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... , Associate Professor, Oslo Metropolitan University. This article (“fagartikkel") has been peer-reviewed according to Fysioterapeuten's guidelines, and was accepted on 4 March 2021. No conflicts of interest stated. The article was first published at www.fysioterapeuten.no. Introduction
Climate change, biodiversity loss, the disruption of biogeochemical cycles, air, water and plastic pollution and the widespread degradation of land and sea are fundamentally changing the environmental conditions that support human life on earth (1). The destruction of our global natural environment has been recognised as the largest threat to human health and flourishing in the 21st century and is already affecting the health of people around the world. Recognised health impacts expected to increase over the coming years include non-communicable disease, exposure to infectious and vector-borne disease, threats to human nutrition and food crops, as well as mental and physical trauma and injury due to extreme weather events, climate migration and other environment- and resource-related displacement and conflicts (2).
In light of the ubiquity and severity of todays interconnected environmental and health crises, it has been recognised that addressing them means working towards more sustainable futures and requires resolute action across all sectors of society, from multi-national endeavours to individual action in daily life. This is clearly stated in the UN Agenda 2030 Sustainable Development Goals (SDGs) explicit call for the ‘mobilisation of all available resources, participation of all countries, all stakeholders and all people' and many other resonant publications (3).
For the health care professions, this represents a clear call for the inclusion of sustainability considerations into all aspects of professional practice, research and education (4,5). Looking towards clinical practice in particular, clinical reasoning has been a cornerstone of physiotherapy for the last few decades and is deeply embedded in phy
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siotherapy education and practice (6). As a complex and multidimensional phenomenon involving problem solving and professional judgment, clinical reasoning combines the cognitive process of the physiotherapist and a narrative process that includes patients and others such as family and other healthcare practitioners (7). Rather than linear, clinical reasoning has been visualized as circular or spiralling, taking into account the interactive process between patient and therapist in the clinical encounter (8). What has been lacking so far, however, is a better understanding of how considerations of environmental sustainability must and can be included in clinical reasoning. We consider this indispensable in a world in which health can no longer be ensured effectively without simultaneously addressing the environmental conditions it is predicated on.

Aim
The aim of this article is to illuminate how the need for sustainability in future physiotherapy can be addressed by advancing the evolution of clinical reasoning. We address the following questions: How does sustainability relate to physiotherapy? In what ways can environmental reasoning inform future clinical reasoning in physiotherapy practice?

Main part
Sustainability in healthcare
In addition to the extrinsic imperative to include sustainability into health care as a central concern due to the health impacts of global environmental degradation, there is a compounding, intrinsic imperative resulting from healthcare's very own contribution to environmental degradation and resulting ill health. A recent study of healthcare's carbon footprint identified that ‘if the global health care were a country, it would be the fifth-largest emitter' of greenhouse gas emissions of the world (9). Further adding to these significant carbon emissions, the healthcare sector is a significant producer of waste, air and plastic pollution, and uses extensive natural resources for transport and the development and provision of specialist services and technologies (10).
The combination of the extrinsic and intrinsic imperative for the inclusion of sustainability concerns implies a twofold mandate for health care that is maybe most clearly expressed in the notion of sustainable healthcare: Firstly, to advocate and contribute to improving sustainability at the general level of society in light of corresponding health implications and, secondly, ensure socially equitable healthcare services over time, where both are guided by the environmental constraints provided by our planetary ecosystem (11).

Positioning environmental sustainability in physiotherapy
A brief look at the notion of sustainability is needed to understand how the twofold sustainability mandate might be operationalised in physiotherapy. The predominant conception of sustainability (qua sustainable development) situates it as a middle ground or balancing of economic growth, social equity and environmental sustainability (12). This conception is likely to continue to receive much political support given its embeddedness in the SDGs as the largest corresponding multinational policy effort. However, t