Physiotherapy Theory and Practice An International Journal of Physical Therapy ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20 Physiotherapists’ conceptions of movement awareness– A phenomenographic study Sirpa Ahola, Liv Helvik Skjaerven & Arja Piirainen To cite this article: Sirpa Ahola, Liv Helvik Skjaerven & Arja Piirainen (2022) Physiotherapists’ conceptions of movement awareness– A phenomenographic study, Physiotherapy Theory and Practice, 38:10, 1438-1452, DOI: 10.1080/09593985.2020.1868028 To link to this article: https://doi.org/10.1080/09593985.2020.1868028 © 2020 The Author(s). Published with license by Taylor & Francis Group, LLC. Published online: 04 Jan 2021. Submit your article to this journal Article views: 1307 View related articles View Crossmark data Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iptp20 PHYSIOTHERAPY THEORY AND PRACTICE 2022, VOL. 38, NO. 10, 1438–1452 https://doi.org/10.1080/09593985.2020.1868028 Physiotherapists’ conceptions of movement awareness– A phenomenographic study Sirpa Ahola MSc, PTa, Liv Helvik Skjaerven PhD, PTb, and Arja Piirainen PhD, PT a aDepartment of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland; bDepartment of Function and Health, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway ABSTRACT ARTICLE HISTORY The phenomenon of movement awareness requires more attention to make it explicit in phy- Received 26 December 2019 siotherapy. The aim of this study was to explore the variation in physiotherapists’ conceptions of Revised 28 July 2020 movement quality, focusing on movement awareness. The informants were 15 physiotherapists Accepted 22 November 2020 from a variety of physiotherapy fields. We collected data through two group interviews and used KEYWORDS the phenomenographic method to analyze them. Four themes emerged from the data: 1) Being in Phenomenography; contact with one’s own moving body; 2) Increased awareness of movement experiences; 3) reflection; conception; Interrelationship between physiotherapist and patient; and 4) Better understanding of movement movement awareness; awareness. These themes varied by four descriptive categories of the movement awareness movement quality; phenomenon: (I) Hesitation regarding own movement experiences; (II) Momentary contact with physiotherapist own movement experiences; (III) Presence in movement awareness and (IV) Better understanding of others’ movement awareness. The physiotherapists’ understanding of the movement awareness phenomenon widened through three critical aspects in the descriptive categories: Recognizing one’s own movement awareness, Distinguishing one’s own and others’ movement awareness and New insights into implementing actions related to movement awareness in physiotherapy. These results can expand the understanding of the phenomenon of movement awareness among physiotherapists, although further research is needed. Introduction Pylvänäinen, 2018). The third stresses the technical approach to increase movements’ perfection and repeti- Physiotherapists are expected to provide evidence-based tion (Ketelaar et al., 2001; Stephenson and Stephens, treatment of human movement and of the phenomenon 2018) using tools (Thomas et al., 2001), and the fourth of movement quality and movement awareness. Human perspective explores the movement experience itself movement is a wide-ranging phenomenon and can be (Ahola, Piirainen, and Skjaerven, 2017; Blaauwendraat, explored from different perspectives, such as the biome- Levy Berg, and Gyllensten, 2017; Olsen et al., 2017). dical, human science, naturalistic, social interaction, or The biomechanical perspective focuses on important holistic perspectives (Shumway-Cook and Woollacott, components for reaching peak quality performance 2017; Wikström-Grotell, 2016). The holistic perspective (O’Sullivan, Schmidt, and Fulk, 2019), whereas the biop- sees human movement as the center of meaning and as sychosocial perspective sees that emotional, cognitive, happening in a bodily encounter with the world environmental, and relational factors all influence (Merleau-Ponty, 2012). movement quality (Moore and Yamamoto, 2012). The Movement quality has various contents and is used in existential perspective sees the phenomenon of move- various contexts in physiotherapy. However, grasping its ment quality as a two-layered model (Skjaerven, 2019; nature appears to be challenging (Skjaerven, 2019; Skjaerven, Gard, and Kristoffersen, 2008), in which the Skjaerven, Gard, and Kristoffersen, 2008; Skjaerven first layer provides a description of general movement et al., 2018). The phenomenon of movement quality quality, representing a synthesis of all interacting move- can be described from different perspectives: the first, ment processes; and the second layer provides the biomedical perspective emphasizes a pathological, a differentiated perspective-specific structure of move- mechanical dysfunction with quantifiable terms ment elements and aspects. Movement quality can be (Tamm, 1993), aiming to normalize movement described as an umbrella embracing and constantly (Farjoun et al., 2020). The second expressive perspective interacting through all four biomechanical, physiologi- emphasizes movement improvisation (Parviainen, 2018; cal, psychosocio-cultural, and existential perspectives of CONTACT Sirpa Ahola sirpa.ahola@metropolia.fi Department of Sport and Health Sciences, University of Jyväskylä, Jyväskylä FI-40014, Finland. © 2020 The Author(s). Published with license by Taylor & Francis Group, LLC. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc- nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. PHYSIOTHERAPY THEORY AND PRACTICE 1439 human movement, expressed in diverse movement movement awareness are promoted (Probst et al., 2016), aspects and qualities (Skjaerven, Gard, and as these are essential elements of health and wellbeing, Kristoffersen, 2008). because of their many positive health influences on Movement awareness (i.e. becoming aware of, identify- movement potential and quality of life, such as tension ing and monitoring subtle nuances of movement quality) regulation and safety experience (Ogden, Minton, and can be described as how movements are performed and Pain, 2009; Song and Yu, 2019; Wikström-Grotell, 2016; experienced, identifying movement reactions of internal, World Confederation for Physical Therapy, 2017). relational and environmental conditions (Skjaerven, 2019). Biopsychosocial perspective-based approaches, such The definitions of movement awareness and body aware- as cognitive-behavioral therapy and motivational inter- ness overlap. Ginzburg, Tsur, Barak-Nahum, and Defrin viewing, are also used in physiotherapy (Guerrero, (2014) described body awareness as sensitivity to bodily Maujean, Campell, and Sterling, 2018; Holopainen signals to become aware of bodily states and to identify et al., 2020; Toye, Seers, and Barker, 2017). Human subtle bodily reactions. Body awareness is a complex, health and well-being, and the interrelationship between multi-dimensional construct (Mehling et al., 2011). health, stress and coping strategies are the focus of the Mehling et al. (2011) defined body awareness as the sub- salutogenic orientation (Antonovsky, 1987; Mittelmark jective, phenomenological aspect of proprioception and et al., 2017). Salutogenic orientation-based approaches interoception that enters conscious awareness, modifiable such as Basic Body Awareness Therapy (BBAT) are used by mental processes such as attention or attitudes. The and needed in physiotherapy to empower the indivi- phenomenon of movement awareness offers a specific duals (Gard, Nyboe, and Gyllensten, 2020; Gyllensten, focus on human movement and differs from body aware- Jacobsen, and Gard, 2019; Skjaerven, 2019; Skjaerven ness, which is more general (Skjaerven and Gard, 2018). et al., 2018). BBAT is a physiotherapy approach that According to Brown and Ryan (2003), awareness is derived promotes movement quality through movement aware- from human consciousness and experiences, and includes ness (Gard, Nyboe, and Gyllensten, 2020; Skjaerven, being relaxed and present. Movement awareness is 2019; Skjaerven et al., 2018). The therapeutic compo- expressed in the body and can be observed through obser- nents to promote movement quality through increasing ving movement quality (Skjaerven, Gard, and movement awareness in BBAT are: 1) the physiothera- Kristoffersen, 2008; Skjaerven, Kristoffersen, and Gard, pist’s own movement awareness as a precondition; 2) 2010), which in turn expresses bodily self-consciousness a platform for promoting movement quality; and 3) (Gyllensten, 2012). Movement quality and movement therapeutic strategies, such as strengthening the pre- awareness are closely related (Skjaerven and Gard, 2018). sence of being in movement, when guided through the Penfield (2006) described movement as our “royal road” to seven-step Movement Awareness Learning Cycle the unconscious. Being in movement focuses on under- (Skjaerven, 2019; Skjaerven, Kristoffersen, and Gard, standing the value and qualities of human movement from 2010). the individual’s perspective (Arnold, 1979; Brown, 2013). The promotion of movement awareness involves the Physiotherapists meet clients with multifactorial whole person, which places high demands on the phy- movement disorders that reveal difficulties in their con- siotherapist’s own movement awareness (Skjaerven and tact with themselves, others and/or the environment, Gard, 2018). Through the body’s ability to sense, phy- which affect movement quality, daily function and par- siotherapists can express their experiences, which can ticipation (Gyllensten, Skär, Miller, and Gard, 2010; support their self-confidence in clinical practice with the Skjaerven, Gard, and Kristoffersen, 2008; Skjaerven, patient. (Ekerholt and Bergland, 2019). Physiotherapists’ Kristoffersen, and Gard, 2010). To optimize wellbeing, understanding of their own movement quality is impor- it is important to unify physical and mental aspects, tant because they must be able to be present and atten- which is a core mental health component of (Probst tive in practical sessions, which are mostly based on et al., 2016) and needed in all fields of physiotherapy. non-verbal communication (Hedlund and Gyllensten, The aim of physiotherapy is to maximize people’s move- 2010, 2013). The physiotherapist’s own movement ment potential for participation in daily life (World experience and sensitivity to movement quality serves Confederation for Physical Therapy, 2017). For phy- as a background in the therapeutic situation, encoura- siotherapists, from an educational point of view, it is ging others to become more present and be in contact important to focus on what they can learn through close with their own movements (Covington and Barcinas, attunement to the human body (Jensen et al., 2017b, 2017; Gyllensten, Skär, Miller, and Gard, 2010; 2017a), in particular human movement Hedlund and Gyllensten, 2010, 2013; Råsmark, Richt, (Wikström-Grotell, 2016). The individual is empowered and Rudebeck, 2014; Skjaerven, Kristoffersen, and Gard, when their physical activity, functional movement and 2010). 1440 S. AHOLA ET AL. Reflection is the process of becoming more aware of world (Åkerlind, 2005, 2008; Marton, 1981; Marton an experience, event, state, or perception (Dilthey, 1989; and Booth, 2013). From a phenomenographic perspec- Mezirow, 1998). An important stage in reflection is the tive, the ways of experiencing the particular phenom- step from the first-order to the second-order perspec- enon are referred to as a second-order perception, and tive, when a person criticizes the premises upon which the investigation is directed at the variation in the infor- they have experienced a challenge (Mezirow, 1998). The mants’ ways of understanding their experiences reflection process can be described in different ways. (Marton, 1981). Mezirow (1991, 1998) developed the often-used model Phenomenographic research focuses on experience at of seven levels of reflection, in which the first four levels the collective level, the full range of possible ways of concern consciousness and the highest three levels cri- experiencing the phenomenon in question, at tical consciousness. As understanding the processes and a particular point in time (Åkerlind, 2005). premises of a phenomenon such as human movement is Phenomenographic research data can be collected important. Mezirow’s levels of reflection are useful when using many methods such as written essays, documents, focusing on movement sensations, and may lead to observations, and drawings (Åkerlind, 2018). The most insights into enhancing awareness of our bodies. To common data collection is interviewing (Åkerlind, understand movement, one must recognize the elemen- 2018). Phenomenography is a data-driven approach, tary nature of one’s own movement experience and which means that all findings arise from the data realize that a reflective second-order understanding of (Åkerlind, 2005, 2008). In phenomenographic analysis, movement quality exists (Mezirow, 1998). In terms of critical aspects can be identified within descriptive cate- reflection, becoming aware of bodily states with gories that represent the expanding awareness of the a particular focus on movements, and expressing move- phenomenon under study (Åkerlind, 2005; Marton and ment quality sensations orally in words (i.e. verbalizing) Booth, 2013; Paakkari, Tynjälä, and Kannas, 2011). can be challenging (Ahola, Piirainen, and Skjaerven, 2017). Previous studies have shown that the physiothera- Informants pist’s ability to be mentally and physically attentive is In accordance with the phenomenographic research the basis for professional communication through method, it was essential to recruit informants who had observing, understanding, and promoting movement clinical experience as physiotherapists and who were quality, which promotes transference to patients during willing to describe their conceptions of movement qual- physiotherapy (Hedlund and Gyllensten, 2010; ity by focusing on movement awareness, which can be Skjaerven, 2019; Skjaerven, Kristoffersen, and Gard, difficult to describe in words (Blackburn and Price, 2010). Physiotherapists’ interpersonal and communica- 2007). The informants recruited for this study were 15 tion skills (O’Keeffe et al., 2016), their role as part of physiotherapists. They had applied to participate during a multidisciplinary team (Lau, Skinner, Lo, and a postgraduate introductory BBAT, a physiotherapeutic Bearman, 2016), their motor imagery during phy- approach well known for its focus on promoting move- siotherapy practice (Dickstein and Deutch, 2007), and ment quality through movement awareness. We their role in identifying gaps in ethical issues (Swisher, assumed that the informants were curious about move- 2002) have all been examined in previous studies. ment quality and movement awareness. The course con- However, there is little research on physiotherapists’ sisted of 40 hours of condensed learning, including conceptions of movement quality that focuses on move- theory, seminars, and movement sessions. ment awareness. The aim of the study was thus to The informants were all female, registered phy- explore the variation in physiotherapists’ conceptions siotherapists, aged 27 to 54 (average age 42), Finnish- of movement quality, focusing on movement awareness. speaking, and born and educated in Finland. They had an average of 15 years of experience as physiotherapists, Methods ranging from one to 30 years (Table 1). They worked in different fields of physiotherapy: Eight in mental health Understanding and describing movement quality while and psychiatry, three in multi-professional rehabilita- focusing on movement awareness from the physiothera- tion for chronic pain or musculoskeletal disorders, and pist’s viewpoint demands a specific research design and one in each of the following fields: family-centered reha- method to reveal physiotherapists’ conceptions. We chose phenomenography as our research design method bilitation, primary health care, special school education, to study how people understand, experience, and and cancer (Table 1). Four of the 15 informants had describe a given phenomenon in the surrounding completed post-graduate courses of shorter duration on, PHYSIOTHERAPY THEORY AND PRACTICE 1441 Table 1. Informants characteristics. Informants (n = 15) Work experience as a physiotherapist (years) Additional PT education Workplace and work sector A 5 s OCPRI B 30 s OCPRI C 18 s OCPRI/OCPUB D 25 l OCPRI E 2 s IWPUB F 28 l OCPRI/OCPUB G >1 - IWPUB H 10 - IWPUB I 13 l IWPUB J 11 l IWPUB K 22 - OCPUB L 13 - OCPRI M 20 - OCPUB N 4 - OCPUB O 24 - OCPUB l = long additional education; s = short-term additional course; IWPUB = inpatient ward, public; OWPUB = outpatient ward, public; OCPRI = outpatient clinic, private; OCPUB = outpatient clinic, public. for instance, breathing, depression, pain, trauma, lym- informants. The interviewer created a permissive, open phatic therapy, riding therapy, Bobath therapy, atmosphere, listening patiently to the informants´ Neurolinguistic Programming, or mindfulness. Four of descriptions (Brinkmann, 2013). The interviewer also the 15 physiotherapists were specialized in psychophy- encouraged the informants to clarify and to illustrate sical physiotherapy (Table 1). their descriptions as much as possible. The study was approved by the committee for educa- The group interviews, which were conducted in tional research ethics (March 20, 2013). Permission for Finnish, had two phases: the first, focused on the infor- the study was requested from both the educational insti- mants’ immediate experience of their own movement, tution and the informants themselves. The recruitment and in the second, the professional physiotherapists, process took place at the start of the course. All those invited the informants to reflect upon their conceptions agreeing to participate signed their informed consent. of movement quality by focusing on movement aware- We have ensured the informants’ anonymity by using ness, and asked them to look back on their clinical pseudonyms when presenting our findings. practice. The interview’s initial question was: How were your experiences of being in movement during this week in BBAT? It then proceed to its main focus: I now invite Data collection you to describe your conceptions of movement quality. What does it mean to you as a physiotherapist? The The data were collected in two group interviews interview continued on the basis of the interviewees’ (Brinkmann, 2013) at the end of the course in the answers. The interviews were audiotaped and tran- same location. Two groups were formed alphabetically, scribed verbatim, yielding 35 transcript pages (15001 according to the 15 informants’ last names; one with words, font = Times New Roman 12, spacing = 1.5), eight informants and one with seven. Two reflection- and forming the research material for this study. The based group interviews (Kvale and Brinkmann, 2009), first interview lasted 65 minutes and the second allowed the informants to describe and reflect upon their 60 minutes. movement experiences as much as possible. A group interview can be even more productive than individual interviews when the members of the group feel equal in Data analysis term of at least one element (Brinkmann, 2013). The informants were all physiotherapists and got to know The phenomenographic analysis (Åkerlind, 2005, 2008) each other during the week. Awareness of “peerness” was carried out by the first author (Figure 1), and exam- and a feeling of “sameness” can enhance dialogue and ined the informants’ descriptions of the phenomenon as social support within a group (Skaniakos and Piirainen, a whole. Their conceptions illustrate how a group of 2019), when it is challenging to make the phenomenon informants can understand and express their experi- under study explicit (Ahola, Piirainen, and Skjaerven, ences of the same phenomenon in such different ways 2017; Blackburn and Price, 2007). (Åkerlind, 2005). The similarities and differences The first author conducted the interviews and was between the experiences of a phenomenon have a physiotherapist, but otherwise unknown to the a systemic order, which takes the form of descriptive 1442 S. AHOLA ET AL. •Repeated reading of the transcripts by the same person. Phase 1 •Identification and classification of the date into themes based on informants’ Phase 2 descriptions of their conceptions of their own movement quality, focusing on movement awareness. •Identification of each theme’s three or four variations. Phase 3 •Based on similarities and differences, the variation of the themes took the from Phase 4 of a hierarchy. •The variation of the themes formed the descriptive categories of the movement Phase 5 awarness phenomenon and assigned a distinctive name to each category. Phase 6 •Identification of the critical aspects of the descriptive categories. Figure 1. Phases of study´s phenomenographic analysis. categories (Marton, 1981). These descriptive categories first author and discussed with the coauthors, and finally illustrate the variation of conceptions of undergoing checked by a native English professional language movement awareness, are structurally and logically editor. inter-related and form a hierarchical whole (Åkerlind, 2005; Marton and Booth, 2013; Marton and Pong, 2005). The presented categories represent the informants Results expanding view on movement quality, focusing on The aim of the present study was to explore the movement awareness (Åkerlind, 2005, 2018; Marton variation in physiotherapists’ conceptions of move- and Pong, 2005). ment quality, focusing on movement awareness. The Figure 1 presents the phases (1–6) of the phenomeno- results of the phenomenographic analysis revealed graphic data analysis in this study. The data presented that the informants’ conceptions of movement aware- the informants’ descriptions of movement awareness ness had four widening, qualitatively descriptive cate- (Figure 1, phase 5). In phenomenographic analysis, the gories (Table 2): I) Hesitation regarding own critical aspects can be identified as descriptive categories movement experiences; II) Momentary contact with of what is important for widening the informants’ own movement experiences; III) Presence in move- understanding of the phenomenon of interest (Marton ment awareness; and IV) Better understanding of and Booth, 2013; Paakkari, Tynjälä, and Kannas, 2011): others’ movement awareness (Table 2). The phy- in this study, movement quality, focusing on movement siotherapists’ conceptions had four themes, which var- awareness. We identified three critical aspects in the ied hierarchically so that they formed four movement descriptive categories (Figure 1, phase 6). awareness categories. The themes distinguishing the The first author listened to the audio-recordings, read descriptive categories were as follows: 1) Being in the transcripts several times and made the first draft of contact with one’s own moving body; 2) Increased the findings. The research group (SA, LHS, and AP) awareness of movement experiences; 3) identified the themes of variation and discussed the Interrelationship between physiotherapist and patient; relations and hierarchies in the descriptive categories. and 4) Better understanding of movement awareness The group constantly evaluated the consistency between (Table 2). the original data and our findings to minimize the influ- The descriptive categories and the variation of themes ence of their own interpretations. All three authors are presented below, using quotes identified as be rele- further elaborated the first draft result, seeking the clear- vant from the informants’ descriptions. The letters est and most original quote that illustrated the results. A through O after each quote represent the participating The group interviews were carried out in Finnish, by the physiotherapists. The varying themes within each first author. The first translation was undertaken by the descriptive category are highlighted in bold. The name PHYSIOTHERAPY THEORY AND PRACTICE 1443 of each variation theme is in italics throughout the In this first, narrowest descriptive category, the interrela- results (Table 2). tionship between physiotherapist and patient was related to the physiotherapists paying attention to their own body. In this theme, the physiotherapists’ descriptions focused Category I: Hesitation regarding own movement on movement awareness from only their perspective. experiences When I work with a patient . . . Well, like I’ve noticed In this first descriptive category, the informants reported that even though you work with your own body how that becoming aware of their own movement sensations strange it is . . . and you have like a very strong relation- was challenging. They described experiencing their own ship with your own body so it will definitely be a lot of work figuring it all out (L). movement as a blind spot. Recognizing their own move- ment awareness was considered a different experience Despite claiming that encountering one’s own move- what they were used to in their earlier physiotherapy work. ment awareness in physiotherapy was challenging, the The first identified theme of variation was being in informants said that they wanted to achieve a better contact with one’s own moving body, which in this understanding of movement awareness (the fourth narrowest descriptive category, was described as a lack theme). In this first descriptive category, the informants of contact with the moving body. The physiotherapists described how learning to be present when moving awa- claimed that it was demanding to be aware of their own kened their curiosity, although it was challenging. The bodily and movement sensations and face their own informants also described that it was easier to focus only bodily and movement needs. One informant described on doing during physiotherapy (Table 2). how they saw their own body movements as automatic As a physiotherapist, I’m learning to be present, here mechanical actions. and now, in the moment. It’s difficult; it would be easier to just concentrate on doing (A). I feel like I can’t listen to my body, I expect my body to work like a machine from day to day . . . I’ve also noticed that it’s difficult for me to let my breath relax and flow freely (C). Category II: Momentary contact with own movement experiences The second variation theme in this descriptive category, The focus of this second descriptive category was on an increased awareness of movement experiences, focused on explorative attitude and being curious, when the infor- remote experience when moving. The informants said they mants encountered their own movement awareness with felt that coming into closer contact with their own move- interest. Movement awareness was described as an ments was a remote experience. They described usually uncertain encounter, and as was sensing that one’s observing only their own vital bodily functions, for exam- own movement awareness could mean (Table 2). ple, their heartbeat, and dismissing and lacking contact The informants’ descriptions of their own experi- with delicate sensations in their own movement awareness. ences of being in contact with one’s own moving body I’ve often taken distance from my body . . . In the rare expanded from the first descriptive category to moments when I actually concentrate on listening to my the second (see Table 2). The informants described own body, I mainly observe the concrete bodily functions their first contact with their own movement awareness (L). as difficult to trust. Table 2. Descriptive categories and themes. Descriptive categories of movement awareness phenomenon Themes: (variation of I: Hesitation regarding II: Momentary contact with III: Presence in movement IV: Better understanding of themes, horizontal) own movement own movement experiences awareness others’ movement awareness experiences Being in contact with Lacking contact with the Gaining first contact Being in contact Reflecting on contact and how one’s own moving body moving body to move Increased awareness of Remote experience Recognition of stronger Distinction between one’s own and – movement experiences when moving sensing of movement the patient´s movement experiences awareness Interrelationship between Paying attention to own Sharing personal movement Sensing one’s own and others’ Reciprocal professional physiotherapist and movement experiences with others movement awareness resources interrelationship patient experiences Better understanding of Learning to be present Recognizing movement Learning new movement strategies Movement awareness as a base movement awareness when moving processes for physiotherapeutic competence 1444 S. AHOLA ET AL. It’s difficult for me to let go and just be guided by my described as being more present in the actual moment, own movement sensation, and not perform the move- when moving. The physiotherapists described how ments correctly and be in control (J). through their bodily presence they felt more connected, In the theme increased awareness of movement experi- both to themselves and to others as their patients or ences, the informants described recognition of stronger other physiotherapists. They also described their own sensing of movement experiences when they started to movement sensations appreciatively with approving explore their own movement. They reported not being description language. able to be fully involved in being in contact with their My body is a part of me. My body is a tool through own movements. Despite starting to explore their own which I can live that reflects my emotions and thoughts. movement awareness, the informants described the pro- My body is also present in various interaction situa- cess of being in contact with and recognizing their own tions; being in one’s own movement, how to appreciate movement sensations as challenging, that it aroused yourself, relationships with others and your living envir- various sensations and was a restless experience. onment (B). I’ve found it challenging recognizing . . . bodily sensa- The increased awareness of movement experiences tions are difficult and detached from real emotion. It’s theme broadened as the informants described not easy . . . I’ve felt it as restlessness in my body (N). a distinction between one’s own and the patient’s move- In this descriptive category, the third theme, the ment awareness. The informants’ noticed being more interrelationship between physiotherapist and patient sensitive to exploring and more broadly understanding was related to the informants’ experience of sharing what happens in clinical practice. In the interview they personal movement experiences with others. In this started to describe how a process like becoming more theme, the focus on movement awareness shifted aware of their own movements was essential to develop between physiotherapist and patient in the clinical their own sensitive guidance of patients (Table 2). physiotherapy situation. When the informants described the close interrelationship between phy- I’ve recently been thinking more about my guidance, how to ask permission to touch, to be sensitive and siotherapist and patient, they described movement understanding in situations where the client doesn’t awareness as how bodily sensations of pleasure or want to be touched (F). fear were similar to those that their patient had experienced and described during a physiotherapy The third theme, interrelationship between physiothera- situation. pist and patient, was described by sensing one’s own and others’ movement awareness resources. In this descriptive Sharing the same bodily experience as my patient, which I have noticed, bodily experience as a physiotherapist. category, the informants reported how the interrelation- The emotion, sensation can be joy or happiness but ship between themselves and the patient had often been usually with sick people it is anxiety, pain and fear (O). an exhausting experience, depleting the informant’s own energy. This process made the informants observe their Better understanding of movement awareness was working habits and culture. They described stretching linked to recognizing movement processes. Their under- their own limits and having no time to reflect. standing of movement awareness expanded further, that the informants reported their own movement awareness I’ve sometimes had a physiotherapy session after which with an open attitude toward recognizing the movement I’m totally exhausted. The next client is already waiting process between therapist and patient. Better under- their turn and you simply don´t have the time to reflect standing of movement awareness was described as on or handle the situation (I). a target to support their patients in physiotherapy. The fourth theme, better understanding of movement I’ve found sensing my own body to be important so that awareness was described as learning new movement I don’t get confused by my client’s bodily reactions and can give them as much as possible as a physiotherapist (M). strategies. The informants reported a growing under- standing of how important calming themselves down and being present in clinical practice situations was for them. Category III: Presence in movement awareness Calming myself down has been the most important In the third descriptive category, being in contact with realization and inspiration . . . in general, I can teach one’s own moving body expanded from the second and apply different approaches, but if I can’t calm descriptive category to the third. Being in contact was myself down and through that calm down my client (H). PHYSIOTHERAPY THEORY AND PRACTICE 1445 Category IV: Better understanding of others’ In my practice, I utilize my own bodily movement movement awareness experience when I guide my patients to find their own bodily experience. I also want to encourage my patients In the fourth, widest descriptive category movement to rely on their own bodily experience . . . walking beside awareness was described as the basis of professional and learning with my patient. The use of all my bodily physiotherapy. It was also described as increasingly senses, which has developed enormously (I). meaningful for informants as a base for continued pro- fessional development. The informants described how movement awareness was important for promoting Summary of results open dialogue between therapist and patient, so no This study revealed a structure that expands the under- variation of the increased awareness of movement standing of movement awareness (Figure 2). It found experiences theme was identified. In this widest descrip- four descriptive, widening categories of movement tive category, the informants’ understanding of profes- awareness. The results showed a transition in the sional ethical attitude increased (Table 2). description of movement awareness, from the narrowest The informants described the being in contact with Hesitation regarding own movement experiences (I) to one’s moving body theme as reflecting on contact and Momentary contact with own movement experiences (II), how to move. They reported how a reflective relationship proceeding to Presence in movement awareness (III) and enabled a continuous explorative view of their own to Better understanding of others’ movement awareness movement awareness in therapy situations with patients. (IV), a broader understanding of the movement aware- They described this curious ongoing process with great ness phenomenon (Figure 2). According to the results, interest. the phenomenon of movement awareness widened through three critical aspects of the descriptive cate- It’s possible to learn to know yourself better by listening to your bodily movements’ reactions and sensations. It gories: 1) Recognizing one’s own movement awareness, 2) ´s extremely interesting to observe your bodily reactions Distinguishing one’s own and others’ movement aware- in different interactive situations (M). ness, and 3) New insights into implementing actions related to movement awareness in physiotherapy The informants described the interrelationship between (Figure 2). These three critical aspects widened the physiotherapist and patient as a reciprocal professional informants’ understanding of movement awareness. In interrelationship. They described listening more openly this study, the movement awareness phenomenon to themselves and agreeing to accept their own as well as emerged in four main issues: being in movement, reflec- their patients’ various movement quality experiences tion, interaction and professionalism in physiotherapy. when, for example, breathing and giving enough time to explore movement sensations. Using more empathic descriptions of movement quality, the physiotherapists Discussion also approvingly described strategies of encouraging The aim of this study was to explore the variation in their patients to patiently explore their own movement physiotherapists’ conceptions of movement quality sensations. while focusing on movement awareness. The results revealed the relationships between the two phenomena It’s making contact, being present, curious about exploring my own bodily movements’ sensations, listen- of movement quality and movement awareness. The ing to my patient’s breathing and giving them time to informants’ descriptions revealed an improved under- explore their own movement sensations (I). standing of movement awareness in themselves and in relation to professional physiotherapy. Previous In this category, the better understanding of movement research has described how movement awareness is awareness theme broadened and expanded to movement expressed in the body and can be observed through awareness as a base for physiotherapeutic competence. observing movement quality (Skjaerven, Gard, and The informants perceived that their own movement Kristoffersen, 2008; Skjaerven, Kristoffersen, and Gard, awareness was a stimulus to promoting their own pro- 2010), and that the expression of bodily self- fessional therapeutic competence in guidance and to consciousness appears in movement quality a shared mutual movement-based relationship with (Gyllensten, 2012). Skjaerven and Gard (2018) also sta- their patient. They reported that this was possible ted that the phenomenon of movement awareness offers through person-centered strategies encouraging their a specific focus on human movement, which differs from patients to trust their own movement awareness experi- body awareness, a more general phenomenon. ence (Table 2). Movement awareness and body awareness overlap, 1446 S. AHOLA ET AL. 3. New insights into implementing actions related to movement awareness in physiotherapy 2. Distinguishing one’s own and others’ movement awareness 1. Recognizing one’s own movement awareness ΙV: Better undrestanding of ΙΙΙ: Presence others’ movement in movement awareness awareness ΙΙ: Momentary contact with own movement experiences Ι: Hesitation regarding own movement experiences Figure 2. Structure of widening understanding of movement awareness. Descriptive categories (I–IV) and critical aspects (1–3) of movement awareness phenomenon. because movement awareness (Skjaerven, 2019) is The fourth issue was professionalism in physiotherapy, described as becoming aware of, identifying and mon- which concerned the work culture and habits of the itoring subtle nuances of movement quality, and body physiotherapists. awareness (Ginzburg, Tsur, Barak-Nahum, and Defrin, The movement awareness process represented 2014) is seen as sensitivity to bodily signals to be aware a challenge in this study, and revealed a less reflected of bodily states and to identify subtle bodily reactions. side of the phenomenon. Being in movement, which The results of the phenomenographic analysis focuses on understanding the value and qualities of revealed the structure and widening understanding of human movement from the individual’s perspective, the movement awareness phenomenon. The four has also previously (Arnold, 1979; Brown, 2013) been descriptive categories were: I) Hesitation regarding found to be a less noted approach to human move- own movement experiences; II) Momentary contact ment. Arnold (1979) identified three dimensions of with own movement experiences; III) Presence in move- movement for learning: 1) Learning about move- ment awareness; and IV) Better understanding of others’ ment; 2) learning through movement; and 3) learning movement awareness. In this study, the four categories in movement. Learning about movement is accom- of the phenomenon of movement awareness constituted plished by teaching human movement as an academic a hierarchy, constructed from four main issues. The first subject, through anatomical, physiological, or socio- issue, being in movement, from hesitation regarding logical methods. Learning through movement is one’s own movement experiences, widened the phy- accomplished by understanding physical activities as siotherapists’ understanding of the movement aware- a way of achieving a goal, as learning a skill. Learning ness process. The second issue was reflection, while being in movement emphasizes movement as becoming more aware of movement awareness and ver- being integrated into the person (Arnold, 1979). balizing one’s experiences to others. The third issue The physiotherapists’ descriptions of movement concerned understanding patient and physiotherapist awareness were reported in the present study from movement awareness as interaction in physiotherapy. only the physiotherapist’s point of view. The results PHYSIOTHERAPY THEORY AND PRACTICE 1447 regarding hesitation are also in line with previous stu- physiotherapists’ own movement awareness through dies, that have found that listening to the signals that movement quality is The Awareness Learning Cycle arise from the senses and coming into contact with one’s (Skjaerven, 2019; Skjaerven, Kristoffersen, and Gard, own movement may be challenging to process for those 2010). who are not used to or have not learned to be in contact Earlier studies have emphasized that concrete move- with their inner bodily movement sensations (Blackburn ment practice that enables contact with a person’s own and Price, 2007; Ginzburg, Tsur, Barak-Nahum, and movement awareness is important in promoting the Defrin, 2014). Alon (1990) also stated that movements experience of safety (Blaauwendraat, Levy Berg, and that are executed without taking contact, listening, or Gyllensten, 2017; Hedlund and Gyllensten, 2013). In being aware may have a mechanical appearance. In this study, the movement awareness process was terms of the physiotherapy profession and clinical prac- a calming experience and involved being more present tice, these results regarding physiotherapists’ descrip- in the clinical situation. The physiotherapists’ descrip- tions of hesitation regarding contact with their own tions of movement awareness used approving descrip- movement experiences and thus, movement awareness, tion language. Other research has also reported that are important: Previous studies have highlighted that if vocabulary is an essential factor in the therapy interven- a physiotherapist lacks sensitivity to their own move- tion itself (Quinn, Anderson, and Finkelstein, 2009; ment quality, it is difficult for them to recognize such movement nuances in others (Skjaerven, Gard, and Skjaerven et al., 2018). Verbal and body-based informa- Kristoffersen, 2008). tion and expressions are seen as belonging together and Concerning verbalization in this study, when describ- complementing each other – it is essential for phy- ing hesitation to take contact, the physiotherapists’ siotherapists in clinical practice to compare their described their own movement sensations using sparse patient’s verbally expressed experiences with their own vocabulary, choosing words, that illustrated incapacity observations of their movements (Thornquist, 2018). or challenging focus. We think that this was an impor- Piirainen (2006) also found that in professional practice, tant finding. Earlier studies have found that vocabulary shared security and shared trust are invisible. Thus by (i.e. how people choose the words to describe movement making communication visible and creating moments of awareness experiences) is important from the profes- language dialogue, we can change the direction of the sional point of view (Skjaerven, Gard, Gomez-Coneza, understanding. and Catalan-Matamoros, 2020). Movement vocabulary Reflection was described in this study as the basis of provides variations in the descriptions of movement physiotherapeutic competence and professional devel- sensations and nuances, which enhance physiothera- opment. The physiotherapists reported how reflective pists’ ability to interpret patients’ understanding of the patient relationships enabled a continuous explorative therapeutic situation (Skjaerven, 2019). view of their own movement awareness, which they The physiotherapists reported an explorative attitude described as an interesting and ongoing process. This and were curious about their own movement experi- kind of process in understanding has been described as ences. Personal movement awareness was reported as reflectivity, the expansion of a professional’s horizon being uncertain and difficult to trust, as physiotherapists (Mezirow, 1998; Skjaerven, Kristoffersen, and Gard, only have fluctuating momentary contact with it. The 2010). In the reflective process (Brookfield, 2017), stres- present study revealed meanings such as a curious atti- sing the experience is important (i.e. reflecting more tude and trust. Other research has also shown that deeply on what has happened on a concrete occasion). a curious attitude and trust are therapeutic components In this study, the fourth descriptive category that enhance movement awareness (Skjaerven, (Understanding more of others´ movement awareness) Kristoffersen, and Gard, 2010), and that physiothera- belonged to Mezirow’s (1991, 1998) first critical con- pists’ personal process of coming into contact with sciousness level because physiotherapists can reflect on their own movements and movement awareness is simi- movement awareness as a basis of competence. For lar to the process among the patients (Skjaerven, professional development, it is important to reach at Kristoffersen, and Gard, 2010). Thus, the therapeutic least the first level of critical consciousness (Mezirow, components, the physiotherapist’s own movement 1991, 1998), as this enables the promotion of profes- awareness, a platform for promoting movement quality, sional development. and the therapeutic strategies within a specific move- Physiotherapists reported listening more openly to ment pedagogy are important for this kind of under- themselves and agreeing to accept their own as well as standing (Skjaerven, 2019; Skjaerven, Kristoffersen, and their patients various movement quality experiences. Gard, 2010). One therapeutic strategy to develop When the physiotherapists used more empathic 1448 S. AHOLA ET AL. descriptions of movement quality and movement aware- own sensitive guidance of the patient. Other researchers ness, they also approvingly described strategies encoura- have highlighted how the reflective relationship plays ging their patients to patiently explore and trust their a crucial role in professionals’ work culture (Illers, own movement sensations. The same kind of results 2014; Mezirow, 1991; Piirainen and Viitanen, 2010; have also been reported regarding the relation between Skjaerven, Kristoffersen, and Gard, 2010). a positive treatment outcome and experiences of well- The physiotherapists in the present study reported being in one’s own movement, and that being safe and that movement awareness promoted dialogue and unconditionally accepted is highly important a relationship based on mutual trust between them and (Gyllensten, Skär, Miller, and Gard, 2010; Ogden, the patient. Physiotherapists need to be adequately Minton, and Pain, 2009; Skjaerven, 2019; Skjaerven, aware of their own movement in order to better under- Kristoffersen, and Gard, 2010). stand others’ movement awareness. Previous research The reflection process of movement awareness was has also shown that movement awareness is an element visible in the physiotherapists’ descriptions. Reflectivity of a physiotherapist’s clinical practice, and is considered was essential to start the process. From the professional’s the basis for professional communication through perspective, the first step of making contact with one’s observing, understanding, and promoting movement own movement is central for understanding more about quality, and for strengthening patients’ movement movement awareness, and studies (Arvala and Malinen, potential for daily life and participation in physiother- 2013; Dewey, 1934; Mezirow, 1991; Skjaerven, 2019; apy (Hedlund and Gyllensten, 2010; Probst et al., 2016; Skjaerven, Kristoffersen, and Gard, 2010) have also Skjaerven, 2019; Skjaerven, Kristoffersen, and Gard, found that establishing contact with your body and 2010). The physiotherapists’ presence enabled learning sharpening your body awareness toward movement new strategies such as calming down, and underlined the and movement awareness understanding is important importance of such strategies for differentiating their for initiating awareness and as well as reflection. own movement awareness experience from that of the Interaction in this study was in relation to the infor- patients. Marton and Booth (2013) also emphasized how mants’ wish to be a good physiotherapist, as they professional competence development takes place when reported wanting to support their patients as much as professionals personally encounter and confront possible. Movement awareness was described as a shared a situation in which the existing understanding is experience between the physiotherapist and patient in unworkable, and reflect on this experience afterward. a clinical situation, which concerned various body-based The physiotherapists described how through under- sensations, such as pleasure or fear. The shared experi- standing their movement awareness they became more ence described in this second category is important for aware of their own exhausting working habits and patients in physiotherapy situations. Also, according to observed their working culture more broadly. The sense Yalom (1995), the sense of “being in the same boat” of being shaken can be an important driver of changing creates a sensation, an experience of connectedness, physiotherapists’ perceptions or ways of working which can reduce the experience of feeling different (Holopainen et al., 2020). Changing habits and move- and alone, and at same time increase awareness. Other ments is not a question of motor capacity; it involves research results have pointed out that searching for physiotherapist as people, human beings (Thornquist, contact with one’s own movement quality is highly 2012). This may be why it is so difficult to change habits, personal and private in nature, therefore resistance and and why change takes time (Thornquist, 2012). discomfort need to be professionally monitored, and The opportunity to gain new insights into implement- decisions regarding treatment or progress in movement ing actions related to movement awareness in physiother- practice need to be carefully weighed in terms of when, apy was considered critical for promoting the profession. where and how to integrate experiences of movement to Movement awareness-based professionalism was empha- enhance understanding (Freiler, 2008; Hedlund and sized as professional interaction and competence, in which Gyllensten, 2013). In this study, the physiotherapists the patient was the center. To understand more of others’ reported how presence strengthened their movement movement awareness, physiotherapists need to reflect on awareness in interaction. Interaction is connected to their own movement awareness, which Mezirow (1991, movement awareness and presence, and not only one’s 1998) also highlighted as the first critical consciousness own but also others’ movement awareness is identified level. This process of understanding has been described as as part of the therapist – patient relationship. Exploring reflectivity, the expansion of a professional’s horizon and understanding the distinction between one’s own (Mezirow, 1998; Skjaerven, Kristoffersen, and Gard, and the patient’s movement awareness and expanding 2010). In the reflective process (Brookfield, 2017), stressing understanding was seen as the basis for developing their the experience is important, i.e. reflecting more deeply on PHYSIOTHERAPY THEORY AND PRACTICE 1449 what has happened on a specific occasion. On Mezirow’s interested in applying movement awareness in phy- (1991, 1998) consciousness reflective levels, this study siotherapy, even though we realized that the informants reached levels one to four, but did not achieve levels six may speak (only) through the experience they gained on or seven of critical consciousness. A consciousness reflec- the course. This may be also a strength of our study; that tive level of six or seven means that physiotherapists can we found informants who had enough experience as recognize the uncertainty in their movement awareness physiotherapists, were willing to describe movement and have other possible interpretations for movement awareness and were curious about it. The introductory awareness. This can increase their knowledge and percep- BBAT course helped the informants make contact with tion and help them recommend other solutions for movement awareness by inviting them to express their patients. The present study revealed that physiotherapists own conceptions. Concerning movement in particular, have a wide range of conceptions regarding movement many studies have found that verbalization presents awareness. It showed that understanding of movement a challenge (Maivorsdotter and Quennerstedt, 2012; awareness deepens when it widens. Panhofer and Payne, 2011). In this study, experienced physiotherapists from different fields of physiotherapy with extensive clin- Limitations and strengths ical knowledge and experience were chosen as key Phenomenography provides a useful methodological informants. Eight of them worked in mental health tool for professional development (Sandberg, 2001). In and psychiatry, three in multi-professional rehabilita- tion for chronic pain or musculoskeletal disorders, this study, the movement awareness phenomenon con- and one informant worked in each of the following sisted of four main issues: 1) being in movement; 2) fields: family-centered rehabilitation, primary health reflection; 3) interaction; and 4) professionalism in phy- care, special school education, and cancer. The col- siotherapy. The results of this phenomenographic study lected data presented the physiotherapists’ descrip- cannot be generalized, but they may be transferable to tions’ of movement awareness. Phenomenography is similar situations or applicable in another contexts a data-driven approach, which means that all findings (Mason, 2010). Those can be used as a tool for develop- arise from the data (Åkerlind, 2005, 2008). ing movement awareness and enhancing pedagogical Triangulation was performed by the three researchers, practices in continuing physiotherapy education. The the authors of this paper, who had earlier experience critical aspects identified in this study can be useful to of working with qualitative methods. One strength of promote physiotherapy in clinical practice or in educa- the research group was that the authors were from tional contexts. different competence areas of physiotherapy: The number of informants in a phenomenographic a professor with expertise in mental health phy- study ranges from 10 to 30 (Stenfors-Hayes, Hult, and siotherapy and BBAT methodology, a researcher of Dahlgren, 2013). This study had enough informants to qualitative research and a doctoral researcher with enable understanding of the phenomenon of interest experience in neurological physiotherapy. The first (Mason, 2010). It comprised interviews of 15 registered author was the interviewer and as a physiotherapist, physiotherapists with an average of 15 years of work a peer, which may have helped the informants talk experience in physiotherapy. There was a gender bias freely although it may also have limited the questions toward women in this study, as 82% of qualified phy- she asked. The informants found this interviewer’s siotherapists in Finland are women (Valvira National role to be more that of a peer learner, which provided Supervisory Authority for Welfare and Health, 2017). favorable conditions for the interviews (Brinkmann, The collected data revealed physiotherapists’ descrip- 2013). tions of their conceptions of movement awareness, so the data (15 001 words) was wide and rich enough to explore the range of understanding within a specific Conclusions group and capture the variability of the chosen phenom- The results of this study make visible the structure of enon (Täks, 2015). the widening understanding of movement awareness. The informants had an average of 15 years of experi- The study identified four main issues: being in move- ence as physiotherapists and had applied to attend ment, reflection, interaction, and professionalism in a postgraduate course. We assumed that the informants physiotherapy, and three critical aspects. The identi- were curious about movement quality, with a focus on fied critical aspects widened the understanding of the movement awareness. The BBAT course presented an phenomenon of movement awareness and can be opportunity to reach physiotherapists who were useful when planning future educational interventions 1450 S. AHOLA ET AL. for promoting physiotherapists’ professional post- Blaauwendraat C, Levy Berg A, Gyllensten AL 2017 One-year graduate development in continuing education or follow-up of basic body awareness therapy in patients with with physiotherapy students in higher physiotherapy posttraumatic stress disorder. A small intervention study of education. The reflective relationship of movement effects on movement quality, PTSD symptoms, and move- awareness provides opportunities for physiotherapists ment experiences. 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