Shirley Sahrmann on the Future of Physical Therapy/Physiotherapy

Shirley Sahrmann on the Future of Physical Therapy/Physiotherapy

I recently attended the Lower Quadrant — Advanced Application course in St. Louis Missouri and was able to ask Dr. Shirley Sahrmann, the course instructor, her thoughts on the physical therapy/physiotherapy profession.

Specifically, I asked Dr. Sarhmann two questions: Where do you see the future of physical therapy/physiotherapy? Where would you like to see the future of physical therapy/physiotherapy?

Emphasis on Movement

Dr. Sahrmann wants to see the physical therapy/physiotherapy profession place its emphasis on movement. She is excited that the 2013 American Physical Therapy Association House of Delegates adopted a new vision of the profession of physical therapy:

Transforming society by optimizing movement to improve the human experience.

She believes that to succeed in the future, the physical therapy/physiotherapy profession needs to do two things.

Identify With A Body System

First, in order for the physical therapy/physiotherapy profession to get the recognition it deserves and in order to organize itself, it needs to be identified with a body system.

Health professions that stand out are those recognized with responsibility for a particular part of the body system. Their claim to fame is not their treatment methods but their diagnostic capabilities and an understanding and responsibility for a part of the body system.

The physical therapy/physiotherapy profession should own the movement system.

Put a Label On It

Second, no one will think that the physical therapy/physiotherapy profession will figure anything out without putting a label on it. We need to define syndromes that are easily done. And since movement is based on kinesiology and anatomy, and a few rules, we need to work out the labels and encourage people to use those labels.

Focus on Anatomical Structure

The physical therapy/physiotherapy profession needs to put an emphasis on the movement system. They should focus on how the anatomical structure became damaged in a client. Specifically, this will involve the musculoskeletal system as well as lifestyle activities.

Annual Physical Therapy/Physiotherapy Checkup

Dr. Sahrmann draws a parallel with the dentistry profession. People visit their dentist once or twice a year to check their teeth. The body is much more visible than are teeth and so should the need for bi-annual checkups of their movement system by a physical therapist/physiotherapist. They should check:

  • Posture, exercise routines as well as cardiovascular fitness.
  • Requirements to optimize their movement system.

The New Business Model

Finally, Dr. Sahrmann indicates that maybe this will require a change in business model.

Conclusion

This is the second in a series of interviews I had with Dr. Sahrmann. In the first interview we discussed her exercise program and approach to aging well. In the third and final interview I ask Dr. Sahrmann about the highlights and disappointments within her career.

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Margaret MartinVoice post by: Margaret Martin

Margaret Martin is a Physiotherapist, Certified Strength and Conditioning Specialist (CSCS), and Certified Yoga Teacher with 30 years experience helping patients achieve their health and fitness goals. She treats patients with low bone density and osteoporosis at her clinic, provides an online service for people who want to improve their bone health, and teaches fellow Physiotherapists how to treat patients with osteoporosis. Margaret is the author of several books and is the recipient of the 2011 Award of Distinction from the College of Physiotherapists of Ontario for her significant contributions and achievements as a Physical Therapist.

Comments

  1. Rachel Prichard says:

    Great to hear Shirley’s views and comments. What a great idea to interview her! Thank you.

  2. Dr Rohan Chandanshive says:

    Grt.

  3. John Ware, PT says:

    I don’t understand how Dr. Sahrmann can advocate on the one hand that PT “own the movement system” and then on the other suggest that we need to focus on damaged anatomical structures in the musculoskeletal system. The movement system is an inherently dynamic system. The nervous system, which signals danger or potential danger within the movement system, routinely creates a perception of pain when no damage is present. Pain is a biopsychosocial problem, not a pathoanatomical problem. The amount of literature supporting this is overwhelming at this point. I can’t figure out why Dr. Sahrmann doesn’t acknowledge that, and that’s unfortunate.

  4. The idea of PT annually for a “check-up” is a bit much in my opinion. Posture has been shown again and again to be a fruitless endeavor, someone with poor posture that has pain, does not necessarily have pain because of poor posture. How about a more in depth understanding of pain science beyond the gait control theory? The narrative therapy uses as a whole is beginning to shake under the weight of evidence against its validity. Biomechanical models fail to see the forest through all the trees. However, I do agree that business models will have to change. So too should the narrative.

  5. Maryke Louw says:

    People do not move in similar patterns and one size does not and cannot fit all due to anatomical and physiological differences. The forefoot vs mid foot vs heel strike running debate and consequent research that did not support the popular theories should tell you this.
    Her proposed model of thinking feels to me like a money making scheme which will harm the reputations of physiotherapists.

  6. Let’s not forget that movement actually begins with a complex series of neurological processes which plan, prepare and execute movement. All of the “cool stuff” happens there and movement, in the most simple explanation, is all of this “cool stuff” that happens to simply contract a bundle of muscle attached to bones.

  7. Spoken from a neuro perspective!

  8. Spoken from a science perspective, not a neuro perspective, science applied to movement or tissue or whatever aspect of a human that a clinician wants to point their finger at, it’s not an either muscle or nerve situation.

    Just because some one can point at a part and call it names doesn’t make them right, being able to differentiate the different contributing qualities and attributes of the necessary tissues does. Where is the science to indicate ‘cognition or perception or emotion or the ability to contextualise’ in muscle cells?

    Wouldn’t it be more appropriate to Transform society by optimizing the human experience to improve movement instead of wondering why those horses standing on the back of a cart aren’t able to pull it forward?

  9. Jason Erickson says:

    Though I respect Sahrmann’s contributions to the field of physical therapy, I am appalled by her suggestions for the “future of the profession”. I will address her several points individually:

    S: “First, in order for the physical therapy/physiotherapy profession to get the recognition it deserves and in order to organize itself, it needs to be identified with a body system… The physical therapy/physiotherapy profession should own the movement system.”

    Me: The is a lymph system, a circulatory system, a reproductive system, etcetera. These involve discrete structures with well-established relationships that help define what they are, and constraints that also help define what they are not.

    There is no “movement system” that can be identified in the same way as other generally-recognized body systems. Since movement is influenced to varying extent by all other body systems and is an output of same, A “movement system” expert would need to have a serious depth of expertise in all body systems. Good luck with that.

    Notice that the APTA’s stated vision doesn’t mention a “movement system”. It says, “Transforming society by optimizing movement to improve the human experience.”

    That vision of focusing on “optimizing movement” seems myopic and a bit misguided to me, for reasons that will become clearer later in this response. In any case, Sahrmann may see some changes she likes in the APTA’s vision statement, but I think her interpretation of it just shows a lot of confirmation bias.

    S: “Second, no one will think that the physical therapy/physiotherapy profession will figure anything out without putting a label on it. We need to define syndromes that are easily done. And since movement is based on kinesiology and anatomy, and a few rules, we need to work out the labels and encourage people to use those labels.”

    Me: There are already many labels, and too many of them are junk labels, such as “runner’s knee”, “pinched disk”, etcetera. These are examples of labels created to “define syndromes that are easily done”. Way to go. Thanks for creating disempowering language designed to convince patients that they have something “wrong” that needs to be “fixed”. Have you looked at the research on how the terms/explanations provided to patients can have a strong, lasting nocebo effect? Movement is based on far, far more than anatomy and kinesiology. Neurology, psychology, genetics, nutrition, neuroimmunology, and other fields of study also may contribute to improved understanding of human movement (and limitations thereof). Instead of teaching people what to think, let’s forget the new labels and focus instead on teaching them HOW to think.

    S: “The physical therapy/physiotherapy profession needs to put an emphasis on the movement system. They should focus on how the anatomical structure became damaged in a client. Specifically, this will involve the musculoskeletal system as well as lifestyle activities.”

    Me: Only the musculoskeletal system? That’s a bit 1960s of you. As noted above, there are many, many other systems and fields of study that have a tremendous role in shaping how/whether we move.

    S: “he body is much more visible than are teeth and so should the need for bi-annual checkups of their movement system by a physical therapist/physiotherapist. They should check:

    Posture, exercise routines as well as cardiovascular fitness.
    Requirements to optimize their movement system.”

    Me: Again, how 1960s of you. Those sound like services currently provided by personal trainers and other members of the fitness industry. Though medical evaluation and rehabilitation are frequently viewed as the province of PTs, there are other medical professionals who can also provide many of those same services – to varying extent. However, many fitness professionals specialize in evaluating and training movement and postural habits. In many cases, they are better suited for working with (predominantly) able-bodied people than are PTs. How many PTs understand how to teach group fitness classes? How many can demonstrate proper squat mechanics and coach newbies in the intricacies of setting up the rack, the various grips and stances, programmed progressions in skill development and progressive overload, etc? Let the fitness professionals rule that, as they should. If they notice something that warrants seeing a PT, they refer to a PT.

    Instead, physical therapists have the opportunity to become real experts in the areas that fitness professionals generally stay out of: chronic pain, neuropathic pain, pain management, etcetera. There are already signs that this is a growing trend in physical therapy. Instead of just labeling syndromes and prescribing programs of basic exercises/stretches, PTs are now delving deep into the complexities of pain science and making serious contributions to the field, in both research and clinical practice. From my vantage point, this seems more likely to be a viable long-term direction for PTs to pursue.

  10. Diane Jacobs says:

    Todd Hargrove’s blogpost from a few years ago speaks to an issue I think is being overlooked in this effort to focus the profession on structure only: http://www.bettermovement.org/2012/souless-bodies-bodiless-souls/

    The problems I see with trying to hold the profession to a pathokinesiological model:
    1. By focusing only on movement we stay stuck in structuralism and miss the opportunity we have to help move humanity along, one person at a time, by explaining pain and nervous system considerations to them. I’m with Joe Brence. We should be facing the complexity of the entire system (including brain), and not trying to get so complicated and compartmentalized thinking only about the end organs of movement.
    2. John Ware is correct – the structuralist/biomechanical/postural model of operating as a profession is kind of at a dead end. Why dust it off and try to make it stand it up again?
    3. As Todd points out in the blog post I linked, structuralism is the other side of the coin from vitalism. We are better than being stuck in either of those sides. Our job is to educate patients. We should have something better to deliver to patients than making them worry over not doing something, some movement, “correctly”, according to an arbitrary system.

    I gotta say, this is like the ’50’s and ’60’s revisited. It has left out vast swathes of pain science and neuroscience that has come along in the last 40 years. I don’t want the future of my profession to be an intellectual ghetto comprised only of conceptualizations around mesodermal derivatives. I want to see less emphasis on “physical” and more emphasis on “therapy.”

  11. Hi Diane,
    I must admit that I did not realize there were such strong opinions within our profession! I love it!!
    Having attended 4 days studying with Dr. Sahrmann she did not box in the body and focus only on the pathokinesiology but rather used it as a framework to start from. Keep the passion.

  12. I agree with what John Ware, PT says:”The movement system is an inherently dynamic system….” I love Dr. Sahrmann, but I think to move truly forward we need to address an aproach of optimizing function through working with movement and not a pathologizing approach to manage dysfuntion, IMO. of course that is the Feldenkrais practitioner coming through….

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  14. I agree that physiotherapists need to identify with a body system. With so many other health professionals whose scope of practice is blending with physiotherapists we need to identify and define our expertise in order to limit confusion in the public eye. At my multidisciplinary clinic in downtown Toronto, we get phone calls on a daily basis with patients inquiring about which professional they should see for “back pain” or for “neck stiffness” for instance. The general public does not quite understand when they should see a physiotherapist in comparison to when they should see their family doctor or when they should seek emergency care for instance. Focusing on the movement system makes sense and can be interpreted as all encompassing (to physios), but that may create some confusion and be limiting from the perspective of the general public (our clients). We need to educate our clients on when they should be seeking physiotherapy care and how we are different than other professionals (massage therapists, chiropractors, osteopaths etc). If we are movement specialists then we need to help clients understand that we:
    1. analyze movement
    2. help to optimize movement strategies by making clients aware of their non-optimal movement patterns or failed load transfer
    3. assist in increasing mobility in joints that are not moving well
    4. assist in increasing stability in joints that are moving excessively
    The above will ultimately reduce patient symptoms/complaints (improve the injured anatomical structure) and prevent recurrences.

    Ultimately, we need our clients/patients/referring professionals to have a better understanding of what we do and how we are different than other health professionals so that our physiotherapy can progress in the future.

    Ultimately

  15. Ferdinando says:
  16. Mandisa Boilane says:

    Goodday. While there are many great points made by the Dr, I agree with many critics about viewing the human system as a whole. Indeed our intervention touches on many variables but our ill defined approach to health is nullifying effort to stand out in the health system as a whole. I just want to point out that physiotherapy is not protected as a unit. We are vulrenable to other health practitoners employing our strategies under rehabilitation umbrella. In South Africa there is a constant tascle between biokinetics, OTs etc over scope of practice. While I may not have a solution I would like to point out that this is painting a bleak picture for growth of the profession but even so public confusion. Indeed it is good to see that there are shared issues globaly.

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