The APTA House of Delegates adopted a new vision for the profession in 2013— “transforming society by optimizing movement to improve the human experience.”1 One of the guiding principles associated with the vision is that the movement system, defined as “the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts,”2 would become the core of physical therapist (PT) practice, education, and research (Figure 1). With this vision statement and accompanying identity statements, we extend an over 40-year discussion3–7 about our professional identity as experts in the movement system.
Incorporating the movement system into clinical practice will require clinicians to evaluate and diagnose movement dysfunction.8 While this practice may be inherent for many PTs, the profession lacks a consistent approach to movement analysis and, importantly, lacks the terminology to describe movement dysfunction in a standardized manner.
Diagnoses identified by physicians that are based on a person's health condition are not particularly helpful in guiding rehabilitation because they typically do not link the health condition with specific movement impairments.9–12 Instead, movement system diagnoses that are created and used by PTs will be composed of clinical findings from the PT's examination to create classifications that are relevant to patient management.
The APTA has previously attempted to develop patient classifications, named Practice Patterns (PPs), in the Guide to Physical Therapy Practice Part II (1999). The PPs were organized around pathology/health condition and included descriptions of management for each pattern. These PPs were never validated13 and were not included in the 3.0 revision of the Guide. Some concerns raised about the PPs were that no rationale was provided for sorting by pathology,14 the language of the PP labels was potentially burdensome,7 and the PPs lacked the specificity necessary to be helpful in prescribing interventions3,7,14 and fostering intervention effectiveness research.3
Achieving success with the profession's new vision requires the development of a framework for movement system diagnoses that will be useful in clinical practice, education, and research.15 The concept of diagnosis by PTs has been most notably influenced in recent years by the Diagnosis Dialog groups,16,17 and in 2015 the APTA endorsed “the development of diagnostic labels and/or classification systems that reflect and contribute to the physical therapist's ability to properly and effectively manage disorders of the movement system.”8 Accordingly, the Academy of Neurologic Physical Therapy (ANPT) appointed a Movement System Task Force in 2015 to explore this issue for individuals with primary neurologic dysfunction.
The purpose of this white paper is to report on the current ideas and recommendations generated by the ANPT Movement System Task Force as a result of 21 months of reviewing existing literature and resources, and discussing the movement system and approaches to patient classification. Specifically, the purpose of this article is to (1) identify the essential elements necessary to develop and implement movement system diagnoses for patients with primary neurologic involvement along with examples of existing movement system classifications from the literature, (2) discuss the potential impact of using movement system diagnoses on clinical practice, education, and research, and (3) provide recommendations for potential next steps to broaden this discussion and foster the development of diagnostic classifications based on the movement system. Although the focus of the Task Force's work has been on movement system diagnoses relevant for patients with primary nervous system involvement, we expect that these ideas and recommendations may also apply to other areas of PT practice.
ANPT MOVEMENT SYSTEM TASK FORCE PROCESS
The ANPT Board of Directors invited ANPT members to apply for a position on the Movement System Task Force in March 2015. Subsequently, the authors of this article were chosen to serve on the Task Force. Task force members have a mean of 30.7 years of experience working with individuals with neurologic disorders (range = 22-39 years). They represent different geographic regions of the United States (3 Midwest, 2 Northeast, 1 Southeast, and 1 Southwest), and varied primary roles (3 academician/researchers, 2 academician/clinicians, 1 clinician/administrator, and 1 academician/clinician/researcher). Of the 7 Task Force members, 3 are American Board of Physical Therapy Specialties (ABPTS)–certified neurologic clinical specialists, and 1 is dual certified by the ABPTS as a clinical specialist in both geriatric and neurologic physical therapy. The Task Force was convened in June 2015 and was charged to (1) develop expertise in the conversation regarding the movement system and diagnosis of movement system problems by reading, studying, and discussing relevant writings, lectures, and professional materials, and (2) develop examples of content (eg, terminology, descriptions, and labels) that may be used to describe human movement system problems. The group conducted monthly phone conferences and one 2-day face-to-face meeting over the 21-month period. The group presented their ideas in an education session at the 2017 Combined Sections Meeting of the APTA.
Figure 2 depicts the Task Force's process to develop expertise in the movement system and diagnosis. Task Force members initially read a series of seminal papers about the professional dialogue regarding the movement system, movement system diagnosis, and physical therapy.3,4,6,7 To understand the variety of approaches used to categorize patients into meaningful groups, members reviewed articles related to patient classification across physical therapy and other disciplines even if this was not the primary intent of the article. Over time, members narrowed the focus of the review to articles specific to neurologic conditions. By the end of this process, the Task Force identified 16 articles that represented varied approaches to patient classification and/or movement analysis. The group then identified 13 characteristics that we thought would be important to consider when assessing the utility of a diagnostic classification framework. These characteristics are embedded in a set of questions that were used to conduct paired reviews of each of the 16 articles to determine the presence of these characteristics (Table 1). Two task force members separately reviewed the same articles and reached consensus when they disagreed. The results from this review are presented in the Appendix (see the Appendix, Supplemental Digital Content 2, available at: http://links.lww.com/JNPT/A199).
Table 1. -
Questions Developed by the Task Force to Guide Article Reviews
|1. Did the article describe classifications of patients for one health condition or across health conditions?
|2. Did the article describe one classification of patients or more than one?
|3. Did the article describe a classification system related to a single task or could it be used for a variety of tasks?
|4. What is the theoretical framework used and/or purpose of the classification system?
|5. Are the included classifications related to impairments, activity limitations, and participation restrictions?
|6. Have the authors provided labels for the classifications? Do they use standard movement language?
|7. Did the article provide a guide to clinical reasoning/decision-making?
|8. Was an examination process for identifying the patient classifications described? Does the clinical examination lead to movement system diagnoses?
|9. Are the classifications linked to prognosis?
|10. Do the classifications lead to evidence-based interventions?
|11. Does the classification system include a behavioral component?
|12. Will the classifications be useful for research?
|13. Have the concepts of the classification system been validated?
Through this process, the Task Force gained an understanding of the movement-related classifications that have been developed and how the logic used in these approaches might apply to a diagnostic framework. Based on our comparative analysis of these classifications, the Task Force then distilled 4 characteristics that provide a foundation for moving forward in developing movement system diagnoses relevant to patients with primary neurologic involvement. The Task Force recommends that movement system diagnoses should (1) be based on a sound, evidence-based theoretical framework, (2) emphasize movement observation and analysis of core standardized tasks as central to the clinical examination and evaluation, (3) represent a unique cluster of movement observations and associated examination findings that can impact a variety of tasks, and (4) provide unique and nonambiguous labels for each movement system diagnosis. While none of the 16 articles we reviewed demonstrated all 4 of these characteristics, we did find examples of each of these characteristics, as shown in Table 2. More details about the characteristics are provided in the second Task Force recommendation at the end of this article.
Table 2. -
Examples of Critical Characteristics for Movement System
||Example of Each Characteristic
|1. Based on sound, evidence-based theoretical framework(s).
||Horak et al:55 The BESTest is a science-based approach derived from research around the motor control of balance in nonimpaired and neurologically-impaired individuals associated with a variety of health conditions. It describes an interactive set of constructs around the control of the center-of-mass relative to a stable or moving base of support. Each construct has been reduced to specific tests and measurement variables that can be used to generate hypotheses about why an individual may be experiencing loss of balance.
|2. Emphasize movement observation and analysis of core standardized tasks as central to the clinical examination.
||Scheets et al:56 This case illustrates how a diagnosis framework guided the clinical examination process and led to the identification of 3 movement system diagnoses for a patient after hip fracture. The appendices describe a detailed clinical examination including movement observation of selected tasks.
|3. Comprise a set of movement system diagnoses that each represents a unique cluster of movement observations and associated examination findings that can impact a variety of tasks.
||Quinn and Busse:52 This categorization was developed to characterize movement problems identified in people with Huntington's disease. The authors identified task-independent motor control issues such as exercise capacity and performance and planning and sequencing of tasks that can be identified with appropriate examination tools.
|4. Provide unique and nonambiguous labels for each movement system diagnosis.
||Hedman et al:57 A consensus-driven Delphi process resulted in expert consensus on the labels and descriptions for requirements for successful locomotion. The study's methodology provides a model for the initial development of diagnostic classifications.
Abbreviation: BESTest, Balance Evaluation Systems Test.
The Task Force recognizes that the development and use of movement system diagnoses will have significant effects on physical therapy clinical practice, education, and research. The following sections summarize these anticipated effects and identify likely implications for these areas.
Clinical reasoning, the thinking and decision-making processes used in clinical practice,18 is a cornerstone of the physical therapy profession. The Patient-Client Management Model13 identifies the iterative process used by PTs to make clinical decisions and manage each patient/client; it consists of the following elements: examination, evaluation, diagnosis, prognosis, intervention, and outcomes. The Task Force identified 4 of these elements in which use of a movement system diagnosis can inform and strengthen clinical reasoning and decision-making in neurologic physical therapy: examination, evaluation, diagnosis, and intervention.
Physical therapists gather a range of multidimensional information during the patient examination. The Guide to Physical Therapist Practice13 describes examination as including patient history, body systems, and review tests and measures of body structure and function, activity and participation (based on the International Classification of Functioning, Disability and Health). However, movement observation and analysis are not mentioned in the Guide and may not be a routine part of clinical practice.
The Task Force proposes that movement observation and analysis are critical to understanding why a patient is experiencing a movement problem and how one might label the movement problem. Movement observation entails observing and describing the way a person moves spontaneously or while performing a task or activity. Importantly, this description is far more detailed than a label of a patient's level of independence. Movement analysis is the synthesis of the movement observations based on knowledge of motor control and taking into consideration all other patient data (eg health condition and impairments in body function). The observation/analysis process is iterative, and we believe it is at the center of assigning a diagnostic label or movement system diagnosis (see the Evaluation and Diagnosis subsection).
Although there are well-described examples in the literature that demonstrate the usefulness of movement/task observation and analysis for clinical reasoning,19–21 there are currently no validated tools that can be used across a range of tasks to reliably detect movement system problems. The Task Force recommends that key tasks be identified and used to systematically observe patients, as they perform each task in a standardized manner. The Task Force used a consensus process to identify core standardized tasks (Table 3) that, when observed in a systematic manner, can provide insights about motor control impairments. The tasks listed in Table 3 place differing demands on the movement system and are likely to be useful across a broad range of patient types.
Table 3. -
Recommended Core Tasks for Movement Observation
|Reach, grasp, and manipulation
In addition to recommending a core set of standardized tasks, the Task Force identified existing literature to inform future efforts to standardize movement observation. The movement continuum, as described by Hedman et al,22 is an example of a useful framework to organize and describe movement observations in a standard manner across all tasks. The 6 stages of the movement continuum consider movement from its preparation to outcome on the task goal and environment. The stages and the key movement attributes associated with each stage are described in Figure 3. Descriptive and quantitative analyses of various functional tasks23,24 will also be instrumental in identifying the critical aspects of movement that characterize each stage of a task. Identifying such critical aspects of movement for each core standardized task25 could lead to the development of a standardized approach to movement observation that can then be tested for reliability, validity, and clinical utility. Such a standardized approach could include visual observations and analysis as well as use of instrumented technology to quantify and describe movement.
Evaluation and Diagnosis
The evaluation and diagnosis steps of clinical reasoning are closely linked. The goal of the evaluation is for the PT to arrive at an understanding of why a person is experiencing a movement system problem so that interventions can be specifically directed at that problem. Synthesis and interpretation of movement observations of standardized tasks is a critical step. Movement observations that are linked to particular stages of movement22 can lead to hypotheses about how motor control is affected. This knowledge, in conjunction with other information gained during the patient examination, provides a strong foundation for the therapist to hypothesize what may underlie different movement strategies. In arriving at the evaluation, the therapist needs to consider all possible sources from across the movement system (from Figure 1, nervous, cardiovascular, pulmonary, integumentary, musculoskeletal, and endocrine systems) when determining possible underlying contributors to the movement problem.22 We believe that this iterative diagnostic process is currently a standard component of practice, although explicit movement observation and analysis of tasks are not routinely included.
At the conclusion of the diagnostic process, a diagnostic label or movement system diagnosis should be assigned. This is another potential missing component of practice that must now be addressed by agreeing on and standardizing movement system diagnoses. We posit that each movement system diagnosis needs to be associated with a clear description of a unique cluster of movement observations and associated examination findings. The clinician will need to interpret all patient examination data including movement observations to recognize these clusters that align with one or more movement system diagnoses. This process of linking the clusters seen in each patient's clinical presentation to known descriptions of movement system diagnoses25 represents a key and novel advance in the decision-making processes used in practice.
Determination of a diagnostic label should guide the practitioner's plan of care, which may include a specific intervention or a defined set of intervention options. The movement system problem should be identified within the diagnostic label to allow clinicians to more clearly state the “bottom line” about each patient from a movement system perspective. This, in turn, may advance clinical reasoning regarding how to select or apply elements of intervention.
Using a shared set of movement system diagnoses across physical therapy practice will enable clinicians to more efficiently identify and select the most effective interventions related to specific movement system problems. Currently, there are no validated movement system diagnoses that organize intervention selection. From the large array of intervention options available in practice, more defined sets of evidence-based interventions related to each specific movement system diagnosis will emerge.
Despite proliferation of practice guidelines, there is still considerable variability in neurologic PT practice.26–29 Unwarranted variability in practice or “differences in care that cannot be explained by illness, medical need, or the dictates of evidence-based medicine”30 undermines the integrity of PT practice and is associated with an increased cost of care and less favorable outcomes.31–33 The expectation is that development and use of movement system diagnoses such as the ones that have been developed and tested for individuals with primarily orthopedic34–41 and urogenital conditions42 may foster a consistent level of neurologic PT practice through the development of associated treatment planning algorithms, clinical pathways, and clinical practice guidelines. Tools such as these may help clinicians sort through evidence more efficiently and can facilitate reduction in unwarranted variability in clinical practice.
An “in depth, integrative knowledge of the movement system and its component elements (anatomical structures and physiological functions)”2 is needed for clinicians to integrate the movement system into practice. This requirement will necessitate that the movement system be the centerpiece of entry-level PT preparation. We therefore wholeheartedly support Deusinger's43 recent call for the profession to adopt the human movement system as a common philosophy of physical therapy education programs' (PTEP) curricula.
The Task Force recommends that PTEP curricula link the development of clinical reasoning and decision-making with knowledge of the movement system. Examples from the literature illustrate how movement science can be integrated into neurologic curricula22 and an entire curricular design.44 PTEP curricula will also need to incorporate movement system diagnoses, as they foster student development of clinical reasoning and decision-making. It will be critical that clinical faculty are included in the process of changing curricula so that they are able to mentor students during their clinical education. The Task Force expects that these changes in curricula will ensure that entry-level therapists have the expertise needed to understand, implement, and further develop movement system diagnoses including the standardized movement observation and analysis. The profession cannot, however, place the responsibility of this paradigm shift on new graduates. All clinicians need to understand the importance of movement system diagnoses and how to implement them in their clinical practice. We anticipate that the Academy can help foster these outcomes by engaging as many clinicians as possible in the process of creating and testing the movement diagnoses, sponsoring ongoing continuing education opportunities, and setting up mentoring networks.
While the concept of movement system diagnoses has been discussed in our profession for many years, the research supporting the development and use of such diagnostic labels has been limited. In 2011, the APTA recognized the need to develop classification systems as a means to improve patient outcomes; their updated research agenda included the charge to develop and evaluate effective patient/client classification methods to optimize clinical decision-making for PT management of patients/clients. In addition, in 2015-2016, the National Center for Medical Rehabilitation Research, part of the National Institutes of Health/National Institute of Child Health and Human Development, developed new priorities for rehabilitation research that included developing methods that may predict rehabilitation treatment response and tailor interventions to individual patients.45 These 2 important agendas for rehabilitation and physical therapy research each place importance on research that facilitates optimal clinical reasoning and decision-making to maximize patient outcomes. Development of movement system diagnoses and classification systems is central to these research strategies.
Recent randomized controlled trials of rehabilitation interventions for patients with neurologic health conditions have demonstrated significant variability in participant responsiveness to the target intervention, even in patients with the same health condition.46,47 At times, there is an effort to explain this variance by examining other factors in the study data such as patient age, gender, time since onset of condition, and extent and location of damage. Importantly, there has been a shift in thinking about factors other than medical diagnosis that may contribute to patient outcomes, such as a patient's underlying movement system problem. To understand which interventions are effective, patients should be categorized, in part, according to movement system problems, and not solely on the health condition.
The Task Force suggests that specific diagnostic labels must be validated and tested empirically to move the concept of movement system diagnoses forward in the profession. This process can utilize a data-driven approach, in which researchers utilize large data sets that are created with standardized observations, outcome measures, and/or interventions to look for patterns among patient groups. Using a data-driven approach, Bland et al48 identified 4 clusters of individuals poststroke based on their sensorimotor, cognition, language, and activity-level impairments. While the primary goal of their study was to identify categories to guide postacute discharge recommendations, such groupings based on large data sets are a first step to developing diagnostic classifications that can use prognostic indicators to guide physical therapy intervention. Another approach to validating diagnostic labels is to use an experience-based approach, in which categories or classifications are developed based on clinical data. An experience-driven approach has been employed by several clinician-researchers utilizing clinical experience to identify patterns of patient characteristics across different health conditions.25,49,50 Experience-driven approaches could inform data analysis plans for data mining when large data sets are available. Such data sets will become ubiquitous for physical therapy researchers in the upcoming years, particularly with the development registry data, such as APTA's Physical Therapy Outcomes Registry.51 The Task Force recommends moving forward by creating movement system diagnoses based on clinical experience, initially testing them for face validity and subsequently using large data sets to further test their validity.
Regardless of the health condition, a patient's movement system problem may be a critical factor predicting responsiveness to rehabilitation intervention. Alternatively, within a given health condition, classification of patient problems based on movement system diagnosis may help better direct interventions and ultimately affect outcomes. Such classification systems are just beginning to be developed and empirically tested.52–54
SUMMARY AND RECOMMENDATIONS
The development and adoption of a coherent movement system diagnostic framework is an important step in fully integrating the movement system concept into physical therapy education, research, and clinical practice. Gaps exist in our understanding of the best way to develop and integrate movement system diagnoses into our profession, and we look forward to further dialogue on this topic. Since ideas on movement system diagnosis are at an early stage of development, time and financial resources must be dedicated by the leadership and members of the Academy. To assist with next stages of the process, the Task Force puts forth the following recommendations:
- Develop and test a systematic process for movement observation and analysis of standardized tasks. This will involve applying the literature to determine key attributes of each task to construct a standardized movement observation scheme that can be tested for validity and reliability.
- Clinicians and researchers should work together to develop a set of movement system diagnoses that address the identified attributes using both experience-based and data-driven approaches. The Task Force developed a set of 4 characteristics that are expected to form the foundation for the development of clinically meaningful movement system diagnoses. Movement system diagnoses should:
- Be based on a sound, evidence-based theoretical framework. This theoretical framework should be based in movement science and offer clear operational definitions, theoretical constructs, measurable variables, and can lead to predictable hypotheses.
- Emphasize movement observation and analysis of core standardized tasks as central to the clinical examination and evaluation. Once core standardized tests are developed and tested, they will become an essential part of the clinical examination to inform the selection of the appropriate movement system diagnosis.
- Represent a unique cluster of movement observations and associated examination findings that can impact a variety of tasks. Defining the diagnostic categories of the movement system will require synthesis of the essential elements, including both movement observations and associated examination findings, which occur together as a cluster across tasks and health conditions.
- Provide unique and nonambiguous labels for each movement system diagnosis. The labels should be descriptive, unique, and nonambiguous. These labels should be applicable across a number of health conditions and tasks, allowing for the identification of movement system problems that are typically found in patients with primary neurologic dysfunction.
- Test movement system diagnoses for their validity (including their ability to predict outcomes and responsiveness to intervention), their clinical utility, and their relationship to clinical practice guidelines. Importantly, any publications related to the development of these diagnoses should include the search term “movement system diagnosis.”
- Promote the movement system and movement system diagnoses as the core of entry-level curricula through publications, continuing education, mentoring, and modification of Commission on Accreditation in Physical Therapy Education (CAPTE) criteria. This fundamental change in PTEP education will require multifaceted and ongoing education of all stakeholders including academic and clinical faculty and CAPTE.
- Promote the establishment, dissemination, utilization, and refinement of movement system diagnoses as priorities of the ANPT. This can be accomplished by reporting on the work related to movement system diagnoses in ANPT publications, educational opportunities, research initiatives, and communications. Surveys of practice can help identify utilization of movement system diagnoses over time, and reveal barriers to their adoption that need to be addressed. The transition to using movement system diagnoses will be challenging, and a commitment to clear communication from the ANPT will be critical.
The authors are grateful for the support of the Academy of Neurologic Physical Therapy for the Task Force. We also acknowledge Dr Barbara Norton for providing feedback on an earlier version of this article.
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