I recently watched this interview of Shirley Sahrmann where she describes the future of physical therapy. Immediately, and predictably of course she launched into her ideas of “developing a diagnostic framework,” “creating labels and using them,” and “identifying a physiologic system and treating that system specifically.” Of course that system is the movement system. No surprise here she has been preaching this stuff for the last 20 or so years.
What’s wrong with that? That seems like all pretty harmless stuff—after all we do deal with movement. To a point this is all true and we have been focused on all this since our profession’s inception. Despite not borrowing much from basic physiology or motor control research we are still creating impractical theories that have poor correlations to the basic science that should at least underpin them. Going back to Sahrmann, I asked her during a course she taught, “How she could explain rapid changes in pain and movement via sarcomeres in series (as she speculated) when they are not likely to be impacted during such a short response time (< 4 weeks)?” To paraphrase, she relayed that she used the concept solely for explanatory purposes and that she had a hard enough time explaining the sarcomere story to physical therapists let alone the more complex concepts of motor control (that would argue against her theory).
This weekend I also opened up PT In Motion as I was curious about the lead article “APTA’s Vision to Transform Society.” Bold right? Well surprise, surprise, the goal is, “Transforming society by optimizing movement to improve human experience.” The article goes into how great and specific this goal is. Yes, this is VERY specific—heavy sarcasm is to be implied. Moving on, under the topic of identity the article goes on to elaborate that “the importance of validating the movement system along with other body systems and affirming physical therapy profession’s responsibility to define it, promote it, and evaluate and manage it in patients and clients.” Shirley Sahrmann all over again, same as it never was.
Again, you’re probably asking, “geeze Eric what is your problem?” Well here is my problem, when I was in PT school I was as much into the movement system as everyone else and I even did some basic science in motor control. Then I started treating patients and things got a little sticky—actually real sticky. Despite taking all of Sahrmann’s courses, patients never really presented themselves in the neat little packages as claimed by Sahrmann or anyone else. I realized that while movement was part of the treatment it was often not the least common denominator of my treatments.
The term movement system implies an agnostic stance with respect to what causes movements and to what movements belong. What do I mean? First movements are produced by intentions: a mix of ideas, emotion and motivation. Second, they are carried out as part of behaviors—which are coordinated with environments in ways to produce effects on environments. Motor control and the physiological adaptations that occur due to movement occur at this narrow junction that binds intentions to behavior. When we approach the problems of humanity from the narrow stance of the movement system we are admitting we either don’t know or don’t care about the other parts. This is the agnostic position that is implied via the treatment of the movement system.
We have been there, done that, tried that, and it has gotten us nowhere. In fact there is a fairly robust literature in biology, motor control, and muscle physiology about how the nervous system optimizes itself WITHOUT a physical therapist ever being involved. In fact one could easily ask, why would evolution require a physical therapist for such optimization—probably a very important topic to be tackled later given the broad claims by the APTA.
I am advocating that it is time as therapists we ditch this agnostic position and put some real skin in the game and start dealing with concepts of intentions and behavior. Whoa, those terms again, those sound like psychological terms one might rejoinder. When does a movement dysfunction become a behavior and when is that behavior guided by an intention? These are the hard questions that our profession faces and it does so with a poverty of language and experience in such fields. Movement unbounded from behavior and intention is essentially meaningless. Last time I checked human behavior is hallmarked by meaning.
When patients visit us in pain, their movements are parts of broader expressions of behavior. These behaviors are guided by intentions. We understand that when a child falls and skins their knee and then looks to mom as means to understand the onslaught of novel sensations flooding their body: they are intending to understand through social referencing. If the mom expresses attention that conveys alarm through her behaviors, the child’s defense system is ramped up and crying commences. If mom express equanimity and acknowledges but does not alarm, the child’s distress resolves quickly and without consequence. The coupling of these seemingly automatic aspects of social referencing occurs without question in children and carries much meaning.
When we divorce our profession of meaning by focusing on “optimizing the movement system” we are inadvertently extricating ourselves from the very fabric of what it means to be human. We create agnostic classification systems that compartmentalize simple acts that our patient’s carry out when they experience novel and perceptually threatening experiences. It is time we grow up as profession and to stop thinking that it is going to be taxonomy of movements or interventions that is going to create a diagnostic panacea in our patient populations.
Eric Kruger, DPT @EkrugerDPT
Categories: Critical Thinking