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Professional Perspective

Theory: The Guide to Clinical Practice and Research

Physical therapists are becoming increasingly aware of the importance of theory

in physical therapy research and practice. In this article, we dejine theory and dis-
Julie Tammivaara
Katherine F Shepard
cuss its uses in both clinical practice and clinical research. We argue that both the
quality of current practice and growth of physical therapy as a profession will be
enhanced as more physical therapists appreciate and use theory to guide their
work. [TammivaaraJ, Shepard kF Theory: the guide to clinical practice and
research. Phys Ther. 1990;70:578-582.1

Key Words: Clinical protocols; Models, theoretical; Research design; Tbeoretical

technics.

One hallmark of a profession is a
unique core of knowledge. Profes-
sional knowledge arises from
research central to the concerns of
those who practice the profession.
For the engineer, research focuses on
how matter and energy can be uti-
lized; for the lawyer, research centers
on issues of justice; for the physical
therapist, research is concentrated on
understanding physical movement,
including its pathologies and treat-
ment, and concerns about communi-
cation in the clinical setting.
During the past 10 years, there has
been a dramatic increase in physical
therapy research as evidenced by the
number and breadth of research stud-
ies published in Physical Therapy,
presented at American Physical Ther-
apy Association (APTA) Combined
Sections Meetings and Annual Confer-
ences, and funded by The Foundation
for Physical Therapy Inc. Concur-
rently, physical therapists have strug-
gled to identify the core of knowl-
edge upon which their practice is
established. How are physical thera-
pists different from exercise physiolo-
gists, kinesiologists, and physiatrists?
Are their research programs leading
them to develop and test knowledge
that is unique to physical therapy
practice?
From several sources, physical ther-
apy educators and practitioners are
hearing that a significant element in
the development of a core of knowl-
edge is too often missing in research
reports. Articles published in physical
therapy journals, organizers of confer-
ences, and various hearings have
focused on encouraging researchers
to include this missing element: the-
ory. Research that focuses on studies
of the mechanical tools of physical
therapy or that is limited by a too-
narrow view of what constitutes valid
research methods does not favor the
development of this core of knowl-
edge. Although much of this research
is very good, it is limited in its useful-
ness to the practitioner. For example,
there are numerous studies on the
reliability and validity of instruments
such as goniometers and electrical
stimulators that lack an underlying
explanatory framework and thus do
not lead to new areas of research.
Second, researchers overly rely on
methodologies, be they descriptive,
quasi-experimental, or experimental,
that produce data that can be ana-
lyzed statistically.Although statistical
studies are appropriate for many
important research questions, a reluc-
tance to use other analytical proce-
dures limits the growth of the field.
There are too few studies that are
designed, for example, to examine
patients and practices longitudinally
and too few studies of intervention
and outcome for patients with com-
plex conditions such as neurologically
involved children or frail elders.

J Tammivaara, PhD, is Associate Professor of Doctoral Studies in Education, Gonzaga University, Although each piece of research con-
Spokane, WA 99258 (IJSA). Address all correspondence to Dr Tamrnivaara. tributed by physical therapists does
add to the collective knowledge of
K Shepard, PhD, PT, FAPTA, is Associate Professor, Department of Physical Therapy, College of
. .
Allied Health Professions., Temolc Universitv. Philadelohia., PA., 19140.
-
certain aspects of the practice, the
sum of this atheoretical research does
This article was submitted Augtcs124, 1989, and was accepted May IG, 1990

56 / 578 Physical TherapyNolume 70, Number 9/September 1990

not advance an integrated understand-
ing of the complex interplay among
body systems in normal and patholog-
ical states or the overlay of pain and
social factors that influence human
movement and function. If research
continues to be limited in these ways,
the goal of a distinctive core of
physical therapy knowledge will not
be met.
For many years, the typical physical
therapy research report has begun
with a brief discussion of prior stud-
ies to which the present study is
related, followed by a presentation of
the design and procedures of the
study, and concluding with a discus-
sion of the results of the study and
exhortations to carry out more such
studies on more subjects in more set-
tings. Absent in such reports is a pre-
sentation of the theory underlying the
research questions. As a result,
authors are unable to connect their
work with what is known in a mean-
ingful way and they are unable to
draw logical implications for future
research. Without the connectedness
of theory, researchers are equally
unable to challenge longstanding
beliefs related to practice.
One of the impediments to the use of
theory in research and practice is, we
believe, a failure to understand what
theory is. For some, theory is seen as
the synthesis of previous research
studies on a given topic. For others,
theory is taken as diffuse and self-
evident statements such as "Applica-
tion of cold reduces swelling." Ampli-
fication of this "theory," such as what
circumstances must prevail for it to
be true (scope conditions), what
other propositions relate to this one,
and so fbrth, is omitted. For still other
professionals, theory is thought to
reside in dusty tomes that are prop-
erly ignored because theory is
believed to have little relevance to
clinical practice.
People .who choose active, involving,
practical avenues of work such as
physical therapy are often impatient
with the notion of theory. As students,
they want (and who can blame them?)
to absorb the kind of information that
Physical. Therapyflolume 70, Number 9/September 1990
can be put to immediate use, whether
it be learning a new modality pur-
ported to relieve pain, observing a
new technique that promises to accel-
erate a child's sitting balance, or
manipulating an adjustable orthosis to
provide optimal equilibrium between
stability and flexibility. As educators
and practitioners, physical therapists
attend conferences, enroll in continu-
ing education courses, read journals,
and consult with colleagues, ever on
the lookout for good ideas that can
be quickly and efficiently applied to
practical settings. Too often, physical
therapists are much less interested in
why things happen the way they d o
than in discovering how to effect
desired results.
Over time, physical therapists add to
their repertoires of skills or "bags of
tricks." Sometimes a trick will work:
the pain will be relieved, the child
will sit up more quickly, a patient's
gait will improve . . . and sometimes
those things will not happen. Thera-
pists have no way of determining why
a procedure works (or does not),
because a framework connecting the
critical elements of and explaining the
phenomenon is missing. In the
absence of such a framework, thera-
pists are hampered in their efforts to
invent sensible solutions to clinical
challenges; they have less power than
they might to control decisions in
clinical practice. The framework they
are missing is theory.
Nonetheless, physical therapists are
beginning to recognize the impor-
tance of theory. In a recent article in
Physical Therapy, Krebs and Harris
stated, "Theory presentation is per-
haps the most important contribution
a professional can make to the litera-
ture in his or her field."lW90) At the
1988 Joint Congress of the APTA and
the Canadian Physiotherapy Associa-
tion in Las Vegas, Nev, an open forum
on theory was presented by the then-
active APTA Committee on Research.
During this forum, enthusiastic partici-
pants discussed the working docu-
ment "Goals and Objectives for
Development of Theory in Physical
Therapy." One result of the forum is
the requirement that manuscripts sub-
mitted to Physical Therapy be
reviewed for the inclusion of a theo-
retical framework. We hope that this
article will add to the understanding
and use of theory and continue the
theoretical conversation. The pur-
poses of this article are to define the-
ory and to give some general as well
as physical therapy examples of how
theory is and can be used to guide
clinical thinking and research.
What Is Theory?
Theory is a word encompassing two
concepts: contemplation and observa-
tion. (The Greek root for theory, thea,
meaning "a viewing," is also the root
for theater.) Through contemplation
and observation, theories o r ideas
about how things relate are devel-
oped. A theory, then, is a distillation
of diverse experiences and notions
such that they can be tied together in
a sensible and powerful bundle. In
other words, theory is a system of
wide-ranging ideas about some cen-
trally important physical or social
issue.
Because theory is built on and con-
sists of ideas, it is by nature abstract.
This can be irksome for many physi-
cal therapy professionals, particularly
those who are committed to and find
most rewarding the "hands-on" aspect
of physical therapy. If something is
abstract, they reason, it is not relevant
to clinicians who are faced with doing
something, now. To the contrary, we
shall argue that it is theory's very
abstractness that makes it especially
relevant to the clinician.
Perhaps an analogy is in order. Con-
sider the frozen-foods section of the
supermarket. There you may select
concentrates of apple, orange, lemon,
grape, and many other fruits. From a
lemon concentrate, for example, one
can make lemonade by adding water,
a lemon cake by substituting the
lemon concentrate for water, lemon
popsicles by adding water and freez-
ing the resulting liquid, salad dressing
by using the concentrate as the acetic
ingredient, and so on. On the other
hand, very few, if any, people would
consume the lemon concentrate by
itself. In the same way, theories are
seldom, if ever, useful by themselves;
they are useful when they are applied
in practical situations. If the concen-
trate is the theory and the lemonade,
lemon cake, lemon popsicle, and
salad dressing are the practical situa-
tions, one can readily see how much
more versatile the concentrate is than
any one of its products. To delve a
little deeper, by contemplating the
lemon concentrate further, one can
see that it is an acetic substance that
can be used in any situation wherein
an edible acid might be needed.
Earlier we stated that a theory is sen-
sible and powerful, that it consists of
a system of wide-ranging ideas about
some important issue. In the lemon-
concentrate example, the concentrate
represents the sensibleness and sys-
tem of the definition; the products in
which it is used represent the power
and wide-ranging aspect of the defini-
tion. The acetic quality of the concen-
trate underlies its importance; under-
standing this, the consumer is free to
invent uses and apply the concentrate
to an infinite number of practical con-
cerns. Thus, theory connects to practi-
cal situations just as the concentrate
connects the lemon with lemonade;
theory connects the past with the pre-
sent and the future. Just as the con-
centrate is the basis for the creation
of many products, theory lays the
groundwork for many sensible and
inventive approaches to practical
issues. In sum, theory provides both a
perspective for understanding and a
basis for effective action.
Earlier we asserted that a theory is a
set of wide-ranging ideas about some
physically or socially significant phe-
nomenon, that theories connect ideas
in a way that helps people understand
phenomena and that helps guide peo-
ple's practical decisions. Theories
have existed and have been used
throughout recorded history. They are
dynamic in that they evolve as new
insights are added to a profession's
body of knowledge. What is the
meaning of theory for physical
therapy?
Use of Theoy in
Clinical Practlce
Upon examination, one discovers that
the practice of physical therapy has a
"shape." For some, the shape is more
defined than for others; nonetheless,
a form is discernible. This shape is
determined by the theories (systems
of wide-ranging ideas) physical thera-
pists hold about the construction and
function of the human body. Physical
therapists, as d o other health care
professionals, evaluate and treat
patients according to the usually
implicit theories they hold.
For example, is the movement from
lying to standing based on the evolu-
tion of righting abilities in the matur-
ing child (theory of maturation of
righting abilities) o r does there exist a
life-span evolution of movement (the-
ory of evolution across individuals
and time)?2 If one practiced according
to the tenets of the theory of matura-
tion of righting abilities, one would
teach an elderly person to come from
lying to standing using the same
movement sequence a typical 6-year-
old child would use. Alternatively, if
one practiced according to the tenets
of the life-span evolution theory, one
would teach an elderly person to rise
using any one of a number of move-
ment sequences based on the
patient's age, flexibility, and body
shape.
In another example of how theory is
intimately tied to practice, consider
soft tissue swelling. Can the swelling
resulting from a sprained ankle be
decreased by the application of cold,
based on the theory that cold mini-
mizes the inflammatory process, or by
alternate applications of heat and
cold, based on the theory that alter-
nating vasodilation and vasoconstric-
tion results in a pumping action that
removes excess fluid?j Depending on
which theory the therapist uses, the
patient would receive either cold
treatment or alternating heat and cold
treatments. If these theories were sys-
tematically tested and appropriately
revised, it is possible that one theory
would hold for some conditions in
which swelling injuries occur whereas
Physical Therapyllrolume 70, Number 9/September 1990
the other theory would suit different
conditions of injury.
The different conditions of injury are
an example of scope conditions that
delimit the situations in which the
theory can be expected to be useful.
When a treatment does not work as
expected, a therapist aware of the
power and usefulness of theory, after
ruling out more immediate causes,
might ask whether the conditions
under which the treatment is sup-
posed to work (ie, the theory under-
lying it) have been met. If so, perhaps
the theory needs revision; if not, per-
haps the application of another theory
would be in order.
If the foregoing argument is accepted,
the reader should be persuaded that
theory is neither irrelevant nor eso-
teric. The problem facing many
practice-oriented professions is that
clinicians are too often unaware of
what theories they are using and how
these theories are helpful. Thus, a
given individual's practice may lack
coherence and may even contain con-
tradictions. If clinicians do not know
and do not reflect upon the theories
they are using, treatments may be
inadvertently misadministered.
It is possible that therapists can intu-
itively develop integrated notions of
treatment that are theoretically, if tac-
itly, sound. Some have, and they are
among those clinicians who are most
admired. If theoretic continuity
remains the province of individual
practitioners who d o not communi-
cate regularly with the profession as a
whole, however, the profession itself
will not continue to develop as it
should. The importance of theory and
its use must be made explicit and a
part of each therapist's professional
life, from the point of entry into edu-
cational programs until retirement
from active practice.
How can physical therapists best con-
tinue moving toward the goal of
developing a core of knowledge and
expanding themselves as profession-
als? The answer, we believe, lies in
how physical therapy research studies
are conceptualized and shared.
Use of Theory In
Cllnlcal Research
Theories can develop in a number of
ways. Most scientific theories have
developed through logical speculation
about some problematic situation.
These theories are not grounded in
experience. Once developed, such a
theory or system of ideas about some
phenomenon is subjected to testing in
the "real world." The testing entails
the derivation of hypotheses or tenta-
tive explanations of the phenomenon
and the assessment through statistical
analysis of the probability that the
hypotheses are correct. Theories
whose hypotheses are not falsified are
taken to be provisionally adequate
explanations of the phenomena they
cover.4Theories whose hypotheses
are falsified through experimentation
are revised or discarded in favor of
more promising theories. Such
hypothetico-deductive theories have
been discussed by Krebs and Harris.'
Theories can also develop through
the accretion of experience. By
reflecting upon experience, it is possi-
ble to note patterns that can be devel-
oped into systematic ideas about phe-
nomena. This kind of theory
development and use is called
"grounded theory" by Glaser and
Strauss5 and is gaining currency in
many disciplines and professional
fields.
To continue this section, we will
briefly discuss the way these two
types of theory can be used to guide
research studies. Consider, for exam-
ple, the phenomenon of health care
compliance or patient cooperation. A
researcher is interested in why some
patients follow the regimen recom-
mended by their physical therapists
and why others do not or do so to a
much lesser degree. According the
social learning theory-a hypothetico-
deductive theory-people organize
their behaviors with respect to the
rewards available in the environment:
The more rewarding a behavior is,
the more likely one is to repeat it.
The researcher might hypothesize that
compliance will be highest among
those patients for whom wellness is
Physical Therapynolume 70, Number 9/September 1990
most central (ie, rewarding). Thus,
the researcher would predict that pro-
fessional athletes will comply more
readily than "weekend warriors" to
home programs designed to remedi-
ate pulled hamstring muscles. The
researcher would reason that a pro-
fessional baseball player cannot play
(and thus gain glory and secure free-
agent status) with a dysfunctional
hamstring muscle, whereas an
accountant can professionally advance
with o r without an injured hamstring
muscle. Similarly, the researcher
would expect a sculptor to be more
compliant with a home exercise pro-
gram for rheumatoid arthritis than a
department store executive.
Having formulated a theory-based
hypothesis, the researcher would
design a study to test the hypothesis
that a relationship exists between cen-
trality of dysfunction and compliance
with home exercise p r o g m s . The
researcher would attend carefully to
the concepts of "centrality" and "dys-
function." Does centrality refer to the
importance of wellness for one's
vocational life, one's social life, or
both? Does centrality refer to the
quality of one's life generally, and, if
so, how shall "quality" be defined?
With respect to the concept of dys-
function, the researcher will perhaps
decide on levels of acuteness and rule
out genetic predispositions. The care-
ful definition of concepts and specifi-
cation of their relationship as guided
by theory will yield a greater under-
standing of physical therapy phenom-
ena. It should be clear that an abstract
theory can yield many types of
research questions and many testable
hypotheses. This use of theory follows
a deductive approach in which the
theory guides the development of
testable hypotheses.
Another way to use theory is explicitly
to ask theoretical questions of clinical
practice. Suppose, for example, a
therapist notices that, even though
professional athletes generally comply
more readily than accountants with
home exercise programs, not all pro-
fessional athletes comply and not all
accountants fail to comply. What is
going on here? To answer this ques-
tion, the therapist-researcher might
identlfy groups of earnest compliers
and noncompliers and carefully
observe and interview them across a
variety of settings: in a clinic with a
physical therapist, with a physician, at
home, at work, and at leisure. The
study would focus on discovering pat-
terns that distinguish people exhibit-
ing different degrees of compliance.
The theory guiding this effort does
not predict behavior under specific
circumstances; rather, it assumes that
people behave in patterned ways, and
the researcher is interested in discov-
ering those patterns. Basic to such
patterns are the meanings people give
to their therapeutic circumstances and
how meanings are transformed into
compliant (or noncompliant) behav-
ior. With such knowledge, researchers
and therapists can develop different
ways of establishing home exercise
programs for different patients.
In the lemon-concentrate analogy, it
was argued that an understanding of
acetic concentrates empowered its
users to apply that understanding in
many and varied circumstances. Con-
sider now the gate-control theory of
pain that was proposed by Melzack
and Wall in 1965.6In 1987, Wang and
Freeman stated
Some of the specifics of the gate con-
trol theory have been found to be
incorrect. However, the concept under-
lying its mode of action, which is that
pain fiber input to the brain can be
reduced or eliminated by the activity of
other neuronal pathways, has been
substantiated and used to develop ther-
apies for the treatment of chronic
pain.7@75)
As a result of understanding the the-
ory-an explanation of pain-physical
therapists can use modalities as
diverse as ice, electrical stimulation,
and acupuncture to control pain.
Additionally, because the gate-control
theory allows for pain control from
both ascending and descending fibers,
the discovery of endogenous mor-
phinelike substances (eg, endorphins)
within the central nervous system
opens up new possibilities for pain
control. In this example, the gate-
control mechanism is analogous to
the lemon concentrate, the physical
therapy modalities are analogous to
the lemon products, and the possibil-
ity of self-stimulation of endorphins
for pain relief is analogous to an
understanding of lemon concentrate
as an edible acetic acid.
As Michels has stated, "Research
without theory does not contribute
to knowledge."a(p134) By using the-
ory as a searchlight to guide think-
ing and focus questions about
physical therapy problems, a sus-
tained program of research can be
pursued. The use of theory invites
the researcher-practitioner to look
deeper into specific phenomena and
to ask how such phenomena are
connected with other phenomena. It
allows questions about why some-
thing works; under what conditions;
and with what pathological states,
modified by what confounding
variables. As the theoretical base for
physical therapy practice and
research grows, so will physical
therapy continue to develop as a
distinct and socially valued
profession.
Acknowledgment
We thank Gail Jensen, PhD, PT, for
her thoughtful contributions and
enthusiastic support throughout the
development of this article.
References
1 Krebs DE, Harris SR. Elements of theory
presentations in physical therapy. Phys Ther.
1988;68:690-693.
2 VanSant AF. Age differences in movement
patterns used by children to rise from a
supine position to erect stance. Phys Ther.
1988;68:1330-1338.
3 Cot6 DJ, Prentice WE Jr, Hooker DN, Shields
EW.Comparison of three treatment proce-
dures for minimizing ankle sprain swelling.
Phys Thm 1988;68:1072-1076,
4 Popper K. Objective Knowledge: An Evolu-
tionary .4pproach. Oxford, England: Oxford
University Press; 1974.
5 Glaser B, Strauss A. The Discovery of
Grounded Theory. Chicago, 111: Aldine Publish-
ing Co; 1967.
6 Melzack R, Wall PD. Pain mechanisms: a
new theory. Science 1965;150:971-979.
7 Wang M, Freeman A. Neural Function. Bos-
ton, Mass: Little, Brown & Co Inc; 1989.
8 Michels E. Enhancing the scholarly base: the
role of faculty in enhancing scholarship.
J Allied Health. 1989;18:129-142.

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60 / 582 Physical TherapyNolume 70, Number 9lSeptember 1990