TheRoleofTreatmentTheoryandEnablementTheoryinShapingRehabilitationTreatmentStudies JohnWhyte,MD,PhD Introduction Treatmentresearchgenerallyprogressesthroughseveralstagesbeforeanewtreatmentcanbe implementedinpractice.Atanearlystage,thegoalistoestablishproofofprinciplethetreatment seemstohavetheeffectonsomeimmediatetargetthatitshypothesizedmechanismofactionpredicts. Inmedicalresearchthiswouldincludeaninvitrostudytodemonstratethatanewantibiotickillsa certainbacterialstrain.Atalaterpoint,clinicaltrialsareperformedwithcarefullyselectedsamplesthat maximizetheabilitytodetectaclinicalbenefit.Forexample,onemightexcludepatientswhoarelikely todiesoonfromothercauses,orhavesuchmildillnessthattheyarelikelytorecoverquicklywithouta treatment.Finally,onemaystudytheeffectivenessofatreatmentonabroaderandmore heterogeneoussampletoensurethatitsbenefitsaremorebroadlyapplicable.Sucheffectiveness studiesassesswhetherthebenefitsoftreatmentsstudiedinpuresamplescanbegeneralizedtoreal worldtreatmentpopulationsandsettings.Criticsofthedrugapprovalprocesshavenotedthatthis stageisinfrequentlyimplemented.

.Sometimesrealworldisthoughtofasacontinuousdimensionas theheterogeneityofthesampleincreasesalongmanydimensionsatonce(e.g.,aswhenatreatment studiedonrelativelyyoungpeoplewithfewotherillnessesisextendedtoolderindividualswithmultiple comorbidities).Atothertimes,onemaybeinterestedinthegeneralizationtospecificsubpopulations as,forexample,whenonestudieshowadrugworksinpatientswithrenalfailure. Rehabilitationresearchfollowsasimilardevelopmentalsequence,thoughthestagesarelesswell definedandmorevariablebasedonthenatureofthetreatment,ascomparedtopharmacologic treatments.Importantly,though,inrehabilitation,generalizationoftreatmentbenefitstobroaderand moreheterogeneouspopulationscanmeanverydifferentthings,thathavedifferentresearchdesign implications.Thesedifferentmeaningsofgeneralization,inturn,relatetothedistinctionbetween treatmenttheoryandenablementtheory,asdiscussedbelow. TreatmentTheory Atreatmenthasanimmediateorproximaltargetwhichitisintendedtochange,referredtoasthe treatmentobject,inanalogywithsyntaxwhereaverbactsonanobject.Theverbinthisanalogyisthe essentialingredientsormechanismofthetreatment.Thetreatmenttheoryspecifieshowtheessential ingredientsaltertheobjectoftreatment.Theessentialingredientsofrehabilitationtreatmentsare extremelyvariable,rangingfrommechanicalforceappliedbyabracetoalimb,tolearningexperiences thatmodifyapatternofbehavior.Accordingly,rehabilitationtreatmenttheoriescomefrommany scientificdomainsandaddressobjectsthatrangefromphysiologicprocessestosocialsystems.Common toallisspecificationofhowatreatmentchangestheimmediatetreatmentobject.

However,manyrehabilitationtreatmentsareintendedtochangethingsfardistaltothetreatment object.Wemay,forexample,providerepetitiveresistiveexercises(object:musclestrength)toimprove stairclimbing.Orwemaytrainsomeoneintheuseofanelectroniccalendar(object:calendaruseskill) toallowmoreeffectivesocialintegration.Butthesetreatmentshavenodirecteffectsonstairclimbing orsocialintegration;theirimpactsinthoserealmsarepredicatedonarelationshipbetweenthe treatmentobject(strength,calendarskill)andamoredistalfunctionaloutcome(stairclimbing,social integration)arelationshipoverwhichthetreatmentmechanismhasnocontrol. EnablementTheory Enablementtheoryaddressesinterrelationshipsamongfunctionalconstructsatdifferentlevelsofthe InternationalClassificationofFunctioning,Disability,andHealth(ICF).Thatis,enablementtheory acknowledgesthatcomplexfunctionsaremultiplydetermined,andseekstomodelthesecomplex interrelationships.Forexample,stairclimbingrequiresnotjuststrength,butbalance,jointrangeof motion,painfreemovement,armmovement(dependingonthedegreeoflegweaknessandbalance loss),etc.;socialintegrationrequiresnotonlykeepingtrackofcommitmentsbutplanningthe transportationtogettothem,initiatingtheaction,beingabletoparticipateinsocialactivitiesonceat theappointment,etc.Inprinciple,awelldevelopedenablementtheorycouldtakeasinputsthelevelof abilityofeachofthesecomponentprocessesandpredictperformanceofthecomplexskills.Similarly,it couldspecifytheclinicalimpactonacomplexfunctionofacertaindegreeofimprovementina componentprocess(i.e.,isitworthapplyingatreatmenttoacomponentprocessifitwillnotimpactthe desiredoutcome?).Whatenablementtheorycannotprovide,however,istoolstochangeanyofthese componentprocesses;itcanonlypredicttheramificationsofsuchchangeselsewhereinthe enablementmodel.Moreover,enablementtheorydoesntcarehowacomponentischanged.Its predictionswouldbethesameregardlessofthemechanismofchange. CombiningTheories Treatmenttheoriesgiveustoolstochangetreatmentobjects,butdonttellusthebroaderimpactof anychangeswecanmake.Conversely,enablementtheorytellsushowchangesthatwemakethrough treatmentwillimpactbroaderareasoffunction,butdoesnttellushowtomakethosechanges. Combiningthe2theoreticalframeworksallowsustotesttheefficacyofatreatmentandtodetermine towhomthattreatmentshouldbeapplied,butcloseconsiderationdemonstratesthatthesearevery differentresearchendeavors. Inrehabilitation,testingtheefficacyofatreatment(i.e.,doesitactuallyinducethechangeits mechanismisintendedtoinduce?)needsonlytoaddressmeasuresofthisproximaltreatmentobjector outcome.Thatis,theultimatetestoftheefficacyofamethodoftrainingcalendaruseiswhetherit enhancestheabilitytousethecalendar.Itmakessensetoconcentrateearlyphasesofclinicalresearch onmaximizingthepotencyofthetreatmentwithrespecttoitsobject.Whatisthefastestandmost enduringmethodfortrainingcalendaruse?Butoncetheefficacyofthetreatmentwithrespecttoits objecthasbeenoptimized,theproblemshiftsfocus.Inwhomwilltheuseofthisoptimizedtraining programresultinimprovedsocialintegration?Thisproblemcantbesolvedbymakingthetraining

programsoeffectivethatithasthisresultinallpatients.Rather,itbecomesaproblemofeither:1)In whichpatientsdoestreatingthisproblem(inabilitytokeeptrackofappointments)inisolationhavea positiveimpactonsocialinteraction?or2)Whatadditionaltreatments(e.g.,transportationservices, socialcommunicationskillstraining)mustbecombinedwithcalendartraininginpopulationXtohavea positiveimpactonsocialintegration? Thus,theearlystagesofefficacytestingareguidedlargelybytreatmenttheory,butthelaterstagesof effectivenessresearchandrealworldimpactareguidedlargelybyenablementtheory.Importantly, thereisnoreasonthatthese2phasesofworkmustbetightlylinkedand,indeed,thereisreasonto thinkthatseparatingthemwouldhaveadvantages,ifmeanscouldbefoundtocoordinatethe2streams ofresearch.Researchontreatmenttheorybenefitsfromexpertiseonthespecificphysiologicalor psychologicalsystembeingtargeted,andontheknownandhypothesizedmechanismsavailableto influencethatsysteme.g.,expertiseinmusclephysiologyoranterogradeandprospectivememory systemsinthepriorexamples.Researchonenablementtheory,incontrast,benefitsfromexpertisein theperformancerequirementsofthecomplexrealworldtasksthatareclinicallytargeted,andhow thoseperformancerequirementsinteract.Thus,differentresearchersarelikelytocontributetothese2 phasesofresearch.Importantly,however,theaboveconceptualizationsuggeststhatthereisnoneedto restudyeachtreatmentforagiventreatmentobjectintermsofitsrealworldimpact.Thatis,suppose weknowthatamethodofcalendarusetrainingsuccessfullyenhancescalendaruse,andweknowthat patientswithspecificpatternsofstrengthsandimpairmentsincreasetheirsocialintegrationafter calendarusetraining.Ifwefindanewmethodofcalendarusetrainingthatisequallyormoreeffective inenhancingcalendaruse,wealreadyknowthatitwillalsobeusefulinthatpatientpopulation.In addition,enablementtheorycansuggestwhatadditionalimpairments(e.g.,writingability,awareness deficits)mayneedtobetargetedinordertoenhancetheimpactofmanycalendarbasedmethodson socialintegration. GeneralizationofRehabilitationTreatments Inlightofthedistinctionbetweenthese2theoreticalframeworks,wecanconsider2differentmeanings ofthegeneralizationofrehabilitationtreatmentbenefits.Oneisclosertotheclassicsenseofstimulus generalizationinanimallearningstudies.Whenapigeonisconditionedtopeckaredkeybutnota greenkey,wecanaskhowoftenthebirdpecksanorangekey.Similarly,ifwetrainsomeonetousea calendartorecorddoctorsappointments,dotheyrecordmoviedates,orifwedolegstrengthening exercisesinaseatedposition,doesitalsoimprovestrengthmeasuredwhenlyingdown?Butanother senseofgeneralizationreferstowhethertreatmentsdirectedatacomponentprocessgeneralizeto enhancedperformanceofacomplextaskorfunction.Doesthepersonwhoistrainedtouseacalendar showupatappointments?Thisclearlyrelatestodomainsfarbeyondthetraineddomain,andwillbe largelydictatedbyenablementtheory. Summary Rehabilitationtreatmentresearch,likebiomedicaltreatmentresearch,proceedsthroughstagesof development.Becauseofthemultifaceteddeterminantsofhumanfunction,however,rehabilitation

treatmentresearchshiftsfocusduringdevelopmentfromanemphasisontreatmenttheorytooneon enablementtheory.Explicitrecognitionofthistransitioncouldenhancestudydesignatdifferent developmentalphases,andhighlighttheneedtoinvolveinvestigatorswithdifferentskillsatdifferent points.