Special communication| Volume 100, ISSUE 1, P146-155, January 2019

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

Published:September 26, 2018DOI:


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


      List of abbreviations:

      POC (point of care), RTSS (Rehabilitation Treatment Specification System), TIDieR (Template for Intervention Description and Replication)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Page P.
        • Hoogenboom B.
        • Voight M.
        Improving the reporting of therapeutic exercise interventions in rehabilitation research.
        Int J Sports Phys Ther. 2017; 12: 297-304
        • Dijkers M.
        • Kropp G.C.
        • Esper R.M.
        • Yavuzer G.
        • Cullen N.
        • Bakdalieh Y.
        Quality of intervention research reporting in medical rehabilitation journals.
        Am J Phys Med Rehabil. 2002; 81: 21-33
        • Dijkers M.P.
        Reporting on interventions: issues and guidelines for rehabilitation researchers.
        Arch Phys Med Rehabil. 2015; 96: 1170-1180
        • Whyte J.
        • Dijkers M.P.
        • Hart T.
        • et al.
        Development of a theory-driven rehabilitation treatment taxonomy: conceptual issues.
        Arch Phys Med Rehabil. 2014; 95: S24-S32.e2
        • Horn S.D.
        • DeJong G.
        • Smout R.J.
        • Gassaway J.
        • James R.
        • Conroy B.
        Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?.
        Arch Phys Med Rehabil. 2005; 86: S101-S114
        • DeJong G.
        • Horn S.D.
        • Conroy B.
        • Nichols D.
        • Healton E.B.
        Opening the black box of post-stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes.
        Arch Phys Med Rehabil. 2005; 86: S1-S7
        • 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.
        Arch Phys Med Rehabil. 2009; 90: 1269-1283
        • Whiteneck G.1
        • Gassaway J.
        • Dijkers M.
        • Jha A.
        New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project.
        J Spinal Cord Med. 2009; 32: 251-259
        • Horn S.D.
        • Corrigan J.D.
        • Bogner J.
        • et al.
        Traumatic brain injury-practice based evidence study: design and patients, centers, treatments, and outcomes.
        Arch Phys Med Rehabil. 2015; 96: S178-S196.e15
        • Dejong G.
        • Horn S.D.
        • Gassaway J.A.
        • Slavin M.D.
        • Dijkers M.P.
        Toward a taxonomy of rehabilitation interventions: using an inductive approach to examine the “black box” of rehabilitation.
        Arch Phys Med Rehabil. 2004; 85: 678-686
        • Boutron I.
        • Moher D.
        • Altman D.G.
        • Schulz K.F.
        • Ravaud P.
        • CONSORT Group
        Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration.
        Ann Intern Med. 2008; 148: 295-309
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • et al.
        Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; 348: g1687
        • Phillips A.C.
        • Lewis L.K.
        • McEvoy M.P.
        • et al.
        Development and validation of the guideline for reporting evidence-based practice educational interventions and teaching (GREET).
        BMC Med Educ. 2016; 16: 237
        • Slade S.C.
        • Dionne C.E.
        • Underwood M.
        • Buchbinder R.
        Consensus on Exercise Reporting Template (CERT): explanation and elaboration statement.
        Br J Sports Med. 2016; 50: 1428-1437
        • Sohlberg M.M.
        • Kennedy M.
        • Avery J.
        • et al.
        Evidence-based practice for the use of external aids as a memory compensation technique.
        J Med Speech Lang Pathol. 2007; 15: xv-li
        • Powell L.E.
        • Glang A.
        • Ettel D.
        • Todis B.
        • Sohlberg M.M.
        • Albin R.
        Systematic instruction for individuals with acquired brain injury: results of a randomised controlled trial.
        Neuropsychol Rehabil. 2012; 22: 85-112
        • Hart T.
        • Dijkers M.P.
        • Whyte J.
        • et al.
        A theory-driven system for the specification of rehabilitation treatments.
        Arch Phys Med Rehabil. 2019; 100: 172-180
        • Johnson-Laird P.N.
        Mental models in cognitive science.
        Cogn Sci. 1980; 4: 71-115
        • Kragel P.A.
        • Koban L.
        • Barrett L.F.
        • Wager T.D.
        Representation, pattern information, and brain signatures: from neurons to neuroimaging.
        Neuron. 2018; 99: 257-273
        • Goedert K.M.
        • Chen P.
        • Foundas A.L.
        • Barrett A.M.
        Frontal lesions predict response to prism adaptation treatment in spatial neglect: a randomised controlled study.
        Neuropsychol Rehabil. 2018; : 1-22
        • Devan D.
        A novel way of treating mallet finger injuries.
        J Hand Ther. 2014; 27: 325-328
        • Roy N.
        • Leeper H.A.
        Effects of the manual laryngeal musculoskeletal tension reduction technique as a treatment for functional voice disorders: perceptual and acoustic measures.
        J Voice. 1993; 7: 242-249
        • Binder E.F.
        • Brown M.
        • Sinacore D.R.
        • Steger-May K.
        • Yarasheski K.E.
        • Schechtman K.B.
        Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial.
        JAMA. 2004; 292: 837-846
        • Winstein C.J.
        • Miller J.P.
        • Blanton S.
        • et al.
        Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke.
        Neurorehabil Neural Repair. 2003; 17: 137-152
        • Dawson D.R.
        • Gaya A.
        • Hunt A.
        • Levine B.
        • Lemsky C.
        • Polatajko H.J.
        Using the cognitive orientation to occupational performance (CO-OP) with adults with executive dysfunction following traumatic brain injury.
        Can J Occup Ther. 2009; 76: 115-127
        • Roy N.
        • Weinrich B.
        • Gray S.D.
        • Tanner K.
        • Stemple J.C.
        • Sapienza C.M.
        Three treatments for teachers with voice disorders: a randomized clinical trial.
        J Speech Lang Hear Res. 2003; 46: 670-688
        • Tiedemann A.
        • Paul S.
        • Ramsay E.
        • et al.
        What is the effect of a combined physical activity and fall prevention intervention enhanced with health coaching and pedometers on older adults’ physical activity levels and mobility-related goals? Study protocol for a randomised controlled trial.
        BMC Public Health. 2015; 15: 477
        • Carlaw C.
        • Finlayson H.
        • Beggs K.
        • et al.
        Outcomes of a pilot water protocol project in a rehabilitation setting.
        Dysphagia. 2012; 27: 297-306
        • Hsieh M.Y.
        • Ponsford J.
        • Wong D.
        • Schönberger M.
        • McKay A.
        • Haines K.
        Development of a motivational interviewing programme as a prelude to CBT for anxiety following traumatic brain injury.
        Neuropsychol Rehabil. 2012; 22: 563-584
        • Hart T.
        • Brockway J.A.
        • Maiuro R.D.
        • et al.
        Anger self-management training for chronic moderate to severe traumatic brain injury: results of a randomized controlled trial.
        J Head Trauma Rehabil. 2017; 32: 319-331
        • Whyte J.
        • Dijkers M.P.
        • Hart T.
        • et al.
        The importance of voluntary behavior in rehabilitation treatment and outcomes.
        Arch Phys Med Rehabil. 2019; 100: 156-163
        • Wade D.T.
        Goal setting in rehabilitation: an overview of what, why and how.
        Clin Rehabil. 2009; 23: 291-295
        • Sliwa J.A.
        • Makoul G.
        • Betts H.
        Rehabilitation-specific communication skills training: improving the physician-patient relationship.
        Am J Phys Med Rehabil. 2002; 81: 126-132
        • Joosten E.A.
        • DeFuentes-Merillas L.
        • de Weert G.H.
        • Sensky T.
        • van der Staak C.P.
        • de Jong C.A.
        Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status.
        Psychother Psychosom. 2008; 77: 219-226
        • Patti F.
        Optimizing the benefit of multiple sclerosis therapy: the importance of treatment adherence.
        Patient Prefer Adherence. 2010; 4: 1-9
        • Lester R.T.
        • Ritvo P.
        • Mills E.J.
        • et al.
        Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial.
        Lancet. 2010; 376: 1838-1845
        • Jack K.
        • McLean S.M.
        • Moffett J.K.
        • Gardiner E.
        Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review.
        Man Ther. 2010; 15: 220-228
        • Whyte J.
        Contributions of treatment theory and enablement theory to rehabilitation research and practice.
        Arch Phys Med Rehabil. 2014; 95: S17-S23.e2
        • Hart T.
        Treatment definition in complex rehabilitation interventions.
        Neuropsychol Rehabil. 2009; 19: 824-840
        • Waterschoot F.P.
        • Dijkstra P.U.
        • Hollak N.
        • de Vries H.J.
        • Geertzen J.H.
        • Reneman M.F.
        Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review.
        Pain. 2014; 155: 179-189
        • Hayward K.S.
        • Brauer S.G.
        Dose of arm activity training during acute and subacute rehabilitation post stroke: a systematic review of the literature.
        Clin Rehabil. 2015; 29: 1234-1243
        • Cifu D.X.
        • Stewart D.G.
        Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions.
        Arch Phys Med Rehabil. 1999; 80: S35-S39
        • Zbogar D.
        • Eng J.J.
        • Miller W.C.
        • Krassioukov A.V.
        • Verrier M.C.
        Movement repetitions in physical and occupational therapy during spinal cord injury rehabilitation.
        Spinal Cord. 2017; 55: 172-179
        • Roy N.
        Optimal dose-response relationships in voice therapy.
        Int J Speech Lang Pathol. 2012; 14: 419-423
        • Neil-Sztramko S.E.
        • Winters-Stone K.M.
        • Bland K.A.
        • Campbell K.L.
        Updated systematic review of exercise studies in breast cancer survivors: attention to the principles of exercise training.
        Br J Sports Med. 2017;
        • Campbell K.L.
        • Neil S.E.
        • Winters-Stone K.M.
        Review of exercise studies in breast cancer survivors: attention to principles of exercise training.
        Br J Sports Med. 2012; 46: 909-916
      1. Chang S.M. Matchar D.B. Smetana G.W. Methods Guide for Medical Test Reviews. Agency for Healthcare Research and Quality (US), Rockville (MD)2012
        • Kennedy M.R.
        • Coelho C.
        • Turkstra L.
        • et al.
        Intervention for executive functions after traumatic brain injury: a systematic review, meta-analysis and clinical recommendations.
        Neuropsychol Rehabil. 2008; 18: 257-299