The Use of Movement Scripts for Clinical Reasoning in Physical Therapist Education and Practice

Abstract

The purpose of this Perspective is to present an application of script-based reasoning to physical therapist education and practice. Illness script–based reasoning has been described as a cognitive strategy for medical practitioners to diagnose and manage health conditions. Analogous to this medical model of patient management, “movement scripts” can be used by physical therapists in clinical reasoning. Movement scripts use features of the human movement system to recognize, categorize, and substantiate clinical problems and can be used to facilitate the development of master adaptive learners across the spectrum of physical therapist education and practice. Movement scripts are also consistent with the concept of the “human body as teacher” as the signature pedagogy proposed by the National Study of Excellence and Innovation in Physical Therapy Education. Movement of the human body, as captured by the concept of the human movement system, is a vehicle for lifelong adaptive learning for the physical therapist. Script-based learning and practice are consistent with other elements of this model, including practice-based learning and the creation of adaptive expertise. As the role of the movement system as a guide to physical therapist practice continues to evolve, movement scripts can provide a structure to facilitate development of clinical reasoning skills for physical therapist practice and education.

Clinical Reasoning, Movement Script, Pedagogy

Background

Clinical reasoning is a fundamental skill for health care providers; however, the abstract nature of clinical reasoning makes teaching, learning, and measuring this construct an ongoing challenge. The American College of Physicians defines clinical reasoning as the “cognitive and non-cognitive processes by which a health care professional consciously and unconsciously interacts with the patient and environment to collect and interpret patient data, weigh the benefits and risks of actions, and understand patient preferences to determine a working diagnostic and therapeutic management plan whose purpose is to improve a patient’s well-being.”¹ The National Study of Excellence in Physical Therapist Education: Part 2—A Call to Reform, recommended that the profession “establish a comprehensive longitudinal approach for the development of learners’ clinical reasoning skills that spans entry-level (professional) education through clinical residencies.”² This requires that faculty in academic and clinical settings develop strategies for teaching, learning, and assessing clinical reasoning skills.²

Cutrer et al³ have described 2 kinds of expertise necessary for clinical reasoning: routine and adaptive. Routine expertise, effective for routine problem solving, involves the mastery of performance so that it becomes efficient and accurate. In contrast, adaptive expertise balances efficiency and innovation when the “routine approach” is not effective to solve a clinical problem. Adaptive expertise requires exploration and innovation to enhance learning using alternative problem-solving strategies. Cutrer et al suggest that clinicians must develop both routine and adaptive expertise.³ Congruent with work in medical education, the study of excellence in physical therapist education identified creating adaptive learners, able to demonstrate adaptive expertise, as a key element in the praxis of learning in physical therapist education.^2,4

Routine and adaptive expertise are closely tied to 2 contrasting reasoning strategies, hypothetico-deductive reasoning (HDR) and pattern recognition. HDR is characterized by the generation of hypotheses based on the presentation of clinical data and testing of these hypotheses in small steps through further examination and inquiry. HDR is a relatively slow process and is often used by clinicians who have less experience in the presenting problem space.⁵ In contrast to HDR, reasoning using pattern recognition is characterized by direct or automatic retrieval of information from a well-structured knowledge base in the presence of a pattern of cues generated from clinical data. Pattern recognition is closely tied to intuitive reasoning using rich knowledge structures and decreases reliance on the slower more methodical process of hypothesis testing.⁵ Understanding how individuals select and use these strategies is often difficult to determine.

The script concept, which originated from cognitive psychology,⁶ has proven to be a useful tool for improving understanding of the use of metacognition and behavior associated with clinical reasoning. The script concept has been applied across a wide variety of disciplines and settings including accounting,⁷ sports,⁸ and medicine.⁹ In medicine, illness scripts are defined as mental representations of clinical symptoms and findings that can be seen with a given disease.¹⁰ The concepts of routine and adaptive expertise in medicine and the health professions can be interpreted within the context of script-based reasoning and the use of illness scripts. We believe the script concept can be applied to physical therapist education and practice.

The American Physical Therapy Association (APTA) House of Delegates passed a motion to affirm the vision that the physical therapy profession will define and promote the movement system, the collection of systems (ie, cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal systems) that interact to move the body or its component parts. The APTA affirms this system as the foundation for optimizing movement to improve the health of society.¹¹ Additionally, the APTA asserts that the movement system is the basis of physical therapist education, research, and practice, and that “physical therapists provide a unique perspective on purposeful, precise, and efficient movement based on knowledge of the movement system and expertise on mobility and locomotion.”¹² In 2017, Jensen et al, through a comprehensive study of excellence in physical therapist education, put forth a conceptual model that suggests that the human body as teacher is a signature pedagogy of the profession and that the teaching of movement is unique to physical therapist education.^2,4 Framed around the concept of “human body as teacher,” a script-based approach that incorporates the movement system may provide an organizational structure to teaching across the physical therapist learner continuum (ie, professional level to residency education). The purpose of this Perspective is to describe an application of script-based reasoning, the movement script, to physical therapist education and practice. We propose that physical therapists use movement scripts in the process of clinical reasoning, and that script-based teaching can facilitate the development of both routine and adaptive expertise across the learner continuum.

Cognitive Scripts

Cognitive scripts are richly organized knowledge networks that are used for effective and efficient analytical thinking. Cognitive scripts are stored in long-term memory as stereotyped events or clusters of knowledge that are developed through routinely performed activities or by direct or vicarious experiences.⁶ The generalized clusters are connected by temporal, causal, or contextual relationships in a process known as “script activation.”⁹ Scripts contain variables or slots that can be used to compare an event that is occurring, or a new cluster of knowledge, with the existing script in a process known as “script instantiation.”⁹

In the process of script instantiation, a new event or cluster of knowledge is represented partly by a generic script and partly by contextual information in the new event. The new event is tagged to the generic script to form an “instantiated script” that is stored in long-term memory. Thus, new incoming information is integrated with existing knowledge to guide behavior or predict consequences of behavior. The new knowledge cluster tagged to the existing generic script decays over time and is replaced by a modified generic script as the more stable memory representation in a fluid, evolving process.⁹

Illness Scripts

Initially described in the medical reasoning literature, illness scripts are types of cognitive scripts that are used by health professionals in patient diagnosis and management.^9,13,14 Illness scripts are mental models developed by individual clinicians to categorize disease by clinical findings, risk factors, pathophysiology, and natural history. Clinicians develop these mental models through knowledge of and experience with a disease. Illness scripts consist of signs and symptoms and the relationships that link them together.^9,13

Illness scripts are high-level, precompiled conceptual knowledge structures that are stored in and can be retrieved from memory.^13,14 Illness scripts represent stereotypical or prototypical sequences present in clusters or patterns that are linked by temporal, causal, or hierarchical relationships. They contain values for attributes (ie, vital signs, lab values, focal and generalized symptoms) that are activated as whole sequences. For each attribute, default or expected values exist, and when the script is activated, the attributes are filled in with existing values and compared with default values.^9,13 Activation of a whole sequence of linked information expands the amount of information that can be considered in the process of clinical reasoning about a particular patient problem. Activation of an illness script allows bypass of the small-step approach of HDR reasoning and offers a major cognitive advantage, leading to increased efficiency and accuracy in clinical reasoning.^9,13–16 For example, activation of an illness script for lumbar stenosis may trigger comparison of the given attributes with the expected values for age range (>50), pain pattern (eg, expectation of diffuse pain in lower extremities), and exacerbating/alleviating factors (eg, worse with erect standing and better with sitting or leaning forward). Linking these presenting items, through activation of the illness script, allows for more efficiency in determining the likelihood of lumbar stenosis compared with analyzing these items separately as part of a comprehensive list of examination findings.

Illness scripts have 3 main components: enabling conditions, fault, and consequences. Enabling conditions include patient factors (ie, age and gender, genetics, and epigenetics in the form of a family history), and contextual factors (ie, description of health behaviors and environmental and social factors) that infer the probability that someone will get a disease or condition and are usually the data that are first accessed in the patient encounter.⁹ Fault describes the underlying physiological process, and this component relies on existing knowledge and experiences gained by the health professional. Consequences refer to the signs and symptoms presented by the patient. As an illness script is activated, information from the patient encounter that fits into the script slots can be processed faster than discordant information, leading to efficiency in the diagnostic and clinical reasoning process.⁹

The use of illness scripts and illness script generation has been well described in the medical literature.^9,13,14,16 In the first stage, as knowledge is gained through learning and experience, elaborate causal networks are developed and used to explain the causes and consequences of disease in terms of pathophysiology.¹⁴ In the second stage, the network is transformed into an abridged network in which information about clinical signs and symptoms is organized under diagnostic labels in a process called encapsulation.¹⁴ In the third stage, this network of knowledge is organized into the 3 components comprising an illness script (enabling conditions, fault, and consequences).^14,16 In the fourth stage, clinicians store these illness scripts as exemplars, prototypes, or global representations of disease categories.¹⁴ Clinicians learn to activate these scripts as they relate to previous patient experiences. Scripts can take the form of conceptual models, representational memories of specific syndromes, or memories of individual patients that illustrate typical presentations.¹⁴ In the process of developing illness scripts, purposeful reflection triggers script confirmation, in which scripts are stored in long-term memory for later access in the presence of triggering cues. Figure 1 illustrates the process of script formation in the context of clinical practice.

Figure 1

The stages of movement script formation.

For the experienced clinician, script activation is unconscious and little active clinical reasoning is required, as long as information matches an existing illness script. When there is conflict between the presenting symptoms and the illness script, the clinician must use HDR to resolve this conflict in a search for alternative hypotheses.¹⁵ For the less experienced practitioner, illness script activation might be conscious and incomplete, but with experience script activation may occur more accurately, automatically, and subconsciously in response to initial cues perceived in the clinical encounter. Thus, novice practitioners cannot rely as extensively on illness scripts, and part of clinical reasoning skill development must focus on the development of illness scripts.

Movement Scripts and Clinical Reasoning in Physical Therapy

As described above, the use of illness scripts for clinical reasoning has been well documented in medical education literature for more than 30 years.^9,13,14,16 The clinical reasoning process for the physical therapist is likely similar to the process used by physicians, although the types of information used by physical therapists are distinct. Physical therapists base their clinical reasoning around the movement system and the interrelationships of components of the movement system.^{4,11,12,17,18} We propose that physical therapists use a type of illness script, a “movement script,” to organize knowledge gained through the examination phase of patient/client management, and inform evaluation, diagnosis, prognosis, interventions, or outcomes. Script-based teaching using concepts foundational to the movement system can be used as an instructional strategy to support the signature pedagogy of the physical therapy profession.

Components of the illness script can be described in the context of the movement system. “Enabling conditions” should consider not only the intrinsic patient factors, but also personal characteristics and activity demands that exist as contextual factors modifying the interaction between human movement and the physical and social environment. “Fault” includes processes associated with the movement system including components of the physiological systems and their roles in human movement. Fault might derive from a physical or cognitive impairment or from pathological processes or might relate to disorders of movement or posture that led to an impairment. Finally, “consequences” are conceptualized as disorders in movement qualities, or abnormal responses to repeated movements or sustained biomechanical alignments. Consequences might also include psychosocial responses such as fear, anxiety, or movement avoidance.

Script-based learning is consistent with the development of expertise in physical therapy. Dual processing theory, Type 1 versus Type 2 thinking, has been used to compare the decision-making strategies of novice versus expert clinicians in routine and complex problem-solving tasks.^19,20 Novice clinicians solving routine problems, or experienced clinicians solving novel or complex problems, may tend to use Type 2, slow, methodical thinking characterized by HDR strategies. This type of reasoning tends to be time consuming and methodical and is significantly impacted by knowledge and experience. As clinical reasoning, reflection, and innovation skills develop, the developing practitioner will be better able to incorporate more efficient Type 1, fast, pattern recognition strategies.^19,20 Physical therapists likely use a combination of slow and fast thinking/reasoning as required by the complexity and familiarity with the problem space.²¹ Master adaptive learners continually develop and refine clinical information in the process of identifying patterns to create rich networks of knowledge that can be conceptualized as movement scripts.²⁰ According to the American Medical Association, “The master adaptive learner model makes an important distinction between routine expertise—mastering performance to the extent that it becomes highly efficient and accurate, drawing on the specific knowledge and skills that an expert has learned over time—and adaptive expertise, which is based on the ideal that individuals will learn and innovate in response to practice challenges.”²²

Figure 2 illustrates how the components of movement and illness scripts are related in the context of a patient with Parkinson disease. Clinical reasoning about a patient presenting with all the variables or slots consistent with the movement script would occur in a relatively quick, automatic, or effortless way, using fast thinking strategies. On the other hand, if the presenting patient had values for attributes that were not matched with the movement script, clinical reasoning might slow down and use hypothetic-deductive thinking to search for an explanation as the physical therapist focuses attentional resources on the anomalies or inconsistencies between the presenting case and the movement script. The information gleaned from the new exposure to the case can be used to refine and confirm the movement script associated with Parkinson disease in an iterative process.

Figure 2

Sample movement script describing Parkinson disease prototype.

For example, when presented with a patient case, the physical therapist might recognize the cardinal signs of tremor, bradykinesia, forward head and posture, and shuffling gait. Using Type 1 thinking, or pattern recognition, the physical therapist might activate 1 or more movement scripts, for example, Parkinson disease, Lewy body dementia, or drug toxicity. These scripts are triggered by the presence of enabling factors, faults, and consequences that identify the appropriate diagnosis, but also guide a confirmatory or exploratory examination plan. The physical therapist would then work through the activated movement scripts, using Type 2, or HDR, to confirm which one best fits the patient presentation. Physical therapists who have developed more routine expertise will have more well-constructed and accessible movement scripts, and those with more adaptive expertise will move the cognitive process of script instantiation and confirmation in a more efficient and effective manner. We suggest that experienced clinicians will use pattern recognition reasoning with simple cases as they go directly from data to classification using movement scripts as a knowledge structure. In contrast, difficult cases may trigger a more incremental process of hypothesis generation and testing.²³

Figure 3 illustrates the process of movement script–based clinical reasoning, and how it can be conceptualized within the patient client management model. Input for script generation occurs as clinicians gain knowledge through experience and learning in classroom and clinic settings. When confronted with a patient case, clinicians activate an existing script or scripts and seek information through the examination process (history, review of systems, tests and measures) to validate the script. Clinical data analyzed for congruency with the script include timeline, environment, presence of risk factors, and impairments and limitations identified in the patient examination. Thus, script output includes the components of the examination triggered in the process of script validation, confirmation of a diagnosis and prognosis, and development of a management plan and expected outcomes.²⁰

Figure 3

The process of movement script–based clinical reasoning, including components of script input and output.

The process of identifying and labeling information to develop movement scripts presents unique challenges due to the high variability of movement and because of the multidimensional nature of movement production. McClure et al¹⁷ have recently suggested that the 6-system movement system model adopted by the APTA is not easily translated into teaching, research, and practice. They have proposed a 4-element movement system model that uses a systematic description of movement qualities to guide education, practice, and research.¹⁷ These movement qualities—motion, force, energy, and motor control—may provide a framework for developing clinicians to formulate movement scripts. Identified impairments related to these 4 elements can be linked to specific movement-related activities to create a knowledge network representing a particular patient problem or health condition. For example, the person with Parkinson disease might show characteristic patterns of these 4 elements such as forward head posture and rigidity with decreased arm swing during gait (motion), generalized weakness of trunk and extremities (force), poor musculoskeletal endurance and bradykinesia (energy), and slowed balance responses and shuffling gait (motor control). These characteristics patterns may be linked together as a mental representation of the movement script for Parkinson disease.

Implications for Physical Therapist Education

Knowledge acquisition and development of knowledge structures and networks are important steps in the process of development of clinical reasoning skills. The process of clinical reasoning strengthens or weakens links between concepts or elements of the knowledge networks.¹⁴ Transformative learning occurs when prior knowledge is used to construct a new revised interpretation that guides future action. Learners can be facilitated to construct a new understanding through their own reasoning activities.²⁴

Specific education strategies can be used to assist developing practitioners to construct a rich library of knowledge networks in the form of movement scripts. Encapsulation and script formation should be supported by integration of basic and clinical sciences early in curricula.¹⁴ Teaching must focus on structure and organization of that knowledge and facilitate the development of knowledge representations in the form of scripts.^10,25 In this context, movement scripts cannot be transmitted or taught, but rather must be constructed by the learner. Thus, novice learners in physical therapist professional education programs must be offered opportunities to actively engage in the educational activity. Exposure can advance from protected clinical reasoning in simulated experiences with standardized patients to experiences with real patients in real-world environments with imposing timeframes and consequences.²⁴ Authentic clinical reasoning with real patients is more complex than reasoning on data that are presented, because reasoning happens simultaneously with data collection.¹⁵ Focused discussion and reflection in action about knowledge connections made during patient encounters fosters and strengthens these connections.

Throughout the learning continuum, teaching and learning activities must be constructed to encourage the linkage of new information to prior knowledge by activating an existing generic script. Teachers should minimize lengthy discussions of complex and unusual cases that neither instantiate the existing scripts nor lead to development of new relevant movement scripts. Teaching of clinical reasoning should focus on knowledge representation and structure rather than simple content knowledge by facilitating the enhancement of skills in acquisition, storage, and recall of knowledge in memory.¹⁰ Emphasis on knowledge representation through script-based teaching can be accomplished by compare/contrast and prototypic patient assignments, and development of algorithms and flow charts.¹⁰

Stages of clinical reasoning can be made explicit by using techniques such as “reflection in/on action.”¹⁴ Think-aloud strategies, in which the learner engages with an expert illustrating clinical reasoning using their own movement scripts, can validate this method of clinical reasoning for the learner.¹⁶ Script-based teaching tools used in classroom settings, such as problem-based or case-based learning activities, and self-explanations can be used to develop and instantiate movement scripts.¹⁶ Problem- or case-based learning strategies help learners to link new knowledge to existing knowledge. This encourages script formation more efficiently than rote-learning strategies. Learners should be encouraged to use self-explanation techniques, either through internal or external dialogues. Teachers can provide guiding questions for textbook readings to help learners integrate and organize information. Finally, the creation of concept maps, mind maps, and other schematic representations of attributes and features of a case can facilitate script generation.¹⁶

Clinical teachers can also emphasize techniques that support movement script formation. Early contact with real patients with common diagnoses provides opportunities for script development. Clinical teachers should encourage learners to create a synopsis of a case using terms that interrelate components of the movement system and reference a movement script. They should also model their own use of movement scripts and share this through think-aloud strategies that link the presenting problem to their own script, highlighting discriminating features by comparing data with the relevant default values on their activated scripts.¹⁶

Paying attention to the language of the learner during observation of performance in the practice environment or during think-aloud activities can help educators determine if and how script-based reasoning is being used. When describing a clinical case, novice practitioners tend to recite exhaustive amounts of data that are heavily focused on fault-related knowledge. As clinicians develop, they are better able to summarize features of a case in a way that captures significant information and links it together with increasing emphasis on enabling conditions.¹⁴ Clinical teachers can assess the extent to which learners are using script-based clinical reasoning by attending to the types of descriptors they use. This also provides an opportunity for the teacher to reinforce the use of appropriate attributes of a movement script and correct erroneous processing.¹⁶ To exemplify this concept, Table 1 compares representations of patient cases that might be made by novice learners with those typical of master adaptive learners. Case 2 provides an example of linking faults with consequences in the description: “the quality of his transitions between positions is probably limited due to weight shifting with decreased trunk rotation.”

Table 1

Comparison of Case Descriptions by Novice Learners and Master Adaptive Learners Using Script-Based Clinical Reasoning

Case Presentation as a Patient Story	Novice Learner Representation	Master Adaptive Learner Using Movement Script
Case 1
Three weeks ago, I was hurt in a car accident and was taken to my local hospital where they operated on my neck. I have been in this collar since the operation. They said I broke my neck high up and that the location affected my breathing. I had a tube in my mouth for a few days that helped me breathe, but now I just need a thick mask at night. Since the accident I cannot move my arms or legs very well or walk. I need 2 people to help me move around in bed and sit and stand. They help me walk with special crutches too. I came here yesterday for rehab to help me get strong again.“	This is a 52-year-old male who was involved in a motor vehicle accident 3 weeks ago. He sustained a cervical injury which was managed with surgery and immobilization with a cervical collar. He was previously intubated. He can roll side-to-side, come to sitting and standing, and take a few steps with crutches and assistance of 2 people. He uses breathing support at night. He was transferred here yesterday for rehab.	This patient is relatively high functioning, most likely classified as incomplete, American Spinal Injury Association Impairment Scale C or D, giving him good potential for independent ambulation with an assistive device. He has restrictive lung disease due to respiratory muscle impairment associated with the level of his injury, but his diaphragm appears to have been primarily preserved. Respiratory muscle performance testing and training will be important to help wean patient from night-time continuous positive airway pressure. Although his lungs appear to be clear of infiltrate at this time, airway clearance techniques will be important to include since his vital capacity is decreased (associated with level of injury). In addition to a respiratory muscle endurance and strengthening program, ambulation, aerobic training, and thoracic stretching will help improve his musculoskeletal pump and cough effectiveness. This will hopefully prevent pulmonary infections that he is at risk for given his level of injury and current limited mobility.
Case 2
“This is my son Jack, and he just celebrated his second birthday. We are here to help him learn to sit and walk. My wife had problems carrying him when she was pregnant, and he was born about 2 months early. He was delivered normally but had to stay in the hospital in a special nursery, the neonatal intensive care unit, for 2 months due to problems with breathing and eating. He is “stiffer” than I remember his siblings being especially in the legs more than the arms. He can roll by himself and get into and out of sitting. He sits a funny way—like a “W.” He can take steps when we stand him to walk, but his legs cross.“	Jack is a 2-year-old male born 2 months prematurely. He was kept in the hospital neonatal intensive care unit for 2 months due to breathing and feeding problems. Based on caregiver report, he is delayed in sitting and walking skills. His lower extremities are stiff and cross when walking with his caregiver’s support possibly due to a range of motion limitation, tone, or strength.	Jack is now approximately 18 months adjusted age and based on caregiver report of his medical and birth history, may have cerebral palsy, spastic diplegia. He was born preterm and spent 2 months in the neonatal intensive care unit where he received treatment to address breathing and feeding issues. He demonstrates significant gross motor delay with stiffness in the lower extremities > upper extremities and possible spasticity in the hip adductors. The quality of his transitions between positions is probably limited due to weight shifting with decreased trunk rotation. He is using a “W” posture to possibly compensate for trunk weakness.
Case 3
Patient presents s/p fall and recurrent pneumonia. Patient states that she has had shortness of breath, which has progressively worsened over the course of the last week. She reports this occurred 3 months ago and was given nebulizer treatments which helped. Patient also reports that 2 days ago the patient was walking out her back door and fell. She states that this happens at least once a week but can catch herself by grabbing onto someone or something in her house.	My patient is an 82-year-old female who complains of shortness of breath which has worsened over the last week. She states the same thing happened a few months ago and was successfully treated. She also reports she fell at home while walking out of her back door. She states that she has lost her balance before but reports furniture walking at home due to fear of falling.	My patient is an 82-year-old female who presents s/p fall while stepping over door threshold to exit back door. Patient reports extensive fall history with no history of use of assistive device or physical therapy intervention. Patient demonstrates increased thoracic kyphosis with increased risk of osteoporosis and vertebral fracture as the patient demonstrates 2 finger rib-to-pelvis distance. Patient also demonstrates poor diaphragmatic recruitment due to posture with increased accessory muscle use, which puts her at continued risk for recurrent pneumonia. She walks with decreased base of support and small step length, looking at feet.

Clinical teachers can search for critical cues, such as semantic qualifiers, or paired opposing descriptors to determine whether the learner is using movement scripts for clinical reasoning. Semantic qualifiers are words that are used to compare hypotheses related to diagnosis and management of patients.¹⁶ In order to use these qualifiers, the learner must have stored knowledge as movement scripts that can be instantiated as a patient representation triggers script activation. For example, Table 1 uses language that suggests a higher level of processing in which opposing explanations are considered, such as the descriptive cues to indicate “restrictive lung disease” in Case 1, and “decreased base of support and small step length” to describe gait abnormalities in reference to normal gait in Case 3.

In the context of postprofessional physical therapist residency and fellowship education, calibrating exposure, with frequent and repeated exposure to common diagnoses and less frequent exposure to rarer diagnoses, will help learners to optimally develop movement scripts over time using the process of script activation, instantiation, and confirmation. These movement scripts become updated through knowledge and learning in both didactic and clinical settings.¹⁶ Therefore, planned, progressive, and moderated clinical exposure to conditions and processes within a defined area of specialty or subspecialty practice must be a central tenet of curricular design in both professional and postprofessional education.

Although movement scripts can support clinical reasoning using pattern recognition processes, individual experiences will impact the frequency, quality, and complexity of movement script generation and instantiation. Errors in clinical reasoning can occur from inappropriate use of movement scripts that introduces bias (eg, confirmation bias and premature closure).²⁶ This can occur in both the less experienced clinician who has poorly developed movement scripts, or in more experienced clinicians who fail to reflect on their logical reasoning in instantiating and confirming more than 1 script.²⁶ For the learner in a clinical practice environment, planned exposure to common movement-related health conditions should be balanced by exposure to atypical presentations, so that learners can experience logical reasoning when a movement script does not fit the patient presentation.

Errors can occur when fast script-based thinking is used in complex and less familiar situations.²¹ The more experienced clinician must be cautious in overconfidence and overuse of the script instantiation process and can benefit from the use of metacognitive strategies in the clinical reasoning process to validate the use of movement scripts in clinical reasoning. Reducing the risk of clinical reasoning error can be accomplished by both knowledge acquisition and organization for less experienced clinicians, and by metacognitive strategies for the more experienced clinicians.²⁶ Metacognition and reflection can be used to analyze what thinking strategies were used in clinical reasoning and whether those strategies are appropriate for the complexity and familiarity of the problem.²¹ To reduce errors and bias, clinicians should strive to be aware of their reliance on movement scripts and acknowledge when they cannot match a presenting problem with an existing script. For the learner in a clinical practice environment, planned exposure to common movement-related health conditions should be balanced by exposure to atypical presentations, so that learners can experience logical reasoning when a movement script does not fit the patient presentation.

Movement Script as a Bridge Between Paradigms

As adoption of the movement system model by the physical therapy profession advances, debate is certain to continue around identification of the key defining elements for the movement system.^17,27,28 For example, Guccione et al²⁹ have proposed a dynamical systems approach to clinical reasoning. In this approach, the value of diagnostic labels is minimized, and it is proposed that clinicians should focus their clinical reasoning on “What is likely to happen over time?” instead of a static understanding of “What is the underlying impairment?“²⁹ However, we do not think that adoption of the movement system model excludes the use of the dynamical systems approach. In fact, we suggest that both can be used synergistically in the development of movement scripts. Because movement scripts are mental models that are individualized to each clinician/learner, focusing on improved ability to develop movement scripts, rather than on the identification of specific diagnoses, provides flexibility in the clinical reasoning process. Thus, clinicians and learners can continue to adapt and refine the ability to identify meaningful movement scripts knowing that the professional context and interpretation of these movement scripts is likely to change over time. For example, the diagnostic labels and descriptors commonly used for lumbopelvic pain syndromes have changed significantly over the last 20 years as our understanding of pain neurophysiology and the neuromuscular responses to pain has grown. However, for many therapists who worked with these patients over this period, these changes were experienced as a gradual evolution of the movement scripts used rather than as an abrupt shedding of one paradigm in favor of another.

Conclusion

For the physical therapy profession, development of a model of movement script–based clinical reasoning can help to integrate and reinforce the movement system as the signature pedagogy and as a foundation for practice. Incorporation of movement script–based methods into didactic and clinical teaching spans the entire continuum of physical therapist education. Movement scripts can be used by clinicians to support continuing professional development and lifelong learning through metacognitive processes. Master adaptive learners are constantly modifying and expanding their knowledge base, and movement scripts can help conceptualize how this occurs.

As with all concepts, adoption of the movement script concept has limitations and challenges. One notable challenge for developing research and guidelines is that movement scripts represent a cognitive process that cannot be directly measured or known. Although master adaptive learners should share many common aspects of their movement scripts, and the movement scripts of novice clinicians should grow more aligned with these common aspects as they progress in their professional development, ultimately movement scripts are individualized mental models, and usage and utility can only be inferred. Further, an overemphasis on movement scripts in physical therapist education, without the proper context, could lead clinicians to overly rely on heuristics or pattern recognition, which is a faster but more error prone form of reasoning.²¹

More research is needed to examine how education strategies and patient contact might affect the development of movement scripts across the learner continuum. We suggest that movement scripts can provide structure to guide development of clinical reasoning skills as the role of the movement system to guide physical therapist practice and education continues to evolve.

Author Contributions

Concept/idea/research design: N.J. Kirk-Sanchez, J.G. Moore, G. Hartley, M. Wong

Writing: N.J. Kirk-Sanchez, J.G. Moore, G. Hartley, M. Wong

Funding

There are no funders to report for this work.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.