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1986; 66:366-367.PHYS THER. Rodney SchlegelTherapy?Is Pathokinesiology Synonymous with Physical
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Is Pathokinesiology Synonymous with Physical Therapy?
RODNEY SCHLEGEL
Key Words: Pathokinesiology, Physical therapy.
Hislop, in her 1975 Mary McMillan Lecture, presented a conceptual framework for the role of pathokinesiology in physical therapy.1 I find it somewhat difficult to address the implications of theory and research in pathokinesiology as it pertains to physical therapy because I have not accepted totally the concept as it has been presented. I agree with Hislop that physical therapists need a strong identification to survive the dilution of health care occupations by newly emerging ones. I further believe that pathokinesiology and its construed synonym movement dysfunction should be a major part of our profession. Pathokinesiology may represent, in fact, what the majority of physical therapists do. I do not agree, however, with His-lop's statement that "establishing a strong identity is not a question of restriction."1 My disagreement is based on descriptions and definitions presented in her lecture, including 1) the concept of the pyramid structure of physical therapy with the apex being therapeutic exercise and pathokinesiology and 2) her statement that "motion is a concept that must be viewed beyond the purposeful contractions of skeletal muscle initiated by a complex nervous system motion occurs at every level in the human organism."1 She then provides examples of motion that occurs at various levels: at the cellular level, phagocytosis; the tissue level, blood flow; the organ level, muscular contraction; the personal level, locomotion; and the systems level, reflex activity. She then defines physical therapy as a "health profession that emphasizes the sciences of pathokinesiology and the application of therapeutic exercise for the prevention, evaluation, and treatment of disorders of human motion."1
I believe that such a definition, in fact, would be restrictive. I believe that forcing the focus on pathokinesiology and therapeutic exercise would hinder our efforts to expand into other areas of health and wellness programs. Those people operating at the political-legislative levels who are defining our legal privilege to practice will not be able to understand the concepts as they have been presented in the pyramid structure or in a multifaceted description of what motion is. We must be able to speak the language of those individuals who are responsible for legislating our practice. These legislators, who are plumbers, lawyers, delicatessen proprietors, and such by trade, for the most part, are extremely busy during legislative sessions and have insufficient time to sit and listen to rhetoric about phagocytosis at the cellular level. I believe that we need to be very careful how we word the definition for physical therapy because of the ultimate restrictions that will be placed on us. For example, physical therapy traditionally has been defined to include physical agents. Thus, the federal reimbursement regulations require even physical therapists who provide only home health care to have an office with whirlpool, ultrasound, and other modalities, even though those modalities may never be used and the office will never be used to see a patient. It is conceivable to me that, should we press the definition of our discipline as being pathokinesiology and exercise, we in the end may be restricted, at least in terms of reimbursement, to only therapeutic exercise or increasing musculoskeletal motion.
Hislop also related that "physical therapy can claim the unique privilege of placing the role of exercise in health and disease in a proper scientific focus and perspective."1 I believe some key words in Hislop's statements regarding our care of motion disorders are the words "prevention" and "unique."
With regard to prevention, we as physical therapists have relied on medical referrals for the care of ill and injured persons. We have, within this model, practiced preventive care primarily in terms of preventing future or recurring injuries or illnesses of those persons referred to us. We have, as a profession, been slow to respond to the emerging area of wellness.
I find difficulty in accepting the label "unique" in light of activities performed by those in other professions. By saying that we are unique in our application of exercise, do we mean that certified athletic trainers do not practice preventive care for athletes to decrease injuries resulting in motion disorders? Does it mean that the graduate exercise physiologist does not work to increase the mobility of the patient with a cardiovascular disorder? Does it mean that persons working in special education do not work to improve the physical capabilities of children with movement dysfunction? Does it, in fact, align us with some of the new faces on the block who refer to themselves as kinetic therapists or movement therapists? I think that the answer to all of these questions is no.
To me, it is less important to know who can provide certain health care services, including pathokinesiology, than it is to know that those providing the services have competence in the area. I believe that the "bottom line" of delivering health care is competence. We should strive in every specialized area of physical therapy to develop the highest level of competence possible. Although in my lifetime I probably will not see competence as being the sole determining factor for allowing or disallowing practitioners to provide health care services to the public, I believe that a step in the right direction is to provide recognition to those who demonstrate advanced clinical competence in a defined area of practice.
Mr. Schlegel is Director of Rehabilitation, The Union Memorial Hospital, 201 E University Pkwy, Baltimore, MD 21218 (USA).
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PATHOKINESIOLOGY
I would like to see specialization developed in a prospective manner. To date, specialization has evolved in response to conflicts between members of disciplines over the right to provide and be paid for certain services. Examples are specialization in sports physical therapy in response to conflicts with certified athletic trainers, certification in clinical electrophysiologic physical therapy following conflicts with physiatry, and certification in cardiopulmonary physical therapy following conflicts with respiratory therapy. I hope that we can expand, as necessary through education, training, and experience, those clinical areas wherein physical therapists need to demonstrate a high level of competence. I also hope that great effort will be exerted by the physical therapy community to incorporate into state practice acts provisions for those with documented advanced clinical competence so that those individuals may provide nontraditional care. I share the dream with Hislop that "clinical specialists, born in science, nurtured in reason, seasoned in practice, and blended with compassion will begin to deal in physical therapy with questions that have challenged the human intellect and the human spirit."1 I further hope that we will provide the numbers of physical therapists with clinical specialization that will be necessary to make an impact on the American health care system. Frankly, we have lost some battles and some areas of responsibility because of our small numbers. On the one hand, it is nice to say that the demand for physical therapists is greater than the supply. On the other hand, we have not been able to expand into certain areas or even to maintain certain areas of responsibility (other than by a select few) because of the unavailability of qualified physical therapists.
I believe that the movement toward specialization will encourage necessary research in physical therapy. One issue that has been and is still being debated is the educational level that a physical therapist should attain to conduct meaningful research. There are those who hold that only those therapists having a Master of Science degree or a doctorate have the requisite background. Hislop related in her lecture that we must support doctoral education in pathokinesiology or physical therapy or we will be reduced to mental pickpockets of others outside our profession who are developing the knowledge that supports advances in our field. I agree that we should support doctorate programs in physical therapy, but I also recognize that many physical therapists without a doctorate have the ability to exercise their intelligence and, in fact, demonstrate a high level of intuitive thinking. These clinicians, experienced in the healing arts, are in an optimal position to identify areas of patient care and wellness needing research. They are in a position to develop hypotheses. At the same time, some "pure" researchers who have the highest level of expertise in the methodology of research either 1) do not know what questions need to be asked to improve patient care or 2) do not have access to a population of patients having various disorders. My experience suggests that development of a cooperative relationship between the two parties is not demeaning to physical therapy, nor does it reduce the non-PhD therapist to a mental pickpocket. Instead, it should be viewed as a cooperative interdisciplinary project, a symbiotic relationship.
Despite the problems just discussed, I believe that the concepts of pathokinesiology as expressed by Hislop are conceived reasonably and have been pre
sented in a logical order. The model of pathokinesiology with its subsciences of anatomy, physiology, pathology, biochemistry, chemistry, and psychology and a physical therapy practice system designed to intervene purposely at the appropriate level of the human organism movement system may serve best as a consistent framework for the physical therapy education curricula, thus, providing a closer common bond between the young therapists entering the profession.
In summary, I believe that physical therapy is a business, a health trade if you will, with complex interactions with other disciplines in an era of fierce competition for recognition as the experts in providing certain types of health care services. We could be wasting our time, and I emphasize "could," by promoting a definition of physical therapy in terms of pathokinesiology and movement dysfunction that is not understood clearly by legislators and that could result in a practice restricted to exercise and musculoskeletal motion.
I believe that it is less important to emphasize the uniqueness of the services that we provide than it is to demonstrate the quality and worth of our services. We need to have available published results of valid research that answer important clinical questions about the indications for, and the worth of, our services. Such documentation absolutely is essential to justify the trust of our patients and our communities and to substantiate the compensation we deserve for our services.
REFERENCE
1. Hislop HJ: Tenth Mary McMillan lecture: The not-so-impossible dream. Phys Ther 55:1069-1080,1975
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1986; 66:366-367.PHYS THER. Rodney SchlegelTherapy?Is Pathokinesiology Synonymous with Physical
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