Teaching prompts to get you started with planetary health, environmental, and sustainability education in physiotherapy. No matter what subject you teach.

The teaching prompts on this page are meant to provide physiotherapy educators around the world with simple starting points to integrate planetary health, environmental, and sustainability education into their teaching, with a focus on one of their most fundamental learning dimensions identified in the majority of leading education and competency frameworks for planetary health, environmental and sustainability education: the interconnections between health, environment, society, and, in our case, physiotherapy.

Identifying such starting points across all subjects taught in physiotherapy curricula, also lays the foundation for further implementation of environmental physiotherapy across curricula and the integration of other key competencies for sustainability. As such, these teaching prompts will also be the central output of the EPT Agenda 2027, which aims at the transversal implementation of environmental physiotherapy across curricula.

How to use these teaching prompts

These EPT teaching prompts are only meant to give you starting ideas and supporting literature to begin the integration of planetary health, environmental and sustainability education into whichever subject you are teaching in a physiotherapy curriculum.

Each teaching prompt is accompanied by a bullet point list with background information, supporting literature, and the name of the contributing author. To access this information, click on the plus (+) sign to the right side of the bar to each teaching prompt.

Feel free to copy, paste and adapt the content into your presentations or use them as inspiration for your explorations of the intersections between physiotherapy, health, society and the environment. Where it seems reasonable please acknowledge this resource in your presentation by including the EPA and ENPHE logos and the name of the contributing author of each respective teaching prompt.

Any ideas for teaching prompts that we can add?

The development of the EPT teaching prompts began at the 2023 European Network of Physiotherapy in Higher Education (ENPHE) seminar in Bergen, Norway following the formation of a new ENPHE subgroup on Environmental Physiotherapy. It now continues in close collaboration with EPT Agenda participating institutions, and we can always use more support. 

If you would like to support the further development of these teaching prompts as a contributing author please contact us here

Anatomy and Physiology

Human anatomy is fundamentally shaped by the environment

Background information

  • All aspects of human anatomy and function are fundamentally shaped by our relationship to the environment
  • Minerals are essential elements and building blocks of the large parts of human bodies and our bones are shaped through constant interaction with gravity
  • The function of our muscles and nervous system depends on energy absorbed from the environment via food, air, and other sources
  • The primary function of our joints is to set us in relation to the environment around us, whether it is to reach a place we want to get to, shake somebody’s hand, or lead a spoon to our mouth
  • This can be acknowledged in teaching about human anatomy and function to provide a broader perspective on the body

Supporting literature

Gomes, C., & Rautureau, M. (Eds.)(2021). Minerals latu sensu and Human Health. Springer. https://doi.org/10.1007/978-3-030-65706-2

Richter, R., & Maric, F. (2022). Ecological Bodies and Relational Anatomies: Toward a Transversal Foundation for Planetary Health Education. Challenges13(2), 39. https://doi.org/10.3390/challe13020039

Ruggiu, A., & Cancedda, R. (2015). Bone mechanobiology, gravity and tissue engineering: effects and insights. Journal of Tissue Engineering and Regenerative Medicine9(12), 1339–1351. https://doi.org/10.1002/term.1942

 

Contributing author

For questions about the content in this specific set please contact Filip Maric (PhD), UiT The Arctic University of Norway. 

Thermoregulation and climate change are deeply connected

Background information

  • In many countries, climate change is resulting in greater levels of heat strain for workers and other people undertaking physical activity during hot and humid months
  • This is particularly so in natural environments where the ambient temperature and humidity are not controlled. In such contexts, core temperature and sweat loss in humans can rapidly rise and exceed safe levels, necessitating strategies to address these concerns and so manage risks of heat illness, heat injuries and, in worst-case scenarios, heat-related deaths
  • Simply taking a break from physical activity and resting in the shade is unlikely to reduce high core temperatures to safer levels within acceptable time frames. In some instances, core temperatures continue to rise despite such rest breaks
  • Human thermoregulatory mechanisms, alone, are frequently unable to adequately reverse core temperature rises in conditions of high heat stress, which are becoming more common with climate change
  • Active cooling and preventive strategies are therefore becoming more important to manage risks to health and to worker productivity and athletic performance

Supporting literature

Brearley, M., Berry, R., Hunt, A. P., & Pope, R. (2023). A Systematic Review of Post-Work Core Temperature Cooling Rates Conferred by Passive Rest. Biology, 12(5), 695. https://doi.org/10.3390/biology12050695

Hall, A., Horta, A., Khan, M. R., & Crabbe, R. A. (2022). Spatial analysis of outdoor wet bulb globe temperature under RCP4. 5 and RCP8. 5 scenarios for 2041–2080 across a range of temperate to hot climates. Weather and Climate Extremes, 35, 100420.  https://doi.org/10.1016/j.wace.2022.100420

Hunt, A.P., Brearley, M., Hall, A., & Pope R. (2023). Climate change effects on the predicted heat strain and labour capacity of outdoor workers in Australia. International Journal of Environmental Research and Public Health, 20, 5675. https://doi.org/10.3390/ijerph20095675

 

Contributing author

For questions about the content in this specific set please contact Prof Rod Pope, Charles Sturt University, Australia.

Thinking about breathing facilitates a different future for the human body and the physiotherapy profession

Background information

  • Oxygen makes up 60% of our body mass – far more than carbon – and our ability to obtain oxygen from the atmosphere means we are intrinsically connected to our local environment and the wider ecosystem that maintains the conditions conducive to organic life
  • Because breathing is a process of exchange, it dissolves the fictional boundary between what we think of as ‘inside’ the body, and what is ‘outside’. After all, when does an oxygen molecule actually become part of ‘me’?
  • Thinking about oxygen, air and breathing as more than just anatomical, physiological and biomedical issues allows us to imagine a broader role for physical therapies that might follow the path of air into questions about things like urban pollution, deforestation and algal blooms, as well as the meaning of breath in different world cultures. Clearly, it is more than just about pulmonary function and the treatment for chronic lung disease
  • So breathing also offers a critique of the traditional belief that physical therapies should be confined to narrow Western biomedical ideals; opening a door to thinking radically about a different future for the profession

Supporting literature

Maric, F., & Nicholls, D. A. (2022). Environmental physiotherapy and the case for multispecies justice in planetary health. Physiotherapy Theory and Practice, 38(13), 2295–2306. https://doi.org/10.1080/09593985.2021.1964659

Nicholls, D. A. (2019). What’s real is immaterial: What are we doing with new materialism? Aporia: The nursing journal, 11(2), 3-13. http://hdl.handle.net/10292/13056

Richter, R., & Maric, F. (2022). Ecological Bodies and Relational Anatomies: Toward a Transversal Foundation for Planetary Health Education. Challenges, 13(2), 39. https://doi.org/10.3390/challe13020039

 

Contributing author

For questions about the content in this specific set please contact Prof David Nicholls, AUT University Auckland, New Zealand. 

Assessment and Analysis

Considering environmental factors in physiotherapy management for structure, function, activity and participation

Background information

  • The International Classification of Function (ICF) compartmentalised the patient together with the patient’s condition into the multiple factors that impact the overall wellbeing of the patient
  • The ICF is used when evaluating disability and health and it considers the patient’s body structures and function, activities and participation, environmental and personal factors in the holistic management of the patient’s condition
  • Climate and other environmental change may be considered in the context of ICF environmental factors that facilitate or inhibit patients function, activity and participation to improve physiotherapy management plans

Supporting literature

Gaskin, C. J., Taylor, D., Kinnear, S., Mann, J., Hillman, W., & Moran, M. (2017). Factors Associated with the Climate Change Vulnerability and the Adaptive Capacity of People with Disability: A Systematic Review. Weather, Climate, and Society, 9(4), 801–814. https://doi.org/10.1175/wcas-d-16-0126.1

Humpel, N. (2002). Environmental factors associated with adults’ participation in physical activity A review. American Journal of Preventive Medicine, 22(3), 188–199. https://doi.org/10.1016/s0749-3797(01)00426-3

Noreau, L., & Boschen, K. (2010). Intersection of Participation and Environmental Factors: A Complex Interactive Process. Archives of Physical Medicine and Rehabilitation., 91(9), S44–S53. https://doi.org/10.1016/j.apmr.2009.10.037

 

Contributing author:

For questions about the content in this specific set please contact Mahitsonge Nomusa Ntinga, University of Cape Town, South Africa.

 

Expanding clinical reasoning to include environmental concerns

Background information

  • Clinical reasoning (CR) is an essential skill of physiotherapists and refers to the conscious and unconscious cognitive operations to integrate information pertaining to a patient’s unique circumstances
  • CR can include diagnostic, therapeutic or narrative and tends to relate to the biopsychosocial model. It should incorporate wider holistic and contextual factors which include environmental considerations as these have significant potential to be implicated as causes of adverse health and barriers to improvement, they may coincide with factors relating to health inequalities
  • Novice and experienced clinicians may use different models of CR but should strive for personalised, prioritised problem lists and shared decision making unique to the situation
  • Tools to support clinical reasoning, for example concept maps and vector diagrams might help prompt clinicians to consider environmental contextual factors and support people to reflect on the impact and influence of environmental concerns and factors related to their health condition, activity, participation and QoL, more research is needed in this area

Supporting literature

Montpetit-Tourangeau, K., Dyer, J.-O., Hudon, A., Windsor, M., Charlin, B., Mamede, S., & Van Gog, T. (2017). Fostering clinical reasoning in physiotherapy: comparing the effects of concept map study and concept map completion after example study in novice and advanced learners. BMC Medical Education, 17(1). https://doi.org/10.1186/s12909-017-1076-z

Cruz, E. B., Caeiro, C., & Pereira, C. (2014). A narrative reasoning course to promote patient-centred practice in a physiotherapy undergraduate programme: a qualitative study of final year students. Physiotherapy Theory and Practice, 30(4), 254–260. https://doi.org/10.3109/09593985.2013.863415

Huhn, K., Gilliland, S.J., Black, L.L., Wainwright, S.F., Christensen, N. (2018) Clinical reasoning in physical therapy: A concept analysis. Physical Therapy, 99(4):440-456. https://doi.org/10.1093/ptj/pzy148

 

Contributing author

For questions about the content in this specific set please contact Dr Katherine Cook, University of Winchester, UK.

To be developed... YOUR IDEA HERE!

Background information

  • You tell us…

Supporting literature

Your suggestion here

 

Contributing author

Your name here

Musculoskeletal Physiotherapy

Using active transport to promote physical activity and reduce carbon emissions

Background information

  • Active transport can be a powerful means to achieve the WHO physical activity recommendations
  • At scale and in combination with public transport, it can also significantly reduce greenhouse gas emissions in urban transport
  • Active transport should be recommended for all commutes under 5km
  • Teaching about physical activity and exercise prescription can easily include knowledge and skills relevant to the promotion of active transport as a clinical planetary health intervention.

Supporting literature

Bull, F. C., Al-Ansari, S. S., Biddle, S., Borodulin, K., Buman, M. P., Cardon, G., Carty, C., Chaput, J.-P., Chastin, S., Chou, R., Dempsey, P. C., Dipietro, L., Ekelund, U., Firth, J., Friedenreich, C. M., Garcia, L., Gichu, M., Jago, R., Katzmarzyk, P. T., … Willumsen, J. F. (2020). World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine54(24), 1451–1462. https://doi.org/10.1136/bjsports-2020-10295

Salvo, D., Garcia, L., Reis, R. S., Stankov, I., Goel, R., Schipperijn, J., Hallal, P. C., Ding, D., & Pratt, M. (2021). Physical Activity Promotion and the United Nations Sustainable Development Goals: Building Synergies to Maximize Impact. Journal of Physical Activity and Health18(10), 1163–1180. https://doi.org/10.1123/jpah.2021-0413

Toner, A., Lewis, J. S., Stanhope, J., & Maric, F. (2021). Prescribing active transport as a planetary health intervention – benefits, challenges and recommendations. Physical Therapy Reviews26(3), 159–167. https://doi.org/10.1080/10833196.2021.1876598

 

Contributing author

For questions about the content in this specific set please contact Filip Maric (PhD), UiT The Arctic University of Norway. 

Integrating outdoor exercise prescription for MSK prevention and rehabilitation

Background information

  • Outdoor exercise and exposure to green and blue spaces can add many benefits to physical activity and its prescription for prevention and rehabilitation
  • Variable surfaces and environments can give diverse challenges and stimulation that can contribute to the development of strength, endurance, proprioception, coordination, and overall physical health
  • In addition to physical health, outdoor exercise has proven benefits for mental health and is increasingly showing potential to reduce the global burden of pain
  • Teaching about physical activity and exercise prescription can easily include knowledge and skills relevant to the promotion of outdoor exercise as a planetary health intervention

Supporting literature

Kondo, M. C., Oyekanmi, K. O., Gibson, A., South, E. C., Bocarro, J., & Hipp, J. A. (2020). Nature Prescriptions for Health: A Review of Evidence and Research Opportunities. International Journal of Environmental Research and Public Health17(12), 4213. https://doi.org/10.3390/ijerph17124213

Stanhope, J., Breed, M. F., & Weinstein, P. (2020). Exposure to greenspaces could reduce the high global burden of pain. Environmental Research187, 109641. https://doi.org/10.1016/j.envres.2020.109641

Stanhope, J., Maric, F., Rothmore, P., & Weinstein, P. (2023). Physiotherapy and ecosystem services: improving the health of our patients, the population, and the environment. Physiotherapy Theory and Practice39(2), 227–240. https://doi.org/10.1080/09593985.2021.2015814

 

Contributing author

For questions about the content in this specific set please contact Filip Maric (PhD), UiT The Arctic University of Norway. 

To be developed... YOUR IDEA HERE!

Background information

  • You tell us… 

Supporting literature

Your suggestion here

 

Contributing author

Your name here

PulMonary Physiotherapy

Antenatal air pollution exposure and chronic obstructive lung disease

Background information

  • Severe and prolonged heat waves, temperature variability, forest fires, consequent air pollution and floods are clear signs of climate changes
  • Besides harming the planet these also put respiratory health at risk and increase morbidity and mortality among patients with chronic health diseases
  • An even more alarming impact concerns antenatal air pollution exposure
  • Maternal exposure to tobacco or fossil fuel-generated air pollutants causes in-utero growth retardation, lung remodelling and immune cell activation increasing the risk of developing asthma or respiratory infections, which seems to contribute to childhood origins of chronic obstructive lung disease by changing the ability for normal lung development and repair

Supporting literature

Voynow, J. A., & Auten, R. (2015). Environmental Pollution and the Developing Lung. Clinical pulmonary medicine, 22(4). https://doi.org/10.1097/cpm.0000000000000095

Bernstein, A. S., & Rice, M. B. (2013). Lungs in a Warming World. Chest., 143(5), 1455–1459. https://doi.org/10.1378/chest.12-2384

Shah, P. S., & Balkhair, T. (2011). Air pollution and birth outcomes: A systematic review. Environment International, 37(2), 498–516. https://doi.org/10.1016/j.envint.2010.10.009

 

Contributing author

For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal.

Air pollution, COPD and acute exacerbations

Background information

  • Environmental factors such as exposure to biomass, fossil fuels, metals and indoor and outdoor air pollution, have a key role on the development of COPD and acute exacerbations
  • These pollutants damage the airways by increasing bronchial activity, airway oxidative stress and inflammation
  • Additionally exposure to these pollutants has also been found to increase hospital admission due to acute exacerbations
  • Addressing air pollution is therefore an indispensable healthcare measure related to COPDs and acute exacerbations

Supporting literature

Dransfield, M., Stolz, D., & Kleinert, S. (2019). Towards eradication of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet , 393(10183), 1786–1788. https://doi.org/10.1016/S0140-6736(19)30950-X

Ko, F. W. S., & Hui, D. S. C. (2012). Air pollution and chronic obstructive pulmonary disease. Respirology, 17(3), 395–401. https://doi.org/10.1111/j.1440-1843.2011.02112.x

Souto-Miranda, S., Gonçalves, A.-C., Valente, C., Freitas, C., Sousa, A. C. A., & Marques, A. (2020). Environmental Awareness for Patients with COPD Undergoing Pulmonary Rehabilitation: Is It of Added Value? International Journal of Environmental Research and Public Health, 17(21), 7968. https://doi.org/10.3390/ijerph17217968

 

Contributing author

For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal.

Good indoor environments are essential for pulmonary health

Background information

  • People spend most of the time in confined environments, such as home, offices among others
  • In indoors environments, the concentration of air pollutants may be too high due to thermal insulation to reduce heat loss and also due to scarce ventilation, thus reducing indoor air quality
  • Studies have reported associations between asthma symptoms and indoor sources of chemical pollutants among others, such as volatile organic compounds, gas appliances or even exposure to tobacco smoke
  • This makes it ever more important to address indoor environments to ensure good pulmonary health

Supporting literature

Hahad, O., Daiber, A., & Münzel, T. (2023). Physical activity in polluted air: an urgent call to study the health risks. The Lancet Planetary Health, 7(4), e266–e267. https://doi.org/10.1016/s2542-5196(23)00055-4

Hulin, M., Simoni, M., Viegi, G., & Annesi-Maesano, I. (2012). Respiratory health and indoor air pollutants based on quantitative exposure assessments. European Respiratory Journal, 40(4), 1033–1045. https://doi.org/10.1183/09031936.00159011

Li, J., Sun, S., Tang, R., Qiu, H., Huang, Q., Mason, T., & Tian, L. (2016). Major air pollutants and risk of COPD exacerbations: a systematic review and meta-analysis. International Journal of Chronic Obstructive Pulmonary Disease, Volume 11, 3079–3091. https://doi.org/10.2147/copd.s122282

Contributing author

For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal.

Other projects and resources in environmental physiotherapy education

    There are an increasing number of projects and resources surrounding planetary health, environmental and sustainability education. For published literature and relevant websites please visit our resources page.

    PREP-IP Persons with Refugee experience Education Project – Interprofessional

    The PREP-IP project addresses the mismatch between the competence of healthcare professionals and the complex rehabilitation needs of a growing population of refugees and migrants in Europe.

    In partnership with physiopedia and Plus, the Environmental Physiotherapy Association has launched an Environmental Physiotherapy Content Development Project and a growing range of Environmental Physiotherapy Courses featuring a growing number of courses related to environmental physiotherapy.

    Environmental Physiotherapy Education Podcast

    by Filip Maric, Shaun Cleaver, Cliona O'Sullivan, Adriane Vieira & Olivia Stone | In Beta Unconference 2020