Do you really have to believe? (Editor's Note).

When an improbable team of losers, the 1969 New York Mets, won the World Series, they were inspired by a relief pitcher who would scream, "You gotta believe!" Perhaps Tug McGraw (who also was famous for saying, "I have no trouble with the twelve inches between my elbow and my palm. It's the seven inches between my ears that's bent") knew something about the value of this mantra, a value that we could not discern because of his quirkiness.

He was implying that belief shaped reality.

Belief does not guarantee success, however, so we might ask whether the eccentric McGraw's message is really true.

When a person is imprisoned in a home by extreme agoraphobia, we have no trouble seeing that mental disorder as the cause of disability. But when a lack of faith in physical capabilities, often as a result of justifiable fear, limits a person's activities, should we view this as a physical limitation or a problem due to a belief? If physical therapy interventions are to be effective, we need to discern how the effects of physical impairments might be different from psychological factors. Having a physical skill matters little if you are too uncomfortable or fearful to use it.

In this issue, Miller and colleagues (pages 856-865) provide us with an intriguing report that deals with the issue of confidence among people with lower-limb amputations. Among the data they offer: identification of the variables associated with levels of confidence. Some of these variables can be influenced by current interventions, and some cannot. This does not mean, however, that the authors are saying we should accept a lack of confidence. On the contrary, from my perspective, there is a clear suggestion that we need to explore interventions targeted at improving confidence.

Although the observations by Miller et al concern people with amputations, they do not differ greatly from past observations about confidence in ambulation among people who are frail and elderly or about fear of falling in other populations. Perhaps one of the most critical decisions made by physical therapists is determining whether further enhancement of physical abilities is even possible when the patient or client does not yet feel inclined to use those abilities to accomplish meaningful tasks. The specter of physical disabilityr--not necessarily the reality of physical impairment--may be the real disabler. If so, we need to learn how to deal with it.

O'Shea and colleagues (pages 888-897) touch indirectly on this topic in their examination of the types of secondary tasks that may lead to degradation of gait in people with Parkinson disease. They found that gait became poorer regardless of whether the subjects did a cognitive task or a motor task while walking. This finding raises the issues of (1) whether gait that requires undivided attention is as functional as gait that allows for simultaneous completion of activities that may be necessary for self-care, work, or leisure and (2) whether we have any consistent ways of characterizing these two gait variants in clinical practice.

We also are left wondering to what extent fear of falling and fear of failure undermined the subjects' gait and led to alterations in the gait pattern. Here again, the possibility is that a person's view of his or her circumstances can shape the reality of those circumstances and limit function.

Elsewhere in this issue, Janssen and associates (pages 866-879) review the copious literature on the sit-to-stand movement, and they conclude that the height of the chair, the use of armrests, and foot position influence success. What they did not find in the literature, however, is whether these biomechanical variables lead to greater success partly because they make a person more comfortable and confident when standing. A patient's perspective and view of his or her own capabilities may make function more or less possible. And if the patient's view does shape the patient's behavior, it might be naive to believe that motor performance can improve before there is concomitant change in the patient's beliefs.

Perhaps we need to develop confidence-inducing exercises. Ironically, we physical therapists often hinder the development of confidence. Fear of liability often leads us to have our patients ambulate with excessive guarding, to the extent that they never experience "real-world" ambulation. Similarly, we take great care to help patients avoid falling when they do transfers or engage in the well-studied sit-to-stand movement. Although protection is paramount and no one wants to see patients fall or get hurt, our behavior might deprive patients of the one thing we know helps people learn--knowledge of results. When we provide excessive guarding or withhold opportunities to fail, we deprive patients of critical information.

Also in this month's Journal, Merians et al (pages 898-915) offer a case report in which virtual reality was used for simulations designed to enhance dexterity in people following stroke. Given the articles in this issue, other uses for virtual reality also come to mind. Using virtual reality, could we expedite the learning of motor behaviors in people with impairments and provide them with better feedback--and also, for the first time, provide them with meaningful feedback about failure without fearing for their safety? Telling patients they would have fallen is not the same as patients experiencing all of the sound and fury of a virtual event.

Nothing breeds confidence more than knowing that you are likely to succeed. Learning whether you are likely to succeed or fail in a fair trial is something that could assist patients who have intact cognitive function, particularly as they attempt to discern to what extent their disabilities are the result of physical or psychological limitations. Further research--most particularly, clinically based research--is needed to elucidate the role of confidence in task achievement. In addition, we need to know whether it is worthwhile to develop interventions that are designed primarily to enhance confidence. After all these years, it would be nice to know whether Tug McGraw was right when he said, "You gotta believe?"

The Journal's articles this month are diverse, but, as this Note shows, they evoke a theme. In fact, this issue of Physical Therapy illustrates a larger truth. Through publication, not only do authors contribute factual information to the profession's knowledge base, they contribute ideas that can stimulate the thinking of others, and they suggest new ideas for practice that can be examined by other researchers even as clinicians consider these new ideas for the patients they see on a daily basis.

In my view, patients do have to believe, as do physical therapists. Physical therapists should believe because of evidence; patients should believe because of their faith in themselves and in what physical therapists can do.