PHYS THER
Vol. 86, No. 2, February 2006, pp. 299-300
Invited Commentary
Richard K Shields
Professor and Director of Graduate Studies
Physical Therapy and Rehabilitation Science
Carver College of Medicine
University of Iowa
1-252 Medical Education Building
Iowa City, IA 52242
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Introduction
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I would like to compliment the multidisciplinary Program Committee and all those who took part in this Summit. The vision, organization, and written documentation are important first steps in developing a framework to advance the research capacity of the field of rehabilitation science. However, I am reminded that identifying the problems and developing action plans, while essential, will not replace the sacrifice, hard work, and diligence that must emerge from the rehabilitation community if measurable advancements in rehabilitation research capacity are to be realized in the future.
The prologue and executive summary of the Summit were not intended to develop a specific research agenda. The participants carefully adopted a definition for research capacity that included individual and institutional development and then identified several obstacles to advancing the field of rehabilitation science. Five elements of research capacity were identified to guide the Summit discussions: researchers, research culture, funding, partnerships, and metrics. Solutions and recommended actions also were put forth. The goal of building rehabilitation research capacity was clearly delineated in this report. However, I am also left asking, "Where do we go from here?" In this commentary, I propose implementing a rehabilitation research model to help build research and training capacity. I also propose that private foundations should help foster the growth of the rehabilitation research culture.
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Rehabilitation Science Model
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We first should adopt a rehabilitation science research model that is inclusive of all research (basic, applied, clinical, and health services research) but that also closely identifies with rehabilitation issues. We must appeal to the scientific community, consumers, and funding agencies, so it is imperative that our message be clear and grounded in "cornerstones" of science. Rehabilitation science, as defined, should represent systematized knowledge (science) about restoring individuals to former capacities or achieving new capacities (rehabilitation). Accordingly, I believe that a plasticity-adaptation-outcome (PAO) model provides a novel framework ideally suited for rehabilitation science. This model encompasses tissue and organ adaptation to stress and how those adaptations influence function, health quality, and health services outcomes. Some key defining elements such as intervention feasibility, intervention dose, intervention cost, longitudinal data, outcomes, and patient adherence should distinguish rehabilitation research under the PAO model from other research models. Other authors1–3 have proposed similar components of this type of model in previous reports.
We next must identify major gaps within this model as they relate to rehabilitation science and develop and focus our training programs accordingly. I will provide 2 examples to illustrate gaps in rehabilitation research and how those gaps pertain to this model.
Currently, there are major voids separating basic research in tissue plasticity from rehabilitation research. For example, the knowledge that skeletal muscle transforms from fast to slow fibers following electrical stimulation for 8 weeks at 24 hours per day does not fit under the PAO model.4 Although this finding highlights important mechanistic principles regarding neuromuscular plasticity, its feasibility, dose, cost, and secondary complication considerations limit its applicability to rehabilitation. Moreover, rehabilitation scientists looking to advance the PAO model should not strive to duplicate a dose that is clearly not feasible. Interventions designed to optimize "an effect" at the expense of feasibility, realism, and cost should become obsolete under the PAO research model. We lack information on intervention dose in rehabilitation research. Sound justification of dose-response issues should ideally precede the randomized controlled clinical trial. If assessing various doses of an intervention on an animal model advances knowledge regarding that intervention, then it fits within the framework of the PAO model.
A second gap in rehabilitation science research is the shortage of comprehensive and sensitive outcome assessment tools that are feasible to use in the clinic.5 An assessment tool designed and recommended for clinical use that is clearly not feasible for that use does not adhere to the PAO model. The PAO model should come to be identified with research that is grounded in strong scientific principles with interventions and outcomes that can drive the knowledge and science of rehabilitation.Multidisciplinary training centers should have quantifiable metrics to demonstrate the gaps that exist in rehabilitation science and to document when those gaps are being filled. Partnerships among the various types of rehabilitation scientists (basic, applied, clinical, health services) should be emphasized in training programs in lieu of narrowly defining the scope of rehabilitation science.
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Research Capacity Support
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Funding the development of rehabilitation research capacity will be critical in the years to come. We must withstand the ebb and flow of federal funding, but, in 5- to 10-year benchmarks, the awareness of the importance of rehabilitation research must be more evident to all funding sources. I propose that we elevate the research culture's awareness of supporting private foundations. Private foundations and other sources of support will need to "rise to the occasion" to assist with developing this research capacity. Deans, department chairs, and senior faculty must lead the charge to bolster the rehabilitation research environment, infrastructure, and culture. Funding agencies should gauge the growth of viable rehabilitation researchers by the number of high-quality grant applications generated.
The Foundation for Physical Therapy has been instrumental in developing research capacity in rehabilitation. Ten million dollars in grant and training support to individuals has been leveraged to rehabilitation researchers, who have, in turn, procured more than $50 million from extramural funding agencies (National Institutes of Health, foundations, and industry).6 In a 2-year span, more than $392,000 was invested to support doctoral training of 33 physical therapists.6,7 The Foundation for Physical Therapy just completed a $1.5 million investment in a clinical research center network to advance the research capacity to perform multicenter controlled clinical trials. Although these accomplishments are laudable, more is possible as the clinical and academic research environment, infrastructure, and research culture becomes more knowledgeable about the benefits of improved rehabilitation research. Partnerships among various foundations and funding agencies (eg, National Institutes of Health) may prove to be an effective strategy to enhance rehabilitation research capacity.
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Summary
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There is no simple answer to the question "Where do we go from here?" as raised at the outset of this commentary. However, initially we should: (1) implement a model, such as the PAO model, that has key elements that identify with rehabilitation science but that is broad in scope; (2) quantify the current gaps within this model as they pertain to rehabilitation science and develop specific metrics to quantify when certain capacities are met; and (3) encourage rehabilitation practitioners and scientists to support the role of private foundations and industry in furthering the development of research capacity. I commend the authors and attendees of this meeting for their many contributions contained in this report. I eagerly anticipate a unified effort of the entire rehabilitation community to advance the capacity to perform research in rehabilitation.
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References
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- Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a proposed "physical stress theory" to guide physical therapist practice, education, and research. Phys Ther 2002;82:383–403.[Abstract/Free Full Text]
- Rymer WZ. Response to "training and retention of rehabilitation research." Am J Phys Med 2005;84:976–979.[Web of Science]
- Shields RK. Muscular, skeletal, and neurological adaptations following spinal cord injury. J Orthop Sports Phys Ther 2002;32:65–74.[Web of Science][Medline]
- Munson JB, Foehring RC, Mendell LM, Gordon T. Fast to slow conversion following chronic low-frequency activation of medial gastrocnemius muscle in cats, II: motoneuron properties. J Neurophysiol 1997;77:2605–2615.[Abstract/Free Full Text]
- Jette AM, Haley SM. Contemporary measurement technique for rehabilitation outcomes assessment. J Rehabil Med 2005;37:339–345.[Web of Science][Medline]
- American Physical Therapy Association. 2004 Annual Report. Available at: http://www.apta.org/AM/Template.cfm?Section=:Search§ion=Annual_Reports&template=/CM/ContentDisplay.cfm&ContentFileID=2764. Accessed January 2, 2006.
- Foundation for Physical Therapy. 2004 Annual Report. Available at: http://www.apta.org/AM/Template.cfm?Section=Search§ion=Annual_Reports2&template=/CM/ContentDisplay.cfm&ContentFileID=2429. Accessed January 2, 2006.
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Copyright © 2006 by the American Physical Therapy Association.
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