Physiotherapy as bricolage: Theorizing expert practice

PERSPECTIVE

Physiotherapy as bricolage: Theorizing expert practice

James A. Shaw, MPT, PhD Candidate and Ryan T. DeForge, MSc, PhD Candidate

Department ofHealth&Rehabilitation Sciences, ElbornCollege,University ofWesternOntario, London,Ontario, Canada

ABSTRACT

Theories about how knowledge is sought and applied in clinical practice are often referred to as practice epistem-ologies, and have not been extensively explored in the physiotherapy profession. Tacit assumptions about whatcounts as physiotherapy knowledge thus form the basis for many approaches to gaining and using informationin practice. The purpose of this paper is to propose a physiotherapy practice epistemology, through the notion ofthebricoleur,which takesanalternativeapproach to understanding howknowledgemight best be viewed in relationto physiotherapy. The term bricoleur refers to a handyman or handywoman who uses all tools and types of knowl-edgeavailable. Thenotionof physiotherapistsas bricoleurs recognizes that all practice knowledge is situatedwithinsocial, cultural, and historical contexts that shape our beliefs about what counts as physiotherapy knowledge. Thisrecognition leads physiotherapists who act as bricoleurs to embrace multiple epistemologies, discovering newways of knowing and clinical reasoning strategies to provide a more holistic approach to physiotherapy practice.The relationships between expertise in clinical reasoning and the epistemology of the bricoleur are then addressed,explicating the utility of multiple epistemologies in achieving excellent physiotherapy care. A bricoleur’s epistem-ology is then applied to the concept of expertise in physiotherapy, de-stabilizing the notion that a single authoritativeapproach to the practice of physiotherapy ought to be idealized.

An epistemology of physiotherapy practice thatcan justify and legitimise the sources of knowl-edge that underpin the inter-subjectivity of inter-personal relationships as well as the proven use ofphysical interventions in effective practice has notbeen fully explored or defined. (Edwards andRichardson, 2008, p. 185)

INTRODUCTION

Distinctions between physiotherapists and other healthservice providers have been a part of the professionaldiscourse of physiotherapy throughout its history(Cleather, 1995; Nicholls and Cheek, 2006; Nichollsand Gibson, 2010), forming the basis for the continualeffort to defend and demarcate the territory of phy-siotherapy as a valued profession in contemporaryhealth care. Initiatives to identify and describe, orperhaps to inscribe, physiotherapy knowledge (Ameri-can Physical Therapy Association, 2003) may be seenas movements to claim function and the body as the

exclusive territory of physiotherapists. What counts as‘physiotherapy knowledge’ has not been as consistentlyor critically explored, leading to unexamined assump-tions in practice that physiotherapists already havephysical rehabilitation ‘figured out’, that we alreadyenact the best possible approach to rehabilitative care.Examining what counts as physiotherapy knowledge,and as physiotherapy epistemology, may help toposition the practice of physiotherapy within its socio-political context; this will allow physiotherapists torecognize ‘that knowledge is always in process,developing, culturally specific, and power-inscribed’(Kincheloe, 2005). Recognizing that physiotherapyknowledge and practice are embedded in a complexand ever-changing socio-historical context will help toclarify the discrepancy between the predominance ofa biomechanical approach to physiotherapy care(Nicholls and Gibson, 2010) and the more complex,nuanced processes of clinical reasoning that exemplifyphysiotherapy expertise (Edwards et al, 2004).

Edwards and Richardson (2008) define practiceepistemology as ‘the focus on how knowledge is gener-ated and used in clinical practice’. Citing the widevariety of influences on the experience of pain, theseauthors suggest that the complexity of issues thatcompose physiotherapy practice areas necessitates a

Address correspondence to JamesA.Shaw,Department ofHealth&Reha-bilitation Sciences, Elborn College, University of Western Ontario,London, Ontario, Canada. E-mail: [email protected]

Accepted for publication 23 January 2012

Physiotherapy Theory and Practice, 28(6):420–427, 2012Copyright © Informa Healthcare USA, Inc.ISSN: 0959-3985 print/1532-5040 onlineDOI: 10.3109/09593985.2012.676941

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broadened understanding of the types and sources ofknowledge that inform physiotherapy approaches tocare. The complexity discussed by Edwards andRichardson (2008) raises another important conceptin understanding the knowledge base for physiother-apy: the notion of ontology. Ontology refers to beliefsabout the nature of reality, addressing the question ofwhat really exists in the world (Denzin and Lincoln,2001). Issues of ontology and epistemology are then,closely related in their influence on physiotherapy prac-tice, as beliefs about what really exists (e.g. in relation tothe body) will have a clear impact on ‘clinical knowl-edge’ and decision-making. Taking ontology and epis-temology together to reflect a person’s fundamentalbeliefs about the world and how the world can beknown is often referred to as paradigm or worldview(Guba and Lincoln, 2004). Just as these issues impactthe way physiotherapists approach clinical practice,they also impact the way researchers approach inquiry.

Previous literature has debated issues around knowl-edge and practice epistemology to guide and representthe physiotherapy profession, largely advocating for adiversity of approaches to knowledge generation andapplication that reflect the multi-faceted nature of phy-siotherapy practice (Edwards and Richardson, 2008;Higgs and Titchen, 1995; Noronen and Wikstrom-Grotell, 1999; Parry, 1997; Plack, 2005). This paperextends these discussions by examining the argumentthat in a field as (ontologically) complex as physiother-apy, a single, consensus-based practice epistemology isinsufficient. We contend that this is so by illustratingthe parallels between ‘expert physiotherapy practice’and ‘bricolage’, an approach to practice epistemologythat embraces multiple ways of knowing and applyingknowledge in physiotherapy care. Drawing on empiri-cal evidence describing expertise in physiotherapy, weargue that embracing bricolage and its many ways ofknowing in practice forms a foundation for the theoryand practice of expert physiotherapy, that is, both inno-vative in conceptualization as well as beingmore reflec-tive of the true depth of complex expert practice. Themulti-faceted approach to physiotherapy knowledgeand practice found in bricolage is not only importantfor its relationship to expertise, but because knowledgeitself evolves with every change in the socio-culturalpolitical life of physiotherapists, clients, and societies.

In this paper, we suggest that an understanding ofepistemology through pluralism, found in the notionof bricolage, is a theoretically rigorous and empiricallygrounded fit for conceptualizing the knowledge thatcomposes, enacts, and arises from expert physiother-apy practice. We then extend this more complexconceptualization of ‘epistemological bricolage’ toquestion the authoritative status of expertise in phy-siotherapy, challenging the epistemological basis for

claims that those who are designated experts inrelation to current approaches to physiotherapy prac-tice ought to be considered ‘right’, ‘true’, or ‘ideal’.We will build on the critique that contemporary phy-siotherapy practice is derived, to a large extent, froma biomechanical view of the body that is theoreticallyand practically limited in its scope (Nicholls andGibson, 2010), and, in a similar vein, argue that inter-preting and enacting expert physiotherapy as bricolagewill help to move physiotherapists in more critical andself-conscious directions. As opposed to portraying anartificial and polemical opposition between the biome-chanical approach to physiotherapy practice and theapproach of a bricoleur, we emphasize that physiother-apy as bricolage integrates biomechanical concernsinto a broader, contextually aware orientation to phy-siotherapy care.

Implicit in our argument is the assumption that allphysiotherapists who are interested in and dedicated toimproving the quality of care they provide in their prac-tice are themselves already endeavoring to move toward‘expertise’ in physiotherapy. In this way, bricolage pro-vides a theoretical understanding of the goal that issought by physiotherapists in general, to the extent thatphysiotherapists may be understood as seeking toachieve expertise in their practice. We will conclude byproviding a resolution to the apparent paradox of advo-cating for one encompassing approach to understandingexpertise in physiotherapy, through bricolage,while sim-ultaneously claiming to de-stabilize the authoritativestatus of any single approach. To set the context forthis discussion, we outline documented differencesbetween physiotherapists in terms of epistemologies, ap-proaches, and professional identities with respect to thepractice of physiotherapy. First though, we introducethe concept of the bricoleur and bricolage.

BRICOLAGE: DOING EPISTEMOLOGYDIFFERENTLY

Bricoleur is a French word that connotes a handymanor handywoman who makes use of any or all of thetools at hand to complete a task (Denzin and Lincoln,2005; Kincheloe, 2005). Initially introduced to thesocial sciences by Levi-Strauss (1966), bricolage (i.e.the product of a bricoleur) was premised on the under-standing that the cultural domain is immenselycomplex and unpredictable (Kincheloe, 2005), thusinsinuating that a bricoleur ought to make use of asmany tools as possible to understand and respond tothis complexity. As an anthropologist teasing apartscience and magic, Levi-Strauss ‘engaged in debatesabout the modes of thinking exhibited by the then

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modernWestern societies and the tribes andnatives en-countered by the early anthropologists and ethnogra-phers of the nineteenth and twentieth century’(Gobbi, 2005). Reluctant to privilege one mode ofknowing over another, Levi-Strauss instead arguedthat it is better to compare science andmyth ‘as twopar-allel modes of acquiring knowledge that have equal val-idity’ and represent ‘two strategic levels at which natureis accessible to scientific enquiry: one roughly adaptedto that of perception and the imagination; the other at aremove from it’ (Gobbi, 2005). This notion of embra-cing multiplicity rather than privileging receivedmodes of knowing/ways of doing forms the conceptualbasis for being a bricoleur.

While the notion of bricoleur as one who embracesmany ways of knowing and doing has been applied to avariety of domains, we focus here on a bricoleur’sapproach to understanding knowledge in general(Denzin and Lincoln, 2005; Kincheloe, 2005); thisis particularly relevant to an inquiry of beliefs aboutknowledge in physiotherapy. Denzin and Lincoln(2005) conceive of a bricoleur as one who is intellec-tually informed, widely read, and able to draw ondiverse conceptions of reality and knowledge – orparadigms – of interpretation. Such emphasis on onto-logical and epistemological diversity has become thehallmark of contemporary bricolage:

Because all observers viewanobject of inquiry fromtheir own vantage points in the web of reality, noportrait of a social phenomenon is ever exactly thesame as another. Because all physical, social, cul-tural, psychological, and educational dynamicsare connected in a larger fabric, researchers willproduce different descriptions of an object ofinquiry depending on what part of the fabric theyhave focused. (Kincheloe, 2005)

This excerpt reflects what Kincheloe calls an ontologyof complexity, wherein social, historical, cultural, andpsychological influences on reality are considered sim-ultaneously. Assumptions of such a complex nature ofreality lead to the embracing of ‘diverse epistemologiesfor their unique insights and sophisticated modes ofmaking meaning’, providing alternative frames ofreference for better understanding the world.

Inherent in a position that seeks out various epis-temologies in the process of making knowledgeclaims is the recognition that contextual nuances pre-clude an ability to generalize findings or practices, andthat context affects what meaning different people findin different words and phrases (Lincoln, 2001;McLaren, 2001). A contemporary bricoleur recog-nizes the processual nature of the world, wherein pro-cesses may be more fundamental than isolate entities,or individual objects, to understanding the socio-

cultural world. In this sense, rather than seeking to un-derstand the world in terms of individual (isolate)phenomena severed from their context, a bricoleurseeks to understand the world in terms of contextualrelatedness (e.g. treating a person and their functionalactivities as opposed to a specific joint). Thus, theterm bricoleur embraces an ontology of relationshipsand connections; a bricoleur understands thatculture and ‘self’ are inseparable. This understandingleads to consideration of the bricoleur’s conceptionsof knowledge in general, recognizing that we asresearchers, clinicians, or people in general can onlyobtain knowledge that is ‘shaped tacitly or consciouslyby discursive rules and practices’ (McLaren, 2001),infusing culture into our knowledge base.

This view of knowledge and its generation differsfrom how epistemologies tend to be understood inmuch contemporary research; as a fixed componentof a paradigm or worldview that is deterministic of aresearchers’ approach to inquiry (Guba and Lincoln,2004). Herein lies one of the greatest challenges forthe bricoleur, who is required to develop the imagin-ation necessary to understand and value different per-spectives and the types of knowledge that accompanythem. Building on this, Kincheloe’s (2005) bricoleurappreciates the intersecting nature of contexts: ‘con-textualization is always a complex act, as it exposesconnections between what were assumed to be separ-ate entities’, calling for the bricoleur to see synergiesemerge from the interaction between types of knowl-edge that were previously assumed to be mutuallyexclusive. As Lincoln (2001) surmises,

Kincheloe’s bricoleur is far more skilled thanmerely a handyman/handywoman. This bricoleurlooks for not yet imagined tools, fashioning themwith not yet imagined connections. This handy-man is searching for the nodes, the nexuses, thelinkages, the interconnections, the fragile bondsbetween disciplines, between bodies of knowl-edge, between knowing and understanding them-selves. … It is ‘boundary-work’ taken to theextreme, boundary-work beyond race, ethnicity,sexual orientation, class. It works the marginsand liminal spaces between both formal knowl-edge, and what has been proposed as boundaryknowledge, knitting them together, forming anew consciousness.

‘Extreme boundary work’, however, is no easy task,particularly along the divisions between and amongdisparate paradigms or worldviews. Reflecting on theresearcher as bricoleur, Denzin and Lincoln (2005)acknowledge that paradigms might not be easilymingled or synthesized. That is, one ‘cannot easilymove between paradigms as overarching philosophical

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systems denoting particular ontologies, epistemologies,and methodologies. They represent belief systems thatattach users to particular worldviews’. That prac-titioners and, indeed, many researchers alike taketheir worldviews for granted (insofar that their beliefsystems remain unarticulated) serves to strengthen theattachment they might have to their (perhaps unarticu-lated) worldview. These observations highlight theimportance of examining the ways that culture hascreated people’s beliefs about knowledge and theworld and to look for ways to embrace new perspectivesand insights, reiterating the task at hand for thebricoleur.

We now turn to a discussion outlining the centralbeliefs that have been proposed as the source(s) of phy-siotherapy knowledge and practice, exploring the epis-temologies, paradigms, and professional identities thathave characterized approaches to physiotherapy care.Thereafter, we encourage practitioners to engage inthe kind of boundary-work outlined above so as tode-stabilize the dominant and largely unquestionedconfidence in the definitiveness and authoritativestatus of expertise in physiotherapy practice vis-à-vis amore skeptical approach to knowledge claims thatnecessitates self-critique in all (methodological or clini-cal) decision-making.

CENTRAL BELIEFS INPHYSIOTHERAPY: GUIDES TOPRACTICE

Research on physiotherapy socialization and the devel-opment of expertise in clinical practice has sought toidentify what characterizes excellent physiotherapycare and how novices can pursue excellence in prac-tice. Efforts addressing what it means to provide thebest possible care have focused on a variety ofconcepts, including the exploration of broad ideaspotentially composing the ‘core’ or ‘essence’ of phy-siotherapy. Scholars have variably described the coreof physiotherapy as being inherent in practice epistem-ologies (Edwards and Richardson, 2008), practiceparadigms (Noronen and Wikstrom-Grotell, 1999;Plack, 2005; Thornquist, 2001), and professionalidentities (Lindquist et al, 2006), and in doing sopropose that all other components of practice are insome way influenced by these central beliefs. In thisway, these core or essential elements of approachesto the practice of physiotherapy reflect the notion ofparadigms or worldviews in research, as outlined inthe introduction to this paper. Recall that beliefsabout ontology (the nature of reality) and epistem-ology (the nature of knowledge) are seen as the

foundation on which decisions about specific researchquestions, methods, and analysis strategies areselected. In a very similar way, processes of clinicalreasoning and hypothesis formation, foci and type oftreatments, and assumptions about diagnosis in aclinical context will come from ontological and epis-temological beliefs of physiotherapists. As we prepareto discuss the notion of physiotherapists as bricoleurs,we will focus here on issues related to knowledge andreasoning in clinical practice.

Edwards and Richardson (2008) provided adetailed exploration of the concept of practice epis-temology, suggesting that it is the general orientationof physiotherapists toward knowledge that in essencedetermines their approach to decision-making andcare. They outlined three distinct epistemologies asparadigms of knowledge generation that lead to twodifferent types of clinical reasoning in physiotherapy.The first is the ‘scientific/experimental/positivist’ para-digm that leads to hypothetico-deductive clinicalreasoning, focusing on objective and predictabletypes of knowledge in practice. An example of thistype of knowledge and reasoning would be the sys-tematic identification of which tissue (ligament,tendon, muscle, etc.) is the source of joint painthrough selective tissue tension testing. The remainingtwo epistemologies are ‘interpretive’ and ‘critical’,both leading to narrative clinical reasoning. Narrativereasoning from an interpretive epistemology focuseson contextual influences, socially constructed knowl-edge, and different lived experiences of patients andtherapists. An example of this type of knowledge andreasoning would be the integration of the patients’wishes, lifestyle, and broader life context into (co-)constructing patient-centered goals for physiotherapy.Narrative reasoning from a critical epistemologyfocuses on historically situated knowledge, how indi-viduals have been empowered or disempowered, andhow knowledge might be used for emancipatoryaims. An example of this type of knowledge andreasoning would be the recognition of the need andprocess to advocate for frail elderly clients whorequire further resources to remain independent athome. This work by Edwards and Richardson(2008) provides a clear depiction of how epistemologi-cal beliefs impact on the knowledge sources that arethe foci of the approaches to clinical practice and thetypes of clinical reasoning different practitionersemploy, serving as evidence that methods in phy-siotherapy care are guided by epistemology in similarways as methods in research projects.

Previous research has identified a central ‘model’ ofthe approach taken by physiotherapists as the primarydriver of physiotherapy practice, differing fromEdwards and Richardson’s (2008) suggestion that



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epistemological beliefs compose the essence of the ap-proach to physiotherapy. Noronen and Wikstrom-Grotell (1999) state that ‘human actions, in practice,are guided by the model a person has adopted’,supporting the assertion that the specific practiceapproach taken by physiotherapists will be a functionof central beliefs or practice models. Thornquist(2001) reported on findings from a doctoral disser-tation on the diagnostic and clinical decision-makingapproaches of physiotherapists practicing in differentspecialties of physiotherapy, specifically manual thera-pists, psychomotor therapists (where psychodynamicphysiotherapy focuses on psychological and physicalbalance), and visiting (home-care) therapists. Shefound fundamental differences in practice betweenthese speciality areas of physiotherapy, specifically interms of guiding concerns, aims, and focus of treat-ments. These differences reflect the central beliefs ormodels taken up by physiotherapists in these differentspecialty areas, leading to different types of knowledgethat are used in clinical practice (Thornquist, 2001).The set of beliefs discussed by Thornquist (2001)might best be referred to as practice paradigms,reflecting a persistent, clinically oriented worldviewthat influences which knowledge is predominantlyused in practice and how it will be used (Plack,2005; Shaw, Connelly, and Zecevic, 2010).

A third perspective from which to articulate theessential core of physiotherapy explores notions ofprofessional identity. In their longitudinal qualitativestudy of the first year of practice in novice physiothera-pists, Black et al (2010) found that the emergence ofan individual professional identity was the centraltheme for their participants. Recognizing the impor-tant role that professional identity plays in determiningapproaches to physiotherapy care, these authorssuggest that ‘who you are becoming shapes what youknow or come to know’. Lindquist et al (2006)studied the professional identities of novice phy-siotherapists, finding three distinct identities inphysiotherapy students about to begin working life.The first identity was the ‘empowerer’, focusing on abroad ‘world’ context and the informal knowledge ofthe life of the patient. The second identity was the‘educator’, focusing on an open fluid context andthe practice knowledge that emerges by interactingwith the patient. The final identity was the ‘treater’,focusing on the specific treatment context and theformal knowledge gained in professional education.Each identity was seen as essentially guiding the phy-siotherapist to attend to certain elements of the thera-pist–patient encounter, composing the foundation fortheir entire approach to physiotherapy care.

In their discussion, Lindquist et al (2006) encour-aged educators to find ways to foster the ability of

students who adopted these different types of identi-ties to learn from one another, indicating that the‘best’ physiotherapists will be those who approachcare while drawing on elements of each identity.This theme has recurred in physiotherapy socializationand expertise literature (Edwards et al, 2004; Jensen,Gwyer, Shepard, and Hack, 2000; Lindquist,Engardt, and Richardson, 2010; Resnik and Jensen,2003), suggesting a pluralistic epistemological per-spective might be most appropriate in the physiother-apy profession.

EVIDENCE ON EXPERTISE INPHYSIOTHERAPY

Edwards et al (2004) conducted research on the clini-cal reasoning of expert physiotherapists. Theseauthors found that experts employed each of the nar-rative and hypothetico-deductive reasoning strategiesas outlined in the discussion of practice epistem-ologies above, as opposed to only one single reasoningstrategy in their clinical practice. They found dialecti-cal reasoning among the different approaches, that is‘an interplay between the different paradigms ofknowledge and reasoning processes that are expressedin each of the various clinical reasoning strategies’.This finding provides an explicit commentary that itis through the interaction between epistemologies,types of knowledge, and types of clinical reasoningthat expert physiotherapy practice can be achieved.

Similarly, Jensen, Gwyer, Shepard, and Hack(2000) and Resnik and Jensen (2003) conductedresearch on experts in different practice fields of phy-siotherapy and found that the practice of ‘experts’ wasexemplified by: multi-dimensional knowledge, clinicalreasoning in a collaborative context, a focus on andunderstanding of movement, and communicatingvirtues of caring and commitment. This collection ofdescriptors suggests that approaching practice fromany single practice epistemology might preclude thepossibility of achieving expert practice. The character-istics found in these studies cannot all be locatedin any one epistemology, paradigm, or identity,but are instead achieved by employing different epis-temologies at different moments in the clinicalencounter. These findings provide further credenceto the assertion that expertise in practice results fromthe integration of and interaction between central epis-temological or paradigmatic beliefs.

In 1997, Parry made the astute assertion that ‘phy-siotherapy is multi-paradigmatic and there is little tobe gained by physiotherapists turning their faces ortheir minds against anything’. This statement echoes



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the sentiments of bricolage outlined above and illus-trates the areas of potential overlap and connectionbetween the notions and practices of physiotherapistsand bricoleurs. As has been explored in the discussionof practice epistemologies, paradigms, and pro-fessional identities, there seem to be different funda-mental beliefs that characterize various approaches toclinical reasoning and decision-making in physiother-apy care. These fundamental beliefs reflect the notionof worldview, including important assumptions aboutepistemology in practice. However, research suggeststhat expertise is only to be achieved through the inte-gration of these various fundamental beliefs, mirroringthe multiple epistemological perspective of the brico-leur. As such, the concept of bricolage introduced inthis paper may provide a useful theoretical tool forconceptualizing and operationalizing the notions ofexpertise found in the literature presented here.

DISCUSSION: PHYSIOTHERAPISTS ASBRICOLEURS

Having summarized the literature on epistemologies,paradigms, and professional identities in terms oftheir relationships to expertise in physiotherapy, wenow turn to consider expert physiotherapists ‘as brico-leurs’. As a starting point, expert physiotherapists asbricoleurs engage with issues of ontology and epistem-ology in order to explore and understand their own as-sumptions about the nature of the world and theirknowledge of it. This self-examination of the relation-ships between self and culture, reality and knowledge,and assumptions and actions forms the foundation forbecoming/embodying a bricoleur. Such a startingpoint extends the current emphasis on reflective prac-tice during the education and training of studentphysiotherapists, and thus invites physiotherapy curri-culum to pay attention to the depth of reflexivityespoused by bricolage. By de-constructing ourassumptions about ontology, epistemology, and howthese ought to inform our clinical practice, weprepare ourselves to engage with types of knowledgewe may not have previously recognized or valued; sim-ultaneously, we are able to view dominant and author-itative knowledge with renewed skepticism andawareness of the socio-cultural, historical powerwithin which that knowledge is situated.

While theoretical models enjoying wide acceptancein physiotherapy education and practice, such as theInternational Classification of Functioning, Disability,and Health (ICF), encourage reflection on a widerange of contextual factors, the notion of physiother-apy as bricolage encourages a level of self-reflection

and awareness that extends the ICF into greaterdepth. The ICF encourages a physiotherapist to con-sider body functions/structures, activities, and socialparticipation, and as such invites critical reflectionon the goals of rehabilitation provided by physiothera-pists. Building upon this critical reflection, the notionof bricolage encourages physiotherapists and traineesto embrace multiple ways of reflecting upon howsocio-cultural norms influence their approach theitems identified within models such as the ICF.

An important effect of embracing multiple epistem-ologies is the recognition of the tentative and hesitantnature of knowledge claims about the world, the body,and clinical practice. In valuing a variety of ways ofknowing about the world, a bricoleur understandsthat each of these ways of knowing deserves to be pri-vileged throughout inquiry into the nature of healthand illness. This leads to a perspective on knowledgethat holds assertions in constant critique, understand-ing that knowledge on which clinical decisions arebased is always changing through the influence ofsocio-cultural power. While physiotherapists in train-ing often seek foundational rules or guidelines toinform their approach to clinical care, understandinghow the patterns they learn are influenced by thesepower dynamics will help students to recognize thateven the most obvious and common practices oughtto be re-visited and held in question. Such a perspec-tive ‘provides bricoleurs with the dangerous knowl-edge of the multi-vocal results of humans’ desire tounderstand, to know themselves and the world’(Kincheloe, 2005). It is through this critique ofone’s own assumptions that a bricoleur can begin to(de)construct knowledge and develop the tentativebelief system that permits an embracing of multipleepistemologies.

Applying this lens to the knowledge base for phy-siotherapy helps us to recognize that biomedical andbiomechanical research and knowledge largely domi-nate the evidence base for physiotherapy (Higgs andTitchen, 1995; Parry, 1997; Williams, 2007). In sub-scribing to the authoritative nature of this biomedicaland biomechanical knowledge base, derived from asingular positivist epistemology, ‘we may have inad-vertently reduced the subtle complexities of healthand illness to a narrow set of biological principles’(Nicholls and Gibson, 2010). Indeed, the view ofthe person as (a) body and the body as machine-likehas historically dominated physiotherapy researchand practice prevents physiotherapists from embracingthe holistic approach to practice that characterizesexpertise in physiotherapy (Ekdahl and Nilstrun,1998; Nicholls and Gibson, 2010). Focusing on a bio-mechanical impairment present within one specificdomain of functioning, for example, range of motion



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or muscle strength at a single joint, prevents phy-siotherapists from considering the constellation offactors that influence both the care that is providedand the outcomes achieved: factors including, forexample, work/labor-related stress, psycho-socialelements of pain, and client confidence in the prac-titioner. Becoming entrenched in this biomechanicalapproach to care that acts to defend and demarcatephysiotherapists’ territory leads to the de-valuing ofalternative understandings and perspectives of phy-siotherapy practice, precluding the multiple ways ofknowing and applying knowledge that are found inphysiotherapy expertise. Thus, physiotherapists whostrive to achieve expertise in their practice are encour-aged to de-construct their habitual practices – what-ever they may be – and instead focus on embracingalternative understandings. As Nicholls and Gibson(2010) have said, this might typically entail a lesseningof one’s grip on all things biomechanical so as toembrace more socially derived insights, but to the phy-siotherapist whose practice is typically of an educatingor empowering orientation (Lindquist et al, 2006),s/he would be equally encouraged to broaden his/herperspective to include (more) biomechanical con-siderations. The role of a bricoleur is to weave togethera myriad of evidence and insights, suggesting thatmultiple types of knowledge and clinical reasoningstrategies, not just those of the dominant biomedicalperspective, might contribute to improving the prac-tice of a physiotherapist seeking expertise.

Kincheloe (2005) considers the knowledge of brico-lage ‘dangerous’ because of its potential to underminedominant bodies of knowledge and ways of knowing ingeneral. This is true insofar as constituents of dominantperspectives necessarily have a vested interest in main-taining their positions of power, and therefore maymarginalize those individuals (the bricoleurs) whoadvocate for a collage of claims and insights thatemphasize the complexity and partiality of culturallymediated professional and practice knowledge. Phy-siotherapist practitioners who enjoy recognition andesteem for their specific technologies or techniques ofcare for the body tend to have less interest in consider-ing approaches to evidence, knowledge, and practicethat might de-stabilize their own approach, leading tothe often unintentional or unnoticed de-valuation ofalternative approaches. By embracing partiality, a bri-coleur’s criticality calls into question the authorityand privilege of singular approaches to contemporarysocial science, including those seen in health care; indoing so, a bricoleur de- then re-constructs theconcept of expertise as a more holistic, less entrenchedway of knowing for physiotherapists.

By embracing multiple epistemologies in practice,physiotherapists acting as bricoleurs consider not only

knowledge that is readily obtained through observationand assessment, but the emotional, social, and politicalexperience of the injury, disease, or condition.Anortho-pedic physiotherapist as bricoleur recognizes that yearsof physical labor under psychologically stressful con-ditions, the politics of income replacement for employ-ees who are unable to work, and altered roles in homeand family life due to pain might further complicaterecovery from chronic over-use injuries. A neurologic-focused physiotherapist as bricoleur understands that itmight not just be function and lifestyle that are soughtduring recovery from a stroke, but re-establishing thevery social identity from which a person derivesmeaning and quality in his or her life. An acute care phy-siotherapist as bricoleur might understand the impor-tance of individual characteristics of the patients theyare treating in determining the applicability of resultsof randomized trials, while educating their patientsfrom an empathetic perspective that recognizes andvalues input from the family as well as other membersof the health-care team. Physiotherapists acting as brico-leurs consider the multiple contextual and dynamicfactors that impact not only the care they choose toprovide, but the perspectives, needs, and preferencesof their clients; this in turn describes the approach toreasoning that characterizes expertise in physiotherapy.

CONCLUSION

The view of physiotherapists being seen as – or becom-ing bricoleurs intends to embrace multiple ways ofknowing and reasoning, and in doing so it puts fortha perspective that de-constructs the authority ofclaims to expertise. In relation to expert physiothera-pists, we propose that the idea of a bricoleur we havepresented is a desirable interpretation of what itmeans to be an expert. Inherent in this position isthe apparent paradox of making a claim to a betterapproach to knowledge and practice (through brico-lage) while claiming that no approach can be betterthan another. In the interest of avoiding being paral-yzed by such an apparently relativist position, the useof the term bricoleur recognizes: (1) that we are privi-leging a combination of knowledges and knowledgeapproaches; and (2) that clinical decisions must bemade with the knowledge that has been sought andacquired by the practitioner. Even if a bricoleur ischarged with having one central belief, the belief isin multiplicity; the charge of replacing one dominantview with another dissipates in the light of bricolagethat seeks knowledge from multiple perspectives andthat recognizes the value in each type of knowledge.

We are troubled by definitions of expertise that elicitnotions of the ideal, the goal, the true way of doing



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things. We believe that it is important to emphasize thatclaims to expertise always consist of partial knowledgeclaims that emphasize different elements of physiother-apy practice. We wish to avoid claims to expertise thatemphasize the authoritative status of experts within theprofession of physiotherapy, instead advocating for aview of expertise that embraces multiple types of knowl-edge inpractice andemphasizes the tentative, contextual,and dynamic nature of physiotherapy epistemologies.

Through our exposition of bricolage, we haveemphasized that embracing knowledge from a varietyof partial perspectives characterizes ‘physiotherapistsas bricoleurs’. Physiotherapists who are bricoleurs donot make claims to authoritarian expertise, butinstead forefront the tentative nature of their knowl-edge claims, recognizing the roles of history, society,and power in creating and changing what they know.Building on this critical and hesitant knowledgebase, they draw from those bodies of knowledge thatare undervalued and marginalized, using philosophi-cal and theoretical insights to explore new and variedways to approach physiotherapy practice. Perhapsthis perspective of multiple epistemologies, drawingon more types of knowledge instead of less, will helpto move the physiotherapy profession toward a moreholistic understanding of health and illness.

Declaration of interest: The authors report nodeclaration of interest.

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Physiotherapy as bricolage: Theorizing expert practice

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