Applying evidence standards to rehabilitation research

Methodological Issues in Rehabilitation Research: A Scoping Review

OBJECTIVE

To identify, synthesize, and categorize the methodological issues faced by the rehabilitation field.

DATA SOURCES

A scoping review was conducted using studies identified in MEDLINE, the Cochrane Library, EMBASE, Web of Science, Scopus, Physiotherapy Evidence Database, and Google Scholar up to August 2018.

STUDY SELECTION

We included all type of publications describing methodological issues in rehabilitation research where rehabilitation is described as a multimodal process. The methodological issues have been categorized and classified.

DATA EXTRACTION

The synthesis included qualitative and quantitative analysis. To focus the attention on rehabilitation, we post hoc divided in "specific issues" (highly related to, even if not exclusive of, rehabilitation research) and "generic issues" (common in biomedical research).

DATA SYNTHESIS

Seventy-one publications were included: 68% were narrative reviews, 15% systematic reviews, 7% editorials, 4% meta-epidemiologic studies, and 5% others. Specific methodological issues include the following: problematic application of randomized controlled trials (32%), absent definition of core outcome sets (28%), poor interventions description (22%), weak methodological (conducting) and reporting quality (21%), scarce clinical practice applicability (14%), lack of blinding assessor (10%), inadequate randomization methods or inadequate allocation concealment (8%), and inadequate participants description and recruitment (8%). "Generic" issues included the following: data and statistical description (31%), authors' methodological training (7%), peer review process (6%, n=4), funding declaration (6%), ethical statement (3%), protocol registration (3%), and conflict of interest declaration (1%).

CONCLUSIONS

Methodological and reporting issues might influence the quality of the evidence produced in rehabilitation research. The next steps to move forward in the field of rehabilitation could be to evaluate the influence of all these issues on the validity of trial results through meta-epidemiologic studies and to develop specific checklists to provide guidance to authors to improve the reporting and conduct of trials in this field.

Content analysis to locate assistive technology in Queensland's motor injury insurance rehabilitation legislation and guidelines

INTRODUCTION

Reforms to Australia's disability and rehabilitation sectors have espoused the potential of assistive technology as an enabler. As new insurance systems are being developed it is timely to examine the structure of existing systems. This exploratory study examined the policies guiding assistive technology provision in the motor accident insurance sector of one Australian state.

METHODS

Policy documents were analyzed iteratively with a set of qualitative questions to understand the intent and interpretation of policies guiding assistive technology provision. Content analysis identified relevant sections and meaningful terminology, and context analysis explored the dominant perspectives informing policy.

RESULTS AND DISCUSSION

The concepts and language of assistive technology are not part of the policy frameworks guiding rehabilitation practice in Queensland's motor accident insurance sector. The definition of rehabilitation in the legislation is consistent with contemporary international interpretations that focus on optimizing functioning in interaction with the environment. However, the supporting documents are focused on recovery from injuries where decisions are guided by clinical need and affordability.

CONCLUSION

The policies frame rehabilitation in a medical model that separates assistive technology provision from the rehabilitation plan. The legislative framework provides opportunities to develop and improve assistive technology provision as part of an integrated approach to rehabilitation.

Functional performance differences between the Genium and C-Leg prosthetic knees and intact knees

Microprocessor prosthetic knees (MPKs) have advanced technologically, offering new features to decrease impairment and activity limitations for persons with transfemoral amputation (TFA). The Genium knee is functionally untested, and functional differences between it and intact knees are unknown. This study sought to determine whether Genium use improves functional performance compared with the C-Leg. A randomized experimental crossover design was used, with a cross-section of five nonamputee controls for comparison to normal. Twenty community-ambulating persons with TFA were trained and tested for accommodation with study components. All subjects (n = 25) were assessed using the Continuous-Scale Physical Functional Performance-10 (CS-PFP10) assessment. Subjects with TFA used both MPK systems. Genium use improved upper-body flexibility, balance, and endurance domain scores (7.0%-8.4%, p </= 0.05) compared with the C-Leg. Only in the endurance domain did Genium users score significantly lower than nonamputees (22.4%, p = 0.05). Comparing the C-Leg with nonamputees, CS-PFP10 total (2.0%-24.4%, p = 0.03) and all domains except upper-body strength were lower than nonamputees (-13.4% to -28.9%, p </= 0.05). Nonetheless, regardless of knee condition, subjects with TFAs did not equal or surpass nonamputees in any functional domain, suggesting room for improvements in TFA functional performance.

Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews

Considering transtibial amputation (TTA) rehabilitation costs and complexity, high-quality literature should inform clinical practice. Systematic reviews (SRs) suggest this is not the case. This article's purpose was to review the highest-quality evidence available to guide clinical practice for TTA regarding five prosthetic intervention areas. Six databases were searched for high-quality SRs and prospective clinical trials (randomized clinical trials [RCTs]). Reviewers screened, sorted, rated (i.e., methodologic quality, bias risk), and extracted article data. Meta-analyses were conducted when possible. Thirty-one references were included (25 RCTs and 6 SRs). Five topical areas emerged (alignment, feet and ankles, interface, postoperative care, pylons). Twenty-three evidence statements were supported by level 2 evidence and eight by level 1 evidence. All RCTs reported randomization and reasonable data presentation. Concealed allocation and blinding were not widely used. Mean attrition was 11%. SRs included no meta-analyses. Functional level was poorly reported. Grouping feet and ankle components by functional classification enabled meta-analyses, though variance was considerable given the small sample sizes. Prosthetic interventions are generally safe for TTAs. High-quality literature enabled formulation of evidence statements to support select clinical practice areas, though quantity was lacking. Thus, numerous topics related to TTA care lack rigorous evidence. Although blinding in prosthetic research requires increased funding and effort, it could greatly improve the methodologic quality of prosthetic research.

Training to Improve Walking after Pediatric Spinal Cord Injury: A Systematic Review of Parameters and Walking Outcomes

Walking or locomotor training is often initiated following pediatric spinal cord injury (SCI). There is no synthesis of the literature on interventions targeting walking for pediatric SCI, although this would assist future clinical trials and interventions. To address this need, we completed a systematic review to summarize the who, what, when, and how of walking interventions in children with SCI. Participant characteristics, training parameters, and walking outcomes with training in pediatric SCI were identified and compared with training parameters and outcomes in adults with SCI. The PubMed, Medline, AMED, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for studies that included participants aged 1-17 years with a SCI acquired post-birth, physical interventions, and pre- and post-training walking measures. Two researchers evaluated each study's risk of bias using a domain-based approach. Training parameters and walking outcomes were extracted. Total training duration (duration × frequency × number of weeks) was calculated. Thirteen pediatric studies (n = 43 children) were included; all but one were case series/reports. Risk of bias was high in the pediatric studies. A 2012 adult review was updated (11 studies added). As with adults, the training durations, frequencies, and modes used with the children varied; however, overground walking practice was included in 10/13 pediatric studies. Improvements in walking capacity, speed, and distance were comparable between children and adults. There was a trend for greater gains with greater total training durations. There is a paucity of high-quality research examining interventions targeting walking after pediatric SCI; however, intensive training, including practice overground, results in notable improvements.

Issues affecting the level of prosthetics research evidence: Secondary analysis of a systematic review

BACKGROUND

Systematic reviews of scientific literature are valuable sources of synthesized knowledge. Systematic review results may also be used to inform readers about challenges inherent to an area of research, guide future research efforts, and facilitate improvements in evidence quality.

OBJECTIVES

To identify methodological issues that affected the overall level of scientific evidence reported in a contemporary systematic review and to offer suggestions for enhancing publications' contribution to the overall evidence.

STUDY DESIGN

Secondary analysis of a systematic review.

METHODS

Publications included in a systematic review related to microprocessor-controlled prosthetic knees were analyzed with respect to established methodological quality criteria. Common issues were identified and discussed.

RESULTS

Internal validity was commonly affected by variable comparison conditions, limited justification of accommodation time, potential fatigue and learning effects, lack of blinding, small sample sizes, limited evidence of measurement reliability, subject attrition, and limited descriptions of selection criteria. Similarly, external validity was affected by limited descriptions of the study sample, indeterminate representativeness, and suboptimal description of the interventions.

CONCLUSION

Results suggest that efforts to address methodological limitations, educate evidence consumers, and improve research reporting are needed to advance the quality and use of evidence in the field of prosthetics.

CLINICAL RELEVANCE

Critical analysis of the strengths and limitations of publications included in a systematic review can inform evidence consumers and contributors about challenges inherent to a field of research. Results of this analysis suggest that efforts to address identified limitations are needed to enhance the overall level of prosthetics evidence.

Outcome prediction in home- and community-based brain injury rehabilitation using the Mayo-Portland Adaptability Inventory

The objective of the study was to develop statistical formulas to predict levels of community participation on discharge from post-hospital brain injury rehabilitation using retrospective data analysis. Data were collected from seven geographically distinct programmes in a home- and community-based brain injury rehabilitation provider network. Participants were 642 individuals with post-traumatic brain injury. Interventions consisted of home- and community-based brain injury rehabilitation. The main outcome measure was the Mayo-Portland Adaptability Inventory (MPAI-4) Participation Index. Linear discriminant models using admission MPAI-4 Participation Index score and log chronicity correctly predicted excellent (no to minimal participation limitations), very good (very mild participation limitations), good (mild participation limitations), and limited (significant participation limitations) outcome levels at discharge. Predicting broad outcome categories for post-hospital rehabilitation programmes based on admission assessment data appears feasible and valid. Equations to provide patients and families with probability statements on admission about expected levels of outcome are provided. It is unknown to what degree these prediction equations can be reliably applied and valid in other settings.

Longitudinal description of the disability rating scale for individuals in the National Institute on Disability and Rehabilitation Research traumatic brain injury model systems national database

OBJECTIVE

To develop a detailed understanding of temporal change (ie, estimated trajectories) at the individual level as measured by the Disability Rating Scale (DRS).

DESIGN

Individual growth curve (IGC) analysis of retrospective data obtained from the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury (TBI) Model Systems National Database.

SETTING

Multicenter longitudinal database study.

PARTICIPANTS

Individuals with TBI (N=8816) participating in the TBI Model Systems National Database project.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE DRS RESULTS

The negative exponential consisting of 3 growth parameters (pseudointercept, asymptote, rate) was successfully used to predict trajectory of recovery on the DRS qualified by the following covariates: race, sex, level of education and age at admission, rehabilitation length of stay, and cognitive and motor FIM scores at rehabilitation admission. Based on these results, an interactive tool was developed to allow prediction of the trajectory of recovery for individuals and subgroups with specified characteristics on the selected covariates.

CONCLUSIONS

With the use of IGC analysis, the longitudinal trajectory of recovery on the DRS for individuals sharing common characteristics and traits can be described. This methodology allows researchers and clinicians to predict numerous individual-level trajectories through use of a web-based computer automated interactive tool.

Measuring treatment fidelity in a rehabilitation intervention study

Attaining and demonstrating treatment fidelity is critical in the development and testing of evidence-based interventions. Treatment fidelity refers to the extent to which an intervention was implemented in clinical testing as it was conceptualized and is clearly differentiable from control or standard-of-care interventions. In clinical research, treatment fidelity is typically attained through intensive training and supervision techniques and demonstrated by measuring therapist adherence and competence to the protocol using external raters. However, in occupational and physical therapy outcomes research, treatment fidelity methods have not been used, which, in our view, is a serious gap that impedes novel treatment development and testing in these rehabilitation fields. In this article, we describe the development of methods to train and supervise therapists to attain adequate treatment fidelity in a treatment development project involving a novel occupational and physical therapy-based intervention. We also present a data-driven model for demonstrating therapist adherence and competence in the new treatment and its differentiation from standard of care. In doing so, we provide an approach that rehabilitation researchers can use to address treatment fidelity in occupational and physical therapy-based interventions. We recommend that all treatment researchers in rehabilitation disciplines use these or similar methods as a vital step in the development and testing of evidence-based rehabilitation interventions.

Evidence-based practice for rehabilitation professionals: concepts and controversies

This article describes evidence-based practice (EBP) in the health professions and sciences in general and in the rehabilitation disciplines specifically. It discusses the following: what counts as evidence and how that has changed over the last 4 decades, trends in the short history of evidence-based medicine and EBP, the fallacious nature of most criticisms of EBP, (perceived) shortcomings of clinical research and the resulting evidence in rehabilitation, resources available to clinicians who want their practice to be evidence-based, and the barriers these clinicians face in keeping up with the evidence and applying it in practice. Lastly, it describes how the development of a new art and science, knowledge translation, may play a role in truly making EBP feasible in rehabilitation services.

Effects of lower limb prosthesis on activity, participation, and quality of life: a systematic review

BACKGROUND

Effects presented on the use of assistive devices such as prosthesis are often based on laboratory findings (i.e. efficacy).

OBJECTIVES

To summarise and evaluate findings from studies on effectiveness of lower limb prostheses for adults in real life contexts, primarily in terms of activity, participation, and quality of life (QoL) and secondarily in terms of user satisfaction, use/non-use, and/or cost-effectiveness.

STUDY DESIGN

Systematic review.

METHODS

We included controlled studies and non-controlled follow-up studies including both baseline and follow-up data. Using 14 different databases supplemented with manual searches, we searched for studies published from 1998 until June 2009.

RESULTS

Out of an initial 818 identified publications, eight met the inclusion criteria. Four studies reported on the effectiveness of a microprocessor-controlled knee (MP-knee) compared to a non-microprocessor-controlled knee (NMP-knee). Results were inconsistent except for quality of life and use/non-use, where the authors reported an improvement with the MP-knee compared to the NMP-knee. The remaining four studies included a diversity of prosthetic intervention measures and types of endpoints.

CONCLUSIONS

Overall, there was an inconsistency in results and study quality. This review highlights the need for high-quality research studies that reflect the effectiveness of different prosthesis interventions in terms of users' daily living and QoL.

CLINICAL RELEVANCE

Clinical guidelines are important to every practitioner. Information on expected effectiveness from assistive devices should be well founded and contain both facts about the device quality and its contribution to users' daily lives. Thus, studies based on users' experiences from prosthetic use in everyday life activities are of great importance.

Epidemiology and impact of scarring after burn injury: a systematic review of the literature

The purpose of this study was to perform a systematic review of the existing literature on the incidence of hypertrophic scarring and the psychosocial impact of burn scars. In a comprehensive literature review, the authors identified 48 articles published since 1965 and written in English which reported the incidence and risk factors for hypertrophic scarring or assessed outcomes related to scarring. Most studies had important methodological limitations limiting the generalizability of the findings. In particular, the absence of standardized valid measures of scarring and other outcome variables was a major barrier to drawing strong conclusions. Among studies on hypertrophic scarring, the prevalence rate varied between 32 and 72%. Identified risk factors included dark skin, female gender, young age, burn site on neck and upper limb, multiple surgical procedures, meshed skin graph, time to healing, and burn severity. With regard to psychosocial outcomes, two studies compared pediatric burn survivors with a nonburn comparison group on a body image measure; neither study found differences between groups. Across studies, burn severity and location had a modest relationship with psychosocial outcome variables. Psychosocial variables such as social comfort and perceived stigmatization were more highly associated with body image than burn characteristics. To advance our knowledge of the epidemiology of scars and the burden of scars, future studies need to implement more rigorous methodologies. In particular, standardized valid measures of scarring and other outcomes should be developed. This process could be facilitated by an international collaboration among burn centers.

Structures promoting research, training, and technology transfer in mobility: lessons learned from a visit to European centers

The purpose of this paper is to describe the education, research, technology transfer, and cooperative models that appear to have the greatest likelihood of successfully tackling the issue of technology to improve mobility. Ideally better models in each of these areas will lead to an increased number of researchers who are more productive. There will be increased international collaboration that will allow for better research with small and/or disadvantaged populations, and the research completed will lead to changes in clinical care that positively impact individuals with impair mobility.

A review on static splinting therapy to prevent burn scar contracture: do clinical and experimental data warrant its clinical application?

BACKGROUND

Static splinting therapy is widely considered an essential part in burn rehabilitation to prevent scar contractures in the early phase of wound healing. However, scar contractures are still a common complication. In this article we review the information concerning the incidence of scar contracture, the effectiveness of static splinting therapy in preventing scar contractures, and specifically focus on the - possible - working mechanism of static-splinting, i.e. mechanical load, at the cellular and molecular level of the healing burn wound.

METHOD

A literature search was done including Pubmed, Cochrane library, CINAHL and PEDRO.

RESULTS

Incidence of scar contracture in patients with burns varied from 5% to 40%. No strong evidence for the effectiveness of static splinting therapy in preventing scar contracture was found, whereas in vitro and animal studies demonstrated that mechanical tension will stimulate the myofibroblast activity, resulting in the synthesis of new extracellular matrix and the maintenance of their contractile activity.

CONCLUSION

The effect of mechanical tension on the wound healing process suggests that static splinting therapy may counteract its own purpose. This review stresses the need for randomised controlled clinical trials to establish if static splinting to prevent contractures is a well-considered intervention or just wishful thinking.

Local and systemic treatments for acute edema after burn injury: a systematic review of the literature

Burn injury is a complex trauma that results in local and generalized edema. Edema fluid limits the exchange of vital nutrients in healing the burn wound and will compromise vulnerable tissues. Although the importance of edema control in tissue salvage is recognized, treatments targeted at edema control have not been critically reviewed. Thus, the objective was to assess the evidence for the effectiveness of local and systemic treatments for edema management immediately after burn injury. Searches for randomized controlled trials were conducted of online databases, research and thesis registers, and grey literature repositories. Handsearches included journals, bibliographies, and proceedings. Authors were contacted to clarify and submit extra study details. Eight studies were included. Management of acute major burn resuscitation including colloid increases lung edema (mean difference [MD], 0.04 ml/ml alv vol; 95% confidence interval [CI], 0.03-0.04; P < .00001) and mortality (risk ratio, 3.67; 95% CI, 1.16-11.58; P = .03). Continuous administration of vitamin C in acute burn resuscitation reduces local wound edema (MD, -3.50 ml/g; 95% CI, -4.63 to -2.37; P < .00001) and systemic fluid retention (MD, -8.60 kg; 95% CI, -13.47 to -3.73; P = .0005). Local acute hand burn edema is reduced (MD, -29.00 ml; 95% CI, -53.14 to -4.86; P = .02), and active hand motion increased (MD, 10.00°; 95% CI, 4.58-15.42; P = .0003), using electrical stimulation with usual physiotherapy. Each review outcome was based on a small single-facility study. Thus, future research in intervention for acute burn edema must focus on multicentre trials and validation of outcome measures in the burn population.

Do unblinded assessors bias muscle strength outcomes in randomized controlled trials of progressive resistance strength training in older adults?

OBJECTIVE

Knowledge of treatment assignment and failing to analyze results by randomized treatment groups--an intention-to-treat analysis--may cause bias in the treatment effect estimate in randomized controlled trials. This study was undertaken to determine the difference in lower limb muscle strength measured by blinded vs. by unblinded outcome assessors in 73 progressive resistance strength training trials conducted in older adults.

DESIGN

Retrospective analysis of randomized controlled trials published before 2007.

RESULTS

Meta-regression analyses showed that trials that used blinded assessors (n = 18) tend to report smaller effect sizes than do those that used unblinded assessors (n = 55), with a difference of -0.80 (95% confidence interval, -1.35 to -0.25). This result still holds even after adjusting for the use of an intention-to-treat analysis, with an adjusted difference of -0.65 (95% confidence interval, -1.26 to -0.04). The reported effects were exaggerated in trials that used unblinded assessors.

CONCLUSIONS

This study suggests that assessor blinding is important and is a safeguard to the internal validity of exercise trials in older adults.

Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: A review of the literature

The purpose of this paper was to review the literature through a structured literature review and provide a grade of recommendation for patient safety, gait energy efficiency, and cost effectiveness of the C-Leg microprocessor-controlled prosthetic knee for transfemoral amputees. Medline (Ovid) and CINAHL (EBSCO) data bases were searched to identify potentially pertinent studies within the 1995-2009 time range. Studies were screened and sorted. Pertinent studies were rated for methodologic quality and for risk of bias. Following assessment of methodologic quality and bias risk, the level of evidence and a grade of recommendation was determined for each of three categories: Safety, energy efficiency, and cost effectiveness. A total of 18 articles were determined to be pertinent: seven for safety, eight for energy efficiency, and three for cost effectiveness. Methodologic quality was low with a moderate risk of bias in the safety and energy effectiveness categories. Studies in cost effectiveness received high scores for methodologic quality. Though methodologic quality varied across the selected topics, there was sufficient evidence to suggest increased efficacy of the C-Leg in the areas of safety, energy efficiency and cost when compared with other prosthetic knees for transfemoral amputees.

Physical therapy management for adult patients undergoing cardiac surgery: a canadian practice survey

PURPOSE

To determine current Canadian physical therapy practice for adult patients requiring routine care following cardiac surgery.

METHODS

A telephone survey was conducted of a selected sample (n=18) of Canadian hospitals performing cardiac surgery to determine cardiorespiratory care, mobility, exercises, and education provided to patients undergoing cardiac surgery.

RESULTS

An average of 21 cardiac surgeries per week (range: 6-42) were performed, with an average length of stay of 6.4 days (range: 4.0-10.6). Patients were seen preoperatively at 7 of 18 sites and on postoperative day 1 (POD-1) at 16 of 18 sites. On POD-1, 16 sites performed deep breathing and coughing, 7 used incentive spirometers, 13 did upper-extremity exercises, and 12 did lower-extremity exercises. Nine sites provided cardiorespiratory treatment on POD-3. On POD-1, patients were dangled at 17 sites and mobilized out of bed at 13. By POD-3, patients ambulated 50-120 m per session 2-5 times per day. Sternal precautions were variable, but the lifting limit was reported as ranging between 5 lb and 10 lb.

CONCLUSIONS

Canadian physical therapists reported the provision of cardiorespiratory treatment after POD-1. According to current available evidence, this level of care may be unnecessary for uncomplicated patients following cardiac surgery. In addition, some sites provide cardiorespiratory treatment techniques that are not supported by evidence in the literature. Further research is required.

Treatment for depression after traumatic brain injury: a systematic review

The aim of this systematic review was to critically evaluate the evidence on interventions for depression following traumatic brain injury (TBI) and provide recommendations for clinical practice and future research. We reviewed pharmacological, other biological, psychotherapeutic, and rehabilitation interventions for depression following TBI from the following data sources: PubMed, CINAHL, PsycINFO, ProQuest, Web of Science, and Google Scholar. We included studies written in English published since 1980 investigating depression and depressive symptomatology in adults with TBI; 658 articles were identified. After reviewing the abstracts, 57 articles met the inclusion criteria. In addition to studies describing interventions designed to treat depression, we included intervention studies in which depressive symptoms were reported as a secondary outcome. At the end of a full review in which two independent reviewers extracted data, 26 articles met the final criteria that included reporting data on participants with TBI, and using validated depression diagnostic or severity measures pre- and post-treatment. Three external reviewers also examined the study methods and evidence tables, adding 1 article, for a total of 27 studies. Evidence was classified based on American Academy of Neurology criteria. The largest pharmacological study enrolled 54 patients, and none of the psychotherapeutic/rehabilitation interventions prospectively targeted depression. This systematic review documents that there is a paucity of randomized controlled trials for depression following TBI. Serotonergic antidepressants and cognitive behavioral interventions appear to have the best preliminary evidence for treating depression following TBI. More research is needed to provide evidence-based treatment recommendations for depression following TBI.

Chapter 53: rehabilitation therapies

This chapter retraces the history and evolution of rehabilitative efforts by physicians and other health professionals to alleviate the symptoms and disabilities associated with neurological disorders. Rehabilitation therapies often provide interventions that go beyond traditional medical treatment aimed at treating impairments, and help those with neurological injuries and illness to re-establish themselves as productive and socially-integrated citizens by reducing their functional disabilities. The chapter considers the early history of practical treatments developed in Greek and Roman times, reviews the scattered attempts at treatment during the Middle Ages and Renaissance, examines the more recent development of specific rehabilitative techniques and disciplines in the 20th century, and also provides discussion of the contemporary application of empirically validated rehabilitation strategies and techniques that emphasize treatment efficacy. The evolution of medical and physical rehabilitation, occupational and vocational rehabilitation, aphasia and cognitive rehabilitation, are all discussed, with additional review of the influence of some of the military conflicts and wars in history that have stimulated the advancement of the clinical practice of rehabilitation. A critique of the benefits of comprehensive rehabilitative programs for traumatic brain injury and stroke is specifically included. The varied skepticism and optimism of treating neurological disorders throughout history is also highlighted.

New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project

BACKGROUND/OBJECTIVE

Limited research evidence is available to show the effectiveness of the many specific interventions provided in spinal cord injury (SCI) rehabilitation; what is available typically focuses on effects of the full rehabilitation package but not specific therapy interventions, medical procedures, patient education, or counseling. Given the problems of conducting randomized controlled trials (RCTs) in rehabilitation, practice-based evidence (PBE) research has been suggested as an alternative methodology for identifying which rehabilitation interventions are associated most strongly with positive outcomes, after controlling for patient differences. Using the PBE research methodology, the SCIRehab project attempts to "open the black box" of acute SCI rehabilitation, provide detailed information on treatments delivered by all rehabilitation disciplines, and contribute to outcomes-based guidelines for clinical decision-making.

METHODS

The SCIRehab project includes 1,500 patients with acute SCI, consecutively admitted to 1 of 6 US inpatient rehabilitation facilities. Details of the rehabilitation process are captured by clinicians from multiple disciplines documenting their interventions in handheld personal digital assistants after sessions with their patients. Outcome data are abstracted from medical records (clinical outcomes data) and obtained from patient interviews at 6 and 12 months after injury. Extensive patient, injury, and other treatment characteristics are abstracted from medical records. SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team.

RESULTS

SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team. These findings are presented in a series of 9 articles.

CONCLUSIONS

To date, SCIRehab's major contribution is a system for categorizing specific contributions of each discipline and a technology for documenting that detail. After data collection is complete, future manuscripts will relate those process elements to outcomes. The SCIRehab Project is an important step toward establishing outcomes-based guidelines for SCI rehabilitation.

Assessing the efficacy, effectiveness, and cost-effectiveness of assistive technology interventions for enhancing mobility

PURPOSE

The aim of this paper is to highlight the contributions that complementary efficacy, effectiveness, and cost-effectiveness studies can make to assessing the outcomes of assistive technology interventions for enhancing mobility.

METHOD

The terms, 'assistive technology outcomes research' and 'assistive technology interventions', are defined. Several bases are examined for the shortage of outcomes research pertaining to mobility-related assistive technology interventions. Three presuppositions are described for the research strategy of interlocking studies being recommended. They are assigning priority to evaluating both recently developed assistive technologies and ones that have long been available, acknowledging the complexity of assistive technology as an intervention, and appreciating the trade-offs necessary for strengthening studies' internal and external validity. Some key study preparations are considered, including treatment theory, treatment specification, and the selection of outcome domains and measures. The essential features of efficacy, effectiveness, and cost-effectiveness studies are outlined, and their interdependence is stressed.

RESULTS AND CONCLUSIONS

To assess the outcomes of assistive technology interventions for mobility in ways that are both methodologically sound and relevant to stakeholder needs, a research strategy is required involving mutually reinforcing efficacy, effectiveness, and cost-effectiveness studies. Collaborative arrangements and funding methods are discussed for fostering the needed research.

Best research evidence for physical medicine and rehabilitation

Evidence-based medicine is a strong movement in this century, and randomized clinical trials continue to be the best level of evidence for establishing cause-effect relationships between treatment interventions and outcomes. The field of physical medicine and rehabilitation has many excellent research questions on the effects of treatment but seems to rely mostly on weak observational methods (eg, chart review, case series, and single-group designs) for answers. This paper highlights 3 basic and relatively simple principles of good experimental design: control, randomization, and replication that were developed by R. A. Fisher for large, complex, agricultural field trials. The principles diffused readily into many scientific arenas, and Fisher even applied the principles in his backyard studies into Mendelian genetics. The thoughts of R. A. Fisher, arguably the most influential statistician of the 20th century, on the promise and challenges of randomized clinical trials in medicine should motivate rehabilitation clinicians to do their own small-scale controlled trials, with Institutional Review Board approval, when faced with equally realistic and plausible treatment options for their patients.

Development and Testing of Interventions in Occupational Therapy: Toward a New Generation of Research in Occupational Therapy

Development, refinement, and testing of occupational therapy interventions require a systematic approach. The authors explain the four phases for clinical trials used in pharmaceutical research and apply them to the development and testing of occupational therapy interventions. The challenges faced by occupational therapy researchers in designing clinical trials include difficulties in specifying the intervention, blinding subjects, therapists, and evaluators, and identifying objective but client-centered measures of primary outcomes. Examples are provided of researchers who have developed and tested occupational therapy interventions in phases.

Towards guidelines for evaluation of measures: an introduction with application to spinal cord injury

BACKGROUND

Both clinical practice and research in spinal cord injury (SCI) continue to struggle with issues of the quality and utility of outcome measures employed. Despite widespread deference to dicta on "reliability and validity," systematic means of grading the level of evidence for measures are lacking.

OBJECTIVES

This paper explains the methods and principles for use in systematic reviews of measures in SCI. It explains how extant measurement standards and principles can be elaborated for extant labels on various types of reliability and validity to define a more judicious method of grading level of evidence. We aim to initiate a process of discussion that will lead to improved systematic review of the measurement quality as a basis for long-term improvements in outcomes measures and their application.

METHODS

This paper is a conceptual review, based on established measurement standards and principles and the incorporation of recent advances in measurement methodology. The scheme of grading of measurement quality is illustrated by examples of measures of health, function, activity/participation, and quality of life after SCI.

RESULTS AND CONCLUSIONS

It is possible to grade the quality of outcome measure in terms of level of evidence, provided the nature of the construct being measured is defined as well as its main use. Definite means of grading the level of evidence for measurement will help to identify priorities for measure development and facilitate more appropriate uses of measures.

Traumatic brain injury research since the 1998 NIH Consensus Conference: accomplishments and unmet goals

In 1998, an NIH sponsored Consensus Conference on Traumatic Brain Injury (TBI) Rehabilitation identified 30 different areas of needed research. A comprehensive review of recently generated research knowledge in the field of TBI has shown that a large number of Class III and IV evidence studies have been published, but relatively few of the more scientifically rigorous Class I or II studies. A rapid growth of publications on TBI rehabilitation has generated new knowledge in the epidemiology of TBI, the management of TBI and its secondary medical complications, rehabilitation of cognitive impairment, impact of TBI on community integration and quality of life, incidence of psychiatric dysfunction, and how caregivers and family members are affected. However, there is need to replicate many of these studies using more scientifically rigorous methodologies, while other areas of important TBI research remain largely unexplored.