The Movement Brainery

There is a longstanding clash between visions for what the physical therapist does: those who envision the PT as the “administrator” of care, doing the high-level diagnostic thinking and evaluation and having their schedule be mostly evaluations while the assistive personnel execute on the plan they create. In contrast, there are those “purist” PTs who enjoy tailoring the daily evaluation and interventions.

I actually think, if both are done well, they can each be viable models for the profession. They each cope with payment cuts in different ways. One by revving up volume, the other by trying to rev up perceived value, hopefully seeing more patients that would pay cash.
There are also many weaknesses with both models, which you probably know well. Besides inherent weaknesses, the other thing to consider is that the APTA only thinks PTAs should be assisting the PT with physical therapy services and AAOMPT and APTA agree joint mobilization (if that’s a part of care) should only be done by PTs.

But something I don’t see a lot of discussion about: are we TRAINING our physical therapists to practice in these two very different models of care?

The first model of care is often justified as “PTs should be using their highest/most valuable skills” such as diagnosis, triage, developing a plan of care, etc. But how well do we train our PTs for that role? At graduation, are PTs well-equipped to be managing 2-3 assistive personnel while doing laser-focused evaluations and developing achievable POCs?

I actually don’t think so.

Conversely, are PTs being trained to be great at efficiency and effectiveness in care, and marketing those services to the public? I also think the answer is no.

I think it’s possible this longstanding conflict between these two delivery models of PT sort of paralyzes educators, where PTs get trained a little bit in each, without being fully ready to execute on either.

I have to admit, sometimes I wonder if the constructs that underpin our decisions are really even valid.

Thoracic outlet syndrome and piriformis syndrome seem much more rare than I initially was led to believe. SI joints flipping out of place seems dubious.

But subacromial impingement actually might be one of these. I am not sure how much more we can do to disprove this theory, which actually predates Dr. Neer and goes way back to the 1930’s. There are a whole host of things that can impact rotator cuffs, but I think the shape of the acromion is probably far down on the list. Most of these injuries just seem to me like typical tensile overload injuries to the tendon that then become sensitive overhead, where there is more compression on a painful structure, and at 90 degrees, where the lever arm is at its longest.