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Guest Editorials |
AL Behrman, PT, PhD, is Associate Professor, Department of Physical Therapy, University of Florida, and Research Investigator, VA Brain Rehabilitation Research Center Malcom Randall VAMC, Gainesville, Fla
P Plummer-D'Amato, PhD, Bphysio (Hons), is Postdoctoral Scholar, University of California, Los Angeles Department of Neurology, Geffen School of Medicine, Los Angeles, Calif
As a clinician and an author, I have often observed colleagues labor over the choice of one word in a sentence or title of a manuscript. They weigh the options and consider the meaning of each word at length. I remember a conversation between the late Florence Kendall and our rehabilitation staff in which she described the effort that she took in carefully selecting each word in her classic text Muscle Function. Florence really did know every word in the text—and understood the value of each of those words in effectively communicating an idea to the reader and clinician.
In his editorials, Jules Rothstein, PT, PhD, FAPTA, PTJ Editor in Chief Emeritus, cautioned us time and again about our selection of words to describe physical therapist practice. In particular, he noted the inadequacy and overuse of such (non)descriptors as function.1 A prolific writer and editor, Jules understood that, once in print, a word becomes a permanent fixture, a lasting representation of thought. The selection of words, he contended, deserves our careful attention and consideration. Should the same level of caution apply when we name or "brand" a therapeutic intervention?
In the context of physical therapist practice, intervention refers to the methods, procedures, or techniques used by a physical therapist to produce changes in a patient's condition.2 Many interventions have been named for the people who developed them—for instance, the Bobath method, the Feldenkrais approach, Williams flexion exercises, the McKenzie method, etc. In some instances, the eponyms have been replaced by more descriptive terms, such as neurodevelopmental treatment (NDT) for the Bobath method. In other instances, a piece of equipment has become synonymous with the therapy—such as "Kin-Com therapy" for isokinetic training—much as "Kleenex" became the popular name for facial tissue.
A range of therapeutic modalities and devices are available to facilitate the provision of goal-directed physical therapist examination and intervention. Isokinetic equipment is used both for testing and training specific muscle performance. Treadmills are used for cardiovascular stress testing and endurance training. In the past decade, there have been major technological advances in the development of equipment designed to enhance rehabilitation. In particular, computerized training systems, robotic-assisted devices, and virtual reality technology have emerged as rehabilitation tools. Another increasingly popular tool for physical therapy intervention is the treadmill with a body-weight support (BWS) system.
Each of these devices provides a unique mode for physical performance testing or for delivery of a goal-directed therapy. But do these tools constitute the test and the therapy?
Computer technology has been used as an adjunct to visual scanning training in patients with unilateral neglect,3 memory training in patients following head injury amnesia,4 and balance training in elderly adults dwelling in the community.5 Thus, computers have become useful tools in providing specific goal-directed interventions. The computer is not the intervention ("computer therapy"); the computer is the medium through which the intervention (eg, visual scanning training) is applied. If our goal is to increase force production, we select a specific training regimen and equipment for this goal. Would our progress note state that we conducted "Thera-Band training"—or would it describe the specific muscles targeted, the movement being performed, the color of the Thera-Band used, and the number of repetitions?
Robotic devices and virtual reality environments are relatively new innovations that are undergoing scientific investigation for their potential role in rehabilitation. Robotic devices have been developed and tested for exercise and gait training,6–8 upper-extremity motor rehabilitation,9–10 and sit-to-stand training.11 Virtual reality refers to a computer-generated scenario with which users can interact in 3 dimensions, allowing them to become part of a virtual world. The use of virtual reality technology is being explored for balance retraining in the elderly12 and in people after traumatic brain injury,13 in upper-limb training14 and gait rehabilitation for people after stroke,15 and in facilitation of cognitive abilities (eg, training people with unilateral neglect to cross a street).16 As with computerized programs for visual scanning training, computer-generated virtual environments are only a tool; virtual reality is not the actual intervention. Similarly, robotic devices aid rehabilitation by providing a medium for goal-directed interventions such as gait training; they are not "robotic therapy."
The same logic applies to the use of BWS systems and the treadmill (BWST) as tools in gait rehabilitation. The BWST apparatus has been used most frequently to retrain walking in people after stroke and spinal cord injury; however, retraining walking in people who have impairments associated with neurological dysfunction is not the only way in which treadmills and BWS systems are used in the physical therapy setting. Body-weight support systems and treadmills also have been used to restore symmetrical inde-pendent gait in people after hip joint replacement,17 maintain conditioning while minimizing knee pain in people with osteoarthritis,18 and reduce loading on healing tissues and enable graduated return to full weight bearing in injured athletes19 and in people with low back pain.20 Because BWS systems and the treadmill, computers, and virtual reality technology are used under specific treatment frameworks to address a variety of rehabilitation goals, it seems counterintuitive to call an intervention "body-weight-supported treadmill training," "computer training," or "virtual reality therapy."
From a documentation standpoint, stating that someone received "treadmill training" or "computer training" is uninformative. Consider this hypothetical title for a research manuscript: "Body-weight-supported treadmill training in adults with hemiparesis." Based on this title, what is the goal of the intervention? "BWSTT" could indicate the use of this equipment for training balance, endurance, or gait; for reducing fear of falling; or for providing an "extra set of hands" to ensure proper trunk alignment or safety. More precise titles, such as "Endurance training in adults with hemiparesis: use of cycle ergometry" or "Endurance training in adults with hemiparesis: use of BWST," would identify the primary purpose of the therapy (to train endurance with an emphasis on the particular device selected for the training).
Defining our therapeutic interventions according to the specific equipment used, without acknowledging the role of the physical therapist, reduces our therapy to a "magic body-weight support system" and implies that the treadmill is the active ingredient for success. Such labeling fails to identify the critical components of an intervention and might even mask or misrepresent the active ingredients of the goal-directed therapy.1 The success of the intervention does not rely predominantly or solely on the equipment, but on far more critical factors, such as the theoretical framework for goal-directed training, the therapist's decision making, progression criteria, exercise prescription based on baseline performance, exercise principles, and the duration, frequency, and intensity of the exercise. That is, the success of an intervention depends on the physical therapist's decision making: the selection of the equipment and the way the equipment is used to achieve the patient's goals. Researchers and clinicians need to clearly explain how they are using the selected equipment and the theoretical basis for their actions. Without such clarification, we will continue to be confused by the plethora of studies using these potentially valuable rehabilitation tools. Emphasis on the equipment as the critical component of the training raises its value relative to all other aspects of training that might contribute to the beneficial effect of training on patient outcomes. Similarly, concerning constraint-induced movement therapy, Wolf21 asks, "Are we too smitten with the mitten?" He encourages critical exploration of the many components and factors that contribute to successful outcomes beyond the mitten itself.
If the success of a therapy is based solely on the use of BWS, a treadmill, a computer, a mitten, or a virtual environment regardless of the therapeutic framework for its use and regardless of the exercise or training protocol, we could expect success from indiscriminate use of that equipment. The keys to evidence-based practice, however, are in clearly defining the intervention, the basis for clinical decision making, and the selection of training parameters.22–24 Controversy in the scientific literature surrounding the selection of an effective training speed on the treadmill to improve walking ability highlights the need to develop a theoretical basis for speed selection relative to the specific goal of the intervention.22,25 If speed of walking is critical to achieving the maximal benefit of training, how can speed be achieved in other environments? If the selection of assistive devices affects the speed of walking, the process of training becomes important, regardless of whether the environment is a treadmill or overground. Such understanding allows for the development of new equipment and tools within an identified theoretical framework. And, within this context, the role of the therapist, the exercise, and the equipment can be identified. Certainly, one device might have advantages over another to achieve a specific goal, and describing the equipment selected to achieve a patient's needs is valuable. Technology, however, will continue to advance new tools based on our theoretical framework. The patient's goals will remain; the tools to achieve them will change.
A patient asks, "Can you help me find a local physical therapist who does Brand X therapy?" In a progress note, a physical therapist writes, "Brand X therapy was provided." One therapist tells another therapist, "We're conducting Brand X therapy at our clinic." These exchanges represent a marketing success for the company that produces Brand X equipment—but they represent a failure for the physical therapy profession to communicate what physical therapists actually do. Our own value as professionals is displaced by the perceived value of Brand X.
PTJ proposes that physical therapists and researchers document and refer to interventions based on the critical objective of training (eg, gait training, locomotor training, endurance training) and explain how the treatment will be provided, including a description of any rehabilitation tools or assistive devices (eg, virtual environment, treadmill). Devices such as computers and treadmills should be viewed as the tools of our profession and not the active ingredient of our therapy or the goal of the training. Defining our role as physical therapists according to our patient's goals is consistent with the scope of physical therapist practice.
Access to the science and theoretical frameworks that guide clinical decision making will readily advance our profession. Naming therapies according to their purpose will place the emphasis on the principles guiding clinical decision making and equipment selection to meet a therapeutic goal.
"What's in a name?" The practice of physical therapy itself.
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  A. L. Behrman Invited Commentary Physical Therapy, June 1, 2009; 89(6): 612 - 615. [Full Text] [PDF]
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