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Differentiation as a Qualitative Research Strategy
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SCHOLARLY PAPER
Differentiation as a Qualitative Research Strategy A comparative analysis of Bobath and Brunnstrom approaches to treatment of stroke patients A T Lettinga P J M,_Helders
A Mol P Rispens
Key Words Content analysis, stroke patients, neurodevelopmental treatment, Brunnstrom approach, quantitative method, qualitative method, system theory, phenomenology.
Summary Conventional physiotherapy and research are currently criticised for being too biomedical and physical in their orientation. Researchers influenced by system theory on the one hand and phenomenology on the other stress that patients are not just isolated bodies. They therefore propose the addition of psychosocia1 knowledge and attentivenessto the perspectiveof the patient. This strategy of adding on ‘human’ factors to physiotherapydoes not suffice when it comes to the question of integrating these different fields of knowledge. In this article an alternative strategy is introduced: ‘differentiation’. It is argued that co-existing treatment programmes in physiotherapy differ in the ways they give place and shape to a patient‘s humanness. The content of these programmes therefore needs to be further analysed. To illustrate this, we present an example of an analysis of two competing programmes for the rehabilitation of stroke patients. The conclusion is that these programmes not only deal with the body differently, but thereby also approach psycho-socialaspects in different ways.
Introduction Theorists of physiotherapy tend to criticise the one-sidedness of its treatment programmes and research methods. They give, however, different characterisations of this one-sidedness. In one tradition conventional physiotherapy is accused of focusing exclusively on the patients’ bodies, while neglecting psychic and social knowledge. Instead of borrowing only from biomedical disciplines like anatomy and physiology, physiotherapy should also draw upon knowledge that comes from the departments of psychology and sociology (Engel, 1981; Dean, 1985; Cambell, 1993). I n a second critical tradition, therapists and researchers are encouraged to focus on the patients’ perspective (Shepard et al, 1993; Mattingly, 1993; Johnson, 1993) rather than t o enlarge their object-scope so as to encompass psychological and sociological knowledge. I n this tradition, it is argued that patients are often treated and studied as if they were ‘mere’objects. Professionals are accused
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of forgetting the fact that patients are subjects as well. Instead of only relying upon their own professional eyes, they should also pay attention to what is seen by other eyes: those of the patients.
A good example of the first tradition is the work of Dean (1985), who argues t h a t physiotherapy should attend to psychosocial factors such as the patients’ lifestyle, their stress management style, their occupation and environment, and their social attributes. In order t o reach a n optimal treatment outcome, Dean wants us to use a ‘psychobiological adaptation model’. He is in favour of assessing treatment outcomes with valid and reliable quantitative measurements that take psychosocial dimensions into account. Cambell (1993)elaborates on this, working on a framework for describing and studying the disabling process ‘that systematically relates measures and outcomes at different levels of human functioning, from the cellular t o the societal’. Scholars of the second tradition consider the quantitative research methods recommended by people like Dean and Cambell t o be too limited. They may enlarge the object-scope of physical therapy, but cannot grasp the patients’ subjectivity. Measuring and counting may yield useful information, but they are insufficient instruments when it comes to gathering data about the way people experience the world in which they live. In order to gather this kind of data, and to study the meanings that participants attribute to their circumstances and the multiple realities in which they live, people like Shepard and co-authors propose supplementing quantitative methods by qualitative methods (Shepard et al, 1993). As Mattingly (1993) puts it in a commentary accompanying their writing: ‘But if treatment is treating a life, so to speak, then it is important to do research that illuminates the phenomenological aspects of treatment, that investigates the meaning of disability and treatment from the perspectives of all key actors: therapist, client, family members, professional colleagues, even institutional contexts.’ So there are two differing critical traditions. The proponents of the first tradition aim to enlarge the scope of physiotherapy by including psychological
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and sociological knowledge, while proponents of the second tradition try t o explore ways to gain knowledge of participants’ experiences and perceptions. The first tradition is inspired by system theory and expects more from quantitative methods, the second has its roots in phenomenology and works with qualitative methods. At the same time, however, the two traditions share a common concern, both attempting t o add on something ‘human’ to conventional physiotherapy and research. Although the first one wants t o supplement another object and the second another perspective, they share the strategy of addition. The difficulty with this strategy is that it leaves the physical core of physiotherapy untouched. Biomedical knowledge and physical techniques are seen as in need of supplementation by something else, not as something requiring any further analysis itself, This is where we disagree and would like to propose a n alternative strategy: differentiation. Instead of trying to add on something human to currently existing treatment programmes, we first want t o examine their content further by analysing the place and the shape of ‘the human’ within these programmes. What kind of body, and with that, what kind of psychic and social realities are pre-supposed, or implicated, in current physiotherapy? Our starting point for these questions is the plurality of physiotherapy. Co-existing treatment programmes, we will show, do not necessarily share the same physical cores. Our claim is that these treatment programmes deal with bodies in different ways, each relating differently t o the patients’ psyche, social environment and perspective. In order t o illustrate this claim we will present a comparative analysis of two competing treatment programmes for stroke patients: the Brunnstrom approach (Brunnstrom, 1970; Sawner and LaVigne, 1992) and neuro-developmental treatment (NDT) (Bobath, 1970, 1978, 1990; Davies, 1985, 1990).
Method Our work draws upon discourse analysis (Foucault, 1975,1976; Canguilhem, 1955, 1978) and actor-network theory (Latour, 1987,1989; Callon and Law, 1989). Unlike system theory these traditions do not take behaviour as their point of departure. They differ from phenomenology in t h a t they do not start from humans and the way they attribute meaning t o their experiences. Instead, their primary object of investigation is the way the elements of a theoretical ‘discourse’ o r of a technical ‘network’ co-constitute each other. Whereas most researchers in this tradition have a philosoph-
ical or a sociological agenda, we work towards the implications our analysis may hold for clinical practice and research in physiotherapy. Both discourse analysis and actor-network theory have their background in semiotics, the study of signs and symbols in language. In semiotics the words of a language are regarded as linguistic tools, actively ordering objects and events in specific ways, rather than as labels representing objects in the world as the positivistic tradition would have it. Semioticians set themselves the task to unravel this ordering activity. Such a n unravelling cannot be done word by word, as if each word exists in isolation. Since languages are appreciated as a network of related signs that give each other meaning, they form the unities of analysis. In a language each single element literally informs the others. Within most types of discourse analysis and all of actor-network theory, however, language itself is in turn seen as being embedded in practices (Foucault, 1975; Latour, 1989; Callon and Law, 1989; Mol, 1993; Mol and Berg, 1994; Mol and Law, 1994; Mol and Mesman, 1996). Reality does not exist solely out of co-constituting words. Words do not only inform each other, they a r e part and parcel of a reality in which they are used and accepted as meaningful. A language comes to be expressed under certain practical conditions. The semioticians by whom we are influenced analyse languages and practices as being closely intertwined. This theoretical framework we use in our analysis of the Brunnstrom and NDT programmes involving a mixture of qualitative research techniques. The Brunnstrom - and NDT - textbooks were the primary source in the unravelling of languages and practices of both programmes. We are also presently engaged in fieldwork, doing ethnographic observations and taking interviews. In this article we use only material gathered with text analysis. That is a matter of argumentive economy and reducing complexity. Contrasting quotes are enough to support our claim that the authors of the Brunnstrom and NDT textbooks articulate the problems of stroke patients differently and order physiotherapy in different ways. Our method consists of treating the Brunnstrom and NDT programmes as if they were ‘languages’. Each treatment programme has a vocabulary of its own in which movement problems, techniques and goals that are discussed are ordered in a specific way. We started out by analysing these biomedical vocabularies, using the contrast between them as a way to reveal their different self-evidences (Lettinga, 1989, 1991). For this article we also analysed the
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psycho-social terminologies, interventions and routines that are intertwined with these programmes. Of course it would also be possible t o contrast Brunnstrom and NDT texts as if they contain different statements about how to treat stroke patients. The validity of each of these statements could then be tested. That, however, is not the object of our inquiry. What interests us here is something else, namely how Brunnstrom and NDT cast a different image of what a stroke patient is. Are the movements of a stroke patient’s affected half ‘primitive’ or ‘pathological’?Should such a patient learn to avoid or to use these movements? Should he be ‘motivated’ to put his shoes on, o r does this require a set of ‘organising abilities’? What kind of body do Brunnstrom and NDT therapists respectively treat, and what kind of human does their language allow them to talk about?
Primitive or Pathological Patients who have undergone a serious stroke may have become hemiplegic, that is incapable of moving one side of their body. In physiotherapy, two conflicting programmes for the treatment of such patients co-exist. One is known by the name of its designer, Signe Brunnstrom, a Swedish physiotherapist who worked in the USA (Brunnstrom, 1970). In 1992 Brunnnstrom’s book was revised by Kathryn Sawner and Jeanne LaVigne (Sawner amd LaVigne, 1992), who have attempted t o preserve the original ideas and approaches of Brunnstrom. The name of the other programme is an acronym of its enterprise, NDT (neuro-developmental treatment). NDT was first designed by Berta Bobath, a physiotherapist, and Karl Bobath, her husband and a neurologist by training, who both came from Germany and worked in Britain (Bobath, 1990). This treatment programme was later refined by Patricia Davies, a South African physiotherapist working in Switzerland. Where there are differences between the Bobaths and Davies, we follow Davies (Davies, 1985, 1990). Brunnstrom and NDT share the desire to overcome the limitations of the treatment programmes offered to stroke patients in the past (Gordon, 1987). Formerly, many physiotherapists directed their attention t o the weakness of the muscles of the affected side of the patients’ bodies. Their treatment was orthopaedic in that it consisted of mobilising and strengthening these weak muscles. Other therapists thought it useless t o attempt t o train the paralysed side of stroke patients, because brain cells are known for their inability to divide themselves and grow new ones
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where the old have died. The latter therapists trained patients t o get dressed, walk, eat and so on making compensatory movements with the healthy side of their body, disregarding the affected side. So, while some attempted to find an orthopaedic solution to the problems of hemiplegia patients, others intervened with functional adaptations. Brunnstrom and NDT have similar attitudes towards these predecessors. Unlike the proponents of the method of compensatory recovery, they share the orthopaedic strategist’s belief that it is worth while to train the paralysed side of a stroke patient’s body. Dead neurones cannot be replaced, but living ones may slightly change their function. Brunnstrom and NDT, however, do not agree with the orthopaedic appraisal of patients’ problems as a weakness of their muscles. This is because stroke patients are often able to contract the muscles of their affected side with great strength. The problem is that these contractions bring about stereotyped mass movement patterns. Brunnstrom and NDT therefore hold that not muscle strength, but muscle co-ordination is disturbed in these patients. Both the Brunnstrom and NDT programmes show a shift in focus from isolated muscles to movement patterns. They disagree however in the assessment of what is wrong with these patterns in hemiplegic patients. According to Brunnstrom, the stereotyped movement patterns of hemiplegic patients are primitive; but according to NDT they are pathological (Lettinga, 1989). These different terms are linked with different practices. For Brunnstrom, the stereotyped movements of stroke patients are an initial, necessary step towards recovery and should be encouraged in therapy. NDT, on the other hand, employs another method to help patients move again and does all it can to prevent patients from getting used t o the pathological movements. The two programmes deal with the stereotyped movement patterns of stroke patients in opposed ways and each have their own neurological rationale. Brunnstrom’s assessment of the stereotyped movements as ‘primitive’ is related to the neurological theory that in the course of evolution higher, more developed parts of the nervous system gained control over lower, more primitive parts. Because some of this modulation is lost in stroke patients, old (primitive) movement patterns emerge. ‘The basic limb synergies of hemiplegic patients are primitive spinal cord patterns which have been retained throughout the evolutionary process. In normal man, these spinal cord patterns are modified in a multitude of ways and their components rearranged through the influence of higher centres. But during the
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spastic stage of hemiplegia they retain their primitive stereotyped character’ (Brunnstrom, 1970, page 3; Sawner and LaVigne, 1992, page 3). In accordance with this line of thought, a Brunnstrom therapist starts her treatment by reflexively invoking the stereotyped movements. ‘Far from preventing further improvement, the synergies appear t o constitute a necessary intermediate stage for further recovery’ (Brunnstrom, 1970, page 4;Sawner and LaVigne, 1992, page 4). When patients are able t o control the synergies, they learn how to make more developed, dissociated movements. The aim of this treatment is to teach patients to exert control over isolated joint movements. According to Brunnstrom it is a natural process that basic synergy patterns develop into more dissociated motor behaviour. The therapists’ task is to facilitate this process. NDT has a different neurological story. It does not
accentuate the biological evolution of the nervous system of the human species, but the lifelong development of the individual neurosystem of each person. In this light, hemiplegia is not seen as a relapse in history, but as the partial damage of a fully grown neurosystem. During the years preceding the accident causing their hemiplegia, patients build up a repertoire of specific movements. These movements are inscribed in the pathways of their neurosystem. After an accident, some of these pathways may still exist. Thus: ‘In the treatment of severely affected patients in particular, the first priority is t o find function circuits that are still intact though at the time not able to be used, and to unblock them by confrontation with suitable material. The activities and objects used are those with which the patient was familiar in his daily life before his illness, because the chance of recognition and recall will then be facilitated during the stage of post-stroke or posttraumatic amnesia’ (Davies, 1985, page 1x1. Where Brunnstrom’s therapy starts with primitive movements, NDT’s starts with normal actions, because the necessary neurological repertoire may still be hidden somewhere inside the body. The appreciation of the nervous system as a flexible network of pathways also gives NDT a reason not t o welcome stereotyped movements as steps towards recovery, but t o try t o prevent them. If stroke patients move in stereotyped synergies they will become used t o the wrong movements, which will become inscribed in the pathways of their neurosystem, since the more a pathway is used, the easier it becomes to use it. If the synergies are not prevented, they may become irreversible. In Davies’ words: ‘If the patient only moves in stereotyped mass movement synergies, he will learn only these, to the exclusion of more defined and selective movements. Abnormal
movements reinforce the spasticity, which increases as a result. The treatment should aim at helping the patient t o move in the most normal and economic way possible right from the beginning, so avoiding his learning abnormal movement patterns through constant repetition’ (Davies, 1985, page 42). The Brunnstrom and NDT programmes have different approaches towards stroke patients. The goal of the Brunnstrom programme is t o teach them t o overcome the primitiveness of their involuntary stereotyped movements by means of superimposed modulation. The NDT programme aims t o stimulate a re-activation of old habits and a careful performance of daily actions, and focuses on avoiding pathological movements so that only normal pathways are created in the nervous system. The two treatment programmes deal with the stereotyped movement patterns of stroke patients in opposed ways. Both therapies are perfectly capable of underpining their strategies with neurologic rationales. Neither is more or less biomedical o r physical than the other, yet they differ enormously.
Motivation or Organisation Brunnstrom and NDT therapists discuss the stereotyped movement patterns of stroke patients in different terms. The way in which they deal with these movement patterns differs even more dramatically in practice. The differences between the objects and objectives of their therapies go on from there (Lettinga, 1991). Brunnstrom’s primary concern is t o improve a patient’s movements. For this purpose, movements have to be brought under voluntary control. ‘If the normal person is told not to move the limb, he can easily control it. But the patient with’hemiplegia cannot always prevent the movement and [he] frequently declares that the limb moved “all by itself” ’ (Brunnstrom, 1970, page 26; Sawner and LaVigne, 1992, page 31). Step-by-step this independent behaviour of the limbs must be put t o an end. After a therapist has for some time induced the stereotyped synergies by provoking the appropriate reflexes, the patient must learn to evoke these reflexes himself and to combine them with voluntary impulses. ‘Semi-voluntary movements may then materialise from an interaction of reflex and voluntary impulses, and the patient experiences the sensation and satisfaction that accompanies a voluntary muscular contraction’ (Brunnstrom, 1970, page 66; Sawner and LaVigne, 1992, page 82). After the semi-voluntary state, the aim is t o attain voluntary movements so that in .the end, the patient should be able t o perform every possible movement at will. Often this stage of
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recovery will never be reached. But so long as improvement can be expected, a Brunnstrom therapist sees it as her task to motivate the patient to keep on trying. In order to do this, she introduces functional activities in the therapy. According to Brunnstrom this should happen early: ‘As soon as feasible, functional activities are stressed. Successful completion of such activities gives a boost to the patient’s motivation; establishing a purpose for a movement helps in developing the required co-ordination; and contact with a body part where sensation is intact no doubt is instrumental in guiding the hand to its destination. A piece of bread is placed in the patient’s hand and he is encouraged to bring it to his mouth‘ (Brunnstrom, 1970, page 75; Sawner and LaVigne, 1992, page 103).
For Brunnstrom, the introduction of daily activities in the therapy is a means to motivate a patient to learn to control the movements of his unwilling body. The patient may even try t o master his basic limb synergies so as t o use them for practical purposes. With these primitive movements a patient may stabilise objects in order to assist the unaffected hand in activities such as writing a letter or opening an envelope. According to Brunnstrom, ‘the training sessions must be planned in such a manner that only [those] tasks which the patient can master, or almost master, will be demanded [of him]’ (Brunnstrom, 1970, page 57; Sawner and LaVigne, 1992, page 67). Success is an important reward, because it maintains interest and boosts motivation. During the training sessions, therefore, a tacit partnership between instructor and patient has to develop. The primary concern within an NDT therapy is not the body’s movements, but rather the normal performance of daily activities. ‘All activities of daily living should be performed in such a way that associated reactions are avoided. The movements should be as economic and normal as possible, and the correct postures encouraged. ... They must become a part of the patient’s repertoire through repeated experience, so that he reproduces them in any situation when they are required, and not only in the presence of the therapist’ (Davies, 1985, page 172). Thus, in an NDT therapy, all kinds of daily activities such as dressing, washing and eating are trained. For some of the activities a patient used t o perform before his accident, the necessary pathways may still be - partly - there and can be unblocked. For others, new pathways have to be created. In both cases the patient is first encouraged t o perform activities with guidance of a therapist’s hands. By following this procedure, the patient is expected eventually to be able to make normal movements automatically.
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As an NDT therapist, at some point, hands a patient a slice of bread and encourages him to eat it, the act of eating is not a way t o motivate the patient; being able to eat normally is a direct aim of the therapy. In a more general way, NDT lacks Brunnstrom’s concern with ‘motivation’. If a patient does not perform a requested activity, an NDT therapist does not begin by doubting his will, but by doubting his ability. The question is whether the patient is capable of managing the required action. Therapists learn that a patient who fails to put on his shoes should not erroneously be called ‘unmotivated’. ‘It is important t o understand the complex requirements for carrying out such tasks and understand why the patient is unable to manage by himself. For the patient there is a huge step between the recognition level, for example putting on the shoe handed to him by the therapist, and producing the whole sequence on his own when he dresses in the morning’ (Davies, 1985, page 56). By practising daily activities, integrating and organising abilities are trained and hopefully inscribed in the patient’s body as well. ‘In daily activities the patient can learn to plan, move and perceive’ (Davies, 1985, page 172). If a patient’s organising abilities fail, the therapist should either continue t o be the patient’s guide, until the required activity has become a habit, or help him t o find a n alternative, less complex way to manage his tasks.
Independent or Embedded Body Brunnstrom and NDT deal with the body differently, or, t o put it more strongly, they deal with different bodies. The first is one that moves if it is under control, the second is one that acts if it is able to plan its actions. Accordingly, each of these bodies is situated in quite a different space. Brunnstrom describes moving bodies in terms of the flexions, extensions, abductions, adductions, endo-rotations and exo-rotations their various limbs can make. These movements are located in a n anatomical space which has a sagittal, a frontal and a transversal plane, and frontal, sagittal and longitudinal axes. The depiction of this space makes it possible for a Brunnstrom therapist to describe a patient’s movements in a standardised way (‘ante-flexion of left arm in sagittal plane’), which greatly facilitates the contact with colleagues in other towns or even other countries. Brunnstrom’s localisation of the body in a kinetic box makes it ‘universal’, the same for all therapists, whether they work in the Netherlands or in the United Kingdom. While Brunnstrom situates the body in an anatomical space, it performs its therapy in the gymnasium. This gymnasium has all the equip-
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ment to enable a patient’s body t o make the required movements: there are dynamometers to help trigger his reflexes and mats to lie down on when flexing and extending his legs. There are also balls to train a patient’s ability to grasp and a mirror for him to observe himself while walking. But there is no material to support the training of everyday activities apart from grasping and walking. With all his separate movements under control, the patient is supposed to be able to control them once he is back home. Therapists confine themselves to the gymnasium, the will of the patient has to reign in the outside world. The space in which an NDT therapist has to work is both more local and further extended. Since the focus within a n NDT therapy is not primarily on the movements but on the activity of the body, its problem is not whether someone can or cannot flex his arm in a sagittal plane. The NDT question is whether a patient is able to turn in his bed and sit up over the hemiplegic side, whether he can put his clothes on in a normal and efficient way, or whether everything gets mixed up so that he cannot complete the task at all. NDT’s space is wherever the action is and it includes such heterogeneous elements as beds, socks, routines, meanings and hands. But, although i t is everywhere, this space is not universal, but locally specific. For it should be of crucial importance to an NDT therapist that a hospital differs from a restaurant, that the places where a Dutch man moves, are not the same as those of a n English woman. The embeddedness of physical actions in their surroundings implies that a good NDT therapist should not confine herself to the gymnasium. ‘Apart from caring for or treating the patient in the hospital or rehabilitation centre, it is important to see how he manages in the world outside, with all its variety and challenge. I t is part of rehabilitation t o observe the patient in as many and as various situations as possible’ (Davies, 1985, page XIIV). Thus if a patient is able to walk in the gymnasium, an NDT therapist should take him out for a walk in town, which is an altogether different activity since there might be cars or lamp-posts to avoid and sidewalks or kerbs to negotiate. The aim of NDT is for the patient t o learn to react to his surroundings and incorporate them. An NDT therapy is not confined to the gymnasium, but to go ‘everywhere’ in one or two hours therapy is not enough. Since every daily activity is important to it, NDT requires far more time than the therapy session. ‘No matter how good the therapy, if during the rest of the time the patient moves with effort in abnormal patterns of movement, sp’asticity will increase and most of what he
achieves during therapy will be lost and not carried over into his daily life. Rehabilitation should therefore be regarded as a 24-hour management or way of life’ (Davies, 1985, page 57). To attain the 24-hour management required, everybody around must submit to NDT. Instead of the international body of physiotherapists, the colleagues in the local hospital or rehabilitation centre are called upon. ‘During the period when the patient is learning how to perform the activities of daily living in a correct and therapeutic way, it is important that all who assist him follow the same procedure. It is confusing when different members of the team give conflicting assistance or advice’ (Davies, 1985, page 188).For NDT, rehabilitation is a way of life. That implies that all health care workers nurses, occupational therapists, speech trainers, etc - and even family and friends have to cooperate and act along with NDT’s guidance. The Brunnstrom approach takes the organisation of co-operation between health care workers differently. Here, the tasks are divided up among the different workers. Instead of asking everyone to act along the same lines, the tasks are distinguished by allowing each discipline jurisdiction over their own domain. A physiotherapist working with the Brunnstrum approach stays in the gymnasium. She knows t h a t the nurses in the wards take care of the patient’s day-to-day needs. And if a patient wants to try two-handed activities or adaptations in the house the supervision of the occupational therapist is available. When the patient is depressed or confused, Brunnstrom’s ideal hospital has psychologists t o call upon. Thus, the task of a Brunnstrom physical therapist is an exclusively physical one: she tries to improve a patient’s control over the movements of his body. She tries to turn the patient into an independent mover.
The Difference It Makes Brunnstrom refers to a neurology that takes the neurosystem as layered. Her favourite conception of the body is evolutionary. A therapy must sustain the evolutionary younger parts of a stroke patient’s nervous system in a n effort t o regain control over the older parts. Davies’ neurology appreciates the nervous system as a network of pathways that become easier to use as they are used more often. During therapy, pathways that have not been totally devasted by the cerebrovascular accident must be reopened and new pathways must be made by training daily activities. In Davies’ favourite model of the body, the nervous system is a plastic organisation. Brunnstrom’s neurology differs from that of Davies. They are both equally physical, but they
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deal with different bodies. Differences regarding the patient’s perspective, psyche and social environment are connected to this. Brunnstrom leaves the patient’s perspective outside the therapy, Davies draws it in. Of course a Brunnstrom therapist may ask her patients how they feel about their lives, their impairment or simply their morning’s breakfast. But she does not need t o know the patient’s view in order t o perform her task, which is defined as improving the movements a patient makes by bringing them under his voluntary control. The voluntary control itself is beyond the therapy, it is supposed to be there and ready to command the body as soon as it obeys again. For NDT this is different. An NDT therapist cannot overlook the patient’s perspective; if she does, that immediately turns her into a bad professional. In choosing the best exercises, the question of what a patient wants to but cannot do, or does without wanting to, must constantly be raised. An NDT therapist has to ask and observe what kind of problems a patient is faced with when he puts on his shoes or eats in a restaurant. Those are the kinds of problems the treatment programme has to tune into. Where Brunnstrom’s ideal is to make the body compliant so that the will can take over, Davies wants the patient’s organising abilities to become inscribed into his nervous system so that the body can sustain itself in its surroundings. This does not mean Brunnstrom is physically reductionist while Davies is holistic. The difference is more interesting: Brunnstrom and Davies attribute a different substance to the psyche. What Brunnstrom leaves untouched by physiotherapy is the latest evolutionary advance: the will. This is in line with Brunnstrom’s concern to motivate patients. If Brunnstrom therapists try t o give the patient meaningful exercises, this is in order to motivate them and strengthen their will. The psyche Davies addresses in NDT therapy is not a will, but a series of perceptual and cognitive capabilities. If an NDT-therapist wants a patient to become capable of handling his changed body in new environments, she must attend t o the patient’s awareness of his own body, his capability to get an overview of a situation and t o plan his actions. Where such capabilities are lacking, habits might help a patient still t o perform daily activities. For training may help t o instil integrating and organising abilities as well as movements learned under the guiding hands of the therapists, into the nerves of the body. The different neurologies that Brunnstrom and Davies draw upon accord different places to the patients’ perspective and a different substance
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to their psyche. They also bring along a different relation to their patients’ social and material surroundings (see also Mol and Lettinga, 1992). For a Brunnstrom therapist, a patient’s surroundings pose no problem. A Brunnstrom diagnosis can be made by assessing movements and the subsequent physiotherapy can confine itself to training these. Of course a Brunnstrom therapist may ask her patients if they live at ground level or on the fifth floor, how they used to earn a living and if they like music, but none of this is essential to the therapy. Brunnstrom’s implicit sociology is that a patient’s surroundings are the setting in which he moves as a free individual. The setting is not of much further concern to the physiotherapist. The physiotherapist’s task is to improve the patient’s physical capabilities so much that he becomes a free-moving individual again. In so far as this goal cannot be reached, and the surroundings have t o be adapted, this is a task for an occupational therapist.
Fo r an NDT therapist, however, knowledge of a patient’s habits and surroundings is crucial to the therapy. If someone never made tea or played football in his entire life, it is a bad idea to start to train these activities once he is hemiplegic. If, on the other hand, a patient loved to eat in restaurants i t is worth while t o train him t o eat properly. This implies that the therapist should not only assess and train the patient’s facial movements, but also that she must know what ‘eating properly’ consists of in the patient’s favourite restaurants; and that she is prepared t o delve into the problems the patient may be confronted with when his favourite restaurant is crowded.
For Brunnstrom, training a body and adapting its surroundings may both be important, but they are separate activities. Davies does not distinguish between physical, psychological and social interventions. Davies focuses on activities. This implies that NDT therapists may go everywhere and interfere in everything. All members of the rehabilitation team are urged to use similar strategies and techniques as patients have t o be trained in a variety of settings. Thus even the attitude of therapists of both schools towards their colleagues is linked up with the different parts of neurology they mobilise while discussing the body.
Conclusion and Discussion Theorists influenced by system theory or phenomenology criticise traditional physiotherapy for being too biomedical, for dealing only with bodies and neglecting the human extra. They praise physiotherapy for what it achieves, but say that it is not enough. They are in favour of supple-
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menting psychosocial knowledge or the patient’s perspective to what is already known. But they do not investigate ‘what is already known’. They do not ‘open up’ the physiotherapy programmes currently in use by comparing the biomedical knowledge they incorporate. We argue that this neglect is a mistake, because different ways to attend to bodies are not neutral with regard to the attention the patient’s perspective and his psychosocial reality may receive. We illustrated this with the example of Brunnstrom and NDT.
(1997). Each programme might not only contain a somatology, but a psychology and a sociology as well. If we are t o work on improvement of physiotherapy, it is important that all the somato-psycho-sociologies that different programmes contain are made explicit. Once these are out in the open, it will be easier t o identify their shortcomings and discuss the possibilities for improvement. Acknowledgment We wish to thank Sarah Lewis for correcting our English.
Neither of the two therapies is any more biomedical than the other. It is not the amount of biomedical reasoning, but its content that differs. Brunnstrom orders the movement problems of stroke patients along the axis primitive/developed, the NDT divides them between pathological and normal. That means that while both Brunnstrom and NDT train movements, they train different movements and they do so with different purposes. Brunnstrom trains movements in order to enable the will to exert control over the body again, NDT facilitates normal movement patterns and activities so that after a while, the body can automatically act again. Brunnstrom tries t o motivate the patient t o bring his movements under control, NDT hopes that the guiding hands of the therapist inscribes a patient’s ‘organising capabilities’ in his body’s repertoire. Brunnstrom silently assumes a n obeying body t o be able t o move in every setting, NDT specifies where activities take place and what demands and supports these surroundings contain. Brunnstrom, finally, takes a multi-disciplinary approach, while NDT requires inter-disciplinary co-operation. These differences make ‘the Brunnstrom uersus NDT case’ a good support for our claim that analysing the contents of treatment programmes, and differentiating between biomedical approaches, is a necessary strategy for critical theorists of physiotherapy. Simply adding on quantitative or qualitative psychological and sociological elements to existing programmes will not work. For the attempt to add a ‘human’ extra to an unknown, unanalysed black box ‘physiotherapy’ fails t o take into account whether or not such an addition is possible in each specific case. Addition may be doomed t o fail if it leads t o twisting internal contradictions. This implies that there is a lot of analytical work t o do, and since actual practices seldom live up t o the textbook, it is important t o complement text analysis with ethnographic observations and interviews. The Brunnstrom uersus NDT case is only one example. But there are of course many more treatment programmes that may be analysed along similar lines as the ones we set out here (see for another example Lettinga and Siemonsma
Authors A T Lettinga MA PT is a lecturer and researcher in the School of Physiotherapy/Department of Human Movement Sciences, and P Rispens PhD MD is professor of human movement sciences at the University of Groningen, The Netherlands.They are currently engaged in a comparative study of NDT and motor re-learning programmes. A Mol PhD MA is professor of philosophy at the University of Twente, Enschede, The Netherlands.
P M J Helders PhD MSc PTis professor of physiotherapy at the University of Utrecht and head of the Department of Physiotherapy, Utrecht University Hospitals. This article was received on August 21, 1996, and accepted on May 19, 1997.
References Bobath, B (1970, second edition 1978, third edition, 1990). Adult Hemiplegia: Evaluation and treatment, William Heinemann Medical Books, London. Brunnstrom, S (1970). Movement Therapy in Herniplegia: A neurophysiological approach, Harper and Row, Hagerstown. Callon, M and Law, J (1989). ‘On the construction of sociotechnical networks: Content and context revisited’, Knowledge and Society, 9, 57-83. Cambell, S K (1983). Commentary on ‘Measurement validity in physical therapy research’, Physical Therapy, 73, 2, 110-1 12. Canguilhem, G (1995). La Formation du Conceptde Reflexe aux XVlle and XVllle Siecles, Vrin, Paris. Cauguilhern, G (1978). On the Normal and the Pathological, D Reidel Publishing Company, Inc (originally published (1943) as: Le Normal et le Bathologique, Presses Universitaires de France, Paris, in 1966 extended with ‘Nouvelles reflexions sur le normal et le pathologique’). Davies, P (1985). Steps to Follow: A guide to the treatment of adult hemiplegia, Springer Verlag, Berlin. Davies, P M (1990). Right in the Middle: Selective trunk activity in the treatment of adult hemiplegia, Springer Verlag, Berlin. Dean, E (1985). ‘Psychobiological adaptation model for physical therapy, Physical Therapy, 65,7, 1061-68. Engel, G L (1981). ‘The clinical application of the biopsychosocial model’, Journal of Medicine and Philosophy, 6,101-1 24. Foucault, M (1975). The Birth of the Clinic: An archaeology of medical perception, Vintage Books Edition, New York (originally published (1963) as: La Naissance de la Clinique, Presses Universitaires de France, Paris). Foucault, M (1976). De Orde van het Vertoog, Broom, Meppel (originally published (1971) as: L’ordre deu Discours, Gallimard, Paris). Gordon, J (1987). ‘Assumptions underlying physical therapy intervention: Theoretical and historical perspectives’, in: Carr, J H and Shepherd, R B (eds) Movement Science: Foundation for physical therapy in rehabilitation, Heinemann, London. Johnson, R (1993). ‘Attitudes don’t just hang in the air. . . Disabled people’s perceptions of physiotherapists’, Physiotherapy, 79, 9, 619-627.
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Latour, B (1987). Science in Action: How to follow scientists and engineers through society, Open University Press, Milton Keynes. Latour, B (1989). The Pasteurization of France, Harvard University Press, Cambridge, Massachusetts and London, England (originally published (1984) as Les Microbes, Metaille, Paris). Lettinga, A T (1989). ‘Diversiteit in de fysiotherapie: Een conceptueleanalyse van de BrunnstromlNDT controverse (Diversity within physical therapy: A conceptual analysis of the BrunnstromlNDTcontroversy)’, Nederlands Tijdschriff Fysiotherapie, 99, 718, 200-206. Lettinga, A T (1991). ‘Divergentie in de fysiotherapie en de consequenties voor effect-onderzoek: De Brunnstrom- en NDT-methode vergelijkenderwijs (Divergence in physical therapy and the consequences for evaluation research: Comparing the Brunnstrom- and NDT-method)’, Nederlands Tijdschrift fysiotherapie, 101, 718, 163-1 68.. Lettinga, AT and Siemonsma, P (1997). ‘Leren van verschil: Neuro Developmental Treatment en Motor Relearning Progreamme geanalyseerd (Learning from Differences: An analysis of NDT and MRP)’, Nederlands Tijdschriff fysiotherapie, 107, 2 , 4 3 4 9 . Mattingly, C (1993). Commentary on: ‘Alternative approaches to research in physical therapy’, Physical Therapy,73,2, 98-101.
Mol, A (1993). ‘What is new? Doppler and its others: An empirical philosophyof innovations’in: Lowy, I, (ed) Medicine and Change: Historical and sociological studies of medical innovation, INSERM, Paris. Mot, A and Berg, M (1994). ‘Principles and practices of medicine: The co-existence of various anomies’, Medicine and Psychiatw, 18,247-265. Mol, A and Law, J (1994). ‘Regions, networks and fluids: Anaemia and social topology’, Social Studies of Science, 24, 641-671. Mol, A and Lettinga, A T (1992). ‘Bodies, impairments and the social construct: The case of hemiplegia’, in: Lachmund, J and Stollberg, G (eds) The Social Construction of Illness: Illness and medical knowledge in past and present, Franz Steiner Verlag, Stuttgatt, pages 163-1 77. Mot, A and Mesman, J (1996). ‘Neonatal food and the politics of theory: Some questions of method, Social Studies of Science, 26,419-444. Sawner, K and LaVigne, J (1992). Brunnstrom’s Movement Therapy in Hemiplegia: A neurophysiological approach, Lippincott, Philadelphia,2nd edn. Shepard, K F, Jensen, G M, Schmoll, B J, Hack, L M and Gwywer, J (1993). ‘Alternative approaches to research in physical therapy’, Physical Therapy, 73,2, 88-97.
Horns and dilemmas: Scientific and clinical editor’s commentary This article was both unusual and difficult to review, primarily because of the analysis technique used by the authors and partly because it contrasted ‘Bobath’ with ‘Brunnstrom’ which is peripheral to the practice and thinking of British physiotherapists rather than with ‘motor learning’ (on which the authors are currently engaged) which would be more pertinent to a UK-centred audience. Although both referees were neurological researchers, neither claimed to be familiar with the analysis technique. While one considered that some readers might find the ‘Methods’ section irrelevant, even off-putting, the other found that it was an interesting and enlightening way of juxtaposing two approaches to neurological rehabilitation, but was unable to decide the extent to which the findings commented faithfully on the two approaches. I was left on the horns of the classic editor’s dilemma: unwilling to alienate some readers but recognising an article that should stimulate thinking and encourage debate. One solution was two separate articles, a scholarly paper on discourse analysis and a research report on its application. However, the theoretical introduction to the article is so closely connected to the empirical case which serves as an illustrative example that separating the interesting interpretation would deprive the analysis of its meaning and its function.
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I recognisethat readers who are not familiar with the qualitative/quantitativedebate in research and reductionism in physiotherapy might find the ‘Methods’ section difficult to follow. However, this debate has profound implicationsfor clinical practice as well as research in the ‘black box’ of physiotherapy. One difficulty in getting to grips with discourse and actor network theory analysis is that it is not really a methodology or a technique. Its influential theorists, Michel Foucault and Bruno Latour, do not offer a methodology which researchers can apply in a straightforward way to their objects of study. Rather, they illustrate their theoretical points with detailed empirical case studies. Discourse analysis, therefore, provides insights and rationales about science, society, language and activities which influence style of working. In comparison, theoretical debates presented in a traditional format are very abstract and hinder thinking about physiotherapy because they are not anchored in clinical reality. Hopefully, the style of empirical philosophy utilised in the article is more attractive and meaningful to practitioners than traditional approaches and, therefore, is fruitful in drawing physiotherapists other than those undertaking or supervising PhD research into theoretical discussions.
SCHOLARLY PAPER
Differentiation as a Qualitative Research Strategy A comparative analysis of Bobath and Brunnstrom approaches to treatment of stroke patients A T Lettinga P J M,_Helders
A Mol P Rispens
Key Words Content analysis, stroke patients, neurodevelopmental treatment, Brunnstrom approach, quantitative method, qualitative method, system theory, phenomenology.
Summary Conventional physiotherapy and research are currently criticised for being too biomedical and physical in their orientation. Researchers influenced by system theory on the one hand and phenomenology on the other stress that patients are not just isolated bodies. They therefore propose the addition of psychosocia1 knowledge and attentivenessto the perspectiveof the patient. This strategy of adding on ‘human’ factors to physiotherapydoes not suffice when it comes to the question of integrating these different fields of knowledge. In this article an alternative strategy is introduced: ‘differentiation’. It is argued that co-existing treatment programmes in physiotherapy differ in the ways they give place and shape to a patient‘s humanness. The content of these programmes therefore needs to be further analysed. To illustrate this, we present an example of an analysis of two competing programmes for the rehabilitation of stroke patients. The conclusion is that these programmes not only deal with the body differently, but thereby also approach psycho-socialaspects in different ways.
Introduction Theorists of physiotherapy tend to criticise the one-sidedness of its treatment programmes and research methods. They give, however, different characterisations of this one-sidedness. In one tradition conventional physiotherapy is accused of focusing exclusively on the patients’ bodies, while neglecting psychic and social knowledge. Instead of borrowing only from biomedical disciplines like anatomy and physiology, physiotherapy should also draw upon knowledge that comes from the departments of psychology and sociology (Engel, 1981; Dean, 1985; Cambell, 1993). I n a second critical tradition, therapists and researchers are encouraged to focus on the patients’ perspective (Shepard et al, 1993; Mattingly, 1993; Johnson, 1993) rather than t o enlarge their object-scope so as to encompass psychological and sociological knowledge. I n this tradition, it is argued that patients are often treated and studied as if they were ‘mere’objects. Professionals are accused
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of forgetting the fact that patients are subjects as well. Instead of only relying upon their own professional eyes, they should also pay attention to what is seen by other eyes: those of the patients.
A good example of the first tradition is the work of Dean (1985), who argues t h a t physiotherapy should attend to psychosocial factors such as the patients’ lifestyle, their stress management style, their occupation and environment, and their social attributes. In order t o reach a n optimal treatment outcome, Dean wants us to use a ‘psychobiological adaptation model’. He is in favour of assessing treatment outcomes with valid and reliable quantitative measurements that take psychosocial dimensions into account. Cambell (1993)elaborates on this, working on a framework for describing and studying the disabling process ‘that systematically relates measures and outcomes at different levels of human functioning, from the cellular t o the societal’. Scholars of the second tradition consider the quantitative research methods recommended by people like Dean and Cambell t o be too limited. They may enlarge the object-scope of physical therapy, but cannot grasp the patients’ subjectivity. Measuring and counting may yield useful information, but they are insufficient instruments when it comes to gathering data about the way people experience the world in which they live. In order to gather this kind of data, and to study the meanings that participants attribute to their circumstances and the multiple realities in which they live, people like Shepard and co-authors propose supplementing quantitative methods by qualitative methods (Shepard et al, 1993). As Mattingly (1993) puts it in a commentary accompanying their writing: ‘But if treatment is treating a life, so to speak, then it is important to do research that illuminates the phenomenological aspects of treatment, that investigates the meaning of disability and treatment from the perspectives of all key actors: therapist, client, family members, professional colleagues, even institutional contexts.’ So there are two differing critical traditions. The proponents of the first tradition aim to enlarge the scope of physiotherapy by including psychological
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and sociological knowledge, while proponents of the second tradition try t o explore ways to gain knowledge of participants’ experiences and perceptions. The first tradition is inspired by system theory and expects more from quantitative methods, the second has its roots in phenomenology and works with qualitative methods. At the same time, however, the two traditions share a common concern, both attempting t o add on something ‘human’ to conventional physiotherapy and research. Although the first one wants t o supplement another object and the second another perspective, they share the strategy of addition. The difficulty with this strategy is that it leaves the physical core of physiotherapy untouched. Biomedical knowledge and physical techniques are seen as in need of supplementation by something else, not as something requiring any further analysis itself, This is where we disagree and would like to propose a n alternative strategy: differentiation. Instead of trying to add on something human to currently existing treatment programmes, we first want t o examine their content further by analysing the place and the shape of ‘the human’ within these programmes. What kind of body, and with that, what kind of psychic and social realities are pre-supposed, or implicated, in current physiotherapy? Our starting point for these questions is the plurality of physiotherapy. Co-existing treatment programmes, we will show, do not necessarily share the same physical cores. Our claim is that these treatment programmes deal with bodies in different ways, each relating differently t o the patients’ psyche, social environment and perspective. In order t o illustrate this claim we will present a comparative analysis of two competing treatment programmes for stroke patients: the Brunnstrom approach (Brunnstrom, 1970; Sawner and LaVigne, 1992) and neuro-developmental treatment (NDT) (Bobath, 1970, 1978, 1990; Davies, 1985, 1990).
Method Our work draws upon discourse analysis (Foucault, 1975,1976; Canguilhem, 1955, 1978) and actor-network theory (Latour, 1987,1989; Callon and Law, 1989). Unlike system theory these traditions do not take behaviour as their point of departure. They differ from phenomenology in t h a t they do not start from humans and the way they attribute meaning t o their experiences. Instead, their primary object of investigation is the way the elements of a theoretical ‘discourse’ o r of a technical ‘network’ co-constitute each other. Whereas most researchers in this tradition have a philosoph-
ical or a sociological agenda, we work towards the implications our analysis may hold for clinical practice and research in physiotherapy. Both discourse analysis and actor-network theory have their background in semiotics, the study of signs and symbols in language. In semiotics the words of a language are regarded as linguistic tools, actively ordering objects and events in specific ways, rather than as labels representing objects in the world as the positivistic tradition would have it. Semioticians set themselves the task to unravel this ordering activity. Such a n unravelling cannot be done word by word, as if each word exists in isolation. Since languages are appreciated as a network of related signs that give each other meaning, they form the unities of analysis. In a language each single element literally informs the others. Within most types of discourse analysis and all of actor-network theory, however, language itself is in turn seen as being embedded in practices (Foucault, 1975; Latour, 1989; Callon and Law, 1989; Mol, 1993; Mol and Berg, 1994; Mol and Law, 1994; Mol and Mesman, 1996). Reality does not exist solely out of co-constituting words. Words do not only inform each other, they a r e part and parcel of a reality in which they are used and accepted as meaningful. A language comes to be expressed under certain practical conditions. The semioticians by whom we are influenced analyse languages and practices as being closely intertwined. This theoretical framework we use in our analysis of the Brunnstrom and NDT programmes involving a mixture of qualitative research techniques. The Brunnstrom - and NDT - textbooks were the primary source in the unravelling of languages and practices of both programmes. We are also presently engaged in fieldwork, doing ethnographic observations and taking interviews. In this article we use only material gathered with text analysis. That is a matter of argumentive economy and reducing complexity. Contrasting quotes are enough to support our claim that the authors of the Brunnstrom and NDT textbooks articulate the problems of stroke patients differently and order physiotherapy in different ways. Our method consists of treating the Brunnstrom and NDT programmes as if they were ‘languages’. Each treatment programme has a vocabulary of its own in which movement problems, techniques and goals that are discussed are ordered in a specific way. We started out by analysing these biomedical vocabularies, using the contrast between them as a way to reveal their different self-evidences (Lettinga, 1989, 1991). For this article we also analysed the
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psycho-social terminologies, interventions and routines that are intertwined with these programmes. Of course it would also be possible t o contrast Brunnstrom and NDT texts as if they contain different statements about how to treat stroke patients. The validity of each of these statements could then be tested. That, however, is not the object of our inquiry. What interests us here is something else, namely how Brunnstrom and NDT cast a different image of what a stroke patient is. Are the movements of a stroke patient’s affected half ‘primitive’ or ‘pathological’?Should such a patient learn to avoid or to use these movements? Should he be ‘motivated’ to put his shoes on, o r does this require a set of ‘organising abilities’? What kind of body do Brunnstrom and NDT therapists respectively treat, and what kind of human does their language allow them to talk about?
Primitive or Pathological Patients who have undergone a serious stroke may have become hemiplegic, that is incapable of moving one side of their body. In physiotherapy, two conflicting programmes for the treatment of such patients co-exist. One is known by the name of its designer, Signe Brunnstrom, a Swedish physiotherapist who worked in the USA (Brunnstrom, 1970). In 1992 Brunnnstrom’s book was revised by Kathryn Sawner and Jeanne LaVigne (Sawner amd LaVigne, 1992), who have attempted t o preserve the original ideas and approaches of Brunnstrom. The name of the other programme is an acronym of its enterprise, NDT (neuro-developmental treatment). NDT was first designed by Berta Bobath, a physiotherapist, and Karl Bobath, her husband and a neurologist by training, who both came from Germany and worked in Britain (Bobath, 1990). This treatment programme was later refined by Patricia Davies, a South African physiotherapist working in Switzerland. Where there are differences between the Bobaths and Davies, we follow Davies (Davies, 1985, 1990). Brunnstrom and NDT share the desire to overcome the limitations of the treatment programmes offered to stroke patients in the past (Gordon, 1987). Formerly, many physiotherapists directed their attention t o the weakness of the muscles of the affected side of the patients’ bodies. Their treatment was orthopaedic in that it consisted of mobilising and strengthening these weak muscles. Other therapists thought it useless t o attempt t o train the paralysed side of stroke patients, because brain cells are known for their inability to divide themselves and grow new ones
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where the old have died. The latter therapists trained patients t o get dressed, walk, eat and so on making compensatory movements with the healthy side of their body, disregarding the affected side. So, while some attempted to find an orthopaedic solution to the problems of hemiplegia patients, others intervened with functional adaptations. Brunnstrom and NDT have similar attitudes towards these predecessors. Unlike the proponents of the method of compensatory recovery, they share the orthopaedic strategist’s belief that it is worth while to train the paralysed side of a stroke patient’s body. Dead neurones cannot be replaced, but living ones may slightly change their function. Brunnstrom and NDT, however, do not agree with the orthopaedic appraisal of patients’ problems as a weakness of their muscles. This is because stroke patients are often able to contract the muscles of their affected side with great strength. The problem is that these contractions bring about stereotyped mass movement patterns. Brunnstrom and NDT therefore hold that not muscle strength, but muscle co-ordination is disturbed in these patients. Both the Brunnstrom and NDT programmes show a shift in focus from isolated muscles to movement patterns. They disagree however in the assessment of what is wrong with these patterns in hemiplegic patients. According to Brunnstrom, the stereotyped movement patterns of hemiplegic patients are primitive; but according to NDT they are pathological (Lettinga, 1989). These different terms are linked with different practices. For Brunnstrom, the stereotyped movements of stroke patients are an initial, necessary step towards recovery and should be encouraged in therapy. NDT, on the other hand, employs another method to help patients move again and does all it can to prevent patients from getting used t o the pathological movements. The two programmes deal with the stereotyped movement patterns of stroke patients in opposed ways and each have their own neurological rationale. Brunnstrom’s assessment of the stereotyped movements as ‘primitive’ is related to the neurological theory that in the course of evolution higher, more developed parts of the nervous system gained control over lower, more primitive parts. Because some of this modulation is lost in stroke patients, old (primitive) movement patterns emerge. ‘The basic limb synergies of hemiplegic patients are primitive spinal cord patterns which have been retained throughout the evolutionary process. In normal man, these spinal cord patterns are modified in a multitude of ways and their components rearranged through the influence of higher centres. But during the
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spastic stage of hemiplegia they retain their primitive stereotyped character’ (Brunnstrom, 1970, page 3; Sawner and LaVigne, 1992, page 3). In accordance with this line of thought, a Brunnstrom therapist starts her treatment by reflexively invoking the stereotyped movements. ‘Far from preventing further improvement, the synergies appear t o constitute a necessary intermediate stage for further recovery’ (Brunnstrom, 1970, page 4;Sawner and LaVigne, 1992, page 4). When patients are able t o control the synergies, they learn how to make more developed, dissociated movements. The aim of this treatment is to teach patients to exert control over isolated joint movements. According to Brunnstrom it is a natural process that basic synergy patterns develop into more dissociated motor behaviour. The therapists’ task is to facilitate this process. NDT has a different neurological story. It does not
accentuate the biological evolution of the nervous system of the human species, but the lifelong development of the individual neurosystem of each person. In this light, hemiplegia is not seen as a relapse in history, but as the partial damage of a fully grown neurosystem. During the years preceding the accident causing their hemiplegia, patients build up a repertoire of specific movements. These movements are inscribed in the pathways of their neurosystem. After an accident, some of these pathways may still exist. Thus: ‘In the treatment of severely affected patients in particular, the first priority is t o find function circuits that are still intact though at the time not able to be used, and to unblock them by confrontation with suitable material. The activities and objects used are those with which the patient was familiar in his daily life before his illness, because the chance of recognition and recall will then be facilitated during the stage of post-stroke or posttraumatic amnesia’ (Davies, 1985, page 1x1. Where Brunnstrom’s therapy starts with primitive movements, NDT’s starts with normal actions, because the necessary neurological repertoire may still be hidden somewhere inside the body. The appreciation of the nervous system as a flexible network of pathways also gives NDT a reason not t o welcome stereotyped movements as steps towards recovery, but t o try t o prevent them. If stroke patients move in stereotyped synergies they will become used t o the wrong movements, which will become inscribed in the pathways of their neurosystem, since the more a pathway is used, the easier it becomes to use it. If the synergies are not prevented, they may become irreversible. In Davies’ words: ‘If the patient only moves in stereotyped mass movement synergies, he will learn only these, to the exclusion of more defined and selective movements. Abnormal
movements reinforce the spasticity, which increases as a result. The treatment should aim at helping the patient t o move in the most normal and economic way possible right from the beginning, so avoiding his learning abnormal movement patterns through constant repetition’ (Davies, 1985, page 42). The Brunnstrom and NDT programmes have different approaches towards stroke patients. The goal of the Brunnstrom programme is t o teach them t o overcome the primitiveness of their involuntary stereotyped movements by means of superimposed modulation. The NDT programme aims t o stimulate a re-activation of old habits and a careful performance of daily actions, and focuses on avoiding pathological movements so that only normal pathways are created in the nervous system. The two treatment programmes deal with the stereotyped movement patterns of stroke patients in opposed ways. Both therapies are perfectly capable of underpining their strategies with neurologic rationales. Neither is more or less biomedical o r physical than the other, yet they differ enormously.
Motivation or Organisation Brunnstrom and NDT therapists discuss the stereotyped movement patterns of stroke patients in different terms. The way in which they deal with these movement patterns differs even more dramatically in practice. The differences between the objects and objectives of their therapies go on from there (Lettinga, 1991). Brunnstrom’s primary concern is t o improve a patient’s movements. For this purpose, movements have to be brought under voluntary control. ‘If the normal person is told not to move the limb, he can easily control it. But the patient with’hemiplegia cannot always prevent the movement and [he] frequently declares that the limb moved “all by itself” ’ (Brunnstrom, 1970, page 26; Sawner and LaVigne, 1992, page 31). Step-by-step this independent behaviour of the limbs must be put t o an end. After a therapist has for some time induced the stereotyped synergies by provoking the appropriate reflexes, the patient must learn to evoke these reflexes himself and to combine them with voluntary impulses. ‘Semi-voluntary movements may then materialise from an interaction of reflex and voluntary impulses, and the patient experiences the sensation and satisfaction that accompanies a voluntary muscular contraction’ (Brunnstrom, 1970, page 66; Sawner and LaVigne, 1992, page 82). After the semi-voluntary state, the aim is t o attain voluntary movements so that in .the end, the patient should be able t o perform every possible movement at will. Often this stage of
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recovery will never be reached. But so long as improvement can be expected, a Brunnstrom therapist sees it as her task to motivate the patient to keep on trying. In order to do this, she introduces functional activities in the therapy. According to Brunnstrom this should happen early: ‘As soon as feasible, functional activities are stressed. Successful completion of such activities gives a boost to the patient’s motivation; establishing a purpose for a movement helps in developing the required co-ordination; and contact with a body part where sensation is intact no doubt is instrumental in guiding the hand to its destination. A piece of bread is placed in the patient’s hand and he is encouraged to bring it to his mouth‘ (Brunnstrom, 1970, page 75; Sawner and LaVigne, 1992, page 103).
For Brunnstrom, the introduction of daily activities in the therapy is a means to motivate a patient to learn to control the movements of his unwilling body. The patient may even try t o master his basic limb synergies so as t o use them for practical purposes. With these primitive movements a patient may stabilise objects in order to assist the unaffected hand in activities such as writing a letter or opening an envelope. According to Brunnstrom, ‘the training sessions must be planned in such a manner that only [those] tasks which the patient can master, or almost master, will be demanded [of him]’ (Brunnstrom, 1970, page 57; Sawner and LaVigne, 1992, page 67). Success is an important reward, because it maintains interest and boosts motivation. During the training sessions, therefore, a tacit partnership between instructor and patient has to develop. The primary concern within an NDT therapy is not the body’s movements, but rather the normal performance of daily activities. ‘All activities of daily living should be performed in such a way that associated reactions are avoided. The movements should be as economic and normal as possible, and the correct postures encouraged. ... They must become a part of the patient’s repertoire through repeated experience, so that he reproduces them in any situation when they are required, and not only in the presence of the therapist’ (Davies, 1985, page 172). Thus, in an NDT therapy, all kinds of daily activities such as dressing, washing and eating are trained. For some of the activities a patient used t o perform before his accident, the necessary pathways may still be - partly - there and can be unblocked. For others, new pathways have to be created. In both cases the patient is first encouraged t o perform activities with guidance of a therapist’s hands. By following this procedure, the patient is expected eventually to be able to make normal movements automatically.
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As an NDT therapist, at some point, hands a patient a slice of bread and encourages him to eat it, the act of eating is not a way t o motivate the patient; being able to eat normally is a direct aim of the therapy. In a more general way, NDT lacks Brunnstrom’s concern with ‘motivation’. If a patient does not perform a requested activity, an NDT therapist does not begin by doubting his will, but by doubting his ability. The question is whether the patient is capable of managing the required action. Therapists learn that a patient who fails to put on his shoes should not erroneously be called ‘unmotivated’. ‘It is important t o understand the complex requirements for carrying out such tasks and understand why the patient is unable to manage by himself. For the patient there is a huge step between the recognition level, for example putting on the shoe handed to him by the therapist, and producing the whole sequence on his own when he dresses in the morning’ (Davies, 1985, page 56). By practising daily activities, integrating and organising abilities are trained and hopefully inscribed in the patient’s body as well. ‘In daily activities the patient can learn to plan, move and perceive’ (Davies, 1985, page 172). If a patient’s organising abilities fail, the therapist should either continue t o be the patient’s guide, until the required activity has become a habit, or help him t o find a n alternative, less complex way to manage his tasks.
Independent or Embedded Body Brunnstrom and NDT deal with the body differently, or, t o put it more strongly, they deal with different bodies. The first is one that moves if it is under control, the second is one that acts if it is able to plan its actions. Accordingly, each of these bodies is situated in quite a different space. Brunnstrom describes moving bodies in terms of the flexions, extensions, abductions, adductions, endo-rotations and exo-rotations their various limbs can make. These movements are located in a n anatomical space which has a sagittal, a frontal and a transversal plane, and frontal, sagittal and longitudinal axes. The depiction of this space makes it possible for a Brunnstrom therapist to describe a patient’s movements in a standardised way (‘ante-flexion of left arm in sagittal plane’), which greatly facilitates the contact with colleagues in other towns or even other countries. Brunnstrom’s localisation of the body in a kinetic box makes it ‘universal’, the same for all therapists, whether they work in the Netherlands or in the United Kingdom. While Brunnstrom situates the body in an anatomical space, it performs its therapy in the gymnasium. This gymnasium has all the equip-
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ment to enable a patient’s body t o make the required movements: there are dynamometers to help trigger his reflexes and mats to lie down on when flexing and extending his legs. There are also balls to train a patient’s ability to grasp and a mirror for him to observe himself while walking. But there is no material to support the training of everyday activities apart from grasping and walking. With all his separate movements under control, the patient is supposed to be able to control them once he is back home. Therapists confine themselves to the gymnasium, the will of the patient has to reign in the outside world. The space in which an NDT therapist has to work is both more local and further extended. Since the focus within a n NDT therapy is not primarily on the movements but on the activity of the body, its problem is not whether someone can or cannot flex his arm in a sagittal plane. The NDT question is whether a patient is able to turn in his bed and sit up over the hemiplegic side, whether he can put his clothes on in a normal and efficient way, or whether everything gets mixed up so that he cannot complete the task at all. NDT’s space is wherever the action is and it includes such heterogeneous elements as beds, socks, routines, meanings and hands. But, although i t is everywhere, this space is not universal, but locally specific. For it should be of crucial importance to an NDT therapist that a hospital differs from a restaurant, that the places where a Dutch man moves, are not the same as those of a n English woman. The embeddedness of physical actions in their surroundings implies that a good NDT therapist should not confine herself to the gymnasium. ‘Apart from caring for or treating the patient in the hospital or rehabilitation centre, it is important to see how he manages in the world outside, with all its variety and challenge. I t is part of rehabilitation t o observe the patient in as many and as various situations as possible’ (Davies, 1985, page XIIV). Thus if a patient is able to walk in the gymnasium, an NDT therapist should take him out for a walk in town, which is an altogether different activity since there might be cars or lamp-posts to avoid and sidewalks or kerbs to negotiate. The aim of NDT is for the patient t o learn to react to his surroundings and incorporate them. An NDT therapy is not confined to the gymnasium, but to go ‘everywhere’ in one or two hours therapy is not enough. Since every daily activity is important to it, NDT requires far more time than the therapy session. ‘No matter how good the therapy, if during the rest of the time the patient moves with effort in abnormal patterns of movement, sp’asticity will increase and most of what he
achieves during therapy will be lost and not carried over into his daily life. Rehabilitation should therefore be regarded as a 24-hour management or way of life’ (Davies, 1985, page 57). To attain the 24-hour management required, everybody around must submit to NDT. Instead of the international body of physiotherapists, the colleagues in the local hospital or rehabilitation centre are called upon. ‘During the period when the patient is learning how to perform the activities of daily living in a correct and therapeutic way, it is important that all who assist him follow the same procedure. It is confusing when different members of the team give conflicting assistance or advice’ (Davies, 1985, page 188).For NDT, rehabilitation is a way of life. That implies that all health care workers nurses, occupational therapists, speech trainers, etc - and even family and friends have to cooperate and act along with NDT’s guidance. The Brunnstrom approach takes the organisation of co-operation between health care workers differently. Here, the tasks are divided up among the different workers. Instead of asking everyone to act along the same lines, the tasks are distinguished by allowing each discipline jurisdiction over their own domain. A physiotherapist working with the Brunnstrum approach stays in the gymnasium. She knows t h a t the nurses in the wards take care of the patient’s day-to-day needs. And if a patient wants to try two-handed activities or adaptations in the house the supervision of the occupational therapist is available. When the patient is depressed or confused, Brunnstrom’s ideal hospital has psychologists t o call upon. Thus, the task of a Brunnstrom physical therapist is an exclusively physical one: she tries to improve a patient’s control over the movements of his body. She tries to turn the patient into an independent mover.
The Difference It Makes Brunnstrom refers to a neurology that takes the neurosystem as layered. Her favourite conception of the body is evolutionary. A therapy must sustain the evolutionary younger parts of a stroke patient’s nervous system in a n effort t o regain control over the older parts. Davies’ neurology appreciates the nervous system as a network of pathways that become easier to use as they are used more often. During therapy, pathways that have not been totally devasted by the cerebrovascular accident must be reopened and new pathways must be made by training daily activities. In Davies’ favourite model of the body, the nervous system is a plastic organisation. Brunnstrom’s neurology differs from that of Davies. They are both equally physical, but they
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deal with different bodies. Differences regarding the patient’s perspective, psyche and social environment are connected to this. Brunnstrom leaves the patient’s perspective outside the therapy, Davies draws it in. Of course a Brunnstrom therapist may ask her patients how they feel about their lives, their impairment or simply their morning’s breakfast. But she does not need t o know the patient’s view in order t o perform her task, which is defined as improving the movements a patient makes by bringing them under his voluntary control. The voluntary control itself is beyond the therapy, it is supposed to be there and ready to command the body as soon as it obeys again. For NDT this is different. An NDT therapist cannot overlook the patient’s perspective; if she does, that immediately turns her into a bad professional. In choosing the best exercises, the question of what a patient wants to but cannot do, or does without wanting to, must constantly be raised. An NDT therapist has to ask and observe what kind of problems a patient is faced with when he puts on his shoes or eats in a restaurant. Those are the kinds of problems the treatment programme has to tune into. Where Brunnstrom’s ideal is to make the body compliant so that the will can take over, Davies wants the patient’s organising abilities to become inscribed into his nervous system so that the body can sustain itself in its surroundings. This does not mean Brunnstrom is physically reductionist while Davies is holistic. The difference is more interesting: Brunnstrom and Davies attribute a different substance to the psyche. What Brunnstrom leaves untouched by physiotherapy is the latest evolutionary advance: the will. This is in line with Brunnstrom’s concern to motivate patients. If Brunnstrom therapists try t o give the patient meaningful exercises, this is in order to motivate them and strengthen their will. The psyche Davies addresses in NDT therapy is not a will, but a series of perceptual and cognitive capabilities. If an NDT-therapist wants a patient to become capable of handling his changed body in new environments, she must attend t o the patient’s awareness of his own body, his capability to get an overview of a situation and t o plan his actions. Where such capabilities are lacking, habits might help a patient still t o perform daily activities. For training may help t o instil integrating and organising abilities as well as movements learned under the guiding hands of the therapists, into the nerves of the body. The different neurologies that Brunnstrom and Davies draw upon accord different places to the patients’ perspective and a different substance
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to their psyche. They also bring along a different relation to their patients’ social and material surroundings (see also Mol and Lettinga, 1992). For a Brunnstrom therapist, a patient’s surroundings pose no problem. A Brunnstrom diagnosis can be made by assessing movements and the subsequent physiotherapy can confine itself to training these. Of course a Brunnstrom therapist may ask her patients if they live at ground level or on the fifth floor, how they used to earn a living and if they like music, but none of this is essential to the therapy. Brunnstrom’s implicit sociology is that a patient’s surroundings are the setting in which he moves as a free individual. The setting is not of much further concern to the physiotherapist. The physiotherapist’s task is to improve the patient’s physical capabilities so much that he becomes a free-moving individual again. In so far as this goal cannot be reached, and the surroundings have t o be adapted, this is a task for an occupational therapist.
Fo r an NDT therapist, however, knowledge of a patient’s habits and surroundings is crucial to the therapy. If someone never made tea or played football in his entire life, it is a bad idea to start to train these activities once he is hemiplegic. If, on the other hand, a patient loved to eat in restaurants i t is worth while t o train him t o eat properly. This implies that the therapist should not only assess and train the patient’s facial movements, but also that she must know what ‘eating properly’ consists of in the patient’s favourite restaurants; and that she is prepared t o delve into the problems the patient may be confronted with when his favourite restaurant is crowded.
For Brunnstrom, training a body and adapting its surroundings may both be important, but they are separate activities. Davies does not distinguish between physical, psychological and social interventions. Davies focuses on activities. This implies that NDT therapists may go everywhere and interfere in everything. All members of the rehabilitation team are urged to use similar strategies and techniques as patients have t o be trained in a variety of settings. Thus even the attitude of therapists of both schools towards their colleagues is linked up with the different parts of neurology they mobilise while discussing the body.
Conclusion and Discussion Theorists influenced by system theory or phenomenology criticise traditional physiotherapy for being too biomedical, for dealing only with bodies and neglecting the human extra. They praise physiotherapy for what it achieves, but say that it is not enough. They are in favour of supple-
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menting psychosocial knowledge or the patient’s perspective to what is already known. But they do not investigate ‘what is already known’. They do not ‘open up’ the physiotherapy programmes currently in use by comparing the biomedical knowledge they incorporate. We argue that this neglect is a mistake, because different ways to attend to bodies are not neutral with regard to the attention the patient’s perspective and his psychosocial reality may receive. We illustrated this with the example of Brunnstrom and NDT.
(1997). Each programme might not only contain a somatology, but a psychology and a sociology as well. If we are t o work on improvement of physiotherapy, it is important that all the somato-psycho-sociologies that different programmes contain are made explicit. Once these are out in the open, it will be easier t o identify their shortcomings and discuss the possibilities for improvement. Acknowledgment We wish to thank Sarah Lewis for correcting our English.
Neither of the two therapies is any more biomedical than the other. It is not the amount of biomedical reasoning, but its content that differs. Brunnstrom orders the movement problems of stroke patients along the axis primitive/developed, the NDT divides them between pathological and normal. That means that while both Brunnstrom and NDT train movements, they train different movements and they do so with different purposes. Brunnstrom trains movements in order to enable the will to exert control over the body again, NDT facilitates normal movement patterns and activities so that after a while, the body can automatically act again. Brunnstrom tries t o motivate the patient t o bring his movements under control, NDT hopes that the guiding hands of the therapist inscribes a patient’s ‘organising capabilities’ in his body’s repertoire. Brunnstrom silently assumes a n obeying body t o be able t o move in every setting, NDT specifies where activities take place and what demands and supports these surroundings contain. Brunnstrom, finally, takes a multi-disciplinary approach, while NDT requires inter-disciplinary co-operation. These differences make ‘the Brunnstrom uersus NDT case’ a good support for our claim that analysing the contents of treatment programmes, and differentiating between biomedical approaches, is a necessary strategy for critical theorists of physiotherapy. Simply adding on quantitative or qualitative psychological and sociological elements to existing programmes will not work. For the attempt to add a ‘human’ extra to an unknown, unanalysed black box ‘physiotherapy’ fails t o take into account whether or not such an addition is possible in each specific case. Addition may be doomed t o fail if it leads t o twisting internal contradictions. This implies that there is a lot of analytical work t o do, and since actual practices seldom live up t o the textbook, it is important t o complement text analysis with ethnographic observations and interviews. The Brunnstrom uersus NDT case is only one example. But there are of course many more treatment programmes that may be analysed along similar lines as the ones we set out here (see for another example Lettinga and Siemonsma
Authors A T Lettinga MA PT is a lecturer and researcher in the School of Physiotherapy/Department of Human Movement Sciences, and P Rispens PhD MD is professor of human movement sciences at the University of Groningen, The Netherlands.They are currently engaged in a comparative study of NDT and motor re-learning programmes. A Mol PhD MA is professor of philosophy at the University of Twente, Enschede, The Netherlands.
P M J Helders PhD MSc PTis professor of physiotherapy at the University of Utrecht and head of the Department of Physiotherapy, Utrecht University Hospitals. This article was received on August 21, 1996, and accepted on May 19, 1997.
References Bobath, B (1970, second edition 1978, third edition, 1990). Adult Hemiplegia: Evaluation and treatment, William Heinemann Medical Books, London. Brunnstrom, S (1970). Movement Therapy in Herniplegia: A neurophysiological approach, Harper and Row, Hagerstown. Callon, M and Law, J (1989). ‘On the construction of sociotechnical networks: Content and context revisited’, Knowledge and Society, 9, 57-83. Cambell, S K (1983). Commentary on ‘Measurement validity in physical therapy research’, Physical Therapy, 73, 2, 110-1 12. Canguilhem, G (1995). La Formation du Conceptde Reflexe aux XVlle and XVllle Siecles, Vrin, Paris. Cauguilhern, G (1978). On the Normal and the Pathological, D Reidel Publishing Company, Inc (originally published (1943) as: Le Normal et le Bathologique, Presses Universitaires de France, Paris, in 1966 extended with ‘Nouvelles reflexions sur le normal et le pathologique’). Davies, P (1985). Steps to Follow: A guide to the treatment of adult hemiplegia, Springer Verlag, Berlin. Davies, P M (1990). Right in the Middle: Selective trunk activity in the treatment of adult hemiplegia, Springer Verlag, Berlin. Dean, E (1985). ‘Psychobiological adaptation model for physical therapy, Physical Therapy, 65,7, 1061-68. Engel, G L (1981). ‘The clinical application of the biopsychosocial model’, Journal of Medicine and Philosophy, 6,101-1 24. Foucault, M (1975). The Birth of the Clinic: An archaeology of medical perception, Vintage Books Edition, New York (originally published (1963) as: La Naissance de la Clinique, Presses Universitaires de France, Paris). Foucault, M (1976). De Orde van het Vertoog, Broom, Meppel (originally published (1971) as: L’ordre deu Discours, Gallimard, Paris). Gordon, J (1987). ‘Assumptions underlying physical therapy intervention: Theoretical and historical perspectives’, in: Carr, J H and Shepherd, R B (eds) Movement Science: Foundation for physical therapy in rehabilitation, Heinemann, London. Johnson, R (1993). ‘Attitudes don’t just hang in the air. . . Disabled people’s perceptions of physiotherapists’, Physiotherapy, 79, 9, 619-627.
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Latour, B (1987). Science in Action: How to follow scientists and engineers through society, Open University Press, Milton Keynes. Latour, B (1989). The Pasteurization of France, Harvard University Press, Cambridge, Massachusetts and London, England (originally published (1984) as Les Microbes, Metaille, Paris). Lettinga, A T (1989). ‘Diversiteit in de fysiotherapie: Een conceptueleanalyse van de BrunnstromlNDT controverse (Diversity within physical therapy: A conceptual analysis of the BrunnstromlNDTcontroversy)’, Nederlands Tijdschriff Fysiotherapie, 99, 718, 200-206. Lettinga, A T (1991). ‘Divergentie in de fysiotherapie en de consequenties voor effect-onderzoek: De Brunnstrom- en NDT-methode vergelijkenderwijs (Divergence in physical therapy and the consequences for evaluation research: Comparing the Brunnstrom- and NDT-method)’, Nederlands Tijdschrift fysiotherapie, 101, 718, 163-1 68.. Lettinga, AT and Siemonsma, P (1997). ‘Leren van verschil: Neuro Developmental Treatment en Motor Relearning Progreamme geanalyseerd (Learning from Differences: An analysis of NDT and MRP)’, Nederlands Tijdschriff fysiotherapie, 107, 2 , 4 3 4 9 . Mattingly, C (1993). Commentary on: ‘Alternative approaches to research in physical therapy’, Physical Therapy,73,2, 98-101.
Mol, A (1993). ‘What is new? Doppler and its others: An empirical philosophyof innovations’in: Lowy, I, (ed) Medicine and Change: Historical and sociological studies of medical innovation, INSERM, Paris. Mot, A and Berg, M (1994). ‘Principles and practices of medicine: The co-existence of various anomies’, Medicine and Psychiatw, 18,247-265. Mol, A and Law, J (1994). ‘Regions, networks and fluids: Anaemia and social topology’, Social Studies of Science, 24, 641-671. Mol, A and Lettinga, A T (1992). ‘Bodies, impairments and the social construct: The case of hemiplegia’, in: Lachmund, J and Stollberg, G (eds) The Social Construction of Illness: Illness and medical knowledge in past and present, Franz Steiner Verlag, Stuttgatt, pages 163-1 77. Mot, A and Mesman, J (1996). ‘Neonatal food and the politics of theory: Some questions of method, Social Studies of Science, 26,419-444. Sawner, K and LaVigne, J (1992). Brunnstrom’s Movement Therapy in Hemiplegia: A neurophysiological approach, Lippincott, Philadelphia,2nd edn. Shepard, K F, Jensen, G M, Schmoll, B J, Hack, L M and Gwywer, J (1993). ‘Alternative approaches to research in physical therapy’, Physical Therapy, 73,2, 88-97.
Horns and dilemmas: Scientific and clinical editor’s commentary This article was both unusual and difficult to review, primarily because of the analysis technique used by the authors and partly because it contrasted ‘Bobath’ with ‘Brunnstrom’ which is peripheral to the practice and thinking of British physiotherapists rather than with ‘motor learning’ (on which the authors are currently engaged) which would be more pertinent to a UK-centred audience. Although both referees were neurological researchers, neither claimed to be familiar with the analysis technique. While one considered that some readers might find the ‘Methods’ section irrelevant, even off-putting, the other found that it was an interesting and enlightening way of juxtaposing two approaches to neurological rehabilitation, but was unable to decide the extent to which the findings commented faithfully on the two approaches. I was left on the horns of the classic editor’s dilemma: unwilling to alienate some readers but recognising an article that should stimulate thinking and encourage debate. One solution was two separate articles, a scholarly paper on discourse analysis and a research report on its application. However, the theoretical introduction to the article is so closely connected to the empirical case which serves as an illustrative example that separating the interesting interpretation would deprive the analysis of its meaning and its function.
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I recognisethat readers who are not familiar with the qualitative/quantitativedebate in research and reductionism in physiotherapy might find the ‘Methods’ section difficult to follow. However, this debate has profound implicationsfor clinical practice as well as research in the ‘black box’ of physiotherapy. One difficulty in getting to grips with discourse and actor network theory analysis is that it is not really a methodology or a technique. Its influential theorists, Michel Foucault and Bruno Latour, do not offer a methodology which researchers can apply in a straightforward way to their objects of study. Rather, they illustrate their theoretical points with detailed empirical case studies. Discourse analysis, therefore, provides insights and rationales about science, society, language and activities which influence style of working. In comparison, theoretical debates presented in a traditional format are very abstract and hinder thinking about physiotherapy because they are not anchored in clinical reality. Hopefully, the style of empirical philosophy utilised in the article is more attractive and meaningful to practitioners than traditional approaches and, therefore, is fruitful in drawing physiotherapists other than those undertaking or supervising PhD research into theoretical discussions.