History: Culture and Physical Therapy

During the month of July, I'll be looking at "roots" and history. One aspect of history is the culture people live in. "Culture" can be tricky to define--"I'll know it when I see it"--so this week I want to dive into an aspect of culture that I am especially familiar with: that relating to physical therapy, my day job.

What is Physical Therapy?

As I define physical therapy to my students, patients, and their families, what I tell them is that physical therapists are human movement system experts, similar to how cardiologists are experts in the heart and blood vessels or immunologists are experts in the human immune system. The human movement system is more functional than structural, because it pulls pieces from different parts of the body that all relate to how well one moves. 

History in the US

Worldwide, physical therapy ("physiotherapy" outside the US) originated as a formalized profession in the 1800s. However, in the United States, the polio epidemic and various internal and external wars provided the impetus for early PTs to function under direct supervision of a physician, focusing on muscle strengthening and stretching as Reconstruction Aides.

Over the next few decades, PTs became more autonomous as their research and scope of practice expanded into all treatment settings including hospitals, nursing homes, assisted/independent living facilities, outpatient clinics, and people's homes. Although in certain settings some insurers still do require medical supervision (that is, a physician signing off on the physical therapy plan of care), the public perspective on physical therapy has grown generally more positive.

The American Physical Therapy Association (APTA) was founded in 1921, with women as the main corpus of members. Many PTs and PT assistants are members in this association, which provides member and nonmember benefits including legislative advocacy and professional development opportunities. Educationally, the first entry-level degree (1927-1990s) was a bachelor's of science, which became a master's in the mid-1990s and a non-PhD doctorate in 1993-present. Currently, the standard for entry-level education as a physical therapist is a post-bachelor's doctorate, and a physical therapist assistant a 2-year college degree.

Philosophical Groundings

A Renaissance Biologist post wouldn't be complete without some talk about philosophy! My sources for this section are two articles from Physical Therapy (research journal) and Physiopedia. Sister Francois** argued in 1967 that a central guiding principle for all rehabilitation specialists (including physical, occupational, and speech therapists) is the widespread impact of physical limitation in all areas of life, including ability to work, valuing of oneself, and interacting with others in society. Thus, it isn't enough simply to assess someone's ability to move and tell them what exercises to do--motivational skills are a key piece of physical therapy practice.

Healthcare ethicist Debra Gorman-Badar, in 2021, looked at the philosophy of PT from an internal morality viewpoint: what values or senses of what's right and wrong (should) guide physical therapists and physical therapist assistants? She contrasted PT with medicine as she applied a medical ethicist's theory (Pellegrino, in turn based on Alasdair MacIntyre's work) to this profession--her entire article is worth reading.

• Disability exists, and medicine is unable to heal 100% of disability resulting from illness, disuse, or injury.
• Professionals act in a certain way differently than non-professionals. This is influenced by the conflict between selfless and selfish behaviors of people in various professions. However, at the core of a profession is the telos of reducing some aspect of human suffering.
• Physical therapists act uniquely, in that patients' functional abilities change over time, patients' interactions and relationships are not only with the PT and family but others in society, and patients' roles in the physical therapy process are more active than passive.
• The telos (end goal) of physical therapy, therefore, is not so much the right decision but the right/good process that includes the patient as an active participant in improving their own physical function.

Finally, Physiopedia puts things a bit more simply: core principles of rehabilitation include

• Individual rights over health ("management" implied)
• Individual worth independent of physical or mental abilities
• Individual responsibility to take an active role in health care
• Therapists' ability to promote adaptation (of individual to environment, or environment to individual)
• Therapists' emphasis of abilities over disabilities
• Therapists' treatment of the whole person, early on in the disease/disability process
• Therapists' prioritization of education to patients and their support systems
• Therapists' concern for people groups (population wellness) over just individual wellness

Biopsychosocial Models of Care

Certain health professions use biomedical models for care--look at signs and symptoms, rapidly selecting the most appropriate high-level evidence to apply, and making a diagnosis that results in a specialist referral and/or a medication prescription (Drench et al. 2012). While this works for most patients, resulting in accurate diagnosis and treatment, it doesn't accommodate for certain factors.

That's where biopsychosocial models come in, adopted by rehabilitation therapies among others. Providers using a biopsychosocial mindset look at each patient's personal factors (like race, socioeconomic status, and degree of family support) and ask patients to collaborate in setting goals for treatment. It does take more time and resources to implement than a biomedical model does.

How is Culture Defined?

I am approaching this question from a perspective of physical therapy and health professions in general. I know that you may come from a different perspective, and I would welcome your thoughts to the discussion!

Drench et al.

The textbook that has been used in the past, including when I took the courses I now teach, is by physical therapist Meredith Drench and colleagues (2012). The concept of culture occupies a fairly small section of the book, because the overall focus is on the psychosocial aspects of a biopsychosocial model of physical therapy practice. 

In chapter 3, the book notes that in the United States, a better metaphor than "melting pot" is "tossed salad" for people living together. Culture, thus, is broader than just race or ethnicity, but better describes a shared pattern of thoughts, feelings, and actions/words. "A critical distinction between the concept of culture and race or ethnicity is that it is learned, not inherited" (p. 38).

Because so many aspects of culture involve unconscious/subconscious guides for words and actions, people who study culture typically break it up into different layers or categories. Drench cites Arredondo's model (1996):

• A Dimension = predetermined characteristics (age, gender, primary language, etc.)
• B Dimension = individually controlled characteristics (education, religion, hobbies)
• C Dimension = larger contexts (history, politics, economics)

I have done graduate work using a different model of cultural classification/analysis, but that is beyond the scope of this post.

Lattanzi & Purnell

Since taking over the courses, I felt that a book by Jill Black Lattanzi and Larry Purnell (2006) was a better fit for the objectives and content. Its definition of culture was fairly similar, emphasizing social transmission, behavioral patterns and artifacts, and the ability of culture to guide both worldview and people's decision making. However, this definition is in chapter 1, and every single one of the remaining 21 addresses some primary cultural characteristic, such as ethnicity, veteran status, disability, or age group. 

The instructional model authors of this text use for helping practitioners and students move along the continuum from "unconsciously incompetent" toward "unconsciously competent" includes interrelated, concentric circles (Figure 2.6, p. 27). Each individual's culture is influenced and partially constituted by these factors:

• Largest circle (periphery) = global society
• Next circle in = community (at whatever scale)
• Next circle in = family (however defined)
• Next circle in = person as an individual. Factors that can interact with each other in a person include:
• Communication aspects
• Family roles and organization
• Workforce concerns
• Biocultural ecology (e.g., genetics)
• High-risk behaviors (e.g., alcohol use)
• Nutritional status and beliefs
• Pregnancy attitudes and practices
• Death rituals
• Spirituality
• Health care practices (e.g., attitude toward "sick" behaviors)
• Healthcare practitioner views
• Overview and heritage (e.g., education)

Why is Physical Therapy Concerned with Culture?

I think of two big reasons for this right away: PTs are "people people", and being attentive to culture achieves better outcomes.

People Profession

PTs have always worked with people directly, often for longer periods of time than other health professionals per appointment. Even though this isn't the case in some settings, it's typical for an initial PT evaluation to last 30-90 minutes. When you're talking one-on-one with someone for that long, a therapeutic relationship can develop and the PT can notice things that wouldn't be apparent in a 10-minute physician's office visit. I got into physical therapy because I'm fascinated with how God designed the human body to move.

Better Outcomes

From a more objective standpoint, there's strong research support for cultural competency in a positive relationship to outcomes of reduced pain, disability, and "falling off the radar" for patients participating in physical therapy. Because PTs are concerned with the health and well-being of not only individuals but also populations (see section above), increasing the practitioner's ability to work well and cordially with people from many different cultures can spread that positive impact.