Welcome back to the Healing Pain Podcast with Andrew Guccione, PT, PhD, DPT, FAPTA
Is the movement system really a system or is it a theory with little clinical application? Should we move beyond impairment-based paradigms as physical therapists? Are we ready to embrace a more holistic approach to rehabilitation and pain management? These are questions that Dr. Joe Tatta addresses in this episode with his guest, Andrew Guccione, PT, PhD, DPT, FAPTA, a distinguished researcher and professor and a visionary thought leader in the physical therapy space. Dr. Guccione explores ideas that challenge the traditional impairment based as well as movement-based paradigms that are common in physical therapy and rehabilitation. Join in and be prepared to receive revolutionary ideas that are going to change the way we do pain management forever!
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Optimizing Movement And Rethinking Impairment-Based Paradigms With Andrew Guccione, PT, PhD, DPT, FAPTA
We have a truly remarkable guest joining us to dive deep into the evolving world of physical therapy. Our guest is a distinguished researcher, professor, and visionary whose work has ignited important conversations within the profession. Dr. Andrew Guccione holds a Doctorate degree in Physical Therapy, PhD, a fellow of the American Physical Therapy Association, and a true luminary in our field.
He joins us to explore ideas that challenge the traditional impairment-based as well as movement-based paradigms that are common in physical therapy and rehabilitation. We’ll be delving into some intriguing questions that are reshaping the way that we think about movement, pain, as well as rehabilitation.
In this episode, Dr. Guccione tackles tough questions that many of us are considering such as, “Is the movement system a system or is it a theory with little clinical application? Should we move beyond impairment-based paradigms as physical therapists? Are we ready to embrace a more holistic approach to rehabilitation and pain management? Finally, how do changing paradigms transform the way we assess as well as treat patients as physical therapists?” Whether you’re a seasoned physical therapist or simply curious about the ever-evolving world of movement science, this episode promises to expand your horizons and challenge some of your assumptions. Without further ado, let’s dive into this enlightening conversation about movement with Dr. Andrew Guccione.
Andrew, thanks for joining me on the show.
Thanks, Joe, for having me. I’m looking forward to talking with you.
I am too. We’re going to be talking a lot about movement and the movement system as part of that. We’ve covered it a couple of times on the evolution of the show. People can go back and find the episode with Shirley Sahrmann as many know she coined the idea of the movement system. Our profession has embraced it in some ways and then there have been people within our profession who have brought up maybe some challenges or problems around it.
It’s like all theories. We test them and bounce them back and forth. We juggle them around a little bit try them out and see how it goes. I know movement has been a big part of your career. You’ve had a very long illustrious career. You’re now a professor emeritus, but can you give us a snapshot of how you’ve tackled movement as a physical therapist and researcher over your career?
2023 is my 45th year as a PT. I’m somewhat ancient. I can talk about the latter part of the 20th Century because I was there in the middle of it and I was a teenager. I was a professional. My interest in the movement started with the initial ideas about diagnosis. In the mid-1980s, the three big names were Jules Rothstein, Shirley Sahrmann, and Steve Rose all talking about diagnosis and I got wrapped up in that.
In fact, I was part of the early PT is about movement for us. I’m very much involved in the House of Delegates. That’s a huge part of my background including being Speaker of the House for four years in the ‘90s. As for those motions, do PTs diagnose? What is the diagnosis in PT? What is our body of knowledge in PT?
That was a very big question in the late ‘70s through the ‘80s and almost to the ‘90s. There was the development of this idea that somehow movement was central. However, I started to grow away from that by the mid-‘90s. In 1991, I published a paper about the relationship between impairment and function because we were very impairment-based.
I suggested that the essence of PT diagnosis was going to be somehow in the relationship where we’re asking how these impairments are causing this functional deficit. I got that through a root in sociology through some Nagi and the Nagi model, which was later supplanted by the international classification of function. However, it was a predominant model in medical sociology in the ‘80s and ‘90s.
For beginning to explain the relationships, he put out pathology impairment function and then the disability. That was the initial model, which over time, progressed into body structure functions, activity, and participation. I was very engaged in that as part of my career. I was intimately involved as an observer in the development of the ICF model and the problems that it had. I was a very active delegate about movement.
However, somewhere along the line in the ‘90s after I wrote that paper, which by the way I’ve pretty much disavowed since I was wrong. I did that publicly in 2010 as part of my McMillan lecture. Don’t listen to me anymore. I thought it was quite important to admit that publicly because we don’t often criticize our theories or return to them.
I thought I was right when I said it and I was as right as I could be at that time given what we knew, what was in the literature, and how people were talking about it. I don’t think that’s a very productive way of talking about it now. Somewhere in the mid-90s, I said, “There are a few more steps here.” After scratching my head, I realized that the ICF gave us a solution even though the ICF didn’t necessarily realize that. It’s because they developed a hierarchy of body structure and function impairment and then they talk about actions, and action is the realm of movement. It’s related to tests that you have to accomplish in order to engage successfully in an activity.
It was one of those a-ha moments. I’ve had two a-ha moments. One was the first time I was in the library and read that Nagi. I went, “This is it. This suddenly structures what we’re trying to do.” The second one was the ICF was my missing links. I went there the intermediate steps because we know that people with impairment do function and some of them function so well. You don’t even realize they have impairments.
One of our big successes is we take people with tremendous impairment. We figured it out and they function beautifully. That’s why people come to us. When I focused on actions and tasks, I started researching what I should have known all along, and how the brain recognizes actions, it doesn’t recognize muscles and body parts.
I also began to look at how children develop what happens as they begin to learn how to manipulate an environment and how environments impact development. I went, “There’s a lot more going on here.” That was not one year and then by the next year, I had it all figured out. Quite frankly, it was about fifteen years of swirling in my hand.
By the time I came to the McMillan lecture to announce that I got it wrong, part of what I suggested there was that, “While movement was central, movement system was not our rubric. Human performance is our rubric because everything we do, whether it’s the level of impairment action or test is to improve human performance.” I favor that. I’m sure some of your audience are as much into wellness and prevention as you are.Human performance is our rubric because everything we do is to improve human performance. Click To Tweet
It’s very hard to make this very strong argument about why we should be involved in wellness and prevention when we’re the kings and queens of impairment. As I read, I became more and more convinced that the literature, particularly movement science, was not speaking about a single movement system. In fact, if you google the movement system, you mostly come up with PT. There is talk of movement systems because movement turns out to have a generic quality but it has also a very highly idiosyncratic quality.
Once we get into why that is, for me, it opens up a huge realm of possibilities for how we intervene with people who have an impairment, but also how we help people who want their movement to be better like athletes and healthy people who are seeking our services. How we can work with that without feeling like, “Am I still a PT when I’m doing this?” The answer is yes. The problem is if you can find PT and define it so narrowly as movement impairments, you’re cutting us out of a whole bunch of good stuff and important things that people will end up going to seek other kinds of movement experts to do, and they’re doing that now. Is that getting started?
It’s an amazing start. I thank you for laying out this red carpet for a big conversation. I appreciate the historical perspective that you brought to the conversation which also ties in with your career and trajectory. I’ve recorded 360 episodes now or something like that and I don’t think anyone has come on and said, “I published a paper. I had a theory and eventually, I said I was wrong.”
As I listened to you, I don’t think that you’re necessarily wrong. Science evolved and then you said let’s evolve with it. Some people said, “We have this theory that we’re building out. We all lashed on to this. Now you’re asking me to modify and change the theory.” That’s what a good scientist and a good practitioner do.
We’ve cut ourselves off from developments that impact how we think. There are a number of cognitive psychologists who have insights that are very important. There are a number of movement scientists who have insights and they don’t come at it from a therapeutic perspective necessarily. That’s where we can contribute to them.
There are mechanisms. If you take the mechanisms and say, “Here’s how you take this theory and the mechanism and apply it to human performance.” I want to make sure that we define human performance because when people hear the word performance, they think of sports performance or dance performance. How does performance map across the human ability spectrum?
Some of our OT colleagues would have less problem with the notion of ADL performance than we did. We have been reluctant to see how others, even our closest professional siblings like OTs and speech therapists begin to think about their work. ADL is a performance. Getting dressed and doing daily hygiene are all performances. It involves movement and selecting actions. Maybe they’re so embedded in our routines that we do things. All of us who drive to work wonder how we got there safely because we don’t pay attention.
Some things are very embedded in our psyches. It’s all a performance. It all puts a biomechanical and bioenergetic demand on our human bodies and we respond to those demands a lot through movement. In that sense, I believe in the primacy of movement to what we’re concerned about. I’m worried that we don’t think of it quite as broadly and as deeply as we should and allow ourselves to be informed outside of the PT literature about how people are doing things because they have some real insights.
You’re saying that the idea of a movement system initially was a good idea, but it was too narrow for the populations of people that we see now. It sounds like along your path somewhere, you said let’s bring things in from motor learning, behavioral therapy, neuroscience, embodiment, and psychology. All these different aspects are biomechanics. Let’s bring all that in to start to support the model in a way that is potentially more useful.
I should mention that it’s particularly important that a lot of this stuff was being circulated through the House of Delegates, which is a political body. The movement as the identity is a political argument. It’s not a scientific argument and some of that was a false assertion. Although I appreciate where we were in the 1980s, we needed a system in order to compete with doctors because competition with doctors and being accepted by doctors was big in the ‘80s. I’d like to think we’re so beyond that or we’re so over that.
Being a physician extender is not my favorite way of describing what we do or a role that many of us should aspire to. We are our own thing and doctors and other professionals either accept us or they don’t. You don’t run your race by looking at somebody else. You run your own race. We’re generally there although every once in a while, they get caught up. Doctors don’t love us. The public doesn’t love us. Nobody knows what we do. Frankly, that’s not true and certainly, if any of your patients leave you and don’t know what PT is, that’s the real problem.
The public doesn’t like physical therapy but once we can get someone through our doors, they love us.
Interestingly, I know they have done some background work and the movement system does not communicate to the public at all. This thing that was supposed to be our key identity isn’t quite doing the trick. Movement does. We got a good thing going because when people say, “I have trouble moving. Maybe I need a physical therapist. I was having trouble moving and my knee was hurting. Now I can do fine because I had this great physical therapist.” That’s where we want the public to be. It’s flexible. It allows them to contextualize what they experience relative to a very distinct problem.
We also don’t want the prevention and wellness of this person who says, “I don’t want to be decrepit when I’m old. I’m doing okay now. How do I keep it there? How do I get it a little bit better?” There are so many senior sports activities. All the people playing pickleball. There are all those injuries that result from pickleball but look at where they are and how we could help them get better. Not only over their impairments but there are even things that we do that would improve their pickleball if we did it in a certain way.
For example, it hurts when I move. Resonates. I’m stiff when I move or I can’t move because I’m stiff. Resonates. I’m having trouble completing a certain activity fill in the blank. Resonates and then there are things that we’ve started to look at like, “I noticed when I move, it improves my mood.” Even that falls squarely within our scope of practice.
That’s not a psychological trick. There is a physiological basis for that. One of the things I think about is what is our biopsychosocial model and whether we have one or not. We’re biopsychosocial, meaning we have a lot of biology, biomechanics, bioenergetic, or anything that starts with bio is us and then there’s psych. Somebody has a mood or they have anxiety or depression and we leave it at that. We regard them as modulators like, “They don’t do this because they’re depressed or anxious, etc.” They talk a little bit about fear avoidance and whatever. Social usually means race, ethnicity, and socioeconomic status. That is important particularly relative to reimbursement.
We say we have a biopsychosocial model and then we go back to bio. If we think about that, there is a physical, psychological, and social step that help status, particularly in the psych. There’s attention, memory, and executive function. You mentioned the things that hurt. What about I move slowly? I can’t move. I get confused when I have to move. I’m uncertain of myself. I don’t anticipate things. Those are hardcore physiological and psychological functions. People’s moods and depression are not this little airy halo foam around somebody’s head. There are real things happening with neurotransmitters. Do you know that translators relate to movement? I hope so.
We could pray out. If we spend time thinking about how the bio and the psych begin to connect in very physiological ways, we can have a great deal of comfort with it because we like that physiology stuff. A lot of it is physiological. We have the ability to manipulate it because we can manipulate one side of that equation very well actually, it turns out. Exercising muscle releases all sorts of proteins into the body. They travel to the brain. That, to me, is very exciting. It should be an old frontier and, in some ways, it is but I don’t think we’ve recognized when we’ve been traversing that territory. It’s going to appear very new but it’s very exciting.
Touching on the biopsychosocial model, I don’t think that we have or use a biopsychosocial model in physical therapy. It’s an underpinning theory that now in programs people learn and people learn wherever it is. Is this like Zeitgeist on social media, but the truth is if you walked into a PT clinic in Main Street America, would you receive a biopsychosocial evaluation? The answer is probably no. I have gone on record with publishing PRISM and PTJ. They wrote this new model to say that the biopsychosocial model is a wonderful thing when it existed or was created or developed many years ago.
As a profession, we should start to take that and evolve things. There have been others that were one evolution. You started talking about the psycho part of the biopsychosocial model. I have two questions about that. You brought up anxiety and depression. PT has been somewhat good at latching on and saying, “The reason why pain is persisting is because these patients have anxiety and depression,” which is weird. 1) It begs the question, can we diagnose one? 2) Can we diagnose a mental health condition in a physical health context?
3) We should change the terminology and say people are having depressive and anxiety symptoms, not that they have anxiety and depression. People do that specifically because they went to school in an impairment model so it’s easy for them to say, “I understand physical impairment. Now I can identify mental impairment.” We do a disservice to ourselves in that sense. You may answer that and then I want to move on to the second part of what you were talking about.
Thank you. You gave a more nuanced appreciation of the words I was throwing around. I do think we do have to be careful about what we are diagnosing and putting a diagnostic label on. What is critical is to not see that symptomatology as dressing on the side that it is part and parcel of what you see as a movement. It gets into an area that is critical.
What I don’t see talked about too much is there is meaning involved in movement situations. This is some of the social thought. A situation you’re in, whether it’s a comfortable one like I’m in my bathroom and I know where the toothpaste and my shade gear are. I’m very comfortable or I woke up in a hotel, “Where is the bathroom?” That’s part of that social environment as well as I see a lot of friendly faces.
I’m walking into a situation where the vibe is not comfortable. Because we’re engaged in go-directed behavior, we are taking in queues from that environment. That includes the things in that environment and the physical details. What floor? Is it a rug? Is it bright? Is it dark? That’s part of the social. Therefore, certain things have meaning. I would think in your pain, audience, a lot of the movements have a negative meaning. If I move in a certain way, I’m afraid it’s going to hurt. Therefore, I’m going to move in this way, either adaptively or maladaptively. I have learned it as a way to control the situation. We’re like, “We’ll get up and walk.” There is meaning and it’s not this deep poetic meaning. It is how you interpret the task in front of you. It’s the, “What are you doing here?”
That has a lot to do with how you move particularly in the pain realm where you’re often dealing with people who have trauma. In their background is psychological trauma. Are we anticipating that they would not move with a different sense of meaning for everything but how difficult it is for that person to enter an unknown circumstance or something that triggers a memory? Where we miss the boat sometimes is recognizing the internal meaning. We talked about lived experience. They throw that. That’s the meaning.
If we’re supposed to help people with their lived experience and optimize movement in the lived experience, how can you do that without getting into that level of biopsychosocial and meaning? What do you attach to it? Again, that goes back to something very physiological. We probably don’t have time to discuss it but perception, action, and coupling.
It happens. That’s what we’re fiddling with ultimately as PTs. How can we get a recoupling here so that it’s pleasing? It’s pain-free. It’s exciting and rewarding. If it’s a reward, it taps into the reward system of the brain and you want to do it more and more. We’re going at 100 miles an hour here, but there are dots to be connected all along the way.
You’re doing it beautifully. People come to the idea of a biopsychosocial model or psychologically informed care, meaning that I’m going to learn a technique that I’m going to use that is then going to 1) Take someone’s pain away or 2) Correct their impairment, which is as old as our profession is. It’s wrong actually. You mentioned that we work with attention memory and executive function.
When you say we have a patient who has fibromyalgia and we have to create a plan that’s going to work with attention, memory, and executive function, how would you do that as a physical therapist? Most people would say, “Those three things are psychology. I don’t work with executive function.” Connecting the dot is a good word.
When you go back to DPT school, PT school, or wherever you went and learn about how the nervous system developed, how reflexes started as a child, and how those reflexes were then suppressed as you learn more active movements or voluntary movements, we work with memory. No one has elevated what we do to that level. They have kept it down on a very mechanical, “Take out the wrench and fix the impairment part.” I’m like, “We’re working with a lifetime of attention memory and executive function around how someone moves their body and what that means to them.”
If people were more tuned in to the motor learning literature, we have emphasized motor control, which is very important because it tells you a lot of what hooks up with what and how things are connected and mechanisms. When you look at motor learning, you would think that the movement authorities would be looking at a lot and yet it seems to be something that died out.
I have a theory that people of my generation were taught by people who came out of physical education and adaptive physical education into PT. I was the last generation that benefited from how they approach things. What I’ve seen in the rigorous motor learning literature is how someone attends. Do they attend to their body too much or too little?
Certainly, with people who are in pain, some of that is to get some of their attention out of their body. There’s some evidence that says when you do that with all sorts of patients, they learn a motor routine better and the self-referential part has got to go. With memory, you’re learning about why elaborate. If it’s learning, memories are involved but in executive function, it’s the ability to adjust movement speed. You don’t trust the potato chips as you craft for them. It becomes very important.
In my last position when I was at George Mason, I had two different research programs over eleven years. One was with complete spinal cord injury and the other one was with people with Parkinson’s disease. The ability, particularly in Parkinson’s disease, is to control the speed of a movement. It’s either too slow or too fast. It has to be worked with directly. If they were ambulatory individuals with incomplete spinal cord injury and we worked on gate and walking, most of the people we saw had been treated by physical therapists at the top places in the country.
If I told you every household name, everybody says, “That’s got to be the best treatment.” It was surprising to me how they told us nobody ever changed the speed. One of the things we would do is say, “We want you to walk as slow as you can. Now we want you to walk as fast as you can.” It’s part of the training. “Now we want you to walk backward.” Even though there’s stuff in the literature that incontrovertibly says walking backward helps people walk forward, they said to us, “The only time I ever walked backward was when they told me I got close to my wheelchair to take one step around and take one step back and sit.” Nobody ever had them walk laterally or sideways.
Again, the movement specialists are like, “As if everybody is walking only forward in a tunnel.” It’s a very straight line. If there’s a turn to the right, it’s a sharp right turn. How do you expect to make them safe and begin to anticipate, “There’s a spill on the floor? I better not walk through it. I need to change my speed. I need to begin to alter my direction.” To me, these are all the things that the movement profession should be clicking through. By patient report to me and of one, that isn’t often happening.
That says we have a very naive underdeveloped notion of movement, let alone of a movement system. We need to begin to account for that because some of that idiosyncratic movement is adaptive and some of it is maladaptive. In fact, in our lab, we banned the words typical and normal. We talked about successful accomplishment to the task and less successful. That’s how we came up with, in 2019, the optimization of movement because there are all sorts of trade-offs that people are making. It’s not always bad to lean in a particular direction if that reduces your pain while you’re moving. That’s a violation of our principles because everybody knows you’re supposed to be rigidly upright. You shouldn’t be leaning in whatever.We have a very naïve, underdeveloped notion of movement, let alone of the movement system. Click To Tweet
If I’m standing still and you’re taking my picture, but if I want to walk across the room and make a sandwich, I may need to lean a little or I need you to baby me. Is that babying a body part a good thing or a benefit? That’s where our expertise comes in. He’ll take that part. Maybe it’s a good thing now, but if you still babying it weeks from now, that’s a problem. Maybe we tried everything and the answer is, “It’s okay. Lean off it a little. Put a little bit more of the weight on your left leg.” That’s the art of what we do.
There are a lot of nuances there that are a whole topic in and of itself. We have to be a little cautious as professionals. because if we originally adhere to this idea that a human being should not have an impairment, they should have this perfect way to move and this perfect posture. There are all these other things that are “textbook.” That comes down to an ableist approach to human function. Ableism is a difficult place for us to land as a profession because now, we’re seen as the profession that helps people with different types of bodies.
We’ve gotten into a very bad habit of regarding variability and movement as errors. It ignores error-based learning. What we proposed in the 2019 paper with my colleagues, Brian Neville and Steve George was that there are zones of tolerable variability. We couldn’t say what those are but I’m sure people want to know. 10.9% are still living. If you’re at 92.73%, do I need to worry? It’s not like that, folks. It’s much more like, “Are they generally getting it in a biomechanically efficient way under the circumstances? Is it the best use of their bioenergetic capabilities?”
Particularly from treating the neuro issues that we were facing, people forget, and I’m sure you see this in the paying populations, how hard it is to move and conserve your energy, how exhausting it is to move against spasticity and when your neurotransmitter is taken out, and what bioenergetic strain that is. With some of that movement, maybe you can fix it or you can’t but you have to accept that and what else is going on.
It’s saying, “I want you to take that one perfect step and then I want you to do another step.” They do and then they go, “I can’t do this for a third step.” “It’s okay. We’re trying to stretch the limits but you’re always working within the limits.” We have forgotten those kinds of trade-offs, particularly how energetically hard it is for certain people with certain conditions or challenges to move. It’s not like picking up the pace. They can’t.
We’ve skipped along this subject or a topic throughout the episode, but we haven’t asked a more direct question around it. As a profession, should we give up the idea of creating a diagnostic system around movement? Part of that movement system theory and movement that happened from there was that people wanted to create specific diagnostic codes around certain conditions.
There’s a lot of effort going into it and I don’t knock it. What’s happening is we’re getting slightly more nuanced impairment-based statements. We’re getting more refined impairment lists. The problem is if movement consists, and we haven’t talked about this, there’s the organism and that’s us. That’s the biological us and the psychological us. There’s the task and there’s the environment. If you want to create a set of movement-oriented diagnostic classifications, you’re at least talking about a triaxial system. I’ll be honest, until we engage to do this punch, I wasn’t thinking, with apologies, much about people with pain. Probably pain is a fourth axis at least because not everything is kerflooey.
It’s the organism attempting this task in this particular environment and with this sensory perception is more successful or less successful. The problem is they’re trying to develop this uniaxial system. I’ll correct myself when I thought it was potentially triaxial. Pain is probably part of the picture and that’s fourth access. Have we ever heard of various axes used to develop diagnostic systems? Here’s a hit, guys. It’s already been done and it works for a very large and helpful profession. Looking at how psychologists have developed their diagnostic systems and along axes is very helpful. In the 2019 paper, we tried to give some sense of what it means to look at an organism. What does it mean to look at tasks? What does it mean to look at the environment? What kinds of issues come up?
We didn’t take it as far as saying, “Here we go. Here’s the answer. Here’s the triaxial system or now the quadric axial system,” because that would have been well outside of what we were doing. However, we were trying to say it’s more complicated than this but we can sort it out and the diagnostic process becomes one of predictions not necessarily to affirm, “Here you are. This is what you got and the discussion.” What’s happening between organisms, tasks, and the environment keeps changing. It keeps changing within the moment and then it changes across moments.
We got into the dynamical systems approach because that’s what’s happening here. All of these things are in movement and let’s face it. If you are engaging someone who maybe has psychological symptoms of depression and they’re doing well and feeling better, that’s going to change the movement. It’s all reiterative. This is hurricane season so it’s a good time to talk about dynamical systems. Where is it going to land? Is it going to be a Category 3 or is it going to go up to a Category 5? They then tell you if it blows out to sea, it’ll pick up more and get pushed in by this high-pressure area and low-pressure area.
That’s a lot of what we do and we don’t want to treat it that way. We want to treat it very linearly like, “Here is your problem. Here’s the one way that this problem gets treated and here is your endpoint.” You’re in a very lucky situation if that’s what all your patients look like. We’re dealing with a very non-linear system. Small inputs can have huge impacts. Large inputs can have nearly no impact and that’s our experience as therapists.
In some way, that’s what makes what we do interesting and exciting although you have to be the person who finds interest and excitement in that. Again, the key is not trying to figure out what the problem is, but looking at how this human organism is, how all these systems converge together and impact what that person is experiencing, and then how I insert myself into that container with my knowledge and my abilities and affect their system. It’s almost twosies. We’re part of that system in some way.
You become part of the environment and a set of stimuli to hopefully an adaptive response. I don’t think we have to throw out everything we know about impairments. People get very worried because if there are impairments, you’re not going to say, “I could fix that but I’m not going to.” You are going to fix things. The question is, are you there as a fixer-treater, which is where many of us end up, or are you closer to a coach or a counselor who’s trying to elicit a better performance? I’ll tell you a quick story of how I got into some of this stuff. I had two doctoral students who were not PTs but had been college division two athletes. They had gone on to do some pro and then semi-pro coaching.
I thought I had a real teaching moment because they were part of the spinal cord project and they were struggling with how we were viewing it. I’ll be honest. I was still viewing it and I couldn’t lose my impairment orientation even though I wanted to. I said to them what I thought was the teaching moment. I said, “If I’m working with your sport, how would you train for it?” I’m putting it in their idiom and I thought, “I’ve got the perfect training moment here.” Two days later, they came back with a program. They worked out, I went home. This is brilliant. They deconstructed the gate cycle and said, “If this were what we were training the athlete to do, here’s how we would break it up. Here’s how we would mix it up. Here’s how you do all these things.”
I went, “My goodness. It’s brilliant.” We did the research programs that evolved around a performance-based approach to treatment. There are two kinds of coaches that people who are in sports will come up with. There’s the coach that says, “You’re going to pitch this way. You’re going to quarterback this way.” There’s a person who says, “Now that I see what you can do, here’s how we can optimize the length of your arms.” If we could all run the same bolt, we probably would have figured it out by now. You have an extraordinary individual, an incredibly perfect length of body parts, and somebody who can reproduce the exact same motion beautifully.
I’m sure a lot of your audience are fascinated like I am with what Lionel Messi has done to appreciate soccer. How does he see the field that way and create these plays that you’re like, “How does he do that?” Anybody who says, “I’m going to watch a lot of Messi tapes then I’m going to take my kid and make them a little Messi.” You’re going to make them a lot messy.
It doesn’t work that way. You have to take the person where they are if you have a child who doesn’t get a set of instructions from the parents about, “This is the way I want you to walk.” One of the things I realized about my therapy is we give a lot of instructions. I want you to bring your foot forward, put your heel down, etc. Kids figure it out on their own.
There’s a good reason for that because the brain is a self-organizing organ. Be quiet a little, set up the conditions, and make the person reflective about what happened there. One of the things we would say to people is, “Tell us about what happened there. That looked good. What do you think you were doing differently?” How are they experiencing it? I’d say, “You’re doing fine and then you wobble in the middle. What did you do?”
They were spot-on and explained their own motor behaviors. You’d see them like a wage-shifting. In down moments, they’d be like, “Can I get it over there? Can I get it over here?” That’s exactly what you want people to do as opposed to, “I want you to bring your foot forward and hit with your heel. Now I want you to shift your weight and bend your knee slightly.”
It took me a while to learn to shut up. Do it my way. Do it the way I learned it from the textbook for the normal gate. That’s not the way to go. They model it. Why do people go to psychologists? Sometimes for deep problems. Sometimes it’s because they think their life can be better if they understood that insight into their behaviors. Some people have a behavior they want and they want to know how to make it stronger. I was happy with the guide. I should say I’m very proud of one fact.
I know I’m the only physical therapist who’s worked on all four editions. They have to do the fifth without me but I’ve had input. That does speak about movement as a behavior. I was in the first workgroup after the movement system was supposed to be our identity. It was not necessarily the most productive experience from my point of view, but I was able to at least push the group. I thought to recognize the movements of behavior. If it’s a behavior, then my relationship with the patient changes dramatically because I’m here to say, “With behaviors, what do you find less successful? How do we get you to be more successful?”
Some of that may be fixing the impairments. I am still going to mobilize your ankle if you don’t have range emotion, but I’m not stopping there. What I see as a danger for what’s happening is we do a great job correcting the impairment and then they go to a Pilates instructor, a dance class, or somebody else that they feel is offering that next level. That is so within our purview and we could do a fabulous job because we could take them through that continuum.
We’re talking about identity so it’s moving as our professional identity. I’m not thrilled with that. I don’t think you are either. I know a lot of therapists aren’t, but as you’re saying, movement is a behavior. If we start to let the idea go a little bit, we treat impairments. We move away from the biomechanistic pathology-oriented view and say movement to behavior. That must mean that, in some way, I’m a behavioral therapist but I work in a sub niche or I work in a niche of behavioral therapy or cognitive behavioral therapy because we keep thoughts in mind. I work with how someone moves, how they feel, relate, and perceive their body. That’s a different conversation than a lot of people in our profession are having right now around what is our professional identity.
I couldn’t agree with you more. It’s not the conversation that people are having, although some are. You’re starting to see this. It’s the conversation that we should have. There are two problems. One is if impairments did the trick, we would have fabulous success as physical therapists and we have good success. I don’t want to knock what we do. It’s not bad. It’s good, but could it be better if we rethought some? The answer is yes. For almost half of the century, we’ve been living in this impairment-based paradigm. The sad fact is what’s going on in the clinic in my 45th year is not that much different than what’s going on in my first year. I’ve worked with some brilliant therapists. I’ve worked in some terrific places.If impairments did the trick, we would have had fabulous success as physical therapists. Click To Tweet
I learned a lot for 45 years from certainly my early days. If the paradigm was going to work, the magic would have happened by now. We know that we get them so far, but we don’t get them that next bit and they are turning to other people. We are approaching by mid-century because we will leave. They break out of the box or are boxed in as fixer-treaters or coaches and guides. I hope people will find it more satisfying. How often can you derive great professional satisfaction from mobilizing a knee, doing the same straight plain exercises, or handing out a piece of TheraBand?
If our eyes and hands don’t impact that movement, which is so essential to human existence, or we could tap into what we can do with that in a much more satisfying way for the therapies, we might have a little bit less burnout. You feel more connected to a person. It’s like, “I fixed a great body part like I changed the spark plugs.” It’s hard to get excited. Maybe necessary, but it doesn’t make you excited forever.
The literature backs it up that when you place clinicians and environments where they don’t have the flexibility to learn or try new things, it’s a formula for burnout.
One of the therapeutic effects is the patient-therapist interaction itself. We cannot ignore that. People misinterpret that as I’m going to get too close and it’s an emotional relationship. It’s connected to emotions but it’s not any of the things that immediately come to mind. It’s capturing people as people in their lived experience as they experience it. You’re adding your professional insight, suggestions, and maybe a little bit of direction if that’s what they’re looking for. It’s a connection that you feel and that’s why people go see psychologists. It’s a very successful model and that’s what they’ve chosen to do. Dentistry can fix teeth and treat and we’re very grateful when we have a toothache for them to do that.
A lot of them are getting into aesthetics, smiles, and how that makes a person feel. Not many but it’s there so if we went the dentistry model, we could be great fixers. Come to me if you got a body part out of whack, I’m going to fix it. I’m a people person and it’s going to do the trick. For the degree, there were people persons. Are we willing to make connections? There’s a vulnerability there. That’s going to make some people unhappy. I’ve been fortunate. I hope I’ve given to patients. I also think they have dramatically impacted my life for the ones that I’ve gotten to know that I connected with.
I’ve been fortunate that there have been enough to have a very rewarding and rich career. I would wish that for everybody. Learn from their patients not in an ooey-gooey emotional way, but some fundamental truths about human existence and how they perceive life. That to me is one of the exciting things. We get to do it with our hands too. We are physical so it’s a very elemental way of interacting with people. It’s rich if we let it be and I’m afraid that we don’t always let it be.
Andrew, thank you for the rich conversation because we’ve taken the idea of what a physical therapist is. That’s what we are. Our identity is that we’re a physical therapist. The beauty within that identity and our profession has always been, “You have the ability to create the professional identity that you want.” If that means inserting more behavioral psychology, cognitive behavioral therapy, neuroscience, or whatever it is, you have the ability to do that.
A lot of that relies on you as the professional to say, “I graduated and got my license. Check that off. Now let me think about how am I going to plan my professional development so that I can now mold the self-identity that I want that helps me and my patients.” The real key is how we start to motivate ourselves into saying, “I’m smart. I have a Doctorate degree. I went to eight years of school plus all the other things I’ve been through. Now I can take this body of knowledge and expand that.” It doesn’t necessarily require PhD to do that. There are lots of ways to do it as a clinician. I’ve done that my whole career.
I would agree. It is interesting because we are the instrument of our profession. We are the tool. Our bodies are the tool and our minds are part of that. We shy away from realizing the power if we harness ourselves as the instruments we can be where we’re frightened of that. It takes a fair amount of self-knowledge and a little bit of being fearsome to confront yourself.
Something we don’t often ask is, am I the therapist for this patient? Can I connect with them in meaningful ways? We immediately go, “I don’t know how to fix or treat that problem so I’ll refer you to my colleague over here because he does all the sacroiliac joints.” We never like, “I can’t connect with you. We cannot develop a relationship where I can coach you to a higher level of performance. We’re not a match.”
Those kinds of questions, if we were asking them more routinely, would suggest to me that we have progressed in 45 years and we’re not doing, in my 45th year, what we were doing in my first year. There is a sufficient number of people that if they felt that they weren’t alone in the way that they were thinking, people would move to that. We all know people who have incredibly successful practices doing fine and surviving. It’s not a monetary challenge. They’re doing fine in their practices. Their patience loves them and they are very satisfied as professionals. They’re bringing an A-game to the situation.
Andrew, you’re a great speaker and I know that. People are excited about the idea of moving away from the movement system and into more of a systems-based approach, which has happened throughout health care, to be honest, not just in physical therapy. There are going to be some people who feel like, “We need to own something and the movement system is the one thing we own,” which technically, we don’t own movement, of course, but that’s going to be out there. If people want to get in touch with you and thank you or maybe challenge you a little bit, how can people learn about you and follow some of your work?
Things get put up on Research Gate. I’m happy to hear from people. One of the joys of being retired, more or less I still find myself doing things, is that you can look forward to email and not feel like, “How am I going to get this done and everything else done?” It’s a real joy to be able to connect with the world in ways that work interferes with. I’m very happy to connect with people if they’d like. There’s a lot more that can be talked about for sure.
I appreciate everything that you’ve done for our profession and your work. It’s a tremendous foundation for people who are interested in looking at this topic. I read about it in the PT Guide. I went in there to read about things related to, can we diagnose as therapists? Diagnose is part of our practice act and the truth is it is. How do we then apply that? It’s what we’re talking about here. If you’re tuning into this episode, I encourage you to share this with your friends and family, and of course, your physical therapy colleagues who are interested in the topic of the movement system or maybe moving away from the movement system as we spoke about here.
I’m interested in your feedback. You can email me. A lot of you are on my email list. You can hop over to the Integrated Pain Science Institute. Go to the Newsletter and you can sign up there or you can find me on Instagram. My handle is @DrJoeTatta. It’s been a pleasure being here with you and we’ll see you in the next episode.
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About Andrew Guccione
Andrew A. Guccione is Professor Emeritus, George Mason University and former chair of the Department of Rehabilitation Science. Previously, he was Deputy Director, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs, Washington, DC. Dr. Guccione also spent 10 years as Senior Vice President, Division of Practice and Research, at the American Physical Therapy Association. Prior to relocating to Washington DC, Dr. Guccione was Director of Physical Therapy Services, Massachusetts General Hospital, and also worked for 11 years with the Boston University Multipurpose Arthritis Center as part of the Health Services Research Unit while teaching at Boston University’s Sargent College of Health and Rehabilitation Sciences.
His primary research interests are in geriatrics, chronic movement dysfunction, and functional outcomes after rehabilitation. In addition to authoring or co-authoring over 75 manuscripts in peer-reviewed journals, he has received grant funding from the Foundation for Physical Therapy and the Arthritis Foundation, and was the recipient of a Special Emphasis Research Career Award from the National Institute on Aging. His clinical practice has centered mainly on movement dysfunction in older adults and both physiological and functional outcomes associated with locomotion training. He edited three editions of Geriatric Physical Therapy, which was translated into Korean, Portuguese and Polish, and previously served on the editorial boards of Archives of Physiotherapy, Arthritis Care and Research, Topics in Geriatric Rehabilitation, and Work.
Dr. Guccione received his PhD in Sociology and a Certificate in Gerontological Studies from Boston University. He also holds a masters degree in Philosophy from Temple University and a masters in physical therapy from Boston University. He was graduated from Boston College with an AB cum laude in English and Philosophy. His DPT was awarded by the MGH Institute of Health Professions. During his career, he has held faculty-level appointments at Sargent College, Boston University; Boston University School of Medicine, Harvard Medical School; MGH Institute of Health Professions; and George Washington University.
Dr. Guccione has served as Member-at-Large on the Executive Committee, chaired the Annual Scientific Meeting Committee, and also was on the Practice Committee of the Association of Rheumatology Health Professionals, which bestowed its Distinguished Scholar Award on him in 1993. He also has received two FACA appointments to the National Research Advisory Committee of the Department of Veterans Affairs.
Dr. Guccione was the first chairperson of the Geriatric Specialty Council for the American Board of Physical Therapy Specialties and led the team that developed the first clinical specialist examination in geriatrics. Nationally, he was elected to two terms on the Board of Directors as Speaker of the House Delegates of the American Physical Therapy Association. He has been honored by APTA with a Lucy Blair Service Award in 1989 and election as a Catherine Worthingham Fellow in 1998. He has been honored with the Association’s Rothstein Award for Scientific Writing, and delivered the Association’s 41st McMillan Lecture on June 17, 2010.