Parallels and problems of normalization in rehabilitation and universal design: enabling connectivities

Physiotherapy, movement, and action

Movement has always been central to physiotherapy practice and theory. But physiotherapists have largely focused on forms of human bodily movement governed by the neuro-mechanical body system in illness or injury. Many other forms of movement exist though, and we argue here that the exploration of these other movements might give physiotherapists new language, concepts, and tools, to guide its adaptation to forms of healthcare that are becoming increasingly complex, diverse, and inclusive. Drawing on Hannah Arendt's concept of vita activa (or "active life"), we examine how physiotherapists have traditionally captured and defined movement. Critiquing past practices for over-emphasizing what Arendt called labor, and work, we suggest that an approach governed by her concept of action, might offer physiotherapists a way to give movement greater significance. We explore what active life might mean for a revised approach to movement, and highlight examples of vita activa already emerging in physiotherapy. We close the paper by calling for a reevaluation of what movement means for the profession and its clients.

Turning toward suffering: Rethinking the patient- clinician relationship in physical therapy practice

In this professional theoretical article, the authors argue that patient care should be centered on connection and that authentically turning toward suffering necessitates an approach to care that transcends medicine's traditional focus on cure and physical restoration and differentiates between pathology and disability. The meaning of illness and suffering for those who have experienced life-changing injuries or illness is explored. Strategies for approaching the lifeworld of these individuals are discussed using the concepts of phenomenology and embodiment, rooted in the work of philosophers from the phenomenological tradition. The authors also propose an approach to patient care offering a case-based example based on postmodernist concepts that elevate connection, relationship, and interdependency above the traditional focus of restoring normality and physical independence for individuals with disabilities. Traditional assumptions about quality of life, illness, and disability are called into question by focusing on the fluidity of being and disability identity, which serves to destabilize static, binary conceptions of individuals as either healthy or ill, disabled, or able-bodied. A postmodern lens invites healthcare practitioners to envision themselves as part of an assemblage that may promote a more expansive view of the relationship between patient and healthcare practitioner.

Drawing on critical disability and universal design perspectives within occupational therapy

BACKGROUND

Critical perspectives which focus on socio-political influences on occupation have gained increased attention within the occupational therapy profession. Critical disability studies (CDS) question prevailing assumptions about disability and how disabling ideologies and practices are perpetuated in society. Universal Design (UD) is a design approach that aims to operationalise issues of inclusion and justice.

AIM

To identify and discuss how the tenets of CDS and UD can contribute to occupational therapy practice and research.

METHODS AND RESULTS

Drawing on the writings of leading scholars within CDS, UD and occupational therapy, we demonstrate the intertwined barriers faced by disabled children, youth, and adults who have participated in our studies and provide ideas on how practice can be guided by the tenets of CDS and UD to promote social equity.

CONCLUSIONS

Incorporating CDS and UD perspectives in occupational therapy practice and research requires a change in mindset and ways of working. Occupational therapy knowledge needs to be expanded to scrutinise disabling hindrances hidden within social and structural spaces, and implemented in services. We recommend working with disability communities to raise awareness and combat disabling barriers at various level of society, as mandated by policy.

Critical physiotherapy: a ten-year retrospective

Critical physiotherapy has been a rapidly expanding field over the last decade and could now justifiably be called a professional sub-discipline. In this paper we define three different but somewhat interconnected critical positions that have emerged over the last decade that share a critique of physiotherapy's historical approach to health and illness, while also diverging in the possibilities for new forms of practice and thinking. These three positions broadly align with three distinctive philosophies: approaches that emphasize lived experience, social theory, and a range of philosophies increasingly referred to as the "posts". In this paper we discuss the origins of these approaches, exploring the ways they critique contemporary physiotherapy thinking and practice. We offer an overview of the key principles of each approach and, for each in turn, suggest readings from key authors. We conclude each section by discussing the limits of these various approaches, but also indicate ways in which they might inform future thinking and practice. We end the paper by arguing that the various approaches that now fall under the rubric of critical physiotherapy represent some of the most exciting and opportune ways we might (re)think the future for the physiotherapy profession and the physical therapies more generally.

Reflecting on challenges and opportunities for the practice of person-centred rehabilitation

OBJECTIVES

To (1) reflect on challenges to the practice of person-centred rehabilitation; and (2) propose opportunities for the development of person-centred rehabilitation.

CHALLENGES

Person-centred practice has received widespread endorsement across healthcare settings and is understood to be an important, positive approach in rehabilitation. However, the rhetoric of this approach does not always translate meaningfully into practice. Emphasis on patient choice, patient involvement in decision making, and increasing patient capacity for self-management have become a proxy for person-centred rehabilitation in lieu of a more fundamental shift in practice and healthcare structures. System (e.g. biomedical orientation), organisational (e.g. key performance indicators) and professional (e.g. identity as expert) factors compete with person-centred rehabilitation.

OPPORTUNITIES

Four key recommendations for the development of person-centred rehabilitation are proposed including to: (1) develop a principles-based approach to person-centred rehabilitation; (2) move away from the dichotomy of person-centred (or not) rehabilitation; (3) build person-centred cultures of care in rehabilitation; and (4) learn from diverse perspectives of person-centred rehabilitation.

CONCLUSION

Fixed assumptions about what constitutes person-centred rehabilitation may limit our ability to respond to the needs of persons and families. Embedding person-centred ways of working is challenging due to the competing drivers and interests of healthcare systems and organisations. A principles-based approach, enabled by person-centred cultures of care, may achieve the aspirations of person-centred rehabilitation.

Texts influencing the accommodation process of students with disabilities in professional rehabilitation programs: an analysis of discourse

PURPOSE

Students with disabilities have lower enrollment and higher attrition than their non-disabled peers. They identify negative attitudes from educators in their accommodation experiences within professional programs, such as occupational therapy and physiotherapy. Educators in these accredited programs must address a myriad of requirements through curriculum delivery. The documents or "texts" containing program requirements include discourses or dominant understandings of reality. The purpose of this study is to identify these discourses and the resulting positions of educators, to better understand the tensions in accommodating students with disabilities.

METHODS

A critical discourse analysis study was conducted. Key informants and inclusion criteria led to the collection of 9 texts, which were subsequently analyzed using Norman Fairclough's three-dimensional conception of discourse.

RESULTS

Three discourses were identified. "Rights and responsibilities" was the most salient discourse, followed by "normative assumptions" and then "inclusion and equity." The associated educator positions are "navigator," "gatekeeper" and "advocate," respectively.

CONCLUSIONS

The discourses and resulting educator positions are varied and in conflict with one another. There is a potential for change in the social practices related to accommodating students with disabilities. However, these changes need to be conscious and deliberate to ensure inclusivity within the occupational therapy and physiotherapy professions.Implications for RehabilitationCritical discourse analysis is a methodology that can raise awareness of implicit assumptions embedded in texts that reflect and potentially perpetuate inequities and power imbalances.Conflicting discourses in the accommodation process provide a valuable opportunity for educators to critically reflect on personal and professional values and beliefs.Critical reflection on unconscious bias while writing policies and practices could ensure a more diverse pool of applicants for professional programs, thereby enriching rehabilitation professions.

The Lived Experience of Interdependence: Support Worker Relationships and Implications for Wider Rehabilitation

Engaging in a meaningful life where one can exercise autonomy has been proposed as a key aim of rehabilitation. Influenced by a neoliberal worldview, this has traditionally been characterised by a pursuit towards individual functional independence in which one completes tasks and activities unassisted. However for many persons, individual functional independence may not be a realistic, prioritised or beneficial goal. Many individuals must learn to work with support workers to exercise choice and control. Such relationships extend beyond a transactional nature and involve many subtle characteristics. In this article, I draw on my lived experience of partnering with support workers to illustrate the complexity of such relationships and how they can enable interdependence to serve as a vehicle to self-determination. I finish with some ideas about what rehabilitation can do to recognise the important role human connections play in facilitating interdependence. Understanding the nature of these relationships is necessary to provide services which value interdependence, supporting people to pursue a meaningful life following impairment.

A posthuman decentring of person-centred care

In this paper, we examine person-centred care through a Deleuzian posthuman lens with the aim of exploring what becomes possible when the concepts of both person and care are de-centred. We do so through a consideration of the sets of relations that produce 'the client' in health care contexts. Our analysis maps particular entangled material-semiotic forces producing 'M/michael', a young man with a diagnosis of Duchenne muscular dystrophy, within a rehabilitation clinic. Drawing on Deleuzian notions of assemblage, affect, and becoming we explore 'person-care' as an active production that dynamically enacts persons-as-clients through clinical arrangements. Persons are thus reconceptualised in terms of locally produced subject positions and their care relations, rather than pre-existing beings who can be 'centred' within health services. Paradoxically, by de-centring persons and care, we work to conjure ways to strengthen the aspirations of person centredness to humanise health practices. In doing so, we consider different possibilities for re-imagining clinical work and contribute to debates regarding how healthcare conceptualises and addresses disability, health, and wellbeing. We suggest that such posthuman analyses can open up new ways of understanding and re/forming healthcare.

Particularizing an Internal Morality of Physical Therapy

While the American Physical Therapy Association has upheld a code of ethics since 1935, the philosophical underpinnings of physical therapist practice have yet to be robustly explicated. Theoretical work in the field of philosophy of medicine can be engaged to study physical therapist practice. Modifying the phenomenological and teleological framework of Edmund Pellegrino, a physician and prominent bioethicist, the purpose of this theoretical paper is to particularize Pellegrino's philosophy of medicine to construct an internal morality of physical therapy. Acknowledging that the internal morality of health care professions is founded in the relationship between a patient and a health care professional, this paper analyzes the nature and telos, or end, of physical therapy through 3 phenomena of physical therapy-the fact of disability, the act of profession, and the act of physical therapy. This paper claims that, rather than medicine's clinical truth of a good treatment decision, physical therapy's clinical truth is a good process that capacitates patients. This relational approach to an internal morality robustly underpins a philosophy and ethics of physical therapy.

Environmental Barriers and Facilitators to Physical Activity among University Students with Physical Disability-A Qualitative Study in Spain

This paper qualitatively examines environmental factors operating as barriers and/or facilitators to participation in physical activity (PA) of people with physical disabilities. Interview data were collected from 27 Spanish university students through the innovative method of two-on-one interviews. Thereafter, data were subject to a flexible thematic analysis. Three themes were constructed: associations; PA practice spaces; and nonhumans. Concepts from different theories were used to generate meaningful interpretations around each theme. Drawing on our results, we offer several reflections and directions. Two key messages can be highlighted. First, environmental barriers and facilitators are context dependent and thus do not precede the circumstances in which they emerge. Second, Spanish universities should work harder to become relevant PA promoting environments for students with physical disability. The knowledge generated in this study is expected to inform the design, implementation and evaluation of programs promoting PA among Spanish university students with physical disability.

The potential impact of experiencing social inclusion in recreation for children with and without disabilities

PURPOSE

Inclusive recreation programs can have individual and community impacts for children with and without disabilities. However, studies that explore the impact of such programs on children's attitudes are mixed. The purpose of this study was to explore the perspectives of children with and without disabilities on the individual impact of an inclusive recreation program.

MATERIAL AND METHOD

This study adopted a generic qualitative methodology. Interviews were conducted with participants between the ages of eight and 18 enrolled in the same program and each participant was interviewed twice. Inductive thematic analysis was used to analyze results.

RESULTS

17 participants were recruited for this study, which included nine children without disabilities (CWODs) and eight children with disabilities (CWDs). This study revealed five themes: a) CWODs have limited exposure to people with disabilities; b) CWODs and CWDs' hopes of change; c) CWODs learned how to interact with people with disabilities; d) CWODs reported greater perceived similarity in functional ability and hobbies/interests between themselves and CWDs, and; e) CWODs become more comfortable being around people with disabilities.

CONCLUSIONS

This study helps broaden understandings of how inclusive experiences in recreation settings impact children with and without disability.IMPLICATIONS FOR REHABILITATIONChildren without disabilities can develop more positive attitudes toward children with disabilities in affective and cognitive domains after participating in an inclusive recreation program.Incorporating inclusive language into program design and implementation may promote positive attitudes toward diversity in recreation settings.Children without disabilities would benefit from more opportunities to interact with children with disabilities in unstructured, inclusive or integrated recreation settings.

Enacting objects and subjects in a children's rehabilitation clinic: Default and shifting ontological politics of muscular dystrophy care

In health care clinics, problems are constructed through interactions, a choreography of human and non-human actors together enacting matters of concern. Studying the ways in which a body, person, family, or environment is objectified for clinical purposes opens discussion about advantages and disadvantages of different objectification practices, and exploration of creative ways to handle the diversity and tensions that exist. In this analysis, we explored objectifications in a Canadian neuromuscular clinic with young people with muscular dystrophy. This involved a close examination of clinical objectification practices across a series of 27 observed appointments. We identified the routinised clinical assessments, and argue these embed a default orientation to how to intervene in people's lives. In this setting, the routine focused on meeting demands of daily activities while protecting the at-risk-body, and working toward an abstract sense of an independent future for the person/body with muscular dystrophy. But the default could be disrupted; through our analysis of the routine and disruptions, we highlight how contesting visions for the present and future were consequential in ways that might be more than what is anticipated within rehabilitation practice.

Is independence enough? Rehabilitation should include autonomy and social engagement to achieve quality of life

PURPOSE

This discussion paper argues that holding independence as the central goal for rehabilitation has limitations that hinder successful outcomes. It shows why autonomy and social engagement should also serve as goals of rehabilitation, in order to achieve quality of life and effective functioning.

METHODS

The paper reviews problems arising from the over-emphasis on independence in rehabilitation. Although independence is a valuable goal on some tasks, it is sometimes not possible or desirable and is best complimented by autonomy and social engagement. Autonomy recognises that enacting some goals requires the support of other people. Autonomy is thus linked to social engagement (connectivity) in the workplace and personal relationships. The paper applies this framework to motor and cognitive disabilities.

RESULTS

The inclusion of autonomy and social engagement as goals for rehabilitation addresses the limitations of independence and can serve the unifying aim of enhancing the person's quality of life. These goals apply equally to motor disabilities and the cognitive and behavioural effects of injuries which affect personal and work relationships.

CONCLUSIONS

Rehabilitation is likely to be more effective if it aims at a combination of independence, autonomy and social engagement, in service of the goal of a good quality of life.

'It's not a part of me, but it is what it is': the struggle of becoming en-wheeled after spinal cord injury

PURPOSE

Many people who experience spinal cord injury become long-term wheelchair users. This article addresses the process of becoming en-wheeled through the case example of a disabled man called Patrick.

DESIGN

An intrinsic case study informed by posthumanist developments was used. Within this design, Patrick and his manual wheelchair were the entangled participants of the inquiry.

METHODS

Interviews and fieldwork observation with Patrick were conducted. Qualitative data were analysed using the posthumanist notion of 'assemblages'.

RESULTS

The results illuminate Patrick's struggle of negotiating a new embodied selfhood that includes the wheelchair. Patrick engaged in ableist rehabilitation after spinal cord injury to recuperate the capacity to walk and break his connection with the wheelchair. After extensive treatment of his body, he reluctantly assumed his cyborg or posthuman condition.

CONCLUSION

The analysis and discussion resulted in a theoretical frame that presents the notions of humanist and posthumanist enwheelment as two directions of a continuum. The paper offers a useful tool for understanding and addressing enwheelment plus other cyborgification processes. We advocate for its acceptance into the disability studies and rehabilitation practice repertoire.IMPLICATIONS FOR REHABILITATIONEnwheelment -the process of becoming one with the wheelchair - is relevant to people after SCI (or other impairments).The notions of humanist and posthumanist enwheelment are developed and presented as two ends of a continuum.Rehabilitation workers should be mindful of the complexities of cyborgification to avoid ableism and help people flourishing within and beyond recovery.

Assembling activity/setting participation with disabled young people

Rehabilitation research investigating activity participation has been largely conducted in a realist tradition that under-theorises the relationship between persons, technologies, and socio-material places. In this Canadian study we used a post-critical approach to explore activity/setting participation with 19 young people aged 14 to 23 years with complex communication and/or mobility impairments. Methods included integrated photo-elicitation, interviews, and participant observations of community-based activities. We present our results using the conceptual lens of assemblages to surface how different combinations of bodies, social meanings, and technologies enabled or constrained particular activities. Assemblages were analysed in terms of how they organised what was possible and practical for participants and their families in different contexts. The results illuminate how young people negotiated activity needs and desires in particular 'spacings' each with its own material, temporal, and social constraints and affordances. The focus on assemblages provides a dynamic analysis of how dis/abilities are enacted in and across geotemporal spaces, and avoids a reductive focus on evaluating the accessibility of static environmental features. In doing so the study reveals possible 'lines of flight' for healthcare, rehabilitation, and social care practices.

Seven-Step Framework for Critical Analysis and Its Application in the Field of Physical Therapy

Critical analysis (or the ability to recognize taken-for-granted assumptions and their effects) is a skill that requires teaching and practice. The purpose of this article is to introduce a framework for critically analyzing assumptions within physical therapy and illustrate its utility through application to 2 examples: a physical therapy clinic logo and an outcome measure for health-related quality of life (HRQOL). This 7-step framework for critical analysis was created for a pilot project to develop reflexivity among senior physical therapist students and further developed through an iterative process of reflecting on its utility for advancing the field of physical therapy. The 7-step framework is an iterative process involving a cascade of 7 steps: (1) name the specific aspect of practice being analyzed, (2) identify the intended purposes of this aspect of practice, (3) uncover the assumptions that support these intended purposes, (4) identify who benefits, (5) identify who is disadvantaged, (6) link these specific ideas to society-level patterns, and (7) conceive of alternatives that mitigate actual or potential harms. It is emphasized that being theoretically critical does not equate to being negative. Rather, the word “critical” is used in the sense of thinking deeply and carefully about the intended and unintended consequences of actions (including common professional practices, ways of speaking, and visual representations) in order to reflect on and mature the field of physical therapy. The purpose of critical analysis is to invite and promote dialogue that assists physical therapist clinicians, researchers, and students to arrive at new insights about the impacts of their day-to-day actions.

Putting Gino's lesson to work: Actor-network theory, enacted humanity, and rehabilitation

This article argues that rehabilitation enacts a particular understanding of "the human" throughout therapeutic assessment and treatment. Following Michel Callon and Vololona Rabeharisoa's "Gino's Lesson on Humanity," we suggest that this is not simply a top-down process, but is cultivated in the application and response to biomedical frameworks of human ability, competence, and responsibility. The emergence of the human is at once a materially contingent, moral, and interpersonal process. We begin the article by outlining the basics of the actor-network theory that underpins "Gino's Lesson on Humanity." Next, we elucidate its central thesis regarding how disabled personhood emerges through actor-network interactions. Section "Learning Gino's lesson" draws on two autobiographical examples, examining the emergence of humanity through rehabilitation, particularly assessment measures and the responses to them. We conclude by thinking about how rehabilitation and actor-network theory might take this lesson on humanity seriously.

Situating universal design architecture: designing with whom?

PURPOSE

To respond to growing calls for a theoretical unpacking of Universal Design (UD), a disparate movement cohering around attempts to design spaces and technologies that seek to allow use by all people (to the fullest extent possible). The on-going embedding of UD into architectural practice and pedagogy represents an opportune juncture at which to draw learning from other distinct-but-related transformatory architectural movements.

METHODS

Sociological-theoretical commentary.

RESULTS

UD has to date, and necessarily, been dominated by the practice contexts from which it emerged. Appealing as a short-hand for description of "designing-for-all", in most cases UD has come to stand in as a term to signal a general intent in this direction and as an umbrella term for the range of technical design resources that have been developed under these auspices. There remains a fundamental ambivalence vis-à-vis the question of users' power/capacity to influence decision-making in the design process in UD; technically-oriented typologies of bodies predominate in influential UD architectural accounts.

CONCLUSIONS

UD represents rich technical and pedagogical resources for those architects committed to transforming the existing built environment so as to be less hostile to a wide range of users. However, within UD, unpacking the social role of the professional architect vis-à-vis a variety of publics is an important, but hitherto underdeveloped, challenge; issues concerning professional-citizen power relations continue to animate parallel architectural politics, and UD can both contribute and draw much from these on-going explorations. Implications for Rehabilitation Universal Design (UD) architecture shares a close affinity with rehabilitation practice, with the creation of built environments that allow use by individuals with a wide range of capacities a priority for both. While an effective communicative "bridge" between professions, UD's deployment typically leaves unspoken the capacity of users to meaningfully affect decision-making in the design process. UD architecture has much to draw from, and contribute to, parallel movements in "participatory architectural design"; debates therein have illuminated much about the social practices underpinning designing for difference. UD could engage more fully with questions relating to the social and political role of the architect.