Abstract

The human body, throughout history, has been the object of study of several areas of health sciences, which present discourses about its use and way of existing. This study comes from an excerpt from a master’s thesis that aimed to understand the body view for physical therapy professionals. The critical phenomenological method was used with the triggering question: “tell me what body is for you.” The study had the theoretical perspective of Merleau-Ponty’s phenomenology. Some professionals described a perception of body focused on physical and biological aspects, contemplating this object at times as structure, at times as a means of locomotion, or even as a machine that serves as a shelter for different stages of life. Others considered the body as a whole, that is, from an integrality that goes beyond the mechanistic notion. However, when faced in the practice with aspects outside this model, professionals find it difficult to deal with this, due to an academic training that does not consider divergent ways of understanding the body. The need for a greater discussion of the concept of body in physical therapy is emphasized, especially on those aspects linked to notions that go beyond the biologizing normativity.

Keywords:
Physical therapy; Body; Critical Phenomenology

Introduction

Throughout history, the human body has been characterized by different knowledges that shaped its use and its way of existing, attributing meanings that emphasize certain particularities at the expense of others, creating its own patterns and transforming the body into the target of interests and beliefs of various sectors such as religion, family, and the State (Separavich; Canesqui, 2010SEPARAVICH, M. A.; CANESQUI, A. M. Girando a lente socioantropológica sobre o corpo: uma breve reflexão. Saúde e Sociedade, São Paulo, v. 19, n. 2, p. 249-259, 2010. DOI: 10.1590/S0104-12902010000200003
https://doi.org/10.1590/S0104-1290201000... ; Barbosa; Matos; Costa, 2015BARBOSA, M. R.; MATOS, P. M.; COSTA, M. E. Um olhar sobre o corpo: o corpo ontem e hoje. Psicologia & Sociedade, Porto Alegre, v. 23, n. 1, p. 24-34, 2015. DOI: 10.1590/S0102-71822011000100004
https://doi.org/10.1590/S0102-7182201100... ; Fernandes; Barbosa, 2016FERNANDES, L.; BARBOSA, R. A construção social dos corpos periféricos. Saúde e Sociedade, São Paulo, v. 25, n. 1, p. 70-82, 2016. DOI: 10.1590/s0104-12902016146173
https://doi.org/10.1590/s0104-1290201614... ). Accordingly, the health scope also weaves its own definitions by choosing the health and disease process as a starting point for understanding phenomena related to the body. In biological processes, valuable information is found for the clinical practice of areas such as medicine, nursing, nutrition, and physical therapy, an occupation that has the human body and its forms of expression as primordial objects for its praxis (Brasil, 2002BRASIL. Conselho Federal de Educação. Resolução CNE/CES 4, de 19 de fevereiro de 2002. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Fisioterapia. Diário Oficial da União, Brasília, DF, 4 mar. 2002.; Lupton, 2012LUPTON, D. Medicine as culture: illness, disease and the body. 3. ed. London: Sage, 2012.; Sá, 2016SÁ, F. E. S. O corpo em processo de adoecimento e suas (re) significações psicossociais no currículo de fisioterapia da Universidade Federal do Ceará. 2016. Tese (Doutorado em Educação Brasileira) - Faculdade de Educação, Universidade Federal do Ceará, Fortaleza, 2016.).

Physical therapy, as a profession, is concerned with restoring the body’s potentialities when taking care of its functionality, preserving and developing the integrity of organs, systems, and functions (Brasil, 2002BRASIL. Conselho Federal de Educação. Resolução CNE/CES 4, de 19 de fevereiro de 2002. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Fisioterapia. Diário Oficial da União, Brasília, DF, 4 mar. 2002.). In this practice, physical therapy allows the body to gain different contours and meanings with the historical advance of the profession and the influences resulting from the transformations caused by multiculturalism and globalization (Sá, 2016SÁ, F. E. S. O corpo em processo de adoecimento e suas (re) significações psicossociais no currículo de fisioterapia da Universidade Federal do Ceará. 2016. Tese (Doutorado em Educação Brasileira) - Faculdade de Educação, Universidade Federal do Ceará, Fortaleza, 2016.). Despite being the core of this area, the body, as a philosophical/theoretical construct, has not been the main interest on the part of professionals - who assume the notion of something “obvious” -, exercising the knowledge of physical therapy without perceiving its theoretical complexity (Sá, 2016SÁ, F. E. S. O corpo em processo de adoecimento e suas (re) significações psicossociais no currículo de fisioterapia da Universidade Federal do Ceará. 2016. Tese (Doutorado em Educação Brasileira) - Faculdade de Educação, Universidade Federal do Ceará, Fortaleza, 2016.; Kelly et al., 2019KELLY, M. et al. Body pedagogics: embodied learning for the health professions. Medical Education, Oxford, v. 53, n. 10, p. 967-977, 2019. DOI: 10.1111/medu.13916
https://doi.org/10.1111/medu.13916... ).

The position of not considering the philosophy and theory about the body may result from the fact that the field of physical therapy, for a long time, was entirely linked to the act of rehabilitation (Kelly et al., 2019KELLY, M. et al. Body pedagogics: embodied learning for the health professions. Medical Education, Oxford, v. 53, n. 10, p. 967-977, 2019. DOI: 10.1111/medu.13916
https://doi.org/10.1111/medu.13916... ). Although there is an incessant movement aimed at the adoption of conducts that prioritize a view and treatment of the body as a whole, the mechanism inherited from the Cartesian model still permeates the training of physical therapy professionals. In the curricular structure of undergraduate programs, mostly, anatomical and biological disciplines are contemplated, which often influence clinical practices, omitting the integral view of the body and manifesting the mechanistic practice directed to the biomedical standard (Meyer, 2005MEYER, P. F. A compreensão do corpo na formação profissional do fisioterapeuta. 2005. Dissertação (Mestrado em Ciências da Saúde) - Universidade Federal do Rio Grande do Norte, Natal, 2005. Disponível em: <Disponível em: https://repositorio.ufrn.br/handle/123456789/13426 >. Acesso em: 22 ago. 2019.
https://repositorio.ufrn.br/handle/12345... ; Bonatti, 2011BONATTI, R. A. A fisioterapia em dupla mão: a percepção do fisioterapeuta sobre o corpo humano. 2011. Tese (Doutorado em Ciências Sociais) - Pontifícia Universidade Católica de São Paulo, São Paulo, 2011.; Zanotelli, 2015ZANOTELLI, G. A. C. Relação dialógica na prática clínica do profissional fisioterapeuta e a visão integral do sujeito-paciente. 2015. Tese (Doutorado em Educação) -, Universidade Federal do Ceará, Fortaleza, 2015.).

In Brazil, the standard curriculum of the Physical Therapy program has little emphasis on disciplines focused on the analysis or understanding of the body beyond the physical aspect, valuing hospital and outpatient practices concentrated in rehabilitation, which bring to light the body/mind dichotomy and fragment the organism into specific parts, so that one loses the view of the patient as a whole, or even as a human being (Lorenzo; Bueno, 2013LORENZO, C. F. G.; BUENO, G. T. A. A interface entre bioética e fisioterapia nos artigos brasileiros indexados. Fisioterapia em Movimento, Curitiba, v. 26, n. 4, p. 763-775, 2013. DOI: 10.1590/s0103-51502013000400006
https://doi.org/10.1590/s0103-5150201300... ; Zanotelli, 2015ZANOTELLI, G. A. C. Relação dialógica na prática clínica do profissional fisioterapeuta e a visão integral do sujeito-paciente. 2015. Tese (Doutorado em Educação) -, Universidade Federal do Ceará, Fortaleza, 2015.). In this context, body evaluation becomes the main concern of professionals, only aimed at the results of diagnostic tests and disregarding touching the patients and their report. These issues are verified in several health areas, raising concerns and showing the need for a better knowledge, on the part of professionals, of themselves, the other, and how to exercise clinical practice seeking an understanding of human beings as individuals, considering their subjectivity (Kelly et al., 2019KELLY, M. et al. Body pedagogics: embodied learning for the health professions. Medical Education, Oxford, v. 53, n. 10, p. 967-977, 2019. DOI: 10.1111/medu.13916
https://doi.org/10.1111/medu.13916... ).

Acknowledging this understanding implies considering the beings under the various aspects that constitute them, understanding them as a constant process of cultural and social construction. Having this understanding of the subject is one of the great challenges of physical therapy professionals and the health area in general (Barbosa; Matos; Costa, 2015BARBOSA, M. R.; MATOS, P. M.; COSTA, M. E. Um olhar sobre o corpo: o corpo ontem e hoje. Psicologia & Sociedade, Porto Alegre, v. 23, n. 1, p. 24-34, 2015. DOI: 10.1590/S0102-71822011000100004
https://doi.org/10.1590/S0102-7182201100... ). Considering these problematized questions, this article aims to identify the understanding of the notion of body from the perspective of physical therapists.

Methods

This is a qualitative research that uses the critical phenomenological method, inspired by the philosophical phenomenology of Maurice Merleau-Ponty, which seeks to understand the experience from the various cultural and ideologically constituted contexts, through which this phenomenon can be perceived, in its multiple forms. In this methodology, critical perspective plays an important role, as it allows ceasing ingenuity and opening the researcher’s eyes to the multiplicity of a phenomenon (Moreira, 2017MOREIRA, V. Clínica Humanista Fenomenológica: estudos em psicoterapia e psicopatologia crítica. 2. ed. Saint-Martin-de-Blagny: MJW Fédition, 2017.).

Data collection took place by individual interviews based on a single guiding question, which gave the participant freedom to speak and assign meanings through the active listening of the researcher, thus producing a particular and pre-reflective discourse of the subject. In this study, the guiding question was: “tell me what body is to you.”

The critical phenomenological method has steps for the analysis of the statements obtained from the interviews. In the literal transcription step - called native text - it is ideal for the transcriber person to be the same person who did the interview, which allows the text to contain not only verbal speech, but also the various nonverbal expressions, such as silences, tones of voice, cries, intervals, etc. The second step consists of dividing the native text into subsequent movements according to the tone of the interview. After this phase, the descriptive analysis of the emerging meanings of each of these movements begins. Finally, the last step of the method consists of the “exit from the parentheses,” in which “researchers look once again at their hypothesis, their suspicions about possible paths to understand their object of study” (Moreira, 2017MOREIRA, V. Clínica Humanista Fenomenológica: estudos em psicoterapia e psicopatologia crítica. 2. ed. Saint-Martin-de-Blagny: MJW Fédition, 2017., p. 126, free translation).

It is worth mentioning that this hypothesis is configured, according to Moreira (2017MOREIRA, V. Clínica Humanista Fenomenológica: estudos em psicoterapia e psicopatologia crítica. 2. ed. Saint-Martin-de-Blagny: MJW Fédition, 2017.), as a hypothesis of mistrust, that is, one that does not follow positivist standards:

The steps of the proposed method are described in Figure 1.

It is noteworthy that, in addition to founding the methodology, Merleau-Ponty’s philosophical phenomenology - mainly addressed in his work Phenomenology of Perception (²⁰⁰⁵MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018.) - will sometimes be used to theoretically support the discussion presented by the interviews. This work was chosen because it contains a chapter exclusively on the topic of body.

The participants of the interviews were physical therapists, without delimitation of age group or sex, working in the profession with experience of more than two years since graduation (this delimitation occurred due to the need to understand the perceptions of professionals with more time of clinical practice about the notion of body). The physical therapists were contacted using the snowball technique, which has the premise of selecting new participants through the indication or suggestion of the participants already part of the research (YIN, 2016YIN, R. K. Escolhas no delineamento de estudos de pesquisa qualitativa. In: YIN, R. K. Pesquisa qualitativa do início ao fim. Porto Alegre: Penso, 2016. p. 91-125.).

This selection was performed, at first, by selecting documents and key informants who were called “seeds,” in order to locate some people with the profile necessary for the research within the general population. Subsequently, the indicated people were asked to designate new contacts with the desired characteristics from their own personal network. It should be noted that the interviewed professionals were not identified, and fictitious names were used. Altogether, 17 professionals were interviewed; however, as it is an excerpt from a Master’s thesis, not all interviews in their integral aspects will be addressed in this study.

Table 1 shows the synthesized information about the research participants. The interviews were conducted in the private offices of each of the respective interviewees, places chosen for the convenience of the participants. Although the critical phenomenological method did not guide the specific period of the interviews’ duration, each interview lasted an average of 45 minutes to one hour.

The research complied with the provisions of Resolution No. 466 of the National Health Council (CNS) of the Brazilian Ministry of Health, of December 12, 2012 (Brasil, 2012BRASIL. Ministério da Saúde. Resolução no 466, de 12 de dezembro de 2012. Diário Oficial da União, Brasília, DF, 12 dez. de 2012.) and of the National Research Ethics Commission (Conep), under Opinion No. 2.542.726.

Results and Discussion

The participants’ statements brought different perspectives on the notion of body. Some professionals described a perception of body focused on physical and biological aspects, contemplating the body sometimes as structure, sometimes as a means of locomotion, or even as a machine that serves as a shelter for different stages of life.

When the professionals talk about “to make it work” and “to improve the locomotor mechanism,” it demonstrates a perception about the human body guided by physical aspects, understanding its functioning from the biomedical paradigm by equaling it to a machine and understanding the perspective of quality of life based on biological principles of the body. Conversely, Merleau-Ponty (2005MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018.) rejects this notion of organism as a machine, or object that moves randomly in a given space; the author considers body as that which perceives and is endowed with knowledge, which moves in the intentionality of lived experiences and in intersubjective relationships, that is, “the anchoring of the active body in an object, the situation of the body in face of its tasks” (Merleau-Ponty, 2005MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018., p. 115).

When thinking from this perspective, we find an idealized and programmable body, such as a machine that has as its main characteristic the physical and chemical processes that regulate and maintain its structure, being its stoppage or “damage” recognized as a “deviation” or a “disease” (Macdonald; Nicholls, 2017MACDONALD, H.; NICHOLLS, D. A. Teaching physiotherapy students to “be content with a body that refuses to hold still”. Physiotherapy Theory And Practice, Abingdon, v. 33, n. 4, p. 303-315, 2017. DOI: 10.1080/09593985.2017.1302027
https://doi.org/10.1080/09593985.2017.13... ). In this perspective, the body loses the subjectivity that is placed by individuals; its particularities are allocated to the background in the understanding of demand, making care practices focused on the standardization of biological aspects. The pain reported by the patient becomes the failure of some regulatory mechanism, resulting in the repression of psychological, social, and environmental variables (Esteves; Fernandez, 2017ESTEVES, D. B.; FERNANDEZ, J. C. A. Velhice, corpo e saúde. Kairós-Gerontologia, São Paulo, v. 20, n. 4, p. 383-401, 2017. DOI: 10.23925/2176-901X.2017v20i4p383-401
https://doi.org/10.23925/2176-901X.2017v... ).

The patient’s body is taken as the means of work that enables the occupation of physical therapists, who in turn seek to promote well-being for this patient by moving the structure of the “anatomical body,” focusing on the solution of the patient’s physical complaint and seeking to maintain and improve bodily functions (Canto; Simão, 2009CANTO, C. R. E. M.; SIMÃO, L. M. Relação fisioterapeuta-paciente e a integração corpo-mente: um estudo de caso. Psicologia: Ciência e Profissão, Brasília, DF, v. 29, n. 2, p. 306-317, 2009. DOI: 10.1590/S1414-98932009000200008
https://doi.org/10.1590/S1414-9893200900... ; Driver et al., 2016DRIVER, C. et al. Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review. Disability And Rehabilitation, Abingdon, v. 39, n. 22, p. 2237-2249, 2016. DOI: 10.1080/09638288.2016.1223176
https://doi.org/10.1080/09638288.2016.12... ). The body as a means of work is taken as a specificity in which the professional’s perspective emerges as the main form of interpretation and the focus shifts towards postural reeducation, motor coordination, muscle strength, and joint movement, which reduces the complexity of processes related to health and illness and limits the role of the physical therapist to the ability to respond to processes that surpass the biological paradigm (Driver et al., 2016DRIVER, C. et al. Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review. Disability And Rehabilitation, Abingdon, v. 39, n. 22, p. 2237-2249, 2016. DOI: 10.1080/09638288.2016.1223176
https://doi.org/10.1080/09638288.2016.12... ).

Merleau-Ponty (2005MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018., p. 81) supports an understanding of the body as a “point of view upon the world, as one of the objects of that world.” For the author, the body is an object, but it cannot be objectified, which goes against the perspectives found in the interviews. This conception is proven when Ponty states that “the body, by withdrawing from the objective world, will carry with it the intentional threads linking it to its surrounding and finally reveal to us the perceiving subject as the perceived world” (Merleau-Ponty, 2005MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018., p. 83).

Other interviewees presented the integral view about the body and not as a mere sum of its parts, demonstrating an understanding that goes beyond the mechanistic paradigm when evaluating the context and totality of individuals, without privileging the physical aspect over the others.

Merleau-Ponty’s statement that addresses the understanding of health and disease as existential phenomena corroborates the view of these professionals by asserting that:

The understanding of the body as a total, not only divisible in anatomical parts, results from the cessation of the biomedical paradigm, as the limitation of this model is perceived when attempting to comprise the entire breadth of care and human health (Hay; Connelly; Kinsella, 2016HAY, M. E.; CONNELLY, D. M.; KINSELLA, E. A. Embodiment and aging in contemporary physiotherapy. Physiotherapy Theory And Practice, Abingdon, v. 32, n. 4, p. 241-250, 2016. DOI: 10.3109/09593985.2016.1138348
https://doi.org/10.3109/09593985.2016.11... ). The notion of body acquires new characteristics when understood and interpreted from the emerging relationships between somatic, psychosocial, and social factors (Schillmeier, 2019SCHILLMEIER, M. Thinking with the living body: the biopsychosocial model and the cosmopolitics of existence. Medical Humanities, London, v. 45, n. 2, p. 141-151, 2019. DOI: 10.1136/medhum-2018-011584
https://doi.org/10.1136/medhum-2018-0115... ).

The aforementioned excerpts demonstrate a thought based on the biopsychosocial perspective. The physical therapy approaches tend to assume a behavior of duality in practice - sometimes adopting a physical-centered view, sometimes it is understood that the physical is impaired by the psychological (Schorne; Bittencourt; Holler, 2014SCHORNE, G.; BITTENCOURT, D. C.; HOLLER, A. Aplicabilidade das técnicas holísticas na prática fisioterapêutica. Saúde Integrada, Santo Ângelo, v. 7, n. 14, p. 89-105, 2014.).

From this discussion, Merleau-Ponty (2005MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018.) defines that body is not a cluster of sensations, but it functions as a system in which all aspects, whether internal or external, present themselves simultaneously through an action that contains meaning in face of an organized whole. Therefore, “the consciousness I have of my body is not the consciousness of an isolated mass; it is a postural schema” (Toadvine; Lawlor, 2007, p. 147); the consciousness of the body takes into account that the body scheme is a unified whole.

Professionals also perceive that the body becomes a vehicle that enables the subjectivity of individuals, signaling possible aspects that patients are experiencing in their life history.

This way of thinking demonstrates a need for understanding the body that is not only physical, but conceived as something that goes beyond the anatomical, and which is interpreted as “art, body and movement,” gaining contours from different experiences, being a point of intersection between biological, psychological, and social (Schillmeier, 2019SCHILLMEIER, M. Thinking with the living body: the biopsychosocial model and the cosmopolitics of existence. Medical Humanities, London, v. 45, n. 2, p. 141-151, 2019. DOI: 10.1136/medhum-2018-011584
https://doi.org/10.1136/medhum-2018-0115... , free translation). Moreover, Merleau-Ponty (2005MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018.) points out that the body can only be explained by its existence in the world, endowed with perceptions:

Considerations about the notion of the body, besides characterizing the way of thinking of professionals, also have consequences for the relationship that is established between patient and professional, reflecting in praxis and the form of intervention that is established. In the obtained statements, the professionals who presented a discourse more focused on the biomedical logic found difficulties in handling or understanding demands other than the physical aspect.

When encountering these topics in practice, the physical therapist professional encounters discomfort and resistance when dealing with social, psychological, and ethical aspects that are not described in the body-as-machine paradigm (Mudge; Stretton; Kayes, 2013MUDGE, S.; STRETTON, C.; KAYES, N. Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disability And Rehabilitation, Abingdon, v. 36, n. 6, p. 457-463, 2013. DOI: 10.3109/09638288.2013.797515
https://doi.org/10.3109/09638288.2013.79... ). Their role, thus, becomes that of specialists on the human body, taking it as a receiver, which limits the value of the individuals’ own perspective on their body. Therefore, physical therapists assume the place of connoisseurs of the needs and priorities of the subjects’ organism, which leads them to the objective and observing view of the demands that arise (Hay; Connelly; Kinsella, 2016HAY, M. E.; CONNELLY, D. M.; KINSELLA, E. A. Embodiment and aging in contemporary physiotherapy. Physiotherapy Theory And Practice, Abingdon, v. 32, n. 4, p. 241-250, 2016. DOI: 10.3109/09593985.2016.1138348
https://doi.org/10.3109/09593985.2016.11... ; Macdonald; Nicholls, 2017MACDONALD, H.; NICHOLLS, D. A. Teaching physiotherapy students to “be content with a body that refuses to hold still”. Physiotherapy Theory And Practice, Abingdon, v. 33, n. 4, p. 303-315, 2017. DOI: 10.1080/09593985.2017.1302027
https://doi.org/10.1080/09593985.2017.13... ).

Patients, then, become a molded and modified object to improve their anatomy; their abilities and knowledge of their demands are underestimated, which causes health-related autonomy to be lost (Mudge; Stretton; Kayes, 2013MUDGE, S.; STRETTON, C.; KAYES, N. Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disability And Rehabilitation, Abingdon, v. 36, n. 6, p. 457-463, 2013. DOI: 10.3109/09638288.2013.797515
https://doi.org/10.3109/09638288.2013.79... ). However, according to Bonnatti,

The notion of body encompassing the totality of the individual also arises in the discourses of professionals who speak from the biopsychosocial perspective, understanding the individual as total and valuing these characteristics in the relationship that is established by looking at facts not addressed in other paradigms.

This conception reverberates in the professional practice of physical therapy by providing practices aimed at understanding the individual characteristics of patients, modifying the role of the physical therapist, who gains new contours, and not being limited to the figure of the specialist or in the practice centered on the therapist, but rather on the patients and their emotional, social, and psychological aspects. In this person-centered relationship, physical therapists maintain their rehabilitation practices, but share their decisions with the people who seek them, respecting their particular aspects, which allows patients to be active participants in their healing process (Mudge; Stretton; Kayes, 2013MUDGE, S.; STRETTON, C.; KAYES, N. Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disability And Rehabilitation, Abingdon, v. 36, n. 6, p. 457-463, 2013. DOI: 10.3109/09638288.2013.797515
https://doi.org/10.3109/09638288.2013.79... ; Josephson et al., 2015JOSEPHSON, I. et al. Evaluative language in physiotherapy practice: How does it contribute to the therapeutic relationship? Social Science & Medicine, Oxford, v. 143, p. 128-136, 2015. DOI: 10.1016/j.socscimed.2015.08.038
https://doi.org/10.1016/j.socscimed.2015... ).

The previous statements bring excerpts of thoughts that relate to the person-centered practice and demonstrate the body in a context with its emotions, avoiding the body/mind dichotomy by bringing to practice the knowledge that only the patients have, their needs, preferences, and life situation (Mudge; Stretton; Kayes, 2013MUDGE, S.; STRETTON, C.; KAYES, N. Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disability And Rehabilitation, Abingdon, v. 36, n. 6, p. 457-463, 2013. DOI: 10.3109/09638288.2013.797515
https://doi.org/10.3109/09638288.2013.79... ). The technical skill only focused on physical rehabilitation becomes insufficient, considering that other skills are needed on the part of the professional, such as effective communication practices and strategies of motivation and social support for the patients that assist in the total understanding of the individuals, together with their biological knowledge about the body (Mudge; Stretton; Kayes, 2013MUDGE, S.; STRETTON, C.; KAYES, N. Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disability And Rehabilitation, Abingdon, v. 36, n. 6, p. 457-463, 2013. DOI: 10.3109/09638288.2013.797515
https://doi.org/10.3109/09638288.2013.79... ; Driver et al., 2016DRIVER, C. et al. Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review. Disability And Rehabilitation, Abingdon, v. 39, n. 22, p. 2237-2249, 2016. DOI: 10.1080/09638288.2016.1223176
https://doi.org/10.1080/09638288.2016.12... ). Nevertheless, these relational attitudes require formal training to be well understood and put into practice to avoid misuse (Driver et al., 2016DRIVER, C. et al. Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review. Disability And Rehabilitation, Abingdon, v. 39, n. 22, p. 2237-2249, 2016. DOI: 10.1080/09638288.2016.1223176
https://doi.org/10.1080/09638288.2016.12... ).

The undergraduate program in physical therapy has little emphasis on disciplines that address person-centered practices, or that focus on a critical field. This hinders the understanding of these skills and compromises the development of critical thinking about physical therapy praxis during the period of professional training (Silva, 2015SILVA, E. A. Dialogicidade entre os mundos da educação e do trabalho no processo de formação em fisioterapia. 2015. Tese (Doutorado em Modelos de Decisão e Saúde) - Universidade Federal da Paraíba, João Pessoa, 2015.). According to Bonatti (2011BONATTI, R. A. A fisioterapia em dupla mão: a percepção do fisioterapeuta sobre o corpo humano. 2011. Tese (Doutorado em Ciências Sociais) - Pontifícia Universidade Católica de São Paulo, São Paulo, 2011.), even when there are subjects focused on human relations in the undergraduate education, they have two apparent difficulties that are either of a theoretical nature only - not establishing relationships with professional practice - or are taught by professors who do not master the topic in this specific area, which makes the content unattractive and unpractical for students.

This gap in academic education on praxis that encompasses factors other than the biological aspect is not exclusively in the field of physical therapy, but is perceived in other areas of healthcare education. Historically, the hegemony of models that only value biological aspects, fragment and compartmentalize the human body affects not only the actions of healthcare professionals, but also the training available to them. Several of these training programs were influenced by the information obtained from the Flexner Report¹1This report was created by Abraham Flexner, and was adopted by medical education in North America. According to Faria and Santos (2021, p. 8, free translation), “From the pedagogical point of view, massifying, passive, hospital-centered, individualistic and aimed at superspecialization, with harmful and even perverse effects”., which modified the perception of teaching in the medical area by valuing fragmented and specialized technicality in the health area, which prioritizes the disease and not the patient (Simon et al., 2015SIMON, E et al. Metodologias ativas de ensino-aprendizagem e educação popular: encontros e desencontros no contexto da formação dos profissionais de saúde. Interface: Comunicação, Saúde, Educação, Botucatu, v. 18, p. 1355-1364, 2015. Suplemento 2.).

We can observe that there are still reminiscences of this paradigm considering that there is no problematization of these aspects in the education process of health professionals, which contributes to the perception of a unicausal model of pathologies, making little room for psychological, social, and political considerations of illness. The criticism of this model is based on the fact that the compartmentalization of illness does not encompass the complexity of what is health, mainly related to the need to consider the different realities or the facticity of the health/disease process (Simon et al., 2015SIMON, E et al. Metodologias ativas de ensino-aprendizagem e educação popular: encontros e desencontros no contexto da formação dos profissionais de saúde. Interface: Comunicação, Saúde, Educação, Botucatu, v. 18, p. 1355-1364, 2015. Suplemento 2.).

This context generates immediate and late consequences for both the theoretical and the practical fields of physical therapy (Macdonald; Nicholls, 2017MACDONALD, H.; NICHOLLS, D. A. Teaching physiotherapy students to “be content with a body that refuses to hold still”. Physiotherapy Theory And Practice, Abingdon, v. 33, n. 4, p. 303-315, 2017. DOI: 10.1080/09593985.2017.1302027
https://doi.org/10.1080/09593985.2017.13... ). A first characteristic to be listed is the difficulty in understanding the subjective aspects that emerge from the human body. There is a tendency for professionals to deal with this topic objectively, supporting the belief that emotional distancing from the demands made by the patient favors the application of praxis (Canto; Simão, 2009CANTO, C. R. E. M.; SIMÃO, L. M. Relação fisioterapeuta-paciente e a integração corpo-mente: um estudo de caso. Psicologia: Ciência e Profissão, Brasília, DF, v. 29, n. 2, p. 306-317, 2009. DOI: 10.1590/S1414-98932009000200008
https://doi.org/10.1590/S1414-9893200900... ; Silva, 2015SILVA, E. A. Dialogicidade entre os mundos da educação e do trabalho no processo de formação em fisioterapia. 2015. Tese (Doutorado em Modelos de Decisão e Saúde) - Universidade Federal da Paraíba, João Pessoa, 2015.). This characteristic prevents the autonomy of subjects and the understanding of the individual possibilities, and preserves the technical role of professionals, which ends up contrasting with the concepts of humanization and care, principles that compose the Brazilian National Health System (SUS) and the curricula of undergraduate programs in health (Sá, 2016SÁ, F. E. S. O corpo em processo de adoecimento e suas (re) significações psicossociais no currículo de fisioterapia da Universidade Federal do Ceará. 2016. Tese (Doutorado em Educação Brasileira) - Faculdade de Educação, Universidade Federal do Ceará, Fortaleza, 2016.).

Accordingly, another consequence that the lack of critical aspects and focus on human relationships in the training of the physical therapist can entail is the difficulty in thinking about the body from different perspectives, hindering the multi-, inter-, or transdisciplinary work in relation to other healthcare professionals (Silva, 2015SILVA, E. A. Dialogicidade entre os mundos da educação e do trabalho no processo de formação em fisioterapia. 2015. Tese (Doutorado em Modelos de Decisão e Saúde) - Universidade Federal da Paraíba, João Pessoa, 2015.). The compartmentalized view of knowledge brings to light the division of mind and body of the very biological paradigm, hindering the understanding of the praxis of other knowledge within the field of health and limiting the function of physical therapy only to its rehabilitation role. This contrasts with the possibilities of the physical therapist’s action in the face of new ways of understanding the health/disease paradigm (Bonatti, 2011BONATTI, R. A. A fisioterapia em dupla mão: a percepção do fisioterapeuta sobre o corpo humano. 2011. Tese (Doutorado em Ciências Sociais) - Pontifícia Universidade Católica de São Paulo, São Paulo, 2011.; Silva, 2015SILVA, E. A. Dialogicidade entre os mundos da educação e do trabalho no processo de formação em fisioterapia. 2015. Tese (Doutorado em Modelos de Decisão e Saúde) - Universidade Federal da Paraíba, João Pessoa, 2015.).

Continuing health education can be deemed as one of the possible proposals for a solution (or at least mitigation) for these consequences by recognizing the characteristics of the dualist logic provided by the biologizing and technical paradigm, which hardens perspectives of truths and functions. Implemented by Ordinances of the Brazilian Ministry of Health No. 198 of February 13, 2004 and No. 1,996 of August 20, 2007 (Brasil, 2004BRASIL. Ministério da Saúde. Portaria nº 198/GM/MS, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Diário Oficial da União, Brasília, DF, 13 fev. 2004. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/MatrizesConsolidacao/comum/13150.html >. Acesso em: 23 jun. 2022.
https://bvsms.saude.gov.br/bvs/saudelegi... ; ²⁰⁰⁷BRASIL. Ministério Da Saúde. Portaria nº 1.996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Diário Oficial da União, Brasília, DF, 20 ago. 2007. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2007/prt1996_20_08_2007.html >. Acesso em: 22 ago. 2019.
https://bvsms.saude.gov.br/bvs/saudelegi... ) as a health policy in Brazil, continuing health education is an ethical-political-pedagogical proposal whose purpose is transforming, qualifying, and organizing practices aimed at health care continuously, rethinking and modifying mechanistic and exclusively biomedical care perspectives (Ferreira et al., 2019FERREIRA, L. et al. Educação Permanente em Saúde na atenção primária: uma revisão integrativa da literatura. Saúde em Debate, Rio de Janeiro, v. 43, n. 120, p. 223-239, 2019. DOI: 10.1590/0103-1104201912017
https://doi.org/10.1590/0103-11042019120... ). In this proposal there is the integration between teaching and practices directed to the exchange between knowledge, which manipulate binary reasoning and critically appropriate it, in order to develop new forms of knowledge, advocating a proposal for prolonged teaching-learning and which does not consider only the knowledge obtained in the initial education. In this perspective, we can understand the indissociability of theory and practice and the need for changes concerning knowledge to understand the vast perceptions about health (Biato; Ceccim; Monteiro, 2017BIATO, E. C. L.; CECCIM, R. B.; MONTEIRO, S. B. Processos de criação na atenção e na educação em saúde: um exercício de “timpanização”. Physis, Rio de Janeiro, v. 27, n. 3, p. 621-640, 2017. DOI: 10.1590/S0103-73312017000300013
https://doi.org/10.1590/S0103-7331201700... ).

Another strategy that can provide significant changes to this context is the offer of disciplines in undergraduate courses in physical therapy about the development of critical thinking, with regard to both the theory of the field and the practice that underpins the activities of physical therapists. Within this context, the presentation of theories, such as Merleau-Ponty’s phenomenology - as a perspective - can corroborate the abandonment of dichotomies and provide a praxis other than the biologizing norm based on an ambiguous view of the body. It is noteworthy that it is not a matter of completely abandoning previous knowledge of the body and the ways from which it can function, as, according to the author himself, no phenomenological reduction can be complete (Merleau-Ponty, 2005MERLEAU-PONTY, M. Fenomenologia da percepção. 5. ed. São Paulo: Martins Fontes, 2018.).

Final considerations

This article raised a critical discussion on the perceptions that physical therapists have about the work object most present in their praxis - the human body -, reflecting on the implications of these conceptions for the theoretical and practical field of the area. In the presented discourses, the plurality of thoughts about the notion of body emerged, demonstrating the different perspectives that professionals have and their consequences for clinical management with their patients. The practice of these professionals is based on their notions about the body, which appears sometimes as a machine - which must be worked and standardized -, sometimes as a whole - influenced by different factors that go beyond the biological aspect.

The results showed the need to bring a critical and reflective discussion in the field of physical therapy about its basic concepts and the consequences of its practice for health. This discussion must take place during the clinical practice of these professionals as well as in undergraduate programs aimed at the training of future physical therapists. In this context, the considerations of the author Maurice Merleau-Ponty about the body, woven from the statements of the professionals, demonstrate that this view can contribute to the cessation of dichotomies and reductionism present in the praxis of physical therapists. In other words, the future of physical therapy lies in the possibility of critically thinking about itself.

Studies similar to ours are necessary to disseminate and bring light to the discussion about the need to rethink the way undergraduate courses approach the role of the physical therapist in health, thinking about aspects that surpass the limits of technique and biology. It is necessary to conduct more studies focused on this critical aspect, as the discussion does not end in only one research.

Finally, it is essential to conduct studies focused on aspects that were not addressed in this article such as the perception of patients in view of the multiple forms of interpretation about the body and its consequences for the clinical aspects of these individuals.

References

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