Wednesday, March 14, 2007

Prevention - On Physical Therapists and Keeping Patients Moving

“Keep moving!”

Alistair Cooke, The Patient Has the Floor, Alfred A, Knopf, 1986

The late Alistair Cooke, the famed American-British journalist, in a talk to the Mayo Clinic, observed Brits outlive their American counterparts even though Brits consume more animal fats.

Cooke explained why in these words;

“Britain, I had noticed, maintains rights-of-way across fields and meadows and builds footpaths alongside highways and uses the phrase ‘Let go for a walk’ almost as an idiom. In America you cannot walk across field except in pursuit of a ball with a liquid center – and there are no footpaths once the town ends. The British walk, and cycle and walk, even in the rain. Let us face it, gentlemen, I said –‘They function!’ ”

So Much for the Opening Movement of This Essay

David Cella, senior editor for Jones and Bartlett, the publishing firm that is publishing my book Innovation-Driven Care: 34 Key Concepts in Transformation in late March, called the other day.

He recommended I speak to Dr. David Duvall, a PhD in physical therapy who heads up an organization called Sports Medicine of Atlanta ( Cella felt Dr. Duvall and I shared a mutual interest in innovative approaches to medical care.

I called Dr. Duvall. He quickly got to the point. He said his group – composed of physical therapists, physiologists, certified athletic trainers, nutritionists, sports and clinical psychologists, recreational therapists, registered nurses, and pastors - has created a new medical model of care.

Movement Science

The model is based on “movement science.” The model aims to keep patients moving. The model, collaboration between physician therapists and the medical establishment, bridges the gap between the traditional medical model, based on diagnosis and pathology, and the alternative practitioner model, dominated in Atlanta by chiropractors.

Duvall said his group, steeped in the discipline of neuromuscular science, evaluates movement impairment disabilities and enhances performance in athletes and non-athletes as well. Perhaps Duvall’s greatest passion is serving as one of nations’ eleven educational centers for physical therapists seeking a PhD. He says 25% of physical therapists now have PhDs, and the percentage of PhD candidates is growing rapidly.

A Movement Model

Sports Medicine of Atlanta is a direct access, multidisciplinary, specialty primary health care center. Most patients walk-in. The group provides access to unique and specialized neuromusculoskeletal care from a movement science perspective. The organization calls itself an Orthopedic-specialty center, although it has no orthopedic surgeons on its staff. Nevertheless, Duvall’s group regularly refers patients to orthopedists, and vice versa, and consider itself and orthopedic surgeons and other referring doctors as essential ingredients of the medical model.

Movement Integration

At Sports Medicine of Atlanta, state of the art diagnostics, interventions, preventative measures, performance enhancement, and wellness programs are integrated. The group has served Atlanta and Gwinnett County citizens since 1981. To identify the cause of movement-related problems, evaluations are performed and diagnoses established to direct the course of interventions.

Physical therapists, who regard themselves as clinical scientists, coordinate care to be received by each client to maximize his or her potential in recovery and/or enhancement of movement performance. They then design an intervention plan aimed at the treatment of movement impairments and their associated functional limitations and disabilities.

Physical and Manual Therapy

Sports Medicine of Atlanta's offers consumers physical and manual therapy based upon evidence-based approaches to patient management.

The group stresses examination and advanced clinical intervention. Its therapists are adept in achieving positive outcomes with difficult conditions. All physical therapy plans of care are designed or approved by an experienced, board-certified and fellowship trained doctor of physical therapy.

Alternative Practitioner Model

There’s another model out there as well. It’s called the alternative care model, or complementary practitioner model, and is based on the proposition that alternative practitioners, not MDs, can effectively treat patients too. I do not quibble with this assertion, except to point it is based on historical traditions and anecdotal evidence rather than on science and controlled studies. Nonetheless, alternative medicine is immensely popular among its followers.

Patients Seek Alternative Outside Traditional Medicine

Alternative medicine has been growing rapidly because patients want an alternative, outside of traditional medicine, free of third party intervention, focused on “natural remedies,” and devoid of potentially dangerous prescription drugs. Consumers are flocking to alternative practitioners outside the medical model – chiropractors, acupuncturists, homeopathic physicians, naturopathic physicians, message therapists, reflexologists, practitioners of herbal medicine.

Often consumers seek these practitioners out because they fail to find relief or satisfaction from traditional physicians. Many consumers suffer from neuromuscularskeletal disorders that manifest themselves as disabilities impairing movement and decreasing their physical performance. These disabilities include arthritis, neuromuscular diabilities, or mysterious ailments like fibromyalgia or fibrositis, or other causes of stiffness and muscle aches and pains that restrict movement.

Physical Therapists – A Logical Alternative

Physical therapists, as part of the medical model, offer a logical alternative to alternative practitioners. Physical therapist services are widely available. In 2004, there were an estimated 155,000 nationwide. Most work in hospitals, their own offices, or in the organizations like Health South, which has more than 1000 offices across the country.

I praise physical therapists for seeking advanced degrees. May the movement towards the advanced physical therapist movement continue.


Dr. Val said...

Dear Dr. Reece,

Movement therapy is indeed a wonderful thing, and I applaud the work of Physical Therapists. Do keep in mind, though, that the field was developed by Physiatrists (the medical specialty of Physical Medicine & Rehabilitation) and our role in advancing the field and promoting physical activity should not be overlooked. Thanks!

Unknown said...

Dear Dr. Reece,
I am always delighted when people point out the tremendous benefits of rehabilitation medicine which is led by physicians who opt to specialize in a small, but important medical specialty called Physical Medicine and Rehabilation (PM&R). Those of us who complete medical school and then a four year internship and residency training program and go on to become board-certified physiatrists do much more than prescribe physical therapy, however. Though we used to be called "physical therapy doctors" modern physiatrists are quick to point out that this is a very antiquated term and that while we work closely with our physical therapy colleagues and we certainly write very specific orders for PT to help people physically recover, we do much more than that including prescribing medications, ordering medical studies, performing many types of injections, and so on. The list is long; however, for more information about physiatrists visit the American Academy of Physical Medicine and Rehabiliation website at

Julie Silver, MD
Assistant Professor
Harvard Medical School
Dept. of PM&R

Richard L. Reece, MD said...

I goofed. My next blog will be devoted to apologizing to physiatrists, who developed the field of movement science, and who spend time helping train physical therapists and treating illnessws such as strokes, spinal cord injuries, and other devastating neuromuscular diseases. I simply fell prey to a degenerative condition I accuse others of -- tunnel vision.

Richard L. Reece, ND

Dr Robert DuVall, PT, ATC said...

Dear Dr Reece,
It was with both pleasure and appreciation that I read your recent Blog of March 14, 2007 entitled "On Physical Therapists and Keeping Patients Moving". I particularly appreciate your recognition that physical therapists, as part of the medical model, offer a logical alternative to alternative practitioners. Likewise, I appreciate the added comments by "Val" and Dr Silver regarding physical therapy's close relationship and evolution with mainstream medicine and particularly physiatry. I accolade the need to recognize the role and contributions of Physiatry as related to the topics of physical medicine and rehabilitation.
On a point of clarification and amplification, I must mention that your erroneously referenced my name to be "David" DuVall. My name is "Bob" DuVall; "David" DuVall is no relation and is the once famous golfer who stared in the NCAA golf world at the Georgia Institute of Technology and use to fair well in the PGA ranks. I have a post-professional doctorate degree, (Doctor of Health Science) and not a PhD.
It is accurate to mention that I serve with great passion as one of the nations’ eleven educational centers for physical therapists. However, it is more descriptive to say that Sportsmedicine of Atlanta's Manual Therapy Fellowship program is credentialed by the American Physical Therapy Association as a post-professional clinical fellowship program for physical therapists in orthopaedic manual therapy, but it does not award a PhD. Further clarification reveals that a growing number of physical therapists hold clinical doctor of physical therapy (DPT) degrees, as most entry-level physical therapy educational programs now award the "DPT" as the entry-level degree.
Thank you again for recognizing the positive contributions that can be made by physical therapists. I hope the medical community as well as the public-at-large will some day come to know physical therapists as traditional, medical model based and collaborative clinical scientists who employ peer reviewed and evidenced-based practices to help solve movement impairments and functional limitations experienced by our patients, while serving as a "logical alternative to alternative practitioners".

Bob DuVall, PT, ATC

jlsmithivan said...

Regarding my debt to physiatrists. As a PT in a large medical center I most certainly work with PMR docs. I truthfully must say that i owe almost none of my education or training either in school or since graduation to them. Where i practice we strive for orders to evaluate and treat and most certainly are open to any suggestions from our doctors, but in the areas of rehab and evaluation I have to say we mostly autonomous and work in conjunction with the doctors as part of a team approach. It is offensive to my education and experience to think otherwise and the days of "specific orders" are much more parallel with the dinosaurs plight. I most definitely see value in working with doctors knowledgeable in my area of practice-as team members, not mentors. This is not to say that we can not all learn something from each other. Hopefully their respect towards us is evolving not devolving as the tone of the article suggests. Respectfully,

Sharon Dunn, PT, PhD, OCS said...

According to the Association of Academic Physiatrists web site, physiatry did not become recognized as a separate medical specialty until 1947. The Physical Therapy profession, however, was first established in the United States during World War I by the Surgeon General, Merritte W Ireland, MD. A report from the Division of Orthopedic Surgery of the Medical Department of the US Army called for the establishment of hospitals for the provision of reconstructive care to our wounded soldiers. Originally identified as “reconstruction aides”, physical therapists were trained to provide rehabilitation within these hospitals. By 1921, physical therapists established the organization known today as the American Physical Therapy Association, and now physical therapists are prepared at the doctoral level in academic institutions across the country. To say that the profession of physical therapy was developed by physiatrists is revisionist history.
So I applaud you Dr. Reece. You are absolutely correct about the physical therapist’s role as a “clinical scientist…maximize(ing) potential in recovery and/or enhancement of movement and… function”. Physical Therapists practice independent of physician prescription or referral in 43 states. They do, however, practice in collaboration with their physician colleagues to achieve the best possible outcomes for their patients.

Sharon Dunn, PT, PhD, OCS
Assistant Professor
LSU Health Sciences Center
Department of Rehabilitation Sciences

1.McKenzie RT. Reclaiming the Maimed. New York, NY: The Macmillan Company; 1918.
2.US Army Medical Services. Medical Department of the United States Army in the World War. The Surgeon General's Office. Washington, DC: Government Printing Office; 1923.

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