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ISSN: 2329-9096
International Journal of Physical Medicine & Rehabilitation
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Standardization of Interdisciplinary Clinical Practice and Assessment in Stroke Rehabilitation

Carolyn L Kinney, Megan C Eikenberry, Stephen F Noll, James Tompkins and Joseph Verheijde*

Department of Physical Medicine and Rehabilitation, Mayo Clinic, 13400 E Shea Boulevard, Scottsdale, AZ, 85259, USA

*Corresponding Author:
Joseph Verheijde
Department of Physical Medicine and Rehabilitation
Mayo Clinic, 13400 E Shea Boulevard
Scottsdale, AZ, 85259, USA
Tel: 480 301 8450

Received Date: September 15, 2013; Accepted Date: November 25, 2013; Published Date: November 29, 2013

Citation: Kinney CL, Eikenberry MC, Noll SF, Tompkins J, Verheijde J (2013) The Standardization of Interdisciplinary Clinical Practice and Assessment in Stroke Rehabilitation. Int J Phys Med Rehabil 1:166. doi: 10.4172/2329-9096.1000166

Copyright: © 2013 Kinney CL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Medical practice has increasingly focused on providing evidence-based interventions. We describe a process to standardize the interdisciplinary assessment of patients presenting for rehabilitation after stroke in a single academic medical center. Multiple assessment tools and outcome measures were reviewed for validity, specificity for stroke population, ease of administration, and utility in research. Interdisciplinary participation in the review process facilitated compliance with new documentation requirements. Measurements were incorporated into the electronic medical record from which an interdisciplinary database was developed for research applications. Clinically, the electronic medical record documentation is accessible to all healthcare providers in our medical system. Objective data from the use of quantifiable outcome measures facilitates clinical decision-making, more appropriate goal setting, and provides opportunities to optimize the value of the care delivered. It creates opportunities for best practices in the rehabilitation of patients with stroke and contributes to the provision of cost-effective patient care. Quantifiable measures also result in improved patient and caregiver understanding of patient impairment and progress, and as we observed, increased patient motivation in therapies. From a research perspective, having an interdisciplinary database in place enhances opportunities for future collaborative and integrated clinical studies. We posit that broad implementation of the care strategy outlined, and the database resulting from it, will also facilitate multicenter clinical research opportunities which will ultimately benefit patients with stroke.


Stroke rehabilitation; REDCap; StrokEDGE task force


Providing evidence-based interventions has become an integral part of stroke rehabilitation. Multiple assessment tools have been developed across all rehabilitation disciplines to objectively quantify impairments and track improvements. The routine use of outcome measures can enhance the patient evaluation process and clinical decision making. It also assists in developing a plan of care and predicting clinical outcomes [1-3]. These practice enhancements are broadly correlated with improved treatment outcomes, greater cost-efficiency of care, and enhanced opportunities for interdisciplinary and multi-center clinical research [4]. “Comprehensive rehabilitation of patients requires multiple health care professionals (e.g. physician, psychologist, occupational therapist, physiotherapist, nurse, social worker, etc.), who build a team to bring the different professions, assessments and evaluations together to obtain a holistic view of the patients’ problems” [5]. The shared decision-making of the interdisciplinary team concept, as opposed to a multidisciplinary team approach, is believed to be more suitable to meet this goal. The term interdisciplinary implies that teams regularly discuss and collaboratively set treatment goals and make it a joint responsibility to integrate separate discipline approaches into a single treatment plan [5]. Conversely, within multidisciplinary teams, professionals enjoy high levels of autonomy and create discipline specific goals and treatment plans for the patient [5]. Medical centers that treat patients with stroke offer an array of rehabilitation interventions, the efficacy of which has been demonstrated in only a few studies, using different outcome measurement tools. Many studies examining interventions for people with stroke are limited methodologically by poor outcome measure selection [6,7]. Practice guidelines have also provided comprehensive reviews and broad recommendations for the use of assessment measures [8,9]. Nonetheless, rehabilitation therapists do not routinely use validated assessment or outcome measures, despite encouragement to incorporate them into routine practice [10]. Frequently cited barriers to clinical use of outcome measures include time constraints, lack of equipment, institution culture and unfamiliarity with assessment tools and their benefits [1,11]. Furthermore, the large number of validated tools hinders consistency of practice even within a single institution.

In order to assure evidence-based best practices for the medical and functional assessment of patients with stroke, in a 7-bed acute inpatient rehabilitation facility, and within an academic medical center (Table 1), we convened an interdisciplinary “Stroke Rehabilitation Standardization” (SRS) team. The team’s charter was to critically evaluate stroke assessment and outcome measures within the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) framework [12-20]. This structure assured that the interdisciplinary team assessed the full spectrum of function from individual impairment to participation in society. There were four objectives for this project: (1) to identify validated assessment tools and outcome measures across all disciplines, (2) to incorporate the selected tools and measures into our electronic medical record (EMR), (3) to create a decision tree to guide clinicians with evaluation and treatment interventions for patients with stroke, and (4) to develop a database for ongoing quality improvement assessment and potential research initiatives. It was anticipated that meeting these objectives would also contribute to the promotion of evidence-based practices in neurorehabilitation throughout the continuum of care at our institution, i.e., acute medical (neuro-critical care, specialized stroke unit), acute inpatient rehabilitation, and outpatient practices.

Rehabilitation Team (7 Bed Inpatient Rehabilitation Facility)
Clinicians: Number
Physical Therapy (PT and PTA) 23
Occupational Therapy (OT and COTA) 17
Speech and Language Pathology 4
Neuropsychology 2
Therapeutic Recreation 1
Physical Medicine and Rehabilitation 7

Table 1: Inpatient Rehabilitation Team.


We established an interdisciplinary SRS team, consisting of clinicians in physical, occupational, speech and recreational therapies, neuropsychology, and Physical Medicine and Rehabilitation, as well as ad hoc members related to database construction and software adaptation. The team met one to two times monthly over the course of 16 months to implement the project charter (Figure 1). The ICF categories of body structures and body function, activities and participation were used as a framework for stratifying assessment measures, with the goal of including measures for all treatment domains at each ICF level, if appropriate (Figure 2) [21]. Potential assessment measures were identified through several sources, including the APTA StrokEDGE task force recommendations [22], the StrokEngine Assess database from McGill University [23], and a published comprehensive literature search [8]. Qualities deemed desirable for inclusion in our standard assessments included: 1) statistical validity, 2) ease of administration, 3)clinical usefulness for stroke, 4) application in research, 5) nominal (versus descriptive) measurements and 6) low or no added expense for implementation. Assessment measures reviewed are listed in Table 2.


Figure 1: Time Line- Mayo Clinic Standardization committee.


Figure 2: International Classification of Functioning Framework (ICF)21.

Reviewed Outcome Measures
Body Structures and Functions
Global Function Voice and Speech Functions Motor and Sensory Related Functions
NIH Stroke Scale Boston Naming Test
Cognitive Linguistic Quick Test
Functional Communication Measures
Montreal cognitive Assessment
Ashworth Scale
Chedoke McMaster Stroke Assessment
Dynavison Assessment
Fugl-Meyer Motor Subscores
Orpington Prognostic Scale
Motor Free Perception Test
Rivermead Motor Assessment
Stroke Rehabilitation Assessment of Movement Limb Subscales
Upper Extremity Use and Activities of Daily Living Mobility Learning & Communication
9 Hole peg Test
Action Research Arm Test
Barthel Index
Box & Blocks Test
Functional Independence
10 Meter Walk test
5 Time Sit Stand Test
6 Minute Walk Test
Berg Balance Test
Dynamic Gait Index
Postural Assessment Scale for stroke Patients
Sensory Organization Test
Timed Up and Go
Trunk Control Test
Tinetti POMA
Trunk Impairment Scale
Cognitive Assessment of Minnesota
Cognitive Performance Test
Lowenstein OT Cognitive Assessment
Montreal Cognitive Assessment
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
Rivermead Behavioral Memory Test
Beck Depression Inventory
Center for Epidemiologic Studies of Depression
Geriatric Depression Scale
Goal Attainment Scale
Hamilton Depression Scale
Modified Rankin Scale
Patient Health Questionnaire 9-item Depression Scale
Stroke- Adapted Sickness Impact scale
Stroke Impact scale
Woodcock-Johnson Tests of Cognitive Abilities

Table 2: Assessments and outcome measures reviewed.

The SRS team systematically reviewed each assessment instrument, confirming the validity of the tool and the integrity of the resources supporting its use. The team discussed clinical applications related to our stroke patient population, identifying strengths and weaknesses, such as “floor” or “ceiling” effects [24]. We reviewed the prevalence of each assessment tool in the neurorehabilitation literature and considered the availability of stroke specific psychometric properties such as reliability, cut off scores, minimal detectable change, and minimal clinically important difference values to assist clinicians with score interpretation [1]. From a practical perspective, we anticipated some challenges associated with incorporating each recommended instrument into our electronic medical record (EMR) and interdisciplinary database. These potential challenges included: provider time necessary to administer each test, the possibility of having excessive, irrelevant, and/ or uninformative details, the clinical feasibility to implement in our setting, and the ability to audit clinician adherence to the identified core measures. In addition, we evaluated the financial impact of acquiring assessment tools, license subscriptions, and any related equipment.

Chosen assessments were formatted into the EMR at our institution, with the assistance of information technology consultants. Where possible, we designed electronic forms that could be completed and scored, if indicated, directly in the EMR. We planned for all assessments to be grouped under one easily located form set in the patient’s record.

We utilized the software program REDCap (Research Electronic Data Capture) to create a database for the SRS information. Study data were collected and managed using REDCap electronic data capture tools [25,26] hosted at our institution. REDCap is “a secure, web-based application designed to support data capture for research studies, providing: 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources” [25].

Project Design

Forty-eight assessments or outcome measures were reviewed by the SRS team and 20 were selected as part of the SRS core set. The list of selected measures is outlined in Table 3. The SRS team set out to select no more than three assessments per therapy discipline within each ICF level. With many assessment tools fitting the selection criteria, practical decisions prevailed in certain cases, such as whether the department owned the necessary equipment and whether the clinicians had broad experience with using the tool. The SRS team also limited the number of assessments chosen within each discipline per ICF category to reduce redundancy among chosen measure in terms of the constructs assessed. For instance, several depression assessments were reviewed in the ICF category for participation; however the team included only two in the final EMR. Tables 4-6 summarize the selected assessments and outcome measures with the rationale for inclusion. The SRS team recognized the dynamic nature of the subject matter and decision making process. Therefore, the team committed to a later review and revision of the list, as the clinicians gained experience with using the assessment tools, both clinically and for research purposes. For clinical application of the process, the SRS team agreed on two initial assessment collection points: (1) admission to acute inpatient rehabilitation and (2) discharge from acute inpatient rehabilitation. Each assessment was to be completed within a 72 hour time window of admission and discharge.

Selected Stroke Assessments
Body Structures/Functions Activity Participation
Functional Communication Measures
Handheld Dynamometry
Montreal Cognitive Assessment
10 Meter Walk Test
6 Minute Walk Test
9 Hole Peg Test
Action Research Arm Test
Battery for the Assessment of Neuropsychological Status
Berg Balance scale
Box 7 Blocks Test
Dynamic Gait index
Functional Independence Measure
Timed Up and Go
Modified Rankin
Stroke Impact Scale
Beck Depression Inventory

Table 3: Selected standardized stroke assessments and outcome measures.

Selected Stroke Outcome Measures
Assessment Description and Rationale for Inclusion Discipline
ICF Category: Body Structures/Function
National Institute of Health Stroke Scale Quantitative measure of neurological deficit post stroke. Assists with stratification of stroke severity [28]. Valid and reliable in acute stroke population [29,30 ]. Recommended by APTA StrokEDGE for clinical and research use [7]. MD-PMR
Stroke Rehabilitation Assessment of Movement Designed for use by physical therapists to provide a quantitative evaluation of motor functioning of the UE and LE after stroke. Reliable and valid in stroke with established stroke MDC values [31-33]. APTA StrokEDGE recommends use in the acute rehabilitation setting and research [7]. Moderately correlated with the Fugl-Meyer but faster to complete [34]. PT
Dynavision Performance Assessment Battery Uses a light board designed to test and train visual scanning, visual attention and visual-motor reaction time [35]. Equipment readily available within our clinic. Reliable and may predict driving ability in individuals with brain injury [31]. OT
Handheld Dynamometry Excellent test-retest reliability in people with neurologic impairment [36]. Age matched norms available [36]. OT
Montreal Cognitive Assessment Cognition screen. Reliable and valid in patients with stroke [37]. Chosen as a screen for mild cognitive impairment secondary to established cut off scores [38]. OT
Functional Communication Measures Series of 8 measures describing aspects of functional communication. Endorsed by National Quality Forum. The FCMs are a component of the American Speech-Language Hearing Association National Outcome Measurement System data collection and reporting tool [27]. ST/OT

Table 4: Selected Outcome Measures-ICF Category: Body Structures/Function.

Selected Stroke Outcome Measures
Assessment Description and Rationale for Inclusion Discipline
ICF Category: Activities
Functional Independence Measure Required in Inpatient Rehabilitation Facilities. Valid in stroke population [39]. MCID stroke values established [40]. Highly recommended for use in acute rehabilitation and research by APTA StrokEDGE [7]. PT, OT, ST, RN
10 Meter Walk Test Brief gait speed assessment. Reliable and valid in stroke population [41,42]. Established stroke specific MCID values [43]. Differentiates between household and community ambulatory [44]. Strongly recommended by APTA StrokEDGE for use in inpatient rehabilitation and research [7]. PT
6 Minute Walk Test Assesses distance walked over 6 minutes as a sub-maximal test of aerobic capacity. Reliable and valid in acute stroke [45,46]. MCID stroke values available [43]. Strongly recommended by the APTA StrokEDGE [7]. PT
Berg Balance Scale Assesses non vestibular balance impairment and functional mobility.  Reliable and valid in patients with stroke [47,48]. Chosen as a balance measure because of established MDC values and ease of administration clinically [49]. Recommended for use in acute rehabilitation and research by APTA StrokEDGE [7]. PT
Dynamic Gait Index Measures gait stability and balance in patients with and without vestibular disorders. Reliable and valid in stroke population with established MDC values [50,51]. Chosen to capture gait stability impairments in higher level patients. Highly recommended for use in acute rehabilitation and research by APTA StrokEDGE [7]. PT
Timed Up and Go Assesses mobility, balance, walking ability, and fall risk. Reliable and valid in stroke. Although a floor effect is present, chosen secondary to its ability to predict falls after acute rehabilitation discharge [52]. Highly recommended for use in acute rehabilitation and research by APTA StrokEDGE [7]. PT
9 Hole Peg Test Reliable and valid in acute stroke population [53]. Established acute stroke specific MDC values [53]. Although there are concerns of a floor effect in patients with acute stroke [54], chosen to capture dexterity in those with emerging hand function. Recommended by StrokEDGE for use in acute rehabilitation setting and research [7]. OT
Action Research Arm Test Reliable and valid in stroke [9,55,56]. Chosen for high correlation with Fugl-Meyer and Wolf Motor Function Test with less time of administration [57]. Equipment available in our clinic. Recommended for use in acute rehabilitation setting and research by APTA StrokEDGE [7]. OT
Box & Blocks Test Assesses unilateral gross manual dexterity. Valid [58] and reliable in stroke population with established stroke MDC values [53]. Recommended for use in acute rehabilitation and research by APTA StrokEDGE [7]. OT
Battery for the Assessment of Neuropsychological Status Quantifies cognitive impairment in 5 domains with index scores and a total score.  Found to be valid in patients with acute stroke [59]. ST/OT

Table 5: Selected Outcome Measures-ICF Category: Activities.

Selected Stroke Outcome Measures
Assessment Description and Rationale for Inclusion Discipline
ICF Category: Participation
Modified Rankin Handicap Scale Single item global outcome that categorized functional ability with consideration of pre stroke level of function.  Valid [60] and reliable in patients with acute stroke [61]. Recommended for use in acute rehabilitation settings by APTA StrokEDGE. MD-PMR
Stroke Impact Scale Self-reported participation measure scoring 8 domains of function. Found to be reliable [62] and valid [63,64] in patients with stroke. Limited data supporting the use of this measure in the acute rehabilitation setting, however it may be reasonable to consider using [7]. As a modification, the last global recovery question was used as a patient reported outcome measure. The SIS in its entirety was less relevant for inpatients. MD-PMR
Short Form-12 12 item health status questionnaire that produces two scores, a physical mental component summary score. Found to be reliable and valid in patients with mild stroke [65]. The SF 36 was strongly recommended in acute rehabilitation setting and research by APTA StrokEDGE [7]. TR
Beck Depression Inventory Quantifies severity of depression, if present. Has been found to be reliable [66] and valid [67] in the stroke population. Due to inherent properties of being a self-report, this inventory may not be appropriate in patients with severe cognitive impairment. TR

Table 6: Selected Outcome Measures-ICF Category: Participation.

The forms for each assessment measure were built into the EMR, grouped under an “Interdisciplinary Stroke Rehabilitation Reference Form” heading for easy tracking. For some assessments, such as the Stroke Rehabilitation Assessment of Movement and the Montreal Cognitive Assessment, the measure was completed in paper format with the summative scores later entered into the EMR stroke reference form. These assessments require patients to input responses, including drawing, and do not lend themselves to direct EMR entry.

The REDCap database was developed capturing only the summated scores for the chosen assessment measures. Data was captured both directly from the EMR, as well as manually from self-report patient questionnaires after scoring, such as the Short Form-12.


After finalizing the list of assessment measures, the new process for rehabilitation evaluation was presented to the rehabilitation therapy staff. We recognized the value of clinician autonomy and a patientcentered evaluation process, and therefore we did not limit the use of the many assessment tools and outcome measures available to clinicians. However, to reduce variability and facilitate consistency, it was required, as a minimum, that all clinicians perform their disciplinespecific core set of assessments proposed by the SRS team. The majority of the clinicians were unfamiliar with at least some of the chosen instruments. Multiple educational sessions provided the clinicians with information on the justification rationale for the selected assessments, how to administer the tests, proper procedures for scoring each assessment, and instruction on how to complete the scoring form in the EMR. Clinicians also completed the certification training required for some measures, such as the National Institute of Health Stroke Scale (NIHSS), the Functional Independence Measure (FIM), and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Additional training to further improve standardization among staff included peer mentoring and video case examples.

A decision tree was created to assist physical therapy clinicians with standardized assessment selection. In some cases, floor effects limited the ability of an assessment to be appropriately completed; therefore, the decision tree assisted clinicians unfamiliar with these limitations. For example, if a patient requires maximal assistance to ambulate, it would be inappropriate to perform a 6 minute walk test, as a condition of this test requires patients to ambulate without physical assistance (Figure 3).


Figure 3: Decision.

The SRS team continued to meet regularly to monitor staff adherence to the SRS project objectives, review any missing data and analyze practical challenges associated with the project’s implementation. In the early phases of the implementation, staff adherence with assessing all components of the selected assessments was 50%. With additional feedback and education to the rehabilitation team, the adherence to completion of all requisite data fields improved to 78%. Based on initial feedback after trial implementation of the process, an important revision was made to the EMR summary form. Despite efforts to avoid the occurrence of missing values, it was noted that several data fields were left blank. Additionally, there were instances that a value of zero was utilized either to indicate a test was not completed or that the value was not relevant to the specific patient’s assessment. We recognized that there could have been several reasons why a value field had been left blank. Potential reasons for this missing data included: failure to enter data, failure to perform the assessment, or a data value that was insufficiently measurement-specific and hence confusing. To avoid that a field would be left blank, the standardization team, with guidance from the biostatistician, decided to include a value option of “N/A.” This N/A value could be entered in cases where the patient was not able to participate in the assessment, where a given assessment tool was not relevant, or was clinically inappropriate. In these instances, a text field was created on the EMR form to add this required notation. The N/A value option permitted all data fields to be completed in the EMR and within REDCap, and clarified absences of data entry, An additional rationale for applying the N/A value is to clearly differentiate between the quantitative value of the number zero and a qualitative entry for a test determined irrelevant or inappropriate. For example, the Timed Up and Go test is measured quantitatively in seconds. It would be impossible to complete the components of the test in zero seconds. Registering a value of zero when the test was not performed will lead to the results being incorrectly analyzed. To mitigate such problems, a “N/A” would be recorded.


We have described one process by which an interdisciplinary rehabilitation team, practicing in a single academic medical center, can standardize the approach for patient assessment after stroke, and track patient progress through the inpatient rehabilitation phase of stroke recovery. Our process differed from other reported implementation efforts by its full interdisciplinary scope, in collaboration for development, in education of the rehabilitation providers, and in the comprehensiveness of its products produced in the EMR and the REDCap database. In addition, this project included current updated, validated assessment measures not previously reported on in the literature [7,27]. At present, we have completed 9-11 months of data collection, and have found the project to provide benefits for clinical staff, patients, and their families. The assessments for each patient are reviewed across disciplines on a weekly basis in a rehabilitation teamrounds format. The specific results assist in guiding the clinical team to address areas of greatest impairments in each patient. The results of the tests are routinely shared with the patient and their families with the goal to engage them as essential members of the health-care team. Although not measured directly, clinicians have noted the patients take a more active role in their rehabilitation when provided objective metrics on their progress. This finding has been reported, though not quantified, in the existing literature [1]. Objective measurement of patient motivation through the use of assessment metrics is worth further investigation, particularly as ongoing constraints in therapy sessions make patient engagement increasingly important. Standardization of practice has resulted in use of consistent assessments tools, facilitating clinical management and auditing of progress. Practice standardization has also improved communication between therapy disciplines, including handoffs and collaboration for treatment plans. It has further enhanced consistency in the communication between clinicians and patients and/ or families regarding treatment expectations.

Clinicians have found that the objective data does not constrain their ability to use a variety of treatment approaches, but rather facilitate clinical decision-making and appropriate goal setting, leading to improved value of care. This outcome is a positive one, but is one that was not anticipated at the initiation of the project. Improved clinical decision-making promotes best practices in the rehabilitation of patients with stroke, enhances patient outcomes and improves cost efficient care delivery [1]. The use of quantifiable outcome measures validates the treatment interventions prescribed and improves the quality of the documentation, all of which can assist in securing reimbursement.

The educational value of the project was evident to all members of the SRS team. It provided a stimulus for clinicians to complete certification requirements for some of the assessment tools. All members of the therapy staff have been trained to administer the assessments pertinent to their discipline. Notably, clinicians are now more knowledgeable about standardized assessment and outcome measures in domains across disciplines, facilitating a true interdisciplinary team approach to patient care. New members of the rehabilitation team receive education in the outcome assessments, similar to the process utilized during the initial implementation of the SRS project. In order to sustain a core set of measurements and keep it current, staff members are encouraged to contribute by introducing new assessments for consideration by the SRS team.

The SRS project included developing both a form for the EMR as well as a database as a platform for clinical research. By choosing certain tools, such as the NIHSS, the rehabilitation database can now be linked to an existing acute stroke database maintained within our institution. The EMR documentation is accessible to all healthcare providers in our medical system. From a research perspective, a combined database enhances opportunities for interdisciplinary clinical studies. We posit that broad implementation of the care strategy outlined, and the database resulting from it, will facilitate multicenter clinical research studies to benefit patients with stroke.

We recognize this project has certain limitations. First there is no consensus on the external validity of the multiple instruments utilized by rehabilitation professionals. We accept that each measurement tool has its own strengths and limitations. Another limiting factor is that the SRS team developed and implemented this project within a closed care-delivery system and with a well-established practice of interdisciplinary collaboration. Stroke rehabilitation is provided at a variety of clinical settings, and our described process may not adapt to other care delivery systems. Our rehabilitation unit is small; however requires a significant number of clinicians to provide continued care on a daily basis. Implementation of an interdisciplinary standardization protocol may be more challenging in larger settings. Furthermore, our project was focused on the inpatient rehabilitation phase of stroke recovery, and we have not yet tested its utility across the continuum of care. The authors also acknowledge as a limitation that during the selection of standards and outcome measures for the discipline of occupational therapy, the focus remained on so-called components based measures. During the ongoing review process, the inclusion of performance based measurements will be assessed. Finally, the logistics regarding expanding this project’s outcomes beyond the acute inpatient rehabilitation facility are currently being developed.


The authors are members of the SRS team. The authors gratefully acknowledge the contributions of these additional SRS team members: Janella Clarke, CCC-SLP; Steven Hust, PT; Joseph G. Hentz, MS; Bernadette Kauffman, CTRS, MSOT; Jeff A. Knecht, MSPT; Dona E. Locke, PhD; Celena Thompson, CCC-SLP; Fred H. White, PT, DPT, GCS; Karen Wooten; Richard Yancey, MSOT.


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