Rehabilitation treatment taxonomy: establishing common ground.

This article introduces the Archives supplement presenting a conceptual framework for the creation of a rehabilitation treatment taxonomy (RTT). It describes the key theoretical and empirical articles and their role, and the commentaries that were solicited. More importantly, based on feedback received to date, it sketches what the RTT is proposed to address, and what it explicitly excludes; therefore, the readers will have appropriate expectations and criteria for what is offered.

Contributions of treatment theory and enablement theory to rehabilitation research and practice.

Scientific theory is crucial to the advancement of clinical research. The breadth of rehabilitation treatment requires that many different theoretical perspectives be incorporated into the design and testing of treatment interventions. In this article, the 2 broad classes of theory relevant to rehabilitation research and practice are defined, and their distinct but complementary contributions to research and clinical practice are explored. These theory classes are referred to as treatment theories (theories about how to effect change in clinical targets) and enablement theories (theories about how changes in a proximal clinical target will influence distal clinical aims). Treatment theories provide the tools for inducing clinical change but do not specify how far reaching the ultimate impact of the change will be. Enablement theories model the impact of changes on other areas of function but provide no insight as to how treatment can create functional change. Treatment theories are more critical in the early stages of treatment development, whereas enablement theories become increasingly relevant in specifying the clinical significance and practical effectiveness of more mature treatments. Understanding the differences in the questions these theory classes address and how to combine their insights is crucial for effective research development and clinical practice.

Development of a theory-driven rehabilitation treatment taxonomy: conceptual issues.

Many rehabilitation treatment interventions, unlike pharmacologic treatments, are not operationally defined, and the labels given to such treatments do not specify the active ingredients that produce the intended treatment effects. This, in turn, limits the ability to study and disseminate treatments, to communicate about them clearly, or to train new clinicians to administer them appropriately. We sought to begin the development of a system of classification of rehabilitation treatments and services that is based on their active ingredients. To do this, we reviewed a range of published descriptions of rehabilitation treatments and treatments that were familiar to the authors from their clinical and research experience. These treatment examples were used to develop preliminary rules for defining discrete treatments, identifying the area of function they directly treat, and identifying their active ingredients. These preliminary rules were then tested against additional treatment examples, and problems in their application were used to revise the rules in an iterative fashion. The following concepts, which emerged from this process, are defined and discussed in relation with the development of a rehabilitation treatment taxonomy: rehabilitation treatment taxonomy; treatment and enablement theory; recipient (of treatment); essential, active, and inactive ingredients; mechanism of action; targets and aims of treatment; session; progression; dosing parameters; and social and physical environment. It is hoped that articulation of the conceptual issues encountered during this project will be useful to others attempting to promote theory-based discussion of rehabilitation effects and that multidisciplinary discussion and research will further refine these rules and definitions to advance rehabilitation treatment classification.

Toward a theory-driven classification of rehabilitation treatments.

Rehabilitation is in need of an organized system or taxonomy for classifying treatments to aid in research, practice, training, and interdisciplinary communication. In this article, we describe a work-in-progress effort to create a rehabilitation treatment taxonomy (RTT) for classifying rehabilitation interventions by the underlying treatment theories that explain their effects. In the RTT, treatments are grouped together according to their targets, or measurable aspects of functioning they are intended to change; ingredients, or measurable clinician decisions and behaviors responsible for effecting changes; and the hypothesized mechanisms of action by which ingredients are transformed into changes in the target. Four treatment groupings are proposed: structural tissue properties, organ functions, skilled performances, and cognitive/affective representations, which are similar in the types of targets addressed, ingredients used, and mechanisms of action that account for change. The typical ingredients and examples of clinical treatments associated with each of these groupings are explored, and the challenges of further subdivision are discussed. Although a Linnaean hierarchical tree structure was envisioned at the outset of work on the RTT, further development may necessitate a model with less rigid boundaries between classification groups, and/or a matrix-like structure for organizing active ingredients along selected continua, to allow for both qualitative and quantitative variations of importance to treatment effects.

Rehabilitation treatment taxonomy: implications and continuations.

In relation to the conceptual framework for a rehabilitation treatment taxonomy (RTT), which has been proposed in other articles in this supplement, this article discusses a number of issues relevant to its further development, including creating distinctions within the major target classes; the nature and quantity of allowable targets of treatment; and bracketing as a way of specifying (1) the skill or knowledge taught; (2) the nature of compensation afforded by changes in the environment, assistive technology, and orthotics/prosthetics; and (3) the ingredients in homework a clinician assigns. Clarification is provided regarding the role of the International Classification of Functioning, Disability and Health, focusing a taxonomy on ingredients versus other observable aspects of treatment, and regarding our lack of knowledge and its impact on taxonomy development. Finally, this article discusses the immediate implications of the work to date and presents the need for rehabilitation stakeholders of all disciplines to be involved in further RTT development.

Describing what we do: a qualitative study of clinicians' perspectives on classifying rehabilitation interventions.

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.

Treatment taxonomy for rehabilitation: past, present, and prospects.

The idea of constructing a taxonomy of rehabilitation interventions has been around for quite some time, but other than small and mostly ad hoc efforts, not much progress has been made, in spite of articulate pleas by some well-respected clinician scholars. In this article, treatment taxonomies used in health care, and in rehabilitation specifically, are selectively reviewed, with a focus on the need to base a rehabilitation treatment taxonomy (RTT) on the "active ingredients" of treatments and their link to patient/client deficits/problems that are targeted in therapy. This is followed by a description of what we see as a fruitful approach to the development of an RTT that crosses disciplines, settings, and patient diagnoses, and a discussion of the potential uses in and benefits of a well-developed RTT for clinical service, research, education, and service administration.

What do clinicians need from a rehabilitation treatment taxonomy? An alternate approach for describing treatment content versus process.

Clinician feedback and thought processes about treatment classification and description will aid development of the rehabilitation treatment taxonomy (RTT) presented in this supplement. Here, we discuss comparisons between the proposed RTT and an inductive practice-based evidence (PBE) model used to describe rehabilitation treatments. Interviews with clinicians well versed with PBE highlight the complexity of rehabilitation treatments, and bring to light potential advantages and challenges of a deductive, theory-driven classification to uncover the black box of rehabilitation.

What would Darwin say? A historical perspective on the next steps in developing a rehabilitation classification system.

This article uses a historical framework to review the rehabilitation treatment taxonomy (RTT). The needs and challenges in creating a comprehensive classification system for rehabilitation treatments are identified based on review of (1) the development of other biological classification systems and (2) the historical foundations for rehabilitation and related theoretical underpinnings. The historical overview is used to identify needs for refining the RTT, including (1) changes needed in the structure of the RTT to address the varied roles of environmental factors in the rehabilitation treatment process, (2) changes needed to link the RTT with clinical documentation and third-party reimbursement, and (3) revisions in the nomenclature for the RTT to enhance clear communication. Finally, challenges with the next steps in developing a comprehensive classification system for rehabilitation are discussed, including (1) the complexity needed to classify a dynamic process and to account for the agents, mechanisms, and objects targeted by that process and (2) the importance of a continued multidisciplinary approach to ensure a classification system that will be broadly useful for a highly diverse and rapidly evolving field.

Is a rehabilitation treatment taxonomy the right answer to the rehabilitation black box?

In this commentary on the development of an interventions taxonomy for medical rehabilitation, a rehabilitation treatment taxonomy (RTT), we acknowledge the authors' valuable contribution to rehabilitation science, and at the same time interrogate the assumption that a taxonomy has essential added value to address the challenge of rehabilitation's black box. The tripartite analytical structure of action of treatment, active ingredient, and mechanism of action, and not an RTT, is the key to addressing the rehabilitation black box. There is a need for clearly defined operationalized requirements of how the 3 components have to be expressed. We also recommend that this concerted effort be linked to all relevant stakeholders and all international endeavors that are pursuing a common goal of enhancing rehabilitation research.

Rehabilitation treatment taxonomy and the international classification of health interventions.

This commentary provides some reactions to the rehabilitation treatment taxonomy project in relation to work already underway to develop an International Classification of Health Interventions. This commentary also includes some comments in response to questions posed by the authors.

Mapping of a standard documentation template to the ICF core sets for arthritis and low back pain.

BACKGROUND AND PURPOSE: To identify the contents of a documentation template in The Guide to Physical Therapist Practice using the International Classification of Functioning, Disability, and Health (ICF) Core Sets for rheumatoid arthritis, osteoarthritis, and low back pain (LBP) as reference. METHODS: Concepts were identified from items of an outpatient documentation template and mapped to the ICF using established linking rules. The ICF categories that were linked were compared with existing arthritis and LBP Core Sets. RESULTS: Based on the ICF, the template had the highest number (29%) of linked categories under Activities and participation while Body structures had the least (17%). ICF categories in the arthritis and LBP Core Sets had a 37-55% match with the ICF categories found in the template. We found 164 concepts that were not classified or not defined and 37 as personal factors. CONCLUSIONS: The arthritis and LBP Core Sets were reflected in the contents of the template. ICF categories in the Core Sets were reflected in the template (demonstrating up to 55% match). Potential integration of ICF in documentation templates could be explored and examined in the future to enhance clinical encounters and multidisciplinary communication.

Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands: cross sectional analyses of data from three clinical databases.

BACKGROUND: Many assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands. METHODS: Cross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands. RESULTS: Age, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands. CONCLUSION: The current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another.

Feasibility of a classification system for physical therapy, occupational therapy, and sports therapy interventions for mobility and self-care in spinal cord injury rehabilitation.

OBJECTIVE: To test the feasibility of a classification system developed to record the contents of treatment sessions intended to improve mobility and self-care by persons with a spinal cord injury (SCI) in clinical rehabilitation. DESIGN: Descriptive study. SETTING: Three Dutch SCI facilities. PARTICIPANTS: Participants (N=36) as well as physical therapists (n=20), occupational therapists (n=14), and sports therapists (n=2). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Questionnaires to assess the clarity of the classification system, time needed to record 1 treatment session, and the distribution of categories and interventions. The classification system consisted of 28 categories at 3 levels of functioning: basic functions (eg, muscle power), basic activities (eg, transfers), and complex activities (eg, walking and moving around outside). RESULTS: Therapists used 1625 codes to record 856 treatment sessions of 142 patients. For 93% of the treatment sessions, the coding caused little or no doubt. The therapists were able to classify 86.3% of the treatment sessions within 3 minutes. The classification system was rated as useful and easy to use. CONCLUSIONS: The findings support the suitability of our classification system as a tool to record the contents of SCI treatment sessions in different settings and by different therapists.

Canadian physical therapists' interest in web-based and computer-assisted continuing education.

BACKGROUND AND PURPOSE: Distance education via computer-assisted learning (CAL), including Web-based and CD-ROM learning, confers a number of advantages compared with traditional learning methods. The purposes of this study were (1) to determine the interest of Canadian physical therapists in participating in continuing education using CAL methods and (2) to determine whether interest in CAL was related to type of employment, area of practice, education, computer skill and access, and other demographic variables. SUBJECTS AND METHODS: A random sample of Canadian physical therapists and all members of cardiopulmonary interest groups were surveyed. RESULTS: Of 1,426 survey questionnaires mailed, 69 were returned (58 were unopened and 11 were duplicates). From the remaining 1,357 potential survey responses, 757 responses were received, for an overall response rate of 56%. Seventy-eight percent of the respondents indicated their interest in participating in CAL. Factors associated with interest in CAL included 2 or more hours of Internet access per week, Internet access at both home and work, computer skill, education level, practice area, and belonging to a cardiopulmonary interest group. DISCUSSION AND CONCLUSION: The findings indicate a large positive interest in CAL. Increasing CAL continuing education opportunities could increase options for physical therapists to meet professional expectations for continuing competency.

Perfil académico del estudiante de fisioterapia / Academic profile of physiotherapist student

El presente trabajo pretende analizar el perfil del estudiante de fisioterapia, concretamente en lo que se refiere a diversas áreas: interés y motivación por los estudios, percepción del futuro laboral, influencia familiar en el estudio, relación con la familia, hábitos de estudio y asistencia a clase, percepción de los compañeros y el profesor, percepción de autoeficacia, conocimientos complementarios (idiomas/informática), y ansiedad, estrés y consecuencias asociadas. Los resultados ponen de manifiesto unas características muy positivas en estos estudiantes en lo que se refiere a motivación por los estudios, apoyo familiar y hábitos de estudio. Sin embargo también se observa una baja percepción de autoeficacia y un alto nivel de estrés en estos estudiantes (AU)

Using clinical outcomes to explore the theory of expert practice in physical therapy.

BACKGROUND AND PURPOSE: Theoretical models of physical therapist expertise have been developed through research on physical therapists sampled solely on the basis of years of experience or reputation. Expert clinicians, selected on the basis of their patients' outcomes, have not been previously studied, nor have the patient outcomes of peer-nominated experts been analyzed. The purpose of our study was to describe characteristics of therapists who were classified as expert or average therapists based on the outcomes of their patients. SUBJECTS: Subjects were 6 therapists classified as expert and 6 therapists classified as average through retrospective analysis of an outcomes database. METHODS: The study was guided by grounded theory method, using a multiple case study design. Analysis integrated data from quantitative and qualitative sources and developed a grounded theory. RESULTS: All therapists expressed a commitment to professional growth and an ethic of caring. Therapists classified as expert were not distinguished by years of experience, but they differed in academic and work experience, utilization of colleagues, use of reflection, view of primary role, and pattern of delegation of care to support staff. Therapists classified as expert had a patient-centered approach to care, characterized by collaborative clinical reasoning and promotion of patient empowerment. DISCUSSION AND CONCLUSION: These findings add to the understanding of factors related to patient outcomes and build upon grounded theory for elucidating expert practice in physical therapy.

Opinión de los fisioterapeutas sobre los factores que influyen en el uso de los protocolos. Estudio cualitativo / Physical therapists' opinion of the factors influencing the use of clinical guideliness. A qualitative study

Fundamento: En los últimos años se ha incrementado la elaboración y difusión de protocolos en los centros de salud, originando un amplio debate sobre la calidad y utilidad de los mismos; sin embargo, los atributos que influyen en el uso de estas herramientas han recibido una menor atención. El objetivo de este estudio es identificar los factores que influyen en el uso de los protocolos clínicos de fisioterapia según la opinión de los fisioterapeutas participantes en diversos grupos focales. Material y método: Estudio cualitativo mediante la técnica de grupos focales. Se realizó con cinco grupos en cinco unidades de fisioterapia de la entidad Fremap, uno en cada una de ellas. Las sesiones fueron grabadas en cinta magnetofónica y posteriormente transcritas. El análisis de cada grupo fue realizado de forma independiente por tres miembros del equipo y, posteriormente, se realizó un consenso de la información definitiva. Resultados: Se identificaron 10 dimensiones principales, relacionadas con las características del documento, del fisioterapeuta y de la organización. Respecto al documento los fisioterapeutas manifestaron expectativas en relación con atributos como flexibilidad, especificidad y validez; respecto a la organización manifestaron el interés de la empresa hacia los protocolos aunque se señalaron oportunidades de mejora que impulsarían más su uso. Los propios fisioterapeutas expresaron sus experiencias y disposición hacia los protocolos. Conclusiones: La metodología de grupos focales permite conocer percepciones y expectativas del fisioterapeuta difíciles de conseguir por otros procedimientos aunque existe la limitación de la investigación cualitativa, donde los resultados obtenidos no pueden ser extrapolados a otras poblaciones. (AU)