P r o f e s s i o n a l

P e r s p e c t i v e

O u t c o m e s  R e s e a r c h
Sh i f t i n g  t h e  D o m i n a n t  R e s e a r c h  Pa r a d i g m  i n P h y s i c a l T h e r ap y

ALAN M JETTE

P ublished  w ith the 
perm ission of

P h y s i c a l  T h e r a p y

A M  Jette, PhD, PT, is 
Chief Research Scientist. 
New England Research 
Institute, 9 Galen St, 
Watertown, M A  02172 

(USA) (alanj%neri@mci- 
mail.com), and 
Professor of Social & 
Behavior Sciences, 
Boston University School 
of Public Health, Boston, 
M A  02215.

An earlier version of 
this article was present­
ed at the Second Joint 
Congress of the 
American Physical 
Therapy Association 
and the Canadian 
Physiotherapy 
Association; Toronto, 
Ontario, Canada; June
5, 1994.

this work was support­
ed, in part, by the 
Edward R Roybal 
Research Center on 

Applied Gerontology 
(AG 11669).

This article was submit­
ted May2, 1995, and 
was accepted August 4, 
1995.

This article discusses outcom es research in physical therapy and p laces its conceptual roots within 
the w o rk on qu ality-of-care assessm ent. An argument is advanced that the outcom es research m ove­
ment in m edicine has stim ulated clinical researchers in p h y sical therapy to address disability out­
com es in addition to traditional im pairm ent outcom es. I f  p h y sical therapy clin ical research m oves 
beyond this broadening o f  clin ical outcom es to investigate explicitly the hypothesized relationship 
betw een im pairm ent and disability, outcom es research will have stim ulated a  shift in the dom inant 
research paradigm  in the profession. The developm ent and testing o f  theory regarding the p a th o ­
genesis o f  disability will be n eeded to guide the direction o f  this type o f  p h y sical therapy research. 
Such a  shift in the dom inant research paradigm  in physical therapy could produce dram atic fin d ­
ings that have direct im pact on clin ical practice. (Jette AM Outcomes research: shifting the d om i­
nant research paradigm  in p h y sical therapy. Phys Ther. 1995;75:965-970)

KEY WORDS: Outcome and process assessment (health care), Quality o f health care, 
Research, Research design.

INTRODUCTION
T h e  T h ir d  R ev o lu tio n  in  th e 
M o d e m  M e d ic a l E ra

A rnold R e im a n ,1 past editor of 
the N ew  E n g lan d  J o u r n a l  o f  
M edicin e, has described  the ascen ­
dancy o f o u tco m es research as the 
last o f three resolu tion s in the 
m od ern age o f m ed icin e as p rac­
tised in  the U nited  States. F irst, he 
e x p la in s , c am e the E ra o f 
E x p a n sio n , from  the end of W orld 
W ar II throu gh the late 1 9 6 0 s , the 
h a llm a rk  o f w h ic h  w as the 
exp an din g role o f the U S federal 
and  state g o v e rn m e n ts  in  the 
financin g o f m ed ical facilities and 
m edical services. T h is first era was 
h ig h lig h te d  b y  a fu n d a m en ta l 
change in  the federal g ov ern m en t’s 
Social S ecu rity  Act. the passage of 
Titles 18  and 19 (M edicare and 
M edicaid ), w h ich  fun d am entally 
changed the role o f the federal 
govern m en t in fin an cin g  h ealth  
care for m any of its citizens. By
1 9 9 0 ,  the 2 5 t h  a n n iv e rsa ry  o f 
M edicare and M edicaid, the total 
exp en d itu re of the U S federal gov­
ern m en t for health care was in 
excess o f $ 1 5 0  b illion , up from 
$ 5 .6  b illion  in 1 9 6 5 /

T he first m o d ern  era of m ed i­
c in e, R eim an exp lains, was fo l­
low ed  b y  the Era o f C ost 
C o n tain m en t, as the increase in 
h e a lth  care e x p e n d itu re s  grew 
relentlessly through the 1 9 7 0 s  and 
1 9 8 0 s  (reach in g $ 6 2 0  billion  in 
1 9 8 9 , 1 1 .2 %  o f the gross national 
p rod u ct). A series o f cost-co n ta in -

m en t reg ulations and  legislative 
actio n s were en acted  d uring the 
1 9 7 0 s  and  1 9 8 0 s  in response to 
the grow th in health care e x p en d i­
tures. O ne exam ple is the in tro ­
d u ction of the d iagnostic related 
groups (D R G s) as the basis for h o s ­
p ital re im b u rse m e n t u n d e r the 
M edicare program . As noted  by 
R eim an, we are cu rren tly in  the 
third stage o f this m od ern revolu­
tion , the Era of A ssessm ent and 
A ccountability, in w h ich  the focus 
has been d irected  toward the q u al­
ity and effectiveness o f health care. 
T h e  em p h asis is n o lo n g er on 
u n brid led  grow th n o r on blin d  
cost con tain m en t, but on a balance 
b e tw e e n  a s se s sm en t o f g ain s 
achieved for certain costs and an 
a c c o u n ta b ility  fo r th o se c o s ts  
incurred.

R eim an 1 has described  the “o u t­
com es m ovem en t in m ed icin e” as 
ch aracterizin g this third stage in 
m o d ern  m edical care. Its p ro p o ­
nen ts have defined  ou tcom es m a n ­
agem ent in m ed icine as the c en te r­
p iece o f this era o f assessm en t and 
accountability. 31 It is a tech n olog y 
o f patient exp erience designed to 
h e lp  p a tie n ts, p ay ers, and 
providers m ake rational m ed ical 
care-related  ch o ices based  on b e t­
ter insight into the effect of these 
ch o ices on the patien t’s life. Today, 
o u tco m es research is b ein g  used in 
m e d ic in e , an d  in c re a sin g ly  in 
physical therapy, to ju stify  policie 
regulating practice, in clu d in g  c o n ­
sensus statem en ts, p ractice gu ide­

lin es , an d  p ra c tic e  p ro to c o ls , 
w h ich  are b ein g  offered in creasin g ­
ly as sta n d a rd s for th ird -p a rty  
reim b u rsem en t and  m alp ractice, 
p ro te c tio n .5'6

T h e ou tcom es m ovem en t w ithin 
m ed icin e has also stim u lated  its 
share of controversy. As A nderson 
recen tly com m en ted  in  the jo u rn a l 
S cien ce, ...5  years and  $ 2 0 0  m illion 
later, c ritics are asking: W h e re ’s the 
b eef? 2<IOHO) Has the U S C ongress 
b e e n  sold as a b ill of goods? C ritics 
have argued that after a spend ing 
nearly $ 2 0 0  m illio n  on  o u tco m es 
research , the A gency for H ealth 
Care Policy and R esearch can not 
p oint to a single case in w hich 
d a ta b a se stu d ie s  h av e ch an g ed  
general c lin ical p ra c tice .2 Or, as 
T an en bau m 7 has argued, in  c o n ­
trast to m an y Europ ean n ations 
that have opted for bu d getary reg­
u lation, U S p hy sician s have c h o ­
sen the path o f behavioral regula­
tion -  through u tilization review, 
p ractice guidelines, and ou tcom es 
research -  as the m ajor regulatory 
strategy for a cco u n tab ility  an d  cost 
con ta in m en t. And in d o in g  so, 
they have sacrificed  con sid erable 
c lin ical au ton om y in favor o f m ore 
e co n o m ic autonomy.

W h a t lessons, if any, do these 
ou tcom es research d evelop m ents 
in m ed icin e have for p h y sical th er­
apy? Is o u tco m es research  a revo­
lu tion ary app roach, rep resen tin g a 
new  paradigm  for c lin ical research 
as its m any vocal ad vocates have 
argued?13'18 Is it the d irection  that

4 SA Jo u r n a l  o f  Ph y s io t h e r a p y  V o l  53 No 2

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physical therapy research should 
be heading toward? Or, as o th ers2-7 
have suggested, is it m erely a regu­
latory strategy that devalues c lin i­
cal ju d g m en t?

To present m y perspective on 
these q uestion s, I will focus on 
several p oints in this article. First, 
I will d escribe the con cep tu al roots 
o f o u tc o m e s  research  w ith in  a 
qu ality-of-care fram ew ork. N ext, 1 
will con trast o u tco m es research 
against the traditional im pairm ent 
research often con du cted  in physi­
cal therapy and show  how  clin ical 
ou tcom es o f im p ortan ce in p h y si­
cal therapy research are shifting 
from im pairm en ts to disabilities. 
Fin ally, I w ill p re s e n t som e 
thou ghts on  the potential for o u t­
com es research to shift the d om i­
na n t re se a rch  paradrgm  w ith in  
physical therapy toward the devel­
op m en t and testin g  o f th e o n e s  
related to the pathogenesis o f dis­
ability and how  this cou ld  have a 
lasting and profou nd  im p act on 
clin ical practice.

DETERMINING QUALITY OF 
PHYSICAL THERAPY
D o n a b e d ia n 9 h as p rov id ed  a 
fram ew ork that can be used to d is­
cuss assessing quality o f physical 
th era p y  care. Q u a lity  o f  c a re, 
accord ing to D onabed ian , can be 
described as the ability to achieve 
desirable ob jectiv es (eg, various 
states o f h ealth) using legitim ate 
m eans (in this case, various aspects 
o f physical therapy care). His c o n ­
c ep tu a l ap p ro a c h  to a ssessin g  
quality of care provided by any 
health  provider in clu des m easure­
m en t o f three elem ents: structure, 
process, and ou tcom es o f that care.

Structural evalu ation  deals with 
stable resources need ed to provide 
care.

S tru c tu r a l e v a lu a tio n  c rite ria  
address issues su ch  as provider 
q u a lrfic a tio n s, ad m in istra tiv e 
organisation, and  facilities. O ne 
exam ple o f structural quality-of- 
care criteria in physical therapy in 
the U n ited  S tates is the 
C om m ission on A ccred itation of 
R eh ab ilitatio n  F a c ilities ’ (C A R F) 
gu idelin e on  a facility utilizin g 
com p eten t, ethical and qualified 
personnel w ho con trib u te to sh ap ­
ing and accom p lishin g its m ission. 
A n o th e r ex am p le is the J o in t  
C om m ission on A ccreditation of 
Healthcare Organizations (JCAHO)

guideline that hospitals have the 
requ ired n u m b er and  m ix o f staff 
m em bers in each un it, area, and 
d ep artm ent to provide for patient 
n eed s. T h e  m a jo r  c r itic is m  o f 
structural criteria is that they are 
necessary but not sufficient criteria 
for ad equate care.

Process evalu ation  o f quality of 
care c o n s is ts  o f ev alu atin g  the 
degree to w h ich  service provided 
to patients m eets professional stan ­
dards of quality. Q uality assurance 
system s using p rocess m easures 
(such as the professional standards 
review organizations) are in w id e­
spread use throu ghou t the m edical 
care system  in the U nited States. A 
p ro c e ss  e v a lu a tio n  e x a m p le  in  
p h y sical th erap y w ould  be the 
d evelopm ent and  use o f practice 
g u id e lin es  or p ra c tic e  s creen s 
designed to identify other practices 
and to bring them  into com p lian ce 
w ith existing standards for practice 
in  the field. A m a jor criticism  o f 
the process approach to d eterm in ­
ing quality o f care, however, is that 
s u c h  p ra c tic e  sta n d a rd s c o u ld  
actually increase the delivery of 
certain  aspects o f care that m ay not 
ultim ately affect the p atien t’s o u t­
com e. In o th er w ords, op tim al 
p rocess o f care d oes n o t ensure an 
optim al o u tcom e unless the lin k 
betw een the two has been  estab­
lished.

U ltim ately , if o n e w an ts to 
im prove the ou tcom e o f care, one 
n e e d s  to ad dress D o n a b e d ia n ’s 
third elem en t in quality o f care, 
the d ete r m in a tio n  o f o u tc o m e s  
directly in term s of d eath, m o rb id ­
ity, disability, or quality o f life.9 A 
positive patient o u tcom e, as this is 
ultim ately the general goal o f m ed ­
ical care, has con sid erab le face 
validity as a m easure o f the quality 
o f care. D efining a positive patient 
o u tco m e, however, is no easy task.

Physical therapy, lik e o th er th er­
apies, is deem ed valuable w hen it 
provides im portan t benefits. O ne 
o f the im portan t c on trib u tion s of 
the ou tco m es research in m ed icine 
has been  the exp an sion  o f the 
scop e o f ou tcom es deem ed u se­
fu l.10 T h e research  has focu sed  
atten tion  on  the con sid eration  of 
ou tcom es o f value to patients, to 
payers, and to c lin ician s as an aid 
to clin ical d ecision  m akin g and to 
in flu e n c in g  h e a lth  care policy. 
O u tc o m e s research in m ed icin e 
has forced m edical researchers to

exam in e ou tcom es o th er than d is­
ease an d  m o r ta lity  ra te s 1011 to 
inclu de im pacts su ch  as patient 
fu n ction and health -related  quality 
o f life. Su ch a broad ening o f o u t­
c om es can certain ly be viewed as 
revolu tionary w ithin m ed icin e; the 
s itu a tio n , h ow ev er, is d ifferen t 
w ith in  p h y sic a l therapy, w here 
con sid eration s o f patient fun ction 
and disability ou tcom es are any­
thing revolutionary.

B ecause the broadening o f rele­
vant and valued ou tcom es m ay not 
be as nontrad ition al in physical 
therapy as it is in m ed icin e, one 
m ig h t ask  w h e th e r o u tc o m e s  
research in physical therapy really 
offers som eth in g  new. O r altern a­
tively, is it anything m ore than 
w hat has always been consid ered  
as “good ” clinical research? Is there 
som eth in g  im portan t going on  in 
o u tc o m e s  re se a rch  in p h y sical 
therapy, or is it the latest fad? I 
argue that the ascend ancy o f o u t­
com es research in  physical therapy 
does have relevance and im p o r­
tance to physical therapy, n o t only 
in sim ilar ways to the ascend ancy 
o f o u tco m es research in m ed icine 
b u t also in ways that are un iqu e to 
research to o u r profession.

P hysical therapists have always 
advocated and respected patient- 
level goals, as reflected in o u r tra­
ditional em phasis on  m axim izing 
p atient fu n ctio n .12 T he im portan ce 
o f p atient fu n ction is certainly seen 
in c o n te m p o ra r y  d e fin itio n s  o f 
physical therapy su ch  as that put 
forth by S a h rm a n n ,13 who defined 
physical therapy as focusing on 
m ovem ent d ysfunction , defined as 
im b alan ce or re s trictio n  in the 
m ovem ent o f segm ents, lim bs, o r 
the w h ole bo d y  (em ph asis added). 
Physical therapy research, how ev­
er, has n o t always m atched  the 
p ro fe s s io n ’s o w n  rh e to ric . 
A lthough it is axiom atic w ithin 
p h y sic a l th era p y  to a d v o cate 
p atient-level ou tcom es, these o u t­
c o m e s  have n o t b e e n  w id ely 
reflected in our research.

RESEARCH PARADIGMS IN 
PHYSICAL THERAPY
K uhn, 14  in his classic w ork on  s c i­
entific change, T he Structure of 
S cien tific Revolu tion s, introduces 
the co n ce p t o f research paradigm s. 
Kuhn argued that one o f the ch a r­
acteristics o f scien ce is w hat he 
c a lls a p arad ig m , an acce p te d

6 Physical
therapy, like oth er 

therapies, is 

d eem ed  valuable 

w hen it provides 

im portant 

benefits

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P r o f e s s i o n a l

fram ew ork that governs the way in 
w h ic h  the s c ie n c e  o p erates. 
D o m in an t p arad igm s gu ide the 
d ev elo p m en t an d  c o n d u c t o f 
research w ithin fields o f inquiry. 
Advances wiLhin an area o f sci­
ence, K uhn argues, are typically 
characterized by a shift from the 
cu rren t one to a new  paradigm . He 
d escribes, for exam ple, the shift 
from an earth-cenLered astronom y 
ad vo cated  b y  the a stro n o m e r 
P tolem y  (w h ere the su n  was 
believed  to revolve arou nd  the 
earth) to the C op ern ican  view o f a 
sun-based  astronom y as a classic 
illustration o f a m a jo r paradigm  
shift that had m ajor con seq u en ces 
in astronomy.

Although designed to d escribe 
change in pure and not applied 
scien ces, K u h n ’s con cep t of sh ift­
ing research paradigm s may be 
helpful in  d escribin g traditional 
physical therapy c lin ical research 
and whaL ou tcom es research could  
con trib u te to the scien ce and p rac­
tice of physical therapy. I believe a 
sh ift in  the d o m in a n t research  
fram ew ork (or paradigm ) guiding 
physical therapy research needs to 
occur, and if it does, this shift 
cou ld  have profound im p lications 
for the d evelopm ent and testing of 
theory and ultim ately could  c o n ­
tribute to the body of know ledge 
guiding physical therapy practice.
1 w ill try to illu s tra te  h o w  a 
resea rch  parad igm  s h ift cou ld  
s tim u la te  the d ev e lo p m e n t of 
p h y sic a l th erap y  resea rch  that 
exam in es Lhe relation ship between 
im pairm en ts and disability, there­
by d ev elo p in g  new  kn ow led ge 
about the pathogenesis o f d isabili­

ty
To describe the shift in research 

paradigm bein g advocated, I first 
will illustrate what I see as the tra­
ditional fram ew ork for physical 
therapy research. C on cep ts in the 
d isablem ent m odel developed by 
Saad N agi,15 "’ or the W orld H ealth 
O rganisation’s Intern ation al C lass­
ification of Im pairm en ts, D isabili­
ties, and H an d icap s,17 provide an 
excellen t lens through w h ich  we 
can view the traditional research 
paradigm  guiding physical therapy 
research. Viewed from the term i­
n ology used w ith these con cep tu al 
fram ew ork s, the d o m in a n t 
research paradigm  guiding physi­

cal therapy research and practice 
can be ch aracterized  as one that 
focuses on im p a irm en t ou tcom es, 
defined as loss or abnorm alities in 
the physiologic or anatom ic stru c­
ture w ithin specific bod y organs or 
sy stem s w ith in  the org an ism . 
E xam p les fam iliar to physical th er­
a p ists w o u ld  b e re se a rch  that 
fo cu se s on  o u tc o m e s  s u c h  as 
re s trictio n  in  range o f m o tio n , 
m uscle w eakness, or pulm onary 
function.

Less com m o n ly  inclu ded  as o u t­
com es w ithin research con d u cted  
by and o f interest to physical th er­
apists is another concepL w ithin 
th ese d is a b le m e n t fram ew ork s, 
variously described  as functional 
lim itations, disability, or handicap. 
This con cep t, w h ich  I will refer to 
as d isa b ility , fo cu ses o u tc o m e  
atten tion  at the level o f the in d i­
vidual’s behaviou r or his or her 
fun ctioning in social roles w ithin 
society (see J e t t e 18 for full d iscu s­
sion o f this con cep t).

O ne exam ple of the traditional 
im p a irm en t re se a rch  parad igm  
guiding research in physical Lhera- 
py is drawn from an article in 
applied physiology by Frontera et 
a l19 titled “Strength C on dition in g 
in O ld er M en: Sk eletal M uscle 
H y p ertro p h y  and  Im p rov ed  
F u n c tio n .” T he Litle o f the article 
clearly  su gg ests that the stud y 
focused on  strength c on d itio n in g ’s 
effects on two levels o f outcom e: 
skeletal m u scle hypertroph y (a tra­
ditional im p airm en t o u tco m e) and 
im proved fun ction (an apparent 
d isab ility  o u tc o m e ). T h e m a jo r 
fin d in g  o f th e SL udy was that 
s tren g th  tra in in g  in  o ld er m en 
resulted in an increase in m u scle 
force prod u ction  (on e repetition 
m ax im u m ) associated w ith m u scle 
hypertrophy. In con trast to the 
im pression conveyed in  the arti­
c le ’s litle, the “fun ctional o u tco m e” 
addressed and reported by these 
in v e stig a to rs  w as m u sc le  force 
generated by the kn ee exten so rs, a 
classic im pairm en t o u tcom e. T he 
stud y did n o t address strength 
tra in in g ’s im p a c t on  in d iv id u al 
fu n ction or d isability level (eg, 
w alking, m obility).

T h e d evelopm ent of outcom es 
research in m ed icin e is affecting 
clin ical research in d iscip lines by

m oving research beyon d  physical 
th era p y  an d  re la te d  tra d itio n a l 
im pairm en t o u tco m es (as illu strat­
ed in the article by Frontera et a l19) 
su ch  as force, range o f m otion , and 
pain to inclu de the m easurem ent 
and evaluation o f broader patient 
ou tcom es su ch  as functional lim i­
tation s and disability. O ne exam ple 
o f this broad ening o f ou tco m es is 
illustrated by an article by Fisher et 
al20 titled “Q uantitative Effects of 
Physical T herapy on  M uscular and 
F u n c tio n a l P erfo rm a n ce  in 
S u b jec ts W ith  O steoarth ritis o f the 
K nees”. In evaluating a physical 
therapy-led exercise intervention 
w ith patients w ho had osteoarth ri­
tis o f the k n ee, these investigators 
exam in ed noL only the ou tcom e on 
force prod u ction  (as was done in 
the 1 9 8 8  study by Frontera et a lla) 
b u t also  o u tc o m e s  in  p a tie n ts ’ 
degree of assistan ce, pain, and dif­
ficulty in clim b in g  stairs, rising 
from a chair, w alking, and other 
individual behaviors (exam p les of 
disability outcom es). T hese inves­
tigators reported positive im pacts 
o f the exercise program  on force 
prod u ction  and individual fu n c­
tioning. A review o f clinical inves­
tig a tio n s re c e n tly  p u b lish e d  in 
P h y sical T h e r a p y  reveals several 
illu s tra tio n s  o f re se a rch  that 
in c lu d e d  d is a b ility  as w ell as 
im pairm en t ou tcom es. E xam ples 
in c lu d e  c a rd ia c  r e h a b ilita tio n ,21 
low b ack  pain treatm en t22'23 and 
reh ab ilitatio n  fo llo w in g  an terio r 
cru ciate ligam ent reco n stru ctio n .24

CHANGING THE DOMI­
NANT IMPAIRMENT 
RESEARCH PARADIGM
A lth ou gh useful, clinical research 
in physical therapy that inclu des 
an exam in ation  o f potential b e n e ­
fits at the level o f disability o u t­
com es as well as that o f m ore tra­
ditional im p airm en t ou tcom es, at 
b e s t, b rin g s  p h y sical th erap y  
research m ore in  lin e w ith the pro­
fession ’s rh eto ric. T h is develop ­
m en t does not portend a funda­
m en ta l s h ift in the fram ew ork 
gu iding clin ical research in the 
profession.

I believe a m ore fundam ental 
shift, if it occu rs in physical th era­
py c lin ical research, m ay ultim ate­
ly have a profound im pact on c lin ­
ical p ractice. Su ch  a shift would

P e r s p e c t i v e

6  I believe a shift 

in the dom inant 

resea rch  

fram ew ork (o r 

pa ra d igm ) gu id in g  

physical therapy 

resea rch  n eed s to

o ccu r 9

L

SA Jo u r n a l  o f  Ph y s io t h e r a p y  V o l  53 No 2 7

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W H ILST W O R K IN G  FO R CO RINTH  M E D IC A L

In order to g e t the m o st ou t o f  your w o r k in g  h olid ay in 

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all o v e r  the w orld c o m b in e  b u sin e ss w ith  p leasure; 

g iv in g  them  the opp ortu nity to w ork w ith the U K 's  

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e n jo y  the d ifferen t cu ltu res and sig h ts. W h a t's m ore, 

as w e ll as top rates o f  pay and an e x c e lle n t p a c k a g e  o f  

b e n e fits, y o u  w o n 't be tied to any b in d in g contracts 

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Please send me yo ur 'W o rk in g  H olid a ys in B ritain ’ b ro chu re .

Tel..

A n tic ip a te d  d ate o f tra v e l:- - Y e a r PTJRSA

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Medical

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T H E  P R O F E S S I O N A L  S T A F F I N G  A G E N C Y

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P r o f e s s i o n a l

threshold  effect exists in the force 
and disability relation ship: above a 
certain threshold o f m u scle force 
that represents the adequate phys­
iologic reserve for certain  fu n c­
tions, individual behavior is not 
lim ited; below  that threshold  level, 
the individual is disabled. Specific 
clinical hy potheses can be derived 
from su ch  form ulations. F o r exam ­
p le, a c u rv ilin e a r re la tio n sh ip  
betw een m uscle force and d isabili­
ty in elderly persons suggests that 
benefit from physical therapy (eg, 
exercise in frail older p ersons), in 
part, will depend on  the status of 
the target group. In  B uchner and 
colleagues’ hy p oth etical Study 1 
w ith frail ad u lts (d isp la y ed  in 
F i g . l ) ,  an ex ercise in terv en tio n  
produces a large im provem ent in 
fun ctioning o f the individuals. In 
Study 2 w ith near frail adults, the 
im p a ct o f fu n c tio n  th ro u g h  
im provem en t in force prod u ction  
is m od est, whereas in Study 3 w ith 
asym p tom atic adults, n o im prove­
m en t in ind ividu al fu n ctio n  is 
observed in the face o f im prove­
m ents in force p rod uction . Figure 
2, adapted from B u ch n er and de 
L ateur27 displays som e actual data 
illustrating that a curvilinear rela­
tion sh ip m ay exist betw een knee 
exten so r torque and health status 
(assessed  u sin g  a h ealth  statu s 
in s tr u m e n t ca lle d  the S ic k n e ss  
Im pact Profile) in a sam ple of 
elderly individuals. Data su ch  as 
these begin  to shed light on  how  
specific im pairm ents and in terv en ­
tions that affect them  m ay have 
su bsequ en t im pacts on  disability 
levels.

E xam ples su ch  as the w ork of 
B u ch n er and colleagues in geri­
atrics2627 illustrate several potential 
d irec tio n s  for p h y sic a l th erap y  
research. First, clin ical research in 
physical therapy need s to con tin u e 
the exam in ation o f disability o u t­
com es in ad dition to im pairm en t 
outcom es. T h is step is necessary, 
b u t n o t sufficient to m ove research 
in  our field forward. Secon d , phys­
ical therapy c lin ical research needs 
to explicitly state and then investi­
gate the nature o f the hypothesized  
r e la tio n sh ip  b e tw e e n  d ifferen t 
im pairm ents and specific disabili­
ties. Inclu d ed  in  such research is 
an exam in ation o f the im p act o f 
changes in im pairm ents on  change 
in disability and the investigation 
o f im p ortan t covariates that alter 
th e se  re la tio n sh ip s . T h ere is a

p a u city  o f ex a m p les  o f su ch  
research in all the h ealth  p rofes­
sio n s’ literature, not only in  physi­
cal therapy. Finally, m oving physi­
cal therapy c lin ical research in this 
seco n d  d irectio n  h ig h lig h ts the 
need for further theoretical fram e­
w orks on the pathogenesis o f dis­
ability in  various target groups 
see n  by p h y sic a l th era p ists. 
Various d iscu ssions o f disability 
theory were illustrated in several 
articles in the recent special issue 
o f P hysical T h era p y  devoted to the 
topic o f physical disability.28 This 
w ork need s to be extend ed  and 
further developed.

CONCLUSION
T h e ou tcom es research m ovem ent 
in  m ed icine has already stim ulated 
c lin ic a l res e a rch e rs  in  p h y sical 
therapy to address broad disability 
o u tcom es in  addition to its trad i­
tional im pairm en t ou tcom es. T he 
b e lie f that disability o u tco m es are 
im p o rta n t in p h y sic a l th erap y 
research, however, does n o t m ean 
that im pairm en t ou tcom es are no 
longer im portan t. Both are relevant 
to physical therapy research and 
practice and  to the d evelopm ent of 
the body o f scientific know ledge in 
th e p ro fe ssio n . A lth o u g h  this 
b ro a d e n in g  o f o u tc o m e s  is an 
im portan t beginn ing, I have tried 
to illustrate why this step will n o t 
b e sufficient. T he field o f physical 
th era p y  re s e a rch  s h o u ld  m ove 
b eyond  the m ere broad ening of 
ou tcom es addressed in its research 
an d  e x p a n d  the n atu re o f its 
in q u iry  a b o u t th ese o u tc o m e s . 
R esearch needs to include both 
im pairm ents and disabilities w hen 
appropriate, and m ost importantly, 
it needs to explicitly investigate the 
nature o f the relation ship assum ed 
to exist betw een im pairm en ts and 
d is a b ility -le v e l o u tc o m e s  across 
various target groups. T h e d evel­
op m en t o f theory regarding the 
p a th o g e n e sis  o f d is a b ility  w ill 
gu ide the p ro g re ss io n  o f this 
research , d raw ing u p o n , w here 
appropriate, theoretical w ork from 
other fields. Shiftin g the d om inant 
physical therapy research fram e­
w ork in this d irection , I believe, 
cou ld  prod uce d ram atic findings 
that cou ld  con ceivably have p ro ­
found im pacts o n  c lin ical p ractice 
in our profession. ♦>

P e r s p e c t i v e

REFERENCES
1 R eim a n  A. A ssessm ent an d a c co u n ta b ility : th e  th ird  re v o lu tio n  in  

m ed ica l care. N  Engl J  M ed. 1 9 8 8 ; 3 1 9 :  1 2 2 0 - 1 2 2 2 .
2 A n d erso n  C. M easu rin g w hai w o rk s in  h ea lth  care. S cien ce. 1 9 9 4 ; 

2 6 3 : 1 0 8 0 - 1 0 8 2 .
3  E llw o o d  P O u tc o m e s  m a n a g em en t; a te ch n o lo g y  o f p atien t ex p e ri­

en ce. N  Engl J  M ed. 1 9 8 8 ; 3 1 8 ;  1 5 4 9 - 1 5 5 6 .
4  E p stein  A. T h e  o u tco m e s  m o v em en t; W ill it get us w here we warn 

to go? N  E n g l]  M ed . 1 9 9 0 ; 3 2 3 ;2 6 6 - 2 7 0 .
5 In s titu te  o f M e d ic in e . G u id e lin e s  f o r  C linical P r a c tic e : F r o m  

D ev elo p m en t to Use. W a sh in g to n , D C: N ation al A c jd e m y  Press; 1 9 9 2 .
6  G a m ic k  DW, H en d rick s A M , B ren n a n  TA. Can p ra ctice gu id elin es 

re d u ce th e n u m b e r and co sts o f m a lp ra c tic e claim s? JA M A . 1 9 9 1 ; 2 6 6 : 
2 8 5 6 - 2 8 6 0 .

7 T a n en b a u m  SJ. S o u n d in g  bo ard : W h a t p h y sicia n s know. N  Engl J  
M ed. 1 9 9 3 ; 3 2 9 :  1 2 6 8 - 1 2 7 0

8  W e n n b e r g J E . D ea lin g  w ith m edical p ra c tic e variatio ns: a pro p o sal 
for a c tio n . H ealth  A ff (M illw o o d ). 1 9 8 4 ; 3 ( 2 ) : 6 - 3 2

9  D o n a b ed ia n  A. Q u ality asses sm e n t an d assu ra n ce : u n ity  o f  p u rp o se, 
diversity o f  m ean s. Inquiry. 1 9 8 8 ; 2 5 : 1 7 3 - 1 9 2 .

1 0  M cD e rm o tt W. A b sen c e o f  in d ica to rs o f the in flu en ce o f  p h y sicia n s 
o n  a s o c ie ty ’s h e a lih . Am  J  M ed. 1 9 8 1 , 7 0 : 8 3 3 -8 4 3 ..

11 Tarlov A R, W are J E ,  G reen field  S, et al. T h e  m ed ica l o u tco m e s  
study: a n d  a p p lic a tio n  o f m eth o d s for m o n ito rin g  the resu lts o f m edical 
care. JA M A . 1 9 8 9 ; 2 6 2 : 9 2 5 - 9 3 0 .

12 R o th s tie n JM . E d ito rs  n o te: D is ability and o u r identity. Phys Ther. 
1 9 9 4 ; 7 4 : 3 7 5 - 3 7 8 .

13  Sa h rm a n n  SA. D iag n o sis b y  the p h ysical th erap isi - a p rereq u isite 
for trea tm en t: a sp e cia l c o m m u n ic a tio n . Phys T h e r  1 9 8 8 ; 6 8 : 1 7 0 3 -  
1 7 0 6 .

1 4  K u hn  T S . T h e S tructure o f  S cien tific R evolutions. C h ica g o , 111: 
U n iv ersity  o f C h ica g o  P ress; 1 9 6 2 .

15  N agi S. So m e c o n c e p tu a l issues in  d isab ility and reh a b ilita tio n . In: 
S u ssm a n  M, eel. S o ciolog y  a n d  R eh a bilita tio n . W a sh in g to n , D C: A m erican  
So c io lo g ica l A sso cia tio n ; 1 9 6 5 : 1 0 0 - 1 1 3 .

1 6  Nagi S. D is a b ility  c o n c e p ts  revisited: im p lica tio n  for p rev en tio n . 
In : Pop e A, Tarlov A, ed s. D isa bility  in A m e ric a : T ow ard a  N a tio n a l A g en d a 
f o r  P revention. W a sh in to n , D C: N atio n al A cadem y P ress; 1 9 9 1 : 3 0 9 - 3 2 7 .

1 7  In t e r n a t io n a l C la s s ific a tio n  o f  Im p a ir m e n ts , D is a b ilitie s , a n d  
H a n d ica p s. G en ev a, Sw itzerlan d : W orld H ealth  O rg a n iz a tio n ; 1 9 8 0 .

1 8  Je tte  AM . Physical d isa b lem en t c o n c e p ts  for p h ysical th erap y 
research  and p ra c tic e. Phys T h e r  1 9 9 4 ; 7 4 : 3 8 0 - 3 8 6 .

19 F ro n tera  W R , M eredith  C N , O ’Reilly KP, et al. Stren g th  c o n d itio n ­
in g in  o ld er m en : sk e leta l m u scle h y p ertro p h y  and im p ro ved  fu n c iio n . 
J  A p p l P hysiol. 1 9 8 8 ; 6 4 : 1 0 3 8 - 1 0 4 4 .

2 0  F is h e r N M , G resh am  G E , A b ram s M, et al. Q u a n titiv e effects o f 
p h y sica l th erap y on m u sc u la r and fu n ctio n a l p e rfo rm a n ce in su b je c ts  
w ith  o ste o a rth ritis o f the kn ees. A rch Phys M ed  R eh ab il. 1 9 9 3 ; 7 4 : 8 4 0 -  
8 4 7

2 1  J e t t e  D U , D o w n in g  J .  H ealth sta tu s o f ind ivid u als e n te rin g  a c a r ­
d iac re h a b ilita tio n  p ro g ram  as m easu red  b y th e M edical O u tc o m e s  Study 
3 6 -I te m  S h o rt-F o r m  Su rvey ( S F - 3 6 ) . Phys Ther. 1 9 9 4 ; 7 4 : 5 2 1 - 5 2 7 .

2 2  Stratford PW, B in k ley  J ,  S o lo m o n  P, et al. A ssessing c h a n g e over 
tim e in  p a tie n ts w ith lo w  b a c k  pain. Phys T h e r  1 9 9 4 ; 7 4 : 5 2 8 - 5 3 3 .

2 3  Erhard  RE, D elitto  A, C ib u lk a  M T  Relative effectiv en e ss o f an 
e x ten sio n  p rog ram  an d a c o m b in e d  p ro g ram  o f m a n ip u la tio n  and flex ­
io n  an d  e x ten sio n  e x e rc ises in p a tie n ts w ith a c u te low  b a c k  syn drom e. 
P hys T h e r  1 9 9 4 ; 7 4 : 1 0 9 3 - 1 1 0 0 .

2 4  Tovin B J, W o lf SL , G reen field  BH , et al. C o m p a riso n  o f  the effects 
o f ex e rcise in  w ater and o n  lan d  o n  the re h a b ilita tio n  o f p a tien ts with 
in tra -a rtic u la r a n terio r c ru c ia te lig a m en t re co n stru c tio n s. P hys Ther. 
1 9 9 4 ; 7 4 : 7 1 0 - 7 1 9 .

2 5  V erbrugge L, Je tte  A. T h e  d isa b lem en t p ro cess. S oc Sci M ed. 1 9 9 4 ; 
3 8 : 1 -1 4 .

2 6  B u c h n e r D M , B eresfo rd  SA, L arson  EB, et al. E ffects o f p h ysical 
activity o n  h ea lth  sta tu s in  o ld er ad u lts, II: in terv en tio n s stu d ies Annu 
R ev P u blic H ealth . 1 9 9 2 ; 1 3 : 4 6 9 - 4 8 8 .

2 7  B u c h n e r D M , de L ateu r BJ. T h e  im p o rta n ce o f sk eleta l m uscle 
stren g th  to p h y sica l fu n ctio n  in  o ld er adu lts. Ann B e h a v  M ed. 1 9 9 1 ; 13: 
9 1 - 9 7 .

2 8  P hysical Disability. Phys Ther. 1 9 9 4 ; 7 4  (sp ecia l issu e ): 3 7 5 - 5 0 5 .

SA J o u r n a l  o f  Ph y sio t h e r a p y V o l  53 No 2 9

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