Moving Precisely? Or Taking the Path of Least Resistance?

Shirley A Sahrmann has been recognized as a distinguished leader in physical therapy for more than 30 years. The scope of Dr Sahrmann's contributions to physical therapy encompasses clinical practice, research, education, and administrative activities.

Dr Sahrmann's commitment to the development of classification schemes for patients with chronic pain and to systematizing the selection of interventions so that outcomes can be more easily measured has formed the groundwork for a new approach to practice. This approach is rooted in the sciences of anatomy, kinesiology, and neurology and emphasizes prevention, effective patient education, and sound clinical decision making.

Dr Sahrmann has served APTA in appointed and elected offices at the national and component levels, and has been a vocal and influential supporter of the Foundation for Physical Therapy since its inception. She has been recognized by APTA at the national level with the Lucy Blair Service Award, the Marian Williams Research Award, election as a Catherine Worthingham Fellow, selection as the first John HP Maley Lecturer, and the Henry O and Florence P Kendall Practice Award. She has also been the recipient of the Missouri Physical Therapy Association's Outstanding Service Award for Research, the Washington University Program in Physical Therapy Alumni Award, and Washington University's Distinguished Faculty Award.

Madam President, honored guests, and colleagues, I am indeed honored to be selected for this award. Being included with all of the notable people who have given this lecture is truly humbling. Unfortunately, the excitement of being selected was quickly replaced with feelings of concern when I read the guidelines for this lecture and realized that I was expected to talk about my contributions to physical therapy. I wondered how I could do that for 45 minutes without being either boring or terribly creative. So I quickly consulted with a colleague for whom I have great respect, Florence Kendall, the 1980 McMillan Lecturer. She said, "That is ridiculous, you cannot talk about yourself." Having been given dispensation by my dear friend, I feel free to discuss, not what I have done, but some of what I believe has happened in physical therapy during my 40 years in the profession, and some ideas that may help guide us through the next 40 years.

As I reflect on the events of the years between 1958 and 1998, the most striking trend I see is that physical therapy is changing from a clinically driven profession to an academically driven one. I believe this change deserves comment because it may be transparent to those who are younger. That's a tricky way of putting a positive spin on aging, but then any tactic is acceptable from my vantage point. I also believe this change is absolutely essential if we want to assume a place among the world's leading health care professions. Thus, all of us, clinicians and academicians alike, must now work together to ensure completion of the change. If we want to succeed in making the transition to an academically driven profession, I believe we must steer ourselves into a slightly different path by making a few adjustments in the way we view our identity, clinical science, academia, and practice. Before proceeding with the specifics of where we are and what I think we need to do in each of these 4 areas, I would like to make a few acknowledgments.

Often when individuals are honored, they thank their family and friends. The expressions of gratitude always impress me as being a nice gesture. But not only is it nice to acknowledge the contributions of others, it is necessary. Clearly, the accomplishments of any individual reflect to a large degree the influence of many others who helped in numerous ways to shape his or her life. In my case, the transition from a stubborn and obstinate child into a tenacious and persevering adult required a lot of help. I am grateful to my parents, who had confidence in my worth; to my brother, Bobby, whose untimely death at age 16 years provided the motivation for me to pursue a career as a physical therapist; and for the support of my sister, Joan, whose intelligence and ability have always left me in awe.

I believe the opportunity to give this lecture is the result of a wise decision I made early in my career. The decision was to enter our profession through Washington University's Program in Physical Therapy and then spend all but my first year of practice at that same wonderful institution. I also believe my selection as this year's McMillan Lecturer is a tribute to the teachers, mentors, and colleagues who introduced me to the importance of physical therapy in health care and who continue to guide and inspire me as we participate in the growth of the profession and its body of knowledge. Among those are my dear friends and colleagues, Kathleen Dixon, who made sure I did not overlook the critical role of participating in Association activities, and Barbara Norton, who, over the past 30 years, has helped me translate and hone many wild and vague notions into concrete and cogent ideas.

I have also been greatly influenced by my younger colleagues, who have played a major role in helping me develop the concepts of movement impairments. I cannot fully express my appreciation to Washington University or give adequate praise to my university colleagues, who are truly an inspirational collection of productive and enjoyable people.

Finally, 3 very special colleagues who had a profound impact on my life directions and professional development were Steven Rose, Eugene Michels, and Marilyn Gossman, all of whom freely shared with me their wonderful ideas, wisdom, values, and love of our profession. Clearly, their dedication and contributions continue to inspire all in their absence. Responding to the inspiration of these visionaries by using the assets of the present to turn loss and challenge into accomplishments is what characterizes physical therapists and physical therapy.

But what do we need to accomplish? Where are we heading, and how will we get there? I have titled this lecture "Moving Precisely? Or Taking the Path of Least Resistance?" I have done so because of the parallel I see between some choices we need to make as a profession and some critical insights I gained from observing and thinking about the different faulty movements demonstrated by the myriads of patients I have seen over the years. The movement faults are probably similar to the kind all of you have observed, but I've just had more years than you to observe them and their consequences. For example, when my fingers are flexed, my wrists are in neutral, and when I extend the fingers on my right hand, my wrist flexes, yet when I extend the fingers of my left hand, my wrist does not flex. The question is, "Why does my right wrist flex when I extend my fingers?" One plausible answer is that motion will occur at a hyperflexible joint, even when that joint ideally should remain stable. Stated a slightly different way, the flexible joint becomes the path of least resistance, and once a path of least resistance is established, it is easy to keep moving along that path, even though it may not be the optimal or most precise path. Unfortunately, motion at these flexible joints is often associated with pain. Thus, the consequence of moving along an easy, but imprecise, path is an undesirable outcome. One lesson that I learned from working with patients is that it is very easy to overlook the subtle changes in the path of movement, but if the changes are addressed early and precise movement is restored, a desirable outcome is relatively easy to obtain.

As I noted a few moments ago, I believe physical therapy is moving along a path to become an academically driven profession. To a certain extent, the ease with which we move along this path is determined by how our past experiences, current influences, and visions of the future affect our identity, clinical science, academia, and practice. We must be sure that we are not just taking the path of least resistance, but that we are moving precisely in the way we use and communicate our body of knowledge. Thus, I believe that, as a profession, we must consider how relatively small changes in the path we are taking can either compromise or secure our place in health care for the next century.

Professional Identity

How a profession is identified at a given point in time provides a direction for future growth. We have made significant strides in the transition from a technical field characterized by individuals skilled in the application of physical modalities to a profession characterized by knowledge of the movement function of the body. Now, we must be even more precise in defining our identity and in developing the concepts inherent in that identity. In my view, to move precisely we must:

* Continue to develop the concept of movement as a physiological system.

Alternatively, we can take the path of least resistance and:

* Limit our idea of movement to that of a phenomenon that becomes impaired by a lesion in a specific anatomical system.

A major step was taken toward establishing our identity as professionals, rather than as technicians, when Helen Hislop, in her 1975 McMillan Lecture, proposed that pathokinesiology should be our defining science.[1] Many throughout the profession, including Steve Rose and our faculty, became committed to building our profession upon the concept of pathokinesiology. But after several years and a great deal of discussion, the prevailing belief was that the more common and broader term "movement" should be used to describe the core of our professional identity. Finally, in 1983, the House of Delegates adopted the philosophical statement defining physical therapy as a health care profession whose primary purpose is the promotion of optimal human health and function through the application of scientific principles to prevent, identify, assess, correct, or alleviate acute or prolonged movement dysfunction.[2] I will never forget how radical the concept of identifying movement as our unique focus seemed in 1983. But today, the concept seems to be inextricably woven into the fabric of our profession.

Now, I believe we must solidify our identity as a profession by developing the concept of movement as a physiological system and by accepting the role of practitioners responsible for a system of the human organism. Did you know that one medical dictionary now defines movement as a physiological system? One of the definitions of movement system is, "A physiological system that functions to produce motion of the body as a whole or of its component parts."[3] Why is defining movement as a physiological system so important? Because, just as Florence Kendall indicated in her 1980 McMillan Lecture, there is concern about the future expansion of physical therapy education and practice if we do not define our role.[4] As she also stated, "medical specialties are based on body systems."[4] Actually, almost all well-established and accepted health care professions have defined their role by establishing themselves as experts on a particular anatomical or physiological system.

So, with movement recognized as a system, we have a wonderful opportunity to become established, just as dentists, optometrists, and others have done. But we must be precise in the way we do it. Adopting the movement system as our focus has different implications for practice and education than adopting a focus on movement as an isolated phenomenon. One of the implications is that not only must we be concerned with the impairments that adversely affect movement, but we must also identify the movements that cause impairments. We must elaborate all the functions and dysfunctions of the movement system. As Florence Kendall and others have indicated, we cannot be defined by our procedures and modalities.[1,4,5] I believe we must be defined by our ability to apply scientific principles for the purpose of diagnosing, treating, and preventing movement-related dysfunctions. Our ability to understand and explain the mechanisms underlying movement impairments and the effects of movement as a therapeutic tool is dependent on increasing our knowledge of the physiology and biomechanics of the movement system. Our colleagues in the health care professions and the general public must come to respect us for this knowledge base. If we are successful in establishing our expertise in knowledge of the movement system, I fully expect that the types of diagnostic tools and treatment options available to us will include radiological methods and pharmacological agents.

Clinicians who focus on the movement system must consider the effects of all the components involved in system function rather than just considering the specific part of the anatomical system affected by a lesion. Just as the physician must consider how all of the systems--gastrointestinal, genitourinary, and cardiopulmonary--affect pH, which is regulated by the metabolic system, so must the physical therapist consider all of the systems contributing to movement. I would like to cite a few examples of how we have neglected to consider some essential components of the movement system. Since the 1960s, physical therapist management of patients with hemiplegia has been focused almost entirely on the increased muscle tone that is attributed to spasticity resulting from the central nervous system pathology. Yet, Berger et al[6] have presented evidence that secondary changes in muscle are a major component of clinically perceived tone. Quite possibly, the secondary muscular changes are the ones that are the most amenable to modification, but, for the most part, we have ignored them.

As another example, consider how rarely we think about motor control as a relevant factor in patients with musculoskeletal pain syndromes. Recently, Babyar[7] published a study of movement patterns in patients after recovery from shoulder pain. She showed that, even in the absence of pain, patients still demonstrated excessive elevation during shoulder flexion. The extensive commentary published with the article reflects the reality that we seldom consider the possibility of anything other than soft tissue as being affected in patients with musculoskeletal pain syndromes. I believe consideration of the interactive roles of the muscular, neurological, cardiopulmonary, and metabolic systems in movement-related syndromes is consistent with physical therapy moving precisely along the path toward the level of professional identity needed for the next century.

Clinical Science

Clinical science can be defined as the study of the signs, symptoms, and course of the patient's disease or dysfunction.[3] The Task Force on Content of Post-baccalaureate Degree Entry-Level Curricula[8] used the term "clinical science" to represent the integration of foundation sciences with our clinical knowledge and procedures. This integration is central to meeting demands for evidence-based practice and for fulfilling the requirement in our philosophy statement that our practice be based on the application of scientific principles. We need to move precisely as we continue to develop our clinical science by:

* Incorporating and integrating current knowledge from basic, medical, and social science into therapists' understanding and communication.

* Conducting clinical and basic research related to the movement system.

* Emphasizing treatments with a rational scientific basis as opposed to those for which explanations either require large leaps of logic or are based on pseudoscience.

* Providing our students with multiple opportunities to learn to defend their treatment choices based on knowledge of clinical science when negotiating with patients, physicians, and insurance carriers.

We must not take the path of least resistance by:

* Teaching basic science without noting ways in which the basic sciences can be used to explain clinical conditions and clinical methods.

* Failing to provide the current pathophysiological information about the impairments of the movement system.

* Teaching clinical techniques without critical analysis of their effect on the impairments for which the patient is being treated.

* Expecting each student to apply information obtained in basic science to clinical practice without faculty or clinicians demonstrating the use of clinical science information.

Receiving my physical therapy education at a time when scientific and clinical information was limited, at least relatively speaking, did have some advantages. One advantage was that my education program involved a great deal of anatomy. In fact, so much time was spent in the dissection laboratory that I was sure my hands were permanently preserved, and that I would never again smell the same as I did before I took anatomy courses. The instruction in physiology was pretty primitive because they had just recently discovered that sodium and potassium had a more important function than flavoring or preserving food. The depth of knowledge conveyed in neuroscience was reflected by the qualifications of the unfortunate physical therapy faculty member who had to teach the subject. She was almost one chapter ahead of the students. Therapeutic exercise was pretty straightforward because the only possibilities were passive, active-assistive, active, and resistive exercise. The basic information about exercise, a strong knowledge of anatomy, some understanding of kinesiology, and skill in manual muscle strength and length testing were all that were needed to practice effectively.

How satisfying it was to treat patients with poliomyelitis because all of the concepts I had learned were applicable, and tutelage by my clinical instructors and co-workers not only helped me improve my examination and treatment skills but furthered my understanding of the clinical condition. Ironically, soon after the Salk vaccine was introduced, my confidence in my clinical skills rapidly diminished because the number of patients with poliomyelitis was decreasing and the number of patients with hemiplegia was increasing. Like many others, I fell victim to the belief that spasticity was the big problem, and so my basic knowledge and skills no longer seemed applicable. I just could not figure out how to modify spasticity so that my patients would be cured. Like all therapists, I wanted to improve my ability to provide effective patient care. In retrospect, it was probably fortunate for me that the neurophysiological approaches had not become widely publicized and that there were few continuing education courses available for learning new clinical approaches. So instead of taking a technique-based course, I decided that I needed to go to graduate school and learn about the underlying mechanisms. My belief was that if I understood the underlying mechanisms, I could apply interventions more effectively than if I remained confused about the basic problems. I do not regret having chosen the course of trying to understanding the phenomena I was observing, but I am concerned that it has become less valued today. Today, more emphasis seems to be placed on learning techniques from continuing education courses than on trying to understand underlying mechanisms. Possibly one of the reasons is the marked growth in the continuing education industry and the effective marketing of techniques, largely based on pseudoscience, that are purported to be both simple to apply and amazingly effective.

In the 1975 McMillan Lecture, Helen Hislop[1] stated that our clinical science was in a state of disarray. In part, I believe, the state of our clinical science was a function of our lack of identity, the profession being clinically driven, and the small number of physical therapist scientists. In 1998, it seems accurate to say that our clinical science is in a state of disuse. I believe this is true because, in general, neither scientists nor clinicians have consistently and systematically applied existing information to practice, nor have we stressed the need to communicate as though we have a clinical science.

A great deal of information is available about muscle biology and physiology that is directly applicable to our clinical practice, but we have not systematically made that information a part of our clinical science. Certainly, students are taught muscle physiology, but are we modeling the application of this information to practice in either the classroom or the clinic? The cellular and clinical manifestations of use, disuse, strain, stretch, stiffness, and anatomical adaptations to imposed length changes are well documented.[9] But judging by my discussions with many experienced clinicians about the management of patients with musculoskeletal pain syndromes, they are not well known. For example, few clinicians can explain muscle plasticity and its clinical manifestations, much less how they could capitalize on the plasticity of muscle to effect change in their patients. Furthermore, I do not believe the positive effect of muscle hypertrophy in improving muscle strength and increasing the amount of connective tissue, both of which improve passive stability of a strained joint, is well known. Certainly, more patients would be referred for instruction in a resistive exercise program following sprain if more physical therapists persuaded physicians of the value of such a program.

Overall, it is my impression that not enough value is placed on basic kinesiological information. For example, how many clinicians know the optimal number of degrees of maximal lumbar flexion or the number of degrees of spinal movement between each vertebral segment in each plane? Such basic information should be well known to therapists who are responsible for the management of patients with low back pain and who set expectations for restoration of mobility. Consider this question: Would you have confidence in a physician who is not familiar with standards for cholesterol levels and blood pressure? Of course not! Everyone, even physical therapists, know acceptable values for these variables because their importance has been stressed by medical practitioners. Have we, as a profession, clearly delineated all the relevant values that therapists should know when treating patients with many of the movement syndromes encountered in practice?

Fortunately, physical therapy is in a better position to develop, organize, and use its clinical science than ever before in its history. We now have a larger number of physical therapists with PhDs in the sciences than we did in 1975. Certainly, the research our scientists conduct is important to our body of knowledge, but their ability to specify the direct applications of science to clinical practice is also of extreme importance. Have you noticed that none of the many articles written about the best method for stretching the hamstring muscles include any information about the mechanisms of shortness or the possible effects of stretching at the cellular level?[10-12] Does this not typify our failure to apply scientific concepts to the most basic of the procedures we use? We need the basic scientists among us to help make the connection between the basic sciences and our clinical sciences. We also need them to help distinguish between scientifically valid explanations and pseudoscientific explanations for the effect of many popular treatment techniques. When we readily consider mechanisms and not just techniques, we will be moving precisely in developing and using our clinical science.

Academia

Mary McMillan established her physical therapy training program here in the United States in an educational environment and not in a clinical environment, as was the mode in England, where she did her training. I believe her choice of the academic route was critical because it made feasible the growth of the field from one that produced technicians to one that would produce professionals. In my judgment, our profession will reach a peak when we complete the transition from being a clinically driven field to being an academically driven one. To do so, we must continue to move precisely by expecting:

* Physical therapy education programs to be true academic units that (1) produce the highest-level professional practitioner and (2) make substantial contributions to the body of knowledge of the profession.

* Graduates of master's degree-level curricula to be skilled in performing a standardized basic physical therapy examination, making accurate diagnoses for basic conditions, designing appropriate management programs, and implementing basic treatment programs.

* Students to attain a relatively high level of skill in developing treatment programs while they are in the academic environment, because it is no longer possible for the clinical environment to provide instruction for those with low-level skills.

* Entry-level [professional] clinical doctorate programs to produce clinicians skilled in (1) rendering diagnoses and prognoses, (2) selecting and implementing optimal management strategies, (3) justifying their decisions and actions using evidence from the literature, and (4) communicating with professional colleagues from all disciplines, as well as with clients, in a manner that conveys expertise in the functions and dysfunctions of the movement system.

* Postprofessional clinical doctorate programs to be developed in order to produce scholar-clinicians who will contribute to our body of professional knowledge, particularly by integrating information obtained through critical analysis of the literature, applying the information to clinical practice, and disseminating the information in the form of case reports.

We must not take the path of least resistance and:

* Continue the proliferation of programs that lack the resources to provide a strong education in clinical science, to produce a highly skilled practitioner, or to contribute to the body of professional knowledge.

* Introduce students to clinical tests and clinical skills, with the expectation that basic proficiency will be acquired during clinical education.

* Introduce students to a wide variety of treatment techniques with the expectation that they will select and apply these techniques at their own discretion.

* Continue to tell students that they should be diagnosticians and then only teach them about the decision-making process, without requiring them to make diagnoses of various types of problems multiple times within the academic environment.

Finally, we cannot:

* Devote time in the professional curriculum to student research that detracts from the time available for students to become skilled in examination, diagnosis, treatment planning, and treatment.

For many years, the prevailing expectation for physical therapy faculty members was that they should have sufficient clinical knowledge and skills to be able to teach the basic concepts to the students, who would then acquire their actual skills in the clinic. Educators were not master clinicians and, thus, were not expected to invent new techniques. In fact, innovation and advancements in practice came primarily from clinicians, such as Berta Bobath, Signe Brunnstrom, Florence Kendall, and Margaret Knott, just to cite a few. Although some of these innovators became associated with education programs, their major contributions were made as clinicians. The more typical faculty member was not a master clinician and did not receive respect for his or her clinical skills. In fact, you frequently heard the statement "Those who can, practice, and those who cannot, teach." To make matters worse, the typical faculty members did not have time for clinical practice because of their heavy teaching loads, so they fell behind in their clinical skills and then received even less respect from students and clinicians. There were few programs operating at the postgraduate level, and program faculty were rarely expected to do research.

A few seeds of the model of a postgraduate program with faculty who conducted research were planted in the 1970s, primarily in California, but growth was slow. By the mid-1980s, an increasing number of programs were beginning to adopt the standards of academic units in other clinical disciplines by requiring faculty to engage in research and clinical practice, in addition to their teaching. As more and more programs made the transition to the new model, the profession was slowly reaching a critical mass of academic units that were able to provide the environments needed to foster investigative and scholarly activity. Eventually, many of the best and brightest physical therapists who wanted to engage in scholarly activity were joining physical therapy faculties rather than leaving the profession for careers in medicine or basic science. Today, substantial numbers of faculty members are either doing research or practicing as master clinicians, or doing both. Consequently, academic units are becoming a primary source of clinical innovation as well as the producers of the research needed to advance the clinical science of physical therapy.

What are some of the implications of the new academic model for the entry-level students and those in clinical practice? In many academic programs, students are taught by physical therapist scientists. The content related to each area of practice, and often the impairments of each area of the body, are taught by a different master clinician faculty member. Therefore, the base of knowledge and the fundamental skills students possess can be broader, be more current, and have a stronger foundation than those of the average clinician. Just as medical students receive their education from the leading scientists in each content area and the best practitioners in each speciality, so is this type of educational experience becoming a reality for physical therapists. Currently, at Washington University, more than 100 individuals, many of them experts, teach students in our program. This fact stands in stark contrast to the fact that during my time as a physical therapist student at the same institution, I was taught by 3 full-time therapist faculty members and a couple of basic scientists.

Regarding clinical education, as you know, medical students' clinical rotations are with the best specialists in each area of medicine. Unfortunately, we have not been able to move precisely along this same path in the past, and now additional burdens are being placed on clinicians that will make it even more difficult for us to move precisely. I fear that the rapid pace of clinical practice today is forcing therapists to model a less-than-optimal pattern of practice behavior to the naive student clinician. This is a problem because (1) studies have shown that the majority of students follow the example of their clinical mentors rather than the pattern of practice they learned in the academic program[13] and (2) time constraints related to the productivity expected of both the student and the clinical instructor seriously limit the amount of guidance that can be provided in the majority of clinical settings. I have asked numerous clinicians whether they would like to be establishing their practice skills under the current conditions, and they all emphatically say, "NO!"

My comments are not intended to detract from the recognized value of either the clinical experience or clinical instructors. Clearly, the academic environment cannot provide (1) the opportunity to participate in intensive patient care, (2) the setting in which to evaluate clinical performance, and (3) exposure to a variety of clinical skills. Extensive practice with patients and guidance from experienced clinicians are invaluable. Nonetheless, the academic programs must assume more responsibility in honing the student's clinical skills and practice patterns than they ever have before in our history. I do not consider this to be an unfortunate or undesirable situation, just a natural consequence of our precise movement toward becoming an academically driven profession.

Now that I have cited what I consider to be very positive steps in our transition, I must also express a concern. I fear that the trend of physical therapy programs following the new model of a strong academic unit is reversing at a relatively rapid rate. In recent years, there has been a proliferation of programs that do not have the resources of highly prepared faculty with skills in research, teaching, or practice required to prepare students for the scope of today's practice. Providing marginally trained personnel to work in today's complex and highly demanding health care environment is not the way the profession is going to gain respect from other professions or the public. Producing students whose preparation is dependent, to a great extent, on rigorous clinical education and experience, when that is becoming a rare commodity, is not advancing either the quality of practice or respect for our profession. Therefore, we need strong academic programs that will require each student to demonstrate that he or she not only can perform an examination, develop a treatment program, and implement that program, but can do so within time constraints that are similar to those imposed in the majority of clinical facilities. In order for students to achieve this level of performance before leaving academia, faculty must "bite the bullet" and design curricula that provide concentrated practice in a standardized examination, practice in designing an appropriate exercise program, and practice in implementing the program, with constructive criticism from experienced faculty clinicians. I believe the students should be well trained in these procedures, even at the cost of forgoing an introduction to a wide variety of techniques.

One of my strongest beliefs is that a system of diagnostic categories designed to direct physical therapy treatment could provide a precise focus for education, as well as practice. For the most part, the medical diagnoses that direct a physician's pharmacological or surgical intervention do not direct our treatment of movement impairments. Therefore, we need to develop categories that describe the impairment syndromes of the movement system. I acknowledge that my dilatoriness in publishing examples of the categories my colleagues and I have been developing is not helping the situation, but that situation will soon be rectified.[14] I hope that many of you will join me in similar attempts to develop and test diagnostic categories that direct intervention by physical therapists.

Given the amount of information that entry-level students must master, I also wonder how long education programs will continue to require research projects that serve little purpose except to detract from the time the student has to learn the profession of physical therapy. Those of us with a PhD know that research is a professional activity that cannot be learned in 2 years. In fact, it takes most PhD students 4 years just to get started. How can we expect our professional students to learn 2 professions in 2 years? The rationale behind requiring research as part of a professional master's degree has never been clear to me. Medical students who are trained at the doctoral level and who have 4 years for their education are not required to do research to qualify for practice. Although there are a few admirable students and advisors who actually publish their projects, have we not done more to compromise the examination and treatment skills of most students than to expand our body of knowledge? Students who want to do research can still do research projects on an independent study basis. Research is important, but it is the faculty that should be doing substantive research to fulfill their role as academicians. They should not be draining their energy by supervising projects small enough to be completed in the time constraints imposed by the student's schedule. Student research is not the criterion for a graduate program. An education program is operating at the graduate level when the students are mastering the knowledge of the profession and when its faculty members are contributing to the body of knowledge of the field.

And speaking of graduate-level education programs, a recent trend in our profession is the development of clinical doctorate programs. One of the reasons cited for increasing the educational level to that of the clinical doctorate is to provide more training in clinical decision making. Education in clinical decision making must not be focused primarily on the process or theory but on the content upon which the decisions are to be made. Based on the prior academic performance of our students, we know they are very good at making decisions. They are not attending physical therapy programs to learn such skills. What their education should provide is the information about what decisions are to be made, information upon which to base their decisions, and lots of practice in making those decisions.

Another frequent justification for offering the entry-level clinical doctorate is that our students take more than the 72 credit hours required for the doctorate. Seventy-two credit hours is the standard number of academic credits for the PhD degree. Everyone who has earned a PhD knows that the requirement of 72 credit hours is close to meaningless. The real hours are spent in the research laboratory, the library, at the computer. They also know that the number of hours spent far exceeds the 72 hours of required course work. But the investigative Doctor of Philosophy degree is not the same as a clinical or professional doctorate. The Table compares the professional doctoral curricula for optometry, pharmacy, chiropractic, podiatry, dentistry, and medicine with a typical physical therapy curriculum on several dimensions. A comparison was made of credits received in the categories of basic science, diagnosis and treatment, professional socialization, and clinical education. Physical therapy lags far behind in all categories.

Table. Comparison of 4 Categories of Course Requirements of 5 Professional Doctoral Programs With That of a Master's Degree-Level Physical Therapy Program(a)

                                         Credit Hours

Course Category                 PT        OD      PharmD      DC

Basic science                   30        51        25       100
Diagnosis and treatment         38        60        52       117
Professional socialization       5         5        21        15
Clinical education              17        52        28        23
Total                           90       168       126       245

                                        Credit Hours

Course Category                DPM       DDS      MD(b)

Basic science                   48        40        723
Diagnosis and treatment         60        65        723
Professional socialization      10         6         42
Clinical education              59        45      4,753
Total                          177       156      6,241

(a) Data from 5 programs in the Midwest that required the least number of credits, with the exception of the medical program. OD = optometry, PharmD = pharmacy, DC = chiropratics, DPM = podiatry, DDS = dentistry, PT = Washington University Program in Physical Therapy.

(b) Clock hours required by Washington University School of Medicine.

But the number of hours spent in the classroom is not even the primary issue. The issue is, what is expected of the clinician with a doctoral degree? How does the product differ from the clinician with a master's degree? As I have stated publicly on many occasions, I am in favor of entry-level doctoral education, but the product must be consistent with the product of other professional doctoral education programs. The large majority of professional programs require the student to acquire expertise in the anatomical or physiological system that defines their profession, including both the normal and abnormal structure and function, as well as how to diagnose abnormal conditions, establish the prognosis, and select the most appropriate treatment option. If we want the respect of other clinical doctorate recipients, we cannot simply expand our clinical education and award the doctorate in physical therapy (DPT) to our existing programs if they do not produce experts in the care of the movement system.

Another type of clinical doctorate education program is being developed for the individual who already possesses an entry-level degree. I believe the development of these postprofessional programs should be encouraged so that the practicing therapist will have the opportunity to be a scholar-clinician, as well as a diagnostician. Because continuing education courses primarily address techniques, clinicians should have the benefit of opportunities to be updated in basic science, medical science, and clinical science. They should be able to learn the latest diagnostic categories, including those from a content area in which they may not be practicing. Many clinicians could benefit from taking course work in critical analysis of the literature and in preparation of case studies so that they could contribute to the body of knowledge. My personal belief is that the degree for these postprofessional clinical doctorate programs should not be DPT but rather something like the Doctor of Health Science in Physical Therapy (DHS/PT) degree to designate that the graduate of the postprofessional program differs from the graduate of the entry-level program. Graduates of the postprofessional clinical program should be contributing to our body of clinical science knowledge. By contrast, graduates of the professional clinical doctorate program should be consumers of the body of knowledge. When graduates of physical therapist programs are practicing as competent diagnosticians of movement impairment syndromes, we will be moving along a precise path toward an academically driven profession.

Practice

Finally, what about practice? The points that have been discussed in relation to our clinical science and academia also apply to practice. But one point I have not addressed is the consequence of the highly individualized approaches to patient management. The individualized approach became the model of practice during the 1960s and 1970s when patients with central nervous system dysfunction comprised the largest group of patients receiving physical therapy. The consequence of this model is that here we are, almost 40 years later, and we still do not have standardized approaches to management for most types of problems. I do not mean that a patient's unique problems should not be assessed but that individualization should occur after the examination is completed and a diagnosis has been made. Then treatment modifications can be based on the patient's special needs. I do not believe many of us would consult a physician who did not perform a standardized examination or follow a relatively standardized treatment plan. We must follow the example of medical practitioners by developing diagnostic categories, standardized examinations, and guidelines for interventions. To move precisely, we must:

* Promote the development and use of diagnostic categories that direct physical therapy.

* Develop and utilize standard examinations and terminology.

* Emphasize treatment that is based on a thorough knowledge of basic anatomy and kinesiology.

* Pursue knowledge of underlying science with as much commitment as we pursue the latest treatment methods.

* Recognize our responsibility to protect patients from treatment fads that have a highly questionable scientific basis.

* Maintain adequate standards of practice by demanding adequate time for examination, development of a diagnosis, and treatment.

We must not take the path of least resistance. We must not make a practice of:

* Using approaches to examination and treatment of patients that are highly eclectic and not based on standards consistent throughout the profession.

* Pursuing fads without pursuing a clear understanding of the relevant scientifically based explanation for the methods.

* Communicating in a manner that typifies nonprofessional personnel.

* Compromising our professional standards of care by providing only partial treatment in order to meet unreasonable demands for productivity.

I have already discussed the importance of developing diagnostic categories and utilizing standardized examinations. I will not repeat what I said, but you better believe that I will not let you forget! What I would like to stress in regard to practice is the importance of having a strong foundation knowledge of anatomy and kinesiology, and knowing how to apply this knowledge to practice. I believe this type of foundation is called the "basics." The advantage of a thorough knowledge of the basics was reinforced when a colleague and I had the opportunity to lecture to the orthopedic residents as part of their educational series in kinesiology of the shoulder. Because our examination and diagnoses are based on anatomy and kinesiology, we combined this information in our presentations. My colleague demonstrated an examination that consisted of analysis of alignment and movement, as well as muscle strength and length testing. After the demonstration, one of the orthopedists, who was clearly impressed, asked whether all physical therapists had the same level of knowledge and skill. He asked because he had just recently referred a patient for physical therapy, and the therapist had called him to ask whether he wanted hot or cold and to seek further clarification about what type of therapy he wanted the patient to receive. The inquiry from the therapist did not leave the physician with the impression that he was interacting with a knowledgeable professional who was assuming care of the patient for a condition about which she was an expert. Keep in mind that, traditionally, orthopedic residents have not been expected to learn kinesiology. They are not the movement experts--we are. Do not ask them what we should do about movement dysfunction.

Our founding mothers established the reputation of our profession using the foundation sciences and basic methods of examination and treatment. Today, we still need to be able to explain the scientific bases of our interventions. For example, if a patient has back pain when his or her lumbar spine is extended, then it does not require a great leap of logic to assume that teaching the patient to contract the abdominal muscles to decrease the lumbar curve by posteriorly tilting the pelvis will decrease the back pain. Yet, I have the impression that many therapists more readily believe the 2 halves of the pelvis can be adjusted in relation to one another than the well-substantiated fact that the abdominal muscles tilt the pelvis posteriorly. To be respected for our expertise, the concepts upon which we base our examinations and treatments must be justified on the basis of scientific rationale and, whenever possible, by the results of clinical studies.

We also need to move precisely in the way we communicate our knowledge. Think about how we describe exercise programs in our documentation. It is not uncommon to find exercises listed in therapists' notes as the "dying bug," the "clam," the "chicken wing," "hip hinging," and the "skater's exercise." Such a list makes it unclear whether the therapist is recommending an exterminator, lunch, or an exercise program. If we are basing our programs on scientific knowledge, our documentation should reflect that knowledge.

I have attempted to point out small changes we can make that can keep us moving in the direction of continued professional growth and toward the completion of our transition to an academically driven profession. Anyone reading the Guide to Physical Therapist Practice[15] cannot help but be impressed by the wide variety of interventions that physical therapists use and the extensive number of conditions that we treat. As physical therapists, we can take pride in the degree of responsibility we have assumed and rightly earned. Perhaps one of the cruelest ironies is now that we have achieved such high levels of expertise and responsibility, we do not have the time to use them. We must carefully consider whether the demands for productivity are consistent with professional and ethical practice or whether we are being expected to practice more like the technicians we once were. This is not the time to compromise what we have achieved. To fulfill our role as diagnosticians, we must find the time to perform a complete examination. Ethically and legally we must examine the patient, not for the sake of tokenism, but as a professional responsibility. Acquiescing to the bottom line is not doing justice to our patients or to our profession.

Defining how much we need to modify our practice patterns of the past, which were definitely less than efficient and cost-effective, is not easy. For sure, we have been on the other side of the coin, providing services that were nice, but not necessary, and that provided greater profit than clinical effectiveness. But there is a balance, and this is just the profession that can find and establish that balance.

A few years ago, I was impressed by a statement I heard President Clinton make when he was discussing the economic and social achievements that have been made in Australia and America. He said, "We have carried the torch through the night, to make the next century brighter for our children." I believe those of us who have been in this profession for the last 20 or more years have had the advantages of the brightness of day. It is those of you in the new generation who will have to carry the torch through the night of these next few years so that there will be a bright world for the profession in the next century. We have laid a foundation that has carried us a long way in the right direction. You must use and expand our scientific foundation. Do not be misled by fads that lack substance. Do not be weakened by unreasonable demands that compromise your responsibilities to your patients and to your profession. Do not take the path of least resistance. Failure to practice and communicate in a manner that reflects the science and ethics of our profession will have a negative impact, not just on the outcome for a few patients but also on the reputation and future of physical therapy. The world needs what we have to offer. We have so much to give to aid the physically challenged and to guide the physically able, be they young or old. Society needs us so they can follow the path of moving precisely toward optimum health.

Acknowledgments

My special thanks to Kathleen Dixon, PT, and Barbara Norton, PhD, PT, for their invaluable help in the preparation of this lecture.

References

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[2] Philosophical statement on physical therapy (HOD 06-83-03-05). In: Applicable House of Delegates Policies. Alexandria, Va: American Physical Therapy Association; 1995:33

[3] Stedman's Concise Medical Dictionary for the Health Professions. 3rd ed. Baltimore, Md: Williams & Wilkins; 1997.

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[8] Working Papers for the Content of Postbaccalaureate Degree Entry-Level Curricula: Impact I Conference. Alexandria, Va: American Physical Therapy Association; 1992.

[9] Lieber R. Skeletal Muscle Structure and Function. Baltimore, Md: Williams & Wilkins; 1992.

[10] Bandy WD, Irion JM. The effect of time of static stretch on the flexibility of the hamstring muscles. Phys Ther. 1994;74:845-850.

[11] Li Y, McClure PW, Pratt N. The effect of hamstring muscle stretching on standing posture and on lumbar and hip motions during forward bending, Phys Ther. 1996;76:836-845.

[12] Webright WG, Randolph BJ, Perrin DH. Comparison of nonballistic active knee extension in neural slump position and static stretch techniques on hamstring flexibility. J Orthop Sports Phys Ther. 1997;26: 7-13.

[13] Stith JS, Sahrmann SA, Dixon KB, et al. Curriculum to prepare diagnosticians in physical therapy. Journal of Physical Therapy Education. 1996;9:46-53.

[14] Sahrmann SA. Diagnosis and Management of Movement Impairment Syndromes. St Louis, Mo: Mosby. In press.

[15] Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163-1650.

[Sahrmann SA. The Twenty-Ninth Mary McMillan Lecture: Moving precisely? Or taking the path of least resistance? Phys Ther. 1998;78:1208-1218.]

SA Sahrmann, PhD, PT, FAPTA, is Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington University School of Medicine, Campus Box 8502, St Louis, MO 63110 (USA) ([e-mail]).

The Twenty-Ninth Mary McMillan Lecture was presented at Physical Therapy '98: Scientific Meeting and Exposition of the American Physical Therapy Association, June 5, 1998, Orlando, Fla.