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Prescription for Change

Field-Fote, Edelle C. PT, PhD

Journal of Neurologic Physical Therapy: March 2010 - Volume 34 - Issue 1 - p 1-2
doi: 10.1097/NPT.0b013e3181d0d716
Editor's Note

It's funny how thoughts take their seemingly random path and carry you along, making connections among concepts that were otherwise unconnected. Beginning to make plans for the American Physical Therapy Association (APTA) Annual Meeting in Boston, MA, got me thinking about that city. Who can think of Boston without thinking of the Boston Tea Party and beginnings of our nation? It is an interesting coincidence that in 1922 the First Annual Conference of the American Women's Physical Therapeutic Association was held in Boston (where members voted to change the name of the organization to the American Physiotherapy Association). Both these historical events are examples of small groups of people committing themselves to an idea; one a ragtag group of patriots who envisioned a great nation and mobilized to make it so, and the other a group of women, led by Mary McMillan, who were committed to a professional society that focused on restoration of physical function.

Thinking about these events, it occurs to me that most significant social changes start this way, with a small group of individuals committed to an idea, who grow into a larger group and that idea becomes a movement. Our own profession has numerous examples of positive changes that began with an idea and the efforts of a small group of individuals united in a cause such as the development of board certified clinical specialties, the establishment of the Physical Therapy Fund (later the Foundation for Physical Therapy), and the efforts for direct access to physical therapist services in all states. The movement toward evidence-based practice is surely a significant effort on par with these. During the past two decades, the Neurology Section has, through JNPT, efforts of the Special Interest Groups efforts, and Combined Sections Meeting programming and regional course offerings, been assisting members in translating evidence into practice and facilitating the link between clinicians and researchers. Other Sections and the APTA have made similar efforts.

Despite the best efforts of the APTA and the Sections, there remains a recognized gap between typical practice and the research evidence, but a new effort is afoot that represents the culmination of forces quietly at work for many years. On December 2–4, 2009, in Philadelphia, PA (not Boston, darn, there goes that thread), the APTA sponsored a workshop entitled Creating a Culture of Collaboration: Vitalizing Practice Through Research and Research Through Practice. The concept of the conference had evolved during the past two years with the guidance of a planning group under the direction of Marc Goldstein, APTA's Director of Research. Conference participants applied to attend and, in their letters of application, addressed ways in which their efforts and experiences supported the conference goal of “developing a structure that will foster research collaborations between physical therapist researchers and clinicians in ways that will lead to enhanced patient care.” Among the 54 participants selected to contribute to the conference, the Neurology Section was well represented by many long-time section leaders.

All the presentations related to this conference are available for viewing by APTA members on the APTA Communities Web site at: These presentations offer examples of real-world approaches currently in place in clinical and academic settings in various parts of the United States, wherein a true reciprocal relationship exists between practice and research. In these settings, physical therapist practice is informed by research and informs research in turn. These innovative ways of combining research and practice have resulted in high levels of both expert practice and patient satisfaction. Conference participants worked in breakout groups to develop practical ideas for fostering a collaborative relationship among clinicians and researchers. The climax of the conference was an exhilarating presentation by each of the breakout groups wherein the ideas generated in the brainstorming sessions were shared. The conference culminated in the drafting of recommendations for tangible steps our profession might to bring these ideas to fruition. The draft list of recommendations is proffered in the Appendix.

That everything changes is a well-worn cliché, as the Greek philosopher Heraclitus said in the 5th century bc: “There is nothing permanent except change.” Although we have little choice about whether there will be change, we do have a choice about the direction in which that change will take us. In his popular book The Tipping Point: How Little Things Can Make a Big Difference, Gladwell1 argues that “context”—small but influential changes in the environment—is one of the principal factors that determines whether an idea will flourish. We are at an exciting time when the state of clinical practice, research, healthcare market forces, and technology are all coalescing into a context that will push us toward new models of patient care. We will all be part of the changes that come, but what are the ways that we can shape these changes and the future of practice?

Grol2 describes a model for implementing change that seems to be well suited to moving forward in a direction of best possible practice. The model begins with developing a concrete proposal for changing clinical practice and identifying obstacles to change. Substantive ideas that are consistent with this model were presented at the research conference. I encourage you to visit the Web site and avail yourself of the conference materials. In the language of Gladwell,1 many of the ideas presented at this conference represent the practice of “innovators” and the first step in getting to the tipping point that will dramatically change physical therapists practice for the better. Each of us has the opportunity to be among the “early adopters” of a model of practice that offers our patients the best possible care by bringing together exceptional clinical practice and research and that brings out the best clinical scientist in each of us.

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1. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. New York: Little, Brown and Company; 2000.
2. Grol R. Beliefs and evidence in changing clinical practice. BMJ. 1997;315:418–421.
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Draft List of Recommendations for Creating a Culture of Collaboration

To create a culture of collaboration, it is recommended that the profession:

  • - Identify mechanisms to discern conditions amenable to the development of clinical practice guidelines.
  • - Develop demonstration projects for integrating and optimizing treatment approaches
  • - Assemble a core set of outcome measurements, which span the patient lifespan and domains of ability/disability, for each of the specialty areas of physical therapist practice
  • - Explore and implement all mechanisms of extramural funding to facilitate communication between research and clinical communities
  • - Advocate within research funding agencies to create funding mechanisms, which will bridge research gaps that limit development of evidence-based treatment protocols.
  • - Coordinate with APTA and the Sections to develop a clinical data registry that includes a minimum data set
  • - Develop incentives for physical therapists collecting data that conforms to the minimum data set to contribute to the clinical registry
  • - Work with federal and private agencies to adopt evidence based-processes of patient care
  • - Define protocols for key practice areas to determine the value of physical therapy when the practitioner adheres to evidence-based treatment protocols
  • - Define changes in education, including but not limited to clinical residency, clinical instructor training, and changes to continuing education, that would facilitate a better understanding and increased use of evidence-based practice
  • - Develop a new specialty in clinical research
  • - Create incentives for clinician/researcher partnerships, and promote these so that they may serve as models for collaboration
  • - Support the development of didactic and clinical models that build the skills of faculty and students, which will enhance collaboration between researchers and clinicians
  • - Utilize decision support systems that can be used across a variety of digital media platforms
© 2010 Neurology Section, APTA