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First Impressions

Updated: Apr 27

Roughly 100 years ago Physical Therapy was born. MD's would ask their spouse to rub the shoulders of a patient, or to put some heat on them. That's it. It probably helped some people, and there is nothing wrong with that. We've come a long way, but that first impression has stuck hard.


During the polio epidemic the field made great progress. It was the beginning of the application of science to the musculoskeletal system. Great PT's like Florence Kendall created what would now be called a spreadsheet that linked every nerve with every muscle. Data would be collected on each patient and using these spreadsheets they would create what would now be called a primitive physical therapy diagnosis, and that diagnosis would guide their care. It was a huge step in the right direction. Here is a pic of one of the "diagnostic spreadsheets " from 1948.


Sometime later the mechanists arrived, and they integrated the skeletal system into the picture. Their work was to a great degree based on the work of Osteopaths. Basically they looked at how bones "lined up" and how joints moved, and of course they paid a lot of attention to the muscles, tendons and ligaments that tied the musculoskeletal system together. They also "borrowed" a lot of techniques that for the most part were manual or "hands on" skills that could be used to treat the bones and muscles and connective tissues.


It was at about that time that one of my professors, Shirley Sarhmann, initiated the concept of "The Movement System". Her thinking was that every other health care provider treated a system. The circulatory system. The endocrine system. Etc. Shirley looked at what we do and applied that worldview. What were PT's all about? The answer was "Movement". Shirley initiated the concept of the Movement System. What comprises the movement system? Well, everything really. Bones, muscles, nerves, and of course the biggest collection of nerves in the body, that is the brain. It all works together to create movement, and to treat a system correctly, you must first diagnose.


How do we evaluate, or make a physical therapy diagnosis of the movement system? Same way everyone else diagnoses their systems: First we screen to make sure the problem isn't coming from something outside of the movement system. Is it cancer or a blood clot or something else that is not musculoskeletal in origin? Yes, we are trained to screen for these things and at our clinic we have caught our share of these problems over the years, prior to initiating treatment.


Once systemic, or non-musculoskeletal issues, are screened out, then we simply apply the scientific method. We gather data, we create a hypotheses, we perform tests, we analyze the data and test results, and we come up with a conclusion. Then we use the best available evidence to create a plan of care that is best suited to this diagnosis. Most PT's call this process clinical reasoning.


We're somewhat unusual in the health care field in that we both do the evaluation/diagnosis and we deliver the treatment as well. I love this about our field, but it can create confusion and to this day many people still see us as someone that simply delivers care. They think we do so based on an order or protocol. It doesn't help that some of our care is delivered by hand. Many people are binary, and they think you're either a thinker or a "doer", and if you use your hands you must be a "doer".


It's easy to understand why this happens - first impressions are strong (remember how we started 100 years ago), and they last. And we do deliver the care, and one of the ways we can do so is with our hands. But please know that first we evaluate and diagnose, and every second of every visit that diagnostic process continues. We are constantly gathering more data, testing, analyzing our results and comparing them to our original hypotheses, modifying our hypothesis, and as a result modifying our treatment. All the while it probably seems like we're simply treating you.


First impressions are strong, and in our case they are true - to a certain extent. We do do manual therapy, and on occasion we still put heat on someone. But that isn't the whole story. 100 years have gone by, and we have learned a lot and changed. We have been diagnosticians as well as clinicians for nearly 40 years now, and we diagnose and treat The Movement System.* As a result we are considered the Preeminent Experts in Movement.


*This post is written in honor of and out of great respect for Shirley A. Sahrmann, PT, PhD, who still lectures worldwide regarding Movement System Impairments, and the late great Steven J. Rose, PhD, FAPTA. Dr. Sarhmann and Dr. Rose were at one time the leaders of the "Camelot" that is the Program in Physical Therapy at Washington University in St. Louis, Missouri. Their influence upon our profession was game changing and it reverberates through each and every Physical Therapy program to this day.


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