BSSR Resources, Methods, and Measures

Rehabilitation Treatment Specification System to Fully Describe Interventions

Rehabilitation is a complex process involving multiple disciplines, settings, interventions, and populations, with patient goals ranging from improvement in function to enhanced participation in societal roles. Many rehabilitation interventions consist of multiple components directed at improving knowledge, enhancing skilled performance, modifying maladaptive behavior, and addressing emotional states. Yet current methods for describing these interventions fail to accurately portray the underlying complexity. A systematic, organized and theory-driven system for specifying the essential elements of rehabilitation treatments could be useful for outcomes research and comparative effectiveness research. Based upon work funded by both the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and the Patient-Centered Outcomes Research Institute (PCORI), the Rehabilitation Treatment Specification System (RTSS) offers a standardized method for defining rehabilitation treatments delivered by all disciplines. Work to date on the RTSS, formerly known as the Rehabilitation Treatment Taxonomy, has focused on developing a framework, concepts, and definitions, which could be useful to OBSSR's efforts to coordinate behavioral and social sciences research programs across the NIH and integrate behavioral and social sciences research within the larger NIH research enterprise, one of OBSSR's foundational processes in the Strategic Plan. A key concept described in the specification system is that complex interventions are composed of multiple treatment components with each component mapped to a corresponding treatment theory. Each treatment theory consists of three parts: • active ingredients (words, actions, devices, substances, or forms of energy delivered or selected by a clinician), • target (a measurable aspect of patient functioning that is hypothesized to be changed directly by the ingredients), • mechanism of action (known or hypothesized process by which the active ingredient(s) bring about the predicted changes in the target) For example, in providing a home exercise program, a clinician may: provide information abou the importance of the exercise program, intended to increase motivation for home exercise; provide information about how to perform the exercises, intended to impart knowledge about how to perform the exercises correctly; and design a set of exercises and rules of progression intended to strengthen specific muscle groups. Using the RTSS, we assert that the active ingredients of these different intervention components could be identified, standardized, and then systematically studied. An interprofessional standardized system for defining rehabilitation treatments could serve as a useful tool to scrutinize multi-component interventions in behavioral and social sciences research. Treatment targets (which are directly changed by the selected treatment ingredients) are distinguished from treatment aims (which are distal functional changes that may result from the individual or collective effect of one or more treatments). Volitional treatments, which require the patient's effortful performance, are distinguished from non-volitional treatments, which can be done "to" patients, with corresponding implications for the need to provide instructional and motivational ingredients within volitional treatments. All rehabilitation treatments can be categorized into three broad groupings of types of ingredients: 1) those that influence the functioning of organs or organ systems; 2) those that lead to development of skills and habits, and 3) those that affect cognitive and emotional states. In turn, the RTSS offers guidance in describing "dosage" appropriately for each of the 3 treatment groups. Use of a systematic approach for defining and, ultimately, measuring the quality and quantity (dose) of specific treatments may enhance research, practice, and training in health care. For research purposes, the RTSS provides the foundation for identifying and comparing different treatments. If research could identify and confirm the most critical active ingredients of interventions, clinicians and researchers would know which elements of an intervention can be modified for individual patients, and which must not be changed, without compromising outcomes. Knowledge of active ingredients for certain targets could help with health initiatives such as precision medicine. Addressing one of the OBSRR Strategic Plan's foundational processes, Training the next generation of behavioral and social science researchers, the RTSS can be used in educating new health care providers on the essential ingredients necessary for treatment fidelity, and transfer knowledge from expert to novice clinicians. Additionally, the RTSS can allow clinical education and training to focus on the delivery of the treatment ingredients that matter; supervisors can verify the appropriate delivery of those ingredients, and such a system can support clinical reasoning by highlighting the relationship between the treatment ingredients selected by the clinician and the functional changes that are desired. Finally, the RTSS may strengthen communications between treatment team members and other stakeholders by providing a common language and framework for interventions. Enhanced communication, particularly needed for transitions of care, could lead to improved outcomes in rehabilitation practice. Representing the American Congress of Rehabilitation Medicine's (ACRM) Rehabilitation Treatment Specification Networking Group, we thank the NIH Office of Behavioral and Social Sciences Research (OBSSR) for this opportunity to comment on new directions for health-related behavioral and social sciences research. ACRM, a non-profit association with 12,500 members, aims to improve the lives of disabled people through evidence-based practice and rigorous research. Sincerely, Susan Lin, ScD, OTR/L, FAOTA Communications Officer American Congress of Rehabilitation Medicine Rehabilitation Treatment Specification Networking Group

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Idea No. 342