Invited Commentary on the Movement Continuum Special Series

The Movement Continuum Theory (MCT), published in 1995,1 built on Hislop's notion of pathokinesiology.2 Our intent was to stimulate discussion and debate about theory in physical therapy. Although the MCT has received international attention, most notably as an influence on the World Confederation for Physical Therapy's international definition of physical therapy,3 there has not been much academic response or further theoretical development in the physical therapy profession, unlike the occupational therapy4,5 and nursing6,7 professions, both of which have given considerable attention to theory over the years. A theoretical framework is an important indicator of an evolving clinical science,8 and the arguments we put forward in 1995 for the need for a theory of physical therapy remain relevant today. Allen's work on further developing the MCT is very welcome, and hopefully her work and this special series will encourage others to enter and continue the debate. The following comments are made in this spirit of advancing debate on physical therapy theory. Perhaps one of the reasons that the MCT has not inspired much empirical research on movement is that the MCT is not actually a theory of movement; rather, it is a theory of how physical therapists conceptualize movement and approach problem solving and decision making with their clients. We identify movement as the central unifying concept of physical therapist practice and attempt to distinguish what makes physical therapy different from other movement sciences. We put forward the MCT as a grand theory of physical therapy, that is, a theory that provides broad conceptualizations and forms the basis for middle-range theories that are more concrete and address specific problems and issues. We originally intended to write a clinical version of the MCT, but—despite the best of intentions—this never transpired. We were very excited, therefore, to see Allen's proposed dimensions that expand the construct of movement in the MCT and are consistent with grand theory. Her Movement Ability Measure (MAM) is an important step in moving the theory to a more clinical, applied level. Allen contends that the 6 proposed dimensions of movement (flexibility, strength, speed, accuracy, adaptability, and endurance) can be applied beyond the levels of movement of the body part or body to the person in his or her environment. Using a more familiar model, the International Classification of Functioning, Disability and Health9 (ICF), these levels correspond to the levels of impairment and activity limitations. She presents examples of sports and activities and of pathologies that can be linked to 1 of the 6 specific dimensions (eg, gymnastics, ballet, and flexibility). However, movement at the level of the person in his or her environment, we believe, is too complex to be categorized as being relevant to only one of the movement dimensions. One could just as easily argue that accuracy, adaptability, and endurance are key to ballet and gymnastics. This does not diminish the value of the proposed dimensions; rather, it suggests that the further one moves along the movement continuum, the more necessary it becomes to incorporate all 6 dimensions when analyzing movement. Certainly, at the level of the person in society (or participation as defined by the ICF9), the 6 proposed dimensions are probably inadequate to capture the complexity and intricacies of, for example, the movement involved in working for a living. The initial identification of the 6 dimensions does not appear to have included the client's perspective. The dimensions certainly resonate with the physical therapy perspective and as such are important contributions to a grand theory of physical therapy. Allen, herself, states that many respondents rate all dimensions similarly, and, for some, this may be because they are not described in terms that are meaningful to them. It would be very interesting to conduct qualitative work with clients to explore how they understand movement and then to try to reconcile their perspectives with the physical therapy view in order to develop dimensions that incorporate both perspectives. For example, rather than strength and flexibility, clients might talk about ease of movement, as they may not differentiate among strength, weakness, stiffness, and lack of range of motion, particularly if their impairments are moderate. In a similar vein, the clients for the psychometric testing of the MAM were sampled from a relatively healthy population with few movement impairments. It will be important to validate the tool with clients with physical impairments prior to its utilization in research and practice. These considerations reflect a noticeable change in physical therapist practice since the publication of the MCT—the rise of a discourse in rehabilitation about client-centeredness.10 The MCT is consistent with this discourse. For example, when goal setting using the MCT, the starting point is to identify the client's goals, specifically, the client's preferred movement capacity (PMC).11 Despite our reservations as to the extent to which the 6 proposed dimensions represent the client's or the therapist's perspective, the exciting thing about Allen's work is that her measure captures information about both the PMC and the current movement capacity (CMC) and, as such, may allow for the measurement of the PMC/CMC differential. Figures 2 through 7 in the first article in the Movement Continuum Special Series nicely illustrate the PMC/CMC differential in different clients and emphasize the importance of considering the client's perspective when goal setting. For example, on a purely objective basis, the 72-year-old man may have less movement ability than the 25-year-old athlete. However, in terms of expectation of movement, the older man appears quite satisfied with his movement in the 6 dimensions, whereas the young athlete identifies a quite significant PMC/CMC differential. Unfortunately, Allen does not suggest how she proposes to use the PMC data or further develop the measurement of the PMC. A discussion of how the MAM might be used to measure the PMC/CMC differential and of the further work needed to achieve this would be welcome. Another major change in physical therapist practice since the publication of the MCT has been the rise of evidence-based practice and the use of outcome measures. Most of the outcome measures currently in use focus on measuring the CMC or using normative data12 to help predict a client's potential (eg, maximum achievable movement potential). There are fewer available measures that capture the client's perspective on achievement of outcomes. Allen's measure has the potential to fill an important measurement gap in physical therapist practice where the focus is often on the acquisition of motor skills to improve functional abilities, with little attention on enabling the client to regain former roles and meaningful activities.11,13 For example, whereas clients following stroke define recovery in terms of returning to the life they lived before their stroke14 and the activities that give them identity and control,13 physical therapists tend to focus on improvements in physical function and the ability to perform basic care tasks.13,15 This disparity between what is important to clients and to physical therapists needs to be addressed if we are to truly be a client-centered profession. In closing, we believe the MCT remains relevant as a grand theory of physical therapy. As such, it may not readily lead to the development of specific hypotheses and propositions at the clinical level, but it can be used to guide research and education around physical therapist practice. We are excited about the possibilities inherent in Allen's work, both in expanding our understanding the construct of movement within the MCT and in the development of a measure that has the potential to explore the PMC and the PMC/CMC differential.

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