The Human Movement System: Our Professional Identity

From Technicians to Professionals

The actions taken by the 2013 HOD reinforce what every physical therapist knows and what has been incorporated into HOD policies since the 1980s. Movement is the core of physical therapy.^1–4 Because the concept of movement as a body/physiologic system may be less familiar than the concept of human movement itself, a brief review of our history is needed. You will see that the evolution of our profession has benefited from the insights and contributions of many individuals. Unfortunately, many of those individuals have not lived to see how their prescient ideas have been manifested, but we need to review the legacy they left for us so we all understand how we evolved to this point.

The newly adopted Identity statement in RC 15-13 is the culmination of an amazing transformation of physical therapy from a technical field to an identified profession. This latest HOD action associates our profession with a system of the body. I think this is an incredibly important step in establishing our unique role in health care. In the early 1960s, a representative of the US Department of Labor observed me performing patient care. The representative was doing an analysis to determine whether physical therapists were technicians or professionals. This observational study established the rather obvious fact that physical therapists made decisions as part of their patient care process. These observations resulted in our designation as professionals, not technicians. Nonetheless, a “prescription” from the physician was still required to initiate physical therapy. The normative practice at that time was for a physician to establish a diagnosis and prescribe treatment prior to referring the patient for physical therapy. However, Catherine Worthingham's historic study and publication in 1970 demonstrated that most of the referrals for physical therapy did not include either a diagnosis or a specific treatment program.⁵ Thus, by the mid-1970s, physical therapists were beginning to emerge from an era in which physician prescription dominated decisions about patient management.

Identifying Our Body of Knowledge

During this time, APTA and some of our most visionary leaders were asking important questions about the identity of our profession and the body of knowledge that supports our work. Helen Hislop, PT, PhD, FAPTA, who stated during her 1975 McMillan Lecture that the profession was experiencing an identity crisis, made a major contribution to our professional discussion when she proposed the idea that pathokinesiology (the study of anatomy and physiology as they relate to abnormal human movement) is the foundation science of the profession.⁶ Although her lecture often has been cited for the power of her recommendations, there is little evidence that her directives had a specific impact on the general direction of the profession at that time. In the 1980 Mary McMillan Lecture, Florence Kendall, PT, FAPTA, discussed the importance of the profession establishing a relationship with a system of the body and cited the example model of medical specialists (eg, cardiologists, neurologists) who were easily recognized by their system.⁷ However, her recommendation that the musculoskeletal system be designated as the focus of the physical therapy profession seemed to exclude those who were involved in treating patients with neuromuscular or cardiovascular and pulmonary conditions. Consequently, her recommendation was not readily adopted.

The identification of physical therapy's body of knowledge was addressed again when specialty sections were evolving and physical therapists were researching and documenting advanced and specialized physical therapist practice. As implied by the names of the sections and certified specialty areas, the systems of the body or the age of the individuals being managed were what classified the focused content areas rather than an overarching or unifying focus for the profession such as human movement. Each specialty has focused on the body of knowledge within a specific scope and many parallel traditional physician specialties. All of these attempts to capture the essence of the profession in the 1980s resulted in recognition of the need to define the fundamental philosophic position of the profession. The Definition of Physical Therapy Task Force was appointed by the Board of Directors in early 1980. As a result of the task force deliberations that included input from across the association, the following philosophic position was adopted by the 1983 HOD: Physical therapy is a health profession whose primary purpose is the promotion of optimal human health and function through the application of scientific principles to assess, correct, or alleviate acute or prolonged movement dysfunction.³

Since it was adopted originally, the statement has been modified twice to make it consistent with other policies and documents, including the Guide to Physical Therapist Practice,⁸ the International Classification of Functioning, Disability and Health (ICF),⁹ and Vision 2020.¹⁰ As is evident in the most recent version below, some of the wording has been changed, but the focus is still on movement and the remediation of impairments: Physical Therapy as a Health Profession, HOD P06-99-19-23 [Initial HOD 06-83-03-05]¹¹ Physical therapy is a health profession whose primary purpose is the promotion of optimal health and function. This purpose is accomplished through the application of evidence-based principles to the processes of examination, evaluation, diagnosis, prognosis, and intervention to prevent or remediate impairments in body structures and function, activity limitations, participation restrictions or environmental barriers as related to movement and health.

Although there has been evolving professional agreement regarding the overall concept of human movement as our professional focus referenced above, there has been less agreement about how to organize, describe, and label that body of knowledge. At the 1984 Annual Conference, the concept of pathokinesiology was revisited at a symposium titled “Pathokinesiology: Theory, Research, and Practice.” The presentations were published subsequently in Physical Therapy (PTJ).¹² Some of the questions that were addressed were: (1) What is pathokinesiology? (2) Does pathokinesiology have the potential to be our basic science? (3) Is pathokinesiology central to our profession's identity? and (4) What are the implications for our body of knowledge? In his introduction to the collection of articles in PTJ, Rothstein noted, “The identity crisis Hislop saw a decade ago has worsened. We, as a profession, may be doing more things, but in no way have we developed a true sense of who and what we are. All too often, we are defined by the tasks we do…. We have many faces…and no singular image.”^12(p365)

One explanation for the limited acceptance of the pathokinesiology concept as our professional identity was its emphasis on pathology that produces abnormal human movement. Even though the term “pathokinesiology” appropriately focused us on movement, it was not broad enough to encompass the full scope of the profession. The narrow definition “study of abnormal movement resulting from pathology” lacks consideration of broader concepts such as the study of conditions that are produced by imprecise or insufficient movement or immobility (kinesiopathology), the study of prescribed movement to enhance task-specific performance, or the study of movement essential to prevention of movement-related disorders.

The Scope of Human Movement

In the early 1990s, a group of individuals who were motivated by the untimely death of Steve Rose, PT, PhD, FAPTA, gathered to continue developing the ideas of professional identity proposed by Dr Rose. The group included Sandy Burkart, PT, PhD, Anthony Delitto, PT, PhD, FAPTA, Marilyn Gossman, PT, PhD, FAPTA, Andrew Guccione, PT, PhD, FAPTA, Scot Irwin, PT, DPT, CCS, Colleen Kigin, PT, DPT, FAPTA, Eugene Michels, PT, PhD, FAPTA, Cynthia Coffin-Zadai, PT, DPT, FAPTA, myself, and several others. One of the group's major conclusions and recommendations was that the profession should develop and promote the concepts of a movement system and movement science. The group presented these concepts at several national meetings and published a special edition of the Journal of Physical Therapy Education in 1993 illustrating how these concepts could be integrated into professional (entry-level) education.¹³ These initial explorations into the concept of the movement system as an integrating focus for professional physical therapist practice initiated what has been a somewhat slow but steady progression toward that goal.

By the mid-1990s, APTA had successfully completed and published the Guide to Physical Therapist Practice (Guide), which authentically described the basic scope and content of practice, including patient/client management by physical therapists.⁸ Although the description is broad regarding the general examination, evaluation (including diagnosis, prognosis, and plan of care), intervention, and outcome phases of physical therapist practice, the care management model is clearly focused on the evaluation and management of the human movement system. The Guide practice patterns identify patients and clients across the spectrum of individuals who benefit from physical therapist management to prevent and treat movement system disorders. The Guide, however, does not represent a full spectrum description of the human movement system, and it is not a complete or specifically descriptive manual for identification and treatment of movement system diagnoses.

During the 1990s, we again made progress toward our goal of adopting a movement system focus when Scot Irwin became a consultant for Steadman's Medical Dictionary. In his consultant role, he had an opportunity to recommend inclusion of the term “movement system” if a definition could be developed. With Florence Kendall's help, the following definition was developed and published in the dictionary: The movement system is a physiological system that functions to produce motion of the body as a whole or of its component parts. The functional interaction of structures that contribute to the act of moving.¹⁴

The value of this definition is that it: (1) describes a physiological system of the body, (2) applies to movement at all levels of bodily function—subcellular, cellular, and system—as well as to interaction of humans with their environment, and (3) applies to dysfunction or impairments in all of the systems that contribute to movement (eg, anterior cruciate ligament insufficiency, pulmonary dysfunction). Most importantly, the concept provides a focus for the primary expertise of all physical therapists.

In the 1998 Mary McMillan Lecture,¹⁵ I presented my conception of the movement system, but the issue was not discussed again at a national level until 2004 when Cynthia Coffin-Zadai delivered the John H.P. Maley Lecture, titled “Disabling Our Diagnostic Dilemma.”⁴ Dr Coffin-Zadai discussed the value of describing a human movement system, with special emphasis on the word “human.” She included comments on why it could be difficult to identify and consistently label the essential structures and functions comprising the movement system to include both normal and abnormal functions across the life span but also stressed the importance of moving forward with the concept. Motivated by Coffin-Zadai's 2004 Maley Lecture, in 2006,¹⁶ Barbara Norton, PT, PhD, FAPTA, organized a series of invitational conferences called Diagnosis Dialog. The purpose of the conferences was to clarify many issues related to diagnosis in physical therapy. These conferences included approximately 35 leaders of the profession from across the country. Through many hours of discussion and debate regarding classification and labeling of the phenomena that are managed within the scope of physical therapist practice, the primary point of agreement with the majority of the participants was that the movement system is the fundamental system of physical therapy.^16,17

Most recently, as noted at the beginning of this article, the 2013 HOD adopted a new vision and a new identity for the entire profession. The newly adopted resolutions are the culmination of ideas that began percolating in the 1960s. The latest HOD actions are incredibly important steps in establishing our unique role in health care. Now, we need to move forward with RC 15-13. We need “to define and promote the human movement system as the foundation for optimizing movement” and our professional identity.

Is the Concept of a Movement System Consistent With the Definition of a System?

According to the American Heritage Dictionary, a system is defined as: “1) A group of interacting, interrelated, or interdependent elements forming a complex whole; 2) A functionally related group of elements, especially: a. The human body regarded as a functional physiological unit, b. An organism as a whole, especially with regard to its vital processes or functions, c. A group of physiologically or anatomically complementary organs or parts: the nervous system; the skeletal system.”¹⁸ Using these criteria for a system, the movement system concept meets the requirements because it is a group of functionally related interacting, interrelated, and interdependent elements forming a complex whole, which produces the function known as movement.

Can the Movement System Be Considered a Physiological System?

According to the Random House Dictionary,¹⁹ physiology is defined as: “1) the branch of biology dealing with the functions and activities of living organisms and their parts, including all physical and chemical processes; 2) the organic processes or functions in an organism or in any of its parts.” Movement is a function of an organism that is produced by a set of interacting organs and systems. Thus, the set of interacting organs and systems that produce movement is a physiological system that can be appropriately labeled the movement system. Recognition of this system will require that all members of the profession, clinicians, academics, and researchers promote and incorporate the concepts in their publications and communications with the public, patients, and other health care professionals. Repeated and frequent use of the term and application of the concepts are necessary to achieve widespread recognition.

What Are the Advantages of Associating Physical Therapy With a System of the Body?

1. Professions that have minimal difficulty gaining recognition for their expertise are associated with a physiological or anatomical system of the body. The expertise of the cardiologist, the neurologist, and even the dentist is well understood. Their professional title connotes the system for which they are responsible. The title of physical therapist does not provide ready association with content expertise. This point also has been addressed in a recent editorial by Jull and Moore,²⁸ indicating there is international concern about this issue. The APTA's efforts at branding movement²⁹ could just as easily, and in the long run more advantageously, be used to promote the concept of the movement system as the foundational scientific construct for describing, defining, and testing examination and intervention strategies focused on optimizing human movement. Acceptance of new terminology is just a matter of information dissemination and publicity. We all know how well Google and Apple have demonstrated the point.

2. Association with a body system provides a parallel to the role of other doctoring professions. Just as the neurologist is responsible for the science, theory, and medical practice focused on the anatomic and physiologic functions and dysfunctions of the nervous system, the physical therapist would have similar responsibility for the movement system. Rather than the neuropathologic diagnosis and pharmacologic or surgical intervention plan produced by the physician, the physical therapist would provide a movement system examination, diagnosis, prognosis, and intervention plan, including the projection of outcome. Movement is a highly desirable, noninvasive form of intervention that requires an equally specific prescription based on reliable and valid test findings wherever possible.

3. Currently identified and validated physical therapy specialties are essential to the comprehensive management of the human movement system over the course of the life span. The descriptions of physical therapist advanced clinical practice have nicely illustrated the integral relationship between physical therapist practice and the movement system. A cursory or in-depth review of the American Board of Physical Therapy Specialties (ABPTS) examination blueprints and highlights the focus of each area of practice to indicate that they collectively represent examination, evaluation, and management of movement-related normality and abnormalities of structures, functions, and person-level performance across the life span.

4. The movement system concept provides a context and format for describing diagnoses within the scope of physical therapy. In 1982, the HOD stipulated that physical therapists must establish a diagnosis.³⁰ Although the medical profession has spent hundreds of years describing and testing pathologic phenomena to develop elaborate diagnostic manuals describing abnormalities of structure and function from the cellular level through the system level, physical therapists have only begun to develop some detailed descriptions of movement system functions and dysfunctions across multiple levels. Identifying movement as a body system with its appropriate structures and functions would help clarify the scope of practice and provide an outline and rubric for developing detailed and testable descriptions of normal and abnormal movement.^15,31 To help start the process of creating a diagnostic classification for movement system phenomena, the Diagnosis Dialog group has been meeting once or twice a year since 2006 to identify, describe, and develop specific movement system diagnostic labels that could be used by physical therapists.^16,17

5. Physical therapy's identity as a profession will be enhanced when other health care professionals can identify or recognize our expertise. Taking on the responsibility for defining and describing components of the movement system emphasizes our professional ability to contribute to the creation of evolving clinical science and theory within a specific scope. Developing and disseminating information about the movement system and the role of the physical therapist was highlighted in a recent editorial by Paula Ludewig, PT, PhD, and colleagues titled “What's in a Name: Movement System Diagnoses Versus Pathoanatomic Diagnoses?”³² They made an important point about the value of developing and using diagnostic labels that are focused on the phenomena we are treating rather than the diagnostic labels naming pathologic structures, particularly those patients treated by other professionals. Ludewig et al stated that “physical therapists treat movement-related impairments rather than structural anatomical abnormalities. As such, using a pathoanatomic model to define physical therapy–related diagnostic labels creates a disconnect between our diagnostic and treatment processes.”^32(p281) There is clearly a growing recognition that pathokinesiological problems are a significant source of musculoskeletal pain that should be addressed rather than exclusively focusing on pathoanatomic problems.^33,34 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.

6. Recognition for contributing to clinical science in a manner that benefits patients, clients, and other health care practitioners. As the profession pursues scientific development of the movement system, including description of normal and abnormal functions and identification of the prevalent diagnostic categories, labeling the identified components with movement system terms will avoid the pitfalls of labels that are “profession specific” (eg, physical therapy diagnosis). Profession-specific terms can be exclusionary and discourage other health care professionals from learning about the movement system or recognizing those diagnoses as an indication to refer a patient to a physical therapist. Although other health care practitioners and the public currently may not know what a movement system diagnosis is, that can be remedied by description, publication, dissemination, and clinical utilization of the language. For example, less than 15 years ago, the term “metabolic syndrome”³⁵ was not commonly recognized as it is today. Less than 10 years ago, few individuals had heard of FAI, now known commonly in the community as femoroacetabular impingement.^23,24