Attaining and demonstrating treatment fidelity is critical in the development and testing of evidence-based interventions. Treatment fidelity refers to the extent to which an intervention was implemented in clinical testing as it was conceptualized and is clearly differentiable from control or standard-of-care interventions. In clinical research treatment fidelity is typically attained by intensive training and supervision techniques and demonstrated by measuring therapist adherence and competence to the protocol using external raters. Yet, in occupational therapy (OT) and physical therapy (PT) outcomes research, treatment fidelity methods have not been utilized, which in our view is a serious gap that impedes novel treatment development and testing in these rehabilitation fields. In this article we describe the development of methods to train and supervise therapists to attain adequate treatment fidelity in a treatment development project involving a novel OT and PT-based intervention. We also present a data-driven model for demonstrating therapist adherence and competence in the new treatment and its differentiation from standard-of-care. In doing so, we provide an approach that rehabilitation researchers can use to address treatment fidelity in OT and PT-based interventions. We recommend that all treatment researchers in rehabilitation disciplines use these or similar methods as a vital step in development and testing of evidence-based rehabilitation interventions.

Objectives For millions of disabled older adults each year, post-acute care in skilled nursing facilities (SNFs) is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly due to therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in post-acute care rehabilitation. Design Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation. Setting Post-acute care unit of a skilled nursing facility in St Louis, MO. Participants 26 older adults admitted from a hospital for post-acute rehabilitation. Intervention Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists (PT/OT) that increase patient engagement and intensity, with the goal of improving functional outcome, through: (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress. Measurements Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and six-minute walk. Results Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 meter/sec vs. 0.08 to 0.22 in standard of care,p=0.003) and six-minute walk (from 73 to 266 feet vs. 40 to 94 feet in standard of care, p=0.026), with a trend for better improvement of Barthel Index (+43 points vs. 26 points in standard of care, p=0.087), compared to participants randomized to standard-of-care rehabilitation. Conclusion Higher intensity and patient engagement in the post-acute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.

Objective. To compare participation in moderate to high intensity physical activities in persons before and after a mild stroke. Methods. We used data from the Cognitive Rehabilitation and Research Group to examine changes in moderate to high intensity physical activity participation in persons who had a mild stroke as defined by an NIH Stroke Scale score of less than 6 (N = 127). Using the Activity Card Sort, we compared the participants' high-demand leisure activity (leisure activities that are moderate to high intensity physical activities) participation at 6-months after stroke with their prestroke level. Results. We found a significant decrease in numbers of high-demand leisure activities in all participants and in each demographic group after mild stroke. Conclusion. These results suggest that persons after mild stroke are not retaining the high-demand leisure activities they were doing prior to their stroke. Health professionals must promote participation in high-demand leisure activities in patients with mild stroke as a tool to enhance health and fitness.