PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of jspinalcordmedLink to Publisher's site
 
J Spinal Cord Med. Jun 2009; 32(3): 283–296.
PMCID: PMC2718817
SCIRehab Project Series: The Occupational Therapy Taxonomy
Rebecca Ozelie, OTR/L, BCPR,1 Catherine Sipple, MS, OTR,2 Teresa Foy, OTR/L,3 Kara Cantoni, OTR/L,4 Katherine Kellogg, OTR/L5, Jennifer Lookingbill, MS, OTR/L,6 Deborah Backus, PhD, PT,3 and Julie Gassaway, MS, RN7
1Rehabilitation Institute of Chicago, Chicago, Illinois; 2Craig Hospital, Englewood, Colorado; 3Shepherd Center, Atlanta, Georgia; 4Carolinas Rehabilitation, Charlotte, North Carolina; 5Mt. Sinai Medical Center, New York, New York; 6National Rehabilitation Hospital, Washington, DC; 7Institute for Clinical Outcomes Research, Salt Lake City, Utah
Please address correspondence to Julie Gassaway, MS, RN, Institute for Clinical Outcomes Research, 699 E. South Temple, Salt Lake City, UT 84102; p: 410 315 8091; f: 801 466 6685 (e-mail: jgassaway/at/isisicor.com).
Received November 17, 2008; Accepted January 11, 2009.
Background/Objective:
Lack of a classification system for occupational therapy (OT) rehabilitation interventions for traumatic spinal cord injury (SCI) rehabilitation in the United States makes conducting outcomes research difficult. This article describes an OT SCI rehabilitation taxonomy (system to categorize and classify treatments).
Methods:
OT clinicians and researchers from 6 SCI rehabilitation centers developed a taxonomy to describe details of each OT session. This effort is part of the SCIRehab study, which uses the practice-based evidence, observational research methodology to examine current treatment processes without changing existing practice.
Results:
The OT taxonomy consists of 26 OT activities (eg, training on activities of daily living, communication, home management skills, wheelchair mobility, bed mobility, transfers, balance, strengthening, stretching, equipment evaluation, and community reintegration). Time spent on each activity is documented along with therapeutic interventions used to facilitate the activity. Treatment descriptions are enhanced further with identification of assistance needs, patient direction of care, and family involvement, which help to describe and guide OT activity selection. The OT taxonomy documentation process includes all OT rehabilitation interventions for patients with SCI while maintaining efficiency in data collection.
Conclusion:
The electronic documentation system is being used at 6 centers for all OT sessions with 1,500 patients with acute traumatic SCI. It is the largest known attempt to document details of the comprehensive OT rehabilitation process for patients with SCI in the United States.
Keywords: Spinal cord injuries, Rehabilitation, physical, Occupational therapy, Taxonomy, Evidence-based practice
Occupational therapists (OTs), much like other healthcare professionals, are challenged to advance clinical practice based on sound evidence (1). This evidence should include parameters of treatment that are deemed important within OT: impairment, activity limitations, and the amount of therapy provided to achieve a given goal with a specific patient group. Similar to other areas of rehabilitation, treatment interventions and patient characteristics often are not defined in research reports evaluating OT interventions for spinal cord injury (SCI) (2). Although the Occupational Therapy Practice Framework: Domain and Process (3) defines OT approaches and interventions, it does not provide evidence for each intervention (or a combination of interventions) that would be most beneficial to reduce a given impairment or dysfunction. Furthermore, this document does not address SCI rehabilitation specifically. To advance research on OT clinical practice in SCI rehabilitation, OT providers and researchers first must have standard classifications for OT interventions.
The idea of defining and quantifying OT treatments used during the rehabilitation process is not novel. Keith (4) described the necessary components that need to be included when evaluating the rehabilitation process. Keith makes 4 recommendations to assist in determining what variables of the rehabilitation program lead to the best outcomes: (a) report hours of service/treatment, (b) define treatment strength (how well the plan was executed, specificity of the plan, dosage, timing), (c) analyze naturally occurring variations in processes and care, and (d) develop a taxonomy.
DeJong et al (5) suggested criteria to evaluate the usefulness of taxonomy efforts and subsequently describe how a group of researchers and clinicians came to a consensus and established a taxonomy for characterizing the rehabilitation process after stroke (6). Richards et al (7) described the OT component of this taxonomy for post-stroke rehabilitation, which also addresses most of the areas put forth by Keith (4). The OT stroke rehabilitation taxonomy included the treatment activity (bed mobility, transfers, wheelchair [WC] mobility and management, activities of daily living, home management, community integration, and leisure activities) and the duration of each activity. It also included whether a session was conducted individually or in a group and the amount of time spent in evaluation/planning and team conferences. Through development of this taxonomy, Richards et al (7) were able to describe the focus of OT interventions for stroke rehabilitation. The multidisciplinary stroke rehabilitation taxonomy of DeJong et al (6) allowed researchers to determine the effect of rehabilitation treatment variables on outcomes after stroke. For example, they evaluated the effect of timing of the start of stroke rehabilitation on outcomes (8), the timing and types of interventions that led to the best speech outcomes (9), and the effects of gait training on walking outcomes (10). The authors' suggest that the taxonomy provided a tool to describe the stroke rehabilitation process, and therefore, may be useful for operationalizing rehabilitation standards of practice and for rehabilitation research.
Recently, van Langeveld et al (11,12) used the International Classification of Functioning (ICF) to develop a classification system to categorize occupational, physical, and sports therapy treatment interventions for mobility and self-care in SCI rehabilitation; it was tested for feasibility and validity in the SCI population in The Netherlands. To develop the classification, the authors solicited expert opinion on level of agreement regarding (a) definitions, (b) terminology, (c) relevance, and (d) completeness of the classification. The experts rated the system as useful and found it easy to use. Thirty-six therapists (14 of whom were OTs) were able to classify 86.3% of treatment sessions using the 3 defined levels and reported that they were able to record codes designating the nature of sessions within 3 minutes. The classification system of van Langeveld et al only includes individual treatment sessions that focus on mobility and self-care domains. It is an important step toward classifying OT treatments for rehabilitation after SCI and showed that a group of individuals can come together to reach consensus on at least a subset of OT activities deemed important in SCI.
Thus, although the literature has begun to include taxonomies related to OT treatments, including a recent classification specifically for SCI, they are not comprehensive to describe the full spectrum of OT treatments used in SCI rehabilitation. A comprehensive taxonomy will provide the foundation to determine the effect of rehabilitation components, individually and in combination, on outcomes while controlling for patient differences.
The SCIRehab Project is a 5-year research effort designed to determine which SCI rehabilitation activities and interventions are associated most strongly with positive outcomes at 1 year after injury, after controlling for underlying patient characteristics including diagnosed level/severity of injury. To describe and quantify specific interventions used by each clinical specialty involved in SCI rehabilitation, a comprehensive taxonomy for each discipline needed to be developed, because current chart documentation at the 6 SCIRehab centers does not include consistent detailed descriptions of each therapy session. The OT taxonomy was produced as part of the first phase of this project, which will enroll 1,500 consecutive initial rehabilitation admissions of patients with traumatic SCI consenting to participate at 6 centers over 2.5 years.
The first article in this Journal of Spinal Cord Medicine SCIRehab series by Whiteneck et al (13) describes the SCIRehab project in detail, including how it uses the practice-based evidence (PBE) methodology that thrives on center-to-center and patient-to-patient practice differences while not specifying or requiring specific therapeutic interventions. It also presents the SCIRehab hypotheses and research questions.
The second article in the series by Gassaway et al (14) describes the iterative process used to develop discipline-specific taxonomies (eg, OT, physical therapy, therapeutic recreation, psychology) and details those elements that are supplemental to the taxonomies but common across disciplines in the SCIRehab project, such as use of group therapy, co-treatment, patient assistance needs, patient/family involvement, and factors impacting a given treatment session.
This article describes the OT taxonomy developed by a group of SCIRehab OTs and explains the elements that were included. The taxonomy is comprehensive of OT activities and interventions used at each of the 6 centers. Center-by-center practice differences are reflected in the array of OT activities in which patients participate and interventions used to facilitate their participation.
The OT documentation system that includes the taxonomy described here is comparable to the format used by all SCIRehab disciplines (14). As shown in Table 1, the OT first describes each therapy session in terms of type (individual or group), co-treatment with other disciplines (if applicable), the extent of the patient directing care, and patient and family involvement. Factors that may limit the session (eg, orthostasis or behavioral issues) are identified. The OT then identifies time spent on assessment and 1 or more of the identified 26 OT-specific activities in which the patient participated during the session. Patient assistance needs (Table 2) may contribute to activity selection; Tables 3 to to2121 contain the assessment and treatment “taxonomy” portions of the documentation and show the intervention details associated with each activity individually. Intensity is measured by the amount of time spent per activity.
Table 1
Table 1
OT Activities and Session Variables
Table 2
Table 2
Options for the Level of Assistance and Education Only Descriptors
Table 3
Table 3
Assessment/Evaluation
Table 21
Table 21
Education Not Covered by Other Activity Areas (Described in Tables 420)
Many of the 26 OT activity categories are supplemented by information about the assistance a patient requires to perform the activity. Table 2 lists the adapted Functional Independence Measure (FIM) (15) options for level of assistance (LOA) used in the OT activity descriptions. The use of adapted FIM descriptors to rate assistance needs consistently by all disciplines is described in the article by Gassaway et al (14). In the SCIRehab OT documentation, a finer delineation of assistance needs is obtained than would be captured with standard FIM application. Assistance needs are associated with specific OT activity components in the OT taxonomy rather than FIM items defined per the FIM manual (16). For example, a person with tetraplegia may improve significantly in a component of lower body dressing, such as donning pants. This improvement in donning pants is noted in the OT taxonomy but may not be reflected in the single FIM score for the lower body dressing item, which also includes assistance needed for donning shoes and socks. If functional work (eg, transfers, activity of daily living [ADL] training) is reviewed with the patient and/or family without the patient actually performing or practicing the task, there is no assistance needed. Thus, Table 2 also contains “education only” options.
Assessment and each of the 26 activities included in the OT taxonomy are contained in Tables 3 to to2121 and described below. Although much treatment work is discipline specific (eg, OT activity of daily living training and physical therapy [PT] gait training), other treatments are initiated by one or both disciplines depending on facility practices. Both OTs and PTs work on transfer training and bed mobility. At some facilities, OTs are responsible for the majority of wheelchair (WC) evaluation and prescription, whereas at other facilities, this is a PT responsibility. Thus, OTs worked with PTs to establish consistent treatment intervention descriptions for those interventions that are a component of each discipline; the PT and OT taxonomy categories for bed mobility training, transfers, WC mobility, equipment evaluation/prescription, and respiratory management follow similar frameworks (17). During analysis, this consistency will allow researchers to examine the impact of WC mobility training or transfer training, for example, regardless of the discipline providing the training. In addition, consistent descriptions provide a common frame of reference to clinicians when they discuss development and use of their taxonomies within facilities and to aid in interpretation of findings.
Assessment/Evaluation
The OT documentation process first indicates areas of patient assessment and time spent performing the assessment. Because of the high prevalence of shoulder pain among patients with SCI (1820), shoulder function is the only assessment topic that is defined further in this documentation. The indication for the shoulder assessment (chronic/acute pain or pain prevention) and the findings of the assessment (subluxation, positive impingement test, pectoralis tightness, decreased shoulder musculature, scapular elevation and scapular protraction/winging) are included (Table 3).
Activities of Daily Living
The next 7 OT activities come under the general rubric of self-care tasks or ADLs. For these activities, the OT assumes the role of a skills teacher (coach) and therapy consists of demonstrating the skill, teaching component or simplified steps, and teaching and rehearsing the entire sequence. Once a patient knows the basics, the OT helps the patient become more efficient at the skill through repeated practice.
Self-Feeding
Table 4 depicts the taxonomy information for OT work on self-feeding skills. It incorporates the main pieces of equipment used at the 6 SCIRehab centers to facilitate the self-feeding process and whether the patient practices this task in a (wheel) chair or in bed. Self-feeding in an upright, supported position, such as the WC, may lead to greater independence with the task than when a less supportive surface (eg, a hospital bed) is used. A variety of adaptive equipment for self-feeding is available; the OT taxonomy incorporates the main pieces of equipment used at the 6 SCIRehab centers.
Table 4
Table 4
Self-Feedinga
Grooming
Grooming, like self-feeding, may be facilitated by position (in bed, WC, or standing; Table 5). The OT taxonomy includes this position along with the specific grooming tasks (eg, face washing, hair combing) worked on during the session, the type of equipment used with each task, and the amount of assistance need for each task, because a different level of assistance may be needed for each aspect of grooming. For patients with less severe injuries who are able to work on “all grooming tasks,” LOA is associated with the full task.
Table 5
Table 5
Grooming
Bathing
Bathing information captured is similar to self-feeding and grooming information (Table 6). However, designation of equipment needed for task completion is limited to none, prefabricated adaptive equipment, or custom adaptive equipment because adaptive equipment used during bathing varies greatly between centers, especially the custom equipment.
Table 6
Table 6
Bathinga
Dressing
Table 7 combines details for upper and lower body dressing; however, they are separate in the OT taxonomy because the equipment used, clothing type, and amount of assistance needed to complete each task often is different. Documentation for both upper and lower body dressing includes the surface where the task occurs, patient position, and adaptive equipment used. Lower body dressing also includes type of clothing donned or doffed during the session.
Table 7
Table 7
Dressing: Upper and Lower
Toileting: Clothing Management and Hygiene
The OT taxonomy includes as separate activities toileting, bladder management, and bowel management, but in Table 8 they are combined. Toileting includes the patient's ability to manage clothing and hygiene, similar to the FIM toileting item. As shown in Table 8, the only information captured for toileting is type of equipment (bed, commode type, tub bench with cut-out) used and assistance needs.
Table 8
Table 8
Bowel and Bladder Management, Toileting: Clothing Management, and Hygienea
Bowel Management
Protocols for teaching bowel and bladder management vary significantly among SCIRehab centers. Nurses at some centers address all teaching needs regarding bowel/bladder management. Some other centers use collaborative efforts of nursing and OT. The remaining centers divide the task based on the patient's level of injury; nursing works with patients with paraplegia, whereas OTs focus on patients with tetraplegia. The SCIRehab centers also vary in how OTs assist patients with upper motor neuron deficits to get consistent bowel results. Table 8 shows taxonomy options for surface, whether training involves a simulation (common before actual performance of the technique is attempted) or an actual performance of bowel management, and techniques and adaptive equipment used for bowel management. Not included in the OT taxonomy are techniques such as drinking a hot beverage before attempts to elicit a bowel movement. However, the time of the treatment session is documented in the SCIRehab study so that bowel management technique training can be associated with mealtimes (eg, rectal clear after breakfast or lunch).
Bladder Management
Between-center variation also is seen for bladder management, and the OT taxonomy allows tracking of such differences. Some centers use a sterile closed technique (prelubricated catheter in a clear collection bag with an introducer tip on 1 end that allows the catheter to be touched less), others use a sterile open system (separately packaged catheters and lubrication), and others use clean (soap and water, no gloves) techniques for catheterization. In addition to the variations in technique used, centers also vary in the type of adaptive equipment used in bladder management and catheterization types for patients with tetraplegia (intermittent catheterization, indwelling [suprapubic] catheter, leg bag, or external collectors).
Communication and Assistive Technology
The OT taxonomy includes 3 types of communication activities: writing, page turning, and phone use. It also includes 2 types of assistive technology: computer access and electronic aids for daily living (EADLs)/call system. Equipment lists include various types of writing devices, splints, and telephones. Generic categories for phone types are included so that rapidly changing technology will fit into these categories over time. In addition, devices to assist with upper extremity function (eg, mobile arm support and overhead sling) are included for assistive technology. Table 9 combines details for communication and assistive technology activities; however, they are separate in the OT taxonomy.
Table 9
Table 9
Communication and Assistive Technology
Home Management Skills
The OT taxonomy includes time spent on teaching instrumental ADLs (IADLs) such as childcare, cleaning, laundry, and meal preparation (Table 10). All patients engage in some IADLs; however, focus on a particular skill may vary by age, sex, and stage of life.
Table 10
Table 10
Home Management Skills
Bed Mobility
Bed mobility is a skill that is inherent in the completion of many ADL tasks (eg, lower body dressing), transfers out of bed, and correct positioning in bed for skin protection and comfort (Table 11). The PT and OT taxonomies follow a similar framework for bed mobility training (17).
Table 11
Table 11
Bed Mobility
It is common to work on just 1 or 2 elements of bed mobility (positioning, rolling, supine-to-sit, and/or scooting) during an OT treatment session. Capturing level of assistance and other details about each bed mobility component describes independence differences that would not be apparent using standard documentation formats such as the FIM. Rolling on a treatment mat or in a hospital bed using railings often is easier than on a standard bed. Learning positioning on a large treatment mat is different than learning positioning in the confined space of a hospital bed. Thus, the taxonomy includes the surface on which bed mobility components are performed. As with many OT activities, adaptive equipment facilitates task completion.
Transfers
OTs and PTs worked together to dissect transfer components and develop a common definition of transfers, including surfaces involved and type of transfer (Table 12). Because therapists intuitively think about a transfer as 1 action back-and-forth between 2 surfaces (eg, getting into and out of a car is considered 1 action) a transfer was defined as a back-and-forth action between 2 surfaces. The PT and OT taxonomies incorporate the same definition of “transfer” and follow a similar framework (17).
Table 12
Table 12
Transfers
A unique transfer training detail included only in the OT taxonomy, however, is whether a transfer is performed dressed or undressed. It is common to have an OT treatment session where tasks such as toilet or bathing transfers are performed with clothing on for the purpose of training; however, in real life, this transfer would most likely be performed undressed. Many individuals require increased assistance when transfers are performed undressed, because they are more prone to stick to the surface or are unable to slide across the transfer board as they may have become accustomed to doing when clothed. Performing transfers with vs without clothing also may have an impact on skin integrity.
Therapeutic Activities
The OT taxonomy category named “therapeutic activities” may be a bit confusing, because all activities conducted during OT sessions are considered therapeutic (Table 13). This all-encompassing category of therapeutic activities includes 10 OT treatments that do not fit easily into any of the other identified OT activities, including edema management, breathing exercise, visual/perceptual training, and cognitive retraining. Selection of “tenodesis training” or “practice of fine motor activities” prompts for additional information about pinch type and splint use.
Table 13
Table 13
Therapeutic Activities
Strengthening/Endurance
The OT taxonomy includes 14 categories for strengthening and increasing endurance; some are common across sites and others are used at some, but not all sites (eg, Motomed; Video Simulation; Playstation EyeToy [Trademark of Sony Computer Entertainment, Europe]; Wii [Nintendo of America, Inc., Redmond, WA]; and yoga; Table 14). When applicable, the OT taxonomy captures information about body position, involved body part, and direction of movement (eg, flexion, extension, protraction) for each of the 14 categories. Position is especially important when using “basic/low-tech equipment” or “no equipment,” because progressing from supine to sitting or from a WC to short sit (unsupported) can represent improvement in strength and balance.
Table 14
Table 14
Strengthening/Endurance
Range of Motion/Stretching
Information about the type of range of motion (ROM) or stretching provided to specific body parts is captured (Table 15). “Intervention” includes the type of range of motion treatment delivered or treatments, such as manual/orthopedic treatment and thermal agents that are common adjuncts to range of motion and stretching.
Table 15
Table 15
Range of Motion/Stretching
Balance
A patient's balance performance can differ significantly depending on her/his body position and the amount of movement involved (Table 16). Thus, movement is categorized as static or dynamic and includes the body position from which balance is addressed.
Table 16
Table 16
Balancea
Modalities
The OT taxonomy seeks to classify and quantify application of specific modalities used with patients with SCI. Table 17 lists the types of modalities included and the indication for use and the anatomic location of application. Modalities can be used for various reasons; for example, Kinesiotape can be used for pain management, neuromuscular re-education, or for edema management.
Table 17
Table 17
Modalities
Wheelchair Mobility
Teaching WC mobility is a crucial OT intervention in SCI rehabilitation to enable environmental exploration and to perform daily tasks at home. Like the skills of bed mobility and transfers, WC mobility skill training falls under other disciplines' scope of practice as well (17). The OT and PT taxonomies capture important attributes of these cross-disciplinary skills as applicable to that discipline. Table 18 combines details for power and manual WC mobility training; however, documentation for each is separate in the OT taxonomy.
Table 18
Table 18
Wheelchair Mobility—Manual and Power
The OT taxonomy includes various manual and power WC mobility skills and skill-specific details; there is some overlap of skill by chair type. Level of independence and surface type is tracked separately for individual skills including propulsion, ramps, and wheelies.
Adaptive equipment often is used with both manual and power WC mobility training to increase the patient's independence. For example, a patient may be unable to propel a manual chair without having a tubing wrap on the wheels.
Management of doors, elevators, and curbs is important for community mobility in either type of chair. Additionally, 2 skills unique to the power chair (WC management and power functions) are included, because patients need to be able to manage seating functions and to position their drive controls properly or to direct someone else in doing so.
Community Reintegration Outings
Community outings help to reintegrate the patient into the community. The OT taxonomy includes the location of the outing and descriptions of the integral role that OTs have in showing the newly injured patient how to cross a street in a WC, navigate curbs, manage money, perform catheterization in a community bathroom (especially the first time), and deal with the stigma or other emotional issues that come with community exposure (Table 19). Therapeutic recreation and PT also include details of community outings in their respective taxonomies.
Table 19
Table 19
Community Reintegration Outing
The following 4 activities are combined into a single table (Table 20).
Table 20
Table 20
Other Activities
Skin Management
SCI centers follow skin care programs to prevent pressure ulcers. OTs, like their colleagues in other disciplines, adhere to pressure relief programs and are involved in procurement of appropriate equipment. Activities and specific therapy interventions included in the skin management section of the OT taxonomy mirror the activities in the PT taxonomy (17).
Equipment Evaluation
Evaluations for ordering of WCs, transfer devices, and equipment for bed, bathing, and toileting are the primary responsibility of OTs in some centers and of PTs in other facilities. Thus, this activity is included in both the OT and PT taxonomies (17).
Adaptive equipment evaluation focuses on identifying a patient's functional deficits (eg, decreased muscle strength, ROM, or fine motor skills) and determining the most appropriate piece of adaptive equipment to optimize independence.
Splint/Cast Fabrication
Throughout the course of rehabilitation, splints and casts may be used in therapy to promote function, for contracture management, or for maintenance of a functional hand position (Table 20). Fabrication of the most commonly used splints is included in the OT taxonomy. The process of splinting and casting may continue throughout the rehabilitation process as patient function changes. Often, it is necessary to adapt existing splints to improve their functional use; this is termed “adaptation to prior” in the OT taxonomy.
Airway/Respiratory Management
OT practice in respiratory management varies greatly among centers, as does respiratory management by PT. The airway management section of both taxonomies includes documentation of chest physical therapy, respiratory exercises, suctioning, and coughing interventions only and an indication of whether the therapist educated the patient and/or family on components of respiratory management.
Education Not Covered By Other Activity Area
Education is an integral component of training in every functional activity and not included separately in the OT taxonomy (Table 21). As stated earlier, if the patient does not practice the functional task, the OT includes this education in the appropriate functional task activity (Tables 420) by selecting an education only option in the level of assistance field (if the functional task is not practiced, there is no assistance needed) in Table 2. For example, the OT reviews transfers techniques with the patient but the patient does not perform the transfer. Because this is education about a functional task that is included in the OT taxonomy, it is recorded in the transfer activity, and the level of assistance is documented as patient education only.
However, much OT education also is provided in the absence of functional task work, and thus, is included separately in the OT taxonomy. As presented in Table 21, the OT taxonomy includes topics that may be reviewed with a patient in an education-only session (eg, home modifications needed for optimal home independence) or during a functional work session with a different focus (eg, during tenodesis training the therapist educates the patient or family on transportation issues). If the education overlaps with a different functional activity, the therapist documents “yes—overlaps with functional work” so that minutes spent on the education do not “double count” minutes spent on the functional work.
DeJong et al (5) outlined criteria that define the usefulness of taxonomy efforts, which helped to guide development of the SCIRehab OT taxonomy. The PBE approach, which relies primarily on the expertise and experience of practicing clinicians who develop the taxonomy, set the groundwork to capture a comprehensive description of OT activities and interventions within the SCI rehabilitation setting. Capturing all domains of OT for SCI rehabilitation, as was desired for the SCIRehab project, is a lengthy process. However, clinicians believe this granularity is important to classify and describe each dimension systematically, and thus, the OT taxonomy for SCIRehab incorporates and organizes each component (theoretical integrity). We hypothesize that 1 of the reasons this classification has not been done previously is because of the complex multidimensionality; it is not practical to use a classification system in a paper format, which would be many pages long. The use of the SCIRehab electronic data capture method (14), however, provides a reliable, efficient, and minimally burdensome method to capture detailed data that fits the busy schedule of OT clinicians. Research utility will be explored when data collection is complete and we attempt to relate OT processes with outcomes in the SCIRehab analyses.
OT lead clinicians, like other discipline leaders involved in this project, recognized the fine line between collecting sufficient detail to show variation in treatment, which will be used subsequently for associating treatment types, amounts, or sequences with outcomes, and collecting too much information to make the process overly burdensome to front-line clinicians. If documentation is so detailed that the clinician has to spend significant time and energy entering the data, there is a significant risk of a decrease in data quality. The electronic data capture method makes gathering most supplemental taxonomic details collected for research purposes in the SCIRehab study acceptable; however, when an OT session involves multiple ADL activities during 1 session (eg, bathing, grooming, and upper and lower body dressing), the documentation burden becomes greater. OT lead clinicians were aware of this risk at the time of development but agreed that the elements included in the taxonomy were necessary to identify and quantify these complex sessions.
The PBE method provides the unique opportunity to examine the totality of the rehabilitation process in all its natural variations and differences in practice among the 6 centers. OTs from the 6 centers shared treatment techniques, some of which were unique to 1 or a few centers, but for which there is little literature to describe effectiveness. One example is the use of short opponens splints to facilitate tenodesis, for which there is minimal evidence. DiPasquale-Lehnerz (21) and Harvey et al (22) offered differing opinions of the utilization of orthoses to facilitate tenodesis. Although the intention of the SCIRehab project is to capture what occurs in day-to-day therapy sessions and not to change practice, participation in these types of discussions may indeed have an effect on practice. Insightful discussions on the perceived benefits of orthoses and the inclusion of these orthoses, for example, in the OT taxonomy may have influenced clinicians to try approaches that would not have been used previously. This may be similar to attending a professional conference where discussions of the advantages of specific interventions spark an interest in clinicians to try the intervention.
Continued refinement of the OT taxonomy for incorporation into permanent rehabilitation center documentation or for future research projects may be influenced by experience with the current taxonomy. For example, clinicians might add leg management skills as an additional component to the “bed mobility” activity. Although this skill is inherent in other components of bed mobility (eg, rolling, scooting), leg management skills also are needed specifically for the task of lower body dressing. This was not included in the SCIRehab taxonomy because of the desire to maintain as much consistency as possible among activities that overlap PT and OT domains, and leg management is not within the PT realm for bed mobility activities. The “upper body dressing” activity is another area where more information might be beneficial; information about specific components of dressing might be added, which would be similar to including donning pants, socks, shoes, etc, in ‘lower body dressing.' Clinicians suggest that including “upper body dressing” components such as bra, button-up shirt, and pullover shirt, could show increments of increased independence that are otherwise not measured. However, we believe such gaps in the taxonomy are minor.
The OT taxonomy has already had a direct impact on daily documentation at several centers. Some centers report a change in how they view OT documentation and are paying more attention to recording the 26 OT taxonomy activities and their associated details. One center's current system of documentation, which uses the subjective/objective/assessment/plan notes approach, requires a significant amount of detail but is not as efficient as the OT taxonomy; they would like to reorganize the daily documentation system to be more similar to the data collection system created for the SCIRehab study. Other centers see the value of including more detailed process information, similar to what is in the OT taxonomy, and are using the taxonomy as a guide for documentation system revisions. One center decided to use the taxonomy to aid in the creation of week-by-week care pathways to ensure consistent treatment, regardless of clinician experience.
CONCLUSIONS
When clinicians in the field are invited to be part of research and realize that the details of their many clinical efforts may contribute to decisions on what interventions work best for what types of patients, they become engaged in the process and continue to ask interesting questions. Can the OT taxonomy be developed further to be used for daily documentation? Could a computerized documentation system incorporate the 26 OT taxonomy activities? Care delivered could be guided by research based on actual data they themselves contributed—evidence-based practice resulting from PBE!
Footnotes
The contents of this article were developed under grants from the Department of Education and NIDRR Grants H133A060103 and H133N060005 to Craig Hospital, H133N060028 to National Rehabilitation Hospital, H133A21943–16 to Carolinas Rehabilitation, H133N060009 to Shepherd Center, H133N060027 to Mount Sinai School of Medicine, and H133N060014 to Rehabilitation Institute of Chicago. However, these contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the federal government.
This is the 4th in a series of 9 articles describing The SCIRehab Project: Classification of SCI Rehabilitation Treatments.
 
  • Bennett S, Bennett J. The process of evidence-based practice in occupational therapy: informing clinical decisions. Austr Occup Ther. 2000;47(4):171–180.
  • Sonn U, Törnquist K, Svensson E. The ADL taxonomy: from individual categorical data to ordinal categorical data. Scand J Occup Ther. 1999;6(1):11–20.
  • American Occupational Therapy Association. Occupational therapy practice framework: domain and process. Am J Occup Ther. 2002;56(6):609–639. [PubMed]
  • Keith R. Treatment strength in rehabilitation. Arch Phys Med Rehabil. 1997;78(12):1298–1304. [PubMed]
  • DeJong G, Horn S, Gassaway J, Slavin M, Dijkers M. Toward a taxonomy of rehabilitation interventions: using an inductive approach to examine the “black box” of rehabilitation. Arch Phys Med Rehabil. 2004;85(4):678–686. [PubMed]
  • DeJong G, Horn S, Conroy B, Nichols D, Healton E. Opening the black box of poststroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S1–S7. [PubMed]
  • Richards LG, Latham NK, Jette DU, Rosenberg L, Smout RJ, DeJong G. Characterizing occupational therapy practice in stroke rehabilitation. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S51–S60. [PubMed]
  • Maulden S, Gassaway J, Horn S, Smout R, DeJong G. Timing of initiation of rehabilitation after stroke. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S34–S40. [PubMed]
  • Hatfield B, Millet D, Coles J, Gassaway J, Conroy B, Smout R. Characterizing speech and language pathology outcomes in stroke rehabilitation. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S61–S72. [PubMed]
  • Latham N, Jette D, Slavin M, et al. Physical therapy during stroke rehabilitation for people with different walking abilities. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S41–S50. [PubMed]
  • van Langeveld S, Post M, van Asbeck F, Postma K, Ten Dam D, Pons K. Development of a classification of physical therapy, occupational therapy and sports therapy interventions to document mobility and self-care in spinal cord injury rehabilitation. J Neurol Phys Ther. 2008;32(1):2–7. [PubMed]
  • van Langeveld S, Post M, van Asbeck F, Postma K, Ten Dam D, Pons K. Feasibility of a classification system for physical therapy, occupational therapy and sports therapy interventions for mobility and self-care in spinal cord injury rehabilitation. Arch Phys Med Rehabil. 2008;89(8):1454–1459. [PubMed]
  • Whiteneck G, Gassaway J, Dijkers M, Jha A. New approach to study the content and outcomes of spinal cord injury rehabilitation: The SCIRehab Project. J Spinal Cord Med. 2009;32(3):251–259. [PMC free article] [PubMed]
  • Gassaway J, Whiteneck G, Dijkers M. Clinical taxonomy development and application in spinal cord injury research: The SCIRehab Project. J Spinal Cord Med. 2009;32(3):260–269. [PMC free article] [PubMed]
  • Fielder R, Granger C. Functional Evaluation of Stroke Patients. Tokyo: Springer-Verlag; 1996. Functional Independence Measure: a measurement of disability and medical rehabilitation; pp. 75–92.
  • UB Foundation Activities. IRF-PAI Training Manual. Section III—The FIM Instrument: Underlying Principles for Use of the FIM. UB Foundation Activities; 2004.
  • Natale A, Taylor S, LaBarbera J, et al. SCIRehab Project Series: the physical therapy taxonomy. J Spinal Cord Med. 2009;32(3):270–282. [PMC free article] [PubMed]
  • Dalyan M, Cardenas D, Gerard B. Upper extremity pain after spinal cord injury. Spinal Cord. 1999;37(3):191–195. [PubMed]
  • Jensen M, Hoffman A, Cardenas D. Chronic pain in individuals with spinal cord injury: a survey and longitudinal study. Spinal Cord. 2005;43(12):704–712. [PubMed]
  • Gutierrez DD, Thompson L, Kemp B, Mulroy SJ. The relationship of shoulder pain intensity to quality of life, physical activity, and community participation in persons with paraplegia. J Spinal Cord Med. 2007;30(3):251–255. [PMC free article] [PubMed]
  • DiPasquale-Lehnerz P. Orthotic intervention for development of hand function with C-6 quadriplegia. Am J Occup Ther. 1994;48(2):138–143. [PubMed]
  • Harvey L, Baillie R, Bronwyn R, Simpson D, Pironello D, Glinsky J. Does three months of nightly splinting reduce the extensibility of the flexor pollicis longus muscle in people with tetraplegia. Physiother Res Int. 2007;12(1):5–13. [PubMed]
Articles from The Journal of Spinal Cord Medicine are provided here courtesy of
Maney Publishing