Rehabilitation Treatment Specification System: Methodology to Identify and Describe Unique Targets and Ingredients

Abstract

Although significant advances have been made in measuring the outcomes of rehabilitation interventions, comparably less progress has been made in measuring the treatment processes that lead to improved outcomes. A recently developed framework called the Rehabilitation Treatment Specification System (RTSS) has potential to identify which clinician actions (ie, ingredients) actively improve specific patient functions (ie, targets). However, the RTSS does not provide methodology for standardly identifying specific unique targets or ingredients. Without a method to evaluate the uniqueness of an individual target or ingredient, it is difficult to know whether variations in treatment descriptions are synonymous (ie, different words describing the same treatment) or meaningfully different (eg, different words describing different treatments or variations of the same treatment). A recent project used vocal rehabilitation ingredients and targets to create RTSS-based lists of unique overarching target and ingredient categories with underlying dimensions describing how individual ingredients and targets vary within those categories. The primary purpose of this article is to describe the challenges encountered during the project and the methodology developed to address those challenges. Because the methodology was based on the RTSS's broadly applicable framework, it can be used across all areas of rehabilitation regardless of the discipline (speech-language pathology, physical therapy, occupational therapy, psychology, etc) or impairment domain (language, cognition, ambulation, upper extremity training, etc). The resulting standard operationalized lists of targets and ingredients have high face and content validity. The lists may also facilitate implementation of the RTSS in research, education, interdisciplinary communication, and everyday treatment.

Keywords: Health care; Methods; Outcome assessment; Rehabilitation; Therapeutics; Translational medical research.

Fig 1

The tripartite structure of a treatment component and the relationship between treatment components and aims. The arrows point in the direction of causality; i.e., the clinician delivers an ingredient (or multiple ingredients) to directly affect a singular treatment target. The mechanism(s) of action is how the ingredient is hypothesized to affect the target. Aims are indirectly changed by 1 or more targets, and ingredients do not directly affect aims. The hypothetical treatment outlined contains 3 treatment components to modify 1 aim. Treatment component 1 is within the Organ Functions group (top row), treatment component 2 is within the Skills and Habits group (middle row), and treatment component 3 is within the Representations group (bottom row). The hypothetical patient has a history of head and neck cancer, presenting with postradiation fibrosis of the jaw (causing trismus manifested by reduced active jaw range of motion) [treatment component 1] and pharynx (causing reduced airway closure and aspiration during the swallow that was minimized by a chin tuck maneuver) [treatment component 2]. The patient is currently not eating by mouth and is maintaining body weight using a percutaneous endoscopic gastronomy tube for all nutrition. Also, the patient self-reports severe anxiety toward eating by mouth [treatment component 3]. Abbreviation: MoA, mechanism of action.

Fig 2

Depending on the clinician’s treatment theory, the 3 black boxes in the center are hypothetical “Targets” (if the ingredient of hyoid pushback directly affects it and it is the clinically desired effect) or “Aims” (if it changes indirectly because of the ingredient of hyoid pushback) for a voice therapy session. The bottom 2 black boxes in the center could also be in the “Mechanisms of Action” if the ingredient directly affects a target box above it. All gray boxes are “Targets” that potentially need to be addressed when the black boxes are voice therapy “Aims.”