What Is the Essence of Physical Therapy? A Grand Theory Is Needed For a Future.

To the Editor:

Twenty-five years ago, while giving the 10th annual Mary McMillan Lecture, Helen Hislop articulated a passionate vision for the successful future of physical therapy.[1] In this lecture, she emphasized the need for clinical research, clinical specialist certification, doctoral programs, and, above all, the need for the profession to have a "sense of its elemental identity."[1(p1070)] I propose that progress has been made in all but the last area. Physical therapy still has the same identity crisis that it did in 1975, and a viable future hinges on its resolution. Before the profession moves on to deal with the myriad of challenges it will face in the future, it needs to be grounded in a sense of its own identity.

The future of physical therapy must begin with physical therapists being aware of the essence of their profession. Such a statement may, on cursory observation, seem to be trite. However, if a group of physical therapists in a similar practice setting were surveyed about the purpose of daily patient care, the answers would likely be vague and refer to the tasks of improving function, decreasing pain, improving motion, and so on. Without demeaning the importance of these tasks, how are they different from the daily undertakings of an occupational therapist, athletic trainer, or any other health care professional? If the same survey were undertaken across specialties, there would probably be a greater variety of similarly vague responses. As a physical therapist who manages patients with orthopedic problems, do I have anything in common with therapists managing patients with neurological impairments? Is there anything unique to all physical therapists, regardless of practice setting, that differentiates us from other health care professionals? Is there an elemental identity or essence that all physical therapists have in common, regardless of the tasks performed during the day?

Perhaps the answer is the formulation of a grand theory or philosophy of physical therapy. A grand theory, as described by Domholdt, is an overarching theory that provides "broad conceptualization of phenomena."[2(p19)] Domholdt[2] contrasted grand theory to middle-range theory, which focuses on a particular area of dysfunction such as the orthopedic dysfunction model proposed by Harris and Dyrek[3] or the neurological dysfunction model of Schenkman and Butler.[4] A grand theory would unite different middle-range theories[5] because the similarities across specialties would be acknowledged and not the differences. Of the few examples of grand theory in physical therapy, the movement continuum theory (MCT)[5] is probably the most comprehensive.

The MCT, as proposed by Cott et al,[5] is based on the principle that movement is essential for human life, taking place on a continuum from the cellular level to an individual's interaction with society. Physical therapy interventions can take place at one or several places along the interdependent continuum. Within the continuum, each individual has a maximum achievable movement potential (MAMP), a preferred movement capability (PMC), and a current movement capability (CMC). Pathologies or developmental limitations have the potential to change the MAMP and to create a differential between the PMC and the CMC. The physical therapy intervention, regardless of the pathology, diagnosis, or required tasks, seeks to assist patients to either achieve their MAMP or reduce the difference between the PMC and the CMC. The MCT builds on the pathokinesiological grand theory developed by Domholdt[2] by encompassing a holistic approach to physical therapy that incorporates both prevention and treatment.

The MCT transcends specialties and different interest groups in physical therapy, conferring on them a commonality in sense of purpose and knowledge of what makes us unique as physical therapists. A grand theory would unify and harmonize increasingly disparate specialty areas while simultaneously distinguishing us from other health care professionals. We need to step beyond the task-oriented understanding of our role in health care[5] and know how we are different from athletic trainers, occupational therapists, and other professionals, who, from a task-orientation perspective, seem remarkably similar. Once physical therapy has achieved this step, then the future has direction. The MCT allows physical therapists to be more involved in preventive care, which is, no doubt, an important aspect of 21st-century health care. The MCT (or another grand theory) also would form a framework for organizing research as we hold our treatments up to the light of scientific scrutiny.

Discussion on grand theory is not an academic exercise in obfuscation that belongs in an ivory tower but a topic that all physical therapists should contemplate. It is a step toward the maturation of the profession, because it represents a form of self-cognizance. In the past 25 years, progress toward "professional greatness"[1] in the formal understanding of an elemental identity has been slow. There will be many opportunities and challenges for the physical therapy profession in the 21st century; however, in order to successfully meet these challenges, an essential step needs to occur. This step is most succinctly put by the ancient Delphic oracle--the profession of physical therapy must know thyself.

Michael O'Hearn, PT, MHS, OCS Lakeland Rehabilitation Center 1901 Niles Ave St Joseph, MI 49085 ([e-mail])

References

[1] Hislop HJ. Tenth Mary McMillan Lecture: The not-so-impossible dream. Phys Ther. 1975;55:1069-1080.

[2] Domholdt E. Physical Therapy Research: Principles and Applications. Philadelphia, Pa: WB Saunders Co; 1993.

[3] Harris BA, Dyrek DA. A model of orthopaedic dysfunction for clinical decision making in physical therapy practice. Phys Ther. 1989;69:548-553.

[4] Schenkman ML, Butler RB. A model for multi-system evaluation, interpretation, and treatment of individuals with neurologic dysfunction. Phys Ther. 1989;69:538-547.

[5] Cott CA, Finch E, Gasner D, et al. The movement continuum theory of physical therapy. Physiotherapy Canada. 1995;47:87-95.