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1986; 66:372-374.PHYS THER. Ruth B PurtiloRetrospective and Look Ahead
A−−Definitional Issues in Pathokinesiology
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Definitional Issues in Pathokinesiology— A Retrospective and Look Ahead
RUTH B. PURTILO
Key Words: Pathokinesiology, Physical therapy.
Ten years have passed since the concept of pathokinesiology was introduced into physical therapy. Examining it from a philosopher's perspective, this article provides a brief retrospective on how the concept originally was described, poses some questions about the type of concept it has become, and suggests what it might now be able to help the profession of physical therapy achieve.
INITIAL DESCRIPTION
What was the initial description of the concept of pathokinesiology! Many physical therapists in the audience experienced a swell of excitement—like a wave that had been approaching and suddenly broke at the shore—when His-lop introduced the term pathokinesiology into physical therapy during her presentation as a Mary McMillan lecturer stating, "What is physical therapy? Physical therapy is knowledge. Physical therapy is clinical science . . . pathokinesiology is the distinguishing clinical science of physical therapy."1
Even though she went on to develop other postulates and ideas, with this paragraph Hislop had taken a bold leap. She intended that the concept of pathokinesiology would provide physical therapy with a much needed identifying characteristic.
Physical therapy today is in the midst of a crisis of identity; it is, indeed, a profession in search of an identity This, of all times in our history, is a time for strong identification. We must ask ourselves if in our attempt to develop in multiple directions we have assumed a cloak of unidentifia-bility; if in our rhetoric we have transmogrified our ideals; and if in our desire for acceptance we have become victims of self-made delusion. Who,
my friends, if not we ourselves, is to speak for the spirit and essence (italics added] of physical therapy?1
In her description of it, pathokinesiology was viewed as critical to the uniqueness of physical therapy. Today, a decade later, pathokinesiology still seems to be accepted as a fundamental physical therapy concept. But because the profession of physical therapy has become developed and refined further in the 10 years since the concept was introduced, it is timely to reevaluate the concept in light of today's profession. No one would encourage this spirit of critical inquiry more enthusiastically than Hislop herself.
VALIDITY OF CURRENT CONCEPTS
On what basis today does the concept of pathokinesiology rest its validity in physical therapy! Any entity, including a concept, can become "real" or "believed in" as having its own validity. For instance, in many religious groups the presence of an afterlife is accepted as a reality. In physics, the formula E = MC2
is accepted as real. There are several methods by which humans "validate" that something is real. Some common methods are 1) someone in authority declaring it to be real, 2) transforming one real thing into another, 3) deductive methods, and 4) induction. In examining the concept of pathokinesiology, it is important to discern which of these methods most accurately describes the basis by which pathokinesiology can be said today to have validity in physical therapy.
Declaration
Probably the most famous example of something becoming real by an authoritative declaration is, "Let there be light, And there was light!" To what extent has pathokinesiology become a valid concept in physical therapy by virtue of
its having been declared "the essence of physical therapy"1 by a respected and revered member of the profession? Clearly, Hislop did not intend to bring it into being solely by saying that it was so. In fact, she solidly grounds her statements in evidence derived from anatomic and physiologic substrates, including exercise physiology, pathokinet-ics, biomechanics, and neuropathology.
Those who have used the term in the decade since it was introduced, however, may not have been as judicious as Hislop in developing a personal understanding of the nature and utility of the concept. Today, this places the profession in danger of treating the concept as a reality simply because for 10 years it has been among us as a "given" (and, of course, has a very scientific "ring"). Uncritical acceptance of any concept eventually coerces persons using the concept to point solely to the authority of the person who introduced it to validate that the concept is real. If physical therapists do not examine critically the concept of pathokinesiology, future generations of physical therapists are at risk of having to accept its validity on the basis that "Hislop [and others promoting the concept] said so." Hislop, herself, warns that such persons will "become victims of self-made delusions."1
Is a concept that has become real only because an authority declared it to be so of any utility? A concept created solely by declaration out of nothing may have a rhetorical utility for a time by persuading users of the term that they rest their identity on a solid conceptual foundation. Some declarations of this sort (eg, religious concepts) also are useful in helping to sustain belief systems that provide meaning and coherence to a person's existence. But by no means can a concept validated by authoritative declaration alone pass scientific scrutiny— a test many users of the concept of path-okinesiology have contended it should, and hoped it would, pass. Consequently,
Dr. Purtilo, is Professor and Chairman, Department of Medical Jurisprudence and Humanities, University of Nebraska Medical Center, 42nd and Dewey Ave, Omaha, NE 68105 (USA).
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PATHOKINESIOLOGY
the danger of disutility is greater than the promise of usefulness if pathokine-siology is simply such a concept, leaving the profession potentially holding the proverbial empty bag.
Alchemy Some concepts gain recognition as
being real by being transformed from an existing concept. That is, such a concept is made from something else that already exists rather than being created from nothing.
In his seminal book The Discovery of Nature, Albert Bettex describes in fetching detail how for almost 2,000 years investigations of many phenomena were governed by the principal of alchemy.2
Most alchemists worked with minerals and material elements. They also worked tirelessly to produce "the philosopher stone" from what they believed to be the basic substances of phosphorus and moisture. The philosopher stone would hold sway over metals and give the human being power over the process of transformation in matter. Many an alchemist's life was spent in pursuit of transforming tin, arsenic, or other common substances into the much hoped for gold.
One motivation of the alchemist was always the hope that there would be a progression toward a more precious substance; for instance, salt had been observed coming out of water. By way of analogy, concepts also can become real by alchemy. Over a period of time, an original concept can be applied to similar but distinct situations so that eventually a new concept replaces the old. The physical therapy concept of patho-kinesiology may have become transformed in this manner in the past 10 years. If this has happened, its utility could be that the concept as it originally was presented by Hislop, and which was useful at the time, has been transformed into a new, yet more accurately expressed and understood, concept. The extent to which this has occurred should become more apparent in the course of reading this series.
A potential disutility exists in the alchemist's approach, however. In alchemy, the result usually was distortion without refinement and sometimes also the loss of the scarce raw materials (in addition to the alchemist's life, should he be hapless enough to be employed by a king). Physical therapists, too, are capable of transforming the original con
cept—which other authors in this series propose has had validity since its introduction by Hislop—into something less essential, or totally nonessential, to the definition of the physical therapy profession.
An example of one distortion taking place is that today some writings about pathokinesiology make no mention whatsoever of the context in which this concept necessarily and integrally was placed by Hislop. The writers are guilty of quoting out of context. According to Hislop, the concept should be discussed and understood only within an overarching pyramidal framework that requires several levels of physical therapy intervention and has its foundations in social and cultural needs. Pathokinesiology, then, as Hislop meant it to be understood, should not be considered outside of a scientific and larger social cultural framework.
In summary, the alchemist developed and refined by working with existing entities, attempting always to improve the substance. The profession of physical therapy will benefit by examining the extent to which transformation into a refined concept might be replacing the original understanding of pathokinesiology. Mere distortion of the concept will lead to disutility, thwarting the goal of helping the profession establish its identity by reference to the concept of pathokinesiology, but refinement can benefit the profession greatly.
Deduction
Some concepts come into being as the result of a deductive process. In deduction, one begins with a basic set of premises and draws from it an understanding of a given phenomenon. Much can be accomplished by this approach. For example, in the late 1800s John Murray deduced the existence of Antarctica. In 1893, he presented to the Royal Geographic Society a correct description of the Antarctic continent, though he had never seen it. Annie Dillard reports:
In his presentation, the conclusions of which he had deduced, he posited a large single continent. Remarkably, he described accurately the continent's typology, including its central plateau, its high pressure system, the enormous glacier which faces the southern ocean, that it had volcanic ranges on one coast, and its lowland ranges and hills on the other.3
In other words, he deduced correctly knowing only the basic theories and the
circumstantial evidence that would support the phenomenon of a land mass exhibiting the various characteristics he described.
To what degree today might the concept of pathokinesiology be a deduced phenomenon? It is a not-so-well-kept secret that we proceed by deduction in some physical therapy procedures, relying less on hard science than on compelling circumstantial evidence.
The utility of a concept arrived at by deduction is that it may embrace many more perspectives than one very narrowly culled out by traditional inductive methods used in science as we know it today. Hislop's creative use of existing practice concepts and methods to discern that pathokinesiology is an important identifying characteristic of physical therapy exemplifies the best use of deductive reasoning, though she also attempted to substantiate the scientific basis of the concept. She was wise in attempting to use both methods in the development of the original concept because physical therapy today increasingly is required to substantiate its methods and the basis of its results scientifically. A concept of pathokinesiology based solely on deduction cannot assist the profession in meeting such a requirement.
Induction
Some phenomena of great utility have come into being as the result of the inductive (ie, scientific) method of inquiry. The emergence of the "magic bullet" is an example.4 The concept that a medicinal substance could be administered to decrease general observable signs and symptoms long has been deduced. However, for antibiotics to be discovered, developed, and understood, the theories, tools, and methods of modern scientific inquiry had to be used. In the justification presented to the American Physical Therapy Association to hold the 1984 Pathokinesiology symposium, the planners said that despite the movement to embrace pathokinesiology as the science of physical therapy, there is no existing retrievable literature in pathokinesiology; there is no theory in pathokinesiology; and without these two essential elements, there is no science of pathokinesiology. The concept of pathokinesiology has the most potential for furthering the profession of physical therapy if it can be demonstrated to
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be a scientifically based concept. Because this series in PHYSICAL THERAPY is devoted to examining the extent to which the science of pathokinesiology exists, nothing more will be said about it here.
In summary, despite the pervasive use of the concept of pathokinesiology as an identifying characteristic of physical therapy, it remains important to examine the grounds for accepting the concept. Today, a decade after the concept was introduced, it might be considered valid solely because it was declared to be, it might have become transformed into something other than its original meaning, it might be solely a deduced phenomenon, or it might be a scientifically derived phenomenon. Likely, it is some combination of the above.
TODAY'S TASKS
What, then, should physical therapists concerned about the concept of pathokinesiology today do? Above all, physical therapists must persevere in evaluating the concept critically and thoroughly. The concept of pathokinesiology surely will become chillingly vacuous or be reduced to simply a shrill slogan if phys
ical therapists neglect to engage in a diligent search for its roots and appropriate shape in today's practice of physical therapy. The charge to engage in continued scrutiny comes directly from Hislop.
I believe that we have the power to shape the future in ways that will vastly improve our condition. On the other hand, we also have the power to destroy our profession as we know it by wandering without a strong identity. The value of physical therapy to the total health care of the public can be assessed only within its [the public's] value system.1
What does the public value? Hislop concludes that the public asks of any profession that the profession have scientific merit, humanistic merit, and social goals. It follows that the concept of pathokinesiology cannot be evaluated accurately outside of the scientific or the larger humanistic and social context.
I hope that the 1984 symposium and this series of articles are not the end but only an important moment in the profession's ongoing inquiry into pathokinesiology as a guiding concept in the profession. In his 1979 Nobel prize lecture, Czeslaw Milosz appeared to have characteristics useful to physical therapists.
What is this enigmatic impulse that does not allow one to settle down in the achieved, the finished? I think it is a quest for reality. I give to this word its naive and solemn meaning, a meaning having nothing to do with philosophical debates of the last few centuries. It is the Earth as seen by Nils from the back of the gander and by the author of the Latin ode from the back of Pegasus. Undoubtedly, that Earth is and her riches cannot be exhausted by any description.5
Each physical therapist can be a part of that enigmatic impulse that moves the profession ahead in ways that will serve both the profession and society well. The examination of the concept of pathokinesiology is one small, but significant, example of the profession's quest for reality.
REFERENCES
1. Hislop HJ: Tenth Mary McMillan lecture: The Not-so-impossible dream. Phys Ther 55:1069-1080,1975
2. Bettex A: The Discovery of Nature. New York, NY, Simon & Schuster Inc. 1965, pp 9-16
3. Dillard A: Teaching a Stone to Talk: Expedition and Encounters. New York, NY, Harper & Row, Publishers Inc. 1983, pp 90-91
4. Lyons AS, Petrucelli RJ: Medicine: An Illustrated History. New York, NY, Harry N Abrams Inc. 1978, pp 589-590
5. Milosz C: Nobel Lecture (translated from Polish). New York, NY, Farrar, Straus & Giroux Inc. 1981, p 6
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1986; 66:372-374.PHYS THER. Ruth B PurtiloRetrospective and Look Ahead
A−−Definitional Issues in Pathokinesiology
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