Authors: Jenny Setchell, David A Nicholls, Nicky Wilson & Barbara E Gibson / Peer reviewed at Physiotherapy Canada / Submitted: 05 February 2019; Accepted: 14 February 2019.
Notes: Reprinted with permission from University of Toronto Press. The original article can be found at https://doi.org/10.3138/ptc.70.4.gee.
In this editorial, we argue that ‘critical’ thinking, research and scholarship are essential to understanding and practising rehabilitation, and yet are under-represented in the existing rehabilitation literature. By using the term critical, we are referring to research and scholarship that draw from social theory to examine pervasive taken-for-granted practices, assumptions, and principles in any field, including health care. Thus, critical work offers opportunities to enact more ethical and socially just rehabilitation practices. In what follows we call for rehabilitation journals to recognise, welcome, seek out and publish submissions in this exciting area of research, and thereby lead the field in promoting a new understanding of rehabilitation’s purpose, goals, practices, and outcomes.
Why critical? Why now?
Critical research addresses the social, cultural, material and political aspects of rehabilitation and it is vital for ethical and deliberate professional practice [1,2]. Today’s health professionals working in rehabilitation face many challenges, including working with people who will likely be living longer and have increased comorbidity, the rise of technologically-mediated medicine, the blurring of professional boundaries and inter-professional competition, resource constraints and public distrust of orthodox medicine  . Many rehabilitation health professionals, trained in traditional models, find themselves inadequately prepared for the complex array of cultural, economic, political and social issues that they face in their work. Holding onto the scaffolds that define rehabilitation, whilst embracing rapid transformation in healthcare, may be causing anxiety for some. Critical research and thinking can help those working in rehabilitation to thrive throughout these changes and develop a wide skill set to support adept responses to a rapidly changing healthcare landscape. More importantly however, critical research and thinking can lead to more ethical and relevant care for those they serve.
Are we already doing critical work?
The word critical can be a source of misunderstanding because it has varied (and at times conflicting) uses. In lay language it can imply judgement; in clinical practice it can refer to a person with an acute illness; and in learning and teaching, it can mean critical appraisal. Critical scholarship is different, taking as its point of departure social and philosophical theories that challenge taken-for-granted assumptions and considerations of power  . Many varieties of critical research exist, underpinned by diverse theoretical perspectives, but they all share an interest in how power works, including examining whose knowledge is considered legitimate and why . These considerations of power can be at a macro-level (e.g. healthcare structures, funding) or micro-level (e.g. interactions between clients and healthcare professionals).
Critical research can take many forms, including both qualitative and quantitative design. Although qualitative research is perhaps better aligned with critical thinking, not all critical research is qualitative and not all qualitative research is critical. Furthermore, quantitative research can be critical if it challenges ingrained assumptions; examples are Setchell and colleagues , and Albert and Laberge . Critical research can also be theoretical (i.e., non-empirical). These multiple forms of critical research are long-established in publications in the humanities, sociology, and philosophy, which focus on how theory can help reconceptualise understandings of the world. However, these forms are often overlooked by rehabilitation sciences, and the limited scope of “acceptable” research designs in most rehabilitation journals (reflected in standardised quality assessment checklists such as CONSORT, STROBE, and COREQ) leaves little space for critical scholarship.
Some important critical rehabilitation research is being published. For example, Rita Struhkamp highlighted potentially problematic assumptions underlying the common practice of “goal setting” in rehabilitation ; Thomas Abrams explored the ingrained notion that upright postures are necessarily superior and its negative effects on wheelchair users and others ; and Bettine Pluut highlighted the problems and potential of divergent perceptions of “patient centred care” . Our own work also considers numerous critical issues across rehabilitation: problems associated with standardised guidelines (such as NICE) , the unintended stigmatising practices of clinicians [11,12], the need for a reconfiguration of ethics in childhood rehabilitation , and the assumptions that underpin exercise as medical intervention . This growing pool of researchers is seeking avenues for disseminating this type of work. However, critical researchers are often forced to publish outside rehabilitation journals because reviewers and editors may be evaluating their work according to erroneous criteria, misunderstanding of its significance, or both.
This issue was recently highlighted during the rejection of a paper (written by two of the authors) by a leading rehabilitation journal; the paper was subsequently published elsewhere. The editors commented, “This is a nice, inspiring piece of work and an agreeable read. … We enjoyed the testimonies.” They also remarked that the paper was an extension of recent work and went on to say,
However, in our editorial discussion we also questioned to what extent these results, obtained in a certain cultural and organisational setting could be generalised beyond their illustrative value. This may be because of our lack of familiarity with the concepts and approach. We also regretted that no “intervention” (such as suggested in your recommendations) was formally tested to see if this situation can be ameliorated. We hope you will be able to submit it successfully to another journal, more suited to these kinds of important studies. [emphasis added]
A call for more criticality
We call for creating a place for critical research, thinking and pedagogy in the rehabilitation literature and knowledge base.
Some efforts already support this work. For example, the Critical Physiotherapy Network (CPN) , an organisation that spans more than 40 countries and has a rapidly expanding network of over 650 researchers, educators and clinicians, promotes critical scholarship in rehabilitation and is a valuable source of both critical work and reviewers. Moreover, a small number of rehabilitation journals have begun to publish critical research and have structures in place to provide appropriate review (e.g., Journal of Humanities in Rehabilitation; Physiotherapy Canada, OpenPhysio; Disability and Rehabilitation; Scandinavian Journal of Occupational Therapy; and Physiotherapy Theory and Practice). However, these journals comprise only a fraction of all the rehabilitation journals.
Therefore, we call for all rehabilitation journals to welcome critical submissions by adding critical scholars to their editorial boards, associate editors and reviewers. We also call on critical researchers to submit their articles to rehabilitation journals and contribute to reviewing papers when called on. In making this call, we envision an enriched knowledge base for rehabilitation that will ultimately benefit those who seek rehabilitation services.
- Trede F, McEwan C. Educating the deliberate practitioner. Amsterdam, The Netherlands: Springer; 2016.
- Gibson BE. Rehabilitation: A post-critical approach. Boca Raton, United States: CRC Press; 2016.
- Gibson BE, Nicholls D, Setchell J, Synne-Groven K. Manipulating practices: A critical physiotherapy reader. Oslo, Norway: Cappelen Damm; 2018.
- Eakin J. Educating critical qualitative health researchers in the land of the randomized controlled trial. Qualitative Inquiry. 2016;22(2):107-18.
- Setchell J, Watson BM, Jones L, Gard M, Briffa K. Physiotherapists demonstrate weight stigma: A cross-sectional survey of Australian physiotherapists. Journal of Physiotherapy. 2014;60(3):157-62.
- Albert M, Laberge S. Confined to a tokenistic status: Social scientists in leadership roles in a national health research funding agency. Soc Sci Med. 2017;185:137-46.
- Struhkamp R. Goals in their setting: A normative analysis of goal setting in physical rehabilitation. Health Care Analysis. 2004;12(2):131-55.
- Abrams T. Is everyone upright? Erwin Straus’ “The Upright Posture” and disabled phenomenology. Human Affairs. 2014;24(4).
- Pluut B. Differences that matter: Developing critical insights into discourses of patient-centredness. Medicine, Health Care and Philosophy. 2016;19:501-15.
- Wilson N, Pope C, Roberts L, Crouch R. Governing healthcare: finding meaning in a clinical practice guideline for the management of non-specific low back pain. Soc Sci Med. 2014;102:138-45.
- Setchell J. What has stigma got to do with physiotherapy? Physiotherapy Canada. 2017;69(1):1-4.
- Setchell J, Gard M, Jones L, Watson B. Addressing weight stigma in physiotherapy: Development of a theory driven approach to (re)thinking weight related interactions. Physiotherapy Theory & Practice. 2017;33(8):597-610.
- Gibson BE. A post-critical physiotherapy ethics: A commitment to openness. In: Gibson BE, Nicholls D, Setchell J, Synne-Groven K, editors. Manipulating practices: A critical physiotherapy reader. Oslo, Norway: Cappelen Damm; 2018. p. 35-54.
- Nicholls D, Jachyra P, Gibson BE, Fusco C, Setchell J. Keeping fit: Marginal ideas in contemporary therapeutic exercise. Qualitative Research in Sport, Exercise and Health. 2018:1-12.
- Critical Physiotherapy Network. Retrieved from https://criticalphysio.net/. Accessed 12th June 2018.