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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