On “Concerns on the Science and Practice of a Movement System.” Joyce CT, Beneciuk JM, George SZ. Phys Ther. 2023;103:pzad087. https://doi.org/10.1093/ptj/pzad087
Year: 2024
Type: letter
Abstract: Discussion of the movement system is both welcome and necessary. Clearly, the current information about the movement system and movement diagnosis is in its infancy. In 1975, Hislop1 warned of the profession’s identity crisis because of a lack of a body of knowledge. In 2013, the American Physical Therapy Association House of Delegates designated the movement system as our identity. As such, it is the foundation of our body of knowledge and critical to our recognition as doctorly educated practitioners. Therefore, discussion should not thwart recognition of physical therapists as responsible for a physiological body system and for diagnoses of that system. The transition from therapists providing treatment based on another practitioner’s diagnosis to doctors of physical therapy diagnosing conditions of the body system within their area of expertise is not only important but necessary for the viability of the profession. Therefore, discussion of the movement system and movement-related diagnoses should be based on thorough and accurate interpretation of available science. The following are major concerns with the Point of View article published by Joyce et al2: Lack of consideration of the reason the House of Delegates adopted the movement system as the identity of physical therapy, and not providing the definition adopted by the House. Selective reporting and interpretation of cited literature and failure to acknowledge the evidence that does exist for movement system diagnoses. Implication that treatment for a movement diagnosis is ineffective when reference was to a nonspecific condition and inappropriate treatment. Suggestions that normal variations in movement preclude being able to identify movements that are provocative and that contribute to dysfunction. In the 50 years after Hislop warned of the identity crisis, few steps were taken until 2013 when the vision statement and identity were adopted.3 The vision of “[t]he physical therapy profession transforming society by optimizing movement to improve the human experience” can be achieved only by becoming experts in the movement system—our identity. The official definition of the movement system is the integration of body systems that generate and maintain movement at all levels of bodily function.4,5 In 2015, the House of Delegates adopted a motion to develop movement system diagnoses.4 National activities were initiated, but only the Academy of Neurological Physical Therapy has continued related activities to fruition. The lack of a body of knowledge required for a movement system expert and diagnostician has resulted in an emphasis on treatment techniques rather than on movement as an etiological factor that can be corrected or as a preventive to optimize health. Practice patterns have not addressed the chronicity and recurrence of musculoskeletal problems that suggest these problems begin prior to symptoms and are not from a sudden onset. Subsequently, as a profession, we are failing to promote the invaluable role of physical therapy in minimizing and preventing movement system problems. The authors misquoted the terminology about diagnostic labels from Sahrmann.6 They used the term aberrant movement, which was neither used nor inferred by Sahrmann. The provocative movements identified in that Perspective were not hypothesized or described as “aberrant” but were described as those eliciting symptoms.6 The Perspective also cited numerous studies demonstrating effective treatment with movement correction, which Joyce et al2 did not acknowledge. Several additional studies7–9 have supported the association of movement and symptoms as well as the reduction of symptoms and improvement in performance with correction of the movement. In their Point of View, however, Joyce and colleagues persistently suggest that the “aberrant” movements are highly theoretical and unable to be identified. Such suggestions are inconsistent with the evidence.7–9 Joyce et al state that “movement assessment is confined to uniplanar segments,” ignoring the research demonstrating the effectiveness of correcting movement of symptom producing basic activities.9 The caution about “expeditious advancement of practice approaches that have yet to be empirically substantiated” is a misrepresentation, because there is more than empirical substantiation: There is evidence for the correction of symptom-producing movement as effective practice.7,8 Another example of selective reporting stems from Hoffman10 regarding “too many diagnoses.” Rather than providing a clear context for the argument, Joyce et al suggest that no more diagnoses should be proposed. Yet Hoffman states that diagnoses should be associated with conditions of pain, dysfunction, and suffering. These conditions are certainly factors addressed by movement diagnoses. The same article also cites the importance of diagnosis: “For health professionals, diagnoses are crucial for forming a conceptual framework, to coordinate communication, and to guide actions.”10 As implied by this statement, movement diagnoses are a way of conveying the relationship of movement to dysfunction and focusing treatment. In their discussion of scapular upward rotation deficit, Joyce et al reveal their understanding of movement and movement dysfunction. They question the value of the diagnosis because some studies addressing “scapular dyskinesia” do not show effectiveness in treatment of shoulder pain. Scapular dyskinesia does not indicate a specific scapular movement problem. The treatment program was to stabilize the scapula. Such treatment is (1) not directed at the specific problem and (2) would be contraindicated treatment for a scapula that is not adequately upwardly rotating. A movement expert would recognize the movement deficiency associated with symptoms that are alleviated with movement correction, the prevailing treatment strategy. Joyce and colleagues suggest that differentiating normal and abnormal movement is difficult if not impossible. They again are using terminology—abnormal movement—that is not used in the relevant literature. They suggest that intrinsic movement variability precludes identifying deviations that are problematic. As a movement expert is aware and as is characteristic of every physiological system, there is the average and standard deviation. No statement is made in the relevant literature that all people move the same. To imply that problematic deviations are not recognizable is the antithesis of the very basis of being a movement expert. Why study anatomy, biomechanics, or kinesiology if deviations associated with problematic conditions are not discernable? Why are there measurements of range of motion and courses on gait and movement analysis and increasing use of technology to quantify problematic deviations? Again, the Point of View overlooks the evidence for movement causing symptoms and correction for remediation as previously cited. The consequences of failing to promote and develop our professional expertise in the functions and dysfunctions of the movement system are many. The consequences include limited use of direct access, reduction in fees for service, the use of apps for exercises, referral to other “exercise” providers, and salaries that are much lower than those of nurse practitioners and physician assistants. These practitioners are believed to have knowledge of body systems and make a diagnosis. Ten years have passed since the adoption of the movement identity, and there has been minimal promotion and action. That identity should be the basis of doctoral level education and practice. All practice, and especially direct access, should stem from the public and other health care practitioners being aware the profession has a body of knowledge, a body system of expertise, and diagnoses of dysfunctions that can be effectively treated. Sooner is necessary to ensure that there is a later. The author completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.
Source: Physical Therapy
DOI: 10.1093/ptj/pzae034
Author: Shirley A Sahrmann
Institution: Washington University in St. Louis
Language: English
Subfield: Rehabilitation
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4392581946