The State of Rehabilitation Research: Art or Science?

Article Outline

• Abstract
• The art and science of rehabilitation
• The need for evidence-based rehabilitation
• An assessment of rehabilitation research accomplishments
  • Studies Published in Archives of Physical Medicine and Rehabilitation
  • PubMed and MEDLINE Searches
  • Other Database Reviews
• Identification of strengths and weaknesses: Challenges and opportunities
• Challenges to rehabilitation science
• Requirements for a common vision of rehabilitation science
• References
• Copyright

Abstract 

Tate DG. The state of rehabilitation research: art or science?

Rehabilitation research has been criticized as not standing up enough to the rigors of scientific method to be called “science.” The field has been portrayed as slow to promote its scientific achievements and to include them under the rubric of evidence-based rehabilitation. Following in the footsteps of psychology, rehabilitation as a broad-based discipline has faced many similar obstacles in achieving scientific status. Controversy exists about what exactly constitutes rehabilitation science versus its art and its respective multidisciplinary domains. The conception of these domains is directly related to current methods available to assess the state of the discipline and its research accomplishments. I used quantitative methods, such as randomized clinical and/or controlled trials (RCTs) and systematic reviews, to assess the status of rehabilitation research. Findings suggest that, as a field, rehabilitation makes significant contributions to science, measurable by the number and quality of RCTs and systematic reviews conducted so far on topics of critical importance for clinical care. In “artful” complement, qualitative approaches can be used as research tools to aid investigators in seeking knowledge beyond that obtained by quantitative methods, assessing many complexities associated with the various contexts of rehabilitation research. Other requirements to develop a common vision of rehabilitation science are also discussed.

Key Words:  Randomized controlled trials , Rehabilitation , Research

I AM MOST PLEASED TO SERVE as the American Congress of Rehabilitation Medicine (ACRM) 2005 Coulter Lecturer. As such, I am deeply grateful to the awards committee, my colleagues, and to the leadership of ACRM for their vote of confidence in selecting me as the 54th person to follow Kristian G. Hansson, MD, the first Coulter Lecturer, to this podium. I am also grateful to my husband for his support of my work and professional career.

It is probably not news to you that rehabilitation has been widely criticized as lagging behind other disciplines in terms of its scientific achievements. Achieving scientific recognition is essential both to our survival as an academic discipline and to those we help within our profession. Toward this achievement, we must strike the right balance between science and what I call the “art of rehabilitation,” an emotional, creative, and intellectual growth that challenges the rehabilitation professional to work comprehensively on the capacity, depth, and scope of knowledge within the discipline. In my own research, for example, science provides me with a sense of security, familiarity, and a solid structure against which to hang my ideas, while as a clinical psychologist I rely on the arts to explore, interpret, and find meaning in one’s life events.

Earlier in my career, my studies of human behavior were based on knowledge mainly derived from biology and experimental psychology. I quickly learned that the complexity of human behavior could not be understood without social context. Thus, through the study of social and community psychology, I began to gain greater insight into concepts of health, disability, and rehabilitation. It is precisely in the context of these broader issues that rehabilitation has received most of its criticisms. It is as though we have received a great gift, but we do not know how to use it.

My goal in this lecture is to show how we can and should use the great gift resulting from a combination of art and science in order to strengthen the quality and credibility of our discipline even further. To accomplish this goal, I will (1) describe the concepts of science and art as they relate to rehabilitation, including the need for a broader definition of science that artistry allows; (2) discuss the need for a knowledge-based discipline; (3) review our progress in terms of research accomplishments during the past 5 years; (4) identify our strengths and weaknesses, challenges, and opportunities; and (5) make recommendations for a common vision of rehabilitation science.

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The art and science of rehabilitation 

Concepts of art and science are often thought of as opposites, yet their twin characteristics of creation and discovery suggest many similarities between the 2. Leonardo DaVinci exemplified this holistic principle. He was a Renaissance painter, architect, engineer, mathematician, and philosopher who flexibly contributed to both scientific and creative fields. Sigmund Freud described him as a man who awoke too early in the darkness, while others were all still asleep.¹ The creation and discovery that underpin art and science become more apparent when we examine how they relate to rehabilitation. Art is defined as “the products of human creativity,” “the creation of beautiful and significant things,” and “a superior skill that you can learn by study and practice by observation.”²

Rehabilitation artistry is perhaps best expressed in an earlier Coulter lecture by Lauro Halstead, MD, when he emphasized the need for going beyond our science to provide humanistic care. Arts and humanities are intrinsically related, whereas art and science are extrinsically related. Like art, science as “humanistic care…refers to the broad accumulation of human experience and knowledge that has evolved over the centuries in each culture and in life events of each individual. It is subjective, intuitive, and empathetic…”^3(p149-50) From a clinical perspective, this process requires that the rehabilitation professional use creative skills, knowledge, and emotions to treat and care for patients. From a research prospective, the art of rehabilitation can be best understood as the portion of unexplained statistical variance associated with test results.

Science, in seeming contrast, is defined by applying the principles of the scientific method, which includes making empirical observations, proposing hypotheses to explain those observations, and testing those hypotheses in valid and reliable ways. “Science also refers to the organized body of knowledge concerning the physical work, both animate and inanimate, but a proper definition would also have to include the attitudes and methods through which this body of knowledge is formed; thus, a science is both a particular kind of activity and also the results of that activity.”^4(p2) In part, this growth in science results from the association of rehabilitation with disciplines such as cell biology and molecular genetics, as they open new opportunities for the treatment and cure of many conditions such as multiple sclerosis and spinal cord injury (SCI). Furthermore, advances in pharmacotherapeutics now provide, if not a cure, certainly control and palliation of so many disabling conditions. This is probably what most people define as “the science of rehabilitation,” because this type of knowledge can be directly derived from empirical and scientific investigations.

The burden of science is to prove truth and existence through methods known and acceptable. When and where such methods do not exist, all science lags behind. We must envision and create our capacity to prove our science. As a broad-based discipline, rehabilitation is limited by the acceptance of existing methods external to its area as the basis for evaluation of its accomplishments. This problem, again, is not unique to our field; in trying to resolve our methodologic limitations, it is beneficial to learn how other disciplines have dealt with it.

The struggle between the art and science of rehabilitation parallels that between biology and psychology as 2 distinct scientific disciplines. This struggle was best illustrated by William James, a 19th-century scientist, who attempted to explain the relations of the mind and body, originally posed as a dilemma by Descartes.⁵ As a professor of psychology at Harvard, James based the study of consciousness on knowledge derived from experimental physiology. His concept of science went beyond that of biologic observations to include the concept of relations or functions among objects, also important to rehabilitation. His main thrust was that the experience of human processes, emotions, and behaviors contains more than just states of consciousness and unconsciousness. Other human experiences, different levels of awareness, also existed simultaneously alongside “waking consciousness.”⁶

These evolving concepts, based on experimental evidence and corroborated by living testimony, altered James’s conception of how a scientific discipline (in this case psychology in tandem with biologic status) could legitimately be conducted. In challenging the supremacy of scientific materialism, he demanded that science not ignore any aspect of reality if it could, in fact, be experienced. James’s theory, that there is more to reality than meets the eye, resonates with some of the difficulties in recognizing the art of rehabilitation as part of our science.

One way of experiencing and thus representing reality is through theoretical frameworks. There are at least 2 theoretical approaches to how science can be used to represent reality. Scientific instrumentalism posits that scientific theories are intellectual structures that provide adequate predictions of what are observed and useful frameworks for answering questions.⁷ Scientific realism, on the other hand, holds that scientific theories go beyond data to posit existence of nonobservable entities such as mental representations and social cognitions. The product of scientific research, here, is the knowledge gained that is independent of a single or unitary theory or methodology, although a particular theory may be useful or favored in organizing knowledge. Based on these principles, one may suggest that rehabilitation science is better served by a theoretical framework derived from scientific realism, because it can better account for its less tangible aspects.

Psychology, like rehabilitation, has long struggled to prove its scientific nature. It became fashionable among early psychologists of the 20th century, for example, to emulate theory construction in the physical sciences by modeling the structure and form of their formulations after Newtonian physics. This tendency to model off the methodologies of basic sciences in order to heighten scientific status spread across other disciplines, making its way to rehabilitation theories as well. This process of close association and the transfer of ideas among related scientific disciplines often resulted in positive outcomes.

A good example of how rehabilitation science has evolved is the parallel development of the neurosciences, particularly how these 2 disciplines contributed to knowledge in brain impairment treatment and research. Through brain-imaging techniques, we learn how information processing is implemented in neural tissue and when specific types of information processing are used, thus affecting brain functioning and behavior. What is known about these findings is changing the research and theoretical perspectives in cognitive rehabilitation, for example. As a result, scientific growth is mutual, occurring in both disciplines (rehabilitation and neuroscience) through mechanisms of translational research.

Advances in brain rehabilitation have thus benefited from a unique combination of approaches including a biologic substrate, a cognitive dimension based on information processes, a social science dimension that covers the activation of these elements, and their behavioral modulation by the social context. It is this mechanism of scientific synergy that makes rehabilitation so much more interesting and unique when compared with many other disciplines that are less emergent and dynamic in nature. It is also this same complexity of factors that poses a challenge to the status and nature of our scientific achievements.

In 1999, Reason and Goodwin⁸ described several principles of scientific complexity, all of which apply to rehabilitation and the object of our studies. These principles include the interconnectivity among diverse components, the iteration of activity patterns, the emergence of order that is only discovered by operating the iterative cycles, and the holism that results from interaction between the component elements of the system. Understanding the symphony as produced by a “rehabilitation orchestra” is more than the precise and distinct role of each element in the production of knowledge. It involves the study of these elements in isolation, in various combinations, and as a whole.

The science of complexity brings us to the threshold of a new relationship with complex processes (eg, physical and physiologic, functional, emotional, and psychologic, social, cultural, and environmental); in rehabilitation, these various processes define the context of our lives in relation to injury, disease, or disability. Emphatically, note that several of these processes fall outside the realm of control and manipulation as known among the basic sciences. However, these processes are not without their own subtle expressions of order. The collective patterns of ordered activity observed in rehabilitation can be understood and described as emergent properties of complex systems, arising from activities and interactions of the component individuals while not reducible to these. Thus, complexity in rehabilitation has its focus on the study of these emergent properties. The question then arises how to best make sense of knowledge governed by these emergent properties. One clear option is to make use of the traditional scientific method to provide us with a tool to interpret and make sense of our findings.

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The need for evidence-based rehabilitation 

The difficulties associated with the use of the scientific method in rehabilitation have been many. They, in turn, have affected the perceived rate of scientific progress in the field. The many impediments related to the adequate execution of clinical trials are just an example of the barriers precluding use of the scientific method in rehabilitation. As a consequence, the field is viewed as lacking the solid foundation of empirically derived data needed to show the efficacy of key interventions.⁹, ¹⁰

This common view that rehabilitation research lags behind other sciences affecting the development of new outcomes and practices suggests the need to devise ways in which we can bolster our science and develop greater research capacity in rehabilitation. After all, progress in any field of knowledge is still very much tied to the rate and quality of its scientific achievements.

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An assessment of rehabilitation research accomplishments 

I conducted an assessment of our accomplishments based on the number and the quality of research studies (specifically controlled trials and randomized clinical trials) and systematic reviews published in rehabilitation during the past 5 years. In the hierarchy of research methodology, randomized controlled trials (RCTs) are viewed as providing evidence of the highest grade.¹¹, ¹² Randomized trials (controlled or clinical) are experiments in which subjects are randomly allocated to receive and not to receive an experimental preventive, therapeutic, or diagnostic procedure and then followed to determine the effect.¹³ In contrast, observational studies or case studies are found to be less reliable and predisposed to overestimate treatment effects.

I searched a number of computerized databases, which included the registration of trials (clinical and controlled) and systematic reviews conducted in rehabilitation, for the period of January 2000 to July 2005. The databases included Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, ClinicalTrials.gov, PubMed and MEDLINE, and reviews of manuscripts published in the Archives of Physical Medicine and Rehabilitation.

Selected key words included randomized controlled trials, clinical trials, and rehabilitation. In some cases, specific diagnostic groupings or categories were also searched. An analysis to evaluate the quality of research studies and evidence derived from them placing weight on rigor of study design was conducted based on abstracts retrieved from each of these databases. This analysis used the hierarchy of 5 levels of scientific evidence, as proposed by Sackett.¹⁴ The hierarchy of levels of scientific evidence describes level 1 studies as large randomized trials with clear-cut results and lower risk of error, level 2 studies as small randomized trials with uncertain results and moderate to high risk of error, level 3 studies as nonrandomized trials with concurrent or contemporaneous controls, level 4 studies as nonrandomized trials with historical controls, and level 5 studies as case series with no controls.

Studies Published in Archives of Physical Medicine and Rehabilitation 

Two searches were completed using the search engine available on the journal’s website (http://www.archives-pmr.org). Research abstracts were critically evaluated and classified by level of scientific evidence.

The first search yielded 170 research studies of both intervention and nonintervention type. When evaluated with respect to meeting levels of evidence, results were distributed bimodally. Of all studies, only 4% met level 1 criteria of being a large RCT, whereas 36% were best classified as small RCTs (level 2 studies) and 44% were nonrandomized studies without control group (level 5 studies). This latter group included surveys, cohort studies, descriptive studies, and observational and case studies (table 1).

Table 1. Research Studies Published in Archives of Physical Medicine and Rehabilitation (2000−2005)

NOTE: Small RCTs include up to 100 subjects, with the mean being 50 or less.

Results showed a large number of level 2 studies, suggesting a trend toward using RCTs with small samples. Not surprisingly, based on issues of complexity previously described, a significant number of rehabilitation studies conducted used designs other than those of controlled clinical trials.

A second search focused on systematic reviews and found a relatively high number of reviews being published on a variety of topics of importance for rehabilitation. These included reviews on motor recovery after stroke, hyperbaric oxygen therapy for traumatic brain injury, the role of Tai Chi, and traction for back pain.¹⁵, ¹⁶, ¹⁷, ¹⁸ A significant number of articles published in Archives have addressed the topics of assessment and outcome measurement in rehabilitation, suggesting a concerted effort to address issues of conceptual relevance and the precision of current rehabilitation measures.

PubMed and MEDLINE Searches 

Three searches were conducted using PubMed and MEDLINE, including citations going back to 1950. Findings from the first search show the total number of RCTs by year and of systematic reviews (table 2).

Table 2. Number of RCTs in PubMed and MEDLINE From 1950 to 2005

NOTE. Only reviews related to rehabilitation during 2 time periods are included here.

Source: PubMed/MEDLINE search (July 2005).

Abbreviation: MeSH, medical subjects heading.

Note that the number of RCTs in rehabilitation has risen dramatically during the past 5 years as compared with the preceding 5-year period (1995−2000). From January 2000 to July 2005, our field has published almost half of what has been published since 1950. A similar growth pattern is noted with respect to systematic reviews conducted, with almost 3 times more reviews produced recently, as compared with the period of 1995 to 2000. These facts conclusively suggest a steady rate of growth in scientific achievements in rehabilitation.

A second PubMed search was conducted to determine specific areas of growth (table 3). Ten diagnostic groups were chosen to reflect areas of rehabilitation practice. Findings were classified by nonrehabilitation and rehabilitation RCTs within 10 diagnostic groups. Cancer tops the list, having the highest number of nonrehabilitation RCTs, followed closely by pain and cardiac or heart conditions. Among rehabilitation RCTs, the highest numbers of trials were in pain (n=1224) and knee arthroplasties (n=887). By comparison, rehabilitation RCTs on brain injury (there were 52 rehabilitation RCTs out of a total of 219 brain injury RCTs), SCI (38/150), and multiple sclerosis (52/381) are less frequent, perhaps reflecting the cost and difficulties associated with conducting these studies. Yet, they make up a significant percentage of all RCTs in these categories, with 24%, 25%, and 14%, respectively. Rehabilitation transplant studies make up 39% (51/129) of all RTCs in this category, showing significant growth for rehabilitation care in this area.

Table 3. RCTs by Diagnostic Groups (1950−2005)

Diagnostic Groups	Nonrehabilitation RCTs	Rehabilitation RCTs	%⁎
Cancer	11,060	298
Pain	9896	1224	12
Cardiac	8369	223
Stroke	2812	392	14
Arthritis	1796	269	15
Pulmonary	1191	142
Spine	1099	129
Arthroplasties	615	887
Hip	1319	165
Knee	1364	300	22

NOTE. Only percentages for diagnosis with highest frequency were calculated.

Source: PubMed/MEDLINE search (July 2005).

These findings bring further support to Johnston’s conclusion that “although rehabilitation represents a small percentage of total biomedical research, RCTs were in fact slightly more frequent in the rehabilitation literature than in the rest of MEDLINE.”^19(pS4) He also notes that the various intervention trials were 1.53% more frequent in rehabilitation than in other areas and concludes by stating “[t]here is no evidence that rehabilitation is relatively deficient in RCTs, given its small size in biomedical sciences as a whole.”^19(pS4)

A third PubMed/MEDLINE search focused exclusively on the number of systematic reviews completed in rehabilitation (fig 1). Results showed a significant number of systematic reviews in cancer rehabilitation, emphasizing the need for establishing standards of care in this area when caring for these complicated patients. Other diagnostic groups included pulmonary rehabilitation, cardiac rehabilitation, and transplants, also suggesting a growing interest about the work being done in these areas.

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• Fig 1. 

  Systematic reviews in PubMed across rehabilitation areas.

Other Database Reviews 

A review of ClinicalTrials.gov focused on comparing currently active interventional trials across disciplines and areas (fig 2). Results showed that rehabilitation has a significant higher number of RCTs (n=28) among its currently open clinical trials (n=57) or 49% of all trials when compared with disciplines like pediatrics (with 11% of RCTs among its clinical trials) or pulmonary care (with 32%).

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• Fig 2. 

  Registered clinical trials and RCTs in rehabilitation and nonrehabilitation disciplines.

Review of these data also suggests that an increasingly significant number of RCTs in rehabilitation are being conducted in foreign countries. A search of clinical trials and RCTs using Cochrane Central resulted in 132 rehabilitation studies. Of these, 30% were conducted abroad. A larger number of all trials (43%) were randomized studies with controls (table 4).

Table 4. U.S. and Non-U.S. Rehabilitation Clinical Trials and RCTs From Cochrane Central

NOTE. Only percentages by areas with highest frequencies were calculated.

Source: Cochrane Central search (July 2005).

The largest number of clinical trials and RCTs are in cardiac and pulmonary rehabilitation, but the highest percentage of RCTs is in pain studies (68%). Among all RCTs in rehabilitation, the majority (85%) appears to meet the criteria of level 2 studies (small randomized trials).

A search of the Cochrane Database of Systematic Reviews yielded a large number of reviews of rehabilitation studies, with the greater number of reviews being conducted on pain, followed by stroke, arthritis, spine, and brain rehabilitation. The overall percentage of reviews in rehabilitation by diagnostic groups ranged from 20% to 30% (table 5).

Table 5. Cochrane Systematic Reviews by Diagnostic Groups With and Without Rehabilitation

Source: Cochrane Systematic Reviews search (July 2005).

The relatively high number of reviews in rehabilitation suggests considerable effort to establish broad-based knowledge in several areas and to guide future research.

Mallett and Clarke,²⁰ in a recent article of a British medical journal, suggest that the field of health care needs approximately 10,000 Cochrane reviews to be able to contribute to evidence-based knowledge in the field. Based on this target, the field of rehabilitation, with its 5075 reviews across these selected diagnostic groups, is making excellent progress in meeting its goal.

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Identification of strengths and weaknesses: Challenges and opportunities 

The information reviewed for this lecture provides a unique perspective on the quantity and quality of rehabilitation research completed during the past 5 years by classifying these studies by levels of scientific evidence and comparing numbers of rehabilitation trials by areas and with those of other disciplines. This information also describes the state of our knowledge, empirical and inventive, based on systematic reviews conducted in our field. Although these indicators of scientific achievement (ie, numbers and quality of RCTs and systematic reviews) are widely accepted as a sign of growth in our discipline, the debate still hinges on the specific scope and domains of rehabilitation knowledge, on what is deemed to be scientific versus what is technically implausible to be explained by traditional quantitative scientific methods. My earlier discussion about the complexity of our science (using the term in a broader, more artful sense of the word) illustrates this precise dilemma.

I chose to address this dilemma by focusing my assessment on acceptable standards of research of a quantitative nature because these standards are currently used to indicate the status of evidence-based knowledge in rehabilitation. By using these standards, I can affirm that the state of rehabilitation science is excellent and its prospects even greater. In support of this opinion, I offer the following points summarizing our collective strengths and opportunities.

Based on these findings, we have made considerable scientific progress in rehabilitation during the past years. However, we increasingly face the task of defining our work in a manner consistent with both a comprehensive disciplinary concept and the scientific method to which it maps. A number of conceptual and methodologic issues continue to hamper higher levels of achievement in our research. These additional methodologic issues are highly interrelated and not exclusive to rehabilitation; indeed, the interrelation of methods is common to other social and behavioral sciences. Rehabilitation science faces the additional challenge of pluralizing its methods to embrace its many voices—medical, psychologic, therapeutic—while still asserting its relevance to fields with more unitary methods.

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Challenges to rehabilitation science 

From a conceptual perspective, rehabilitation research covers a wide range of issues and domains. The multidisciplinary nature of its domains makes rehabilitation interdisciplinary by nature and, therefore, difficult to define by contrast. Rehabilitation research is often context specific and defined as the interaction between the individual and the environment. As such it includes physical, social, institutional, and cultural conditions of life and practice, which are interconnected and can be peeled back like the layers of an onion to reveal the central core of each individual’s spirituality.²¹ It is dealing with these many layers, multidimensional facets, and separate yet intrinsically related complex domains that poses significant challenges to rehabilitation. Thus, how we define the domains of our studies brings about both risk and opportunities.

The process by which we measure these broader rehabilitation domains and test our theories about reality shapes what constitutes rehabilitation knowledge. Following a scientific approach, and like psychology, rehabilitation borrows its methods from those used by the basic sciences. Unlike psychology though, rehabilitation has yet to explore other ways of measuring subjectivity and interconnectivity. Until this is done, the process of both individuating from other basic sciences and integrating our many domains into 1 discipline is not complete and our science stays limited. Paradoxical for a science of many domains, we design research tailored to the rigor of traditional scientific method, minimizing our differences in order to reduce “unwanted” variance.

We appear to be making a serious mistake by reducing scientific evidence in our field to 1 methodologic approach that mainly emphasizes quantification of data. The translation of research into practice cannot be limited by data that is quantifiable, objective, and devoid of all individualities; on the contrary, it must include the richness of methods that can best help us capture individual variation in its physical, social, and psychologic contexts. These are, in essence, the gifts of our science.

Because the dedication of qualitative ethnographic and social research approaches to rehabilitation research is rare, we claim the apparent lack of scientific progress under these seemingly less objective areas of rehabilitation as “art” in a negative sense, as though use of nonquantitative methods suggests the artifice of these modes. More persuasively, qualitative methodologies of all sorts already provide rehabilitation researchers with knowledge as one might even argue that, because of our multiple domains, the opportunity for qualitative and quantitative science is equally great in clinical practice, if we continue to develop our capacity and creativity in this direction. But why should we? Qualitative methods can provide rehabilitation with another approach to appraise reality. It provides us with “the ability to perceive and contextualize the world of our own experiences as well as the capacity to project as meta-empirical conceptualization onto those contexts of life and social institutions with which we have not had direct experience.”^22(p2) Differences of experiences among researchers, participating subjects, and practitioners can be attributed to factors such as age, culture, professional training, sex, and minority and disability status among others. It is only by adopting qualitative methods of inquiry that we can truly transcend these disparities.

It may well go beyond James’s concept of “experiencing one state of consciousness” to capture the interactions that occur in context. We must define reality as including all that we experience, recognizing that “we all bring our values and belief into the clinical situation” and, beyond that, to our theoretical models and research (it is simply how we as rehabilitation scientists or artisans perceive reality). This is perhaps the biggest challenge we face in becoming a mature discipline.

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Requirements for a common vision of rehabilitation science 

Defining the scope of rehabilitation research to include its several conceptual domains, as discussed during the 2005 Rehabilitation Medicine Summit meeting,²³ requires the object of our studies to be contextually interpreted with its facets best suited to be tested through a variety of scientific methods to include a combination of both quantitative and qualitative designs. Building a common science in rehabilitation requires that we embrace its many domains and redefine our science to include our artistry. Our theories and our methods must follow suit.

Because traditional science tends to discount personal experience as a source of valid and reliable data, it reinforces the passivity of research subjects and obscures their voices as true participants in the research process. This practice has been countered by use of pluralistic methods derived from orientations beyond traditional scientific authorities, such as community-based participatory research (CBPR).²⁴ Combination methods like CBPR have much to offer to our discipline by including the main features of rehabilitation (eg, being collaborative, involving multiple issues and contexts of participation, promoting empowerment as a process by which participants are actively involved in research meaningful to them) in its approach to create useful knowledge.

The importance of the CBPR is being increasingly recognized by the National Institutes of Health and its institutes as well as other federal agencies such as the National Institute on Disability and Rehabilitation Research and the Agency for Health Care Research and Quality. CBPR is already understood for its role in deepening and enriching our base of knowledge in specific areas such as health disparities, health promotion, and disease prevention. Community-partnered research processes applied to rehabilitation potentially offer better informed hypotheses, more effective interventions, and more precise translation of research results into practice. While presenting powerful opportunities for us to reflect on our science, such alternative methodologies advance and exact evidence-based research among the populations that rehabilitation typically serves.

Qualitative methods like these can add valuable and valid information to quantitative findings, but quantitative methods such as RCTs still are understood as providing reliable and timely solutions for problems requiring specific answers. RCTs have made significant contributions to treatment efficacy and effectiveness and can be more cost-effective for addressing preventable problems that affect large numbers of rehabilitation consumers. When relevant and feasible, level 1 studies (multicenter trials) provide greater validity to results by being better suited to address the issue of patient recruitment and generalizibility of findings to various settings. Multicenter trials, like other research designs that use prospective longitudinal methodologies, can benefit from collaboration among centers in the United States and abroad by contributing cross-cultural relevance to an increasingly ethnically diverse patient population. Sharing results among researchers around the globe should start by registering all research protocols in common databases such as Cochrane Central. Such collaborations can add to an existing body of knowledge and improve our ability to design more focused, relevant, and robust rehabilitation studies in the near future.

In this lecture, I have highlighted some important conceptual and methodologic issues to consider when assessing the status of rehabilitation research. They deserve careful consideration as we plan and execute future studies. My findings underscore our commitment to research, as shown by the quality of our studies and systematic reviews conducted. Further progress to increase research capacity in rehabilitation needs to take into account the potential contributions of other methodologies to our science.

We have come a long way in our journey toward science, despite all obstacles encountered thus far. Whether we call rehabilitation’s disciplinary future a figment of science or art, the fruits of our labor have been gathered for our inspection, for us to harvest as we pursue a common goal—the improvement of the quality of life for people with disabilities. I have every confidence that ACRM’s leadership and membership can powerfully influence the future of our discipline. Rehabilitation is advanced enough to sow new ideas as we reap. I firmly believe we have every motivation, every skill, and every opportunity to rise to the challenge!

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