Tessa Hart, PhD Moss Rehabilitation Research Institute Elkins Park, PA, USA

Transcription

1 Tessa Hart, PhD Moss Rehabilitation Research Institute Elkins Park, PA, USA

2 Interdisciplinary team Physical Medicine & Rehabilitation: John Whyte, MD, PhD Sociology: Marcel Dijkers, PhD Psychology: (moi) Speech-Language Pathology: Lyn Turkstra, PhD, CCC- SLP; Jarrad Van Stan, MA, CCC-SLP Occupational Therapy: Mary Ferraro, OTR/L, PhD; Christine Chen, OTR/L, ScD Physical Therapy: Jeanne Zanca, PhD; Andrew Packel, MPT Funding from 2 US Agencies: National Institute on Disability and Rehabilitation Research Patient-Centered Outcomes Research Institute

3 What is the nature of this work; why is it important? What is the Rehabilitation Treatment Taxonomy (RTT) project? Why should it work better than other schemes for defining or classifying treatments? What have we accomplished.and what else do we plan to do? [after lunch: More details, examples, problems]

4 Rehabilitation is said to have a weak evidence base, compared to other branches of medicine We cannot say for sure: Why and how patients improve What treatments work best, for what kinds of problems, and for whom, in what dosage What parts of rehabilitation work (as active ingredients ) and what parts may be unnecessary (inactive), perhaps done out of custom How best to time rehabilitation (when) to maximize recovery

5 No accepted way to characterize (specify, define, describe) the treatments in rehabilitation Can t measure what you can t define Can t analyze the effects of what you can t measure... Case Mix TREATMENT Outcomes Treatment effects!

6 In contrast to measurement of treatment, we have exquisitely detailed measures of the beginning and the end of this equation.

7 The person and their family Their impairments Functional limitations Rehab Inc. We improve lives?? (Slide stolen from M. Dijkers PhD) Improved function & participation Better quality of life

8 A black box in which the specific ingredients and their effects remain largely unknown A Russian doll in which ingredients are nested within layers of complexity (e.g., subacute vs. acute rehabilitation )

9 Since it s hard to see or disentangle the specific ingredients in rehabilitation, we can t measure them well, and it s hard to test their effects (individually or in combination) Case Mix Outcomes?????

10 Are we not as smart as people in other branches of medicine?? No, that s not it. Rehabilitation treatments are more complex and harder to measure than other medical treatments. How so?

11 Wide variety of populations served Some improving, some not Some involving Central Nervous System, some not Variations in ability to learn and self-manage conditions Wide variety of settings and service delivery models Hospitals, clinics Home- and community-based treatment Day treatment/ milieu therapies

12 Great variety of goals at different levels of functioning: We work at all levels of the ICF, from function (impairment) to societal participation As we move out from the person-- from function activity participation, increasing diversity/ complexity in goals patients want to achieve Consider: Visual function vs. Dressing (activity) vs. Social roles working, friend and family relationships, etc. Affected by many factors extrinsic to the person

13 Changing behavior is complex by definition Depends on learning, motivation, and such processes that are not completely understood Are based in/ affected by interpersonal relationship factors operating between patient and clinician Affected by the social / physical environments in which behavior takes place

14 Creates great richness, but also means differences in traditions, concepts, theories, language used to describe treatments Difficult to synthesize Pragmatic orientation ( whatever works ) Rehabilitation is said to be theory-poor no over-arching framework to help organize how treatments are conceptualized and new ones developed

15 .. How do we currently measure rehabilitation treatments? BY TIME: Length of stay = 23 days BY DISCIPLINE: X hours of OT, Y hours of PT BY PROBLEM: Gait training, memory retraining, vocational rehabilitation, adjustment counseling

16 BY TIME: Length of stay = 23 days what did the patient do and what was done to the patient during that time? BY DISCIPLINE: X hours of OT, Y hours of PT what was done during these hours? Same treatments, different, overlapping? BY PROBLEM: Gait training, memory retraining, vocational rehabilitation this is tautological (restates the problem) and tells us nothing about how the problem was addressed

17 Bottom-up, or inductive Therapists list and then count various activities Addresses questions about what therapists actually do (by self-report; a few video studies) Some have shown interesting findings on a local level: e.g., inpatient therapists spend very little time on caregiver training or preparation for community Tyson & Selley, 2006; Latham et al., 2006

18 Most ambitious bottom-up studies to date Therapists (within disciplines) list activities done per 5 minutes in each therapy session for entire stay These data are analyzed with detailed data on case mix, medications, all kinds of events during hospital stay, to determine effects on outcome for thousands of patients Separate analyses for stroke, SCI, joint replacement, and now TBI (Archives PM&R August 2015)

19 Even in the very large PBE studies, therapy activities have opaque names PT: Therapeutic exercise Gait training OT: Cognitive activity Dressing SLP: Education Psych: Psychotherapeutic and behavioral intervention

20 What might be the solution?

21 Not bottom-up, but top-down Use not the surface characteristics of treatment, but the theory (ies) underlying them, to define, specify, and ultimately classify all treatments in rehabilitation But there is no over-arching theory that can explain all of the effects of rehabilitation Or is there?

22 some set of propositions that describe what goes on during the transformation of input into output, that is, the actual nature of the process that transforms received therapy into improved health. --Keith & Lipsey, 1993 That is, a statement of how and why a particular treatment works.

23 We have elaborated a 3-part model of treatment theory by which a clinician/ researcher may specify any treatment according to its: Target: specific aspect of (patient, recipient) functioning to be changed Ingredients: specific clinician actions chosen to bring about change Mechanism of action linking ingredients to the changes in the target, i.e., how do they work?

24 Most activities that a clinician calls a treatment actually consists of >1 target and multiple ingredients. We use treatment component to refer to elements of treatment with different targets

25 Teaching a patient to use a memory notebook has several treatment components: 1. Organizing the book with the features needed by a certain patient (size; sections such as calendar, diary, etc.) 2. Providing education/rationale for why it s important to use the book 3. Training and providing practice in using the book in different situations All of these have different targets, different ingredients

26 CAUSALITY Ingredients MoA Target What the clinician says, does, provides How the treatment is expected to work Aspect of functioning directly targeted for change Effects beyond the Target (=Aims) are NOT explained by Treatment Theory.

27 CAUSALITY Ingredients MoA Target What the clinician says, does, provides How the treatment is expected to work Aspect of functioning directly targeted for change PROCESS OF TREATMENT SPECIFICATION What can I do to effect this change? How might this be changed? What needs to change?

28 Targets are the direct, specific outcomes of treatment Not names of problems ( gait, social skills )..but measurable aspects of these Faster gait over a certain type of surface? Eye contact or turn taking during conversation? ALWAYS observable and measurable (in principle) Otherwise, there s no way of knowing if the selected ingredients are working

29 Borrowed from pharmacology (or, cooking) what s added by the chemist (cook) to achieve the desired effect. In rehabilitation, ingredients are anything selected/ said/ done/ provided by the clinician to help make the desired changes in the target Ingredients are active if they effect change in the target; inactive if they do not

30 Ingredients, like targets, are ALWAYS measurable and observable in principle This means that ingredients are NOT: Different schools of thought as to how therapy is supposed to work Therapists plans, hopes or intentions with regard to treatment If schools of thought or intentions or plans are translated into measurable behaviors, then they are ingredients Otherwise, cannot affect the patient in a tangible way Cannot be replicated if we can t observe/ measure them

31 Not usually observable Predicted or inferred from effects of ingredients on targets For passive medical treatments (medications), these may be well detailed (receptor binding, etc.) For passive physical treatments (e.g., tendon lengthening) they may be obvious (apply mechanical energy or heat energy, intrinsic elasticity of tissue allows it to stretch)

32 We are often hard pressed to specify mechanisms: Learning Maybe implicit learning; semantic learning Information processing How much vaguer can we get? We need help here! Currently studying work of S. Michie et al. taxonomy of behavior change techniques and MoA that explain their effects, in Health Psychology

33 Didn t get very far (yet) with Linnaean structure We have developed (discovered?) 4 groups of treatment components used in rehabilitation that: Encompass all treatments (we think) Are mutually exclusive in their: Types of targets Mechanisms of action Essential active ingredients To discuss after lunch For now, some last points

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35 Why is using theory better than a bottomup approach? Theory (even if it s wrong) tells us how to compare important variations in ingredients as to how (well) they achieve certain kinds of targets (i.e., which ones are active?) Otherwise, we are left with blind empirical comparisons Treatment A vs. Treatment B. What if one works better? we still don t know why.

36 We observe that clinicians use an IMPLICIT theory (or hypothesis) for every treatment; even if it is just practice makes perfect or it will work because my supervisor told me. We are trying to make these implicit treatment theories explicit, more precise, and open to being tested.

37 Research: Ability to replicate treatments Examine fidelity of treatment delivery Clinical Practice: Implement successful treatments accurately Use common language and treatment components across disciplines Simplify documentation of treatment Communicate better with patients, outside agencies Training, Program Evaluation

38 Developing a Manual of Rehabilitation Treatment Specification Detailed outline of the process by which to specify treatment components, targets, & ingredients of a given clinical intervention To validate, will train clinicians on use of the manual, compare their ability to specify treatments (according to criteria such as ability to replicate) from pre to post training

39 2014 Supplement to Archives of Physical Medicine & Rehabilitation Articles about the RTT scheme and commentaries from leaders in the field Or me: THANK YOU for your attention!