Have you ever, just for grins, browsed through the JNPT archive? If you have, then certainly it was immensely apparent how far we've come in our endeavors to develop the evidence that forms the foundations for the practice of neurologic physical therapy. The articles in this IV STEP compendium reflect the diversity of clinical populations, study designs, interventions, and outcome measures that comprise neurologic physical therapist practice and research. The first article by Harris and Winstein conveys the remarkable progress we've made over the years, as embodied in the proceedings of the STEP meetings.
Despite the broad diversity of neurologic physical therapy, as Van Sant notes in her article, the movement system is a construct that transcends all areas of our practice and research. Movement is typically our primary intervention, as well as our primary outcome measure. Across the spectrum of clinical populations with whom we work, the outcome measures that we employ, and the interventions we apply, the movement system is the unifying, organizing construct around which everything we do coalesces.
As with the concept of the movement system, another notion that infuses all areas of our practice is actually a conceptual question—that of “what key elements make the difference to the outcomes of our interventions?” As the articles in this compendium illustrate, it is clear that the key elements include characteristics of the patient as well as characteristics of the intervention. The article by Stewart and Cramer illustrates this concept, showing that genetic variables may be able to explain some of the differences we observe in the outcomes of our interventions. Conversely, while we have long assumed that dose of intervention is an element essential to outcomes, as Basso and Lang show in their article, there are instances wherein dose alone cannot account for differences in outcome. Building on the matter of dose, Burridge and colleagues describe ongoing studies that will answer questions about whether technology may provide an opportunity to address the issue of dose, as well as other important contributors to outcomes such as motivation and adherence.
While improved movement is generally the primary outcome of interest in both our practice and research, the motivation toward this outcome derives from the impact that movement has on all areas of life. Behrman and colleagues highlight the need to consider benefits of practice and training that may be different from those for which we are aiming. They also describe a scale to assess ability to perform functional movements without assistance or compensation. Moreover, Quinn and Morgan show that by prescribing targeted movement interventions, neurologic physical therapists can play a meaningful role in improving our patients' fitness and participation, possibly, even influencing disease processes. McGough and colleagues take this concept one step further, describing the evidence available to indicate that, beyond movement, modifiable risk factors associated with dementia are also responsive to physical activity and exercise.
From the perspective of what we know today, it goes without saying that the extraordinary advances we will witness and the progress we will make in the years leading up to V STEP are entirely inconceivable. We will continue to build our body of evidence—starting with single-case studies that demonstrate safety and tolerability of theory-based intervention, progressing to quasi-experimental pre-/post studies that provide insights into dose-response relationships and allow refinement of the intervention, and then on to randomized trials to enable assessment of whether the intervention is more efficacious relative to a comparison group. Much work remains to be done, as there are few areas in neurorehabilitation for which the evidence has reached the highest level, wherein the accumulated outcomes of numerous high-level studies confirm the superior efficacy of one particular approach in comparison to others.
While it is true that statements about efficacy (results under ideal conditions) can only be made when the intervention has outcomes superior to that of a comparison group, its imporant to remind ourselves that efficacy is not the same as effectiveness (results under “real-world” conditions). Because of the complexity inherent in our clinical populations, the strict inclusion/exclusion criteria of traditional randomized trials will always be problematic from the perspective of generalizability. It seems highly likely that in the years leading up to V STEP, we will see increasing use of pragmatic randomized clinical trial designs in neurorehabilitation research. As electronic health records become more and more sophisticated, and our ability to extract information from large data sets expands, our access to evidence from the real world of the clinic will likewise expand. Accordingly, as the amount of high-level evidence grows, there will be an increasing need to understand how best to implement research findings into real-world practice. The coming decade will surely evince a perpetual iterative cycle, wherein the growth of pragmatic randomized clinical trials leads to greater numbers of knowledge translation/implementation studies to help guide the implementation of evidence in our practice.
As the concluding article by Kimberley and colleagues illustrates, numerous forces external to neurorehabilitation research are certain to transform our practice, including valuable insights into the biological basis of disease, as well as unknowable evolutions in health care policy. The exponential pace of discoveries in medicine, science, and technology will undoubtedly lead to developments that exceed our wildest imagination. An untold number of these discoveries will surely have implications for movement, motor control, and motor learning. One thing is certain however, regardless of where our steps take us, movement will always have immeasurable importance for the lives of our patients, and hence for the practice of neurologic physical therapy.