This year at the 2010 Combined Sections Meeting in San Diego, CA, the Board of Directors, leaders from our special interest groups and committees, and the membership discussed what the term translational research meant to each of us. Varied perspectives were heard from our own individual points of view as tenure-track research faculty, clinician scientists, clinical specialists, early career physical therapists, and students.
Now more than ever there is a need for the Neurology Section to develop a research strategic plan that addresses practical and clinically important questions that have meaning to the patient, their families, and the frontline rehabilitation professionals that provide their care. This need is particularly relevant in the area of movement rehabilitation where findings from basic and clinical science research demonstrate that the nervous system has the capacity to respond and recover in response to motor training that is specific, intense, and involves the acquisition of motor skills. However, the diversity of needs that was reflected in our various discussions revealed to me a need for all of us to understand the terms and appreciate the philosophical underpinnings of what translational research may mean in the area of neurorehabilitation.
In the National Institutes of Health (NIH) Roadmap,1 the term bench to bedside is used to describe the emphasis on NIH priorities to support translational research efforts to move scientific discoveries from bench research more rapidly to clinical practice. Translational research is the practical application of scientific discoveries from basic science research (ie, research of disease or injury at a molecular or cellular level) translated to clinical science research (ie, applied research that takes advances in basic science to generate new approaches to treatment of disease) to improve human health for people.2 Thus, translational science is an evolving discipline that could lead a basic science researcher or clinical science researcher to focus efforts on translational research.
This terminology is even more confusing when translational researchers discuss the latest NIH terminology to describe the research enterprise, which is the process by which universities and academic researchers compete for NIH grant funding. Thus, the terminology of translational research type 1 (T1) or type 2 (T2) is used.2 T1 translational research describes the basic science research whereby understanding disease mechanisms from the laboratory (thus, the term “bench” research) leads to development of therapies (typically, pharmaceuticals or medical devices) that can lead to developments to improve human health. T2 translational research describes the translation of clinical studies into everyday clinical practice. Thus, clinical trials are examples of T2 translational research where the “laboratory” is now the clinical setting such as an ambulatory care center or a community-based hospital.
As a note, this may be confusing to the practicing clinician who is encouraged to incorporate research evidence into his or her clinical practice. However, evidence-based practice is an approach to patient care by which a clinician such as a therapist, physician, or nurse integrates findings from current basic or clinical research with his or her own clinical expertise and the individual client's perspectives to provide the client with optimal healthcare.
In 2009, the Cumberland Consensus Working Group,3 a collective group of basic, applied, and clinical scientists, proposed an alternative model to the “translational research pipeline” based on their observations that the translation of basic science research from bench to bedside is “painstakingly slow.”3 The typical research pipeline is a relatively stepwise process from the translation of preclinical, findings at the molecular level to clinical interventions for a patient with disease or injury. This is particularly true for disease or injury to the nervous system because it has a huge impact on the individual and requires a complex intervention such as those inherent in neurorehabilitation. Thus, the traditional method of driving the translational research in a unidirectional and hierarchical manner has not been effective in driving substantial change in rehabilitation clinical practice.
The Cumberland Group proposed a modification to the traditional, unidirectional research pipeline and suggests a solution that is interactive, bidirectional, and respectful of the challenges of clinical practice. Thus, a T2 translational scientists needs to understand the theoretical and design requirements of an randomized controlled trial that complies with CONSORT4 requirements but should also develop an appreciation for the challenges and culture of the clinical environment. The researcher who wants to conduct clinical trial research also needs to develop relationships with the administrators, managers, and clinicians who care for the patients in their “laboratory,” the community hospital or outpatient practice. Thus, the figure (adapted from the Cumberland Group's rendition) depicts the organizational facilitators and theoretical framework where each member in the organizational pipeline has a unique and valued perspective that influence the translation of basic science research to clinical trials, and hopefully, to health services research and healthcare delivery.
Through the course of my career in physical therapy, I have experienced neurorehabilitation along my journey from clinician to clinician scientist. I have had the opportunity to practice in the clinical setting as a neurorehabilitation physical therapist and a healthcare manager during the transition from the fee-for-service rehabilitation delivery system to managed care. During the journey from practice to research, my clinical questions were replaced with scientific questions that revealed the mechanisms associated with neuroplasticity, neurorecovery, and neuroprotection. It was during this time that I experienced the cultural gap that separates the basic science researchers from the clinical researchers and the researchers from the clinicians.
One of the greatest moments of my career was the day I walked into Sharp Memorial Rehabilitation Center in San Diego, CA, as a clinical scientist researcher and invited all to work with me as one of the clinical sites for the Locomotor Experience Applied Post-Stroke (LEAPS) (http://www.clinicaltrials.gov/ct2/show/NCT00243919?term=LEAPS&rank=2). The circle was complete because I had left Sharp in 1992 as a member of the clinical management team and returned in 2002 to mutually join the administration, the physical therapy managers and clinicians, and the medical director of the rehabilitation hospital to conduct a clinical trial whose aim was to understand, and hopefully positively influence, walking recovery in people after stroke. I want to thank the therapists, physicians, and administrators at Sharp who taught me how to function effectively and efficiently in the “laboratory” of healthcare delivery. I want to thank all our LEAPS clinical sites for the incredible translational research journey that we have all shared together these past five years.
The journey of translational research is not just down the pipeline from science to clinical practice but is a reciprocal journey from clinical practice to science; a journey that should engender respect for every member along the pipeline (Figure 1). Each member along the pipeline provides a unique contribution that leads to the ultimate goal: the delivery of high-quality health service research that results in tangible changes to patient care within the health service delivery system. I truly hope that our next generation of clinicians, clinical specialists, and clinician scientists will lead our Section in setting the future vision for a research agenda that values and respects each of us in the translational pipeline. I hope the research agenda of the Neurology Section will embrace a model of translational research that will lead to substantive improvements in neurorehabilitative care for children and adults with health conditions that affect the nervous system.
1.Zerhouni E. MEDICINE: The NIH Roadmap. Science.
2.Woolf SH. The meaning of translational research and why it matters. JAMA.
3.Cumberland Consensus Working Group, Cheeran B, Cohen L, et al. The future of restorative neurosciences in stroke: driving the translational research pipeline from basic science to rehabilitation of people after stroke. Neurorehabil Neural Repair.
4.Moher D, Schulz KF, Altman DG; CONSORT Group. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. J Am Podiatr Med Assoc.