Rehab Treatment: The Path to Clarity and Precision in Therapeutic Practice

1. Treatment Taxonomy and Specification Help OT Clinical Reasoning Christine C. Chen, ScD, OTR, FAOTA Professor and Program Director of MOT Program University of Texas at El Paso El Paso, TX

5. What this presentation is about • Introduction of a new way of thinking about rehab treatment, i.e., what we do and why we do it/them • Past effort of rehab treatment “classification” • Project history (RTTS) • Introduction of the tripartite treatment theory • Distinction between treatment theory and enablement theory • Treatment target and aim • The role of “volition” • Implications of RTTS to OT education, practice, and research

6. Rehab treatment • Rehabilitation has been referred to as a “black box” • Our goals are to improve function: i.e., from improve impairment, to reduce activity limitations, to improve role participation • How do we describe what our treatment ? • # sessions of OT per week • a label of the intervention such as ADL training, NDT treatment, SI • Our treatment outcome can be as specific as “to increase X degrees of finger ROM” or as vague as “D/C to community living” (Does it imply being independent in X, Y, Z?)

7. Past effort to classify rehab treatment • The Practice-Based Evidence (PBE) studies: using a “bottom-up” approach—asking clinicians to document treatment activities, interventions and the amount of time (broad categories provided) • Interventions: ROM, balance training, NDT/PNF, cognitive training • Activities: UB dressing, perceptual activities, cognitive activities • Time: number of minutes • The researchers studied rehab treatment in patient groups of CVA, joint replacement, SCI, and TBI • Papers published in Archives of Physical Med & Rehab

8. The problem is: • Clinicians expressed their difficulties capturing their 30-45 minute treatment onto a single sheet of paper • One treatment activity can be for multiple purposes / goals • We still do not know what (i.e., the essential ingredients) go into the treatment for what purpose(s) (i.e., tx targets). • Example: Cognitive training, what exactly is it? • Can another OT replicate your treatment when you go on vacation? • Why some patients get better while others don’t? after receiving exact amount of the “same” treatment?

9. We need a top-down and systematic approach to describe or specify rehab treatment • Need to be more precise when we describe our treatment (i.e., the content) • Need to be specific and measurable, the target, the ingredients [what we put into our treatment and how much (i.e., dosage, frequency, intensity)] • Need to be comprehensive @ all components, and the target and ingredients. • Need to describe/specify active ingredients and the dosing parameters. • How are treatment ingredients delivered? • Are the target(s) the same when it is under the direct supervision of the clinician and when the patient continues the regiment at home • Need to describe/specify progression of the treatment (or sometimes called just-right-challenge)? • Need to distinguish what is the immediate (target(s)) vs. longer term goal (aim)

10. Before I go on, a little history: • RTT task force of ACRM (mid-2000s) • 2008-2014 NIDILRR funded a 5-year project “Classification and measurement of medical rehabilitation intervention” to Mount Sinai School of Medicine (Rehabilitation Medicine) New York and Moss Rehab in Philadelphia (my role: member of the steering committee) • 2015-2017 PCORI funded a 3-year project to Moss Rehab: Better rehabilitation through better characterization of treatment: Development of the Manual for Rehabilitation Treatment Specification (my role: member of the Clinical Core Team)

11. The first project (2008-2014) We preliminarily identified the following: • What is “treatment” • The structure of the theory • Treatment grouping • Treatment components and ingredients • Difference between a treatment theory and enablement theory

12. Current project (2015-2017): RTTS team • PI’s: • John Whyte, MD, PhD (Physician and Cognitive Psychologist) • Tessa Hart, PhD (Psychologist) • Marcel Dijkers, PhD (Psychologist and Methodologist) • Clinical Core Team: • Christine Chen, ScD, OTR • Mary Ferraro, PhD, OTR • Andrew Packel, PhD, PT • Jeanne Zanca, PhD, PT • Lyn Turkstra, PhD, CCC-SLP • Jarrad Van Stan, PhD, CCC-SLP

13. Project aims • Develop a reliable and effective Manual for Rehabilitation Treatment Specification and associated training materials describing a standardized set of steps that will guide researchers, clinical educators, and clinicians in applying the tripartite structure of treatment theory to: • Determine whether a “treatment” needs to be decomposed into distinct treatment components; • Specify the treatment target for a particular treatment component, and distinguish it from (“downstream”) clinical aims; • Specify in observable/measurable form the ingredients required to initiate the (known or hypothesized) mechanism of action of the treatment component.

14. Iterative process (Method) • Weekly conference calls among team members, weekly calls among the 3 PIs, regular progress reports with the participation of the PCORI Project Officer, and additional annual face-to-face Advisory Board Meetings • Discussions, debates on concepts and “boundaries” between concepts • Convening clinical panels to learn what each discipline considers as treatment and identify common treatments (PT, OT, SLP, MDs and Nurses, Psychologists) • Core team members then assigned to write 4-5 clinical vignettes from each discipline • We specified treatment components, targets, ingredients, individually and in small groups (our own vignettes)

15. Iterative process (continued) • Looked into ICF categories to look for relevant terms and constructs • Drafting of the manual • Manual reviewed by Advisory Group (nationally recognized clinical researchers in OT/PT/SLP/RT/Psychologists, and representatives from national associations) • Face-to-face meeting to solicit feedback and discussion • Repeating the process (manual revised, reviewed, solicitation of feedback, face-to-face meeting) • Educational webinars (3 lectures, assignments, 3 discussion sessions with small groups, feedback)

16. Treatment theory vs. enablement theory • Treatment theory explains what clinicians do to bring about functional change in a pt— how and why a treatment works • Enablement theory explains the relationships among impairments, activity limitations, and participation restrictions, i.e., how they may be causally related to one another, but the theory does not explain how a treatment directly changes a patient’s status in any of those domains

18. Treatment theory vs. enablement theory -continued • A, B, C, D, E are different (body) function • Treatment A may improve letter/word conversion (B), it may or may not improve reading, because reading also depends on functions C and D. Reading is an aim and not dir target of Treatment A. • Say, Treatment B is providing a device which can scan the printed text and produce auditory input, Treatment B would improve patient’s reading (thus reading is a direct target of Treatment B)

19. Treatment theory vs. enablement theory -continued • A pt. had a stroke resulting in moderate hemiplegia and spatial neglect. OT treatment may involve using dressing activities to address spatial neglect • Decreasing neglect when putting on clothes is an immediate tx target • There might be other problems that prevented the pt. from dressing independently. Dressing independently or D/C to the community would be “aims” • Other example: anti-depressant meds and psychotherapy treat depression but may not save the marriage

20. Some general rules • Treatment has to be selected, prescribed or administered by the clinician • Tx is delivered to the patient, family or caregivers, or employers • We are not concerned with assessment, either prior to or during treatment • Not concerned with structure or process features of a treatment program that may (eventually) affect care • Not concerned with services provided on behalf of an absent patient such as case management • Not concerned with environmental modification that affect a whole group of people, such as curb cuts, ramp to a restaurant

21. Many Aspects of Rehabilitation Service Provision Contribute to Outcomes System of Care Rehab Program (structure, process, etc.) Care of Individual Patient Assessment Treatment Ingredient(s) Our focus is here Direct Outcome (Target) Indirect Outcome (Aim)

22. But remember: • The diagram is simplified to show clarity. • It looks as if there is just one treatment target. • However, during the patient’s entire course of care, a therapist usually works on several targets .

23. To recap: tripartite treatment theory has 3 elements • Target: functional change • Ingredients: medication, modalities, devices, or clinician words and actions chosen to bring about changes • MoA: is the causal chain linking ingredients to the changes in the target. In other words, how do the ingredients work? • What we traditionally talk about “treatment”, we often mean target(s) plus ingredients as a “composite” concept, and not distinguish between target(s), ingredients, let alone MoA(s).

24. Introduction of a tripartite treatment theory • Ingredients of the treatment • Mechanism of action • Target of treatment Tx IngredientsTx Target MoA

25. A treatment often has several components; each component has its own target • Medication for depression • The medication itself (its effect—how it works) • Education about the medication (its side effects, when to take, how long it takes to start working, adherence issues, i.e., do not stop taking it when pt. feeling better, etc.) • Management of medication: Help the pt. or caregiver to develop a system to help the patient take the meds regularly and on time (e.g., using a pill box)

26. Another example: nocturnal splint for CTS • The splint itself (its treatment effect—how it works—reduce pain and tingling, preventing pressure on median n.) • Education about the splint (wearing schedule, for how long) • Management of the splint (how to don and doff the splint, cleaning/maintenance)

27. When we identify different treatment components, it • Allows us to better understand: • What is happening during complex treatment interactions • How sequential or simultaneous delivery of different combinations of components act to optimize outcomes • How treatment may be delivered differently for different types of patients based on our treatment theory (For example: some pts need more encouragement, or some may have a secondary impairment that interferes with the MoA of the essential/active ingredient leading to direct target)

28. Target vs. aim • Target: Aspect of functioning directly targeted for change (by the treatment ingredients, i.e., what the therapist says, does, provides, demonstrates, and pt’s volitional behavior) • Aim: effects beyond the target—NOT explained by treatment theory, BUT by enablement theory • Example: A TBI patient, you can treat his attention and hand strength and dexterity, which may be necessary for independent performance of ADLs, but does not guarantee his going back to work (which would be an aim)

29. When is it a target or an aim? • A desired change can be either a target OR an aim – depending on your treatment theory • Example: • Training and practice walking • on even and uneven surfaces (can be direct target or “generalization” as an aim) • A central idea in the RTTS is that targets should be specific and direct • Should be observable andmeasurable (e.g., improved eye contact or turn-taking during conversation) rather than an abstract construct such as “social skills”

30. Treatment groups • Organ functions: changes in organs or organ systems, including brain • Skills and habits: “learning by doing”; skills or habits can be “function-like” (such as balance, attention) or “activity-like” (such as dressing) • Representations: “information processing” to result in changes in mental representations (underlying knowledge, belief, attitude, motivation and volition, propensity to act)

32. Treatment groups • The 3 groups should be mutually exclusive in terms of: • Targets • MOA • Essential ingredients • Organ replacement is an O-group tx. EX: fitting an artificial arm • Training to use the prosthetic arm/hand to reach and grasp is an S & H group tx (requiring repeated practice) • Persuading the patient to use the prosthetic arm and hand for functional activities as much as possible at home is an R group tx (counseling, to increase motivation and propensity to act)

33. Concept of volition • Effort applied to the performance of an action, willing to do something • Non-volition treatments are done to the patient without effort on his/her part (medication, surgery, PROM) • Volitional treatments: requiring active effort on patient’s part. Example: AROM • Volition may be required in treatments across O, S&H, and R groups

34. Concept of volition--continued • When you provide PROM, you ask the ptto relax so you can range his/her with less resistance • When you provide “sensory retraining” or other treatment (serial casting, splinting) which may be unpleasant at first, you explain to the pt about what to expect (i.e., possible discomfort) and ask him/her to “try to relax” • When you treat pt for ADL, such as dressing/grooming training • You provide pt. education or motivational interviews to convince him/her to do what you ask him/her to do (e.g., do this at home, wear the splint, use a reminder, etc.) • So as you can see, volition may be required in treatment across all tx groups

35. Why bother to think about volition? • Help tease out why a treatment might have failed • The clinician picked the wrong ingredients for the direct target, or administered them incorrectly. • Wrong treatment • Not enough practice opportunities • Not clear or inaccurate information • And/Or: • The patient did not perform, did not put effort in (resistance, not motivated), did not pay attention to or remember the information = failure of volition

36. Other ingred. Volition ingredients Direct target: Change in organ fn, skill/habit, or representations Perf of tx activity Other ingred.

37. Importance of volition • … ingredients affecting volition are sometimes neglected in rehabilitation, difficult to pin-point or articulate • Strong volitioningredients are needed if/when…. • The activity not supervised by the therapist • The task is painful or unpleasant • The task is disliked by the patient • The patient has deficits in drive, initiation, comprehension, memory, or other faculties that enable volitional behavior…

38. Volition target are representations group targets • Targets such as change in knowledge, attitudes, motivation, or volition – all of which are internally represented in the brain • MoA: we use “information processing” for now • Require pt’s volition (cooperation) • Changes in representations are on a continuum, from “thoughts” to “action” • What OTs do: we try to “motivate” or educate our patients by providing reassurance, explanations (e.g., importance of the treatment) and information, and we try to influence patient’s propensities to act (i.e., willing to try a strategy)

39. In Summary • Treatments consist of 1 or more treatment components • Each treatment component has 1 target • Targets come from one of the 3 groups depending on the type of change desired: • Organ functions • Skills & habits • Representations • Target: expressed as functional change that is measurable • Addressing/considering volition

40. Ingredients • Directed at O targets: Biologically active chemicals, forms of energies or delivery vehicles, delivered to different tissues, organs, etc. • Examples: meds, heat, sensory stimuli, manual stretch (tension on soft tissues around a joint), splints, repeated muscle contraction against resistance • Directed at S&H targets: • Task specific ingredients such as clothing when practicing dressing • Other theoretically important objects or materials, or systematic variations in objects (types of clothing) / contexts / environments to promote generalization (also think about relevance to the pt) • Directed at R targets: information, instruction (delivered in different forms or modalities), guidance, persuasion, scheduling, goal-setting, rapport, feedback, reinforcement, etc.

41. Dosing parameter • Many ingredients are simply present or absent • Or, vary by type. (Ex. One may choose to administer feedback, or not to do so; or, may be visual vs. verbal feedback) • Other ingredients vary quantitatively—we call them dosing parameters • Can be expressed by number, frequency, etc. • Sometimes can be interval type (e.g., speed), sometimes is ordinal in nature [e.g., more tension, or progression (“theraband”)]

42. Discussion • How does RRTS help clinical reasoning? • Theory based, top down instead of “trial and error” • Distinguish target vs. aim • Think of treatment components? • Is treatment outcome affected by volition? Do I need to include volition ingredients? • What are the ingredients which result in desired change (Direct Target)? • Do I need a separate volition target?

43. In person treatment vs. unsupervised home exercise/activities • The COM-B framework • Capability: Should the task be adapted so that it is within pt’s capability • Opportunity: How can I offer pt optimal context (opportunity) to try/perform/practice • Motivation: Should I ask the ptfor his/her preference if/whenever it is appropriate? • Just right challenge

44. Some Case Examples • For the following section (20 minutes), we will break into small groups • Each group will be given a case scenario • The group will discuss and come up with specification of a treatment using a grid • We will then come back together and talk about what you have done • We will then discuss the implications to you as an OT

45. Implications to Occupational Therapy • Sharpens our clinical reasoning when • Designing treatment • Planning treatment activities • Considering client factors (capability, volition), but also creating opportunities for the client to perform, learn or receive treatment • Allows us to examine what works/not work, and why • Enhances communications (about our treatment to others (patient, family, other professionals, payers)) • Implications to research • Evidence-based, theory-driven • Treatment effectiveness studies

46. Acknowledgments • Funding to Dr. Chen is provided by Einstein Health Network (Moss Rehab) • Contract from: Patient Centered Outcomes Research Institute (PCORI) • Past funding: NIDRR (or now called NIDILRR)

47. Questions? • My contact info: • cchen5@utep.edu