At MossRehab, clinical work and research form a unique symbiotic relationship that benefits the progress of both. With the creation of Moss Rehabilitation Research Institute (MRRI) in 1992, an infrastructure was put in place to maintain a high level of contact between researchers and clinicians. MRRI researchers assist MossRehab clinicians in designing study protocols. In turn, MossRehab’s clinicians help develop clinically relevant research topics and provide access to a large patient population willing to participate in research studies.

Research Data Supplants Subjective Clinical Impressions

Findings from research have greatly influenced clinical care, often replacing subjective clinical impressions with concrete data about when and for whom particular interventions are best utilized. John Whyte, MD, PhD, Director, MRRI, for example, designed double-blind, placebo controlled studies that resulted in the first firm evidence that methylphenidate improves attention in TBI patients during the post-acute phase of recovery. Consequently, this medication now is indicated for patients with moderate to severe TBI who suffer from attention deficits during this phase of recovery. Clinician impressions, however, remain important catalysts for targeting research and helping to shape theoretical frameworks for study.

This productive synergy also supports the “Black Box of TBI Rehabilitation,” a research project federally funded through the National Institutes of Disability and Rehabilitation Research and led by MRRI scientist Tessa Hart, PhD. The study seeks to advance TBI rehabilitation therapy to a quantifiable science by specifically identifying what occurs during rehabilitation sessions.

Most medical specialties develop evidence-based practices by objectively defining their active ingredients through chemical formulas, surgical procedures and easily delineated control groups. Identifying the active ingredients that yield much of rehabilitation’s efficacy and effectiveness, however, is far more difficult. Active ingredients may include a combination of factors including the discipline and experience of the clinician, task content, interaction method, intervention frequency and duration, patient effort and therapeutic setting. Treatments also can be described at many levels: at a broad level, one could compare subacute rehabilitation to outpatient rehabilitation, while at a more detailed level one could compare particular exercises for a specific muscle weakness.

These differences have complicated the process of developing research paradigms, conducting studies, understanding data significance, drawing meaningful conclusions and discussing findings.

Black Box Research Project Defines Rehab Session Content

In an innovative step toward identifying active ingredients, Dr. Hart and her team are recording and defining the exact content of inpatient TBI rehabilitation sessions conducted at MossRehab. The project employs assiduously trained clinicians who study videotaped speech, occupational and physical therapy (PT) sessions. These clinicians use specific codes to consistently and objectively record content during each minute of a session.

Clinicians meticulously record codes as directed by a one-of-a-kind manual that the MRRI team created based on the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) coding system. Codes may denote body functions, such as repetitive body movements or flexibility maintenance, or activity/ participation functions such as feeding or grooming.

Data gatherers choose from among 35 different content codes.The team also developed four additional codes to indicate supplemental content information such as device use or delivery of specialized TBI information. This comprehensive manual dictates exact cues that enable multiple clinicians to code session content in an identical and reproducible manner. It also helps those coding to discard assumptions of what is occurring during the session. For instance, a MossRehab therapist’s moderately implied intent for a patient to begin lifting a weight does not trigger a code – only a strong implication. The actual cue or commencement of weightlifting triggers the code. As clinicians code sessions, multiple codes may apply during any given minute. For example, a patient brushing his teeth while bathing would result in two codes: one code for the act of grooming and a second code for the act of bathing.

MossRehab Team Assesses Value of Coding Paradigm

The MRRI team continues to refine the manual to more accurately describe session content. Robin Myers, Physical Therapist, PT Clinical Team Leader and Neurologic PT Residency Coordinator, explained one refinement. “Initially, we recorded root finding – people’s ability to develop an internal map that helps them find their way to a place – under the executive function code,” Myers said. “This broad code definition made it difficult to code root finding consistently.Therefore, we created a unique code for root finding that improved coding consistency and helped us more specifically describe session content.”

The MRRI team plans to publish results for the PT segment of the study. Meanwhile, they continue gathering data, analyzing the reliability of data gathering techniques and determining whether this tool – the manual and coding paradigm – describes content accurately.The tool, and in turn the project, may help to produce a shared understanding regarding the content of rehabilitation sessions, assist in standardizing a common vocabulary to discuss that content and enable more productive research in the future.

The goal is to eventually use the tool to determine what interventions are most effective for particular patients, describe the amount of time patients should spend in active learning during sessions and provide to evaluate the consistency of therapists when executing treatment approaches for specific patients.