"Any movement-related profession—personal trainers, athletic trainers, dance therapists, yoga instructors—who can observe impairments such as a weak muscle can try to fix it," said Beth Fisher, PT, PhD, FAPTA, in delivering the 24th John H. P. Maley Lecture on June 14 at Combined Sections Meeting. However, too often the "fix" involves the patient compensating with movement patterns that interfere with the ability of an affected limb to improve to its true potential. Fisher argued that with their level of education and skill, physical therapists (PTs) can and should identify and help the patient recover that capability.
During her presentation "Beyond Limits: Unmasking Potential Through Movement Discovery,"
Fisher said that in earlier clinician practice with patients with stroke and brain injury she continually hit ends points with her patients, but she realized "these were my endpoints and not the patient's, [because] at least 1 aspect of the movement abnormalities…were the results of compensation." Given the brain's ability to continuously alter its structure and function, and the body's ability to achieve movement goals in more than 1 way, people with an impairment tend to progress toward the movement pattern that is most efficient—achieves a goal using the least amount of energy and the fewest body parts. And while a compensatory solution may get the job done overall, this easy route that comes naturally may not lead to optimal improvement, thus denying the patient the best possible outcome. In fact, "the compensations [patients] choose may be the source of the problem—may actually predispose the problem to occur," Fisher said, by keeping the patient from exploring better ways to achieve their movement goals.
She asked: Is this really the best we can do? "If we want to reach someone's full capacity, then we need to go beyond this limited choice that patients come up with on their own without a physical therapist," Fisher said. However, she argued, PTs have been academically trained to view movement from an impairment-driven perspective—the assumption that a patient's compensatory movement pattern results from an impairment that is masking his or her capability. And so both PT and patient expect that compensation will provide the best—or only—results.
"If I have minimal expectations," Fisher asked, "how is that going to impact my patient's expectations? What is that going to do for recovery potential?" Instead, as professionals with the expertise to look beyond compensation approaches, PTs must encourage potentially riskier, more-difficult solutions. "With what we know about brain plasticity, it is our job to help patients realize that they have more options," she said.
By modifying that implicit choice, the PT can help patients discover a capability they may not have even realized they have. "The most rewarding moments I have had in my career have come when I hear ‘I didn't know my leg (or arm) could do that,'" Fisher said.
She noted that PTs can't ignore impairment, "but if we are only viewing the problem from that perspective then we and our patients will reach a plateau-minimizing capacity."
Instead, every student and every therapist should include the perspective of looking at how a movement choice can mask capacity. "We need to start from the bottom up," Fisher said, "and teach students to observe movement and hypothesize how implicit choices—not just impairments—may be driving movement faults." Otherwise, "we have limited patients and their potential to discover other options for movement by a perspective that does not consider the choices they make."