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

Bundling implementation strategies supports outcome measure adoption in stroke rehabilitation: preliminary findings

BACKGROUND

Over 80% of people who experience a stroke present with residual impairment of the upper extremity, such as the shoulder, elbow, wrist, and hand. However, rarely do stroke rehabilitation practitioners (e.g., occupational therapists) use standardized outcome measures to objectively evaluate upper extremity function. Accordingly, the purpose of this project was to develop a bundle of implementation strategies that supports practitioners' adoption of the Fugl-Meyer Assessment of the Upper Extremity in stroke rehabilitation practice.

METHODS

We used tenets of Implementation Mapping to guide the development of our implementation strategy bundle. We partnered with one, large academic health system serving over 200 stroke patients annually through intensive rehabilitation care. Strategies were selected and developed through a multi-method process that included a review of the literature, qualitative input from our health system's practitioners and managers, and expert consultation. We also specified the hypothesized implementation "mechanisms" our strategies intended to change. Practitioners' adoption (yes/no) of the Fugl-Meyer Assessment was calculated by analyzing electronic health record documentation of the 6-month time frame before strategies were deployed compared to the 6-month time frame after deployment.

RESULTS

Practitioners were exposed to the following implementation strategies to support Fugl-Meyer adoption: conduct educational meetings, prepare outcome measure champions, provide equipment, develop training materials, and adapt documentation systems. In the 6-months before deployment of our implementation strategies, practitioners implemented the Fugl-Meyer with 14.8% of stroke patients. In the six months after deployment, adoption of the Fugl-Meyer increased to 73.8% (p < .001).

CONCLUSIONS

When systematically developed in collaboration with health system partners, a bundle of implementation strategies may support outcome measure adoption in stroke rehabilitation. Improving the use of standardized outcome measures is of paramount importance in stroke rehabilitation to objectively monitor patients' progress or decline, to demonstrate the value of rehabilitation services for enhancing patients' recovery, and to advocate for continued reimbursement for rehabilitation care. Future opportunities lie in further specifying the mechanisms through which implementation strategies are intended to work and how those mechanisms contribute to strategy effectiveness.

TRIAL REGISTRATION

NCT registration: NCT04888416; May 06, 2021.

AMEsobreRuedas Early Powered Mobility in Children with Spinal Muscular Atrophy Type I: Protocol of a Randomized Controlled Trial

Background: Young children with spinal muscular atrophy type 1 (SMA1) have limited independent mobility and participation that may lead to cognitive development delays. Implementing early powered mobility in interventions may help them to learn self-initiated movement, play, and having fun to participate in natural settings. The aim of this study is to evaluate the effectiveness of an early power mobility intervention for increasing participation, functional ability, and quality of life in young children with SMA1. Methods: AMEsobreRuedas is a randomized waiting list controlled clinical trial. A sample of 24 children (10 months-5 years old, with SMA1) will be randomly allocated to two groups. The experimental group will perform a family-centered intervention with powered mobility for 16 weeks in their natural environment: a 12-week-structured program three times a week; and a 4-week follow-up with free use of the powered mobility device. The control group (waiting list) will keep their routine and will receive the same intervention after the experimental group. Five assessments will be carried out at baseline and weeks 4, 8, 12, and 16. Primary outcomes are participation (YC-PEM); functional ability (PEDI-CAT); and quality of life (PedsQL-Neuromuscular module). Results: It is expected that this study will provide further knowledge about the positive impact of powered mobility for the analyzed variables. Moreover, family engagement in the intervention and establishment of functional goals may help to add valuable information about real needs in future research. Conclusions: Early powered mobility could increase the opportunities for children with SMA1 to learn to move independently and participate in their natural environment.

Early Boost of Linguistic Skills? Individualized Non-Invasive Brain Stimulation in Early Postacute Aphasia

Non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS), has been shown to increase the outcome of speech and language therapy (SLT) in chronic aphasia. Only a few studies have investigated the effect of add-on tDCS on SLT in the early stage of aphasia; this may be due to methodological reasons, in particular the influence of spontaneous remission and the difficulty of establishing stimulation protocols in clinical routines. Thirty-seven participants with subacute aphasia (PwA) after stroke (23 men, 14 women; mean age 62 ± 12 years; mean duration 49 ± 28 days) were included in two consecutive periods of treatment lasting two weeks each. During the first period (P1) the participants received 10 sessions of SLT, during the second period (P2) the aphasia therapy was supplemented by anodal left hemispheric 2 mA tDCS over the left hemisphere. Severity-specific language tests (Aachen Aphasia Test (AAT), n = 27 and Bielefeld Aphasia Screening-Reha (BIAS-R), n = 10) were administered before P1, between P1 and P2, and after P2. Where information was available, the results were corrected for spontaneous remission (AAT sample), and the therapy outcomes of P1 and P2 were compared. Participants' overall language abilities improved significantly during P1 and P2. However, improvement-as measured by the AAT profile level or the BIAS-R mean percentage value-during P2 (with tDCS) was significantly higher than during P1 (p < 0.001; AAT sample and p = 0.005; BIAS-R sample). Thus, tDCS protocols can be implemented in early aphasia rehabilitation. Despite the limitations of the research design, which are also discussed from an implementation science perspective, this is preliminary evidence that an individually tailored anodal tDCS can have a significant add-on effect on the outcome of behavioral aphasia therapy in subacute aphasia.

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.