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Describing What We Do: A Qualitative Study of Clinicians' Perspectives on Classifying Rehabilitation Interventions

      Abstract

      Objective

      To gain an understanding of clinical thought processes about treatment classification and description, and to identify desired characteristics of and challenges to be addressed by a future rehabilitation treatment taxonomy.

      Design

      Qualitative analysis of data collected via focus groups and semistructured interviews.

      Setting

      Inpatient rehabilitation programs.

      Participants

      Clinicians (N=84) in 7 disciplines involved in data collection for practice-based evidence studies of spinal cord injury and traumatic brain injury rehabilitation.

      Interventions

      Not applicable.

      Main Outcome Measure

      Summary of themes reported by clinicians, determined by content analysis of focus group and interview transcripts.

      Results

      The multifaceted nature of rehabilitation treatment was identified as a major challenge to the process of classifying interventions. Simultaneous delivery of multiple interventions, performance of integrated tasks that challenge multiple body systems, and conversation-based treatments were reported to be difficult to classify. Clinicians reported that treatment classifications that make reference to goals of treatment were clinically intuitive, but they also reported difficulties when attempting to classify activities that could address multiple goals. These rehabilitation practitioners considered the setting in which treatment occurs, equipment used, assistance or cueing provided, type of treatment participants, and specific tasks performed to be important descriptors of their interventions. They recommended creating a classification system that can be applied at greater or lesser levels of detail depending on the purpose for which it is being used.

      Conclusions

      Treatment descriptors identified may be useful for differentiating classes of treatments or characterizing treatments within classes. Precise definition of the concept of the goal as it relates to treatment theory and definition of boundaries between treatments may aid classification of multifaceted treatment activities. A balance between detail and feasibility of use will facilitate successful clinical application of a future classification system.

      Keywords

      List of abbreviations:

      OT (Occupational Therapy), PBE (Practice-Based Evidence), POC (Point of Care), PT (Physical Therapy), RT (Recreation Therapy), RTT (Rehabilitation Treatment Taxonomy), SCI (Spinal Cord Injury), ST (Speech Therapy), TBI (Traumatic Brain Injury)
      A system for classifying rehabilitation interventions is needed to give the rehabilitation field a common language with which to communicate about interventions in clinical practice, billing, education, and research. A number of efforts have been made to systematically describe the nature of interventions provided in rehabilitation. Publications, such as the Guide to Physical Therapist Practice
      • American Physical Therapy Association
      Guide to physical therapist practice.
      and the Occupational Therapy (OT) Practice Framework,
      Occupational Therapy Practice Framework: domain and process.
      • Honaker D.
      The Occupational Therapy Practice Framework.
      • Butts D.S.
      • Nelson D.L.
      Agreement between Occupational Therapy Practice Framework classifications and occupational therapists' classifications.
      • Gutman S.A.
      • Mortera M.H.
      • Hinojosa J.
      • Kramer P.
      Revision of the occupational therapy practice framework.
      have been created by professional organizations to describe the scope and nature of the activities in their practice areas. Several observational research studies have been conducted to describe interventions provided by a number of rehabilitation disciplines, primarily physical therapy (PT),
      • Bode R.K.
      • Heinemann A.W.
      • Semik P.
      • Mallinson T.
      Patterns of therapy activities across length of stay and impairment levels: peering inside the “black box” of inpatient stroke rehabilitation.
      • Alexander H.
      • Bugge C.
      • Hagen S.
      What is the association between the different components of stroke rehabilitation and health outcomes?.
      • van Vliet P.M.
      • Lincoln N.B.
      • Robinson E.
      Comparison of the content of two physiotherapy approaches for stroke.
      • Putman K.
      • de Wit L.
      • Schupp W.
      • et al.
      Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: a comparison between four European rehabilitation centres.
      • Bernhardt J.
      • Chan J.
      • Nicola I.
      • Collier J.M.
      Little therapy, little physical activity: rehabilitation within the first 14 days of organized stroke unit care.
      • Sulch D.
      • Perez I.
      • Melbourn A.
      • Kalra L.
      Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation.
      OT,
      • Bode R.K.
      • Heinemann A.W.
      • Semik P.
      • Mallinson T.
      Patterns of therapy activities across length of stay and impairment levels: peering inside the “black box” of inpatient stroke rehabilitation.
      • Alexander H.
      • Bugge C.
      • Hagen S.
      What is the association between the different components of stroke rehabilitation and health outcomes?.
      • Putman K.
      • de Wit L.
      • Schupp W.
      • et al.
      Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: a comparison between four European rehabilitation centres.
      • Bernhardt J.
      • Chan J.
      • Nicola I.
      • Collier J.M.
      Little therapy, little physical activity: rehabilitation within the first 14 days of organized stroke unit care.
      • Sulch D.
      • Perez I.
      • Melbourn A.
      • Kalra L.
      Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation.
      and speech therapy (ST).
      • Bode R.K.
      • Heinemann A.W.
      • Semik P.
      • Mallinson T.
      Patterns of therapy activities across length of stay and impairment levels: peering inside the “black box” of inpatient stroke rehabilitation.
      • Alexander H.
      • Bugge C.
      • Hagen S.
      What is the association between the different components of stroke rehabilitation and health outcomes?.
      • van Vliet P.M.
      • Lincoln N.B.
      • Robinson E.
      Comparison of the content of two physiotherapy approaches for stroke.
      • Bernhardt J.
      • Chan J.
      • Nicola I.
      • Collier J.M.
      Little therapy, little physical activity: rehabilitation within the first 14 days of organized stroke unit care.
      Still other efforts have been made to develop systematic classification systems to describe interventions provided to patients with specific kinds of conditions, such as stroke
      • Ballinger C.
      • Ashburn A.
      • Low J.
      • Roderick P.
      Unpacking the black box of therapy – a pilot study to describe occupational therapy and physiotherapy interventions for people with stroke.
      • Pomeroy V.M.
      • Niven D.S.
      • Barrow S.
      • Faragher E.B.
      • Tallis R.C.
      Unpacking the black box of nursing and therapy practice for post-stroke shoulder pain: a precursor to evaluation.
      and spinal cord injury (SCI).
      • van Langeveld S.A.
      • Post M.W.
      • van Asbeck F.W.
      • et al.
      Reliability of a new classification system for mobility and self-care in spinal cord injury rehabilitation: the Spinal Cord Injury-Interventions Classification System.
      • van Langeveld S.A.
      • Post M.W.
      • van Asbeck F.W.
      • et al.
      Contents of physical therapy, occupational therapy, and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres.
      • van Langeveld S.A.
      • Post M.W.
      • van Asbeck F.W.
      • et al.
      Comparing content of therapy for people with a spinal cord injury in postacute inpatient rehabilitation in Australia, Norway, and The Netherlands.
      The most extensive efforts yet undertaken to systematically gather data on the type and amount of specific therapies provided in the real world of rehabilitation have occurred in the context of practice-based evidence (PBE) studies conducted in recent years.
      • Horn S.D.
      • Gassaway J.
      Practice based evidence: incorporating clinical heterogeneity and patient-reported outcomes for comparative effectiveness research.
      These large-sample observational studies are intended to open the black box of rehabilitation by identifying and quantifying specific rehabilitation interventions delivered to particular diagnostic categories of patients, and examining associations between these treatments and rehabilitation outcomes, adjusted for multiple case-mix characteristics. To date, PBE methodology has been used to study rehabilitation interventions provided to 4 diagnostic groups: stroke, joint replacement, SCI, and traumatic brain injury (TBI).
      • DeJong G.
      • Hsieh C.H.
      • Gassaway J.
      • et al.
      Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities.
      • Gassaway J.
      • Horn S.D.
      • DeJong G.
      • Smout R.J.
      • Clark C.
      • James R.
      Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results.
      • Whiteneck G.
      • Gassaway J.
      SCIRehab: a model for rehabilitation research using comprehensive person, process and outcome data.
      • Dijkers M.P.
      • Brandstater M.
      • Horn S.
      • Ryser D.
      • Barrett R.
      Inpatient rehabilitation for traumatic brain injury: the influence of age on treatments and outcomes.
      A key component of PBE data collection is point of care (POC) documentation, which is designed by teams of clinicians in each participating discipline. The POC documentation forms are used by frontline clinicians to classify the type and document the duration of interventions provided to their patients during each encounter with the patient (session, nursing shift, etc) over his/her entire hospital stay, and to document other aspects of the rehabilitation process that may influence outcomes. The POC forms contain lists of terms that identify types of interventions or treatment activities with which other information may be associated to provide further description of the treatment (eg, the number of minutes spent performing the activity, what equipment was used [assistive devices, exercise machines, etc], what deficits or therapeutic objectives were being addressed [processing speed, memory, self-esteem, anxiety, balance, endurance, etc], the type of cueing provided [verbal, visual, tactile], and the amount of physical assistance provided [minimal, maximal, etc]). Additional information about the session in general, such as session type (group vs individual), type of session participants (patient only, patient and family, cotreating therapists from other disciplines), and factors impacting the conduct of the treatment session (pain, medical complications, etc), are also documented on the POC forms. Seven disciplines have used POC forms to classify and document their interventions for the 2 most recent PBE studies (which examined SCI
      • Whiteneck G.
      • Gassaway J.
      SCIRehab: a model for rehabilitation research using comprehensive person, process and outcome data.
      and TBI
      • Dijkers M.P.
      • Brandstater M.
      • Horn S.
      • Ryser D.
      • Barrett R.
      Inpatient rehabilitation for traumatic brain injury: the influence of age on treatments and outcomes.
      inpatient rehabilitation): PT, OT, ST, psychology, social work/case management, recreation therapy (RT), and nursing. A series of articles presents detailed information about the content and use of the POC forms for the SCI PBE study (SCIRehab Study).
      • Abeyta N.
      • Freeman E.S.
      • Primack D.
      • et al.
      SCIRehab Project series: the social work/case management taxonomy.
      • Cahow C.
      • Skolnick S.
      • Joyce J.
      • Jug J.
      • Dragon C.
      • Gassaway J.
      SCIRehab Project series: the therapeutic recreation taxonomy.
      • Gassaway J.
      • Whiteneck G.
      • Dijkers M.
      Clinical taxonomy development and application in spinal cord injury research: the SCIRehab Project.
      • Gordan W.
      • Spivak-David D.
      • Adornato V.
      • et al.
      SCIRehab Project series: the speech language pathology taxonomy.
      • Johnson K.
      • Bailey J.
      • Rundquist J.
      • et al.
      SCIRehab Project series: the supplemental nursing taxonomy.
      • Natale A.
      • Taylor S.
      • LaBarbera J.
      • et al.
      SCIRehab Project series: the physical therapy taxonomy.
      • Ozelie R.
      • Sipple C.
      • Foy T.
      • et al.
      SCIRehab Project series: the occupational therapy taxonomy.
      • Wilson C.
      • Huston T.
      • Koval J.
      • Gordon S.A.
      • Schwebel A.
      • Gassaway J.
      SCIRehab Project series: the psychology taxonomy.
      Although previous efforts to systematically document and classify the types of interventions provided in rehabilitation have contributed to our understanding of the rehabilitation process, none intended to produce a comprehensive classification system that is inclusive of all disciplines that collaborate in the rehabilitation process and all interventions that are provided to the various patient populations seen in rehabilitation. Furthermore, past classification systems have not used treatment theory as a basis for their design and nomenclature. A theory-driven classification system would aid the conduct of research to better understand the mechanisms and effects of treatment, would support efforts to train new clinicians, and would explicate the rationale underlying rehabilitation interventions to audiences within and beyond the rehabilitation field. An extensive discussion of the current state of rehabilitation treatment classification and the need for a theory-driven rehabilitation treatment taxonomy (RTT) is presented elsewhere.
      • Dijkers M.P.
      • Hart T.
      • Tsaousides T.
      • Whyte J.
      • Zanca J.M.
      Treatment taxonomy for rehabilitation: past, present, and prospects.
      With support from the National Institute on Disability and Rehabilitation Research, an effort is currently underway to develop a comprehensive theory-driven classification of rehabilitation interventions that can be used across disciplines and specialty areas.
      • Dijkers M.P.
      • Hart T.
      • Tsaousides T.
      • Whyte J.
      • Zanca J.M.
      Treatment taxonomy for rehabilitation: past, present, and prospects.
      Rehabilitation clinicians are among the most important potential end users of a future RTT. To create a system that meets their needs, it is desirable to include their perspectives in the development process. However, most clinicians do not have extensive experience in the classification of rehabilitation interventions in daily practice. Fortunately, the initiation of the RTT development effort coincided with the conduct of the PBE studies focused on SCI
      • Whiteneck G.
      • Gassaway J.
      SCIRehab: a model for rehabilitation research using comprehensive person, process and outcome data.
      and TBI.
      • Dijkers M.P.
      • Brandstater M.
      • Horn S.
      • Ryser D.
      • Barrett R.
      Inpatient rehabilitation for traumatic brain injury: the influence of age on treatments and outcomes.
      Although the classification systems used in these and other PBE studies were not theory driven and are likely to differ greatly from the future RTT, the conduct of these studies produced a cohort of clinicians with extensive experience in treatment classification. The process of completing POC forms required clinicians to think about the treatment activities performed in a given session, identify the number and classify the type of treatments they delivered, and match those activities to appropriate categories on the POC forms. Such a process mirrors what will ultimately be required in the clinical application of the RTT currently under development. The aspects of the POC forms that clinicians found helpful (including the nature of the terminology used to describe treatments) and the challenges they encountered when trying to classify their interventions using these forms will reveal characteristics of a future classification system that are likely to be considered acceptable by clinicians and highlight issues that will need to be addressed to facilitate clinical adoption of a future RTT. Thus, clinicians who participated in the PBE studies are uniquely knowledgeable about attempting to classify rehabilitation in the real world, and their experiences are likely to offer insights to those involved in the creation of a clinically relevant RTT.
      The qualitative study described herein aimed to distill the collective wisdom of these clinicians by seeking their feedback on experiences classifying and describing their daily treatment activities in the context of the PBE studies. The objectives of the current investigation were to gain an understanding of clinical thought processes about treatment classification and description, and to identify desired characteristics of and challenges to be addressed by a future RTT.

      Methods

       Participants

      Physical therapists, occupational therapists, speech therapists, psychologists, social workers, recreation therapists, and nurses who participated in data collection for the SCIRehab
      • Whiteneck G.
      • Gassaway J.
      SCIRehab: a model for rehabilitation research using comprehensive person, process and outcome data.
      and TBI-PBE
      • Dijkers M.P.
      • Brandstater M.
      • Horn S.
      • Ryser D.
      • Barrett R.
      Inpatient rehabilitation for traumatic brain injury: the influence of age on treatments and outcomes.
      studies were invited to participate in the project. Invitations to participate were shared via e-mail, flyers, and communications with clinical supervisors. Participants were recruited from 8 centers: Mount Sinai Medical Center, Shepherd Center, Rehabilitation Institute of Chicago, Ohio State University, Craig Hospital, Carolinas Rehabilitation, Medstar National Rehabilitation Hospital, and Brooks Rehabilitation Hospital. Efforts were made to include both novice and experienced users of the POC documentation forms, and those clinicians who participated in the development of the forms. A total of 84 clinicians (37 TBI, 47 SCI) from a variety of disciplines (table 1) participated in this study, which underwent institutional review board review prior to subject recruitment and was considered exempt by the Mount Sinai Institutional Review Board.
      Table 1Education and experience of focus group participants
      Specialty Area and DisciplinenHighest Level of Education (%)Years of Experience, Median (range)
      BachelorsMastersDoctorateIn RehabilitationIn SCI/TBI Specialty Area
      SCI
       PT182839338 (2–30)4 (1–25)
       OT7435705 (2–30)3 (1–30)
       ST30100015 (6–18)5 (2–8)
       PSY40505012 (2–22)11 (1–22)
       SW617
      Percentages do not add up to 100% because of missing data.
      67
      Percentages do not add up to 100% because of missing data.
      0
      Percentages do not add up to 100% because of missing data.
      10 (1–21)7 (1–21)
       RT650
      Percentages do not add up to 100% because of missing data.
      33
      Percentages do not add up to 100% because of missing data.
      0
      Percentages do not add up to 100% because of missing data.
      4 (1–6)2 (1–3)
       NU333
      Percentages do not add up to 100% because of other degree types.
      Percentages do not add up to 100% because of missing data.
      008 (6–9)4 (2–6)
      TBI
       PT8050504 (2–10)2 (1–5)
       OT7297105 (1–24)3 (1–15)
       ST8088
      Percentages do not add up to 100% because of missing data.
      06 (4–22)6 (3–12)
       PSY7014862 (1–21)2 (1–21)
       SW5010007 (1–15)5 (1–15)
       RT2100004 (2–6)2 (1–2)
      All clinicians842052216 (1–30)4 (1–30)
      Abbreviations: NU, nursing; PSY, psychology; SW, social work.
      Percentages do not add up to 100% because of missing data.
      Percentages do not add up to 100% because of other degree types.

       Data collection

      Clinician feedback was gathered through a combination of focus groups and 1-on-1 interviews. Twenty-five focus groups (involving 77 participants) were conducted by conference call to enable clinicians from centers in a variety of geographic locations to participate. Each call was approximately 2 hours in length. Separate conference calls were held for each rehabilitation discipline and diagnostic specialty area (TBI vs SCI). Calls were structured in this way so that participants would have a common basis for discussion, having used the same type of POC form to classify and describe their interventions. In situations where a clinician wished to participate in the project but could not attend any of the scheduled conference calls, a 1-on-1 telephone interview was conducted instead (7 interviews). All discussions were moderated by the first author (J.M.Z.). Discussion questions to guide the focus groups/in-depth interviews were developed based on an extensive prior review of the PBE study POC forms and their accompanying instructions, feedback provided to the first author by clinicians with whom she worked locally on PBE study data collection, and members of the RTT project team. Discussion questions were presented to focus group/interview participants during the conference calls/interviews via a web-based meeting interface to elicit discussion on the topics of interest. Discussion topics included features of the POC that participants found to be helpful, challenges encountered when trying to classify and describe interventions using the POC forms, features they would like to see in a future classification system (including those needed to enable another practitioner to reproduce a given treatment session), and the extent to which the POC documentation matched the ways in which participants thought about their interventions. Additional questions were asked as needed to explore issues raised during discussion. During focus group discussions, the moderator presented a summary of her understanding of the ideas expressed, and focus group members were provided an opportunity to affirm agreement with the summary or offer corrections as needed. Discussions were recorded and were transcribed by a third-party transcription service. The lead author and a research assistant who was present for the discussions reviewed the transcripts for completeness and accuracy by comparing them to the audio recordings.
      Prior to the focus groups or interviews, participants completed a brief questionnaire to provide information about themselves, including years of experience in rehabilitation, years of experience in their specialty areas, and frequency and duration of POC form use in the PBE studies.

       Data analysis

      The first author (J.M.Z.) served as the primary coder. A subset of transcripts was reviewed to identify high-level themes emerging from the data, which were documented using an open coding process, which was facilitated by the use of qualitative data management software.a These initial codes were reviewed to identify areas of overlap, collapse codes where needed, and develop working definitions of the content to be included at each high-level coding node. The initial transcripts were then recoded with newly defined nodes, and content within each node was examined to identify subthemes, which underwent a similar process of review, redefinition, and recoding. Coding of additional transcripts proceeded using the high-level codes and subthemes, with additional codes added as needed to reflect new themes arising from the discussions. All transcripts were read completely; detailed coding of transcripts continued until no new themes or subthemes could be identified in the transcripts reviewed (indicating that saturation was achieved). Those transcripts not coded in detail (5 transcripts) were reviewed for illustrative quotations or examples to include in the presentation of findings. To aid the presentation of findings, quotations were edited on a limited basis to remove content that did not convey meaning (repeated words, stutters) or focus on the key content. In quotations, we use… to note removal of such extraneous content. Square brackets are used in quotations to supply words omitted by the speaker.

      Results

       Participant characteristics

      A master's degree was the most common level of education in the group (52%) (see table 1). The sample was diverse with respect to years of rehabilitation experience (range, 1–30y; median, 6y) and years of specialization in SCI or TBI rehabilitation (range, 0.5–30y; median, 4y). Participants had 5 months' to 2 years' experience documenting interventions for the PBE studies. The TBI PBE study started data collection approximately 1 year after the SCIRehab study; therefore, the TBI clinicians had less experience completing POC documentation than their SCI counterparts (≤1y vs 1–2y).

       Discussion themes

       THEME 1: The goal of treatment is an important consideration in treatment description and classification

      Review of the POC documentation forms prior to the focus groups showed that many terms on the POC forms made reference to the deficit or functional area being addressed, either as part of the treatment's name or as a descriptive detail that could be associated with the treatment type. Examples of such terms included “upper body dressing,” “gait,” “transfers,” “sentence production,” “attention,” “processing speed,” “anxiety,” “depression,” among others. Participants were asked about this goal-oriented language (language that makes reference to what the clinician was trying to address with treatment) and what they found helpful about it during the process of classifying their treatments using the POC forms. Participants' comments touched the following subthemes.

       Theme 1A: Goal-oriented naming and description of treatments fits well with the way clinicians think about their interventions

      Many participants indicated that grouping or naming treatment activities in terms of their goals was clinically intuitive and fit naturally with the way they think about their treatments when identifying types of treatments provided. They described a thought process that flowed from patient deficits to treatment goals to interventions.For me, [the POC documentation] mirrors pretty closely how I think about my own [clinical] documentation because the form allows you to identify what's the target for why you're seeing the patient. It allows you to choose the skilled interventions that are being used to address that target or problem and it allows you to track what you've done to directly impact the patient… –TBI Psychologist…I do think about “why did I do that activity?” I did it because I wanted to strengthen whatever…I guess it's a quick way for me to think, okay, “What did I do?” and “Why did I do it?”…I was playing toss, catch and release or whatever with my patient, but I was doing that because of balance. So I'll go to the balance section [of the POC form] and put it under there. I think that for the most part, those categories—it's logical for me. It makes sense why they're described that way. –SCI Occupational TherapistI'm used to thinking about what deficits I want to address and then thinking about how I want to address them rather than the other way around. –TBI Speech Therapist
      Some participants also felt that goal-oriented naming of treatments was self-explanatory and that fellow clinicians would be able to picture what was happening in a session because the goal-oriented treatment name would suggest the kinds of activities being worked on and what was being asked of the patient.Balance training—OK, it's not specific—but we know that there is a balance deficit and, you know, balance training is pretty straightforward in terms of what your objectives are… So I think in that sense at least it's straightforward, even if it's not fully descriptive of what you’re doing. –TBI Physical Therapist
      Some of the POC forms allowed clinicians to associate activities being performed in therapy (reading, doing puzzles, route finding, etc), with the functional areas thought to be improved via those activities (memory, orientation, coordination, etc). Several participants reported trying to address multiple deficits at once with a single treatment activity and found the ability to link problem areas and activities to be helpful in describing their interventions.A lot of times we can use the same activity to address various different deficits… We could do math problems as an attention task. We could do math problems to actually work on problem solving and math, or we could do math problems to work on working memory… A lot of times we are addressing multiple deficits with one activity, so it's nice to be able to list everything. –TBI Speech Therapist
      Several participants expressed a desire for a future classification system to allow deficits and interventions to be associated with one another, and to consider the goal of treatment in the naming and organization of treatments within the system.

       Theme 1B: The use of goal-oriented language in treatment naming and classification assists in the evaluation and justification of treatment plans

      Some participants found it beneficial to define treatments in terms of their goals to provide justification for their treatments. They felt it was important to stay goal-oriented in their treatment descriptions, to make it clear to patients and families why a particular activity is important for them, and avoid issues with reimbursement (given the need to document medical necessity).I think our facility right now is very focused on documentation and documenting goals for medical necessity and that kind of thing, so having something that helps to back up what you're doing in terms of—transfers is a big category, [for example]—you more than likely have a transfer goal so you can document how you're working toward that goal. –TBI Physical Therapist
      Some participants also felt that classifying or naming treatments based on their goals helped them evaluate the extent to which their treatment plans are addressing important goals.It may help just increase awareness of how comprehensive your plan of care is. Surveying all of the topics and just keeping in mind an area that maybe [you've] gotten stuck focusing on to the extent that you're not addressing something else. –SCI Physical TherapistI think that does help when we go to do documentation and we are thinking about—“OK, what goals am I achieving”—running it through your head even though you know this patient in and out and you work with them every day. It does make you think about every day and also just really realize what areas you are treating and touching on. –TBI Recreation Therapist

       THEME 2: The multifaceted nature of treatment creates challenges when attempting to classify rehabilitation interventions

      When asked about types of treatment situations that were challenging to classify, participants often referred to their tendency to be flexible during sessions and to address many problems at once. They described interventions that were challenging to classify as “multifaceted,” “fluid,” “mixed,” “intertwined,” “holistic,” “overlapping,” “paired with other things,” “go with the flow,” “multitasking,” “package,” “embedded,” and “[not] linear.”
      The examples participants provided of these multifaceted treatment situations fell into 3 categories. First were separate but simultaneous activities in which 2 treatment activities that can otherwise stand alone are being conducted at the same time.For instance, I might have somebody on the mat and I might be heating them, having a prolonged stretch, and then doing education. I could have e-stim running and all this stuff is happening at once… –SCI Occupational TherapistYou have somebody in the standing frame and they're working on upright tolerance, but they're also working on upper body strengthening. –SCI Physical Therapist
      Second were integrated activities, activities that require the patient to use multiple body systems simultaneously or to perform multiple tasks in a coordinated way. Such activities were reported to be used to increase the demands placed on the patient or to provide a means of addressing multiple deficits with a single activity.…I'm having them read signs while they're walking. Or maybe holding a cup of water while they're ambulating or [I'm] having them throw a ball back and forth while they're walking. –TBI Physical Therapist…I have somebody in the kitchen and they have a weak side and a stronger side, so I might have them standing in the kitchen with their weaker side in a weight bearing [position] on the counter and then I might have them doing something with their stronger side, some fine motor—stirring or opening a package… I'm working on balance. I'm working on fine motor… There's lots of different areas that I could say that I was working on. –SCI Occupational TherapistThe other day we were working on standing and sitting balance, but at the same time we were playing a game that was working on cognition. So, he had to work on both at the same time. –TBI Occupational TherapistLet's say we take a patient on an outing and the outing is to a restaurant. You know collectively we're looking at social interaction and multiple cognitive goals but we might also, because we're at a restaurant and our patient is on a dysphagia diet, be addressing swallowing during the actual meal. –TBI Speech Therapist
      Third were conversation-based interventions, verbal education, or counseling interactions that used multiple approaches, covered multiple topics, or were given in bits and pieces throughout the day.Every time I interact with the patient and am doing some education, I don't sit down and say, okay, I'm going to go in and do education for 10 minutes. It flows more organically. A new medication has been started, so you go in and you talk with them for a couple of minutes and do some teaching. Or the spouse is having problems with wheelchair management, so we spend 10 or 15 minutes… working on the chair. –SCI NurseI take patients to a disability resource center and educate them about community resources. But at the same time, we're talking about funding and I [am] also doing education on everything from the types of wheelchairs… to funding resources to specific teams or clubs that they can join in their community… So, in my documentation, it might [be] really vague that I just did education with them. But there were 5 different types [of education] that I did. –SCI Recreation TherapistThat's the way therapy is, though… It is mixed. And it's easier when I'm just doing an assessment, like testing—certainly that's more clear. But often after the initial evaluation, I'm both doing the psychotherapy and some of the [time] evaluating cognition as well. –TBI Psychologist
      Several participants described the need to “break down” or “separate out” their treatments in order to classify them using the POC forms, and found that to be challenging.…I feel like we're trained as therapists to think holistically, so when we approach a session, that's the way we approach it. We're not just trying to get one thing accomplished at once. We're trying to get as much [done] as we possibly can do at once. So, there might be 3 things going on… You're starting a therapy session with multiple things in your mind that you want to accomplish and then at the end of the session, you have to sit down and break it down and almost simplify your thinking. –SCI Occupational TherapistEven if you're working on cognition you're working at multiple things at the same time, like orientation, memory, attention… all of that can be wrapped up, and you can't really separate them out as well. –SCI Speech TherapistI mean, often I do cognitive remediation embedded in the therapy and… I'll [be] asking them questions about their lives and they're really memory exercises. But then they’ll start talking about something that brings up emotion. And sometimes it's hard to parse out how much time exactly is spent on one or the other… –TBI Psychologist
      Several participants described situations where they had difficulty classifying a treatment that they perceived to address multiple goals.…There have been times when I've done things and they're sort of multifaceted, like when I'm doing tenodesis training. I'm doing it within an ADL [(activities of daily living)] activity and it's like, where should I put it? [Under the ADL heading or under tenodesis?] When I've talked to [our lead clinician] about that, she's like, “What was the main reason you were doing this?” And the problem is, as a therapist, I oftentimes don't have a main REASON. I have main REASONS. –SCI Occupational Therapist

       THEME 3: Similar activities used to address different therapeutic goals may differ in observable characteristics

      In the course of discussions about the multifaceted nature of treatment, participants identified a number of situations in which a given activity (painting, standing, singing, cooking, etc) could be used in different ways to address different therapeutic goals. Examples provided by participants are presented in table 2. In follow-up to these comments, participants were asked how a particular activity might look different to an observer if it was being used for one purpose or another. Participants identified a variety of aspects of the setup of the task and of cueing or feedback provided that might differ. They also indicated that the way in which an activity might be progressed from session to session would likely also differ when that activity was being used for one purpose versus another.
      Table 2Examples of treatment activities used for different therapeutic purposes
      Treatment ActivityPurpose 1 and Associated CharacteristicsPurpose 2 and Associated Characteristics
      SingingAttention
      • Might have a timer and cue the patient that the goal is to sing for at least 1min
      • Number of minutes would increase from session to session
      Voice production
      • Cues to patient might relate to volume, setting goal to hear a voice instead of a whisper for at least 2 words out of this line of lyrics
      Meal preparation/cookingCognition
      • Might begin by taking patient through task multiple times with maximal verbal cues
      • Would give fewer and fewer cues to “wean [patient] off” therapist's assistance and transition patient to a checklist that he/she can use as a tool for completing the task
      • Focus might be on following directions
      Physical functioning
      • Focus would be on remaining upright
      • Might cue patient to hold pot and mix without leaning on anything to make the activity more physically challenging
      PaintingTrunk balance
      • For patient with paraplegia, might place painting supplies and paper farther away so that patient must reach for them, providing a balance challenge
      Cervical range of motion
      • For patient with tetraplegia, might place paper and paint in locations that require more turning of head as a means of working on cervical range of motion
      StandingPregait
      • Weight shifting within base of support
      • Therapist may be providing physical support (eg, “blocking” the weak knee to help keep the patient upright)
      • Therapist might be giving cues to patient about what muscles to activate, “telling them what to do”
      Balance
      • Weight-shifting activities that require patient to move outside base of support
      • Might be standing or sitting on a compliant surface (foam, soft mattress)
      • Might be standing in single limb or tandem stance
      • Therapist's hands-on assistance would be relatively minimal, guarding the patient or providing light contact to “steady” him/her
      • Therapist might be doing things to try to “throw off” the patient to increase the level of challenge (eg, providing perturbations, verbally distracting the patient)

       THEME 4: Many details are considered important for complete treatment description

      Participants were asked to describe the kinds of information that they felt would be needed to describe a treatment well, particularly the kinds of details that would be needed to allow another clinician to reproduce what they did in a session. Between them, the participants proposed an extensive list of treatment details (table 3), including aspects of the physical or temporal setting of treatment, use of equipment, cueing or assistance provided, type of participants in the treatment session, tasks being performed, how tasks are modified in response to patient performance, and others. These details appear to include a mixture of descriptors that characterize the treatment type, the characteristics of those to whom treatment is given, how the treatment is progressed over time, and the context in which the treatment is delivered.
      Table 3Treatment descriptors identified by participants
      Topic of DescriptorDescriptor Examples
      Physical setting/arrangement of treatment
      • Physical context or location (bedside, office, community, other location within hospital, garden, supermarket, etc)
      • Individual vs group session, size of group
      • Surface on which the treatment is taking place (level, ramp, stairs—specify height, pliable or shifting surface, therapeutic ball, etc)
      • Position of surface (eg, elevated or not)
      • Position of patient (supine, sidelying, supported on wedge, single limb stance, tandem stance, etc)
      • Location/body part/body structure at which treatment is being applied
      • Position of therapist relative to patient
      • Level of stimulation in the environment (quiet, distracting noises present, etc)
      Temporal setting/organization of treatment
      • Time of day treatment is given
      • Length of treatment
      • Frequency of treatment
      • Number of repetitions of task within treatment session
      • Sequencing of tasks or subtasks
      Equipment being used
      • Adaptive/assistive devices (cuffs, braces, etc)
      • Gym machines (rickshaw, wall pulleys, etc)
      • Weights, bands, and others to provide resistance
      • Other “accessories”—timer, mirror
      Assistance or cueing (presence, frequency/amount, and content)
      • Tactile cueing or facilitation
      • Verbal cueing (includes verbalizing the task, may include asking questions or giving multiple choice answers, specific instructions/commands given to patient during functional or other activity)
      • Visual cueing (gesturing, demonstration)
      • External feedback (mirror, tape lines, borders on sides of page, etc)
      • Amount of patient effort vs clinician effort
      • Extent to which patient is directing the activity
      • Whether self-support or external support is allowed/provided (eg, is the patient allowed to use his/her arms during a seated balance task)
      Treatment participants
      • Recipients of treatment (patient only, caregivers with patient, caregivers only)
      • Nature of participation of recipients (observation, hands-on training, return demonstration)
      • Involvement of other clinicians, peer mentors
      • Nature of patient's deficits
      Specific task being performed
      • Task descriptions: picking up cones, mopping floor, folding laundry, naming types of animals, performing a particular exercise
      • Nature of compensatory strategy being used (internal vs external)
      • Whether the patient is performing simultaneous activities (sitting while doing an upper extremity task vs sitting statically; walking vs walking while carrying something)
      How tasks may be modified based on performance or abilities of patient
      • Using a simulated task rather than a real one (real fishing vs casting practice indoors)
      • Simplifying task in response to poor performance (shifting to smaller denominations in a money counting task if having difficulty with larger denominations)
      Treatment approach
      • Examples included proprioceptive neuromuscular facilitation, Bobath, supportive, behavioral

       THEME 5: A comprehensive yet flexible classification system is desired

      Participants provided feedback about the scope of a future RTT, including the level of detail it should contain and the extent to which it should include interactions that do not directly involve the patient. The following recommendations were shared.

       Theme 5A: Balance need for detail with feasibility of use

      Participants expressed mixed feelings about the level of detail that should be present in a future system for classifying rehabilitation interventions. Many participants felt that too much detail would consume time and complicate the classification process by requiring them to review many codes to find the one that best fit their treatment intervention. However, many participants felt that too little detail would not allow them to describe their treatments well, would provide insufficient information to allow another clinician to reproduce the treatment, and would make it more difficult for them to show how treatments progressed over time. In general, participants felt that a taxonomy should include as much detail as is feasible but that the level of detail used in each instance should depend on the application of the taxonomy.I think it just depends on what the goal of the classification system is. If you truly want to be able to reproduce a treatment session then I mean the more detail the better… I think that in an ideal world if it didn't matter how much time we spent doing these [POC forms] and we weren't seeing a whole patient case load and doing documentation in addition to this, then I think that it would have been beneficial in the long run to have more detail… However, in reality we ended up having to collapse the interventions so that it was more practical. –TBI Occupational Therapist
      Participants recommended that a classification system (1) subdivides broader categories whenever possible; (2) separates more complex tasks into components; (3) be capable of describing treatments in detail; and (4) be flexible, allowing different levels of detail to be captured depending on the application.

       Theme 5B: Include nonpatient interactions

      Participants emphasized the importance of family or caregiver training in their treatment plans, and felt it was very important that the classification system be able to address interventions directed to family or other caregivers.…Caregivers and family members have a huge influence on patient's progress. They can either help it or hinder it tremendously… Sometimes, family members will come to some of the groups that I do, like that wheelchair maintenance group, and I'll educate them the same way as the patient, too, because they need to know how to break down the chairs and diagnose problems and make repairs. –SCI Recreation TherapistI also think that when you look at outcomes and the importance of the family in their contribution to the patient being successful… they are a necessary part of the patient's ability to recover and to become less disabled or handicapped so to speak out in the community… Like with the minimally conscious patients, there are families that are adamant that they are taking these patients home. And so the only individuals you can have any type of intervention with is the family. You have to train them to be able to care for this type of patient in a home setting and then they're successful keeping the patient at home and out of …[an] institutionalized setting. –TBI Psychologist
      Many participants expressed that they spend a significant amount of time communicating with other team members and that interdisciplinary collaboration is an important part of the rehabilitation process.In particular, capturing… formal things like team conference or the team meetings where you're actually doing collective case formulation and treatment plan development versus the informal [meeting] where you're pulled aside in a hallway [when] a therapist is asking you what's the best way to manage this behavior when it occurs… It's a rich environment to show the benefits of multiple disciplines working together that you don't get… consistently in most other environments other than rehab. –TBI Psychologist
      When asked if such interactions belonged in the RTT, many participants agreed that these communications were not treatment per se, but they expressed a desire for these efforts to be captured somehow.I think that the reason it does belong there is because the focus of what we do is so interdisciplinary and so team oriented that I don't see how we could even know what to do unless we had those team meetings… I just feel like [in these meetings] you're so directly impacting treatment. That doesn't say whether or not it is treatment… I have a hard time thinking that I could totally remove that. –TBI Social Worker/Case Manager

      Discussion

      The implications of the participants' comments for the future development of an RTT are subsequently discussed, organized by the major themes that were discovered.

       THEME 1: The goal of treatment is an important consideration in treatment description and classification

      In the PBE studies and in other recent efforts to develop classification systems for rehabilitation interventions,
      • Bode R.K.
      • Heinemann A.W.
      • Semik P.
      • Mallinson T.
      Patterns of therapy activities across length of stay and impairment levels: peering inside the “black box” of inpatient stroke rehabilitation.
      • Putman K.
      • de Wit L.
      • Schupp W.
      • et al.
      Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: a comparison between four European rehabilitation centres.
      • Bernhardt J.
      • Chan J.
      • Nicola I.
      • Collier J.M.
      Little therapy, little physical activity: rehabilitation within the first 14 days of organized stroke unit care.
      • Sulch D.
      • Perez I.
      • Melbourn A.
      • Kalra L.
      Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation.
      • Ballinger C.
      • Ashburn A.
      • Low J.
      • Roderick P.
      Unpacking the black box of therapy – a pilot study to describe occupational therapy and physiotherapy interventions for people with stroke.
      • Pomeroy V.M.
      • Niven D.S.
      • Barrow S.
      • Faragher E.B.
      • Tallis R.C.
      Unpacking the black box of nursing and therapy practice for post-stroke shoulder pain: a precursor to evaluation.
      • van Langeveld S.A.
      • Post M.W.
      • van Asbeck F.W.
      • et al.
      Reliability of a new classification system for mobility and self-care in spinal cord injury rehabilitation: the Spinal Cord Injury-Interventions Classification System.
      • van Langeveld S.A.
      • Post M.W.
      • van Asbeck F.W.
      • et al.
      Contents of physical therapy, occupational therapy, and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres.
      • van Langeveld S.A.
      • Post M.W.
      • van Asbeck F.W.
      • et al.
      Comparing content of therapy for people with a spinal cord injury in postacute inpatient rehabilitation in Australia, Norway, and The Netherlands.
      the functional domain or problem area being addressed by the treatment has been used as a means of naming treatment types and/or defining treatment categories—a phenomenon referred to earlier as using goal-oriented language. This qualitative study provided an opportunity to explore some of the reasoning behind the use of such language, and its advantages and disadvantages. Participants felt that using goal-oriented language fit well with their thought processes when making treatment decisions, helped them to explain the relevance and importance of the treatments being delivered to treatment recipients and others, and aided evaluation of treatment plans. However, they faced uncertainties in how best to classify treatment activities that they felt addressed multiple clinical goals, a common occurrence in rehabilitation practice. Given the prominence of treatment goals in clinical thinking, a future taxonomy must allow the goal of treatment to be part of its conceptualization of treatment classes and subtypes if it is to be acceptable to rehabilitation practitioners. However, the concept of goal must be defined in a manner that provides greater certainty in how a particular treatment activity should be classified.
      Our impression from the comments offered by clinicians is that many of them are accustomed—and are likely encouraged—to think broadly about what their treatments will accomplish for the patient, particularly the potential benefits for the patient's functioning at home and in the community. Such a thought process is productive from the standpoint of keeping treatment relevant to the functional needs of patients and in justifying treatment to its recipients and payers, but it appears to complicate treatment classification in systems that use aspects of functioning to define treatment types, particularly in cases where a given treatment could benefit multiple functional domains. In the conceptual framework we have established for the RTT (described in detail elsewhere
      • Whyte J.
      • Dijkers M.P.
      • Hart T.
      • et al.
      Development of a theory-driven rehabilitation treatment taxonomy: conceptual issues.
      ), we emphasize that treatment classification should be based on *treatment theory, which specifies the aspect of functioning that is (hypothesized to be) directly changed by the treatment (referred to as the *treatment target), what the therapist does to create change in that target (*ingredients), and the processes by which the ingredients are thought to create changes in the target of treatment (*mechanism of action).
      • Butts D.S.
      • Nelson D.L.
      Agreement between Occupational Therapy Practice Framework classifications and occupational therapists' classifications.
      • Gutman S.A.
      • Mortera M.H.
      • Hinojosa J.
      • Kramer P.
      Revision of the occupational therapy practice framework.
      (Words and phrases that are specifically defined in supplemental appendix S1 [available on page A9 of this supplement and online at http://www.archives-pmr.org/] are marked with an asterisk and italicized when initially used.) Any aspects of functioning that are indirectly changed by treatment are not relevant to treatment classification. In practice, determining what is changed directly by a given treatment versus what is changed indirectly because of relations between the treatment target and other domains of functioning (the *aim(s) of treatment as specified by *enablement theory) may be challenging to determine in some cases. In principle, though, this approach has the potential to simplify treatment classification by eliminating the need for a clinician to consider all the downstream effects of a given treatment when deciding how it should be classified. Furthermore, by including the target in the definition of treatment type but excluding other, downstream aims of treatment, it is hoped that the conceptual framework balances the desire for goals to be considered in the classification process with a need to clarify how treatments perceived to benefit multiple aspects of functioning should be classified.
      We have further recognized the importance of goals of treatment by defining the first level of *treatment groupings by target domains rather than ingredients or mechanisms of action. This was done to align the treatment groupings with clinical thought patterns, which typically begin with identification of the area of functioning to be improved, then progress to the selection of treatment activities (with ingredients and their assumed mechanisms of action) that are thought to bring about change in that area of functioning. We believe that ingredients will cluster within these target domains in meaningful ways, allowing further subdivisions for various approaches that may be used to bring about change in a particular target domain.

       THEME 2: The multifaceted nature of treatment creates challenges when attempting to classify rehabilitation interventions

      The RTT development team encountered challenges similar to those described by the therapists when attempting to establish rules and guidelines for how multifaceted treatments should be dealt with by the taxonomy. Separate but simultaneous activities (eg, doing bicep curls while in a standing frame) pose less of a challenge from a theoretical standpoint, in that here it is easy to argue that the 2 treatments taking place are addressing very different targets of treatment via different mechanisms—they just happen to be taking place at the same moment for purposes of efficient time use. However, integrated activities, in which different systems or skills are being challenged at the same time, are more challenging to define. Additional careful thought about how integrated activities are varied over time (eg, what aspects are changed to maintain the level of challenge of the treatment activity) may provide insight about the target of treatment, and may then provide guidance about how to classify a given treatment activity. In the example of reading a magazine, one could envision a therapist changing the task over time by requiring the patient to read smaller and smaller type (vision-related target), read for longer and longer periods of time (sustained attention target), or manipulate the magazine with less physical assistance (fine motor target). Thus, depending on how the magazine reading activity is varied over time, it may be used as a delivery vehicle for 3 (or more) different treatments, differentiated by their targets, ingredients, and/or mechanisms of action. The most appropriate ways of classifying conversation-based interventions remain to be determined, and consideration will need to be given to the extent to which classification should be based on the nature of the interaction (didactic instruction via verbal presentation, performance of an exercise promoting self-discovery, etc), rather than specific topics discussed (dietary needs, transportation resources, attitudes toward disability, etc).

       THEME 3: Similar activities used to address different therapeutic goals may differ in observable characteristics

      Within our RTT research group, there has been considerable discussion and uncertainty about when an activity that at various times is being used for 2 purposes becomes 2 different treatments rather than a single treatment with multiple effects (see examples in table 2). Making such a distinction is crucial in determining how a given treatment activity should be classified. Although participants also expressed uncertainty about when an activity used for 2 different purposes becomes 2 treatments rather than one, they were able to describe a number of ways in which a particular treatment activity might be conducted differently when addressing one purpose versus another (see table 2). The ways in which the activity might differ suggest the existence of different *essential ingredients of the activity that are necessary for addressing different targets, and indicate that rehabilitation practitioners can describe how tasks can be manipulated to address different targets of treatment, even if the theories underlying the execution of these activities are not yet clearly articulated.

       THEME 4: Many details are considered important for complete treatment description

      Many of the details that participants felt would be important to document in order to allow another clinician to reproduce the treatment correspond with what we have identified as ingredients of treatment, such as the use of cueing or feedback. The extent to which the details they identified represent essential or active ingredients will depend on how treatment theories are articulated. For example, in one theory, the performance of a task with feedback may be considered essential to its effect on a given target; in another theory, feedback may not be mentioned. Participants indicated that many of the details they identified as being important relate to their perception of task complexity, and will be important to demonstrate progression of treatment over time or perhaps to distinguish different treatment subtypes. However, in discussing aspects of treatment sessions that they said needed to be documented to describe a treatment well (see table 3), rehabilitation practitioners included a number of descriptors that do not address what the treatment is (ie, what was done to improve what) but instead refer to other aspects of the treatment recipients or process, including the patient deficit(s) being treated, whether it was a group or individual session, the amount of assistance the patient required, or the specific activity being performed. Further examination of treatment theories will help to differentiate those descriptors that indicate treatment type (by referring to the target, ingredients, or mechanism of action of a given treatment) from those that are not relevant to treatment classification (but may be needed for in-depth description).
      Participants indicated a desire, in cases where a treatment involves the performance of a task (eg, naming animals, picking up cones), to identify the specific task being performed in order to characterize the treatment. Defining all possible tasks that could be done in treatment is a daunting undertaking, and would result in a taxonomy of considerable complexity. We believe that it is the therapeutic aspect of the task that is most important to its classification, not necessarily the specific task itself. In our conceptual framework, we envision use of bracketed notation
      • Whyte J.
      • Dijkers M.P.
      • Hart T.
      • et al.
      Development of a theory-driven rehabilitation treatment taxonomy: conceptual issues.
      • Dijkers M.P.
      • Hart T.
      • Whyte J.
      • Zanca J.M.
      • Packel A.
      • Tsaousides T.
      Rehabilitation treatment taxonomy: implications and continuations.
      to capture aspects of treatment that may be informative but are not relevant to the classification of treatment type. Such notation may simplify treatment classification by preventing the need to have separate treatment classifications for every possible task, focusing more generally on the aspects of these potential tasks that are therapeutic, but still providing a mechanism for specifying the task for purposes of treatment documentation or reproduction.
      Interestingly, participants listed the deficits of the patient among the details needed to classify or describe the treatment they were receiving. They reported that making reference to the patient's deficits in their treatment documentation conveyed information about what was happening in treatment. We believe that this desire will be addressed, in part, through more specific articulation of treatment theory, including the target of treatment, which would make reference to the aspects of functioning that the treatment is hypothesized to address directly. The treatment theory may also address what faculties and other strengths need to be intact for the treatment to be feasible, perhaps as part of the description of a mechanism of action.
      Greater definition of the essential ingredients of various established treatment approaches (proprioceptive neuromuscular facilitation, Bobath, etc) will be needed to determine how treatments associated with these approaches should be classified.

       THEME 5: A comprehensive yet flexible classification system is desired

      Participants felt strongly that interventions provided to people other than the person with a disability should be included in the taxonomy. The conceptual framework we have established for the RTT recognizes that family members, other caregivers, employers, and others in the social environment of the person with a disability may receive training and education from rehabilitation providers acting on behalf of the person with a disability; therefore, our terminology includes the broader term *recipients of treatment, which includes persons other than the patient who receive rehabilitation interventions.
      The conceptual framework also recognizes interventions that do not directly involve the patient but have therapeutic effects, such as the selection of an assistive device without direct involvement of the patient. However, we have defined the scope of the taxonomy to include treatment only, excluding other activities in which rehabilitation practitioners participate that may also impact rehabilitation outcomes. Among these are consultations with other members of the clinical team that are done for purposes of planning treatment or aiding integrated treatment delivery. These activities may be helpful in avoiding duplication of effort, selecting and prioritizing therapeutic needs, and fine-tuning the treatment; research has associated aspects of team functioning with better rehabilitation outcomes.
      • Strasser D.C.
      • Falconer J.A.
      • Stevens A.B.
      • et al.
      Team training and stroke rehabilitation outcomes: a cluster randomized trial.
      • Strasser D.C.
      • Falconer J.A.
      • Herrin J.S.
      • Bowen S.E.
      • Stevens A.B.
      • Uomoto J.
      Team functioning and patient outcomes in stroke rehabilitation.
      • Strasser D.C.
      • Burridge A.B.
      • Falconer J.A.
      • Herrin J.
      • Uomoto J.
      Measuring team process for quality improvement.
      • Stevens A.B.
      • Strasser D.C.
      • Uomoto J.
      • Bowen S.E.
      • Falconer J.A.
      Utility of treatment implementation methods in clinical trial with rehabilitation teams.
      However, unless these coordination efforts are translated into actual work for and with the patient, they have no treatment effect in and of themselves. As Whyte
      • Whyte J.
      Invited commentary on quality of care indicators for the rehabilitation of children with traumatic brain injury, and quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury.
      has argued, the physical and social structure of the rehabilitation facility only set limits to what can be delivered; actual delivery of effective treatments may or may not take place. Consequently, while team rounds and the many other coordinative activities that are needed to turn a small or large group of individuals into an efficient team may be useful in describing processes, they do not by themselves explain results. In our opinion, consideration should be given to the creation of a separate classification of these activities so that they may be defined and quantified for the purposes of outcomes-oriented research and documenting rehabilitation processes.
      The level of detail that a specific treatment classification will ultimately involve remains to be determined. We recognize that a system that is too difficult to apply will likely not be useful in rehabilitation practice; on the other hand, developers must ensure that sufficient detail is available to enable appropriate treatment classification. It was interesting, however, that participants generally expressed a desire for more detail, rather than less, in a future classification system, indicating a desire to be able to fully describe treatments to “do justice” to the nuances of the decisions they make about how to work with their patients each day. Building a flexible system that allows detail to be provided when needed but enables treatments to be classified efficiently will be important to the successful clinical application of a future classification system.

      Conclusions

      The multifaceted nature of rehabilitation complicates the classification of interventions. It will be important to establish guidelines for determining when multifaceted activities represent multiple treatments versus a single treatment addressing a complex skill. The clinical goal of treatment is featured prominently in clinicians' thinking about treatment classification and description. Redefining the concept of treatment goal to focus what is being changed directly based on treatment theory (rather than areas that may be indirectly changed) may aid the classification process. Clinicians identified a number of possible descriptors of treatment that may be useful for differentiating treatment classes or characterizing treatments within classes. Building a system with sufficient flexibility to provide detail when needed but allows treatments to be classified efficiently will be important in the successful clinical application of a future classification system.

      Supplier

      • a.
        NVivo; QSR International Pty Ltd, 2nd Fl, 651 Doncaster Rd, Doncaster, Victoria 3108, Australia.

      Acknowledgments

      We thank the staff at all participating facilities (Brooks Rehabilitation Hospital, Carolinas Rehabilitation, Craig Hospital, The Mount Sinai Hospital, National Rehabilitation Hospital, Ohio State University, Rehabilitation Institute of Chicago, and Shepherd Center) for their assistance with this project. We also thank the principal investigators of the PBE studies (John Corrigan, PhD, Susan Horn, PhD, Gerben DeJong, PhD, and Gale Whiteneck, PhD) for their permission to use point-of-care documentation forms to prepare for this project, Rebekah Frimpong for her assistance with focus group implementation, Mary Slavin, PT, PhD, for her assistance in developing discussion questions for the focus groups, and our colleagues on the project team (Mary Ferraro, PhD, OTR/L, Tessa Hart, PhD, Andrew Packel, MSPT, Theodore Tsaousides, PhD, and John Whyte, MD, PhD) for their valuable feedback during the conception and revision of this manuscript.

      Supplemental Appendix S1. Glossary of Terms

      Active ingredients – Attributes of a treatment, selected or delivered by the clinician, that play a role in the treatment's effects on the target of treatment. These include the essential ingredients associated with the treatment's known or hypothesized mechanism of action, and any other ingredients that moderate the treatment's effect(s) but may be common to multiple treatments.
      Aim(s) (of treatment) – Aspect(s) of the patient's or other recipient's functioning or personal factors that is predicted to change indirectly (via mechanisms specified in enablement/disablement theory) as a result of the treatment-induced change in the treatment target. A single treatment may have multiple aims, and there may be a chain of treatment aims (eg, exercises leading to increased strength leading to improved ambulation leading to greater community participation) with at least 1 (in the case of treatments delivered to other recipients) involving the patient's functioning. Although highly relevant to the ultimate clinical value of a treatment, these distal treatment aims are not relevant to the definition or classification of the treatment. (As previously noted, when the target of treatment is clinically and functionally significant in its own right, we avoid calling it a treatment aim to avoid confusion about direct vs indirect effects of treatment.)
      Course of treatment – Series of treatment sessions or therapist-recipient contacts that are pursuing change in a specific treatment target, sometimes with some form of treatment progression within or between contacts.
      Dosing parameters – Quantitative variations in the strength, intensity, frequency, and/or quantity of treatment ingredients; these are often expressed as an amount of time during which the recipient is continuously exposed to the ingredient, the number of times a discrete ingredient is administered, or the magnitude of the ingredient on a quantifiable scale.
      Enablement/disablement theory – Conceptual system that specifies how change in one aspect of a patient's functioning (eg, at the level of an International Classification of Functioning, Disability and Health component: body structure, body functioning, activity/activity limitation, participation/participation restriction, personal factor, or environment) will translate into changes in another aspect, specifically a characteristic classified elsewhere in the framework being used.
      Essential ingredients (of a treatment) – Active ingredients, selected or delivered by the clinician, that define a particular treatment and distinguish it from other treatments. The essential ingredients are those that are specified by the corresponding treatment theory, and are hypothesized or known to be necessary for the treatment's effects on the treatment target.
      Inactive ingredients (of a treatment) – Attributes of a treatment that do not define or moderate the impact of the treatment on the target. Ingredients may be presumed to be inactive because they are not addressed by a treatment theory (eg, the building in which the treatment is conducted) or have been empirically determined to be inactive.
      Ingredients – See Treatment ingredients.
      Mechanism of action – Process by which the treatment's essential ingredients induce change in the target of treatment. A treatment theory should specify how the essential ingredients engage mechanisms of action to bring about desired treatment effects, that is, specification of the mechanism of action explains how the essential ingredients alter the treatment target within the framework of the treatment theory. Similarly, additional mechanisms of action specify how other active ingredients moderate the effects of the treatment.
      Nonvolitional treatments – Treatments whose hypothesized mechanisms of action require no effort on the part of the recipient (other than cooperation/nonresistance). Unlike volitional treatments (subsequently defined), the recipient of nonvolitional treatment is always the patient/client undergoing rehabilitation, not a third party (eg, caregiver).
      Patient/client – Person with a disability or at risk of a disability who is the intended beneficiary of treatment.
      Progression – Clinician's deliberate, systematic alteration of the treatment to maintain, over time, the degree of challenge to the body system/behavior(s) selected for change. Progression is often triggered by improvements in the target of treatment; therefore, the pace of progression (within a single treatment contact or a course of treatment) typically depends on the pace of change in the treatment target. The form that treatment progression takes (and hence the nature of the challenge that is being maintained) is often specified by the treatment theory; therefore, multiple treatment sessions may need to be observed to distinguish between one treatment and another.
      Recipient (of treatment) – Individual whose function/behavior is intended to be changed directly as a result of treatment. In most cases this is the person with a disability (patient/client recipient), but in some instances a caregiver or employer may be the other recipient who is changed by the intervention (eg, to provide care or intervention to the patient/client or to create a more supportive environment for the patient/client).
      Rehabilitation treatment taxonomy – System of classifying rehabilitation treatments based on a principle or set of principles that allows for distinctions between treatments, which have practical and/or theoretical utility.
      Session (of treatment) – Individual episode of treatment (typically minutes to a few hours), which may be repeated during a course of treatment.
      Target of treatment/treatment target – Aspect of the recipient's functioning, or personal factor, that is predicted to be directly changed by the treatment's mechanism of action. Specification of the target of treatment in a theory in terms of an International Classification of Functioning, Disability and Health variable(s) helps to define the scope of the treatment/treatment theory. (The aim of treatment refers to changes in functioning obtained in indirect ways—see Aim(s) (of treatment), above. Although there are instances where the target of treatment is functionally important in its own right, without reference to distal enablement effects, we nevertheless reserve the term treatment aim only for the functionally relevant clinical effects that are distal to the treatment target.)
      Taxonomy – System of classification or categorization based on characteristics that have important pragmatic or theoretical implications.
      Treatment – Action taken by a health professional, in the context of contact with a treatment recipient, to alter the functioning of an individual with a disability or at risk of a disability. Treatment is defined broadly to include provision of information, devices, and referrals, specific active experiences, and passive interventions.
      Treatment grouping – Broad class of treatments that is similar in essential ingredients (eg, forms of energy) and is able to act on a class of similar treatment targets (eg, tissue properties).
      Treatment ingredients – Observable (and, therefore, in principle, measurable) actions, chemicals, devices, or forms of energy that are selected or delivered by the clinician. See also Active ingredients, Dosing parameters, Essential ingredients, and Inactive ingredients.
      Treatment theory – Conceptual system that predicts the effects of specific forms of treatment on their targets, specifying the law(s) that expresses the relations between essential ingredients and treatment target changes. (This is similar to Mechanism of action but may be broader and more inclusive.)
      Volitional treatments – Treatments where a hypothesized mechanism(s) of action requires some effort on the part of the treatment recipient.

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