17 Traits and characteristics of professional physiotherapy

If reductionism is one of the most subtly influential forces shaping how physiotherapy is practiced, then trait theory is perhaps one of the most obvious. Every position description, definition of physiotherapy, guideline for best practice or ethical conduct; every patient assessment, evidence-based treatment plan, and clinical record, is underpinned, on some level, by functionalist thinking. With a few notable exceptions, almost all of the writing about what physiotherapy is, returns to the functionalist idea of the traits and characteristics, that define physiotherapy and differentiate it from other professions. Recall Catherine Worthington’s argument in 1961 that ‘if your objective is to develop physical therapy into a profession — you must give attention to the differences between technicians and professional persons’ ^[1].

One of the first attempts to define the profession theoretically came in Julius Sim’s 1985 paper Physiotherapy: A professional portrait ^[2]. This made reference to many of the key works in the sociology of the professions, but concentrated on functionalist questions of what the profession is, and whether it matters whether it calls itself a profession or not. Echoes of this can be seen in Katherine Shepard and colleagues’ seminal 1999 paper Describing expert practice in physical therapy ^[3]. In their comprehensive study designed to establish a theoretical framework that adequately mapped and accounted for the complexities and diversities of the profession, the authors focused initially on the ‘characteristics and factors’ inherent in practice. This was supplemented in 1991 with data that focused on the attributes that characterised ‘expert’ clinicians. These ‘attribute dimensions’ were strongly influenced by trait theory. Gradually, the study moved towards more performative and relational approaches, and finally reported in 1999 with the goal of understanding how expert clinicians ‘sought knowledge of the patients as persons’ ^[4]. But perhaps one of the most telling findings from this study justifies Edgar Burns’ argument that professionals will always justify their existence in classical functionalist terms ^[5]. In this case, citing the importance of physiotherapists demonstrating personal responsibility for maintaining one’s health, moral rectitude in practice, dedication, compassion, and modesty about the limits of one’s knowledge ^[6].

Perhaps one of the people who have done most to excavate the meaning of physiotherapy, however, is Professor Joy Higgs. Over more than three decades, Higgs has written, amongst other things, about physiotherapy education ^[7][8], and practice ^{[9][10][11][12]}, the profession’s approach to clinical reasoning and the development of practice expertise ^{[13] [14][15][16]}. Her 2001 paper, Portrait of the physiotherapy profession, written with Australian colleagues Kathryn Refshauge and Elizabeth Ellis, though, is particularly significant in the way it draws on functionalist motifs.

In the paper, the authors ask ‘what is physiotherapy?’ Pointing to published definitions by World Physiotherapy (formerly WCPT – the World Confederation for Physical Therapy) and others, they highlight the profession’s autonomy and freedom to exercise profession judgement; its international professional associations; its distinctive roles and functions (being ‘concerned with the promotion of health and well-being and with prevention, treatment or rehabilitation of disorders or dysfunction of human movement’, for example ^[17]); its training in specific tasks (‘motor skills, exercise therapy, joint mobilisation and manipulation’ etc. (ibid, p. 82)), and its avoidance of approaches to health that ‘belong’ to others (invasive procedures and pharmaceutical remedies, for example). The profession’s ‘body of knowledge and approach to management of patients clearly distinguishes physiotherapy from the other health professions’, they argue ^[18].

Whilst being distinguishable for their ‘deep and broad understanding of normal movement and impaired function’ (ibid), physiotherapists also maintain a direct connection between physiotherapy and medicine, through a shared appreciation for ‘anatomy, pathology, biomechanics, medical sciences and psychology’, as well as the adoption of standard Western medical approaches to the assessment, diagnosis, treatment planning, intervention, and evaluation of health and illness (ibid). The authors are confident enough in the maturity of the profession to argue that by 2001, physiotherapy had ‘reached a stage of consolidation of its development as a profession’ (ibid), in high-income countries at least, evidenced by ‘high levels of status, qualification and recognition, of expansion of the discipline’s knowledge base, critical self-evaluation or systems of self-regulation, advances in clinical practice and specialisation’ (ibid). Perhaps the only aspect of professional status remaining in doubt, the authors suggest, is physiotherapy’s autonomy; ’Beyond peer regulation, the essence of professional practice in physiotherapy is professional autonomy and the responsibility for one’s actions which is inherent in this autonomy’ (ibid).

Taken together, this is the model of a functionalist analysis of physiotherapy, touching on all of the ways in which the profession has come to define itself, how it functions alongside others, and restores balance in society. The traits it defines as the key features of physiotherapy (its professional body, affective neutrality, mastery and exclusive competency, universalism, service ideal, autonomy, and ethical comportment), are almost exactly the traits of elite professions identified by Parsons in the 1930s. A similar argument is made by Rob Jones in his edited collection Management in Physiotherapy ^[19]. Here, Jones acknowledges a debt to the sociology of the professions, but focuses almost exclusively on the early functionalist thinkers ^[20][21][22]. Jones argues that physiotherapy possesses now familiar traits, and, as a result, is progressing towards full professional autonomy (ibid).

The same approach to understanding physiotherapy can be seen in numerous other studies published in recent years: in Randy McCombie, Shelby O’Connor, and Sarah Schumacher’s paper comparing the personality traits of occupational therapists and physiotherapists ^[23]; in Emer McGowan and Emma Stokes’ paper on leadership in physical therapy ^[24]; and in Marlena Calo and colleagues’ analysis of the grit and resilience needed by physiotherapy students ^[25]. In Marianne Eliassen, Nils Henriksen, and Siri Moe’s recent paper ^[26], you have characteristics of reablement practice, and in David Martínez-Pernía, Óscar González-Castán, and David Huepe’s historical review of physical rehabilitation ^[27], functionalism is explicitly cited as a driving force in shaping practice.

In most cases, functionalism serves as an invisible influence on studies that look at what physiotherapy is and where it comes from. But only occasionally do authors acknowledge that their analyses are shaped this way. Rarer still are studies that actively use the work of functionalist authors as the philosophical basis for analysis. In recent years, though, there has been something of a resurgence of interest in new forms of functionalism — or neo-functionalism — especially in the work of Andrew Abbott ^[28][29][30] and Harold Wilensky ^[31].