Clinical Research Agenda for Physical Therapy.

Key Words: Agenda, American Physical Therapy Association, Clinical research, Profession.

Introduction

Evidence-based practice requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research.[1] In a recent article on the value of evidence, Rothstein[2] identified the conundrum that ensues in the absence of a research foundation in rehabilitation science: "Neither the suspension of practice until research is performed is tenable or humane, nor is the continuation of practice without systematic inquiry and empirical justification any longer tenable or humane."[2] Not surprisingly, the same dilemma hinders the practice of physical therapy, which represents the largest proportion of all rehabilitation services. In the everyday practice of a physical therapist, there is often a lack of evidence derived from systematic research to support interventions beyond the level of biological plausibility provided by the anatomic and physiologic literature. In an effort to enhance this body of knowledge with systematic research into the effectiveness of intervention, the American Physical Therapy Association (APTA) developed its Clinical Research Agenda (Appendix).

The impact of a research agenda on research directions within a profession cannot be underestimated; yet, because of fear that a profession's agenda will devalue any one individual's own research program, the goal of having a single agenda to meet the needs of a profession can prove elusive. The Task Force on Medical Rehabilitation Research, convened by the National Institutes of Health in 1990, opined that although there was much research relevant to the interests and aims of rehabilitation medicine, the overall effort had no coherence.[3] Physical therapy has faced a similar predicament. The Clinical Research Agenda presented in this article was not the first effort undertaken by APTA to develop such an agenda. The APTA attempted to generate a research agenda in December 1993 that would have aggregated research efforts into a cohesive effort. A panel of researchers, representing different clinical foci and levels of expertise, was convened to develop the agenda. The effort was not as successful as anticipated, as the group could not reach consensus on a clinical agenda that would be most beneficial to the profession as a whole. The group's conclusion was that each participant's own area of study was important, and no decisions could be made concerning the prescription of a program of research for the profession.

Individuals have continued since 1993 to conduct their own programs of research. However, neither the inability of physical therapy to identify a cohesive research plan nor the failure of other health care professions to develop such programs has diminished the need for a clinical research agenda for physical therapy. The problems that physical therapy addresses are problems of human potential thwarted by pathology, impairment, functional limitations, and disability. From the perspective of APTA, in order for the profession to justify itself as unique in the application of clinical sciences to the human condition, it is imperative to aggregate research efforts into a unified scientific program that maximizes the expenditure of individual efforts and produces an organized body of evidence for clinical practice.

Subsequent to APTA's initial effort to generate a research agenda in 1993, the health care environment changed substantially, and the need for evidence to support clinical practice has increased accordingly. Thus, when the idea of developing an agenda was reintroduced, APTA's paramount expectation was an agenda that would support, explain, and enhance physical therapist practice and result in research that is useful to clinicians from all areas of practice.

Once the decision to create an agenda was adopted, a number of formats were considered in the effort to ensure its development. Various disciplines and professions have published questions that could comprise an agenda in their professional journals and have invited comments about these questions and the relative priority of each.[4-6] Others have commissioned written papers, which were then presented and responded to by a larger group of experts in the field.[7] Another technique is to convene a panel of experts and, through a series of group processes, allow the panel to reach consensus on the most important research questions that need to be answered and that can be answered in the near term.[8] The APTA adopted a process similar to the latter method and expanded it well beyond planning and conducting a series of conferences, using a number of different formats for communication so that maximum input from individuals representing both the research and clinical segments of the profession would have the opportunity to shape the final document (Fig. 1).

[Figure 1 ILLUSTRATION OMITTED]

Process of Agenda Development

The process was begun with a call to the presidents of all components (eg, state chapters and sections), academic administrators of physical therapist education programs, and members of the Section on Research for nominations of individuals who might become participants in the development of the Clinical Research Agenda. Of the total 176 individuals who were nominated, 48 were selected to participate in the process. Selection was based on the need for an agenda that represented a diverse mix of clinical and academic interests.

The first meeting of this group took place from August 30 to September 1, 1998. The intent of the meeting, as well as a second meeting held in December 1998, was to identify those clinical research questions that routinely challenge physical therapists. Participants were required to be able to identify how a physical therapist might use the answers to the questions in clinical situations in order for the questions to be included in the draft agenda. Furthermore, each question had to be one that was answerable within 5 years based on available technology and current state of knowledge. The initial clustering of questions generated at the first conference was created in accord with the systems orientation of the Guide to Physical Therapist Practice[9] ("the Guide"). Conference participants were placed in groups according to their expertise, and questions were designed based on each of the 4 systems described in the Guide (ie, musculoskeletal, neuromuscular, cardiopulmonary, and integumentary). Guide language was maintained in each of the questions suggested by participants.

Prior to the second conference, a smaller editorial advisory panel (EAP), consisting of 4 member consultants and 3 APTA staff members, met to edit questions generated from the first conference. In addition to editing questions, the group chose a format for construction of the Clinical Research Agenda based on the patient/client management model adopted by the APTA House of Delegates (HOD 06-95-25-15) and described in the Guide. Rather than solely grouping questions based on the 4 systems delineated in the Guide, new categories within which questions were to be placed were selected using the elements of the patient/client management model. These new headings--"Examination," "Evaluation and Diagnosis," "Prognosis," and "Intervention/ Outcomes"--were incorporated following the outline of the Guide.

The EAP also decided at that time to incorporate a series of health services research questions that had been developed separately on another occasion by a group of member consultants and staff but that had never been published. The decision was made to publish a single, unified document based on the fact that many questions from the health services research agenda overlapped with questions that were being developed as part of the draft agenda. The EAP noted that, in fact, the distinction between health services and clinical research may be an artificial one. The decision to combine health services questions within this clinical research agenda was supported by other researchers outside of physical therapy. Cohen[5] referred to health services research as "applied applied clinical research." Eisenberg[10] included health services research as part of a continuum of health-related research and believes that the boundaries between biomedical and health services research are not sharp, nor should they be. Perhaps the most cogent description of the similarities between clinical and health services research has been expressed by Bennett,[11] who cited a continuum developed by staff at Rockefeller University to describe clinical investigation. The continuum includes research questions anchored at one end by research to explore unresolved issues in human biology and at the other end by studies on the assessment of health care practices and delivery systems.

After categorization based on the new format using the patient/client management model, and the addition of the health services research questions, an edited draft agenda was sent to each of the individuals who were to participate in the second conference. A cover letter was included with this mailing that explained the tasks to be completed. Participants were informed that the revised structure of the agenda, based on the Guide, was essentially inviolate. The primary tasks to be completed during the second conference were (1) to select which research themes would serve as the protean structure for the research that the profession needed to conduct and (2) to refine the examples to give a broad overview of the research to be conducted in particular content areas. At the conclusion of the second conference, the scope of the edited questions was identified, broader questions included within research themes were developed, critical examples of researchable questions were placed within these broader categories, and a determination of which particular questions should be considered for inclusion was made.

Subsequent to the conference, the EAP was reconvened to review the work produced by conference participants and to ensure that questions considered for inclusion were clearly worded and relevant to the purpose of the agenda. The group met once on-site at APTA headquarters and conducted 5 conference calls to complete the task.

The final draft agenda of 128 questions was disseminated widely among the membership for comment. The field review version of the agenda was mailed to all members of the Section on Research, all academic administrators of physical therapist education programs, all component presidents, a random sample of 500 clinical specialists certified by the American Board of Physical Therapy Specialties (ABPTS), and a random sample of 500 additional members of APTA. Respondents' tasks were to rate each question based on the importance of the question to a clinician and how often the clinician would use the answer to a particular question in clinical practice. A total of 227 copies of the review form were returned, including forms from 22 components.

Analysis of Field Review

The purpose of the analysis of the data from the field review was to prioritize areas of research related to the theory and practice of physical therapy. This was done by first assigning a numeric score to each of the questions included in the draft agenda. This score was intended to approximate the perceived priority of a question as a research topic. The score was based on 2 ratings on a 5-point Likert-type scale for each question: (1) the importance of the question to clinical practice and (2) the frequency of occurrence in clinical practice of the issue addressed by the question. Once scores were assigned, questions could be ranked and priority levels could be assigned.

The formulation of a composite measure that could represent the overall research priority of a question was explored. Five different methods of calculating a composite score were evaluated. Three of these methods yielded scores that were sums of the number of individuals who rated each question at or above designated values on the scale. The first composite measure was a sum of the number of individuals who rated a question as "important" (4) or "extremely important" (5) on the importance measure plus the number of individuals who rated the question as "often" (4) or "very often" (5) on the frequency measure.

The second method for determining a composite score was based on a sum of individuals who rated a question at or above the midpoint of either rating scale (eg, "moderately important," "important," or "extremely important" on the importance scale or "sometimes," "often," or "very often" on the frequency scale). The third composite score was determined from the number of individuals who rated a question at the highest rating point on either scale (ie, 5). The fourth composite was an average of how each question ranked on the first 3 composite scores. For example, let us assume that a particular research question had the highest composite score (ie, a ranking of I on the first method), the second highest score (ie, a ranking of 2 on the second method), and the fourth highest score by the third method for calculating a composite score (ie, a ranking of 4). The average ranking for this particular question would be 2.33 (ie, [1+2+4]/3=2.33). The fifth scoring method calculated a sum of the average importance rating and the average frequency rating.

Despite the inherent differences in the construction of the composite scores, all scores were highly related in terms of what they measured. Composite 1 has a correlation (Pearson product moment correlation coefficient) with each of the other composites of over .92 (P [is less than] .01). Even the composite scores related the least (those developed from composites 2 and 3) had a correlation over .77 (P [is less than] .01). These correlations indicated that the assignment of priority level would change little as a result of the approach selected to construct a composite score. Composite 5 was ultimately selected because it was straightforward in its interpretation and because all scale points of the ratings were taken into account.

The initial approach adopted for the assignment of priority level was to rank the questions with respect to their score using the fifth method and then identify breaks or gaps among groups of questions. The intent of this procedure was to base the assignment of priority level on naturally occurring characteristics of the distribution of scores. However, most of the 128 questions were considered to be "very important" by most respondents and were considered to be related to issues that have frequent clinical application. Of a possible maximum score of 10 (ie, an average importance rating of 5 plus an average frequency rating of 5), the average for all questions was 7.6 [+ or -] .64. As result of this clustering of questions at the upper end of the distribution, the only breaks in the distribution appeared at the low end, and these breaks involved only a few of the research questions.

Because the spread of scores had insufficient gaps in distribution to justify assigning level of priority, scores were investigated for statistically significant differences among questions. This approach proved to be of little value. With the exception of the 9 questions that were ranked lowest, no significant differences among questions were evident. Therefore, it was decided that the proportion of respondents at various ratings would be incorporated into the assignment of priority level. That is, priority would be assigned on the basis of the percentage of respondents who gave a question a particular rating regardless of the score. For example, a question that was rated by 100% of the respondents as extremely important and as occurring very often in practice would be assigned to the highest priority.

Four levels of priority were used. All of the questions in levels 1 through 3 had summed average importance and average frequency above 6.6 (ie, on a scale from 1 to 10). Level 1 contained those questions for which 40% or more of the respondents rated the question as extremely clinically important and occurring very often in clinical practice. Level 3 contained those questions for which 10% or more of the respondents rated the questions as unimportant or occurring infrequently. The boundaries of level 2 were scores for questions that fell between the criteria for level 1 and level 3. The fourth level included questions that had score values of less than 6.6. This group was identified by a break in the distribution of the scores at the low end. These definitions resulted in 14 questions at priority level 1, 40 questions at priority level 2, 65 questions at priority level 3, and 9 questions at priority level 4.

The analysis described above was performed using all 227 respondents. In order to determine whether clinicians who were not members of the Section on Research had different research priorities than clinicians who were members of the Section on Research, the sample was split into 2 parts, and the entire analysis was repeated for each part. In order to ensure that no questions thought to be important by either group were omitted from the agenda, questions that received a priority ranking of 1 or 2 in at least 1 of the 3 analyses (ie, the whole sample, the clinicians, or the nonclinicians) were included in the final agenda. The Table presents the ratings for each of the items comprising the draft agenda. The Table depicts ratings among clinicians, researchers, and all respondents to the field review. Note that each item that was included in the draft agenda is presented. The boldfaced items represent the questions included in the final agenda. The 72 questions comprising the final agenda adopted and promulgated by APTA's Board of Directors are included in the Appendix. A summary of the process to develop the final agenda is presented in Figure 2.

[Figure 2 ILLUSTRATION OMITTED]

[TABULAR DATA NOT REPRODUCIBLE IN ASCII]

Discussion

As stated earlier, the process for development of the Clinical Research Agenda was completed over a lengthy period of time and included input from a substantial number of member consultants and an even larger number of APTA members. The decision analysis used to discriminate among items accounted for the feedback from individuals representing those constituencies comprising the profession. The resultant agenda reflects these efforts. The questions that were ultimately included in the Clinical Research Agenda were those questions whose answers, the participants believed, will be able to support, explain, and enhance physical therapy practice. Each of these questions, when answered, will provide evidence for the most important and frequently asked clinical questions.

The final Clinical Research Agenda of 72 questions was organized according to the elements of the physical therapist patient/client management model. The content represented by the questions covers the entire spectrum of physical therapist practice. Although the scope of the agenda is broad, the agenda is held together by the use of the patient/client management model as the foundation for each of the questions. This model was designed to provide a framework for intervention that will lead to optimal outcomes. Thus, by having access to the answers to those questions comprising the agenda, clinicians will be able to practice through the use of evidence that is not currently available. This evidence can be used to build the scientific base of physical therapy, and clinical practice should be enhanced.

It is crucial to note that no element of physical therapist patient/client management is without a substantial number of questions. These 72 questions, although often particular to a disease, condition, or site, are universal to scientific clinical practice in all disciplines, including physical therapy. Therefore, the fact that there is a plethora of unanswered questions does not mean that there is a lack of scientific underpinning to the clinical care provided by physical therapists. On the contrary, most physical therapist practice has almost always been justifiable on the grounds of the biological plausibility of its intervention. Rather, the breadth of the Clinical Research Agenda indicates that the time-tested practice of physical therapists can evolve into a full-blown science of physical therapy. There is hope that the completion of this first Clinical Research Agenda will culminate in a radical change in the profession: the full metamorphosis of the physical therapist into a scientific practitioner.

Although the Clinical Research Agenda has been developed, the process for increasing the scientific base of the profession is far from complete. The APTA is now challenged to ensure that these questions generate appropriate and timely scientific investigations in the physical therapy profession as well as in other professions and disciplines. The Foundation for Physical Therapy has already committed itself to taking the necessary steps to ensure that the Foundation's research program will be driven by those questions comprising the Clinical Research Agenda. In fact, discussions have already begun to develop the most effective infrastructure to ensure that funded research will be undertaken to answer these questions.

Physical therapy cannot rely solely on the resources of the Foundation for Physical Therapy or APTA to answer these questions, however. Other funding agencies, as they attempt to fulfill their own research mission, should recognize the contribution of this agenda to the health of the nation.

For example, the APTA Clinical Research Agenda has highlighted a number of questions related to the care of individuals with dysfunction of the musculoskeletal system, specifically low back pain. Any merger of the research program of other funding agencies (eg, the National Institutes of Health, the National Institute for Disability Research and Rehabilitation, the Agency for Health Care Research and Quality, private foundations) and some of the 72 questions listed in this agenda should benefit patients and stimulate and influence the direction of scientific inquiry.

Strategies for implementation of the agenda remain to be determined. It will be incumbent upon physical therapist researchers to compare APTA's agenda with the programs of various agencies. The response to the agenda may entail collaborative efforts with colleagues from other professions or disciplines. Physical therapists may not necessarily be the primary investigator in these studies. It may also be necessary to involve those outside the profession in the conduct of studies to answer identified questions and have physical therapists serve as contributors of data or in some other consultative manner. These strategies can be articulated to a greater extent in the near future. What remains most important, however, is the fact that the APTA Clinical Research Agenda took a substantial commitment of time and effort, and the work devoted to the creation of the agenda must be continued to enhance the contribution that has been made thus far.

Data obtained by use of this agenda, in concert with data from studies examining questions not included in the agenda, should provide coherence to the clinical research effort with the profession. The clinically relevant questions that have been generated should, when answered, expand the scientific base of physical therapy and have an impact on the provision of physical therapy services. This should enhance the quality of the outcomes of this care. The Clinical Research Agenda can serve as a benchmark for the systematic progression of physical therapy science. It can, and will be, re-evaluated periodically by APTA and its members to assess its relevance and effectiveness in assisting the profession in refining and expanding the scientific basis for clinical practice. If answers to the 72 questions in the agenda can be obtained and generally incorporated into clinical practice in the immediate future, the scientific basis of physical therapy practice should be enhanced to an extent never before seen. In addition, practice will have been shaped by facts and data, and that will not only justify reimbursement but also allow therapists to apply the most effective interventions possible. Failure to make substantial progress toward completion of the agenda within the next 5 years, however, would hinder the scientific development of the profession. It would also mark physical therapy as a profession unwilling to examine itself and to be accountable for what it does, unlike other professions that now more than ever realize a need for evidence-based practice. This would be a detriment not just to the profession but also to patients.

The physical therapy profession has its roots in rehabilitation of those injured by national calamities, epidemic diseases, and wars. The profession grew out of national need to alleviate human suffering, and it continues to be recognized for the humanistic qualities of its members. A profession, such as physical therapy, that has been able to mobilize resources in times of national need should be able to respond to this call for research by the year 2005. To do less would betray the physical therapy profession's moral mission, a mission aimed at assisting in the achievement of optimal human function.

References

[1] Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine: How to Practice and Teach EBM. New York, NY: Churchill Livingstone Inc; 1997.

[2] Rothstein JM. Developing a research line in rehabilitation medicine: profits and pitfalls. Journal of Rehabilitation Sciences. 1994;7:6-9.

[3] Report of the Task Force on Medical Rehabilitation Research. Hunt Valley, Md: Task Force on Medical Rehabilitation Research; 1990.

[4] Daltroy LH, Liang MH. Patient education in the rheumatic diseases: a research agenda. Arthritis Care and Research. 1988;1:161-169.

[5] Cohen HJ. An agenda for clinical research in geriatrics. Cancer. 1997;80:1294-1301.

[6] Mohr WK, Fantuzzo JW. The challenge of creating thoughtful research agendas. Arch Psychiatr Nurs. 1998;12:3-11.

[7] Halfon N, Schuster M, Valentine W, McGlynn E. Improving the quality of healthcare for children: implementing the results of the AHSR research agenda conference. Health Serv Res. 1998;33:955-976.

[8] Hawk C, Meeker W, Hansen D. The National Workshop to Develop the Chiropractic Research Agenda. J Manipulative Physiol Ther. 1997; 20:147-149.

[9] Guide to Physical Therapist Practice. Alexandria, Va: American Physical Therapy Association; 1997.

[10] Eisenberg JM. Health services research in a market-oriented health care system. Health Aff (Millwood). 1998;17;98-108.

[11] Bennett JC. Clinical investigation: definition and future directions. In: Harrison DC, Osterweis M, Rubin ER, eds. Science in the 21st Century. Washington, DC: Association of Academic Health Centers; 1991:26-33.

Appendix. Clinical Research Agenda

1. What is the usefulness of information derived from examination (history, review of systems, tests and measures) for patient classification that can be used to direct/guide intervention?

1.1. What measures could be used to classify patients?

* What factors can be used to classify patients with thoracic disorders?

* What factors can be used to classify patients following a cerebrovascular accident?

* Do motor control strategies differ in people with low back pain compared with people without low back pain, and, if so, how?

1.2. What are the psychometric properties of tests and measures used for patient classification?

* What are the relationships between self-report of function and observed measures?

* What are the psychometric properties of performance-based and self-assessment measures of physical function designed to predict functional limitations and disability in elderly people?

* What is the reliability of segmental mobility testing in the cervical spine?

* What are the reliability and validity of assessment of pronation of the foot in patients with knee pain?

1.3. What are the psychometric properties of classification systems?

* What is the reliability of the McKenzie classification system for the cervical spine?

1.4. How can data best be used for clinical decision making?

* What information from the diagnosis/prognosis is used in patient/client management?

* What factors beyond the diagnosis/prognosis determine patient/client management?

* When multiple tests and measures are used, how is the information weighted in determining a diagnosis?

* What combination of examination data can be used to guide clinical decision making for patients with pain in the sacroiliac region?

* How does information from the systems review influence tests and measures chosen?

* How does information from the history influence tests and measures chosen?

* Do measures of postural alignment in people with spinal disorders influence clinical decision making, and, if so, how?

* What factors influence the transfer of functional skills from the therapeutic environment to the community?

1.5. Are there combinations of measures of impairment and critical levels of function that would predict disability, and, if so, how can we determine them?

* What are commonly performed physical functional tasks, and how do they differ across the life span?

* Do measures of impairment and function predict a person's ability to work or return to work?

* What are the variables, if any, that predict return of function in individuals following stroke?

* What impairment-level and functional-level measures predict work capacities?

* What information from measures can be used to predict physical function in community-dwelling elderly people?

* What measurements of ambulation are useful for predicting patients' function?

* Are there measures that can be used to predict independent function in an urban community, and, if so, what measures and at what thresholds?

* Are there measures of ambulation that can be used to predict independent function in various communities, and, if so, at what thresholds?

* Are there elements of motor control and cognitive function that can be used to predict physical function in individuals with central nervous system dysfunction?

2. What is the usefulness of information derived from examination (history, review of systems, tests and measures) for prognosis?

2.1. What measures are currently used for prognosis?

* Are there measurements from the initial examination that predict future or concurrent mobility or disability, and, if so, how?

* What factors are used by physical therapists to determine their recommendations of settings to which patients are discharged?

* What tests and measures should be used to predict the physical therapy services patients will require upon discharge from inpatient care to achieve maximum function?

2.2. What are the natural histories of conditions for which physical therapists provide services?

* What are the modifiable risk factors for cumulative trauma syndrome?

* How are responses to exercise different in patients with neurological impairments?

2.3. What are the relationships among pathology, impairment, functional limitation, and disability?

* How do impairments affect disability in patients?

* To what extent do variables such as pharmacology, psychosocial factors, and environmental factors influence the relationship among impairment, functional limitation, and disability in people receiving physical therapy interventions?

* Are there critical levels and elements of motor control that must be present to permit household ambulation in individuals with brain dysfunction, and, if so, what are they?

2.4. What are the effects of demographic factors (eg, age, language, race, ethnicity, sex, social history, comorbidity, culture, family/caregiver resources) on the outcome of physical therapy interventions?

* What are the characteristics of people who respond to various forms of therapy for low back pain?

* Do patient knowledge, attitude, culture, understanding, and expectations affect the outcome of physical therapy interventions, and, if so, how?

* How can patient characteristics and environmental factors be used to predict adherence to home programs?

* What are the factors that motivate patients to adhere to a plan of care?

* Is there a relationship between a patient's satisfaction with care and adherence to his or her physical therapy care plan?

* How does the physical environment in which the patient must function (eg, work requirements, mobility barriers) influence the effectiveness of treatment interventions?

* How does the environment in which the patient must function influence the choice of physical therapy interventions?

3. What are the optimal characteristics of an intervention to achieve a desired effect or outcome (function, satisfaction, cost) for given diagnoses?

3.1. What is the effectiveness of physical therapy intervention?

* What is the effectiveness of segmental mobilization/manipulation in reducing impairment and improving functional outcomes in patients with reduced segmental mobility?

* Are manual techniques effective in the treatment of impairments and functional limitations?

* What is the effect of exercise (duration, intensity, and type) on bone density?

* Can physical therapy interventions for patients with spasticity or rigidity improve function?

3.2. What is the optimal frequency, intensity, and duration of an intervention to achieve a desired effect or outcome for a given diagnosis?

* What interventions designed to change movement strategies can be used for patients with lumbar segmental instability, and what is the optimal pattern?

* What interventions designed to decrease pain and paresthesias can be used for patients with upper-extremity entrapment syndromes, and what is the optimal pattern?

* What is the effect of various intensities and durations of intervention on the rate and degree of functional recovery after anterior cruciate ligament injury?

* Is there a relationship between weight-bearing exercises and the risk of fractures for people with bone demineralization, and, if so, what is the relationship between exercise and risk?

* What are the conditions of repetition and practice (whole/part, intermittent/continuous, attended/unattended, number of trials per day) that optimize function in people with neuromuscular dysfunction?

3.3. Are there optimal time periods for interventions that influence pathology, impairment, functional limitation, and disability?

* Are there optimal time periods for interventions that influence pathology, impairment, functional limitation, and disability in patients in whom multiple episodes of care are expected over the life span?

* What is the optimal dose/response relationship for interventions (eg, aerobic and strengthening exercise, manual therapy, physical agents, traction/mechanical modalities, flexibility), given a specific category of a classification system for low back pain?

* Are there changes to behavior and the environment that can be used to enhance function and prevent impairments, and, if so, what is the optimal pattern of use to achieve a therapeutic outcome?

* Does immediate postoperative physical therapy intervention improve the rate of recovery of function in patients with impaired cardiovascular function, and, if so, how?

* Does immediate postoperative physical therapy intervention affect the rate of recovery of function in patients following orthopedic surgery, and, if so, how?

* Can interval training be used to improve physiological and functional outcomes in frail elderly people? If yes, can the process of interval training be standardized with frail elderly people?

* Are outcomes of treatment following peripheral nerve injury using neuromuscular re-education improved by early assessment and staged interventions?

3.4. What is the relative effectiveness of 2 or more interventions for a particular patient diagnostic classification?

* What is the relative effectiveness of immobilization versus mobilization in patients with musculoskeletal impairments on tissue healing and recovery of function?

3.5. What is the optimal combination of interventions to achieve desired patient outcomes?

* Does the coordination of exercise and surgical interventions affect patient outcomes, and, if so, what is the optimal pattern of intervention?

* Does the coordination of exercise and pharmacological interventions affect patient outcomes, and, if so, what is the optimal pattern of intervention?

* What are the interactions between physical therapy interventions and pharmacological interventions?

* What is the optimal resource schedule and utilization to achieve a desired effect or outcome for a given diagnosis?

* What are the factors that affect cost for physical therapy services within specific diagnostic groups?

3.6. Are there factors that interact with physical therapy interventions, and how do they interact to affect patient outcomes and clinical decision making?

* Which, if any, devices and equipment (assistive, adaptive, orthotic, protective, supportive, or prosthetic) can be used by physical therapists to enhance function and prevent impairments, and what is the pattern of use to achieve a therapeutic outcome?

* Do changes to behavior and the environment reduce the incidence of work-related cumulative trauma disorder?

* Do physical therapists knowledge, attitude, culture, understanding, and expectations affect the outcome of physical therapy interventions, and, if so, how?

* Is there a difference in patient outcomes and costs dependent on whether services for a given diagnostic condition are provided by physical therapists or others?

* How have changes resulting from health care reorganization affected the quality of physical therapy, services, access to physical therapy services, patient satisfaction, staff productivity, staff longevity, and professional development?

* Do payer source and policies influence satisfaction with access to physical therapy services in patients with acute conditions?

* Do payer source and policies influence satisfaction with access to physical therapy services in patients with chronic conditions?

* How does the requirement of referral before treatment affect whether patients have access to and are likely to utilize physical therapy services?

3.7. What factors predict supply, demand, and need for physical therapy services?

* What is the effect of the availability, cost, and payment source of physical therapy services on patient outcomes?

* What are the factors that determine whether patients have access to and are likely to utilize physical therapy services?

The Clinical Research Agenda Conference Participants were: Paul Beattie, PT, PhD, OCS; Janet Bezner, PT, PhD; Jill M Binkley, PT, MCIS, COMP, FAAOMPT; Joseph PH Black, PhD; Susan K Brenneman, PT, MS; Lori Thein Brody, PT, MS, SCS, ATC; Nancy N Byl, PT, PhD; Julie P Chandler, PT, ScD; Cynthia M Chiarello, PT, PhD; Carol Coogler, PT, ScD; Rebecca L Craik, PT, PhD, FAPTA; Senobia Crawford, PT, PhD; Anthony Delitto, PT, PhD; William E DeTurk, PT, PhD; Gerard C Gorniak, PT, PhD; Laurita M Hack, PT, MBA, PhD, FAPTA; Dennis L Hart, PT, PhD; Kenneth J Harwood, PT, MA; Diane U Jette, PT, ScD; Janice Kehler, PT, MSc; Loretta M Knutson, PT, PhD; David E Krebs, PT, PhD; Tanya LaPier, PT, PhD; Sandra J Levi, PT, PhD; Michelle Lusardi, PT, PhD; Kathleen Kline Mangione, PT, PhD, GCS; Susan L Michlovitz, PT, PhD; Scott D Minor, PT, PhD; Barbara J Morgan, PT, PhD; Mary Jane Myslinski, PT, EdD; Diane E Nicholson, PT, PhD, NCS; Virginia Nieland, PT, MS; Barbara J Norton, PT, PhD; Carol A Oatis, PT, PhD; Patricia Ohtake, PT, PhD; Robert J Palisano, PT, ScD; Marilyn Phillips, PT, MS; James A Porterfield, PT, MA, LAT; Daniel Riddle, PT, PhD; Jules M Rothstein, PT, PhD, FAPTA; Anne Shumway-Cook, PT, PhD; Maureen Simmonds, PT, PhD; Guy Simoneau, PT, PhD; Sue Ann Sisto, PT, PhD; Lynn Snyder-Mackler, PT, ScD, OCS; Gary L Soderberg, PT, PhD, FAPTA; Lisa Ann Stehno-Bittel, PT, PhD; Andrea Taylor, PhD; Frank B Underwood, PT, PhD, ECS; Ann F VanSant, PT, PhD; Jessie M VanSwearingen, PT, PhD; Steven L Wolf, PT, PhD, FAPTA; Lisa Zuber, PT, MS.

APTA Board of Directors Liaisons to the Clinical Research Agenda Conferences and the conference participants were Jan K Richardson, PT, PhD, OCS, President, and Jayne L Snyder, PT, MA, Vice President.

The Editorial Advisory Panel consisted of Rebecca L Craik, PT, PhD, FAPTA; Janet Gwyer, PT, PhD; Diane U Jette, PT, ScD; Jules M Rothstein, PT, PhD, FAPTA; Ann F VanSant, PT, PhD. APTA staff who assisted in the development of the Agenda were: Andrew A. Guccione, PT, PhD, FAPTA; Marc Goldstein, EdD; Steven Elliott, PhD; M Scott Sullivan, PT, PhD; Lisa Culver, PT, MBA; Allen Wicken, PT, MS; Mary Jane Harris, PT, MS; Jody Gandy, PT, PhD; Tracy Temanson, MSLS; Michele Katsouros; Rene Malone; and Sarah C Miller.

Writing and statistical analysis were provided by Andrew A Guccione, PT, PhD, FAPTA, Senior Vice President, Division of Practice and Research, American Physical Therapy Association (APTA), Alexandria, Va ([e-mail]); Marc Goldstein, EdD, Director, Research Services, APTA; and Steve Elliott, PhD, Director of Analytic Support, APTA.