A critical perspective on stigma in physiotherapy: the example of weight stigma

"Manipulating practices is the first ever collection of critical physiotherapy studies and comes at a time of unprecedented change in the profession. Written as a collaboration between 20 authors, many members of the Critical Physiotherapy Network (CPN), the book uncovers the growing body of critical thinking now emerging in physiotherapy. From topics as diverse as 21st century education, ethics, evidence-based practice, touch, and equine therapy; and approaches as varied as disability and performance studies, feminism, logic, narrative theory, new materialism, and phenomenology, the book explores ways of thinking ‘otherwise’ about physiotherapy. Over 16 chapters written by authors from six different countries, Manipulating practices offers insights from some of physiotherapy’s most radical thinkers. The book is also an innovative venture into open source publishing, making it entirely free to download and read. In keeping with the objectives of the CPN, the chapters expose a range of concepts, ideas and practices to critical scrutiny, and reflect the profession’s growing interest in critiquing taken-for-granted ways of practicing and thinking. Manipulating practices will be of interest to clinicians, lecturers, policy-makers, researchers and students, and will provide new impetus to help physiotherapists imagine how the profession might grow and develop into the future.""«Manipulating practices» er den første vitenskapelige antologien som samler kritiske studier innen fysioterapi, og lanseres i en tid der profesjonen er preget av store forandringer. Antologien representerer et samarbeidsprosjekt mellom 20 forskere, hvor majoriteten er medlemmer av Critical Physiotherapy Network (CNP) – et internasjonalt nettverk av forskere og klinikere fra hele verden. Antologien synliggjør den økende tendensen til kritisk tenkning som er i ferd med å vokse frem innenfor fysioterapi. Gjennom å fokusere på varierte tema som utdanning, etikk, evidensbasert praksis, berøring og terapiridning, samt en bred tilnærming som inkluderer funksjonshemming, performance-studier, feminisme, logikk, narrativ teori, ny materialisme og fenomenologi, utforsker antologien nye og annerledes tanker om fysioterapi som fag og profesjon. Antologiens 16 kapitler er skrevet av forskere fra seks ulike land og gir innsikt i forskningen til noen av de mest radikale forskerne i det internasjonale fysioterapimiljøet. Boken er også innovativ gjennom at den publiseres som open access, hvilket betyr at den kan lastes ned og leses gratis og dermed gjøres allment tilgjengelig. I tråd med ambisjonen for CPN, utforskes en rekke ulike begreper, ideer og praktiske tilnærminger relatert til kritisk tenkning innenfor fysioterapi. Slik gjenspeiles også profesjonens økende interesse for å kritisere etablerte måter å praktisere og tenke på, som tidligere har vært tatt for gitt. «Manipulating practices» vil være av interesse for forskere, klinikere, forelesere, politikere og studenter. Antologien vil forhåpentligvis bidra med nye impulser med henblikk på hvordan fysioterapiprofesjonen vil vokse og utvikle seg fremover.

A critical perspective on stigma in physiotherapy: the example of weight stigma

This chapter explores what might be learnt about physiotherapy by considering its intersection with stigma. Stigma was described by Goffman as a phenomenon whereby an individual has an attribute that is deeply discredited by society, and is rejected as a result as a result of the attribute; where “normal identity” is “spoilt” by the process of stigmatisation. From a post-structuralist critical perspective, stigma is not static or finite but is (re)constructed in various social, historical, cultural and political environments. A characteristic that is stigmatised in one context may not be in another. Considering this, the context of physiotherapy has the possibility to (re)create or (re)inforce stigmatisation of certain a critical perspective on stigma in physiotherapy attributes not only in ways that may reflect general societal stigma, but also in ways that may be specific to the profession. In this chapter, we discuss stigma in physiotherapy broadly, considering what it is about physiotherapy that may contribute to the discrediting of certain attributes. We use the example of weight stigma, a topical and little explored form of stigma that is becoming more evident in healthcare in the current climate of “the obesity epidemic”. We draw from empirical research, definitions and narratives of physiotherapy in different countries (particularly our home countries of Nigeria and Australia) to help examine weight stigma in physiotherapy. We explore how weight stigma is enacted in a physiotherapy context – a profession in which there is an inherent focus on bodies. We conclude with a discussion of possibilities for the physiotherapy profession to learn from a greater consideration of stigma

Performative acts of physiotherapy

There are elements of performance and acting techniques that are relevant and applicable to the (physio)therapeutic encounter. Specifically, we consider Keith Johnstone’s heuristic framework of theatrical improvisation around which performers can create interesting narratives and relationships. The concepts of “status” and “blocking” seem particularly pertinent to the therapeutic interaction. Much has been written about the power differential in a variety of healthcare encounters, including physiotherapeutic ones. Collaborative interactions in healthcare are considered favourable, yet physiotherapists have been criticised for continuing to engage in predominantly therapist-centred models of communication. We extend some of Johnstone’s theatrical constructs with the theories of feminist poststructuralist Judith Butler to consider how they might be useful in understanding physiotherapists’ clinical interactions. For Butler, there is little distinction between personal and political, where even the most mundane-seeming acts are scripted by (and script) hegemonic belief systems. She outlines how identities are formed through repetition of certain “speech acts”, postures and movements. Butler’s theories of performativity can help physiotherapists understand how they (re)produce patterns of interaction in clinical encounters that (re)inforce therapist-centred interactions. Understanding these interactions using a Butlerian reading of Johnstone’s techniques can provide physiotherapists tools for recognising, and resisting hegemonic physiotherapy practices

Navigating whiteness: affective relational intensities of non-clinical psychosocial support by and for culturally and linguistically diverse people

Mental health is political, with intersecting economic, cultural, racialized, and affective dimensions making up the care assemblage, signalling how care is conceptualised and who is deserving of care. In this article, we examine emotions circulating in a non-clinical psychosocial support program for culturally and linguistically diverse people experiencing mental ill-health, foregrounding the relations between culture, race, economy, and assumptions underpinning understandings of care. The mental health program under study offers psychosocial support for culturally and linguistically diverse people to manage life challenges and mental ill-health exacerbated by navigating the complexities of Australia’s health and social care systems. We draw on interviews with clients, staff, and providers of intersecting services, employing Ahmed’s concept of affective economies and Savreemootoo’s concept of navigating whiteness to examine the care assemblage within interview transcripts. We provide insight into affective intensities such as hate, anger, and indifference embedded in white Anglo-centric services, positioning culturally and linguistically diverse people on the margins of care. Non-clinical psychosocial support programs can counter such affective intensities by training and employing multicultural peer support workers—people with lived experience—prioritising relational and place-based approaches to care and supporting and providing clients with relevant skills to navigate an Anglo-centric care system. However, this support is filled with affective tensions: (com)passion, frustration and fatigue circulate and clash due to the scarcity of resources, further signalling what type of care (and with/for whom) is prioritised within Australian relations of care

Effect of a consumer-focused website for low back pain on health literacy, treatment choices, and clinical outcomes: randomized controlled trial

BACKGROUND: The internet is used for information related to health conditions, including low back pain (LBP), but most LBP websites provide inaccurate information. Few studies have investigated the effectiveness of internet resources in changing health literacy or treatment choices. OBJECTIVE: This study aims to evaluate the effectiveness of the MyBackPain website compared with unguided internet use on health literacy, choice of treatments, and clinical outcomes in people with LBP. METHODS: This was a pragmatic, web-based, participant- and assessor-blinded randomized trial of individuals with LBP stratified by duration. Participants were randomly allocated to have access to the evidence-based MyBackPain website, which was designed with input from consumers and expert consensus or unguided internet use. The coprimary outcomes were two dimensions of the Health Literacy Questionnaire (dimension 2: “having sufficient information to manage my health;” dimension 3: “actively managing my health;” converted to scores 1-100) at 3 months. Secondary outcomes included additional Health Literacy Questionnaire dimensions, quality of treatment choices, and clinical outcomes. RESULTS: A total of 453 participants were recruited, and 321 (70.9%) completed the primary outcomes. Access to MyBackPain was not superior to unguided internet use on primary outcomes (dimension 2: mean difference −0.87 units, 95% CI −3.56 to 1.82; dimension 3: mean difference −0.41 units, 95% CI −2.78 to 1.96). Between-group differences in other secondary outcomes had inconsistent directions and were unlikely to be clinically important, although a small improvement of unclear importance in the quality of stated treatment choices at 1 month was found (mean difference 0.93 units, 95% CI 0.03 to 1.84). CONCLUSIONS: MyBackPain was not superior to unguided internet use for health literacy, but data suggest some short-term improvement in treatment choices. Future research should investigate if greater interactivity and engagement with the website may enhance its impact. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001292369; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372926 INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2018-02751

Design, Delivery, Maintenance, and Outcomes of Peer-to-Peer Online Support Groups for People With Chronic Musculoskeletal Disorders: Systematic Review

Background: Online support groups (OSGs) are one way for people with chronic diseases, their family or friends, and health professionals to communicate, gain information, and provide social support. As the number of peer-to-peer OSGs for chronic musculoskeletal conditions grows, it is important to gain insight into the different designs of groups available, who is accessing them, if and how they may be effective, and what strategies are being used to implement or increase consumer engagement. Objective: The objectives of this systematic review of people with musculoskeletal conditions were to (1) describe the design features (functions, usage options, moderation, and expert input) of peer-to-peer OSGs, (2) describe the characteristics of the individuals using peer-to-peer OSGs, (3) synthesize the evidence on outcomes of participation, and (4) identify strategies used in the delivery and maintenance of OSGs. Methods: A search comprising terms related to the population (people with musculoskeletal disorders) and the intervention (peer-to-peer OSGs) was conducted in 6 databases. Results were filtered from 1990 (internet inception) to February 2019. Studies identified in the search were screened according to predefined eligibility criteria using a 2-step process. Quantitative studies were appraised by 2 reviewers using the Risk Of Bias In Non-Randomized Studies of Interventions tool. Qualitative studies were appraised by 2 different reviewers using the Critical Appraisal Skills Programme checklist. Extracted data were synthesized narratively. Results: We examined 21 studies with low to moderate risk of bias. Of these studies, 13 studies included OSGs hosted on public platforms, 11 studies examined OSGs that were conducted in English, and 6 studies used moderators or peer leaders to facilitate engagement. Studies either reported the number of OSG members (n=1985 across all studies) or the number of posts (range: 223-200,000). The majority of OSG members were females who were not full-time employees and with varied levels of education. There were no randomized controlled trials measuring the efficacy of OSGs. Qualitative and quantitative studies identified empowerment, social support, self-management behavior, and health literacy as primary constructs to measure OSG efficacy. Neutral or marginal improvement was reported in these constructs. Sharing experiences and a greater level of engagement appeared to have an important influence on OSGs efficacy. The extent to which members posted on the website influenced engagement. Conclusions: Across a diverse range of designs, languages, included features, and delivery platforms, peer-to-peer OSGs for chronic musculoskeletal conditions attract predominantly female participants of all ages and education levels. The level of participation of a member appears to be related to their perceived benefit, health literacy, and empowerment. Future studies are needed to identify which design and maintenance strategies have superior efficacy and whether there are concomitant improvements in health outcomes for people with chronic musculoskeletal conditions resulting from participation in OSGs

A definition of flare in low back pain (LBP): A multiphase process involving perspectives of individuals with LBP and expert consensus

Low back pain (LBP) varies over time. Consumers, clinicians and researchers use various terms to describe fluctuations of LBP symptoms. Although "flare" is commonly used to describe symptom fluctuation, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved derivation of a preliminary candidate flare definition based on thematic analysis of consumers' views in consultation with an expert consumer writer. In Step 2, a workshop was conducted to incorporate perspectives of LBP experts into the preliminary flare definition, which resulted in two alternative LBP flare definitions. Step 3 refined the definition using a two-round Delphi consensus process with experts in musculoskeletal conditions. The definition favoured by experts was further tested with individuals with LBP in Step 4, using the definition in three scenarios. This multiphase study produced a LBP flare definition that distinguishes it from other LBP fluctuations, represents views of consumers, involves expert consensus, and is understandable by consumers in clinical and research contexts: "A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions". Perspective: A multiphase processes produced a low back pain (LBP) flare definition that distinguishes it from other LBP fluctuations, involves expert consensus and represents consumers' views