An Introduction to Environmental Physiotherapy

Original Editor - Filip Maric Top Contributors - Pierre Roscher, Tarina van der Stockt, Lucinda hampton, Kim Jackson, Jess Bell, Olajumoke Ogunleye, Filip Maric and Robin Tacchetti

Introduction

Environmental Physiotherapy (EPT) started as an idea that encompassed a new field of physiotherapy, where key aspects of the relationship between the environment, human health and functioning and physiotherapy are considered and respected to mutually benefit patient health, the physiotherapist and the environment. EPT covers areas of clinical practice, research and education, and bridges the various clinical specialities within physiotherapy (musculoskeletal, cardiology, neurology etc.).

What EPT is About

The field of EPT is rapidly developing and will expand greatly as more physiotherapy clinicians, students, researchers and educators get involved. To follow and contribute to these developments it is necessary to understand their broader context.

The Big Global Issue

Nature provides us with essential resources to sustain human life such as air, water and food. As human populations have grown, our need to consume resources has increased, but we have not replenished and rehabilitated the eco-systems that we have damaged in our quest to develop industries and technologies. Human industrial activity has destroyed natural habitats to build cities, burnt down forests to create grazing lands for our cattle, and mined the earth to extract minerals and precious metals for advancing technologies. All of these activities have had the negative effect of degrading natural ecosystems through air, water and land pollution, loss of biodiversity, global warming and more. Industrial, technological and economic growth have sacrificed planetary health and wellbeing. It is unfortunately the poorer communities with the fewest resources that suffer most from these environmental and health problems, thus further highlighting considerable social and environmental inequality around the world.

** Historically, the healthcare sector has focused more on human health over environmental health despite the link between the two. Promoting awareness between human and environmental health can be a pivotal role of the healthcare sector.

Examples of the Impact of a Warming Climate

A warming climate affects human health directly and indirectly. Increasing temperatures affect maize crops around the world, and create more suitable conditions for infectious diseases. Extreme weather is also linked to mental health issues due to sleep irritation and lack of sleep caused by extreme heat.

The Global Move Towards Change

Approaches such as EcoHealth, OneHealth, Planetary Health and Sustainable Healthcare are all based on the understanding that human health and flourishing depend on our environment. The UN Agenda 2030 Sustainable Development Goals are closely related to these approaches in that they further endorse the understanding that human health and wellbeing cannot be achieved without establishing a natural and social environment that supports it. It is now time for physiotherapists to join this global movement and make the best possible contribution that we can.

Essential steps towards an environmental physiotherapy

In order for us to change, we first need to look at our own profession and reflect on ways that we can align ourselves with a more environmentally aware and responsible way of thinking and practising physiotherapy. Change may take some time to occur, but the following basic steps may guide the process of crossing over into an environmentally friendly physiotherapy practice:

Step 1: Understanding the relationship between health and the environment

Step 2: Identifying the aspects of our physiotherapy practice that need to change

Step 3: A willingness to make a change based on new knowledge

Step 4: Expanding on this new field of physiotherapy, and inspiring others to do the same

Theoretical and Scientific Foundations for EPT

We are in need of developing robust theoretical and scientific foundations for environmentally aware and responsible physiotherapy. To develop such foundations for environmental physiotherapy, it will be critical that we learn from traditional and indigenous ways of life, knowledge and the way they have long integrated environment, health and community with each other (eg Maori definitions of health and the body, Sami understandings of healthcare and related practices). We will also need to draw on philosophical and social science work that will enable us to integrate concepts of environmental ethics, social justice and equity into physiotherapy.

Understanding the ecological foundations of human health, function and wellbeing

There is a need to understand the ecological foundations of human life on planet Earth by drawing on earth history, current understanding of nature’s contribution to people, ecosystems services, the ecological determinants of health and more.

Understanding the ecological foundations of human health and functioning has extensive implications for physiotherapy. For example, the way we think about anatomy and physiology, or the environmental composition of the human body, including oxygen exchange, cell composition, the role of nutrients, and the gut-microbiome.

Environmental issues and their health impacts

Another key foundation for environmental physiotherapy is a robust understanding of the global environmental issues we are facing today alongside their health impacts. These include, for example: biodiversity loss, climate change, air and plastic pollution and extreme weather events, and the way these contribute to a range of health problems, directly and indirectly, relevant to physiotherapy.

We will also need to understand the local environmental issues and their health impacts that physiotherapists will be dealing with in different places around the world.

The causes of global environmental change and related health issues

There is an urgent need to understand the causes of global environmental degradation if we are to improve the health problems resulting from it. This includes our beliefs and values, colonialism, agriculture, industrialism, capitalism, racism and more. Importantly, we need to understand how to these relate to health, functioning and physiotherapy, which includes both how we perpetuate them and how we might help to address and reduce them directly in and outside of physiotherapy.

EPT in Patient Care

There is a need to engage with and learn from patients to understand the ways in which the environment is perceived as a threat or support to their health and wellbeing.

In addition, we must explore the benefits for physical and mental health provided through nature-based interventions (including outdoor exercise and greenspace exposure). The prescription of active transport provides a good example of the opportunities that could be harnessed here.

Active transport: A simple way for physiotherapists to encourage change

As physiotherapists, we have a unique opportunity to contribute to planetary health and wellbeing. We can advocate for and encourage active transport concepts such as cycling to and from work. There are of course challenges and barriers to active transport, but European countries like the Netherlands, Denmark and Germany have successfully implemented this concept by ensuring that the infrastructure and other necessary facilities are set up for this initiative.

Watch this video on Active Transport:

The environment in physiotherapy specialty fields and related pathologies

Building on active transport as an exemplary environmental physiotherapy intervention in the context of physical activity, there is a need to understand the way in which the environment relates to existing physiotherapy specialty fields and the pathologies and health challenges they seek to address. This understanding will enable us to improve practice for the benefit of patient health across musculoskeletal, neurologic, paediatric, and cardio-pulmonary physiotherapy, as well as physiotherapy in mental health, occupational health and ergonomics.

Sustainable Physiotherapy

In addition to patient care, the environment also needs to be considered in the operations and provision of physiotherapy in different settings. This requires a general understanding of the concept of sustainability and its applications to different parts of physiotherapy service provision.

Physiotherapy as an environmentally friendly practice

Environmentally friendly physiotherapy practice utilises a "low tech", hands-on and interpersonal approach to managing patients by focussing on movement, touch and communication as its primary tools. Though more research is needed in this area, there is a high likelihood that physiotherapy has the potential to minimise the negative impact that healthcare systems have on the environment.

The environmental cost of physiotherapy practice

Despite being a largely environmentally friendly healthcare approach, physiotherapy also has an environmental footprint of its own that could be further reduced. For example, the use of non-renewable resources like paper records and disposable products being used to run a physiotherapy service may also contribute to the environmental cost. This also includes aspects such as the amount of unnecessary electricity being used, and ways to use less electricity (e.g. sun/air drying linen and towels instead of using a dryer), and exploring options to use energy from renewable sources.

Transportation costs related to physiotherapy

Building on our understanding of the potential of active transport, looking at how patients reach our services may be another way to reduce our environmental footprint. Incentives may be offered to patients who are able to walk or cycle to appointments where possible and appropriate. Patients may be encouraged to adopt this principle with other appointments or errands too where appropriate. We also need to look at transportation for clinicians to attend meetings, congresses and functions relating to our own clinical upskilling, and implement and adopt ways of reducing the impact that transportation has on the environment.

Environmentally friendly clinical setup

Most physiotherapy practices are indoors and require additional lighting and air-conditioning, but what if there was a way to incorporate natural light and airflow into our setups, without compromising patient privacy and care?

Each of these aspects may seem small and you may be thinking "how much can an individual really do to save the environment". While it is generally true that the major contributors to negative environmental change are big industries, it is also the collective effort of individuals that has a meaningful impact on the environment and can help tip the scales toward a sustainable future.

Beyond the physiotherapy clinic

The closely related environmental and health challenges we are facing today require extensive efforts across all sectors of society to achieve the transformative change called for in the Sustainable Development Goals. This also means going beyond the usual confines of our current practice, reaching out to go the extra mile, and contributing to novel approaches and solutions. For example, physiotherapists are excellently positioned to promote, develop and support:

• Environmentally friendly and physical activity supportive urban planning and work environments
• Natural environments as clinical settings
• Environmental conservation, care and restoration as a physiotherapy intervention

Physiotherapy and the other-than-human

Physiotherapy is related to the environment in many more ways that are yet to be explored. Some of these may include:

• The understanding and role of animals in animal physiotherapy, as well as animal-assisted physiotherapy

• The role of plants in physiotherapy clinic rooms, the rehabilitation process and experience, in client lives, health and living spaces, as nutrition, medicine, clothing, shelter, and more

• The role of tools and other objects in physiotherapy, including their contribution to the clinical environment of physiotherapy, as used natural resources, and the role of digitalisation in the future of sustainable physiotherapy

* The fundamental motivation and belief underpinning this page is ultimately that it is time to recognise and appreciate the fundamental role of the environment in our daily lives, health and professional physiotherapy practice, and adjust our thinking and actions accordingly.