Abstract
Replication and application of research in clinical practice require that interventions be described in detail by the producers of that research. Lack of treatment specificity in publications is thought to contribute to the nearly 17-yr gap between the publication and clinical implementation of best practices. In this editorial I explore a means of addressing this problem in the Rehabilitation Treatment Specification System (RTSS) and present an application of the RTSS to sensory integration intervention.
The interprofessional Rehabilitation Treatment Specification System (RTSS) has great potential for reporting in a way that helps bridge the gap between research and practice, and while there are challenges to its implementation and widespread adoption that are currently being addressed, the American Journal of Occupational Therapy encourages authors to consider using RTSS components when describing rehabilitation interventions.
Research articles, such as those published in the American Journal of Occupational Therapy (AJOT), serve as one of the main sources of communication between producers and consumers of research (e.g., clinicians). Although authors are encouraged to describe their interventions in such a way as to be replicable, their ability to do so may be limited by things such as journal word count restrictions or the need to seek special permissions to share research protocols. Since 2019, AJOT has required those submitting a clinical trial to also submit, with their manuscript, the Consolidated Standards of Reporting Trials (CONSORT) checklist (Schulz et al., 2010). Item 5 on this checklist requires that authors attest that the “intervention for each group [was described] with sufficient details to allow replication” (Schulz et al., 2010, p. 2), including how and when the interventions were administered. However, as Hoffmann and colleagues (2014) noted, many journals requiring the CONSORT statement continue to publish articles that fail to describe interventions and protocols in enough detail to allow for replication.
In 2014, it was recommended that the Template for Intervention Description and Replication (TIDieR) checklist be used in conjunction with the CONSORT checklist to guide authors in reporting the experimental and comparison interventions in such a way as to promote reproducibility of the intervention (Hoffmann et al., 2014). The 12-item TIDieR checklist includes items related to the elements essential to the intervention, materials needed, activities or processes used in the intervention, description of the providers, modes of delivery, location of the intervention, dosage, tailoring and modifications that were allowed, and how fidelity was assessed (https://www.equator-network.org/wp-content/uploads/2014/03/TIDieR-Checklist-PDF.pdf). It is important to note that with both the CONSORT and the TIDieR checklists, materials may not be provided directly in the published research article but are available through links to websites or online training materials. AJOT currently recommends that authors submitting to the journal use the TIDieR guidelines in conjunction with the CONSORT checklist.
Despite many academic journals requiring CONSORT and TIDieR as a means of advancing research reporting, concerns remain that research findings are not being translated into practice. It has been suggested that part of this problem is that neither CONSORT nor TIDieR requires authors to specify the way in which the treatment delivered leads to functional change in clients. As Alan Jette, Editor-in-Chief of Physical Therapy, noted, “Although the TIDieR guidelines are a very useful tool, they fall short of providing a multidisciplinary framework and language for naming and describing rehabilitation treatments” (Jette, 2020, p. 883). By failing to clearly articulate the essential characteristics, elements, and clinical reasoning processes that underlie complex and multifaceted rehabilitation interventions, a barrier is created by which clinicians cannot use research articles to make good clinical decisions or replicate the intervention in practice. This phenomenon has been termed the black box of rehabilitation, and it is seen as a major barrier to progress and communication within and between rehabilitation disciplines (Dijkers, 2019). It is also thought to contribute to the nearly 17-yr gap between publication of research findings and clinical implementation (Morris et al., 2011; Munro & Savel, 2016).
For the past decade, a multidisciplinary group of research producers (researchers) and users (clinicians), aided by an international advisory board, has worked toward the goal of solving the black-box problem and attempted to develop concepts, methods, and terminology by which rehabilitation interventions can be specified across disciplines (Hart et al., 2019). Among the fruits of this effort is the Rehabilitation Treatment Specification System (RTSS), which is described in the Manual for Rehabilitation Treatment Specification (Version 6.2) and is available for use and can be downloaded for free at https://acrm.org/wp-content/uploads/2019/02/Manual_Treatment_Specification_v6.2_ confidential.pdf (Hart et al., 2018).
The purpose of the RTSS is to provide a universal system for describing, or specifying, rehabilitation interventions using a theory-based framework (Zanca et al., 2019). In contrast to general statements, such as “The client received occupational therapy three times a week to address social skills training,” the proposed RTSS gives a set of rules and procedures for researchers to be more precise about what impairments they are treating and what aspects (i.e., ingredients) of their treatment are expected to effect a functional change (Dijkers, 2019).
The RTSS defines a treatment as consisting of a triad of key elements, including (1) the intervention target; (2) the active ingredients of the intervention; and (3) the hypothesized mechanism of action, which is based on the clinician’s or researcher’s treatment theory. In this model, the targets are measurable outcomes that are changed directly on the basis of the selected treatment ingredients enacted by the clinician (Hart et al., 2018; Zanca et al., 2019). Unique to the RTSS model is the inclusion of the hypothesized mechanism of action, which is the stated relationship between the intervention ingredients and the functional targets. As Jette (2020) noted, this formal structure has the potential to help clinicians explicitly state why they are selecting a given treatment approach and assist clinicians and researchers in establishing what cause-and-effect relationships may hold true for which clients.
Putting the RTSS Into Practice
As someone who is fairly new to the RTSS, I decided a good way to evaluate its usability and benefit was to apply it to my own work. In 2021, I coauthored an article published in AJOT titled “Effectiveness of Occupational Therapy Using a Sensory Integration Approach: A Multiple-Baseline Design Study” (Andelin et al., 2021). The study examined the use of Ayres Sensory Integration® (ASI), a theory-based treatment approach, with children with sensory-based dyspraxia. The study was registered with Clinicaltrials.gov, and a CONSORT statement was completed upon submission to the journal. In the article, we noted that during the intervention phase participants took part in 60-min ASI therapy sessions 3×/wk for 10 wk with a licensed occupational therapist trained in the ASI approach. We noted that the intervention followed the principles of ASI as outlined by A. Jean Ayres and had been described in detail by other authors (references are provided in the article). We also noted that we used a data-driven decision-making process (Schaaf, 2015; Schaaf & Blanche, 2012) to set goals, develop hypotheses, and tailor interventions. The context and many of the treatment ingredients of the intervention were described, including the active engagement of the child, facilitation of adaptive responses by the therapist, and presentation of the just-right challenge during motor tasks. Finally, we described the way in which fidelity to intervention was assessed (Parham et al., 2011) and which measures were used to evaluate our outcomes.
Despite the level of detail provided in the article, it is clear that the intervention we delivered could not be replicated or fully understood on the basis of this stand-alone publication. Even if users of this research (clinicians) went to the other sources we referenced in the article, it is unlikely that the level of detail would be adequate to fully understand the relationships between our treatment ingredients and the direct targets of our intervention; in essence, our study lacked a description of the proposed mechanisms of action needed for clinical decision-making based on our treatment theory.
In contrast, Table 1 explains the RTSS framework to highlight some of the key ingredients of our ASI intervention for children with dyspraxia, the target outcomes for the intervention, and the hypothesized mechanism of action. Although the key elements are grounded in sensory integration theory (Bundy & Lane, 2020; Bundy & Szklut, 2020), I think many would find this framework to be more specific to the intervention used in our study for children with dyspraxia. In addition, the RTSS framework described in Table 1 provides insight into the researcher’s clinical reasoning and decision-making processes, increasing the potential for the intervention to be replicated in practice with a specific population of children.
Application of the RTSS Within the Context of a Sensory-Based Pediatric Intervention
Note. RTSS = Rehabilitation Treatment Specification System.
Based on Ayres Sensory Integration® theory (Ayres, 1979). Many are adapted from Bundy and Szklut (2020) and Parham et al. (2011).
The exercise of completing Table 1 also elucidated the connection between the underlying treatment theory (ASI) and the selection of treatment components. Ayres (1979) originally posited that praxis had both motor and sensory components and was influenced by cognition. The treatment ingredients listed in Table 1 thus include sensory, motor, and cognitive/volitional elements. Similarly, Ayres proposed that foundational developmental skills, such as establishment of a body scheme, postural control, bilateral integration, and ocular control, were precursors to mature praxis abilities, which is why many of these skills are targets of the intervention described. Finally, the mechanisms of action, though hypothesized, are grounded in the current understanding of neuroscience, motor learning, sensory processing, and brain development. As such, the RTSS model can serve to ground intervention in theory as well as to build theory from the testing and use of therapeutic interventions.
Challenges to Using and Implementing the RTSS Model
Although the RTSS’s triadic approach to describing treatment ingredients, mechanisms of action, and targets may be beneficial when specifying an intervention protocol, the targets themselves are what Schaaf (2015) referred to as proximal or direct outcomes of a given treatment. When establishing treatment goals with clients, occupational therapy practitioners and researchers typically focus on more distal outcomes focused on participation and the ability to engage in life roles. Within the RTSS model, the term aims is used to refer to these distal, downstream effects of treatment that are thought to result from the achievement of a combination of specific goals (Hart et al., 2018). For example, improving constructional praxis and ocular–motor control may contribute to the distal aim of a child being able to complete handwriting skills at grade level, but to achieve that aim the therapist may need to address additional targets, such as bilateral motor coordination and sequencing praxis. In addition, aims may be affected by factors external to the intervention, such as the availability of tools and materials in the school environment and the expectations within the classroom. As Hart et al. (2018) noted, “The distinction between targets and aims is critical because the act of specifying treatments depends on selecting a target or targets that are specific and achievable with the ingredients that the clinician will provide” (p. 10); as such, the downstream functional aims may appear less central when specifying the intervention.
Another challenge of the RTSS model is related to the application of specific terminology. Although the RTSS was meant to create a common language between rehabilitation disciplines, it may have created a barrier that some producers and users find challenging to cross. This is likely because each discipline already has its own language (e.g., the Occupational Therapy Practice Framework [4th ed.; OTPF–4]; American Occupational Therapy Association, 2020) in addition to the World Health Organization’s (2001) classification system, the International Classification of Functioning, Disability, and Health (ICF). Whereas taxonomies like the OTPF–4 and ICF provide a structure to identify what is addressed (e.g., occupations, performance skills, body functions), the RTSS intends to specify how those targets are addressed by the treatment ingredients. Despite this distinction, incorporating new rules and structures into how research is reported may seem arduous to some researchers and create a steep learning curve for clinicians who are not regular researcher consumers.
Cieza and Bickenback (2014) argued that one way forward is for researchers to focus more of their work on articulating and evaluating the proposed mechanisms of action to enhance the development of rehabilitation treatment theories. In the example provided in this editorial related to ASI, it is easy to see how specific mechanisms of action could be tested in more discrete trials to enhance this already well- developed intervention.
A final consideration for moving the RTSS model into more mainstream publishing is more pragmatic in nature. Providing the specifics of an intervention using the RTSS format could potentially require greater page and word allowances that journals may or may not be willing to provide. Publishers will need to consider whether they will allow for links to external sources (maintained by the researchers) or for online publishing of additional tables, figures, or appendixes that are needed to describe interventions in detail.
Conclusion
The interprofessional RTSS framework for treatment specification has great potential for reporting research interventions in a way that helps bridge the gap between research and practice. It also has the potential to improve the study and understanding of how theory-based mechanisms of action inform the selection of ingredients that are appropriate for a given treatment target. There are challenges to its implementation and widespread adoption that are currently being addressed by a multidisciplinary group. Here at AJOT we will continue to monitor developments, but we encourage our authors to consider using RTSS components when describing rehabilitation interventions.
Footnotes
Acknowledgments
Stacey Reynolds has served as an advisory board member to the RTSS group as part of a Patient-Centered Outcomes Research Institute–funded project (Principal Investigator: Jeanne Zanca; 2022–present), Award EASCS-24311, “Facilitating Rehabilitation Clinician Uptake of PCOR/CER Results Via Improved Research Reporting.”