Moving Precisely? Or Taking the Path
of Least Resistance?
Shirley A Sahrmann, PhD, PT, FAPTA
Shirley A Sahrmann has been recognized as a distinguished leader in
physical therapy for more than 30 years. The scope of Dr Sahrmann's
contributions to physical therapy encompasses clinical practice,
research, education, and administrative activities.
Dr Sahrrnann's commitment to the development of classification schemes
for patients with chronic pain and to systematizing the selection of
interventions so that outcomes can be more easily measured has formed
the groundwork for a new approach to practice. This approach is rooted
in the sciences of anatomy, kinesiology, and neurology and emphasizes
prevention, effective patient education, and sound clinical decision
making.
Dr Sahr~nannhas served AF'TA in appointed and elected ofices at the
national and component levels, and has been a vocal and influential
supporter of the Foundation for Physical Therapy since its inception. She
has been recognized by APTA at the national level with the Lucy Blair
Service Award, the Marian Williams Research Award, election as a
Catherine Worthingham Fellow, selection as the first John HP Maley
Lecturer, and the Henry 0 and Florence P Kendall Practice Award. She
has also been the recipient of the Missouri Physical Therapy Association's
Outstanding Service Award for Research, the Washington University
Program in Physical Therapy Alumni Award, and Washington University's
Distinguished Faculty Award.
[Sahrmalzn SA. The Twmh-Nzn,th Mary McMiLLan Lectuw: Moazng precisely? Or takin,g the path of Least re~istatice?
Phys TILer. 1998;78:1208-1218.1
Shirlqr A Sahrmann
Physical Therapy. Volume 78 . Number 1 1 . November 1998
M
adam President, honored
guests, and colleagues, I
am indeed honored to be
selected for this award.
Being included with all of the notable
people who have given this lecture is
truly humbling. Unfortunately, the
excitement of being selected was
quickly replaced with feelings of concern when I read the guidelines for this
lecture and realized that I was expected
to talk about my contributions to physical therapy. I
wondered how I could do that for 45 minutes without
being either boring or terribly creative. So I quickly
consulted with a colleague for whom I have great
respect, Florence Kendall, the 1980 McMillan Lecturer.
She said, "That is ridiculous, you cannot talk about
yourself." Having been given dispensation by my dear
friend, I feel free to discuss, not what I have done, but
some of what I believe has happened in physical therapy
during my 40 years in the profession, and some ideas
that may help guide us through the next 40 years.
As I reflect on the events of the years between 1958 and
1998, the most striking trend I see is that physical
therapy is changing from a clinically driven profession to
an academically driven one. I believe this change
deserves comment because it may be transparent to
those who are younger. That's a tricky way of putting a
positive spin on aging, but then any tactic is acceptable
from my vantage point. I also believe this change is
absolutely essential if we want to assume a place among
the world's leading health care professions. Thus, all of
us, clinicians and academicians alike, must now work
together to ensure completion of the change. If we want
to succeed in making the transition to an
academically driven profession, I believe
we must steer ourselves into a slightly
different path by making a few adjustments in the way we view our identity,
clinical science, academia, and practice.
Before proceeding with the specifics of
where we are and what I think we need
to do in each of these 4 areas, I would
like to make a few acknowledgments.
Often when individuals are honored, they thank their
family and friends. The expressions of gratitude always
impress me as being a nice gesture. But not only is it nice
to acknowledge the contributions of others, it is necessary. Clearly, the accomplishments of any individual
reflect to a large degree the influence of many others
who helped in numerous ways to shape his or her life. In
my case, the transition from a stubborn and obstinate
child into a tenacious and persevering adult required a
lot of help. I am grateful to my parents, who had
confidence in my worth; to my brother, Bobby, whose
untimely death at age 16 years provided the motivation
for me to pursue a career as a physical therapist; and for
the support of my sister, Joan, whose intelligence and
ability have always left me in awe.
I believe the opportunity to give this lecture is the result
of a wise decision I made early in my career. The
decision was to enter our profession through Washington University's Program in Physical Therapy and then
spend all but my first year of practice at that same
wonderful institution. I also believe my selection as this
year's McMillan Lecturer is a tribute to the teachers,
mentors, and colleagues who introduced me to the
SA Sahrmann, PhD, PT, FAPTA, is Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington University
School of Medicine, Campus Box 8502, St Louis, MO 63110 (USA) (sahrmann@medicine.wustl.edu).
The Twenty-Ninth Mary McMillan Lecture was presented at Physical Therapy '98: Scientific Meeting and Exposition of the American Physical
Therapy Association, June 5, 1998, Orlando, Fla.
Physical Therapy . Volume 78 . Number 1 1 . November 1998
Sahrmann . 1209
"We must be sure
importance of physical therapy in health care and who
continue to guide and inspire me as we participate in the
growth of the profession and its body of knowledge.
Among those are my dear friends a n d colleagues, Kathleen Dixon, who made sure I did not overlook the
critical role of participating in Association activities, and
Barbara Norton, who, over the past 30 years, has helped
me translate and hone many wild and vague notions into
concrete and cogent ideas.
I have also been greatly influenced by my younger
colleagues, who have played a major role in helping me
develop the concepts of movement impairments. I cannot fi~llyexpress my appreciation to Washington University or give adequate praise to my university colleagues,
who are truly an inspirational collection of productive
and enjoyable people.
Finally, 3 very special colleagues who had a profound
impact on my life directions and professional development
were Steven Rose, Eugene Michels, and Marilyn Gossman,
all of whom freely shared with me their wonderful ideas,
wisdom, values, and love of our profession. Clearly, their
dedication and contributions continue to inspire all in
their absence. Responding to the inspiration of these
visionaries by using the assets of the present to turn loss and
challenge into accomplishment^ is what characterizes physical therapists and physical therapy.
that we are nOtiust
taking the path of
least resistance, but
that We are m0v;ng
precisely in the w a y
the subtle changes in
the path of movement,
but if the changes are
addressed early and precise
movement
is
restored, a desirable
outcome is relatively
to
.,
w e use and
As I noted a few
moments ago, I believe
communicate our
physical therapy is
moving along a path to
body of
become a n academiknowledge."
cally driven profession.
To a certain extent, the
ease with which we
move along this path is determined by how our past
experiences, current influences, and visions of the
future affect our identity, clinical science, academia, and
practice. We must be sure that we are not just taking the
path of least resistance, but that we are moving precisely
in the way we use and communicate our body of
knowledge. Thus, I believe that, as a profession, we must
consider how relatively small changes in the path we are
taking can either compromise or secure our place in
health care for the next century.
Professional Identity
But what d o we need to accomplish? Where are we
heading, and how will we get there? I have titled this
lecture "Moving Precisely? O r Taking the Path of Least
Resistance?" I have done so because of the parallel I see
between some choices we need to make as a profession
and some critical insights I gained from observing and
thinking about the different faulty movements demonstrated by the myriads of patients I have seen over the
years. The movement faults are probably similar to the
kind all of you have observed, but I've just had more
years than you to observe them and their consequences.
For example, when my fingers are flexed, my wrists are
in neutral, and when I extend the fingers on my right
hand, my wrist flexes, yet when I extend the fingers of my
left hand, my wrist does not flex. T h e question is, "Why
does my right wrist flex when I extend my fingers?" One
plausible answer is that motion will occur at a hyperflexible joint, even when that joint ideally should remain
stable. Stated a slightly different way, the flexible joint
becomes the path of least resistance, and once a path of
least resistance is established, it is easy to keep moving
along that path, even though it may not be the optimal
or most precise path. Unfbrtunately, motion at these
flexible joints is often associated with pain. Thus, the
consequence of moving along an easy, but imprecise,
path is an undesirable outcome. One lesson that I learned
from working with patients is that it is very easy to overlook
12 10 . Sahrmann
How a profession is identified at a given point in time
provides a direction for future growth. We have made
significant strides in the transition from a technical field
characterized by individuals skilled in the application of
physical modalities to a profession characterized by
knowledge of the movement function of the body. Now,
we must be even more precise in defining our identity
and in developing the concepts inherent in that identity.
In my view, to move precisely we must:
Continue to develop the concept of movement as a
physiological system.
Alternatively, we can take the path of least resistance and:
Limit our idea of movement to that of a phenomenon that becomes impaired by a lesion in a
specific anatomical system.
A major step was taken toward establishing our identity
as professionals, rather than as technicians, when Helen
Hislop, in her 1975 McMillan Lecture, proposed that
pathokinesiology should be our defining science.' Many
throughout the profession, including Steve Rose and our
faculty, became committed to building our profession
upon the concept of pathokinesiology. But after several
years and a great deal of discussion, the prevailing belief
Physical Therapy . Volume 78 . Number 1 1 . November 1998
"We must solidify
was that the Inore common and broader term "movement" should be used to describe the core of our
professional identity. Finally, in 1983, the House of
Delegates adopted the philosophical statement defining
physical therapy as a health care profession whose primary
purpose is the promotion of optimal human health and
function through the application of scientific principles to
prevent, identifii, assess, correct, or alleviate acute or prolonged movement dysfunction." will never forget how
radical the concept of identifying movement as our unique
focus seemed in 1983. But today, the concept seems to be
inextiicabky woven into the fabric of our profession.
Now, I believe we must solidify our identity as a profession bv d~eveloping the concept of movement as a
physiological system and by accepting the role of practitioners responsible for a system of'the human organism.
Did you know that one medical dictionary now defines
movemenl as a physiological system? One of the definitions of movement system is, "A physiological system that
functions to produce motion of the body as a whole or of
its component parts."" Why is defining movement as a
physiological system so important? Because, just as Florence Kendall indicated in her 1980 McMillan Lecture,
there is concern about the future expansion of physical
therapy eclucation and practice if we d o not define our
role."
she also stated, "medical specialties are based
on body system^."^ Actually, alrnost all well-established
and accepted health care professions have defined their
role by establishing themselves as experts o n a particular
anatomical or physiological system.
our identity a s a
movement a s a
the movement system,
I fully expect that the
types of diagnostic
tools and treatment
options available to us
will include radiological methods and pharmacological agents.
~ h ~ s i o l o g i cSystem
al
clinicians who t ~ c u s
profession by
developing the
concept of
on the movement system must consider the
effects
of all the comrole of practitioners
ponents involved in sysresponsible for a
tem function rather
than just considering
system of the human the specific part of the
anatomical
system
organism. "
affected by a lesion.
Just as the physician
must consider how all
of the systems-gastrointestinal, genitourinary, and cardiopulmonary-affect
pH, which is regulated by the
metabolic systern, so must the physical therapist consider
all of the systems contributing to movement. I would like
to cite a few examples of how we have neglected to
consider some essential components of the movement
system. Since the 1960s, physical therapist management
of patients with hemiplegia has been focused almost
entirely on the increased muscle tone that is attributed
to spasticity resulting from the central nei-vous system
pathology. Yet, Berger et a16 have presented evidence that
secondary changes in muscle are a major component of
clinically perceived tone. Quite possibly, the secondary
~nuscularchanges are the ones that are the most amenable
to modification, but, for the most part, we have ignored
them.
and by accepting the
So, with movement recognized as a system, we have a
wonderfill opportunity to become established,just as dentists, optometrists, and others have done. But we must be
precise in [he way we do it. Adopting the movement system
as our focus has different implications for practice and
education than adopting a focus on movement as an
isolated phenomenon. One of the iinplications is that not
As another example, consider how rarely we think about
only must we be concerned with the impairments that
motor control as a relevant factor in patients with
musculoskeletal pain syndromes. Recently, Babyar7 pubadversely affect movement, but we must also identify the
lished a study of movement patterns in patients after
movements that cause impairments. We must elaborate all
recovery from shoulder pain. She showed that, even in
the functions and dysfiinctions of the movement system.
the absence of pain, patients still demonstrated excessive
As Florence Kendall and others have indicated, we
during shoulder flexion. The extensive comcannot be defined by our procedures and ~ n o d a l i t i e s . ~ ~ ~elevation
..~
mentary published with the article reflects the reality
I believe we must be defined by our ability to apply
that we seldom consider the possibility of anything other
scientific principles for the purpose of diagnosing, treatthan soft tissue as being affected in patients with muscuing, and preventing movement-related dysfunctions.
loskeletal pain syndromes. I believe consideration of the
Our ability to understand and explain the mechanisms
underlying movement impairments and the effects of
interactive roles of the muscular, neurological, cardiomovement as a therapeutic tool is dependent on increaspulmonary, and metabolic systems in movement-related
ing our knowledge of the physiology and biomechanics
syndromes is consistent with physical therapy moving
of the movement system. Our colleagues in the health
precisely along the path toward the level of professional
identity needed for the next century.
care professions and the general public must come
to respect us for this knowledge base. If we are sucjcesst'ul in establishing our expertise in knowledge of
Physical Therapy. Volume 7 8 . Number 1 1 . November 1998
Sahrmann . 121 1
Clinical Science
Clinical science can be defined as the study of the signs,
symptoms, and course of the patient's disease or dysfunct i o n . V h e Task Force on Content of Postbaccalaureate
Degree Entry-Level Curricula%sed the term "clinical
science" to represent the integration of foundation
sciences with our clinical knowledge and procedures.
This integration is central to meeting demands for
evidence-based practice and for fulfilling the requirement in our philosophy statement that our practice be
based on the application of scientific principles. We
need to move precisely as we continue to develop our
clinical science by:
Incorporating and integrating current knowledge
from basic, medical, and social science into therapists' understanding and communication.
Conducting clinical and basic research related to
the movement system.
Emphasizing treatments with a rational scientific
basis as opposed to those for which explanations
either require large leaps of logic or are based on
pseudoscience.
Providing our students with multiple opportunities
to learn to defend their treatment choices based on
knowledge of clinical science when negotiating with
patients, physicians, and insurance carriers.
We must not take the path of least resistance by:
Teaching basic science without noting ways in
which the basic sciences can be used to explain
clinical conditions and clinical methods.
Failing to provide the current pathophysiological
information about the impairments of the movement system.
Teaching clinical techniques without critical analysis of their effect on the impairments for which the
patient is being treated.
Expecting each student to apply information
obtained in basic science to clinical practice without faculty or clinicians de~nonstratingthe use of
clinical science information.
Receiving my physical therapy education at a time when
scientific and clinical information was limited, at least
relatively speaking, did have some advantages. One
advantage was that my education program involved a
great deal of anatomy. In fact, so much time was spent in
the dissection laboratory that I was sure my hands were
permanently preserved, and that I would never again
smell the same as I did before I took anatomy courses.
The instruction in physiology was pretty prirnitive
because they had just recently discovered that sodium
and potassium had a more important function than
flavoring or preserving food. The depth of knowledge
1212
. Sohrmann
conveyed in neuroscience was reflected by the qualifications of the unfortunate physical therapy faculty member who had to teach the subject. She was almost one
chapter ahead of the students. Therapeutic exercise was
pretty straightforward because the only possibilities were
passive, active-assistive,active, and resistive exercise. The
basic information about exercise, a strong knowledge of
anatomy, some understanding of kinesiology, and skill in
manual muscle strength and length testing were all that
were needed to practice effectively.
How satisfying it w a q to treat patients with poliomyelitis
because all of the concepts I had learned were applicable,
and tutelage by my clinical instructors and co-workers not
only helped me improve my examination and treatment
skills but furthered my understanding of the clinical condition. Ironically, soon after the Salk vaccine was introduced, my confidence in my clinical skills rapidly diminished because the number of patients with poliomyelitis
was decreasing and the number of patients with hemiplegia
was increasing. Like many others, I fell victim to the belief
that spasticity was the big problem, and so my basic
knowledge and skills no longer seemed applicable. I just
could not figure out how to modify spasticity so that my
patients would be cured. Like all therapists, I wanted to
improve my ability to provide effective patient care. In
retrospect, it was probably fortunate for me that the
neurophysiological approaches had not become widely
publicized and that there were few continuing education
courses available for learning new clinical approaches. So
instead of taking a technique-based course, I decided that
I needed to go to graduate school and learn about the
underlying mechanisms. My belief was that if I understood
the underlying mechanisms, I could apply interventions
more efliectively than if I remained conf~lsedabout the
basic problems. I do not regret having chosen the course of
trylng to understanding the phenomena I was observing,
but I am concerned that it has become less valued today.
Today, more emphasis seems to be placed on learning
techniques from continuing education courses than on
trying to understand underlying mechanisms. Possibly one
of the reasons is the marked growth in the continuing
education industq and the effective marketing of techniques, largely based on pseudoscience, that are purported
to be both simple to apply and amazingly effective.
In the 1975 McMillan Lecture, Helen Hislop1stated that
our clinical science was in a state of disarray. In part, I
believe, the state of our clinical science was a function of
our lack of identity, the profession being clinically
driven, and the small number of physical therapist
scientists. In 1998, it seems accurate to say that our
clinical science is in a state of disuse. I believe this is true
because, in general, neither scientists nor clinicians have
consistently and systematically applied existing informa-
Physical Therapy . Volume 7 8
. Number 1 1 . November 1998
"Physical therapy is
tion to practice, nor have we stressed the need to
coinmunicate as though we have a clinical science.
A great deal of information is available about muscle
hiology and physiology that is directly applicable to our
clinical practice, but we have not systematically made
that information a part of our clinical science. Certainly,
students are taught muscle physiology, but are we modeling the application of this information to practice in
either the classroom o r the clinic? The cellular and
clinical manifestations of use, disuse, strain, stretch,
stiffness, ;and anatomical adaptations to imposed length
changes are well documented."ut
judging by my
disc~issioiiswith many experienced clinicians about the
management of patients with musc~iloskeletalpain syndromes, they are not well known. For example, few
clinicians can explain muscle plasticity and its clinical
manifestations, much less how they could capitalize o n
the plasticity of muscle to effect change in their patients.
Furrhermore, I d o not believe the positive effect of
muscle hypertrophy in improving muscle strength a n d
increasing the amount of connective tissue, both of
which improve passive stability of a strained joint, is well
known. Certainly, more patients would be referred for
instruction in a resistive exercise program following
sprain if more physical therapists persuaded physicians
of the value of such a program.
Overall, it is my impression that not enough value is
placed on basic kinesiological information. For example,
how many clinicians know the optimal number of
degrees of maximal lumbar flexion or the number of'
degrees of spinal movement between each vertebral
segment in each plane? Such basic information should
be well known to therapists who are responsible for the
management of patients with low back pain and who set
expectations for restoration of mobility. Consider this
question: Would you have confidence in a physician who is
not familiar with standards for cholesterol levels a n d
blood pressure? Of course not! Everyone, even physical
therapists, know acceptable values for these variables
because their importance has been stressed by medical
practitioners. Have we, as a profession, clearly delineated
all the relevant values that therapists should know when
treating patients with many of the movement syndromes
encountered in practice?
Fortunately, physical therapy is in a better position to
develop, organize, and use its clinical science than ever
before in its history. We now have a larger number of
physical therapists with PhDs in the sciences than we did in
1975. Certainly, the research our scientists conduct is
important to our body of knowledge, but their ability to
specif).the direct applications of science to clinical practice
is also of extreme importance. Have you noticed that none
of the many articles written about the best method for
Physical Therapy
. Volume 78 . Number 1 1 . November 1998
in a better position
stretching
the
ham-
to develop,
string muscles include
any information about
organize, and use its the mechanisms of
shortness or the possiclinical science than
ble effects of stretching
at the cell~ilarl e ~ e l ? ~ ~ - l ~
ever before in its
Does this not typify our
failure to apply scientific
history.
concepts to the most
basic of the procedures
we use? We need the
basic scientists among us to help make the connection
between the ba9ic sciences and our clinical sciences. We
also need them to help distinguish between scientifically
valid explanations and pseudoscientific explanations for
the effect of many popular treatment techniques. When we
readily consider mechanisms and not just techniques, we
will be moving precisely in developing and using our
clinical science.
"
Academia
Mary McMillan established her physical therapy training
program here in the United States in an educational
environment and not in a clinical environment, as was the
mode in England, where she did her training. I believe her
choice of the academic route was critical because it made
feasible the growth of the field from one that produced
technicians to one that would produce professionals. In my
judgment, our profession will reach a peak when we
complete the transition from being a clinically driven field
to being an academically driven one. To d o so, we must
continue to move precisely by expecting:
Physical therapy education programs to be true academic units that (1) produce the highest-level profes
sional practitioner and (2) make substantial contributions to the body of knowledge of the profession.
Graduates of master's degree-level curricula t o be
skilled in performing a standardized basic physical
therapy examination, making accurate diagnoses
for basic conditions, designing appropriate management programs, and implementing basic treatment programs.
Students to attain a relatively high level of skill in
developing treatment programs while they are in
the academic environment, because it is no longer
possible for the clinical environment to provide
instruction for those with low-level skills.
Ent~y-level [professional] clinical doctorate programs to produce clinicians skilled in (1) rendering
diagnoses and prognoses, (2) selecting and implementing optimal management strategies, (3) justifying their decisions and actions using evidence
from the literature, and (4) communicating with
professional colleagues from all disciplines, as well as
Sahrrnonn .
12 1 3
with clients, in a manner that conveys expertise in the
functions and dysfunctions of the movement system.
Postprofessional clirlical doctorate programs to be
developed in order to produce scholarclinicians who
will contribute to our body of professional knowledge,
particularly by integrating information obtained
through critical analysis of the literature, applying the
i~lfomationto clinical practice, and disseminating
the information in the form of' case reports.
We must not take the path of least resistance and:
Continue the proliferation of progranls that lack
the resources to provide a strong education in
clinical science, to produce a highly skilled practitioner, o r to contribute to the body of professional
knowledge.
Introduce students to clinical tests and clinical
skills, with the expectation that basic proficiency
will be acquired during clinical education.
Introduce students to a wide variety of treatment
techniques with the expectation that they will select
and apply these techniques at their own discretion.
Continue to tell students that they should be diagnosticians and then only teach them about the
decision-making process, without requiring them to
make diagnoses of various types of problems multiple times within the academic environment.
Finally, we cannot:
Devote time in the professional curriculum to student research that detracts frorn the time available
for students to become skilled in examination,
diagnosis, treatment planning, and treatment.
For many years, the prevailing expectation for physical
therapy faculty members was that they should have
sufficient clinical knowledge and skills to be able to
teach the basic concepts to the students, who would then
acquire their actual skills in the clinic. Educators were
not master clinicians and, thus, were not expected to
invent new techniques. In fact, innovation and advancements in practice came primarily from clinicians, such as
Berta Bobath, Signe Brunnstrom, Florence Kendall, and
Margaret Knott, just to cite a few. Although some of
these innovators became associated with education programs, their major contributions were made as clinicians. The more typical faculty member was not a master
clinician and did not receive respect for his o r her
clinical skills. In fact, you frequently heard the statement
"Those who can, practice, and those who cannot, teach."
To make matters worse, the typical faculty members did
not have time for clinical practice because of their heavy
teaching loads, so they fell behind in their clinical skills
and then received even less respect from students and
12 14 . Sahrmann
clinicians. There were few programs operating at the
postgraduate level, and program faculty were rarely
expected to d o research.
A few seeds of the model of a postgraduate program with
faculty who conducted research were planted in the
1970s, primarily in California, but growth was slow. By
the mid-1980s, an increasing number of programs were
beginning to adopt the standards of academic units in
other clinical disciplines by requiring faculty to engage
in research and clinical practice, in addition to their
teaching. As more and more programs made the transition to the new model, the profession was slowly reaching a critical mass of academic units that were able to
provide the environments needed to foster investigative
and scholarly activity. Eventually, many of the best and
brightest physical therapists who wanted to engage in
scholarly activity were joining physical therapy faculties
rather than leaving the profession for careers in medicine or basic science. Today, substantial numbers of
faculty members are either doing research or practicing as
master clinicians, or doing both. Consequently, academic
units are becoming a primary source of clinical innovation
as well as the producers of the research needed to advance
the clinical science of physical therapy.
What are some of the implications of the new academic
model for the entry-level students and those in clinical
practice? In many academic programs, students are
taught by physical therapist scientists. The content
related to each area of practice, and often the impairments of each area of the body, are taught by a different
master clinician faculty member. Therefore, the base of
knowledge and the fundamental skills students possess
can be broader, be more current, and have a stronger
foundation than those of the average clinician. Just as
medical students receive their education from the leading scientists in each content area and the best practitioners in each speciality, so is this type of educational
experience becoming a reality for physical therapists.
Currently, at Washington University, more than 100
individuals, many of them experts, teach students in our
program. This fact stands in stark contrast to the fact that
during my time as a physical therapist student at the
same institution, I was taught by 3 full-time therapist
faculty rnembers and a couple of basic scientist$.
Regarding clinical education, as you know, medical
students' clinical rotations are with the best specialists in
each area of medicine. Unfortunately, we have not been
able to move precisely along this same path in the past,
and now additional burdens are being placed on clinicians that will make it even more difficult for us to move
precisely. I fear that the rapid pace of clinical practice
today is forcing therapists to model a less-than-optimal
pattern of practice behavior to the naive student clini-
Physical Therapy. Volume 78
. Number 11 . November 1998
cian. This is a problem because (1) studies have shown
that the majority of students follow the example of their
clinical mentors rather than the pattern of practice they
learned in the academic programw and (2) time constraints related to the productivity expected of both the
student and the clinical instructor seriously limit the
amount of guidance that can be provided in the majority
of clinic,al settings. I have asked numerous clinicians
whether they would like to be establishing their practice
skills uncler the current conditions, and they all emphatically say, "NO!"
My comments are not intended to detract from the
recognized value of either the clinical experience o r
clinical instructors. Clearly, the academic environment
cannot provide (1) the opportunity to participate in
intensive patient care, (2) the setting in which to evaluate clinical performance, and (3) exposure to a variety of
clinical skills. Extensive practice with patients and guidance from experienced clinicians are invaluable. Nonetheless, the academic programs must assume more
responsibility in honing the student's clinical skills and
practice patterns than they ever have before in our
history. I do not consider this to be an unfortunate o r
undesirable situation, just a natural consequence of our
precise movement toward becoming an academically
driven profession.
Now that I have cited what I consider to be very positive
steps in our transition, I must also express a concern. I
fear that the trend of physical therapy programs following the new model of a strong academic unit is reversing
at a relatively rapid rate. In recent years, there has been
a proliferation of programs that d o not have the
resources of highly prepared faculty with skills in
research, teaching, or practice required to prepare students for the scope of today's practice. Providing marginally trained personnel to work in today's conlplex and
highly demanding health care environment is not the
way the profession is going to gain respect from other
professions or the public. Producing students whose
preparation is dependent, to a great extent, o n rigorous
clinical education and experience, when that is becoming a rare co~nmodity,is not advancing either the quality
of practice or respect for our profession. Therefore, we
need strong academic programs that will require each
student to demonstrate that he or she not only can
perform an examination, develop a treatment program,
and implement that program, but can d o so within time
constraints that are similar to those imposed in the
majority of clinical facilities. In order for students to
achieve this level of performance before leaving academia, faculty must "bite the bullet" and design curricula that provide concentrated practice in a standardized
examination, practice in designing an appropriate exercise program, and practice in i~nplementingthe pro-
Physical Therapy. Volume 78 . Number 1 1
. November 1998
gram, with constructive criticism from experienced faculty clinicians. I believe the students should be well
trained in these procedures, even at the cost of forgoing
an introduction to a wide variety of techniques.
One of my strongest beliefs is that a system of diagnostic
categories designed to direct physical therapy treatment
could provide a precise focus for education, as well as
practice. For the most part, the medical diagnoses that
direct a physician's pharmacological or surgical intervention d o not direct our treatment of movement
impairments. Therefore, we need to develop categories
that describe the impairment syndromes of the movement
system. I acknowledge that my dilatoriness in publishing
examples of the categories my colleagues and I have been
developing is not helping the situation, but that situation
will soon be rectified.'" hope that many of you ivilljoin me
in similar attempts to develop and test diagnostic categories
that direct intervention by physical therapists.
Given the amount of information that entry-level students must master, I also wonder how long education
programs will continue to require research projects that
serve little purpose except to detract from the time the
student has to learn the profession of physical therapy.
Those of us with a PhD know that research is a professional activity that cannot be learned in 2 years. In fact,
it takes most PhD students 4 yearsjust to get started. How
can we expect our professional students to learn 2
professions in 2 years! The rationale behind requiring
research as part of a professional master's degree has
never been clear to me. Medical students who are
trained at the doctoral level and who have 4 years for
their education are not required to do research to
qualify for practice. Although there are a few admirable
students and advisors who actually publish their projects,
have we not done more to compron~isethe examination
and treatment skills of rrlost students than to expand our
body of knowledge! Students who want to do research
can still d o research projects on a n independent study
basis. Research is important, but it is the faculty that
should be doing substantive research to fulfill their role
as academicians. They should not be draining their
energy by supervising projects small enough to be completed in the time constraints imposed by the student's
schedule. Student research is not the criterion for a graduate program. An education program is operating at the
graduate level when the students are mastering the knowledge of the profession and when its faculty members are
contributing to the body of knowledge of the field.
And speaking of graduate-level education programs, a
recent trend in our profession is the development of
clinical doctorate programs. One of the reasons cited for
increasing the educational level to that of the clinical
doctorate is to provide more training in cli~iicaldecision
Sahrmann
. 1215
Table.
Comparison of 4 Categories of Course Requirements of 5 Professional Doctoral Programs With That of a Master's Degreelevel Physical Therapy
Programa
I
Credit Hours
PT
Course Category
~p
Basic science
Diagnosis and treatment
Professional socialization
Clinical education
Total
-
-
30
38
5
17
90
OD
PharmD
DC
--
51
60
5
52
168
DPM
M D ~
DDS
~p
~p
25
52
21
28
126
100
117
15
23
245
48
60
10
59
177
40
65
6
45
156
723
723
42
4,753
6,241
" I h t a from 5 programs in the M i d v r \ ~that required the least number of credits, with l h r exception of the medical progl-am. OD=oplonietly,
Pl~artnD=pharmacy,DC=chiroprartic\, DPM=podiatly, DDS=dentistly, PT=Wa.;hingtori University Program in Physical Therapy.
"Clock hours required h) Washington University School of Medic~ne
making. Education in clinical decision making must not
be focused primarily on the process or theory but on the
content upon which the decisions are to be made. Based
on the prior academic performance of our students, we
know they are very good at making decisions. They are
not attending physical therapy programs to learn such
skills. What their education should provide is the information about what decisions are to be made, information upon which to base their decisions, and lots of
practice in making those decisions.
Another frequentjustificatiot~for offering the entry-level
clinical doctorate is that our students take more than the
72 credit hours required for the doctorate. Seventy-two
credit hours is the standard number of academic credits
for the PhD degree. Everyone who has earned a PhD
knows that the requirement of 72 credit hours is close to
meaningless. The real hours are spent in the research
laboratory, the library, at the computer. They also know
that the number of hours spent far exceeds the 72 hours
of required course work. But the investigative Doctor of
Philosophy degree is not the same as a clinical or
professional doctorate. The Table compares the professional doctoral curricula for optometry, pharmacy, chiropractic, podiatry, dentistry, and medicine with a typical physical therapy curriculum on several dimensions. A
comparison was made of credits received in the categories of basic science, diagnosis
and treatment, professional socialization, and clinical education. Physical therapy lags fir behind in all categories.
But the number of hours spent in the classroom is not
even the primary issue. The issue is, what is expected of
the clinician with a doctoral degree? How does the
product differ from the clinician with a master's degree?
As I have stated publicly on many occasions, I am in favor
of entry-level doctoral education, but the product must
be consistent with the product of other professional
doctoral education programs. The large majority of
professional programs require the student to acquire
expertise in the anatomical or physiological system that
defines their profession, including both the normal and
12 16 . Sahrmann
abnormal structure and function, as well as how to
diagnose abnormal conditions, establish the prognosis,
and select the most appropriate treatment option. If we
want the respect of other clinical doctorate recipients,
we cannot simply expand our clinical education and
award the doctorate in physical therapy (DPT) to our
existing programs if they d o not produce experts in the
care of the movement system.
Another type of clinic.al doctorate education program is
being developed for the individual who already possesses
an entry-level degree. I believe the development of these
postprofessional programs should be enco~iragedso that
the practicing therapist will have the opportunity to be a
scholar-clinician, as well as a diagnostician. Because
continuing education courses primarily address techniques, clinicians should have the benefit of opportunities to be updated in basic science, medical science, and
clinical science. They should be able to learn the latest
diagnostic categories, including those from a content
area in which they may not be practicing. Many clinicians could benefit from taking course work in critical
analysis of the literature and in preparation of case
studies so that they could contribute to the body of
knowledge. My personal belief is that the degree for
these postprofessional clinical doctorate programs
should not be DPT but rather something like the Doctor
of Health Science in Physical Therapy (DHS/PT) degree
to designate that the graduate of the postprofessional
program differs from the graduate of the entry-level
program. Graduates of' the postprofessional clinical program should be contributing to our body of clinical
science knowledge. By contrast, graduates of the professional clinical doctorate program should be consumers
of the body of knowledge. When graduates of physical
therapist programs are practicing as competent diagnosticians of movement impairment syndromes, we will be
moving along a precise path toward an academically
driven profession.
Physical Therapy . Volume 78 . Number 1 1
. November 1998
Practice
Finally, what about practice? The points that have been
discussed in relation to our clinical science and academia also apply to practice. But one point I have not
addressed is the consequence of the highly individualized approaches to patient management. The individualized approach became the model of practice during
the 1960s and 1970s when patients with central nervous
system dysfunction comprised the largest group of
patients receiving physical therapy. The consequence of
this model is that here we are, almost 40 years later, and
we still d o not have standardized approaches to management for most types of problems. I d o not mean that a
patient's unique problems should not be assessed but
that individualization should occur after the examination is completed and a diagnosis has been made. Then
treatment modifications can be based o n the patient's
special needs. I d o not believe many of us would consult
a physiclan who did not perform a standardized examination o r follow a relatively standardized treatment plan.
We must follow the example of medical practitioners by
developing diagnostic categories, standardized examinations, and guidelines for interventions. To move precisely, we must:
Promote the development and use of diagnostic
cat~sgoriesthat direct physical therapy.
Develop and utilize standard examinations and
terminology.
Emphasize treatment that is based on a thorough
knowledge of basic anatomy and kinesiology.
Pursue knowledge of underlying science with as
much commitment as we pursue the latest treatmen t methods.
Recognize our responsibility to protect patients
frorn treatment fads that have a highly questionable
scientific basis.
Maintain adequate standards of practice by
demanding adequate time for examination, developinent of a diagnosis, and treatment.
We mus,t not take the path of least resistance. We must
not make a practice of:
Usnng approaches to examination and treatment of
patients that are highly eclectic and not based on
standards consistent throughout the profession.
Pursuing fads without pursuing a clear understanding of the relevant scientikically based explanation
for the methods.
Communicating in a manner that typifies nonprofessional personnel.
Compromising our professional standards of care
by providing only partial treatment in order to meet
unreasonable demands for productivity.
Physical Therapy. Volume 78
. Number
11 . November 1998
I have already discussed the importance of developing
diagnostic categories and utilizing standardized examinations. I will not repeat what I said, but you better
believe that I will not let you forget! What I would like to
stress in regard to practice is the importance of having a
strong foundation knowledge of anatomy and kinesiology, and knowing how to apply this knowledge to
practice. I believe this type of foundation is called the
"basics." The advantage of a thorough knowledge of the
basics was reinforced when a colleague and I had
the opportunity to lecture to the orthopedic residents as
part of their educational series in kinesiology of the
shoulder. Because our examination and diagnoses are
based on anatomy and kinesiology, we combined this
information in our presentations. My colleague demonstrated an examination that consisted of analysis of
alignment and movement, as well as muscle strength and
length testing. After the demonstration, one of the
orthopedists, who was clearly impressed, asked whether
all physical therapists had the same level of knowledge
and skill. He asked because he had just recently referred
a patient for physical therapy, and the therapist had
called him to ask whether he wanted hot o r cold and to
seek further clarification about what type of therapy he
wanted the patient to receive. The inquiry from the
therapist did not leave the physician with the impression
that he was interacting with a knowledgeable professional who was assuming care of the patient for a
condition about which she was an expert. Keep in mind
that, traditionally, orthopedic residents have not been
expected to learn kinesiology. They are not the movement experts-we are. Do not ask them what we should
do about movement dysfunction.
Our founding mothers established the reputation of our
profession using the foundation sciences and basic
methods of examination and treatment. Today, we still
need to be able to explain the scientific bases of our
interventions. For example, if a patient has back pain
when his or her lumbar spine is extended, then it does
not require a great leap of logic to assume that teaching
the patient to contract the abdominal muscles to
decrease the lumbar curve by posteriorly tilting the
pelvis will decrease the back pain. Yet, I have the
impression that many therapists more readily believe
the 2 halves of the pelvis can be adjusted in relation to
one another than the well-substantiated fact that the
abdominal muscles tilt the pelvis posteriorly. To be
respected for our expertise, the concepts upon which we
base our examinations and treatments must be justified
on the basis of scientific rationale and, whenever possible, by the results of clinical studies.
We also need to move precisely in the way we comtnunicate our knowledge. Think about how we describe
exercise programs in our documentation. It is not
Sahrmann
. 12 17
uncommon to find exercises listed in therapists' notes as
the "dying bug," the "clam," the "chicken wing," "hip
hinging," and the "skater's exercise." Such a list makes it
unclear whether the therapist is recommending an
exterminator, lunch, o r an exercise program. If we are
basing our programs on scientific knowledge, our documentation shoiild reflect that knowledge.
I have attempted to point out small changes we can
make that can keep us moving in the direction of
continued professional growth and toward the completion of our transition to an academically driven profession. Anyone reading the Guide to Pl~ysiral Therapist
P ~ n r t i c e cannot
~~
help but be impressed by the wide
variety of intewentions that physical therapists use and
the extensive number of' conditions that we treat. As
physical therapists, we can take pride in the degree of
responsibility we have assumed and rightly earned. Perhaps one of the cruelest ironies is now that we have
achieved such high levels of expertise and responsibility,
we do not have the time to use them. We must carefully
consider whether the demands for productivity are consistent with professional and ethical practice or whether
we are being expected to practice more like the technicians we once were. This is not the time to compromise
what we have achieved. To fulfill our role as diagnosticians, we must find the time to perform a complete
examination. Ethically and legally we mugt examine the
patient, not for the sake of tokenism, but as a professional responsibility. Acquiescing to the bottom line is
not doing justice to our patients or to our profession.
Defining how much we need to modify our practice
patterns of the past, which were definitely less than
efficient and cost-effective, is not easy. For sure, we have
been on the other side of the coin, providing sewices
that were nice, but not necessary, and that provided
greater profit than clinical effectiveness. But there is a
balance, and this is just the profession that can find and
establish that balance.
A few years ago, 1 was impressed by a statement I heard
President Clinton make when he was discussing the
economic and social achievements that have been made
in Australia and America. He said, "We have carried the
torch through the night, to make the next century
brighter for our children." I believe those of us who have
been in this profession for the last 20 or more years have
had the advantages of the brightness of day. It is those of
you in the new generation who will have to carry the
torch through the night of these next few years so that
there will be a bright world for the profession in the next
century. We have laid a foundation that has carried us a
long wav in the right direction. You must use and expand
our scientific foundation. Do not be misled by fads that
lack substance. Do not be weakened by unreasonable
12 18 . Sohrmann
demands that compromise your responsibilities to your
patients and to your profession. Do not take the path of
least resistance. Failure to practice and commurlicate in
a manner that reflects the science and ethics of our
profession will have a negative impact, not just on the
outcome for a few patients but also on the reputation
and future of physical therapy. The world needs what we
have to offer. We have so much to give to aid the
physically challenged and to guide the physically able, be
they young o r old. Society needs us so they can follow the
path of moving precisely toward optimum health.
Acknowledgments
My special thanks to Kathleen Dixon, PT, and Barbara
Norton, PhD, PT, for their invaluable help in the
preparation of this lecture.
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Physical Theropy . Volume 7 8 . Number 1 1 . November 1998
, PhD, PT, FAPTA
seek today.
who has made a distinguished contributi
may be submitted by individual rnembe
nents of the Association. Recipients of
selected by the APTA Awards Cw~nmi
bers representing the APTA Committees on
ducati ion, and Research.
Physical Theropy . Volume 78
. Number 11
. November
1998