What will it take? The need for large-scale trials.

To the Editor:

With regard to Dr Jette's Editor's Note entitled "The Peril of Inadequate Evidence" (April 2005 issue); I would suggest that his remarks extend well beyond the "75% rule" and inpatient rehabilitation settings. In general, all areas of physical therapist practice and rehabilitation are under-researched.

I agree that the steps taken by the Foundation for Physical Therapy (FPT) and the American Physical Therapy Association (APTA) are giant leaps forward in addressing the problem. APTA has very clearly articulated the Clinical Research Agenda (CRA) that was built from a grassroots effort, and the profession's major funding arm has unequivocally prioritized those questions posed in the CRA. Dr Jette speaks of the "need to redouble our efforts to secure funding at all levels for a new generation of clinical and health services research ventures--both to investigate the evidence base of the interventions we provide today and to develop theory-grounded, more effective treatments for tomorrow." I would suggest that the major target of this "call to arms" is the academic community--which leaves me to ask about the preparedness of our "army" of researchers.

A "call to arms" requires resources directed appropriately and an army prepared to efficiently execute a well-defined strategy. Specifically, what is our profession's capacity to conduct the large-scale trials necessary to sway the opinion of panels similar to the one at the recent workshop sponsored by the National Institutes of Health (NIH), where the goal is to recommend provision of rehabilitation services to funding agencies?

Exactly what will it take to increase our efforts? I suggest the following:

* Establishment of solid strategies to offer as much help as possible to future researchers whose intent is to conduct large-scale clinical research, the results of which will have health policy ramifications. I believe that it is no longer adequate to prioritize research consistent with the CRA and that researchers need to look further and articulate how the direction of their proposed work will have health policy ramifications. It is not my intent to rain on the parade of tremendous success of seed money from the FPT that has turned into large-scale NIH funding with physical therapists as principal investigators. This type of investment has had a profound and positive effect on our capacity. The questions I pose are related to the sufficiency of this strategy, especially for our future needs, keeping in mind (1) Dr Jette's call to "redouble our efforts" and (2) the target of these efforts--a research direction that will lead to health policy changes.

* Partnership among physical therapist academic programs that have access to environments that are conducive to conducting the kind of research that Hill eventually lead to health policy ramifications. There are more than 200 professional physical therapist education programs, which, on the surface, would appear to be a formidable resource. However, few programs have the capacity and resources to conduct largo scale trials. The FPT Clinical Research Network was a very effective strategy that directly addressed this shortfall. In redoubling our efforts, should we begin looking at funding similar efforts?

Some may scoff at investing large amounts of money in research that may or may not turn out to support current physical therapist practice. Research always comes with the risk that the results may not always lead to answers that the profession Hill embrace. Having served on panels similar to that described by Dr Jette in his Editor's Note, I can assure the readership that professional opinion alone, regardless of how well it is articulated, will not convince panels seeking evidence-based support for recommendations about interventions.

With an ever-shrinking health care dollar, what will our profession be able to put forth with regard to tangible evidence to support physical therapy interventions when future panels are convened recommend funding and reimbursement decisions? As stewards of our profession's future, will we be able to look back and say that we did enough?

Anthony Delitto, PT, PhD, FAPTA Associate Professor and Chairman Department of Physical Therapy School of Health and Rehabilitation Sciences University of Pittsburgh

Vice President, Education and Research Centers for Rehab Services University of Pittsburgh Medical Center [e-mail]