In the March 2014 edition of the Physical Therapy Journal, Shirley Sahrmann wrote a perspective paper regarding our role as movement specialists. Her paper was written in response to the 2013 APTA House of Delegates new vision statement, "transforming society by optimizing movement to improve the human experience." A key guiding principle of that vision statement is that "the physical therapy profession will define and promote the movement systems as the foundation for optimizing movement." 

Sahrmann states several purposes of the paper, two of which I am going to elaborate on in this post:
1. Advocate for promoting both kinesiopathology and pathokinesiology as important movement system concepts 
2. The movement system must be embraced by physical therapists who seek to achieve the full potential of their critically important role in society. 

1. Advocate for promoting both kinesiopathology and pathokinesiology as important movement system concepts 
Without question, movement is at the heart of the physical therapy profession. In a sense, it is our identity. This message has been proclaimed for decades, most notably by Florence Kendall who throughout her career discussed "the importance of the profession establishing a relationship with a system of the body." However, if movement is truly what we do, we need to start promoting a model that reflects our practice. These models are both pathokinesiology and kinesiopathology.     

By promoting pathokinesiology and kinesiopathology, we are intentionally moving away from the standard pathoanatomical model. Rotator cuff tear, disc herniation, trochanteric bursitis, etc. will not be the focus of our treatments as they do not incorporate the underlying movement dysfunction. For example, a person with a referring dignosis of disc herniation might actually have a disc herniation, but that is not what we are treating. Our job is to treat the movement pattern that is causing that person's symptoms. The cause of their disc herniation could be due to poor proximal strength, adverse neural tension, poor lumbopelvic disasociation, or others. Documenting in your assessment that the patient has a disc herniation provides no explanation for the type of physical therapy treatment you intend to perform. This is a difficult concept to fully grasp as much of PT school and the APTA are still focused on the anatomy of the pathology. If you look at the Orthopaedic Section's monographs, most of the content is broken down by pathology: osteoarthritis, tendinopathy, impingement, etc. If we are going to identify ourselves as movement specialists, we need to begin moving away from pathoanatomical terms and starting speaking the language of pathokinesiology. We are not treating the anatomy, we are treating the underlying movement dysfunction. 

2. The movement system must be embraced by physical therapists who seek to achieve the full potential of their critically important role in society. 

If we are not treating the anatomy and we are focusing on the movement dysfunction, we need to start identifying ourselves with a specific movement system. The system needs to be universal and recognized by all individuals that practice it. Current systems I have been exposed to are the Sahrmann movement impairment systems and the Selective Functional Movement Assessment (SFMA). Both of these systems focus on identifying the cause of the cause of a patient's symptoms.. For example a patient with a rotator cuff tear may present as a Sahrmann shoulder downward rotation syndrome. Using the SFMA, they could be classified as dysfunctional painful (DP) in the shoulder patterns. Both systems would likely find the primary impairments as weak lower traps, weak serratus anterior, strong downward rotators, and poor thoracic mobility depending on how the patient presents. The impairments were found by analyzing movement and help guide the therapist in his or her diagnostic process.  

Adopting a movement system will standardize our treatment programs, improve outcomes, and help us reach autonomy. As Sahrmann states in her perspective paper, "if we are able to successfully define the components of the movement system such that they can be reliably tested and validly treated, we will be illuminating that area of human function and be recognized for that expertise." 

I want to conclude with another Sahrmann quote:
""Labeling a condition is most often the first step in treatment. Referral sources should expect a label from us. Yet, currently, "Physicians refer to consultants for diagnosis. They refer to PTs for treatment. Autonomy will be actualized when physicians refer to PTs to obtain diagnoses."" 

At the student physical therapist, we know we do not have all the answers, but at the very least we want to bring the question to the table. Are you practicing and documenting in a model of pathoanatomy or pathokinesiology? What movement system do you follow? Do you think physical therapists should adopt a specific movement pattern? 

Article: The Human Movement System: Our Professional Identity

-Jim       

References: Sahrmann, Shirley. "The Human Movement System: Our Professional Identity."Physical Therapy (2014): 3.1-29. Web. 15 June 2014.

Some of you may remember reading this post on Doctors of Physical Therapy Website about a year ago, but we believe its message is consistent. One of the biggest barriers to changing our profession is a lack of patient education and understanding of who we are and what we do. 

This post presents a simple, consistent message: " I am (a) ___________." 
-Musculoskeletal Expert, Movement Analysis Specialist, Direct Access, Cost Effective, etc.   

We must advocate for our profession from the Patient-Upward and not strictly Top-Down. We cannot expect to persuade the AMA or Insurance Companies to give us rights if we have little support from our consumer. 
 
Spread the Word!!!

Our roles as physical therapists is constantly changing & seems to differ extraordinarily depending on what type of patient population you see. Currently, I see A LOT of chronic pain. If someone presents with chronic pain, usually this means the traditional medical model of care will not suffice. In these situations, it is important to use the biopsychosocial model of care if I plan to be successful. Part of the biopsychosocial model is understanding what barriers a person has to therapy. By addressing these barriers, the therapist will best be able to address impairments in the scope of the patient's life. Also by looking at these barriers, you will be able to see if a patient is ready for physical therapy. "Ready" you may be asking yourself? One reality I quickly stumbled across while practicing at a community hospital is that certain people have so many life stresses that take priority before their musculoskeletal health. If a patient comes to see you with cLBP, but also has a history of depression, transportation issues, financial problems, family problems, and reports little to no exercise, strengthening the PGM may not be the first thing they need. I would recommend starting this patient on a general exercise program and a few basic exercises. Going back to barriers, one of the biggest barriers I face each day is patient adherence and compliance. I often struggle with how to address these issues. Which clients are appropriate for PT and which are unfortunately not ready to change? Check out this post by Chris Johnson. He poses some great questions that will put you and the patient on the same level regarding your goals and their expectations of physical therapy. They may save you some time down the road.

-Jim     

Already as a resident, I am seeing my clinical practice change dramatically. Whether it is dropping old habits, modifying a technique, or understanding the diagnostic process more thoroughly, I am constantly changing and improving my skills. Generally, these changes are made based off changes in the research and learning from expert practitioners. 

Last Friday, Dr. E wrote a post regarding his top 5 things he has abandoned over the years. It was a very well written post defining how an expert practitioner has modified his practice. In physical therapy school, we all learn so much information. Frankly, it is overwhelming. There is tendency to believe that every skill one learns in school needs to be practiced OR that these are the only skills available. As you continue to practice and continue to develop your area of expertise, you gain a sense of what is important and what may be less efficient aspects of your clinical practice. You also begin to attend continuing education courses AND learn the different schools of thought. To be an expert clinician you need to recognize these changes in your own practice and think about why you changed that old habit. Read Dr. E's post to gain a sense of what I mean. 

23 1/2 hours is a short video by Dr. Mike Evans regarding the BEST intervention for patients of all diagnosis'. He assessed risk factors such as drinking, smoking, sedentary lifestyle, and more. After years of research, he found one intervention that was the single most important thing you could do for your health. The video has some great information for you as a health care practitioner, and also can be used as a teaching tool for your patients. 

We found this gem recently posted on the ilovephysicaltherapy blog by Stelios Kolomvounis. MIT OpenCourseWare offers over 2,100 courses, which can be selected by topic or department. There are not too many PT specific courses yet, but MIT offers a variety of other topics available to the public for free! 

Check it out at the link below:
http://ocw.mit.edu/courses/find-by-department/ 

Knowing what path to take following graduation can be very difficult. If you are like us, you have many unanswered questions: What continuing education courses should I take? How can I maximize my success with patients? What common professional mistakes can I avoid making and how? 

We recently reached out to some of the top professionals to find out what steps they took to become successful. The answers below are brought to you by Dr. E (The Manual Therapist).  

1. What advice do you have for physical therapists in their first years of professional practice?
My advice is to get a system of assessment and treatment. Most schools still teach the tired and not so true history, AROM, PROM, palpation, special tests up the wazoo, come up with a diagnosis, and now what? I know we have to learn basics in school, but this ends up leaving most novice clinicians with too much info! Any clinician needs a system of assessment which leads to treatment. Classification has been shown in the research to improve outcomes versus treatment of patho-anatomical models. This leads me to my next answer!

2. What is one continuing education course you would recommend every physical therapist attend? Please provide a brief explanation.
Years ago, I would have told any new grad to take a series of manual therapy courses like Paris, Maitland, Grimsby, NAOIMPT, etc... While these courses will enhance your clinical decision making eventually, you will be overwhelmed with options. Your first day back with live patients, you will be left with dozens of ways to passively assess movement and often hundreds of new treatment techniques. Is complex better? Often not... it's also less reliable. That is why I tell all my students to take McKenzie Courses A-D. Certification is not necessary, but helps solidify your knowledge by getting you to really study the system and then have your knowledge practically and didactically tested. It's one of the most proven methods of assessment for reliability, and has been shown to have superior long term outcomes versus traditional OMPT in the lumbar spine.

3. What are some important components a new graduate should look for in their search for a first job?
If possible, you should look for freedom to assess and treat, plus quality time with your patients. I realize beggars cannot be choosers and I worked two jobs for the first two years of my career seeing 4-6 patients an hour and having 30 minutes for evals. Do not be discouraged or complacent. I have seen too many students settle on clinics that see way too many people and cannot possibly provide quality care. The clinics that do provide 1:1 are out there, and sometimes you have to form your own. I did not think that was possible 7-8 years ago, but decided to take a risk 10 years in and finally have a practice of my own.

Your future employer should be open to how you want to evaluate and treat, not dictate pathways per diagnosis.  A recent fellow mentee finished his hours, graduated from the program only to be employed by someone who wanted everyone to get a "fru-fru" type of massage and have the patients dictate the Tx a la carte, not the clinician. She took also took away IASTM and spinal manipulation even though on the interview, she said these treatments would be fine. Lastly, you want to have an employer that pays for a decent amount of con-ed. One to two courses per year are enough to keep up with your learning.

4. What is one thing you would have done differently early in your career? And why?
I wish I would've learned to be lighter with my hands a long time ago. Telling patients to suck it up, and I have to plastically deform their fascia and joint capsules left a lot of people sore and occasionally bruised. That's not cool. If going lighter and lighter all the time with my forces and getting patients better faster is not an indication that interaction, education, and then manual therapy are the way to go, I don't know what is!

5. Any other words of advice for the new graduate?
Yes, you're always a student! Keep up with the learning, the more you learn the less you know and that is how it should be! As a know it all, I thought after taking Paris' courses that I was a bullet proof clinician. Yet, somehow 12 years ago, it was taking me 15-20 visits to make patients better. There are so many resources available to you online from twitter to facebook and of course blogs! You are practicing in a very exciting time! I find myself changing assessment, treatment, educational and interaction models with patients every 2 years or so. If you haven't had a paradigm shift in 2-3 years, you're not learning enough!

One last piece of advice. I thrive as a mentor. Feel free to post in the forum or contact me via the link in the sidebar. I try to get back to everyone within one business day! Good luck out there!

About Dr. E:
Dr. Erson Religioso III, DPT, MS, MTC, CertMDT, CFC, CSCS, FMS, FMT, FAAOMPT, graduated from D'Youville College in 1998 with a dual Bachelor's of Science and Master's of Science in Physical Therapy. His interests in Orthopaedics and Manual Therapy lead him to pursue a Doctor of Physical Therapy degree from the University of St. Augustine. Studying under StanleyParis, Ph.D, PT, internationally known for his manual skills and knowledge of the spine as well as his distinguished faculty, Dr.Religioso earned his DPT and Manual Therapy Certification in 2000. He later became credentialed in Mechanical Diagnosis and Treatment of the Spine in 2000, and in 2008 became one of four mentors in the country who can train orthopaedic manual therapy to MDT Diplomats, of which there are only several hundred in the world.

Thanks to extensive training and certification from Dr. Mariano Rocabado, PT, of Chile, one of the world’s foremost experts in treatment of temporomandibular joint dysfunction, Dr. Religioso became certified in evaluation and treatment of oromaxillary, craniofacial, and temporomandibular pain in 2005. Later in 2005, he obtained Fellow status in the American Academy of Orthopaedic Manual Physical Therapists and serves as a mentor for future Fellows through Daemen College’s Fellowship in OMPT program. He recently became certified in FMS level 1 in December 2011 and expects certification in level 1 of the Selective Functional Movement Assessment soon. In January 2013, Dr. Religioso became an official FMT level 2 certified Rock Doc, a start of the art method of kinesiotaping. In mid to late 2013, Dr. Religioso is pursuing courses leading to the completion of the Postural Restoration Institute's PRC Certification.

Dr. Religioso is adjunct faculty of D’Youville College, Daemen College, and SUNY at Buffalo, where he teaches orthopaedic manual physical therapy in the DPT programs. He founded themanualtherapist.com to help mentor and teach professionals around the world and physioanswers.com to help educate consumers and the general public on the profession of physical/physiotherapy. He also is the creator of the EDGE Tool, a high quality stainless steel tool for assisted soft tissue manipulation, the EDGEility Tool, a lower cost, high quality plastic tool for IASTM, the CupEDGE, silicone cups for cupping massage and assisted tissue manipulation, the EDGE Mobility Bands, for enhancing mobility with compression wrapping and self mobilization from neck to foot, and the Stop Thought Viruses Challenge, for individuals in chronic/persistent pain states. He also is an importer of high quality Mirror Boxes for pain, arthritis, stroke rehab, and neuroorthopaedic problems.

In 2013, courses in the continental US, Canada, and Chile will be available on the Eclectic Approach to TMD and Facial Pain, Neurodynamics, Soft Tissue Manipulation feat. the EDGE, Spinal Thrust Manipulation, and Assessment and Treatment of the Upper and Lower Quarter (2 separate courses).

As some of you may have noticed, we have a strong interest in evidence-based practice. In fact, one of the missions of this website is to increase awareness of the latest literature. However, to what point should we rely on evidence? Having read more than a few studies that showed little support for modalities in general (Yes, there are some pathologies that respond extremely well), you can imagine we would be hesitant to administer things like ultrasound, hot packs, etc. in the clinic. Coming across patients who request these modalities during treatment can be frustrating as we know they often have little effect physiologically. We have all had the experience of a patient saying, "last time I had therapy, the TENS Machine was really what got me through the day." On one hand you know you do not want to spend valuable treatment time performing these interventions, but on the other you feel it may benefit the patient psychologically. So, where do we go from here?

Having recently listened to David Butler's and others' audio recordings from IFOMPT, the importance of the biopsychosocial role really stood out to us. We cannot underestimate the impact of the mind. The neuroplastic changes associated with chronic pain often are as big a part of a patient's complaints as a mechanical component. Patients have been suffering with pain or have had dysfunctional movement for so long that the nervous system has adapted to the new "norm," and it is the true normal movement that feels abnormal. Butler, in fact, states that the biggest predictor of low back pain is depression and that we must explain to patients that the source of there pain is not necessarily mechanical (if a patient is grouped here).

So how does this tie in with evidence-based practice? Knowing how the nervous system can affect the patient's perception of pain, there may indeed be a role for interventions with low evidence, such as certain modalities, if a patient believes the treatment will help them return to function. We are not saying that these interventions should consume a significant portion of our treatment time (or that we should go to them at all), but it is something to consider for a trial to calm the patient's fears and give us time for them to "buy into" our methodology, especially if they made a request for that treatment. That being said, we cannot stress enough the importance of educating our patients. Perhaps spend some time explaining to the patient how physiologically, there is little evidence of changes occurring at the cellular level with that specific intervention and then continue to educate the patient on what the literature shows as having the best outcomes. Obviously, education on proper movement patterns and posture must be included as well. You might be surprised at how literal some of our comments are taken. Consider the idea that you teach your patient to lift with a slight lordotic posture, so as to minimalize the stress on the back. Some patients might incorporate this posture into all aspects of their life, thinking that they should never bend their back if they want to avoid pain. Think of all the compensations that might result! We must evaluate all faulty movement patterns a patient presents with and educate them clearly on better strategies.

Of course, we should still utilize our clusters, clinical prediction rules, and clinical practice guidelines when treating patients, but we must be aware that not everyone falls into those groupings. Some people have a larger biopsychosocial role than others, and it is these patients that we must spend even more time on education. Yes, maybe we should consider the use of interventions with lower quality evidence early in our treatment plans, but in it, we must include education and interventions with higher quality evidence as well so that we can move toward the desired outcomes.

As new graduates and professionals in the field of physical therapy, we are often asked what specialty degrees we plan on earning after graduation: manual therapy certifications, dry needling, active release, or whatever the current coolest technique on the block might be. While we are excited to learn these techniques and add fancy interventions to our PT toolbox, we must remember what is at the core of our treatment sessions: Movement. 

In this recent blog post by Allan Besselink, he does an excellent job reminding us of this concept. The following quote should give you a glimpse of what he is talking about: "Our profession has ignored that which makes us unique in the spectrum of health and health care. We are a movement profession. We are the experts in exercise prescription, in restoring function, and in enhancing performance. No other profession – including physicians, chiropractors, massage therapists, you name it – knows movement and function like we do." 

While specialty certifications serve their purpose, they are blurring the image of what we do best. We hold a unique position in the healthcare market and need to capitalize on this potential before it is too late. We all need to demonstrate and practice the same passion as Allan for unifying our profession if we ever expect to become more autonomous.