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A Theory-Driven System for the Specification of Rehabilitation Treatments

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Abstract

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

Section snippets

Scope and structure of the RTSS

The RTSS is intended to apply to all rehabilitation treatments administered by clinicians, that is, rehabilitation professionals, from any discipline in any setting or format. The focus of the RTSS is on treatment of the individual patient or another recipient who will interact with an individual patient, such as a family member learning how to administer care, or an employer learning how to adjust his or her behavior to help the patient adapt to his or her work environment. As in the RTT

The rationale for a theoretical structure underlying treatment specification

What do we mean when we say that the RTSS is based on treatment theory, and why do we emphasize theory at all? Rehabilitation is notoriously lacking in theory,14 tending to follow instead a pragmatic, whatever it takes approach. The multiple disciplines collaborating in rehabilitation, each with its own theories focused on specific aspects of care (eg, motor learning, behavior management), have also contributed to the lack of overarching theories for the specialty as a whole. And as discussed

Three groups of treatment components

Because key treatment ingredients (and associated mechanisms of action) do tend to vary systematically among broad classes of targets, we have found it useful to retain the concept of treatment groups, containing mutually exclusive targets, that was introduced in the RTT.7 However, we have collapsed 2 of the previous groups into 1, resulting in the 3 groups depicted in table 2. We have also further elaborated some of the groups and the distinctions among them, as described below.

The Organ

Special considerations for treatment specification

In addition to the increased emphasis on volitional behavior as a target of treatment, the RTSS includes some topics relevant to the distinction between targets and aims of treatment, in several domains often encountered in rehabilitation. One example is societal participation, which is a key concept in the ICF and the ultimate goal of many rehabilitation endeavors. However, many participation goals—employment, parenting, establishing a social network—are so broad that it is very unlikely that

The treatment specification process

In the RTSS we have developed an algorithm for treatment specification, summarized in fig 2. The first step in specification is to determine the number of treatment targets (and corresponding treatment components) to be specified; the process shown in the figure is then applied to each treatment component. Although the details of this process cannot be captured in an article of this length, interested readers may download the entire Manual for Rehabilitation Treatment Specification from //mrri.org/innovations/manual-for-rehabilitation-treatment-specification/

Conclusions

The ultimate worth of the RTSS will be borne out in its uptake by rehabilitation clinicians, researchers, and clinical educators. What could be its major benefits to these users, and to the field as a whole?

This article began by reiterating the problem of the black box. If the contents of rehabilitation are opaque, or if they are enumerated and described in different ways by each practitioner, there can be no meaningful examination of their specific effects on specific aspects of patient

Acknowledgment

We thank the members of our Advisory Board, who provided valuable feedback on the concepts presented here. Research reported in this publication was funded through a Patient-Centered Outcomes Research Institute® (PCORI®) Award (contract number ME-1403-14083). The views, statements, and opinions presented in this publication are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute® (PCORI®), its Board of Governors

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    Supported by Patient Centered Outcomes Research Institute (contract number ME-1403-14083).

    Disclosures: none.

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