• Feature

    The Movement System Brings It All Together

    An upcoming summit will explore the implications and goals of recognizing the movement system as the core of physical therapist practice, education, and research. Meanwhile, here's some background to bring you up-to-date.

    Feature - Movement System

    The first principle of APTA's vision for the profession—transforming society by optimizing movement to improve the human experience—is "Identity."1,2 Within that principle, the movement system is called a "foundation" and "the core of physical therapist practice, education, and research."

    Just as important, the movement system is meant to serve as a unifying term for a profession that some people within it believe is fragmented by practice setting (hospital, private practice, home health, academia, and so forth), patient population (geriatric, pediatric, and others), and even body part or function (musculoskeletal, cardiovascular, pulmonary, neuromuscular, and integumentary, for example).

    Who We Are, Not What We Do

    "Physical therapists too often are identified by what they do, and not by what they know as professionals," notes an APTA white paper, "Physical Therapist Practice and the Human Movement System."3 Or, as Lisa Saladin, PT, PhD, FASAHP, put it in a video dispatch recorded at APTA's Combined Sections Meeting in February: "We don't have a hundred years of knowledge just to basically be taken over by other people saying they can 'do physical therapy.'"

    Saladin, APTA Board of Directors vice president, is a staunch supporter of the movement system identity. As a leading participant in developing and promoting the APTA vision—adopted by the House of Delegates in 2013—she often refers to the vision's "Identity" principle, reminding association members that embracing the movement system is, thus, an integral part of achieving the vision.

    The question, then, is, what does it mean to embrace the movement system?

    But we're getting ahead of ourselves. Before we can determine how the profession can best embrace and apply it, we need to agree on a definition of "the movement system." Enter a Board of Directors-appointed work group that in 2015 developed one. It's actually in 2 parts, for reasons explained in the APTA white paper. First is the definition itself:

    • The human movement system comprises the anatomic structures and physiologic functions that interact to move the body or its component parts.

    The definition is intentionally broad and nonspecific to physical therapy so that other health care professionals, and other constituents outside health care, can recognize, understand, and use it. Our profession is not meant to "own" the movement system, and we want it to resonate with collaborating health care partners. It's the second part, a companion description, that ties the movement system to physical therapist practice:

    Physical Therapist Practice and the Human Movement System

    Human movement is a complex behavior within a specific context.

    • Physical therapists provide a unique perspective on purposeful, precise, and efficient movement across the lifespan based upon the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion.
    • Physical therapists examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes.
    • Physical therapists maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.

    The companion description outlines the PT's distinct role in evaluating a patient's or client's movement behavior and any underlying impairments that affect the patient's function, performance, and quality of life.

    One Profession

    So, back to "What does it mean to embrace the movement system?"

    In the annual Rothstein Roundtable discussion at the 2015 NEXT Conference, Saladin (who is on the Movement System Task Force that developed the definition) noted that for many experienced and expert clinicians, it's primarily a change in terminology, because "they're doing that now."4  

    "That" is seeing patients as a whole and integrating evaluation and care across the human body systems, which is not necessarily new to physical therapist care. "We have always been doing this," Chris Powers, PT, PhD, FAPTA, FACSM, said during an interview in December for a podcast series, Healthy, Wealthy & Smart, hosted by Karen Litzy, PT, DPT.5  

    If that's the case, the PT's unique expertise based on that knowledge is movement analysis. Powers made this point at a 2015 NEXT Conference session that followed the Rothstein Roundtable. He showed a video taken in a physical therapy clinic of an athlete with a recent ACL reconstruction taking a running jump and landing poorly. There was a collective groan from the audience, as they all could see that the athlete wasn't ready to return to play. Powers called attention to the room's collective observation, saying they identified the problem because PTs are the experts in movement.

    In theory, PTs look at the entire person and analyze movement throughout that person's body, from the flexing of a wrist to the steadiness of standing on 1 foot, from the breathing pattern to the heart beat. But in practice, is the overarching concept of movement analysis sometimes undermined by the individual techniques used or by the different "domains" of physical therapist practice?

    Proponents of the movement system are concerned about that disconnect. They believe that, for many clinicians, embracing the movement system could mean changing the way they clinically approach patients. "To be honest," Powers said in the December podcast, "We've been isolated historically. Orthopedic PTs kind of 'forget' that patients have brains and that the nervous system is a huge part of what makes them move. On the other side, the neurologic PT can 'forget' there's gravity, and biomechanics, and muscle strength issues. We in practice tend to be separated by these domains, but in reality we treat the entire human system. To do that, we have to be expert in all these systems."

    Saladin would agree. "How many PTs," she asked during the 2015 Rothstein Roundtable, "are boxed into their 'worlds'—the musculoskeletal world, the neuromuscular world, the cardiopulmonary world—and how often does that contribute to missing key problems with patients because they don't see the patient as a whole? My stroke patient has a heart; in fact, the cardiovascular system is probably what got him or her in trouble in the first place."

    To foster behavior change in practice, education would need to undergo a similar shift. Current approaches tend to compartmentalize students by separately addressing the established body systems. Saladin in the Rothstein Roundtable noted: "We typically teach musculoskeletal, neuromuscular, and cardiopulmonary content in separate courses." And while that's appropriate, Saladin is concerned that when students get to their courses on, say, the neuromuscular system, they often become so focused on that course's content that they forget that joint and/or muscle dysfunction are contributing to the patient's movement problems.

    Powers voiced a similar need for changes in education, saying that's where the shift needs to start. "Students come in and are bombarded with myriad courses sometimes they lose sight of the big picture—how does it all fit together?" What you learn in orthopedics, for example, may help you treat a patient who has had a stroke.

    In a PT in Motion article last year on the future of education,6 then-APTA Lead Academic Affairs Specialist Jody Frost, PT, DPT, PhD, FNAP, envisioned that PTs will consider the patient's motivation and function, among other factors, to analyze how and why he or she is moving. All those considerations will help determine which areas of movement are problematic. "Education is going to be oriented a little differently," Frost was quoted in the article. "Instead of an Orthopedics 1 class, you might find an integrated curriculum around the movement system."

    Common Identity Requires Common Language

    Movement system proponents agree that one of the biggest obstacles to incorporating the movement system into education and daily practice is the lack of consistent terminology and methods. The definition is a start, but it isn't enough. "How do we diagnose [movement dysfunction]?" Powers asked in his podcast interview. "Right now, we don't have a consistent way of evaluating and diagnosing movement dysfunction across the different body systems."

    In adopting the position Management of the Movement System (P06-15-25-14), the 2015 House of Delegates endorsed the development of "diagnostic labels and/or classification systems" as a start to filling this vacuum (see "Management of the Movement System" below).

    Toward that end, later this year APTA will host the Movement System Summit to, among other things, address the lack of standards and consistency. Anita Bemis-Dougherty, PT, APTA vice president of practice and staff liaison to the Movement System Summit Task Force, says a goal of the summit is to develop a "road map" for incorporating the movement system into education, practice, and research. This includes discussion of standards in such areas as a patient or client examination that focus on the movement system. For example, "participants in the summit may talk through the key elements of a movement system exam that PTs could be conducting for all individuals," Bemis-Dougherty says.

    Summit participants—about 100 are expected—will represent all areas of practice, education, and research from across the country. Nominations were sought earlier this year from APTA's sections; the American Board of Physical Therapy Specialties; the American Council of Academic Physical Therapy and Commission on Physical Therapy Education; the Foundation for Physical Therapy; the Federation of State Boards of Physical Therapy; the American Academy of Orthopaedic Manual Physical Therapists; geographic caucuses and the PTA caucus; and experts in the areas of electronic health records, coding and billing, and the International Classification of Functioning, Disability, and Health. From the nominations, the task force will finalize the attendees and the agenda for the event, to be held December 8-10.

    Not an Overnight Sensation

    Bemis-Dougherty refers to the summit's goal as a road map because it will mark the beginning of a journey, not a final product or decision. "It won't end with the summit," she says, "but it will give us an idea of where we need to go to incorporate the movement system into education, practice, and research."

    The implication is that the summit won't result in hard answers, and change won't happen overnight. Most of those involved in promoting the movement system agree that seeing it fully embraced is an effort for the long haul. "Remember when the patient/client management model was introduced?" Bemis-Dougherty asks. "It took several years, and now PTs know and use the elements of the model consistently. The movement system will require the same type of long-term effort."

    Long-term, however, doesn't mean the profession shouldn't expect to see anything happening in the interim. And while it's true that the priority is for the profession to self-identify with the movement system and practice accordingly, another goal is for that identification to translate into public recognition—to help clarify to colleagues in health care and to consumers how physical therapists are unique from professionals in other health care disciplines, as the experts in movement analysis and treatment.

    Consider APTA's Move Forward campaign, and the extensive public information available on the website MoveForwardPT.com. What the movement system is to the profession, Move Forward is to the public. Since APTA introduced it in 2009, Move Forward has been a unifying message to raise awareness of who PTs are and what and how they treat, build brand identity and recognition, and promote PTs as the movement experts. The Move Forward brand and MoveForwardPT.com are impartial to practice setting or focus, and the messaging is relevant to all conditions physical therapists evaluate and treat.

    The movement system lifts the brand up a notch, particularly with the growing prevalence of collaborative care models that encourage teams of providers around a single patient or episode of care. Embracing the movement system has real implications for solidifying the role of physical therapists as the movement experts among health care system disciplines.

    This article has been modified slightly from the version in the printed edition based on more recent information.

    References

    1. APTA House of Delegates. Vision Statement for the Physical Therapy Profession (HOD P06-13-18-22). Alexandria, VA: American Physical Therapy Association; 2013.
    2. APTA House of Delegates. Guiding Principles to Achieve the Vision (HOD P06-13-19-23). Alexandria, VA: American Physical Therapy Association; 2013.
    3. Physical Therapist Practice and the Human Movement System. An American Physical Therapy Association White Paper. Alexandria, VA: American Physical Therapy Association; 2015.
    4. Hunter S, Norton B, Powers C, Saladin L, Guccione A, Delitto, A. Rothstein Roundtable podcast-putting all of our eggs in one basket: human movement system [data supplement]. Physical Therapy. November 1, 2015. DOI: 10.2522/ptj.2015.95.11.1466. http://ptjournal.apta.org/content/95/11/1466/suppl/DC1.
    5. The human movement system w/ Dr Chris Powers [podcast]. Healthy, Wealthy & Smart. Episode 190; December 21, 2015. http://podcast.healthywealthysmart.com/category/episodes/page/2/.
    6. Wojciechowski M. The future of physical therapist education. PT in Motion. 2015;7(1):23.

    Showing Value: The Movement System and Payment Reform

    One reason for embracing the movement system is to recognize the value of what physical therapists (PTs) know and the importance of that knowledge on their clinical decisions, rather than focusing solely on the interventions they perform. If that sounds familiar from a different context, it should. The profession's payment reform efforts also emphasize the value of the PT's knowledge and judgment over the types and number of techniques used.

    That the 2 efforts are related isn't an accident. APTA's strategic initiatives toward recognition of the movement system and toward adoption of payment reform both speak to making constituents aware of the valuable role PTs and physical therapist assistants (PTAs) play in helping health care consumers with movement dysfunction.

    While payment reform efforts revolve around the role of physical therapy in meeting the triple aim of health care—improved health for individuals, improved health care for societies, and contained costs—and ensuring that PTs are paid fairly for their contribution to it, the impetus behind the movement system includes a unifying self-identification within the profession. The movement system may for some time remain a term for those within the profession, but it evokes the more public terminology found in APTA's Move Forward brand campaign that promotes PTs and PTAs as the experts in improving mobility and motion.

    Find out more about APTA's payment reform efforts at www.apta.org/PaymentReform.

    Visit APTA's public website MoveForwardPT.com to see how physical therapists are promoted as the experts in movement. For materials and guidance on adopting the Move Forward brand to promote you and your practice, visit www.apta.org/BrandBeat (APTA login required).

    Management of the MOVEMENT SYSTEM (HOD P06-15-25-24)

    Whereas, It is the vision of the physical therapy profession1 to optimize movement to improve the human experience;

    Whereas, The vision's guiding principle of identity is that the physical therapy profession will define and promote the movement system as the foundation for optimizing movement to improve the health of society;

    Whereas, The vision's guiding principle of quality is that the physical therapy profession will commit to establishing and adopting best practice standards across the domains of practice, education, and research;

    Whereas, The vision's guiding principle of collaboration is that the physical therapy profession will demonstrate the value of collaboration with other health care providers, consumers, community organizations, and other disciplines to solve the health-related challenges that society faces; and,

    Whereas, APTA endorses best practice standards within and across the domains of practice, education, and research that will lead to improving the ability and skill of physical therapists to diagnose, plan, and provide effective interventions for movement system disorders;

    Resolved, APTA endorses the development of diagnostic labels and/or classification systems that reflect and contribute to the physical therapists' ability to properly and effectively manage disorders of the movement system.

    Resources

    Available on APTA's Movement System webpage

    www.apta.org/MovementSystem:

    • "Human Movement System" definition and companion description of physical therapist practice
    • White Paper: Physical Therapist Practice and the Human Movement System
    • Video: Embracing the Movement System Identity with Lisa Saladin, PT, PhD, FASAHP
    • Podcast: Rothstein Roundtable on the Movement System

    Healthy, Wealthy & Smart podcast with Chris Powers, PT, PhD, FAPTA, FACSM, and host Karen Litzy, PT, DPT

    https://itunes.apple.com/us/podcast/healthy-wealthy-smart/id532717264?mt=2, episode #190, or http://healthywealthysmart.libsyn.com/2015/12


    Comments

    I am really liking this change in approach and direction for our profession. I get it. I seemingly practice in this realm and yet relate to the concern of not incorporating the cardiovascular, neurologic or pulmonary systems in our work on healing the musculoskeletal system. This of course is specific to each individual realm. I believe we keep these systems in our background minds as we evaluate and treat. But as stated the concern is that we may not, as a profession, consistently consider the interconnectivity of these systems consistently in our care. This as many of us practice in solitary systems. We often depend on our co professionals to assess systems that do not directly relate to our care plan. We rely on them. This is a part of the problem. But we cannot be everything to one individual. Incorporating a multi system component to our education may be a place to start. Towards the senior end of curriculum courses that bring these separate systems and function back together in the total evaluation and treatment schematic. Break it down then put it all back together again. I love our profession I love the direction it is pursuing. I do not fear that we will loose our significance in healthcare. One hundred years yes but only in its infancy still. I observe. My main skill is that I observe Dr Kaethe A Flynn PT, DPT
    Posted by Kaethe Flynn -> =GP`AM on 4/26/2016 7:17:37 PM
    A very interesting read. Myself and other colleagues remain highly concerned regarding the adoption of the human movement system. We've written about it briefly http://ptthinktank.com/2016/02/28/what-problem-does-the-human-movement-system-solve/ and recorded two podcasts to address our concerns as well as feedback on our position: https://directory.libsyn.com/episode/index/show/conatusathletics/id/4163407 https://directory.libsyn.com/episode/index/show/conatusathletics/id/4163407 We'd be wise to learn from psychologists and those attempting to characterize mental disorders: http://philosophybites.com/2016/01/steven-hyman-on-categorising-mental-disorders.html Further, chiros made up an identify (subluxation theory of disease) without collaborating with other experts. Does the NIH fund studies of the subluxation model? Do physicians collaborate on research regarding it? Do other healthcare practitioners discuss it or address it? Regardless of the product, the process is also lacking in robustness and colloboration. Where are our physician colleagues? Experts in physiology and physiologic system construction? How about engineers? Systems experts? Mathematicians? What wold they say or critique? How about other stake holders? I don't see how the HMS improves education, research, nor clinical practice. If we think we have an identify and/or communication problem how does the creation of a new, internal nomenclature improve that? Can we at least discuss or outline some of the concerns and or critiques of this before jumping in head first?
    Posted by Kyle Ridgeway -> @KS]AM on 4/26/2016 9:28:05 PM
    Just the thought that the APTA as a body is opened to explore the pos/cons of Human Movement as the core of the profession, is such a positive, encouraging first step. Discussing, consulting and interacting with a common opened mind will definitely produce wonderful outcomes. Congrats to the initiators and participants in this exploratory expedition. May wonderful results crown your efforts.
    Posted by Agnes A. Sheffey Dr, OT, MSEd, OTR/L, PT. on 4/27/2016 11:40:40 AM
    I have worked in acute care in the last 16 years and I can say that I have been more aware of incorporating movement system analysis during my evaluations. It especially makes it easy to see someone who has a conversion disorder or someone who is malingering. One can tell how they do not behave or move with normal patterns of movement. It is certainly applicable in all the other orthopedic, neurologic or cardiopulmonary patients where pain, weakness or limitations of movement changes normal movement patterns.
    Posted by Mary-Rosalie Batalla-Pombuena on 5/2/2016 12:38:23 AM
    Don’t throw the baby out with the bathwater. The authors of this article seem to be arguing that we throw out our clinical practice framework including sections, special interest groups, specialists and how departments provide services to take on some other organizational structure. Efficient and effective patient care, and the published evidence, is typically organized around the ICD framework – the generally accepted diagnostic framework. Kinesiology (movement systems) hasn’t been a driving force for clinical service structure or patient care. While it is possible to change “sports medicine” and “neurorehab” to “movement systems (kinesiology)”, I need to know what the advantages would be to homogenizing PT. The historical unifying concept for Physical Therapy was “Physical Rehabilitation” which also crosses physiological systems. Since that time, the profession has evolved. I look forward to more discussion on the advantages and disadvantages of this novel "movement systems" conceptual approach vs. current frameworks in physical therapy/physical health.
    Posted by Murray Maitland on 5/6/2016 4:13:42 PM

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