotherapists and children relate to each other will be decisive for what knowledge is perceived as significant and developed during a therapy session.

In order to examine this we have been inspired by Max van Manen who holds that:

Knowledge does manifest itself in practical actions. And we may ‘discover’ what we know in how we act [8] (p 22)

The message in this quote may be seen as a significant inspiration to choose the method of close observation to obtain insight to the knowledge at stake and put into play during physiotherapy with children. Close observation is recognised to be particularly suitable for research focussed on examining interaction [9]. Based on this, the empirical material was generated as part of the first author’s doctoral research, and derives from close observations of seven children between six and 11 years of age during regular weekly therapy sessions with five physiotherapists. Seven observations were performed during the participants’ regular weekly therapy sessions. Post-session written notes, along with the first author’s comments and questions, constitute the database.

In the phenomenological analysis, we aimed to be open to the uniqueness and meaning of knowledge expressed and exchanged. The complementing analytical moves of bracketing and reduction, and the process of phenomenological writing involved systematic analysis of meaning structures embedded in the various situations. Writing anecdotes involved reflecting on experiences and attempting to recreate the actual events using language geared to the experiential or lived sensibility of the lifeworld. This process inevitably represents a transcended form of the actual experience [10].

Results

By presenting anecdotes from the empirical material we show how children take initiative and display playful knowledge both of their body, moving capacity and of the equipment and tasks introduced in therapy.

The following anecdote is one example, an excerpt from the observation of Susanne and her physiotherapist:

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.’ Both walk 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 five minutes 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.

While the physiotherapist is concerned about Susanne’s toes pointing straight ahead, she 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.

In our analysis, the relationships between the physiotherapists and the individual child might be seen to involve a kind of tacit acceptance of the other’s knowledge, even though little or no active interaction and exchange of knowledge takes place between them. It is as if their encounters are a form of stagnant coexistence in which a lack of knowledge exchange result in a lack of contact. It is through dialogue and being with, individuals might establish common ground where the knowledge of each is interwoven with that of the other to form a dual being that neither of them could create alone [5]. From this perspective, the coexistence and knowledge exposed, expressed and given attention in our study shows the importance of involvement and creative collaboration between the therapist and the child to be established for knowledge to be shared and developed. In the anecdote presented here, however, the knowledge given attention and significance appears to belong exclusively to the physiotherapists’ knowledge base. Yet, even though this knowledge is dominant, in a way it also seems to be ‘un-exposed.’

Conclusion

The interactions between physiotherapists and children illustrate a lack of give-and-take; both parties seem to have their own agenda. They 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. No joint venture is established between the child and the physiotherapist and the exchange and translation of knowledge between them takes place as if between ‘healer’ and ‘sufferer’. Physiotherapists are called upon to view children as possessing knowledge relevant to their own therapy, and to recognise children’s ‘playful and ambivalent’ forms of participating as meaningful contribution in their own therapy. There is timely and critical to recognise physiotherapy as a knowledge exchanging practice dependent on the physiotherapists’ capability and willingness to engage with the kind of knowledge and playful way of being children contribute in their own therapy.

Implications

The findings reveal the significance of integrating different knowledge perspectives in order for therapy to develop along qualitative and creative lines. By integrating different knowledge perspectives physiotherapists will be able to support children’s active and knowledge creative participation in their own therapy. To recognising playfulness and play as serious and meaningful way of being, for all humans, physiotherapy with children might open up new and meaningful ways of doing physiotherapy.

Acknowledgment

This paper is based on an article accepted for publication in Physiotherapy, Theory and Practice titled: Which knowledge? - An examination of the knowledge at play in physiotherapy with children.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by The Norwegian Fund for Post-Graduate Training in Physiotherapy through the FYSIOPRIM project [360/90].