Moving Forward.

Abstract

In 2009, the Journal of Neurologic Physical Therapy published the President's Perspective, written by Katherine J. Sullivan, PT, PhD, then President of the Neurology Section of the APTA.1 In this perspective, she presented her vision for neurologic physical therapy practice in the United States in light of practitioners' continued embrace of traditional treatment approaches for patients with acute-onset neurologic injuries, including neurodevelopment treatment (NDT), proprioceptive neuromuscular facilitation (PNF), and associated interventions that derived from these initial rehabilitation paradigms. She described the development of these approaches based on the available science in the early decades of our profession and the current struggles of clinicians and educators in their efforts to decide when and how much of these historical approaches to present. Like others in the decades before her, she emphasized how our understanding of the factors that influence neural function and recovery following injury has evolved substantially from the early work that formed the basis for traditional frameworks. Recognizing the historical importance of these strategies, she advocated for embracing the advancing rehabilitation science at this time, in which the principles of neuroplasticity, as studied primarily in animal models, were being tested and applied to patients with neurologic injury. Data regarding the relative efficacy of these principles, including the type of interventions, dosage parameters (frequency, intensity, and duration), and practice conditions, were just emerging in the first decade of the century. Her perspective spoke directly to the educators and clinicians on the front line attempting to navigate the balance between the emerging evidence and the historical rehabilitation models on which many were raised. The perspective article was the source for vigorous debate, with many proponents and opponents for these traditional models articulating their positions on the list-serve ([email protected]). In the decade since its publication, this debate has continued in manuscripts and commentaries appearing in peer-reviewed articles,2–10 and is familiar to many in the field of neurologic physical therapy, as a similar if not identical dialogue of previous decades. Published commentaries,11 including the II step conference and associated proceedings,12,13 were platforms for clinician-researchers to articulate the necessity of embracing the developing scientific literature regarding specific factors that may improve sensorimotor function following neurologic injury. These discussions continued at conferences and in the literature,14,15 and the difficulty with transitioning from traditional models has been apparent to even the novice clinician, educator, or student. This dialogue continues today, as indicated by its reemergence this past summer on the neurologic PT list-serve. A question posed by a clinician-educator grappling with decisions on which concepts and interventions to emphasize to students re-invigorated the conflict between embracing traditional rehabilitation models with more recent, evidence-based strategies. In the 12 years since Dr Sullivan's perspective, an abundance of research evidence has emerged related to the validity of the principles of neuroplasticity in patients with neurologic injury. Multiple studies have reinforced theories from decades prior that specificity, amount, and intensity of task practice may be critical factors influencing recovery.16 For example, studies focused on locomotor recovery following neurologic injury suggest the amount and intensity of task-specific practice are key determinants of gains in walking function.17–24 Emerging data also suggest allowing, or even imposing, movement errors and enhancing task difficulty and variability can influence walking ability.25–28 Similar findings have been observed for improving balance and reducing fall risks, with less emphasis on amount of practice, but greater attention toward increasing task difficulty and inducing errors.29–34 For upper extremity function, particularly in patients post-stroke, the data supporting the utility of these principles are less clear,35–37 as some practice may be beneficial but the magnitude of functional recovery may be limited by the extent of spared neurologic tissue.38,39 Recent efforts have further suggested these findings have shaped clinical practice through focused knowledge translation and implementation strategies,22,40–42 and many entry-level and resident physical therapy curricula have integrated these concepts to promote the use of evidence-based practice by their students. Conversely, evidence to support the use of traditional rehabilitation models has not progressed substantially in the past 3 decades. Very little high-quality evidence regarding the efficacy of traditional strategies has been published, with most all studies indicating very little or no superiority of their techniques over other strategies. This position was emphasized in a 2009 systematic review regarding the lack of comparative efficacy of NDT,43 which was recently reinforced.44 Research utilizing PNF has also been published, although the validity of the findings is constrained by uncontrolled research designs or the use of control interventions that have shown limited benefit or would not be expected to improve function.45–49 For other interventions, including Neuro-IFRAH, there is no evidence to support their utility.50 Regardless of the name or type of techniques performed, some of the fundamental theories underlying traditional rehabilitation models have been tested both implicitly and explicitly. For example, facilitation of normal movement in an effort to achieve optimal recovery has shown to be unnecessary51,52 and often does not restore normal movement as compared with other strategies.27,28,53 Studies have indicated that strength and coordination, not spastic motor behaviors, are primary impairments that limit function,54–57 and efforts to reduce spasticity do not improve volitional movement.58–60 The need to attain postural stability prior to initiation of mobility interventions may have been misguided,18,61,62 as observational, cohort, or randomized studies suggest therapists may be able “leap-frog” over postural control treatment strategies and provide mobility training even in those with severe mobility impairments. Importantly, the physiological basis of traditional approaches, at the time of their development, was grounded in available scientific data underlying the neuromuscular control of movement. However, the findings of subsequent research in the decades since have provided greater insight into the “active ingredients” of physical therapy interventions, which largely contrast with basic tenets of traditional therapies. Nonetheless, the arguments from the proponents of various techniques persist, and are nearly identical to those articulated immediately prior to and following Dr Sullivan's perspective. The efforts directed toward utilizing the best available evidence to guide neurologic physical therapy education and clinical practice is clearly not specific to our field. Every specialty and subspecialty of medicine relies on available and emerging research to advance clinical decision-making and optimize patient health. Disciplines outside of the field of medicine, including economics, politics, marketing, or even professional sports, rely heavily on the use of data and analytics to optimize performance and efficiency.50,63–65 As an analogy, we could consider a scenario in which a medication with little or no evidence regarding its efficacy is prescribed by a physician, particularly when another medication with greater efficacy at similar cost is available. Many clinicians would consider this negligent, and patients likely expect to receive the best available treatment for their ailments. Indeed, strong arguments have been made that clinicians have a moral and ethical obligation to prescribe treatments with the best available evidence to address the specific disease symptoms or signs. While the Academy recognizes the historical importance of traditional approaches and their contributions to advancing the field of neurologic physical therapy, to persist with these approaches that are not supported by the best available evidence runs contrary to the vision set forth by our predecessors and the tenets of evidence-based medicine.66 Accordingly, the position of the Academy of Neurologic Physical Therapy (ANPT) is to emphasize the use of the best available evidence and research in the treatment of adults with acute-onset movement disorders following neurologic injury. Currently, the best available evidence in our field does not support the use of traditional rehabilitation strategies, including NDT, PNF or Neuro-IFRAH, for which high-quality research to demonstrate their comparative efficacy is weak or absent. Rather, the available evidence supports the application of training parameters that offer the greatest probability of harnessing the effects of neuroplasticity and functional gains, including specificity, amount, intensity, and saliency of task practice. Indeed, traditional interventions are likely less effective because these training principles are not considered nor applied. Our concern about the utilization of interventions without strong external supporting evidence extends to other techniques51,67 or devices27 that embrace some of the “active ingredients” of amount of task practice, but also retain some of the traditional principles of neurofacilitation. These techniques, when developed, were theoretically sound with selected research to support their use, and generated substantial enthusiasm across the rehabilitation. To date, however, these strategies have also resulted in suboptimal findings of comparative efficacy, as other “ingredients” were not utilized, emphasized, or as established at that time. As in any health care discipline, the field of neurologic rehabilitation will continue to advance with evolving scientific findings. The strategies advocated today may be obsolete decades from now, as new research uncovers different answers for the problems facing patients with acute-onset neurologic injury. Regardless, the position of the ANPT to guide our clinical practice and education at this time and going forward will be based on the best available evidence. Given the prevalence of traditional interventions in clinical practice and the impact current practice has on the licensing examination and new clinician behavior, enacting changes to support this position will require a multifaceted approach. The Academy is updating its strategic plan to reflect educational, clinical, and research activity related to the use of traditional or other rehabilitation interventions. From an educational perspective, the Academy recognizes the need to promote strategies for educators to disseminate the best available evidence while acknowledging the historical perspectives that emerged from early attempts to bridge the evidence practice gap. Resources for educators will continue to expand, and we will ensure those who teach in entry-level and residency programs have access to this information. Examples will include additional web-based content, updated learning experiences, strategies for addressing licensing examination content, and core competency statements for neurologic education. For clinicians and researchers, the Academy will continue to develop and update clinical practice guidelines (CPGs) to provide both the evidence for specific interventions and knowledge translation strategies to implement these recommendations in multiple clinical settings. Factors considered when topics are selected for CPG development include the amount and quality of evidence available, potential patient impact, and ANPT member feedback. For less common patient diagnoses or clinical presentations with insufficient evidence to guide practice, we anticipate development of consensus documents to support increased standardization of patient care to reduce unwarranted variability of practice patterns. The ANPT Annual Conference to be held for the first time virtually in October 2021 will emphasize knowledge translation strategies and provide an opportunity for networking among practitioners. An additional task force is being created through a call to members to better understand the challenges associated with embracing evidence-based interventions in favor of traditional models and strategies to de-implement common clinical practice at an individual or organizational level. For researchers, future studies will likely continue to enhance our understanding of the contributions of certain training variables or the influence of adjunctive therapies on functional recovery. Of greater value in this context may be for researchers to evaluate the efficacy of interventions that can be more readily replicated in the clinical setting to facilitate implementation. The success of these multiple endeavors can only be enhanced by a coordinated effort by all associated parties to maximize outcomes through delivery of evidence-based rehabilitation services. With the evidence generated in the 30 years since the initial attempts to evolve neurologic physical therapy practice, the ANPT is confident that our membership will be equipped to continue this evolution toward embracing evidence-based practice. Academy of Neurologic Physical Therapy, Board of Directors Patricia L. Scheets, PT, MHS, DPT, President T. George Hornby, PT, PhD, Director of Knowledge Synthesis Susan B. Perry, PT, DPT, MS, Director of Education Patrick Sparto, PT, PhD, Director of Research Nora Riley, PT, PhD, Treasurer Wendy Romney, PT, DPT, Director of Practice Dennis Fell, PT, MD, Vice President Katherine Kugler, PT, DPT, Secretary Timothy Nordahl, PT, DPT, Director of Communications