Invited Commentary

My commentary on the report “Toward a Rehabilitation Treatment Taxonomy: Summary of Work in Progress”¹ reviews the history of the project, highlights the significance of this effort to the rehabilitation field, and summarizes its relevance to physical therapy. Efforts to develop the rehabilitation treatment taxonomy (RTT) began as an offshoot of a multisite study to examine relationships among rehabilitation treatments and poststroke outcomes using practice-based evidence methods. Rather than adopt a “black box” approach that views all treatments as standard and interchangeable (eg, 30 minutes of physical therapy), the study goal was to analyze the effects of specific components of rehabilitation treatments on poststroke outcomes. Because treatment information could not be reliably extracted from medical records, researchers worked with members of rehabilitation teams at each site to develop standardized treatment documentation forms for each discipline.² This study demonstrated the need for language and terminology to accurately define, describe, and categorize rehabilitation treatments. At the American Congress of Rehabilitation Medicine (ACRM) meeting in 2002, presentations discussing efforts to document rehabilitation treatments served as the impetus to establish a multidisciplinary task force to explore development of a rehabilitation treatment taxonomy. In 2008, funding from the National Institute on Disability and Rehabilitation Research (NIDRR) provided an opportunity to formally advance this work.

The inability to specify the content of rehabilitation treatments is described by Keith as the “most glaring omission in research on rehabilitation outcomes,”^2(p1302) and it is a serious impediment to advancing rehabilitation research. Furthermore, lack of a systematic approach to describe and categorize rehabilitation interventions hinders our ability to communicate within and across disciplines, seriously undermining clinical practice and professional education.³ There may be many reasons why rehabilitation treatments have not been systematically defined and categorized, but one reason is indisputable—it is an extremely difficult task.

Early in the development of the RTT, the research team decided to develop a theory-driven classification system, and lack of an explicit theory for rehabilitation treatment was immediately apparent. Development of the “tripartite treatment theory” forms the basis for the RTT and provides a conceptual framework that can be applied across all rehabilitation disciplines and patient conditions. Use of this conceptual framework promotes a disciplined thought process that requires identification of targets for the treatment along with specification of proposed mechanisms of action and active ingredients. The tripartite treatment theory prevents us from merely describing the goal of treatment as the treatment (eg, the treatment used to train gait is defined as gait training). Instead, we are required to define and organize treatments by their targets, mechanisms of action, and active ingredients. Conceptual frameworks are used to organize knowledge, and they facilitate knowledge retrieval and application.⁴ Furthermore, as noted by Gail Jensen in her 2011 Mary McMillan Lecture, conceptual frameworks facilitate “habits of the mind” that are critical for developing professional competency.⁵ Using the tripartite treatment theory conceptual framework can create a “habit of the mind” that has the potential to deepen our understanding of the targets, mechanisms of action, and active ingredients that define physical therapy treatments. Moreover, a common conceptual framework and language will help us communicate important information about physical therapy treatments to other rehabilitation professionals. The benefit of adopting a shared conceptual framework and terminology is demonstrated by the impact the International Classification of Functioning, Disability and Health (ICF) has had on rehabilitation research, patient care, and professional education. There is no doubt that adoption of the ICF conceptual framework and terminology has advanced our ability to understand, describe, and study domains of functioning that are the focus of rehabilitation treatments.⁶ In light of the impact of the ICF on the rehabilitation field, there is great potential for using the tripartite treatment theory conceptual framework to improve how we think about, describe, and study rehabilitation treatments.

It is important to note that multidisciplinary participation is an integral part of the RTT development, including involvement of professional organizations. Throughout the RTT development process, meetings provided a forum to identify and discuss common concerns across rehabilitation professions. Efforts to define practice within professional organizations, such as the Guide to Physical Therapist Practice⁷ and the Occupational Therapy Framework,⁸ are ongoing. The RTT does not replace the role of rehabilitation professional organizations in defining practice. Instead, the RTT provides an opportunity to inform these efforts so that, where appropriate, consistent terminology and common frameworks are adopted. Development of the RTT is an audacious task that has just begun. Next steps involve identification of treatment categories that are “mutually exclusive” based on differences in treatment targets, mechanisms of action, and active ingredients. Any student, clinician, educator, or researcher who has struggled to use jargon-free language to provide a meaningful and accurate description of physical therapy treatments can appreciate the effort outlined in this report and recognize the potential for future contributions as this work continues.

• © 2014 American Physical Therapy Association