Next Steps: The Evolution of Neurologic Physical Therapy Practice and Research

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Have you ever, just for grins, browsed through the JNPT archive? If you have, then certainly it was immensely apparent how far we've come in our endeavors to develop the evidence that forms the foundations for the practice of neurologic physical therapy. The articles in this IV STEP compendium reflect the diversity of clinical populations, study designs, interventions, and outcome measures that comprise neurologic physical therapist practice and research. The first article by Harris and Winstein conveys the remarkable progress we've made over the years, as embodied in the proceedings of the STEP meetings.
Despite the broad diversity of neurologic physical therapy, as Van Sant notes in her article, the movement system is a construct that transcends all areas of our practice and research. Movement is typically our primary intervention, as well as our primary outcome measure. Across the spectrum of clinical populations with whom we work, the outcome measures that we employ, and the interventions we apply, the movement system is the unifying, organizing construct around which everything we do coalesces.
As with the concept of the movement system, another notion that infuses all areas of our practice is actually a conceptual question—that of “what key elements make the difference to the outcomes of our interventions?” As the articles in this compendium illustrate, it is clear that the key elements include characteristics of the patient as well as characteristics of the intervention. The article by Stewart and Cramer illustrates this concept, showing that genetic variables may be able to explain some of the differences we observe in the outcomes of our interventions. Conversely, while we have long assumed that dose of intervention is an element essential to outcomes, as Basso and Lang show in their article, there are instances wherein dose alone cannot account for differences in outcome. Building on the matter of dose, Burridge and colleagues describe ongoing studies that will answer questions about whether technology may provide an opportunity to address the issue of dose, as well as other important contributors to outcomes such as motivation and adherence.
While improved movement is generally the primary outcome of interest in both our practice and research, the motivation toward this outcome derives from the impact that movement has on all areas of life. Behrman and colleagues highlight the need to consider benefits of practice and training that may be different from those for which we are aiming. They also describe a scale to assess ability to perform functional movements without assistance or compensation. Moreover, Quinn and Morgan show that by prescribing targeted movement interventions, neurologic physical therapists can play a meaningful role in improving our patients' fitness and participation, possibly, even influencing disease processes. McGough and colleagues take this concept one step further, describing the evidence available to indicate that, beyond movement, modifiable risk factors associated with dementia are also responsive to physical activity and exercise.
From the perspective of what we know today, it goes without saying that the extraordinary advances we will witness and the progress we will make in the years leading up to V STEP are entirely inconceivable. We will continue to build our body of evidence—starting with single-case studies that demonstrate safety and tolerability of theory-based intervention, progressing to quasi-experimental pre-/post studies that provide insights into dose-response relationships and allow refinement of the intervention, and then on to randomized trials to enable assessment of whether the intervention is more efficacious relative to a comparison group.
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