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Editorials |
When I sit back to "take in" the content of our May issue, several thoughts come to mind that I want share with you. First and foremost, each article is relevant to our readers, regardless of the breadth of the content represented. I know how very busy we all are, but I truly believe that our specialty content is enriched when we climb out of our silos of "expertise and comfort" and read about research findings in other areas.
The article by Farquhar et al,1 "Persistence of Altered Movement Patterns During a Sit-to-Stand Task 1 Year Following Unilateral Total Knee Arthroplasty," will immediately attract those who are interested in musculoskeletal diagnoses. I would contend, however, that the message offered by this article is more universal and is an important addition to the findings of a 2004 paper that described outcomes of an evidence-based, high-quality intervention after total joint arthroplasty.2
At 1 year postsurgery, the intensive intervention (17 visits over 6 weeks) helped participants return to age-, height-, and body mass index–matched control levels for quadriceps isometric force production and functional performance. Success? Well, it depends. When the investigators examined the movement patterns used to stand from a chair, the people with total knee arthroplasty demonstrated an increased hip flexion and a larger hip extensor moment reminiscent of a compensatory strategy to "protect" a painful knee. This finding raises all sorts of questions, regardless of content expertise. Is it possible to teach movement strategies that become automatic? What is the most effective approach to enhance motor learning, and would degenerative consequences to the other joints be reduced if the compensatory strategy was replaced?
Bear with me as I ask you to consider another article that many of you might believe is far outside of your area: "Locomotor Training Restores Walking in a Nonambulatory Child With Chronic, Severe, Incomplete Cervical Spinal Cord Injury," by Behrman et al.3 Naturally, this article would appeal to a neuromuscular content expert. It's remarkably exciting to the neuroscience community because of the implications for nervous system plasticity (see Edgerton's commentary4). But this paper also emphasizes a principle that holds regardless of your interest (or noninterest) in neural plasticity.
Here's what happened: 16 months after a severe cervical spinal cord injury, a 4
-year-old child was classified as nonambulatory and received appropriate assistive technology and equipment with which to compensate. After 14 weeks of locomotor training using both treadmill and overground settings, the child attended kindergarten using a rolling walker full time without orthotic devices. Quality of the movement pattern is not as important in this report as in the Farquhar paper, in my opinion. When and why to develop a plan of care focused on compensation or on recovery seems much more important in the article by Behrman et al, where compensation means mobility using a wheelchair versus ambulation using a walker. It's easy to transfer this decision to the person who has had a stroke: should the focus be on teaching compensatory strategies with the ipsilesional upper extremity, or on recovery in the contralesional upper extremity? A similar type of decision also is faced by the clinician who has just examined an older adult who has a high risk of falls. Should instruction be focused on wheelchair/scooter mobility to prevent falls, or should instruction focus on learning how to fall? And—here's where we really need to climb out of our silos—doesn't the clinician who is working with the person with a severe rotator cuff tear have to decide whether to teach strategies to accomplish overhead tasks using the other upper extremity or to develop new muscle activation patterns in the involved limb to lift it in nearly full flexion?
If we all can agree that the issue of compensation versus recovery is important regardless of content expertise, we then can ask "mega" questions that could benefit all of us, regardless of our specialty:
Just as the above articles have relevance beyond their topic areas, the 5 articles in this issue that examine clinical tests go well beyond the issue of reliability. A theme that emerges from the results of these studies is the reported variability of performance—regardless of whether it is upright balance, reaching, walking, or stair climbing, for example. All of the results highlight the need to quantify the extent of the variability so that "real" change can be quantified. A second theme that emerges is the difference between patient performance and able-bodied performance and the need to select the correct reference standard.
Because clinical measurement and Jules Rothstein, PTJ's Editor in Chief Emeritus, are almost synonymous in my mind, I reread some of his editorials, and 2 of them seemed apropos: "Sick and Tired of Reliability?"5 and "Living With Error."6 The first editorial reminds us that we have "literally hundreds of measurements... of dubious quality that are used for questionable decision making ..."5(p774) Guess what, Jules! In this issue, we have published an article that recommends discarding a clinical assessment tool. Holm et al7 examined the responsiveness (one of a number of variables) of the Keitel Functional Test (KFT) in people with rheumatoid arthritis. The authors reported that measurements obtained using the KFT are not sensitive to changes over time, and they recommended that the KFT not be used to monitor function in clinical practice and not be used as an outcome measure or as a predictor of functional changes. To the best of my knowledge, the KFT is among the few clinical tests whose psychometric properties have undergone careful scrutiny and have been recommended for discard.
Jules goes on in his editorial to state that he "look[s] forward to printing fewer measurement studies because of what we will know, because of what we are doing—and because our focus could be on innovation and refinement."5(p774) We have made a huge leap since 2001 when this editorial was published. Hanna et al,8 for example, are refining the Gross Motor Function Measure (GMFM), a tool that is used to help set goals for children with cerebral palsy and that is based on data from more than 600 children with cerebral palsy who are 2 to 12 years of age—not from children without cerebral palsy. The GMFM was first introduced in 2002 and was adopted rapidly for use in both the research and practice arenas. In this article, the team provides a refinement to help the clinician to compare a child to others within a particular classification and to determine whether change in motor behavior has occurred over time.
Although the concept of reference percentiles is familiar with respect to reporting that a child is within the 90% percentile on physical growth charts or reporting a good or bad serum cholesterol value,9 reference percentiles are not commonly used in physical therapist examination tools. The addition of 3rd, 5th, 10th, 25th, 50th, 75th, 90th, and 97th percentiles for the GMFM within a Gross Motor Function Classification System (GMFCS) level provides a clearer picture of the "normal" variability associated with development in a child with cerebral palsy. The data illustrate the variability in performance for motor tasks including rolling, sitting, crawling, walking, running, and jumping at one point in time for children who have the same GMFCS classification. Motor task performance variability over time also is emphasized, as data were collected longitudinally over a 4-year period.
Wagner et al10 attempt to answer another question posed by Jules: "Is the error so large that using the measurement would be unlikely to provide useful information?"6(p423) The investigators determined test-retest reliability and minimal detectable change (MDC) for kinematic variables that describe contralesional arm reaching in a sample of people following stroke. Participants performed forward-reaching tasks while seated in a straight-back chair with their trunk stabilized. The time between the 2 measurement sessions was approximately 37 days. Measurement error was calculated, and the data suggest that a change of greater than 35% is needed in particular variables for this particular group of people poststroke in order to indicate a real change in reaching performance. Eleven different variables were used to describe details of the reach speed, efficiency, smoothness, coordination, extent, and range of motion.
The study by Wagner et al begins to examine the clinical utility of variables that are more often viewed as laboratory based. I end with this study because it takes us back to the beginning: the article that reported on movement strategies in people 1 year after total knee arthroplasty. Like Farquhar et al, Wagner et al are interested in identifying variables that will describe the quality of the movement.
So, consider this your official invitation from me to climb out of your silo! Take advantage of the breadth offered in this and other issues of PTJ. You might learn a new way to analyze your data, identify a different population to help you answer a question, or apply a different assessment tool or a different method to examine performance.
In fact, if you find yourself reading an article that is not within your immediate area of practice or expertise, and you learn something that you know you will be able to apply, please e-mail ptjourn{at}apta.org to tell us about it. We want to know whether and how you are using the information in our articles. We might ask your permission to post your thoughts at www.ptjournal.org; or you can post your comments directly by going to my May editorial online and clicking on the "Submit a response" link on the top right of the page.
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