Opening the Black Box: Lessons Learned From an Interdisciplinary Inquiry Into the Learning-Based Contents of Brain Injury Rehabilitation

This article describes challenges encountered and lessons learned in an effort to explore the black box of rehabilitation. A multidisciplinary team created detailed, mutually exclusive operational definitions for the contents of learning-based treatments administered in a brain injury unit. The function and activity levels of the International Classification of Functioning, Disability and Health were used to organize content definitions, which included examples of therapy activities and therapist behaviors, such as cues. Pairs of trained coders independently identified defined learning episodes within each minute of 128 videotaped physical, occupational, or speech therapy sessions. Interrater agreement was generally acceptable and did not vary by discipline of session, discipline of coder, or whether coders were clinically trained. Disagreements typically involved the threshold for determining that a learning episode had occurred, or deciding between function and activity codes where the surface content of the sessions were similar. The focus on individual therapy sessions allowed for rich qualitative detail, but a less granular analysis will be necessary for comprehensive efforts to characterize the contents of therapy.