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Phys ther 1986-walker-382-6

  1. 1. Research in Pathokinesiology−−What, Why, and How Joan M Walker PHYS THER. 1986; 66:382-386.The online version of this article, along with updated information and services, canbe found online at: This article, along with others on similar topics, appears in the following collection(s): Kinesiology/Biomechanicse-Letters To submit an e-Letter on this article, click here or click on "Submit a response" in the right-hand menu under "Responses" in the online version of this article.E-mail alerts Sign up here to receive free e-mail alerts Downloaded from by guest on April 14, 2012
  2. 2. Research in Pathokinesiology—What, Why, and HowJOAN M. WALKER Key Words: Pathokinesiology, Physical therapy. The University of Southern California Department of Phys- which is designed for clinical use. We also have documentedical Therapy (USC-PT) is honored in being invited to present the effects of exercise under adverse climatic conditions ora review of some of our research activities in pathokinesiology. with muscle imbalance.3-5 Measurements are needed that canSpecifically, I will address the following questions posed by be performed in the clinic without elaborate equipment orthe organizers of this symposium: 1) Why has USC-PT been extraordinary space. Refinement of testing methods will im-conducting research in thefieldof pathokinesiology? 2) What prove the quality of data needed to quantify patient perform-has been accomplished? 3) How was it accomplished? and 4) ance. Results of testing are used to assess the severity of theHow has this effort contributed, if it has, to the science of patients problem and to reach decisions regarding the treat-pathokinesiology? ment program. The percentage of error of the measurements Many individuals deserve credit for providing the impetus, used must be established so that changes in results on repeatedinspiration, and opportunity to conduct research on normal tests can be considered in the proper perspective. Adams (N.and abnormal movement. I recognize Dr. Helen Hislop, J. Adams, unpublished data, March 1976) and otherChairman of USC-PT and author of the pivotal paper "The researchers6-19 have accomplished this to some degree for gaitNot-So-Impossible Dream"1 that today retains its relevance. and for energy studies; these studies are still in progress.As presenter, I am simply a voice for the many who have Data in these areas have contributed to the establishmentcontributed to these research efforts. The USC-PT effort has of more realistic goals for the rehabilitation of patient groups,been undertaken in cooperation with personnel from the local such as those with spinal traumas, myelodysplasia, cerebralarea, particularly from Rancho Los Amigos Medical Center, palsy, hemiplegia, amputations, and fractures.13-15 The exer-such as Dr. J. Perry, who is also a member of the USC-PT tion requirements of activities such as crutch gaits in patientsfaculty. Drs. R. Waters, J. Hackney, D. McNeal, and B. with spinal traumas, fractures, or amputations have beenBowman have assisted with space, equipment, and financial defined more clearly.14,16,20-23 The determination of endurancesupport. limits for particular patient groups now allows a realistic We have taken a pragmatic and perhaps simplistic approach estimation of the feasibility of independent living (eg, a childto pathokinesiological research with emphasis on identifying with myelodysplasia attending a regular school) or provides aand answering questions that will provide clinically useful rationale for the acquisition of equipment for mobility (eg,data and a basis for the solution of clinical problems. Our an electric wheelchair).central mission at USC has been to build a body of knowledge Without quantification of the energy cost of an activity,that will provide a solid foundation for the profession of poor patient performance (ie, less than that expected by healthphysical therapy and contribute to improved methods of care providers) may be thought to relate to inadequate moti-health care. Before analytical studies can be performed, nor- vation. Our energy cost data clearly show that motivationmative data are needed. alone will not allow some disabled individuals to perform The specific aims of our research into the science of path- some routine activities on anything other than an occasionalokinesiology are as follows: 1) to develop methods to quantify basis.13,15,16,18,20-23 Eventually, the high energy demands ofhuman performance with emphasis on the everyday activities such activities may seriously compromise the individualsof human motion, such as gait and similar exercise demands; health.2) to establish baseline data for healthy individuals (eg, sex, Data regarding force, power, and work performed by bothage, race), "normative" values to which patient performance healthy subjects and patients still are incomplete; these studiescan be compared, thus, permitting clearer definitions of dis- are ongoing. Equipment for these studies is readily availableability and the extent of deconditioning that will assist in the now, both in clinics and in laboratories of many physicalformulation of short-term and long-term goals for patients therapy education programs.and contribute to treatment response predictability; 3) toestablish data bases for various patient groups that will permit USC-PT RESEARCH EFFORTthe definition of grades of impairment within injury or diseasegroups; and 4) to compare the performances of healthy and Levels of Researchpatient groups and obtain quantitative measures of disability Research is a requirement in all of our programs: the entry-important to the assessment of treatment effectiveness, em- level masters degree program, the advanced masters degreeployment potential, and disability pension reviews. program, and the doctoral degree program. Faculty members, How has this effort contributed to the body of knowledge especially those in the tenure track, are expected to conductof pathokinesiology? We have been involved in the develop- their own research programs. Ideally, students sponsored byment of the means to quantify human performance; for an individual faculty member will work on a project consti-example, the development of the Rancho Gait Analyzer,2 tuting part of that faculty members research endeavor. Fac- ulty members also conduct research in collaboration with local clinicians. These collaborative efforts offer the greatest Dr. Walker is Associate Professor, Department of Physical Therapy, Univer-sity of Southern California, Rancho Los Amigos Medical Center, 12933 Erick- potential for conducting analytical studies on the effects ofson Ave, Bldg 30, Downey, CA 90242 (USA). specific therapeutic approaches.382 PHYSICAL THERAPY Downloaded from by guest on April 14, 2012
  3. 3. PATHOKINESIOLOGY Constraints on our research in pathokinesiology that still TABLE 1require attention are insufficient laboratory space, equipment, Areas of University of Southern California Department ofand human expertise in the form of mechanical and electrical Physical Therapy Research in Pathokinesiology, 1979-1985engineers and computer programmers; insufficient time, afactor in entry-level student research; inadequate funding, Area nincluding the availability of faculty members who have the Energy cost 16ability to write grant proposals; and too few patient samples Force 15with characteristics that are relatively homogeneous and data Gait 12that are collectable over a reasonable time period. Increasingly Hemiplegia 12 Cardiovascular 10restrictive medical, legal, and ethical restraints also exist; for Anaerobic threshold 9example, the use of muscle biopsies, roentgenograms, needle Joint mobility 9electromyograms, and animal studies. Electrical stimulation 9 Existing constraints to pathokinesiological research may be Pediatrics 5lessened by remembering the important interrelationships Physical therapy education 5between research plans, grants, and publications. These inter- Nerve stimulation 4relationships, we believe, should enhance the successful ac- Special senses 4quisition of funds to support additional research efforts in Miscellaneous 7pathokinesiology and reduce the aforementioned constraintsto this research. The individual and the department as a wholemust have a research plan. Accomplishment of that plan TABLE 2should result in the publication of research findings in a peer- Publication Sites of University of Southern California Departmentreviewed journal. Such publication enhances the potential for of Physical Therapy Research Papersfuture successful grant awards. Archives of Physical Medicine and Rehabilitation Journal of Bone and Joint Surgery. American VolumeMaster Plan Clinical Orthopaedics and Related Research Medicine and Science in Sports and Exercise Our research effort has not been directed according to any Developmental Medicine and Child Neurologyformal long-term master plan with a single theme. This is not Physical Therapyto say that the research has been conducted without any European Journal of Applied Physiology and Occupationaldirection. Rather, the effort has been directed by the identi- Physiologyfication of a clinically relevant problem out of which several Perceptual and Motor Skillsstudies have developed. The completion of one study has led Circulationoften to the need to conduct further studies. Sometimes, Physiotherapy Canadacompletion of a particular project is delayed because only a Journal of Applied Physiology Journal of Orthopaedic and Sports Physical Therapycertain number of students may work on one problem in any Physical and Occupational Therapy in Geriatricsone year and then with a less than desirable sample size. As a Yale Journal of Biology and Medicineresult, similar studies may be conducted over a period of two Journal of Pediatric Orthopedicsto five years to obtain an adequate sample size, to test bothsexes, or to test subjects representing different age groups.Some examples would be the establishment of normative Areas covered in these studies are presented in Table 1. Thirty-temporal gait characteristics; range-of-motion studies; nor- one studies examined energy cost or force-work-power abili-mative data for two-point discrimination; the study of daily ties. Gait studies and studies on hemiplegic patients accountactivities, such as the act of rising from a chair; or the day-to- for 12 each. Thirty-seven studies have been conducted today variability of routine clinical measurements.6-11,24-28 A examine the cardiovascular responses to exercise, to identifymajor impetus to the direction of our research efforts to date the anaerobic threshold, to assess joint mobility, and to meas-has been provided by questions addressed in grants acquired ure the effects of electrical stimulation. Fewer studies haveby the Rancho Los Amigos Medical Center (RLAMC) Path- been performed on children, nerve conduction characteristics,okinesiology Service, and currently the RLAMC Rehabilita- physical therapy education, and the special senses. We alsotion Center, and the availability of equipment. Hislops plan have conducted basic studies at the tissue and cellular level,to establish a regional pathokinesiology research center that investigating spinal cord programming and aging changes withwould serve clinicians, faculty members, and students is de- and without exercise, in muscles and in joints.layed because of the decrease in funds from major agencies. We estimate that since 1972 we have presented 67 papers What, then, has been accomplished in research efforts at at national conferences, and we have published about 30USC-PT? Between 1979 and 1983, about 120 studies were papers over the same time period. These papers were pub-completed by students and faculty members. Few studies were lished in a variety of journals, which are listed in Table 2. Noconducted solely by a faculty member without student in- journal entitled Pathokinesiology yet exists! The end point ofvolvement. These 120 studies involved more than 170 entry- any worthwhile research project, however small-scale, is thelevel students and 25 advanced masters level students. Three presentation of the findings at meetings and, if suitable,doctoral studies were completed during 1984. The majority submission of a paper for publication.of these studies were descriptive or they were designed to We must address the question, has this research effort madedetermine if differences existed between various groups. a major contribution to the science of physical therapy, ofEleven of these studies were analytical. In 20 studies, the pathokinesiology? I will say yes but leave the degree of thatresults of testing patient and healthy groups were compared. contribution to be assessed by others and time.Volume 66 / Number 3, March 1986 383 Downloaded from by guest on April 14, 2012
  4. 4. Strengths and Weaknesses on knowledge gained by the basic science studies and encour- age documentation of the effects of physical therapy by actual Among our strengths must be counted the exposure, just measurements of changes in physiological functions and phys-in the last four years, of more than 200 physical therapists to ical characteristics. This documentation will define better thethe research process. These experiences in designing and scientific basis of physical therapy and will help define theconducting research in pathokinesiology should make them need for further studies. I believe that, despite research con-more intelligent users of researchfindings,the only legitimate ducted in many places over the years, it is still true to say thatbasis for decision making in clinical practice. They also should no physical therapy approach has been tested more appreciative of the limitations and variability ofresearchfindings.I hope that some of the former students willcontinue to participate in research, even if only at the single- Future Plans and Direction of Researchpatient level. Most of the research tools used in our studiesare tools that also can be found in clinics and hospitals with We plan to expand the vitally necessary normative datapatient testing laboratories. As studies were designed to answer bases and patient data. We need to obtain data on the char-clinical questions or to provide normative data against which acteristics and variability of patients with different disordersto evaluate patient performance, the value of research to the and the degrees of those disorders. Do the gait characteristicsprofession, in terms of improving patient care, should be of a patient group, for example, vary with severity of theclear. Some unknowns have been identified, standards have disease? Can treatment also be assessed by monitoring im-been formulated, and variability within healthy groups has provement in walking? I selected gait because most peoplebeen established. walk in some manner, and tools such as the Rancho Gait Results must be shared to ensure the growth of the body of Analyzer,2 developed for use in the clinic, make it possibleknowledge that will establish a recognizable science of path- for any therapist to quantify a patients performance by theokinesiology. We acknowledge that our publication efforts measurement of the gait characteristics. How do members of a specific patient group differ from healthy subjects? How dohave lagged behind completion of research studies. When they differ from other patient groups? Establishing these dif-several students work on a clinical question over a period of ferences, if differences do exist, may contribute to the under-two to five years, someone else must analyze thefinalsample standing of the disease process and the patients rehabilitation.and write the paper. An inadequate number of people have When such data become available, we plan to place greaterbeen available to do that, to write grants, to supervise ongoing emphasis, as conditions permit, on analytical studies to testresearch, and to fulfill normal faculty responsibilities. These whether different treatments produce different effects, and ifare problems familiar to most physical therapists. Further- so, what those effects are. We intend to continue to identifymore, wefindthat students are keen to complete their research variables that may affect data. Does the distance over whichprojects because completion terminates their formal studies gait data are collected, for example, influence those data?and allows them to sit for the state board examination. In What distance is ideal for an indoor gait walkway? What istheirfirstclinical appointment, however, conversion of their the influence of the time of day on data collection? Does itaccepted university paper to one suitable for submission for matter? Should patients with disorders such as rheumatoidpublication in a professional journal has low priority, despite arthritis only be tested after 10 AM? Is this hearsay or real?prompting from faculty members. This problem decreases the What else is hearsay or real?potential impact of the research conducted, but it has no easy We also will expand the methods of data analysis. We, forsolution. We have changed from the thesis format to a directed example, will make better use of multivariate and discrimi-research format that permits the paper to be written in the nant analyses; identify major variables that influence perform-style of the journal to which it may be submitted. The number ance to determine which data should be collected; and im-of papers independently converted for publication and sub- prove the criteria for selection of candidates for specificmitted by former students shows that this format change is therapeutic interventions, such as strengthening programs ornot enough. Where physical therapy faculty members are functional electrical stimulation. These plans include educat-highly involved in the supervision of student research, their ing physical therapy students to have exposure to research, tocontribution to the science of pathokinesiology, and the over- gain a sound awareness of the importance of research to theall development of the science of pathokinesiology, can be profession in providing the legitimate basis for clinical deci-lessened by high involvement with students below the doctoral sion making, and to participate in some form of research inlevel of study. If the body of knowledge is to be increased, the their clinical practice.direction of those efforts of the still small number of ade-quately qualified and trained faculty members needs to be We need to reevaluate the kinds and scope of research thatreconsidered. are requirements at the entry and advanced masters degree levels. I believe that this component of our educational pro- Other weaknesses in the research that may be identified but grams has the potential to affect significantly the developmentnot rectified easily are small sample sizes; subjects restricted of the science of pathokinesiology; to either increase or delayin age, geographic origin, and social group; inadequate use of its development. We need to identify the approach that willappropriate higher level statistical tests; a dearth of studies on be the most effective in achieving the goal of building a soundhomogeneous patient groups; and absence of analytical stud- knowledge base for the practice of physical therapy. Academicies investigating the effects of treatment regimens. These requirements for student research must be balanced by thefactors, not unique to our situation, impede the growth of the necessity of allowing faculty members adequate time to per-science of pathokinesiology. form their own responsibilities. As the number of doctoral We must discourage the tendency of the members of our programs increases, the need for additional faculty membersprofession to speculate about the rationale for treatment based to provide adequate supervision and to serve as role models384 Downloaded from by guest on April 14, 2012 PHYSICAL THERAPY
  5. 5. PATHOKINESIOLOGYto their students also increases. In facilitating the acquisition the scientist, is obligated to delineate, without prejudice, whatof grant monies by faculty members and in providing sound is known, what is not known, and what probably is knowntraining to the future physical therapy research leaders, faculty using current methods.29 The advocate, the physical therapymembers will need to determine where their time would be clinician, advances or defends a particular approach throughspent most profitably—in giving research education to entry- selective presentation of information to support that ap-level students or to more advanced students, such as those at proach. The physical therapy clinician and the lay personthe doctoral level. need to understand the uncertainty associated with scientific A research laboratory, or laboratories, under the direction knowledge and to understand the concept of probability.and control of the physical therapy education program is Without this understanding, it is difficult, if not impossible,pivotal to the achievement of the objectives specified in a to use scientific knowledge as a basis for decision making. Iresearch plan. A gait laboratory is a vital component. Humans hope that the research efforts of USC-PT not only haveare bipedal and upright. Walking is a goal to be achieved by contributed to the body of knowledge of pathokinesiology butmost patients; thus, motor activity associated with gait is a also have prepared clinicians to understand, use, and partici-common denominator of health, injury, and disease. Change pate in the research gait characteristics provides an index of motor ability andindependent function regardless of a patients specific disease CONCLUSIONor diagnostic label. A thought for the future, indeed now, is contract research, I end with a quote from Hislops paper:in which a research project will be conducted by faculty If you want a bee to make honey you do not issue directivesmembers for a clinical group or a manufacturer of physical and protocols on carbohydrate metabolism and solar naviga- tion. You put him together with other bees. If the air is right,therapy equipment, similar to the management of Depart- the science will come in its own season, like pure honey.1ment of Defense contracts. This may maximize the cliniciansskills and the research expertise available in the university In this review of one facilitys efforts toward the develop-and in the clinical facilities. Such an arrangement should help ment of the science of pathokinesiology, I have described andus obtain answers to the many questions posed by clinicians discussed the many facets of research at our facility. Research,who lack the time or facilities to pursue them. scientific inquiry, is the sole means whereby the profession of physical therapy stands to gain a sound scientific basis for its practice. The growing body of knowledge of pathokinesiologyThe Research Process and Roles is that basis. To paraphrase a recent article on engineering by Harrison,29 REFERENCESthe research process consists of selecting a problem, the meth- 1. Hislop HJ: Tenth Mary McMillan lecture: The not-so-impossible dream.odology, and the protocol; executing the study; and reducing Phys Ther 55:1069-1080,1975the data. This process results in the development of constructs 2. Perry J: Clinical gait analyzer. Bull Prosthet Res 10-22:188-192,1974 3. Hackney JD, Linn WS, Buckley RD, et al: Vitamin E: Supplementation andthat are useful in assessing the reliability of the results and in respiratory effects of ozone in humans. Abstract. Am Rev Respir Disestablishing the clinical importance of statistically significant 117:238,1977 4. Hackney JD, Linn WS, Buckley J, et al: Studies in adaptation to ambientresults. The legacy of investigating clinical problems or phe- oxidant air pollution: Effects of ozone exposure in Los Angeles residentsnomena will be scientific knowledge, a data base, an array of vs. new arrivals. Environ Health Perspect 18:141-146,1976methods, and an array of concepts. This is the legacy of 5. Hackney JD, Linn WS, Buckley RD, et al: Experimental studies on human health effects of ozone. Abstract. Environ Health Perspect 16:184-185,problem-solving investigations. This process of investigation 1976should lead to improved patient care, more efficient treatment 6. Graff S, Wong L, Gronley J, et al: Variation in selected gait characteristicsapproaches, and more realistic predictions of the outcomes of of normal females. Abstract. Phys Ther 61:688,1981 7. Dorner PM, Ryan SV, Gronley J, et al: Influence of a slow-walking speeddisease or injury. on knee motion, stride length, and cadence. Abstract. Phys Ther 62:684, To test, reevaluate, and revise constitutes the safeguard of 1982 8. Boyne LJ, Darr N, Thomas L, et al: Stabilization lengths in gait analysis ofknowledge integrity. It is necessary and valuable for studies men. Abstract. Phys Ther 64:712,1984to be repeated, in the same or different laboratories, to ensure 9. Cashen A, Gregory R, Gronley J, et al: Gait variability of middle-agedthat the standards the profession may use are soundly based. women. Abstract. Phys Ther 64:712,1984 10. Didone L, Jenkins SF, Thomas L, et al: Pre-collection and data collection The exposure of students to the scientific process will zones in gait analysis. Abstract. Phys Ther 64:711,1984facilitate communication and collaboration among physical 11. McCue C, Veres M, Walker JM, et al: Gait variability of young men.therapy faculty members and scientists in university or private Abstract. Phys Ther 64:712,1984 12. Locke M, Perry J, Campbell J, et al: Ankle and subtalar motion during gaitresearch institutions and among clinicians. Endeavors to ex- in arthritic patients. Phys Ther 64:504-509,1984pand knowledge and the understanding of the scientific proc- 13. Williams LO, Anderson AD, Campbell J, et al: Energy cost of walking and wheelchair propulsion in children with myelodysplasia: Comparison toess are the responsibility of scientists and clinicians. These normal children. Dev Med Child Neurol 25:617-624,1983two groups should maintain their distinctive roles and, in 14. Thomas LK, Hislop HJ, Waters RL: Physiological work performance intheir respective roles, serve as expert witnesses and advocates. chronic low back disability: Effects of a progressive activity program. Phys Ther 60:407-411,1980Clinicians more often adopt the role of the advocate. This 15. Brown M, Hislop HJ, Waters RL, et al: Walking efficiency before and afterrole is adopted when a value judgment is made in favor of a total hip replacement. Phys Ther 60:1259-1263,1980particular therapeutic approach that then is supported over 16. Waters RL, Hislop HJ, Perry J, et al: Energy cost of normal and pathological gait. Orthop Clin North Am 9:351-356,1978other approaches (eg, neurodevelopmental therapy over pro- 17. Wolfe GA, Waters RL, Hislop HJ: Influence of floor surface on the energyprioceptive neuromuscular facilitation or Williamss flexion cost of wheelchair propulsion. Phys Ther 57:1022-1027,1977routine over MacKenzies extension approach). This waives 18. Waters RL, Perry J, Antonelli D, et al: Energy cost of walking of amputees: The influence of level of amputation. J Bone Joint Surg [Am] 58:42-46,the role of the expert who should have attained and demon- 1976strated competence in a specific area of expertise. The expert, 19. Beaver N, Mazel S, Walker JM, et al: Functional evaluation of juvenile rheumatoid arthritic patients. Abstract. Phys Ther 64:709,1984Volume 66 / Number 3, March 1986 385 Downloaded from by guest on April 14, 2012
  6. 6. 20. Waters RL, Campbell J, Thomas L, et al: Energy cost of ambulation in 25. Boone DC, Walker JM, Perry J: Age and sex differences in lower extremity lower extremity plaster casts. J Bone Joint Surg [Am] 64:896-899, 1982 joint motion. Abstract. Phys Ther 61:688, 198121. Cerny K, Waters RL, Hislop HJ, et al: Walking and wheelchair energetics 26. Smith JR, Walker JM: Knee and elbow range of motion in healthy older in persons with paraplegia. Phys Ther 60:1133-1139, 1980 individuals. Physical and Occupational Therapy and Geriatrics 2:31-38,22. Pagliarulo MA, Waters RL, Hislop HJ: Energy cost of walking among below 1983 knee amputees having no vascular disease. Phys Ther 59:538-542, 1979 27. Walker JM, Sue D, Miles-Elkousy N, et al: Active mobility of the extremities23. Campbell J, Ball J: Energetics of walking in cerebral palsy. In Waters RL, in older subjects. Phys Ther 65:919-923, 1985 Hislop HJ, Perry J, et al: Energetics: Application to the Study and Manage- 28. Wheeler J, Woodward C, Ucovich RL, et al: Rising from a chair: Influence ment of Locomotor Disabilities. Orthop Clin North Am 9:374-377, 1978 of age and chair design. Phys Ther 65:22-26, 198524. Pohl PS, Ando AD, Walker JM, et al: Age changes in two-point discrimi- 29. Harrison AJ: Common elements and interconnections. Science 224:939- nation. Abstract. Phys Ther 63:778-779, 1983 946, 1984386 PHYSICAL THERAPY Downloaded from by guest on April 14, 2012
  7. 7. Research in Pathokinesiology−−What, Why, and How Joan M Walker PHYS THER. 1986; 66:382-386.Subscription and Reprints for Authors Downloaded from by guest on April 14, 2012