I thought that it might be interesting to have a discussion on the topic of zhielka. My colleagues of many years know that this is a topic that is near and dear to my heart as I did my PhD work on zhielka. Hmm, you thought I did my dissertation on turtles? It's true; so then why then do I refer to it as zhielka? I do this to make the point that it's only a turtle because you and I have agreed to use the Latin alphabet and the English language; we have agreed on the order of the letters, and the sound that each will make to represent the concept of a turtle. If I were to use the Cyrillic alphabet and the Macedonian language, where turtle is zhielka, then we would have difficulty understanding each other. Language is an example of standardization. This standardization allows us to communicate with each other, and without standardization we would have great difficulty exchanging ideas.

Our society depends on standards for optimal efficiency, productivity, health, and well-being. Imagine life without drinking water standards, standards for building construction, standard traffic rules, and so on. Within our profession there are a number of areas in our profession wherein we have good standards to follow, examples include the standardized assessment of student physical therapist (PT) clinical performance (Physical Therapist Clinical Performance Instrument), accreditation standards (Commission on Accreditation in Physical Therapy Education), normative models of PT education, and lately we have seen the development of a number of excellent clinical practice guidelines. Standards are intended to promote quality. Sadly, in the 3 areas that are most important for consistently achieving high quality in the client management model, that being diagnosis, intervention, and outcomes measurement, our profession has an appalling lack of standardization.

Surveys of PTs in the developed world have shown that this situation is not unique to the United States. The use of standardized outcomes measures (OMs) is reported to be approximately 48% in the United States,1 and in the statistics are not much different in Australia (66%),2 Canada (43%),3 and the Netherlands (70%).4 Furthermore, in those countries where the use of standardized OMs is highest, most PTs report using these measures mostly for the assessment of impairment at the level of body structure and function. There is far less use of standardized OMs for measurement in the ICF domains of activities and participation, domains that are likely to have much greater meaning for our patients. To complicate matters, even among PTs who do use standardized measures, there is little agreement on what measures to use. For example, in the measurement of hand and arm function, one might choose between a number of equally valid and sensitive measures such as the Jebsen Taylor Test, the Wolf Motor Function Test, or the Chedoke Arm and Hand Inventory. The problem is that intertest differences make it difficult to compare outcomes of different interventions when different tests are used to assess change.

Imagine that the same were true in other areas of health care delivery. Let's say, for example, that you visited your cardiologist and, using an echocardiogram, he diagnosed aortic valve stenosis. He recommended that you return in 6 months to reassess your cardiac status. You dutifully return 6 months later and find that your cardiologist has retired. For that reason you see his associate, who decides that she prefers to assess your cardiac status using a 12-lead electrocardiogram-do you know anything about the change in your cardiac status? You decide this situation is less than optimal, so you consult with a third cardiologist, who decides that he will not use either an echocardiogram or an electrocardiogram, but instead a chest radiograph. If you're like me, you would find this situation completely unacceptable. And, yet this is the situation that we are faced with in PT practice.

What are the consequences if we continue with this lack of agreement on what OMs to use (or even worse, lack of agreement that OMs must be used at all)? There are many negative consequences, but I believe that the following 3 consequences are the most detrimental. First, is the effect on our patients; without a way to measure the outcomes of our interventions we will continue to be unable to identify best practice and therefore continue to have unwarranted variation in practice. A second, related consequence is the effect on our profession, wherein the true value of physical therapy remains concealed by our lack of ability to measure the changes we effect. A third consequence is that we risk our professional autonomy, as legislation could dictate what measures we must use; this has already occurred in the home health arena where the use of the Outcome Assessment and Information Set (OASIS) is required.

On the bright side the Neurology Section is growing an excellent cadre of PTs who recognize the importance of standardized OMs across the ICF spectrum, who can speak to this issue with authority, and who have the knowledge to incorporate standardized OMs into their practice. We've already discussed the consequences of not agreeing on standardized sets of OMs, but what are the opportunities if we make good on this effort? I believe that the opportunities are almost too numerous to count, but I'll list those that I believe are the most important. First, our patients will benefit, as we will be able to identify the most valuable interventions to meet their needs. We will be able to compare intervention outcomes, apples to apples, and answer questions about Who (...shows the greatest change?), What (...interventions are associated with the greatest change?), When (...is the intervention associated with the greatest change?), Where (...is the setting where the intervention is best delivered?), and How much (...dose is optimal?) related to our practice. Second, our practice will benefit as the use of standardized OMs will inform the plan of care, improve accountability and justify intervention, and improve efficiency and effectiveness by facilitating the duplication of expert knowledge (why should each and every PT need to spend time deciding what measures to use for a given patient?). Third, there are benefits to clinical research and translation of research to practice in the ability to communicate in a common language and make meaningful comparisons between studies to identify the most effective approaches.

Kudos to all colleagues in the Neurology Section who have recognized the importance of using standardized OMs for reducing unwarranted variations in practice and delivering optimal PT services, for demonstrating the value of PT services, and for building the PT evidence base. I believe that the efforts of the Neurology Section demonstrate that the APTA Section structure is well-suited to moving these efforts forward. Unfortunately, all Sections may not have the resources to take on such an effort, so for this reason an institutional, profession-wide commitment will be necessary so that smaller Sections are supported in these efforts. You can feel gratified to know that our example is being explored by those in other areas of practice, and that the groundwork laid down by the Neurology Section will provide a sensible path for others to follow.

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