The Intersection of Movement and Clinical Reasoning: Embodying “Body as a Teacher” to Advance the Profession and Practice

``Transforming society by optimizing movement to improve the human experience”1 moves well beyond the previous vision statement of the American Physical Therapy Association and addresses the fundamental matter of the professional identity of the physical therapist. To embody this vision, all physical therapists must utilize a unique body of knowledge, skills, and expertise related to movement and claim the movement system as the theoretical and philosophical base for physical therapist education and practice. Movement has been described as “an aim, intervention or treatment and as an indicator.”2 The core concept of movement as an “indicator” or as a critical source of data, and the role and relation of movement to clinical reasoning, is not well understood or richly described in physical therapist literature. This is a call to action to address the intersection of movement and clinical reasoning to advance the profession. A previous study of excellence in physical therapist education identified the signature pedagogy of the profession as “body as a teacher.”3 Applying the principle of “body as a teacher,” physical therapists must be able to explicitly identify movement using data collected from all senses (auditory, visual, kinesthetic/tactile–facilitation [both self-knowledge of the movement and feeling it with the hands]). The data gained from this analysis of movement must be linked as a core component of the physical therapist’s clinical reasoning. Establishing physical therapy’s value proposition requires adoption and identification of best practices. Comprehensive documentation of clinical judgment describing services delivered is 1 tactic that physical therapists can employ to demonstrate value through clinical reasoning of movement.4 Although many physical therapists commonly focus on movement and function in clinical practice, standardized methods for describing and assessing the movement system remain elusive. Our core documents,5–9 despite ongoing revisions, do not explicitly state the role of embodied movement and the movement system as part of the physical therapist’s clinical reasoning. Physical therapists do not have a definition or description of clinical reasoning that is universally accepted. Higgs described it as “a context-dependent way of thinking and decision making” to guide action.10 More recently, clinical reasoning in physical therapy has been conceptualized as contextual, iterative, and collaborative, utilizing both therapist and client perspectives.11 This concept analysis11 reported the majority of literature related to clinical reasoning was focused on the cognitive aspects, with only a few studies describing the broad role of psychomotor and observational skills in clinical reasoning. Attention to movement within the context of clinical reasoning has been described as observation of the patient’s movement12 and as movement patterns that are codified as scripts.13,14 In addition to therapists’ description of movements, Oberg et al identified that physical therapists rely on their own movement awareness to gain information from their patients to inform clinical reasoning.15 Additionally, the patient is a trusted source because of their sense of “knowing” the movement, which impacts the therapist’s clinical reasoning. Teaching and learning of movement were also identified as an intended outcome of clinical reasoning, but, again, depth and breadth of knowledge and skill are not suggested in this literature.16–17 How are we as physical therapists to achieve the transformation of society by optimizing movement if we have not explicitly described, and richly explored, the role of movement in our core skill of clinical reasoning? The purpose of this call to action is to elucidate steps necessary to claim movement, holistically, as the theoretical basis for physical therapist practice and as a critical source of information for clinical reasoning. To achieve the adoption of movement and the movement system as the foundation of the profession and explicate its inherent importance to clinical reasoning, the authors propose recommendations and suggestions in the areas of research, education, and clinical practice. Recognizing the interrelatedness of these areas, each will be discussed separately; however, they must be developed concurrently. It is the authors’ hope that these preliminary recommendations will spur further discussion with collective action to actualize the American Physical Therapy Association vision statement. The intersection of movement and clinical reasoning to enhance the human experience. The intersection of movement and clinical reasoning to enhance the human experience. Although physical therapists uniquely use movement in practice, the research to support the validity, accuracy, reliability, and understanding of movement and the movement system in clinical reasoning is lacking. Existing studies provide conflicting evidence to support the accuracy and reliability of physical therapists’ observations and are not explicit regarding the relationship to clinical reasoning.17,18 As structural suggestions come from multiple stakeholders, these can be used to guide future research. However, research should examine the integral role of embodied movement related to diagnosis and intervention and its impact on clinical reasoning. Educational research to determine the content essential to instruction of the skills of movement should include data gathering through all of the therapist’s senses (kinesthetic, tactile, auditory, visual, etc). Studies are needed to explore how physical therapists use movement as a component of clinical reasoning to develop a curricular framework building upon the movement continuum.19 The recent publication by Hedman et al19 provides an initial list of functional tasks that all physical therapists should know. Other needed research studies include comparison of movement pedagogy, exploration of how movement is used in clinical reasoning, and clinical instructors’ use of movement and clinical reasoning.20 Alongside educational research, a wide range of movement-based experimental and quasi-experimental laboratory, population-based, and clinical research studies/case reports are essential. Research is needed to (1) establish and validate standardized phases of selected functional movements and useful categorizations (diagnoses) within the movement system across all areas of practice; (2) establish the clinician’s reliability of observational analysis of fundamental movements and the link to clinical reasoning; and (3) investigate relationships between identified movement impairments, pain, and activity limitations or participation restrictions. Ludewig et al21 suggested that investigations examine movement system paradigms, patient outcomes, cost-effectiveness, and intervention efficiency. Investigations of movement optimization should be thoughtfully related to the movement system both to further instruction/education and to impact clinical practice. Two main components to be addressed in physical therapist education include (1) explicitly identifying and using both therapist and client movement, a specific component of clinical reasoning; and (2) developing standardized pedagogy about movement analysis. Suggestions related to best practices for teaching clinical reasoning are primarily from research in medical education with an obvious lack of incorporation of movement as a component of clinical reasoning. Physical therapist educators need to include the role of movement, both the therapists’ (observation, facilitation, palpation, demonstration, etc.) and the clients’ movements (embodiment) as a critical element of reasoning. Covington and Barcinas20 have identified that clinical instructors use movement to facilitate students’ clinical reasoning. Further work is needed to establish best practices of how clinical instructors can facilitate students’ attention to movement as well as awareness and use of auditory, visual, and tactile cues as part of clinical reasoning. Health care practitioners (radiology and dermatology) recognized for skilled observation are explicitly instructed in a systematic method of observation that informs decision making, documentation, and diagnosis.22–24 Similar to any skill in physical therapy, the skill of observation using all senses must be explicitly taught.25 As physical therapist education joins conversations about competency-based educational models,26 it is critical to develop clear evidence-based procedures and competencies for movement and its integration with clinical reasoning. Concurrent with the importance of the psychomotor skill of movement analysis is the ability to address the explicit communication regarding movement, the movement system, and its influence in clinical reasoning to colleagues, patients, clients, and payers. Jette27 stated, “The ability to communicate with one another and to speak and be understood across related professional disciplines is fundamental to the science and practice of physical therapy.” The International Classification of Functioning, Disability, and Health is the foundation of contemporary practice, but it is insufficient to capture the explicitness of language needed to identify the physical therapist’s unique use of movement. The language of movement should represent the intricacies of the relationship between movement and clinical reasoning. As studies demonstrate the challenges, this is essential to the establishment of reliability, accuracy, and utility of movement as a component of physical therapists’ clinical reasoning. It is imperative to standardize and operationally define movement, functional movement patterns and tasks, and the movement system and establish a common, easily understood, and consistently communicated language. Two suggestions to address the language of clinical practice are highlighted in the Figure 1. The authors suggest nomenclature to describe interventions associated with the movement system. Historically, physical therapists would use “home exercise program” to vaguely describe an intervention that addresses a movement dysfunction. This phrase is inadequate to describe the contents and the intent of a series of interventions that are designed to optimize the patient’s movement. Thereby, the suggestion of a “movement optimization program” should be used to capture the variety of interventions that are focused on addressing the patient’s movement. A second suggestion is construction of a movement system diagnosis that explicitly identifies and connects the qualitative components of the patient’s/client’s movements or tasks within the context of the International Classification of Functioning, Disability, and Health. Each of these suggestions emphasizes uniformity and clarity of language. The intent of this call to action is to address the intersection of movement and clinical reasoning to advance the profession. Preliminary suggestions have been made. To meet the vision of the profession, change and forward progression on several levels are necessary to advance the theoretical and philosophical base for physical therapist education and practice. Additionally, professional core documents should evolve to reflect the importance and value of movement and clinical reasoning. Given the current health care environment, it is imperative for physical therapists to claim unique ownership of movement in the clinical reasoning that enhances our patients’ experiences. Concept/idea/research design: C.A. Sebelski, B.J. Hoogenboom, A.M. Hayes, E. Held-Bradford, S.F. Wainwright, K. Huhn Writing: C.A. Sebelski, B.J. Hoogenboom, A.M. Hayes, E. Held Bradford, S.F. Wainwright, K. Huhn Project management: C.A. Sebelski Consultation (including review of manuscript before submitting): C.A. Sebelski, B.J. Hoogenboom, A.M. Hayes There are no funders to report. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.