Open Book


Physiotherapy Otherwise? What are the Challenges Facing the Profession and What Will This Mean for its Consumers, Regulators, and Practitioners?

There are many changes taking place in global health care that directly impact physical therapy. This article is based on a 2020 Annual Meeting presentation by Professor David Nicholls from AUT University in Auckland, New Zealand.


The world is rapidly changing all around us. While the future of health care may seem like a secondary concern for regulators, in fact, they must understand how the practice is likely to evolve to be able to protect the public.
My book The End of Physiotherapy (2017, Routledge) addresses the conditions that made physical therapy possible in the past, its present struggles, and what the future for the profession might look like. To be clear, I am not an advocate for change for change’s sake; I am an advocate for change because I think we have no choice. I advocate for change that is beneficial to PT colleagues and, of course, to our broader community.
Physical therapies are not going away. People have used certain modalities, such as heat and cold, across cultures for generations. However, the question is whether physical therapy as a profession will survive into the future?

The profession is facing volatile long-term economic pressures on traditional health care services that will affect the profession's ability to meet the needs of the community. The COVID-19 pandemic has only enhanced the sense that there is enormous pressure among governments to support health care services. We have aging populations and people with multiple comorbidities along with a growing socio-economic divide with enormous under-served populations. The amount of student debt is starting to affect individuals’ ability to train and join the profession. And the public is losing faith in institutions and authority figures, including health care institutions and medical providers. As Daniel and Richard Susskind argued,

 “Professionals play such a central role in our lives that we can barely imagine different ways of tackling the problems that they sort out for us. But the professions are not immutable. They are an artefact that we have built to meet a particular set of needs in a print-based industrial society. As we progress into a technology-based Internet society, however, we claim that the professions in their current form will no longer be the best answer to those needs. To pick out a few of their shortcomings—we cannot afford them, they are often antiquated, the expertise of the best is enjoyed only by a few, and their workings are not transparent. For these and other reasons, we believe today’s professions should and will be displaced by feasible alternatives.”
 - The Future of the Professions: How Technology Will Transform the Work of Human Experts, Richard and Daniel Susskind

We also have different attitudes toward our health compared to those our parents and grandparents held. Health used to be binary: most people thought of themselves as either healthy or sick. The civil rights movement helped alter this perception by bringing to light marginalized voices and the health issues and concerns that affected populations beyond a privileged elite.

Now, we continuously strive for optimal health. However, “optimal” health is not really an achievable goal. Who would say that there is no way they could be physically, spiritually, mentally, and emotionally healthy than they are at this moment? This elusive goal of optimal health has created a market for goods and services that we now consume in enormous quantities. Health is no longer binary. You are never well enough, and there is always more work to do and more products to help you get there.

Previously, people had radical surgeries because they needed them. Today, people increasingly see their bodies as projects: you can work on your body all the time. You can have body changes made not just because you need to, but because you want to. We are not too far away from people wanting limbs removed so that they can replace them with superior, prosthetic limbs, or having robotic eye implants. Some people might find this shocking; others might think it is perfectly fine.

These cultural changes have also put more emphasis on personal responsibility. We live in a time of more skepticism and uncertainty about the nature of facts in health care. People have lost some faith in medicine’s promise to rid the world of illness. And stories of malpractice chip away at the power of medicine’s authority.

The traditional pathways to health care are changing as people move to DIY health care via the internet. People demand more freedom of choice, and a poorly structured public health system is struggling to cope with demand. However, this demand also spurs a new marketplace for innovation.
Care robots are becoming more prevalent, and some evidence shows that they may be preferable to human workers, who are often poorly paid and inconsistent. A robot that is a constant companion, never judges you, and learns how to handle youliterally—may be the exact thing that vulnerable patients need.

Technological advances will have a direct effect on physical therapy in the future. If autonomous vehicles reduce the incidence of head injuries by 80 percent in the coming years, what effect will this have on physical therapy services? While that may be “bad for business”, it is clearly good for people.

Knowledge previously held by professionals is now available to everyone. New devices, via a smartphone, can diagnose conditions such as cancer. We are in an on-demand culture. We can access the exact songs we want. We are never lost any more. And we can access most of what we need to learn and understand for free. Innovations like this will dramatically change how future generations think about physical therapy.

With all of these advances, the institutional structures of the past have been dissolving. Experts have lost some sway as social media encourages validation by popularity, not proof. 

Regulators need to acknowledge the emerging skepticism people have towards regulatory institutions. People have a perception of greater freedom without institutional barriers. For example, you do not need to be in school to learn; you do not need to be in the office to work; you do not need to be in the PT clinic to receive care.

These technologies—and others besides—strike at the heart of what it means to be the experts and historical arbiters of “truth” about health and health care. What does it mean to be a professional now if our protective enclosures are dissolving and health is being “opened up”? What role should regulators play as health care becomes radically open?

Physical therapy faces some real and significant challenges in the future. Its work tends to be person-to-person and highly expensive. There is a high demand for physical therapists, but physical therapy educators, clinicians, and regulators also (deliberately) limit supply in order to control the profession’s market for services. Naturally, though, this results in massive unmet need, particularly among under-served populations. Is there a broader role for professional regulators here, beyond protecting the public?

“The agenda for healthcare in developed countries in the 21st century will be dominated by a vision of quality which seeks to address the deep seated problems of the past… The need for health services to give priority to developing health professionals equipped to practise in a new way and thrive in new organisational environments requires a rapid response to reshape curricula and training programmes…. Health care in the 21st century will require a new kind of health professional: someone who is equipped to transcend the traditional doctor-patient relationships to reach a new level of partnership with patients; someone who can lead, manage and work effectively in a team and organisational environment; someone who can practise safe high quality care but also constantly see and create the opportunities for improvement.”
 - Sir Liam J Donaldson

We have many things to consider. Will today’s six-year-olds still see physical therapy training and practice as relevant when health care moves away from elite professional dominance? Will professions be just one (increasingly marginal and expensive) way of organizing health care? If not, how should we rethink people’s need for physical therapies in the next few decades? Additionally, what should regulators be doing to support that drive?
Finally, if change involves breaking the old to create the new, what should we do with practitioners who break the rules? How do we encourage people to innovate and be creative if we punish those who go beyond their scope or look to work in new ways? How do we encourage people to drive the change that we need in the future?

Yes, we will still need forms of regulation, but we need to be open to rethinking them. We will need to let go of the old, protective professional enclosures and recognize that professional health care is only one of many ways to offer health care services to the public. We need to resist a push for elitism and isolation (autonomy) through specialization. We need to use the lessons of the long fuse, big bang of automation, AI, digitization, and robotics to open up physical therapies.

I want to conclude with two powerful quotes to guide us forward:

“Sometimes you have to imagine in a radical way that makes you seem a little crazy, that puts you in an embarrassing light, in order to open up a possibility that others have already closed down with their knowing realism.” – Judith Butler

“The things we want are transformative, and we don’t know or only think we know what is on the other side of that transformation. Love, wisdom, grace, inspiration — how do you go about finding these things that are in some ways about extending the boundaries of the self into unknown territory, about becoming someone else?” - Rebecca Solnit






Photo of David Nicholls

Professor David Nicholls is a physiotherapist, lecturer, researcher and writer, with a passion for critical thinking in and around the physical therapies. David is the founder of the Critical Physiotherapy Network, co-founder and chair of the International Physiotherapy History Association Executive, and founding Executive member of the Environmental Physiotherapy Association. David’s research focuses on the critical history of physiotherapy and considers how physiotherapy might need to adapt to the changing economy of health care in the 21st century. He has published numerous peer-reviewed articles and book chapters, many as first author. He was co-editor on the first collection of critical physiotherapy writings – Manipulating Practices – and he is lead editor for the follow-up titled Mobilising Knowledge. He is also very active on social media, writing nearly 700 blogposts for criticalphysio.net over the last five years. David has taught in physiotherapy programmes in the UK and New Zealand for over 25 years and has presented his work all around the world. The End of Physiotherapy – the first book-length critical history of physiotherapy, and written by David – was published by Routledge in mid-2017, and a second sole-authored book titled Physiotherapy Otherwisewill be published in late 2021.