Toward a taxonomy of rehabilitation interventions: using an inductive approach to examine the “black box” of rehabilitation

Rehabilitation Treatment Specification System: Content and Criterion Validity Across Evidence-Based Voice Therapies for Muscle Tension Dysphonia

PURPOSE

Systematically improving voice therapy outcomes is challenging as the clinician actions (i.e., active ingredients) responsible for improved patient functioning (i.e., targets) are relatively unknown. The theory-driven Rehabilitation Treatment Specification System (RTSS) and standard, voice-specific terminology based on the RTSS (RTSS-Voice) may help address this problem. This qualitative study evaluated if the RTSS and RTSS-Voice can describe four evidence-based voice therapies for muscle tension dysphonia without missing critical aspects (content validity) and identify commonalities and differences across them (criterion validity).

METHOD

Qualitative interviews were completed between the clinicians (protocol experts) who developed and/or popularized the vocal function exercises, laryngeal reposturing, circumlaryngeal massage, and conversation training therapies as well as RTSS experts to produce RTSS specifications that met two consensus criteria: (a) The protocol expert agreed that the specification represented their treatment theory, and (b) the RTSS experts agreed that the specifications correctly adhered to both the RTSS framework and the RTSS-Voice's standard terminology.

RESULTS

The RTSS and RTSS-Voice comprehensively described voice therapy variations across and within the four diverse treatment programs, needing only the addition of one new target: overall auditory-perceptual severity.

CONCLUSIONS

The RTSS and RTSS-Voice exhibited strong content validity. The standard RTSS-Voice terminology helped identify, for the first time, commonalities and differences in treatment ingredients, targets, and mechanisms of action across four treatments developed for the same patient population. In the long term, the RTSS and RTSS-Voice could provide the framework for an ever-growing collection of clinically meaningful and evidence-based therapy algorithms with potential to improve research, education, and clinical care.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25537624.

The application of virtual reality to home-based rehabilitation for children and adolescents with cerebral palsy: A systematic review and meta-analysis

BACKGROUND

Home-based rehabilitation enables children and families to participate in therapeutic activities built into their daily routines without the barriers of arrangement and transportation to facilities. Virtual reality is an emerging technology which has shown promising outcomes in rehabilitation.

PURPOSE

This systematic review aims to examine the feasibility and effects of virtual reality-enhanced home rehabilitation on Body functions and structures, Activity, and Participation outcomes in children and adolescents with cerebral palsy.

METHODS

Interventional studies were searched across five biomedical databases on November 26, 2022. Two independent reviewers conducted study selection, data extraction, and quality assessment. The Physiotherapy Evidence Database scale and National Institutes of Health Study Quality Assessment Tools were used to evaluate the quality of included studies. Meta-analysis was performed to examine the effects of the intervention.

RESULTS

Eighteen studies were included in this review. Home-based virtual reality rehabilitation appears feasible with effects on upper extremity and gross motor function, strength, bone density, cognition, balance, walking, daily activity performance, and participation. Meta-analyses revealed significant improvements in hand function (SMD = 0.41, p= .003), gross motor function (SMD = 0.56, p= .0002), and walking capacity (SMD = 0.44, p= .01) following home-based virtual reality intervention.

CONCLUSION

Home-based virtual reality may serve as an adjunct to conventional facility-based therapy to promote participation in therapeutic exercises and maximize rehabilitation outcomes. Further properly designed randomized controlled trials using valid and reliable outcome measures with adequately powered sample sizes are warranted to enhance the current body of evidence using home-based virtual reality in cerebral palsy rehabilitation.

Knowledge, attitudes, and perceptions of physical therapists towards conventional physical therapy-across-sectional study

Background

Conventional physical therapy (CPT) is widely used in clinical practice and known to contribute beneficially to patient's health conditions but remains loosely defined. Research has shown inconsistency in the definition and utilization of CPT among physical therapists in clinical and research settings, limiting its generalisability and reproducibility. Therefore, this study evaluates physical therapists' knowledge, attitudes, and perceptions toward CPT.

Methods

A cross-sectional study using a self-administered questionnaire containing 36 questions was distributed among 238 licensed physical therapists. Descriptive and inferential statistics were used to measure the physical therapists' knowledge, attitudes, and perceptions towards CPT.

Results

Physical therapists showed limited knowledge of CPT in rehabilitation (4.09±1.698, 51%). However, the knowledge scores were significantly associated with age (P=0.002), educational levels (P=0.006), and years of work experience (P=0.001). Nevertheless, physical therapists showed an overall positive attitude towards CPT and perceived it as essential to rehabilitation.

Conclusion

Most physical therapists have low knowledge about CPT but positive attitudes and perceptions. Therefore, customized medical education is necessary to incorporate CPT theories and applications into physical therapists' rehabilitation programs.

Tracking activity-based therapy for people living with spinal cord injury or disease: insights gained through focus group interviews with key stakeholders

PURPOSE

The development of a tool to track participation in activity-based therapy (ABT) for people with spinal cord injury or disease (SCI/D) was identified as a priority of the Canadian ABT Community of Practice. The objective of this study was to understand multi-stakeholder perspectives on tracking ABT participation across the continuum of care.

MATERIALS AND METHODS

Forty-eight individuals from six stakeholder groups (persons living with SCI/D; hospital therapists; community trainers; administrators; researchers; and funders, advocates and policy experts) were recruited to participate in focus group interviews. Participants were asked open-ended questions concerning the importance of and parameters around tracking ABT. Transcripts were analyzed using conventional content analysis.

RESULTS

Themes reflected the Who, What, Where, When, Why and How of tracking ABT. Participants described the importance of involving hospital therapists, community trainers and individuals with SCI/D in tracking ABT to capture both subjective and objective parameters across the continuum of care and injury trajectory. Digital tracking tools were favoured, although paper-based versions were regarded as a necessity in some circumstances.

CONCLUSIONS

Findings highlighted the importance of tracking ABT participation for individuals with SCI/D. The information may guide the development of ABT practice guidelines and support the implementation of ABT in Canada.

Unpacking the black box of voice therapy: A clinical application and revision of the Motor Learning Classification Framework (MLCF)

PURPOSE

Voice therapy is a complex behavioural intervention. Understanding its components is integral for continued advancement of voice therapy research, translation of evidence into the clinical setting and improved client care. The Motor Learning Classification Framework (MLCF) offers an excellent opportunity for increasing such knowledge, specifically in relation to identifying variables that affect motor learning (ML), an important mechanism hypothesised to bring about voice change during voice therapy. The MLCF has shown promising results in identifying speech-language pathologists' (SLPs) use of ML variables during experimentally controlled voice therapy contexts. The purpose of this study was to test the feasibility of applying the framework in the clinical context of everyday voice therapy practice.

METHOD

Data consisted of two video-recorded voice therapy sessions representing usual voice therapy care. Classification of ML variables used by SLPs during the recorded sessions was attempted based on the MLCF.

RESULT

Several problematic features of the framework were identified. Based on deliberations between the authors of the current paper, the MLCF was revised using an iterative process. This resulted in the construction of an updated version of the framework (MLCF-V2). The MLCF-V2 organises ML strategies into two broad categories: directly observable behaviours and learning processes. The framework incorporates greater consideration of theory and empirical evidence supporting motivational, attentional focus and subjective error estimation influences on ML. Several examples of each ML variable are included as well as an attempt to provide clearer classification instruction.

CONCLUSION

It is anticipated that the MLCF-V2 will provide a more useful and reliable classification for use in future investigations of SLPs' use of ML variables during usual voice therapy practice.

Physiotherapy practices in acute and sub-acute stroke in a low resource country: A prospective observational study in Benin

BACKGROUND AND OBJECTIVE

Physiotherapy is highly recommended for early recovery from stroke. This study aimed to document physiotherapy practices for people with acute and early sub-acute stroke in Benin.

METHODS

In this prospective observational study, physiotherapists working with acute stroke people documented the content of their treatment from six hospitals in Benin during the first session, at 2-week, and 1-month post-stroke with a standardized physiotherapy documentation form. We used the motricity index (MI) and trunk control test (TCT) to assess impairments, and the 10-meter walk test (10mWT), functional independence measure (FIM), walking, stair climbing, and dressing upper body subscales were used for activity limitations.

RESULTS

Fifteen physiotherapists (60 % male, mean±SD age=31.3±5.8 years) recorded treatment sessions for 77 stroke participants (53.2 % male, mean±SD age=57.7±12.5 years). Physiotherapists focused on conventional physiotherapy approaches, including musculoskeletal (67 % of pre-functional activity time) and neuromuscular (53 % of sitting activity time) interventions. A significant difference was found between the therapy time delivered for people with mild, moderate, and severe stroke (p < 0.001). The MI (p= 0.033) and TCT (p= 0.002) measures showed significant improvement at 2-week and 1-month (p< 0.001) post-stroke, while 10mWT, FIM walking, stair climbing, and dressing upper body items significantly increased at 1-month (p< 0.001) but not at 2-week post-stroke.

CONCLUSION

Physiotherapists working with acute stroke patients in Benin mainly use conventional neuromuscular and musculoskeletal interventions. In contrast, aerobic exercises were rarely employed regardless of stroke severity. Furthermore, our findings showed that the volume of physiotherapy sessions varied by stroke severity.

Classification and Quantification of Physical Therapy Interventions across Multiple Neurological Disorders: An Italian Multicenter Network

Despite their relevance in neurorehabilitation, physical therapy (PT) goals and interventions are poorly described, compromising a proper understanding of PT effectiveness in everyday clinical practice. Thus, this paper aims to describe the prevalence of PT goals and interventions in people with neurological disorders, along with the participants' clinical features, setting characteristics of the clinical units involved, and PT impact on outcome measures. A multicenter longitudinal observational study involving hospitals and rehabilitation centers across Italy has been conducted. We recruited people with stroke (n = 119), multiple sclerosis (n = 48), and Parkinson's disease (n = 35) who underwent the PT sessions foreseen by the National Healthcare System. Clinical outcomes were administered before and after the intervention, and for each participant the physical therapists completed a semi-structured interview to report the goals and interventions of the PT sessions. Results showed that the most relevant PT goals were related to the ICF activities with "walking" showing the highest prevalence. The most used interventions aimed at improving walking performance, followed by those aimed at improving organ/body system functioning, while interventions targeting the cognitive-affective and educational aspects have been poorly considered. Considering PT effectiveness, 83 participants experienced a clinically significant improvement in the outcome measures assessing gait and balance functions.

Proposal of a common terminology for the neuropsychological rehabilitation

The literature on neuropsychological intervention (NI) uses a variety of terms to refer to equivalent constructs, making it difficult to compare intervention programmes and their outcomes. The purpose of this work is to propose a unified terminological framework for describing NI programmes. The terminological framework was developed based on a previous proposal for common terminology by Johnstone and Stonnington (Rehabilitation of neuropsychological disorders: A practical guide for rehabilitation professionals. Psychology Press, 2011) and driven by Cognitive Psychology concepts. The terminological framework was organized into two sections: (a) NI, which includes types of NI, methods and approaches, instructional methods, and strategies; and (b) neurocognitive functions, which include temporal and spatial orientation, sensation, perception, visuo-constructional abilities, attention, memory, language, reasoning of several sorts (e.g., abstract reasoning, and numerical reasoning), and executive functions. Most NI tasks target a main neurocognitive function, but there are underlying neurocognitive functions that may impair performance in the former. Since it is difficult to create a task that is solely focused on one neurocognitive function, the proposed terminology should not be viewed as a taxonomy, but rather as dimensional, with the same task allowing to work different functions, in varying grades. Adopting this terminological framework will allow to define the targeted neurocognitive functions more accurately and simplify the comparison between NI programmes and their outcomes. Future research should focus on describing the main techniques/strategies for each neurocognitive function and non-cognitive interventions.

A mixed-method feasibility study of the use of the Complete Vocal Technique (CVT), a pedagogic method to improve the voice and vocal function in singers and actors, in the treatment of patients with muscle tension dysphonia: a study protocol

BACKGROUND

Muscle tension dysphonia (MTD) results from inefficient or ineffective voice production and is the cause of voice and throat complaints in up to 40% of patients presenting with hoarseness. Standard treatment is voice therapy (SLT-VT) delivered by specialist speech therapists in voice disorders (SLT-V). The Complete Vocal Technique (CVT) is a structured, pedagogic method which helps healthy singers and other performers optimise their vocal function enabling them to produce any sound required. The aim of this feasibility study is to investigate whether CVT administered by a trained, non-clinical CVT practitioner (CVT-P) can be applied to patients with MTD before progressing to a pilot randomised control study of CVT voice therapy (CVT-VT) versus SLT-VT.

METHODS/DESIGN

In this feasibility study, we use a mixed-method, single-arm, prospective cohort design. The primary aim is to demonstrate whether CVT-VT can improve the voice and vocal function in patients with MTD in a pilot study using multidimensional assessment methods. Secondary aims are to assess whether (1) a CVT-VT study is feasible to perform; (2) is acceptable to patients, the CVT-P and SLT-VTs; and (3) whether CVT-VT differs from existing SLT-VT techniques. A minimum of 10 consecutive patients with a clinical diagnosis of primary MTD (types I-III) will be recruited over a 6-month period. Up to 6 video sessions of CVT-VT will be delivered by a CVT-P using a video link. The primary outcome will be a change in pre-/post-therapy scores of a self-reported patient questionnaire (Voice Handicap Index (VHI)). Secondary outcomes include changes in throat symptoms (Vocal Tract Discomfort Scale), acoustic/electroglottographic and auditory-perceptual measures of voice. Acceptability of the CVT-VT will be assessed prospectively, concurrently and retrospectively both quantitatively and qualitatively. Differences from SLT-VT will be assessed by performing a deductive thematic analysis of CVT-P transcripts of therapy sessions.

CONCLUSION

This feasibility study will provide important data to support whether to proceed with a randomised controlled pilot study focusing on the effectiveness of the intervention compared to standard SLT-VT. Progression criteria will be based on demonstrating a positive outcome in treatment, successful delivery of the pilot study protocol, acceptability to all stakeholders and satisfactory recruitment rates.

TRIAL REGISTRATION

ClinicalTrials.gov website ( NCT05365126 Unique Protocol ID: 19ET004). Registered on 06 May 2022.

Physical functioning and health-related quality of life after COVID-19: a long-term perspective case series

The purpose of our study was to monitor the long-term changes in physical functioning and health-related quality of life in individuals who received outpatient rehabilitation after COVID-19. Individuals referred to outpatient rehabilitation for post-COVID-19 physical therapy were assessed before the treatment, at the end of the treatment, and 2 and 6 months after the end of the treatment. The physical functioning was assessed by Barthel Index, Timed Up and Go test, Short Physical Performance Battery test (SPPB), Patient-Specific Functioning Scale (PSFS), and EuroQOL 5D-3L. Friedman's test was utilized to assess changes in the assessments. The proportions of individuals showing variation in performance equal to or greater than the absolute minimal detectable change (MDC) value of the SPPB and PSFS were calculated. Forty-four cases were monitored for 7.3-15.6 months. At baseline, they showed substantial independence in activities of daily living, moderate mobility limitations, and below-average health-related quality of life. Their status significantly improved over time (Friedman's test P = 0.002 to <0.001); post hoc analysis confirmed the improvement of mobility and health-related quality of life at 6-month follow-up relative to the baseline. After accounting for MDC values, 55% meaningfully improved on SPPB and 45% on PSFS, although some worsened (11 and 5%, respectively) and the remaining showed no meaningful change. Despite good independence in activities of daily living and perceived health, individuals surviving the COVID-19 may not have fully recovered their premorbid functioning status seven to 15 months after the infection.

Automating provision of feedback to stroke patients with and without information on compensatory movements: A pilot study

Providing effective feedback to patients in a rehabilitation training program is essential. As technologies are being developed to support patient training, they need to be able to provide the users with feedback on their performance. As there are various aspects on which feedback can be given (e.g., task success and presence of compensatory movements), it is important to ensure that users are not overwhelmed by too much information given too frequently by the assistive technology. We created a rule-based set of guidelines for the desired hierarchy, timing, and content of feedback to be used when stroke patients train with an upper-limb exercise platform which we developed. The feedback applies to both success on task completion and to the execution of compensatory movements, and is based on input collected from clinicians in a previous study. We recruited 11 stroke patients 1–72 months from injury onset. Ten participants completed the training; each trained with the rehabilitation platform in two configurations: with motor feedback (MF) and with no motor feedback (control condition) (CT). The two conditions were identical, except for the feedback content provided: in both conditions they received feedback on task success; in the MF condition they also received feedback on making undesired compensatory movements during the task. Participants preferred the configuration that provided feedback on both task success and quality of movement (MF). This pilot experiment demonstrates the feasibility of a system providing both task-success and movement-quality feedback to patients based on a decision tree which we developed.

A systematic review opens the black box of "usual care" in stroke rehabilitation control groups and finds a black hole

INTRODUCTION

In experimental trials, new methods are tested against the "best" or "usual" care. To appraise control group (CG) interventions provided as "usual care," we focused on stroke as a leading cause of disability demanding rehabilitation as a complex intervention.

EVIDENCE ACQUISITION

For this methodological appraisal, we conducted a systematic review of RCTs without timespan limitation. The PICO included stroke survivors, rehabilitation, control group intervention, lower limb function. To assess the risk of bias, we used the Cochrane risk of bias tool (RoB). We identified the terminology describing the CG Program (CGP), performed a knowledge synthesis and conducted a frequency analysis of provided interventions.

EVIDENCE SYNTHESIS

We included 155 publications. 13.6% of the articles did not describe the CG, and 11.6% indicated only the professionals involved. In the remaining 116 studies, three studies provided an intervention according to specific guidelines, 106 different "usual care" CGPs were detected, with nine proposed twice and two between four and five times. The most adopted terminology to state "usual care" was "conventional physiotherapy."

CONCLUSIONS

This study shows that usual care in CG does not actually exist, as both specific terminology and consistency within CGP contents are missing. Reporting guidelines should give better assistance on this issue. These results should be verified in other fields.

Social participation interventions targeting relational outcomes for young people with physical and developmental disabilities: an umbrella review and narrative synthesis

Purpose: To synthesize knowledge about social participation interventions targeting relational outcomes for young people with physical and developmental disabilities.Method: An umbrella review with a narrative synthesis was conducted to integrate findings of review articles examining social participation interventions targeting relational outcomes (e.g., peer interaction and friendships). Six databases were searched to identify reviews published between 2010 and 2021.Results: Five reviews were identified, examining participation interventions, social/community integration interventions, recreational sport programs, online peer mentorship programs, and augmentative and alternative communication interventions to promote social interaction with peers. Interventions associated with improvements in relational outcomes included group-based programs, programs involving personalized goals, arts-based programs, and multi-component social communication interventions. Recommendations for future research included better description of interventions to identify active ingredients and key mechanisms, measurement of participants' experiences, and the need for interventions to be aligned with the nature of the outcomes examined. Preliminary intervention principles are proposed to guide the design of social participation interventions: individualizing, contextualizing, and immersion in social settings.Conclusions: There are multiple pathways by which to influence the relational outcomes of young people with disabilities. There are implications for the design of social participation interventions based on an ecological/experiential and relational perspective.IMPLICATIONS FOR REHABILITATIONImprovements in relational outcomes are associated with participation in group-based programs, programs involving personalized goals, arts-based programs, and multi-component social communication interventions.Three evidence-informed principles can help guide the design of social participation interventions: (1) personalizing, (2) contextualizing, and (3) immersion in social settings.Greater attention to aligning the nature of intervention with desired outcomes is needed to more effectively measure and promote relational outcomes.

Intervention Goals for Preschoolers With Language Difficulties and Disorders: A Scoping Review Using the International Classification of Functioning, Disability and Health Framework

PURPOSE

The primary aim of this scoping review was to categorize language therapy goals reported in intervention studies for preschoolers (i.e., children from birth to 5;0 [years;months]) with language difficulties and disorders within the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework. A secondary aim was to determine whether different therapy goals were reported for two language difficulty/disorder subtypes (i.e., comparing language difficulty/disorder associated with a biomedical condition to those without an associated biomedical condition).

METHOD

The scoping review followed Arksey and O'Malley (2005) guidelines. Articles were retrieved from speechBITE, with age (under 5 years), intervention area (language), and study design (all but systematic reviews and clinical practice guidelines) specified as inclusion criteria. Language goals were extracted and categorized into the ICF components, and the distribution of goals across ICF components was compared for studies involving children with the two language difficulty/disorder subtypes.

RESULTS

A total of 287 articles were identified; 140 met inclusion criteria. Of the 293 goals extracted, 48% aligned with the activities component of the ICF framework, followed by participation (26%), environmental factors (20%), body functions and structures (3%), and personal factors (3%). Most participation-focused goals were reported from intervention studies involving preschoolers with a language difficulty/disorder associated with a biomedical condition.

CONCLUSIONS

Few participation-focused goals were reported in intervention studies for preschoolers with language difficulty/disorder without an associated condition. Future work is needed to support integrating the ICF framework in goal setting for both research and practice.

A qualitative evaluation of participants experiences of living with back pain, lumbar fusion surgery, and post-operative rehabilitation

Background

The use of lumbar fusion surgery is increasing in developed economies. High levels of patient dissatisfaction are reported post-operatively. To address this need, we developed a theoretically informed rehabilitation programme for use following lumbar fusion surgery (the REFS programme). We conducted a mixed methods randomised controlled feasibility study (REFS v ‘usual care’). The numerical and feasibility outcomes are reported separately. The current qualitative study was ‘nested’ within the main feasibility study to explore participants’ experiences before and after lumbar fusion surgery including the impact of rehabilitation content. This facilitated a deeper understanding of potential mechanisms of action, for theoretical and programme refinement.

Methods

A purposive sample (n = 10 ‘usual care’, n = 10 REFS) was identified from the main feasibility study cohort. Individual semi-structured interviews were conducted post-operatively (median 8 months, range 5–11). Interview data were transcribed verbatim, coded, and analysed thematically.

Results

Three themes were constructed: the breadth and severity of impact associated with a chronic lumbar disorder was summarised in theme 1, ‘Ever-decreasing circles; living with a chronic lumbar disorder’. Theme 2, ‘What have I done? Reflections on recovery from lumbar fusion surgery’, illustrated participants post-operative helplessness, which was associated with worsening mental health, problematic use of opioids, fear related to the instillation of metalware, and the important mitigating effect of informal social support. Theme 3 ‘Rehabilitation experiences’ identified critical rehabilitation programme content including exercise, a shared rehabilitation experience, the opportunity for vicarious learning, and professional expertise.

Conclusions

To enhance patient benefit future REFS programme iterations should consider reinforcement of the identified valued programme content. Additional content should be considered to mitigate post-operative fear, which frequently aligned with the instillation of metalware into the spine. Participant’s perceptions regarding the necessity of lumbar fusion surgery has potential implications for the surgical consent process.

Trial registration

Study registration; ISRCTN60891364, date registered 10/7/2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01050-y.

Higher Frequency of Acute Occupational Therapy Services Is Associated With Reduced Hospital Readmissions

IMPORTANCE

Hospital readmissions are associated with poor patient outcomes, including higher risk for mortality, nutritional concerns, deconditioning, and higher costs.

OBJECTIVE

To evaluate how acute occupational therapy service delivery factors affect readmission risk.

DESIGN

Cross-sectional, retrospective study.

SETTING

Single academic medical center.

PARTICIPANTS

Medicare inpatients with a diagnosis included in the Hospital Readmissions Reduction Program (HRRP; N = 17,618). Data were collected from medical records at a large urban hospital in southeastern Wisconsin. Outcomes and Measures: Logistic regression models were estimated to examine the association between acute occupational therapy service delivery factors and odds of readmission. In addition, the types of acute occupational therapy services for readmitted versus not-readmitted patients were compared.

RESULTS

Patients had significantly higher odds of readmission if they received occupational therapy services while hospitalized (odds ratio [OR] = 1.18, 95% confidence interval [CI] [1.07, 1.31]). However, patshients who received acute occupational therapy services had significantly lower odds of readmission if they received a higher frequency (OR = 0.99, 95% CI [0.99,1.00]) of acute occupational therapy services. A significantly higher proportion of patients who were not readmitted, compared with patients who were readmitted, received activities of daily living (ADL) or self-care training (p < .01).

CONCLUSIONS AND RELEVANCE

For patients with HRRP-qualifying diagnoses who received acute occupational therapy services, higher frequency of acute occupational therapy services was linked with lower odds of readmission. Readmitted patients were less likely to have received ADL or self-care training while hospitalized. What This Article Adds: Identifying factors of acute occupational therapy services that reduce the odds of readmission for Medicare patients may help to improve patient outcomes and further define occupational therapy's role in the U.S. quality-focused health care system.

Artificial Intelligence in Rehabilitation Targeting the Participation of Children and Youth With Disabilities: Scoping Review

BACKGROUND

In the last decade, there has been a rapid increase in research on the use of artificial intelligence (AI) to improve child and youth participation in daily life activities, which is a key rehabilitation outcome. However, existing reviews place variable focus on participation, are narrow in scope, and are restricted to select diagnoses, hindering interpretability regarding the existing scope of AI applications that target the participation of children and youth in a pediatric rehabilitation setting.

OBJECTIVE

The aim of this scoping review is to examine how AI is integrated into pediatric rehabilitation interventions targeting the participation of children and youth with disabilities or other diagnosed health conditions in valued activities.

METHODS

We conducted a comprehensive literature search using established Applied Health Sciences and Computer Science databases. Two independent researchers screened and selected the studies based on a systematic procedure. Inclusion criteria were as follows: participation was an explicit study aim or outcome or the targeted focus of the AI application; AI was applied as part of the provided and tested intervention; children or youth with a disability or other diagnosed health conditions were the focus of either the study or AI application or both; and the study was published in English. Data were mapped according to the types of AI, the mode of delivery, the type of personalization, and whether the intervention addressed individual goal-setting.

RESULTS

The literature search identified 3029 documents, of which 94 met the inclusion criteria. Most of the included studies used multiple applications of AI with the highest prevalence of robotics (72/94, 77%) and human-machine interaction (51/94, 54%). Regarding mode of delivery, most of the included studies described an intervention delivered in-person (84/94, 89%), and only 11% (10/94) were delivered remotely. Most interventions were tailored to groups of individuals (93/94, 99%). Only 1% (1/94) of interventions was tailored to patients' individually reported participation needs, and only one intervention (1/94, 1%) described individual goal-setting as part of their therapy process or intervention planning.

CONCLUSIONS

There is an increasing amount of research on interventions using AI to target the participation of children and youth with disabilities or other diagnosed health conditions, supporting the potential of using AI in pediatric rehabilitation. On the basis of our results, 3 major gaps for further research and development were identified: a lack of remotely delivered participation-focused interventions using AI; a lack of individual goal-setting integrated in interventions; and a lack of interventions tailored to individually reported participation needs of children, youth, or families.

Consensus on Terminology for Describing Child Language Interventions: A Delphi Study

Purpose Language intervention for children with language disorder may be effective; however, lack of detailed and consistent terminology for describing language interventions poses barriers for advancement within the field. This study aimed to develop consensus from speech-language pathologists (SLPs) in Australia on a taxonomy with terminology for describing language interventions for school-aged children and investigate SLPs' application of taxonomy terminology when describing child language interventions. Method A taxonomy with terms for describing interventions was developed with reference to contemporary literature and presented to clinicians and researchers with expertise in child language disorders in a three-round Delphi study. We asked Delphi participants to indicate agreement with the taxonomy or propose changes. Application of the taxonomy was investigated by asking participants to use taxonomy terminology to describe interventions presented in two case studies. Results The taxonomy consists of five aspects across which interventions may be described: modality/domain, purpose, delivery, form, and teaching techniques. Consensus on the taxonomy was established in both Round 1 (55 participants) and Round 2 (43 participants), with 100% of SLPs strongly agreeing or agreeing with the overall structure of the taxonomy and at least 87.3% of SLPs strongly agreeing or agreeing with each aspect. In Round 3 (32 participants), consensus was reached on 45/54 taxonomy categories (4/12 of the components) for Case Study 1 and 45/54 taxonomy categories (7/12 of the components) for Case Study 2. Conclusions Consensus on a taxonomy with terminology for describing language interventions represents a significant advancement in the field of child language intervention. Future actions may be needed to facilitate consistent application of taxonomy terms. Supplemental Material https://doi.org/10.23641/asha.16435290.

The meaning of rehabilitation: a qualitative study exploring perspectives of occupational therapists and physiotherapists working with older people in acute care

OBJECTIVE

To explore how occupational therapists and physiotherapists constructed and interpreted the meaning of rehabilitation in relation to older people in acute care.

DESIGN

A focussed ethnographic study was undertaken, primarily using observation, interviewing and review of clinical records within one acute medical ward in a general hospital in the UK. Five patient participants gave consent for their episode of care to be studied, with observations and interviews primarily involving the identified patients and five occupational therapy and physiotherapy professionals.

RESULTS

Four themes were identified: rehabilitation as a process to facilitate physical improvement; rehabilitation as physiotherapy-led; rehabilitation as a place…but not here; and rehabilitation as a process which prioritises safety over function. Such conceptualisations of rehabilitation were recognised as rooted in social and historical perceptions and challenged the ideals of rehabilitation professionals.

CONCLUSIONS

The meaning of rehabilitation in acute care is shaped by a range of cultural, contextual and systemic influences. Recognising these influences, and subsequent challenges to rehabilitation ideals, can encourage professionals to work towards meaningful change.Implications for RehabilitationA reductionist version of rehabilitation was evident within this context which placed value on physical improvement, achieving optimum safety and led by physiotherapy.This version of rehabilitation was unsatisfactory to occupational therapists and physiotherapists in this setting and different to their ideals.Where rehabilitation may be associated with another place, practitioners should reflect on whether this is influencing patients becoming a lower priority for interventions whilst waiting and address this, if required, within their own reasoning, prioritisation and delegation.Those who recognise similarities with their own practice context could individually, and within teams, revisit definitions of rehabilitation to notice, document and have conversations about the ideals of their professions versus the reality of practice.Occupational therapists and physiotherapists can be champions for organisational and cultural change to promote rehabilitation as a multi-disciplinary phase of care working towards optimising improvements in wellbeing, function and safety, irrespective of location.

The rehabilitation of physical function after severely disabling stroke: a survey of UK therapist practice

Background/aims

Individuals who are severely disabled from stroke (survivors of severely disabling stroke) experience poorer outcomes compared to those who are less disabled from stroke. However, there is a paucity of evidence describing current therapy practice in the management of severely disabling stroke. The aim of the study was to describe intervention and outcome measure use by physiotherapists and occupational therapists in the rehabilitation of physical function of survivors of severely disabling stroke.

Methods

A mixed-methods survey was conducted, involving an online questionnaire and follow-up interviews. Survey participants were UK-based physiotherapists and occupational therapists with experience treating stroke. Questionnaire data were analysed with descriptive and inferential statistics. Interview data were analysed using content analysis.

Results

A total of 452 therapists (59% physiotherapists) responded to the questionnaire. Out of the respondents, 18 self-selected therapists participated in follow-up interviews to explain questionnaire data. Whole body positioning, training of upper limb handling and positioning, and sitting balance practice were the most frequently used interventions. Inpatient-based therapists performed more active rehabilitation interventions, whereas community-based therapists performed more training and education. The Barthel Index, Modified Rankin Scale and National Institutes for Health Stroke Scale were the most frequently used outcome measures. Outcome measure use was generally low and was more likely to be completed when it was part of a national audit. Reasons for low outcome measure use were perceived lack of time and insensitivity to detect clinical change.

Conclusions

A variety of interventions and outcome measures are used in the rehabilitation of survivors of severely disabling stroke. There is a need to evaluate the effectiveness of frequently used interventions and identify outcome measures that are sensitive to the needs of survivors of severely disabling stroke.

Decision-making aids for upper limb interventions in neurological rehabilitation: a scoping review

PURPOSE

To summarise the range and nature of decision-making aids that guide upper limb (UL) neurorehabilitation.

METHODS

Our scoping review followed Arksey and O'Malley's 6-step framework. Electronic databases were systematically searched; grey literature was hand-searched. Included papers were: (1) published in English; (2) related to UL rehabilitation for people with upper motor neuron conditions; and (3) provided a description of, or research on, a decision-making aid that guides therapists when choosing between two or more intervention approaches, techniques, or applications of a technique. Levels of evidence were rated. An expert panel of occupational therapists working in UL neurorehabilitation was consulted.

RESULTS

The 24 included articles described 15 decision-making aids with varying breadth and depth of the assessment process and suggested interventions. Six aids had published research, but lacked high quality evidence. The expert panel identified four key decision-making aids as being clinically useful. Preferred aids either included client-centred goal-setting within a holistic assessment or matched specific intervention options to distinct UL assessment results. Prompts to re-evaluate client performance are desirable.

CONCLUSION

Few decision-making aids guide therapists to holistically assess and make specific intervention decisions across all domains of UL neurorehabilitation. Their usefulness depends on the purpose, setting, and therapist experience.Implications for rehabilitationConsidering the complexity and heterogeneity of upper limb (UL) neurorehabilitation, a selection of evidence-based and purpose-designed decision-making aids may assist therapists across different experience levels and practice settings to choose individualised interventions.Decision-making aids for UL interventions in neurorehabilitation may be more clinically useful if they include a holistic and client-centred information gathering process that focuses on daily life goals.Decision-making aids should illustrate a clear clinical picture based on UL assessment results, with corresponding UL intervention recommendations provided.Inclusion of a cyclic process to re-evaluate client performance and function could also enhance the usefulness of a decision-making aid.

Effects of Finding the Speech-Language Pathologist Likeable on Postlaryngectomy Speech Intelligibility Outcomes

INTRODUCTION

Speech-language pathologists (SLPs) work with patients after total laryngectomy (TL) to regain verbal communication. The influence of the quality of the therapeutic relationship on the success of TL voice rehabilitation in terms of speech intelligibility is not known. Finding each other likeable is an important factor in establishing and maintaining interpersonal relationships in everyday life. The fit of therapist and client is relevant to the therapeutic relationship. The purpose of this study therefore was to assess the association between the degree of SLPs' likeability ratings and postlaryngectomy speech intelligibility.

METHODS

In a multicentre prospective cohort study, participants rated their SLPs' likeability after finishing TL rehabilitation. Speech intelligibility was measured objectively with the Post-Laryngectomy Telephone Intelligibility Test and subjectively with the Questionnaire for Adjustment after Laryngectomy. The association of SLPs' likeability with speech intelligibility was analysed using hierarchical logistic regression, expressed with odds ratios (OR) with corresponding 95% confidence intervals (CI).

RESULTS

Altogether 124 patients from 13 institutions participated. The degree of finding the SLP likeable was not significantly associated with objective speech intelligibility (OR 1.30; 95% CI 0.78-2.18; p = 0.32) or subjective speech intelligibility (OR 1.01; 95% CI 0.60-1.72; p = 0.96) after controlling for age, sex and education factors.

DISCUSSION/CONCLUSION

In this patient cohort, there was no evidence for an association between ratings of SLPs' likeability and speech intelligibility outcomes after rehabilitation. Future studies could consider the use of alternative instruments for measuring likeability.

The development of a return to work intervention programme for stroke survivor (SReTWIP): a Delphi survey

BACKGROUND

Even though clearly defined pathways for vocational re-entry are well recognized for conditions such as mental health, musculoskeletal dysfunction (MSD) and traumatic brain injury (TBI), none has been identified for stroke. There has been a lack of consensus regarding such clear pathways to vocational re-entry and the essential contents of return to work (RTW) interventions for stroke survivors. As part of a larger study aimed to design a RTW programme for stroke survivors, this study describes the concluding process through which Stroke Return to Work Intervention Programme (SReTWIP) was developed.

METHODS

Experts in the field of neurorehabilitation and vocational rehabilitation (VR) from 6 countries participated in this 3-round Delphi survey via e-mail. Concept mapping was used to triangulate findings from the Delphi with previous phases of the larger study. Content thematic analysis was conducted on qualitative data while descriptive statistic was used to analyze quantitative data.

RESULTS

Fifteen experts with a mean age and mean duration of practice of 44.73 ± 9.48 years and 18.26 ± 8.71 years respectively participated in this study. The developed RTW programme (SReTWIP) is a 12 week programme that consisted of four interconnected phases of intervention viz.: an assessment phase, clinic-based work and non-work specific intervention phase, a work test placement phase and a client full participation in worker role phase. The experts agreed on a set of implementation strategies that included the use of interdisciplinary team, the tailoring of intervention to meet stroke survivor's need, as well as the use of case management approach.

CONCLUSION

The SReTWIP is the first step in developing a VR pathway that can ultimately enhance the RTW rates and quick resumption of the worker role of stroke survivors. The stroke survivor can move along the different phases of the SReTWIP after achieving competency in a preceding phase. Future work will include a feasibility study with other key stakeholders involved in RTW such as employers, informal caregivers and stroke survivors before its implementation.

Describing language assessments for school-aged children: A Delphi study

Purpose: Given the barriers that inconsistent terminology poses for the Speech-Language Pathology (SLP) profession, this study aimed to develop an agreed-upon taxonomy with well-defined categories for describing language assessment practices for children.Method: A taxonomy with illustrative terms for describing assessments across four aspects (modality/domain, purpose, delivery and form) was developed with reference to contemporary literature. In a three round Delphi study, SLPs with expertise in child language were asked to indicate their level of agreement with the taxonomy and provide feedback. Participants were also asked to apply the taxonomy by categorising assessments presented in case studies.Result: A total of 55 participants completed round one, while 43 and 32 completed rounds two and three respectively. Agreed consensus with the taxonomy was achieved in both rounds one and two, with at least 88% of participants agreeing with each aspect and 100% agreeing with the overall structure. In round three, an agreement was reached on 7/10 components for one case study and 4/10 for the other.Conclusion: The development of this taxonomy represents a significant step towards providing detailed terminology for describing language assessments. Future research is needed to investigate implementation strategies to facilitate consistent application of the taxonomy by SLPs.

Tracking the evolution of virtual reality applications to rehabilitation as a field of study

Background

Application of virtual reality (VR) to rehabilitation is relatively recent with clinical implementation very rapidly following technological advancement and scientific discovery. Implementation is often so rapid that demonstrating intervention efficacy and establishing research priorities is more reactive than proactive. This study used analytical tools from information science to examine whether application of VR to rehabilitation has evolved as a distinct field of research or is primarily a methodology in core disciplines such as biomedical engineering, medicine and psychology.

Methods

The analysis was performed in three-stages: 1) a bibliographic search in the ISI Web of Science database created an initial corpus of publications, 2) the corpus was refined through topic modeling, and 3) themes dominating the corpus from the refined search results were identified by topic modeling and network analytics. This was applied separately to each of three time periods: 1996 to 2005 (418 publications), 2006 to 2014 (1454 publications), and 2015 to mid-2018 (1269 publications).

Results

Publication rates have continuously increased across time periods with principal topics shifting from an emphasis on computer science and psychology to rehabilitation and public health. No terminology specific to the field of VR-based rehabilitation emerged; rather a range of central concepts including “virtual reality”, “virtual gaming”, “virtual environments”, “simulated environments” continue to be used. Communities engaged in research or clinical application of VR form assemblages distinguished by a focus on physical or psychological rehabilitation; these appear to be weakly linked through tele-rehabilitation.

Conclusions

Varying terms exemplify the main corpus of VR-based rehabilitation and terms are not consistent across the many scientific domains. Numerous distinguishable areas of research and clinical foci (e.g., Tele-rehabilitation, Gait & Balance, Cognitive Rehabilitation, Gaming) define the agenda. We conclude that VR-based rehabilitation consists of a network of scientific communities with a shared interest in the methodology rather than a directed and focused research field. An interlinked team approach is important to maintain scientific rigor and technological validity within this diverse group. Future studies should examine how these interdisciplinary communities individually define themselves with the goals of gathering knowledge and working collectively toward disseminating information essential to associated research communities.

Searching for the "Active Ingredients" in Physical Rehabilitation Programs Across Europe, Necessary to Improve Mobility in People With Multiple Sclerosis: A Multicenter Study

BACKGROUND

Physical rehabilitation programs can lead to improvements in mobility in people with multiple sclerosis (PwMS).

OBJECTIVE

To identify which rehabilitation program elements are employed in real life and how they might affect mobility improvement in PwMS.

METHODS

Participants were divided into improved and nonimproved mobility groups based on changes observed in the Multiple Sclerosis Walking Scale-12 following multimodal physical rehabilitation programs. Analyses were performed at group and subgroup (mild and moderate-severe disability) levels. Rehabilitation program elements included setting, number of weeks, number of sessions, total duration, therapy format (individual, group, autonomous), therapy goals, and therapeutic approaches.

RESULTS

The study comprised 279 PwMS from 17 European centers. PwMS in the improved group received more sessions of individual therapy in both subgroups. In the mildly disabled group, 60.9% of the improved received resistance training, whereas, 68.5% of the nonimproved received self-stretching. In the moderately-severely disabled group, 31.4% of the improved, received aerobic training, while 50.4% of the nonimproved received passive mobilization/stretching.

CONCLUSIONS

We believe that our findings are an important step in opening the black-box of physical rehabilitation, imparting guidance, and assisting future research in defining characteristics of effective physical rehabilitation.

Description of the Services, Activities, and Interventions Within School-Based Physical Therapist Practices Across the United States

BACKGROUND

Students with disabilities receive school-based physical therapy services under the Individuals with Disabilities Education Improvement Act of 2004. Little research exists regarding therapy services in schools.

OBJECTIVE

This study explored the school-based services that students received and the activities and interventions that physical therapists implemented, and determined if services differed based on the student's functional gross motor ability and age.

DESIGN

This was a prospective observational cohort study using a practice-based evidence design.

METHODS

Data were collected by 109 physical therapists for 296 students, aged 5 to 12 years, receiving school-based physical therapy. Physical therapists completed the School-Physical Therapy Interventions for Pediatrics data form for 20 weeks during 1 school year. This evaluation included the type of service delivery, the amount of time spent on each student (consultation/documentation), minutes spent in activities, the specific interventions implemented, and the student's level of participation. The Gross Motor Function Classification System (GMFCS) was used to describe the students' functional ability.

RESULTS

Physical therapists provided an average of 26.7 min/wk (standard deviation [SD] = 15.1) of direct services and 13.1 min/wk (SD = 7.7) of services on behalf of the student. Primary activities were physical education/recreation (7.7 min/wk, SD = 8.2), mobility (6.7 min/wk, SD = 7.9), and sitting/standing/transitions (6.3 min/wk, SD = 8.1). Primary interventions were neuromuscular (32.5 counts per student, SD = 15.9), mobility (15.3 counts per student, SD = 14.65), and musculoskeletal (14.4 counts per student, SD = 10.3). Differences existed based on GMFCS but not student age.

LIMITATIONS

Physical therapists reported School-Physical Therapy Interventions for Pediatrics data weekly, not necessarily after each therapy session. The GMFCS was used as a proxy of students' functional gross motor ability.

CONCLUSIONS

Our description of services is provided to encourage physical therapists to reflect on the services they provide and to foster future examinations of service effectiveness.

The Rehabilitation Treatment Specification System: Implications for Improvements in Research Design, Reporting, Replication, and Synthesis

Despite significant advances in measuring the outcomes of rehabilitation interventions, little progress has been made in specifying the therapeutic ingredients and processes that cause measured changes in patient functioning. The general approach to better clarifying the process of treatment has been to develop reporting checklists and guidelines that increase the amount of detail reported. However, without a framework instructing researchers in how to describe their treatment protocols in a manner useful to or even interpretable by others, requests for more detail will fail to improve our understanding of the therapeutic process. In this article, we describe how the Rehabilitation Treatment Specification System (RTSS) provides a theoretical framework that can improve research intervention reporting and enable testing and refinement of a protocol's underlying treatment theories. The RTSS framework provides guidance for researchers to explicitly state their hypothesized active ingredients and targets of treatment as well as for how the individual ingredients in their doses directly affect the treatment targets. We explain how theory-based treatment specification has advantages over checklist approaches for intervention design, reporting, replication, and synthesis of evidence in rehabilitation research. A complex rehabilitation intervention is used as a concrete example of the differences between an RTSS-based specification and the Template for Intervention Description and Replication checklist. The RTSS's potential to advance the rehabilitation field can be empirically tested through efforts to use the framework with existing and newly developed treatment protocols.

The generation of consensus guidelines for carrying out process evaluations in rehabilitation research

BACKGROUND

Although in recent years there has been a strong increase in published research on theories (e.g. realist evaluation, normalization process theory) driving and guiding process evaluations of complex interventions, there is limited guidance to help rehabilitation researchers design and carry out process evaluations. This can lead to the risk of process evaluations being unsystematic. This paper reports on the development of new consensus guidelines that address the specific challenges of conducting process evaluations alongside clinical trials of rehabilitation interventions.

METHODS

A formal consensus process was carried out based on a modified nominal group technique, which comprised two phases. Phase I was informed by the findings of a systematic review, and included a nominal group meeting with an expert panel of participants to rate and discuss the proposed statements. Phase II was an in depth semi-structured telephone interviews with expert panel participants in order to further discuss the structure and contents of the revised guidelines. Frequency of rating responses to each statement was calculated and thematic analysis was carried out on all qualitative data.

RESULTS

The guidelines for carrying out process evaluations within complex intervention rehabilitation research were produced by combining findings from Phase I and Phase II. The consensus guidelines include recommendations that are grouped in seven sections. These sections are theoretical work, design and methods, context, recruitment and retention, intervention staff, delivery of the intervention and results. These sections represent different aspects or stages of the evaluation process.

CONCLUSION

The consensus guidelines here presented can play a role at assisting rehabilitation researchers at the time of designing and conducting process evaluations alongside trials of complex interventions. The guidelines break new ground in terms of concepts and theory and works towards a consensus in regards to how rehabilitation researchers should go about carrying out process evaluations and how this evaluation should be linked into the proposed trials. These guidelines may be used, adapted and tested by rehabilitation researchers depending on the research stage or study design (e.g. feasibility trial, pilot trial, etc.).

School-based physical therapy services and student functional performance at school

AIM

We explored relationships of school-based physical therapy to standardized outcomes of students receiving physical therapy.

METHOD

Using a practice-based evidence research design, School Function Assessment (SFA) outcomes of 296 students with disabilities (mean age 7y 4mo [standard deviation 2y]; 166 males, 130 females), served by 109 physical therapists, were explored. After training, therapists completed 10 SFA scales on students at the beginning and end of the school year. Therapists collected detailed weekly data on services (activities, interventions, types, student participation) using the School-Physical Therapy Interventions for Pediatrics (S-PTIP) system. Stepwise linear regressions were used to investigate S-PTIP predictors of SFA outcomes.

RESULTS

Predictors of SFA section outcomes varied in strength, with the coefficient of determination (R² ) for each outcome ranging from 0.107 to 0.326. Services that correlated positively with the SFA outcomes included mobility, sensory, motor learning, aerobic/conditioning, functional strengthening, playground access interventions, and higher student participation during therapy (standardized β=0.11-0.26). Services that correlated negatively with the SFA outcomes included providing services within student groups, within school activity, with students not in special education, during recreation activities, and with positioning, hands-on facilitation, sensory integration, orthoses, and equipment interventions (standardized β=-0.14 to -0.22).

INTERPRETATION

Consideration of outcomes is prudent to focus services. Overall results suggest we should emphasize active mobility practice by using motor learning interventions and engaging students within therapy sessions.

WHAT THIS PAPER ADDS

No specific interventions predicted positively on all School Function Assessment (SFA) outcomes. Active movement practice seems related to overall better SFA outcomes. Active mobility practice improved SFA participation, mobility, recreation, and activities of daily living. Engaging students in therapy activities and interventions improved outcomes.

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.

Advancing Rehabilitation Practice Through Improved Specification of Interventions

Rehabilitation clinicians strive to provide cost-effective, patient-centered care that optimizes outcomes. A barrier to this ideal is the lack of a universal system for describing, or specifying, rehabilitation interventions. Current methods of description vary across disciplines and settings, creating barriers to collaboration, and tend to focus mostly on functional deficits and anticipated outcomes, obscuring connections between clinician behaviors and changes in functioning. The Rehabilitation Treatment Specification System (RTSS) is the result of more than a decade of effort by a multidisciplinary group of rehabilitation clinicians and researchers to develop a theory-based framework to specify rehabilitation interventions. The RTSS describes interventions for treatment components, which consist of a target (functional change brought about as a direct result of treatment), ingredients (actions taken by clinicians to change the target), and a hypothesized mechanism of action, as stated in a treatment theory. The RTSS makes explicit the connections between functional change and clinician behavior, and recognizes the role of patient effort in treatment implementation. In so doing, the RTSS supports clinicians' efforts to work with their patients to set achievable goals, select appropriate treatments, adjust treatment plans as needed, encourage patient participation in the treatment process, communicate with team members, and translate research findings to clinical care. The RTSS may help both expert and novice clinicians articulate their clinical reasoning processes in ways that benefit treatment planning and clinical education, and may improve the design of clinical documentation systems, leading to more effective justification and reimbursement for services. Interested clinicians are invited to apply the RTSS in their local settings.

Provider reliability with interventions for knee impairments: a preliminary investigation to facilitate development of an MDT-based knee intervention taxonomy

Objectives: The lack of a standardized intervention taxonomy in comparative effectiveness research trials has led to uncertainty regarding the management of individuals with knee impairments. Inconsistently and poorly defined interventions affect frontline-care providers' abilities to understand and assimilate research findings into practice. An intervention taxonomy could help overcome the lack of treatment specificity commonly found in research trials. Methods: In the present study, we aimed to develop a Mechanical Diagnosis and Therapy (MDT)-based taxonomy and test the levels of reliability between providers who currently manage individuals with knee impairments in a rehabilitation setting. A total of 182 participants accessed the study during the study period, in which 180 consented to participate and 59 completed the survey (98.9% participation rate; 32.7% completion rate). Results: A total of 89.8% of the participants who completed the survey were physical therapists. Fleiss kappa values for the primary, secondary, and tertiary categories were 0.90, 0.89, and 0.71, respectively. The results of our investigation suggest substantial to almost perfect levels of reliability for identifying diverse MDT-based knee interventions displayed in video and vignette format within a sample population primarily of physical therapists who currently manage individuals with knee impairments in a rehabilitation setting. Discussion: Our findings show acceptable levels of reliability and provide support for using this standardized MDT-based intervention taxonomy as a way to improve intervention specificity and generalizability in comparative effectiveness research. Level of Evidence: 5.

Ethics reporting practices in randomized controlled trials of physical therapy interventions after stroke

BACKGROUND

Adequate reporting of ethics-related research methods promotes convergence on best ethics practices. In physical therapy, studies on ethics reporting are limited to few aspects, and none focuses on stroke research. Our objectives were to investigate the reporting of multiple ethics-related features and its variation over time, and the characteristics of the studies associated with ethics reporting in Randomized Controlled Trials (RCTs) of physical therapy interventions after stroke.

METHODS

A random sample of RCTs published in the years 2004, 2009 and 2014, was extracted from the PubMed database, regardless of the publishing journal. For each trial we investigated year of publication, trial registration, sample size, stroke subtype, phase of the disease, setting, interventions and dosing, outcome measures, outcome of the study, PEDro score and 5-year impact factor of the publishing journal. Reporting of ethics-related issues was analyzed. Differences between groups were examined. Multiple regression was used to evaluate the relationship between ethics-related issues reporting and some studies' characteristics.

RESULTS

Eighty studies were reviewed. Groups differed in the proportion of registered trials (p = .009), 5-year impact factor (p = .011), assessment of cognitive capacity (p = .049), declaration about conflict of interest (p < .001), and number of ethics-related issues reported (p = .009). The proportion of issues reported ranged from 92.5% (consent obtaining) to 0% (eventual follow up care). Post-hoc comparisons showed significantly greater reporting of ethics issues in trials published in the year 2014 compared to 2004 (p = .014, 95%CI = 0.40/4.26). Year of publication and PEDro score were significant predictors of adequate reporting.

CONCLUSIONS

Authors, editors, and reviewers should be more rigorous and demanding about the reporting of ethic-related methods in randomized controlled trials of physical therapy interventions after stroke.

Amount and Content of Sensorimotor Therapy Delivered in Three Stroke Rehabilitation Units in Quebec, Canada

Purpose: This study creates a baseline clinical portrait of sensorimotor rehabilitation in three stroke rehabilitation units (SRUs) as a first step in implementing a multi-centre clinical research platform. Method: Participants in this cross-sectional, descriptive study were the patients and rehabilitation teams in these SRUs. Prospective (recording of therapy time and content and a Web-based questionnaire) and retrospective (chart audit) methods were combined to characterize the practice of the rehabilitation professionals. Results: The 24- to 39-bed SRUs admitted 100-240 inpatients in the year audited. The mean combined duration of individual occupational and physical therapy was 6.3-7.5 hours/week/patient. When evening hours and the contributions of other professionals as well as group therapy and self-practice were included, the total amount of therapy was 13.0 (SD 3) hours/patient/week. Chart audit and questionnaire data revealed the Berg Balance Scale was the most often used outcome measure (98%-100%), and other outcome measure use varied. Clinicians favoured task-oriented therapy (35%-100%), and constraint-induced movement therapy (0%-15%), electrical stimulation of the tibialis anterior (0%-15%), and body weight-supported treadmill training (0%-1%) were less often used. Conclusions: This study is the first to provide objective data on therapy time and content of stroke rehabilitation in Quebec SRUs.

Examining Guided and Directed Cues in Strategy Training and Usual Rehabilitation

Therapist approach and feedback during rehabilitation may influence patient outcomes. It is unclear how much guided cueing, the approach used in strategy training, is present in usual rehabilitation care. We compared the frequency of guided and directed cueing in strategy training sessions with cueing in usual care occupational and physical therapy. We videotaped strategy training, occupational therapy, and physical therapy sessions among 20 patients admitted to inpatient rehabilitation after stroke. Using a standardized coding scheme, we coded and analyzed frequencies of therapists' cues (guided or directed). The proportion of guided cues was significantly higher in strategy training intervention (42%) compared with occupational therapy (4%) and physical therapy (3%). Preliminary research suggests that guided cueing may be more prevalent in strategy training than in usual care. Given that guided cueing provides more opportunity for patients to take an active role in their rehabilitation, guided cueing may lead to superior outcomes.

Non-pharmacological interventions for spasticity in adults: An overview of systematic reviews

OBJECTIVES

Spasticity causes significant long-term disability-burden, requiring comprehensive management. This review evaluates evidence from published systematic reviews of clinical trials for effectiveness of non-pharmacological interventions for improved spasticity outcomes.

METHODS

Data sources: a literature search was conducted using medical and health science electronic (MEDLINE, EMBASE, CINAHL, PubMed, and the Cochrane Library) databases for published systematic reviews up to 15th June 2017.

DATA EXTRACTION AND SYNTHESIS

two reviewers applied inclusion criteria to select potential systematic reviews, independently extracted data for methodological quality using Assessment of Multiple Systematic Reviews (AMSTAR). Quality of evidence was critically appraised with Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

RESULTS

Overall 18 systematic reviews were evaluated for evidence for a range of non-pharmacological interventions currently used in managing spasticity in various neurological conditions. There is "moderate" evidence for electro-neuromuscular stimulation and acupuncture as an adjunct therapy to conventional routine care (pharmacological and rehabilitation) in persons following stroke. "Low" quality evidence for rehabilitation programs targeting spasticity (such as induced movement therapy, stretching, dynamic elbow-splinting, occupational therapy) in stroke and other neurological conditions; extracorporeal shock-wave therapy in brain injury; transcranial direct current stimulation in stroke; transcranial magnetic stimulation and transcutaneous electrical nerve stimulation for other neurological conditions; physical activity programs and repetitive magnetic stimulation in persons with MS, vibration therapy for SCI and stretching for other neurological condition. For other interventions, evidence was inconclusive.

CONCLUSIONS

Despite the available range of non-pharmacological interventions for spasticity, there is lack of high-quality evidence for many modalities. Further research is needed to judge the effect with appropriate study designs, timing and intensity of modalities, and associate costs of these interventions.

Effectiveness of edema management techniques for subacute hand edema: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Prolonged hand edema can have detrimental effects on range of motion and function. There is no consensus on how best to manage traumatic subacute edema. This is the first systematic review which examines the clinical effectiveness of edema treatments on hand volume.

PURPOSE OF THE STUDY

The purpose of this systematic review was to examine the evidence of effectiveness of treatments for sub-acute hand edema.

METHODS

A literature search of AMED, CINAHL, Embase, and OVID MEDLINE (from inception to August 2015) was undertaken. Studies were selected if they met the following inclusion criteria: randomized controlled or controlled trials in adults who have subacute swelling after a recent upper limb musculoskeletal trauma or cerebral vascular attack or after surgery. Two independent assessors rated study quality and risk of bias using the 24-point MacDermid Structured Effectiveness Quality Evaluation Scale (SEQES).

RESULTS

Ten studies met the inclusion criteria. Study quality ranged from 23 to 41 out of 48 points on the SEQES. A total of 16 edema interventions were evaluated across the studies. Due to heterogeneity of the patient characteristics, interventions, and outcomes assessed, it was not possible to pool the results from all studies. Therefore, a narrative best evidence synthesis was undertaken. There is low to moderate quality evidence with limited confidence in the effect estimate to support the use of manual edema mobilization methods in conjunction with standard therapy to reduce problematic hand edema.

CONCLUSION

Manual edema mobilization techniques should be considered in conjunction with conventional therapies, in cases of excessive edema or when the edema has not responded to conventional treatment alone; however, manual edema mobilization is not advocated as a routine intervention.

LEVEL OF EVIDENCE

2b.

Description of interventions is under-reported in physical therapy clinical trials

•

A clear definition and description of the interventions in randomized controlled trials are pre-requisites for implementation in clinical practice.

•

There is a trend among investigators to describe control group interventions poorly compared to the experimental group.

•

The readers would not be able to apply the findings of the trial to their clinical practice if the interventions are poorly described.

Background

Amongst several barriers to the application of quality clinical evidence and clinical guidelines into routine daily practice, poor description of interventions reported in clinical trials has received less attention. Although some studies have investigated the completeness of descriptions of non-pharmacological interventions in randomized trials, studies that exclusively analyzed physical therapy interventions reported in published trials are scarce.

Objectives

To evaluate the quality of descriptions of interventions in both experimental and control groups in randomized controlled trials published in four core physical therapy journals.

Methods

We included all randomized controlled trials published from the Physical Therapy Journal, Journal of Physiotherapy, Clinical Rehabilitation, and Archives of Physical Medicine and Rehabilitation between June 2012 and December 2013. Each randomized controlled trial (RCT) was analyzed and coded for description of interventions using the checklist developed by Schroter et al.

Results

Out of 100 RCTs selected, only 35 RCTs (35%) fully described the interventions in both the intervention and control groups. Control group interventions were poorly described in the remaining RCTs (65%).

Conclusions

Interventions, especially in the control group, are poorly described in the clinical trials published in leading physical therapy journals. A complete description of the intervention in a published report is crucial for physical therapists to be able to use the intervention in clinical practice.

Defining the content of individual physiotherapy and occupational therapy sessions for stroke patients in an inpatient rehabilitation setting. Development, validation and inter-rater reliability of a scoring list

Objective : To develop a valid and reliable scoring list to define the content of individual physiotherapy and occupational therapy sessions for stroke patients in inpatient rehabilitation.

Design : A list was developed based on previous lists, neurological textbooks and recorded therapy sessions. Content validity was verified and inter-rater reliability evaluated on videos of treatment sessions. In each of four rehabilitation centres, a researcher recorded and scored five physiotherapy and five occupational therapy sessions. These 40 treatment sessions were also scored by the first author. The scores of the researchers and first author were statistically compared.

Settings and subjects : Forty stroke patients in four European rehabilitation centres.

Results : The scoring list consists of 49 subcategories, divided into 12 categories: mobilization; selective movements; lying (balance); sitting (balance); standing (balance); sensory and visual perceptual training and cognition; transfers; ambulatory activities; personal activities of daily living; domestic activities of daily living; leisure- and work-related activities; and miscellaneous. Comparing the frequency of occurrence of the categories resulted in intraclass correlation coefficients, indicating high reliability for eight categories, good for one, and fair for two. One category was not observed. Spearman rank correlation coefficients were high to very high for 24 subcategories and moderate for four. Twenty-one subcategories contained too few observations to enable calculation of Spearman rank correlation coefficients. Average point-to-point percentage of agreement in time of the treatment sessions equalled 76.6 ± 16.2%.

Conclusions : The list is a valid and reliable tool for describing the content of physiotherapy and occupational therapy for stroke patients.

A Scoping Review of Clinical Practice Improvement Methodology Use in Rehabilitation

Context

The Clinical Practice Improvement (CPI) approach is a methodological and quality improvement approach that has emerged and is gaining in popularity. However, there is no systematic description of its use or the determinants of its practice in rehabilitation settings.

Method

We performed a scoping review of the use of CPI methodology in rehabilitation settings.

Results

A total of 103 articles were reviewed. We found evidence of 13 initiatives involving CPI with six different populations. A total of 335 citations of determinants were found, with 68.7% related to CPI itself. Little information was found about what type of external and internal environment, individual characteristics and implementation process might facilitate or hinder the use of CPI.

Conclusion

Given the growing popularity of this methodological approach, CPI initiatives would gain from increasing knowledge of the determinants of its success and incorporating them in future implementation.

Physical Therapy-Related Child Outcomes in School: An Example of Practice-Based Evidence Methodology

PURPOSE

To describe the use of practice-based evidence research methodology in a prospective, multisite observational study to investigate changes in students' participation in school activity, self-care, posture/mobility, recreation/fitness, and academic outcomes, and the relationships of these changes to characteristics of school-based physical therapy.

METHODS

One hundred nine physical therapists completed the training and data collection and 296 students, 5 to 12 years of age (mean age = 7.3 years) had 6 months of complete data. Therapists completed individualized (Goal Attainment Scaling) and standardized (School Function Assessment) outcome measures for students at the beginning and end of the school year and during the year collected weekly data on services to and on behalf of the students.

SUMMARY

This research design enabled the investigation of complex research questions related to school-based practice. The findings of this study, to be reported later, should influence school-based therapy by providing guidance related to what activities, interventions, and services influence student outcomes.

Overcoming practical challenges to conducting clinical research in the inpatient stroke rehabilitation setting

BACKGROUND

There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work.

OBJECTIVE

This paper describes our institution's experience devising practical solutions to research barriers in this setting.

METHOD

Through concentrated efforts to overcome research barriers, such as by cultivating collaborative relationships and capitalizing on unanticipated benefits, we successfully facilitated conduct of five simultaneous inpatient stroke studies.

RESULTS

Tangible benefits realized include increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team.