There has been a flurry of interest in the value of exercise as a therapeutic remedy in some sections of physiotherapy social media in recent months. Some of this, at least, appears to be a reaction to what have been called ‘passive’ treatments, and a neoliberally-inspired desire to see people take more responsibility for their future health and well-being.
Exercise is clearly a very valid and appropriate intervention for some people. It has been for as long as human civilisation has walked erect, and it almost certainly will continue to be useful into the future.
But a recent special edition of the journal Qualitative Research in Sport, Exercise and Health has cast doubt on some of the idea that exercise is obviously beneficial and ‘good’.
In a paper published a few days ago titled Exercise is medicine? Most of the time for most; but not always for all, the authors argue that, ‘health professionals, academics and policy-makers need to prescribe to more ethical forms of exercise promotion that may lead to more efficacious, person-sensitive interventions’, and that ‘It is important to scrutinise the broad discourse of EiM as grand narratives like this can run unchecked … despite their power to shape cultural, institutional and personal practices’.
As part of this special issue, a number of Critical Physiotherapy Network colleagues have collaborated on a paper that looks at some of the unforeseen harms of therapeutic exercise. In the paper, titled Keep fit: Marginal ideas in contemporary therapeutic exercise, myself, Patrick Jachyra, Barbara Gibson, Caroline Fusco and Jenny Setchell argue that;
Exercise has a long history as a therapeutic modality and has existed, in some form, in all cultures throughout recorded history. In recent years, therapeutic exercise has taken on new significance as a relatively low cost medical intervention designed to improve people’s health and wellbeing and reduce the downstream effects of comorbidity. Drawing our inspiration from Foucault and Deleuze, we argue that seeing therapeutic exercise as primarily ‘medical’ carries with it consequences – some recognised, others unseen – that are problematic and worthy of consideration. Our focus is on the acts of marginalisation, exile and exclusion implicit in the quotidian practice of therapeutic exercise, and how these acts mediate people’s daily lives. In the paper we explore how therapeutic exercise is being instrumentalised, normalised and constrained, arguing for much greater critical attention towards its putative ‘goodness’ and virtue as a health intervention [Abstract].*
What is so important about this kind of work is that it challenges the taken-for-granted obviousness of people’s claims that one modality is in any way superior to another, or that simple weight of evidence is enough to undermine the truth claims of one group and privilege another. It is highly likely that exercise based rehabilitation will be a feature of physiotherapy practice long into the future, but that does not mean that it is unquestionably good or superior to other modalities, and such claims are likely, themselves, to be overwhelmed by new ideologies before too long.
* Nicholls, D.A., Jachyra, P., Gibson, B.E., Fusco, C., & Setchell, J. (Forthcoming, 2018). Keep fit: Marginal ideas in contemporary therapeutic exercise. Qualitative Research in Sport, Exercise and Health. doi: 10.1080/2159676X.2017.1415220 has been accepted for publication and is in the final proofing stages now. A full version of the paper should be in print in early 2018.
I welcome a critical discussion about exercise in physiotherapy. There are two aspects in particular that I have long been concerned about, the latter increasingly in the current development of health service politics. These are firstly the complexity and therefore the need for careful attention and follow-up when using exercises and secondly, what essentially flies in the face of this, that is the erroneous mechanical approach to human movement, which is used to justify leaving clients to their own devices, coming away with little or nothing but a few sequences of stick-figures and verbal instructions from their perhaps single meeting with the physio. The paying structure here in the UK is a case worth looking at in this respect. Physios receive a lump sum for patients coming through the National Health Service. While there is an upper limit to the number of times they can expect to be seen by the physio, if they know about it, the lump sum structure encourages physios to see them for as few times as they can possibly get away with, the extreme case being only a single session. For the health authorities this means a larger number of cases going through, and for the service providers it means numerically increased “productivity”. In the case of the private physios and private clinics, the fewer times a client is seen, the higher the hourly rate. It is noteworthy that in the case of private patients, both those who pay themselves directly and those coming through the insurance companies, the structure of payment is different, ensuring incentive to treat one-to-one in more than one session. So one aspect of this whole thing is clearly a discrimination between those who go thorough the state funded system and those who go through the private sphere; the former, and thereby in the long run the publicly funded approach, being disadvantaged and run down.