Authors: Marijn Hafkamp (AMU)

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On the Knowledge-to-Action gap in Rehabilitation – An interview with ‘Revalidatie Friesland’

The knowledge-to action gap

Advancements in the science of rehabilitation play a crucial role in safeguarding public health. From the development of new training programmes to the design of state-of-the art prostheses: biomedical research is vital to the well-being of those who are impaired. But despite this connection between rehabilitation science and rehabilitation practice, a gap is experienced between academia and the clinic. In literature, this is known as the knowledge-to-action (KTA) gap (Graham et al., 2006). The KTA gap is for instance reflected in the time it takes for research output (journal articles, conference contributions etc.) to be transformed into policy and products (treatments, programmes, etc.). Current estimates are that this takes about 17 years, spanning almost two decades of a lifetime (Di Rienzo et al.,). The large KTA gap reduces the societal benefit of research and ultimately undermines the trust in academia. This is particularly problematic for the field of rehabilitation, which was brought to life to help people in their daily functioning. As such, it is of utmost importance that science and practice in the field of rehabilitation are reconnected.

This toolbox

This toolbox, developed in the context of REPAIRS, is intended to provide a fresh perspective on how the KTA gap in rehabilitation could be reduced. In part 1, we provide some background on the topic. How is scientific knowledge currently disseminated and implemented in the field of rehabilitation? And what obstructs this process, to result in the KTA gap? In part 2, we present an interview with two practioners from Dutch rehabilitation center ‘Revalidatie Friesland’, held on the 8^th of July 2024. The goal of the interview was to understand the KTA gap from the perspective of a rehabilitation clinic. How are theories and models implemented in the daily practice of rehabilitation? In other words, how does knowledge find its way to the clinic? In part 3, we reflect on this interview and conclude with some suggestions to improve the interaction between science and practice in the field of rehabilitation.

1. Background

Dissemination of knowledge

The knowledge-to-action gap is widely acknowledged as a problem for both science and practice. To reduce the KTA gap, many efforts have already been made to facilitate the transfer of knowledge from the research institutes to the daily practice of rehabilitation in hospitals, clinics and health care centers. In fact, the dissemination of knowledge has changed considerably in recent years. Traditionally, the only way for scientists to spread their knowledge was to present the output of their research to peers. This happened via talks and posters pitches at conferences and ensured that professionals, mostly within the academic circle, would get acquainted with each other’s work. Implementation of that knowledge would follow naturally, so was the assumption. Nowadays, researchers have become aware that this form of dissemination is not enough to ensure the transfer of knowledge from science to practice. Using the power of social media, scientists have learned to spread their work to greater audiences. Dissemination no longer only concerns presenting at conferences, but it also concerns maintaining a scientific blog, engaging in podcasts (e.g., Perception & Action Podcast by Rob Gray, Figure 1), contributing to science fairs or hosting public events. Think, for instance, about the annual European Research Night organized by the EU in cities across the entire continent (Figure 2). Taking a step back allows us to see that the resources for presenting one’s research have significantly increased over the years, also in the domain of rehabilitation.

Despite these efforts, however, the KTA gap in rehabilitation is persistent. Practioners and clinicians continue to feel a distance between the questions that emerge in rehabilitation and the answers that are provided by academic research. This will also come to the fore in the interview. To understand how this is possible, we must take a critical look at the concept of knowledge and how it is transferred from field to another.

Coordination of practices

Knowledge, in the form of scientific theories and models, is generally treated as a product (Greenhalgh & Wieringa, 2011). This is reflected in the way we talk about the relationship between science and practice. We speak about a transfer of knowledge, as if theories and models are physical objects that can be transported from one place (the research institute) to another (the clinic). In reality, however, knowledge is not tangible and cannot be detached from the scientific environment in which it was developed. Theories and models have been devised in a research institute that has its own norms, values and practices. As such, knowledge is a cultural product that is integrated within the practice of academia (Restifo & Phelan, 2011). Rehabilitation clinics and public health institutes, on the other hand, have their own norms, values and practices, including their own forms of knowledge. From this viewpoint, the KTA gap in rehabilitation is not caused by the long time it takes for practioners to pick up on the theories and models produced by scientists. On the contrary, the KTA gap is caused by the cultural differences between the practice of science and the practice of health care! There is, in other words, a discontinuity in the ways that academia and clinic behave (Di Rienzo et al., toolbox). In this light, the only way for the KTA gap to be reduced is to coordinate the practices in academia with the practices in a clinic. That is the challenge.

Closing the gap

A first step towards a coordination of practices, so we argue, is to gain a mutual understanding of each other’s workplaces. Knowledge of the culture in which people work, including the struggles that occur in daily practice, can help to close the KTA gap. This may shed light on the problems that obstruct a transfer of knowledge and on possible misunderstandings on either side of the gap. As early stage researchers (ESRs) pursuing a PhD within a university department, we –the authors– look at rehabilitation from an academic point of view. Therefore, we decided to conduct an interview with people who consider rehabilitation from a more practical and applied point of view. As such, we decided to visit ‘Revalidatie Friesland’, a Dutch rehabilitation center that formed one of the partners of REPAIRS (Figure 3).

Revalidatie Friesland

‘Revalidatie Friesland’ is a modern rehabilitation center that provides health care for children and adults recovering from (motor) injury or disability. The center offers both inpatient and outpatient treatment and it is particularly known for its patient-centered approach with multidisciplinary caregiver teams (https://www.revalidatie-friesland.nl/). With multiple locations across the Friesland region, the center is well integrated in the health care system of the country. For the interview, we visited the rehabilitation center in Beetsterzwaag, a small village in the north of the Netherlands. This large center, housed in the historic Huize Lyndenstein is specialized in impatient rehabilitation. It includes a swimming pool, a sports hall and several treatment rooms with state-of-the art technology. Patients treated here suffer from stroke, spinal cord injury, chronic pain or brain related injuries. The center is also well known for the treatment of children and young adults, which dates back to the time when Huize Luyndenstein was a children’s hospital.

2. The interview

On the 8^th of July 2024 we visited Revalidatie Friesland Beetsterzwaag to conduct an interview. We were welcomed by Heleen Reinders-Messelink, a senior researcher at the institute who has worked at Revalidatie Friesland for over 27 years. After a guided tour through the clinic, we also met Sanne Nieuwhof, a physiotherapist at Revalidatie Friesland who joined us for the interview.

To recapitulate, the goal of the interview was to understand the knowledge-to-action gap in rehabilitation from a clinical perspective. Coming from the side of academia, our aim was to gain insight into how the transfer of knowledge from science to practice was experienced by practioners in a rehabilitation center. In line with this goal, the interview consisted of three parts. In the first part, we talked about the daily functioning of the clinic. Our questions were intended to reveal the culture of a rehabilitation center, including the struggles that come up in daily practice. In the second part, we talked about the center’s use of scientific knowledge and its interaction with academia. We were interested in how theories and models found their way from research institutes to rehabilitation centers and whether ‘Revalidatie Friesland’ participated in any cohort studies. In the third and last part, we talked briefly about multi-agent tasks, which constitute our own expertise as early stage scientists. In particular, we were interested in a clinical perspective on our research projects.

In the transcription of the interview, both interviewer and interviewees are paraphrased to facilitate readability. Interviewer and author Marijn Hafkamp is indicated as M., while interviewees Heleen Reinders-Messelink and Sanne Nieuwhof are respectively indicated as H. and S. After each section, a brief reflection on the interview is provided.

Daily functioning of the clinic

M. : Thank you for your warm welcome and for taking the time to join us for an interview. I will first ask you about the daily functioning of the clinic. Can you describe, to begin with, what type of patients you treat in this center?

S. : I work in the adult clinic and I see a lot of people after stroke. That is the main group. But the diversity is large. Patients come to us after staying at the Intensive Care for a while and they may have orthopedic traumas or chronic pain.

H. : There is also a children’s clinic.

M. : How long do people stay here?

S. : Of course it’s different for every patient. But the usual stay is about four weeks on average. It ranges from two weeks to three months, and nowadays it is shorter and shorter.

Why does the stay become shorter nowadays?

H. : Because of finances. And because of a mentality shift: if patients can do the rehabilitation from home, that is preferable. They do exercises at home and regularly come for exercises – about two to three days a week.

M. : Do patients like the home exercises?

S. : Well most patients only come here once, so they don’t have anything to compare it with…

H. : But generally, most patients like this, since they want to go home as early as possible. At the same time, there are also severely injured patients who are too afraid to go home. They stay longer.

S. : The goal is always to go home as soon as possible. Sometimes we even go home with the patients so as to help them do exercises at home. Even patients who have to stay at the clinic are encouraged to go home on the weekends. If possible, all patients are at home in the weekends

M. : Then a question about the interaction between professionals in the clinic. If a patient with traumatic injury comes in, how many people are involved in helping that patient and what does the line of treatment look like?

H. : A lot of people are involved. The physician, a social worker, an occupational therapist, everyone that is deemed necessary from the diagnosis made at the hospital.

S. : A patient process starts with a meeting with all professionals together, where we check the diagnosis made at the hospital and ask the planning to make a treatment schedule based on our judgement. For instance, 5 times physiotherapy, 5 times occupational therapy etc.

M. : Is the patient involved immediately?

S. : In that first meeting, the patient is not yet involved.

M. : And at what stage does the patient get involved?

S. : Once an empty bed is found, the patient can be transported from the hospital to the clinic and the process for the patients starts. Luckily this often happens within one or two days after the request is made.

H. : Note that this also means that the decision for what is needed is taken before the patient arrives in the clinic. During the process the rehabilitation doctor is the head responsible, the coordinator, for the patients’ treatment.

Reflection

This brief survey of the day-to-day business at Revalidatie Friesland highlights an important aspect of the practice of rehabilitation. The primary purpose of a rehabilitation clinic, like Revalidatie Friesland, is to help the patient in their process of rehabilitation. Notably, this purpose is distinct from the purpose of academia. Although universities and research institutes also aim to contribute to the well-being and health care of the people, their primary purpose is not to help people directly. Instead, their aim is to develop knowledge so as to help them indirectly. This difference in goal is also reflected in the way both institutes are organized. At first glance, this organization may seem quite similar. Both research institutes and rehabilitation clinics are organized in a hierarchical manner with multi-disciplinary teams that cooperate to achieve their goals. However, while the teams at a research institute are centered around themes or topics, teams at ‘Revalidatie Friesland’ are centered around the patient! Such patient-centered health care is convenient for the patient and it increases the chance for a positive clinical outcome. But it also has repercussions for the interaction between science and practice. In interpreting the meaning and value of either other’s work, it is important for both academia and rehabilitation practice to keep in mind that the goals of their enterprises are different. As we will come to see in the next section of the interview, this crucial difference often gets lost in translation, with a gap in understanding the relevance of each other’s work as a consequence.

Interaction with academia

M. : This brings us to the next category: the interaction with academia. I’ve been told that you have a department for research at this clinic. Can you tell me more about the use of scientific knowledge at Revalidatie Friesland?

H. (jokingly): Well, we pick the theories we like and the others we ignore…No, without joking, it is good to know that we are not an academic clinic, so most of the time the National Guidelines are followed. Although occasionally we investigate or explore a new treatment. An example of this is speech-music therapy for aphasia. This started with ideas from our clinic, from practice. And afterwards a colleague did a PhD on the speech-music therapy for aphasia. But that is an exception to the rule.

M. : Can you tell me a bit more about that example?

H. : It started with experience from practice! A speech therapist and a movement therapist talked and started a collaboration with a particular patient with aphasia. Their idea was to set the speech therapy on music, for a change. Because they thought that the movement of music would help re-learning speech. The music therapist had heard this somewhere, perhaps at a conference.

S. : We therapists sometimes go to conferences or courses, hear about treatments and then bring this knowledge into a clinic.

M. : Sounds good. So there is money or funding for conferences?

S. : There is a small budget for that.

H. : Sometimes therapists are doing a Masters’ study at a university and then they are allowed to present their work at a conference. The budget is also for going to courses.

S. : After following a course we tell our colleagues what we learned so that everyone can learn from it. We find it important, though, that things are evidence-based.

M. : As a clinic, do you participate in larger cohort studies?

H. : Well… that has been a wish of ours for longer! In an ideal world, all the data we generate can be used for larger evaluation studies. Unfortunately that does not happen much, yet. Most of the research we participate in is from academic clinical centers that ask us to participate. For instance, there are some neuropsychological studies on stroke patients in Arnhem in which we participate, and a “Power to Walk” study for children, also coordinated from Amsterdam. But there are also projects from the UMCG in which we are involved.

M. : Do you, as a clinic, approach them to volunteer? Or is it the other way around, does the researcher approach you to participate?

H. : This is dependent on the project. We see interesting projects coming by at academic conferences. But sometimes a physical therapists reads or hears from a certain study research and ask for participation.

S. : Doctors also often come with new evidence-based treatments.

M. : And how did you get involved in REPAIRS?

H. : Raoul Bongers and I know each other well. When he wrote the grant proposal, he called me as a partner from practice. Immediately I knew, this might be a bit too fundamental for us. But then I thought of the ‘Oefenlandschap’, which was planned to start half a year after my talk with Raoul. This aligned quite well with REPAIRS, since a lot of the projects were related to arm-hand functioning. So the idea was to bring these two worlds together. Indeed, one student of Raoul has joined the arm-hand functioning group and she has conducted a literature study. That was quite a success!

M. : Some of the work we do in REPAIRS which is indeed quite fundamental. Do you see any value or relevance in that type of academic studies, for future rehabilitation?

S. : The way I see it, fundamental research is not immediately relevant for a clinic like this. Yes, we use a lot of evidence-based research in the clinic, but not the type of experiments you do in REPAIRS.

H. : For me, when I read about research projects, I instantly think: “Can we use this kind of knowledge in practice?” If not, I tend to forget about it, I’m afraid…

S. : The way I see it, research should be done with functional tasks, like grasping something from a cupboard. Only tasks that patients do at home are actually functional for daily life. If not, the things they learn will not transfer to their life outside the clinic and findings are irrelevant. For instance, when the patient wants to walk the stairs, we practice walking the stairs nothing else.

H. : One of the lessons from practice is: practice what you want to achieve, nothing else. Transfer is very difficult. So we keep that in mind in all of our treatments here.

M. : But then my question would be this: Surely a patient cannot practice all of the activities in life? How do you deal with this?

H. : Well that is indeed a challenge. We try to practice as many different tasks as possible here. Because transfer is so difficult.

S. : It also depends on the condition of the patient. For stroke patients the transfer from one task to another is more difficult than for other patients.

H. : That is also one of the main reasons for home training: they can practice the activities in their daily life. In other patients the generalization (transfer) is much easier. More generally, the ability for transfer is dependent on the cognitive abilities of the patient. Since stroke patients often have cognition problems, the transfer is low.

M. : Then a question about the gap between science and practice. Do you have the feeling that the knowledge-to-action gap has changed over the years?

H. : I see different developments. When I started, they said about the rehabilitation practice: “Everything is too eclectic. We need to build evidence, we need to find general principles and create protocols for treatment.” So at the time, there was tendency towards more fundamental research and an effort was made to develop general protocols. This worked for a while, but it also went slow. Because research takes time, it can take up to 20 years, and in practice you need solutions right now. In a way, the gap between science and practice was too large. So nowadays, ‘ZonMW’ (a funding institute for biomedical research) not only funds fundamental projects, but also practice-based research and implementation projects. I think that is a good development and it shows that the KTA gap is closing again.

M. : Do you have any recommendations as to how the KTA gap could be decreased?

H.: We need to talk more to each other! Researchers should get the information from practice and then use this in their thinking. This is required to ‘reach’ each other.

S.: And for us, there should be more budget to go to conferences and courses.

H. : Also, we want to welcome more students from Human Movement Sciences to do literature studies.

Reflection

This second part of the interview highlighted the different ways in which research, both fundamental and applied, is integrated in the daily practice of a rehabilitation clinic. First and foremost, clinicians use National Guidelines for rehabilitation. These Guidelines are evidence-based and thus follow from decades of scientific work. However, they are only updated once every few years, and thus miss out on the most recent innovations and experiments in the lab. Fortunately, one of the interviewees also told us that clinicians have a budget for conferences, courses and workshops that can help them to pick up on the state-of-the-art treatments. The speech-music therapy for aphasia is an excellent example of this. In the third place, rehabilitation clinics are involved in larger cohort studies, like the “Power to Walk” study coordinated from Amsterdam. As one of the interviewees noted, the interaction between science and practice could be improved by sharing patient data from the clinic with academic institutes, so that it can be used in cohort studies.
The interview also revealed some subtle differences in the vocabulary of the clinic and of academia. For instance, it turned out that the meaning of the word ‘functional’ is dependent on the context in which it is used. In rehabilitation practice, clinicians use the word functional to describe a task that is related to the daily life of a patient, such as making coffee or climbing the stairs. In contrast, motor control literature uses the word functional to describe any movement that is goal-directed or intentional, whether this is in the context of daily life activity or not. Although subtle, such differences in vocabulary are likely to result in misunderstandings between the two fields. This unintendedly increases the gap between science and practice, because it leads to a mutual undervaluation of each other’s contribution to rehabilitation. On the one hand, clinicians do not understand why scientists study tasks that are so irrelevant for the daily life of patients. And on the other hand, scientists do not understand why clinicians fail to incorporate findings of their research into daily practice. The only way to resolve such misunderstandings and decrease the KTA gap, is to communicate openly and regularly with each other. H.: “We need to talk more to each other!”

Interactive tasks

M. : At REPAIRS, we work with interactive motor tasks like the ball-and-beam task and a dual pong task. Are interactive tasks used in rehabilitation practice as well?

S. : Yes, we do tasks with throwing balls to each other, for instance. But be aware, we only do that when the patient wants to practice that in the context of his or her daily life. So for example, we play volleyball if the patients wants to re-learn to play volleyball. But most exercises they do alone.

H. : Also, when you try to mobilize patients to walk, you walk with them, you give them support. That is also interaction of course.

S .: Indeed, for an occupational therapist, there are things like moving the arm of the patients and giving support. Or giving each other a cup. Sometimes we also ask patients to pass on the cup to someone else.

M: Why do you ask that?

S. : Well, the other patient needs to practice as well! Then they can practice together.

M : And in your experience, is interacting with other patients (like handing over objects) more difficult for patients to do than interacting with lifeless objects?

S. : It depends on the patient. Not necessarily.

H. : But perhaps we are also missing out on some atypical behavior in the interaction simply because with are not looking for it! Perhaps they interact in a different way, but that is not what we are focused on here.

M : I understand that. Thank you for your time!

Reflection

The last part of the interview beautifully demonstrates how the different aims of science and practice result in different ways of looking at the same phenomenon. For us, as scientists, interactive tasks are intriguing because they require a fine coordination between individuals. They are an object of research. For a physiotherapist, however, interactive tasks are a way to have two patients practice together. They are a tool for health care. The fact that human interactions, either between therapist and patient or between two patients, may influence the process of rehabilitation has not crossed the mind of the clinician. This is most likely because the focus of health care is always on the individual patient and its needs. Here, the scientist could contribute by adopting a more holistic, ‘birds eye view’ on the practice of rehabilitation.

3. Conclusion

The goal of this toolbox was to give a fresh perspective on the knowledge-to-action gap in rehabilitation. To do so, we conducted an interview with a senior researcher and a physiotherapist of ‘Revalidatie Friesland’, with the aim to understand the KTA gap from the viewpoint of rehabilitation practice. Overall, the interview revealed several differences between the clinical world and the academic world, including the structure of the organization and the vocabulary that is used. But the interview also demonstrated that both worlds are already intricately related. Students from Human Movement Sciences (University of Groningen) have internships at the clinic, while physiotherapists go to academic conferences to pick up on the latest developments in research. Of course, this could be further improved by increasing the budget for learning in the clinic and by making more patient data available for university research. In our view, however, the most powerful way to reduce the KTA gap is to communicate. Research institutes and rehabilitation clinics each have their own cultures, with their own norms, values and priorities. The only way to overcome these differences and to collaborate in a fruitful manner, to have regular and open conversations with each other. We sincerely hope that this toolbox can serve as an example of how to do that!

References

Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26(1), 13–24. https://doi.org/10.1002/chp.47
Greenhalgh, T., & Wieringa, S. (2011). Is it time to drop the ‘knowledge translation’ metaphor? A critical literature review. Journal of the Royal Society of Medicine, 104(12), 501–509. https://doi.org/10.1258/jrsm.2011.110285
Restifo, L. L., & Phelan, G. R. (2011). The cultural divide: Exploring communication barriers between scientists and clinicians. Disease Models & Mechanisms, 4(4), 423–426. https://doi.org/10.1242/dmm.008177