Language Matters

In an article published recently in JAMA Neurology, Clarke et al concluded that “physiotherapy and occupational therapy were not associated with immediate or medium-term clinically meaningful improvements in ADL or quality of life in mild to moderate PD [Parkinson's Disease].”¹ As part of the physical therapy arm of the study, patients in the experimental group received a median of 4 hour-long outpatient sessions consisting of what the authors called “routine physical therapy practices” that are universally established—within the United Kingdom's National Health Service—for the treatment of PD. As physical therapist researcher and professor Dr. Terry Ellis noted, “The study may have more to say about a particular intervention model used in England than it does about the effectiveness of physical therapy on individuals with Parkinson's Disease.”² Or, as Ahlskog cautioned in an editorial in the same issue of JAMA Neurology, “these conventional physical therapy practices take no advantage of what has now become increasingly apparent: ongoing aerobic exercise may slow the progression of PD.”³

Clarke and colleagues' imprecise use of language in labeling the intervention as “physiotherapy and occupational therapy” is not unusual; rather, it represents an unfortunate norm in the scientific literature.^4–6 Rarely are individual rehabilitation interventions accurately described in labels. I am shocked by the imprecise use of generic terms like “physical therapy” that investigators so cavalierly use—and editors allow—in describing rehabilitation interventions and in reporting the results of clinical trials. Such imprecision can inflict serious damage on our understanding of the rehabilitation interventions that are and are not effective in the management of various conditions, and it also can create troublesome challenges when researchers try to systematically review and synthesize the literature on a particular topic, such as the management of PD. This challenge can be seen in the descriptions of interventions in Table 4 of the systematic review by Bürge et al⁷ on page 783.

Does anyone think that journal editors would tolerate such imprecise language in labeling medical interventions? Can you ever imagine JAMA publishing the results of a clinical trial that concluded, “Medical intervention was not associated with immediate or medium-term clinically meaningful improvements in ADL or quality of life in mild to moderate PD”? Never! Reviewers and editors would rightly insist that the authors label and describe the actual medical intervention that was applied and evaluated.

Why does such imprecise language persist with regard to rehabilitation interventions? Some have argued that—in marked contrast to the detailed specification used in pharmacological, medical, and surgical research—we lack an adequate system to classify and describe the complex interventions that constitute rehabilitation interventions.⁸ To address this concern, investigators have begun to develop and disseminate taxonomies—systems of concept categories or groups—for rehabilitation interventions.^9,10 Although taxonomies do not yet appear to have gained wide acceptance in the rehabilitation field, the expectation is that using a taxonomy of treatments will bring needed systemization, greater clarity, and more precision to describing what happens in the rehabilitation process, and thus serve as a stronger foundation for measuring intervention efficacy and effectiveness.

There are positive signs that investigatory reporting norms may be changing. For instance, Winstein et al¹¹ recently published the results of a clinical trial of an experimental rehabilitation intervention following motor stroke. Instead of describing their intervention as “physical therapy and occupational therapy,” these authors carefully described the experimental intervention as a structured, task-oriented, upper extremity training program. And they provided a specific label for the intervention: Accelerated Skill Acquisition Program. Their intervention was principle based, impairment focused, task specific, collaborative, patient centered, and delivered at a specified dose, intensity, and duration. The operational definition provided by the authors was precise and sufficiently detailed to allow readers to understand what actually was delivered in this trial and allow researchers to conduct careful replication of the trial in the future.

It is interesting to note that the CONSORT (Consolidated Standards of Reporting Trials) Statement, developed to alleviate the problems arising from inadequate reporting of randomized clinical trials, requires that interventions for each group be reported with sufficient detail to allow replication, including how and when they were actually administered.¹² CONSORT does not, however, have a standard for how interventions are labeled. CONSORT might consider adding to its list of standards one that instructs investigators to use intervention labels that appropriately describe the interventions being investigated.

In the meantime, rehabilitation journals such as PTJ have an important role to play. Editors, editorial board members, and reviewers have an opportunity to accelerate changes in investigatory reporting norms by requiring that authors use appropriate language in the labels they assign to describe the rehabilitation interventions that are being investigated. Standardization and precision in how we label and describe interventions will greatly strengthen our ability to communicate and to make comparisons across a wide range of conditions, interventions, and outcomes. In fact, standardization and precision are imperative if we are to build a strong evidentiary foundation and advance physical therapy and rehabilitation science.

In the July issue, look for an editorial that represents a collaboration among physical therapy journal editors worldwide to require that authors use the Template for Intervention Description and Replication (TIDieR) checklist and guide.

• © 2016 American Physical Therapy Association