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PHYSICAL THERAPY
JULY 2017 r VOLUME 29 r NUMBER 3 Supplement

Table of Contents
S1 Editorial

INTRODUCTION TO IV STEP
S2 The Past, Present, and Future of Neurorehabilitation: From NUSTEP Through IV STEP and Beyond
Susan Harris and Carolee Winstein
This introduction: presents the history and aims of the STEP conferences; describes the interdependence of prevention,
prediction, plasticity, and participation; reflects on where we stand today regarding those four Ps; and discusses how future
neurorehabilitation should look for individuals with movement disorders.

SPECIAL COMMUNICATION
S10 Regenerative Rehabilitation: Combining Stem Cell Therapies and Activity-Dependent Stimulation
Chet Moritz and Fabrisia Ambrosio
This review describes the potential for synergy between the fields of regenerative medicine and rehabilitation, provides
translational examples, and recommends combined therapy and technology with the goal of enhancing long-term recovery.

S16 Excellence in Promoting Participation: Striving for the 10 Cs—Client-Centered Care, Consideration of
Complexity, Collaboration, Coaching, Capacity Building, Contextualization, Creativity, Community, Curricular
Changes, and Curiosity
Lisa Chiarello
This perspective explores the complex and multidimensional construct of participation and presents recommendations for
practice, education, and research to transform pediatric physical therapy service delivery.

S23 Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults: Prevention, Plasticity, and
Participation
Judy Deutsch and Sarah Westcott McCoy
We explore aspects of virtual reality in rehabilitation that address the four “Ps” of IV STEP

S37 Coupling Timing of Interventions With Dose to Optimize Plasticity and Participation in Pediatric Neurologic
Populations
Mary Gannotti
The purpose of this paper is to summarize evidence about effective intervention programs with a focus on timing of services to
maximize plasticity and participation of children with neurologic dysfunction, specifically cerebral palsy.

S48 Use of Lower-Limb Robotics to Enhance Practice and Participation in Individuals With Neurological
Conditions
Arun Jayaraman, Sheila Burt, and William Zev Rymer
This is a review lower-limb technology currently available for persons with neurological disorders, such as spinal cord injury,
stroke, or other conditions. We focus on three emerging technologies: treadmill-based training devices, exoskeletons, and
wearable robots.
PEDIATRIC
PHYSICAL THERAPY
JULY 2017 r VOLUME 29 r NUMBER 3 Supplement

Table of Contents Continued

S57 Research Design Options for Intervention Studies
Michele Lobo, Sarah Kagan, and John Corrigan
Three types of research designs and their application to physical therapy research are described: single-case research,
observational research, and qualitative research.

S64 Knowledge Translation in Rehabilitation: A Shared Vision

Jennifer Moore, Keiko Shikako-Thomas, and Deborah Backus
This special communication summarizes knowledge translation, describes the current knowledge translation practices in
rehabilitation science, and provides suggestions for its application in clinical care.

S73 Overweight and Obesity in Children: More Than Just the Kilos
Edgar van Mil and Arianne Struik
We focus our review on the prevention, management, and reduction of the prevalence of overweight, obesity, and related
chronic diseases.

SUMMARY OF IV STEP
S76 Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations and Inspirations
Teresa Jacobson Kimberley, Iona Novak, Lara Boyd, Eileen Fowler, and Deborah Larsen
This is a summary of key points and call for action. We review the information presented and the field at large as it relates to
the 4 P’s: prediction, prevention, plasticity, and participation.

State of Our Profession Over the Decades
This special supplement of the IV STEP Conference Pro-
ceedings 2016 marks the continuation of a process that began
in 1966 with The Northwestern University Special Therapeutic
Exercise Project (NUSTEP). This original conference brought
together many of the leaders in rehabilitation for a series of lec-
tures and demonstrations representing the state of the art for
neurologic rehabilitation for children and adults. The proceed-
ings from that conference served as the text for physical therapy
education for many years. My personal copy of that 1200-page
tome is creased and battered after many long hours of study
as a physical therapy student at the University of Wisconsin-
Madison.
It has been a privilege to participate in and experience the
growth of physical therapy since those early student experi-
ences. The initial NUSTEP conference 50 years ago was followed
in 1990 with II STEP Special Therapeutic Exercise Project, in
2005 with III STEP Symposium on Translating Evidence into
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
E D I T O R I A L
Practice, and now the most recent conference held in 2016, IV
STEP Prevention, Prediction, Plasticity, and Participation. These
last 3 conferences have been jointly sponsored by the Academy
of Pediatric Physical Therapy and the Academy of Neurologic
Physical Therapy. Our thanks for all the extraordinary efforts
given by members of both academies to plan and implement
these conferences. The Academies are jointly publishing these
proceedings. Our thanks to the authors for their contributions.
You can access all of the manuscripts at:
• http://journals.lww.com/pedpt
• http://journals.lww.com/jnpt
Linda Fetters
Editor-in-Chief, Pediatric Physical Therapy
Los Angeles, California
DOI: 10.1097/PEP.0000000000000434
Editorial S1
 I N T R O D U C T I O N T O I V S T E P

The Past, Present, and Future of Neurorehabilitation: From NUSTEP Through IV STEP
and Beyond
Susan R. Harris, PT, PhD, FAPTA, FCAHS; Carolee J. Winstein, PT, PhD, FAPTA, FAHA
Department of Physical Therapy (Dr Harris), Faculty of Medicine, University of British Columbia, Vancouver, Canada; and Division of Biokinesiology &
Physical Therapy, and Department of Neurology, Keck School of Medicine (Dr Winstein), and Motor Behavior & Neurorehabilitation Laboratory, Ostrow
School of Dentistry, University of Southern California, Los Angeles.

Purposes: To present the history and aims of the STEP conferences; describe the interdependence of prevention, prediction,
plasticity, and participation; reflect on where we stand today regarding those 4 Ps; and discuss how future
neurorehabilitation should look for individuals with movement disorders.
Key Points: Physical therapists have focused primarily on tertiary prevention, emphasizing primary/secondary prevention far
less. Predicting optimal response to intervention is essential for primary prevention. Research examining neurorehabilitation
effects mediated by brain plasticity is evolving from an emphasis on impairment outcomes toward examination of
participation outcomes.
Clinical Practice Recommendations: (1) Capitalize on primary and secondary prevention. (2) Administer simple,
environmentally relevant predictive measures. (3) Partner with researchers to examine exercise-induced brain plasticity
effects via neuroimaging. (4) Encourage physical activity to promote secondary prevention of lifestyle-related diseases and
enhance participation. (5) Integrate psychological/social sciences with physiological sciences to move forward with advances
in mindful health and patient-centered practices. (Pediatr Phys Ther 2017;29:S2–S9)
Key words: neuroplasticity, neurorehabilitation, participation, prediction, prevention

HISTORY AND PURPOSES OF THE STEP CONFERENCES
The inaugural STEP conference took place 50 years ago
in Chicago. The Northwestern University Special Therapeutic
Exercise Project (NUSTEP) lasted 4 weeks (July 25 to August 19,
1966) and the conference proceedings, published in the Amer-
ican Journal of Physical Medicine and as a stand-alone textbook,
totaled nearly 1200 pages.1 Developed primarily for physical
therapy (PT) educators who taught adult and pediatric neu-
rology courses,2 the goal of NUSTEP was “to analyze older
and newer methods of therapeutic exercise and to search for
0898-5669/293S-00S2
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Susan R. Harris, PT, PhD, FAPTA, FCAHS, Depart-
ment of Physical Therapy, Faculty of Medicine, University of British
Columbia, 212-2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada
(susan.harris@ubc.ca).
The authors declare no conflicts of interest.
This work was previously presented at the IV STEP Conference, orga-
nized and sponsored by the Academies of Neurologic and Pediatric Phys-
ical Therapy of the American Physical Therapy Association, at Ohio State
University in Columbus, Ohio, on July 14, 2016.
DOI: 10.1097/PEP.0000000000000376
ways to meet future needs of physical therapy students through
reconsideration of objectives and of curriculum content.”1(p19)
Neurofacilitation approaches of the prevailing gurus were pre-
sented (eg, Bobath, Brunnstrom, Knott and Voss, Rood), and
overall content included the basic sciences of neurophysiology,
motor development, motor learning and motor behavior.2 The
NUSTEP conference proceedings became a primary textbook for
PT students in the latter 1960s, 1970s, and into the 1980s.
Not until 1990 was the concept of a STEP conference revis-
ited when the Neurology Section and the Section on Pediatrics of
the APTA collaborated to present II STEP (Special Therapeutic
Exercise Project)—an 8-day conference (July 6 through 13) at
the University of Oklahoma’s continuing education center in
Norman. Modeled after NUSTEP, the purpose of II STEP was
“to bring new theory and knowledge arising from the same
content areas addressed at NUSTEP to an audience of phys-
ical therapy educators who work in both academic and clinical
settings.”2(pvii) The proceedings were published by the Founda-
tion for Physical Therapy in a 29-chapter book in the sequence
in which plenary sessions, panel discussions, and small-group
discussions were given.3
Fifteen years after II STEP, the neurology and pediatric sec-
tions organized and presented III STEP (Symposium on Trans-
lating Evidence into Practice) at the University of Utah in Salt
Lake City, Utah (July 15-21, 2005). More so than the previous
2 STEP conferences, III STEP included a heightened emphasis
on neuroplasticity, motor learning, and motivation, with a theme

S2 Harris and Winstein Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
of linking movement science to intervention.4 Furthermore,
III STEP was specifically aimed at translating knowledge about
movement science into effective clinical interventions.5 Articles
based on III STEP plenary and breakout sessions were published
as a special series in Physical Therapy (2006-2007).6-17 Five addi-
tional articles based on III STEP presentations18-22 as well as a
perspective on the effect of the conference on clinical practice23
appeared in a special issue of the Journal of Neurologic Physical
Therapy.
In July 2016, a half century after the seminal NUSTEP
conference, the APTA neurology and pediatric sections joined
forces again to organize and host IV STEP: “a summer institute
for clinicians, educators, and researchers designed to explore
new theory and research evidence related to movement science,
and to translate this theory and evidence into physical therapy
practice for individuals of all ages with neurologic disorders.”24
Held at Ohio State University in Columbus from July 14 to 19,
IV STEP focused on 4 Ps: prevention, prediction, plasticity, and
participation, relating those Ps to roles and responsibilities of
today’s PTs and designed to guide PT practice over the next
decade.24
In the following sections of this article, we list the objectives
of IV STEP, define the 4 Ps and describe their interdependence,
and provide thoughts and reflections on where we stand today
with regard to prevention, prediction, plasticity, and participa-
tion. Finally, we discuss what we believe the future should look
like for neurorehabilitation of children and adults.
IV STEP OBJECTIVES
The IV STEP Planning Committee developed 4 objectives
for the conference, each relating to 1 of the 4 Ps:
1. Explore physical therapists’ role(s) in preventing
disabling conditions among at-risk and preclinical
populations.
2. Evaluate ways to classify individuals’ movement disor-
ders, as well as strategies to link classification with accu-
rate predicted outcomes.
3. Summarize critical periods for the emergence of neu-
roplasticity and strategies, including dosage, timing,
and technology, for maximizing experience-dependent
plasticity.
4. Analyze and apply emerging measures and interven-
tions to optimize participation within the patient-
centered care model.
These objectives will be integrated into our definitions of
the 4 Ps and their interdependence.
DEFINITIONS AND INTERDEPENDENCE OF PREVENTION,
PREDICTION, PLASTICITY, AND PARTICIPATION
Definitions of the 4 Ps
With the goal of advancing PT practice, IV STEP
defined prevention, prediction, plasticity, and participation and
explored their interdependence as related to the roles and
responsibilities of today’s therapists.
Pediatric Physical Therapy
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Unauthorized reproduction of this article is prohibited.
Prevention. The term prevention refers to actions taken to
prevent the onset of disease (or disability), to stop its progress,
and to minimize its consequences.25 Primary prevention aims to
prevent specific diseases or disabilities through risk-reduction
strategies, such as modifying lifestyle behaviors. In both children
and adults, for example, we know that wearing bicycle helmets
can reduce the risk of traumatic brain injury (TBI) if the cyclist
falls or is hit by a car. In secondary prevention, procedures to
“detect and treat pre-clinical pathological changes” for the con-
trol of progression to disability are implemented.25 Examples of
secondary prevention include screening premature infants for
cerebral palsy (CP) or prescribing graded aerobic exercise for
individuals at risk for stroke because of hypertension.
Tertiary prevention, with the goal of minimizing the effect of
movement disorders on the patient’s activity, participation, and
quality of life, is the type of prevention with which most PTs
are currently involved. For example, studies have shown that
gait and step perturbation training reduces falls in persons with
Parkinson disease (PD)26 and that adaptive seating systems may
improve home-based activity and participation in children with
severe CP.27
Prediction. According to the IV STEP Planning Com-
mittee: “Prediction of optimal response to intervention choice is
fundamental to effective practice. It begins with meaningful
movement system diagnoses and measurement. Prediction is
also essential as it relates to primary prevention.” At IV STEP,
classification of movement disorders was discussed, as well as
strategies to link classification with predicted outcomes.
One of the best-known systems for classifying children
with movement disorders, used in hundreds of studies around
the world, is the Gross Motor Function Classification System
(GMFCS), a 5-level, ordinal system based primarily upon sitting,
walking, and wheeled mobility.28 Developed initially for chil-
dren with CP,28 the GMFCS has been also used to classify chil-
dren with Down syndrome.29 In 2007, the GMFCS was revised
and expanded to include an age band for children 12 to 18 years
and to encompass environmental and personal factors that influ-
ence mobility, now referred to as the GMFCS—Expanded and
Revised (GMFCS-E&R).30
Classification on the GMFCS has been linked to predic-
tions of type of mobility used (walking, wheeled mobility, or
assisted mobility) in different environments (home, school, and
outdoors) at different ages by children and young adults with
CP31 and the rate of developmental gain in mobility and self-
care activities in preschool-aged children with CP.32
Classification of adults with movement disorders into fallers
and nonfallers has been a focus of predictive neurorehabilitation
research for the past 25 years, with introduction of the Berg Bal-
ance Scale33 (developed by PTs) and the Timed Up & Go34 in the
early 1990s. One or both of these simple tests have been used
to accurately predict falls in persons with multiple sclerosis,35
individuals poststroke,36 and those with PD.37,38
Another type of classification system, the American Spinal
Injury Association Impairment Scale (AIS)39 is the interna-
tional standard for categorizing injury severity in persons with
spinal cord injury (SCI). A multicenter study of more than
1000 patients indicated that AIS classification at admission to
inpatient rehabilitation was the strongest predictor of overall
The Past, Present, and Future of Neurorehabilitation S3
physical functioning at 1 year postdischarge.40 In another large
multicenter study, AIS also predicted likely walking function
at 1 year postinjury based on scores obtained within the first
2 weeks of SCI.41
Plasticity. The third P, plasticity, has been defined as “the
capacity of cerebral neurons and neural circuits to change, struc-
turally and functionally, in response to experience.”42(p1) Brain
plasticity is critical not only for sensory function maturation
during development and behavioral adaptability to the environ-
ment but also for brain repair resulting from injury or disease.42
Exposure to enriched environments including cognitive, sen-
sory, and motor interventions, for example, is one noninva-
sive approach to enhancing brain plasticity.42 In a meta-analysis
comparing the effects of enriched environments to standard care
in infants at high risk for CP, Morgan and colleagues43 found a
small positive effect on motor outcomes (standard mean differ-
ence = 0.39; 95% confidence interval = 0.05-0.72) in favor of
the infants exposed to enriched environments. Enriched envi-
ronments were defined as “interventions that aim to enrich
at least 1 of the motor, cognitive, sensory, or social aspects
of the infant’s environment for the purposes of promoting
learning.”43(pe737) One example was to adapt the infant’s physical
and play environment to provide opportunities for self-initiated
motor activity.43
Another interesting area of adult neuroplasticity research
is examining the effects of aerobic exercise on brain changes
poststroke, suggesting that aerobic exercise can “enhance the
neuroplastic milieu.”44(p9) Two recent systematic reviews (SR)
involving animal studies showed that daily, moderate, forced
exercise initiated within 48 hours after stroke reduced the
volume of the stroke lesion, protected the surrounding tissue
against damage and inflammation for at least 4 weeks,45
and enhanced synaptogenesis in multiple brain regions.46
Researchers in this area suggest that combining aerobic exercise
with task training “may enhance activity-induced plasticity” in
humans.44(p9)
Participation. The most widely known definition of par-
ticipation comes from the World Health Organization’s Interna-
tional Classification of Functioning, Disability and Health: the
“involvement of people in all areas of life” or the “functioning
of a person as a member of society”; participation restrictions are
“problems an individual may experience in involvement in life
situations.”47(p10) Functioning within society is as important for
children and adults with movement disorders as for individuals
who can move easily within their environment. Unfortunately,
however, there has been less emphasis in rehabilitation research
on interventions to affect participation outcomes than on strate-
gies to improve the neurological impairments that characterize
individuals with movement disorders.
A 2015 SR examined the effects of interventions aimed at
improving participation for children with disabilities. Adair and
colleagues48 were able to identify only 3 studies that included
participation as a primary outcome. Participants included chil-
dren with hemiplegia, Down syndrome, and those with a
variety of other intellectual, emotional, or physical disabili-
ties. Studies were limited to randomized controlled or pseudo-
randomized trials. Not surprisingly, the authors of this review
concluded that “few high-quality studies have reported favor-
S4 Harris and Winstein
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Unauthorized reproduction of this article is prohibited.
able participation results after interventions in children with
disabilities.”48(p11)
In a randomized trial involving 7 Canadian cities, the
effects of a structured, community-based intervention aimed at
enhancing participation in individuals within 5 years of stroke
onset were examined.49 Participants with cognitive impairment
and/or who were not independent in toileting were excluded.
The 12-week intervention program was based on preferences
from focus groups of people poststroke and included exercise
(aerobic, core strength, balance, and flexibility) and activities to
promote leisure, learning, and social interaction. The primary
outcome was time spent in meaningful activities. Although only
45% of participants achieved the targeted level of 3 additional
hours per week spent in meaningful activities, the mean increase
across all participants was 1.88 hours.49
Interdependence of the 4 Ps
How are prevention, prediction, plasticity, and participa-
tion interrelated? Figure 1 illustrates a conceptual relation-
ship among the 4 Ps. Let us use a hypothetical example of a
4-month-old (corrected age) female infant born at 35 weeks’ ges-
tational age (GA). Although she was born preterm, many high-
risk follow-up programs now focus on infants born at extreme
prematurity (ie, less than 28 weeks’ GA). Because this infant
was relatively low risk, she did not qualify for community-
based, preterm follow-up. However, because she had a 5-year-
old brother born at 27 weeks’ GA and later diagnosed with
spastic diplegia, her parents were understandably concerned
and asked their son’s PT to assess their infant daughter.
The PT administered the Alberta Infant Motor Scale
(AIMS)50 to screen for motor delays and possible CP, an example
of a type of secondary prevention. From reading the research lit-
erature, the PT knew that the AIMS had been shown to be rea-
sonably accurate in prediction of motor outcome at preschool age,
especially for infants at 4 months of age.51 The therapist was
aware also that brain plasticity is greatest during infancy and
early childhood but that capacity is reduced in infants born
preterm.52
Fig. 1. Interdependence of the 4 Ps.
Pediatric Physical Therapy
 The infant scored in the 70th percentile rank on the AIMS,
suggesting motor performance within normal limits for her cor-
rected age. Although this result allayed some of the parents’ con-
cern, their son’s PT suggested that they might want to enroll
their daughter in the center’s inclusionary day care program to
enhance her participation with other infants developing typi-
cally as well as those with special needs. This example illustrates
how physical therapists can capitalize on the interactions among
prevention, prediction, plasticity, and participation to facilitate
optimal outcomes in our clients.
Figure 1 depicts the interdependence of the 4 Ps, with
definitions of each construct. The arrow direction depicts the
hypothetical effect each would be expected to impart on cen-
tral nervous system plasticity. Participation and prevention are
expected to directly impact central nervous system plasticity
through behavior change, whereas prediction variables are not
thought to directly impact plasticity. Instead, the arrow points
from plasticity toward prediction to capture a growing body of
research showing that measures of structural brain impairment
such as diffusion tensor imaging can be used to predict response
to motor therapies in stroke.53,54
WHERE DO WE STAND TODAY WITH REGARD TO PREVENTION,
PREDICTION, PLASTICITY, AND PARTICIPATION?
Thoughts and Reflections on Where We Stand Today
Prevention. PTs have been more involved in tertiary pre-
vention than in primary or secondary prevention. One interven-
tion aimed at tertiary prevention that has been studied exten-
sively in recent years is functional electrical stimulation (FES).
Three recent SRs examining the effects of FES in persons post-
stroke have shown that (1) stimulation of the peroneal nerve for
foot drop is more effective than ankle-foot orthoses in decreasing
physiological cost and is preferred by patients55 ; (2) FES in
combination with conventional therapy is more effective than
therapy alone in preventing or reducing early shoulder sublux-
ation (less than 6 months after stroke)56 ; and (3) compared with
placebo or no treatment, FES improves activity and is more
beneficial in combination with activity training than training
alone.57 Two recent reviews, albeit not SRs, described evidence
for the use of FES in tertiary prevention in adults58 and children
with SCI.59 For children with spastic CP, a recent SR showed that
FES was more effective than no FES in enhancing activity but
that specific activity training was as effective as FES for activity
enhancement.60
Prediction. Walking is one very simple and clinically rele-
vant activity, used both as a predictor variable and as an outcome
measure. Using attainment of independent walking (≥3 steps)
as the desired outcome in 80 young children with CP, Begnoche
and colleagues61 found that the most important predictor was
functional strength, as operationalized by transitions from sit to
stand and stand to sit.
As a predictive measure, self-paced walking (gait speed)
was shown in a pooled analysis of 7 studies of community-
dwelling elderly adults to significantly predict future disability
and mortality.62 A comfortable gait speed has also been shown
to predict success in community ambulation for adults with PD
of mild-to-moderate severity, with fear of falling adding further
Pediatric Physical Therapy
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Unauthorized reproduction of this article is prohibited.
to the predictive capability of gait speed.63 In a scoping review,
Kikkert and colleagues64 identified 20 longitudinal studies that
examined the predictive relationship between walking ability at
ages 65 years or more and later cognitive abilities; gait speed
was the predictor variable in 18 of the studies. Slow gait speed at
baseline (1.00 m/s) predicted cognitive decline and/or dementia
an average of 4.3 years later. As Perera and colleagues62(p70) com-
mented: “gait speed is a simple, clinically feasible independent
indicator of risk of future disability.”
Plasticity. Research examining the effects of neuroreha-
bilitation on brain plasticity has been most notable in studies
involving adults poststroke and children with unilateral CP, with
constraint-induced movement therapy being the prime inter-
vention example for both groups.65-68 But what about other neu-
rological patient populations and other types of interventions?
Fisher and colleagues69 studied 30 people with mild PD
who were within 2 years of diagnosis, and showed that high-
intensity treadmill training increased corticomotor excitability
and improved self-selected walking speed and other gait param-
eters. Later, Fisher and colleagues70 reported that intensive
treadmill training (3 times per week for 8 weeks) resulted in
an increase of striatal D2 dopamine-binding receptor as well as
improved postural control in adults with early-stage PD.
In a study of 19 children with moderate-to-severe TBI
(ages 8.5-19 years) and 28 similar-aged children who had
typical development, Drijkoningen and colleagues71 examined
whether an 8-week, home-based balance training program
could enhance balance and whether it was associated with neu-
roplastic brain changes. After training, the children with TBI
showed significant improvements in balance as well as signif-
icant increases in MRI mean diffusivity in the inferior cerebellar
peduncle. Published in 2015, this study was the first to establish
relationships between training-induced balance changes and
cerebellar white matter structure in children with TBI.71
Participation. Where do we stand today with regard to
participation? We know from recent research that school-aged
children with disabilities are just as good as their parents in set-
ting and attaining task-oriented goals, and that the children’s
goals were directed primarily at participation (ie, activities of
daily living, school work, and leisure), whereas the parents’ goals
focused primarily on activities of daily living.72 We know also
from children and young persons with physical disabilities that
leisure for them is composed of elements of fun, freedom of
choice, fulfillment, and friendships—and that participation in
leisure activities enhances quality of life and overall health.73
In adults with moderate-to-severe neurologic disabilities,
we know that a 10-week, community-based exercise program
designed by PTs and aimed at leading to independent exer-
cising resulted in significant improvements in health-related
quality of life, with 44% of participants becoming independent
exercisers.74
WHERE DO WE GO FROM HERE? WHAT SHOULD THE FUTURE
LOOK LIKE FOR NEUROREHABILITATION OF CHILDREN AND
ADULTS?
There is an urgent need for PTs to become more involved in
primary and secondary prevention for persons with movement
The Past, Present, and Future of Neurorehabilitation S5
disorders. What can we do as clinicians to help in preventing,
for example, concussion in children and adults?
Based on results of 2 recent SRs,75,76 there is insufficient
high-quality evidence that lifestyle interventions (eg, aerobic
exercise, health education, and life management skills) will
reduce the incidence of further cardiovascular events or lower
the risks for such events in persons who have sustained strokes
or transient ischemic attacks—leading the PT authors of these
reviews to call for robust, high-quality, longer term trials to
investigate this focus of secondary prevention.75,76
The future of PT clinical practice should include adminis-
tration of simple and environmentally relevant measures shown
to be predictive of later performance, such as transitions from
sit to stand and stand to sit as a measure of functional strength
and a predictor of independent walking for young children with
CP.61
Scores on the AIMS administered to infants at 4 months of
age have been shown to be predictive of motor performance at
age 4 years in very preterm children; not surprisingly, the pre-
dictive accuracy improved with serial assessments (at 4, 8, and
12 months).51 For very preterm infants, clinicians should
consider also using the Neuro-Sensory Motor Development
Assessment77 to accurately predict later CP in infants at 1 year
of age.51
Speed of self-paced walking is a very reliable and simple
measure to capture in the clinic, having been shown to pre-
dict community walking ability in adults with PD,63 dementia in
older adults,64 and future disability and mortality in the elderly
living in the community.62 Self-selected walking speed has also
been shown to predict the ability to run in adults who have expe-
rienced TBI, the vast majority of whom had sustained severe
injury, and was a stronger predictor than postural stability or
quality of gait performance.78 As Perera and colleagues62(p70)
commented: “Physical performance measures, including gait
speed, may serve as examples of universal outcomes to mon-
itor health and function, evaluate novel interventions, and test
innovations in the organization of health care.”
In a review article titled “How Can You Mend a Broken
Brain?” members of the Canadian Partnership for Stroke
Recovery posited that enriched rehabilitation, composed of
environmental enrichment and task-specific therapy, provides
a very promising combination for improving recovery after
stroke.79 Based on animal research over the past 2 decades, these
authors suggested that “stroke recreates a cerebral milieu sim-
ilar to that of early brain development, a period characterized
by rapid brain growth and remodeling of synaptic connections.”
79(p234)
A pilot study involving people poststroke in an inpatient
rehabilitation unit supports the beneficial effects of an enriched
environment (ie, those in the experimental group were more
likely to participate in cognitive and social activities whereas
the control group participants were more likely to be inactive,
alone, or asleep).80 These results parallel those of Morgan and
colleagues’43 SR, showing that enriched environments were ben-
eficial for infants at high risk for CP.
The future of neurorehabilitation for children and adults
must also include greater emphasis on physical activity (PA),
to promote secondary prevention of lifestyle-related diseases as
well as provide strategies for enhancing participation.81 On the
S6 Harris and Winstein
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
basis of a comprehensive literature review, expert opinion, and
longstanding clinical experience, Verschuren and colleagues82
recently published exercise and PA recommendations for chil-
dren and adults with CP that could be incorporated into clin-
ical settings or research protocols. Similarly, the American Heart
Association and American Stroke Association’s recently released
Guidelines for Adult Stroke Rehabilitation and Recovery made the
following recommendation: Following successful screening, an
individually tailored exercise program is indicated to enhance
cardiorespiratory fitness and reduce the risk of stroke recur-
rence (class 1A for improved fitness; 1B for reduction of stroke
risk).83
In qualitative interviews of 19 adults with a range of
movement disorders (eg, stroke, SCI, PD, and multiple scle-
rosis), Mulligan and colleagues84 reported that PA was best
promoted (and more apt to be maintained) when individuals
chose their own preferred form of recreational exercise. The
authors proposed that future research could include interven-
tion studies to test the effectiveness of these findings. In a sample
of 260 individuals living in the community with PD, Ellis and
colleagues85 investigated the barriers to exercise participation
using the self-report barriers subscale of the Physical Fitness and
Exercise Activity Levels of Older Adults Scale. Their findings
that low expectation of exercise, lack of time to exercise, and
fear of falling appeared to present barriers to exercise engage-
ment provide important insights about issues that can be tar-
geted for application in people with PD who do not regularly
exercise.
Finally, a concerted effort to integrate the psychological and
social sciences with the physiological sciences86 in our entry-
level and residency programs, elegantly exemplified by new the-
oretical models,87 intervention practices,4 and approaches88,89
will be critical for moving forward in concert with recent
advances in understanding the importance of mindful health90
and patient-centered health care practices.91,92
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Pediatric Physical Therapy The Past, Present, and Future of Neurorehabilitation S9

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 S P E C I A L C O M M U N I C A T I O N

Regenerative Rehabilitation: Combining Stem Cell Therapies and Activity-Dependent

Stimulation
Chet T. Moritz, PhD; Fabrisia Ambrosio, MPT, PhD
Departments of Rehabilitation Medicine, Physiology & Biophysics, Electrical Engineering (Dr. Moritz), UW Institute for Neuroengineering, Center for
Sensorimotor Neural Engineering, University of Washington School of Medicine, Seattle; and Departments of Physical Medicine & Rehabilitation, Physical
Therapy, Bioengineering, and Microbiology & Molecular Genetics (Dr. Ambrosio), McGowan Institute for Regenerative Medicine, University of Pittsburgh,
Pennsylvania.

The number of clinical trials in regenerative medicine is burgeoning, and stem cell/tissue engineering technologies hold the
possibility of becoming the standard of care for a multitude of diseases and injuries. Advances in regenerative biology reveal
novel molecular and cellular targets, with potential to optimize tissue healing and functional recovery, thereby refining
rehabilitation clinical practice. The purpose of this review is to (1) highlight the potential for synergy between the fields of
regenerative medicine and rehabilitation, a convergence of disciplines known as regenerative rehabilitation; (2) provide
translational examples of regenerative rehabilitation within the context of neuromuscular injuries and diseases; and (3)
offer recommendations for ways to leverage activity dependence via combined therapy and technology, with the goal of
enhancing long-term recovery. The potential clinical benefits of regenerative rehabilitation will likely become a critical
aspect in the standard of care for many neurological and musculoskeletal disorders. (Pediatr Phys Ther 2017;29:S10–S15)
Key words: neural engineering, neuroplasticity, neuroprosthesis, regeneration, regenerative rehabilitation, stem cells, tissue
engineering

INTRODUCTION way we approach the treatment of acute and chronic conditions

The combination of rehabilitation together with engineered
devices and regenerative therapies holds potential to improve
quality of life after neuromuscular injury or disease. The field of
regenerative medicine is based on the assumption that the health
of our population would benefit from a paradigm shift in the
0898-5669/293S-0S10
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Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Chet T. Moritz, PhD, Departments of Rehabilitation
Medicine and Physiology & Biophysics, Box 356490, University of
Washington School of Medicine, Seattle, WA 98195 (ctmoritz@uw.edu).
Grant Support: Chet Moritz is supported by a Paul G. Allen Family
Foundation Allen Distinguished Investigator Award, the UW Institute
for Neuroengineering, the Christopher and Dana Reeve Foundation
International Consortium on Spinal Cord Repair, GlaxoSmithKlein
Bioelectronics Innovation Challenge, and the Center for Sensorimotor
Neural Engineering, a National Science Foundation Engineering Research
Center (EEC-1028725). Fabrisia Ambrosio is supported by the Alliance
for Regenerative Rehabilitation Research & Training (AR3 T), which is
funded by the Eunice Kennedy Shriver National Institute of Child Health
& Human Development, the National Institute of Biomedical Imaging
and Bioengineering, and National Institute of Neurological Disorders and
Stroke of the National Institutes of Health (P2CHD086843).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000378
so as to maximize clinical outcomes. As proposed by Daar and
Greenwood1 :
Regenerative medicine is an interdisciplinary field of
research and clinical applications focused on the repair,
replacement or regeneration of cells, tissues or organs
to restore impaired function resulting from any cause,
including congenital defects, disease, trauma and ageing.
It uses a combination of several converging technolog-
ical approaches, both existing and newly emerging, that
moves it beyond traditional transplantation and replace-
ment therapies. The approaches often stimulate and sup-
port the body’s own self-healing capacity.
Regenerative medicine technologies have been investigated
as a means to enhance the functional capacity of a host tissue
when endogenous regenerative mechanisms are inadequate
or fail altogether. The enthusiasm surrounding regenerative
medicine continues to build, and this enthusiasm is being
matched with clinical deliverables at an accelerating pace. Over
the next decades, stem cell and tissue engineering protocols
hold the possibility of becoming the standard of care for a
number of diseases and injuries. Although early stem cell appli-
cations were initially limited to the treatment of potentially fatal
conditions, clinical trials are increasingly investigating a diverse
array of applications, including musculoskeletal and neurolog-
ical systems. As an example, the Clinical Trials registry (www
.clinicaltrials.gov) lists 7 active studies investigating cellular
therapies for the treatment of Duchenne muscular dystrophy

S10 Moritz and Ambrosio Pediatric Physical Therapy

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(accessed July 19, 2016). Cell sources for these trials include
umbilical cord mesenchymal stem cells and bone marrow–
derived cells. A similar query using the Boolean search terms,
“stroke” and “stem cell,” yields 102 hits (accessed July 19, 2016).
With return to normal tissue function as the ultimate goal of
these biological therapies, it is clear that regenerative medicine
shares an increasingly convergent path with rehabilitation.
OVERVIEW OF REGENERATIVE REHABILITATION
Physical rehabilitation has foundations in the targeted appli-
cation of mechanical stimuli to enhance intrinsic tissue healing
potential. Mechanobiology is a growing scientific field that
seeks to better understand how mechanical forces induce cel-
lular and tissue responses, and how these forces contribute
to tissue development, homeostasis, and pathophysiology.
A central area of study within mechanobiology is mechanotrans-
duction, the process by which mechanical stimuli are sensed,
transmitted, and translated into biologic responses (reviewed
in Dunn and Olmedo2 and Thompson et al3 ). There is robust
evidence supporting biologic adaptations in response to both
dynamic and static mechanical stimuli. Advances in mechanobi-
ology suggest that changes in cell mechanics, extracellular
matrix (ECM) structure and composition, and mechanotrans-
ductive sequences may contribute to the pathophysiology of
many inheritable and acquired disabling conditions (reviewed
in Dunn and Olmedo2 and Thompson et al3 ). Applied mechan-
ical stimuli represent a potent stimulus to harness intrinsic tissue
healing capacity. This concept has served as a foundation for the
application of rehabilitation protocols for the treatment of dis-
eased or injured tissues.
Similar mechanical and biological stimuli can also be used
to activate the nervous system to induce reorganization and
potentially repair. Pairing physical movement with activity in the
nervous system is the foundation for many therapies aimed at
promoting neuroplasticity. These approaches leverage the phe-
nomenon discovery by Donald Hebb in the 1950s, now para-
phrased as “neurons that fire together wire together.”4 Cur-
rent approaches to physical therapy promote recovery by lever-
aging this activity-dependent plasticity via assisted movement
and stimulation applied to the muscles, nerves, spinal cord,
or brain. Going forward, such activity and timing-dependent
strategies will be needed in combination with stem cell or tissue
engineering solutions to guide the incorporation of tissue grafts
or promote the regeneration and functional organization of
endogenous stem cells.
Just as endogenous musculoskeletal and neural tissues ben-
efit from the application of rehabilitation protocols to promote
functional tissue recovery after injury and with disease, it is
increasingly recognized that the functional efficacy of regenera-
tive medicine technologies may be enhanced when coupled with
mechanical and electrical stimuli.5-11 The recognized poten-
tial for synergy between the fields of regenerative medicine
and rehabilitation science has in recent years launched the
birth of a new field, regenerative rehabilitation.12-14 The Inter-
national Consortium for Regenerative Rehabilitation defines
regenerative rehabilitation as “the integration of principles
and approaches from the fields of rehabilitation science and
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regenerative medicine. Regenerative medicine focuses on the
repair or replacement of tissue lost to injury, disease, or age, pri-
marily via the enhancement of endogenous stem cell function
or the transplantation of exogenous stem cells. A focus of Reha-
bilitation science is the use of mechanical and other physical
stimuli to promote functional recovery. The integration of these
two approaches will optimize independence and participation
of individuals with disabilities” (www.ar3t.pitt.edu).
SUCCESSES IN REGENERATIVE REHABILITATION
AND RELATED THERAPIES
Musculoskeletal Regenerative Rehabilitation
Progress in regenerative rehabilitation research has arguably
been the greatest when considering musculoskeletal applica-
tions, such as the treatment of traumatic skeletal muscle injuries.
Although skeletal muscle is capable of remarkable regenerative
potential, when the injury or disease is extensive and destroys
the underlying architecture, regeneration is aborted and is char-
acterized, instead, by scar tissue formation (reviewed in Huard
et al15 ). The consequence is severely impaired functional
capacity of the damaged tissue. In cases such as these, cel-
lular therapies have been investigated as a means to boost
tissue regenerative capacity. Unfortunately, the therapeutic ben-
efit of these interventions has often been limited by massive
cell death following transplantation and a poor transplanta-
tion efficiency,16,17 ultimately resulting in poor functional out-
comes. To overcome this barrier, studies have demonstrated
that the combination of stem cell transplantation and muscle
loading increases the engraftment of donor cells, both in cases
of myopathy6,7,18 and injury.5,19
Accordingly, surgical placement of acellular biologic scaffold
materials (a tissue engineering approach) composed of mam-
malian ECM promotes constructive tissue remodeling in cases
of volumetric muscle loss.20-22 The mechanisms underlying the
reported functional improvements have yet to be elucidated, but
it has been hypothesized that donor ECM-mediated response
occurs through the recruitment of stem/progenitor cells at the
site of implantation.23-26 The application of rehabilitation pro-
tocols following ECM implantation has been suggested to be
beneficial—even crucial—for providing the needed mechanical
signals to encourage site-specific tissue remodeling (reviewed in
Gentile et al27 and Badylak et al28 ). Future randomized studies
to determine whether and how optimal rehabilitation protocols
may enhance functional outcomes following the application of a
tissue engineering device for the treatment of volumetric muscle
loss are warranted.
Neurological Regenerative Rehabilitation
In the central nervous system (CNS), electrical and chem-
ical signaling is believed to be the strongest driver of plasticity
and remodeling. Following injury to the CNS, fibrosis forma-
tion can alter the biophysical tissue properties and may trigger
a multitude of downstream cellular responses and strongly
influence plasticity and recovery. Indeed, static mechanical
and electrical properties of the cellular microenvironment have
been shown to exert potent effects on mesenchymal stem cell
Regenerative Rehabilitation and Plasticity S11
regenerative potential.29,30 Spinal cord and hippocampal neu-
rons grown on a soft gel substrate were shown to form 3 times as
many branches compared with neurons grown on stiffer gels.31
Together, these studies suggest that complementary methods to
optimize the biophysical microenvironment (eg, through phar-
macological or cell-based therapies) may be a critical step in
realizing the full potential of rehabilitation protocols after spinal
cord injury, stroke, or traumatic brain injury.
More traditional interventions for CNS trauma involve
activity-dependent therapies. For example, following spinal
cord injury or stroke, assisted locomotor training is used with
the goal of delivering synchronous input both above and below
a lesion.32,33 As reviewed later, such interventions may also
employ electrical stimulation of the muscles, peripheral nerves,
or spinal cord to activate the affected neuromuscular tissue. In
addition to direct efferent activation, such stimulation often also
results in activation of sensory afferents, providing coordinated
input to the CNS distal to a lesion.32-34
Several methods exist for electrically or magnetically acti-
vating the brain and spinal cord after injury. Methods of
electrical stimulation include application of current to the
dorsal surface of the spinal cord, termed epidural stimulation
(Figure 1). Early human studies are possible because of the off-
label use of stimulators designed to alleviate chronic pain.35-37
Noninvasive methods of spinal stimulation are also possible
using magnetic fields, which have improved spasticity following
spinal cord injury for up to 24 hours.38-40 Magnetic stimulation
of the lumber spinal cord can be triggered by upper extremity
Fig. 1. Illustration of spinal stimulation techniques applied distal to an injury.
Epidural stimulation is applied to the dorsal surface of the spinal cord, adapting an
FDA-approved treatment for chronic pain. Epidural stimulation most likely activates
sensory afferents and dorsal roots to recruit spinal networks below the injury. In the
presence of constant epidural stimulation, people with otherwise complete paral-
ysis can move their joints individually, and have lasting improvements in autonomic
function. Intraspinal microstimulation is applied via thin wires implanted within the
spinal cord to target the intermediate and ventral lamina where the motor neuron
cell bodies are located. Intraspinal microstimulation can evoke functional syner-
gies from select stimulating locations and lead to long-term recovery of function
when applied therapeutically or in an activity-dependent manner. Reprinted with
permission from Mondello et al.45
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movement to create an activity-dependent paradigm where step-
ping movements are synchronized with arm swing in spinally
intact volunteers.41
Parallel work in animals uses hair-like wires within the
spinal cord, termed intraspinal microstimulation (Figure 1).
Intraspinal microstimulation can evoke functional synergies for
walking42 and reach/grasp.43,44 Such stimulation can also lead
to long-term improvements in forelimb function in animal
models of spinal cord injury,11 especially when triggered by
residual muscle signals in an activity-dependent paradigm.10
Although intraspinal stimulation is more invasive than epidural
stimulation, it is currently scheduled for the first human exper-
iments and provides much greater specificity of activation that
may benefit the incorporation of regenerative therapies.45
In both the brain and spinal cord, pairing of artificial stimu-
lation can benefit individuals recovering from stroke and spinal
cord injury.46,47 Application of peripheral nerve stimulation fol-
lowed by transcranial magnetic stimulation after an appropriate
latency can reinforce48,49 or inhibit47 connections either within
the intact brain or for subjects recovering from stroke. Similar
mechanism have been applied to the cervical spinal cord after
injury46 to reinforce weak but spared connections bypassing a
lesion. Even stimulation applied directly to the brain surface
improves function in animal models of ischemic stroke.50,51
Furthermore, paired stimulation delivered to the brain or brain
and spinal cord can lead to long-term changes in synaptic
strength in the intact52,53 and injured CNS.54 Building on the
success of constraint-induced therapy,55,56 if such methods of
stimulation can incorporate time or activity dependence, they
may induce long-term plasticity and recovery. Going forward,
efforts are required to ensure that such stimulation methods are
effectively combined with physical therapy, and eventually cel-
lular and regenerative therapies, to optimally improve function
after injury.
Appropriate neural activity is likely a prerequisite for stem
cells to improve function in the damaged CNS. Neural activity
is critical for avoiding cell death following insult,57,58 improves
blood perfusion and the related health of neurons,59 and upreg-
ulates brain-derived neurotrophic factor, which is implicated in
plasticity and recovery.60,61 In contrast, reduced activity such as
that observed in models of spinal muscular atrophy is associated
with reduced axon growth.62 On the basis of this cumulative
evidence, one of the most successful stem cell transplant studies
coupled brief electrical stimulation of the peripheral nerve with
motor neuron cell grafts and demonstrated impressive cell sur-
vival and muscle reinnervation.63 This landmark study suggests
that the combination of regenerative cell therapies and artifi-
cial stimulation may be critical for achieving targeted plasticity
and functional recovery following injuries or degeneration of the
neuromuscular system.
OBSTACLES AND BARRIERS TO REGENERATIVE
REHABILITATION—WHAT IS HOLDING US BACK?
The clinical translation of regenerative medicine approaches
for the enhancement of physical functioning presupposes the
existence of a critical mass of basic scientists working in
close collaboration with rehabilitation clinicians. Unfortunately,
Pediatric Physical Therapy
although interdisciplinary research is conceptually desirable,
there are few opportunities providing rehabilitation scientists
with the resources and training necessary to become engaged
in the field of regenerative medicine. Of the almost 1300 cur-
rently funded studies investigating “stem cell transplantation”
or “tissue engineering” listed on National Institutes of Health
(NIH) reporter, only 8 are housed in rehabilitation departments
(Accessed July, 2016).
One reason for the disconnect between regenerative biology
and rehabilitation studies may be that many rehabilitation pro-
grams lack faculty members with the expertise necessary to
teach principles and concepts in the domain of cellular and
regenerative biology. Physical therapy and occupational therapy
departments are often in schools without basic science research
programs, thereby limiting opportunities for interaction with
basic science colleagues. Similar barriers have impeded those
working in the basic sciences from understanding application
of their work to clinical practice, as they generally have lim-
ited exposure to rehabilitation practice. As a result, regener-
ative medicine scientists may not consider clinically available
approaches, technologies such as robotics and modalities such
as neuromuscular electrical stimulation or ultrasound that may
be beneficial in targeting the mechanotransductive pathways, so
fundamental for driving the tissue regenerative cascade. More-
over, given that functional benefit is the ultimate goal of all trans-
lational regenerative therapies, basic scientists stand to benefit
from the expertise of rehabilitation specialists in functional out-
comes assessment.
There is also a large unmet need for better preclinical models
of rehabilitation. Currently, preclinical models of rehabilita-
tion are limited, and the bulk of the studies employ tread-
mill or wheel running, for example. Yet clinical rehabilitation
consists of much more than just the presence or absence of
exercise, and investigation into combined rehabilitation modal-
ities such as neuromuscular electrical stimulation and ultra-
sound to enhance stem cell transplantation or implantation of
a tissue engineering device is needed. Finally, timing, dosing,
and intensity are all critical variables for both pharmacological
and rehabilitation interventions following CNS injury, and work
is ongoing to determine the optimal paradigm for combining
multiple therapies.64,65
CONCLUSIONS AND CHARGE TO THE FIELD
As is our tradition, rehabilitation practice must contin-
uously evolve such that it may be responsive to scientific
and technological innovations that impact clinical practice.
Undoubtedly, progress in the field of rehabilitation will increase
proportionately with the pace at which rehabilitation profes-
sionals keep up with innovations in medical practice. Just as the
prescription of rehabilitation is the standard of care following
the onset of most musculoskeletal and neurologic injuries
and diseases, it is likely that rehabilitation will necessarily be
the standard of care, as regenerative medicine technologies
increasingly make their way to clinical practice.
To drive knowledge transfer and the technical capabilities
of medical rehabilitation researchers to perform cutting-edge
regenerative rehabilitation investigations, we must begin to
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systematically promote the integration of basic scientists with
rehabilitation specialists. We must train rehabilitation clini-
cians who can help oversee the quality, safety, and validity of
these innovative regenerative rehabilitation technologies and
protocols.
In addition, to be effective in this partnership, there is a need
for an improved mechanistic understanding by which mechan-
ical forces and modulation of the tissue microenvironment (eg,
through exercise and modalities) may be used to optimize out-
comes following a regenerative medicine intervention. Molec-
ular and cellular mechanisms must be the foundation upon
which clinical regenerative rehabilitation protocols are derived,
and a better understanding of these mechanisms will allow for
the more rational design of clinical protocols that elicit targeted
and specific cellular and tissue responses. In the absence of these
guiding mechanisms, clinical protocols will be left to a trial-and-
error approach, an approach that is ineffective in terms of clinical
outcomes as well as economics.
Finally, our ability to use engineered devices to interact
with the neuromuscular system is beginning to accelerate.
Implanted stimulators capable of triggering activity-dependent
stimulation are now in early human studies for essential tremor
and Parkinson disease.66 Experimental devices are already
capable of delivering electrical, magnetic,67 optical,68 and
pharmacological69 stimulation to targeted locations within the
brain and spinal cord, as well as the peripheral nerves and
muscles.70 Optogenetics, or light activation of neurons,71,72
is currently under trial to treat blindness.73 This technique
may soon be combined with stem cell interventions to enable
targeted activation of grafts in situ. Given the current pace
of technological advancement, there is tremendous poten-
tial to leverage engineered solutions to enhance biological
regeneration.
The combination of regenerative therapies such as stem cell
or tissue grafts with methods to induce appropriate mechanical
or electrical stimuli within the injury or diseased site is likely
critical to the success of regenerative rehabilitation. If emerging
technologies can be effectively coupled with sound physical
therapy practice to induce activity-dependent remodeling of
injured tissues, regenerative rehabilitation therapies may soon
dramatically improve plasticity and participation for people with
injuries to the neuromuscular system.
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52. Jackson A, Mavoori J, Fetz EE. Long-term motor cortex plasticity
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Regenerative Rehabilitation and Plasticity S15
 S P E C I A L C O M M U N I C A T I O N

Excellence in Promoting Participation: Striving for the 10 Cs—Client-Centered Care,

Consideration of Complexity, Collaboration, Coaching, Capacity Building,
Contextualization, Creativity, Community, Curricular Changes, and Curiosity
Lisa A. Chiarello, PT, PhD, PCS, FAPTA
Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, Pennsylvania.

Participation of children with physical disabilities is critical to optimizing their life roles and lived experiences. This
perspective explores the complex and multidimensional construct of participation and presents recommendations for
practice, education, and research to transform pediatric physical therapy service delivery. Two models are reviewed of
participation-based service delivery grounded in client-centered care and the principles of coaching to engage clients in their
rehabilitation. The roles and responsibilities of the physical therapist and the importance of team collaboration are
emphasized. Considerations are presented for ecological measurements and interventions to support client participation
goals for children of all ages in home and community settings. Practitioners, educators, and researchers are encouraged to be
advocates and change agents to ensure that services support meaningful participation for children in real-life contexts.
(Pediatr Phys Ther 2017;29:S16–S22)
Key words: intervention, measurement, participation

Legislation in the United States advocates for the rights of
individuals with disabilities to be included and participate in
all aspects of society. Professionals and researchers have linked
participation to positive developmental outcomes, well-being,
and quality of life, including the promotion of learning, friend-
ships, self-determination, self-efficacy, sense of mastery, and
fulfillment.1-3 Supporting home and community participation
of children with physical disabilities is thought to be impor-
tant for optimizing their life roles and lived experiences.4,5 Yet,
despite at least 2 decades of scholarly perspectives and research,
embracing participation in pediatric physical therapy appears
hindered by an incomplete understanding of the construct, chal-
lenges in measurement, limited evidence for interventions,6 and
0898-5669/293S-0S16
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Lisa A. Chiarello, PT, PhD, PCS, FAPTA, Drexel Uni-
versity, 1601 Cherry St, Mail Stop 7502, Philadelphia, PA 19102
(lisa.chiarello@drexel.edu).
Grant Support: Research supported by Shriners Hospital for Children
(COS 9197), National Institute of Disability and Rehabilitation Research
(H133G060254), Canadian Institutes of Health Research (MOP 81107,
MOP 119276), and Patient Centered Outcomes Research Institute (Contract
5321) has informed my perspective.
The author will receive an honorarium from the IV STEP Conference and
has no other conflicts of interest to disclose.
DOI: 10.1097/PEP.0000000000000382
inadequate service delivery systems restricting novel approaches
to care. Participation is complex and we still have more
questions than answers, including: what is participation, what
factors influence participation, and how can we measure and
intervene to support participation? The purpose of this article is
to explore the construct of participation for pediatric rehabilita-
tion and to propose the need to mind our Ps (prevention, predic-
tion, plasticity, and participation) and Cs (client-centered care, con-
sideration of complexity, collaboration, coaching, capacity building,
contextualization, creativity, community, curricular changes, and
curiosity) to transform service delivery.
Our profession has progressed from a primary focus on
impairments in body structure and function to activity-focused
intervention. Today, pediatric physical therapy practice is more
client centered and goal directed, but we still have a way to
go to ensure that our services support meaningful participation
in real-life contexts. Since before II STEP, through the systems
models of motor control, we have acknowledged that individ-
uals perform tasks within a physical and social environment and
that context matters. I am optimistic that an appreciation for
what we know and a vision for our field will help change the
focus of therapy from activity to participation.
To make this change happen, I believe the first step is
to strengthen the foundation by explicitly defining participa-
tion. The second step requires establishing a common philos-
ophy for practice and clear expectations that pediatric rehabilita-
tion and educational teams support children’s participation. The
third step entails putting support for participation into action
by identifying clients’ participation goals, doing a “participation
analysis,” and implementing participation-based interventions.

S16 Chiarello Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
Furthermore, we can ensure continued transformation by edu-
cating others and conducting research on participation-based
therapy.
DEFINING AND UNDERSTANDING PARTICIPATION
As pediatric physical therapists we are familiar with
the World Health Organization’s definition of participation
as “involvement in life situations.”7 Although this definition
respects the broad nature of participation, it may not be particu-
larly useful to guide research, teaching, and practice. Definitions
proposed in the literature have highlighted that participation
refers to engagement in a set of activities that is meaningful to
the individual and setting specific.2,4,8,9 Key attributes of par-
ticipation include its individuality, complexity, and subjectivity.
Participation has multiple elements and occurs in various con-
texts. Individuals can participate in a range of routines including
those related to family life, school, leisure and recreation, spiri-
tuality, citizenship, and employment.
Imms and colleagues10 conducted a systematic review to
examine the language and definitions used by researchers to
describe participation. The 25 studies reviewed were diverse
in regard to participants, settings, and intervention focus.
Although 4 studies specifically defined participation, the lan-
guage used to describe the construct lacked consistency and
clarity. From this review they conceptualized preference as a
precursor to participation, and participation as having 2 dimen-
sions, attendance and involvement, leading to key outputs of
activity competency and sense of self. These outputs influence
future participation, thus reflecting a cyclic nature. Their frame-
work also depicts the external factors that influence partici-
pation, including the environment and how available, acces-
sible, affordable, accommodating, and acceptable opportunities
are for individuals with disabilities. Researchers, educators, and
practitioners can use this framework to unify and guide their
work in advancing the field.
Preferences, as the precursor to participation, was defined
as “the opportunity to choose and be able to undertake activi-
ties that are meaningful and valued.”10(p100) The authors high-
lighted how preferences relate to previous personal experi-
ences and serve as a motivator for participation. Hoogsteen and
Woodgate,2 in a concept analysis of participation, identified
choice or control as one of the defining attributes of participa-
tion. The consideration of preferences may need to be modified
in some situations. When we think of participation in activities
that someone needs to or is expected to do, the opportunity for
choice and how the activities are valued may be very different
from activities that someone wants to do. When the goal is par-
ticipation in a set of activities that the child is required to do, I
believe it is important for therapists to partner with the child to
identify the benefits of participation and aspects where the child
may be able to exert control. When the preference for participa-
tion is a set of activities that the child has no prior experience
with, therapists may need to explore experiences in related sit-
uations and partner with the child and family to prepare them
for the new opportunity.
Involvement, the actual in-the moment aspect of participa-
tion, is complex. Involvement reflects what the experience is like
Pediatric Physical Therapy
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during the situation. Imms and colleagues10 use the term engage-
ment when describing involvement, and they found that almost
half of the studies reviewed used the terms participation and
engagement interchangeably. Although Imms and colleagues10
defined involvement as affect, motivation, and social con-
nection, I believe that involvement in the moment includes
affective, cognitive, and behavioral elements; how the person
is feeling, thinking, and behaving. The social component of par-
ticipation, viewed as important by researchers, youth, and par-
ents, is not, however, universal to all situations. It is recog-
nized that individuals can participate alone in a set of activ-
ities. Coster and Khetani’s inclusion of “personally or socially
meaningful,”8(p643) when defining participation, honors this
consideration.
Participation can be valued for the experience itself, as
well as the benefits arising from the experience. Imms and
colleagues10 identified activity competence and sense of self
as resulting from the participation experience. Activity compe-
tence refers to the quantity or quality of the activities compared
with an expected standard.7 The output, sense of self, refers to
a person’s satisfaction and how participation affects his or her
confidence and self-esteem. Although these are observable out-
comes of participation, activity competence could also be con-
sidered part of behavioral involvement and sense of self could be
expressed through affective and cognitive involvement during
the experience.
As we continue to explore and understand participation, it is
important to expand our conceptual framework from the clients’
perspective. Parents also expressed that participation comprises
both the amount of and engagement in activities.9 Parents and
children with physical disabilities emphasized the importance of
enjoyment, being with family and friends, performing activities
as independently as possible, and feeling successful.11 Parents
also identified the critical influence of environmental context,
resources, supports, and barriers.9,11
My colleagues and I conceptualized optimal participation
as arising from the dynamic interaction among the child, family,
and environmental determinants of participation, and the ele-
ments of participation, which we identified as the physical
doing, social belonging, and self being, including how a person
is thinking and feeling.12 Much of the research on determi-
nants of participation has focused on participation in leisure and
recreational activities, and aspects of the child have consistently
been found to be associated with this type of participation.13-22
These predictors of participation include child preferences, enjoy-
ment, age, gender, motor and communication abilities, cogni-
tion, self-care, adaptive behaviors, associated health conditions,
and body structures and functions. This knowledge helps ther-
apists understand how participation varies by child characteris-
tics, but it may be challenging to apply this information to an
individual child to guide intervention decisions. The situation
is further complicated by the influence of family income and
ecology,13,19-23 as well as geographic area of residence, policies,
attitudes of others, transportation, and availability and accessi-
bility of community programs.13,22-24 Models for participation-
based practice, developed in the past 5 years, can assist thera-
pists in using the knowledge on determinants of participation
for focused examination and intervention.
Excellence in Promoting Participation S17
PRINCIPLES AND MODELS FOR PARTICIPATION-BASED
PRACTICE
Two models for participation-based pediatric rehabilita-
tion, Palisano and colleagues’ participation-based therapy12
and Pathways and Resources for Engagement and Partic-
ipation (PREP),25,26 emphasize the importance of the fol-
lowing principles: child and family-centered, strengths-based,
goal-oriented, collaborative, ecological, self-determined, and
capacity building. As therapists broaden their approach to sup-
port children’s participation, I believe it is important for them to
consider if their philosophy of care embraces these principles.
Because these models are goal-oriented and capacity building,
interventions are provided during a short-term episode of care.
The principle of collaboration is a key feature of the model
of participation-based service delivery.12 This model reflects
child and family engagement as well as collaboration with other
service providers and the community. The model includes 5 pro-
cesses. First, the therapist attends to building and sustaining a
relationship that is founded on respect between themselves and
the family. Second, the therapist supports the family and child in
identifying a personally, meaningful goal for community partic-
ipation. Third, the therapist guides an assessment process that
consists of a participation analysis specific to the child’s goal.
Fourth, the therapist and family implement the intervention
in the real-world setting where the goal occurs. The therapist
serves as a coach to the child, family, and community members
to support them in discovering their own solutions. Fifth, the
family and child also collaborate in the evaluation of the pro-
cesses and the outcomes. They identify their current participa-
tion level across the dimensions relevant to them—performance
of the activities, social involvement, enjoyment, and satisfaction
as well as what they learned from the experience. These out-
comes and reflections on the intervention approach (what was
most helpful, what worked, what did not work) guide the future
direction of services as well as provide the family and child with
the capacity to realize new participation experiences.
PREP25,26 is an environment-based intervention approach
consisting of 5 steps: make goals, map out a plan, make it
happen, measure the process and outcomes, and move forward.
These steps are similar to the processes in the model by Palisano
et al.12 PREP emphasizes identifying the environmental barriers
and facilitators (physical, social, and organizational) to partici-
pation, including the demands of the activity. Further explana-
tion of how to implement these models and case illustrations has
been previously published12,25,26 and can serve as a roadmap for
therapists to address participation in their practice.
Both the Palisano et al12 and PREP25,26 practice models
are founded on a deep understanding of family/client-centered
care.27 Therapists foster the development of a relationship and
partnership with the family and child, and support them to par-
ticipate in the intervention process. It is important for thera-
pists to display positive beliefs about the client’s strengths and
capabilities and to demonstrate respect, sensitivity, trust, and
empathy. Therapists support participation by focusing on client
priorities, offering choices, sharing information, and working
together. The therapist and family members discuss and estab-
lish individual roles and responsibilities, ensuring that they
are clear and manageable. Therapists strive to support client
S18 Chiarello
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engagement and their active investment and involvement in the
process.
Coaching principles and processes also resonate with
participation-based intervention and both practice models
described include aspects of coaching. Coaching is a
client-centered, interactional, collaborative approach to engage
clients and other team members.27,28 Clients are actively
involved in the intervention through joint planning, action,
reflection, and feedback. The therapist may model, demon-
strate, teach, and practice activities with the child; however
the child, family, and community members are supported to
problem-solve, try the identified strategies, modify them as
indicated, and develop new solutions. The therapist serves
as a partner, listener, facilitator, and consultant. To apply the
participation-based models to practice, it is important for
therapists to be comfortable and competent in family-centered
and coaching approaches to service delivery.
PHYSICAL THERAPISTS’ ROLE, INTERPROFESSIONAL
PRACTICE, AND TEAM COLLABORATION
Because participation is complex and multidimensional,
service providers need to consider who should support a child’s
participation goal and we need to have open discussions around
this question. For some clients it will be physical therapists
and for other clients it may be other providers. Participation-
focused interventions complement but do not replace or
specifically address other important aspects of physical therapy
services; however, I believe it is essential that we have clear
expectations that our practice includes direct support for par-
ticipation. For individuals with physical disabilities, physical
therapists have a unique role in supporting participation. As
movement specialists,29 we have expertise to support safe
mobility within the context of interactions with people, objects,
and the environment. We can foster fitness, energy conserva-
tion, and pain management to optimize health for participation
in physical activity. We offer skilled interventions such as
environmental modifications, task adaptations, and applica-
tion of assistive technology. Our training in health promotion
enables us to conduct environmental surveillance and train
others in safety measures and precautions to prevent accidents
and injuries and to minimize secondary health complications.
Furthermore, as health care professionals with a strong medical
background and interprofessional experiences, we have the
knowledge and skill to identify when referrals to other pro-
fessionals are warranted or to consult with other providers to
support a client’s participation goal.29
I believe it takes a collaborative community to realize full
inclusion of individuals with disabilities. Interprofessional prac-
tice is “a partnership between a team of health professionals
and a client in a participatory, collaborative and coordinated
approach to shared decision-making around health issues.”30(p1)
With children it is appropriate to extend this partnership to
include their educational team as well as community members.
Sharing of information, knowledge, perspectives, resources,
and responsibilities is an effective and efficient way to ensure
that children receive the supports they need. Team collabora-
tion is essential, including communication, coordination, and
Pediatric Physical Therapy
consultation with others.27 Competence in these 4 Cs as well
as leadership skills are needed to effectively develop and enrich
partnerships and to efficiently and precisely take the steps nec-
essary to realize participation for children.
Depending on the setting in which a therapist is serving
children, team collaboration may occur through a transdisci-
plinary/primary service provider or interdisciplinary/multiple
service provider approach to care. Developmental services to
support home and community participation of children birth
to 3 years of age, use both the transdisciplinary and interdis-
ciplinary approaches,31 and educational-based services to sup-
port school participation for children and youth 3 to 21 years of
age predominantly, use the interdisciplinary approach.32 Both
participation-based models presented include a primary ser-
vice provider approach that could be adapted across settings.
I believe that a gap exists in service provision in that we do not
have an adequate mechanism to support home and community
participation for children and youth 3 to 21 years of age. Hos-
pital and outpatient therapy address immediate health and func-
tional needs. Both outpatient and school services may indirectly
support home and community participation, but I believe we
need to advocate for a paradigm shift and transform services to
focus on measuring participation and designing effective inter-
ventions to directly support participation in all environments,
for all ages.
MEASURING PARTICIPATION
Measuring participation is challenging and complex.6,33
Great strides have been made in the development of tools to
measure participation. The various tools such as the Children’s
Assessment of Participation and Enjoyment,34 Participation and
Environment Measure for Children and Youth,9 and the Child
Engagement in Daily Life35 recognize that participation is multi-
dimensional. A key message is that there is a need for researchers
and practitioners to measure what we are trying to accomplish.
Imms and colleagues10 noted a mismatch between researchers’
description of participation and the outcome measures used.
Frequency of participation was a common measured element.
If we are trying to impact attendance or overall participation in
a variety of contexts, then measuring frequency is appropriate.
If we want to optimize participation within a specific activity
setting then we need to carefully consider the best approach to
measure the child’s involvement. As our research and practice
may be directed toward the environment and building a com-
munity to foster participation, a related consideration is the use-
fulness of measuring the environment and activity setting itself.
Imms and colleagues10 found that a common element of
involvement measured by researchers was the performance
of the activities. This included frequency counts of observed
behaviors, time to perform a task, and degree of independence.
They noted that researchers measured performance on the basis
of what was “appropriate” for the child’s development or situa-
tion or “correct” in regard to interactions with objects or people.
The authors cautioned that “the inference associated with this
language is that an increase in skill is equal to an increase in
participation,”10(p1098) which may not be an accurate assump-
tion. Activity competence may or may not be important, and
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when important it is necessary to consider what standard should
be used as a criterion. I believe it is essential to ask the client
what aspect of doing they want to change. There are many pos-
sible ways to measure doing, including but not limited to, what
parts of the activities a person is doing, the extent a person uses
adaptations and modifications, how playful a person is, and how
hard a person is working during activities.
In a pilot study for participation-based therapy,12 a client
and his peers provided our research team with valuable lessons
regarding what aspects of doing were important and that com-
petency can be framed from various perspectives. The client’s
goal was participation in the church youth group. The physical
therapist and youth leader identified that eating was a primary
activity and began to consult with an occupational therapist on
adaptive utensils. The youth made it clear that this was not the
important part for him, that it was acceptable to him to have
assistance from a person for eating, and that he would rather
put his energies into participating more fully in other activi-
ties, such as singing. The client sang the lyrics, albeit, after they
were sung by the rest of the group. The therapist wondered
whether this was acceptable to the other youth and discovered
that the youth perceived this as “harmonizing,” a very acceptable
performance.
Deciding on the best approach to capture the essence of par-
ticipation is further complicated by consideration of the type
of measure. Qualitative approaches document the client’s own
words or pictures about the experience through interviews,
focus groups, journals, and media. Another approach that also
gathers client perceptions is self-report measures, an approach
commonly used in most existing participation measures. For
young children and/or older children with significant cognitive
limitations, these questionnaires have been designed to be com-
pleted by parents as proxy. Use of individual goals, written as
behavioral objectives through standardized approaches, such as
Goal Attainment Scaling36 or the Canadian Occupational Per-
formance Measure,37 is aligned with the outcome of participa-
tion and the frameworks discussed. The rating of goal attain-
ment can be conducted collaboratively, by client report, or by
independent observation. The experience of the research teams
that I have been part of, including collaborative research with
parents, suggests that including individualized goal attainment
when measuring participation is most meaningful and valued
by clients. Observational rating approaches of participation offer
another option. Lastly, physiological responses during participa-
tion can be used to capture the clients’ body functions.38
PARTICIPATION-BASED INTERVENTIONS: PLANNING AND
IMPLEMENTATION
I believe it is essential that the client’s goal guide our inter-
vention. Table 1 includes an example of the evolution of goal
development. In the past, therapists identified an impairment
in balance, established a goal for balance, and provided inter-
ventions to improve this focused outcome. Presently, thera-
pists demonstrate an awareness of the link between the bal-
ance goal and an important participation goal identified by the
child, doing a dance routine. Therapists intervene and monitor
outcomes at the body function and activity levels, including a
Excellence in Promoting Participation S19
 TABLE 1
Evolution of Goals to Guide Intervention
Past Charlotte balances on one foot with her hands on
her hips for 10 s
Present Charlotte balances on one foot with her hands on
her hips for 10 s so that she can participate in a
dance class.
Charlotte kicks a stationary ball 5 ft
Present and future Charlotte participates in a 3-min dance routine
during her dance class without falling
functional task such as kicking a ball. Therapists are now begin-
ning, or are encouraged, to explicitly use the client’s goal. To
impact a child’s ability to participate in dance class, it is impor-
tant for a therapist to consult with the dance teacher to under-
stand the dance moves, collaborate to adapt the routine or
modify the environment as indicated, and to optimize balance
within the context of dancing. Listening to music and dancing
in therapy is motivating and fun, especially in a group setting. If
it is not possible to provide intervention in the real-life setting of
the dance class, today’s technology makes it possible for a ther-
apist to view a video of the child’s dance class, videoconference
with the dance instructor, and send a video of possible strategies
and suggestions that have been tried during a therapy session.
To effectively provide participation-based interventions, I
believe that therapists need to conduct a “participation anal-
ysis.” As therapists we have been trained to conduct task analysis
to use motor learning principles to guide a client in learning a
new task. In a participation analysis, an ecological assessment
enables us to broaden our frame of reference to gather infor-
mation on the child-environment interaction. Therapists col-
laborate with the family and child and actively involve them
in the assessment process. Information is gathered on aspects
of the child, family, and environment individualized specifically
to the participation goal.12 The therapist interviews the people
involved in the activity, observes the child in the activity setting,
and conducts a focused functional examination within the real-
life context. When examinations cannot take place in the nat-
ural setting of the activity, the process can be modified through
the use of video technology, as exemplified earlier. Knowledge
of the child’s interest and understanding of the participation
goal, physical and communication abilities and social interac-
tions related to the participation activities, and health consid-
erations provide a foundation to guide intervention. Similarly,
the family’s interest and desire for the child’s participation in
the activities, their routines and resources to support the par-
ticipation goal, their concerns, and their insights on the child’s
abilities and readiness inform the development of a collabo-
rative partnership. Information on the accessibility and safety
of the community environment, availability of physical assis-
tance and social/emotional supports, and community resources
to support the child’s goal provide a vital link for the feasibility
of goal attainment. Through this process the goal, intervention
focus, and environment for service are confirmed, the interven-
tion strategies are selected, and first action steps and responsi-
bilities are discussed.
The ecological approach to participation suggests that effec-
tive interventions will be specific for a client within the set-
S20 Chiarello
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
ting and context of the desired goal. I propose that the active
ingredient may be the collaborative, ecological process and
not necessarily a particular intervention strategy. A systematic
review last year found only 3 intervention studies with children
with disabilities that focused specifically on participation.39
These studies with interventions by educators, occupational
therapists, and psychologists provide support for both indi-
vidual and group sessions that use individualized education,
coaching, and mentoring. Pilot work and initial testing of the
participation-based therapy models by Palisano et al12 and Law
and colleagues25,26 show promise for the individualized, collab-
orative, and environmental approach. These models use inter-
vention strategies that have been associated with participation:
environmental accommodations, tasks adaptations, assistive
technology, and the extent services have focused on function and
meeting the child’s needs.13,40,41 Community partnerships and
resources such as transportation, funding, and environmental
modifications are necessary to ensure availability, accessibility,
and affordability of participation opportunities. Providing real-
life experiences and solution-focused coaching enable children
to respond to environmental situations, broaden their repertoire
of behaviors, request adaptations and modifications when nec-
essary, and try new things. Adaptations and modifications to
avoid “token” participation and facilitate meaningful participa-
tion require creativity and envisioning the possibilities. As the
life course of children with disabilities includes associated health
conditions and given the uniqueness of various activity settings,
it is important for therapists to be available for periodic guidance
and support.
IMPLICATIONS FOR DPT CURRICULUM AND PHYSICAL
THERAPY RESEARCH AGENDA
On the basis of the past 2 decades of legislation, professional
perspectives, and research, curricular changes are warranted to
prepare future health care providers to optimize services and
participation outcomes. I encourage educators to advocate for
the construct of participation to be a theme embedded across the
curriculum. Students need to be exposed to the top-down model
of examination where examination and intervention planning
is guided by the client’s goal. It is important for students to
learn and practice the art of doing a participation analysis,
teaming, and coaching. Health care users, youth with disabil-
ities, and parents of children with disabilities should be valued
instructors. Physical therapist students should have opportu-
nities to learn with, interact, and develop solutions together
with students from other health care professionals. Experiential
learning in real-world activity settings and collaborating with
other providers and clients around participation goals are essen-
tial. Interprofessional education is now mandated by CAPTE,
but I encourage programs to embrace this approach not because
we have to do it but because it prepares our students with
the values and competencies they need to communicate with
other providers, establish roles and responsibilities, and pro-
vide team-based practice to effectively support client’s health
and goals.42 Resources to support this approach are available
through the National Center for Interprofessional Practice and
Education.43
Pediatric Physical Therapy
 TABLE 2
Recommendations for Practice, Education, and Research for Promoting Participation

Practice Education Research

• Client-centered care
• Collaboration with client, family, other
service providers, and community
• Ecological participation analysis
• Interventions in context of real-world
activity settings
• Coaching
• Environmental and task supports
• Participation as curricular thread
• Children and adults with disabilities and
their families as teachers
• Interprofessional learning
• Experiential learning
• Competencies in collaboration and
coaching
• Participation-focused examinations and
interventions
• Qualitative and case series research
• Intervention studies with participation as
the primary focus
• Families and individuals with disabilities as
part of the research team
• Advocate for funding
• Longitudinal studies to demonstrate
societal effect and cost/benefit ratio

Curiosity and creativity are needed to drive research to dis-
cover the knowledge we need to transform practice. We can
learn a lot from qualitative studies and case series to better
unravel the complexities of participation from the perspec-
tives of clients and service providers across various activity
settings and populations. Research needs to focus on exam-
ining the effectiveness of interventions aimed at participation
goals and outcomes. To accomplish this task, it is important
that families and clients be active members of the research
team. It is also imperative that we advocate for funding for
this line of research. Determining the cost-benefit analysis and
broad societal effect will take time and require longitudinal
research. Although participation-focused research is not as pow-
erful as discovering a cure, it has the potential to improve the
quality of lives of individuals with disabilities aimed at preven-
tion of social isolation and depression and supporting employ-
ment, physical and mental well-being, and inclusion in society.
To realize the transformation of practice, outcomes-oriented
research and grassroots advocacy are needed to justify insurance
reimbursement, policy change to create other funding sources,
or use of fee for service mechanisms for participation-based
interventions.
I encourage all of us to reflect on our current practice,
teaching, and research; call forth our own plasticity and take
small steps to make a change. Table 2 summarizes recom-
mended approaches. We need to challenge boundaries and
expand horizons to support participation of children with dis-
abilities. In doing so I am optimistic that we discover answers
to our many questions. What competencies do providers need
to support participation? How can we step out of the box to
provide services in the home and community for preschool and
school-aged children? What infrastructures need to be in place
in the community to support participation?
ACKNOWLEDGMENTS
I acknowledge my collaboration with my colleagues from
the following research teams: CAPS, Move and PLAY, PT
COUNTS, On Track, and Participation-Based Therapy.
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Occup Ther Pediatr. 2012;32(3):272-287.

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Pediatric Physical Therapy
 S P E C I A L C O M M U N I C A T I O N

Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults:

Prevention, Plasticity, and Participation
Judith E. Deutsch, PT, PhD, FAPTA; Sarah Westcott McCoy, PT, PhD, FAPTA
Rivers Lab, Department of Rehabilitation and Movement Sciences (Dr Deutsch), School of Health Professions, Rutgers University, Newark, New Jersey; and
Department of Rehabilitation Medicine (Dr Westcott McCoy), University of Washington, Seattle.

Use of virtual reality (VR) and serious games (SGs) interventions within rehabilitation as motivating tools for task specific
training for individuals with neurological conditions are fast-developing. Within this perspective paper we use the
framework of the IV STEP conference to summarize the literature on VR and SG for children and adults by three topics:
Prevention; Outcomes: Body-Function-Structure, Activity and Participation; and Plasticity. Overall the literature in this area
offers support for use of VR and SGs to improve body functions and to some extent activity domain outcomes. Critical
analysis of clients’ goals and selective evaluation of VR and SGs are necessary to appropriately take advantage of these tools
within intervention. Further research on prevention, participation, and plasticity is warranted. We offer suggestions for
bridging the gap between research and practice integrating VR and SGs into physical therapist education and practice.
(Pediatr Phys Ther 2017;29:S23–S36)
Key words: neurologic physical therapy, participation, pediatric physical therapy, plasticity, prevention, serious games,
virtual reality

INTRODUCTION and designed with principles of motor learning for example,

Virtual reality (VR) was developed in the early 1900s
through application of in-flight simulations.1 VR is the gen-
eration of simulated or virtual environments (VE) that allow
user interactions through multiple sensory (visual, auditory,
and haptic-sense of touch) channels.1 Customized VR systems
have been designed using specialized hardware, such as haptic
robotic interfaces, or off-the-shelf hardware such as the Kinect
camera. Specialized VEs are based on enriched environments
0898-5669/293S-0S23
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Judith E. Deutsch, PT, PhD, FAPTA, Rivers Lab,
Department of Rehabilitation and Movement Sciences, School of Health Pro-
fessions, Rutgers University, Newark, NJ 07101 (deutsch@shp.rutgers.edu).
Grant Support: Pediatric research: National Institute on Disability and
Rehabilitation Research (NIDRR) of the Office of Special Education and
Rehabilitative Services in the US Department of Education; UW Commer-
cialization Gap Fund; UW Institute of Translational Health Sciences; Walter
C. and Anita C. Stolov Research Fund; American Physical Therapy Associ-
ation, Section on Pediatrics; National Institutes of Health, National Insti-
tute on Alcohol Abuse and Alcoholism, #R21AA019579; R33AA019579-03;
adult research: University Science Center, QED Program; Rutgers Founda-
tion; Rivers Lab.
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000387
with feedback and task specificity.2
A special characteristic of VR systems is that they create
the illusion that a person is interacting with a synthetic world.
These states have been defined as presence, immersion, and
flow. The state of presence, or the experience that the environ-
ment is real,3 is created in part by the system’s capacity to deliver
the illusion of reality or degree of immersion. Hardware used to
deliver the VE creates the immersion characterized along a con-
tinuum, with highly immersive customized environments using
head-mounted displays and caves. Caves are room-size visual-
izations that multiple users sharing the same experience. It is
the most immersive with desktop computers or tablets using
off-the-shelf video games as the least immersive. The degree of
immersion is not necessarily related to the effectiveness of the
VR system. The interactivity of the VE is important to create
engagement. The user experience is characterized by attributes
of challenge, positive affect, “endurability” aesthetic and sensory
appeal, attention, feedback, novelty, interactivity, and perceived
user control.4 VR and video games create a state of flow, a multi-
dimensional construct, describing the user in an optimal perfor-
mance zone.5 For people to sustain intense activity, regarded as
central for neurorehabilitation, the person’s attention and moti-
vation matter. Although not the main focus of this article, it is
important to realize that the manipulation of the virtual envi-
ronments, feedback, and the state of the person in the VE are all
important considerations for rehabilitation.
Rehabilitation applications of VR emerged for adults and
then children for the management of pain associated with
burns.6,7 The term “virtual rehabilitation” was created at the

Pediatric Physical Therapy Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults S23

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
first Workshop on Virtual Rehabilitation.8 The first publica-
tions in adult rehabilitation focused on people poststroke,9-12
with publications in pediatrics primarily focused on children
with cerebral palsy, although children with other disabilities
have been studied.13 Physical therapists have used both cus-
tomized VEs and active video games or commercial off-the-
shelf games. The active video, off-the-shelf games were devel-
oped for recreation but are adapted for rehabilitation and take
advantage of the motion-sensing features of the games. For this
article, we refer to these commercial games, such as Nintendo
or Kinect, as serious games (SG) because they were adapted for
a purpose other than entertainment. Studies of rehabilitation
have incorporated the games as safe, motivating, engaging, and
fun task-specific practice to facilitate restoration of movement
capabilities.2,14,15 Customized laboratory-based systems in par-
allel with SGs have been explored for their potential to motivate
and provide meaningful intensive repetitive practice in ecologi-
cally valid environments.2,13,16-18
PREVENTION
VR and SG offer an engaging and affordable way to
encourage and increase physical activity. VR and SG as a sec-
ondary prevention intervention to increase fitness and decrease
obesity and the related health risks in children with neuro-
motor conditions began in 2006. Widman et al19 demonstrated
that 8 children with spina bifida could increase their energy
expenditure to a moderate level while arm cycling within a
VE. More recently, Fehlings et al14 reported on 4 studies20-23
enrolling 52 children with cerebral palsy (CP) using Wii Sports,
DanceDanceRevolution, Sony Playstation Eye Toy, a robot for
ankle impairments, and an Internet-mediated interactive motor
and cognitive training program. The VR or SG dose prescribed
within these studies varied. Common outcomes reported were
the metabolic equivalent for tasks (METs) and the 6-minute walk
test (6MWT) with varied improvements reported. Most partic-
ipants did show moderate energy expenditure, with some chil-
dren reaching vigorous levels; however, the 6MWT results were
conflicting between studies. More recently, Robert at al24 mea-
sured energy expenditure in 10 children with CP playing Wii
games and also found children could reach moderate levels of
energy expenditure. Similar findings were reported for children
with autism.25 The length of time spent at a higher intensity of
physical activity could be increased with use of VR and SG.
For adults with neurological conditions, direct evidence for
use of VR in a secondary and tertiary prevention model is sparse.
The research exists primarily in the form of modifying risk fac-
tors for falls. Reducing fall risk has been reported both in studies
for people with Parkinson disease (PD)26 and people with mul-
tiple sclerosis (MS).27 There is work with active video games for
wellness fitness for prevention.
There are several research groups reported energy expen-
diture of people poststroke while playing Wii28 and Wii and
Kinect games.29,30 There is a hierarchy for energy expenditure
with standing balance games having the lowest requirements
and standing activities that involved the upper limb, such as
boxing with the largest expenditure. People poststroke worked
in the lower end of the moderate range, which was comparable
S24 Deutsch and Westcott McCoy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
to overground walking. The games therefore may be suitable for
wellness, but are not intense enough for fitness.
One of the limitations to increasing energy expenditure is
that it takes place in an environment where the movement type
and intensity is self-selected. It is possible that coupling video
games as well as VEs with a closed system such as bicycling may
address this limitation. Pilot work with a “sensorized” bicycle
yoked to a virtual cycling environment31 supported that people
poststroke could train for up to an hour, 2 times a week over
a period of 8 weeks, and improve their VO2 as well as their
gait speed.32 For people with PD, a cycling VE embedded with
cueing and feedback increases cycling speed.33 VEs coupled
with bicycles may augment the existing cycling programs used
to improve fitness for people with PD.34,35 Similar improve-
ments in fitness have been shown with VR arm and leg cycling
systems in children with CP.19,36 Although these studies are
promising for secondary prevention, larger and longitudinal
evaluations of the effects of active VR and SG on wellness or
health and fitness are necessary to demonstrate efficacy, deter-
mine dose, and document prevention of future health problems.
Health and wellness outcomes after VR should be compared
with active physical exercise in the natural environment.
OUTCOMES OF VR AND SG INTERVENTIONS
VR and SG offer the potential of practice in VEs that simulate
natural environments yet allow for safer practice by individuals
with neuromotor disorders. The majority of studies of adults
and pediatrics had body function and structure and activity out-
comes. We included a brief review of intervention studies of chil-
dren and adults with outcomes across the International Classi-
fication of Function (ICF) domains.
Studies With Children as Participants
VR and SG applications for children include the use of SG
and customized systems for specific motor practice.15 Outcomes
varied in the ICF domains, with most measurements related
to body structure and function and overall gross or fine motor
activity. Some studies focused on sensory impairments including
visual spatial training37 and sensory attention for balance,38
and some focused on intensity of exercise for improving
fitness.19-25 Children with CP have been the most common
participants20-24,36,37,39-72,73-79 ; however, there are several
studies with children with Down syndrome,80,81 developmental
coordination disorder,82,83 , autistic spectrum disorder,25 mus-
cular dystrophy,46,51 and spina bifida.19 Studies are underway
for children with acquired brain injury.84 The primary VR and
SG systems used in the studies are the Wii Fit, sports, and bal-
ance systems. Many specialized systems have been developed
for both upper43,45,47,56,59,60,69,72 and lower23,36,41,76 extremity
applications as well as greater motor control.41,76,82 Improve-
ments in postural control have been studied primarily with use
of the Wii and Kinect systems.53,54,57,63,
Outcomes: Body Structure/Function and Activity ICF
Domains
Twelve published systematic reviews (Table 1) included
9 that focused on VR and SG intervention with motor
Pediatric Physical Therapy
 TABLE 1
Summary of Current Systematic Reviews of VR, VE, and SG Research in Pediatricsa

Participants Participation
(Studies Activity Outcomes Outcomes
Authors Purpose and Participants Reviewed),b n VE/VR-SG BS/F Outcomes (+; ±; −) (+; ±; −) (+; ± ;−)

Sandlund et al13 To determine effectiveness of 245 (16) Gesture-Tek (IREX, Mandala Gesture fMRI + BOTMP ± COPM ±
application of interactive computer Xtreme), sensory glove, Eye-Toy, Sensory profile ± M-ABC − ToP +

Pediatric Physical Therapy

play in rehabilitation of children interactive metronome, other Kinematics ± QUEST ±
with sensorimotor disorders custom system Arm motor control + PDMS-2 ±
Spatial orientation ± Line tracing +
Motivation +
Galvin et al86 To determine effectiveness of VR to 32 (5) Eye-Toy-Play, IREX, PITTS, Kinematics + BOTMP ± COPM ±
improve upper limb function in Gesture-Tek Extreme Accuracy + QUEST ±
children with neurological Visual motor + MAUULF +
impairment BBT +
9-hole peg test +
PDMS-2 +
Mitchell et al87 To determine effectiveness of VR on 28 (4) Mitii, Wii, IREX, SonyPlay Station Isometric strength ± Physical activity (steps) +
physical activity capacity and Functional strength + TUDS +
performance in children with early Time over 3 METs ± 6MWT ±
brain injuries (TBI/ABI) including 1MWT −
CP
Fehlings et al14 To determine effectiveness of 364 (24) Nintendo Wii Sports or Fit, Mitii, UE UE COPM ±
interactive computer play to EyeToy for Sony PlayStation, VE + kinematics + Function ± AMPS +
improve motor performance CIMT, VE + Cycling, VE + Active ROM + Melbourne ± Level of
(including motor control, strength, Treadmill, other custom system Muscle activation + QUEST − participation +
or cardiovascular fitness) in Movement speed + MAUULF ±
individuals with cerebral palsy Movement accuracy − Reaching +
LE AHA −
Ankle ROM + MABC-2 +
Joint stiffness + BOTMP-UE ±
Dorsiflexion strength ± MACS
SCALE + LE
Balance ± SWOC +
PBS + GMFM +

Unauthorized reproduction of this article is prohibited.

Gait steadiness + MABC-2 +
Gait symmetry + BOTMP −
Treadmill speed + SACND +
Functional strength + Cardio
Cardio Number of steps +
VO2 + Time spent in activity +
6MWT ±
Bruce treadmill test +
METs +
Total energy expenditure +
LeBlanc et al88 To explain the relationship between 161 (9) (only Wii, DDR, Kinect VIM + MAUULF +
AVGs and 9 health and behavioral studies for TVMI + BOTMP +
indicators in the pediatric children with TSIF + Functional mobility +

Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults

population (CP, DS, autism) neuromotor Time in MVPA +
conditions Correct responses on VR game +

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
S25
reported) Max work capacity +
(continues)
 TABLE 1
Summary of Current Systematic Reviews of VR, VE, and SG Research in Pediatricsa (Continued)

Participants Participation
(Studies Activity Outcomes Outcomes
Authors Purpose and Participants Reviewed),b n VE/VR-SG BS/F Outcomes (+; ±; −) (+; ±; −) (+; ± ;−)

Monge Pereira To determine the effect of the use of 97 (13) Wii, IREX, EyeToy, other custom Postural tone + SACND ± COPM−
et al15 VR systems in the improvement system Postural alignment + QUEST −

S26 Deutsch and Westcott McCoy

and acquisition of functional skills Proximal stability + Active function +
in children with CP Balance + MABC 2 +
Coordination + BOTMP −
Quality UE movement + Steps/meter travailed +
Bone health +
fMRI +
1MWT −
Gait speed and stride length +
Knee joint torque +
sEMG faster activation +
Chen et al89 To determine the effect of VR on UE 125 (14) EyeToy, Gesture Extreme, Wii, PDMS-2 (UE) + COPM ±
function in children with CP Ultra-glove, other custom system BOTMP ±
JB −
ABILHAND +
CHEK +
MAUULF ±
QUEST ±
SHUEE ±
PMAL +
BBT −
Bonnechere et al85 To determine the use of SG in 419 (31) Wii, Mitii, VE + Cycling, EyeToy, Benton Judgment of Line + Computer-based and COPM ± =
rehabilitation in children with CP Kinect, other custom system Orientation test + non-computer-based Participation +
Arrows subtest of the Nepsy + games − ToP +
Roads test + QUEST − questionnaire on
SPPC + BOTMP ± engagement

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Strength + MACS − and
PBS + Reaching task + participation +
Bone mineral density + GMFM −
Knee muscle torque + Fine motor +
Pediatric Volitional Questionnaire TUG
(motivation) + BBT +
Reaching kinematics + JT +
fMRI + ABILHAND-Kids +
ROM + TUDS −
Borg Scale of Perceived Exertion + MAUULF ±
Total energy expenditure + PMAL +
Number of steps + FMA (UE) +
Time spend to play + Functional mobility +
MAS − Hand function +
(continues)

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Pediatric Physical Therapy
 TABLE 1
Summary of Current Systematic Reviews of VR, VE, and SG Research in Pediatricsa (Continued)

Pediatric Physical Therapy

Participants Participation
(Studies Activity Outcomes Outcomes
Authors Purpose and Participants Reviewed),b n VE/VR-SG BS/F Outcomes (+; ±; −) (+; ±; −) (+; ± ;−)

MTS −
SCALE +
6MWT +
Balance ±
Gait speed +
Heart rate +
fMRI −
Visual perceptual skills +
Posture Scale Analyzer +
Number of correct movements +
Forearm bone density +
Pelvic ROM +
Trunk control +
Dewar et al90 To evaluate the efficacy and 34 (3) Wii, IREX Standing balance ± BOTMP −
effectiveness of exercise Reactive balance − TUDS −
interventions to improve postural Directional control and synchronized GMFM −
control in children with CP standing −
Functional balance +
CBMS +
6MWT +
ROM −

Abbreviations: +, supporting evidence; ±, inconclusive evidence; − no change/no difference; ABILHAND, ABILHAND-Kids Questionnaire; AHA, Assisting Hand Assessment; AMPS, Assessment of Motor and
Process Skills; AVG, active video game; BBT, Box and Blocks Test; BOTMP, Bruininks-Oseretsky Test of Motor Performance; CBMS, Community Balance and Mobility Scale; CHEK, Children’s Hand Use Experience

Unauthorized reproduction of this article is prohibited.

Questionnaire; CMIT, constraint-induced movement therapy; COPM, Canadian Occupational Performance Measure; CP, cerebral palsy; DDR, Dance Dance Revolution; DS, Down syndrome; FMA, Fugl-Meyer
Assessment; fMRI, functional magnetic resonance imaging; GMFM, Gross Motor Function Measure (66 or 88 items); IREX, Interactive Rehabilitation Exercise System; JTHF, Jebsen-Taylor Hand Function Test;
MABC-2, Movement Assessment Battery for Children-2; MACS, Manual Ability Classification System; MAS, Modified Ashworth Scale; MAUULF, Melbourne Assessment of Unilateral Upper Limb Function; MET,
metabolic equivalent of task; MTS, Modified Tardieu Scale; MVPA, moderate to vigorous physical activity; 1MWT, 1-minute walk test; PBS, Pediatric Balance Scale; PDMS-2, Peabody Developmental Motor Test-2nd
ed; PITTS, Pediatric Intensive Therapy System; PMAL, Pediatric Motor Activity Log; QUEST, Quality of Upper Extremity Skills Test; ROM, range of motion; SACND, Sitting Assessment for Children with Neuromotor
Dysfunction; SCALE, selective control assessment of lower extremities; sEMG, surface electromyography; SG, serious games; SHUEE, Shriner’s Hospital Upper Extremity Evaluation; 6MWT, 6-minute walk test; SPPC,
self-perception profile for children; SWOC, Standardized Walking Obstacle Course; ToP, Test of Playfulness; TSIF, Test of Sensory Integration Function; TUDS, Timed Up and Down Stairs; TUG, Timed Up and Go;
TVMI, Developmental Test of Visual Motor Integration; UE, upper extremity; VE, virtual environment; VMI, Visual Motor Integration test; VO2 , maximum volume of oxygen; VR, virtual reality.
a Within the systematic reviews, there was repetition of some articles, with 62 original studies included overall among all reviews.
b A search of the literature was completed within PubMed in June 2016 limited by age (birth to 18 years), English language, and the search words of Bonnechere et al85 (serious gaming, serious games, virtual reality,

telerehabilitation, virtual environment, computer game, exergaming) and additionally “interactive computer play” all with “rehabilitation.”

Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
S27
outcomes.13-15,85-90 The 9 systematic reviews were completed
between 2009 and 2015 and varied in focus (Table 1). Within
the reviews, there were 12 randomized controlled trials (RCT)
and 85 other types of intervention studies, suggesting a rela-
tively larger amount of research on VR and SG in pediatrics.
Each review, however, suggested that the overall design quality
of the research studies was low, level 2b through 5 on the
Center for Evidence Based Medicine scale.91 Children aged 4
to 20 years participated in these studies, including 776 chil-
dren with neuromotor conditions. Seventy percent of the par-
ticipants were children with CP, with the remaining participants
having Down syndrome and coordination disorders. The rec-
ommended VR or SG dose was between 1 and 70 hours (mean
15 hours, standard deviation 12; median and mode 9 hours).
Improvements in body structure/function included balance,
range of motion, strength, coordination, and kinematics, with
activity domain outcomes improving in some studies and not in
others.
Two recent RCTs and 2 nonrandomized clinical trials, not
included in the above reviews,18,92-94 compared VR and SG
interventions to control conditions with children with CP18,92,93
and children with fetal alcohol spectrum disorder who had
motor disabilities.94 Mixed results for children with CP using
MiTii exercise are reported. One group reported statistically
but not clinically significant higher performance with MiTii
than the standard care group. Whereas Lorentzen et al,92 who
used double the dose of the previous study, reported a large
training effect for changes in gross and fine motor activity as
compared with a group who received no intervention. Tarakci
et al.93 reported similar findings for children with CP as per the
previous reviews with positive improvements on balance out-
comes after use of the Wii Balance system. Jirikowic et al94 eval-
uated a customized game-based VR system delivered through
an head-mounted display (Sensorimotor Training to Affect Bal-
ance Engagement and Learning, STABEL) to provoke practice of
standing balance in a sensory environment designed to require
a shift of sensory attention from vision and somatosensation
to vestibular sensation to maintain balance. Statistically and
clinically significant improvements in both balance and overall
motor ability after 4 hours of intervention were reported in
the intervention but not in the control group who received
no intervention. These recent results are similar to the ear-
lier research, with generally positive improvements in body
structure/function domain but mixed results in activity domain
outcomes.
Outcomes: Participation Domain
Eight of these studies measured a participation outcome.
Five used the Canadian Occupational Performance Measures
(COPM), which includes the collaborative creation of individu-
alized goals,18,59,70,95,96 one study used the Test of Playfulness,58
and 2 used the Assessment of Motor and Process Skills.18,92
Most studies indicated a positive improvement in participation.
However 2 studies96,97 indicated that the differences between
the VR and SG system and standard care groups were not clini-
cally significant.
S28 Deutsch and Westcott McCoy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Adults as Participants
The use of VR and video games for adults with neuro-
logical conditions can be grouped into enhancement of upper
limb (UL) use, balance and mobility training, sometimes termed
lower limb training, activities of daily living, neglect, and cog-
nition. We report on movement outcomes for people with
stroke, PD, and MS but not activities of daily living, neglect, or
cognition.
Body Structure/Function and Activity Domains
The largest body of work is with people poststroke reflected
by a Cochrane review that was updated until July 2014, with a
2015 publication and currently being revised for a third time.98
Since the Cochrane review there are 6 systematic reviews with
meta-analyses on balance and mobility.99-104 These reviews
(Table 2) have different objectives including the evidence on
the Wii,99 discriminating between VR coupled with treadmills,
customized systems that do not involve a treadmill and off-the-
shelf games.103 Treadmills coupled with VR, off-the-shelf video
games, and custom systems built by investigators that are not
available commercially, were used. There is a small but con-
sistent benefit for VR in gait measured by gait speed,100,102-104
balance measured by the Berg Balance Scale, and the Timed
Up and Go.100-104 The meta-analyses favor VR with balance
outcomes; these studies do not meet the minimal clinically
important difference.
Three systematic reviews synthesize the work on use of VR-
based activities for the UL poststroke.98,105,106 The early studies
reviewed by Saposnik and Levin106 were primarily single-group
studies that measured body function/structure and activity-level
outcomes. VR improved UL function for people in the chronic
phase poststroke. The review by Lohse et al105 considered SGs
and VEs and described support for an additive effect for SGs
and VR-based activities over traditionally presented UL reha-
bilitation activities. The most detailed analysis was provided
by Laver et al98 in the Cochrane review and support that VR-
augmented therapy for the UL enhances UL use; people in the
acute phase poststroke fare better than those in the chronic
phase and the dose of intervention matters. People who received
more than 15 hours of intervention improved more than those
who received less than fifteen. Taken together these studies
show a steady progression of support to incorporate VR into UL
interventions for people poststroke. Innovation and optimiza-
tion of these therapies are underway, with the advent of smaller
sensing devices as well as less intrusive and less expensive UL
supports.
For people with MS, there are a combination of SG used
for rehabilitation, primarily the Wii and treadmills coupled
with VEs. Taylor and Griffin107 published a narrative systematic
review of 11 studies and 1 protocol using gaming technology,
both the Wii and the Kinect, for rehabilitation of people with
MS. They reported that use of Wii Fit games in a clinical setting
yielded improvements in postural control108 as well as func-
tional balance.27,109,110 One group of investigators designed a
dynamic platform that was coupled with the Wii games. This
created a more dynamic balance challenge than using the Wii
Pediatric Physical Therapy
 TABLE 2
Summary of Systematic Reviews of VR and SG for Balance and Mobility of Persons Post-Strokea

Pediatric Physical Therapy

Body Function
Author Purpose n VR-SG Structure Activity Participation

Cheok et al99 Use of Wii for stroke rehab 170 (6)b Nintendo Wii Postural control ± WMFT + TUG + SIS ±
BBS ± FAC ±
FIM ± BBT ±
Corbetta et al100 VR for balance and walking 341 (15) Treadmill + VR Kinematics Gait speed + BBS + Community
poststroke Nintendo Wii postural Control TUG + 6MWT ambulation +
Customized VR FM BI FIM
FRT ABC
10MWT
Li et al101 VR for balance + gait poststroke 428 (16) Treadmill + VR Postural control ± BBS + TUG +
Nintendo Wii Temporal spatial ± FRT ± ABC ±
Customized VR
Gibbons et al102 VR for LL outcomes poststroke 522 (22) Treadmill + VR Postural control + BBS + FRT+
Nintendo Wii Temporal spatial + Gait Speed + TUG +
Customized VR MMAS + 6MWT + WAQ +
Tardieu + ABC ± DGI ±
FM ±
Ashworth +
Chedoke ±
Iruthayarajah VR for balance + gait for chronic 984 (20) Nintendo Wii Fit Postural control ± BBS + TUG +
et al103 stroke Treadmill + VR Activity FRT ± 10MWT +
Postural VR 6MWT ± BBA ±
Tinneti ±
de Rooij et al104 VR for gait and balance poststroke w/ (21) Treadmill + VR Temporal spatial ± Gait speed + BBS +
matched dosing Balance board Postural control + 10MWT ± TUG +

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Activity FRT + BBA ±
Tinetti ±

Abbreviations: +, favor VR; ±, inconclusive; −, favor control; ABC, Activity Based Confidence Questionnaire; BBA, Brunel Balance Assessment; BBS, Berg Balance Scale; BBT, Box and Blocks Test; BI, Barthel Index;
DGI, dynamic gait index; FAC, Functional Ambulation Capacity; FIM, Functional Independence Measure; FM, Fugl-Meyer; FRT, Functional Reach Test; LL, lower limb; MMAS, Modified Motor Assessment Scale; SG,
serious games; SIS, Stroke Impact Scale; 6MWT, 6-minute walk test; 10MWT, 10-m walk test; TUG, Timed Up and Go; VR, virtual reality; WAQ, Walk Activity Questionnaire; WMFT, Wolf Motor Function Test.
a Systematic reviews of the literature on VR and SG for adults were searched on PubMed (published by June 2016) using the following terms: virtual reality, virtual environments, video games, serious games, Wii,

Kinect, and specific conditions stroke, Parkinson disease, and multiple sclerosis. These populations were selected because they represent people who are seen frequently by physical therapists and the corresponding
VR literature is sufficiently valid to have been summarized in systematic reviews.
b Half the studies were dose matched, included upper limb and lower limb studies.

Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
S29
platform alone, which did not result in improved postural con-

Abbreviations: +, favors VR; −, favors control; ABC, Activity Balance Confidence Questionnaire; BBS, Berg Balance Scale; DGI, dynamic gait index; FRT, functional reach test; FSST, Four-Square Step Test; MFIS,
Modified Fatigue Impact Scale; MI, motor imagery; MoCA, Montreal Cognitive Assessment; MSIS, Multiple Sclerosis Impact Scale; MSWS-12, Multiple Sclerosis Walking Scale; SG, serious games; SLS, simple-limb
trol or functional balance.110 Feasibility of a telerehabiliation

Participation
model was tested and demonstrated improvements in activity-

Adherence
based balance measures for both the local group and remote

MFIS ±
MSIS +
groups using Kinect. The remote group had postural control
improvements, which the control group did not.111 A walking
study, coupling VR with a treadmill, produced gait and dual task
balance improvements.112 Overall there is a small body of work
with studies at level 2b to 5 on the Center for Evidence Based

MSWS-12 +
Medicine scale.91

TUG +

ABC ±
DGI ±
FRT +

FRT +
BBS +
For people with PD, the literature has been summarized
(Table 3) with narrative reviews on assessment and treatment

Activity
of balance and gait using VR113 and exergaming (use of video
games for physical activity).114 Nine studies used either the Sony
Playstation115 the Wii,116-121 a customized balance board,122

Stride length +
Step latency ±

stance; SOT, Sensory Integration Test; TUG, Timed Up and Go; 25-FWT, 25-Foot Walk Test; UPDRS, Unified Parkinson Disease Rating Scale; VR, virtual reality.
Gait speed +
or a treadmill VR combination.26 The findings generally have

25-FWT +
4 square +
UPDRS ±
UPDRS ±
activity-based outcomes that favor VR. More recently, investiga-

FSST +
TUG ±
BBS ±
SLS ±

SLS +
tors have used the Kinect to develop customized applications
for balance training123 and reported preliminary positive bal-
ance findings in a cohort study. Another study suggested no dif-

Summary of Reviews on VR and SG for Persons With Parkinson Disease

ference when comparing home-based therapy with home-based

Postural control +

Postural control ±
VR therapy.124 In a study with dancing (with the K Pop Dance

Body Function
Structure

Kinematics ±

Kinematics ±
Festival from the Wii) added to the standard of care, participants
had reduced symptoms of depression and improved balance.125

MoCA ±

SF-36 ±
SOT ±
The results of the largest multicenter clinical trial on walking
with VR, VTIME, are pending.126
Across all the populations studied, researchers have exam-
ined SGs, predominantly the Wii (although newer studies are
TABLE 3

reporting use of the Kinect), customized balance systems, and

treadmills yoked to VR and UL robotic interfaces connected

Playstation Eye Toy

to VR. Research has evolved to more dose-matched studies of
VR-SG

Treadmill + VR
Motor imagery

higher quality. The highest levels of evidence are for studies on Nintendo Wii
Nintendo Wii

Nintendo Wii
Xbox Kinect
UL use and balance and mobility training for people poststroke.
There is a lag between commercial video game development and
VR

application to practice as evidenced by very few studies using

the Kinect.
645 (16)

298 (12)
102 (7)

Participation Domain
n

Measures of participation were absent from all the system-

atic reviews on balance and mobility of people poststroke, with
the exception of Mirelman et al,127 who measured improve-
ments in ambulation in the community for 1 week before and
VR effectiveness in multiple
gait in Parkinson disease
VR and MI for balance and

1 week after the conclusion of the VR intervention. For the UL

studies in people poststroke, the Stroke Impact Scale is reported,
Parkinson disease
VR’s effectiveness in
Purpose

as a participation measures in only 2 studies.106,128 By contrast,

in a review article on use of Wii for rehabilitation of people with
sclerosis

MS participation, measures were included in 3 of the 9 RCTs or

cohort studies.107 A study protocol129 included measures of par-
ticipation. Participation outcomes improved on measures such
as the Physical Activity and Disability Survey, the SF-36, the
Multiple Sclerosis Fatigue Impact Scale,27,130 and the Multiple
Sclerosis Impact Scale.109
Mirelman et al113

For people with PD, change in participation was reported

Barry et al114

Griffin107
Taylor and

on the basis of scores on the Parkinson Disease Questionnaire

Author

(PDQ) in 2 cohort studies and 1 RCT.116,121,131 People with

PD who were on average 5 years postdiagnosis played Wii
Sports (specifically tennis, boxing, and bowling) for 12 1-hour

S30 Deutsch and Westcott McCoy Pediatric Physical Therapy

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sessions over 1 month and improved in the PDQ that lasted
4 months postintervention.121 Changes in the PDQ were
reported by a group that used the Wii as a balance training
tool131 and similarly by a group that used the Kinect Adven-
tures games to improve balance.116 By contrast, a home-based
VR intervention for balance and mobility was no different from
standard of care home physical therapy in changing the PDQ.124
The frequency with which participation is used as an outcome
in studies of people poststroke was lower than that reported for
people with PD or MS. This may in part be explained because
of the progressive nature of MS and PD and the belief that par-
ticipation may be altered but body function/ structure may not.
PLASTICITY
Plasticity is a complex cellular and molecular process
depending on genetic, epigenetic, and environment and
activity.132-135 VR and SG interventions potentially offer a
method to promote meaningful, through engagement and flow,
repetitions of movements to change brain structures. Noninva-
sive measurement of brain changes, however, is complex and
little data are available related to either pediatric or adult VR
and SG interventions. This is partially due to the relative dis-
comfort and difficulty remaining still for brain scans, especially
for children, and the cost of the scans. Other issues relate to the
variability of neural activity between individuals, reliability and
sensitivity of brain scan results in children, and lower relation-
ships between magnetic resonance imaging (MRI) results and
motor ability.136
Two studies of children with hemiplegic CP (n = 4) eval-
uated for brain changes after VR and SG interventions. Func-
tional MRI findings from one participant in the You et al72
study suggest that IREX (Interactive Rehabilitation Exercise
System), a computer interaction with sensor gloves intervention,
influenced greater contralateral control of the child’s affected
arm. Golomb et al,47 using a sensor glove and the PlaySta-
tion 3 system, found expanded activation of the primary motor
cortex and cerebellum and greater contralateral activation. Two
studies84,137 with larger numbers of participants are ongoing
that include brain scans in children with acquired brain injury
and CP.
Five studies of adults with neurologic conditions have eval-
uated use-dependent plasticity associated with learning. Two
early studies of people poststroke reported functional improve-
ments in UL use and gait that paralleled a shift from con-
tralesional sensorimotor activation pretherapy to predominantly
ipsilesional activation posttherapy.138,139 More recently, Saleh
et al140 reported changes in connectivity between the lesioned
and nonlesioned hemisphere, with one subject demonstrating
increases and the other subject decreases in the lesioned hemi-
sphere. In contrast, Orihuela et al,141 reported contralesional
activation of the unaffected motor cortex as well as cerebellar
recruitment and compensatory prefrontal activation. These
studies included participants in the chronic phase poststroke
and the total number was fewer than 20; thus, the findings
are limited. The remaining 2 studies included participants with
MS. Prosperini et al142 reported balance improvements after a
12-week training program with the Wii that were associated
Pediatric Physical Therapy
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with increased structural integrity of the superior cerebellar
peduncle. Cognitive-based video games reporting experience-
dependent plasticity are not included in this article.
Short-term plasticity has been demonstrated with VR
manipulations of visual representations. Using the phenomenon
of visuomotor discordance, that is reconciling the discrep-
ancy between intended actions and discrepant visual feedback,
investigators have shown that motor area (M1) activation is
increased, as healthy adults try to reconcile this discrepancy.143
This manipulation may result in use-dependent plasticity and
more permanent structural changes.
The use of brain scans within pediatric and adult practice
could add significantly to the understanding of the baseline neu-
rological problems of individuals with neuromotor conditions
and also could provide guidance for evaluating and adjusting
intervention programs that use VEs.144 Scanning could poten-
tially determine neurological reorganization and assist with
understanding restoration versus compensation.
BRIDGING THE GAP FROM EVIDENCE TO PRACTICE
VEs and SG have appealed to practitioners and participants.
Transferring the technology to the clinic and home and the
knowledge to implement technologies remain a challenge. VR
systems that were customized in a laboratory are not available
for purchase. With the wide availability of VR through motion-
controlled games such as Wii and Kinect, the technology has
become more accessible and clinicians have indicated willing-
ness to adopt them in practice.145 However, barriers exist to
implementing these technologies in clinical practice including
lack of knowledge about the VR systems and time to imple-
ment them into practice are barriers. There are concerns that
the variety of games makes it difficult to find the best exercise
to meet a person’s needs and may shift the person’s attention
from the movement practice itself to the game play, which may
degrade the movement practice.146 We offer suggestions for edu-
cation, practice, and research that may enhance informed adop-
tion of the technology.
Education
Education may take the form of continuing education for
clinicians and formative education for students in training.145
Researchers suggest that training should result in students and
therapists being able to problem-solve the active ingredients
within various VE and VR or SG systems and use the systems
to their clients’ advantage.145
For students at entry to the profession, we suggest that
selecting the correct technology and application is an extension
of clinical reasoning that may be best taught in a distributed
model across classes rather than as a unit in one class. Specific
suggestions include students learning to evaluate the evidence
supporting the technology as well as practicing the implemen-
tation of the technologies as tools for therapeutic exercise and
movement reeducation on themselves and through integrated
clinical experiences before their clinical internships. Practicing
therapists should consider the VR and SG systems as one more
addition to their intervention toolbox that should be systemati-
cally analyzed and applied judiciously.
Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults S31
Resources for Clinicians and Educators
Although clinicians were enthusiastic with the introduc-
tion of VR and SG in practice, there are challenges with under-
standing the content and application of the systems. Early pub-
lications incorporating SG into practice aimed to describe the
games as well as the rationale for selecting them for a spe-
cific practice application.44,147 Galvin and Levac147 suggested
a method for consideration of VR and SG systems for pedi-
atric rehabilitation that may generalize to adult rehabilitation.
They created an algorithm for selection of the most appro-
priate system on the basis of an analysis of system variables
including ability to manipulate, track, target body movements,
adjust motor demand, and focus on quality of movement and
user variables such as upper and lower limb requirements to
play the game. With this system, students and therapists can
consider the intensity of physical activity, the nature of move-
ment, amount and frequency of active movement, and adjust-
ment to the therapeutic goals for the client. Levac and Galvin148
offer case examples of using the classification system for deci-
sions about VR and SG systems for children.
There have been efforts to analyze the Wii and Wii Fit
games that are bundled with the console and balance board
for ease of use and practice.149 This game analysis identified
game applications for rehabilitation of balance, strength, and
endurance, and it extracted both the knowledge of results and
knowledge of performance information. The games provided
more knowledge of results and positive feedback than knowl-
edge of performance. Clinicians need to be mindful of the
movement strategies clients use while playing the games. More
recently, 5 investigators have collaborated on a game analysis
of the Kinect Adventure Games.150 The Kinecting with Clini-
cians (Kwic) resource is used online with cases and videos (/http:
//kinectingwithclinicians.com/). This online resource illustrates
with case studies the implementation of video games into the
rehabilitation for children and adults. The authors have created
descriptions of the games using motor learning definitions and
practice terminology. Studies are underway to determine its use-
fulness and whether it is scalable and sustainable.
Linking Clinicians and Researchers
Although the SG systems are appealing because of their
low cost, they are limited by the lack of customization and
rehabilitation-relevant theoretical framework that informs their
design. Customized systems are superior to SG in balance and
mobility studies in people poststroke and with upper extremity
function in children with CP.89,102 One problem with these cus-
tomized systems is that many are developed and tested and then
discarded because no method exists to transfer them out of the
laboratory and into the clinic. To address this gap, clinician sci-
entists and engineers from Spain, Portugal, and the United States
have created an online resource, Open Rehabilitation Initiative,
to share executable versions of the VR and SGs.151 This resource
was tested by clinicians, VR, and robotic developers and awaits
the next phase of development, which is soliciting and posting
simulations. The creators hope that this forum allows clinicians
to inform the development of the technology and use it. For
S32 Deutsch and Westcott McCoy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
contribution to or tracking the development of this site, readers
can contact openrehabinitiative@gmail.com.
REFLECTIONS AND RECOMMENDATIONS
Virtual reality is a rapidly developing area with advances in
technology that often outpace the research. Evidence is accu-
mulating to support the use of VR and SGs either alone or in
addition to standard of care. The body of evidence remains con-
founded by the challenge of parsing the customized laboratory-
based simulations with the off-the-shelf games and the hybrid
systems that use off-the-shelf hardware with customized soft-
ware. As the development, research, knowledge translation, and
application move forward, physical therapists play an integral
role in shaping the process. Physical therapists are currently
involved in all aspects and can influence the types of technolo-
gies that are developed for their clients by contributing to devel-
opment as well as application.
Prevention, plasticity, and participation effects of VR and SG
are understudied. Larger numbers of participants are needed
for prevention studies, and the studies need to be directed at
primary as well as secondary and tertiary prevention. Evalu-
ations of brain changes through the process of plasticity from
VR and SG intervention depend to a great extent on the brain
scanning technology and cost of these services. Research inves-
tigating recovery in more acute stages postnervous system insult
could guide use of VR and SG. Most of the research on VR and
SG has been done at the body structure/function and activity
domain, particularly in studies of balance and locomotion. For
chronic adult conditions such as PD and MS, participation is
more regularly documented. In the pediatric literature, there
are reports including participation outcomes, based on individ-
ualized client goals as measured with the COPM, but participa-
tion is not included in the majority of studies. The COPM cus-
tomizes goals, which can be directed toward participation. This
tool may be well suited across a variety of populations. Because
of some conflicting evidence on carryover of motor improve-
ments within VR systems to the natural environment, future
research on participation outcomes should also evaluate VR and
SG practice alone and within natural environments to determine
programs leading to the best movement outcomes.100,127,131,132
Standardization of behavioral outcome measures across studies
would increase the usefulness of meta-analyses. Control inter-
ventions should be standardized and described in addition to
the VR and SG programs.
If these technologies are to be used in practice, a synergy
between commercial entities, researchers, educators, clinicians,
and clients needs to occur. We advocate for partnering of com-
munities through professional organizations such as the Amer-
ican Physical Therapy Association, Academies of Neurology and
Pediatric Physical Therapy, the International Society of Virtual
Reality, International Industry Society Advanced Rehabilitation
Technology, and interested academic and industry partners to
standardize technology development and research. This work
should be guided by a patient-centered approach to achieve the
goal of clinical application of VR/VE and SG to improve move-
ment, function, and participation in clients with neuromotor
conditions.
Pediatric Physical Therapy
ACKNOWLEDGMENTS
We thank participants and their families for contributing to
the knowledge base for use of VR and SG with individuals who
have neurological conditions. Thanks as well to Sean Hickey,
SPT, Essie Kim, SPT, Eric Previte, SPT, and Katie Metrokotsas,
SPT, for active participation in journal clubs that reviewed rel-
evant literature presented in this article and to the many DPT
and PhD students who have assisted with the studies presented
from our laboratories.
REFERENCES
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Pediatric Physical Therapy
 S P E C I A L C O M M U N I C A T I O N

Coupling Timing of Interventions With Dose to Optimize Plasticity and Participation

in Pediatric Neurologic Populations
Mary E. Gannotti, PT, PhD
Department of Rehabilitation Sciences, University of Hartford, West Hartford, Connecticut.

Purpose: The purpose of this article is to propose that coupling of timing of interventions with dosing of interventions
optimizes plasticity and participation in pediatric neurologic conditions, specifically cerebral palsy. Dosing includes
frequency, intensity, time per session, and type of intervention. Interventions focus on body structures and function and
activity and participation, and both are explored. Known parameters for promoting bone, muscle, and brain plasticity and
evidence supporting critical periods of growth during development are reviewed. Although parameters for dosing
participation are not yet established, emerging evidence suggests that participation at high intensities has the potential
for change. Participation interventions may provide an additional avenue to promote change through the life span.
Recommendations for research and clinical practice are presented to stimulate discussions and innovations in research and
practice. (Pediatr Phys Ther 2017;29:S37–S47)
Key words: cerebral palsy, critical periods, dose, participation, plasticity

INTRODUCTION challenge is to integrate knowledge about the effective dose (fre-

Optimizing plasticity and participation of pediatric popu-
lations with neurologic conditions is aligned with the profes-
sion’s vision to “transform society by optimizing movement.”1
To enact this vision, education at the doctorate level provides
us with skills to be evidence-based practitioners, clinician-
researchers, advocates, and community leaders. Determining
treatment effectiveness for pediatric populations with neuro-
logic conditions is a priority identified by the Institute of
Medicine2 and by pediatric physical therapists.3 It is a complex
problem with many factors.4 Our knowledge of children, fam-
ilies, environment, development, and interventions can inform
practice and research.3,5,6 Dose is operationally defined by its
parameters: (1) frequency; the number of sessions a week and
number of weeks; (2) intensity; strenuousness of exercise; (3)
time per session; and (4) the type of intervention.7 Type of
intervention refers to the focus of the intervention, for example,
changing body structures and function, or activity and partici-
pation. Critical periods of plasticity reinforce the importance of
age of intervention, that is, the timing of the intervention. The
0898-5669/293S-0S37
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Mary E. Gannotti, PT, PhD, 200 Bloomfield Ave, West
Hartford, CT 06117 (gannotti@hartford.edu).
The author declares no conflicts of interest.
DOI: 10.1097/PEP.0000000000000383
quency, intensity, and time per session) given the different types
of interventions with attention to the optimal timing of inter-
ventions to maximize plasticity and participation.
The optimal dose of an intervention ideally produces sus-
tainable changes at the level of body structures and function
and activity and participation.4 Determining the optimal dose
given a child’s individual, family, and community characteristics
is a national priority for the Federal Government,8 third-party
payers, school districts, pediatricians, rehabilitation centers,
therapists, and the children.2 Development of practice guide-
lines that promote optimal outcomes (satisfaction, function,
health, participation) and minimize costs to families, society, the
individual, and the providers are is. 4,9
Interventions cannot be optimally dosed if there is no evi-
dence of demonstrated effectiveness at either the structural or
functional level. Effective interventions are “worth it”10 if the
effort yields positive short- and long-term outcomes. We have
previously described a path model for dosing4 pediatric reha-
bilitation services (Figure 1), and moderating and mediating
factors of treatment effectiveness. Dose is a factor that can be
modified. Exercise dosing includes the type of intervention, fre-
quency, intensity, and time per session. Regardless of type, the
time per session, effort, and frequency of performance of an
activity appear to be a key factor.3 Age is a moderating factor, and
optimizing timing of interventions, or age at intervention, has
potential to improve treatment effectiveness. Interventions may
have the greatest effect when harnessing the increased potential
for plastic changes during critical periods of brain, bone, and
muscle development. Moreover, activity based and participation
interventions have the potential to increase dose in the natural

Pediatric Physical Therapy Timing and Dose in Pediatrics S37

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Fig. 1. Path model for dosing interventions for children with cerebral palsy. Emphasis on the type, dose, age, plasticity of muscle, bone, and brain, and performance in
everyday life. Reprinted with permission from Gannotti et al.4
environment, and if dosed high enough may yield changes.11
Combining the 2 factors of dose and timing of interventions may
open new pathways for promoting positive outcomes.
The path model for dosing (Figure 1) classifies type of
intervention according to the International Classification of
Functioning, Health, and Disability (ICF). These classifica-
tions are impairments, activity limitations, or participation
restrictions.4,12 Type of intervention also refers to the specific
physiological mechanisms by which the intervention creates
change (eg, muscle hypertrophy, motor learning, increased tra-
becular bone formation, or increased movement or engagement
in everyday life). Types of interventions can be at the level of
body structures and function and plasticity supported (changes
in muscle, bone, or brain); at the level of activity and partici-
pation (changes in movement and interaction with the environ-
ment) and participation driven, or both. The differential effect of
optimal type of intervention is explored with recommendations
for research and clinical practice.
COUPLING TIMING AND DOSE
Dose is important in determining the effectiveness of pedi-
atric rehabilitation interventions. Interventions at the body
structures level may affect changes at the level of body struc-
tures and function and link to performance in everyday life
(Figure 2). Interventions at the activity and participation level
may affect changes in performance capacity and in everyday life
and capacity with changes in structure and function. Age at time
of interventions moderates outcomes. Optimal timing of inter-
ventions has the potential to increase treatment effectiveness.
Dosing parameters for interventions focused on body struc-
tures and function and activity and participation are described
next. For each type of each of intervention described, evi-
S38 Gannotti
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Unauthorized reproduction of this article is prohibited.
dence for effective frequency, intensity, and time per session
are reviewed. Evidence is given to support optimal timing or
age at intervention. Tables 1 and 2 summarize interrelation-
ships among factors that mediate and moderate interventions
that capitalize on the plasticity of the musculoskeletal system of
the central nervous system or those that increase participation
in daily life to create structural and functional change.
Interventions That Harness Plasticity to Create Change
Improving Bone Structure and Function. There are inter-
ventions that optimize skeletal development during critical
periods in early infancy and prepuberty. Most of the fetal bone
accrual occurs in the last trimester of pregnancy and is depen-
dent on movement.13 Newborns with limited movement in
utero have smaller, weaker bones and are at greater risk for
fracture.14,15 Spontaneous movement or the lack of activity is
associated with bone strength in healthy infants and very low-
birth-weight infants with unilateral brain insults.16 Infants who
are born prematurely may have fewer opportunities for move-
ment during the first few weeks of life during hospitalization as
compared with infants who are born full term and are able to
move in utero.17 Evidence supports passive, flexion, and exten-
sion range of motion exercises of the upper and lower extrem-
ities in preterm infants, 10 minutes for 4 to 8 weeks, with an
increased effect after 8 weeks17 to positively impact bone health.
Growth hormones facilitate bone modeling that occurs pre-
puberty and during puberty. Adolescents accumulate 25% of
their adult bone during the 2 to 3 years after maximal height is
reached, on average 13.4 years for boys and 11.8 for girls.18-20
Interventions provided before maximal height is reached may
provide the greatest treatment effect.20 Interventions for bone
during childhood may provide a lifetime of benefit.20
Pediatric Physical Therapy
 Fig. 2. Path model abbreviated for harnessing plasticity-driven interventions and age at time of intervention.

Dose. Key factors for exercise interventions to improve
bone health for children developing typically are frequency and
duration of the activity, loading on the skeleton during the
activity, and age at the time of activity.21 For activities with lower
loading on the skeleton, increasing the frequency of the activity
within a session or during the week can increase osteogenic
potential.22 The osteogenic index of an exercise is calculated
as intensity × ln (frequency + 1) × times per week.22 An
example of an exercise intervention that was effective imme-
diately, after 3 and 8 years with healthy prepubertal children,
required children to jump high enough for a ground reaction
force 8 times their body weight, 100 times (10 minutes), 3 times
a week, for 7 months.23 This yielded an osteogenic index of
110. For children who cannot perform activities that produce a
ground reaction force of 8 times their body weight (jumping off a
60-cm box), but can produce a ground reaction force 2 times
their body weight, an osteogenic index of 110 to 115 can be
obtained by increasing the number of loading cycles to 1200
and the frequency to 9 episodes per week. Bone requires about
8 to 10 hours’ rest, so a frequency of twice-a-day bone loading
is possible.22
Bone health should be monitored in children with cere-
bral palsy (CP)24,25 ; however, there is no consensus for dosing
exercise interventions.24 In a systematic review, Novak et al10
identify a “worth it” line of interventions for children with CP.
Whole body vibration is on the line of just being “worth it,” and
standing frames are closer to “probably do it.”10 Bone response
to skeletal loading in children with CP appears to be more pos-
itive when standing programs are performed frequently and for
a long duration (3 times a week for 9 months).26,27 Dynamic
standers may have increased effect on bone in children with
severe CP as compared with static standers.28-30 Multimodal
programs that include aquatics, body weight support (BWS)
treadmill training, and progressive resistive exercises have evi-
dence of effectiveness for children with Gross Motor Functional
Classification System (GMFCS) levels I to IV.31,32 Whole body
vibration tends to increase bone in the tibial plateau,33 cycling,
and standing exercise may increase bone in the distal femur.31,34
Vibrating pads placed on long bones while children are sitting
in chairs have demonstrated some effect on bone.35 Insufficient
evidence exists to support any of the types of bone interventions
for prevention of spinal and hip deformity into adulthood.36,37

TABLE 1
Features of Intervention Types

Type Characteristics Other Factors Site Specific

Harnessing plasticity
Harnessing plasticity and
participation driven
Participation driven
Resistance training for muscle High resistance Muscle length, type of Yes
strength contraction
Velocity training for muscle High resistance at high speed Muscle length, type of Yes
performance contraction
Bone loading for bone health High effect (relative to usual) Adequate nutrition, effects of Yes
medications
Activity-based interventions Functional context, many Feedback, task variation Usually
to improve motor skills repetitions Opportunities for practice
and body structures and Active engagement
function Time spent performing
Contextual interventions to Natural environment, active Individualized to preferences Not determined
improve activity and engagement and context
participation

Pediatric Physical Therapy Timing and Dose in Pediatrics S39

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 Improving Muscle Structure and Function

First year of life77 ; again

Prepuberty; presence of
Interventions for muscle are generally focused on improving

growth hormones22

first 6-8 y of life89

Age 5 y and above50

Age 5 y and above50

joint range of motion or muscle performance including strength

Timing
and power.
Timing for Change in Muscle. Muscles are highly plastic
and responsive to activity or inactivity.38 Development of muscle
architecture is closely connected to the development of the
spinal central pattern generators, corticospinal development,
motor unit formation, and motor activation patterns from early

(min 3 mo)
Duration

fetal development, through infancy and early childhood. 39

9-12 mo
8-20 wk

8-20 wk

Activity refines both systems,39 including cell differentiation (eg,

Months
muscle fibers from type I to type 2 and nerve cell types), mat-
uration of cells, and epigenetic transcription.38,40 Dotan et al41
argue a complex interrelationship among a muscle’s metabolic
Needed for consolidation
24 h between sessions

24 h between sessions

profile, muscle structure, fiber composition, and the cortical

1-2 min between sets;

1-2 min between sets;

1-10 s between reps;

impulses directing firing of motor units, accounts for differences

4-8+ h between
Rest

in muscle performance between adults and children. Both the

muscle and its relationship with the motor unit create differ-
sessions

ences in activation patterns. Muscles develop in response to

interaction with their neurophysiological environment,41 and
differences are present in infants with early brain injury.42
Summary of Known Dosing Parameters and Optimal Timing

Evidence suggests that “critical muscle symptoms” begin

Task dependent, more

movement pattern?
(nonconsecutive)

(nonconsecutive)

(nonconsecutive)

early in life. Infants with brain injury spontaneously kick fewer

than competing
Frequency

times, at slower velocity, and within a more constrained range

3-6 times/wk
2-3 times/wk

2-3 times/wk

of movement than age-matched peers without brain injury.43

A study of infants born preterm and full term correlated mag-
netic resonance spectroscopy metabolic findings (indicating
brain injury) with kinematic measures of infant motor perfor-
TABLE 2

Concentric part “as fast as

mance, specifically greater knee flexion and plantar flexion in

possible”; return, slow,

standing.44 In addition, infants at high risk for CP had less

musculotendinous extensibility and cross-sectional area of ankle
Slow to moderate;

and controlled
Speed

Task dependent

musculature at 6 and 12 weeks’ corrected gestational age com-

controlled

High strain

pared with infants at low risk, indicating muscular architectural

differences may occur much earlier than previously thought in
infants at high risk for CP.45
Children who develop CP may have moved less in utero,13
and because of prematurity, had less time to move in utero,
Repetitions

Build to 3 sets

Build to 6 sets

moved less as infants,43 and as children, moved less than

hundreds
Dozens to
of 6-10

peers.46 The lack of activity during these critical periods of

of 5-6

50-100

muscle development may also predispose children with CP

to metabolic disease, fatty infiltrate in muscle, early-onset
sarcopenia,47 and negative consequences for diseases of aging.48
Self-initiated movements42 in infancy combined with active
2 h, total time more than
High ground reaction force

beneficial; Time 20 min,

assistive and passive movements that are developmentally

appropriate17,49 take advantage of plasticity in muscle struc-
Mental engagement
40%-80% of 1 RM
Load

ture, motor unit, and corticospinal tracts during this time and
85% of 1 RM

may influence genetic transcription for later in life.38 Promo-

tion of muscle activation and muscle performance should con-
90 h

tinue throughout life, and become more aggressive at about

Abbreviation: RM, repetition max.

age 5 years. Resistance training can begin as early as age

5 years.50 Training rate of force development has potential for
increasing gait speed51 or reaching52 by promoting changes in
reaching training89
Strength resistance

Motor learning for

Velocity training59

muscle structures. Training at the structural level to increase

Bone mass and

performance at earlier ages has the potential for an increased

structure22
training59

treatment effect. Changes in movement activity, gait speed or

reaching, may sustain changes at the structural level of the
Type

muscle. Maintaining muscle volume and strength across the

lifespan requires a regular exercise program.53

S40 Gannotti Pediatric Physical Therapy

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 Dosing Joint Range of Motion. Range of motion in chil-
dren with CP decreases with age.54 Reviews of physiolog-
ical and clinical studies55-57 suggest that manual resistance is
not effective for maintaining or improving range of motion.58
Stretching before strengthening activities is not recommended
by the National College of Strength and Conditioning for youth
adults, as it reduces the ability of the muscle to generate force as
the tendon and sarcomeres become overlengthened, although
a dynamic warm-up is recommended.52,59 Evidence supports
that although CP is a brain injury, “critical symptoms”38,60
appear in the muscle including change in muscle sarcomere
length, fiber type, extracellular concentration, fiber and fiber
bundle stiffness, reduced stem cell numbers, and epigenetic
transcription that may perpetuate these traits.
Interventions that focus on changing pathology in muscle
structures may provide new avenues for treatment.38,60 Com-
bined active and passive movement (using a robotic device)
3 to 5 times a week for 30 minutes or more for 6 or
more weeks produced positive structure-function outcomes.
Participants obtained increased range of motion, decreased
spasticity,49 elongated muscle fascicles, reduced muscle penna-
tion angle, reduced fascicular stiffness, decreased tendon length,
and increased Achilles tendon stiffness.49,61
Prolonged positioning is effective at a dose of 3 to 5 times
per week for more than 30 minutes for at least 9 months.55
Positioning links structure, in terms of joint motion and func-
tion. Yet, it is unclear as to the mechanism on the structural
level.55 The overlengthened tendons and sarcomeres may be
elongating such that the muscle is more inefficient.55,57 Joint
range of motion is enhanced by changes in movement activity
such as rock climbing, horseback riding, bike riding, and
soccer.
Dosing Muscle Performance. Children with CP gain
muscle strength by performing open-chain progressive resis-
tive exercise, use of functional electric stimulation, loaded sit-
to-stand or functional training, and velocity training using a
total gym or isokinetic dynamometer.62,63 Despite moderate
increases in strength, there is no evidence to support that
resistance training improves walking speed64 or changes in
gross motor function.65 One study demonstrates that resis-
tance and velocity training both increase strength, but only
velocity training produced positive changes in muscle architec-
ture and gait speed.51 Insufficient dose is common for resistance
programs for children with CP, and using parameters estab-
lished by the National Strength and Conditioning Association
is recommended.52,66
Participation-Driven Interventions
Activity-based interventions such as reaching training and
locomotion training use plasticity of body structures and
function to improve activity and participation. Evidence to
support the activity dependency of corticospinal projections
and the development of spinal motor neurons suggests that
lack of activity has a pervasively negative effect on the ner-
vous system.39,67,68 Theories of motor learning69 and motor
control70,71 with evidence for neuroplasticity69,72-74 guide inter-
ventions designed to improve motor control, and place the focus
on plasticity of the central nervous system as the mechanism
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for improving motor control and function. Plasticity of muscu-
loskeletal and cardiorespiratory systems may also contribute to
changes.
Timing for Plasticity of the Central Nervous System.
Although brain plasticity is present throughout life,75 “early in
development there may be a critical period in which the brain
possesses high capacity for reorganization to compensate for
injury and the extent of this period is still unknown.”76(p6) This
critical period has not been identified, but the period immedi-
ately after injury is important. Friel et al77 used an animal model
to demonstrate the effects of reaching training with constraint
of uninvolved side to remediate motor function after develop-
mental injury; early intervention recipients had a greater treat-
ment response.
Prereaching behaviors and the development of reaching
behaviors in infants who are preterm and high risk are dis-
tinguished by lack of movement, speed, and asymmetry.78-80
Intervention early in life81 has potential for improving reaching
behaviors, mitigating the consequences of loss of exploration
and interaction experienced by infants with poor reaching.
The reciprocal movements of the lower extremities are
present at infancy and forward locomotion begins around the
first year of life.82 Infant kicking provides opportunities for
decoupling extremities, producing variability in movement pat-
terns, and developing speed of movement.82 Walking experi-
ence is critical to learning to walk.83 Early locomotion using
BWS accelerates walking in children with Down syndrome,84
and for a child with spinal cord injury has resulted in recovery of
walking abilities.85 The critical period for optimizing gait is not
clear for children with brain injury, although precursor move-
ments occur early in life. Gait speed decreases with age in chil-
dren with CP,86 and adults with CP often stop walking because
of pain and fatigue.87,88 Hence, locomotion training may be
impactful across the lifespan.
Dosing Reaching Training for Changes in Participation.
Reaching training is effective in changing motor abilities for both
bimanual activities and modified constraint-induced therapy.89
A key component of effectiveness appears to be time, with a rec-
ommendation of more than 90 hours of practice.89 Changes in
brain structure and function (eg, diffuse tenor imaging changes
in corticospinal tracts and changes in activation of motor cortex)
have been demonstrated with changes in reaching abilities.90,91
However, the association of changes in reaching abilities and
participation or performance in everyday life is not clear.92 Con-
textual factors may shape participation regardless of changes
in activity level. The essential components of effectiveness of
reaching training to create changes in the central nervous system
and in motor abilities are intensity of practice, the number of
repetitions, the time per session, and the engagement of the
child.89
Dosing Locomotion Training for Changes in Participa-
tion. A systematic review of interventions to improve gait speed
confirms the effectiveness of gait training, whether overground
or using BWS.64 The interventions have similar effectiveness,93
although there is a trend for greater effect sizes in studies with
overground training.64 Studies with locomotion training that
occurred at a frequency of at least twice a week, for 30 minutes,
for greater than 9 weeks had the largest effect sizes.64 Results
Timing and Dose in Pediatrics S41
of several studies report changes at the level of body struc-
tures and function, including improved endurance,94-97 reduced
ankle stiffness,97 increased H-reflex latency,98 and improved gait
kinematics.99 One investigation used coherence of electromyo-
graphy (EMG) analysis as a way of measuring and detecting
changes in the output of the motor cortex and its transmission to
the spinal cord through the corticospinal tract during functional
muscle activation. There was improved EMG-EMG coherence of
anterior tibialis motor neurons of children with CP after training
on an incline treadmill 30 minutes for 30 days consecutively.100
Evidence to link locomotion training with changes in the cen-
tral nervous system structure and function is scarce. Maintaining
gains from locomotion training requires changes in everyday
performance, and little evidence exists to support changes in
participation with changes in locomotion abilities. The optimal
dose is unclear for locomotion training to obtain changes in
activity, body structures, and function and participation.
Participation Interventions
Participation interventions, or context-based interventions,
are those interventions that change the task or the environment,
and do not change the impairments of the child.101 In the path
model (Figures 1 and 3), community and environment influ-
ence dose. Environmental modifications can provide additional
opportunities for movement. If movement is repeated, there
is the potential for changes in body structures and function,
for example to brain, muscle, or bone. Context-based interven-
tions can provide more time for practice, more engagement, and
movement that is self-initiated, all features that promote change.
Interventions occur in the home, school, or community, occur-
ring outside a therapy session.
Timing for Participation Interventions. Optimal timing
for participation interventions appears to be immediately after
birth and throughout lifespan. Evidence supports the impor-
Fig. 3. Path model abbreviated for participation-driven interventions and age at time of interventions.
S42 Gannotti
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Unauthorized reproduction of this article is prohibited.
tance of interaction with the environment for optimal devel-
opment of cognitive, social, emotional, visual, perceptual, and
motor skills during childhood.102,103 Descriptions of typical and
atypical mobility and visuospatial development of infants,104
typical toddler movements in a room, typical infant movements
throughout the day,105 and children’s106 and adult’s spatial
movement patterns in their homes and communities will inform
both timing and dose. Understanding the disparity found in
time, quality, and space of individual environmental interactions
can inform the amount and ages for participation interventions
and may yield sustainable changes in activity and participation
and body structures and function.
Dosing Participation Interventions to Create Change.
The evidence to support an optimal dose for participation-based
interventions is not clear. A randomized controlled trial demon-
strated that context-based interventions are at least as effec-
tive as impairment-based interventions in improving participa-
tion. The authors suggested that perhaps the interventions were
underdosed.107 Although optimal dose of participation inter-
ventions is not known, interventions that provide more time
for practice have potential for driving sustainable change. Tech-
nology can provide new opportunities for participation. A mod-
ified toy car for mobility in the home for children who are not
ambulatory108 provides a high frequency of child-environment
interaction and a high level of engagement. A suspension har-
ness can allow toddlers and children with mobility challenges
the opportunity to safely explore their environment.109 A self-
initiated prone scooter assists infants with floor mobility110 and
allows exploration. Microsensors on infants’ lower extremities
can activate crib mobiles and provide opportunities to improve
lower extremity movement patterns.42 Contextual interventions
can be provided throughout the day, and infants, children, and
adults can spend more time practicing. How much practice is
enough to elicit changes is still unknown.
Pediatric Physical Therapy
PRIORITIES FOR RESEARCH
Six priorities for research are described that have the poten-
tial to impact clinical practice in the next decade.
Dosing Participation Interventions
For pediatric physical therapists to design effective inter-
ventions, which use participation-driven interventions, more
information is needed about the dose of a particular par-
ticipation intervention to change either participation of the
individual, body structures and function, or both. What is
typical participation across developmental ages and activities?
Descriptive longitudinal studies of participation of children,
or interaction of infants and children with and within their
environment, are needed as baseline reference values of typical
child behavior across geographic regions and sociocultural
groups. We need a greater understanding of the mobility
patterns of children and adolescents in their homes, schools,
and communities. More information is needed on typical
infant spontaneous leg and arm movements. We need a greater
understanding of the physical exploration of toddlers of their
environment.
What are the logistics of dosing participation at high intensi-
ties? If high-risk infants and children require sophisticated tech-
nology for participation interventions, can low-cost technology
do the same? How can we build environments to promote par-
ticipation in home, schools, and communities? Can we increase
frequency per week of a particular activity by partnering with
community centers, specialized and nonspecialized fitness cen-
ters, or local physical therapy education programs? Is it real-
istic to think that service delivery models, policy, and payment
sources will support therapists, as we move from center-based
practices to practices in homes, schools, and communities? Will
practice patterns and professional training shift, as pediatric
physical therapists become coaches, trainers, and supervisors
for paraprofessionals and families in the community?
Critical Thresholds
Given the characteristics of the child, family, and environ-
ment, what is that threshold when change occurs at the level
of body structures and function and activity and participation?
What combination of factors is the tipping point at which struc-
ture and function are changed? When will the infant be able
to crawl independently; when the eyes and head coordinate, or
when the infant is very motivated and engaged in obtaining an
object? What combination of factors needs to be in place for a
child/infant to advance in motor skills? How do these factors
vary given individual differences in children, families, and loca-
tions? How do these factors vary given the different motor skills?
Optimizing Dosing Given Genotype
The identification of alleles associated with CP and, more
recently, clinically relevant copy number variation111 detected
in genetic profile of children with CP provide insight as to
why 2 infants can respond differently to the same type of
brain injury or intervention. Do children with certain genetic
characteristics require pharmacological interventions, such as
dopamine, or does the dose of the intervention need to be
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
increased? Does the environment need to be changed, eg,
supporting positive family practices for behavior management
and stimuli or cognitive behavior therapy for the individual
with CP?
Closing the Knowledge Gap About Effective Interventions
for Individuals With Severe Motor Involvement
Limited information on effective interventions for children
GMFCS IV-V exists; although published reports are available
on service utilization, feasibility of intense interventions,112 and
participation interventions to improve health-related quality of
life.113 Patterns of service utilization for children with varying
levels of severity are not clear. Palisano et al114 report children
with more severe involvement ages 2 to 6 years receive more
therapy in clinic and school settings in the United States and
Canada. Conversely, Bailes and Succopl115 report children with
higher GMFCS levels receive less therapy in a large outpatient
medical center in the United States. Data from the National
Survey of Children with Special Health Care Needs reveals chil-
dren with more functional limitations have more unmet needs
for therapy and mobility aids.116 For children with more severe
involvement, patterns of service utilization may vary by geo-
graphic locations or setting, and it is not clear how utilization
patterns are associated with better outcomes in the short or long
term.
Several active clinical trials (clinicaltrials.gov) are investi-
gating effective ways to measure and improve postural control
in children with disability, a significant issue for individuals
with severe gross motor impairment. Later in life, individuals
with severe motor impairment are more likely to incur the
greatest cost for care, as they are at highest risk for depen-
dent care and development of costly secondary conditions.117
Participation interventions dosed appropriately, hold promise
for improving body structures and function, and can promote
health across the lifespan for individuals with severe motor
involvement.
Adult Outcomes
There is a lack of information about interventions to pro-
mote participation of adults with CP. This gap in information
is even more poignant when we consider that adults with CP
outnumber children with CP. The needs of children with CP
as they transition to young, middle, and later adulthood are
largely unmet. We need to establish links between childhood
treatments and positive adult outcomes to investigate whether
efforts for some interventions have effect in the long term.10
How can we harness the potential for change of the cardiovas-
cular, musculoskeletal, and central nervous systems to optimize
health, wellness, and function? What are the needs and the dif-
ferential preventative measures needed for people with different
movement disorder subtypes of CP?118 How can we best address
the physical therapy needs of adults with CP?
Health Services Research
Population patterns in utilization of services, health status,
participation, activity, consumer satisfaction, and cost for
Timing and Dose in Pediatrics S43
rehabilitation services for people with chronic childhood con-
ditions are largely unknown. Disease-specific registries can be
useful to monitor prevalence as well as long-term outcomes, and
cost-benefit ratio. Intervention-specific information, including
discipline type, type of intervention, time, and frequency per
week, is needed as routine data entry information in electronic
health records for hospitals, school systems, and other practice
settings. Developing an infrastructure for quality improvement
is needed to analyze practice patterns.
IMPLICATIONS FOR PRACTICE
Three challenges are provided as an impetus for aligning
practice with evidence. Significant social and financial barriers
exist to meet these challenges, but reflection on these challenges
is warranted.
Are we intervening too late or not at all? We have multiple
tools to identify infants at risk. There is much that can be done
before the child is diagnosed. Many critical periods are immedi-
ately after birth and during the first year of life. How can physical
therapists provide information and services more consistently to
families and infants at risk? Are we taking advantage of muscle
and bone plasticity in middle childhood and throughout ado-
lescence with adequately dosed interventions?
Are we doing enough? Intensity can refer to engagement,
effort, or force production depending on intervention type. Are
interventions dosed appropriately (thousands of repetitions for
motor learning, 70% of 1 repetition max for strengthening) for
effectiveness given the information we currently have? Is current
evidence being used to prescribe exercise to promote changes for
muscle, bone, and brain?
Measurement
Are we measuring what we are doing so we can evaluate
best practice? Measurement is needed within sessions, across
sessions, within hospitals outpatient/outpatient, school, birth to
3. Are we documenting the salient features of the intervention
session? Are we documenting important characteristics of the
child, such as level of severity, cognition, communication, and
family characteristics such as values and coping? How are we
using the data we collect to improve practice?
CONCLUSION
Although parameters for dosing participation are not yet
established, emerging evidence suggests participation at high
enough intensities may yield changes. Given plasticity present
immediately after birth and in the first year of life, intense
participation interventions seem ideal for infants. Participation
interventions if dosed appropriately may provide an additional
avenue to promote change throughout the lifespan. Tech-
nology, social change, and change to the physical environment
hold promise to provide participation interventions at high
frequencies and intensities to promote change. To break the
cycle of accumulated disability in individuals with CP, we need
to continue to work on many fronts: bench science, clinical
S44 Gannotti
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Unauthorized reproduction of this article is prohibited.
science, knowledge translation, advocacy, and institutional
practices.
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Timing and Dose in Pediatrics S47
 S P E C I A L C O M M U N I C A T I O N

Use of Lower-Limb Robotics to Enhance Practice and Participation in Individuals

With Neurological Conditions
Arun Jayaraman, PT, PhD; Sheila Burt, BS; William Zev Rymer, MD, PhD
Max Nader Center for Rehabilitation Technologies & Outcomes, Center for Bionic Medicine, Rehabilitation Institute of Chicago, and Departments of Physical
Medicine & Rehabilitation, Physiology, and Biomedical Engineering, Northwestern University, Chicago, Illinois (Dr Jayaraman); Center for Bionic Medicine
(Ms Burt), Rehabilitation Institute of Chicago, Illinois; and Sensory Motor Performance Program, Rehabilitation Institute of Chicago, and Departments of
Physical Medicine & Rehabilitation, Physiology, and Biomedical Engineering (Dr Rymer), Northwestern University, Chicago, Illinois.

Purpose: To review lower-limb technology currently available for people with neurological disorders, such as spinal cord
injury, stroke, or other conditions. We focus on 3 emerging technologies: treadmill-based training devices, exoskeletons, and
other wearable robots.
Summary of Key Points: Efficacy for these devices remains unclear, although preliminary data indicate that specific patient
populations may benefit from robotic training used with more traditional physical therapy. Potential benefits include
improved lower-limb function and a more typical gait trajectory.
Statement of Conclusions: Use of these devices is limited by insufficient data, cost, and in some cases size of the machine.
However, robotic technology is likely to become more prevalent as these machines are enhanced and able to produce
targeted physical rehabilitation.
Recommendations for Clinical Practice: Therapists should be aware of these technologies as they continue to advance but
understand the limitations and challenges posed with therapeutic/mobility robots. (Pediatr Phys Ther 2017;29:S48–S56)
Key words: exoskeletons, rehabilitation, robot-assisted gait training, robotics, spinal cord injury, stroke

INTRODUCTION Initially developed as a research tool to study motor

As the patient population ages in the United States and
the prevalence of neurological disorders increases, rehabilita-
tive care for individuals with stroke, spinal cord injury (SCI),
and other diseases of the nervous system remains an urgent
issue that poses many unique challenges.1 Regaining functional
mobility and walking ability continues to be a top priority for
people, as recovery after neurological impairments affects suc-
cessful reintegration into society.2 Unfortunately, conventional
treatment options for this patient population are still limited in
achieving desirable levels of functional mobility.
0898-5669/293S-0S48
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Arun Jayaraman, PT, PhD, Rehabilitation Institute of
Chicago, 1771, 345 E. Superior St, Chicago, IL 60611 (ajayaraman@
ricres.org).
Grant Support: HHS grant award number 90RE5010-01-01; NIDILRR
grant number 90RE5014-02-00.
The views expressed in this article are the authors’ own and do not reflect
the official position of any institution or funder.
Dr Rymer is a member of the Scientific Advisory Board for Hocoma Inc. and
Ekso Bionics. The authors declare no other potential conflicts of interest.
DOI: 10.1097/PEP.0000000000000379
learning,3 rehabilitation robots are evolving to help clini-
cians diagnose, treat, augment physical therapy methods,
and promote functional restoration.4,5 In using robots with
other physical therapy interventions, patients may be able to
experience more intense stepping practice and achieve more
typical movement trajectories while reducing the high physical
demands placed on therapists.6 Rehabilitation robots were
initially designed based on studies that supported task-specific,
high-repetition locomotor training therapy, with varying levels
of intensity and repeatability. Therapy with these task char-
acteristics strengthens muscles and exploits plasticity after
neurological injuries.7 Further research in animal models sug-
gests that locomotor training may also induce spinal plasticity
in animals with incomplete SCI.8 Therapeutic robots were
introduced to improve lower extremity function and facilitate
neurological recovery in specific neurological populations while
enhancing the productivity of therapists. Studies are beginning
to investigate whether training with robotic devices can reduce
the prevalence of secondary complications associated with pro-
longed immobility, such as bladder or urinary tract infections,
or circulatory and other medical issues.9-13
The 3 most widely used robotic technologies currently
being evaluated in research settings are treadmill-based robotic
devices, robotic exoskeletons, and other modular wearable
robots. This article focuses solely on devices aimed at improving
lower-limb function.

S48 Jayaraman et al Pediatric Physical Therapy

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
TREADMILL-BASED ROBOTS
Treadmill-based trainers, developed in the past 30 years,
were one of the first types of therapeutic machines specifically
designed to augment physical therapy. With these machines, a
patient’s body weight is supported through an overhead harness,
such that patients can safely begin therapy sessions earlier after
disease or trauma onset, and practice symmetrical loading and
unloading of the limbs. During therapy sessions, clinicians man-
ually assist patients’ legs to help them produce stepping motions
that follow a typical gait pattern.11 By providing task-specific
training, body-weight-supported treadmill training may help
patients practice physiological gait patterns, strengthen lower-
limb muscles, and enhance walking endurance, coordination,
and posture.12
Although this therapy showed great promise in animal
models13 and became a more widely accepted form of therapy
in the 1990s following studies in humans,14 specialized tread-
mills and support systems still required up to 3 or 4 therapists
to manually assist a patient.11 Some patients with severe neuro-
logical conditions could not benefit from this therapy because
of the high physical burden imposed on both the patient and
therapists.
To reduce the demand on physical therapists and provide
more specialized rehabilitation care specific to patient needs
based on dose, intensity, specificity, and variation, motorized
body-weight-supported treadmill training machines emerged
in which a robotic control system helps control and move a
patient’s walking. Most of these devices require 1 or a maximum
of 2 physical therapists to work with 1 patient,12 and devices
included assessment and recording tools to measure progress.
One of the most researched, commercially available robotic
gait training systems is the Lokomat (Hocoma Inc, Norwell,
Massachusetts, and Volketswil, Switzerland), which consists
of a robotic gait orthosis, treadmill, weight support through
a harness, and software that allows patients to participate
in game-like exercises that encourage greater effort.15 It is
available in 3 options: LokomatPro (Figure 1), a smaller
LokomatNanos, and LokomatPro Pediatric. A recently devel-
oped optional “FreeD” module for the LokomatPro supports
balance and correct weight shifts through lateral and rotational
movements of the pelvis. Other commercialized treadmill-
based training machines include the Aretech ZeroG (Aretech,
Ashburn, Virginia) and the Gait Trainer GT I (Reha-Stim Medtec
Fig. 1. The LokomatPro. Picture: Hocoma, Switzerland.
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
GmbH & Co, Berlin, Germany). A few other devices, such as
the Lower Extremity Powered Exo Skeleton (LOPES) and the
PAM/POGO, are currently used in research settings.16-18
Potential Benefits
Treadmill-based robotic devices have been evaluated for
a wide-range of conditions affecting the central nervous
system, including stroke, SCI, Guillain-Barré, and multiple
sclerosis.19-21 We focus only on studies related to SCI and stroke,
2 of the most researched patient populations. Research studies
conducted over the last decade on the potential benefits of these
machines have had mixed results, with some studies showing
that robotic training provides similar results to other therapy,
whereas some studies show superior outcomes.20 We describe
some examples.
SCI. In one study conducted in 29 individuals with
incomplete SCI, Niu and colleagues16 found that the Lokomat
improved walking capacity and speed, with increased effec-
tiveness in combination with the antispasmodic tizanidine in
individuals with limited walking function. Shin et al,17 in a
study evaluating 60 patients with incomplete SCI, indicated that
robotic training resulted in significant improvements in func-
tional skill progression compared with other care. Similarly,
Esclarin-Ruz et al,18 Benito-Penalva et al,22 and Alcobendas-
Maestro et al23 suggest that robotic treadmill has positive effects
on individuals with SCI.
Stroke. A recent study by Bae et al24 examining high-
intensity robot-assisted gait training in patients with chronic
stroke found that therapy with the Lokomat improved patients’
motor function, gait ability, and symmetric pattern compared
with conventional robot-assisted gait training, supporting its
safety and effectiveness. Dundar et al,25 comparing physical
therapy versus physical therapy with robotic therapy, found
that the combined intervention resulted in better improvements
in Functional Independence Measure and Mini-Mental State
Examination scores with patients with subacute and chronic
stroke. Similarly, in recent publications, Bang et al, Uçar et al,
and Schwartz et al have shown significant benefits using robotic
treadmill training in individuals with stroke (chronic and sub-
acute), though it has been noted that more long-term studies
are needed in the chronic population.26-28 Guidelines by the
American Heart Association suggest the importance of robotic
training in the lower limb but also acknowledge inconclusive
results.29
Limitations
Despite potential benefits, the efficacy of robotic treadmill-
based devices remains uncertain. Across studies in individuals
with neurological injuries, improvements seen relative to base-
line and control data often indicate that robotic training is
effective but not significantly better than other therapies.30-35
Mehrholz et al,21 evaluating locomotor training for walking after
spinal cord injury, noted that the strongest evidence to sup-
port treadmill-based machines was limited to case reports or
single cohort studies. Improved walking in neurological pop-
ulations may be due to improvements in volitional strength,
balance, and gait efficiency. However, the authors did not find
Robotics That Target Lower-Limb Function S49
significant differences between different forms of training. Some
of these mixed results could be attributed to the fact that the
early versions of the hardware and software of the robotic sys-
tems were not well matched to the needs of the specific neu-
rologically impaired populations, and that participants did not
volitionally participate in the training and the robot did all the
work.35
Based on our review, research on these devices lacks
structured discussions on whether the studies used appro-
priate patient selection, evaluation, and training strategies. For
example, it is rarely considered whether the study design and
outcome measures are appropriate to both robotic and tradi-
tional intervention groups; whether the specific patient popu-
lations used in the studies were suitable for robotic training;
or whether specific training strategies, progression, and evalua-
tion techniques for each patient population were identified.23-33
Finally, many of these machines are large and expensive; wide-
range use and general agreement on specific clinical needs might
bring costs to affordable levels, thus making these devices more
common in practice.
OVERGROUND LOWER EXTREMITY ROBOTIC EXOSKELETONS
Rehabilitation exoskeletons are emerging as therapeutic
technologies. In comparison to treadmill-based robots, which
are limited by training guided by the machine on a treadmill,
exoskeletons have the potential to provide task-specific over-
ground training as well as personal mobility, for individuals
with lower extremity paralysis or partial paralysis and weakness.
Exoskeletons are marketed for individuals with a wide-range
of neurological conditions, including SCI, stroke, and multiple
sclerosis. Most studies have investigated exoskeleton potential in
persons with incomplete SCI, although research on stroke and
other conditions is forthcoming.36-37
Many of the first exoskeletons were designed for military
applications to augment soldier capability and were massive,
complex machines.38 As batteries, motors, and other mate-
rials have become smaller, rehabilitation exoskeletons specif-
ically designed for therapeutic or personal mobility purposes
are emerging.38 Each class of exoskeleton differs in its control
system and features, but most commercially available devices
include a rigid outer frame, sensors that detect a user’s desired
movements, a computerized controller, motors or actuators,
and lightweight batteries. Exoskeletons are regulated as Class II
(moderate to high risk) devices by the Food and Drug Admin-
istration (FDA). The FDA cited the risk of falling, mechanical
failure, and skin abrasions as potentially adverse events.39 At the
time of publication, 3 exoskeletons (Table 1) have received FDA
approval: the Ekso, ReWalk, and Indego.40-42 The HAL for reha-
bilitation use (Hybrid Assistive Limb; Cyberdyne Inc, Tsukuba,
Japan), a full lower-body exoskeleton for people with SCI or
weakened leg muscles due to other neurological conditions, has
received Conformité Européenne Marking (CE) or conformity
marking [CE 0197], in Europe (similar to FDA) and is being
evaluated in Germany.43 Across the world, more than 2 dozen
exoskeletons are in research or development (Table 2).44
Based on our experience the progression for using an
exoskeleton follows a sequence. Therapists trigger the device
at the early learning stage followed by participants and
family members triggering the device. As users become more

TABLE 1
Commercially Available Exoskeletons in the United States

Device (Manufacturer) FDA Approval Description Intended Population Inclusion Criteria

ReWalk (ReWalk Yes: therapy and Independently controlled
Robotics, Inc) personal mobility bilateral hip and knee joint
motors, a rigid pelvic frame
that links both lower limbs,
ankles comprise double-action
orthotic joints with limited
motion and adjustable
spring-assisted dorsiflexion
Indego (Parker Hannifin Yes: therapy and Consists of a hip segment and
Corporation) personal mobility right and left thigh and shank
segments.40 Four motors, one
at each hip and knee joint,
power movement, and built-in
ankle-foot-orthoses support
the ankles29
Ekso (Ekso Bionics) Yes: therapy Incorporates hip and knee
motors, passive ankles, and
femoral and tibial shanks
support body weight
Motor complete/incomplete Age 18-55; ability to stand using
SCI T7-L5 (for home and a standing device; height
community settings) and between 160 and 190 cm (5 3
T4-T6 (rehabilitation to 6 2 ); weight up to 100 kg
institutions) (220 lb)
Motor complete/incomplete 5 1 to 6 3 , weight under
SCI T7-L5 (for home and 250 lb, passive range of
community settings) and motion at shoulders, hips, and
T4-T6 (rehabilitation knees, and ankles, sufficient
institutions) upper body strength
Motor complete paralysis Functional bilateral upper
C7 or below or stroke extremity strength or
(hemiparesis or functional strength of 1 upper
hemiplegia) extremity and 1 lower
extremity; stroke; adequate
height and weight (weight of
≤220 lb; height between 5 2
and 6 2 ); near normal range
of motion at the hips, knees,
and ankles

Abbreviation: SCI, spinal cord injury.

S50 Jayaraman et al Pediatric Physical Therapy

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 TABLE 2
List of Exoskeleton Businesses/Startups

Company (Location) Project(s)

20 Knots Plus Ltd (Chichester, UK) Marine Mojo

Active Bionics Inc (Ottawa, Canada) MODO
Againer (Riga, Latvia, EU) AGAINER System
AlterG (Freemont, California) Bionic Leg
AxoSuit (Oradea, Romania) AxoSuit
B-Temia (Quebec City, Canada) Revision Military Kinetic Operations Suit (PROWLER), KEEOGO
Bama Teknoloji (Ankara, Turkey) Robo Gait, Visio Gait
Bionic Power (Vancouver, Canada) PowerWalk Kinetic Energy Harvester
Bionik Laboratories (Toronto, Canada) ARKE
Bioservo Technologies AB (Kista, Sweden) Robotic Soft Extra Muscle (SEM) Glove
CYBERDYNE (Ibaraki Prefecture, Japan) HAL, Care Support—Lumbar
Daewoo Shipbuilding & Marine Engineering (Seoul, South Korea) Prototype Phase
Daiya Industry (Okayama, Japan) Pneumatic Power Assist Glove
Ekso Bionics Holdings, Inc (Richmond, California) Ekso, eLEGS, HULC, ExoHiker, Ekso Works, Warrior Web
ExoAtlet (Moscow, Russia) ExoAtlet
Gobio Robot (Carquefou, France) Various exoskeletons for work & industry
GOGOA Mobility Robots (Gipuzkoa, Spain) Hank, Hand of Hope
GoXtudio (Scottsdale, Arizona) N/A
Hocoma (Volketswil, Switzerland) LokomatPro, Armeo
Honda (Tokyo, Japan) Stride Management and Bodyweight Support Assist
Hyundai Motor Company (Seoul, Korea) Hyundai Wearable Robotics for Walking Assistance and Industry
Innophys (Tokyo Japan) Hip auxiliary muscle suit
Interactive Motion Technologies (Watertown, Massachusetts) InMotion ANKLE, InMotion WRIST
Kinetek—Wearable Robotics (Ghezzano, Italy) ALEx, Track-Hold
Kinetic Innovations Ltd (Faygate, UK) Ski∼Mojo
Laevo (Zuid-Holland, Netherlands) Laevo
Lockheed Martin (Maryland) FORTIS, HULC
Marsi-Bionics (Madrid, Spain) Based of Atlas
Mitsubishi Heavy Industries (Tokyo, Japan) Power Assist Suit (PAS) For Nuclear Disasters
Myomo Inc (Cambridge, Massachusetts) MyoPro
Noonee AG (Rüti, Switzerland) Chairless Chair
Otherlab Orthotics (San Francisco, California) Inflatable Soft Exoskeleton
Ottobock (Duderstadt, Germany) C-Brace
Panasonic—Activelink (Kadoma, Japan) Power Loader Light, Power Jacket – REALIVE
Parker Hannifin (Ohio) Indego
PhaseX AB (Gävle, Sweden, EU) Exo-Legs
RB3D (Auxerre, France) Hercule
ReWalk Robotics (Yokneam Ilit, Israel) ReWalk
Rex Bionics (Rosedale, New Zealand) Rex
Rotbot Systems (Nes Ziona, Israel) Crowd Sourced Industrial Exoskeleton
Sarcos LC (Salt Lake City, Utah) XOS 2, XOS 1
SRI International (Menlo Park, California) Super Flex Exosuit, Pediatric Soft Exosuit
StrongArmTech (New York) V22 and FLx
US Bionics/SuitX (Berkeley, California) Phoenix

Source: Exoskeleton Report (http://exoskeletonreport.com/2015/02/businesses-that-have-or-are-exploring-exoskeleton-products-in-alphabetical-order/).

experienced with using the device, they initiate steps by trig-
gering the device independently through movement of their
trunk, shift of center of gravity, or body weight transition. User
progression is also based on the severity, level (in case of SCI)
of the disability, cognitive ability, and their physical tolerance to
be in the device and ability to initiate movements.
The control system for each exoskeleton is unique (Table 1;
Figure 2). For example, one unique feature of the Ekso-
exoskeleton is its variable, smart assist function, which allows
a therapist to adjust the amount of motor and trajectory assis-
tance the machine provides. This alters targets such that users
have to shift depending on their capabilities.40 With the Ekso, a
user must complete forward and lateral weight shifts to initiate
steps predetermined by a trainer. The ReWalk has a watch-like
wireless communicator that can be worn on the user’s wrist, and
steps are based on the user’s minor trunk forward movements.41
The Indego, a modular full lower-body exoskeleton, is operated
through a tablet.42 All movements are based on body position,
specifically the angle of a user’s thigh relative to the ground.
Each device differs in suitability based on an individual’s
level and extent of injury and residual capabilities. It is impor-
tant for clinicians to closely consider a person’s level of injury,
standing tolerance, range of motion, strength, balance and
trunk control, spasticity, skin integrity, as well as device fit and
proper joint alignment. All the commercially available exoskele-
tons come with a detailed training manual, and therapists are
required to attend a training course and be precertified before
using the device with patients.

Pediatric Physical Therapy Robotics That Target Lower-Limb Function S51

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Fig. 2. Commercially available exoskeletons in the United States (from left): Ekso GT, Indego, and the ReWalk Personal 6.0. Photos courtesy of Ekso Bionics, Parker Hannifin
Corporation, and ReWalk Robotics.
Potential Benefits
Preliminary data indicate that exoskeletons have the poten-
tial to help patients improve their ability to initiate gait or
improve gait mechanics through intense overground stepping
practice. Overground stepping practice is important, as it may
activate dormant cortical pathways, exploiting neuroplasticity
and providing muscle loading and sensory feedback for motor
recovery.45 Other potential benefits of long-term exoskeleton
use include improved posture, reduced spasticity, enhanced
bone density, and psychological benefits, as well as reduced sec-
ondary complications affecting cardiovascular, gastrointestinal,
and renal systems.10,46-50 Exoskeletons provide comfortable and
metabolically efficient mobility options, in contrast to cumber-
some long-leg braces for individuals with complete or severe
incomplete SCI. Thus, exoskeletons may provide an alternative
strategy with the same benefits as more labor-intensive, less con-
trolled motor learning strategies.51
A key advantage of exoskeletons is that they are not limited
to a laboratory or clinical setting. Users can wear them in com-
munity and home settings, providing the opportunity to practice
walking outside of a clinic. Exoskeletons may be used for exer-
cise and to promote wellness in outpatient settings. However,
injury risk from falls remains an unresolved issue.39
Multicenter trials evaluating the efficacy of exoskeletons
are ongoing at institutions in North America and Europe, and
will likely expand as the technology progresses.52 In March
2016, the VA announced a 4-year, multicenter trial evaluating
use of the ReWalk for veterans with SCI.53 This efficacy study
will determine whether veterans with chronic SCI who use the
ReWalk improve mental health, bowel and bladder function,
patient-reported outcomes, and reduced total body fat mass,
compared with those who use a wheelchair for mobility. A
study, sponsored by the Department of Defense at the James J.
Peters Veterans Affairs Medical Center in New York, is inves-
tigating whether patients with chronic SCI can achieve suc-
cessful walking over 36 sessions in 3 months with the ReWalk
and Ekso. Outcome measures include the 10-meter walk test,
6-minute walk test, Timed Up-and-Go test, and secondary out-
come measures.9
S52 Jayaraman et al
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Safety and Efficacy
A limited number of studies support the safety and effi-
cacy of exoskeletons for individuals with SCI and stroke. Some
individuals with paraplegia transitioned to limited community
ambulation after only 5, 1.5-hour gait training sessions using
the Indego.54 It has been reported that the Indego requires
less effort than knee-ankle-foot orthoses, and subjects perform
strength and endurance tests 25% to 75% faster.55 In a prospec-
tive study with 8 participants with SCI at the T1 level and
below, the Ekso could also be used safely, when monitored by a
trained therapist.56 People with complete SCI achieved walking
speeds and distances comparable to people with motor incom-
plete injuries, although few changes in leg muscle activation
or neuromuscular health were observed.57 Similar studies with
the ReWalk indicate that it is safe and can provide ambulation
options for individuals with SCI.41
Limitations
Approximately 550 exoskeletons have been sold worldwide
(author’s estimate based on industry information), and product
commercialization has preceded vigorous clinical research. Lim-
ited information is available on disease-state-specific patient
evaluations, training strategies, and device-based therapeutic
strategies to enable the safe and effective use of these devices
for therapeutic purposes and to enhance mobility in individ-
uals with neurological conditions. We do not know the specific
characteristics of the patient populations who could benefit from
these devices.
Exoskeletons have a high cognitive demand. Users must
constantly move to control the device and these motions can
be strenuous. Thus, exoskeletons may not be suitable for
all patients. Further studies on bowel and bladder function,
spasticity, bone density, muscle mass, and the amount of use
needed for physical benefits are required to justify insurance
reimbursement.
Further, hardware and control is constantly adapting and
may not address a person’s specific rehabilitation needs, which
makes it difficult to assess clinical results. Meanwhile, fall
preventions and fall recovery strategies are being tested and
Pediatric Physical Therapy
evaluated and will be implemented into the future versions of
these devices.
MODULAR WEARABLE ROBOTIC DEVICES
As exoskeletons have become smaller and more lightweight,
other single joint or modular wearable robotic devices have also
emerged in the field. Currently, there are more than 2 dozen
modular exoskeletons being tested and evaluated for com-
mercialization. Examples of devices undergoing clinical trials
include the Stride Management Assist® (Honda Research and
Development Company, Ltd, Wako, Japan),58 AlterG Bionic
LegTM (AlterG Inc, Fremont, California),59 and KeeogoTM
(B-Temia Inc, Quebec City, Quebec)60 (Figure 3).
The Stride Management Assist (SMA) is a lightweight
(6.17 lb with battery) device that assists hip joint flexion and
extension.58 Designed for people with weakness because of
stroke or aging, it is worn like a belt and fits around a user’s waist
and thighs. Motors provide support in hip flexion or extension
to help achieve greater stride and thus better physiological gait
assist as needed, based on data obtained from hip angle sensors
located just above the thigh support frame.61 As other examples
of modular robotic devices, the AlterG Bionic Leg and Keeogo
are powered knee exoskeletons used for therapeutic and per-
sonal mobility.59,60 These devices are not approved by the FDA.
Potential Benefits
Emerging modular exoskeletons have the potential to help
restore strength, speed, and endurance in the lower limb while
also being smaller, lighter, and easier to don and doff in compar-
ison to a full-body exoskeleton. However, data are preliminary
and limited to a few peer-reviewed publications and case studies.
In comparing the effects of wearing the SMA with functional
task-specific training on gait parameters in patients with stroke,
Buesing et al62 concluded that individuals who used the SMA
showed additional improvements across more functional gait
parameters compared with task-specific training. The authors
noted that additional research is needed before using the devices
at home. The Keeogo has been studied on persons with multiple
sclerosis, knee and hip osteoarthritis, Parkinson disease, and
Fig. 3. Honda Stride Management Assist (SMA), AlterG Bionic Leg, and the Keeogo. Photos courtesy of HONDA R&D Americas, Inc, AlterG, Inc, and B-TEMIA Inc.
Pediatric Physical Therapy
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peripheral artery disease at institutions in Quebec, Canada.60
It is currently part of a multicenter clinical trial at institutions
in North America aimed at gathering data for FDA approval.60
Research on the AlterG is also ongoing and limited to a few case
series, abstracts, and clinical publications.59 One case series, by
Wong et al,63 found that 3 people who were ambulatory after
stroke used the device during 18 one-hour sessions within a
6-week physical therapy program and improved balance, gait,
and function.
Limitations
These devices are designed for people with mild impair-
ments and do not benefit people with more severe injuries.
Rigid components of these devices limit the use for people with
severe balance problems and joint contractures. Because of the
modular nature of these devices, there are limitations on fitting
based on a user’s weight, limb length, and height. Some are not
available in sizes that could accommodate a range of patients.
There are no defined patient populations and training protocols
have not been established for these modular devices. The lack of
data on device use prevents the identification of other potential
limitations.
PHYSICAL THERAPISTS AND ROBOTIC TECHNOLOGY
The ultimate goal of physical therapy is to help patients
achieve the highest quality of life. As technology evolves, reha-
bilitation robots will gain a widespread role in rehabilitative care
and help patients and therapists achieve defined goals.
The manufacturer, Medicare and other payers, and the FDA
set current guidelines for robotic gait trainers and exoskeletons.
Monitoring by therapists is still required. Guidelines include
generalized procedures for a broad user population. However,
a greater understanding of their use in the clinic and home
is needed. Clinicians must understand the limitations and
advantages of robotic therapies specific to the patient treated.
Regardless of which robotic device is used, standardized patient
evaluation and training strategies and specific clinical outcome
measures have yet to be established, and are necessary to assess
efficacy. The potential of exoskeletons, especially as personal
Robotics That Target Lower-Limb Function S53
mobility devices, has yet to be realized; their speed is far
too slow and they are still too complex and expensive to be
considered viable alternatives to wheelchairs.
We do not know how to best combine or sequence the
various robotic technologies into a coherent therapeutic frame-
work. It is likely that larger treadmill-based trainers, such as the
Lokomat, will perform best when patients are weak and have
limited or no spontaneous walking. In this case, using fixed
guidance gait trainers may reestablish patterned discharge of
neural oscillators in the spinal cord. As locomotor functions are
reestablished, less rigid training systems, which enable and facil-
itate voluntary motion, such as exoskeletons or even overground
support devices like the ZeroG, may facilitate the emergence of
natural locomotion. Finally, if impairment is limited to specific
joints, for example knee flexion or foot drop, localized devices
may be sufficient.
FUTURE DIRECTIONS
Robotic devices continue to evolve and are becoming more
sophisticated, with multiple degrees of freedom and advanced
control algorithms to support complex movements.64 With fur-
ther advances, rehabilitation robots will be developed to aug-
ment functional ability while continuing to promote recovery.
They will become more adaptable, less expensive, and may pro-
vide patients with therapy benefits in a home setting, to further
the continuum of care.
Because of their size and cost, treadmill-based robotic gait
trainers may continue to be limited to large hospitals and to
help patients begin locomotor training earlier. The development
of control strategies that are based on clinical insights will be
important factors in the evolution of these devices.
The future of exoskeletons also presents unique design chal-
lenges for engineers and clinicians. Exoskeletons must become
safer and less expensive to be more realistic personal mobility
options compared with a wheelchair. Future exoskeletons will
likely incorporate functional electrical stimulation to provide
additional control, sensors to provide feedback in real time, and
brain-machine interfaces for enhanced control. It is also fea-
sible that a hybrid exercise-personal mobility exoskeleton will
be developed.
A new generation of soft, wearable robotics and exoskele-
tons is emerging. These technologies use lighter and less con-
straining materials to fit more comfortably while reducing
energy consumption.65 As one example, ReWalk Robotics, in
collaboration with Wyss Institute for Biologically Inspired Engi-
neering at Harvard University, is developing an “assistive exo-
suit” for people poststroke or with multiple sclerosis. This device
transmits power to leg joints through technology similar to
that used in the ReWalk, although the device is less rigid and
lighter in weight than the full-body exoskeleton.66 Finally, new-
generation exoskeletons are expected to include fall preven-
tion and fall recovery strategies into the controls to address
risk of falling, a major potential complication from a safety
standpoint. Other promising areas of research include modular
robots for people with less severe impairments, and advanced
real-time controllers that learn and adapt to a person’s specific
biomechanics.
S54 Jayaraman et al
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Unauthorized reproduction of this article is prohibited.
CONCLUSIONS
Robotics designed to enhance lower-limb recovery and
function continue to evolve, as technological advancements
allow for smaller and more lightweight devices. The field of
robotic devices will continue to progress at a rapid pace. Effi-
cacy of these devices and specific training protocols needed
to optimize their performance remains uncertain. Establishing
clearer guidelines, safety, and feasibility will create possibili-
ties for exoskeletons to become more widely used in clinics
and homes. Therapists should anticipate training with robotic
technologies but should also recognize the limitations of these
devices.
ACKNOWLEDGMENTS
We thank Ann Barlow, PhD, for her help in preparing and
editing the article. We also thank Kate Scanlan, PT, DPT, Kristen
Hohl, DPT, and CK Mummidisetty, MS, for their clinical and
engineering insight.
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S56 Jayaraman et al Pediatric Physical Therapy

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 S P E C I A L C O M M U N I C A T I O N

Research Design Options for Intervention Studies

Michele A. Lobo, PT, PhD; Sarah H. Kagan, RN, PhD, FAAN; John D. Corrigan, PhD
Department of Physical Therapy (Dr. Lobo), Biomechanics & Movement Science Program, University of Delaware, Newark; Department of Biobehavioral
Health Sciences (Dr. Kagan), School of Nursing, University of Pennsylvania, Philadelphia; and Department of Physical Medicine & Rehabilitation
(Dr. Corrigan), The Ohio State University, Columbus.

Purpose: To review research designs for rehabilitation.

Summary of Key Points: Single-case, observational, and qualitative designs are highlighted in terms of recent advances and
ability to answer important scientific questions about rehabilitation.
Statement of Conclusions: Single-case, observational, and qualitative designs can be conducted in a systematic and rigorous
manner that provides important information that cannot be acquired using more common designs, such as randomized
controlled trials. These less commonly used designs may be more feasible and effective in answering many research
questions in the field of rehabilitation.
Recommendations for Clinical Practice: Researchers should consider these designs when selecting the optimal design to
answer their research questions. We should improve education about the advantages and disadvantages of existing research
designs to enable more critical analysis of the scientific literature we read and review to avoid undervaluing studies not
within more commonly used categories. (Pediatr Phys Ther 2017;29:S57–S63)
Key words: observational research, qualitative research, research designs, single-case research

INTRODUCTION and invited the authors to present 3 types of research designs

The purpose of this article is to report on the proceedings
from the Research Design Plenary Session from the IV STEP
2016 Conference on Prevention, Prediction, Plasticity, and Par-
ticipation. The Academies of Pediatric and Neurologic Physical
Therapy recognize that research in the field of rehabilitation
would benefit from using a greater breadth of research designs
0898-5669/293S-0S57
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Michele A. Lobo, PT, PhD, Physical Therapy Department,
University of Delaware, 540 S. College Ave, Room 210K, Newark, DE
19713 (malobo@udel.edu).
Grant Support: Dr Lobo’s contribution to this article was supported by the
Eunice Kennedy Shriver National Institute of Child Health & Human Devel-
opment (NICHD) (1R21HD076092-01A1, Lobo, PI). Dr Corrigan’s con-
tribution was supported by a Traumatic Brain Injury Model System Cen-
ters grant from the National Institute on Disability Independent Living and
Rehabilitation Research (NIDILRR) to The Ohio State University (grant no.
90DP0040-01-00).
This article does not reflect the official policy or opinions of NIDILRR or
NICHD and does not constitute an endorsement of the individuals or their
programs.
The authors declare no conflict of interest.
DOI: 10.1097/PEP.0000000000000380
that could advance rehabilitation science: (1) single case, (2)
observational, and (1) qualitative.
As the profession of physical therapy engages in evidence-
based practice, a medical research model with a focus on ran-
domized controlled trials (RCTs) has been supported to jus-
tify and understand the cost and effect of interventions.1 In the
common hierarchy of research designs, RCTs and meta-analyses
of RCTs are at the top of a pyramidal structure, suggesting they
are superior to the designs below in the structure or to designs
that are not in the structure (Figure 1).2,3
Although RCTs can be useful for answering many questions
in rehabilitation especially related to pharmaceutical trials, there
are other research questions that can best be answered using
less common research methods and designs. Publications have
increased for disciplines outside of health sciences such as edu-
cation and psychology that use these less common designs. Fed-
eral funding agencies like the Institute of Education Sciences
(US Department of Education) have an objective to support
the development of improved statistical analysis techniques for
these less commonly used methods, recognizing their value in
helping us understand how to best optimize therapeutic out-
comes. Measures to report and evaluate the quality of research
using these designs have been developed.4-6
We define single-case, observational, and qualitative
research designs and describe the use of these designs to inform
researchers and clinicians in rehabilitation science professions.
Table 1 lists recommended readings.

Pediatric Physical Therapy Research Design Options for Intervention Studies S57

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Unauthorized reproduction of this article is prohibited.

Fig. 1. The common hierarchy of research design positions RCTs and studies ana-
lyzing and reviewing these trials at the top. Single-case designs and qualitative
research designs are not depicted in this hierarchy, and observational designs
are positioned lower on the hierarchy, incorrectly suggesting these categories of
studies cannot be as rigorous and informative as RCTs. RCT indicates randomized
controlled trials.
SINGLE-CASE RESEARCH DESIGNS
Single-case research designs (SCDs; single-subject, single-
participant, n = 1, intrasubject designs) include the repeated
observation of outcomes (dependent variables) across time
under different levels of at least one intervention (manipu-
lated independent variable).7 These studies include phases that
can vary in length from minutes to months or longer during
which the intervention condition manipulated. Repeated mea-
surements occur throughout each phase and at least one of the
phases is a baseline. Case studies and case series are not exam-
ples of SCDs because they do not typically involve controls for
the levels of intervention across time.8,9
SCDs should involve more than one participant to improve
external validity, the ability to generalize the results to a larger
population.8,9 For this reason, statisticians and methodologists
support the use of SCD rather than terms suggesting a single
participant as a key feature.
SCDs can be designed to test a causal relationship between
an intervention and an outcome.8,9 Therefore, SCDs have
external validity and internal validity. Causality is demonstrating
through repeatability. For instance, when the effects of an
intervention are observed immediately after intervention and
behavior reverts to baseline when the intervention is removed,
repeatability is supported. Repetition can be demonstrated using
multiple phase designs such as ABA, ABAB, ABABA, where A
signifies a baseline phase (no intervention) and B signifies an
intervention phase. This design is useful for studies using feed-
back, task modification, environmental supports, or technolo-
gies (eg, mobility devices, robotics, and exoskeletons) when
rapid improvements during intervention with function reverting
to baseline after removing the intervention are both expected
(Figure 2).
For educational and procedural interventions, immediate
effects are not typically observed and return-to-baseline func-
tion at the end of the intervention phase is not commonly
observed nor is it desirable. Repeatability and determination of
causality in these interventions can be achieved when the effects
of the intervention are repeated across multiple participants.8,9
For example, causality is not determined from an AB design
with 1 participant. If similar effects are observed across mul-
tiple participants using this design, causality is strengthened.
Although participants are not randomly assigned to groups,
they can be randomly assigned to intervention levels. A causal
relationship can be inferred from a multiple-participant AB
design if participants are randomly assigned to interventions
during which baseline length or start time of intervention phase
is varied.10 This may be important when improvements in func-
tion could be attributed to experience, maturity, or recovery. For
example, an intervention to improve sitting with a baseline from
4 to 6 months of age and an intervention beginning at 6 months
of age is confounded by sitting independence typically emerging
at 6 months of age. The sitting intervention study could
Fig. 2. A fictional A1 B1 A2 B2 single-case study design that tracks distance travelled
by an individual with movement impairments in the community with and without
a powered mobility device. A1 represents the first and A2 the second baseline
phase (distance travelled without the device); B1 represents the first and B2 the
second intervention phase (distance travelled with the device). A clear difference is
observed in the level/amount of community mobility observed between periods of
device use and nonuse, suggesting the change in amount of mobility was caused
by the use of the device.

TABLE 1
Suggested Readings

Carter R, Lubinsky J. Rehabilitation Research: Principles and Applications. 5th ed. St Louis, MO: Elsevier, Inc; 2016.
Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Washington, DC: Sage Publications, Inc; 2013.
Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Washington, DC: Sage Publications, Inc; 2013.
Gast DL, Ledford JR. Single Case Research Methodology: Applications in Special Education and Behavioral Sciences. 2nd ed. New York, NY: Routledge; 2014.
Horn SD, Corrigan JD, Dijkers MP. Traumatic brain injury rehabilitation comparative effectiveness research: introduction to the traumatic brain
injury-practice based evidence archives supplement. Arch Phys Med Rehabil. 2015;96(8):S173-S177.
Kratochwill TR, Levin JR. Single-Case Intervention Research. Washington, DC: American Psychological Association; 2014.

S58 Lobo et al Pediatric Physical Therapy

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Fig. 3. A fictional multiple baseline AB single-case study design that tracks independent sitting time for infants at risk for delays. A represents the baseline phase when no
intervention is provided; B represents the intervention phase when the sitting intervention is provided. Participants began the study at 4 months of age, but participant 1
began the intervention at 5 months, participant 2 at 6 months, and participant 3 at 7 months of age. Independent sitting typically emerges around 6 months of age. Duration
of independent sitting changed with respect to the onset of intervention rather than in relation to age, strengthening the suggestion that the intervention caused the change
in sitting behavior.

randomly assign participants to begin baseline at 4 months and if the baseline is from 0 to 30 days after stroke and the inter-
begin intervention at 5, 6, or 7 months (Figure 3). Similarly, vention begins at day 31. Here, the baseline could begin imme-
natural recovery, rather than the intervention, may account for diately after stroke, with participants randomly assign to begin
changes in outcomes for people in a stroke rehabilitation study intervention at 1, 2, or 3 months poststroke.

Pediatric Physical Therapy Research Design Options for Intervention Studies S59

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 A variety of statistical techniques can be used to analyze
data from SCDs. The US Department of Education funded
the development of improved analysis techniques for these
designs.8,9,11,12 An example of a more recent analysis technique
includes randomization analysis in which P values can be deter-
mined for individual participants and then analyzed using meta-
analysis techniques across multiple participants in the same
study.13-15
The key characteristics of RCTs can be incorporated into
SCDs. These include randomization of participants to condi-
tions, comparison of intervention outcomes with control out-
comes, identification of causal relationships between inter-
ventions and outcomes, generalization of the outcomes.8,10,16
SCDs can address confounding variables, a key limitation
of RCTs and other group designs.8,9 When designing group
studies, researchers must identify confounding variables that
may impact outcome. These could be a long list of variables such
as strength, age, time from injury, gender, social support, med-
ication use, and cognitive level of participants. Researchers aim
to control these confounding variables by randomizing partic-
ipants to groups and large samples, with the assumption that
levels of confounding variables are evenly represented among
the groups. It is not always possible to identify all confounding
variables or to have sufficient sample sizes. An important benefit
to SCDs is that each participant serves as his/her own control.
Most confounding variables will therefore be the same across
conditions for each participant. SCDs require fewer participants
and resources to answer rehabilitation questions. They support
high-quality, controlled research studies in real-world natural
and clinical settings. SCDs also reduce the gap between research
and practice by reporting individual changes, where therapists
serve people, rather than reporting group averages that may not
represent any one individual. SCDs provide details of process
and change in relation to interventions by collecting data more
frequently on fewer participants. These designs offer an ethical
intervention design for people when withholding an interven-
tion compromises safety or ethics.8,9
OBSERVATIONAL RESEARCH DESIGNS
There are a variety of observational research designs. Obser-
vational studies make comparisons of differences among people
with a condition when observed at a single point in time (ie,
cross-sectional designs), change over time among people with a
condition (ie, case series or, with large data sets, longitudinal
designs), change over time among people with and without
the condition of interest (ie, retrospective or prospective cohort
designs), and differences between people with a condition and
those selected for specific similarities who do not have the con-
dition (ie, case control). These types of studies can take advan-
tage of large data sets.
One difference between observational designs and experi-
mental designs (eg, RCTs) is that causality cannot be concluded
from relationships described in observational studies. Observed
associations may be due to a variable that was not measured
but is related to both predictor and outcome. Randomization
in experimental designs accounts for this possibility in a way
that observational designs cannot. However, causality can be
S60 Lobo et al
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Unauthorized reproduction of this article is prohibited.
suspected when an association has specific characteristics: a
relationship is found consistently in multiple studies with
varying samples, methods, and predictors; a monotonic rela-
tionship is observed between a variable and a hypothesized
effect (sometimes called a “dose relationship” because the greater
the magnitude of the predictor, the greater the effect on the out-
come); or, a study includes all known or suspected covariates in
an analysis of the relationship, thus, ruling them out as sources
of the association. However, some people do not believe that
causality can be established without an experimental design.
This decade has seen the creation and development of mul-
tiple large data sets with outcomes for populations with neuro-
logical conditions, including traumatic brain injury (TBI). Two
of these data sets were specifically designed to evaluate reha-
bilitation outcomes after TBI: the TBI Model Systems National
Database (TBIMS-NDB)17 and the TBI Practice Based Evidence
(TBI-PBE) Study.18 Both data sets examine rehabilitation out-
comes using observational designs, yet differ in structure and
composition and, as a result, the observational methods used to
examine treatment outcomes.
The TBIMS-NDB is funded by the National Institute on
Disability, Independent Living and Rehabilitation Research, US
Department of Health and Human Services since 1987.17 It
houses data on participants older than 16 years with mod-
erate to severe TBI treated for inpatient rehabilitation at one
of the participating centers. Data are collected about prein-
jury status, injury and inpatient rehabilitation, and longitudinal
progress at 1, 2, and 5, years and every 5 years thereafter. As
of March 31, 2016, the TBIMS-NDB included approximately
15 000 participants giving 50 000 interviews, with some inter-
views 25 years postinjury. Critical to its utility as a longitu-
dinal data set, the TBIMS-NDB has follow-up rates exceeding
82% across all years.19 Standardized protocols for data collec-
tion result in very high test, retest reliabilities for follow-up
measures.20
The TBIMS-NDB yielded hundreds of peer-reviewed
articles. One important contribution is the longitudinal
analyses. Analytic techniques, including individualized growth
curve analysis, support a different understanding of long-term
recovery after TBI. As the TBIMS-NDB gains cases at the 15-,
20-, and 25-year follow-up, more insight is expected into the
interaction with comorbidities as well as the effects of aging.
These discoveries are aided by increasingly sophisticated ana-
lytic techniques for longitudinal data.
Another TBI database, the TBI-PBE, uses a “Practice-Based
Evidence” approach to observational research that was first used
by Horn et al18 in acute hospital care and nursing homes.
PBE studies take advantage of naturally occurring variations in
treatment patterns.18,21 Data are analyzed regarding the effect
of interventions on outcomes taking into account a myriad
of patient differences. PBE studies differ from other observa-
tional studies in that they include detailed information about
the participants, their disease states, and the interventions. This
research technique was first extended to rehabilitation in a
study of stroke,22 which was followed by a study of spinal cord
injury23 and joint replacement.24
The TBI-PBE study was funded in 2007 to collect data
on participants older than 13 years with TBI treated at
Pediatric Physical Therapy
10 rehabilitation centers in the United States and Canada.25 The
data set contains information about treatment during rehabili-
tation. Point-of-care (POC) forms capture details of each treat-
ment episode, each day, provided by each member of the reha-
bilitation team. There are an average of 165 POC forms per
patient, nearly 6 forms for each day of stay. The TBI-PBE data
set has yielded many results, and the data set continues to be
analyzed.
The Propensity Score Analysis26 from the TBI-PBE study
is an analytic technique that is gaining attention. A propen-
sity score is calculated for each case in the data set and is
the probability that a given individual would receive a specific
treatment. The score is derived from prediction models applied
to baseline characteristics known before the initiation of the
treatment. There are multiple approaches to matching the sam-
ples for their propensity score that, when successful, allow the
researcher to examine outcomes for a group of participants who
received a treatment when compared with a group that had
an equal chance of receiving the treatment but did not. The
Propensity Score Analysis is evolving and requires skilled statis-
ticians to assist the researcher. However, the potential to sim-
ulate randomization in historical data sets could be a powerful
tool.
The TBIMS-NDB and TBI-PBE studies illustrate the appli-
cation of observational techniques to the study of rehabilitation
outcomes. Their strengths are different: the detailed treatment
data in the TBI-PBE study provide opportunities for under-
standing inpatient TBI rehabilitation interventions, whereas
the extensive longitudinal scope of the TBIMS-NDB is an
unprecedented window into the long-term effects of TBI. A
characteristic of both data sets is the rigor used during data
collection. As data sets become more available with the elec-
tronic capture of clinical records, we have greater opportunities
to apply observational methods. However, our methods will
be only as good as the data captured. Greater prospective
quality control in record keeping may be necessary to take full
advantage of the electronic medical record for research.
QUALITATIVE RESEARCH DESIGNS
Designs in qualitative research are similar to those employed
in positivist (the scientific philosophy of measurable verifica-
tion) quantitative research, but those familiar designs are used
differently.16 Postpositivist qualitative research presumes and
privileges multiple subjective truths in human experience as
opposed to the objectivist single truth of positivist quantitative
research. Hence, within-group variation of an experience and
subjective reflection on that experience are important in deter-
mining nature and scope of investigation.
The terms “design” and “methodology” are sometimes used
synonymously, typically obscuring the full range of methods
from design through analysis. Data collection techniques are
sometimes misrepresented as a method, for example, refer-
ence to focus group technique as a stand-alone qualitative
method.27 However, such use obscures understanding overar-
ching methods employed from approach through design to spe-
cific methodological traditions and techniques, limiting sub-
stantiation of scientific quality.28 Critically, the intent of a study,
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
along with specific research questions to be investigated, must
guide selection of study design as well as a specific method. Data
collection techniques are matched to the method rather than
to the design. Sources of text or visual data such as videos or
photographs include spoken and written words from individ-
uals and groups. Data are obtained from interviews, events, doc-
uments, or other records of the experience under study. Clarity
regarding alignment of approach and method with design and
data collection is essential to successfully designed qualitative
research and delivery of high-quality results.
Qualitative research uses a variety of specifically defined
methods, anchored in specific behavioral, cultural, or social the-
ories, in philosophy, or in an explicitly atheoretical orientation,
to describe and interpret human experience. Where quantita-
tive research most broadly aims to tell clinicians what to do
under a specific set of circumstances, qualitative inquiry com-
monly attends more closely to illuminating how to be, what it
is to experience a state, process, or situation, and how these
experiences feel or what they mean. These human experiences
represent various facets of being and meaning, and with conse-
quences for the person receiving physical therapy as well as the
physical therapist.
Qualitative research, as in quantitative research, uses time
as a prominent dimension of human experience to define
research design. Time undergirds processes, relationships, and
other experiences of interest in physical therapy research. Time
is often represented in chronological terms, for example, at
different points after therapy is initiated. However, gauging
response to or understanding of an event like an injury or ill-
ness may be better represented in narrative or experiential time.
Qualitative designs offer capacity to make use of cross-sectional
or longitudinal time perspectives by matching data collection
methods (eg, individual or group interviews as opposed to field
observation) to the representation of time-specified design of
the study. Finally, any qualitative design is amenable to different
levels of analysis required to address individual, group, commu-
nity, or defined case as the focus of inquiry.
Time frames possibilities for describing and interpreting
phenomena of interest in qualitative research design. The phe-
nomenon may be approached in “snap shot” form using cross-
sectional designs. Cross-sectional design offers flexibility in
accruing participants, used with the goal of understanding a
single or multiple points of interest in an experience. Iso-
lating a point or points of interest in the phenomenon under
study implies a chronological perspective and suggests that
participants are recruited in relation to predetermined times.
Alternatively, emphasizing narrative or experiential time implies
using cross-sectional design to gather a variety of perspectives
from different points across an experience. This sense of cross-
sectional design enables participants to reflect on their experi-
ences and allows investigators to analyze across an experience,
capturing how it evolves over time across participants. In con-
trast to cross-sectional design, longitudinal design in qualitative
work offers potential to represent intraindividual experiences
over time. Narrative methods, phenomenology, and participa-
tory methods like photo-voice and appreciative inquiry typically
value longitudinal design with engagement of participants over
the duration of an experience. Qualitative case study design may
Research Design Options for Intervention Studies S61
make use of either chronological or narrative interpretations of
time, as the case is defined and data sources identified.29
Qualitative research relies on participant engagement, over
time, to delimit the scope and nature of an investigation. As a
result, the role of participants in qualitative studies of any design
is prioritized in relation to that of the investigator. Typically, the
investigator becomes the agent of data collection in contrast to
positivist quantitative science where measures and instruments
are used. There is a range of roles for participants depending
on the investigator’s approach and on the method used. Par-
ticipant involvement may appear similar to quantitative studies
where qualitative data are collected and analysis may be verified
through member checking and other strategies. Conversely, par-
ticipants may be more engaged with inception of a study, cocre-
ating and serving as researchers as in participatory and action
methods. Qualitative case study design uses participant engage-
ment differently, depending on the nature of the case. Reflec-
tion on the extent of partnership with participants to whom the
phenomenon under investigation belongs helps refine design,
leading to more precise identification of the best method suited
to the phenomenon and investigative partnership.
Qualitative designs, while similar to quantitative research,
differ in the way in which underlying principles, drawn from
postpositivist paradigms of science, guide design selection and
development. The role of participants, representation of time,
and focus of analysis are critical to defining design. Aligning
design with aim, method, data collection, and analytic technique
support a successful qualitative study. Design is most broadly
understood as cross-sectional or longitudinal, with either cat-
egory requiring a match to the elements of the experience to
be explored. The option of defining a case as the focus of a
study further refines qualitative design when considering com-
plex, multilayered phenomena. Determining the extent of part-
nership desired with participants further refines design and
thus commensurate identification of method and data collection
techniques.
DISCUSSION
There is a need for physical therapy to acknowledge that
there are many rehabilitation research questions that can best
be answered using single-case, observational, or qualitative
research designs. We are a profession that values problem
solving and determining the optimal intervention for a person.
We teach our students to avoid “one size fits all” approaches that
claim to work for everyone. Rather, we educate students to criti-
cally think about each person’s needs, to review the evidence on
potential interventions, and to determine the optimal interven-
tion for each client.
We propose that this same thought process should be
applied when selecting the best design to answer a spe-
cific research question and applied when teaching students to
review literature, articles for publication, and grants. A redesign
of the common research design hierarchy would be useful.
The redesign should focus on the design characteristics that
strengthen internal and external validity, with examples of a
variety of designs that describe each of those design character-
istics. This would replace the ranking of specific design cate-
gories. The hierarchical ranking of research designs presumes
S62 Lobo et al
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Unauthorized reproduction of this article is prohibited.
that designs within each of the categories are all of higher quality
than any design in lower ranking categories. This would empha-
size research designs that now fall lower on the pyramid and
could incorporate useful designs that are not currently listed in
the pyramid.
Physical therapists are typically well educated to appreciate
the advantages of RCTs and meta-analyses but may lack edu-
cation in other types of research design and methods. This can
result in a variety of inaccurate assumptions. For instance, RCTs
and meta-analyses of RCTs are generally considered optimal for
answering most research questions related to intervention, and
other designs are often dismissed as weaker or simply as a step
in the process of moving toward an RCT.1,2 Qualitative mea-
sures may be dismissed as not being objective.30 Basic statis-
tics courses teach that studies with fewer than 30 participants
may be dismissed as too small to be useful.31 These are exam-
ples of possible assumptions that can reflect a lack of under-
standing of the benefits of less commonly used research designs.
These assumptions may have negative consequences such as
enabling the dismissal of entire bodies of literature and research
designs that can be informative for clinicians and deterring
those without extensive resources from engaging in the research
process.
We advocate for a problem-solving-based approach to
research design and evidence review, whereby the research ques-
tion, feasibility, ethical, and safety issues are considered when
determining the optimal research design. We propose this will
result in the implementation of a larger variety of research
designs and will enhance the quality and depth of our under-
standing of the interventions and the individuals we serve.
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1. Jewell DV. Guide to Evidence-Based Physical Therapist Practice. 3rd ed.
Burlington, MA: Jones & Bartlett Learning; 2015.
2. Garattini S, Jakobsen JC, Wetterslev J, et al. Evidence-based clinical
practice: overview of threats to the validity of evidence and how to min-
imise them. Eur J Intern Med. 2016;32:13-21.
3. Graham JE, Kannarkar AM, Ottenbacher KJ. Small sample research
designs for evidence-based rehabilitation: issues and methods. Arch Phys
Med Rehabil. 2012;93(8):S111-S116.
4. Tate RL, Perdices M, McDonald S, Togher L, Rosenkoetter U. The
design, conduct and report of single-case research: resources to improve
the quality of the neurorehabilitation literature. Neuropsychol Rehabil.
2014;24(3/4):315-331.
5. Tate RL, Perdices M, Rosenkoetter U, et al. The Single-Case Reporting
Guideline in Behavioural Interventions (SCRIBE) 2016 Statement
(Reprinted from Arch Sci Psychol, vol 4, pg 1-9, 2016). Phys Ther.
2016;96(7):932-932.
6. Trainor AA, Graue E. Evaluating rigor in qualitative methodology and
research dissemination. Rem Spec Educ. 2014;35(5):267-274.
7. Onghena P. Single case designs. In:Everitt BS, Howell DC, eds. Encyclo-
pedia of Statistics in Behavioral Science. Vol 4. Chichester, England: John
Wiley & Sons, Ltd; 2005:1850-1854.
8. Kratochwill TR, Levin JR. Single-Case Intervention Research. Washington,
DC: American Psychological Association; 2014.
9. Richards SB, Taylor RL, Ramasamy R. Single Subject Research: Applications
in Educational and Clinical Settings. Belmont, CA: Wadsworth; 2013.
10. Kratochwill TR, Levin JR. Enhancing the scientific credibility of
single-case intervention research: randomization to the rescue. Psychol
Methods. 2010;15(2):124-144.
11. Levin JR, Ferron JM, Kratochwill TR. Nonparametric statistical tests for
single-case systematic and randomized ABAB…AB and alternating treat-
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12. Parker RI, Hagan-Burke S. Useful effect size interpretations for single
case research. Behav Ther. 2007;38(1):95-105.
13. Bulte I, Onghena P. An R package for single-case randomization tests.
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14. Bulte I, Onghena P. Randomization tests for multiple-baseline designs:
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15. Gage NA, Lewis TJ. Hierarchical linear modeling meta-analysis of single-
subject design research. J Spec Educ. 2014;48(1):3-16.
16. Ponterotto JG. Qualitative research in couseling psychology: a primer
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17. Dijkers MP, Harrison-Felix C, Marwitz JH. The traumatic brain injury
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Research Design Options for Intervention Studies S63
 S P E C I A L C O M M U N I C A T I O N

Knowledge Translation in Rehabilitation: A Shared Vision

Jennifer L. Moore, PT, DHS, NCS; Keiko Shikako-Thomas, OT, PhD; Deborah Backus, PT, PhD
South Eastern Norway Regional Knowledge Translation Center, Sunnaas Rehabilitation Hospital, Oslo, Norway, and Rehabilitation Institute of Chicago,
Illinois (Dr Moore); School of Physical and Occupational Therapy, McGill University, and Center for Interdisciplinary Research in Rehabilitation of the Greater
Montreal, Montreal, Quebec, Canada (Dr Shikako-Thomas); and Shepherd Center (Dr Backus), Atlanta, Georgia.

Purpose: Advances in rehabilitation provide the infrastructure for research and clinical data to improve care and patient
outcomes. However, gaps between research and practice are prevalent. Knowledge translation (KT) aims to decrease the gap
between research and its clinical use. This special communication summarizes KT-related proceedings from the 2016 IV
STEP conference, describes current KT in rehabilitation science, and provides suggestions for its application in clinical care.
Summary of Key Points: We propose a vision for rehabilitation clinical practice and research that includes the development,
adaptation, and implementation of evidence-based practice recommendations, which will contribute to a learning health
care system. A clinical research culture that supports this vision and methods to engage key stakeholders to innovate
rehabilitation science and practice are described.
Conclusions: Through implementation of this vision, we can lead an evolution in rehabilitation practice to ultimately prevent
disabilities, predict better outcomes, exploit plasticity, and promote participation. (Pediatr Phys Ther 2017;29:S64–S72)
Key words: evidence-based practice, knowledge translation, rehabilitation

INTRODUCTION enced harm as a consequence.5,6 These shortfalls lead to sub-

The Institute of Medicine (IOM) characterizes today’s health
system as a 3-stage process, including knowledge development
(science), translation into medical evidence, and application
of evidence-based care to patients.1 The IOM also described
prominent inefficiencies in each stage that result in missed
opportunities, waste, and harm.1 Delivery of health care is
increasingly fragmented, medical conditions are increasingly
complex, and patient care is more demanding and costly.2-4
More than half of the patients receive care that is not evi-
dence based, and approximately one-third of patients experi-
0898-5669/293S-0S64
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Keiko Shikako-Thomas, OT, PhD, School of Physical and
Occupational Therapy, McGill University, 3654 Promenade Sir-William-
Osler-D30, Montreal, QC H3G 1Y5, Canada (keiko.thomas@mcgill.ca).
Grant Support: Department of Health and Human Services, Administra-
tion for Community Living, NIDILRR grant number 90RT5027 (Dr Moore);
NeuroDevNet Network of Centers of Excellence, Canadian Institutes of
Health Research, Edith Strauss Knowledge Translation in Rehabilitation
Projects (Dr Shikako-Thomas); and National Multiple Sclerosis Society,
National Institute on Disability, Independent Living, and Rehabilitation
Research (Dr Backus).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000381
optimal quality, safety, and outcomes (Figure 1).1
Although the IOM was referring to the US health care
system, rehabilitation research suggests that current clin-
ical practice in rehabilitation may be consistent with this
description. High-quality rehabilitation evidence is exponen-
tially growing, resulting in knowledge development, and a rapid
improvement in our understanding of rehabilitation science.7-9
Technological innovations in data collection and analytics pro-
vide the infrastructure to use clinical data to improve quality and
outcomes, and to generate new knowledge.10,11 As a result of
scientific advances, rehabilitation providers have access to evi-
dence that can help prevent complications, predict rehabilita-
tion outcomes, exploit nervous system plasticity, and optimize
life participation. However, more than 17 years may pass before
this research is used in clinical practice.12 Routine rehabilitation
practice across practice settings and geographical locations does
not consistently integrate evidence,13-18 suggesting a critical gap
in the translation and application of science into practice.
Knowledge translation (KT), a new area of science and prac-
tice, aims to decrease this gap between research, evidence, and
clinical practice.19 The Canadian Institutes of Health Research
defines KT as “a dynamic and iterative process that includes syn-
thesis, dissemination, exchange and ethically-sound application
of knowledge to improve the health of [the population], provide
more effective health services and products and strengthen the
health care system.”20 KT research examines the determinants
of knowledge (ie, evidence) use and the effectiveness of strate-
gies to promote its use. KT practice focuses on implementation
of evidence and evaluation of its effect.19 KT includes “letting

S64 Moore et al Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
 Fig. 1. The IOM’s schematic of today’s health system. Republished with permission of IOM (Institute of Medicine).1

it happen” by publishing data (diffusion), distributing resources A VISION FOR EVIDENCE-BASED PRACTICE AND
to “help it happen” (dissemination), and actively implementing PRACTICE-BASED RESEARCH
evidence to “make it happen” (implementation) in clinical and To transform clinical practice and research, we must share
real-life settings.21 Several theoretical frameworks and models a vision and an understanding of its importance. We pro-
inform KT initiatives.22,23 pose a vision for rehabilitation clinical practice and research
The implementation of evidence into practice requires col- that includes development and adaptation of evidence-based
laborative efforts to overcome barriers such as limited access practice (EBP) recommendations, systematic implementation
to articles, lack of understanding of critical appraisal and evi- of these recommendations, and development of a learning
dence application, and time limitations that prohibit finding health care system that facilitates use of clinical data for quality
and evaluating appropriate articles.24-26 Although other indi- improvement and generation of knowledge (Figure 2). This
vidual, organizational, and political barriers exist, rehabilitation- vision vastly differs from the description of the current health
specific barriers should also be considered.25,27 Limited funds care system provided by the IOM (Figure 1), which illustrates
and reimbursements often result in short episodes of care28 and the health system as a linear model with several missed oppor-
treatment time is often distributed among many interventions, tunities, waste, and harm. As depicted in Figure 2, the proposed
possibly to target competing rehabilitation goals.29,30 As a result,
novel treatment interventions may not be used or the dose
of each intervention is substantially lower than recommended
doses recommended.13,30-33 This can potentially lead to subop-
timal facilitation of change through plasticity and recovery. Suc-
cessful KT efforts require openness to change, time, and collab-
orative efforts among rehabilitation providers and stakeholders.
Good examples exist such as strategies employed during
guideline development for upper limb treatments in people
poststroke,34 and the subsequent development of intensive
upper extremity training for children with hemiplegic cerebral
palsy.35
Albert Einstein stated, “The world as we have created it
is a process of our thinking. It cannot be changed without
changing our thinking.”36 To innovate rehabilitation practice
and research, improve its evidence base, and rapidly imple-
ment scientific advances, we must collaborate, secure resources,
and shift efforts and thinking toward developing a clinical
research culture that fosters coordinated KT activities.37 We
describe a vision for scientifically grounded clinical prac-
tice, a clinical research culture that supports this vision,
and the stakeholders that should be engaged to innovate
rehabilitation. Fig. 2. A vision for clinical practice and research.

Pediatric Physical Therapy Knowledge Translation in Rehabilitation S65

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
vision includes a circular model in which data collected within and creation of user-friendly EBP documents. The “to action”
clinical practice inform research and are used to improve care cycle requires problem identification, assessment of facilita-
quality. Furthermore, preferences and priorities of stakeholders, tors and barriers, local adaptation of evidence (as previously
such as patients, policy makers, clinicians, and administrators, described), KT interventions (ie, audit and feedback, mentoring,
are completely integrated. Although this vision is novel to the education sessions, etc), monitoring use, outcomes assessment,
field of rehabilitation, it was created using existing KT theories, and sustaining the practice. Several studies have demonstrated
the EBP literature, and the learning health care system as a foun- positive outcomes after using the K2A framework to implement
dation. If adopted, each component of the vision should be a evidence including studies of balance and gait assessment,52
part of entry-level education, as well as postprofessional training dysphagia,53 and vocational rehabilitation.54 As new practices
for rehabilitation clinicians, scientists, and academicians. are implemented, data collection in each phase of the K2A
cycle can assist in determining success of implementation (ie,
Development and Adaptation of Practice Recommendations change in clinician behavior and/or improved patient out-
The first step to implementing EBP is the prioritization comes), ensuring ongoing quality improvement and generating
and use of assessments and interventions that are supported new knowledge.19
by high-quality evidence.19 Clinical practice guidelines and
systematic reviews provide guidance. Publication of guidelines Development of a Learning Health Care System
does not directly improve practice38 ; therefore, after guide-
The IOM recommends that health care organizations
lines are published, differences in organizational, regional,
develop a learning health care system (LHCS) that integrates
or cultural circumstances may require guideline adaptations
clinical operations, research, patient engagement, and a robust
to facilitate their use.19 Stakeholders should collaborate by
technology infrastructure to improve health care quality and
providing recommendations for the guideline adaptation
generate new knowledge.1,55 Within an LHCS, the standard-
while protecting the integrity of the evidence, transparently
ization and reporting of assessments improve care delivery,
reporting methods, considering rehabilitation context, and
increase transparency of outcomes, link clinicians’ performance
conducting an external review of the adapted guideline.19,34
to patient outcomes against benchmarks, improve processes and
ADAPTE and CAN-Implement (http://www.cancerview.ca/
public health, and generate new knowledge.1 An LHCS sys-
treatmentandsupport/grcmain/grcgdguidelineadaptation/) are
tematically captures and continuously translates knowledge into
examples of internationally recognized guideline adaptation
practice (Figure 3). Importantly, the patients, clinicians, and
tools.39,40
communities are at the center of the model, indicating engage-
Additional factors to be considered while adapting guide-
ment and the alignment of care with their priorities. Broad lead-
lines are (1) assessment recommendations: administration,
ership and incentives are aligned to facilitate a new culture of
standardization, interpretation, and use for clinical decision-
scientifically based care.1
making41,42 ; and (2) intervention recommendations: measure-
In rehabilitation, an LHCS would facilitate robust data col-
ment practices that support appropriate intervention, including
lection, analysis, and rapid generation of practice-based evi-
assessments that assist in selecting the intervention for a patient
dence that has potential to quantify rehabilitation outcomes,
(ie, rule in/out the appropriateness of the intervention)43 and
identify responders/nonresponders to interventions, predict
outcome measures.41 An evidence-based intervention dose
future outcomes, and determine optimal intervention doses.
should be included. The FITT (Frequency of exercise, Intensity
[ie, challenge], Time per session, and Type of intervention44-46 )
principle can be used to guide intervention prescription.
Optimal FITT principles (ie, doses) for most rehabilitation
interventions are unknown; however, the recommended dose
can be adapted from evidence to suit individual patient and
clinical needs. Systematic reviews and guidelines are available
to support implementation of a new practice. Rigorous review
methods can assist with determining the level of existing evi-
dence and necessary adaptations to the specific setting to deter-
mine the optimal dosage.40,47,48 The use of reporting guidelines
and checklists facilitates appropriate use of the interventions
in clinical practice.49 Poorly described research interventions
may result in compromised fidelity during implementation
into practice.50,51 Tools such as the TIDiER (Template for
Intervention Description and Replication) checklist to describe
interventions50 guide intervention description for publication.

Systematic Implementation of Recommended Practices

Theoretical frameworks, such as the knowledge-to-action
(K2A) framework,19 may expedite implementation of EBP. Fig. 3. The IOM’s schematic of the continuously learning health care system.
Knowledge creation includes research articles, research synthesis, Republished with permission of IOM (Institute of Medicine).1

S66 Moore et al Pediatric Physical Therapy

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Availability of clinical data may contribute to prevention of com-
plications, slowing disease progression, exploiting plasticity, and
ultimately maximizing participation. Knowledge gained from
implementing EBP should continuously improve and refine
rehabilitation, creating a vision of ongoing evolution of clinical
practice.1
BUILDING A CULTURE THAT SUPPORTS THE VISION
Implementation of the vision of an ongoing evolution of
clinical practice requires a fundamental change in the view that
the clinician and the researcher, or the clinical environment
and the research lab, are distinct and separate. Such a change
requires a model that facilitates the interaction between gener-
ating science and translating it into clinical practice.
The Clinician as a Researcher
In her 2015 McMillan lecture, Snyder-Mackler56 called
for the clinician scientist to advance physical therapy prac-
tice. This model calls for some clinicians to engage full-time
in research. The model must include more clinicians who
adopt the scientist-practitioner model. The concept of a scientist-
practitioner, suggested by Thorne as a theoretical basis for
advancing clinical psychology,57-59 may be useful for advancing
rehabilitation practice and research. The scientist-practitioner
is the practicing clinician versed in the scientific method, or
specifically, the logical, systematic, and objective process of eval-
uating a problem or question.57-60 The scientist-practitioner
employs the scientific method in every aspect of practice,
including application of scientific principles for observation,
generation of testable hypotheses, intervention, and evaluation
(Figure 4).57,58 The education of the scientist-practitioner
should begin during entry-level education for application of the
scientific model to clinical practice.
Fig. 4. Diagram demonstrating parallels between research method and clinical
reasoning.
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Hayes et al61 suggest 3 roles for the scientist-practitioner,
including becoming a critical consumer of the literature who
is able to locate and critically assess research, an evaluator of
one’s own interventions and programs using validated tools
and methods, and a researcher who produces and reports new
data from interactions with patients to the scientific community.
Recently, a fourth role has emerged for the scientist-practitioner
to assist in the dissemination and implementation of knowledge,
or disseminator.62 In this role, the scientist-practitioner facilitates
the use of self-generated evidence to advance clinical practice.
To be successful in these 4 roles, the scientist-practitioner should
develop several core competencies, all of which involve the sci-
entific method (Table 1).58,63,64
Common EBP barriers include lack of time, financial
constraints, limited access to evidence, lack of a structured
engagement process, and limited communication between
stakeholders and researchers.59,65 Strategies to overcome
these barriers are needed to support and enable the scientist-
practitioner to thrive. The clinical and organizational environ-
ment must support the application of the scientific method in
daily practice.7,58,59,63,64
Establishing the Clinical Research Culture to Foster
and Facilitate the Scientist-Practitioner
Establishing this culture requires building an environment
of shared values, attitudes, and patterns of behavior that pro-
vides structure and significance for the related activities.66 A
culture of scientific inquiry and rigor, a clinical research cul-
ture, allows for clinicians to engage in the scientific method,
helps develop the scientist-practitioner, and facilitates KT and
EBP.59,66 Such a culture sets the expectation that all clini-
cians will engage in the scientific method and participate in
the research process. Ultimately, a clinical research culture can
advance clinical care, improve patient outcomes, and generate
new rehabilitation knowledge.58,59,61,63,64
TABLE 1
The Intersect Between the 4 Key Roles of the Clinician Scientist and These
Core Competencies
Research consumer Conduct literature searches/locate evidence
Critique research articles
Summarize for knowledge translation
Create/lead research discussion/journal club
Evaluator Identify valid outcome measures/evaluation tools
Implement evaluation plan
Researcher Conduct a research study
Access research support
Select valid outcome measures
Write research proposal/IRB proposal
Collect outcomes
Manage data
Analyze data
Interpret data
Disseminator Write an abstract
Create and present research poster
Develop and present scientific talk
Write manuscript for publication
Develop guidelines
Abbreviation: IRB, Institutional Review Board.
Knowledge Translation in Rehabilitation S67
 There are several key characteristics shared by institutions TABLE 3
that are effective at creating a clinical research culture.59,63,64 Return on Investment
Establishing and sustaining a clinical research culture should Develops clinician Develops a clinical leader and scientist
be a part of the vision and mission of the institutions. At scientists Thinks beyond patient to population
a minimum, clinicians should include scientific inquiry into Mentors staff in research and knowledge
translation
daily practice. The effective institutions support the breadth of
Improves clinical practice quality and
the research experience in which a scientist-practitioner may efficiency
engage, from being critical consumers of scientific literature to Increases accountability
participating in various or all aspects of research. Opportuni- Leads to innovation
ties are provided (didactic, experiential, or mentored) to attain Creates supportive Develops and supports the
environment scientist-practitioner
the skills necessary to participate in these research activities.
Attracts outstanding clinicians
Clinicians should be engaged early and often in research, and Increases patient access to innovative
scientist-practitioners should be recognized for research contri- approaches and treatments
butions and productivity. This might include recognition at an Enhances facility Improves relationships with payer groups
annual meeting or a research-focused career ladder with appro- reputation as a leader
in the field
priate time for participation and financial factors.
Providing opportunities to create research competence and
expertise is critical and can be accomplished in many ways, standard are to improve the function, quality of life, and partici-
including provision of research education and training (Table 2). pation for the people we serve. We must engage clinicians as well
Distance learning programs could provide training for clinicians as patients, families, organizations, and policymakers (Figure 3),
in rural areas. Programs from the nursing and rehabilitation as opposed to assigning them the role of “recipient of knowl-
fields provide examples of ways to promote the development edge” or “knowledge user” at the end of the research process.
of the scientist-practitioner within the clinical setting.59,64,65 Incorporating the stakeholders’ views and experiences assists
Allowing clinicians to work in the clinic while attaining research in the generation of meaningful outcomes and can facilitate KT
skills may facilitate EBP implementation, KT champion devel- efforts. Successful KT and implementation must also inform and
opment, standardized data collection, and dissemination of drive decision making and policy.67 Integrating stakeholders in
knowledge. Clinicians may develop a more positive percep- the entire K2A cycle contributes to the commitment to spread
tion and attitude about research (Table 3). Evaluating the effect innovations and implement meaningful and cost-effective clin-
of preparing the scientist-practitioner and creating a clinical ical and systems-level changes.68
research culture on productivity and finances are important However, recent studies comparing research and patient
topics for future research. priorities suggest that academic research is not aligned with
patients’ beliefs about health care priorities.69,70 Policy-makers’
information needs and rehabilitation research outputs are
CREATING A SHARED VISION often not aligned.71 New initiatives such as PCORI (Patient-
Although the vision proposes a gold standard for clinical Centered Outcomes Research Institute),72 SPOR (Strategic
practice (Figure 2), it is critical to acknowledge that goals of this Patient-Oriented Research),73 and INVOLVE 74 emphasize the

TABLE 2
Examples of Training Programs to Facilitate the Scientist-Practitioner

Location Elements

Ronald Reagan University of California-Los Angeles
Medical Center, Gawlinski and Becker64
Shepherd Center PT/OT Research Fellow
Rehabilitation Institute of Chicago
What: Year-long evidence-based practice fellowship to assist staff nurses
Goal: Apply current evidence and use research methods to resolve current clinical issues
Who: Directed by doctorally prepared research nurse
Components: Didactic experience and mentored evidence-based project
What: 2-y combined clinical practice and research training (2-d clinic/3-d research)
Goal: To train clinicians in research methods and facilitate integration of research into clinical
practice
Who: PT or OT
Components: Didactic experience and mentored research experience; completion of a research
project
What: 1-y fellowship with protected time to conduct a clinical research project. Time varies
based on demands of the project
Goal: To train clinicians in all aspects of a clinical research project and facilitate
implementation of EBP
Who: PT, OT, and SLP
Components: Grant development, mentored research experience; completion of a research
project; submission of project for publication; presentation about research project at
conferences

Abbreviations: EBP, evidence-based practice; OT, occupational therapist; PT, physical therapist; SLP; speech language pathologist.

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importance of patient-centered research and outcomes. These
initiatives endorse the need and support the development of sys-
tematic methods to engage stakeholders in the research process.
The integrated knowledge translation (iKT) framework75(p2)
provides guidance in how to use the research process as an
opportunity for collaboration with stakeholders, “including the
development or refinement of the research questions, selec-
tion of the methodology, data collection and tools development,
selection of outcome measures, interpretation of the findings,
crafting of the message and dissemination of the results.”
The objective of iKT is to engage stakeholders across the
research continuum from awareness about research, to par-
ticipation in research, and finally to co-creation of research
(Table 4).76 Barriers and facilitators for stakeholder engage-
ment are reported in health care research, but iKT activities
are not adequately described or theoretically supported.77 In
rehabilitation, there are similar gaps with stakeholder groups,
such as policy and decision makers rarely included. A stake-
holder engagement framework or model may guide engagement
and planning of the research approach and result in successful
implementation.78
The INVOLVE framework suggests a structured approach
to stakeholder engagement on the basis of the pillars of
respect, support, transparency, and responsiveness. These
values should be apparent through constant communication
among researchers and stakeholder groups, budget allocation
for engagement, and power sharing among all involved.74
The Ottawa Model for Research Use supports the under-
standing of changes in behaviors, such as those needed to imple-
ment EBP and to drive societal change. Behavior change occurs
through a structured process, helping in the assessment of indi-
vidual and system barriers and facilitators to use of new knowl-
edge, tools, or practice.79-81 This model can assist in the identi-
fication of individual stakeholder barriers (values, social norms,
beliefs) and environmental barriers (economics, political cli-
mate, built environment, norms) that may prevent stakeholder
engagement and research dissemination and implementation.
The K2A model implicitly allows stakeholder engagement
throughout the research process (Table 4). Stakeholders can be
involved in curating the evidence and validating research find-
ings, evaluating clinical practice guidelines, newsletters, and
policy briefs.77,78,82 During implementation, stakeholders may
identify new research questions and set priorities.83-85 Simi-
larly, stakeholders can monitor use and evaluate outcomes much
more closely with a vested interest that researchers and clinicians
may not provide.86
Identifying and Addressing Stakeholder Needs
Stakeholders vary on the basis of the type of research that
is translated, disseminated, and mobilized (Table 4).47,52 Stake-
holders should include key leaders within organizations to max-
imize effect.87 When selecting stakeholders, consider individ-
uals who share key features with the group they represent, are
willing to speak for the group, have effective communication
skills, and ensure diversity. The roles of the stakeholder groups
and committees should be clearly identified.78 Consider “who
is not at the table” and include stakeholders who are not fre-
quently involved, such as decision makers, extended family and
fathers in pediatric research, and community organizations.
Including stakeholders in environmental scans and needs
assessments may result in the collection of information that
would not be identified by researchers. When asked how
research can inform policy, stakeholders agree that researchers
and clinicians must have an understanding of policy processes,
regulation of service, the rights and benefits of clients, and
how existing mechanisms can support participation, equip-
ment purchases, health care access, and overall community
engagement.54,55 This information guides research question
development and clinician-researcher partnerships to ultimately
inform policy.

TABLE 4
Integrating Stakeholders in Research and Knowledge Translation
Steps Map: Engage: Measure: Sustain participation:
The stakeholders that Use evidence-based Report methods and Develop sustainable
should be involved, the methods to engage evaluate outcomes of engagement
existing policies, stakeholders stakeholder mechanisms over time
clinical processes that engagement and as part of a
can support your research culture
research outcomes
Continuum of engagement76 Awareness of evidence Participation in research Contribution to new Developing a sense of Co-creation
→ studies → projects → ownership → of research
Examples of stakeholder ↓ ↓ ↓
engagement through the
knowledge to action73
Knowledge creation: Implementation: Monitoring:
Participation in Participation in studies and regular meetings with Participation in quality control and users
systematic reviews, research team, “stakeholder faculty” models, committees
guideline appraisal, policy response units
public forums
Stakeholder groups to engage Patients/clients (including children and youth), families (including extended families), clinicians (across disciplines), admin-
istrators (program managers), policy makers (from clinical and hospital administration to elected officials and other
bureaucrats and government officials), regulatory bodies (professional orders), industry (eg, adaptive and assistive tech-
nology and product developers), funding agencies, scientists in other fields (technology, social sciences, humanities, policy,
ethics), community organizations

Pediatric Physical Therapy Knowledge Translation in Rehabilitation S69

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 To support the development of iKT projects, a stepped
approach is necessary. To illustrate these steps, we provide an
example of pediatric research in promoting the participation of
children with disabilities.
Example: Promoting Participation for Children
With Disabilities
Children with disabilities and their families identify partic-
ipation outcomes as key to their health and well-being.88 How-
ever, most interventions and research target body function or
activity limitations.89 Projects engaging stakeholders in devel-
oping solutions that include children, families, rehabilitation
professionals, and society could address this gap. Environment-
based and context-based rehabilitation interventions are under
development. Adopting an iKT framework, researchers and clin-
icians identified that training monitors who offer leisure activi-
ties and services in the community, and making modifications in
the environment addressing the needs of individuals with dis-
abilities can support participation goals. These interventions are
efficacious interventions,90 cost-effective, and have improved
patient-centered care.91
A study, using a participatory action research approach92
created a network of stakeholders to support the development
of participation interventions for children with disabilities. This
network, CHILD LeisureNET, includes more than 150 stake-
holders such as policy makers, families of children with disabil-
ities, clinicians, education professionals (teachers, school rep-
resentatives), and community organizations (leisure promotion
centers, disability advocacy groups). These stakeholders assem-
bled in forums and were presented evidence on leisure partic-
ipation. Stakeholders identified existing barriers and possible
solutions to promote participation. Using a business model93
these solutions were described and prioritized by different stake-
holders. Working groups developed solutions. Stakeholder-
driven solutions included the development of a mobile app
(www.jooay.com), listing adapted and inclusive community
leisure activities, partnering with school-based initiatives, devel-
oping peer-mentorship programs,94 and creating policy tables
to disseminate best practices at the municipal and provincial
levels in Canada (www.childhooddisability.ca/leisure). These
examples demonstrate how steps of engagement can generate
new practice, stakeholder-driven research, and evidence-based
practice.
CONCLUSIONS
As a rehabilitation community we must equip ourselves
with knowledge about how to generate, share, and apply knowl-
edge. KT, including active EBP, is becoming a mandatory step in
both research and practice, and is an opportunity to create value
for rehabilitation.95,96 Through ongoing recommendations and
implementation of EBPs, collection and use of practice-based
evidence to improve quality and generate new knowledge,
development of a clinical research culture, and engagement of
patients, families, decision makers, and communities, we can
achieve a new culture of rehabilitation care. With a focus on this
vision, we will improve clinical practice and research, innovate
rehabilitation, and prevent disabilities.
S70 Moore et al
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Pediatric Physical Therapy
 S P E C I A L C O M M U N I C A T I O N

Overweight and Obesity in Children: More Than Just the Kilos

Edgar van Mil, MD, PhD; Arianne Struik, MSc
Department of Pediatrics (Dr van Mil), Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands; and Institute for Chronically Traumatized Children
(Ms Struik), Perth, Australia.

A new model of diagnostics and treatment for overweight in children is used for implementation of a new approach toward
childhood obesity. Although based in a hospital setting, it is part of a cure and care network with other professionals. By
psycho-education about the body at a 6-year-old level, parents and children become informed and competent partners. This
knowledge increases their autonomy and ability to make choices. Collaboration with the family’s support group or network
reduces isolation and increases the feeling of being connected and supported. Together with their support network, they can
maintain this healthier lifestyle or adjust it where needed. Family workbooks and worksheets support the child and parents
and increase their autonomy, self management skills, and motivation to take part in the cure and care network. The
approach is a based on the three basic needs that determine motivation, namely autonomy, competence, and connectedness.
(Pediatr Phys Ther 2017;29:S73–S75)
Key words: childhood obesity, overweight, support network

INTRODUCTION With focus both on prevention and management, the reduc-

Overweight and obesity have reached epidemic pro-
portions. In the Netherlands, the prevalence of overweight
including obesity among children rose from 4% to 15% in boys
and from 7% to 18% in girls between 1980 and 2003. In the
last decade, the prevalence reached 30% in specific large ethnic
minorities.1,2
Obesity adversely affects each of the major risk factors for
heart and vessels including diabetes, blood pressure, and lipid
profile during childhood and adolescence. As a result, obesity
is associated with an increased risk of death, especially from
cardiovascular disease. More recently, evidence supports that
certain forms of cancer and kidney disease are associated.3 But
obesity also affects the well-being of children and their families.
Many children experience bullying,4,5 and anxiety, depression,
a negative self-image, and behavioral problems are common.6
These negative feelings can lead to “comfort eating,” isolation,
and inactivity thus, aggravating the problem. Parents are often
criticized and can feel incompetent, guilty, and powerless in
helping their children.5
0898-5669/293S-0S73
Pediatric Physical Therapy
Copyright © 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical
Therapy of the American Physical Therapy Association
Correspondence: Edgar van Mil, MD, PhD, Jeroen Bosch Hospital,
Henri Dunantstraat 1, 5253 GZ, ‘s-Hertogenbosch, the Netherlands
(e.g.vanmil@jbz.nl).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000384
tion of overweight, obesity, and related chronic diseases are
objectives of the Dutch Ministry of Health, Welfare and Sport.
A partnership has been established for all relevant stakeholders,
including the national organizations of health care providers,
health insurance companies, and patient organizations, to col-
laborate and develop an integrated health care standard for the
management and prevention of obesity. This standard involves
strategies for diagnosis and early detection of individuals at
high risk—strategies for appropriate lifestyle intervention for
those who are overweight and obese and, when appropriate,
additional medical therapies.7
Despite all efforts in managing the obesity epidemic, the
prevalence of overweight is increasing. The general approach
of the professionals working in the field of care and prevention
of obesity might explain this increase. Professionals’ approach
is to advise. Advice includes healthy foods, how to stimulate an
active lifestyle, or general advice about a healthy lifestyle, such
as getting adequate amounts of sleep. Unfortunately, in only a
few cases is this approach successful. Most families with chil-
dren with obesity know what a healthy lifestyle for their chil-
dren should be and are willing to invest in the future health of
their children, but are often not able to provide this lifestyle.
The challenge for the health care professional is to identify the
problems for each child and family. This knowledge can help the
family solve the problems or work around issues. This may lead
to an increase in parents’ intrinsic motivation to provide their
children with the best future.8
At the same time, even with motivation, living a healthy
lifestyle remains hard work for parents. They have to be good
examples for their children and also tolerate the children’s dis-
appointment when they do not get what they want. The desire

Pediatric Physical Therapy Overweight and Obesity in Children S73

Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
to eat can be very strong and is influenced by the pituitary-
hypothalamic area in the brain, the center for hunger and
satiety.9 This center is developed to react to a visual or olfac-
tory stimulus by producing a feeling of an urgent need to eat.10
The satiety center is part of the greater limbic system in the brain
that supports a variety of functions including emotion, behavior,
motivation, and long-term memory. The limbic system enhances
the experience of food with emotion, which powerfully influ-
ences behavior. Because of this connection we eat when we feel
happy, depressed, or stressed and can also remember the taste of
good food for a lifetime. Evolution created this connection for
a reason. Because this center continues to influence our eating
behavior, this system must be important for survival.11 Indeed,
during evolution the craving for food helped us to survive. The
strong influence that craving has on our behavior made and con-
tinues to make humans fight for food. Eating may be a necessary
addiction. Knowing how strongly the craving for food influences
our behavior gives us a different perspective on overweight and
urges us to redefine the development of overweight.
THE NEED FOR A DIFFERENT VIEW ON OBESITY
A more useful approach toward obesity could be described
using the definition “overweight is an ancient and normal reac-
tion to an obesogenic environment.” With this definition, being
overweight is no longer a sign of sloth, but merely means the
individual is capable of storing the excess calories in his or her
body for survival by keeping his or her energy balance posi-
tive for a longer period. This person is not aware, willing, or
capable of influencing his or her energy balance to decrease his
or her weight. And if gaining weight is a normal reaction of our
body, we should not “fight” this reaction or start a battle against
the kilos and overweight. We should not fight our own body
because we cannot win. This is an important mind shift which
gives people pride and enhances participation in society.
To lose weight one needs to create a slightly negative energy
balance. In practice, parents and children, especially teenagers,
want to lose weight quickly. A large and rapid weight loss is
seen as a sign of an effective obesity intervention. The success
of an intervention is often expressed in amount of weight loss
in kilograms per week. However, when overweight is seen as a
normal reaction of the body, one could understand that a sudden
negative energy balance will create a state of emergency in the
body, because weight gain is its goal. And it becomes difficult to
maintain this weight loss.10
Rapid weight loss is the most powerful stimulus for the
hunger and satiety center to activate.9 The body has a large
number of defense mechanisms to prevent further weight loss
and to stimulate regain of storage weight, and they are all acti-
vated. The body is fighting further weight loss and focused on
recovering the energy stores by using several defense mecha-
nisms such as lowering of the basal metabolic rate. As a result,
this battle is lost with a regain of weight when, in fact, the child’s
body demonstrates excellence by surviving (another) famine.
This is extremely frustrating and disappointing for the child and
his or her parents. They have fought and struggled and suffered
for nothing, feeling they have lost the battle, when in fact their
child’s body showed strength.
S74 van Mil and Struik
Copyright © 2017 Wolters Kluwer Health, Inc. and the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Thinking from this perspective and accepting the idea that
fighting with a body that is trying to survive is an almost impos-
sible task, we can acknowledge that a different approach is
needed. Instead of fighting the body, the approach is to collabo-
rate. By choosing a lifestyle change that creates only a slightly
negative energy balance, the body’s defense mechanisms will
less likely be activated. Eating fat, salty, and sweet food has a
calming effect on the body and gives a sense of pleasure and
safety. By using other replacing activities, like music or pos-
itive human interaction, the same reward system that creates
a happy satisfactory feeling is activated.12,13 And by creating
structured moments of enjoyment in the lifestyle adaptation,
the new weight-controlling behavior becomes less hostile. These
patterned and structured activities influence the brain and are
necessary to develop the brain.13
Another important step is increasing social support and
stimulating the feeling of being connected to family or friends.
Our approach to childhood obesity is oriented to the family
system.7 If the family, with parents and caregivers as role models,
adopts changes, the obese child will feel less rejected and more
accepted. And parents and family members will only do that,
if this changed lifestyle is enjoyable, is matched to them and is
designed by them. They will only participate and start to self-
manage and feel empowered if these choices are theirs. That may
take time, because parents may feel powerless. They feel they
have failed and often this is an issue within their own histories.
By supporting and believing in their strength and competence,
the professional invites the parents and caregivers to become the
vital part of the treatment team.
In the care for children with obesity, this is a shift in
paradigm. Traditionally, care is based on supply whereas when
care centers on self-management, it is driven by demand. The
self-managing patient creates a health care demand, which is
independent of the health care professional. The professional
needs to communicate using education to increase competence
in parents and children. Professionals may have stigmatizing
thoughts, such as assuming that the family lacks perseverance.
This prevents professionals from accepting the family as team
members. Child and parents, however, not only participate, but
also create their own approach and the professionals participate
temporarily in the journey.
THE ACTIVE HEALTHY LIFESTYLE
Becoming more active may be the most enjoyable and pow-
erful intervention for a new lifestyle. Families are challenged
to find activities they enjoy and can enjoy together. A daily
pillow fight after dinner with parents and children is easier than
sticking to a diet while feeling the craving for sweet, salt, or fatty
foods. Physical contact such as massage gives pleasure and cre-
ates the feeling of connection. Becoming more active leads to all
family members feeling fitter. A more active lifestyle is associated
with not only loss of overweight but also a significant improve-
ment in health.14 An increase in aerobic fitness is associated with
a decrease in insulin resistance, thereby improving the cardio-
vascular risk profile. This type of information is important for
the children and their parents to stay motivated when weight
loss has not yet occurred. Increasing physical activity is one
Pediatric Physical Therapy
element in the treatment of depression in children and adults
and may also influence the anxiety level in obese children. Phys-
ical therapists are therefore key players in helping, challenging,
and motivating less active children to become more active.
This approach is challenging for parents. They need to learn
to set boundaries, tolerate negative emotions, and change their
own lifestyle. If parents feel empowered, they may view the
changes as not only helping them manage their child’s weight,
but also in other parenting tasks such as chores, homework, and
reducing screen time.
A NEW METHOD FOR THE APPROACH OF THE OBESE CHILD
WITHIN A FAMILY
In the department of pediatrics of the Jeroen Bosch hospital,
this new model of diagnostics and treatment15 was put into prac-
tice. Parents and children become informed and competent part-
ners using education about the body and its mechanisms. Edu-
cation was aimed at a 6-year-old level. This knowledge increased
their autonomy and ability to make choices.16 Collaboration
with the family’s support group or network reduced isolation
and increased the feeling of being connected and supported.
Together with their support network, parents and children can
maintain this healthier lifestyle or adjust it as needed.13 Family
workbooks and worksheets support the child and parents to
increase their autonomy and self-management skills. According
to Deci and Ryan,16 the level in which the 3 basic needs—
autonomy, competence, and a connectedness—are met deter-
mines motivation. The approach is based on these needs, in
combination with relevant knowledge.
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Pediatric Physical Therapy
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Overweight and Obesity in Children S75
 S U M M A R Y O F I V S T E P

Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations

and Inspirations
Teresa Jacobson Kimberley, PT, PhD; Iona Novak, OT, PhD; Lara Boyd, PT, PhD; Eileen Fowler, PT, PhD;
Deborah Larsen, PT, PhD
Department of Physical Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis (T.J.K.); Cerebral Palsy
Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Camperdown, Australia (I.N.); Department of Physical Therapy and Djavad
Mowafaghian Centre for Brain Health, The University of British Columbia, Vancouver, British Columbia (L.B.);; Department of Orthopaedic Surgery, Center
for Cerebral Palsy, University of California, Los Angeles (E.F.); and School of Health and Rehabilitation Sciences, The Ohio State University, Columbus (D.L.).

Background and Purpose: The IV STEP conference challenged presenters and participants to consider the state of science in
rehabilitation, highlighting key area of progress since the previous STEP conference related to prediction, prevention,
plasticity, and participation in rehabilitation.
Key Points: Emerging from the thought-provoking discussions was recognition of the progress we have made as a profession
and a call for future growth. In this summary article, we present a recap of the key points and call for action. We review the
information presented and the field at large as it relates to the 4 Ps: prediction, prevention, plasticity, and participation.
Recommendations for Practice: Given that personalized medicine is an increasingly important approach that was clearly
woven throughout the IV STEP presentations, we took the liberty of adding a fifth “P,” Personalized, in our discussion of the
future direction of the profession. (Pediatr Phys Ther 2017;29:S76–S85)
Key words: IV STEP, participation, personalized, plasticity, prediction, prevention

INTRODUCTION
Taking place roughly every 10 to 15 years, the STEP con-
ferences are designed to disseminate best-available evidence and
set future directions in physical therapy education, research, and
practice as they relate to individuals with neurologic conditions
across the life span. IV STEP took place in July 2016 at The
Ohio State University in Columbus, Ohio, and certainly accom-
plished this goal with enthusiastic presentations and discussion
(Table 1). The purpose of this article is to highlight the key
messages and themes that emerged from IV STEP. As stated
by Marylou Barnes after II STEP, “the enormity of what has
0898-5669/293S-0S76
Pediatric Physical Therapy
Copyright © 2017 Academy of Neurologic Physical Therapy, APTA.
Reprinted from the Journal of Neurologic Physical Therapy, Volume 41,
Issue 3S, pp S63-S72.
Correspondence: Teresa Jacobson Kimberley, PT, PhD, Department of Phys-
ical Medicine, Division of Physical Therapy and Rehabilitation Science,
University of Minnesota, MMC 388, 420 Church St SE, Minneapolis, MN
55455 (tjk@umn.edu).
All authors received honorarium for participating in the IV STEP confer-
ence, but no other sources of funding were associated with this work.
This manuscript is a summary of presentations and discussion at the IV
STEP conference, July 2016.
No conflicts of interest are declared.
DOI: 10.1097/PEP.0000000000000435
taken place at this conference has not yet struck any of us full
force.”1 Indeed, this STEP conference, consistent with its pre-
decessors, served as an unrestrained environment where ideas
and plans were not constrained by “real-world” issues. Accord-
ingly, the attendees and this IV STEP summary article coauthor
group were challenged to analyze the state of current evidence
in physical therapy practice; to develop priorities for education,
research, and practice for the coming decade; and to present
ideas to spur change for the future.
The IV STEP conference planning committee, after much
discussion and review of current trends in practice and research,
identified 4 critical themes on which to focus the conference
presentations: prediction, prevention, plasticity, and participa-
tion (ie, the 4 Ps). The committee strategically observed that
the emerging evidence in these 4 thematic areas was escalating
and would critically impact the next decade of physical therapy
practice in the area of neurologic conditions. Each invited
presenter was given a specific charge that included reviewing
the current evidence of his or her topic related to one or more
of the themes and highlighting future research priorities of the
profession (see the Appendix for speakers and charges).
We recap the key findings of the IV STEP conference in a
diagram, which has 3 stages: (1) personalization, (2) interven-
tion, and (3) outcomes (Figure 1). Stage 1 involves intervention
planning for “personalized” care. In this stage, the physical
therapists must consider the “4Ps”: Prediction, Prevention,
Plasticity, and Participation. Intervention planning involves
inviting the patient to set goals for the intervention; the physical

S76 Kimberley et al Pediatric Physical Therapy

Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
 TABLE 1
IV STEP Demographic Information
Attendees
701 (413 >40 y, 218 <40 y) (M: 67; F: 567; unreported 67)
Speakers
34
Section affiliation
387 neurology
124 pediatric
91 dual membership
99 nonmembers
Primary setting
331 clinicians
295 academicians
Geographic representation
44 US states as well as people from Australia, Canada, Chile,
Denmark, Iceland, India, South Korea, Kosovo, Malaysia,
Netherlands, South Africa, United Kingdom
therapist then considers the person’s neuroimaging, genetic, and
classification data to inform planning and predicting outcomes
(left section). Stage 2 is delivering the intervention (center
section). Key principles of intervention include teamwork
and partnership with the patient and other providers in their
team. Physical therapy intervention will likely include exercise;
intense motor training; virtual reality; self-efficacy and self-
management training; and health promotion activities. Stage 3
is the measurement of intervention outcomes (right section).
The desired outcomes of physical therapy intervention include
better motor skills; better health; prevention of impairments;
and measuring whether or not the patient’s goals are achieved.
PREDICTION
A key element that will advance physical therapy prac-
tice is the ability to predict outcomes. Prediction of outcomes
will lead to clearer patient expectations and better selection
of interventions to match the individual. Predicting outcomes
and guiding treatment with classification systems, including
Fig. 1. Summary of the IV STEP conference key messages.
Pediatric Physical Therapy
Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
movement system diagnosis, is an important area of research.
Examples of classification systems used in life span neuro-
logic physical therapy practice include the American Spinal
Cord Injury Association (ASIA) Impairment Scale (AIS)2 and
the Gross Motor Function Classification Scale (GMFCS).3 The
GMFCS is widely used for children with cerebral palsy to guide
treatment and predict outcomes. In adults, no single measure
is used in such widespread fashion, perhaps because no single
measure is yet this effective in predicting outcomes.
Notably, the American Physical Therapy Association
recently published a white paper that defines the human move-
ment system as a foundation for physical therapy practice.4
Building on the concept that physical therapists are the experts
in diagnosis and treatment of human movement, it is clear that
a common language is needed that enables the diagnosis of
movement dysfunction, development of appropriate treatment
options, and prediction of outcomes for individuals with neu-
rological disorders. Movement system diagnosis has been pro-
posed as one means of achieving this across medical diagnoses
with 9 movement deficit categories: (1) movement pattern coor-
dination, (2) force production, (3) sensory detection, (4) sen-
sory selection and weighting, (5) perception of vertical orienta-
tion, (6) fractionated movement, (7) hypermetria, (8) hypoki-
nesia, and (9) cognitive.5 Yet, little research to date has exam-
ined the practical use of movement system diagnosis, that is,
is it effective in determining treatment measures or outcomes
by diagnostic category? The thinking behind proposing a move-
ment system diagnosis focus is to promote use of a common
language across neurologic conditions that would guide treat-
ment choice, potentially decreasing treatment variability while
improving communication between practitioners, and facilitate
research through better grouping of study participants.
There is a growing focus in the profession on devel-
oping disease-specific classification systems, such as the AIS
for spinal cord injury; however, there is considerable vari-
ability in the level of function of patients classified within a
given category.6 In response, the Neuromuscular Recovery Scale
Stepping Up to Rethink the Future of Rehabilitation S77
(NRS) was developed to differentiate function on 11 critical
motor tasks for people classified as AIS C and D (motor incom-
plete), focusing on recovered movement patterns instead of
compensatory movements.7,8 More recently, a pediatric NRS
has been developed.9 The NRS has been shown to be respon-
sive to change in function over time8 and can be used as an
outcome measure; however, it has not been evaluated as a
predictive instrument. The GMFCS, a 5-level motor severity
classification system. It is not an outcome measure but has
a strong predictive relationship with a child’s development of
gross motor function measured on the Gross Motor Function
Measure (GMFM-66 items).10 Cerebral palsy gross motor curves
have been generated that further predict gross motor function
as a function of age and GMFCS level. These curves can (a)
guide the timing of physical therapy intervention through iden-
tification of children who lag behind during early development
or exhibit an unexpected loss of motor function during adoles-
cence and (b) help predict realistic outcomes from treatment, for
example, when to use active motor training versus when to use
compensation (such as a powered wheelchair) to achieve inde-
pendent mobility. Development of disease-specific measures,
such as the GMFCS, GMFM, and NRS, is critical for the future of
neurologic physical therapy, so that changes in function can be
measured across the life span. Specifically, such measures could
focus treatment and enable the accurate prediction of outcomes.
Effective prediction, however, may require more than
just behavioral measures. For example, the PREP (Predicting
Recovery Potential) algorithm that was developed to predict
functional arm recovery poststroke uses (a) early motor func-
tion (manual muscle testing of Shoulder Abduction, Finger
Extension = SAFE), (b) transcranial magnetic stimulation (TMS)
(if the 2 SAFE scores sum to <8), and (c) diffusion imaging (if
the TMS fails to elicit a motor-evoked potential in the finger
extensors) to determine the degree of integrity within the corti-
cospinal tract.11 This work demonstrates that combining mea-
sures of motor function, neurophysiological analysis, and neu-
roimaging can predict long-term outcomes with 88% specificity
and 73% sensitivity in people with mild to moderate stroke
severity.11 The PREP algorithm also illustrates the need for mul-
timodal data to effectively predict outcomes in individuals with
neurologic conditions.
Efforts to develop predictive algorithms are exciting; how-
ever, it is imperative for our profession to identify the factors
that result in change in classification levels for individuals and
to explain why, in some cases, there is a disparity in the predic-
tive value of algorithms. Factors that may disrupt the predictive
ability of algorithms include environmental, behavioral, moti-
vational, and treatment variations. Furthermore, at this time,
predictive algorithms have not accounted for what the indi-
vidual considers to be meaningful outcomes; this is critical, as
the capacity for recovery (the ability to perform a task as mea-
sured on objective assessments) does not always mirror perfor-
mance (task completion within natural environments). Patient
report must inform our assessments and classification methods
to accurately plan treatments and predict long-term outcomes.
Relatedly, the development of clinical pathways (ie, deci-
sion trees/algorithms, and/or practice guidelines) is critical for
evidence-based treatments and education of therapists. The
S78 Kimberley et al
Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
utility of clinical pathways stems from their use of individual
patient data that enables personalization of treatment, which
can lead to prediction of recovery. Adoption of the template for
intervention description and replication (TiDIER) guideline12
for clear reporting of the key ingredients of rehabilitation inter-
ventions will help ensure that we are comparing “apples with
apples” in the future. The use of electronic medical records and
registries also makes treatment comparisons feasible. There is a
need to evaluate trajectories of recovery and eventual outcomes
based on well-defined treatment approaches; this will ulti-
mately facilitate comparison of outcomes across individuals and
settings.
PLASTICITY
It is clear that to move forward as a field, neurologic
physical therapists must embrace technologies that facilitate
positive plasticity. Technology can be used to enhance intensity,
motivation, dosing, and consistency of practice as well as to
quantify exercise parameters and outcomes. Technological
innovations are progressing at a rapid rate, and a flood of new
Food and Drug Association–approved robotics, devices, and
so forth, is readying for market release. Yet, we must ensure
that rehabilitation needs, not marketing, drive purchasing.13
Optimal technological design should include all stakeholders
including physical therapists, patients, and caregivers. Use
of robotic gait orthothes as a component treadmill-based
locomotor training has transitioned from research laboratories
to common clinical use. Active participation appears to be a
key ingredient, if improved overground walking is the goal.14
Walk-assist exoskeletons, single and multiarticular, are now
commercially available for community use. While promising,
device limitations include a lack of balance reaction mecha-
nisms to prevent falls, unnatural gait patterns, low battery life,
skin integrity, and cumbersome donning and doffing.13 Physical
therapists must oversee training with these devices to ensure
safety and provide feedback for refinement of this technology.
Video gaming technology is another area that shows great
promise, but future versions must increase the challenge and
reward scheme to optimize and maintain patient engagement
and effect. Gaming especially motivates pediatric patients. Chil-
dren may not fully appreciate the benefit of exercise but must
engage fully for optimal motor learning. They can also easily
“become bored” by the same game; accordingly, there is a need
to find ways to match the speed of technology development with
their appetite for novel challenges.15
Neural imaging technology techniques are advancing
our research and practice. Functional and structural neu-
roimaging, electrodiagnostic, and electrical stimulation tech-
nologies, touched upon during plenary sessions, were a focus of
many IV STEP poster presentations. Physical therapy interven-
tion can be targeted for specific brain structures and can eval-
uate the effect of our treatments. Transcranial magnetic stim-
ulation is an exciting and promising area of research that can
be used to evaluate neuronal circuitry, promote neural plas-
ticity, and inhibit maladaptive plasticity. Although many repet-
itive TMS trials to date have been disappointing,16 this area
of research has taught us that priming the brain for motor
Pediatric Physical Therapy
learning and recovery is possible.17 Further work may elu-
cidate the key parameters of stimulation, which, when com-
bined with practice, are optimal for promoting neural reorga-
nization in the developing child.18,19 Other forms of cortical
priming are rapidly gaining attention, including transcranial
direct current stimulation,18,20 and acute bouts of exercise.21,22
Evidence suggests that epidural stimulation may also provide a
level of excitatory priming in the cord that allows those with
incomplete spinal cord injuries to activate local circuitry for
muscle activation.23 Furthermore, it appears that the use of
repetitive TMS, in at least recovery from stroke, may be influ-
enced by genetic factors.24 Data such as these simply reinforce
the need for predictive algorithms that account for numerous
individual factors in decision making regarding optimal
interventions.
PREVENTION
The goals of physical therapy must extend beyond func-
tion to include health promotion. “Physical activity,” an essential
component of health, refers to body movement during playing,
working, active transportation, house chores, and recreational
activities.25 Exercise, a subcategory of physical activity, refers
to purposeful movement designed to meet a fitness goal (eg,
resistive exercise, aerobic training, flexibility).25 It is critical for
physical therapists to recognize the need for physical activity
for people with neurologic conditions across the life span. While
some exercise is better than none, there is a positive relationship
between exercise intensity and enhanced physical function.26
Even those with chronic disability and very limited mobility may
benefit from low levels of exercise to optimize emotional and
physical health.27 While the evidence is limited, there is growing
evidence that we can prevent secondary conditions associated
with chronic health conditions if we intervene early in the dis-
ease or injury process and incorporate personalized strategies to
prevent reoccurrence or reinjury.
Exercise interventions can also enhance neural reserve and
capacity28 ; interestingly, the type of exercise influences the area
of brain affected.29 With exercise, it is possible to change the tra-
jectory of a progressive disease and delay onset of motor symp-
toms in others. Physical fitness is positively associated with brain
volume, and both aerobic and nonaerobic exercise can improve
cognition in people with dementia.30,31 High levels of phys-
ical activity are associated with delayed symptom progression in
individuals with the Huntington disease gene.32 A similar delay
in onset of Parkinson disease symptoms has been found.33
For childhood-onset disability, physical activity and exer-
cise are essential for optimal development of body systems, and
there may be critical time periods for intervention.34,35 In addi-
tion to the promotion of skilled movement, physical activity and
exercise interventions are beneficial for premature infants. Exer-
cise that benefits bone health can begin in the neonatal intensive
care unit within days after birth.36 Children with cerebral palsy
are more sedentary and their physical activity levels are approx-
imately 30% lower than recommended guidelines.37,38 Less is
known about other childhood-onset disabilities.
Children with disability, who are unable to run and play at
sufficient intensities to optimize health, must be provided with
Pediatric Physical Therapy
Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
alternative exercise programs to develop strong musculoskeletal
and cardiorespiratory systems. There is evidence that exer-
cise can improve academic performance in adolescents without
disability39 and psychosocial health in children with cerebral
palsy.40 It is hoped that promotion of physical activity in child-
hood can set the course for a healthy lifestyle that prevents or
minimizes fatigue, pain, and depression experienced by adults
with cerebral palsy and other childhood-onset disabilities.41
Physical therapists need to be involved early to intervene
on behalf of individuals with all types of neurologic conditions,
incorporating physical activity and exercise into treatment pro-
tocols that consider personal preferences. We are the movement
experts best able to design safe and effective ways to develop,
improve, and maintain physical health for people with or at risk
for neurological conditions. However, we must network with
our health promotion colleagues in schools and the community
to ensure success in this endeavor.
PARTICIPATION
The ultimate goal of rehabilitation throughout the life span
ought to be that people with neurological disabilities are fully
included and participating in life activities that matter to them.
Participation in a full life is the human right of every person
with a disability and a core tenet of the International Classifica-
tion of Functioning and Disability and is endorsed by the United
Nations and the World Health Organization.42 While much of
this work has been done in pediatric populations, the concepts
apply to adults as well.43 There are varying definitions of par-
ticipation that include “involvement in life situations”43 and a
“set of activities that are completed in order to achieve a setting-
specific personally or socially meaningful goal.”44 Full participa-
tion in childhood has been characterized by doing immensely
engaging activities that are meaningful to the child, belonging
and being accepted socially, and being with a sense of self-
purpose and identity.45
People with disabilities and their families identify soci-
etal attitudes, the built environment, lack of support, low per-
sonal confidence, and pain and fatigue as barriers to partici-
pation. It is the therapist’s role to optimize home and commu-
nity participation.45 A person’s participation will be influenced
by his or her preferences, his or her locality and the opportu-
nities it affords, his or her family’s context and routines, and
the person’s physical abilities.45 Evidence indicates that framing
intervention by a person’s preferences and priorities increases
participation.45,46 To develop an optimal intervention plan for a
child, both the child and the family should be assessed to iden-
tify strengths, interests, desires, and concerns that are specific to
the participation goal. In addition, the environment should be
evaluated for safety, accessibility, physical/social/emotional sup-
ports, and community resources.47 When planning and carrying
out treatment and research, physical therapists must, therefore,
remain cognizant that improving a person’s physical perfor-
mance at the body’ structures function level of the International
Classification of Functioning and Disability does not automat-
ically transfer to improved participation. Intervention aiming
to improve participation will need first to look at the barriers
to participation and address these; some of these may be the
Stepping Up to Rethink the Future of Rehabilitation S79
person’s physical abilities but others may not (eg, community
access, societal attitudes).
Remote capture of physical activity and exercise at home
and in the community, using wearable technologies, may inform
our treatment plans because it can provide quantitative outcome
measures of spontaneous self-selected physical activity, and
GPS locaters might provide participation profiles, for example,
how often does the person leave his or her home?. Yet, to
date, our attempts at monitoring physical activity remotely
(patient compliance logs, accelerometers) have been limited and
have provided incomplete information. While lower extremity
activity monitors are an effective means of capturing commu-
nity walking,48 upper extremity activity monitoring is more
complex. Reports have found improved motor function on
behavioral measures (eg, Action Research Arm Test49 ) with and
without increased activity measures from accelerometry50 ; con-
versely, study participants with stroke have reported improved
arm use without a concomitant improvement in measured arm
function.51 Attention needs to be paid, and new methods con-
ceived, for integrating self-report with technological measure-
ment of activity. Advances in complex monitoring may allow us
to provide therapies that increase Participation, and allow us to
accurately measure Participation as an outcome.
Telemedicine is just being established for physical therapy
practice and the rules and guidelines are still being developed,
but it shows great potential, especially for outreach to rural com-
munities. Telemedicine technology enables people to receive
intervention within their own environment, and this is impor-
tant because ecologically bound intervention is more likely
to accurately reflect a person’s real-life participation barriers,
needs, levels, and opportunities.
PERSONALIZED
Personalized medicine is an increasingly important
approach that was clearly woven throughout the IV STEP
presentations, so we have taken the liberty of adding a fifth “P”
to the 4P model for setting the future direction of the profession.
It is becoming clear that there is no “one size fits all” reha-
bilitation intervention for individuals with neurological disor-
ders. This is true for both adult and pediatric clients. Thus, the
future of our profession is to incorporate individualized health
care to create personalized rehabilitation interventions that are
informed by (1) capacity—brain and muscle structure or func-
tion; genetics, epigenetics, metabolic influences; and (2) client
and family goals that define the right treatment at the right time
for the right person. Recently, there have been a number of large
randomized controlled trials (RCTs) considering novel rehabili-
tation interventions,52 the dosing of practice within and across
session,8 the timing of rehabilitation onset,53 and the numbers
of rehabilitation sessions in a week.54 When considering the
“average” individual, each of these trials reported no advantage
for their specified intervention over that found for the control
intervention, which was described as “standard care” (or in the
case of a recent trial on dose response, a lower amount of prac-
tice per rehabilitation session51 ). In particular, at IV STEP, the
results of this dose-response trial by Lang et al were presented;
the finding that there was no additional benefit to larger num-
S80 Kimberley et al
Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
bers of practice trials per session was met with much dismay by
the attendees. Taken together, the results of these large, well-
run, randomized trials may indicate that high-quality “stan-
dard care” (ie, that employs intensive practice at the peak of
the patient’s increasing abilities) is adequate for recovery after
stroke. However, earlier trials55 found intensive therapy more
effective than standard care, which may indicate that standard
care has improved over the last decade, but it may also mean that
more is not always better. It is unknown, however, how much
variability exists in “standard care” throughout the country.
Studies that emerged out of III STEP suggest that the
dosing and type of exercises performed in neurologic rehabil-
itation were below that which is used in “standard care” control
interventions.56-58 Relatedly, experience suggests that the “stan-
dard care” delivered in many clinics may not be at the same level
as that tested in the study settings. These data may also be sig-
naling that effective rehabilitation interventions require person-
alization of their content. Personalized interventions would be
designed to address the specific needs of each client and modi-
fied to suit the precise capacity of each biological system.
Research disseminated at IV STEP illustrates both the chal-
lenge and the promise of moving toward personalized rehabili-
tation interventions for individuals with neurological disorders.
The importance of genetics in numerous aspects of neuroplas-
ticity was articulated. It is clear that different genetic markers
have a profound influence on motor learning.59 As an example,
the expression of dopamine genes has a large influence on both
motor learning and neuroplastic change in the motor cortex;
critically, it was a combination of genes not a single factor that
revealed these relationships.59 At this time, however, the consid-
eration of genetics in responses to rehabilitation is in its infancy.
Little work has considered specific neurological populations.
Furthermore, the role of epigenetics has yet to be revealed.
Epigenetics encompasses the study of modifications to DNA
and DNA packaging, which can potentially affect gene expres-
sion, without changing the nucleotide sequence.60 Differential
DNA methylation patterns in the BDNF61 and DRD262 genes
impact gene expression and have been associated with psychi-
atric disorders.63,64 Yet at this time, no data exist to explain
whether variation in DNA methylation patterns contributes to
interindividual variability in individuals with neurological dis-
orders. Given that epigenetics are affected by our environment
and behavior throughout the life span,65 it is likely that their
influence on recovery trajectories and treatment responses will
be profound.
Although not explicitly considered at IV STEP, other can-
didate biomarkers that may enable the development of per-
sonalized interventions include brain structure and function.
Brain imaging is noninvasive and easily accessible, enabling
the categorization of brain anatomy, function, chemistry, and
connectivity.66,67 Another potential recovery biomarker is neu-
rophysiological status as mapped using noninvasive brain
stimulation (ie, TMS).11 Transcranial magnetic stimulation–
based neurophysiological measures of the electrophysiological
relationship(s) between the 2 cortical hemispheres and the
integrity of the corticospinal tract via the generation of motor-
evoked potentials relate to motor outcome in chronic66 and
acute adult stroke.11 However, their value in predicting the
Pediatric Physical Therapy
best type of rehabilitation intervention is not well under-
stood. In addition, work in this area has focused on adults
with stroke; a rich opportunity exists to broaden these ques-
tions to include other types of neurological disorders68 as
well as ask questions across the life span. Children appear to
respond differently since their motor skills and repertoire are
still being established, and, therefore, treatment plasticity and
reorganization are different to adults with well-defined motor
maps and pathways.
Finally, it is crucial that the perspective, goals, and needs
of the client be incorporated into personalized rehabilitation
interventions. Through focus groups and surveys of individuals
with stroke, it has become clear that what is meaningful to this
group is the use of their arm in their real-world environments.69
Research in pediatric populations confirms this finding as well
that goal-directed, salient practice of real-life tasks in real-world
environments leads to the greatest functional improvements.
These data are not surprising as they match the optimal con-
ditions for inducing plasticity. For our rehabilitation interven-
tions to be truly effective for each person, we must identify what
is meaningful recovery to the individual and index changes in
quality of life. Only when these goals are met will we have cre-
ated truly effective interventions. Relatedly, future STEP confer-
ences should consider increasing participation from other stake-
holders groups, such as patients and families, to further ground
our discussion in this important issue.
PLANNING FOR THE FUTURE
Research and the critical discussion of findings will con-
tinue to fuel the advancement of neurologic physical therapy
practice. Critical to this advancement must be a paradigm
shift in terms of how we approach rehabilitation research in
terms of both design and interpretation. We have known for
some time that patients have different outcomes from treat-
ment, some respond, while others do not (ie, nonresponders).
More precise data delineating the responder/nonresponder phe-
nomenon would enable more accurate prediction of prognosis.
The innovative movement of “individualized (or personalized)
medicine” addresses the responder/nonresponder phenomenon
by tailoring clinical care to counter an individual’s (epi)genetic
makeup, environment, and goals. Individualized medicine also
necessitates an expansion of the way in which the field needs to
think about designing, analyzing and appraising clinical reha-
bilitation research. Although RCTs are the current gold stan-
dard methodology for evaluating treatment efficacy, they are lim-
ited by their analysis at group mean level. Individual responder
results can be obscured and washed out by nonresponders in
group mean reporting.
The RCT model, which emerged from pharmaceutical trials,
appears to be ill suited for rehabilitation interventions. A key
limitation of this model in rehabilitation is the identification
of the control condition: how do you provide sham physical
therapy? A good control must provide similar nonessential expe-
rience and test the essential ingredients to the treatment. In the
case of a drug, that is a relatively easy pharmacological achieve-
ment (eg, a placebo sugar pill). But, what is the “essential ingre-
dient” to physical therapy? Is it salience, dose, intensity, timing,
Pediatric Physical Therapy
Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
or attention from a caring provider? We have not yet parsed these
elements out; thus, the hypothesis-driven questions must con-
tinue to attempt to elucidate what is the critical component to
be included in our therapies.
Within rehabilitation in the past several years, there has
been reference to “failed trials” of rehabilitation. In the recon-
sideration of rehabilitation research, the term “failed trial” needs
to be clarified. This term comes from drug trials where a drug
has failed to produce a prespecified effect or the negative effects
outweigh the positive. A failed trial means that the drug will not
go to market for use. However, in PT, due to the complex and
multifaceted aspects of an intervention that cannot necessarily
be controlled, an RCT may fail to support a primary hypothesis
but often illuminates other critical aspects of an intervention.
Potentially important findings could include rate of recovery,
treatment effectiveness in the nonprimary outcome measures,
predictors of responsiveness, and so forth. Use of the term “failed
trial” suggests that the intervention is not effective; when often
a more accurate assessment may be that, on average, it is not
better than a different PT intervention but for certain individuals
it may be. A better term may be “equally effective” or “no differ-
ence,” which accurately describes the failed primary hypothesis
but may allow appropriate appreciation and discussion of the
findings to continue to build the science of rehabilitation. As
mentioned previously, important consideration also needs to be
made for what the control intervention is and how that relates
to true “standard care” being delivered in clinics throughout the
country.
Other trial designs, including comparative effectiveness
studies, single-subject designs, and pragmatic designs, should
be embraced to overcome these aforementioned methodolog-
ical problems in rehabilitation research. Single case design, com-
parative effectiveness research, and population registries are 3
alternative research methodologies that enable analysis at the
individual level. These designs overcome the problem of average
performance not reflecting population variability. The principle
benefit of the single case design is that it charts and reports
individual results and, therefore, allows the opportunity to pro-
vided detail descriptions of responders.70 Single case design is
useful and often necessary in low-incidence disorders in which
adequate statistical power cannot be achieved using traditional
empirical designs.70-72 The added benefit of comparative effec-
tiveness research and population registries is that big data enable
comparison of an individual’s performance to the population of
interest.73 Indeed, the RCT should not be abandoned and will
likely continue to be the favored design of funding agencies, but
other pragmatic designs74 are emerging as valid methodologies
for high levels of evidence and should be considered.
Comparative effectiveness research allows for the evalu-
ation of treatment outcomes to improve health care quality
by providing patients, health care providers, and other stake-
holders with better information about the risks and benefits
of different treatment options. APTA Connect (http://www
.apta.org/CONNECT/) and the Patient-Centered Outcomes
Research Institute (http://www.pcori.org/research-results/
patient-centered-outcomes-research) are good resources on this
topic. However, this type of research requires a set of common
data elements that encompass valid, reliable measures. Recent
Stepping Up to Rethink the Future of Rehabilitation S81
work demonstrates both the promise and the challenges of
this type of approach to research.75 To date, few of us report
a common set of data elements; this significantly hampers the
combination of small studies into what might be considered
“big data.” These challenges stem from the plethora of measures
that exist. Fortunately, online resources are being developed
that can facilitate measurement selection. For example, the
National Institute of Neurological Disorders and Stroke has
created an open resource Common Data Elements Web site
(https://www.commondataelements.ninds.nih.gov) that is dis-
ease specific with common measures across multiple diseases.
Cerebral palsy common data elements, to be completed in
2016, will include physical therapy classifications and mea-
sures. Going forward, the physical therapy profession must
embrace single case design research and big data methodologies
to stay on the forefront of individualized medicine. Big data
methodologies will require us to foster collaborative partner-
ships between clinicians, providers, insurers, and government.
Future work may harness information from a vast network
of providers, taking inspiration from crowd source science
practices.
As knowledge rapidly advances in the field of phys-
ical therapy, an imperative exists to embrace effective knowl-
edge translation strategies. First, ensure that patients receive
evidence-based leading-edge therapy. Second, ensure that the
policy governing the funding and reimbursement of care
matches best-available evidence. Knowledge translation to the
policy level must seek to ensure that policy evolves to include
billing codes and/or funding for new and proven treatments and
at the same time, discontinues reimbursement for ineffective
treatments. Numerous systematic reviews exist to guide clin-
icians, educators, researchers, and policy makers about how
best to translate leading-edge research knowledge into routine
patient care. Known effective knowledge translation strategies
supported by high-quality evidence include audit and feed-
back; clinical practice guidelines; continuous quality improve-
ment; financial incentives; mass media; opinion leaders; out-
reach visits; peer comparison feedback; reminders including
computerized decision supports; research-active staff in the
workplace; tailored interventions; and combinations of these
approaches known as multifaceted interventions.43,76 Knowl-
edge translation requires clinicians, researchers, and academics
to “stretch” their role to include advocacy for evidence-based
practice at policy, insurance, and systems levels.
SUMMARY: FROM CHAOS TOWARD CLARITY
In Mary Lou Barnes’ summary article of II STEP in 1990,1
she spoke of a “breaking down of ideas” and a “sense of chaos”
in the profession, where dearly held beliefs were being dis-
mantled. The gurus of the profession and distinct “sects” were
finally being harmonized as physical therapists were performing
research that was not only informing practice but also advancing
understanding of neurophysiologic mechanisms. Rereading of
her philosophical epitaph is a worthy reminder of the value
of historical reflection. At each of these seminal conferences,
we may experience a feeling of chaos or discomfort where cur-
rent understanding and beliefs are challenged or destroyed; we
S82 Kimberley et al
Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
must face the idea that we were wrong. As Dr Barnes stated,
the primary charge for the profession was to embrace the chaos,
merging old and new ideas, because from that we advance
toward truth. In the poetic manner of history repeating itself, we
can draw comfort and inspiration from our predecessors at the
conclusion of IV STEP. We advocate for embracing the discom-
fort of challenging ideas and harnessing it to leverage forward
movement. We may need to drastically reconsider our dearly
held ideas and be willing to be uncomfortable to continue our
forward momentum with novel research designs of hypothesis-
driven questions. We will not be in the same place as a profession
at V STEP, and someday the future may look back at the highly
novel and disrupting findings presented at this conference and
characterize them as quaint realizations. That is worthy of cele-
bration, indeed.
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Pediatric Physical Therapy
 Appendix

Pediatric Physical Therapy

Speakers and the Charge From the Planning Committee

Speaker(s) Charge

Carolee Winstein, Susan Harris Summarize the history of the STEP conferences, your thoughts/reflections on current PT practice and introduce the 4 Ps and their
interdependences.
Ann VanSant Explain the development of movement system diagnoses and how these will assist with prediction of optimal response to
intervention choice, as well as strategies to link classification with accurate predicted outcomes.
Andrea Behrman, Susan Harkema, Elizabeth Ardolino Provide current knowledge of how movement system diagnoses and/or classifications can predict and direct treatment for
neuromuscular recovery in adults and children.
Steve Cramer, Jill Stewart Provide current knowledge of and future direction for genetics and epigenetics related to prediction and plasticity to achieve the
most effective and efficient physical therapy interventions.
Chet Moritz, Faby Ambrosio Provide current knowledge of and future direction for regenerative rehabilitation in the context of physical therapy practice for
prevention, plasticity, and participation, related to the future of how to provide effective and efficient physical therapy.
Jane Burridge, Alan Chon Lee Discuss current telehealth physical therapy practice and how these services may assist with improving prevention, participation,
and perhaps assist with plasticity.
Ellen McGough Discuss how physical therapists should be involved in primary health promotion practices to prevent or delay the development of
neurological disorders.
Edgar van Mil Discuss how pediatric physical therapists should be involved in primary health promotion practices to prevent or delay obesity
and/or neurological disorders.
Don Morgan, Lori Quinn Discuss how physical therapy promotes health and contributes to further motor disorders in adult (Quinn) and pediatric (Morgan)
neurologic populations.
Catherine Lang, Michele Basso Discuss the most effective rehabilitation program from the perspective of amount and timing of services to maximize plasticity and
participation in adult neurological populations and whether this is the same when the objective is plasticity or participation or
both.
Mary Gannotti Summarize the research that indicates what the most effective rehabilitation program is from the perspective of amount and timing
of services to maximize plasticity, participation, or both in pediatric neurological populations.
Judy Deutsch, Sally McCoy Review the types of technology, which have been shown to effectively induce neuroplasticity, are, therefore, likely to improve
participation, and discuss how physical therapists could utilize technology presently and in the future.
Arum Jayaraman Review the kinds of robotic technology that have presently been shown to be effective from a plasticity perspective, the types of
robotics that improve participation, and how PTs could employ robotic technology now and in the future.
Lisa Chiarello Discuss how we can measure participation and design effective interventions to improve participation? What research needs to be
done in the future to improve rehabilitation services that are focused on assisting our clients to participate in family, recreation,
and daily activities?
Sarah Kagan, Michele Lobo Present the key points of research designs other than the randomized controlled trials (qualitative, single subject, big data/
epidemiology) that may assist researchers in answering important scientific questions about rehabilitation focused on any of the
4Ps, but especially participation.
Deborah Backus, Jennifer Moore, Keiko Shakako-Thomas Enlighten the audience about key points of promoting evidence-based practice, how to best achieve knowledge translation, and
how service providers can change their behaviors and adopt alternate practice, based on scientific evidence.

Copyright © 2017 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
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