A Theory-Driven System for the Specification of Rehabilitation Treatments

The Flu-ID: A New Evidence-Based Method of Assessing Fluency in Aphasia

PURPOSE

Assessing fluency in aphasia is diagnostically important for determining aphasia type and severity and therapeutically important for determining appropriate treatment targets. However, wide variability in the measures and criteria used to assess fluency, as revealed by a recent survey of clinicians (Gordon & Clough, 2022), results in poor reliability. Furthermore, poor specificity in many fluency measures makes it difficult to identify the underlying impairments. Here, we introduce the Flu-ID Aphasia, an evidence-based tool that provides a more informative method of assessing fluency by capturing the range of behaviors that can affect the flow of speech in aphasia.

METHOD

The development of the Flu-ID was based on prior evidence about factors underlying fluency (Clough & Gordon, 2020; Gordon & Clough, 2020) and clinical perceptions about the measurement of fluency (Gordon & Clough, 2022). Clinical utility is maximized by automated counting of fluency behaviors in an Excel template. Reliability is maximized by outlining thorough guidelines for transcription and coding. Eighteen narrative samples representing a range of fluency were coded independently by the authors to examine the Flu-ID's utility, reliability, and validity.

RESULTS

Overall reliability was very good, with point-to-point agreement of 86% between coders. Ten of the 12 dimensions showed good to excellent reliability. Validity analyses indicated that Flu-ID scores were similar to clinician ratings on some dimensions, but differed on others. Possible reasons and implications of the discrepancies are discussed, along with opportunities for improvement.

CONCLUSIONS

The Flu-ID assesses fluency in aphasia using a consistent and comprehensive set of measures and semi-automated procedures to generate individual fluency profiles. The profiles generated in the current study illustrate how similar ratings of fluency can arise from different underlying impairments. Supplemental materials include an analysis template, extensive guidelines for transcription and coding, a completed sample, and a quick reference guide.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27078199.

Introducing a specified on-line multimodal prehabilitation approach for total knee replacement surgery candidates using data from the COVID-19 pandemic: An exploratory field-based, pre-post, mixed methods implementation pilot study

RATIONALE

Individuals waiting for total-knee-replacement surgery are at risk of developing morbidities and frailty which may affect their postoperative recovery. Multi-modal prehabilitation could mitigate these unintentional effects.

AIMS AND OBJECTIVES

To implement and evaluate a specified online multi-modal prehabilitation intervention in patients waiting for total-knee-replacement surgery in a large urban acute hospital trust.

METHOD

A non-randomised, pre/post analysis implementation pilot with a nested qualitative study was conducted and is reported following the standards for implementation studies (StaRI) guidance. Of 35 listed cases, 12 (34%) were eligible, recruited, and completed an 8-week multi-modal online intervention incorporating 5 modalities (i) cardiovascular exercise, (ii) strength/balance function, (iii) smoking cessation, (iv) opioid use, (v) nutritional intake. Interventions were specified using the Rehabilitation Treatment Specification System, where rehabilitation treatment theory accounts for discrete treatment components. Two participated in an online qualitative interview post-intervention. Process evaluation included intervention fidelity, eligibility/recruitment/retention rates, and clinical outcomes included knee function, frailty, gait velocity, anxiety/depression, and quality of life.

RESULTS

Five participants (42%) completed the intervention and were retained at follow-up. The intervention was delivered online at specified doses, frequency/durations indicative of high respective adherence, quantity, and exposure fidelity. There was significant improvement in median oxford knee score (p = 0.015), gait velocity (p = 0.040) and anxiety (p = 0.023). The interview revealed 5 themes; surgery preconceptions, motivation, acceptability, postoperative experiences, and future recommendations confirming acceptance of the intervention by virtue of adhering to the treatment exposure delivered as planned.

CONCLUSION

The specified multi-modal prehabilitation was acceptable, implementable, and demonstrated evidence of preliminary efficacy. Further experimental pilot work that represents the spectrum of frailty, obesity, quality of life, and comorbidities associated with total-knee-replacement surgery is indicated.

Floating Ball Voice Therapy: Preliminary Effects on Outcomes and Predicting Individual Patient Differences in Generalization

PURPOSE

Floating ball voice therapy (FBVT) is a voice-controlled virtual environment based on a common treatment component across multiple evidence-based therapies: improved vocal efficiency (target) via practicing voicing with modified resonance and airflow (ingredient). This study preliminarily tested FBVT's effects on outcomes and the potential for its novel variability metrics to predict individual patient generalization.

METHOD

Ten patients with nonphonotraumatic vocal hyperfunction (NPVH) practiced FBVT for 10 days. Outcomes were assessed by a vocal efficiency ratio, a validated NPVH index, the patient-reported Voice-Related Quality of Life (V-RQOL), and forced-choice auditory judgments of overall severity. Exploration in early practice (Day 1) was estimated by how the patient's two-dimensional variability (mean airflow and intensity) related to error (difference between the patient-produced and normative vocal efficiency ratio). Generalization from the game to spontaneous speech was evaluated using the validated NPVH index.

RESULTS

Ten days of FBVT were associated with improved vocal efficiency (Cohen's d = 1.3), NPVH index (d = -1.1), V-RQOL total score (d = 0.9), and overall severity (odds ratio = 2.5). Patients who generalized on Day 10 exhibited airflow/intensity exploration that was more aligned with the error gradient on Day 1 (d = 0.6-1.2).

CONCLUSIONS

A relatively small dosage of FBVT (i.e., 10 practice sessions) was associated with multiple improved voice therapy outcomes. The FBVT variability metrics on Practice Day 1 demonstrated strong potential to predict which patients generalized to connected speech. Future work can more thoroughly evaluate effects on outcomes and characterizing the quality of vocal exploration with a larger patient population.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27040873.

Characterizing usual-care physical rehabilitation in Canadian intensive care unit patients: a secondary analysis of the Canadian multicentre Critical Care Cycling to Improve Lower Extremity Strength pilot randomized controlled trial

PURPOSE

Physical rehabilitation (PR) in the intensive care unit (ICU) may improve outcomes for survivors but clinical trial results have been discordant. We hypothesized that discordant results may reflect treatment heterogeneity received by "usual care" comparator groups in PR studies. Usual-care PR is typically underspecified, which is a barrier to comparing results across treatment studies. The primary objective of the present study was to describe the usual-care PR received by critically ill patients enrolled in the Canadian multicentre Critical Care Cycling to Improve Lower Extremity Strength (CYCLE) pilot randomized controlled trial (RCT) of PR. Other objectives were to help contextualize current research and provide data for international comparison.

METHODS

In this secondary analysis of the CYCLE pilot RCT, patients were randomized to in-bed cycling and usual-care PR or usual-care PR alone. Physiotherapists documented usual-care PR including therapy received, type of activity, duration, adverse events and consequences, reasons for no PR, and concurrent relevant medical interventions. We characterized usual care using descriptive statistics at the cohort and patient levels.

RESULTS

Across seven Canadian centres, 30 patients were randomized to usual-care PR. The median [interquartile range (IQR)] ICU stay was 10 [9-24] days and patients received PR on a median [IQR] of 5 [3-9] days for 23 [17-30] min per day. Eighteen patients (60%) stood, marched, or walked during usual care. Transient adverse events occurred in three patients on 1.5% (3/198) of days and none prompted session termination.

CONCLUSIONS

In the usual-care arm of the CYCLE pilot RCT, PR was delivered on half of ICU days and over half of patients stood, marched, or walked. Adverse events during usual-care PR were uncommon.

STUDY REGISTRATION

ClinicalTrials.gov ( NCT02377830 ); first posted 4 March 2015.

Defining paediatric neurorehabilitation: You cannot improve what you cannot characterize

Neurorehabilitation is the primary therapy for neurological impairment in children, yet its potential to achieve change remains incompletely understood and probably underestimated. Understanding 'the difference neurorehabilitation can make' against a background of neurological repair and recovery as well as ongoing neurological development is an enormous challenge, exacerbated to no small extent by the lack of a 'common currency' for the description and measurement of the neurorehabilitation services a child is receiving. This review addresses attempts to parse neurorehabilitation treatment content in theoretically and mechanistically valid ways that might help address this challenge.

Identificação de ingredientes de intervenções não invasivas para crianças deambuladoras com paralisia cerebral usando as minhas palavras favoritas: uma revisão de escopo

Objetivo

Mapear os ingredientes das intervenções não invasivas fornecidas às crianças deambuladoras com Paralisia Cerebral (PC).

Método

Os artigos foram selecionados e as características dos estudos extraídas. Os ingredientes das intervenções foram descritos em termos do Sistema de Especificação de Taxonomia de Reabilitação (RTSS) e vinculados às minhas palavras favoritas. Os resultados foram interpretados e validados por meio da abordagem de Envolvimento de pacientes e do Publico em Pesquisa (EPP).

Resultados

Sessenta e um artigos foram incluídos, dos quais 55,5% foram classificados como ensaios clínicos randomizados. Os estudos selecionados incluíram um total de 2187 crianças (a idade média variou de 3 meses a 5,9 anos), a maioria de países desenvolvidos. Os estudos incluídos investigaram um total de 27 intervenções, que juntas apresentaram ingredientes representando todas as minhas palavras favoritas, na seguinte ordem de frequência: “Saúde” (ex., treinamento de força e resistência), “Funcionalidade” (ex., prática ativa e repetitiva de uma tarefa), “Família” (ex., terapia focada no contexto), “Diversão” (ex., inclusão de atividades amistosas para crianças), “Amigos” (ex., atividades em grupo) e “Futuro” (ex., compartilhamento de informações didáticas). Assim, os ingredientes relacionados à palavra “Futuro” foram os relatados com menos frequência.

Interpretação

Terapeutas e famílias precisam estar cientes da correspondência mais apropriada entre as metas elencadas por meio das minhas palavras favoritas e os objetivos, ingredientes e alvos das intervenções. Finalmente, “Diversão”, “Amigos” e “Futuro” devem ser abordadas como desfechos potenciais em estudos futuros.

F-words ingredients of non-invasive interventions for young ambulant children with cerebral palsy: A scoping review

AIM

To map the ingredients of non-invasive interventions provided to young ambulant children with cerebral palsy.

METHOD

Articles were screened and each study's characteristics extracted. The intervention ingredients were described in terms of the Rehabilitation Treatment Specification System and linked to the 'F-words'. Results were interpreted and validated by a patient and public involvement group.

RESULTS

Sixty-one papers were included, of which 55.5% were classified as randomized controlled trial design studies. The selected studies included a total of 2187 children (mean age range 3 months to 5 years 11 months), most from high-income countries. The included studies investigated a total of 27 interventions, which together presented ingredients representing all F-words, in the following order of frequency: 'fitness' (e.g. strength and endurance training), 'functioning' (e.g. active and repetitive practice of a task), 'family' (e.g. context-focused therapy), 'fun' (e.g. inclusion of child-friendly activities), 'friends' (e.g. group activities), and 'future' (e.g. didactic information sharing). Thus, ingredients related to the F-word 'future' were the most infrequently reported.

INTERPRETATION

Therapists and families need to be aware of the most appropriate match between the F-word goals, ingredients, and targets. Finally, 'fun', 'friends', and 'future' should be addressed as potential outcomes in future studies.

The use of music and music-related elements in speech-language therapy interventions for adults with neurogenic communication impairments: A scoping review

BACKGROUND

A growing body of research indicates that music-based interventions show promising results for adults with a wide range of speech, language and communication disorders.

AIMS

The purpose of this scoping review is to summarize the evidence on how speech-language therapists (SLTs) use music and music-related elements in therapeutic interventions for adults with acquired neurogenic communication impairments.

METHODS

This scoping review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. A systematic search of three databases (Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature and OVID Medline) was conducted and articles were included if they (1) incorporated adult human participants; (2) received an assessment or intervention facilitated by an SLT; (3) incorporated techniques and interventions which included music-related elements (e.g., rhythm, melody, harmony and dynamics); (4) were written in the English language; and (5) were peer-reviewed full-text articles. Data were extracted using the Rehabilitation Treatment Specification System framework.

MAIN CONTRIBUTION

A total of 25 studies met the inclusion criteria. The studies included participants with neurogenic communication impairments secondary to stroke, Parkinson's disease, dementia and traumatic brain injury. Musical interventions identified in the studies were Melodic Intonation Therapy, Modified Melodic Intonation Therapy, choral singing, singing therapy and songwriting. The majority of the studies reported interprofessional collaboration between SLTs and at least one other healthcare clinician and/or musician. Many studies also included music-based interventions lead and facilitated by musically trained SLTs.

CONCLUSION

The results of the studies included in this review indicate that SLTs are using music-based interventions to target therapeutic goals to improve speech, language, voice and quality of life in collaboration with other clinicians and professional musicians.

WHAT THIS PAPER ADDS

What is already known on this subject A growing body of research indicates that interventions using music (i.e., choirs and songwriting) and musical elements (i.e., rhythm and dynamics) show promising results for adults with neurogenic communication impairments. Currently, however, there is no clear indication of how speech-language therapists (SLTs) are using music in their clinical practice. What this study adds This scoping review collates the current evidence on how SLTs use music and musical elements in their clinical practice. SLTs are using music and musical elements for individuals with neurogenic communication impairments in populations such as Parkinson's disease, dementia and traumatic brain injury. Common interventions described in the literature include Melodic Intonation Therapy, choral singing, singing therapy and songwriting. What are the clinical implications of this work? Many SLTs collaborate when delivering music-based interventions, particularly with music therapists (MTs). This scoping review suggests that SLTs should continue to explore music-based interventions in collaboration with MTs and professional musicians to target therapeutic goals to improve speech, language, voice and quality of life.

Attention Training After Moderate-to-Severe Traumatic Brain Injury in Adults: A Systematic Review

OBJECTIVE

To determine the extent and efficacy of attentional training as a form of neuropsychological rehabilitation to ameliorate attention deficits in adults with moderate-to-severe traumatic brain injury.

DATA SOURCES

Articles published in Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, PubMed, PsycINFO, Scopus, and Web of Science were searched between January 17, and February 27, 2021.

STUDY SELECTION

Two reviewers blindly assessed studies for eligibility according to the following criteria: any article evaluating the efficacy of any type of behavioral intervention that targeted attention (by means of cognitive rehabilitative, psychoeducational, or neuropsychological strategies, at either an individual or group level) in adults who had sustained a formally documented moderate-to-severe traumatic brain injury.

DATA EXTRACTION

Methodological quality of each article was blindly assessed by 2 reviewers. Data were extracted from each study, including study type, sample size, sample characteristics, summary of intervention, measures used to assess attention, statistical outcomes and results, effect size, conclusion, and limitations.

DATA SYNTHESIS

7314 articles were retrieved from databases, 4325 articles remained after duplicate removal, and finally 21 articles met eligibility criteria and were included in this review. Articles represented varied methodological quality in group or single subject design. Irrespective of the heterogeneity regarding intervention types and attentional outcome measures used across the studies, overall findings suggest that attentional gains can be made in this sample, irrespective of time since injury, age, and injury severity. Further, a growing interest in technology-based interventions is frequently used and holds promise to bettering rehabilitation efforts. However, there is still limited evidence supporting the ecological validity of attentional training interventions (eg, the transfer of treatment effects to daily activities).

CONCLUSIONS

This article plays a crucial role in informing ongoing rehabilitation practices, guiding clinicians with evidence-based strategies and shaping future research directions for more effective attentional training guidelines.

Connecting Auditory-Perceptual Prompts Used in Voice Therapy to Anatomy and Physiology: Application to the Estill Voice Model and the Rehabilitation Treatment Specification System

PURPOSE

This clinical tutorial will present the concept of applying auditory-perceptual prompts (implicit instruction) typically used in voice therapy to the anatomy and physiology of the voice production system (explicit instruction) via the Estill Voice Model (EVM) and the Rehabilitation Treatment Specification System (RTSS).

METHODS

EVM offers an integrated implicit-explicit instructional approach to voice training allowing for isolated practice of vocal structures (explicit) that interact to produce functional voice qualities (implicit), such as modal speech and louder projected voice qualities. In EVM, voice quality is correlated with the specific anatomy and physiologic adjustments via 13 Estill Figures and Options (eg, Larynx Figure has three options: High, Mid, and Low). RTSS provides a framework to connect client change in functioning (ie, target) with clinician action (ie, ingredients). Mechanisms of action connect the target to the ingredients by hypothesizing how the treatment is expected to work.

RESULTS

Evidence is provided for connecting auditory-perpetual voice prompts with the anatomy and physiology of voice and supporting an integrated implicit-explicit approach to voice therapy. The concept of linking commonly used implicit auditory-perceptual prompts used in voice therapy (eg, humming, loud "aahh") to explicit anatomy and physiology training (eg, 13 Estill Figures and Options) is demonstrated using EVM and the RTSS framework with case studies and video examples.

CONCLUSIONS

Clinicians may choose to use anatomy and physiology of voice to define and provide explicit instruction for typically used implicit auditory-perceptual prompts. Future research is warranted to test the concept applied to voice therapy models in the literature across prevention and treatment of voice disorders.

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.

Partnered dance evokes greater intrinsic motivation than home exercise as therapeutic activity for chemotherapy-induced deficits: secondary results of a randomized, controlled clinical trial

Introduction

Dance has been proposed to support superior intrinsic motivation over non-dance forms of therapeutic physical activity. However, this hypothesis has yet to be evaluated empirically, particularly among populations living with neuropathology such as survivors of cancer with neurologic complications from chemotherapy treatment. Questions about motivation are relevant to clinical outcomes because motivation mediates neuroplasticity. We conducted this secondary analysis of a randomized-controlled study to begin to investigate the relationships between personal motivation and neurophysiologic effects of dance-based intervention for healthy aging among populations with neurologic complications of cancer.

Methods

We measured motivation using the Intrinsic Motivation Inventory, a validated patient-reported outcome from the psychological approach of Self Determination Theory. We assessed intrinsic motivation, extrinsic motivation, and satisfaction with intervention within a randomized controlled trial of dance versus exercise designed to alleviate symptoms of chemotherapy-induced impairment. Fifty-two survivors of breast cancer with chemotherapy-induced neuropathy diagnosis and associated sensorimotor functional deficits were randomized (1:1) to 8 weeks of partnered dance or home exercise, performed biweekly (NCT05114005; R21-AG068831).

Results

While satisfaction did not differ between interventions, intrinsic motivation was higher among participants randomized to dance than those randomized to exercise (p < 0.0001 at all timepoints: 2 weeks, 4 weeks, 6 weeks, and 8 weeks of intervention), as was extrinsic motivation at 2 weeks (p = 0.04) and 8 weeks (p = 0.01).

Discussion

These data provide evidence that social dance is more motivating than the type of home exercise generally recommended as therapeutic physical activity. The results inform directions for future study of the effect of dance-based therapeutics on embodied agency, neuroplastic changes, and clinically-relevant neuropathic improvement.

Elizabeth Usher memorial lecture. Models, mind maps, and metacognition: How theory is the true hero

Within the educational context of identifying the critical ingredients of an effective speech-language pathologist, this paper highlights the centrality of theory in underpinning every level of our practice. A spotlight is placed on us knowing how language and communication work, what makes our interventions work, how we can make the most difference through our choices in therapy, and what makes both us and our clients respond. So, what are the critical ingredients of an effective speech-language pathologist, of an effective therapy, of an effective therapeutic alliance, and why is this so important? While there are many foundational and guiding habits upon which new graduates, early career, and experienced clinicians shape their practice, no one habit is regarded as more important than us exploring the theoretical underpinnings of what we are doing and why. To underscore the role of theory in our everyday practice, a discourse level intervention for people with aphasia is used as an exemplar to track the complex contribution of different theories to a single intervention. Discourse level interventions are relatively new on the scene in the area of acquired language disorders. Child language interventions, on the other hand, have frequently revolved around the story, aiming to bridge the oral-literate divide through the development of narrative structure. This paper will aim to weave its own story around discourse level interventions, combining the narrative genre with the everyday genres used by adults in conversation. I will highlight how this approach taps into lexical theories, sentence processing theories, discourse organisation, and the cognitive underpinnings of language, and closely examine how this multilayering of language in context may hold some of the answers to questions around generalisation, impact, and making the greatest difference to individuals.

Identifying Non-Traditional Approaches to Swallowing Rehabilitation: A Scoping Review

In recent years, dysphagia care has shifted toward a more patient-centered approach. This means that dysphagia clinicians are considering more factors in the treatment process including the goals of care, quality of life, and cultural values. The purpose of this scoping review was to examine relevant research and identify dysphagia interventions outside of those traditionally used by dysphagia clinicians that may improve swallowing function. A review of relevant studies was conducted using search terms related to swallowing and treatment. The search yielded 8439 unique studies. Of the 283 articles that underwent a full-text review, 37 articles were included in the final review. These articles highlighted three potential areas of non-traditional dysphagia intervention that may serve to provide holistic care, while also aiming to improve swallowing mechanisms: acupuncture and Eastern medicine interventions, vocal exercises, and physical function exercises. The results suggest that dysphagia clinicians should work collaboratively with other allied health professionals and consider non-traditional approaches to dysphagia care. Through the identification of potentially effective but non-traditional or non-Eurocentric interventions for dysphagia care, clinicians may promote a culturally relevant, patient-centered approach, in turn increasing patient acceptance of treatment plans and compliance. Future research should explore the efficacy and feasibility of these interventions in dysphagia rehabilitation, as well as their effectiveness compared to more traditional approaches.

Effectiveness of remotely delivered motivational conversations on health outcomes in patients living with musculoskeletal conditions: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of remotely delivered motivational conversations on health outcomes in musculoskeletal populations.

METHODS

Four electronic databases (inception-March 2022) were searched and combined with grey literature. Randomised control trials (RCTs) evaluating the effect of remotely delivered motivational conversation-based interventions within musculoskeletal populations, using valid measures of pain, disability, quality of life (QoL), or self-efficacy were included. Overall quality was assessed using GRADE criteria. Meta-analyses were performed using random effects models with pooled effect sizes expressed as standardised mean differences ( ± 95%CIs).

RESULTS

Twelve RCTs were included. Meta-analyses revealed very-low to moderate quality evidence that remote interventions have a positive effect on pain and disability both immediately post intervention and at long-term follow-up compared to control, and have a positive effect on self-efficacy immediately post intervention. There was no effect on QoL immediately post intervention or at long-term follow up.

CONCLUSION

Remotely delivered motivation-based conversational interventions have a positive effect on pain, disability, and self-efficacy but not on QoL.

PRACTICE IMPLICATIONS

Motivational conversations, delivered remotely, may be effective in improving some health-related outcomes in MSK populations. However, higher quality evidence is needed to determine optimal intervention durations, and dosing frequencies using sufficient sample sizes and follow-up time frames.

Conceptualizing Adult Dysphagia in the United States Within the International Classification of Functioning, Disability and Health (ICF)

Despite the well-documented safety concerns and effect on quality of life, there does not yet exist a wide-reaching framework that links the etiologies of swallowing disorders to the potential short- and long-term outcomes in the context of International Classification of Functioning, Disability and Health (ICF). This paper introduces an expert-reviewed conceptual framework to highlight common etiologies of dysphagia as well as integrate immediate outcomes of dysphagia with long-term outcomes of dysphagia in terms of medical problems, health-related quality of life, functional effect, and psychosocial features. It also outlines the potential cyclical nature of long-term dysphagia outcomes perpetuating the original dysphagia. This framework serves to inform clinicians of important dysphagic outcomes and to bring awareness to long-term outcomes that should be monitored by health care professionals, caregivers, or people with dysphagia.

Shedding Light on the Black Box of Rehabilitation: Differential Short- and Long-Term Effects of Multidisciplinary Multiple Sclerosis Rehabilitation

BACKGROUND

The study of the effectiveness of multidisciplinary rehabilitation (MDR) and how the symptoms and needs of individuals with multiple sclerosis (MS) interplay with the diversity of MDR interventions is still a conundrum, often referred to as a black box.

METHODS

We conducted a partial crossover randomized controlled trial with follow-ups at 1 (discharge), 6, and 12 months. Based on their rehabilitation goals, each patient was categorized into 1 of 5 main focus areas (MFAs) prior to admission: Resilience, Cognitive Function, Energy, Physical Function, and Personal Needs. The Functional Assessment of Multiple Sclerosis (FAMS) instrument scores were the primary outcome.

RESULTS

MFA groups varied in age (P = .036), MS type (P = .002), Expanded Disability Status Scale score (P < .001), time since diagnosis (P = .002), and FAMS at baseline (P < .001), as well as in composition and quantity of MDR services. At discharge, significant FAMS improvements were found in all 5 MFA groups (FAMS change > 10.4, P < .05), but the affected subdimensions and persistence of improvements varied among MFA groups. At the 6-month follow-up, estimates of controlled differences in FAMS were 9.9 (P =.001), 5.6 (P = .196), 8.5 (P = .008), -1.4 (P = .548), and 17.9 (P = .012) for the Resilience, Cognitive Function, Energy, Physical Function, and Personal Needs groups, respectively.

CONCLUSIONS

This study demonstrated that inpatient MDR improves functioning and health-related quality of life in people with MS; the type, degree, and persistence of the benefits are associated with a patient's main focus area of rehabilitation, which signifies the importance of the goal-setting process in MDR.

Indirect causal path from motor function to quality of life through daily use of the affected arm poststroke after task-specific training: a longitudinal mediation analysis

PURPOSE

Task-specific training generally targets motor function, with the ultimate goal of improving quality of life (QoL). This study aimed to determine whether motor function indirectly affects QoL through daily use of the affected arm and activities of daily living (ADL) in patients with chronic stroke.

METHODS

This was a retrospective cohort study of 155 patients who received training for 90-120 min/session, 3-5 sessions/week, for 4-6 weeks. The training involved specific mirror or robot-assisted therapy, followed by functional task practice for 15-30 min in each session. Patients were assessed before and after the intervention.

RESULTS

At both pre-test and post-test, significant indirect effects of motor function on QoL through daily use of the affect arm and ADL were observed (β = 0.087-0.124). When the change scores of the measures between the pre-test and post-test were used, significant mediating effects of daily arm use on the relationship between motor function and QoL were identified (β = 0.094-0.103).

CONCLUSIONS

Enhanced motor function after intervention may lead to an increase in arm use for daily activities and subsequently result in an improvement in QoL. These results highlight the critical role of daily arm use in task-specific training aimed at improving QoL.

A Review of Poststroke Aphasia Recovery and Treatment Options

Poststroke aphasia, which impacts expressive and receptive communication, can have detrimental effects on the psychosocial well-being and the quality of life of those affected. Aphasia recovery is multidimensional and can be influenced by several baseline, stroke-related, and treatment-related factors, including preexisting cerebrovascular conditions, stroke size and location, and amount of therapy received. Importantly, aphasia recovery can continue for many years after aphasia onset. Behavioral speech and language therapy with a speech-language pathologist is the most common form of aphasia therapy. In this review, the authors also discuss augmentative treatment methodologies, collaborative goal setting frameworks, and recommendations for future research.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke 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.

A Conceptual Framework and Treatment Taxonomy for Respiratory Lung Volume Training (RLVT)

OBJECTIVES

The purpose of this study was to describe the theoretical and procedural framework of a novel intervention, Respiratory Lung Volume Training (RLVT), and to implement a standardized treatment taxonomy to operationalize the RLVT treatment paradigm.

STUDY DESIGN

This study involved a prospective design with a consensus treatment classification process.

METHODS

The RLVT paradigm was developed based on biomechanical constructs governing the interactions of the respiratory and phonatory systems in voice production and principles of motor learning theory. In RLVT, higher levels of lung volume (LV) during speech are trained using multiple speech breathing strategies while providing real-time visual biofeedback with superimposed guidelines for desired LV initiation and termination levels. For people with primary muscle tension dysphonia (MTD), RLVT can capitalize on nonmuscular respiratory forces to increase efficiency of voice production with reduced speaking effort. To define and operationalize the treatment components of RLVT, six investigators with training in RLVT used the Rehabilitation Treatment Specification System to delineate the treatment targets, mechanisms of action, ingredients and dosing through a multistage, consensus decision-making process.

RESULTS

The finalized taxonomy for RLVT included four treatment targets, with three addressing the area of Respiratory Function and one addressing Somatosensory Function. For each treatment target, three categories of ingredients were defined: (1) provide opportunities to practice breathing during voicing/speech, (2) provide feedback, and (3) provide volition ingredients. Within each ingredient category, three to seven specific ingredients were ultimately defined to further operationalize RLVT.

CONCLUSIONS

The RLVT paradigm is a theoretically driven approach for optimizing speech breathing patterns to increase efficient voice production in people with primary MTD. By applying a standardized, systematic treatment taxonomy system to specify the components of RLVT, future researchers and clinicians can implement RLVT with improved fidelity and consistency to optimize treatment outcomes.

Usability of a visual feedback system to assess and improve movement disorders related to neck pain: Perceptions of physical therapists and patients

A prototype visual feedback system has been developed to assess and improve movement disorders related to neck pain. The aim of this study was to assess the usability of the prototype in a rehabilitation setting. Twelve physical therapists integrated the device into their regular therapy programs for 24 neck pain patients with movement disorders. Each patient performed three individual therapy sessions with the device under physical therapist supervision. Usability was assessed by the physical therapists and patients using therapy diaries, the System Usability Scale, and focus group or personal interviews. Based on an overall usability rating of marginally acceptable, the visual feedback system was generally found to be a device with the potential to assess and train neck pain patients but needs improvement. To become a useful adjunct to regular physical therapy, improvements in the hardware and software, and further system developments are required.

Rehabilitation Treatment Specification System for Voice Therapy: Application to Everyday Clinical Care

PURPOSE

Rehabilitation intervention descriptions often do not explicitly identify active ingredients or how those ingredients lead to changes in patient functioning. The Rehabilitation Treatment Specification System (RTSS) provides guidance to identify the critical aspects of any rehabilitation therapy and supported the development of standardly named ingredients and targets in voice therapy (Rehabilitation Treatment Specification System for Voice Therapy [RTSS-Voice]). This study sought to test the content validity of the RTSS-Voice and determine if the RTSS-Voice can be used to identify commonalities and differences in treatment (criterion validity) across clinicians in everyday clinical practice.

METHOD

Five speech-language pathologists from different institutions videotaped one therapy session for 59 patients diagnosed with a voice or upper airway disorder. Specifications were created for each video, and iterative rounds of revisions were completed with the treating clinician and two RTSS experts until consensus was reached on each specification.

RESULTS

All 59 sessions were specified without the addition of any targets or ingredients. There were two frequent targets: (a) increased volition and (b) decreased strained voice quality. There were three frequent ingredients: (a) information regarding the patient's capability and motivation to perform a therapeutic behavior, (b) knowledge of results feedback, and (c) opportunities to practice voicing with improved resonance and mean airflow. Across sessions treating vocal hyperfunction, there was large variability across clinicians regarding the types and number of treatment components introduced, types of feedback provided, and vocal practice within spontaneous speech and negative practice.

CONCLUSIONS

The RTSS and the RTSS-Voice demonstrated strong content validity, as they comprehensively characterized 59 therapy sessions. They also demonstrated strong criterion validity, as commonalities and differences were identified in everyday voice therapy for vocal hyperfunction across multiple clinicians. Future work to translate RTSS principles and RTSS-Voice terms into clinical documentation can help to understand how clinician and patient variability impacts outcomes and bridge the research-practice gap.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24796875.

Opening the black box of cognitive rehabilitation: Integrating the ICF, RTSS, and PIE

BACKGROUND

Cognitive rehabilitation is a complex and specialized area of practice, as it aims to support individuals with diverse neuropsychological profiles, personal characteristics, and intersectionalities in achieving meaningful, functional change in personally relevant aspects of their everyday lives. In many ways, cognitive rehabilitation is the epitome of a 'black box': it has complicated internal processes that are mysterious to users. We argue that this complex practice has suffered from a lack of specificity of clinical processes and treatment components, resulting in negative consequences for both providers and clients.

AIM

To unpack the black box of cognitive rehabilitation by describing a unifying set of frameworks that can effectively direct clinical practice across clinical disciplines: the International Classification of Functioning, Disability, and Health (ICF), the Rehabilitation Treatment Specification System (RTSS), and the Planning, Implementation, and Evaluation framework (PIE). We present a clinical case that illustrates the application of the three frameworks.

CONCLUSION

Implementation of these three integrated frameworks supports clinical reasoning, replication of treatments, and communication across disciplines with the ultimate impact of improving rehabilitation outcomes. The frameworks provide a structure for clinicians to clearly define both the what and the how of treatment, with a level of specificity to maximize both effectiveness and efficiency of intervention.

Virtual INSIGHT: Improving natural social interaction: Group reHabilitation after traumatic brain injury

BACKGROUND

There is a growing body of literature that indicates positive outcomes of group treatment approaches to intervention for communication difficulties in chronic traumatic brain injury (TBI). The published research to date examines face-to-face group intervention.

AIM

This study draws on one of these approaches, 'Improving Natural Social Interaction: Group reHabilitation after Traumatic brain injury' (INSIGHT), and examines the adaptation of this program to a virtual setting. The principles underlying the program, which involved providing an authentic contextualised and natural environment for group interactions and enhancing opportunities for identity expression, were maintained.

METHODS & PROCEDURES

Six participants with mild to severe TBI and cognitive communication difficulties participated in an 8-week pilot program of the virtual INSIGHT program. Goal Attainment Scaling (GAS) scores completed over the course of the intervention served as the primary outcome measure. Secondary outcomes measures included The Repeatable Battery for the Assessment of Neuropsychological Status Update, The Awareness of Social Inference Test-Revised, the La Trobe Communication Questionnaire and the Satisfaction with Life Scale.

OUTCOMES & RESULTS

A mixed multilevel analysis revealed significant improvement in GAS scores. A Wilcoxon signed rank test revealed no significant changes in secondary measures.

CONCLUSIONS & IMPLICATIONS

There is a growing potential for this group treatment approach, in an online medium, and progress towards individualised goals was clear. The data have implications for examining the assessment measures typically used to document functional outcomes in clinical intervention. Future directions indicate a need to pursue more ecologically valid assessment methods.

WHAT THIS PAPER ADDS

What is already known on the subject Recent literature has focused on the benefits of group intervention for cognitive communication diffuclties after traumatic brain injury (TBI). However, research to date examines only face-to-face group rehabilitation. As there has been a demand for a shift in the way we communicate worldwide, we must make adaptations to current intervention procedures to continue to serve individuals with diverse communication needs. What this paper adds to existing knowledge This study contributes new information about the feasibility of a virtual communication skills group for individuals with TBI. This virtual INSIGHT (Improving Natural Social Interaction: Group ehabilitation after Traumatic brain injury) group intervention facilitates progress towards collaboratively set communication goals and the online setting has the potential to increase the accessibility of these services. What are the potential or actual clinical implications of this work? Progress towards cognitive and social communication goals can be facilitated by an online group intervention. However, this progress was not correlated with scores on standard assessments of cognitive communication, social communication and quality of life. This has implications for the evaluation of the assessments typically used and their ecological validity and applicability to the communication context.

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.

A Systematic Review of Speech-Language Pathology Interventions for Presbyphonia Using the Rehabilitation Treatment Specification System

BACKGROUND

The prevalence of voice disorders for people aged >65 years is four times higher than for the population at large. The most common cause of dysphonia in this group is presbyphonia, the preferred first-line treatment for which is voice therapy with a speech-language pathologist. This systematic review seeks to identify how voice therapy affects multidimensional voice outcomes in people with presbyphonia.

METHODS

A systematic search of CINAHL, Embase, Emcare, MEDLINE, and Google Scholar was conducted in March 2023. Comparative and noncomparative studies of voice therapy in participants aged >50 years with presbyphonia were considered for inclusion. No limitations were placed on date or language of publication. Study quality and risk of bias were assessed with the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies. Subgroup analysis was used to compare studies based on participant sex, intervention duration, study design, and intervention content. Interventions were specified using the Rehabilitation Treatment Specification System (RTSS) employing a consensus methodology among reviewers. The results were synthesized utilizing meta-analysis when outcomes were adequately specified and narrative analysis when they were not.

RESULTS

Twenty-three studies were included with 1050 subjects (mean age: 72.5 ± 8.6 years; 51% female). The most reported intervention was vocal function exercises. Per the RTSS, 14 interventions employed a predominantly Organ Functions approach, and the 14 remaining interventions employed a Skills & Habits approach. Meta-analysis confirmed posttherapy improvement in patient-related outcome measures of 0.93 standard mean difference (P < 0.00001, 95% confidence interval [CI]: 0.70-1.17); studies with predominantly males and with longer treatment periods were associated with larger improvements, while randomized controlled trials reported more modest improvements. Meta-analysis also identified a mean posttherapy increase in maximum phonation time (MPT) of 5.37 seconds (P < 0.00001, 95% CI: 3.52-7.22). Treatments with an Organ Functions focus resulted in greater gains in MPT than those with a Skills & Habits focus (7.52 seconds versus 2.90 seconds). Finally, meta-analysis identified reductions in acoustic perturbation measures (jitter: 0.62%, P < 0.001, 95% CI: 0.26%-0.97%; shimmer 1.05%, P < 0.00001, 95% CI: 0.67%-1.44%). Narrative synthesis further identified improvement in auditory-perceptual voice quality in all active treatment groups as well as improved glottal function in most studies that reported this.

CONCLUSIONS

Despite the uncertainty around internal validity introduced by the inclusion of a wide range of study designs, there is convincing evidence that voice therapy for presbyphonia results in significant improvement in patient-reported, aerodynamic, acoustic, and expert-rated voice outcomes. Treatments with an Organ Functions focus may better address the underlying physiological deficits of presbyphonia, although future comparative studies with multidimensional voice assessment are warranted.

Studying the Specificity of Research Reporting for Ayres Sensory Integration® Interventions in the Published Literature: A Scoping Review

IMPORTANCE

A contributing factor to the gap between research publication and clinical implementation is the lack of specificity used when reporting findings.

OBJECTIVE

This scoping review used the Rehabilitation Treatment Specification System (RTSS) to determine which elements of specificity are most often present and omitted from research using Ayres Sensory Integration® (ASI).

DATA SOURCES

The following databases were searched: PubMed, CINAHL, PsycINFO, Cochrane Library, and ERIC.

STUDY SELECTION AND DATA COLLECTION

Eligible studies used ASI in an outpatient setting with children who had sensory integration or processing difficulties. Studies selected were quantitative (Level 1, 2, 3, or 4), available in full text, peer reviewed, and published in English within the past 20 yr.

FINDINGS

Of the 22 studies that met inclusion criteria, 100% included ingredients (actions of the therapist), 63% included mechanisms of action (reasoning behind these actions), 86% included targets, and 23% described client progression. We also found that 49% of all ingredients were listed in conjunction with a target, 15% were listed in conjunction with a mechanism of action, and 11% were listed in conjunction with both a target and a mechanism of action.

CONCLUSIONS AND RELEVANCE

Findings indicate that many studies list ingredients but often omit the mechanism of action. This omission makes replication of the intervention increasingly difficult and prevents a deeper understanding of the clinical reasoning process behind the intervention. Plain-Language Summary: Gaps identified in this scoping review highlight inconsistencies in the reporting of treatment specificity that may affect the replication and translation of Ayres Sensory Integration® (ASI) research into practice.

Volitional and Non-volitional Devices Used in Voice Therapy and Training: A Scoping Review-Part A

OBJECTIVE

To map the volitional and non-volitional devices used by speech and language pathologists (SLPs) in voice training and therapy and characterize their use in research on voice interventions.

METHODS

This scoping review is the first part of a larger study. The electronic search was carried out by mapping the references in PubMed/Medline, LILACS/BVS, Scopus, Web of Science, EMBASE, and the Cochrane Library, and the manual search was carried out in the grey literature. Two blind independent reviewers selected and extracted data; divergences were solved by consensus. The data extracted in this part of the study were the authorship and year of publication, country, study design, sample characteristics, intervention modality, ingredient, target, mechanism of action, dosage, and outcome measures. They were addressed with descriptive analysis.

RESULTS

Publications that use devices as ingredients are mostly from the last two decades, mainly carried out in the United States of America and Brazil, in adults of both sexes with behavioral dysphonia. Forty-two types of devices were used, many of them with similar approaches but different nomenclatures. Most devices were used voluntarily, focusing on vocal function, and aiming to increase source and filter interaction. Most studies used silicone tubes. The most reported technical specification to apply the ingredient was surface electrodes on the neck. Device dosage was time-controlled, and the most used outcomes were self-assessment and acoustic analysis.

CONCLUSION

Devices are currently used as ingredients in vocal interventions, with a greater focus on increasing the source and filter interaction, associated with silicone tubes (the most used devices in these studies), which have been dosed with performance time. Outcomes were measured with self-assessment instruments.

Speech-language pathologists' treatment goals for preschool language disorders: An ICF analysis

PURPOSE

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) provides a comprehensive framework to conceptualise clinical services. This study explored how speech-language pathologists (SLPs) conceptualised therapy goals for preschoolers with language difficulties and disorders within the ICF framework.

METHOD

An online survey was distributed to SLPs practising in a publicly funded Preschool Speech and Language program in Ontario, Canada. SLPs rated their familiarity with the ICF framework, and then reported all therapy goals for one child with language difficulty/disorder on their caseload. For each reported goal, SLPs indicated the ICF component(s) they felt the goal addressed. Researchers then independently categorised SLPs' reported goals into the ICF components.

RESULT

Ninety-three SLPs completed the survey, and 81% reported they were at least "somewhat" familiar with the ICF framework. On average, SLPs reported three therapy goals per child, and felt the Activities and Participation components were most frequently targeted (73% and 72% of all reported goals, respectively). Researchers categorised SLPs' reported goals differently, and identified 57% of goals addressing the Activities component, and 21% the Participation component.

CONCLUSION

There is a need to better understand how SLPs and researchers conceptualise the ICF framework, particularly the Participation component.

What Factors Determine the Use of Volitional and Non-Volitional Devices in Vocal Interventions Performed by Brazilian Speech-Language Pathologists?

OBJECTIVE

To analyze the determining factors for using devices in vocal interventions and characterize their use by Brazilian speech-language pathologists (SLPs).

METHODS

This cross-sectional observational study had a sample of 148 SLPs with clinical practice in voice. They answered an online questionnaire via Google Forms about sociodemographic data, training, work in the area, and the use of devices in vocal interventions. Data were analyzed descriptively and inferentially.

RESULTS

Tubes, straws, and masks were the most commonly used devices. SLPs specializing in voice are more inclined to use thermotherapy and kinesio tapings while being less inclined to use therapeutic ultrasounds and nebulizers. Voice specialists are less likely to employ electrostimulation. The choice to use photobiomodulation and auditory monitoring devices is influenced by the years of clinical experience, whereas the speech-language therapy training duration affects the use of electrostimulation. The age of the professional also plays a role in the utilization of vibratory stimulation. Vibratory stimulation, auditory monitoring devices, thermotherapy, and nebulization are more frequently utilized among individuals who rely on their voices for occupational purposes, whereas electrostimulation is less common. The use of photobiomodulation is infrequent in children; vibratory stimulation is more common in adolescents, and thermotherapy is relatively common among older individuals. Most of these devices are typically prescribed in execution time during vocal intervention.

CONCLUSION

The specialization, the time since graduation and in the occupation, and the target population of the service are the determining factors for the use of devices. They are used in vocal therapy and training, targeting vocal function.

Pre and Post-operative Voice Therapy Intervention for Benign Vocal Fold Lesions: A Systematic Review

Benign vocal fold lesions cause dysphonia by preventing vocal fold closure, causing irregular vibration and increasing compensatory muscle tension. Voice therapy delivered in addition to phonosurgery may improve voice and quality of life outcomes but the evidence base is lacking and what constitutes voice therapy for this population is not defined. The purpose of this systematic review is to critically evaluate the evidence for pre and post-operative voice therapy to inform the development of an evidence based intervention.

STUDY DESIGN

Systematic Review.

METHODS

Electronic databases were searched using key terms including dysphonia, phonosurgery, voice therapy and outcomes. Eligible articles were extracted and reviewed by the authors for risk of bias and for information regarding the content, timing and intensity of any pre and post-operative voice therapy intervention.

RESULTS

Of the 432 articles identified, 35 met the inclusion criteria and were included in the review. 5 were RCTs, 2 were individual cohort studies, 1 was a case control study and 26 were case series. There was considerable heterogeneity in participant characteristics. Information was frequently lacking regarding the content timing and intensity of the reported voice therapy intervention, and where present, interventions were highly variable.

CONCLUSION

Reporting in relevant literature is limited in all aspects of content, timing and intensity of intervention. Further intervention development work is required to develop a robust voice therapy treatment intervention for this population, before effectiveness work can commence.

Move&Connect-Youth: A Virtual Group Intervention for Youth Experiencing Persisting Symptoms After Concussion

Move&Connect-Youth (M&C-Y) is an interdisciplinary virtual group intervention for youth experiencing persisting symptoms after concussion (PSAC) that includes psychoeducation, active rehabilitation, and goal-setting. Using an intervention mapping framework, this paper describes the iterative development of M&C-Y and findings from initial feasibility testing. Ten youth participated in M&C-Y completing pre-intervention demographic questionnaires and semi-structured exit interviews to understand participants' experience and gather feedback. M&C-Y was feasible based on apriori criteria and findings from interviews provided insights related to: (1) intervention structure, (2) intervention engagement, and (3) intervention takeaways. M&C-Y is a meaningful, feasible, and engaging intervention for youth with PSAC.

Repetition Priming Treatment for Anomia: Effects of Single- and Multiple-Exemplar Protocols

INTRODUCTION

Repetition priming can lead to improved naming ability in people with aphasia, but concerns have arisen from prior research about using only a single picture exemplar for each target. Specifically, it is unclear whether the observed improvements were due to learning simple correspondences between particular words and pictures rather than changes at a deeper level of lexical-semantic processing. In addition, implications for generalization after training with single exemplars were unclear. This study replicated and extended previous work to address these questions.

METHOD

Five participants with chronic aphasia participated in this repeated-measures design study, which repeatedly paired words and pictures with no feedback provided. Two participants engaged in a single-exemplar condition, with a single picture exemplar of each target used for every presentation of that target. The remaining three participants engaged in a multiple-exemplar condition, with several different pictures used for each target. Half of these targets used training pictures during naming probes, whereas half did not.

RESULTS

Primed items led to greater improvements in naming than items that were practiced but not primed. The data indicate that improvements may extend beyond stimulus-specific correspondences. Maintenance and generalization effects were mixed.

CONCLUSIONS

These data provide further support for the efficacy of repetition priming treatment for anomia. Implications and future directions are discussed.

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.

Incorporating Metacognitive Strategy Training Into Semantic Treatment Promotes Restitutive and Substitutive Gains in Naming: A Single-Subject Investigation

PURPOSE

This study tested the effectiveness of a modified semantic feature analysis (SFA) treatment protocol that incorporated metacognitive strategy training (MST). Regarding its restitutive component, SFA most reliably results in improved word retrieval for treated items and untreated, semantically related items, but evidence of response generalization is often small/inconsistent. Regarding its substitutive component, SFA is thought to facilitate successful communication via habituation of the SFA circumlocution strategy. However, repeated practice with SFA's strategy in the absence of direct MST may not result in independent strategy use and/or generalization. Furthermore, people with aphasia's independent use of the SFA strategy in moments of anomia is presently underreported. To address these limitations, we incorporated MST into SFA and directly measured substitutive outcomes.

METHOD

Four people with aphasia participated in 24 treatment sessions of SFA + MST in a single-subject, A-B experimental design with repeated measurements. We measured word retrieval accuracy, strategy use, and explicit strategy knowledge. We calculated effect sizes to measure changes in word retrieval accuracy and strategy use and used visual inspection to assess gains in explicit strategy knowledge from pre- to posttreatment and retention.

RESULTS

Participants achieved marginally small to medium effects in word retrieval accuracy for treated; untreated, semantically related; and untreated, semantically unrelated items and marginally small to large effects in independent strategy use. Explicit strategy knowledge was variable.

CONCLUSIONS

Across participants, SFA + MST yielded positive changes in word retrieval accuracy or strategy use, or both. Positive changes in word retrieval accuracy were comparable to other SFA studies. Positive changes in strategy use demonstrate preliminary evidence of this treatment's ability to yield restitutive and substitutive gains. Overall, this study offers preliminary evidence of SFA + MST's effectiveness and highlights the importance of directly measuring SFA's substitutive outcomes, which showed that people with aphasia can respond to this treatment in multiple successful ways-not just improved target word production.

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.

Behavioral Therapy for Tremor or Dystonia Affecting Voice in Speakers with Hyperkinetic Dysarthria: A Systematic Review

INTRODUCTION

Hyperkinetic dysarthria is characterized by atypical involuntary movements within the speech mechanism that may affect the respiratory, laryngeal, pharyngeal-oral, or velopharyngeal-nasal subsystems and may alter speech production. Although articulatory impairments are commonly considered in hyperkinetic dysarthria, speakers with hyperkinetic dysarthria may also present with changes in voice quality, pitch, and loudness. In approximately 70% of speakers with hyperkinetic dysarthria, these voice alterations are associated with tremor or dystonia. The purpose of this systematic review was to investigate the association between behavioral therapy for tremor or dystonia affecting voice in speakers with hyperkinetic dysarthria and improvement in the functional, perceptual, acoustical, aerodynamic, or endoscopic characteristics of voice.

METHOD

MEDLINE (PubMed), Embase, PsycINFO, and ClinicalTrials.gov online databases were searched in August 2017, December 2018, and April 2020 for relevant studies. The searches provided 4,921 unique records, and six additional unique records were added from other sources. Twelve studies met the criteria for inclusion in the systematic review. Participants who received concurrent medical treatment were included in this review to ensure that the search was inclusive of all relevant studies and informative for typical clinical scenarios.

RESULTS

The most commonly administered treatment ingredient was relaxation training, which was investigated in three of the four studies on tremor and three of the eight studies on dystonia. Of these six studies, only one used an experimental design and administered relaxation training as the only behavioral approach. This single-case experiment reported a significant reduction in participant ratings of tremor severity and interference with activities of daily living, although the speaking subscale reportedly did not improve and oral medications were administered concurrently. In two group studies that tested potential behavioral therapy targets, production of a low pitch improved acoustical measures for participants with essential tremor and improved auditory-perceptual judgments for participants with laryngeal dystonia. Behavioral therapy improved functional, acoustical, and aerodynamic outcomes in participants with laryngeal dystonia who were also receiving botulinum toxin injections in a randomized cross-over study and a non-randomized controlled study. Because one study employed easy onset and breathing exercises, while the other employed loud voice exercises, the mechanism of action for improvement in voice associated with behavioral therapy requires further investigation.

CONCLUSION

This systematic review describes the current evidence for treatment of tremor and dystonia affecting voice in speakers with hyperkinetic dysarthria and highlights the need for future research on behavioral therapy for these disorders.

A randomized crossover single-case series comparing blocked versus random treatment for anomia

The motor learning literature has demonstrated that blocked practice facilitates better acquisition of motor skills, whereas random practice facilitates retention and transfer. The verbal learning and memory literature offers similar evidence. The purpose of this study was to investigate effects of blocked versus random practice in treatment for anomia. The study used a single site, randomized crossover design, with two replicated experimental phases (two blocked and two random) for each of 10 individuals with anomia. Each phase consisted of a cued picture-naming treatment. Individual treatment and maintenance effects, as well as weighted averages and group effects, were calculated using Tau-U based on the proportion of correctly named probes. Nine of 10 participants demonstrated treatment effects during each of the four phases. Acquisition was comparable for blocked and random practice. Maintenance effects were observed following seven blocked phases of treatment and 12 random phases of treatment across participants. For four of 10 participants the random schedule resulted in better maintenance of trained items. Although further research is needed, the present data suggest that for word retrieval treatment with multiple repetitions of the same items, a random presentation may benefit maintenance of treatment gains.

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.

Subjective valuation of performance feedback is robust to trait cognitive fatigue in multiple sclerosis

BACKGROUND

Performance feedback is vital to rehabilitation interventions that treat cognitive impairments from multiple sclerosis (MS). Optimal treatment relies on participants' motivation to learn from feedback throughout these interventions. Cognitive fatigue, a prevalent symptom of MS, is associated with aberrant reward processing, which necessitates research into how fatigue affects perceived reward value of feedback in these individuals. The current study investigated how trait fatigue influences subjective valuation of feedback and subsequent feedback-seeking behavior in people with MS.

METHODS

33 MS and 32 neurotypical (NT) participants completed a willingness-to-pay associative memory paradigm that assessed feedback valuation via trial-by-trial decisions to either purchase or forego feedback in service of maximizing a performance-contingent monetary reward. Participant ratings of trait fatigue were also collected. Generalized logistic mixed modeling was used to analyze factors that influenced trial-wise feedback purchase decisions and task performance.

RESULTS

Despite reporting greater trait fatigue, MS participants purchased comparable amounts of feedback as NT participants. Like NT participants, MS participants were more likely to purchase feedback when they were less confident about response accuracy. MS participants also performed comparably to NT participants, who both particularly benefited from purchase decisions that yielded negative feedback (i.e., indicating a response error).

CONCLUSIONS

Trait cognitive fatigue may not impact performance feedback valuation in people with MS. Nonetheless, confidence in performance may drive their feedback-seeking behavior and may serve as a target for improving learning throughout cognitive rehabilitation and maximizing treatment success.

Improving Standards of Research Reporting in Intervention Research: Considerations for the Rehabilitation Treatment Specification System Model

Replication and application of research in clinical practice require that interventions be described in detail by the producers of that research. Lack of treatment specificity in publications is thought to contribute to the nearly 17-yr gap between the publication and clinical implementation of best practices. In this editorial I explore a means of addressing this problem in the Rehabilitation Treatment Specification System (RTSS) and present an application of the RTSS to sensory integration intervention.

Comparator Groups in ICU-Based Studies of Physical Rehabilitation: A Scoping Review of 125 Studies

To characterize comparator groups (CGs) in ICU-based studies of physical rehabilitation (PR), including the type, content, and reporting.

DATA SOURCES

We followed a five-stage scoping review methodology, searching five databases from inception to June 30, 2022. Study selection and data extraction were completed independently, in duplicate.

STUDY SELECTION

We screened studies by title and abstract, then full-text. We included prospective studies with greater than or equal to two arms enrolling mechanically ventilated adults (≥ 18 yr), with any planned PR intervention initiated in the ICU.

DATA EXTRACTION

We conducted a quantitative content analysis of authors' description of CG type and content. We categorized similar CG types (e.g., usual care), classified content into unique activities (e.g., positioning), and summarized these data using counts (proportions). We assessed reporting using Consensus on Exercise Reporting Template (CERT; proportion of reported items/total applicable).

DATA SYNTHESIS

One hundred twenty-five studies were included, representing 127 CGs. PR was planned in 112 CGs (88.2%; 110 studies), representing four types: usual care (n = 81, 63.8%), alternative treatment than usual care (e.g., different from intervention; n = 18, 14.2%), alternative treatment plus usual care (n = 7, 5.5%), and sham (n = 6, 4.7%). Of 112 CGs with planned PR, 90 CGs (88 studies) reported 60 unique activities, most commonly passive range of motion (n = 47, 52.2%). The remaining 22 CGs (19.6%; 22 studies) reported vague descriptions. PR was not planned in 12 CGs (9.5%; 12 studies), and three CGs (2.4%; three studies) reported no details. Studies reported a median (Q1-Q3) of 46.6% (25.0-73.3%) CERT items. Overall, 20.0% of studies reported no detail to understand planned CG activities.

CONCLUSIONS

The most common type of CG was usual care. We identified heterogeneity in planned activities and CERT reporting deficiencies. Our results could help guide the selection, design, and reporting of CGs in future ICU-based PR studies.

Defining a Treatment Model for Self-Management of Fatigue in Rehabilitation of Acquired Brain Injury Using the Rehabilitation Treatment Specification System

Systematic treatment descriptions to standardize and evaluate management of fatigue after acquired brain injury (ABI) are lacking. The purpose of this multi-phase qualitative study was to formulate a treatment model for promoting self-management of fatigue in rehabilitation of ABI based on practice-based understandings and routines. The study was conducted in a community-based rehabilitation center in Denmark. The model was defined using the Rehabilitation Treatment Specification System. Phase 1 comprised co-production workshops with five service providers (occupational therapists, physiotherapists, and a neuropsychologist) to elicit preliminary treatment theories. In Phase 2, four case studies were conducted on management of fatigue in vocational rehabilitation. Interviews (n = 8) and treatment log entries (n = 76) were analyzed thematically to specify treatment targets and active ingredients. The treatment model comprised five main components: (i) Knowledge and understanding of fatigue, (ii) Interoceptive attention of fatigue, (iii) Acceptance of fatigue, (iv) Activity management, and (v) Self-management of fatigue. For each component, lists of targets and active ingredients are outlined. In conclusion, management of fatigue includes multiple treatment components addressing skills, habits, and mental representations such as knowledge and attitudes. The model articulates treatment theories, which may guide clinical reasoning and facilitate future theory-driven evaluation research.

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

OBJECTIVE

To explore rehabilitation professionals' experiences and perspectives of barriers and facilitators to implementing the Rehabilitation Treatment Specification System (RTSS) in research, education, and clinical care.

DESIGN

A 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).

SETTING

Rehabilitation professionals across research, educational, and clinical settings.

PARTICIPANTS

One 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).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency of reported CFIR barriers and facilitators, as well as keywords related to CFIR and ERIC constructs.

RESULTS

The 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.

CONCLUSIONS

When 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.

Reporting of Classroom-Based Morphological Awareness Instruction and Intervention for Kindergarten to Grade 3 Students in the Literature: A Scoping Review

PURPOSE

The purpose of this scoping review was to document how the literature reports morphological awareness instruction and interventions delivered by speech-language pathologists (SLPs) and/or educators in classroom settings for kindergarten to Grade 3 students.

METHOD

We followed the Joanna Briggs Institute's methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guidelines. Six relevant databases were searched systematically with article screening and selection completed by two reviewers calibrated for reliability. For data charting, one reviewer extracted content and a second reviewer verified it was pertinent to the review question. Charting for the reported elements of morphological awareness instruction and interventions was guided by the Rehabilitation Treatment Specification System.

RESULTS

The database search yielded 4,492 records. After removal of duplicates and screening, 47 articles were selected for inclusion. Interrater reliability for source selection exceeded the pre-established criterion of k = .61. Our analysis generated a comprehensive description of the elements of morphological awareness instruction as reported in the included articles.

CONCLUSIONS

Our findings provide school-based SLPs and educators a systematic means of reviewing the literature to identify key elements of morphological awareness instruction in published articles for application of evidence-based practices with fidelity, thus helping to close the research-to-practice gap. Our manifest content analysis revealed reporting of the elements for classroom-based morphological awareness instruction was varied, and in some cases, underspecified in the articles included in our study. Implications for clinical practice and future research to advance knowledge and promote implementation of evidence-based practices by SLPs and educators in today's classrooms are discussed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22105142.

Use of the Rehabilitation Treatment Specification System (RTSS) in the management of nitrous oxide (N2O)-induced spinal cord injury

Nitrous oxide (N₂O) is an inhaled anaesthetic gas and a popular intoxicant. Excessive recreational use can cause spinal cord myelopathy. Previous studies have discussed the medical management. However, none have specified the sensorimotor rehabilitation management. This case report documents the investigations, physical rehabilitation and functional outcomes in two cases of N₂O-associated myelopathy. Both presented with lower limb strength and sensorimotor integration impairments resulting in ataxic ambulation. Dorsal column signal abnormality was observed on T2-weighted MRI in one case. Myelopathy was diagnosed based on clinical presentation and both were treated with vitamin B₁₂ Rehabilitation was conceived and specified using the Rehabilitation Treatment Specification System (RTSS). Both cases achieved independent indoor gait on hospital discharge, and full function at 9 months in one case. Appropriate and timely medical management and reasoned rehabilitation provided excellent functional outcomes for N₂O-related myelopathy. By using the RTSS, reasoned rehabilitation efficacy can be tested in the future.