feasibility of a classificatio system for physical therapy, and sports therapy

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RIGINAL ARTICLE

easibility of a Classification System for Physical Therapy,ccupational Therapy, and Sports Therapy Interventions forobility and Self-Care in Spinal Cord Injury Rehabilitation

acha A. van Langeveld, PT, Marcel W. Post, PhD, Floris W. van Asbeck, MD, PhD, Karin Postma, PT, MSc,
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ABSTRACT. van Langeveld SA, Post MW, van AsbeckW, Postma K, Leenders J, Pons K. Feasibility of a classifi-ation system for physical therapy, occupational therapy, andports therapy interventions for mobility and self-care in spinalord injury rehabilitation. Arch Phys Med Rehabil 2008;89:454-9.

Objective: To test the feasibility of a classification systemeveloped to record the contents of treatment sessions intendedo improve mobility and self-care by persons with a spinal cordnjury (SCI) in clinical rehabilitation.

Design: Descriptive study.Setting: Three Dutch SCI facilities.Participants: Participants (N�36) as well as physical ther-

pists (n�20), occupational therapists (n�14), and sports ther-pists (n�2).

Interventions: Not applicable.Main Outcome Measures: Questionnaires to assess the

larity of the classification system, time needed to record 1reatment session, and the distribution of categories and inter-entions. The classification system consisted of 28 categoriest 3 levels of functioning: basic functions (eg, muscle power),asic activities (eg, transfers), and complex activities (eg,alking and moving around outside).Results: Therapists used 1625 codes to record 856 treatment

essions of 142 patients. For 93% of the treatment sessions, theoding caused little or no doubt. The therapists were able tolassify 86.3% of the treatment sessions within 3 minutes. Thelassification system was rated as useful and easy to use.

Conclusions: The findings support the suitability of ourlassification system as a tool to record the contents of SCIreatment sessions in different settings and by differentherapists.

Key Words: Classification; Rehabilitation; Spinal cordnjuries.

© 2008 by the American Congress of Rehabilitation Medi-ine and the American Academy of Physical Medicine andehabilitation

From the Rudolf Magnus Institute of Neuroscience, University Medical Centertrecht (van Langeveld), Rehabilitation Centre De Hoogstraat, Utrecht (van Lange-eld, Post, van Asbeck, Leenders), and Rehabilitation Centre Rijndam, RotterdamPostma, Pons), The Netherlands.

Supported by the Rehabilitation Center De Hoogstraat, Utrecht, The Netherlands.No commercial party having a direct financial interest in the results of the research

upporting this article has or will confer a benefit upon the authors or upon anyrganization with which the authors are associated.Reprint requests to Sacha A. van Langeveld, PT, Rehabilitation Centre De Hoogstraat,

O Box 85238, 3508 AE Utrecht, Rembrandtkade 10, Utrecht, 3583 TM, The Nether-ands, e-mail: [email protected].

0003-9993/08/8908-00672$34.00/0doi:10.1016/j.apmr.2007.12.044

rch Phys Med Rehabil Vol 89, August 2008

HYSICAL THERAPY, occupational therapy, and sportstherapy are thought to contribute to the improvement of

obility and self-care among patients with SCI.1-3 However,vidence for interventions for mobility and self-care is sparse.4

CI rehabilitation research has mostly focused on isolated andasy-to-define interventions5-8 and new technologic develop-ents.9-11 To be able to determine and compare the effective-

ess and efficiency of comprehensive SCI rehabilitation pro-rams, it is necessary to describe the contents of theserograms in a standardized and unambiguous way.12

To date, however, no classification system is available forherapeutic interventions in SCI rehabilitation. We have there-ore developed a classification system based on the main do-ains of SCI rehabilitation, mobility, and self-care.13

The classification system consists of 28 categories at 3 levelsf functioning (appendix 1). The levels of the classificationystem and the selection of the categories were derived fromhe ICF14,15 and the model by van Dijk.16,17 The interventionsere identified from clinical practice, general SCI literature, 1-3

he Guide to Physical Therapy Practice,18 and the Occupa-ional Therapy Practice Framework,19 as well as classificationystems developed for stroke rehabilitation.20-22

The levels used in our classification system are defined asollows: (1) basic functions—for example, interventions aimedt the physiologic functions of body systems and/or anatomicalarts of the body (comparable with the components bodyunctions and structures of the ICF)14; (2) basic activities—forxample, interventions aimed at skills and techniques for po-itions and movements (comparable with the component activ-ty of the ICF)14; and (3) complex activities—for example,nterventions aimed at task-oriented activities with a meaning-ul goal for the person (more advanced activities). The differ-nce between the last 2 levels is the difference in context and/orhe environment in which the activities take place. For exam-le, walking exercises between parallel bars are aimed atracticing components (eg, muscle power and/or endurance) ofhe movement itself. Walking with the goal of moving fromoom to room is primarily aimed at the goal of being able toalk in a task-related context. The rationale for a distinctionetween basic and complex activities has been described else-here.23-26 According to the definition of the ICF, participation

ncompasses involvement in a life situation.14,15 Because ourehabilitation setting does not provide interventions in lifeituations, a classification for participation interventions wasot developed.Each of the 28 categories includes several types of interven-

ions. Examples of interventions within certain categories are

List of Abbreviations

ICF International Classification of Functioning, Disabilityand Health

SCI spinal cord injury

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1455CLASSIFICATION OF THERAPY INTERVENTIONS, van Langeveld

rovided in appendix 2. Exercises and/or training interventionsonsist of 3 to 5 specific methods and techniques of therapeuticxercises or functional training. Modalities include electro-herapeutic modalities (eg, electric stimulation) and physicalgents (eg, cryotherapy). Assessment involves examination andvaluation. Education involves all kinds of patient-related in-tructions. Equipment includes the prescription, application,nd production of devices and other equipment. The unspeci-ed code was added to record therapeutic activities not listed in

he classification system as presented.The first version of the classification system was tested in aodified Delphi procedure27 to achieve consensus about the

ategories and interventions and to refine them if necessary. Aotal of 30 therapists from 10 rehabilitation centers partici-ated. Sufficient consensus was obtained for the definitions ofhe 3 levels (range, 87%–100%). Percentages of consensus forhe terminology used and the completeness of the categoriesanged from 75% to 100%. The perceived relevance of theategories for everyday work varied per discipline.13

To confirm the feasibility of the classification system, how-ver, its actual use needed to be evaluated in practice.

This article presents the results of a multicenter study intohe feasibility of the classification system for use by therapists,n various settings and various disciplines. Feasibility wasvaluated by the following criteria: (1) completeness: therapistshould be able to classify all clinical activities into 1 or morenterventions listed in the categories28; (2) mutually exclusive-ess: therapists should be able to choose without doubt be-ween the levels, categories, and interventions in the classifi-ation system28; (3) speed: therapists should be able to recordhe contents of a treatment session within 3 minutes; and (4)ase: the classification system had to be easy to use as assessedy the clarity of the general and the detailed information in theanual.

METHODS

ampleThe study included all physical therapists, occupational ther-

pists, and sports therapists (n�36) working with patients withCI at 3 specialized Dutch rehabilitation centers. Therapistsho were expected to be off-duty for more than half of the timeuring the study (eg, because they went on holiday) werexcluded.

reatment SelectionAll treatment sessions of patients with SCI at the inpatient

nd outpatient departments were included if (1) the patient washysically present, (2) the treatment session was an individualreatment, and (3) the treatment session was aimed at theomains of mobility and self-care.

rocedureAfter approval of the study by the scientific and ethical board

f each center, the study was introduced during a special staffeeting, and therapists were asked to participate on a voluntary

asis. All participating therapists (n�36) gave verbal consento participate in the project. The therapists then received thelassification system and a manual consisting of 3 parts: (1)eneral information on the structure of the classification sys-em, (2) detailed descriptions of all coded interventions, and (3)

1-page summary with coding instructions. The contents ofnd procedures for the use of the classification system wereiscussed with all therapists at a further instructional meeting.he therapists were then asked to practice recording their
essions with the classification system for a period of 1 week. t
After this first week, a second instructional meeting was heldt each center. Next, the participants were asked to record allelevant treatment sessions over a period of 2 to 4 weeks. Afterhis period, the participants were sent a questionnaire on theeasibility of the classification system.

easuresTo obtain data for evidence of completeness, the participants

ad to record their treatment sessions with codes. The formsed to record treatment sessions allowed users to record aaximum of 5 different interventions a session and to indicate

he amount of time spent on each intervention in 5-minutencrements. If the therapists were unable to record an interven-ion in one of the listed categories, they could record it asnspecified. To obtain data for evidence of completeness, mu-ually exclusiveness, speed, and ease of use, each recordingorm also included 5 questions (questionnaire A) relating to (1)he difficulty users had when classifying interventions (7-pointcale ranging from no doubt to too much doubt about whichevel, category, and intervention to choose), (2) (if therapistsad been in doubt about which code to use) an open-endeduestion to describe what caused the doubt, (3) the time theyeeded to classify the activities in a treatment session (�1min,�3min, �3min), and (4) (if the manual had been consulted)he clarity of the general information in the manual, and (5) theetailed descriptions of interventions (7-point scale rangingrom very clear to very unclear).

To obtain information related to the opinion of the therapistsn completeness, mutually exclusiveness, speed, and ease ofse, a questionnaire (questionnaire B) with 13 questions wasdministered at the end of the recording period. These ques-ions related to the therapist’s opinion on the instructionaleeting, the various sections of the manual (7-point scale from

ery good to very poor), and whether they felt the average timeeeded to classify the activities in a treatment session wascceptable for research purposes and for daily use (7-pointcale from very acceptable to very unacceptable).

tatistical AnalysisBecause the practice week did not reveal major problems,

he data collected in this week were merged with the dataollected in the other weeks. Descriptive statistics were usedor the distribution of classification system codes and the timepent on each therapeutic activity. The percentage of unspec-fied codes was used as an indicator of the completeness of thelassification system. Sufficient user satisfaction was defined as0% or more of the therapists having a positive opinion on theeasibility of the classification system. To assess this, the 1hrough 7 scales were dichotomized into positive opinionsscores 1–3) and neutral or negative opinions (scores 4–7).

RESULTS

herapistsA total of 20 physical therapists, 14 occupational therapists,

nd 2 sports therapists participated on a voluntary basis. Theistribution of the 3 disciplines varied by center: in center A, 8hysical therapists and 5 occupational therapists participated;n center B, 8 physical therapists, 5 occupational therapists, and

sports therapist participated; and in center C, 4 physicalherapists, 4 occupational therapists, and 1 sports therapistarticipated. One sports therapist of center A and 1 occupa-ional therapist and physical therapist of center C were ex-luded according to the criteria. The participating physical
herapists had been working with patients with SCI for a mean �
Arch Phys Med Rehabil Vol 89, August 2008

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1456 CLASSIFICATION OF THERAPY INTERVENTIONS, van Langeveld

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D of 10.4�5.6 years (range, 3–20y) and the occupationalherapists for a mean � SD of 4.8�3.4 years (range, 1–10y).he sports therapists in centers B and C had been working withatients with SCI for 5 years and 1 year, respectively.

reatment CharacteristicsThe number of recorded treatment sessions varied in each

enter (257 in center A, 357 in center B, 242 in center C), byiscipline (521 for physical therapy, 283 for occupational ther-py, 52 for sports therapy), and by therapist (7–51). A total of72 treatment sessions were recorded during the practice week,nd 584 were recorded during the recording weeks. Treatmentessions of 142 different inpatients and outpatients with SCIere recorded. The number of patients did not differ signifi-

antly by center (45 in center A, 48 in center B, 49 in center C).he mean age of the patients was 49 years; they included 88en and 54 women. The types of SCI included motor-complete

etraplegia (n�21), motor-complete paraplegia (n�26), motor-ncomplete tetraplegia (n�42), and motor-incomplete paraple-ia (n�53).

odes and Time by Treatment SessionThe participants recorded a total of 1625 codes. Thirty-nine

ercent (335/856) of all treatment sessions required only 1 codeo describe the therapeutic activities during the session, 32%273) required 2 codes, 23% (199) required 3 codes, 5% (42)equired 4 codes, and only 1% (7) required 5 codes. The meanime spent on the first coded activity varied from 15.8�8.9

inutes for physical therapists to 22.5�15 minutes for occu-ational therapists and 22.2�10.2 minutes for sports therapists.he largest amount of time spent on therapeutic activities byode was 60 minutes for physical therapists, 90 minutes forccupational therapists, and 45 minutes for the sports thera-ists.

ompletenessThe participants used interventions from all 3 levels. The

hysical and occupational therapists recorded at 3 levels ofunctioning, whereas the sports therapists recorded only at theevel of basic functions and basic activities. Table 1 shows theumbers of codes in the various categories of the classificationystem. The therapists used 27 of the 28 categories. Only theategory of bowel interventions at the level of complex activ-ties was not used. Of the 27 categories used, 23 (85.1%) weresed by at least 2 disciplines. The largest number of recordingsccurred in the categories of muscle power, muscle length,alking, wheelchair driving, and handbiking. The physical

herapists made most of their recordings in the categories ofuscle power, muscle length, joint mobility, and walking. The

ccupational therapists made most of their recordings in theategories of wheelchair driving and handbiking, maintainingnd changing body positions and movements, partial tasks ofelf-care, and arm and hand use. The largest numbers of re-ordings by the sports therapists were made in the categories ofheelchair driving and handbiking, swimming, arm and handse, and muscle length.All types of interventions, exercises and training, modalities,

ssessment, education, and equipment were used at all 3 levels.f the 1625 codes, only 24 (1.9%) were recorded as unspeci-ed. Another 42 codes (2.9%) were recorded for exercises and

raining without further specification.

utually ExclusivenessThe therapists were able to classify the activities in most of the

reatment sessions, with 767 (89.6%) of 856 involving little or no s


oubt. There was no significant difference in the level of doubtetween the practice week and the recording weeks. A reason foroubt about the right classification was given in 140 cases. In only7 of these 140 cases did the doubt concern the choice between thelevels of the classification system. Other comments concernedhere to classify equipment, the difficulty in finding the category

or the intervention (eg, walking the stairs, cycling), and difficultyn separating simultaneously performed interventions.

peedThe therapists recorded 756 (88.3%) of the 856 treatment

Table 1: Distribution of the Recordings of Various TherapeuticActivities in Treatment Sessions in the Feasibility Study

Category Code No.* %† Total Time‡

Basic functionsMuscle power 101 224 13.8 4220Muscle length 102 157 9.7 2755Muscle tone 103 80 4.9 1080Joint mobility 104 129 7.9 1910Sensory functions 105 7 0.4 125Neuropathic pain 106 5 0.3 45Musculoskeletal pain 107 23 1.4 445Skin and related

structures (1)§ 108 3 0.2 35Skin and related

structures (2)§ 109 42 2.6 965Cardiovascular system 110 34 2.1 655Respiratory system 111 20 1.2 210Total NA 724 44.5 12,444

Basic activitiesHand and arm use 201 74 4.6 1215Subtasks of self-care 202 59 3.6 1270Basic body positions

and movements 203 127 7.8 2110Transfers 204 84 5.2 1670Standing 205 89 5.5 1360Walking 206 150 9.2 2400Wheelchair driving and

handbiking 207 140 8.6 3095Use of driving

transportation 208 29 1.8 670Swimming 209 19 1.2 360Total NA 771 47.5 14,150

Complex activitiesWalking and moving

around indoors 301 51 3.1 900Walking and moving

around outside 302 24 1.5 465Transfers 303 20 1.2 240Washing and caring

for body parts 304 12 0.7 260Toileting: bladder 305 1 0.1 45Toileting: bowel 306 0 NA NADressing 307 16 1.0 500Eating and drinking 308 6 0.4 95Total NA 130 8 2505Total of all recordings NA 1625 100 29,099

bbreviation: NA, not applicable.Total number of recorded codes per category.Percentage of the total number of recorded codes.Total time spent (in minutes) on therapeutic activities, per category.There were 2 categories for skin and related structures: (1) generalnd (2) pressure ulcers.

essions within 3 minutes and 388 (45.4%) of 856 within 1

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inute. The time needed to record a treatment session waslightly longer in the practice week than in the recordingeeks. The percentage of recordings taking more than 3 min-tes was similar for the 2 periods (12.5% and 11.3%, respec-ively), but the percentage of recordings taking 1 to 3 minutesecreased (56.6% and 36.5%, respectively), while the percent-ge of recordings taking less than 1 minute was higher in theecording weeks (30.9%, 52.1%, respectively).

The therapists recorded most treatment sessions immediatelyfter the session or later that same day. All therapists consid-red the time needed to classify a treatment session acceptableor recording for research purposes. Twenty-two of 36 thera-ists rated the time needed to classify a treatment session foraily use acceptable or neutral.

ase of UseThe therapists consulted the general information about the

tructure of the classification system in the manual in 25129.3%) of 856 of the recorded treatment sessions. If consulted,his information was rated by 193 (76.9%) of 251 as clear toery clear. The detailed descriptions of interventions in theanual were consulted in 405 (47.3%) of 856 of the recorded

reatment sessions. If consulted, this information was rated by63 (89.4%) of 405 as clear to very clear. Over 80% of theherapists had a favorable opinion on the general information,he detailed descriptions of the interventions, the recordingnstructions, and the recording form.

ommentsThe therapists were finally invited to mention possible im-

rovements to the classification system. In most cases, theherapists suggested including more examples in the detailedescriptions of the interventions. The occupational therapistsentioned the difficulty in distinguishing self-care interven-

ions at the level of basic activities from self-care interventionst the level of complex activities. The occupational therapistslso mentioned the difficulty in classifying interventions in-olving equipment.

DISCUSSIONThe primary aim of this study was to test the feasibility of

ur recently developed classification system to record the con-ents of SCI rehabilitation sessions by physical therapists, oc-upational therapists, and sports therapists. This study con-rmed that the classification system was complete and that theategories and interventions were mutually exclusive to recordreatment sessions of a wide range of patients with SCI in 3ostacute rehabilitation settings in The Netherlands. The gen-ral instructions and coding guidelines were sufficiently clear,nd the amount of time needed to classify was within reason-ble limits. Second, this study demonstrated that it is possibleo record the contents of SCI rehabilitation to assess the inter-entions provided, as has been found previously in strokeesearch.21,23-25 The experience gained in earlier studies onaxonomies and/or classification systems shows that the valid-ty and reproducibility of such classifications can be improvedy providing accurate and detailed descriptions of interven-ions.12,21,22,29 Our classification system aimed at capturing theetails to be able to differentiate between therapeutic activitiesor the various types of patients with SCI during differenthases of rehabilitation.Almost all categories and all types of interventions listed in

he classification system (exercises and training, modalities,ssessment, education, equipment) were used. There were only
few cases in which the therapists were unable to classify their
reatment sessions. For the few categories that were rarelysed, therapists indicated this was a result of the short period ofecording. Hence, we may conclude that the interventions listedre fairly complete and are relevant to clinical practice.

The results show that therapists considered the time neededo classify a treatment session acceptable for research purposes,nd most indicated that it was feasible for clinical use. Al-hough the primary aim of this study was not to examine theistribution of interventions in SCI rehabilitation, we were ableo show differences between disciplines in terms of the focusy level (ie, occupational therapists and sports therapists wereore activity-oriented than physical therapists) as well as dif-

erences in the focus on categories (ie, physical therapists wereore focused on muscle power than on muscle length). Fur-

hermore, our data reveal differences in the time spent onctivities per discipline and per patient, and describe the type ofntervention—for example, exercise or assessment.

tudy LimitationsAlthough the data provide evidence for the feasibility of our

ecently developed classification system, this study was subjecto certain limitations. Our results may not be generalized tother settings, because the classification system was developedor use in the Dutch SCI rehabilitation system, which mightiffer from that in other countries with respect to patientopulation and type of interventions applied. However, be-ause we included a wide range of patients with SCI, fromarly admission to outpatient treatment, the sample might beonsidered representative of the whole spectrum of patientsith SCI in postacute care. Further, international literature wassed to identify relevant physical and occupational therapistnterventions,18,19 and our terminology was as much as possi-le derived from the ICF.14,15

A second limitation is that the study included only 2 sportsherapists, so we cannot conclude that the treatment sessionsecorded in this study by the sports therapists were represen-ative of the Dutch situation.

There were several comments from therapists that will besed to refine the classification system. Ongoing research in-ludes more sports therapists and an investigation of interraternd intrarater reliability. Further research is currently examin-ng the interrater and intrarater reliability of the classificationystem.

CONCLUSIONSThis study revealed that the recently developed classification

ystem of SCI rehabilitation interventions can be used to recordhe contents of treatment sessions intended to improve mobilitynd self-care among patients with SCI by different therapistsrom different disciplines in different postacute rehabilitationettings. The classification system allows us to describe andompare the nature and quantity of therapeutic activities in SCIehabilitation.

Acknowledgments: We thank the physical therapists, occupa-ional therapists, and sports therapists of the rehabilitation centersijndam, St. Maartenskliniek, and De Hoogstraat for their enthusiasticarticipation in this research.

APPENDIX 1: CLASSIFICATION OF THERAPEUTICACTIVITIES INTO CATEGORIES

Basic functions

101 Muscle power
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Basic functions

103 Muscle tone104 Joint mobility105 Sensory functions106 Neuropathic pain107 Musculoskeletal pain108 Skin and related structures I109 Skin and related structures II110 Cardiovascular system111 Respiratory system

Basic activities

201 Hand and arm use202 Subtasks of self-care203 Maintaining and changing body positions and movements204 Transfers*205 Standing206 Walking†

207 Wheelchair driving and handbiking208 Use and/or driving of human-powered and/or motorized

transportation209 Swimming

Complex activities

301 Walking and moving around indoors‡

302 Walking and moving around outside‡

303 Transfers§

304 Washing oneself and caring for body parts305 Toileting: bladder306 Toileting: bowel307 Dressing308 Eating and drinking

Transfers at the level of basic activities (204) are directed primarilyt the training of skills and techniques of transfers, eg, learning howo transfer from the wheelchair to the floor and back.Walking at the level of basic activities (206) is directed primarily athe training of skills and techniques of walking, eg, walking to im-rove the coordination, step frequency, etc.Walking at the level of complex activities (301, 302) is directedrimarily at the location and the circumstances (goal of action) inhich it takes place, eg, walking to go to the toilet.

Transfers at the level of complex activities (303) are directed pri-arily at the location and the circumstances (goal of action) in which

hey takes place, eg, transfers to a car seat with the goal of beingransported in the car.

APPENDIX 2: EXAMPLES OF CATEGORIES AT THE3 DIFFERENT LEVELS OF THE CLASSIFICATION,

WITH THE CODED TYPES OF INTERVENTIONS

Categories Types of Interventions

101 Muscle power 101.1 Exercising, training, andmodalities

101.1.1 (Assisted) active exercises withadaptive exercise aids

101.1.2 Active exercises with/withoutphysical aid by therapist

101.1.3 Active exercises with fitnessequipment

101.1.4 Active exercises with specifichand-function equipment

101.1.5 Modalities
101.2 Assessment

PPENDIX 2: EXAMPLES OF CATEGORIES AT THEDIFFERENT LEVELS OF THE CLASSIFICATION,ITH THE CODED TYPES OF INTERVENTIONS

(Cont’d)

Categories Types of Interventions

101.3 Education101.4 Equipment101.5 Unspecified

206 Walking 206.1 Exercising and training of skillsand techniques

206.1.1 Walking on treadmill (� supportsystem)

206.1.2 Walking in water (hydrotherapy)206.1.3 Walking indoors206.1.4 Walking outside206.1.5 Walking in sports activities206.2 Assessment206.3 Education206.4 Equipment206.5 Unspecified

302 Walking andmoving aroundoutside

302.1 Exercising and training skills andtechniques in meaningful contextand/or environment

302.1.1 In immediate area ofrehabilitation center

302.1.2 In immediate area of one’s ownhome

302.1.3 To go to stores/buildings in theimmediate area of rehabilitationcenter

301.1.4 To go to stores/buildings �1kmfrom rehabilitation center

302.1.5 To be outdoors/in recreationalareas

302.2 Assessment302.3 Education302.4 Equipment302.5 Unspecified

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feasibility of a classificatio system for physical therapy, and sports therapy

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