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OBJECTIVE: To examine the utility of the sleep disturbance item of the Patient Health Questionnaire-9 (PHQ-9) as a screening tool for insomnia among individuals with moderate to severe traumatic brain injury (TBI). SETTING: Telephone interview. PARTICIPANTS: A sample of 248 individuals with a history of moderate to severe TBI participated in an interview within 2 years of their injury. DESIGN: Observational, cross-sectional analysis. MAIN MEASURES: The PHQ-9 was administered along with the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Sleep Hygiene Index, Epworth Sleepiness Scale, and the Insomnia Interview Schedule. RESULTS: Receiver operating characteristic curve analysis was conducted for the PHQ-9 sleep item rating against a set of insomnia criteria to determine an optimal cutoff score. A cutoff of 2 on the PHQ-9 sleep item maximized sensitivity (76%) and specificity (79%), with an area under the curve of 0.79 (95% CI, 0.70-0.88). The 2 groups formed using this cutoff differed significantly on all sleep measures except the Epworth Sleepiness Scale. CONCLUSIONS: The PHQ-9 sleep item may serve as a useful screener to allow for detection of potential sleep disturbance among individuals with moderate to severe TBI. Those who screen positive using this item included in a commonly used measure of depression can be prioritized for further and more comprehensive assessment of sleep disorders.
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Lesões Encefálicas Traumáticas , Distúrbios do Início e da Manutenção do Sono , Transtornos do Sono-Vigília , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico , Estudos Transversais , Humanos , Questionário de Saúde do Paciente , Sono , Distúrbios do Início e da Manutenção do Sono/diagnóstico , Distúrbios do Início e da Manutenção do Sono/etiologia , Transtornos do Sono-Vigília/diagnóstico , Transtornos do Sono-Vigília/etiologia , Sonolência , Inquéritos e QuestionáriosRESUMO
Peer reviewing is a key mechanism underlying science publishing, but during their graduate training clinicians and researchers are unlikely to be taught the skill. This paper sets forth the art of peer reviewing in general, and the types of reviews that are most useful to the Editors of Spinal Cord (SC). The topics addressed are: the SC editorial process; the role of the referee; review process steps; the content and language of a review; and resources available to peer reviewers.
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Políticas Editoriais , Traumatismos da Medula Espinal , Humanos , Revisão por Pares , EditoraçãoRESUMO
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.
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Exoesqueleto Energizado , Transtornos Neurológicos da Marcha/reabilitação , Humanos , Recuperação de Função FisiológicaRESUMO
ABSTRACT: Clear reporting on rehabilitation treatments is critical for interpreting and replicating study results and for translating treatment research into clinical practice. This article reports the recommendations of a working group on improved reporting on rehabilitation treatments. These recommendations are intended to be combined with the efforts of other working groups, through a consensus process, to arrive at a reporting guideline for randomized controlled trials in physical medicine and rehabilitation (Randomized Controlled Trials Rehabilitation Checklist). The work group conducted a scoping review of 156 diverse guidelines for randomized controlled trial reporting, to identify themes that might be usefully applied to the field of rehabilitation. Themes were developed by identifying content that might improve or enhance existing items from the Template for Intervention Description and Replication. Guidelines addressing broad research domains tended to define reporting items generally, from the investigator's perspective of relevance, whereas those addressing more circumscribed domains provided more specific and operationalized items. Rehabilitation is a diverse field, but a clear description of the treatment's separable components, along with distinct treatment theories for each, can improve reporting of relevant information. Over time, expert consensus groups should develop more specific guideline extensions for circumscribed research domains, around coalescing bodies of treatment theory.
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Lista de Checagem/normas , Medicina Física e Reabilitação/normas , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Pesquisa de Reabilitação/normas , Pesquisa Biomédica/normas , Humanos , Guias de Prática Clínica como Assunto , Projetos de Pesquisa/normas , Terminologia como AssuntoRESUMO
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.
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Pesquisa Biomédica/normas , Ensaios Clínicos como Assunto/normas , Fidelidade a Diretrizes , Projetos de Pesquisa/normas , Relatório de Pesquisa/normas , HumanosRESUMO
OBJECTIVE: The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines. DESIGN: Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations. RESULTS: All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53). CONCLUSIONS: Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.
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Medicina Física e Reabilitação/normas , Guias de Prática Clínica como Assunto/normas , Garantia da Qualidade dos Cuidados de Saúde , HumanosRESUMO
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.
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Guias de Prática Clínica como Assunto , Reabilitação/organização & administração , Humanos , Reabilitação/normasRESUMO
OBJECTIVE: To determine whether the 12 items of the Template for Intervention Description and Replication (TIDieR) can be combined into a single summary score reflecting intervention reporting completeness and quality. DESIGN: Systematic review and reanalysis of published data. After a systematic search of the published literature, 16 review articles were retrieved with 489 sets of 12 TIDieR ratings of experimental intervention, comparator, or the 2 combined as reported in primary studies. These 489 sets were recoded into a common format and analyzed using Rasch analysis for binary items. SETTING: Not applicable. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Psychometric qualities of a Rasch Analysis-based TIDieR summary score. RESULTS: The data fit the Rasch model. Infit and outfit values were generally acceptable (range, 0.70-1.45). TIDieR was reasonably unidimensional in its structure. However, the person (here: study) separation ratio was 1.25 with a corresponding reliability of 0.61. In addition, the confidence interval around each estimate of reporting completeness was wide (model standard error of 0.78). CONCLUSION: Several Rasch indicators suggested that TIDieR is not a strong instrument for assessing the quality of a researcher's reporting on an intervention. It is recommended that it be used with caution. Improvements in TIDieR itself may make it more helpful as a reporting tool.
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Objective: To examine the factors associated with the remission of insomnia by examining a sample of individuals who had insomnia within the first two years after traumatic brain injury (TBI) and assessing their status at a secondary time point.Design and Methods: Secondary data analysis from a multicenter longitudinal cohort study. A sample of 40 individuals meeting inclusion criteria completed a number of self-report scales measuring sleep/wake characteristics (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Insomnia Severity Index, Sleep Hygiene Index), fatigue and depression (Multidimensional Assessment of Fatigue, Patient Health Questionnaire-9), and community participation (Participation Assessment with Recombined Tools-Objective). One cohort was followed at 1 and 2 years post-injury (n = 19) while a second cohort was followed at 2 and 5 years post-injury (n = 21).Results: Remission of insomnia was noted in 60% of the sample. Those with persistent insomnia had significantly higher levels of fatigue and depression at their final follow-up and poorer sleep hygiene across both follow-up time-points. A trend toward reduced community participation among those with persistent insomnia was also found.Conclusion: Individuals with persistent post-TBI insomnia had poorer psychosocial outcomes. The chronicity of post-TBI insomnia may be associated with sleep-related behaviors that serve as perpetuating factors.
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Lesões Encefálicas Traumáticas , Distúrbios do Início e da Manutenção do Sono , Transtornos do Sono-Vigília , Lesões Encefálicas Traumáticas/complicações , Fadiga , Humanos , Estudos Longitudinais , Autorrelato , Distúrbios do Início e da Manutenção do Sono/etiologiaRESUMO
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.
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Autoria , Bibliometria , Publicações Periódicas como Assunto/estatística & dados numéricos , Medicina Física e Reabilitação/estatística & dados numéricos , Sucesso Acadêmico , Comportamento Cooperativo , Humanos , Distribuição por Sexo , Estados UnidosRESUMO
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.
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Publicações Periódicas como Assunto/história , Medicina Física e Reabilitação/história , História do Século XX , História do Século XXI , Revisão da Pesquisa por Pares , Estados UnidosRESUMO
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.
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Lesões Encefálicas Traumáticas/reabilitação , Família , Alta do Paciente , Participação Social , Adulto , Conjuntos de Dados como Assunto , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Pontuação de Propensão , Centros de Reabilitação , Estados UnidosRESUMO
STUDY DESIGN: A narrative review of principles, benefits and disadvantages, as well as methods of research data sharing. OBJECTIVES: To assist prospective Spinal Cord authors and others with understanding and implementing data sharing, so that various benefits of such sharing can accrue to all spinal cord injury research stakeholders. SETTING: International. METHODS: The medical research and health care services literature was reviewed nonsystematically for relevant articles, and web sites were explored for information and services offered by various pertinent organizations. RESULTS: Grant makers, professional organizations, research journals, publishers, and other entities in the research field increasingly stress the ethics as well as societal and practical benefits of data sharing, and require researchers to do so within a reasonable time after data collection ends. Sharing data, retrospectively, generally requires much time and resources, but when a data management plan is part of a research proposal from the start, costs are limited, and grant makers allow these costs to be part of a budget. There are many organizations that offer information on or even assist with preparing data for sharing and actual deposit in a data repository. CONCLUSIONS: The requirement of data sharing is not likely to go away, and researchers interested in submitting their reports to Spinal Cord would do well to familiarize themselves with the myriad practical issues involved in preparing data for sharing.
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Disseminação de Informação , Acesso à Informação , Pesquisa Biomédica/métodos , Coleta de Dados , Curadoria de Dados , Humanos , Traumatismos da Medula EspinalRESUMO
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.
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Lesões Encefálicas Traumáticas/reabilitação , Hospitalização/economia , Medicare , Participação do Paciente , Reabilitação/economia , Adulto , Conjuntos de Dados como Assunto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Centros de Reabilitação/normas , Fatores de Tempo , Estados UnidosRESUMO
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.
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Participação do Paciente/psicologia , Reabilitação/psicologia , Volição , Humanos , Resultado do TratamentoRESUMO
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.
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Avaliação de Resultados em Cuidados de Saúde/métodos , Planejamento de Assistência ao Paciente/normas , Medicina Física e Reabilitação , Projetos de Pesquisa , Protocolos Clínicos , HumanosRESUMO
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.
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Tomada de Decisão Clínica/métodos , Protocolos Clínicos/normas , Planejamento de Assistência ao Paciente/normas , Medicina Física e Reabilitação/métodos , Algoritmos , Humanos , Medicina Física e Reabilitação/normasRESUMO
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.