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Objective: To evaluate the quality of descriptions of interventions in health care research reports, based on a synthesis of reviews that used the Template for Intervention Description and Replication (TIDieR) to rate the completeness and quality of intervention reporting., Design: Overview of published reviews. In a systematic search of the literature, 56 review articles were retrieved that had evaluated 3454 primary studies (index articles) using all or most of the 12 TIDieR items, applied to experimental treatment only or treatment and comparator both, separately. If available, percentages "reported completely" were extracted based on the index article, the index article supplemented by related information, and these 2 supplemented by e-mailing the author. Information on the review's methodology was also extracted., Setting: Not applicable., Participants: Not applicable., Interventions: Not applicable., Main Outcome Measures: Percentage of primary studies receiving "adequately reported" ratings on each of the 12 TIDieR items., Results: While for treatment arms TIDieR items 1 (name of treatment) and 2 (why of treatment) are generally judged to be reported adequately, the percentage is between 25% and 75% for most other items and is as low as 10% for item 10 (modifications). Comparators are reported even more poorly. Use of additional publications on a trial increased percentages "reported adequately" marginally; e-mailing resulted in significant increases in completeness of reporting. Rehabilitation trials were reported better than nonrehabilitation trials for some TIDieR items and worse for others., Conclusions: Reporting on the interventions and comparators of trials is substandard. More extensive use of supplemental digital content and of versions of TIDieR customized for specific domains of research may improve the situation., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe systematic reviews (SRs) of the use of exoskeletons for gait and mobility by persons with neurologic disorders and to evaluate their quality as guidance for research and clinical practice., Data Sources: PubMed, EMBASE, Web of Science, CINAHL Complete, PsycINFO, Cochrane Database of Systematic Reviews, PEDro, and Google Scholar were searched from database inception to January 23, 2018., Study Selection: A total of 331 deduplicated abstracts from bibliographic database and ancestor searching were independently screened by 2 reviewers, resulting in 109 articles for which full text was obtained. Independent screening of those 109 articles by 2 reviewers resulted in a final selection of 17 SRs., Data Extraction: Data were extracted by 1 reviewer using a pretested Excel form with 158 fields and checked by a second reviewer. Key data included the purpose of the SR, methods used, outcome measures presented, and conclusions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and A MeaSurement Tool to Assess Systematic Reviews version 2 were used to evaluate reporting and methodological quality, respectively, of the SRs., Data Synthesis: The SRs generally were of poor methodological and reporting quality. They failed to report some information on patients (eg, height, weight, baseline ambulatory status) and interventions (eg, treatment hours or sessions planned and delivered) that clinicians and other stakeholders might want to have, and often failed to notice that the primary studies duplicated subjects., Conclusions: Published SRs on exoskeletons have many weaknesses in design and execution; clinicians, researchers, and other stakeholders should be cautious in relying on them to make decisions on the use of this technology. Future primary and secondary studies need to address the multiple methodological limitations., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the quality of rehabilitation Clinical Practice Guidelines (CPG), specifically with respect to their applicability., Data Sources: The Medline, Embase, Web of Science, CINAHL, PsycINFO, and Cochrane Library databases were searched for papers published between 2017 and 2019 that applied the Appraisal of Guidelines for Research & Evaluation II (AGREE II) CPG quality assessment tool to rehabilitation CPGs., Study Selection: Deduplicated abstracts (N=449) were independently screened by 2 authors, resulting in 47 articles. Independent screening of 47 full texts by 2 authors resulted in a final selection of 40 papers appraising 544 CPGs., Data Extraction: Data were extracted by 1 author using a pretested Excel form and were checked by a second author. Key data on the review papers included: purpose, methods used for finding and appraising CPGs, and observations and conclusions on CPG quality, specifically applicability. Key data on each CPG included the 6 AGREE II domain scores or 23 item scores, as well as 2 global evaluations., Data Synthesis: The mean AGREE II domain scores for the 544 CPGs (all on a 0-100 scale) were: scope and purpose (72), stakeholder involvement (53), rigor of development (56), clarity of presentation (71), applicability (34), and editorial independence (50). Only 36% of CPGs were recommended without modification. The 40 review authors generally stated that all or most of the CPGs they appraised were poor or mediocre, especially with respect to applicability. They only infrequently pointed out what information, going beyond that specified in AGREE II, would enhance applicability., Conclusions: CPGs in principle are an ideal means to move knowledge obtained from clinical research into practice. Our review of reviews of rehabilitation CPGs shows that they commonly have deficits, especially in terms of applicability. Much work needs to be done by guideline developers to make it easier for the average rehabilitation organization and clinician to implement CPGs in daily practice., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the authors who have contributed articles to the Archives of Physical Medicine and Rehabilitation (APM&R) over the 100 years of its existence., Design: Extraction of relevant information from a sample of APM&R articles., Setting: Not applicable., Participants: A total of 4933 authors contributing to 1787 articles., Main Outcome Measures: Number of authors and their gender, professional education, and country of residence., Results: The average number of authors per article increased from 1.1 in 1922 to 5.8 in 2017. The percentage of women authors grew from <5% to about 40%. In 1922 the majority of authors had an MD degree (85%); this declined to <30% by 2017, while the percentage of authors with a PhD grew from about 10% to about 30%. The percentage of contributors with a bachelor's degree initially was about 1%, grew to 13%, and then declined again. While in APM&R's early years, >90% of authors were from the United States, this percentage went into a steep decline beginning in about 1997 and now is around 35%., Conclusions: The APM&R has seen major transformations in the nature of its contributors over a century of publication; many of these parallel the changes seen in other areas of health care and medical science, but some characteristics and shifts (especially in gender and level of training of its authors) appear unique., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The Archives of Physical Medicine and Rehabilitation was born as a radiology journal, and over its century of existence it has gone through various names and owners while shifting its contents from radiology to physical medicine to physical medicine and rehabilitation. These developments are sketched in light of the growth and eventual merger of physical medicine and rehabilitation in the United States and societal historical developments in the United States and elsewhere., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge., Design: Propensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data., Setting: Nine inpatient rehabilitation centers in the United States., Participants: Patients (N=1835) admitted for first inpatient rehabilitation after an index TBI., Intervention: Family attendance during therapy sessions., Main Outcome Measures: Participation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9., Results: Participants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance., Conclusions: Family involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients' families in the rehabilitation process to maximize outcomes., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine if patients' level of effort (LOE) in therapy sessions during traumatic brain injury (TBI) rehabilitation modifies the effect of compliance with the 3-Hour Rule of the Centers for Medicare & Medicaid Services., Design: Propensity score methodology applied to the TBI Practice-Based Evidence database, consisting of multisite, prospective, longitudinal observational data., Setting: Acute inpatient rehabilitation facilities (IRF)., Participants: Patients (N=1820) who received their first IRF admission for TBI in the United States and were enrolled for 3- and 9-month follow-up., Main Outcome Measures: Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9., Results: When the full cohort was examined, no strong main effect of compliance with the 3-Hour Rule was identified and LOE did not modify the effect of compliance with the 3-Hour Rule. In contrast, LOE had a strong positive main effect on all outcomes, except depression. When the sample was stratified by level of disability, LOE modified the effect of compliance, particularly on the outcomes of participants with less severe disability. For these patients, providing 3 hours of therapy for 50% or more of therapy days in the context of low effort resulted in poorer performance on select outcome measures at discharge and up to 9 months postdischarge compared to patients with <50% of 3-hour therapy days., Conclusions: LOE is an active ingredient in inpatient TBI rehabilitation, while compliance with the 3-Hour Rule was not found to have a substantive effect on the outcomes. The results support matching time in therapy during acute TBI rehabilitation to patients' LOE in order to optimize long-term benefits on outcomes., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Most rehabilitation treatments are volitional in nature, meaning that they require the patient's active engagement and effort. Volitional treatments are particularly challenging to define in a standardized fashion, because the clinician is not in complete control of the patient's role in enacting these treatments. Current recommendations for describing treatments in research reports fail to distinguish between 2 fundamentally different aspects of treatment design: the selection of treatment ingredients to produce the desired functional change and the selection of ingredients that will ensure the patient's volitional performance. The Rehabilitation Treatment Specification System (RTSS) is a conceptual scheme for standardizing the way that rehabilitation treatments are defined by all disciplines across all areas of rehabilitation. The RTSS highlights the importance of volitional behavior in many treatment areas and provides specific guidance for how volitional treatments should be specified. In doing so, it suggests important crosscutting research questions about the nature of volitional behavior, factors that make it more or less likely to occur, and ingredients that are most effective in ensuring that patients perform desired treatment activities., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Rehabilitation clinicians strive to provide cost-effective, patient-centered care that optimizes outcomes. A barrier to this ideal is the lack of a universal system for describing, or specifying, rehabilitation interventions. Current methods of description vary across disciplines and settings, creating barriers to collaboration, and tend to focus mostly on functional deficits and anticipated outcomes, obscuring connections between clinician behaviors and changes in functioning. The Rehabilitation Treatment Specification System (RTSS) is the result of more than a decade of effort by a multidisciplinary group of rehabilitation clinicians and researchers to develop a theory-based framework to specify rehabilitation interventions. The RTSS describes interventions for treatment components, which consist of a target (functional change brought about as a direct result of treatment), ingredients (actions taken by clinicians to change the target), and a hypothesized mechanism of action, as stated in a treatment theory. The RTSS makes explicit the connections between functional change and clinician behavior, and recognizes the role of patient effort in treatment implementation. In so doing, the RTSS supports clinicians' efforts to work with their patients to set achievable goals, select appropriate treatments, adjust treatment plans as needed, encourage patient participation in the treatment process, communicate with team members, and translate research findings to clinical care. The RTSS may help both expert and novice clinicians articulate their clinical reasoning processes in ways that benefit treatment planning and clinical education, and may improve the design of clinical documentation systems, leading to more effective justification and reimbursement for services. Interested clinicians are invited to apply the RTSS in their local settings., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The field of rehabilitation remains captive to the black-box problem: our inability to characterize treatments in a systematic fashion across diagnoses, settings, and disciplines, so as to identify and disseminate the active ingredients of those treatments. In this article, we describe the Rehabilitation Treatment Specification System (RTSS), by which any treatment employed in rehabilitation may be characterized, and ultimately classified according to shared properties, via the 3 elements of treatment theory: targets, ingredients, and (hypothesized) mechanisms of action. We discuss important concepts in the RTSS such as the distinction between treatments and treatment components, which consist of 1 target and its associated ingredients; and the distinction between targets, which are the direct effects of treatment, and aims, which are downstream or distal effects. The RTSS includes 3 groups of mutually exclusive treatment components: Organ Functions, Skills and Habits, and Representations. The last of these comprises not only thoughts and feelings, but also internal representations underlying volitional action; the RTSS addresses the concept of volition (effort) as a critical element for many rehabilitation treatments. We have developed an algorithm for treatment specification which is illustrated and described in brief. The RTSS stands to benefit the field in numerous ways by supplying a coherent, theory-based framework encompassing all rehabilitation treatments. Using a common framework, researchers will be able to test systematically the effects of specific ingredients on specific targets; and their work will be more readily replicated and translated into clinical practice., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Despite significant advances in measuring the outcomes of rehabilitation interventions, little progress has been made in specifying the therapeutic ingredients and processes that cause measured changes in patient functioning. The general approach to better clarifying the process of treatment has been to develop reporting checklists and guidelines that increase the amount of detail reported. However, without a framework instructing researchers in how to describe their treatment protocols in a manner useful to or even interpretable by others, requests for more detail will fail to improve our understanding of the therapeutic process. In this article, we describe how the Rehabilitation Treatment Specification System (RTSS) provides a theoretical framework that can improve research intervention reporting and enable testing and refinement of a protocol's underlying treatment theories. The RTSS framework provides guidance for researchers to explicitly state their hypothesized active ingredients and targets of treatment as well as for how the individual ingredients in their doses directly affect the treatment targets. We explain how theory-based treatment specification has advantages over checklist approaches for intervention design, reporting, replication, and synthesis of evidence in rehabilitation research. A complex rehabilitation intervention is used as a concrete example of the differences between an RTSS-based specification and the Template for Intervention Description and Replication checklist. The RTSS's potential to advance the rehabilitation field can be empirically tested through efforts to use the framework with existing and newly developed treatment protocols., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Several guidelines have been published with the goal of increasing the usefulness of reports of clinical research. Although such guidelines may clarify key features of study design, the way in which rehabilitation treatments themselves are described continues to be problematic and limits the ability to replicate research, synthesize evidence across studies, or apply these treatments in practice. Lohse et al report little improvement in the description of rehabilitation treatments in recent years, with particular limitations in the description of comparison or standard-of-care treatments. This commentary explores the kind of published treatment descriptions that would be most useful in supporting evidence synthesis and clinical implementation and examines the degree to which a developing conceptual framework-the Rehabilitation Treatment Specification System-might support improvements in research reporting., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort., Design: Prospective, multicenter, longitudinal cohort study., Setting: Acute TBI rehabilitation programs., Participants: Patients (N=1946) receiving 138,555 therapy sessions., Interventions: Not applicable., Main Outcome Measures: Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS)., Results: The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001)., Conclusions: Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population., Design: Prospective, longitudinal, observational study., Setting: Ten inpatient rehabilitation centers., Participants: Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury., Interventions: Not applicable., Main Outcome Measures: Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being., Results: The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations., Conclusions: This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This supplement of the Archives of Physical Medicine and Rehabilitation is devoted to the Traumatic Brain Injury-Practice Based Evidence study, the first practice-based evidence study, to our knowledge, of traumatic brain injury rehabilitation. The purpose of this preface is to place this study in the broader context of comparative effectiveness research and introduce the articles in the supplement., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the amount and content of group therapies provided during inpatient rehabilitation for traumatic brain injury (TBI), and to assess the relations of group therapy with patient, injury, and treatment factors and outcomes., Design: Prospective observational cohort., Setting: Inpatient rehabilitation., Participants: Consecutive admissions (N=2130) for initial TBI rehabilitation at 10 inpatient rehabilitation facilities (9 in the United States, 1 in Canada) from October 2008 to September 2011., Interventions: Not applicable., Main Outcome Measures: Proportion of sessions that were group therapy (≥2 patients were treated simultaneously by ≥1 clinician); proportion of patients receiving group therapy; type of activity performed and amount of time spent in group therapy, by discipline; rehabilitation length of stay; discharge location; and FIM cognitive and motor scores at discharge., Results: Of the patients, 79% received at least 1 session of group therapy, with group therapy accounting for 13.7% of all therapy sessions and 15.8% of therapy hours. On average, patients spent 2.9h/wk in group therapy. The greatest proportion of treatment time in group format was in therapeutic recreation (25.6%), followed by speech therapy (16.2%), occupational therapy (10.4%), psychology (8.1%), and physical therapy (7.9%). Group therapy time and type of treatment activities varied among admission FIM cognitive subgroups and treatment sites. Several factors appear to be predictive of receiving group therapy, with the treatment site being a major influence. However, group therapy as a whole offered little explanation of differences in the outcomes studied., Conclusions: Group therapy is commonly used in TBI rehabilitation, to varying degrees among disciplines, sites, and cognitive impairment subgroups. Various therapeutic activities take place in group therapy, indicating its perceived value in addressing many domains of functioning. Variation in outcomes is not explained well by overall percentage of therapy time delivered in groups., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury., Design: Multisite prospective observational cohort study., Setting: Inpatient rehabilitation settings., Participants: Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups., Interventions: Not applicable., Main Outcome Measures: Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined., Results: Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay., Conclusions: The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Observers commonly note the poor reporting of research, including rehabilitation research. The Consolidated Standards of Reporting Trials (CONSORT) checklist (supplemented by the CONSORT extension for nonpharmacologic interventions) has been published for improving the reporting of intervention research. However, the items on these checklists are considered to be inadequate to guide authors as to which information to include when reporting on the intervention(s) studied, and the Template for Intervention Description and Replication, Journal Article Reporting Standards, and the checklist of the Western Journal of Nursing Research are recommended to rehabilitation researchers. The Rehabilitation Treatment Taxonomy framework is recommended as a conceptual scheme to assist authors in thinking through the linkages between intervention ingredients, targets of treatment, and the mechanisms of action linking these 2 areas. Recommendations are made for prospective authors and journal editors who desire to see improved reporting of rehabilitation interventions., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the psychometric properties of the Spinal Cord Injury-Functional Index (SCI-FI) short forms (basic mobility, self-care, fine motor, ambulation, manual wheelchair, and power wheelchair) based on internal consistency; correlations between short forms banks, full item bank forms, and a 10-item computer adaptive test version; magnitude of ceiling and floor effects; and test information functions., Design: Cross-sectional cohort study., Setting: Six rehabilitation hospitals in the United States., Participants: Individuals with traumatic spinal cord injury (N=855) recruited from 6 national Spinal Cord Injury Model Systems facilities., Interventions: Not applicable., Main Outcome Measures: SCI-FI full item bank, 10-item computer adaptive test, and parallel short form scores., Results: The SCI-FI short forms (with separate versions for individuals with paraplegia and tetraplegia) demonstrate very good internal consistency, group-level reliability, excellent correlations between short forms and scores based on the total item bank, and minimal ceiling and floor effects (except ceiling effects for persons with paraplegia on self-care, fine motor, and power wheelchair ability and floor effects for persons with tetraplegia on self-care, fine motor, and manual wheelchair ability). The test information functions are acceptable across the range of scores where most persons in the sample performed., Conclusions: Clinicians and researchers should consider the SCI-FI short forms when computer adaptive testing is not feasible., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Many rehabilitation treatment interventions, unlike pharmacologic treatments, are not operationally defined, and the labels given to such treatments do not specify the active ingredients that produce the intended treatment effects. This, in turn, limits the ability to study and disseminate treatments, to communicate about them clearly, or to train new clinicians to administer them appropriately. We sought to begin the development of a system of classification of rehabilitation treatments and services that is based on their active ingredients. To do this, we reviewed a range of published descriptions of rehabilitation treatments and treatments that were familiar to the authors from their clinical and research experience. These treatment examples were used to develop preliminary rules for defining discrete treatments, identifying the area of function they directly treat, and identifying their active ingredients. These preliminary rules were then tested against additional treatment examples, and problems in their application were used to revise the rules in an iterative fashion. The following concepts, which emerged from this process, are defined and discussed in relation with the development of a rehabilitation treatment taxonomy: rehabilitation treatment taxonomy; treatment and enablement theory; recipient (of treatment); essential, active, and inactive ingredients; mechanism of action; targets and aims of treatment; session; progression; dosing parameters; and social and physical environment. It is hoped that articulation of the conceptual issues encountered during this project will be useful to others attempting to promote theory-based discussion of rehabilitation effects and that multidisciplinary discussion and research will further refine these rules and definitions to advance rehabilitation treatment classification., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The idea of constructing a taxonomy of rehabilitation interventions has been around for quite some time, but other than small and mostly ad hoc efforts, not much progress has been made, in spite of articulate pleas by some well-respected clinician scholars. In this article, treatment taxonomies used in health care, and in rehabilitation specifically, are selectively reviewed, with a focus on the need to base a rehabilitation treatment taxonomy (RTT) on the "active ingredients" of treatments and their link to patient/client deficits/problems that are targeted in therapy. This is followed by a description of what we see as a fruitful approach to the development of an RTT that crosses disciplines, settings, and patient diagnoses, and a discussion of the potential uses in and benefits of a well-developed RTT for clinical service, research, education, and service administration., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This article introduces the Archives supplement presenting a conceptual framework for the creation of a rehabilitation treatment taxonomy (RTT). It describes the key theoretical and empirical articles and their role, and the commentaries that were solicited. More importantly, based on feedback received to date, it sketches what the RTT is proposed to address, and what it explicitly excludes; therefore, the readers will have appropriate expectations and criteria for what is offered., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Rehabilitation is in need of an organized system or taxonomy for classifying treatments to aid in research, practice, training, and interdisciplinary communication. In this article, we describe a work-in-progress effort to create a rehabilitation treatment taxonomy (RTT) for classifying rehabilitation interventions by the underlying treatment theories that explain their effects. In the RTT, treatments are grouped together according to their targets, or measurable aspects of functioning they are intended to change; ingredients, or measurable clinician decisions and behaviors responsible for effecting changes; and the hypothesized mechanisms of action by which ingredients are transformed into changes in the target. Four treatment groupings are proposed: structural tissue properties, organ functions, skilled performances, and cognitive/affective representations, which are similar in the types of targets addressed, ingredients used, and mechanisms of action that account for change. The typical ingredients and examples of clinical treatments associated with each of these groupings are explored, and the challenges of further subdivision are discussed. Although a Linnaean hierarchical tree structure was envisioned at the outset of work on the RTT, further development may necessitate a model with less rigid boundaries between classification groups, and/or a matrix-like structure for organizing active ingredients along selected continua, to allow for both qualitative and quantitative variations of importance to treatment effects., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether the Short-Term Executive Plus (STEP) cognitive rehabilitation program improves executive dysfunction after traumatic brain injury (TBI)., Design: Randomized, waitlist controlled trial with minimization and blinded outcome assessment., Setting: Community., Participants: Participants with TBI and executive dysfunction (N=98; TBI severity 50% moderate/severe; mean time since injury ± SD, 12±14y; mean age ± SD, 45±14y; 62% women; 76% white)., Intervention: STEP program: 12 weeks (9h/wk) of group training in problem solving and emotional regulation and individual sessions of attention and compensatory strategies training., Main Outcome Measures: Factor analysis was used to create a composite executive function measure using the Problem Solving Inventory, Frontal Systems Behavior Scale, Behavioral Assessment of the Dysexecutive Syndrome, and Self-Awareness of Deficits Interview. Emotional regulation was assessed with the Difficulties in Emotion Regulation Scale. The primary attention measure was the Attention Rating and Monitoring Scale. Secondary measures included neuropsychological measures of executive function, attention, and memory and measures of affective distress, self-efficacy, social participation, and quality of life., Results: Intention-to-treat mixed-effects analyses revealed significant treatment effects for the composite executive function measure (P=.008) and the Frontal Systems Behavior Scale (P=.049) and Problem Solving Inventory (P=.016). We found no between-group differences on the neuropsychological measures or on measures of attention, emotional regulation, self-awareness, affective distress, self-efficacy, participation, or quality of life., Conclusions: The STEP program is efficacious in improving self-reported post-TBI executive function and problem solving. Further research is needed to identify the roles of the different components of the intervention and its effectiveness with different TBI populations., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To gain an understanding of clinical thought processes about treatment classification and description, and to identify desired characteristics of and challenges to be addressed by a future rehabilitation treatment taxonomy., Design: Qualitative analysis of data collected via focus groups and semistructured interviews., Setting: Inpatient rehabilitation programs., Participants: Clinicians (N=84) in 7 disciplines involved in data collection for practice-based evidence studies of spinal cord injury and traumatic brain injury rehabilitation., Interventions: Not applicable., Main Outcome Measure: Summary of themes reported by clinicians, determined by content analysis of focus group and interview transcripts., Results: The multifaceted nature of rehabilitation treatment was identified as a major challenge to the process of classifying interventions. Simultaneous delivery of multiple interventions, performance of integrated tasks that challenge multiple body systems, and conversation-based treatments were reported to be difficult to classify. Clinicians reported that treatment classifications that make reference to goals of treatment were clinically intuitive, but they also reported difficulties when attempting to classify activities that could address multiple goals. These rehabilitation practitioners considered the setting in which treatment occurs, equipment used, assistance or cueing provided, type of treatment participants, and specific tasks performed to be important descriptors of their interventions. They recommended creating a classification system that can be applied at greater or lesser levels of detail depending on the purpose for which it is being used., Conclusions: Treatment descriptors identified may be useful for differentiating classes of treatments or characterizing treatments within classes. Precise definition of the concept of the goal as it relates to treatment theory and definition of boundaries between treatments may aid classification of multifaceted treatment activities. A balance between detail and feasibility of use will facilitate successful clinical application of a future classification system., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status., Design: Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury., Setting: Inpatient rehabilitation and community follow-up at 6 SCI treatment centers., Participants: Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation., Interventions: Not applicable., Main Outcome Measures: Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI)., Results: Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school., Conclusions: Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe group therapy utilization in spinal cord injury (SCI) inpatient rehabilitation., Design: Prospective observational study., Setting: Six inpatient rehabilitation facilities., Participants: Patients (N=1376) receiving initial rehabilitation after traumatic SCI., Interventions: Not applicable., Main Outcome Measure: Time spent in group versus individual therapy for physical therapy (PT), occupational therapy (OT), therapeutic recreation (TR), and psychology (PSY) therapies., Results: The majority (98%) of patients participated in at least 1 group therapy session, with 83%, 81%, 80%, and 54% of patients receiving group PT, OT, TR, and PSY, respectively. On average, 24% of treatment sessions and 27% of treatment time was provided in group sessions, with TR providing the greatest percent of its time in groups. Group therapy time and time spent in specific activities varied among patient subgroups with different injury characteristics. Group therapy time also varied widely among centers (range, 1.2-6.6h/wk). Across all injury subgroups, individual and group therapy hours per week were negatively correlated for OT and positively correlated for TR. Patient characteristics, clinician experience, and treatment center predicted 32% of variance in group hours per week. PT and OT strengthening/endurance interventions and TR outings were the most common group activities overall., Conclusions: While the majority of inpatient SCI rehabilitation consists of individual sessions, most patients participate in group therapy, which contributes significantly to total therapy time. Patterns of group utilization fit with functional expectations and clinical goals. A trade-off between group and individual therapy may occur in some disciplines. Utilization of group therapy varies widely among centers, and further study is needed to identify optimal patterns of group therapy utilization., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the frequency of and reasons for missed therapy sessions during inpatient rehabilitation after traumatic spinal cord injury (SCI), and to assess the influence of demographic, medical, and injury factors on the missing of therapy sessions., Design: Prospective cohort study., Setting: Six inpatient rehabilitation centers., Participants: Individuals with SCI (N=1376) consecutively admitted for inpatient rehabilitation at participating sites; 1032 participants were randomly selected for model development, and 344 participants were selected for model cross-validation., Interventions: Not applicable., Main Outcome Measures: Total hours of missed therapy; total minutes missed per week; and reason for missed therapy., Results: Patients missed an average of 153 minutes of therapies per week, or a total of 20 hours over their rehabilitation stay. Common reasons for missing physical, occupational, and speech therapy were lack of patient readiness and medical reasons. Therapeutic recreation sessions were commonly missed because of patient refusal. More missed therapy (for any reason) was predicted by having C5-8 tetraplegia, paraplegia, greater morbidity, higher motor and cognitive functional independence, higher percent of sessions limited by fatigue, violent SCI etiology, longer rehabilitation length of stay, and treatment center. Older age, ventilator use, and percent of sessions limited by spasticity were predictive of less therapy time missed., Conclusions: On average, patients missed about 2.5 hours of therapy weekly. In view of the potential impact on rehabilitation outcomes and given the potential cost of lost resources, missed therapy deserves further study and administrative attention. In addressing this issue, there may be potential for the rehabilitation facility to intervene to reduce such lost time, including addressing equipment/therapist availability, patient readiness, patient engagement, and center-specific approaches., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Comparative effectiveness research (CER) has been receiving much attention (and government funding) in recent years, stemming from dissatisfaction with much medical and health care research, which does not produce actionable evidence that can be used by clinicians, patients, and policymakers. Rehabilitation research has been characterized by similar weaknesses and by often inadequate research designs. The SCIRehab study of the outcomes of inpatient spinal cord injury rehabilitation is one of a small number of rehabilitation practice-based evidence (PBE) studies in recent years that allows for the comparison of interventions by all disciplines for relevant real-life outcomes. This introduction to a series of articles resulting from the SCIRehab project discusses the need for and the nature of CER, and places the SCIRehab study and other PBE studies in the light of CER. After a description of the highlights of the analyses in this supplement, we provide a preliminary evaluation of SCIRehab, counting the articles and presentations from the study, the resources that went into this vast project, and the lessons learned that may benefit future rehabilitation PBE investigators., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe therapist-reported factors affecting therapy sessions in spinal cord injury (SCI) inpatient rehabilitation and explore their impact on the patient's rehabilitation program., Design: Prospective observational longitudinal cohort design. Data were obtained from systematic recordings of interventions by clinicians and from medical record abstraction., Setting: Six inpatient rehabilitation programs., Participants: Patients (N=1376) with traumatic SCI admitted for initial rehabilitation., Interventions: Not applicable., Main Outcome Measures: Factors recorded as impacting the objective or content of treatment sessions by physical therapy, occupational therapy, speech therapy, and therapeutic recreation, patients' participation in treatment as rated using a modified Pittsburgh Rehabilitation Participation Scale (PRPS), length of stay (LOS), medical morbidity measured using the Comprehensive Severity Index, hours of therapy per week, and missed therapy minutes., Results: Patients received 151,172 treatment sessions from 483 therapists. Pain, fatigue, and spasticity were commonly reported factors; other medical, behavioral, and logistical factors were also frequent, with 30% of sessions being affected by at least 1 factor. The number of factors was correlated with missed therapy minutes and with the PRPS score. Patients with more reported factors, overall or per average session, had a longer LOS and fewer hours of treatment per week., Conclusions: Medical and other factors complicating therapy are common. Those who need a longer stay because of their injury level or for other reasons have more opportunity to have sessions affected, but having many treatment sessions impacted by 1 or more factors also is likely to increase LOS. The nature of these factors and their impact on rehabilitation processes and outcomes deserve further study., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe pain during inpatient rehabilitation and its impact on delivery of inpatient rehabilitation services for persons with spinal cord injury (SCI)., Design: Prospective observational study and retrospective chart review., Setting: Six inpatient rehabilitation facilities participating in the SCIRehab Study., Participants: Patients (N=1357) receiving initial rehabilitation after traumatic SCI, for whom pain data were available., Interventions: Not applicable., Main Outcome Measures: Self-reported rating of pain intensity (0-10), pain locations, and treatment time by various rehabilitation disciplines., Results: The vast majority of patients (97%) reported pain at least once during the rehabilitation stay, with an average pain intensity ± SD of 4.9 ± 2.4. Average pain intensity over the stay was severe (rated 7-10) for 30% of patients, moderate (4-6) for 42%, and mild (1-3) for 25%. Pain prevalence at admission was greater than at discharge (87% vs 74%), as was pain intensity (6.0 vs 4.6). Most (79%) of the 177 participants who did not have pain at admission reported pain at least once later in the rehabilitation stay, but their average high pain intensity over the stay was lower than that of the full sample (1.9 vs 4.9). Nearly half (47%) of patients reported pain at ≥ 3 locations during the stay, with the back, neck, and shoulder commonly reported. Patients with severe pain spent fewer days in rehabilitation, received less rehabilitation treatment time (hours per week and total hours), and had more treatment sessions altered in objective or content because of pain than those with lower pain levels., Conclusions: Pain is a common problem for persons receiving inpatient rehabilitation for traumatic SCI and adversely impacts delivery of therapy services., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Change and growth are the bread and butter of rehabilitation research, but to date, most researchers have used less than optimal statistical methods to quantify change, its nature, speed, and form. Hierarchical linear modeling (HLM) (random/mixed effects or latent growth or multilevel modeling, individual/latent growth curve analysis) generally is superior to analysis of (co)variance and other methods, but has been underused in rehabilitation research. Apropos of the publication of 2 didactic articles setting forth the basics of HLM, this commentary sketches some of the advantages of this technique., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the calibration of the Spinal Cord Injury-Functional Index (SCI-FI) and report on the initial psychometric evaluation of the SCI-FI scales in each content domain., Design: Cross-sectional survey followed by calibration data simulations., Setting: Inpatient and community settings., Participants: A sample of participants (N=855) with traumatic spinal cord injury (SCI) recruited from 6 SCI Model Systems and stratified by diagnosis, severity, and time since injury., Interventions: None., Main Outcome Measure: SCI-FI instrument., Results: Item response theory analyses confirmed the unidimensionality of 5 SCI-FI scales: basic mobility (54 items), fine motor function (36 items), self-care (90 items), ambulation (39 items), and wheelchair mobility (56 items). All SCI-FI scales revealed strong psychometric properties. High correlations of scores on simulated computer adaptive testing (CAT) with the overall SCI-FI domain scores indicated excellent potential for CAT to accurately characterize functional profiles of adults with SCI. Overall, there was very little loss of measurement reliability or precision using CAT compared with the full item bank; however, there was some loss of reliability and precision at the lower and upper ranges of each scale, corresponding to regions where there were few questions in the item banks., Conclusions: Initial evaluation revealed that the SCI-FI achieved considerable breadth of coverage in each content domain and demonstrated acceptable psychometric properties. The use of CAT to administer the SCI-FI will minimize assessment burden, while allowing for the comprehensive assessment of the functional abilities of adults with SCI., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning., Design: Cross-sectional., Setting: Inpatient and community., Participants: Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury., Interventions: None., Main Outcome Measure: Spinal Cord Injury-Functional Index (SCI-FI) measurement system., Results: Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models., Conclusions: Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the predictive value of preinjury factors for satisfaction with life (SWL) at 1-year posttraumatic brain injury (TBI)., Design: Secondary analysis of prospective, longitudinal registry using data collected during inpatient rehabilitation and at 1-year post-TBI., Setting: Fifteen specialized brain injury units providing acute rehabilitation care as part of the Traumatic Brain Injury Model Systems (TBIMS) program., Participants: Community-dwelling persons (N=444) with moderate to severe TBI aged 16 to 64 years enrolled in the TBIMS program between October 2007 and October 2008 with 1-year follow-up data., Interventions: Not applicable., Main Outcome Measure: Satisfaction With Life Scale (SWLS)., Results: Hierarchical stepwise linear regression revealed that injury-related and demographic variables did not contribute significantly to the explained variance in SWLS scores. In contrast, the preinjury functioning (education, productivity/employment) and preinjury condition (psychiatric and substance use problems, severe sensory dysfunction, learning problems, prior TBI) blocks each contributed significantly to the explained variance in SWLS scores. Preinjury functioning accounted for 2.9% of the variance and preinjury conditions for 3.8%., Conclusions: Although their contributions are small, preinjury functioning and preinjury conditions are important to consider in the prediction of SWL post-TBI. Educational level and history of psychiatric and other premorbid difficulties are particularly important for clinicians to consider when implementing or developing interventions for persons with moderate to severe TBI., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether use of neighborhood characteristics derived from U.S. Census Bureau information contributes to the prediction of outcomes after traumatic brain injury (TBI) beyond the variance accounted for by individual characteristics., Design: Cross-sectional analysis of follow-up interviews conducted 1, 2, and 5 years postinjury., Setting: Twelve Traumatic Brain Injury Model Systems (TBIMS) centers., Participants: Patients 16 years of age and older with moderate or severe TBI enrolled in the TBIMS National Database (N=472)., Interventions: None., Main Outcome Measures: Satisfaction With Life Scale and Participation Assessment with Recombined Tools-Objective., Results: Individual characteristics alone accounted for 26% and 48% of variance in life satisfaction and participation, respectively; neighborhood characteristics alone accounted for 6% and 9% of variance, respectively. Models combining both types of characteristics included significant neighborhood and individual predictors for participation but not life satisfaction; however, for participation, prediction only improved beyond that found for individual characteristics alone by 1.2%., Conclusions: The results did not support the hypotheses that characteristics of a person's neighborhood would increase outcome prediction beyond that which can be accomplished based on characteristics of the individual alone. Though neighborhood characteristics were statistically significant in prediction models, the improvement in percent of variance accounted for was negligible. Refinements in conceptualization and methodology are suggested for continued exploration of the contribution of neighborhood characteristics to TBI outcomes., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The Clinical Practice Committee of the American Congress of Rehabilitation sponsored this supplement to address 2 critical, related issues for the rehabilitation field: how to develop clinical rehabilitation research to generate useful, high-quality evidence and how to use evidence to improve rehabilitation practice. The 2 are linked by the methods of evidence-based practice (EBP) used to evaluate research evidence and make recommendations for practice. Supplement authors tackle challenges, such as identifying treatment effects and how study design decisions can impact the internal and external validity of research findings, in 4 articles that describe: a 3-phase process for the development of rehabilitation treatments; small-N study designs; the design, implementation, and statistical analysis of rehabilitation clinical trials; and observational research designs used to compare the effectiveness of rehabilitation treatments. Two articles present contemporary best methods for developing and evaluating rehabilitation prediction models and outcome measures. The supplement also addresses issues of evaluating research evidence and translating evidence into clinical decisions or recommendations. An overview of tools that EBP adherents have developed to help the clinician find, synthesize, and apply evidence is presented, followed by an article that identifies 8 primary steps in the production of a systematic review. The last article outlines 13 recommendations for improving systematic evidence reviews and applying their resulting knowledge to clinical practice. In addition to recommending best methods, the supplement addresses challenges specific to the behavioral complexity of developing rehabilitation research and applying it in a way that improves the health, function, and quality of life of persons served., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This article describes evidence-based practice (EBP) in the health professions and sciences in general and in the rehabilitation disciplines specifically. It discusses the following: what counts as evidence and how that has changed over the last 4 decades, trends in the short history of evidence-based medicine and EBP, the fallacious nature of most criticisms of EBP, (perceived) shortcomings of clinical research and the resulting evidence in rehabilitation, resources available to clinicians who want their practice to be evidence-based, and the barriers these clinicians face in keeping up with the evidence and applying it in practice. Lastly, it describes how the development of a new art and science, knowledge translation, may play a role in truly making EBP feasible in rehabilitation services., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Interventions and programs for people with disability should be based on the best--the most discriminating and rigorous--methods of systematic review and knowledge translation possible. Extant systems for systematic review and practice recommendations have excellent features but severe difficulties are encountered when attempting to apply them to disability and rehabilitation. This article identifies issues in evidence synthesis and linked practice recommendations and describes both new and long-tested methods to address them. Evidence synthesis in disability and rehabilitation can be improved by: explicating criteria for evaluating nonrandomized evidence, including the regression discontinuity, interrupted time series, and single-subject designs, as well as state-of-the-art methods of analysis of observational studies; greater use of meta-analysis; considering effect size, direction of biases, and dose-response relationships; employing more discriminating methods of evaluating flaws in masking, considering also measurement reliability and objectivity; considering overall biases and conflicts of interest; increased attention to composition of review panels; and greater transparency in reporting of the bases of reviewers' judgments. Review methods need to be developed for assistive technology and for measurement procedures. Application to practice can be improved by attention to treatment alternatives, explicit evaluation of generalizability, synthesizing clinical experience as a source of evidence, and a focus on the best--rather than the ideally most-rigorous--evidence. Study outcomes should be measured and reviewed in terms meaningful to persons served. In sum, methods are available to improve evidence synthesis and the application of resulting knowledge. We recommend that these methods be employed., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The research literature that rehabilitation clinicians need to be familiar with has become too large for anyone to read, and numerous published studies are too complex for many practitioners to understand and fruitfully use. One method to keep up with new findings is through systematic reviews. Systematic reviews can be effective tools that help guide rehabilitation practice by identifying the best research that provides the evidence for enhanced clinical decision-making. This article describes how systematic reviews are created, indicates where rehabilitation clinicians may find them, and refers to a resource that may be of use in evaluating their quality and applicability., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify factors predicting acute hospital discharge disposition after moderate to severe traumatic brain injury (TBI)., Design: Secondary analysis of existing datasets., Setting: Acute care hospitals., Participants: Adults hospitalized with moderate to severe TBI included in 3 large sets of archival data: (1) Centers for Disease Control and Prevention Central Nervous System Injury Surveillance database (n=15,646); (2) the National Trauma Data Bank (n=52,012); and (3) the National Study on the Costs and Outcomes of Trauma (n=1286)., Interventions: None., Main Outcome Measure: Discharge disposition from acute hospitalization to 1 of 3 postacute settings: (1) home, (2) inpatient rehabilitation, or (3) subacute settings, including nursing homes and similar facilities., Results: The Glasgow Coma Scale (GCS) score and length of acute hospital length of stay (LOS) accounted for 35% to 44% of the variance in discharges to home versus not home, while age and sex added from 5% to 8%, and race/ethnicity and hospitalization payment source added another 2% to 5%. When predicting discharge to rehabilitation versus subacute care for those not going home, GCS and LOS accounted for 2% to 4% of the variance, while age and sex added 7% to 31%, and race/ethnicity and payment source added 4% to 5%. Across the datasets, longer LOS, older age, and white race increased the likelihood of not being discharged home; the most consistent predictor of discharge to rehabilitation was younger age., Conclusions: The decision to discharge to home a person with moderate to severe TBI appears to be based primarily on severity-related factors. In contrast, the decision to discharge to rehabilitation rather than to subacute care appears to reflect sociobiologic and socioeconomic factors; however, generalizability of these results is limited by the restricted range of potentially important variables available for analysis., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a new measure, the Participation Assessment With Recombined Tools-Objective (PART-O), based on items from 3 participation instruments., Design: Instrument development based on survey research., Setting: Community., Participants: Adults (N=400) with traumatic brain injury (TBI) 1 to 15 years postinjury, recruited from 8 TBI Model Systems (TBIMS)., Interventions: None., Main Outcome Measure: Community Integration Questionnaire version 2; Participation Objective, Participation Subjective; Craig Handicap Assessment and Reporting Technique; PART-O., Results: Using Rasch rating scale analysis to evaluate the psychometric properties of participation items drawn from 3 instruments, a set of 24 items was developed that covered a broad range of participation content and formed a measure with person separation of 2.47, person reliability of .86, item spread of 4.25 logits, item separation of 11.36, and item reliability of .99. Items were well targeted on the sample with only 1 item misfitting. The PART-O showed expected relationships with measures of impairment, activity limitations, and subjective well-being., Conclusions: The 24-item PART-O is an acceptable measure of objective participation for persons with moderate and severe TBI. It has been adopted as the measure of participation in the TBIMS., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop and compare 2 scoring algorithms for a measure of participation, the Participation Assessment with Recombined Tools-Objective (PART-O) based on the assumption that more participation is better versus an alternative that reflects balance in domains of participation., Design: Survey., Setting: Community settings., Participants: Three groups of participants under the age of 65 years were included: (1) persons with spinal cord injury, traumatic brain injury, stroke, and other disorders who are commonly treated in acute rehabilitation settings (n=220), and (2) participants from the general population who did (n=366) or (3) did not (n=284) self-report limitations indicative of a disability who participated in the 2006 Colorado Behavioral Risk Factor Surveillance System (N=870)., Interventions: Not applicable., Main Outcome Measure: PART-O., Results: We developed PART-O subscores using a consensus process and then evaluated them empirically. We combined subscores using 2 contrasting algorithms, one using average scores and the other reflecting the amount of participation and variation in participation across 3 domains. The algorithms for the total scores yielded normal distributions in all 3 samples and were equally sensitive to the impact of disability. While strongly correlated, about 30% of the variance of the 2 total scores was not shared., Conclusions: Two scoring algorithms for the PART-O illustrate contrasting perspectives of the construct of participation. The 2 algorithms may be used in future studies to expand our understanding of the construct of participation., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the applicability of marital resource (marriage has substantial benefits for well-being over not being married) or marital crisis (marital dissolution leads to poorer well-being) models to the spinal cord injury (SCI) population by studying the effects of sex, marital status, and marital transitions on well-being., Design: Prospective cohort study from the SCI Model Systems National Database., Setting: Community., Participants: Men (n=4864) and women (n=1277) who sustained traumatic SCI and completed a minimum of 1 follow-up interview beginning at 1 year through 15 years postinjury., Interventions: None., Main Outcomes Measures: Life satisfaction, depressive symptoms, and self-perceived health status by using linear mixed models for longitudinal data., Results: In general, well-being improved over time since injury. Hypothesis testing supported the marital crisis model, as marital loss through being or becoming separated or divorced and being or becoming widowed, had the most consistent and negative impact across well-being outcomes, whereas being or becoming married had an advantage for only lower depression symptoms over time. However, marital dissolution or loss did not have a uniformly adverse impact on well-being outcomes, and this effect often was moderated by sex, such that widows had higher depressive symptoms and poorer self-perceived health than widowers, but separated or divorced women had higher life satisfaction and self-perceived health than men. Irrespective of sex, being separated or divorced versus being single was associated with higher depressive symptoms over time., Conclusions: Results support the marital crisis model and that women and men can experience marital dissolution differently. All marital loss does not result in compromised well-being and all marriage does not enhance well-being, highlighting complex dynamics worthy of further investigation in this population., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI)., Design: Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview., Setting: Inpatient and postdischarge rehabilitation programs., Participants: Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study., Interventions: Not applicable., Main Outcome Measures: Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews., Results: Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services., Conclusions: SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and outcomes., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

While participation is increasingly defined as the key outcome of rehabilitation, disagreements on and shortcomings in the definition, operationalization, and measurement of this concept abound and interfere with the progress of clinical services and research. This article explores a number of the major issues related to the quantification of participation and makes suggestions for new directions, using the following orienting questions: What is the definition of participation? Where is the border between Participation and Activity? Is there more to participation than performance? What domains should be included in a participation measure? What are the appropriate metrics in quantifying participation? How do we define adequate participation? How should participation be operationalized? What is the proper measurement model for participation instruments? How should we collect data on participation? How do we evaluate the quality of a participation instrument?, (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Rehabilitation is supported by research evidence that is limited in both number and quality. In order for more and better evidence to be published, researchers need to improve their reports of randomized controlled trials and other interventional research. Making it likely that these reports can contribute to the cumulation of scientific knowledge through their inclusion in systematic reviews imposes some special requirements. This article discusses the following steps that investigators should follow: trial registration; reliance on Consolidated Standards for Reporting Trials guidelines in protocol development and report writing; use of recommendations by authoritative groups for the use of specific measures or data sets; adherence in writing to the style and other guidelines offered by the American Medical Association, the American Psychological Association, the International Committee of Medical Journal Editors, and the target journal's instructions for authors; clear declarations of deviations from commonly accepted study methods; and use of informal peer review.

For rehabilitation and disability research, participation and environment are 2 crucial constructs that have been placed center stage by the International Classification of Functioning, Disability and Health (ICF). However, neither construct is adequately conceptualized by the ICF, and both are difficult to measure. This article addresses conceptual and methodologic issues related to these ICF constructs, and recommends an improved distinction between activities and participation, as well as elaboration of environment. A division of the combined ICF categories for activity and participation into 2 separate taxonomies is proposed to guide future research. The issue of measuring participation from objective and subjective perspectives is examined, and maintaining these distinct conceptual domains in the measurement of participation is recommended. The methodological issues contributing to the difficulty of measuring participation are discussed, including potential dimensionality, alternative metrics, and the appropriateness of various measurement models. For environment, the need for theory to focus research on those aspects of the environment that interact with individuals' impairments and functional limitations in affecting activities and participation is discussed, along with potential measurement models for those aspects. The limitations resulting from reliance on research participants as reporters on their own environment are set forth. Addressing these conceptual and methodological issues is required before the measurement of participation and environmental factors can advance and these important constructs can be used more effectively in rehabilitation and disability observational research and trials.