The American Physical Therapy Association (APTA) provided funding for a series of meetings among a small group of leaders representing the research and clinical communities whose task was to plan a conference, the outcome of which would be a “road map” for the process of generating evidence that would be implemented by clinicians so that the provision of services might be enhanced. Two of these planning sessions were held and resulted in a decision to focus a conference on the identification of strategies to lessen perceived “gaps” between physical therapist clinicians and researchers and the development of strategies to bridge the “gaps” between the 2 groups. These meetings ultimately resulted in the Vitalizing Practice Through Research and Research Through Practice Conference hosted by APTA.
A perceived gap between research and practice has been cited as a problem by others within and outside the profession as well. In a recent editorial in the Journal of Orthopaedic and Sports Physical Therapy, Bechtel et al stated, “We have a problem in manual therapy, and perhaps in the whole profession of physical therapy. Our problem is the growing chasm between researchers on the one hand, and clinicians on the other.”1(p451) A recent Institute of Medicine workshop titled “Transforming Clinical Research in the United States: Challenges and Opportunities” echoed this theme and identified bridging the divide between research and practice as one of the most critical needs facing clinical research.2 Discussion of the perceived gap between research and practice extends internationally, as Demers and Poissant3 lamented that research would be meaningless if it did not affect clinical practice. Furthermore, Demers and Poissant discussed the value of creating partnerships across the research process, from conception to dissemination of results.
Translational Research
Translational research, at its most macroscopic level, essentially refers to efficient movement of new discoveries into clinical practice. This research is typically connoted by the phrase “bench to bedside,” implying that the majority of translation is directional, from the basic science arena to the clinical arena. Authors define translational research slightly differently. Although a number of definitions for translational research exist,4–7 we adopted for the conference the definition generated by the Institute for Translational Health Sciences (ITHS), a consortium of 38 medical research institutions supported by the National Institutes of Health, which defines translational research as moving knowledge and discovery gained from the basic sciences to its application in clinical and community settings.8 The ITHS model delineates 5 phases of translational research and labels the phases from T0 to T4 (Fig. 1). The model recognizes that translational research can be described via a continuum that extends from the identification of opportunities and approaches to a health problem (basic research), to the impact of practice on the health of the population (outcomes research).8 Furthermore, it should be recognized that the model is bidirectional and should not be interpreted as moving only from identification of opportunities and approaches to a health problem through the study of practice to population health impact.
The Institute for Translational Health Sciences (ITHS) model of translational research.8
Regardless of the specific definition or model used to describe translational research, the goal is similar: to provide a framework that describes how basic and clinical research will interact in the future.
Knowledge Translation
Concomitant with an acknowledgment of the importance of the need for translational types of research is the recognition that an infrastructure needs to be developed so that the evidence created is utilized adequately. Thus, although the focus of translational research is the creation of new knowledge, there is a coexisting need to facilitate consistent application of the findings in practice. This concept of translating evidence into practice has been given a number of designations, among them “diffusion theory,”9 “implementation science,”10 and, more often, “knowledge translation.”11–17 Knowledge translation has been formally defined by the Canadian Institutes of Health Research as a dynamic and iterative process that includes the synthesis, dissemination, exchange, and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system.13 Regardless of what it is called, the implementation of knowledge is as important as the creation of new knowledge and technologies to improve health outcomes.18
For a clinical science such as physical therapy, the importance of embracing the concept of knowledge translation should not be undervalued. Clearly, the issue of translating knowledge into practice is one that transcends physical therapy. It is a concern affecting all of health care. The lack of consistent implementation of evidence into practice is illustrated by McGlynn et al,19 who evaluated physician performance on 439 evidence-based indicators of quality of care for 30 common acute, chronic, or preventative conditions. Through telephone interviews and chart reviews across 12 US cities, the authors determined that patients received the right care at the right time less than 55% of the time. These results appear to represent a lack of timely translation of research findings into clinical practice and warrant our attention as physical therapists, as the authors stated that one solution to this issue is the routine availability of information on performance of providers. To provide an example related to physical therapy, a recent retrospective study demonstrated that adherence to recommendations of clinical practice guidelines in treatment of people with acute low back pain was more likely to result in better clinical outcomes and lower costs.20 The rate of adherence to the guideline recommendations was 40.4%, which suggests that although clinical practice guidelines have been developed and following the recommendations may result in better care, active strategies are needed to increase awareness of the guidelines, implement the evidence in practice, and improve adherence.
Given that both translational research and knowledge translation rely on a dynamic and iterative process, important infrastructure systems need to be in place throughout academia or other settings whose purpose is, in part, to create knowledge; throughout care delivery systems; and within funding sources. With this in mind, the Vitalizing Practice Through Research and Research Through Practice Conference was designed to reinforce to the profession the importance of translational research and to identify the need for infrastructure and resource development that would augment the existing research capability of physical therapists nationwide, as well as ensuring that this evidence is used to enhance practice. The success of the conference will be judged by how well it serves as the impetus for additional translational studies and leads to the creation of such an infrastructure, one that supports translational research and enhances knowledge translation.
The Vitalizing Practice Through Research and Research Through Practice Conference
With the goal of generating evidence and enhancing practice, as outlined above, as the incentive, the Vitalizing Practice Through Research and Research Through Practice Conference was planned over the course of 2 meetings. The meetings were directed by a planning committee that had been appointed by the APTA Board of Directors and convened by APTA staff. Planning meeting discussions were guided by 2 assumptions: (1) the quality of physical therapy is threatened by the inappropriate variation in the care delivered, and (2) there is a lack of consistency or uniformity in tracking outcomes. The planning group acknowledged a need for the development of infrastructure to disseminate information to clinicians and to examine the effectiveness of evidence-based care delivery by measuring clinical and cost outcomes. In order to create processes for optimum care to be delivered to patients, the following were anticipated outcomes of the conference:
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Clinician attendees would depart the conference with an understanding of what it means to have a systematic approach to data collection;
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Development of a model for a minimum data set necessary to describe the process of care;
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Creation of strategies to develop relationships with external stakeholders to enhance patient care delivery; and
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Creation of new collaborations among researchers and clinicians to enhance patient care.
Conference Design and Format
The conference was designed to provide value to both researchers and clinicians. The themes discussed by the planning group attempted to ensure that conducted research would be useful to clinicians. Conversely, the relevant evidence generated from the research investigations would be adopted to enhance the delivery of care. Thus, the first phase of the conference recognized the importance of translational research (ie, the movement of knowledge and discovery gained from research to its application in clinical and community settings).8
The second phase of the conference was designed to address infrastructure development. Topics such as development of databases, registries, and clinical research networks were deemed important, as the planning committee realized the creation of a hub from which studies could be conducted and results disseminated was vital to knowledge translation.
To publicize the conference, a series of announcements using various media were used to disseminate the purpose of the conference and to invite nominations of the individual receiving the announcement or a colleague. Conference participants were selected by members of the planning committee using the following guidelines: (1) ensure adequate representation of clinicians and researchers, (2) select individuals who would act collegially, and (3) select participants who adhere to the principle that collaboration between clinicians and scientists will enhance clinical practice outcomes. Fifty-four participants were selected from 128 nominations (Appendix 1). Thirty-four of the participants considered themselves to be research investigators, and 20 considered themselves to be primarily clinicians. The participants ranged from individuals who were relatively new physical therapists to those with more than 40 years of experience. Nearly every setting in which physical therapists work was represented, although the largest number of participants were members of university faculties. A total of 75 individuals attended the conference, including the members of the planning committee and APTA staff members.
The planning committee chose conference speakers who understood the concepts of translational research and knowledge translation as evidenced through publications and presentations. Each of the conference presentations had a common theme, which was the importance of translational research to the clinical community, payers, and policy makers.
Speakers represented a mix of clinicians and researchers: 5 were physical therapist clinicians, and 4 were physical therapist researchers. Two speakers were from outside the physical therapy profession: one was a health services researcher, and one maintained both research and administrative responsibilities in a large health care system.
The conference took place on December 2–4, 2009, in Philadelphia, Pennsylvania. The majority of the presentations were recorded prior to the conference. Participants reviewed the presentations prior to attending the conference in preparation for active discussion (Appendix 2). Viewing these presentations ahead of time facilitated the accomplishment of the first anticipated outcome, which stated that participants would have an understanding of what it means to have a systematic approach to data collection.
The core of the conference focused on guided discussions among participants. Four small groups, with an equal representation of clinicians and researchers, were charged to develop strategies to encourage researchers and clinicians to work more collaboratively. A member of the planning committee facilitated each group's work.
The groups' discussion was guided by 2 basic questions—“Does research inform practice?” and “Does practice inform research?”—and a series of subquestions (Fig. 2). Answers to the questions were focused on how well research and practice currently inform each other and on identifying barriers to and solutions for optimal integration. Clinicians were encouraged to articulate how they can influence the behavior of researchers, and researchers were asked to describe ways their research could be made more useful to clinicians. This portion of the group discussion focused on issues such as:
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Clinicians having the opportunity to influence the questions asked by researchers,
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The value of clinician concerns when lines of research are formulated,
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Clinical innovations serving as an impetus for additional study, and
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The infrastructure necessary to create communication between clinicians and researchers.
Guiding questions for breakout sessions.
The questions do not necessarily relate to either the desired outcomes or foci of the conference. Rather, the planning group decided during the course of the meeting that the best way to generate discussion and guide the work of the breakout groups was to assign very generic questions and permit the discussions to lead in a direction that would result in appropriate responses to the original outcomes and foci. We are convinced that the strategy was a sound one, as the conference produced recommendations that exceeded the expectations of the planning group.
These small-group deliberations were shared in a plenary session that completed the activities of the second day. Summaries from each of the groups were very similar. The discussions generally could be categorized into the following themes:
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Clinicians must determine methods to gain access to clinical information, including clinical guidelines. An underlying theme was the importance of clinical registries or databases.
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There must be mutual respect and collaboration between the clinical and research communities.
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Physical therapists should take advantage of research generated external to the profession as well as studies conducted by physical therapist scientists.
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The appropriate outcomes measures should be specified and outcome instruments selected so that physical therapists can justify their interventions among both payers and policy makers.
A health care economist discussed the need to develop an infrastructure to support the concept of value-based practice. Value-based practice maintains that a patient's values are pervasive and powerful parameters influencing decisions about health, clinical practice, and research.21 The session introduced the idea of value-based practice, which is complementary to evidence-based practice, patient-centered care, and ethical care and provided the perspective on improving health care effectiveness by a stakeholder outside the profession.
The conference concluded with participants identifying recommendations they felt were most essential. A number of themes emerged from this plenary session. The obvious central role of the patient in the process of care, as a driving motivation for research, was acknowledged and respected in this discussion. The need for patients to assist in driving a research agenda is not novel.22,23 In response to recognition of the important role of the patient, the group discussed taking advantage of a variety of media platforms, similar to an iPhone application, to make decision support systems available to individual consumers potentially in need of physical therapy. Participants stressed that creating a collaborative culture would be costly and that all mechanisms of external funding should be explored to facilitate and bridge communication between the research and clinical communities, if the goals of translational research were to be accomplished.
Recommendations and Conclusions
Based on the deliberations of the small groups and the ensuing presentations during the plenary session, recommendations were made. These recommendations were consolidated by the planning committee into 4 key recommendations. These recommendations are not addressed to any one specific group; rather, the acknowledgment and implementation of the recommendations are the responsibility of the entire physical therapy profession.
Recommendation 1
Identify mechanisms to distinguish conditions amenable to the development of clinical practice guidelines. The development of such guidelines will distinguish physical therapist practice that is supported by evidence from physical therapist practice that is not supported by evidence, as well as assist in the identification of outcomes.
The recommendation of creation of guidelines is not a new or unique idea. As an example, APTA's Section on Orthopaedics has already begun the process. The Canadian Medical Association, in its series on knowledge translation, has strongly advocated for the use of guidelines.24 Furthermore, it has been cited that interventions to implement guidelines do, in fact, affect the process and outcomes of care, although the effect size (10%) is small.25
Simply creating guidelines and making them available to clinicians will not ensure that they will be widely used. Evidence of this statement abounds. In their widely cited article, McGlynn et al19 estimated that evidence-based health care is delivered to patients approximately 55% of the time. One strategy to assist in bridging the gap between evidence and practice is the expanded use of electronic databases to accelerate the diffusion of new evidence into practice. A goal of electronic databases is to make it easier for those who provide care by making evidence more readily available at the point of care.26 In a recent article, a group of researchers in the Netherlands demonstrated that adherence to evidence-based guidelines for low back pain resulted in greater improvement in patient functioning, lower utilization of care, and fewer treatment sessions.27 Although clinical guidelines are being developed and clinicians are using electronic databases,28–32 recommendation 1 urges that these efforts be expanded.
Recommendation 2
Develop clinical registries, minimum data sets, outcome databases, and core sets of outcome measures that cover the patient life span and the domains of ability and disability for each area of physical therapist practice.
The coordination of local or, perhaps, national registries or databases is a necessity for developing the infrastructure to its optimum capacity. Patient registries are defined as an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure and that serves one or more predetermined scientific, clinical, or policy purposes.33 Potential uses of a registry include the determination of clinical effectiveness and cost-effectiveness of physical therapy intervention.
Recommendation 3
Form a consultant group to investigate the development and implementation incentives for physical therapists to collect minimum data sets that are included within a clinical registry from which reports can be generated to develop optimal clinical practice guidelines, guide research, and enhance practice.
The third recommendation is essentially an extension of the second recommendation and calls for the establishment of a consultant group, perhaps overseen by APTA, to administer development and implementation of these registries. This group will be integral to the success of all of the recommendations generated.
Recommendation 4
Ensure that the consumer is the center of efforts for the provision of physical therapy services. There needs to be a transformation from the physical therapist as the “driver” of the provision of care; rather, it must be recognized that the consumer must be the beneficiary of services that are based on evidence.
A primary theme of the conference was the recognition that researchers and clinicians must more effectively collaborate to benefit the physical therapy profession and our patients. These collaborations are to be devised so that the best care possible, at the least expense, can be provided to the patient. The patient should be at the core of any system that is developed and implemented. Throughout most of the history of health care, the clinician rather than the consumer has been the focus.26 The role of the patient cannot be overlooked in the development of new models that might be created as a result of the conference. A focus on the consumer is consistent with the outcomes of the recent APTA Physical Therapy and Society Summit (PASS)34 and with the focus of APTA's Research Agenda.35
We realize that the recommendations specifically do not mirror the original anticipated outcomes of the conference. This slight lack of congruence was a result of the enthusiasm demonstrated by conference participants and their motivation to modify the outcomes initially developed by conference planners. We believe these new recommendations exceed, in value, the original anticipated outcomes of the conference.
The Vitalizing Practice Through Research and Research Through Practice Conference provided a unique format for physical therapist researchers and clinicians to interact, plan, and prepare for the future of the profession. The dialogue provided a clear indication that: (1) the pursuit of translational research will have a definite impact on physical therapist practice, and (2) infrastructure will need to be developed so that physical therapy's impact can be monitored not only at the level of an individual patient but also at the systems level. The dialogue also resulted in 4 recommendations to provide specific direction for meeting these goals.
Based on anecdotal reports following the conference, the potential exists for substantive results to develop as a function of the efforts of those in attendance. The conference, however, was only the first step in “vitalizing practice and research.” An ongoing evaluation process will assess the implementation of the recommendations that were generated. The results of the evaluation process will truly measure the impact of the conference and determine its role in the creation of a larger cadre of clinical scientists who enhance the manner in which physical therapy care is currently delivered.
The evaluation process will be based on the desire that conference recommendations must be implemented throughout the profession. These recommendations stress the idea that there needs to be more collaboration between clinicians and researchers than is currently the case. Conference participants cited examples where collaborative efforts have succeeded in improving patient care and reducing the costs of interventions, not only of physical therapy but of all therapeutic care provided throughout the episode. It is hoped that the examples cited at the conference will generalize across the profession and increase services that are based on evidence so that evidence- and value-based practice becomes the norm throughout the profession.
The evaluation process cited above also will affect the entire profession. The first stage of the process involves presentations that have been made and will continue to be made at local, regional, and national meetings to describe the conference and inform audiences of the recommendations developed at the conference. However, this is only the initial step. Over time, those physical therapists who are practicing either based on evidence or in collaboration with researchers will be provided opportunities to share their experiences with groups of physical therapists as well. Dissemination of these experiences can lead to more collaboration, to the development of additional databases of evidence that can be contributed to and used by larger numbers of clinicians, and, ultimately, to the enhancement of patient care.
One of the recommendations was that the client should be at the center of efforts for the provision of services and consumers must be the beneficiary of services based on evidence. The recognition of evidence-based services for the ultimate benefit of the client is motivating individual clinicians and networks. The conference can and will be judged successful if this mode of practice is adopted by a substantial proportion of the profession. Adoption of these recommendations will only enhance our status as a profession.
Conference Evaluation
Simply conducting a conference without assessing its value almost defeats the purpose of having a conference. Therefore, an extensive evaluation will be undertaken that will span into the future. The extended time frame is warranted, as it will likely take a substantial amount of time for the recommendations to be fully implemented. The evaluation of the effectiveness of the conference will follow a modified version of the CIPP (Context-Input-Process-Product) model developed by Stufflebeam.36,37 This model accounts for the context in which decisions have to be made. Thus, inputs, process, and outputs of a decision have to be evaluated. In the evaluation of this particular conference, we will have to account for behavioral changes of clinicians and researchers and cite how these changes affect the context or the environment in which services are provided. Thus, the evaluation will proceed over a somewhat lengthy period of time until the profession can be confident that its services are provided in the optimum manner.
The effectiveness evaluation model will be modified, as not all components are applicable. The portion of the model that deals with all post-conference activities contains the most useful elements; these are the elements that will be used to assess the value of the conference. Thus, the evaluation will contain the following elements:
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Impact evaluation, which assesses a program's reach to the target audience,
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Effectiveness evaluation, which assesses both the quality and significance of outcomes, and
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Sustainability evaluation, which assesses the extent to which a program's contributions are successfully institutionalized and continued over time.24
Given that the evaluation process will encompass a lengthy period of time, the expectation is that the conference is only the first step in a process that, ideally, will change the behaviors of both researchers and clinicians. Any discussion of a time frame would have to be couched in terms of increments. It is incumbent on conference planners to assess any adaptive behaviors over a period of years.
Having said that, however, during the upcoming year, a series of assessments will be made that will allow conference planners to determine at least the preliminary effects of the conference on the profession. At least 2 presentations involving a panel of conference participants will be given during the upcoming year.
Appendix 1.
Conference Participants
Appendix 2.
Conference Presentationsa
a Information regarding the conference and the presentations is available at: http://www.apta.org/ResearchConference2009.
Footnotes
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All authors provided concept/idea/project design, writing, and consultation (including review of manuscript before submission).
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The authors would like to recognize and thank the following individuals for contributing to the conference and this article: Ralph Nitkin, PhD, and Daofen Chen, PT, PhD, who were instrumental in conference planning, and Steven Z. George, PT, PhD, and Gregory Hicks, PT, PhD, who reviewed and commented on an earlier draft of the manuscript. Their input is greatly appreciated.
- Received October 18, 2010.
- Accepted April 15, 2011.
- © 2011 American Physical Therapy Association
References
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