Should we base the standards of care for physical therapy on clinical research, or do we need a different model to speed adoption of new treatment approaches such as functional electrical stimulation (FES) for physical injuries?
That’s the controversial question posed by Gad Alon, PT, PhD, Emeritus Associate Professor at the University of Maryland School of Medicine, Department of Physical Therapy and Rehabilitation Science.
At the NEXT conference of the American Physical Therapy Association last summer in Nashville, TN, Dr. Alon made a case for adopting FES as a standard of care based on a new model for making standards of care for people with physical limitations.
The controversy stems from the clinical research model that has long been used in clinical practice. The current legacy approach advises physical therapists to only use treatment modalities that have “statistically significant and clinically meaningful findings.” However, achieving such results often takes years of academic or clinical research, with many more years of commercial development following before a useful product reaches the market. Still worse, the current model makes it so that product is only used for patients who are like the patients in the original research studies.
Let’s look at an example. Suppose a therapist treats patients who have hemiparesis after a stroke. The clinic also treats patients with multiple sclerosis, traumatic brain injury, and other neurological disorders. In an effort to better treat these patients, the therapist uses the clinical research model by doing some research on treatment options. The therapist finds a lot of research papers about how FES has a statistically significant and clinically meaningful effect on upper extremity function for patients after a stroke, and so the therapist starts using FES with the patients who have had a stroke and need help with upper extremity function. The therapist does not find as many papers about FES for lower extremity function or for other disorder groups, so those patients are never offered FES, even though many of them would probably benefit greatly from FES treatment.
This is the legacy approach that Dr. Alon criticizes, because patients are highly varied in types and levels of impairments and functional limitations. In other words, the functional goals of one patient with a physical impairment may be very different from another person with the same impairment. It doesn’t make sense for both patients to wait for years for a study of a device or regimen to enroll enough participants and reach some predefined outcome over years of testing before they can have access to an intervention that may or may not meet their individual goals.
To counter this limitation of the current model, Dr. Alon advocates adopting a different model for physical rehabilitation based on “personalized rehabilitation programs.” He proposes that such a model seeks to address each individual’s functional goals with a focus on determining which treatment approaches are most likely to advance that person’s goals.
He stresses that no single intervention can maximize functional outcomes, and the goal should not be “normal” movement, but “visibly better” performance.
To that end, Dr. Alon advocates for adopting functional electrical stimulation or FES combined with task-specific interventions to reach best possible outcomes as the standard of care for patients who are candidates for FES.
Dr. Alon also pointed to a pair of additional obstacles to the adoption of FES as a standard of care. One is the difficulty of using the devices by clinicians and the second is the high cost of the technology both for physical therapy clinics and for home use.
Two of MYOLYN’s guiding principles are to make its FES technology easy-to-use and affordable both for in-clinic and home use.
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