A Theory-Driven System for the Specification of Rehabilitation Treatments

The field of rehabilitation remains captive to the black-box problem: our inability to characterize treatments in a systematic fashion across diagnoses, settings, and disciplines, so as to identify and disseminate the active ingredients of those treatments. In this article, we describe the Rehabilitation Treatment Specification System (RTSS), by which any treatment employed in rehabilitation may be characterized, and ultimately classified according to shared properties, via the 3 elements of treatment theory: targets, ingredients, and (hypothesized) mechanisms of action. We discuss important concepts in the RTSS such as the distinction between treatments and treatment components, which consist of 1 target and its associated ingredients; and the distinction between targets, which are the direct effects of treatment, and aims, which are downstream or distal effects. The RTSS includes 3 groups of mutually exclusive treatment components: Organ Functions, Skills and Habits, and Representations. The last of these comprises not only thoughts and feelings, but also internal representations underlying volitional action; the RTSS addresses the concept of volition (effort) as a critical element for many rehabilitation treatments. We have developed an algorithm for treatment specification which is illustrated and described in brief. The RTSS stands to benefit the field in numerous ways by supplying a coherent, theory-based framework encompassing all rehabilitation treatments. Using a common framework, researchers will be able to test systematically the effects of specific ingredients on specific targets; and their work will be more readily replicated and translated into clinical practice.     

Defining the Neurobiological Mechanisms of Action in Aphasia Therapies: Applying the Rehabilitation Treatment Specification System Framework to Research and Practice in Aphasia

The Rehabilitation Treatment Specification System (RTSS) was developed as a systematic way to describe rehabilitation treatments for the purpose of both research and practice. The RTSS groups treatments by type and describes them by 3 elements: the treatment (1) ingredients and (2) the mechanisms of action that yield changes in the (3) target behavior. Adopting the RTSS has the potential to improve consistency in research, allowing for better cross-study comparisons to strengthen the body of research supporting various treatments. Because it is still early in its development, the RTSS has not yet been widely implemented across different rehabilitation disciplines. In particular, aphasia recovery is one area of rehabilitation that could benefit from a unifying framework. Accordingly, this article is part of a series where we illustrate how the RTSS can be applied to aphasia treatment and research. This article more specifically focuses on examining the neurobiological mechanisms of action associated with experimental aphasia therapies, including brain stimulation and pharmacologic intervention, as well as more traditional behavioral therapy. Key elements of the RTSS are described, and 4 example studies are used to illustrate how the RTSS can be implemented. The benefits of a unifying framework for the future of aphasia treatment research and practice are discussed.     

Demystifying the Complexity of Aphasia Treatment: Application of the Rehabilitation Treatment Specification Systemx

A considerable body of research supports the use of behavioral communication treatment as the standard of care for aphasia. In spite of robust progress in clinical aphasiology, many questions regarding optimal care remain unanswered. One of the major challenges to progress in the field is the lack of a common framework to adequately describe individual treatments, which, if available, would allow comparisons across studies as well as improved communication among researchers, clinicians, and other stakeholders. Here, we describe how aphasia treatment approaches can be systematically characterized using the Rehabilitation Treatment Specification System (RTSS). At the core of the RTSS is a tripartite structure that focuses on targets (the behavior that is expected to change as a result of treatment), ingredients (what a clinician does to affect change in the target), and mechanism(s) of action (why a given treatment works by linking the ingredients to the target). Three separate articles in the current issue specifically describe how the RTSS can be used to describe different kinds of aphasia treatment approaches: functional approaches, cognitive-linguistic approaches, and biological approaches. It is our hope that the application of the RTSS in clinical aphasiology will improve communication in published studies, grant proposals, and in the clinical care of persons with aphasia.     

Evaluating Cognitive-Linguistic Approaches to Interventions for Aphasia Within the Rehabilitation Treatment Specification System

The Rehabilitation Treatment Specification System (RTSS) provides a framework to identify specific components of treatments developed within various rehabilitation disciplines (eg, physical, occupational, or speech-language therapy). Furthermore, this framework offers the opportunity to identify the target and active ingredients of a therapy approach as well as the mechanism of action by which it is hypothesized to effect change in abilities or functions. In this article, we apply the RTSS framework to the characterization of a sample of treatments for aphasia that are based on cognitive-linguistic models of language processing. Our discussion of these applications centers on the benefits of this classification system and additional criteria to consider when evaluating cognitive-linguistic treatments for aphasia.     

Selection for inpatient rehabilitation after acute stroke: a systematic review of the literature

Hakkennes SJ, Brock K, Hill KD. Selection for inpatient rehabilitation after acute stroke: a systematic review of the literature.

Objective

To identify patient-related factors that have been found to correlate with functional outcomes post acute stroke to guide clinical decision making with regard to rehabilitation admission after acute stroke.

Data Sources

We systematically searched the scientific literature between 1966 and January 2010. The primary source of studies was the electronic databases Medline, CINAHL, and Embase. The search was supplemented with citation tracking.

Study Selection

Two reviewers independently applied the inclusion criteria to identify relevant articles from the citations obtained through the literature search. Eligible studies included systematic reviews of prognostic indicators, studies of prognostic indicators of acute discharge disposition, and studies of rehabilitation admission criteria after acute stroke. Of the 8895 studies identified, 83 articles, representing 79 studies, were included in the review.

Data Extraction

One reviewer extracted the data relating to the participants, prognostic indicators, and outcomes. A second reviewer independently checked data extracted with disagreement resolved by a third reviewer. Quality of included studies was assessed for internal and external validity.

Data Synthesis

Of the 79 studies, 26 were systematic reviews of prognostic indicators of functional level and/or discharge disposition, 48 were studies of prognostic indicators of acute discharge disposition, and 6 were studies of rehabilitation selection criteria. The methodologic quality of the included studies was generally poor. Age, cognition, functional level after stroke, and, to a lesser extent, continence were found to have a consistent association with outcome across all 3 research areas. In addition, stroke severity was also associated with acute discharge disposition, final discharge disposition, and functional level. Sex and side of stroke appeared to have no association across all 3 of the research areas.

Conclusions

This review highlights a number of important prognostic indicators and rehabilitation selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation after stroke, although the quality of many studies is low. Further high quality studies and reviews of prognostic indicators and clinician decision making with regards to rehabilitation acceptance are required.     

The Pittsburgh Rehabilitation Participation Scale: reliability and validity of a clinician-rated measure of participation in acute rehabilitation

OBJECTIVE: To demonstrate interrater reliability and predictive validity of the Pittsburgh Rehabilitation Participation Scale (PRPS), a clinician-rated 6-point Likert-type item measuring patient participation in inpatient rehabilitation sessions. DESIGN: Prospective measurement of patient participation in physical and occupational therapy sessions during inpatient rehabilitation. SETTING: University-based, freestanding acute rehabilitation hospital. PARTICIPANTS: Two hundred forty-two inpatients, primarily elderly, with a variety of impairment diagnoses (eg, stroke), who were admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in the 13 motor items from the FIM trade mark instrument, from admission to discharge. RESULTS: The PRPS had high interrater reliability (intraclass correlation coefficient [ICC]=.91 for occupational therapists; ICC=.96 for physical therapists). The subjects had mean PRPS scores +/- standard deviation of 4.73+/-0.76. Mean PRPS scores predicted rehabilitation outcome (N=242, r=.32, P<.0001), as measured by change in motor FIM. The strength of this association did not change in a multivariate model that controlled for age, gender, race, impairment group, medical comorbidity count, length of stay, and admission FIM. CONCLUSIONS: Patient participation during acute inpatient rehabilitation can be easily and reliably measured, and PRPS scores predict functional outcome. The PRPS may have applicability in clinical and research outcome measurement.     

Rehabilitation Treatment Specification System: Identifying Barriers,Facilitators, and Strategies for Implementation in Research,Education, and Clinical Care

ObjectiveTo explore rehabilitation professionals' experiences and perspectives of barriers and facilitators to implementing the Rehabilitation Treatment Specification System (RTSS) in research, education, and clinical care.DesignA cross-sectional survey with free text and binary responses was completed by rehabilitation professionals. Survey data were analyzed with a deductive approach of directed content analysis using 2 implementation science frameworks: Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC).SettingRehabilitation professionals across research, educational, and clinical settings.ParticipantsOne hundred and eleven rehabilitation professionals—including speech-language pathologists, occupational therapists, physical therapists, physicians, psychologists, researchers, and clinic directors—who explored possible uses or applications of the RTSS for clinical care, education, or research (N=111).InterventionsNot applicable.Main Outcome MeasuresFrequency of reported CFIR barriers and facilitators, as well as keywords related to CFIR and ERIC constructs.ResultsThe barriers and facilitating strategies differed according to the end-users’ intended use, that is, research, education, or clinical. Overall, the 4 most frequently encountered CFIR barriers were the RTSS's complexity, a lack of available RTSS resources, reduced access to knowledge and information about the RTSS, and limited knowledge and beliefs about the RTSS. The ERIC-CFIR matching tool identified 7 ERIC strategies to address these barriers, which include conducting educational meetings, developing and distributing educational materials, accessing new funding, capturing and sharing local knowledge, identifying and preparing champions, and promoting adaptability.ConclusionsWhen attempting to use the RTSS, rehabilitation professionals commonly encountered barriers to understanding and skillfully using the framework. Theory-driven implementation strategies have been identified that have potential for addressing the RTSS's complexity and lack of educational and skill-building resources. Future work can develop the identified implementation strategies and evaluate their effects on RTSS implementation.     

Significance of poor patient participation in physical and occupational therapy for functional outcome and length of stay

OBJECTIVES: To determine the frequency of poor patient participation during inpatient physical (PT) and occupational therapy (OT) sessions and to examine the influence of poor participation on functional outcome and length of stay (LOS). DESIGN: Prospective observational study. SETTING: University-based, freestanding acute rehabilitation hospital. PARTICIPANTS: Two hundred forty-two inpatients, primarily elderly (age range, 20-96y), with a variety of impairment diagnoses (eg, stroke), who were admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Pittsburgh Rehabilitation Participation Scale, the 13 motor items from the FIM instrument (FIM motor), LOS, and discharge disposition. RESULTS: We categorized the sample into 3 groups: "good" participators were those for whom all inpatient PT and OT sessions were rated 4 or greater (n=139), "occasional poor" participators were those with less than 25% of scores rated below 4 (n=53), and "frequent poor" participators were those with 25% or more of scores rated below 4 (n=50). Change in FIM motor scores during the inpatient rehabilitation stay was significantly better for good and occasional poor participators, compared with frequent poor participators (mean FIM improvement: 23.2, 22.8, and 17.6, respectively; repeated-measures analysis of variance group by time interaction, P <.002). LOS was significantly longer for occasional poor participators, compared with good and frequent poor participators controlling for admission FIM differences (adjusted means: 13.9d, 11.0d, and 10.9d, respectively; analysis of covariance, P <.001). CONCLUSIONS: Poor participation in therapy is common during inpatient rehabilitation and has important clinical implications, in terms of lower improvement in FIM scores and longer LOS. These results suggest that poor inpatient rehabilitation participation and its antecedents deserve further attention.     

The American Congress of Rehabilitation Medicine (ACRM) and rehabilitation research in a changing postacute landscape. The 2007 ACRM presidential address

DeJong G. The American Congress of Rehabilitation Medicine (ACRM) and rehabilitation research in a changing postacute landscape. The 2007 ACRM presidential address.Postacute rehabilitation is on the threshold of several major changes that have implications for rehabilitation practice and research. The most important of these is the desire of the Centers for Medicare & Medicaid Services to establish a uniform patient assessment method and implement a more setting-neutral prospective payment system across all major postacute settings. The proposed uniform patient assessment instrument will in all likelihood displace the FIM instrument as the industry standard. The rehabilitation research community needs to remain vigilant about the nature, scope, and measurement properties of the proposed uniform patient assessment instrument. A new instrument and setting-neutral payment system may provide new opportunities for service innovation and research. Neurorehabilitation has been one of the strengths of the American Congress of Rehabilitation Medicine (ACRM). ACRM needs to build on this strength and examine more earnestly the rehabilitation interventions and outcomes associated with the increasing prevalence of people with orthopedic and musculoskeletal conditions seen in rehabilitation centers today. ACRM’s ability to do so will depend in part on its ability to join forces with other professional and consumer organizations to increase research funding significantly for each of the major federal agencies that currently fund rehabilitation research.     

It's more than a black box; it's a Russian doll: defining rehabilitation treatments

Research on treatment efficacy and effectiveness requires that the treatments of interest be objectively defined. Such definitions are relatively straightforward for pharmacologic and surgical treatments, in which the active ingredients can be specified in terms of chemical structure or anatomic result. Definitions of treatment are more difficult for the many experience-based interventions employed in rehabilitation. This has led to the criticism that much clinical rehabilitation research has characterized the treatments of interest as a "black box," allowing little insight into the active ingredients contained therein. Moreover, rehabilitation care may involve the simultaneous application of multiple different treatments, raising the question of whether to define the individual components or the service delivery system. In this article, we consider how the levels of analysis considered in rehabilitation (disease, impairment, activity, and participation) and the role of theory shape the definition of treatment, and we address the need to develop protocol-based treatments and tools to objectively verify their contents. Rigorous definition of rehabilitation treatments, supported by theory, will facilitate needed efficacy research, will allow replication of that research, and will ultimately foster dissemination of effective treatments into clinical practice.     

书画行为疗法在精神分裂症患者临床康复中的应用效果

目的 探讨书画行为治疗对住院精神分裂症患者的康复效果.方法 30例住院精神分裂症患者(观察组)采取正性强化、负性强化和行为量化评分等手段进行书法绘画治疗,共8 w,并与30例具有一定可比性的住院精神分裂症患者(对照组)进行对比.应用护士用住院患者观察量表(NOSIE)、简明精神病量表(BPRS)、阴性症状量表(SANS)、住院精神病人康复疗效评定量表(IPROS)对患者进行康复效果评定.结果 观察组患者均能参加并完成书法绘画治疗.治疗前NOSIE、BPRS、SANS以及IPROS评定两组无差异(P＞0.05),治疗后各量表的评定两组差异有显著性(P＜0.01).结论 对住院精神分裂症患者进行正规、系统的书画行为疗法,有利于改善精神分裂症患者的病情,促进社会功能的康复,具有良好的临床康复效果.     

精神分裂症衰退期病人的康复治疗探讨

目的探讨康复治疗对精神分裂症衰退期病人的社会功能和自护能力的影响。方法我们将80例精神分裂症衰退期病人随机分为实验组和对照组,对照组只进行常规抗精神病治疗和护理,观察期为半年,实验组不仅进行常规的抗精神病治疗和护理、还进行了为期半年的系统的社会功能和自护能力的康复治疗。结果实验组病人的社会功能和自护能力与观察组比较有明显的提高。结论对精神分裂症衰退期病人进行系统的社会功能和自护能力的康复治疗,能逆转病人的衰退,甚至能显著提高病人的社会功能和自护能力。     

Chronic pain in persons with neuromuscular disease

OBJECTIVE: To examine the nature and scope of pain in persons with neuromuscular disorder (NMD). DESIGN: Survey study. SETTING: University-based rehabilitation research programs. PARTICIPANTS: Adults with NMD (N=193). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pain presence or absence, pain severity, pain quality (Neuropathic Pain Scale), pain interference (Brief Pain Inventory), pain site, quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]), and pain treatment. RESULTS: Seventy-three percent of the sample reported pain, with 27% of these reporting that this pain was severe (> or =7 on a 0-10 scale), on average. "Deep," "tiring," "sharp," and "dull" were the words used most frequently to describe NMD pain. Patients with amyotrophic lateral sclerosis and myotonic muscular dystrophies reported the greatest pain interference, and patients with Charcot-Marie-Tooth the least, among all NMD diagnoses. The most frequent pain site, overall, was back (49%), followed by leg (47%), shoulder (43%), neck (40%), buttock and hip(s) (37%), feet (36%), arm(s) (36%), and hand(s) (35%). The study participants reported significantly greater dysfunction than subjects in the SF-36 normative sample (persons without health problems) on a number of the SF-36 scales. However, we found no significant differences between the study participants and the US norms on the SF-36 role-emotional or mental health scales. A number of pain treatments were used by the study sample, but no treatment appeared to be effective for all participants, and some of the treatments reported as most effective (eg, chiropractic care) were used by very few participants. CONCLUSIONS: Pain is a common problem among patients with NMDs. There are many similarities, but also some important differences, between NMD diagnostic groups on the nature and scope of pain and its impact. More research is needed to identify and test effective treatments for NMD-related pain.     

Measuring Value in Postacute Care

The value of postacute care (PAC) is unclear. While experienced clinicians understand the appropriateness of each specific site of PAC, clear evidence-based guidelines are not available, and many referrals to PAC today are made based on bed availability rather than patient need. Measuring value (value=outcomes/cost) for the entire episode of care has been proposed as an effective method to both evaluate and enable faster innovation in care. Instituting value-based care will increase patient engagement, improve quality and reduce cost with the potential of unifying the goals for all stakeholders—patients and families, providers, and payers. To achieve a goal of value-based care, rehabilitation researchers will need to measure outcomes and cost for the entire episode of care. Recent laudable efforts by the Centers for Medicare & Medicaid Services (CMS) to standardize data across PAC may not include the entire episode of care since outpatient care and measurement from home are not included. In addition, the true cost of services delivered is rarely measured. To implement value-based care in rehabilitation and facilitate cost-effective care improvements, outcomes research in PAC should focus on 4 areas. First, outcome measures need to reflect the patient’s perspective. Second, new methods must be implemented to acquire comparable valid and reliable data from all postacute settings and the home. Third, a predictive model for individual patients should be utilized to guide patient referral from acute care to PAC and monitor progress. And fourth, timely specific measures of true cost (resources consumed) for the outcomes achieved are needed.     

Impact of transfer delays to rehabilitation in patients with severe trauma

OBJECTIVE: To measure the effect on rehabilitation outcomes of administrative delays in transferring patients from a level I trauma center to inpatient rehabilitation. DESIGN: Retrospective cohort study. SETTINGS: Level I trauma center and an inpatient rehabilitation center in Quebec, Canada. PARTICIPANTS: A total of 289 patients with severe trauma admitted to inpatient rehabilitation from a level I trauma center between 1994 and 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS) in rehabilitation, motor and cognitive function at discharge from rehabilitation, interruptions in rehabilitation, and disposition at discharge. RESULTS: Shorter administrative delays were associated with shorter rehabilitation LOS (P<.01) improved cognitive function (P=.02) and had a negative but statistically nonsignificant association with motor function at discharge. No effect was observed for rehabilitation interruptions or dispositions at discharge. CONCLUSIONS: Transferring trauma patients more quickly to inpatient rehabilitation can affect rehabilitation outcomes positively. It can also lead to an economy of resource use in both acute and rehabilitation settings.     

Analyzing the ingredients of a telephone counseling intervention for traumatic brain injury

Abstract

Purpose: To develop reliable coding for five treatment ingredients hypothesized to be “active” in a scheduled telephone intervention (STI) for traumatic brain injury (TBI); to examine factors associated with delivery of ingredients over the first year post-injury. Method: Operational definitions of directive and non-directive action planning; TBI education; reinforcement; and reframing, were refined until kappa >0.80 across multiple coders. Codes were assigned for presence/absence of ingredients in 253 recorded calls delivered to 49 participants in a randomized controlled trial on effects of STI versus usual care. Using multivariate analyses, we tested hypotheses about effects of TBI severity, time and other factors on delivery of ingredients. Results: Longitudinal analyses revealed that TBI education decreased over time, as expected. Non-directive action planning increased over time, according to hypotheses; unexpectedly, directive action planning did not concurrently decline. Reinforcement and reframing both increased over time, with reframing also increasing with TBI severity. Therapist differences were pronounced, despite extensive supervision designed to promote uniform treatment delivery. Conclusions: Reliable operational definitions of therapist behavior for each ingredient were achieved, but at the sacrifice of sensitivity in the coding scheme. Behavioral operational definitions of ingredients may be useful for treatment specification, for therapist training and supervision, and for testing hypotheses about the strength of specific components within the “black box” of rehabilitation.

• Implications for Rehabilitation

• Operationally defining active ingredients of rehabilitation can allow measurement of adherence to specified treatment protocols, and can facilitate the study of the relationship between delivery of specific ingredients and resulting outcomes.

• In this study, there were strong differences in delivery of ingredients by different clinicians despite frequent joint supervision and a shared treatment philosophy. Defining active ingredients in advance may help focus training and supervision on specific clinician behaviors that convey key ingredients of treatment.

• Complex treatments such as counseling, where the therapist’s behavior is partly determined by the client’s behavior and vice versa, are particularly challenging to define operationally since the opportunity to deliver certain ingredients varies with the problems the client presents and the way they are presented.