Environmental Physiotherapy: A New Lens for Patient Care

[00:00:09] All right. Well, Philip and Emma, thank you so much for being with me today. I was actually given your website by a colleague of mine. And when I saw this, I thought I have to put this on the podcast because I had no idea that this was out there. And I think so many people in AAOMPT would love to hear about what the work that you're working on. Let's start with just introducing yourselves. Where are you tuning in from? And how did you get involved with the Environmental Physical Therapy Association?

[00:00:41] Philip L. Yeah, so I can start. So my name is Philip. I'm an associate professor in physiotherapy at UIT, the Arctic University of Norway. And I'm also the founder and current lead of the Environmental Physiotherapy Association. So it kind of, you know, it was some sort of brainchild of mine to do something like this and then reach out to other people. And thankfully, one of the people I've managed to reach out to is Emma, who is here with me today. Yeah.

[00:01:09] Yeah. And I'm Emma and I'm from Sweden, Stockholm. And I'm currently working at Karolinska Institute as a researcher and a teacher within the physiotherapy program. And I got to know Philip and environmental physiotherapy. I think it must be like three years ago or something, three, four years ago. And I actually also found it on the web page.

[00:01:35] And just I was looking for something regarding environmental climate change and stuff like that and physiotherapy and health care. And then I saw this web page and I reached out to Philip. And now I'm kind of very involved in this work, so to speak. Yeah. I love that. I think a lot of us that are in health care obviously are in line with the values of the work that you're doing. So I'm excited to highlight this.

[00:02:04] Philip, why don't you tell us a little bit about how you started, when you started? Just paint us a picture of where the organization has grown to. Philip, why don't you tell us a little bit about how you're doing? Yeah. So for me, kind of as an idea, this whole thing grew out of my PhD in a way, but not as a central theme, more as something that kind of like marginally also popped up.

[00:02:24] And that was simply the realization that somehow in our profession, I felt like the environment was not considered explicitly enough and kind of clearly enough, if you will, like in everything that we do. And so I thought, ah, there's something going on there. You know, it needs further exploration and so forth. And then in kind of as that thinking grew, you know, eventually I sort of like started putting down something in writing.

[00:02:51] And together with my friend and colleague, Professor David Nichols from New Zealand, we published a kind of like a brief editorial calling for the exploration of this idea of an environmental physiotherapy. And that was published in physiotherapy theory and practice in mid-2019.

[00:03:10] And we used that publication to launch the Environmental Physiotherapy Association, which essentially we just initially thought of as a somewhat of a network or kind of, you know, group of people that might be interested in exploring what could environmental physiotherapy be and mean and, you know, so forth. And so that's been going, as I said, since mid-2019. And we are now over one and a half thousand people from all around the world. And yeah, it just continues to grow and evolve.

[00:03:41] And it's a really exciting exploration. It's also, I think, an urgent exploration, if you will, and very urgent new research activity, educational activity, clinical activity in our profession. And yeah, it's been a fantastic ride. And I'm glad to be here tonight to talk to more colleagues yet again about exactly that. Yeah, I would love to bring this to the United States and more awareness. And amazing how much you've grown in such a short time.

[00:04:10] And I could read on your website when I was first deciding to do this that you're passionate about it. It's very clear the way that it's written and the connections you've already made that this is something that was a brainchild. And it's the fact that it's developed is clear that people are on board with what you're doing. So I think my first question for you, and this is what I had when I was looking, was how is this different from just making your clinic more sustainable? Yeah, I think it's very different. But I would say that it also includes that, right?

[00:04:40] Like it can encompass that and naturally it will and does. But ultimately for me, you know, environmental physiotherapy for me is like in somewhat short terms is something like an entirely new lens through which to look at physiotherapy and think through physiotherapy and all of its aspects. And sorry, I'm just realizing I'm speaking to a U.S. audience and saying physiotherapy. I clearly mean physical therapy. We understand that. It's interchangeable for us.

[00:05:10] Okay, good. Yeah, okay. So I'm probably going to kind of end up saying physiotherapy mostly. But yeah, so it's essentially, you know, for me and kind of like a new lens, a new way to think through everything we do and kind of everything we think in physiotherapy, every single kind of specialization that we have.

[00:05:30] And as a new lens, it also kind of like it has something to say about or it has something to contribute in terms of changing what we do, both in very small ways and kind of like essentially sort of like continuing more or less a business as usual, but a little bit better, which would be sort of like making your clinic a bit more greener, a bit greener, but continuing to do the same work.

[00:05:53] But it also, I think, has much more fundamental implications, which we're kind of still working on exploring in terms of really sort of like changing of what we think is physiotherapy. And then what does that mean for how its practice should look and how could it and would it be fundamentally different? I have one other way that I sometimes also put kind of the answer to this question of what is environmental physiotherapy. And it's essentially that for me, you know, it's for me, it started from a question.

[00:06:19] And so the what environmental physiotherapy is, is an engagement with the question of what does the environment have to do with physiotherapy all in any aspect of physiotherapy. Right. But if you study that question for a while, then you realize that the environment like is not necessarily always just ecological. It's also social. And, you know, there's all kinds of different sort of like understandings of what is the environment.

[00:06:41] And so really the question expands a little bit and it becomes more of a question of what do health, environment and society have to do with each other? And how does that play out in all aspects of physiotherapy? You know, in terms of how does it affect all aspects of physiotherapy and what could it mean in terms of what physiotherapy would do differently as a result? Right. So for me, environmental physiotherapy, in other words, also an engagement with exactly that kind of really broad question.

[00:07:11] Right. So, yeah. Yeah. That's a great answer. Emma, what does it mean to you or do you have anything else to add to that? Yeah, I totally agree with Philip. But I would like to say it's a very wild field. And I think it's worth saying at the start. And we also we enter this kind of field from different doors. And even Philip and I has entered it from different doors. And that's totally OK to do that.

[00:07:36] And regarding the sustainable clinic, I think, as Philip said, that's only one part of environmental physiotherapy. But it is about the practice own footprint. And it's totally worth it. But that's more about, you know, recycling, energy, waste, people getting to work. But environmental physiotherapy goes to a deeper layer.

[00:08:01] It's all about this connection between the patient, yourself and the environment. And for me, my doors opened when I kind of heard about how the environment is affecting your patient regarding everything I do within physiotherapy has something to do with the environment.

[00:08:21] And it started actually for me from the perspective of climate change, loss of biodiversity and air pollution and actually the health consequences of being in an environment that isn't healthy for you. And also from the perspective of nature connectedness and how can we use physical activity as another way to to enhance planetary health and not only the human health, but of course also the sustainable health care perspective.

[00:08:51] So it's it's such a broad perspective and such a broad field. And I don't think we also have all the answers yet. We are still in this kind of exploring phase of what the environment is. But I think, I mean, the purpose of our profession is to have people moving in the world. And if we don't bother to think about what that world or the environment is, what are we then doing?

[00:09:20] So I think that's the whole thing. The environment can't be separated from physiotherapy as a whole. But I think also it's important to say that if we're trying to mainstreaming an agenda like doing environmental physiotherapy as a core concept within physiotherapy,

[00:09:41] we also have this kind of risk of, you know, make it everyone's responsibility and no one cares and makes it a speciality and people kind of put everything in there and then just move on. So we have to still be clear about what are we trying to, you know, change?

[00:10:01] What are we trying to do instead of just making it something invisible in somehow to kind of everyone should do it, but no one does it. So I think it's very important to show these different kind of angles we enter these doors from. I really like that. I've never heard you say that, Emma, before this thing with the doors and kind of the different doors.

[00:10:25] We're trying to support people that come into the Environmental Physiotherapy Association in exactly that process of kind of recognizing what interest or what door they come in through. And then having them understand how that also is part of what we're trying to work out together. Right. And for me, you know, I mean, my actual my background is in MSK, physiotherapy and manual therapy. So I feel sort of like at home speaking to to your crowd, Antigone.

[00:10:55] But but but my Ph.D. was kind of like an exploration of ethics, a very critical exploration of ethics and physiotherapy. And I came to environmental physiotherapy to the questions I've had about our ethics, kind of our professional ethics, if you will. So it's through that angle that I came in, you know, like so it's really I think that speaks to the breadth of everything that this can can encompass. And still sort of, as Emma is saying, is kind of still evolving.

[00:11:23] We're still trying to work out all of what it can be and is. And that's a really exciting process. And I just want to add to that when you're talking about the ethics at the same time as the environmental physiotherapies, you know, exploring and looking at all of these different topics. Things are also happening in the health care world or in the research world.

[00:11:46] So these questions regarding environmental health care or sustainability is actually right now also being built in to the methodology of health care, meaning that we have, for example, the grade system, which is the system that kind of looks at the evidence for different clinical guidelines.

[00:12:08] And now this I think it was in springtime, something the guidelines published new planetary health guidelines. I think it's called grade 46, which actually looks into how do we move these environmental aspects into the clinical guidelines and also the Helsinki Declaration of Research. I think it was in 2024. I think it was in 2024. I think it was in 2024.

[00:12:34] They revised the 60-year-old Helsinki Declaration and added an 11th paragraph about how to already in the design phase incorporate environmental aspects into research. So things is actually happening simultaneously now, not only like a idea from some colleagues or from some kind of organization, but it's actually incorporated into the methodology. So it's not optional anymore.

[00:13:04] It's already in there or it's starting to get in there in our clinical decision making when we look at guidelines. Well, you both demonstrated how short-sighted that question really was. And as you were talking, I'm thinking about not only clinic sustainability, but also the environment our patients are exercising in. You just brought up research, like how are we conducting research in academia?

[00:13:29] Like the roles of physical therapy and physiotherapy and all these different roles have an environmental imprint and impact. And it's not only just about health and wellness of our patients, but what are we doing and what are we preventing and how can we all be better? It's a very interesting question that I can guarantee a lot of people haven't thought about.

[00:13:52] Also, when I was thinking and you, as you were talking, I realized that a lot of what we do for our job is try to prevent or reduce unnecessary health care costs. And we think about that in terms of the patient and health and wellness. But how could we also think about that in terms of the work that you're doing now? Yeah. Would you like to start, Philip? No, go ahead, Emma. Go ahead.

[00:14:15] Well, the meat of the thought I was thinking about is, of course, the concept of sustainable health care when you're talking about the imprint we're doing. And that's of which both Philip and I said it's only one part of environmental physiotherapy. But I think it's worth saying that when we talk about sustainable health care or the green clinic, we often go to this kind of, you know, recycling, energy, waste, transport and stuff like that. And that's only one part of the sustainable health care.

[00:14:45] Sustainable health care has like three different principles. And the third principle is more like the, would you say, the sustainable purchase chains, the energy, the transport. But we also have this two other principles that is mostly about how do we prevent care from even happening? How do we prevent people from being ill in the first time, meaning using more prevention, using more health promotion strategies?

[00:15:15] And if we look at, for example, numbers from the NHS, the National Health Service in England, which has been working with this for a long time, they managed to reduce their emissions from 2009 to 2019 to 62 percent. But at the same time, there was so much more health care needed. So the absolute numbers was actually only 26 percent.

[00:15:43] So working with only this decarbonization of health care isn't enough. We have to use other methods also to have people gaining more health, not being ill. And when we do health care, we also have to think about how do we deliver health care? And I think your public is more familiar perhaps than the Swedish and Norwegian population with the concept of choosing wisely.

[00:16:08] And it started already in 2012, where you should actually try to avoid unnecessary care. Because we know that 60 percent, only 60 percent of the care that we are giving is higher value care. And 30 percent is low value and 10 percent is actually harmful. So we also have to choose evidence-based care and perhaps also change the way we deliver care.

[00:16:32] So we don't just provide more care in every single way we know, but also try to decrease the amount of care we give. But of course, that's only relevant if it's in a context where people get too much care in some countries. And in some contexts, people need more care, of course.

[00:16:56] So I think we have to think about the way we are treating our patients and what kind of interventions we are actually using. And I think environmental physiotherapy could help people think in another way of how we could have both co-benefits for both health and planet, but also if we can perhaps change the way we look at intervention or where we provide different kind of physical activities.

[00:17:25] And so forth. Yeah. That's a great point about and probably tricky to measure when you're trying to say, hey, we're trying to actually expand access and quality, but we're also trying to decrease environmental impact. And so how do we measure those two things? Because those numbers could probably pose challenges and inflate the others. So it demonstrates the challenge, but also the opportunity to skew that graph a little bit.

[00:17:55] Yeah. Yeah. Yeah. I mean, I have only some simpler terms in some ways to what Emma has just put forward in a much more elaborate way. So, you know, I was thinking many, no, not many years ago, no, what feels like many years ago, but, you know, a while ago, you know, when we started arguing that, okay, so one of the things that also essentially needs to be considered in physiotherapy is this whole sort of like footprint, imprint, whatever, environmental footprint, let's say specified to environmental footprint has to be considered in whatever we do.

[00:18:24] And so I think there is two sort of like basic directions here in relation to physiotherapy. One is that, that of course, physiotherapy, like every other healthcare service and so forth, has its, has its environmental footprint. So one aspect of like what needs to be done is to try and reduce that as much as we possibly can. Right. And so people are trying to work out what is actually the environmental footprint that our, that our work has and how do we go about reducing it. Right.

[00:18:47] So that, that's very much sort of something that's in the works, both in terms of research, but also in terms of people just like trying out different things in their kind of clinical environments. I think the other aspect is that physiotherapy of course is just one sort of piece in the puzzle and the whole healthcare system as such. And so, you know, environmental footprints of healthcare systems are probably more readily assessed so far than, than of specific services in a way.

[00:19:12] And so what, what in some ways we don't necessarily know, but can quite, quite, quite confidently claim is that physiotherapy among sort of like the different kinds of healthcare services that can be provided is probably to be counted among the sort of like relatively low environmental footprint options. Because in our working with, for example, touch manual therapy, if you will, or working with movement, right. With physical activity, all of those like don't necessarily require a lot of like technology.

[00:19:42] You know, we don't know, we don't need a lot of these kinds of material resources for those purposes. So in some ways we're much sort of with a lower carbon or lower environmental footprint alternative to hospital stays, to, you know, surgeries, to, to even pharmacological treatment pathways. Right. And so there is this sort of like twofold pathway here. It's very sort of like a simple, that it's a good, simple starting point when we're trying to get into, okay, so what's this whole environmental physiotherapy, sorry, environmental footprint thing and how does it relate? Right.

[00:20:11] But from a broader environmental physio perspective, I would say we should probably also think of a similar things in terms, in social terms, right. Like social footprint, you know, both positively and negatively and kind of like, you know, because that kind of would be more of a perspective of a total environment that's both ecological and social and cultural and et cetera, et cetera. Right. Like, so there would be other facets to explore.

[00:20:34] But the environmental footprint thing gives a good sort of like easy starting point and what kind of thinking is that and where to start. Yeah. And I think that's good, Philip, because sometimes when I talk to my students, they're kind of just talking about this. We're such a low carbon profession, if you would like to say that way. And we are probably. And that's the thing with the environmental physiotherapy.

[00:21:00] We have to explore if our interventions could also add something more. If we go beyond this carbon footprint measuring. If, for example, if we take physical activity, I think most manual therapists actually give recommendations also about physical activity. And what about physical activity?

[00:21:24] Is it so that we always have to think about physical activity in this instrumental way of, you know, type, dose, frequency, duration, and be very, you know, specific on that point? Or can we use physical activity as a way to have people gaining a much deeper connection with nature, for example? And there is something called planetary health enhancing physical activity.

[00:21:52] Or it's kind of a concept that is emerging and blooming right now. If we could perhaps use physical activity as physiotherapists as a way to have patients be more in a relational contact with, for example, nature, doing something good for nature at the same time as I'm doing something good for my own health.

[00:22:15] So trying to explore our different interventions in another way, not just be satisfied with, you know, there's evidence for physical activity being very sufficient and very healthy for X, Y, so, and so on. But could it be something more? Could we use it as a way to explore the environment, the planet, and our relation to this other world or the parallel world or our world?

[00:22:44] Or if you would like to say so. So I think the carbon footprint is only one part. And if we go beyond that, we see so much more things that we could explore and try to figure out if we could do something even better with physiotherapy.

[00:23:02] Could it be a profession that has more to offer than just this bodily evidence effect of, you know, decreased pain, increased muscle strength, and so forth. Yeah. This is beautiful. I'm getting the image of a tree and not just what we see, but the roots and how deep the work that we're doing is really growing.

[00:23:24] And in a world where we're so excited about the newest technology or what can we measure or the flashing lights and how can that affect PT, I think it's brilliant to say, hey, not only can we use our hands to do a lot of these same things and exercise, but they have these secondary and tertiary impacts that we're not really claiming or probably promoting or, you know, talking about enough to our patients, to our political leaders, etc.

[00:23:53] It's amazing how deep this can go. So I can see Philip how when you first had this idea, it probably was like, whoa, you know, how do we attack this problem? How do we define this problem? How do we demonstrate that we're making strides toward this? So I think this is all amazing and really making me think a lot. Good. I also don't know that we define ourselves as part of the solution. You know, I bet I'm a private practice owner.

[00:24:22] I have my own clinic. So, you know, one of the questions I want to ask you is what could I be doing or how should I be measuring or something tangible or a resource that I could go to to help me figure those questions out. But I don't know that I think of myself as part of the solution the way that I could be. I mean, so for me, I think it's interesting that you're using this sort of like terminology of, you know, are we, you know, are we like what is the problem and how do we even define the problem?

[00:24:53] You know, clearly there are problems that, you know, that need to be addressed within this space. So when we're talking about environment, right, like there's substantial problems with climate and biodiversity loss and so forth. And we have, you know, I mean, our world, I think at the moment is pretty crazy in every kind of way, whatever the problem might be.

[00:25:13] But so I think like for me, more so, you know, because I kind of came from this sort of like different question around ethics and something. I mean, I was, you know, I was clearly aware of, you know, all of these sort of like ecological problems that we're having and crises that we're having really at the moment. But in some ways, curiosity driven, I much more thought, oh, this is like, this is so cool.

[00:25:38] Like it could be so cool for our profession to engage with this much more with this question that I had. Right. So it's more so in the space of an opportunity in the way. And I tend to hold myself there, like in the kind of like opportunity space, not in terms of monetary opportunity, but in terms of, wow, what great new knowledge we could have. What great sort of different approaches we could take to our practice, to, you know, what we are and so forth. So it's kind of from that I'm coming from that angle quite a lot.

[00:26:07] And if I think about it that way, actually, I think so, you know, if you're a clinician, you know, in, you know, whatever capacity, I mean, I would always say, you know, the first start is, you know, to start learning as well. Right. Like it's, you know, I think physios, we always want to jump into the doing and that's fair. It's lovely that we were doers, but, but let's prefix some learning also and give our space to do that.

[00:26:31] And so from that perspective, you know, I would say the environmental physiotherapy association website, we've, we've created it, I think into a really sort of like a hub for learning a resource hub, if you will. That I've already heard that, as you said, you know, we've not been going for that long, actually, you know, it's, I mean, what is it? 2026. Now it's been seven years, let's say. And, and I've already heard from people that they've come onto the website and thought, oh my God, this is overwhelming. I don't even know where to start. Right.

[00:27:00] Like, so you could spend a half year to a year, I would say, no, just working your way through all the material there, all the research articles that have been published, the educational material that we've created, the, you know, clinical practice kind of like support thingies that we've created. Just all of the ideas that are kind of being shared by people from around the world in our blog that we regularly publish as well. So, you know, I would say just don't worry about doing something right away.

[00:27:28] Just start learning first and enjoy yourself doing it because it's really like, there's so much fascinating stuff there. Right. Like that's, I think it's also anyway, there's always so much more new stuff to learn and this is part of it. Right. Like, so enjoy that. It's a good starting point. I would say the other thing that I've also, you know, I've shared.

[00:27:46] I've shared this in other kind of contexts as well is, you know, sometimes I think if we're, if we're coming from this door of, you know, climate change, et cetera, then we can sometimes feel quite desperate, you know, because it's really sort of like dire and we don't know what to do. And we feel so small. The thing that really helps there is just to connect with others. And so this is a bit of a shameless plug, but if you wanted to connect with others interested in this, you know, join up, join up. It's for free.

[00:28:13] It's just a community of people that think together and that do stuff together. And yeah. And then from that, all kinds of action emerges. Right. So yeah, that's my take. I love that. I'm going to link to the website and in the show notes, you know, the blog and all of those things. So at minimum people can connect with you. Yeah. Emma, what did you want to say about that? Well, absolutely. Go into the web page. It's fabulous, actually.

[00:28:42] But I think it's very hard to give like individual advice for a clinician what to do. But I think that perhaps it's trying to have a shift in how you think and how you are curious about where your patient comes from. Let me give an example. If you, for example, work with some kind of behavioral change, you're working with physical activity or you have this kind of, I don't know, exercise you want them to do.

[00:29:09] And you feel like there is no adherence to the regime you're giving. Most often we kind of do some kind of victim individual blaming to that problem. We kind of assign the non-adherence to that patient.

[00:29:27] But if we start to be more curious about why is it so that this patient, for example, had a relapse of the kind of exercise or physical activity program, could it be something with the environment that has to do with it? It could be like, has it been a heat wave or is it an unsafe walking street?

[00:29:50] Trying to see, could it be the street that is the problem and not the kind of adherence or motivation problem within the individual? Because most often as physiotherapists, we go to our patients and we work with this, you know, very individualized behavioral change plan instead of looking at what about the environment within all of this? Has it been more air pollution, for example, or is it seasonal variation due to some other effects? Or have they rebuilt the streets?

[00:30:20] Are the lights out at night where they usually go? How come our patients are not following our advices? Look at the environment. And I mean, not only the environment, it could also be the social environment, of course, at home. But start kind of see the patient in a broader lens and see behavioral change for what it is. It's not just individual behavior change.

[00:30:46] The whole socio-ecological system is part of why people move or not move. So start kind of look at your patient with a very curiosity in mind to see if you have the answers. I think it's really great because I think there's, I just want sort of like to mention, I think that's, that kind of, to do the kind of work and thinking that Emma is suggesting.

[00:31:13] Actually, we have traces of that historically in our profession quite a lot also already. Or we have, and we have specialty fields in our profession that are much more sort of like tuned into that kind of thinking. I mean, if I think a lot about sort of like pediatric physiotherapists, for example, they're very sort of like cued into thinking about the family environment, right?

[00:31:34] Like, and how that sort of provides or, or the school or the kindergarten or that kind of, you know, how does the kindergarten support my children to move this or that way and so forth. So it's kind of like cued into that, that kind of environmental thinking. I think also in like in people, in physiotherapists that work in occupational health and ergonomics, I mean, they're wondering about the work environment, right? And so, so, so that's also there.

[00:31:59] I mean, even in, in like aquatic physiotherapy or like whatever, you know, there's different names to it, but people working with physiotherapy, like and with patients in water, there is a realization that somehow in that environment, something else becomes possible. That's conducive to my client's health, right?

[00:32:18] So I think what, and also, I mean, like, I don't know how it is in the US, like in terms of the ICF, if the, if the ICF model is like meaningful, but the largest category in the ICF are the environmental factors. Look at the size of the different categories. The largest is the environmental factors. And yet, you know, if, if just a few years ago, when I was talking to people about that, they were like, oh yeah, but we always just think about the, you know, the function activity participation.

[00:32:45] And I'm like, yeah, but you know, that thing there is like, it's enormous compared to all of those three categories. And so, so we have that stuff somewhere, like we have it ready at hand in theory, you know, biopsychosocial, whatever, you know, that kind of thinking, it lends itself to thinking about environmental factors.

[00:33:04] And so while those traces exist in our profession, and they have been in different niches, I think what environmental physiotherapy also does and gives us is the space to think about it in a much more abstracted and generalized way, right? So it's not either the work environment or the home environment or the, you know, whatever kind of other type of therapeutic environment, but it's all of those and the environment in general, right? Yeah. Definitely.

[00:33:33] You made me, I think we do a good job of saying, what's my patient going to do for home? Where are they going to, or how much are they going to do it? How long are they going to do it? How heavy is it going to be? But we don't say, where are they doing it? And even if we do say where, and we go that step, you know, we're thinking about the environment in terms of, can they do it there? Like, do you have a floor? Do you have a corner? But not like, would it be better if you did it somewhere else? Like, would it be better if you walked outside versus on a track?

[00:34:01] Would it be better if you swam in the lake versus a pool for all of the reasons, not just, you know, the obvious reasons, but the chlorine versus, you know, the exposure. I mean, there's so many, it just goes so deep now that you're talking about it. And just to follow up on that, you know, and would it sometimes be better if you didn't do it in a certain place? Like, for example, because there was air pollution or there is a bloody wildfire somewhere that's, you know, moving fumes your way and so forth, you know. I mean, also that, right? Like, yeah. Yeah, definitely.

[00:34:31] I'm already thinking about adding a question to my intake paperwork of has your environment changed? We have a lot of people that move, you know, from the city or they move up, you know, from a different state or a different country. And I don't know that I would associate a new onset as related without some sort of cueing into that. So you're right that there's so much that can be taken into account. And while we have some hand on the pulse, I don't know that we fully understand the whole system, if you will.

[00:35:00] I think we've been so occupied by talking or telling this narrative about what physiotherapy does to the body instead of, you know, opening up to questions. What is physiotherapy doing with a body in a place over time and to what costs of that place in the system that we're living in? So it's like trying to see the body in a place also and things we're doing and what does that do to the system?

[00:35:30] So it's kind of opening up to so many more questions. And I think the question also that Philip raised there about air pollution, it's so easy to talk about, for example, doing physical activity in nature as only a positive thing. We really have to start thinking also when is it not good to being outside and not prescribing outdoor activities as a default.

[00:35:54] We have to provide these seasonal variation or even daily variations of when you should actually be outside in the forest, for example, and doing physical activity. And I've read about, I don't know about the name now because I don't want to take the credit of it, but physical activity has actually also been described as both a victim, a perpetrator and a solution.

[00:36:18] So that we are both a victim, for example, for climate change regarding physical activity, that we can't do everything outside when it's a heat wave. But we are also a perpetrator if we use physical activity in the wrong environments, for example, when we disturb different biodiversity areas. And we are also part of the solution, of course, if we use it as an active transport.

[00:36:42] So even physical activity is so, I mean, it's so many dimensions of physical activity. And we shouldn't just use it as a default and say that it's always good to be outside. Some of this reminds me a little bit, sorry to sort of chime in with that, but it reminds me a little bit of, I was giving a talk on environmental physiotherapy a few years ago.

[00:37:07] Thankfully, you know, gratefully, a keynote at a physio conference or physio educators conference. And I started the keynote by saying that if anybody in the room could give me, could tell me about any aspect of physiotherapy that is not in one or other way related to the environment, I would stop my keynote and leave the room at that moment. And, I mean, try it. Tell me one. I have yet to have somebody actually, like, talk to me about any aspect of physiotherapy that doesn't have anything to do with the environment.

[00:37:36] I mean, in the simplest terms, exactly what Emma just mentioned, you know, movement. How do we think of movement as not happening in an environment at all times, right? Like, so, of course, it always does, right? And so if that's the case, I think, like, it's strange somehow, but we somehow haven't made that explicit to ourselves, let alone to our patients, right? So I think this is, you know, going, I'm still sort of like, I always revolve around this question of what is environmental physiotherapy.

[00:38:05] It's probably my favorite question. But, you know, it's really that. It's really this opportunity to sort of like rethink physiotherapy at this fundamental level. It's like, oh, yeah, the whole thing is totally an environmental, everything of it is environmental, right? Yeah. Yeah. And I think you've definitely demonstrated that this is not a niche, right? This is not a cause. This is a layer to what we're doing that we just need to start with being aware of and then realizing how impactful we could be.

[00:38:35] It's really awesome. And maybe like coincidentally and for good reason, it includes all those niches and causes that people maybe initially would readily associate with hearing this notion of environmental physio. So, yes, of course, it includes climate change and biodiversity loss and greening your clinic and all of those things. But it's also, you know, a bit more than that. Yeah. Yeah. Yeah, definitely.

[00:39:01] So my question to you is knowing all that you know, and what I'm hearing is obviously you're providing us with resources and this conversation is just going to get people thinking. And so I hope listeners share it. I hope they go to the resources that you're sending and start to read some of the stuff and it becomes a nice ripple effect. But what's one actionable thing that someone could do on Monday, despite where they're at, whether they're a clinician, whether they're an academia researcher?

[00:39:29] What's something they could do on Monday that would help the idea of what you're trying to propose here? Well, I would say start asking more questions about the environment surrounding the patient more than you could ever, I mean, think of. I mean, try to be very curious a little bit more in your history taking. Just ask some more questions.

[00:39:56] It's like 90 seconds where you can ask just one more question and see if that will affect the advice or the regime or the treatment protocol that you're proposing will change in some way. Or you're thinking about how these patients would like to adhere to your advice. I think that would be my answer. Yeah.

[00:40:22] I think, you know, for me, you know, beyond this, what I said about going to the website and just starting somewhere, not to be sort of sarcastic, but I would say if you find yourself in a situation that you think all of this is just crazy talk and, you know, yep, the environment, whatever, important, but nothing to do with physiotherapy or nothing to do with health or whatever. I mean, maybe one thing to do is just hold your breath for a while and rethink what you're starting to. Like, I mean, how fundamental is the environment to our health? Really?

[00:40:52] Like, really? You know, I mean, it's the ground you're standing on. It's the air you're breathing. It's the nutrients you're eating. There's nothing more fundamental than that. Right. Like, so just sort of like really allowing that to sink in is a huge thing in itself, I think. Love that. And I could also give you my favorite exercise that I always give my students.

[00:41:15] Take your phone and just Google or do, you know, Safari, whatever. Put in a diagnosis of your patient and then type heat wave and their air pollution and then press enter and see what do you find when you do that?

[00:41:32] You will find so much material and evidence for that almost all diseases and symptoms that you might find in your patients can be linked to environmental causes. I mean, it will always affect the health of your patients. So just do that exercise on Monday or even when you're listening to this, just Google a name of a disease, heat wave and air pollution and you'll find tons of materials.

[00:42:03] All the connections. Yeah. Yeah. Do you guys have any other things coming up? Are there any talks? Are there any events? What other ways are coming up? Are there any opportunities you want that you want to ask for and hope that a listener can come throw your way? Yeah. So we have events, you know, I won't say regularly in terms of always the same dates, but we're constantly running some sort of events on the website. You can also find information about that. We actually have something coming up next week.

[00:42:32] That's again, a little bit education oriented because we're also very active in thinking through how we can bring some of this into education, right? Or a lot of this into education. And so we've got, it's really, is it next week or the week after? No, week after. 25th of September is our next event as far as that is concerned.

[00:42:49] I can already say that I'll probably just say it here publicly for the first time, actually, that at the end of next year, for sure, we will have our second ever environmental physiotherapy festival, which essentially is an international online conference. Really sort of like focusing on this field. So that's going to be next year. People are both welcome as listeners, as well as contributors in all kinds of ways. Information about that will come out towards the end of this year, probably.

[00:43:19] And yeah, there's always something happening. So just sort of like stay tuned on the website, I would say. That's amazing. Thank you both so much for staying up late so that we could connect and we could do this. I think this conversation is going to be, is going to make changes and be awesome. So I will definitely ask you to give me links and everything you talked about so we can put that in the show notes and we can encourage as many people to check this out.

[00:43:48] Just start thinking about it, share it, follow you, and hopefully attend some of the events you're doing. This is amazing work and I really appreciate your time. I should also say, sorry, I'm sorry for saying this now, but there is actually, so just looking at the US, I think the American Physical Therapy Association, APTA, right? It actually did release kind of like a policy statement. I think it was on environmental stewardship. I don't know the year now, but quite a few years ago.

[00:44:19] And also in one of the subgroups of APTA, there is a special interest group on environmental physical therapy that's also kind of like connected to us and is just trying to mobilize a little bit more locally in the US. We're also trying to produce sort of like more specific material to different regions at the moment that the US is one of those regions. So as far as your listeners are kind of, you know, in the US, I just want to want to flag that as well.

[00:44:44] You know, there's kind of like the international work, but we're also sort of like trying to increase more regional momentum, if you will. And there is stuff happening in the US as well. Yeah, thank you for calling that out because we're associated with international, different international groups, right? I found all these things and it's nice to see the overlap and use each other's reach and to support each other. And actually, I found is also working on this stuff. There is now a dedicated task force, specifically in this case, on environmental sustainability within I found.

[00:45:13] So that work also exists and is like ongoing now. Amazing. Amazing. Any last remarks? No. Awesome. We could go on forever. We could go on forever. I can tell. I love that. It was an easy conversation. You both are so passionate. But as you're talking about it, I mean, I'm already inspired. So I know this will inspire listeners.

[00:45:42] And I'm just so grateful that you chose to do this and coordinate it and give this up. So thank you both again. And I will continue to spread the message. Thank you for having us. Yeah, thank you. Of course. Of course. Thanks for listening to Hands On, Hands Off, the official podcast of AOMT. Subscribe now so you never miss an episode. And connect with us at aomt.org or at AOMT on social.

[00:46:11] Opinions are those of the guests and not official AOMT policy. See you next time. See you next time.