29 Implications for physiotherapy

Marxian analyses ask a number of searching questions of the professions:

• How reliant is the profession on capitalism? Is it a victim of it, a passive beneficiary, or a willing partner?
• How much agency do individual professionals have in the face of a hegemonic capitalistic system, or does the responsibility for action fall on the collective?
• How would the profession look had it not operated under capitalism? Would it even exist?

Perhaps the most fundamental question we can ask about physiotherapy, from a Marxian perspective, though, is whether the profession itself is capitalistic? Clearly, any institution that prospers, as physiotherapy has, within a Western capitalist system, must have some affinity with it. Identifying these affinities are not difficult. Physiotherapy, for instance, depends on its ability to commodify, standardise, and control concepts like the body, movement, function, touch, manipulation, mobilisation, exercise, posture, and rehabilitation, and regulate how these concepts are understood, taught, thought, and practiced. Many of the physical therapies have been practiced by all civilisations for thousands of years, but physiotherapy as a profession can only exist when aspects of them are colonised and turned to the profession’s market advantage. Instead of continuing to share these openly and freely, physiotherapy has turned the physical therapies into marketable commodities that need to be purchased either directly or through people’s taxation.

Physiotherapists are directly involved in servicing capitalism by rehabilitating people so that they can return to their place within the machinery of industry. This is as true of working age adults as it is of children, the elderly, and unemployed, who must ensure that they continue to lead independent, productive, active lives, in order to contribute to their own personal and collective (economic) prosperity, and not be a drain on social resources.

The profession also embraces objective performance measurement, outcome measures, and task specificity, that provide confidence that the profession understands the instrumental logic behind industrial capitalism ^[1]. Physiotherapists have been subject to the kinds of deskilling imperatives of scientific management, as much as any of the health professions (i.e., the replacing of independent clinical decision-making with standardised assessments and treatment plans; clinical audit; standardised care plans; universal evidence-based treatment regimes; and so on). But they have also contributed to the scientific management of client/patient time and labour, emphasising the importance of maximising people’s functional capacity, movement efficiency, and physical potential as much, if not more than, most other health professionals.

Arseli Dokumacı has recently taken up Braverman’s Marxist critique of scientific management to argue that physiotherapy’s focus on functional limitation has played an important role in ‘defining disability in relation to the capacity to work’ ^[2]. Indeed, Dokumacı reminds us of David Mitchell and Sharon Snyder’s recent evidence that the term disability was originally used in the mid-nineteenth century for those incapable of work due to injury ^[3].

In effect, capitalism helped to create the idea of the disabled individual by designating human labour as a labour market concern, and in doing so, created the conditions necessary for a new ‘medical’ labour force to maximise the work capacity of those deemed disabled ^[4]. Following Braverman’s deskilling thesis, the work of rehabilitation specialists like physiotherapists could not be left un-managed, and needed to be brought within the system concerned with controlling labour supply ^[5]. And a key part of this control required physiotherapists, occupational therapists, and others to refine ever more sophisticated assessments of functional limitation as a crucial tool in determining ‘whether and to what extent a person is worthy of public assistance’ ^[6].

‘Capitalism demands individual economic productivity and this enshrines the notion of biophysical fitness, and its fulfilment as a key element in the quest for fashionable self-identity. Scientific medicine provides the means for measuring ‘fitness’ and identifying deviations from its statistical norm. Consequently, the hegemonic notion of the disabled body constructed in terms of corporeal or intellectual ‘deficit’. To overcome this deficit, the disabled body requires the services of scientific medicine and rehabilitation’ ^[7].

Physiotherapists also work to remedy some of the ill effects of capitalism (injury, chronic illness, social isolation, pain, loss of function, etc.), but has little tangible investment in remedying the social causes of illness, injury, and disability. Action on social determinants like unemployment, poor quality housing, pollution, poor standards of education, and workplace safety hardly feature in the physiotherapy literature (see more on this in Chapter 4). Physiotherapy is quiet on most forms of social action, concerned, perhaps, that it be seen to critique the system that it draws its prestige and power from.

An example of this is the profession’s lack of action against collision sports that are known to cause high levels of serious injury (concussions, traumatic brain injury, extensive musculoskeletal injuries, etc.). To date, there have been no calls from within physiotherapy to ban these sports. Preferring to fall back on capitalistic discourses of personal choice and responsibility, physiotherapists have been happy to take up the rewards of being lead rehabilitation providers when people do become injured. Perhaps practitioners are worried that criticising these sports might lead to others claiming their commodity control? This illustrates Gramsci’s argument about the power of hegemonic discourses like capitalism to influence people’s decisions and actions.