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.
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.
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.
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.
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.
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.
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.
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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