When I told some of my peers that I was doing my dissertation on environmental sustainability in physiotherapy, I got lots of comments like “But… why?” or “Wow that’s very niche!” With a degree with such a high workload already, why would you add sustainability to the curriculum? We didn’t choose to do an environmental sciences degree, and physiotherapists are burnt out already.

I understand these ideas, but once I started reading the blogs from the Environmental Physiotherapy Association (EPA), I was hooked. I found it strange that the World Health Organisation called climate change “the single biggest threat facing humanity” and yet I hadn’t heard anything about this during my healthcare course.

These blogs, and further research, made me realise how the health impacts of climate change affect us in so many ways, and how sustainability is relevant to many areas of physiotherapy. Examples I have found include:

Orthopaedics & musculoskeletal care (MSK)
Pathways have been developed to reduce the impact of MSK care on the environment (Palstam et al., 2022).

Non-communicable diseases
Links between air pollution and many health conditions exist, including COPD, asthma, hypertension, type 2 diabetes, and others (Committee on the Medical Effects of Air Pollutants, 2010; Hansel et al., 2015; Kelly & Maynard, 2018; Maynard, 2022; Tiotiu et al., 2020; Vallianou et al., 2021).

Links have been found between poor environmental conditions and certain diseases (Louis et al., 2023; Zammit et al., 2021). This is a new area of research, so there is more to discover.

Sustainable Development Goals (SDGs)
These goals represent many population health issues, none of which happen in isolation and all of which affect health (United Nations, 2015).

Biopsychosocial model (BPS)
Understanding that every aspect of a person’s experience happens within their environment is important but often missed. This links to access to green spaces and population health issues such as poor housing (Lehman et al., 2017).  

Communicable diseases
The origin of diseases that put many people in hospital, can be traced back to our relationship with the planet and other animals (Mishra et al., 2021).

Communication about climate change
Signposting to resources such as the Talking Climate Handbook (Webster & Marshall, 2019) could improve confidence in talking about these issues – an important step in creating change (Maibach, 2021).

Millie Kent

Millie Kent

PT, BSc (Hons), University of Nottingham

Millie is a new-graduate Physiotherapist in England, who has recently received her registration. She is interested in musculoskeletal and neurological physiotherapy and the power of physical activity to improve function and wellbeing. In her spare time, she enjoys running, wild swimming and yoga.

These are just some ways that link nicely into the topics already covered by current physiotherapy degrees. I’m sure there are many others too.

However, we cannot forget the concerns that my peers had, because new ways of working are more likely to be adopted when the opinions of all the stakeholders are involved (Fagiewicz et al., 2021).

This is where the idea for my dissertation came from. I did a questionnaire exploring the opinions of physiotherapy students and graduates on this topic, the full paper is available here. All students and graduates from the University of Nottingham could participate, as my research aimed to inform curriculum development here. 34 students and 11 graduates responded. I analysed the results descriptively and some of the main findings were:

Twenty-eight (62%) of participants believed sustainability topics should be included in physiotherapy education. The remaining seventeen (38%) did not.

Thirty participants had positive initial reactions to SHE (interested, excited, pleased, relieved), five had negative reactions (boring, frazzled, not interested, neutral), and eighteen mentioned being confused by the concept.

Three main barriers to implementation were identified
(1) Belief that planetary health is not relevant to clinical practice.
(2) Concern that it would increase the workload for students.
(3) Belief that there are bigger priorities to learn about in healthcare.

If students learned about the health impacts of climate change alongside expected topics (as previously explained) the barrier of relevance & and confusion would not be an issue, because the links to current practice would be explicit. Using it as a theme would also give a broader understanding of how the environment affects every aspect of life, and therefore every part of physiotherapy. This approach would also minimise the workload, which was another concern highlighted by the questionnaire.

The other barrier of sustainability not being a priority in healthcare is complex. Understaffing and underfunding are massive issues, and the care of the patient is always paramount, leaving little time to think about much else. Changing these underlying issues requires a change in strategy at a national level, to focus more on the prevention of incidents, rather than constantly reacting (Hewitt, 2023). However, this would require significant investment, leaving many health professionals feeling helpless to make a change. If they were given the tools and confidence to advocate for changes, it may help to create a healthier and more sustainable society (Maibach et al., 2021).

Another idea was that sustainability and patient care contradict each other. Sterilising equipment and essential single-use plastics are sometimes necessary to ensure everyone’s safety. But there are also examples where resources are being used unnecessarily, for example, non-sterile gloves (Flores & Wrigley, 2019), and unnecessary procedures (Born et al., 2022). Furthermore, some treatments with similar patient outcomes have different environmental impacts (Jeswani & Azapagic, 2019), and learning to factor this into clinical reasoning is increasingly important (Mortimer et al., 2018). Finally, there are many examples of interventions being beneficial for people and the environment. Examples include active transport, healthy eating, and access to insulated housing (GOV.UK, 2022). This demonstrates that patient care could even be improved by advocating for a more sustainable health system.

In conclusion, students and graduates have varied opinions on learning about sustainability in physiotherapy courses, and this must be respected. I have described some of my ideas of how to overcome the barriers identified by the survey, but there are many ways to go about this, as seen in the EPA blogs. Experimentation and conversation are always essential when investigating innovative ideas (Maibach, 2021).


Header image by Leeloo Thefirst


Born, K., Levinson, W., & De Freitas, L. (2022). Reducing harm from overuse of healthcare. BMJ, 379. https://doi.org/10.1136/BMJ.O2787 

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