The Importance of Voluntary Behavior in Rehabilitation Treatment and Outcomes

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.

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.

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.

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.

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.

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.

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.

Errorless, Errorful, and Retrieval Practice for Naming Treatment in Aphasia: A Scoping Review of Learning Mechanisms and Treatment Ingredients

PURPOSE

Increasingly, mechanisms of learning are being considered during aphasia rehabilitation. Well-characterized learning mechanisms can inform "how" interventions should be administered to maximize the acquisition and retention of treatment gains. This systematic scoping review mapped hypothesized mechanisms of action (MoAs) and treatment ingredients in three learning-based approaches targeting naming in aphasia: errorless learning (ELess), errorful learning (EFul), and retrieval practice (RP). The rehabilitation treatment specification system was leveraged to describe available literature and identify knowledge gaps within a unified framework.

METHOD

PubMed and CINHAL were searched for studies that compared ELess, EFul, and/or RP for naming in aphasia. Independent reviewers extracted data on proposed MoAs, treatment ingredients, and outcomes.

RESULTS

Twelve studies compared ELess and EFul, six studies compared ELess and RP, and one study compared RP and EFul. Hebbian learning, gated Hebbian learning, effortful retrieval, and models of incremental learning via lexical access were proposed as MoAs. To maximize treatment outcomes within theorized MoAs, researchers manipulated study ingredients including cues, scheduling, and feedback. Outcomes in comparative effectiveness studies were examined to identify ingredients that may influence learning. Individual-level variables, such as cognitive and linguistic abilities, may affect treatment response; however, findings were inconsistent across studies.

CONCLUSIONS

Significant knowledge gaps were identified and include (a) which MoAs operate during ELess, EFul, and RP; (b) which ingredients are active and engage specific MoAs; and (c) how individual-level variables may drive treatment administration. Theory-driven research can support or refute MoAs and active ingredients enabling clinicians to modify treatments within theoretical frameworks.

Altered functional connectivity during performance feedback processing in multiple sclerosis

Effective learning from performance feedback is vital for adaptive behavior regulation necessary for successful cognitive performance. Yet, how this learning operates in clinical groups that experience cognitive dysfunction is not well understood. Multiple sclerosis (MS) is an autoimmune, degenerative disease of the central nervous system characterized by physical and cognitive dysfunction. A highly prevalent impairment in MS is cognitive fatigue (CF). CF is associated with altered functioning within cortico-striatal regions that also facilitate feedback-based learning in neurotypical (NT) individuals. Despite this cortico-striatal overlap, research about feedback-based learning in MS, its associated neural underpinnings, and its sensitivity to CF, are all lacking. The present study investigated feedback-based learning ability in MS, as well as associated cortico-striatal function and connectivity. MS and NT participants completed a functional magnetic resonance imaging (fMRI) paired-word association task during which they received trial-by-trial monetary, non-monetary, and uninformative performance feedback. Despite reporting greater CF throughout the task, MS participants displayed comparable task performance to NTs, suggesting preserved feedback-based learning ability in the MS group. Both groups recruited the ventral striatum (VS), caudate nucleus, and ventromedial prefrontal cortex in response to the receipt of performance feedback, suggesting that people with MS also recruit cortico-striatal regions during feedback-based learning. However, compared to NT participants, MS participants also displayed stronger functional connectivity between the VS and task-relevant regions, including the left angular gyrus and right superior temporal gyrus, in response to feedback receipt. Results indicate that CF may not interfere with feedback-based learning in MS. Nonetheless, people with MS may recruit alternative connections with the striatum to assist with this form of learning. These findings have implications for cognitive rehabilitation treatments that incorporate performance feedback to remediate cognitive dysfunction in clinical populations.

Clear Speech Variants: An Investigation of Intelligibility and Speaker Effort in Speakers With Parkinson's Disease

PURPOSE

This study investigated the effects of three clear speech variants on sentence intelligibility and speaking effort for speakers with Parkinson's disease (PD) and age- and sex-matched neurologically healthy controls.

METHOD

Fourteen speakers with PD and 14 neurologically healthy speakers participated. Each speaker was recorded reading 18 sentences from the Speech Intelligibility Test in their habitual speaking style and for three clear speech variants: clear (SC; given instructions to speak clearly), hearing impaired (HI; given instructions to speak with someone with a hearing impairment), and overenunciate (OE; given instructions to overenunciate each word). Speakers rated the amount of physical and mental effort exerted during each speaking condition using visual analog scales (averaged to yield a metric of overall speaking effort). Sentence productions were orthographically transcribed by 50 naive listeners. Linear mixed-effects models were used to compare intelligibility and speaking effort across the clear speech variants.

RESULTS

Intelligibility was reduced for the PD group in comparison to the control group only in the habitual condition. All clear speech variants significantly improved intelligibility above habitual levels for the PD group, with OE maximizing intelligibility, followed by the SC and HI conditions. Both groups rated speaking effort to be significantly higher for both the OE and HI conditions versus the SC and habitual conditions.

DISCUSSION

For speakers with PD, all clear speech variants increased intelligibility to a level comparable to that of healthy controls. All clear speech variants were also associated with higher levels of speaking effort than habitual speech for the speakers with PD. Clinically, findings suggest that clear speech training programs consider using the instruction "overenunciate" for maximizing intelligibility. Future research is needed to identify if high levels of speaking effort elicited by the clear speech variants affect long-term sustainability of the intelligibility benefit.

Musicokinetic and exercise therapies decrease the depression level of elderly patients undergoing post-stroke rehabilitation: The moderating effect of health regulatory focus

This study aims to investigate the impact of musicokinetic and exercise therapies on the depression level of elderly patients undergoing post-stroke rehabilitation and its possible moderators, the promotion focus (i.e., achieve gains) and prevention focus (i.e., avoid losses or non-gains), which are the two motivational orientations of health regulatory focus. An eight-week randomized controlled trial was employed. Sixty-five elderly patients undergoing post-stroke rehabilitation in a hospital in Shanghai, China. Patients were randomly assigned to the musicokinetic (n = 32) therapy group or the exercise (n = 33) therapy group. The Mini-mental State Examination Scale measuring the patients’ cognitive functions was used to screen participants. The Hamilton Depression Rating Scale and the Health Regulatory Focus Scale were applied to assess their levels of depression and health regulatory focus on weeks 0, 4, and 8, respectively. The musicokinetic therapy had a significantly better effect than the exercise therapy for individuals who had a lower level of prevention focus, whereas the exercise therapy had a significantly better effect than the musicokinetic therapy for individuals who had a higher level of prevention focus. Musicokinetic therapy and exercise therapy were both effective in decreasing post-stroke depression for elderly patients. But it is important to choose an appropriate type of therapy per the health regulatory focus of elderly patients with post-stroke rehabilitation.

Logistic Model and Gradient Boosting Machine Model for Physical Therapy of Lumbar Disc Herniation

Objective. Physical therapy is a common clinical treatment for patients with lumbar disc herniation. The study is aimed at exploring the feasibility of mathematical expression and curative effect prediction of physical therapy in patients with lumbar disc herniation using a logistic model and gradient boosting machine (GBM). Methods. A total of 142 patients with lumbar disc herniation were treated with physical therapy. The pain was evaluated by the visual analogue scale (VAS) before each treatment. The logistic model was used to conduct a global regression analysis on patients with lumbar disc herniation. The final results of the whole course of treatment were predicted by the measured values of 2-9 times of treatment. The GBM model was used to predict and analyze the curative effect of physical therapy. Results. The mathematical expression ability of the logistic regression model for patients with lumbar disc herniation undergoing physical therapy was sufficient, and the global determination coefficient was 0.721. The results would be better for more than five measurements. The AUC of GBM mode logistic regression analysis was 0.936 and 0.883, and the prediction effect is statistically significant. Conclusion. Both the logistic and GBM model can fully express the changes in patients with lumbar disc herniation during physical therapy.

A Preoperative Spinal Education intervention for spinal fusion surgery designed using the Rehabilitation Treatment Specification System is safe and could reduce hospital length of stay, normalize expectations, and reduce anxiety

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Methods

POSE was offered to 150 prospective patients over ten months (December 2018 to November 2019) Some chose to attend (Attend-POSE) and some did not attend (DNA-POSE). A third independent retrospective group of 150 patients (mean age 57.9 years (SD 14.8), 50.6% female) received surgery prior to POSE (pre-POSE). POSE consisted of an in-person 60-minute education with accompanying literature, specified using the RTSS as psychoeducative treatment components designed to optimize cognitive/affective representations of thoughts/feelings, and normalize anxieties about surgery and its aftermath. Across-group age, sex, median LOS, perioperative complications, and readmission rates were assessed using appropriate statistical tests.

Results

In all, 65 (43%) patients (mean age 57.4 years (SD 18.2), 58.8% female) comprised the Attend-POSE, and 85 (57%) DNA-POSE (mean age 54.9 years (SD 15.8), 65.8% female). There were no significant between-group differences in age, sex, surgery type, complications, or readmission rates. Median LOS was statistically different across Pre-POSE (5 days ((interquartile range (IQR) 3 to 7)), Attend-POSE (3 (2 to 5)), and DNA-POSE (4 (3 to 7)), (p = 0.014). Pairwise comparisons showed statistically significant differences between Pre-POSE and Attend-POSE LOS (p = 0.011), but not between any other group comparison. In the Attend-POSE group, there was significant change toward greater surgical preparation, procedural familiarity, and less anxiety.

Conclusion

POSE was associated with a significant reduction in LOS for patients undergoing spinal fusion surgery. Patients reported being better prepared for, more familiar, and less anxious about their surgery. POSE did not affect complication or readmission rates, meaning its inclusion was safe. However, uptake (43%) was disappointing and future work should explore potential barriers and challenges to attending POSE. Cite this article: Bone Jt Open 2022;3(2):135–144.

Intervention reporting and dissemination of information for the management of hand osteoarthritis

INTRODUCTION

A variety of exercise programs are recognized to be effective for the management of hand osteoarthritis (HOA). It is important to report the essential elements of these exercise programs for clinicians to replicate properly and facilitate their implementation with individuals who suffers from HOA, especially if they are found to be effective programs.

PURPOSE OF THE STUDY

The objective of this article was to assess content reporting using three exercise reporting standardized assessment tools among exercise interventions randomized controlled trials (RCTs) involving individuals with HOA.

STUDY DESIGN

A descriptive study was used.

METHODS

Two pairs of trained assessors independently identified, selected, and scored the reporting quality of the exercise programs of RCTs on the management of HOA using three standardized assessment tools: the Consensus on Exercise Reporting Template (CERT) checklist, Consensus on Therapeutic Exercise Training (CONTENT) scale, and Template for Intervention Description and Replication (TIDieR) checklist to review the quality of reporting of 11 RCTs included in a recent Ottawa Panel guideline.

RESULTS

Based on consensus reached by two different pairs of reviewers and an arbitrator, the mean total scores for the 11 included exercise programs were reported as follows: the mean total score for the CERT, CONTENT, and TIDieR was 10.58/19 ± 4.34, 3.27/9 ± 1.90, and 5.92/12 ± 2.54, respectively. The overall Pearson's Correlation (r) between the methodological quality and intervention reporting was 0.86, 0.71, and 0.54 for moderate-to-high RCTs and 0.47, 0.79, and 0.42 for fair-to-poor methodological quality for the CERT checklist, CONTENT scale, and TIDieR checklist, respectively.

CONCLUSIONS

The intervention reporting in the management of HOA is poor among low-, moderate-, and high-quality clinical trials. The least reported information was intervention parameters related to behavior change. Improving reporting is recommended to ensure replication of effective exercise programs to enhance quality of life of individuals with HOA.

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

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

Demystifying the complexity of aphasia treatment: Application of the Rehabilitation Treatment Specification System (RTSS)

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

Applying the Rehabilitation Treatment Specification System (RTSS) to Functional Communication Treatment Approaches for Aphasia

There are many different approaches to the rehabilitation of aphasia, a communication disorder that affects a person's understanding and expression of spoken and written language. One approach called "functional communication interventions" aims to enhance communication success as opposed to solely improve linguistic abilities. This approach encompasses many skills (e.g., gesturing) and factors (e.g., access to communication supports) that support sending and receiving messages in "real world" daily activities and environments. Functional communication treatments are highly diverse and not always well described. A framework that may provide structure to the description of functional communication interventions for aphasia is the Rehabilitation Treatment Specification System (RTSS). The RTSS was developed by an interdisciplinary research team to describe interventions across any rehabilitation discipline and in any setting or format. The RTSS uses a common language and a systematic approach to describing treatment and includes three connected elements - a single target, one or more ingredients, and a mechanism of action - that, taken together, attempt to explain how and why a treatment works. While the RTTS has been described previously within the field of speech-language pathology, it has not yet been applied to the field of aphasiology. We applied the RTSS framework to a sample of peer-reviewed studies that represent functional communication treatments, including Promoting Aphasics' Communicative Effectiveness (PACE), Modified Response Elaboration Training (M-RET), Script Training, Conversation Treatment, and Communication Partner Training. We discuss both the advantages and disadvantages of using the RTSS framework to better understand the important elements of functional communication treatment approaches for aphasia.

Musculoskeletal Neural Network path generator for a virtual upper-limb active controlled orthosis

In this paper, a non-parametric model of the neuromusculoskeletal system for the biceps brachii is presented. The model serves to generate angular paths for the control of a virtual active orthosis. The path generator uses a differential neural network (DNN) identifier that obtains the reference angular position and velocities using the raw electromyographic (EMG) signals as input. The model is validated using experimental data. The training and closed-loop implementation of the proposed model are described. The control strategy ensures that the user reaches a set-point with a predefined position constraint and that the device follows the natural reference path that corresponds to the raw EMG signal.

Voice Therapy According to the Rehabilitation Treatment Specification System: Expert Consensus Ingredients and Targets

Purpose Clinical trials have demonstrated that standardized voice treatment programs are effective for some patients, but identifying the unique individual treatment ingredients specifically responsible for observed improvements remains elusive. To address this problem, the authors used a taxonomy of voice therapy, the Rehabilitation Treatment Specification System (RTSS), and a Delphi process to develop the RTSS-Voice (expert consensus categories of measurable and unique voice treatment ingredients and targets). Method Initial targets and ingredients were derived from a taxonomy of voice therapy. Through six Delphi Rounds, 10 vocal rehabilitation experts rated the measurability and uniqueness of individual treatment targets and ingredients. After each round, revisions (guided by the experts' feedback) were finalized among a primary reader (a voice therapy expert) and two external readers (rehabilitation experts outside the field of voice). Consensus was established when the label and definition of an ingredient or target reached a supramajority threshold (≥ 8 of 10 expert agreement). Results Thirty-five target and 19 ingredient categories were agreed to be measurable, unique, and accurate reflections of the rules and terminology of the RTSS. Operational definitions for each category included differences in the way ingredients are delivered and the way individual targets are modified by those ingredients. Conclusions The consensus labels and operationalized ingredients and targets making up the RTSS-Voice have potential to improve voice therapy research, practice, and education/training. The methods used to develop these lists may be useful for other speech, language, and hearing treatment specifications. Supplemental Material https://doi.org/10.23641/asha.15243357.

The Template for Intervention Description and Replication as a Measure of Intervention Reporting Quality: Rasch Analysis

Objective

To determine whether the 12 items of the Template for Intervention Description and Replication (TIDieR) can be combined into a single summary score reflecting intervention reporting completeness and quality.

Design

Systematic review and reanalysis of published data. After a systematic search of the published literature, 16 review articles were retrieved with 489 sets of 12 TIDieR ratings of experimental intervention, comparator, or the 2 combined as reported in primary studies. These 489 sets were recoded into a common format and analyzed using Rasch analysis for binary items.

Setting

Not applicable.

Participants

Not applicable.

Interventions

Not applicable.

Main Outcome Measures

Psychometric qualities of a Rasch Analysis-based TIDieR summary score.

Results

The data fit the Rasch model. Infit and outfit values were generally acceptable (range, 0.70-1.45). TIDieR was reasonably unidimensional in its structure. However, the person (here: study) separation ratio was 1.25 with a corresponding reliability of 0.61. In addition, the confidence interval around each estimate of reporting completeness was wide (model standard error of 0.78).

Conclusion

Several Rasch indicators suggested that TIDieR is not a strong instrument for assessing the quality of a researcher's reporting on an intervention. It is recommended that it be used with caution. Improvements in TIDieR itself may make it more helpful as a reporting tool.

Recommendations for Reporting on Rehabilitation Interventions

ABSTRACT

Clear reporting on rehabilitation treatments is critical for interpreting and replicating study results and for translating treatment research into clinical practice. This article reports the recommendations of a working group on improved reporting on rehabilitation treatments. These recommendations are intended to be combined with the efforts of other working groups, through a consensus process, to arrive at a reporting guideline for randomized controlled trials in physical medicine and rehabilitation (Randomized Controlled Trials Rehabilitation Checklist). The work group conducted a scoping review of 156 diverse guidelines for randomized controlled trial reporting, to identify themes that might be usefully applied to the field of rehabilitation. Themes were developed by identifying content that might improve or enhance existing items from the Template for Intervention Description and Replication. Guidelines addressing broad research domains tended to define reporting items generally, from the investigator's perspective of relevance, whereas those addressing more circumscribed domains provided more specific and operationalized items. Rehabilitation is a diverse field, but a clear description of the treatment's separable components, along with distinct treatment theories for each, can improve reporting of relevant information. Over time, expert consensus groups should develop more specific guideline extensions for circumscribed research domains, around coalescing bodies of treatment theory.

Mapping Meta-Therapy in Voice Interventions onto the Rehabilitation Treatment Specification System

Meta-therapy refers to the clinical dialogue via which direct and indirect voice treatments are introduced and discussed, and which helps build a useful conceptual framework for voice therapy. Meta-therapy was idiosyncratically defined in previous work. However, the current colloquial narrative of meta-therapy is not standardized or specific enough to be reliably taught, rigorously studied, or clinically delivered with high fidelity. Therefore, this article uses a standard framework (the Rehabilitation Treatment Specification System or RTSS) to further articulate and operationalize meta-therapy in vocal rehabilitation. Meta-therapy's conceptual framework generally aligns with the RTSS's treatment theory and associated concepts; e.g., the treatment component and its underlying ingredients, mechanisms of action, and target. Because the treatment theories in meta-therapy most frequently involve mechanisms of action related to information processing, they primarily map onto the RTSS's Representations treatment components. The treatment targets in meta-therapy are often focused on changes in the patient's cognitions, knowledge, beliefs, attitudes, intentions, and/or awareness regarding voice-related modifications. The ingredients in meta-therapy are frequently clinician actions conveying information with the goal of appropriately shaping the patient's mental representations, and are delivered with verbal cues, stories, analogies, etc. This manuscript provides specific examples of how meta-therapy is applied in clinical voice practice. Considerations for future investigation of meta-therapy are proposed.

Overview of Reviews Using the Template for Intervention Description and Replication (TIDieR) as a Measure of Trial Intervention Reporting Quality

OBJECTIVE

To evaluate the quality of descriptions of interventions in health care research reports, based on a synthesis of reviews that used the Template for Intervention Description and Replication (TIDieR) to rate the completeness and quality of intervention reporting.

DESIGN

Overview of published reviews. In a systematic search of the literature, 56 review articles were retrieved that had evaluated 3454 primary studies (index articles) using all or most of the 12 TIDieR items, applied to experimental treatment only or treatment and comparator both, separately. If available, percentages "reported completely" were extracted based on the index article, the index article supplemented by related information, and these 2 supplemented by e-mailing the author. Information on the review's methodology was also extracted.

SETTING

Not applicable.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percentage of primary studies receiving "adequately reported" ratings on each of the 12 TIDieR items.

RESULTS

While for treatment arms TIDieR items 1 (name of treatment) and 2 (why of treatment) are generally judged to be reported adequately, the percentage is between 25% and 75% for most other items and is as low as 10% for item 10 (modifications). Comparators are reported even more poorly. Use of additional publications on a trial increased percentages "reported adequately" marginally; e-mailing resulted in significant increases in completeness of reporting. Rehabilitation trials were reported better than nonrehabilitation trials for some TIDieR items and worse for others.

CONCLUSIONS

Reporting on the interventions and comparators of trials is substandard. More extensive use of supplemental digital content and of versions of TIDieR customized for specific domains of research may improve the situation.

Rehabilitation Treatment of Motor Dysfunction Patients Based on Deep Learning Brain-Computer Interface Technology

In recent years, brain-computer interface (BCI) is expected to solve the physiological and psychological needs of patients with motor dysfunction with great individual differences. However, the classification method based on feature extraction requires a lot of prior knowledge when extracting data features and lacks a good measurement standard, which makes the development of BCI. In particular, the development of a multi-classification brain-computer interface is facing a bottleneck. To avoid the blindness and complexity of electroencephalogram (EEG) feature extraction, the deep learning method is applied to the automatic feature extraction of EEG signals. It is necessary to design a classification model with strong robustness and high accuracy for EEG signals. Based on the research and implementation of a BCI system based on a convolutional neural network, this article aims to design a brain-computer interface system that can automatically extract features of EEG signals and classify EEG signals accurately. It can avoid the blindness and time-consuming problems caused by the machine learning method based on feature extraction of EEG data due to the lack of a large amount of prior knowledge.

Psychoeducational Interventions for Problematic Anger in Chronic Moderate to Severe Traumatic Brain Injury: A Study of Treatment Enactment

OBJECTIVES

Treatment enactment, a final stage of treatment implementation, refers to patients' application of skills and concepts from treatment sessions into everyday life situations. We examined treatment enactment in a two-arm, multicenter trial comparing two psychoeducational treatments for persons with chronic moderate to severe traumatic brain injury and problematic anger.

METHODS

Seventy-one of 90 participants from the parent trial underwent a telephone enactment interview at least 2 months (median 97 days, range 64-586 days) after cessation of treatment. Enactment, quantified as average frequency of use across seven core treatment components, was compared across treatment arms: anger self-management training (ASMT) and personal readjustment and education (PRE), a structurally equivalent control. Components were also rated for helpfulness when used. Predictors of, and barriers to, enactment were explored.

RESULTS

More than 80% of participants reported remembering all seven treatment components when queried using a recognition format. Enactment was equivalent across treatments. Most used/most helpful components concerned normalizing anger and general anger management strategies (ASMT), and normalizing traumatic brain injury-related changes while providing hope for improvement (PRE). Higher baseline executive function and IQ were predictive of better enactment, as well as better episodic memory (trend). Poor memory was cited by many participants as a barrier to enactment, as was the reaction of other people to attempted use of strategies.

CONCLUSIONS

Treatment enactment is a neglected component of implementation in neuropsychological clinical trials, but is important both to measure and to help participants achieve sustained carryover of core treatment ingredients and learned material to everyday life.

Occupational Therapy Can Benefit From an Interprofessional Rehabilitation Treatment Specification System

To advance evidence-based practice across rehabilitation professions, clinicians, and researchers could benefit from a structured way to clearly describe the treatment interventions used by their discipline. Development of the Rehabilitation Treatment Specification System is an interprofessional effort to use a theory-driven and systematic approach to define, specify, and quantify the complex nature of rehabilitation treatments. In this article, we introduce this novel approach and provide a case example that illustrates application to clinical practice. We invite occupational therapy practitioners to consider how clear specification of the content and process of their interventions could benefit practice, research, and education.

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

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

A Theory-Driven System for the Specification of Rehabilitation Treatments

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

Advancing Rehabilitation Practice Through Improved Specification of Interventions

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