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Movement Continuum Theory |
KJ Sullivan, PT, PhD, is Assistant Professor of Clinical Physical Therapy, and Director, Entry-Level Program, Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 E Alcazar St, CHP-155, Los Angeles, CA 90089-9006
Address all correspondence to Dr Sullivan at: kasulliv{at}usc.edu
Every day physical therapists walk into a clinic, meet an individual with movement dysfunction, and attempt to determine the problems that can be ameliorated by a physical therapy intervention in order to improve function and quality of life for their patient. How does theory affect reality? How does theory affect one's practice?
In science, theory is generally derived from a set of basic principles to provide a model or framework that either originates from or is supported by experimental evidence. Propositions of a theory can be tested through the scientific method. Empirical findings can provide evidence that either provides support or refutes aspects of the theory. In this Movement Continuum Special Series by Allen, the Movement Continuum Theory (MCT) proposed by Cott et al1 is the basis for the exploration that unfolds in these 3 articles. The originators of the MCT propose it as a potential "grand theory" of physical therapy. Whether this is the theory that truly will represent the reality of clinical practice is subject to question. However, Allen has provided an important step to support or challenge this theory; she has proposed a multidimensional model of movement in order to develop a self-reported outcome measure of movement ability.
This series provides a thoughtful approach to link theory with practice. Parts 1 and 2 of the series incorporate contemporary standards of instrument development that result in the Measurement Ability Measure (MAM) proposed by Allen. The instrument derives from a conceptual theory or framework (ie, MCT) and uses sound statistical methods to establish the set of 6 dimensions with 4 items to result in a 24-item measurement tool (part 1). The resultant tool is a patient-centered, self-report instrument. Initial support for the MAM's content and construct validity and reliability have been demonstrated, albeit in a sample of individuals with little or no movement dysfunction (part 2). The movement ability plots (Figs. 2–7) are visually effective depictions of the 6 dimensions of the model (ie, flexibility, strength, accuracy, speed, adaptability, endurance).
One potential limitation to the methods used for item identification is that items were derived predominately from the movement science literature discussion with "professional informants" (part 1). Although consistent with contemporary standards for measurement tool development, this may not lead to an instrument that is sensitive to movement-related problems from the patient's perspective. In fact, part 3, which investigates the responsiveness of the MAM in an outpatient orthopedic clinical setting before and after a course of physical therapy, found that patients’ perceptions of their own movement ability were significantly higher than the physical therapist's perception. Furthermore, the items identified on the MAM appear to be more relevant to the problems encountered by individuals with musculoskeletal dysfunction who have relatively minimal movement dysfunction as well as the potential to recover to functionally normal lives.
In the discussion of part 1, Allen proposed that MCT and a movement framework that includes dimensions of movement such as flexibility, strength, accuracy, speed, adaptability, and endurance could serve as an alternative to the disablement model that is the basis of the Guide to Physical Therapist Practice.2 It is very unlikely that this could occur, given the multifactorial issues with which an individual with movement dysfunction deals every day. The MCT and movement dimensions identified and measured with the MAM may serve as an adjunct to a more comprehensive framework such as the International Classification of Functioning, Disability and Health (ICF).3 This framework provides a comprehensive perspective on the effect that any health condition has on the individual, including those individuals with movement dysfunction. The movement dimensions of flexibility, strength, accuracy, speed, adaptability, and endurance would be considered body structure impairments in the ICF framework. Movement-related impairment that results in functional movement dysfunction is a common element for individuals with low back pain, postsurgical anterior cruciate ligament repair, spinal cord injury, and stroke. However, the effect that movement dysfunction has on each individual life with any of these health conditions can be profoundly different.
The major concern associated with the MCT overall and the MAM as a measure of movement ability is that this theory and conceptual model may not generalize to people with more profound movement dysfunction than is typically observed in an outpatient orthopedic setting. The complexity of creating a measurement tool that can effectively deal with movement and function across the spectrum of health conditions managed by physical therapists is great and further complicated by our perceptions as health care providers compared with the individuals and their families who live with the health condition each day. The alternative is to develop and select the outcome measures that may be most relevant to a health condition or to a group of health conditions that may share common movement-related impairments. For example, the MAM may be an effective self-reported questionnaire for individuals with musculoskeletal pain who more commonly have limitations in the dimensions of flexibility, strength, accuracy, speed, adaptability, and endurance that affect their daily activities.
In contrast, the Stroke Impact Scale (SIS) is a self-reported questionnaire that was derived specifically from focus groups of individuals with stroke and their family members to measure the effect that stroke has related to their stroke-specific impairments and quality of life.4 There are several strengths associated with the SIS in addition to its established validity and reliability.5,6 First, it is derived from the patient's perspective; therefore, it addresses the difficulty that individuals with stroke report that they deal with in stroke-related impairment domains (eg, arm, hand, and leg strength) and the effect these impairments have on daily activities that include home as well as community tasks. Second, it has the sensitivity to detect meaningful changes as a result of therapy. The MAM attempts to link 6 dimensions of impairment that may or may not be related to the factors that affect poststroke mobility, performance in daily activities, and quality of life.
Yesterday, I had the opportunity to experience a dose of reality in the clinic. I was mentoring a neurologic physical therapy resident in an outpatient neurologic rehabilitation setting. We were co-treating a 26-year-old man who had an acute onset of quadriplegia 4 months earlier with a confirmed diagnosis of Guillain-Barré syndrome. He is beginning to get some motor return in his legs; however, he is on a ventilator and has no head control. He is completely dependent for all of his health care needs. What theoretical basis will guide our practice today?
As in physics, a field that has more than one theory (eg, Theory of Relativity, Theory of Quantum Mechanics), physical therapy will need more than one theory or conceptual framework to unify assessment and therapeutic management for patients with movement dysfunction. I commend Allen for her efforts in providing a theoretical framework (MCT) to test a multidimensional model of movement. In addition, she proposes the use of the MAM as a measurement tool to empirically test the 6 movement dimensions of the model. We have been provided a theory and a movement construct that can be tested through experimental observation. Clearly, many hypotheses can be generated from this series of articles.
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