On “Storm Clouds on the Horizon: The 3 Perils of Unconstrained Academic Growth in Physical Therapist Education.” Deusinger SS, Landers MR. <i>Phys Ther.</i> 2022;102:pzac046. https://doi.org/10.1093/ptj/pzac046

I strongly urge Deusinger and Landers1 and Gordon and Tilson2 in their subsequent letter to the editor not to react hastily and to rethink their position on their perceived “storm clouds on the horizon” vis-à-vis “unconstrained academic growth in physical therapist education.” Rather than a “gloom and doom” forecast, this perceived crisis is a prime opportunity for continued growth of our profession to better serve the public, society, and humanity consistent with contemporary professional values and mission statements. As said in Chinese, the word crisis is 2 characters—one for “danger” and one for “opportunity”—and implies time for reflection. Historically, the profession of physical therapy has been hallmarked by its unifying values and “noninvasive” clinical lens,3,4 rather than primarily by areas of specialization or “techniques”—a trend that has predominated in more recent decades. Associated with the emergence of specialization within the profession is a reduction in the reflexivity that is needed in clinical practice to address the contemporary issue of patients’ multimorbidity, rather than the persisting, primary focus on a singular complaint reflecting the no-longer-tenable single-disease framework that characterizes the traditional biomedical model. Admittedly, physical therapist practice has been slow to advance in a commensurate fashion with epidemiological indicators over the past 80 years, but, hopefully with professional “awakening,“5–7 time remains to dismantle an outdated un-reflexive paradigm and create a new one. Aligning our values with societal need suggests physical therapists are needed more than ever, given the global pandemic of chronic noncommunicable diseases and the fact that, based on substantial evidence, these diseases are best prevented, managed, and even reversed with conservative approaches. Addressing these diseases and their risk factors augments functional capacity and mobility as well as overall health and well-being. To be reflexive, we need to recruit the “best and the brightest” and those among us with the vision: those eager to pick up the gauntlet and move the profession forward to realize its full potential in these critical times. Specifically, I urge Deusinger and Landers and Gordon and Tilson, who are “influencers” yet appear convinced that we are overproducing physical therapists in relation to demand, to examine their metrics regarding demand for our professional expertise in contemporary times and the foreseeable future. Thinking outside the proverbial box needs to be a way of life for health professionals to ensure they are ever responsive to changing individual and societal health care needs consistent with their professional values, rather than being attached to and hamstrung by outdated paradigms. Apparent advances such as standardized practice and clinical practice guidelines need to be constructed to build reflexivity and broad-based holistic practice into them. The issue is not that we are producing too many physical therapists, but rather we have not moved expediently enough to better align these core values and the literature with contemporary practice priorities—the patient with multimorbidity—which supports the need for a critical mass of physical therapists worldwide. To address the question of how the profession can return to being more reflexive while at the same time maintaining established practice standards, we need only to look at our history and evolution. At mid-twentieth century, the Second World War, which had followed closely on the heels of the First World War, had ended. The global economy was growing and has continued to do so in the intervening decades. The so-called Western lifestyle emerged, hallmarked by the consumption of an increasing array of engineered, processed, and ultra-processed foods; animal-sourced foods; sedentarism; reduced activity; increased prevalence of smoking; poor sleep quality; and increased life stress. All of these factors have now been well documented to adversely affect human health and contribute to the current leading causes of disability and premature death in high-income countries—and, increasingly, in middle- and low-income countries as the Western lifestyle becomes more pervasive. On perusing the professional textbooks and journals published over the past century, there is a turning point around 1975. Prior to 1975, journal articles tended to be descriptive and focus on topics reflecting changing societal needs, such as the 3 polio epidemics, injuries including fractures and infection control that emanated from the war years, ulcers, amputations, tuberculosis, burns, and management of deformity (eg, club feet and scoliosis). Only some 30 years after World War II did it become apparent to the World Health Organizations and its member countries that the predominant Western lifestyle was seriously injurious to human health based on the progressive escalation of heart disease, cancer, high blood pressure, stroke, type 2 diabetes, obesity, and Alzheimer disease. Correspondingly, around 1975, 3 trends emerged that significantly impacted physical therapist practice and its direction and place within heath care. First, the profession began to recognize the need for quality research particularly if physical therapist professional education was to remain at the university. Second, the construct of evidence-based practice emerged. Third, quality assurance and control become central in health care along with practice standards, clinical guidelines, and specialization. Although these trends have generally augmented standards of physical therapist practice and specialty-specific outcomes, they failed to effectively accommodate reflexivity of its practice in addressing patients’ overall health and well-being. In addressing these trends, the profession was slow to respond to the new reality of noncommunicable diseases, both in terms of their risk factors in most patients including children and in terms of their manifestations. A case in point is the common clinical lens for the physical therapist management of a patient with pain, particularly back pain. Typically, back pain is characterized as an orthopedic complaint when, in fact, its origins and risk factors are often those associated with noncommunicable diseases.8 Thus, lifestyle practices warrant being a primary focus not simply as a secondary goal to promote a healthier lifestyle. Musculoskeletal conditions are significantly exacerbated by lifestyle practices such as smoking, poor nutrition, overweight, poor sleep, and unmanageable stress, in addition to sedentarism, inactivity, and lack of structured exercise.9–11 The profession has a moral imperative to be true to its values and translate the knowledge consistent with contemporary physical therapist practice into its conventional practice regardless of whether noncommunicable disease risks or manifestations are the primary reason for referral or ostensibly secondary issues.12 The specialty of pediatrics is another case in point. Our children are in peril. All contemporary indicators support the need to prevent and manage risk factors for noncommunicable diseases in the pediatric population, most notably childhood obesity and hypertension, yet the focus of the specialty remains largely as it was in the polio years, specifically in neurodevelopment. Without question, neurodevelopment remains critically important; however, in terms of long-term impact and cost, noncommunicable diseases are not adult diseases. They begin in childhood, and children today can expect to live years with disability, suffering, and substantial health care costs and can expect a premature death. This is the first generation of children whose longevity is not expected to surpass their parents. The pediatric practice lens warrants being expanded to one of multimorbidity. In moving forward, physical therapists need to recognize and embrace their unequivocal professional evidence-based strength and strategic position in health care in turning the tide on noncommunicable diseases worldwide. This lens extends to addressing these diseases or their risk factors in every patient regardless of which “specialist” might be treating them. Physical therapy has become the third largest established health profession in the world (except dentistry and pharmacy, given their distinct practice patterns). The profession has enormous potential that needs to be recognized and expanded rather than restricted. Physical therapists have a practice pattern well suited to health counselling and behavior change in conjunction with contemporary practices, that is, long treatment sessions often over days, weeks, and even months. Moving beyond the musculoskeletal stereotype of what physical therapy is, we need to ignite the passion both of recruits to the profession and of the “best and brightest” and influencers such as educators already within the profession. We need to inspire them to hold the vision of how powerfully and significantly physical therapists can contribute collectively to addressing global health priorities given their professional values, one patient at a time, in a critical period in human history—the era of preventable, mostly reversible noncommunicable diseases—with changes in lifestyle choices and practices. Addressing lifestyle factors augments health overall and, in turn, functional capacity and mobility. This is the profession’s prime opportunity to be responsive and reflexive to the societal needs that we profess to value. The author completed the ICMJE form and declares no conflicts of interest.

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