Given that health care expenditures are expected to reach almost 20% of gross domestic product in the next 5 years,1 service reimbursement based on outcomes, or "pay-for-performance," is likely to be an increasingly compelling driver of change in the way health care services, including physical therapy, are delivered. A systematic review of studies intended to assess the impact of pay-for-performance on quality improvement found that most studies identified a positive impact on quality.2 The Institute of Medicine defines quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."3 The assumption that forms the foundation of pay-for-performance is that increased quality of care decreases costs by reducing ineffective practices and inappropriate care. The quality indicators under pay-for-performance assume that if best clinical practice can be defined then it can also be measured--the challenge is to define best clinical practice.

In efforts to define and promote best clinical practice, there is a justifiable emphasis on the research literature and on knowledge translation. When "knowledge translation" is applied to physical therapist practice, most commonly the reference is to interpreting the meaning of the research findings in the context of the real-world clinical setting. JNPT's Clinical Points of View, which now appears in each issue (as the product of a collaborative effort with the Research Committee) represents an effort at this form of knowledge translation. However, the translation of the latest research findings into applications for clinical practice is but one of several forms of knowledge translation,4 and I would argue that it may not be the form that will best aid us in realizing our vision of "transforming society by optimizing movement to improve the human experience."5

The focus on translating the latest findings to practice seems to belie the point that most advances in practice are rather incremental and that real differences between alternative forms of intervention are usually small.4 There are excellent examples of this in our own neurorehabilitation research literature. While the EXCITE trial is one that we can hold up as showing a real and meaningful difference between the experimental and standard-practice approaches,6 numerous large clinical trials-think of the LEAPS,7 SCILT,8 and Everest9 trials--have shown that, for the most part, conventional physical therapy approaches are as effective as the new-fangled experimental approaches. While not a large trial by comparison, the study by Dibble et al10 in this issue serves to make this same point. Far from being a reason to lament "negative" results, these and other neurorehabilitation studies showing that more conventional neurorehabilitation interventions are nearly as effective, or even as effective, as the experimental interventions are an endorsement of the value of our conventional physical therapy interventions.

Is the limited translation of research to physical therapist practice the principal concern when discussing translation of evidence to practice? I believe that the real concern is that the conventional physical therapy used in clinical trials is often not "usual practice" in the sense that it often does not represent the way all physical therapists practice; in truth, the conventional intervention more often represents an evidence-based approach that characterizes the way exceptional physical therapists practice-it represents best clinical practice. This suggests that there may be value in rethinking what we wish to translate to the clinic-that the best way to ensure that the largest number of patients are receiving the best possible care is not by focusing on the next big thing, but instead by consolidating efforts to help all physical therapists provide the best possible "conventional" physical therapy. While we may not yet have the systematic reviews and meta-analyses that comprise the highest levels of evidence, in most areas of neurologic physical therapist practice there exists a body of evidence in the neurorehabilitation literature to allow us to codify best practices.

It is heartening that there are now numerous efforts underway to codify and facilitate best clinical practice. In my opinion, among the most valuable of these are the efforts to (1) develop clinical practice guidelines (CPGs) to standardize intervention based on best available evidence, (2) standardize outcomes assessment through identification of core sets of outcome measures, thus allowing direct comparisons to be made among different interventions, and (3) classify movement system dysfunction with nomenclature of diagnosis that will guide intervention11 (see also the case study by Scheets et al12 in this issue). We can take pride in the fact that the Neurology Section is among the leaders in these efforts; our Section has led the way in developing recommendations for selection of outcome measures (see http://www.neuropt.org/professional-resources/neurology-section-outcome-measures), provided algorithms to guide other sections in this process. Section members are now actively involved in the development of CPGs via the activities of the Practice Committee.

It is important to bear in mind that the development of CPGs is only the first step in the process, there are other hurdles to implementation of the CPGs that represent variations on the theme of knowledge translation-clinicians must apply and adhere to the guidelines. The strategies for overcoming these hurdles comprise a form of knowledge translation research commonly referred to as implementation science, wherein one goal is to identify how best to assist clinicians in adhering to CPG. One aspect of implementation science research delves into questions about the elements of education, administration, infrastructure, etc, that best facilitate the use of guidelines. Neurology Section members will have numerous opportunities to learn more about implementation science research in 2015-16 year, with both JNPT and Physical Therapy having Special Issues on this topic (see the Call for Papers in this issue), as well as a Catherine Worthingham Fellow's Forum presented by thought leaders in implementation science at the 2015 APTA NEXT meeting in National Harbor. I believe that the JNPT editors and editorial board members would agree that efforts to assist neurologic physical therapists in applying current best practices must be a priority to prevent the value of our services from being lost in translation.

REFERENCES