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The movement continuum theory of physical therapy

Article in Physiotherapy Ca nada ·January 1995

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Allhough there e.rea nurrber of middle range

PhysicalTherapy theories, there is no bread IlIE MOVEMENT CONTINUUM
lheory o1 physicalTherapy on which to base
th development o1a distinct body of
kn<lwledge. The purpose of this arlicle is10
IlIEORY OF PHYSICAL 1HERAPY
conceptualize Physical Therapy practice and Che ry l A . Cott
to place ilinto atheoretical contexlthat
distinguishes it 1rom c;ither movement E lsp eth F i n ch
sciences. The proposed Movement D ia ne Gas n e r
Continuurn Theory ot Physical The1apy
describes the unique approach of physical
K a r e n Y os h i d a
therapists to rnovement rehabilitalion lhat S c o t t G . T (z.o m a s
incorporales knov.1edge of pathology l'li!h a M . C . ( M o ll y ) Ve rr ier
,holistic view of rnovement that includes the
influence alphysical,social and Why a Theory of Physical Therapy? rehabilitation professions. However, it is
psychologcal factors. The theo¡y conslsts of Th.e Physical Therapy professíon has necessary to integrate this knowledge into a
eight principies o! roovernent, three of which
evolved considerably over the last theoretical perspective specífic to Physícal
are shared l'lith other rooverrent sciences
andfive of which arespecific to Physical 100 years as a health discipline specializing in Therapy. The purpose of this paper is to
Therapy. The theory provides afrarrework the use of physical methods for rehabilitation. conceptualize Physical Therapy and place it
for the entire profession that isapplicable lo The history of Physical Therapy is into a theoretical context that distinguishes it
education,research andclinical practica. characterized by attempts to establish and from other professions concerned with
consolidate its position withln the health care movement.
KEY WORDS: 7ñeory, movement, system which initially involved seeking Theories deal with the abstract; they attempt
physical therapy sponsorship from the medica! profession.1 to explain why things occur as they do.
Bien qu'il existe uncerlain nombre de More recently, Physical Therapy has strived Theories are conceptual frameworks which
théories de porlée moyenne sur la for an equal footing with other health care are scru,tinized by putting them into practice
physiothérapie, iln'existe aucune théorie professions by improving educational and rneasuring and analyzing the outcomes.
généralede la physiothérapie sur laquelle on standards, broadening the scope of practice, The theory is, thereby, tested using the
pourraitbaser l'élaboration d'un ense!Tble increasing admirustrative control, achieving scientific method. Cooper and Saarinen2 have
cistinct ele connaissances. Le but decet
greater political influence and developing a expressed concem about the relative lack of a
article e.st deconceptualiser lapralique de la
scientific core of knowledge specific to theoretical base for rehabilitatíon professions .
physiothérapie et de laplacer dans un
contexte théorique qui la ctistingue dautres
Physical Therapy.1 Progress has been made They emphasize the need to clarify the
sciences durrouvement. La théorie towards achieving many of these goals. relationshlp between theory, clínical models
proposée de lacontinuité du m:iuvementde However, there remains a lack of consensus and research to prevent a growíng schism·
laphysio1hérapie décri! rapproche unique,de on the definition of what constitutes Physical between the three.2
laparl des physiothérapeutes , de la Therapy and its uruque .contribution to the Domholdt3 describes the scope of two
réadaptation du mouvement qui incorpore health care field. Current defirutions focus on different types of theories. Grand theory
des connaissancesen palhologie a une the task-oriented aspects of Physical Therapy provides broad conceptualizations of
holistiquedu rnouvement qui inclut Finfluenoe practice without identifying the underlying phenomena and fonns the basis for
de facteurs physiques, s_Qciaux et rationale and contribution of the profession to middle-range theories which are more
psychologiques. La thé01ie se cornpose de
health care. concrete and address specific problems and
huit príncipesde mouvement, dont lrois sont
communsa d'autres sciences du moLNement The practice of Physical Therapy is based on issues. There are numerous examples of
et dontcinq sont parliculiers a la a body of knowledge that incorporates approaches based on middle-range theory in
physiothérapie. La théorie oflre, pour la relevant infonnation from other sciences and the Physical Therapy literature such as
disciplines. In one sense, this is a strength of
profession tout entiere uncadre quiest Brunnstrom 4 Kaltenborri.5 and Maitland6.
, ,
applicable alaforma!ion, a larecherche et a the profession; in another sense, it is a These middle range theoties attempt to
la p¡atique clinique. weakness. The incorporation of other explain the nnderlying causes of specific
disciplinary knowledge intó Physical Therapy movement disorders and the subsequent
practice has often obscured the separate and approach to trea.tment, and are generally
distinct conceptualization of the unique body focused on a particular area of practice.
of knowledge which distinguishes Physical Two examples of middle range theories with
Therapy from medicine and other a theoretical base, are the work of Harris and

Chety/Cott, BPT, MSc, PhD, Lecturer, Dept ofehysical M C.(Mol/y) Verrier,Dip.P&OT, MHSc,Associate Professor
Therapy, UniversityofToronto, Ont J and Chair,Dept of Physíca/ Therapy, Universíty ofToronto,
Elspeth Rnch, BSc P&OT, MHSc,Assístant Professor, Ont.
School otOT/PT, McMasterUníversity, Hamilton, Ont.
Correspondance: Cheryl Cott, Depa.rtmentof Physicaf
Diane Gasner, BSc(PT), JI.A.A, Senior Tutor,Dept of Physica/ Therapy, Facu/l'¡ofMedicine , UniversityofToronto,256
Therapy, UniversityofToronto, Cflt McCau/Street, Toronto,ONM5T 1W5
Karen Yoshida, BSc(PT), MSc, PhD,Assistant Profes.sor
At the 6me thís artic/e was written, Dr.Cottwas a doctoral
and Career Scien6st (Ontario MinistJy of Health), Dept. of student in lhe Department of Community Hea/th
Physica/ Therapy, University of Toronto, Ont (Behavioura/Scíence), University ofToronto, and Prof.
Scott Thoma.s, PhD, Assistant Professor, Dept. of Physical Fmch was an AssistantProfessorin the Departmentof
Therapy, UniversityofToronto, Ont. Physícal Therapy, University ofToronto.

Phvsi.otheram¡ Canada • Svrinq 1995 • Vol.47. No. 2 07

 Dyrek7 and Schenkman and But!er8 Rothstein10 appeals for a re-examination conceptualization of Physical Therapy
, .
7
Harris and Dyrek deve!oped a model of the meaning and intent of that subsumes existing middle ra.nge
for orthopaedic dysfunction which is pathokinesiology. Schegel11 sees the theories and represents an overall
specific to Physical Therapy and emphasis on pathokinesiology limiting ' conceptual framework.
provídes altematives to the medica! the expansion of Physical Therapy into The Movement Continuum Theory of
model of etiology, diagnosis and the areas of health and wellness, and Physical Therapy ·
treatment. They look instead at the voices concem over the failure to The key coLi.cept in this theory is
etiology of dysfunction and include a consider function and dysfunction on a movement. The concept of movement is
model for decision making related to continuum. Pratt12 has !Ooked at four not unique to Physical Therapy, but the
tissue response to insuJt. Schenkman possible bases for the practice of way in which physical therapists
and Butler 8 developed a model for Physical Therapy: scientific knowledge; conceptualize movernent is what
neurological dysfunction based on the the medical model of health /i!lness; a differentiates them from other
work of Harris and Dyrek7 ;their model holistic view of the person; and professíons. Physical therapists
integrates direct and índirect empirical decision making and conceptualize movement on a
12
impairments occurring in different body treatment. Pratt sees the base varying continuum that incorporates physícal
systems·and the use of these according to the specificity of the and pathological aspects of movernent
impairments as predictors of disability. treatment area; nevertheless, he with social and psychological
By focusing on middle range theories recognizes the limitation of each and considerations. Itis, therefore,
there has been little thought given to urges further work on the development movement which comprises the primary
conceptualizing how these theories fit of a theory of Physical Therapy. · focus of Physical Therapy.
into a global context. Energy has been Development of grand theory related The Movement Continuum Theory of
expended on debating the merits of to dísablement has been ongoing Physical Therapy consists of eight
different middle range theories, at the throu.gh the use of the Intemational principles (see Table I). 1breebasic
expense of identifying common concepts Classification of Impairment, Disability, principles are paramount to the sdence
and overarclúng principies. In contrast, and Handíca (ICIDH) model and of movement and are shared with other
the most notable example of grand terminology 1 . Badley and Lee14 disciplines.
theory in the Physical Therapy literature explore the relationship between the l. Movement is essential to human
is Hislop's 9 Mod.el of Pathokinesiology underlying condition, impairment, and lile. Movement involves a change of
that is pertinent to all aspects of the disability as a model for assessing the positi.on of the body and its components.
profession and has maintained consequences of disease. They conclude This ex:tends to change in location of the
relevance over ti'me.' His1op9 that functional limitation is the crucial whole body from one physical space to
conceptualizes movement as occurring element. Nagi 15 relates the concepts of another. The act of movement allows
at six different levels of the hwnan sickness, illness and disability to humans to sustain life; to explore their
organism: cells, tissues, organs, systems, rehabilitation potential¡ his rnodel is physical and social environment; and to
16
persons, and family. She purports that supportéd by Guccione who seek out their basic needs, hou.sing,
Physical Therapy intervention is emphasizes the relatíonship between companionship, knowledge and
directed at tissu.e, organ, system, or impairment and functional limitation as self-actu.alization.
person levels but also l'ecognizes that the primary focus of Physical Therapy. II. Movement occurs on a continuum
alterations at any one level have the In spite of the importance of consistent f.rom the microscopic level to the level
potential to influence all levels. In terminology, however, the use of IODH of the individual in society. Movement
adclition, she recognizes both the art and terminology or modifications of this occurs on a continuu.m ranging from
the science of Physícal Therapy and its model <loes not,in itself, provide a indívidual components within the body
interaction with other sciences, as well useful theory of Physícal Therapy. to the person moving in his or her
as the imP,ortance of scientific validation. The shortcomings in Physícal Therapy environment. Movement may be of
Hislop's9 model is only two theory become increasingly obvious molecules (ion flux within the muscle or
dimensional; it recognizes levels witlún during planning far curriculum and nerve cell), of body parts (flexing the
the human organism and views Physical research development. Recognition of knee), or of the whole person
Therapy interventions as interacting the need for a theory of Physical (transferring from bed to chair or
with these levels. The model fails to Therapy to guide educational and participating in community activities).
reflect the interaction of indíviduals research endeavors has led to the III. Movement levels on the
with society and with their development of this theoretical model - continuum are influenced by physical,
envirorunent. It does, however, provide The Movement Continuµm Theory of psychological, social and
the basis of a sound theory upon which Physical Therapy. The Jirrpose was to environmental factors. Movement does
to build. Many other authors have tried develop a theory tha t met the following not occur in isolation. The control of an
to explain and interpret Hislop's 9 críteria: (1) it must be central or unique inclividual's movement is dependent on
theory. Rothstein 10 and Schege111 have to Physical Therapy; (2) it must be broad internal and externa! factors that have
explored the use of the term enough to apply to all aspects of important qualitative and quantitative
9 Physical Therapy; (3) it must be able to
pathokinesiology, employed by Hislop , influences on that movernent.
to describe the distinguishing clinical . inform research and education; and (4) it Movement is dependent on iriternal
science of Physical Therapy. Hislop9 must apply to both current and future physical elernents such as anatomical
defined pathokinesiology as the study of Physical Therapy practice. The structures and physiolog:ical systems.
anatomy and physiology as they relate Movement Continuum Theory of At the microscopic leve!,movement is
to abnormal human movement. Physical Therapy provides a broad

88 Physiotherapy Canada • Spring 1995 • Vol.47, No. 2

-·
-------·--- ----
 \ ' b:

the individual. Itis context dependent

on physical factors such as architectural
TABLE J components and environmental
elements. For example, respiration is
affected by temperature, humidity and
General Principies air composition . Head movement is
1 Movement is essential to human life. influenced by light and sound. The
11 Movement occurs on a continuum from the microscopic leve! to the leve! of
physical layout of externa! surroundings·
and dimensions of objects either
the individual in society.
facilitate or impede the quality and
111 Movement levels on the continuum are·influenced by physical, quantity of movement.
psychological, social and environmental factors, Social factors such as educatíon,
Physical Therapy Principies occupation, income, and domicile will
IV Movement levels on the continuum are interdependent. have an impact on movement. The
V At each leve! on the continuum there is a maximum achlevable movement social environment provides multiple
potential (MAMP) which is influenced by the MAMP at other levels on the influences on an individual's movement.
continuum and physical, social, psychological and environmental factors. Various cultural norms and roles and
the perceptions of those roles will
VI Within the limits set by the MAMP, each human being has a preferred
influence the motivation, frequency, and
movement capabillty (PMC) and a current movement capabil1ty (CMC) quality of movement. The formal and
which in usual circumstances are the same. informal social interactions in which an
VII Pathological and developmental factors have the potential to change the individual participates may also
MAMP and/or to create a differential between the PMC and the CMC. influence movement. These are
VIII The focus of Physical Therapy is to minimize the potential and/or existing °'ediated through the expeetations of
PMC/CMC differential. others and the individual's own
IX The practice of Physical Therapy involves therapeutlc movement, interpretations of them. For example,
modalities, therapeutic use of self, education, and technology and the family unit, neíghbours, Jeisure and
environmental modifications. work groups, and their expectations of
the individual, may affect the
performance of essential and
dependent on the presence of molecular . neurodevelopment, age, gender and discretionary tasks.
mechanisms whii:h are responsible for related. physical and social factors will Ina broader context, the economic and
such complex processes as cell growth, affect movement of the person. There is political envirorunents influence
division, metabolism, differentiation, a reciprocal relationship between movement. Econonúc considerations
and development. Excitation of cells in rnovement and these interna!physical include the indívidual's social economic
neural assemblies, nerve transduction, factors. Movement is influenced by status and society's econonúc climate.
electrical and chemical transport along genetically determined parameters such Legislation regarding accessibility and
membranes and acr()Sf synapses, as limb length or muscle fibre type eligibility to programs such as health
leading to muscle activation, are composition. At the same time, regular and other social services, will have an
complex micro level functions which physical activity can enhance movement impact on an individual's movement.
fonn the basis of movement. capability by altering adiposity, heart Por example, changes to building codes
The conduction of impulses along the dimensíons, musde capillarization and have the potential to increase or
nerve is dependent on the integrity of muscle enzyme activities. decrease accessibility for people with
neurological tissue; whereas, meaningful However, humans are not simply mobility, vísion and hearing disabilities.
and controlled movement requires passive, mechanical beings. They are Physical Therapy builds on these three
integrity in both the central and thinking, feeling, responding basic principles of movement by
peripheral nervous systems. Muscle individuals with needs and desires that considering both biophysiological and
activation and integration result from protjde the drive or motivation for them social-psychological influences. Based
controlled neurophysiological inputs to move. Psychological elements such as on the three basic principies cited above,
transmitted to the muscle at the personality, attitudes, emotions, and Physical Therapy further conceptualizes
neuromuscular junction. The muscle general well being, as well as cognitive movement in the following manner :
responds to these stimuli as well as abilities,are important factors affecting a IV. Movement levels on the
changes in length, external torque, and person' s motor learnirj or ability to continuum are interdependent.
proprioceptive input. Ali are influenced move. Depression or anxiety and Movement at each leve! on the
by neurochemical interactions of difficulties with motor learning, related continuum is influenced by movement
substances, many of which are still to cognition, may affect abili:t and at levels preceding and following. The
unidentiñed . willingness to move. Engel's 7 relationshlps are dynamic and
Neuromuscular activity is also biopsychosocial model explains how responsive to changes over time.
dependent on other factors. For these components can be integrated into Essential to Physical Therapy is the
examp1e, the physiologicalfunction of our understanding of the health of an understanding that movement has
cardiovascular, digestive and endocrine irtdividual. properties and relationships that emerge
systems are critical to normal muscle Movement is also influenced by as one moves from the micro to the
activity: Inaddition, timed stages of physical and social factors externa! to

PhusiotheraVtl Canada • Svrinr 1995 • Vol.47, No. 2 89

 macro ends of the continuum. For
example, a potential voltage difference
may exist at the cellular level, but goal Person

directed movement does not emerge

until the level of the functioning person.
Movement a t the micro levels becomes
the basis for the complexities of an
Externa! tactors
individual moving and interacting with
his or her envirorunent. For example, in Interna! factors
individuals who have had a stroke, the
status of descending tracts in the lndividual/environment
interface
brainstem has been related to wper
extremity motor perfonnance 1 ,
Macro
muscular perfonnance has been related
Continuum of movement
to gaít 19, and distance walked has been
linked to independence in community
ambulation20. Interference with
m.ovement at any 1evel has the potential Figure 1. Multídímensional movement contínuum.
to affect movement at the macro end of
the continuum . Conversely, influences
adversely affecting movement of the
total person can, in turn, affect considered in both the individual schematic is multídimensional: the
movements at the micro level. social-psychological context and the longitudinal dimension represents entry
Movernent at the level of the muscle larger physical and social contexts. points along the continuwn, and the
fibre, for example, is a refined process of These contexts shape how índividuals oroítal dimension, as seen
interaction between and within its view movement and how they act upon cross-sectionally, depicts influences
cornponent parts: the myofibril, the their rnovement needs. affecting movement at any level on the
sarcomeres and the actin and myosín In using this framework, Physícal continuurn .
filaments. To analyze movement or Therapy places emphasis on the intra V. At each level on the continuum
activation of the total muscle, the concept and interrelatedness of the interna! there is a ma::címum achievable
of motor unit recruitment must be components and functions of the body as movement potential (MAMP) which is
considered. When an individual body well as the influences from the external influenced by the MAMP at other
part is moved, there is a finely environment. For example, posture will levels on the continuum as well as
coordinated action between musde influence respiratíon, and. respiration, in physical, social, psychological and
agorústs, antagonists and/ or synergists turn, may influence arterial oxygen environmental factors. Each human ·
in their role of producing movernent tension and neural control of movement. being has a finite ability to move at each
aro\lll.d. a joint. The movement of the At the same time, the physical therapíst level on the movement continuum. This
total person involves a multitude of joint recognizes that there may be any theoretical upper limit is the Maxímum
and muscle actions as well as number of interna! factors influencing Achievable Movement Potential
neurological integration. Interference the person' s posture such as: a (MAMP) (Figure 2). The limits to the
with any level has the effect of altering neurological insult that has affected MAMP may be biologically determined
the whole. Inthe situatíon where an postural t:ontrol mechanisms;a scoliosis (capacity for movement at a joint,
individual is not moving freely within during growth and developmént;painful cardiovascular. performance);
his or her environment, the integration vertebral joints causing adjustment of psychologically. determined. (the
and coordination of movement can be posture; or a depressed mood affecting individual's motivation or interest in
affected, the muscles may atrophy, and posture and energy levels . The moving); and/or socially determine::!. (by
the amount of contractile protein may relationship between interna! and the presence of transportation services).
decrease21• The relationship between extemal factors is demonstrated by the MA.MP is usually determined by a
levels on the continuum can therefore be influence of daily work ergonomícs on combínation of these factors. Biologícal
affected in both directions. an individual's posture, such as the factors such as physiological
These interna! and external factors are habitual sitting or standing posture considerations and stage of development
variables affecting both the quantity and adopted to perform work-related tasks. assume more importance in setting the
quality of movement. Unique to The long-term interaetio'p between the limits on the micro end of the
Physical Therapy is the consíderation of individual and the envitürunent continuum. Social and environmental
the effects of varying pathologies on therefore has considerable influence on factors such as accessibility and
movement inaddition to these interna! movement. availability of resources asswne more
and externa! factors. Physical Therapy A cylindrical schematic can be used to importance in setting limits to moveinent
operates from an interactíve perspectíve represent The Movement Continuum at the macro end of the continuum. Each
that incorporates two concurrent Theory of Physical Therapy (see Figure individual will have a MAMP at each
standpoints; first, an understanding of 1). The concurrent círcles represent level of the Movement Contir\uum
physíological functioning and the effects orbits and suggest that the influences at determined by his or her particular
of pathology on the body; and second, an any level are not static and can affect combination of biological, psychologícal
understanding that movement must be movement in different ways. The and social factors.

qn Phusiother Wll Cano.da • Sprin!l 1995 • Vol. 47, No. 2

·
··--------·--··· ------------
 \ l&
.

preferred and current capability for

movernent at each level of the
continuum. For example, at the level of
joint movement, the MAMP, PMC and
CMC at a person' s shoulder joint are
influenced by a number of interna! and
externa! factors. First, he or she will
have a MAMP at the level of joint
movement that is determine:! by factors
such as genetically determined levels of
ligamentous laxity and age changes in
collagen which will affect the
extensibility of tissues. His or her CMC
will be determined by factors such as
previous and current levels of activity of
Birth Senescence
Tim"' (llfe span) the limb. These factors interact wíth
each other in their effect on movement as
B!i:l Maxímum acntevabie -Currenl movsrnent -Preferred movement well as with other interna! factors such
· movement poteritial cap;ibíllty capability
as habitual posture, injuries to the
tissues, changes in the circulation and
nutrition of the tissues. For example, a
ten year old swímrner will have a
Figure 2. Temporal profile of movement constraints. MAMP at the level of the shoulder joint
that is determined by gender, genetic
íactors, and stage of development, while
the CMC will be determined by his or
MAMP is influenced by age and limits to MAMP rnay be counterbalanced her level and duration of traíning.
gender, siage of development, and by changes inthe PMC will differ among individuals
presence of pathology. These factors individual/ environment interface wíth the same CMC. For example,
interact with each other. For example, through the use of energy saving devíces. whereas limited shoulder elevation may
the effects of a cerebrovascular insult on VI.Within the limits set by the be of little functional significance for a
MAMP may cliffér if it occurs prenatally, MAMP, each human being has a sedentary adult, it may represent a
during childhood or senescence. In each preferred movement capability (PMC) considerable concern for an athlete. In
of these instances, the interaction of and a cunent movement capability addition to the example of movement at
pathology and stage of development will (CMC) which in usual circumstances the joint level, the individual will have a
affect the MAMP. are the same. Although MAMP sets the MAMP, PMC and CMC at other levels:
"MA11P is not static, but varies over upper limit for movement ability, most the person (i.e. for walking), at the leve!
time according to the,physiological age indivíduals do not function at this leve! of the environment (i.e. stair climbing
of the individual, and the availability of on a regular basis. Instead, they function and social dancing), as well as at the
technology . Whereas biological aging at a level that is cornfortable to meet their leve! of the body part (ie. capability for
may set limits on exercise capacity, social basic everyday needs. For example, an peak contraction of the quadriceps) and
changes such as more disposable income individual' s choice of comfortable gait tissue leve! (i.e. capability for supplying
and!eisure time may actually increase speed is not always the same as hls or oxygen to a specific muscle).
22
movement potential in society. her maximum gait speed (MAMP). A Although differences may exist
Símilarly,activíty patterru; during person's usual leve! of movernent is between MAM1', PMC and CMC in a
childhood that are shaped by family, conceptualized as consistíng of the given individual or a given population,
peers and educational experience, wíll Preferred Movement Capability (PMC) in usual círcumstances they are ina state
influence exercise capacity duríng and the Current Movement Capability of balance or equilibrium. However, ali
adolescence and adulthood. As well, (CMC), which in most circumstances are three have the potentíal to change and
advanees in technology have increased the same (see Figure 2). PMC refers to do vary throughout a person's lífetime.
the MAMP of human beings in terms of the individual's chosen movement PMC can change over time depending
transportation and adaptation to the ability at the levels of goal-directed on changes in the individual's
environment. · movement and CMC efers to the circumstances and requirements for
Changes in :MA11P at one 1evel of the individual' s present i:Jovement ability. movement. For example, an individual
movement continuum can have Each individual has a unique set of may be capable of running a marathon
implications for MA1vfP at other levels. physical, social and psychological (MAMP) but chooses not to do so (Th1C).
For exarnple, íf an individual's characteristics whlch will determine his However, if that person then changes his
cardiovascular performance decreases or her MAMP,PMC and CMC. Within or her PMC and chooses to run a
due to cardiovascular disease,this wíll the limits set by MAMP, the particular marathon, this requires a change in the
also have implications for the biological physical and psychological CMC at the leve! of cardíovascular
limits to MA1vfP at the leveJ of characteristics of the individual, and the performance, strength and endurance.
movement of the person in his or her environment and society in which that CMC at each level of the continuurn is
environment. Conversely, the biological individual lives, he or she wíll have a subject to change throughout life due to

Phvsiotheraw Canada • Sprinf? 1995 • Vol. 47, No. 2 91

 a variety of factors including pathology,
usual activity pattems, work and leisure
activities. Sorne factors such as usual
activity and posture can be changed;
others such as hereditary or ]i
developmental factors are less 'E
modifiable. In addition, changes in an J:! '
o.
c '
individual's CMC at one level on the
1
movement continuum can have E ,
implications for CMC at other levels. Far .>
Q)
o
'

example, decreases in an individual's ::¡;; '

activity leve!by becoming more
sedentary will eventually affect his or her
CMC at the physiological level.
A range of externa! factors including Fracture 3 months post fracture
cultural, political and social norms Time (months)
related to the inditjdual's home, work, gMaxímum achievable 1111111! Curren! movement -Prelerred movement
and community can also have an ímpact movement patential capability capability
on his or her MAlvfP, PMC and CMC.
Within the physical envirorunent, the
individual will be influenced by the
physical set-up at home and work, the
amount and type of physical activity Figure 3, Hip fracture as an example of MAMP, PMC and CMC dysequilibrium.
performed, the availability of assistance
for physical work, the availabílity of
sports facilities and even the climate. For l\iAMP, PMC and CMC at the level of t:hat his or her CMC could be higher
example, the :tvfAMP of a disabled the body part will be changed post-fracture than pre-fracture.
individual at the level of the person in dramatically after a fall that results in a The differentiation between MAMP
his or her envirorunent rnay be lúp fracture (see Figure 3). and PMC is crucial to physical therapists
determined by the availability of Immediately post-fracture, MAMP at in planning interventions. If the physical
assistive technologies and human the level of the body part would be a few therapist is unaware of what the
resources. repetitions of less than usual hip limitations on movement are in a specific
Thirty years ago, the MAMP of movement. CMC could be less than or instance, he or she will be unable to
individuals who were quadriplegic equal to the individual's :MAMP. At that determine the appropriate intensity of ·
following poliomyelitis, was limited to particular moment in time, PMC may be therapy for that client and will be unable
remaining in bed ventilated. With the to move as little as possible due to pain. to help the client determine appropriate
development of portable ventilating However, in most cases, the eventual goals. The physical therapist needs to
devices and electric wheekhairs, the PMC would be to return to at least the know what movement to encourage at
MAMP of these individuals now same CMC as prior to the fracture. At any point in time to ensure maximum
Íncludes independent mobility around present, MAMP, PMC and CMC are no gains are achieved while minimizing the
their communities. However, the ability longer in balance, and a differential exists potential to further increase the
and frequency with which they function betvveen PMC and CMC. PMC/CMC differential.
at the level of their MAMP and take MAMP at the leve! of the body part VIII. The focus of Physical Therapy is
advantage of these new technologies will three months post fracture will be to minimize the potential and/or
depend on their PMC and CMC which affected by the nature and extent of the exísting PMOCMC diff erential.
may be limited by interest or an acute trauma, the medica! and surgical . Physical therapists usually become
illness that limits their ability to be up interventions, the degree of healing and involved.when the client presents with a
and about. Inthe latter instance, if they the course of recovery, the presence of CMC that differs from their PMC
would prefer to be up and about but underlying pathology leading to the fall, (PMC/CMC differential) or when there
cannot be, there would now exist a as well as the person's age, gender, and is the potential for a PMC/CMC
differential between the PMC and the usual activity 1evels23 . Depending on differential to develop at the levef of the
CMC. these factors, the 3 mont post-injury tissue, body part, body or ,Person!in the
VII. Pathological and developmental MAMl' may be equal or ij¡ss than the environment. This differel)tial may
factors have the potential to change the pre-injury MAMP. Within the limits set occur as a result of iUness, injury or
MAMP and/or create a different:ial by the 3 rnonth post-injury MAMP, the 3 developmental abnormalities. The focus
between the PMC and CMC. lliness, month post-fracture CMC cou).d of Physical Therapy is to minimize
injury and developmental factors ali conceivably be greater, equal or less than existing or potentíal PMC/CMC
ha ve the potential to temporarily or the pre-fracture CMC. For example, if differentials, thus enhancing movement.
perrnanently change MAMP, and/or the person fell because of general The physical therapist may accomplish
create a differential between PMC and deconditioning related to an increasingly this by acting as an advocate for the ·
CMC at different levels of the sedentary activity level, depending on client, by prornoting prevention
continuum. For example, a person's the course of recovery, it is conceivable strategies to groups of peóple, or by

92 Physioth f:ra py Canada • Sprinz 1995 • Vol.47, No. 2

------- ------ ---- -- --- .
 providíng direct treatrnent to findings of both. lnitial assessment physical environments within which the
indíviduals or groups. targets the leve! of the movement client is moving. The more uncertain the
The first step is to identify the potential impairment. This "entry level" is etiology, the broader the assessment
causes of a discrepancy between PMC suggested by the pathology, health and needed to develop an hypothesis of the
and CMC. MAMP is predicted for that social history and/or the individual's source of the PMC/CMC differential.
particular individual and PMC and concems. Initial assessment will target This may involve collecting further
CMC are determined. The movement or that level of the continuum . For infonnation from the person, his or her
activity of concern will be decided by example, if a person presents with a family and/ or from other professional
client preference. On assessment, the specific joint dysfunction such as pain sources. Once the data are collected the
physical therapist identifies the interna! and stiffness in the wrist, initial physical therapist establishes a list of the
and/or external factors which are assessment would enter the movement possible factors related to the PMC/CMC
constrairtlng the performance of that continuum at the leve1of single joint differential and establishes a clinical
activity and determines the appropriate movement. Ho':\'ever, if he or she diagnosis.
leve! of intervention. The decision as to presents with ari inability to perform a Most Physical Therapy rrúddle range
which treatment strategies will be the transfer from bed to chair, then the theory has been directed at identifying
most effective, requires an physical therapist's initial assessment sources of PMC/CMC differentials. For
understanding of the interaction of would target th continuum at the level example, the contributing factors to the
factors affecting movement as well as of combinations of joint movements. PMC/CMC movement differential in a
their potential for change at different (2) Scope of attention on the client with hemiplegía and the treatment
levels on the continuum. Moyement Contlnuum. The approach adopted will differ for
The physical therapist predicts MAMP interrelationships of the levels of the . physical thera ists who subscribe to
in each situation based on the client's movement continuum form the basis of Brunnstrom' s middle range theory in
history and usual pattems of activity, the clinical trunhng of the physical contrast to those who subscribe to
the therapist' s knowledge of pathology, therapist. The seope of attention on the bath's24. Similarly, middle range
and gender and age specific movement continuum is not limited to theories exist that postulate different ·
physiological parameters. Based on the the entry leve!. Once the leve! for entry contributing factora to PMC/CMC
above information, the physical has been determined, the physical differentials in clients with orthopaedic
therapist creates a hypothesis for therapist also as5esses the levels and respiratory conditions. However 1
MAMP. Por example, ifthe diagnosis is immediately preceding and following despite the underlying middle range
a complete spinal cord lesion at T12, the the entry leve!. For example, in the theory, the physical therapist will be
therapist would be aware that MAMP of situation of the individual presenting striving to minimize the PMC/CMC
this particular client would be unlikely with an inabílity to perform a transfer, differential.
to include independent ambulation although the enti;y level into the The aíro of Physical Therapy practice is
without aids. movement contiriuum would be at the to: 1) prevent deterioration of CMC to
The physical therapist and client level of combinations oÍ joint lower levels; 2) maintam CMC at the
identify PMC in each situation based on movements, attention would also be present leve!;and/or 3) improve CMC.
the person's needs, the predicted gíven to individual joint movements Physical Therapy ínterventions are
post-injury or illness-WMP and the (preceding Jevel on the continuum) as dírected at mirúmizing the PMC/CMC
potential for change in CMC. The initial well as increasingly complex transfers to dífferential at different levels of the
post-injury or illness MAMP and PMC a toilet or car (next level on the movement continuum. Although these
are often set tentatively and remain continuum) . Depending on the interventions may infl.uence movement
flexible depending on the person's uncertainty of tsources of the at all levels of the movement continuum1
response to Physical Therapy. MAMP PMC/CMC dif:ferential, the assessment they are usually specifically addressed at
and PMC are constantly re-evaluated as may continue to expand in both the middle range·of the continuum, from
Physical Therapy progresses. CMC is ditections along the movement the tissue leve! fo the movement of the
determined by a detailed¡assessment on continuum as indicated by the individual in the envíronment.
the part of the physical therapist. Unless therapist's clirúal findings. Although a clear understanding and
specifically contravened by MAMP or (3) lntemal and externa! factors that consideration of movement at levels
the PMC defined by the client, the airn of affect the Movement Continuum. The below and above this range on the
Physical Therapy would be to retum the physical therapist also considers the continuum are crucial to Physical
post-injury ar illness CMC to at least the factors in other systems that have Therapy practice these levels are not
level of the pre-injury or illness CMC implications for movement such as usually addressed dírectly.
whenever possible. cognitive capacity1 em,tional factors1 The interventíons chosen will depend
Three concepts are crucial to and physiological capacity. For on the potential modifiability of CMC
understanding the Physical Therapy example, consideratíon would be given and the level of the movement
apprc>ac to identifying the potential to the possibility of fear of falling in the continuum affected. If it is determine<:!
sources of a discrepancy between an elderly person who presents wíth an that the sources of the PMC/CMC
individual's PMC and CMC: inability to walk, yet has sufficient differential are potentially modiliable by
(1) Entry Level into the Movement strength and range of movement to changing intra-client factors {such as
ContJnuum. lnitial assessment consists allow for ambulation. Externa! muscle strength, joint range of motion or
of á client interview, physical influences on movement are also balance) then this becomes the focus of
asse8si:nent, plus the interpretation of the considered, particularly the social and treatrnent. However, if it is unlikely that

Phusi.otheravv Canada • StJrini;r 1995 • Vol. 47. No. 2

 CMC is modifiable by changing intemal Temporarily alleviating the tissue leve! affected level(s), and to ensure that
factors, the focus is shlfted to modifying factors that are increasing the movement at other related levels on the
extemal factors particularly at the PMC/CMC differential enhances the continuum is a!so enhanced.
individual-environment interface. The therapeutic movement at higher levels of DISCUSSION
level of the movement continuum where the continuum. This lessens the The Movement Continuum Theory of
the PMC/CMC dilierential occurs also PMC/CMC differential at all levels. Physical Therapy describes the urúque
influences the choice of intervention. Therapeutic movements and approach of physical therapists to
Different therapeutic movement modalities are interventions that target movement rehabilitation that
strategies form the primary basis of interna! factors. As well, interventions incorporates knowledge of pathology
Physical Therapy practice . These refer to such as the use of technology and with a holistic view of rnovement,
a range of physical and movement skills environmental modifications are used to including the influence of physical,
used to enhance CMC at different levels target externa! factors at the social and psychol!?8ical factors. It
of the movement continuum. These individual/ environment interface. builds on Hislop 1s9 Theory of
skills range from: These interventions are often selected Pathokinesiology by further developing
Therapeutlc movements pertormed when CMC is not sufficiently modifiable the notion of a continuwn to include
by the theraplst. These are speciali,zed through effect on interna! factors alone. more macro leve! influences.
techniques designed to increase CMC at Inthese instances, the PMC/CMC Placing movement on a continutun that
the level of the tissue and body part differential is minimized by targeting incorporates both micro and macro
through the hands-on intervention of the externa! factors influencing movement at levels has a number of advantages. First,
therapist (í.e. mobilizations, passive the level of the individual/ environment by focussing on movement rather than
movements, massage, mani.pulation and interface. These interventions may aTuo on dysfunction, the theory is able to
vibration). be used as a temporary measure, until accomodate prevention, wellness and
Therapeutlc movements where the interventions targeted at interna! factors health. Second, it is possible to position
theraplst physlcally facllltates the have had sufficient effect to a!low Physical Therapy within a broader
individual's movement. Therapeutic · movement without assistance. context that identifies the profession' s
movements are used where the therapist Therapeutic use of self is a critica! linkages to other movement sciences and
and the individual move together with component of all these Physical Therapy the physical and social sdences. Third,
th therapist using his or her body to interventions . The physical therapist the theory can be applied to both
support, guide, assist or resist the provides an integral aspect of any indiViduals and groups. This allows the
movement. These therapeutic intervention aimed at minimizing the concepts and principies to be useful in
movements are targeted at the leve! of PMC/CMC differenti.al. Therapeutic use the evaluation and management of
the body part and the body. of self involves the use of verbal and individual clients as well as in
Therapeutic movements that the non-verbal cornmunication throughout developing and evaluating programs for
individual performs under the the intervention that facilitates the groups of similar clients. Ali of these
direction or supervíslon of the individual's ability to understand and factors are key to the development of
theraplst. These therapeutic movements take control of his or her own educational curricula, research agendas
are accornplished by the individual movement. It includes behaviours such and professional strategic planning.
without physical assisnce but with the as listening. observing. reflecting, The theory moves beyond the current
. physical therapist guiding the questioning, demonstrating, shaping, task-oriented definitions of Physical
movement verbally. They are targeted at verbal reinforcement, encouragement, Therapy by providing a
the level of the body part, the body, or and counselling. Information is provided conceptualization of the rationale
the person in lús or her environment. at times and in ways so that the underlying all Physical Therapy practice.
These three therapeutic strategies may individual can hear and use the As such, it subsumes existing middle
be used in sequence. The goal of information. range theories. It does not attempt to
Physical Therapy, to move along the Concurrent with the use of these replace these middle range theories,
continuum to greater complexity of therapeutic strategies to enhance rather ít places them into an overall
movement, is paralleled by the flow of moveroent, the physical therapist selects framework that identifies common
the therapeutic inovement continmun appropriate information and educational concepts and overarching principles. It
towards more independent movement strategies to provide the dient with an is therefor not a treatment model.
by the individual. As movement unders¡anding of the nature of the Rather its purpose is to provide the
progresses along the continuum, so also movement problem. This information theoretical base on which treatment
will therapeutíc movement strategy includes the likely prognosis of the models will be developed specific to
change, depending on the entry level PMC/Ov.fC differential frith and various areas of practice.
into the movement continuum and the without treatment, and fue present and As with most theories, the Movement
underlying source of the PMC/CMC future behaviours that will minirnize the Continuum Theory of Physical Therapy
differential. PMC/CM:C differential.
will continue to evolve. However, as
Therapeutic movement strategies may The therapeutic strategies chosen are
presented, it contributes to further
be complemented by the use of often based on the middle range theory
discussion and theoretical development
modalities. Modalities are usually used subscnbed to by the physical therapist. within the profession, essential far the
when the source of the PMC/CMC Despite the approach used, the ongoing development and growth of
differential is at the tissue leve!, i.e. the underlying intent is always to minimize Physical Therapy.
presence of pain or swelling. the PMC/CMC differential at the

94 Phusiotheravv Can.ad.a • Svrin 1995 • Vol. 47,No. 2

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of Health, Education and Welfare Qystic Fibrosis

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e
ooo
o
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1986
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bilitation. American Sociological Did you know that 1 in 25
Association and Vocational Rehabilita-
Canadians is a carrier of a
tion Association and U.S. D epartment
defective gene csin g cystic
fibrosis? Chances are 1 in 4 that
a child born of two paren t
carriers will have CF. Support CF
research.
A Canadian
cg>
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1)h.1J"..;_,.,fh.<>rarn; C.'ano.da. • Svrim 1995 • Vol. 47.No. 2 95