Making models more attractive.

Delicate balances, like all things precarious, are hard to achieve. Within physical therapy we need more balance in our knowledge base, but the means of achieving it remain obscure, and while we await the balance, subgroups within the profession grow more alienated from one another. Clinicians bemoan the irrelevance of research, and researchers bemoan the fickle nature of practitioners who appear to become enamored with fads. Each seems incapable of assisting the other in a search for knowledge. It is as if we know how best to do each other's task, but not our own.

In this issue, two articles address the contact pressures seen following replacement of a patient's femoral head with an instrumented prosthesis. The papers, by Strickland et al and Givens et al, provide some insight into how clinicians and researchers may work more symbiotically. They offer basic information that may or may not prove to be of value in the development of effective rehabilitation protocols. The authors certainly have attempted to use data obtained under very artificial conditions in order to elucidate what occurs with patients who undergo routine forms of arthroplasty. The authors' efforts represent a typical approach used in the biomedical sciences--the use of a model to obtain data that can then be used to generate protocols that can be tested for their efficacy. The authors have done an admirable job in presenting considerable data.

What is beyond the ability of the authors is to require the next step: the generation and testing of clinical protocols. Articles such as these, and others that use models and generate clinically relevant hypotheses, should be a call to action. Clinical efficacy studies would not be the likely first sequelae, but what we should be seeing is the thoughtful development of clinical protocols and the careful documentation of these protocols and their effects through published case studies. Then, with more illustrative data available and ideas further developed, more complete and rigorous studies could be initiated. In these efforts, there is a role for every clinician and every researcher. The creation and testing of ideas is not and can never be the province of one community within the profession--and neither should publication.

The use of models, particularly the use of animal models for studying clinical phenomena, can be easily dismissed with clever remarks and snide arguments detailing how one never treats frogs or rats. Similarly, one could scoff at the artificiality of basing treatment on data obtained through use of an instrumented prosthesis on one person. As can be seen from the commentary that accompanies the articles in this issue, there are reasons to think about the relevance of the model, but it is this thinking that matters most. We should be spurred on to think and to rethink based on models. When we scorn the contributions of those who offer us models, we lose sight of the fact that most existing clinical techniques were actually developed from concepts derived from far-distant sources. Consider our understanding of neuronal functioning, wound healing, and dozens of other basic mechanisms. This knowledge was acquired from models obtained while studying a veritable Noah's Ark of species. In addition, we often hear promoters of treatment strategies stating that they base their arguments on practice and not on esoteric research, but while doing so, they freely justify their arguments with references to models and animal research. In fact, often their only real data have been liberally extrapolated from very unapplied and clinically distant sources.

Like most clinicians, I want to know more about practice, and any research that makes specific claims about practice should be conducted in relevant contexts. But I also appreciate that until we have a more fully developed knowledge base, a more mature cadre of researchers, and a more robust funding stream for clinical studies, we must maximize the use of all sources of knowledge. The task is not to deride the models, but to critically evaluate them, refine the concepts, implement relevant elements, and then publish information about that development and implementation. This is not a call for us to return to earlier abuses, when ideas liberally borrowed from basic research were seen as justifications for treatments. Rather, it is a suggestion that we seek balance through the contributions of all who care about the nature and quality of practice.

Jules M Rothstein, PhD, PT Editor